EDITOR

Donald A. Wiss MD
Director of Orthopaedic Trauma Cedars-Sinai Medical Center Los Angeles, California

P.vii
Contributors
Amr A. Abdelgawad, M.D.
Assistant Professor
Department of Orthopaedic Surgery and Rehabilitation
Texas Tech University Health Sciences Center in El Paso
El Paso, Texas

David P. Barei, M.D., F.R.C.S.C.

Associate Professor
Department of Orthopaedic Surgery
University of Washington
Orthopaedic Traumatology
Harborview Medical Center
Seattle, Washington

Craig S. Bartlett, III M.D.

Associate Professor of Orthopaedics
Medical Director of Orthopaedic Trauma
The University of Vermont
Burlington, Vermont

Andrea S. Bauer, M.D.

Orthopaedic Surgeon
Orthopaedic Hand and Upper Extremity Service
Massachusetts General Hospital
Boston, Massachusetts

Michael R. Baumgaertner, M.D.

Professor
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
Chief, Orthopaedic Trauma Service
Yale—New Haven Hospital
New Haven, Connecticut

Daphne M. Beingessner, B.Math, B.Sc., M.Sc., M.D., F.R.C.S.C.

Associate Professor
Department of Orthopaedics
University of Washington
Orthopaedic Traumatology
Harborview Medical Center
Seattle, Washington

Michael J. Beltran, M.D.

Chief Resident
Orthopaedic Surgery
San Antonio Military Medical Center
San Antonio, Texas

Stephen K. Benirschke, M.D.

Professor
Department of Orthopaedics
University of Washington
Harborview Medical Center
Seattle, Washington

Pascal Boileau, M.D.

Head
Department of Orthopaedics
Department of Orthopaedics and Sports Traumatology
University of Nice-Sophia-Antipolis
Nice, France

Sreevathsa Boraiah, M.D.

Westchester Medical Center
Valhalla, New York

Matthew R. Camuso, M.D.

Orthopaedic Trauma and Fracture Care
Maine Medical Center
Portland, Maine

Kyle F. Chun, M.D.

Resident
Department of Orthopaedics and Sports Medicine
University of Washington
Harborview Medical Center
Seattle, Washington

Michael P. Clare, M.D.

Director of Fellowship Education
Foot and Ankle Fellowship
Florida Orthopaedic Institute
Tampa, Florida

P.viii
Peter A. Cole, M.D.
Chief of Orthopaedic Surgery
Regions Hospital
Professor
University of Minnesota
St. Paul, Minnesota

Cory A. Collinge, M.D.

Director of Orthopaedic Trauma
Harris Methodist Fort Worth Hospital
Clinical Staff
John Peter Smith Hospital
Fort Worth, Texas

Brett D. Crist, M.D., F.A.C.S.

Associate Professor
Co-Director, Orthopaedic Trauma Service
Co-Director, Orthopaedic Trauma Fellowship
Associate Director, Joint Preservation Service
Department of Orthopaedic Surgery
University of Missouri
Columbia, Missouri

Kenneth A. Egol, M.D.

Professor and Vice Chairman
Department of Orthopaedic Surgery
NYU Hospital for Joint Diseases
Langone Medical Center
New York, New York

Christopher G. Finkemeier, M.D., M.B.A.

Co-director
Orthopaedic Trauma Surgeons of Northern California
Granite Bay, California

Thomas Fishler, M.D.

Instructor
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, Connecticut

Paul T. Fortin, M.D.

Associate Professor
Oakland University School of Medicine
William Beaumont Hospital
Royal Oak, Michigan
John T. Gorczyca, M.D.
Professor
Chief, Division of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
University of Rochester Medical Center
Rochester, New York

James A. Goulet, M.D.

Professor of Orthopaedic Surgery
The University of Michigan Medical School
The University of Michigan Health System
Ann Arbor, Michigan

George J. Haidukewych, M.D.

Professor of Orthopaedic Surgery
University of Central Florida
Academic Chairman and Chief Orthopaedic Trauma and Adult Reconstruction
Orlando Health
Orlando, Florida

David L. Helfet, M.D.

Professor of Orthopaedic Surgery
Weill Medical College of Cornell University
Director, Orthopaedic Trauma Service
Hospital for Special Surgery/New York-Presbyterian
Hospital
New York, New York

Daniel S. Horwitz, M.D.

Chief, Orthopaedic Trauma
Geisinger Health Systems
Danville, Pennsylvania

James J. Hutson, Jr. M.D.

Orthopaedic Surgeon
Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
University of Miami
Miami, Florida

Clifford B. Jones, M.D.

Clinical Professor
Michigan State University
Orthopaedic Associates of Michigan
Grand Rapids, Michigan
Jesse B. Jupiter, M.D.
Hansjorg Wyss/AO Professor
Harvard Medical School
Department of Orthopaedic Surgery
Massachusetts General Hospital
Boston, Massachusetts

Enes M. Kanlic, M.D., F.A.C.S.

Professor
Department of Orthopaedic Surgery and Rehabilitation
Texas Tech University Health Sciences Center in El Paso
El Paso, Texas

Matthew D. Karam, M.D.

Clinical Assistant Professor
Department of Orthopaedics and Rehabilitation
University of Iowa Hospitals and Clinics
Iowa City, Iowa

James C. Krieg, M.D.

Associate Professor
Department of Orthopaedics and Sports Medicine
University of Washington
Harborview Medical Center
Seattle, Washington

P.ix
Sumant G. Krishnan, M.D.
Director
Shoulder Fellowship
Baylor University Medical Center
Attending Orthopaedic Surgeon
Shoulder Service
The Carrell Clinic
Dallas, Texas

Erik Noble Kubiak, M.D.

Assistant Professor
Department of Orthopaedics
University of Utah
Salt Lake City, Utah

Lionel E. Lazaro, M.D.

Orthopaedic Surgeon
Orthopaedic Trauma Service
Weill Medical College of Cornell University
Hospital for Special Surgery and New York-Presbyterian
Hospital
New York, New York

Mark A. Lee, M.D.

Associate Professor
Department of Orthopaedic Surgery
Director
Orthopaedic Trauma Fellowship
University of California, Davis
Sacramento, California

Ross Leighton, M.D.

Professor of Surgery
QEII Health Sciences Centre
Dalhousie University
Halifax, Nova Scotia, Canada

Wai-Yee Li, M.D., Ph.D.

Plastic Surgical Resident
University of Southern California
Los Angeles, California

Dean G. Lorich, M.D.

Chief
Department of Orthopaedics at New York-Presbyterian
Associate Director
Orthopaedic Trauma Service at Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery
Weill Cornell Medical Center
New York, New York

Jason A. Lowe, M.D.

Assistant Professor
Orthopaedic Trauma Surgery
Director
Fragility Fracture Program
Department of Orthopaedic Surgery
University of Alabama at Birmingham
Birmingham, Alabama

Arthur L. Malkani, M.D.

Orthopaedic Trauma Surgeon
Chief of Adult Reconstruction Service
Professor of Orthopaedic Surgery
Department of Orthopaedics
University of Louisville School of Medicine
Department of Orthopaedic Surgery
The University of Louisville
Louisville, Kentucky

Joel M. Matta, M.D.

Founder and Director
Hip and Pelvis Institute at St. John's Health Center
Santa Monica, California

Elaine Mau, M.D., M.Sc.

Resident
Division of Orthopaedic Surgery
University of Toronto
St. Michael's Hospital
Toronto, Ontario, Canada

Michael D. McKee, M.D. F.R.C.S. (C)

Professor of Orthopaedic Surgery
Division of Orthopaedic Surgery
University of Toronto
St. Michael's Hospital
Toronto, Ontario, Canada

Berton R. Moed, M.D.

Professor and Chairman
Department of Orthopaedic Surgery
Saint Louis University School of Medicine
Saint Louis, Missouri

Steven J. Morgan, M.D.

Mountain Orthopaedic Trauma Surgeons
Swedish Medical Center
Englewood, Colorado

Rafael Neiman, M.D.

Co-director
Orthopaedic Trauma Surgeons of Northern California
Roseville, California

Xavier Ohl, M.D.

Orthopaedic Surgeon
Department of Orthopaedics and Sports Traumatology
L'Archet 2 Hospital
Nice, France
Robert F. Ostrum, M.D.
Director of Orthopaedic Trauma
Cooper University Hospital
Professor
Department of Surgery
Cooper Medical School of Rowan University
Camden, New Jersey

P.x
Kagan Ozer, M.D.
Clinical Associate Professor of Orthopaedic Surgery
The University of Michigan Medical School
The University of Michigan Health System
Ann Arbor, Michigan

Guy D. Paiement, M.D.

Residency Director for Orthopaedic Surgery
Cedars-Sinai Medical Center
Los Angeles, California

William H. Paterson, M.D.

Orthopaedic Surgeon
Shoulder Service
The Carrell Clinic
Dallas, Texas

Hamid R. Redjal, M.D.

Fellow
Hip and Pelvis Institute
St. John's Medical Center
Santa Monica, California

Mark C. Reilly, M.D.

Assistant Professor of Orthopaedics
Co-Chief, Orthopaedic Trauma Service
University of Medicine & Dentistry of New Jersey
New Jersey Medical School
Newark, New Jersey

David Ring, M.D.

Associate Professor of Orthopaedic Surgery
Harvard Medical School
Director of Research
Hand and Upper Extremity Service
Department of Orthopaedic Surgery
Massachusetts General Hospital
Boston, Massachusetts

Melvin P. Rosenwasser, M.D.

Robert E. Carroll Professor of Orthopaedic Surgery
Columbia University College of Physicians and Surgeons
Director, Orthopaedic Trauma Service
New York Presbyterian Hospital
Director, Hand and Microvascular Service
New York-Presbyterian Hospital
New York, New York

Milton L. Chip Routt, Jr. M.D.

Professor of Orthopaedic Surgery
University of Washington
Harborview Medical Center
Seattle, Washington

Adam P. Rumian, M.D., F.R.C.S.(Tr&Orth)

Consultant Orthopaedic Surgeon
Department of Trauma and Orthopaedics
East and North Hertfordshire NHS Trust
Hertfordshire, England

Nicholas Sama, M.D.

Orthopaedic Trauma Surgeon
Center for Bone & Joint Surgery of the Palm Beaches
Royal Palm Beach, Florida
Hospital for Special Surgery
New York, New York

Roy W. Sanders, M.D.

Chief, Department of Orthopaedics
Tampa General Hospital
Director, Orthopaedic Trauma Services
Florida Orthopaedic Institute
Clinical Professor of Orthopaedic Surgery
University of South Florida
Tampa, Florida

Bruce J. Sangeorzan, M.D.

Professor
University of Washington
Harborview Medical Center
Seattle, Washington
Milan K. Sen, M.D., F.R.C.S.C.
Chief
Orthopaedic Trauma Service
Department of Orthopaedic Surgery
The University of Texas Health Science Center at Houston
Houston, Texas

Benjamin Service, M.D.

Orthopaedic Resident
Orlando Health
Orlando, Florida

Babar Shafiq, M.D.

Director of Orthopaedic Trauma
Howard University Hospital
Washington, District of Columbia

Randy Sherman, M.D.

Vice Chair
Department of Surgery
Cedars Sinai Medical Center
Los Angeles, California

Jodi Siegel, M.D.

Assistant Professor
Department of Orthopaedics
University of Massachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts

James P. Stannard, M.D.

J. Vernon Luck Sr. Distinguished Professor & Chairman
Department of Orthopaedic Surgery
University of Missouri
Columbia, Missouri

P.xi
Benjamin W. Stevens, M.D.
Springfield Clinic
Springfield, Illinois

Rena L. Stewart, M.D., F.R.C.S.(C)

Associate Professor, Orthopaedic Surgery
Chief, Section of Orthopaedic Trauma
Division of Orthopaedics
Department of Surgery
University of Alabama at Birmingham
Birmingham, Alabama

J. Charles Taylor, M.D.

Orthopaedic Surgeon
Specialty Orthopaedics, P.C.
Memphis, Tennessee

David C. Templeman, M.D.

Associate Professor of Orthopaedic Surgery
University of Minnesota
Department of Orthopaedic Surgery
Hennepin County Medical Center
Minneapolis, Minnesota

Frederick Tonnos, D.O.

Assistant Clinical Professor
Michigan State University
East Lansing, Michigan
Sutter Rosevale Medical Center
Roseville, California
Mercy San Juan Medical Center
Carmichael, California

Paul Tornetta, III M.D.

Professor and Vice Chairman
Department of Orthopaedic Surgery
Director of Orthopaedic Trauma
Boston, Massachusetts

J. Tracy Watson, M.D.

Professor of Orthopaedic Surgery
Chief, Orthopaedic Traumatology
Department of Orthopaedic Surgery
St. Louis University School of Medicine
Saint Louis, Missouri

Neil J. White, M.D., F.R.C.S.(C)

Fellow, Hand and Microvascular Service
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
New York, New York

Patrick J. Wiater, M.D.

Attending Orthopaedic Surgeon
Department of Orthopaedic Surgery
William Beaumont Hospital
Beverly Hills, Michigan

Donald A. Wiss, M.D.

Director of Orthopaedic Trauma
Cedars-Sinai Medical Center
Los Angeles, California

Brad Yoo, M.D.

Assistant Professor
Department of Orthopaedic Surgery
University of California, Davis
Sacramento, California

Bruce H. Ziran, M.D.

Director, Orthopaedic Trauma
Orthopaedic Surgery Residency Program
Atlanta Medical Center
Atlanta, Georgia

Navid M. Ziran, M.D.

Orthopaedic Surgeon
Department of Orthopaedic Surgery
Santa Clara Valley Medical Center
San Jose, California
2013
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Library of Congress Cataloging-in-Publication Data
Fractures / editor, Donald A. Wiss. — 3rd ed.
p. ; cm. — (Master techniques in orthopaedic surgery)
Includes bibliographical references and index.
ISBN 978-1-4511-0814-9
I. Wiss, Donald A. II. Series: Master techniques in orthopaedic surgery.
[DNLM: 1. Fractures, Bone—surgery. 2. Fracture Fixation, Internal—methods. WE 185]
617.1′5—dc23
2012007461
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in this text are in accordance with current recommendations and practice at the time of publication. However, in
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Dedication
To My Beloved Mother Dorothy Zuckerman Wiss Who Passed Away As This Book Was Going To Press A
lasting bond, a quiet trust, a feeling like no other. A gratitude that fills the heart, A son's love for his mother.
Series Preface
Since its inception in 1994, the Master Techniques in Orthopaedic Surgery series has become the gold standard
for both physicians in training and experienced surgeons. Its exceptional success may be traced to the
leadership of the original series editor, Roby Thompson, whose clarity of thought and focused vision sought “to
provide direct, detailed access to techniques preferred by orthopaedic surgeons who are recognized by their
colleagues as ‘masters’ in their specialty,” as he stated in his series preface. It is personally very rewarding to
hear testimonials from both residents and practicing orthopaedic surgeons on the value of these volumes to their
training and practice.
A key element of the success of the series is its format. The effectiveness of the format is reflected by the fact
that it is now being replicated by others. An essential feature is the standardized presentation of information
replete with tips and pearls shared by experts with years of experience.
Abundant color photographs and drawings guide the reader through the procedures step-by-step.
The second key to the success of the Master Techniques series rests in the reputation and experience of our
volume editors. The editors are truly dedicated “masters” with a commitment to share their rich experience
through these texts. We feel a great debt of gratitude to them and a real responsibility to maintain and enhance
the reputation of the Master Techniques series that has developed over the years. We are proud of the progress
made in formulating the third edition volumes and are particularly pleased with the expanded content of this
series. Six new volumes will soon be available covering topics that are exciting and relevant to a broad cross
section of our profession. While we are in the process of carefully expanding Master Techniques topics and
editors, we are committed to the now-classic format.
The first of the new volumes is Relevant Surgical Exposures, which I have had the honor of editing. The second
new volume is Essential Procedures in Pediatrics. Subsequent new topics to be introduced are Soft Tissue
Reconstruction, Management of Peripheral Nerve Dysfunction, Advanced Reconstructive Techniques in the
Joint, Sports Medicine, and Orthopaedic Oncology and Complex Reconstruction. The full library thus will
consist of 16 useful and relevant titles.
I am pleased to have accepted the position of series editor, feeling so strongly about the value of this series to
educate the orthopaedic surgeon in the full array of expert surgical procedures. The true worth of this endeavor
will continue to be measured by the ever-increasing success and critical acceptance of the series. I remain
indebted to Dr. Thompson for his inaugural vision and leadership, as well as to the Master Techniques volume
editors and numerous contributors who have been true to the series style and vision. As I indicated in the preface
to the second edition of The Hip volume, the words of William Mayo are especially relevant to characterize the
ultimate goal of this endeavor: “The best interest of the patient is the only interest to be considered.” We are
confident that the information in the expanded Master Techniques offers the surgeon an opportunity to realize
the patient-centric view of our surgical practice.
Bernard F. Morrey, MD
Preface
American medicine remains in the midst of a profound and wrenching transformation. The government, the
insurance industry, Wall Street, and patients have demanded improved medical care at lower cost. Better
medicine (orthopaedics) occurs when doctors practice medicine consistently on the basis of the best scientific
evidence available, set up systems to measure performance, analyze results and outcomes, and make this
information widely available to patients and the public. Reduced costs have been achieved partly through a
wholesale shift to health maintenance organizations, capitation, and managed care.
Trauma is a complex problem where initial decisions often dramatically determine the ultimate outcome. Death,
deformity, and medicolegal entanglements may follow vacillation and error. When treatment is approached with
confidence, planning, and technical skill, the associated mortality rate, preventable complications, permanent
damage, and economic loss may be significantly reduced. Uncertainty, inactivity, and inappropriate intervention
by physicians are all detrimental to patient care. Certain traditional concepts and fixation techniques need to be
abandoned and new approaches learned.
This text attempts to address society's mandate to our profession: better orthopaedics at reduced cost. It
provides both residents and practitioners with surgical approaches to 46 common but often problematic fractures
that, when correctly done, have proven to be safe and effective. It is my hope that the third edition of this
textbook remains a valuable fixture in the catalog of literature on fracture management.
Donald A. Wiss, M.D.
Acknowledgments
The modern scientific world is drowning in information. We have more data than we can possibly use or absorb
in our professional lifetimes. There is an avalanche of scientific journals, books, videos, and CME courses
competing for our attention. The Internet has allowed anyone with a computer to search the World Wide Web for
virtually any topic in any field including orthopaedics and fracture care. So why another textbook about fractures?
First, the tremendous success of the two previous editions of this text is strong testimony to the fact that
students, house-staff, and practicing orthopaedic surgeons still desire a highly organized, informative, and
readable textbook to guide treatment of patients with difficult fractures. Second, our specialty continues to
relentlessly change in terms of imaging modalities, reduction techniques, and fixation devices. Thus a third
edition was undertaken to fill these perceived needs.
My role as Editor is to extract meaning from reams of data, yet remain selectively and self-consciously blind
knowing what to ignore, what is extraneous, and what is critical to improve our knowledge base. I could not have
devoted 30 years of my life to the study of fractures and nonunions without a passion for this problem and the
lessons they offer patient care. I have spent thousands of hours reading, studying, attending courses, reviewing
cases, analyzing data, and of course operating, trying to understand fracture management. No sane person
would devote such labor, let alone so much of one's life to the pursuit of questions that did not touch one's heart
and soul while stimulating the mind.
The third edition of Master Techniques in Orthopaedic Surgery: Fractures was 2 years in the making. Anyone
undertaking such a work will incur debts of gratitude to a number of people who worked on the project with
considerable commitment and little public recognition. I am enormously grateful to my wife Deborah for her
unwavering support and love while working on this project often in the evenings and weekends “stealing” our
precious family time.
In a textbook on surgical techniques, the illustrations and artwork take on primary significance. I am particularly
appreciative of the masterful work of the book's medical illustrator, Bernie Kida. His knowledge of
musculoskeletal anatomy, beautiful illustrations, and experience provided a crucial visual correlation with the text,
often allowing a near operating room experience.
I would like to acknowledge and extend my gratitude to Pamela Swan, my Practice coordinator of 20 plus years.
She assisted me with the manuscript preparation for virtually every chapter in the book during the inevitable
revision process. This book would have been considerably more difficult without her editorial and organizational
talents.
Special thanks are due to Eileen Wolfberg, the contact person between the authors, myself, and publisher. For
the record, Eileen has worked with me on all three editions of the Master Techniques in Orthopaedic Surgery:
Fracture text. Her 30 years of experience in the publishing field and previous professional relationships with
many of the contributors to the book made for an unbelievably smooth transition. Eileen, I could not have done
this book without you!
The contributions of Elise Paxson, Robert Hurley, Brian Brown, and the entire publishing team at Wolters-Kluwer
were crucial to the success of this project. I am particularly indebted to Robert Hurley who “adjusted the budget”
to make this such a beautiful book.
Finally, my heartfelt thanks and appreciation to the each of the contributing authors who answered the “bell”
once again with yet another academic request for their precious time. Their willingness to share their
considerable expertise and to explain the details and nuances of fracture care will unequivocally benefit
orthopaedic surgeons everywhere who treat patients with musculoskeletal trauma.
Donald A. Wiss, M.D.
Editor
 1
Clavicle Fractures: Open Reduction and Internal Fixation
Donald A. Wiss

INTRODUCTION
Clavicle fractures are common injuries and account for approximately 35% to 40% of fractures in the shoulder
region. Most occur in the midshaft, and the majority are treated nonoperatively. Nonsurgical management of this
injury was based on historic, retrospective, surgeon, or radiographic studies that equated union with success.
These early studies concluded that the residual shoulder deformity was primarily cosmetic and that shoulder and
upper limb function were satisfactory. In the past 15 years, there has been a paradigm shift in the evaluation and
treatment of clavicle fractures because contemporary studies have reported that nonoperative treatment of
widely displaced fractures in adults is associated with persistent anatomical deformity, residual shoulder pain
and weakness, and subtle neurologic impairment. Furthermore, recent randomized clinical trials comparing
nonoperative with surgical treatment of widely displaced clavicle fractures in adults have shown a 15% rate of
nonunion and symptomatic malunion, respectively, in nonoperatively treated patients. These newer studies also
used patient-oriented limb-specific outcome measures such as the Constant, Dash, or ASES scores and
demonstrated statistically significant improvement in validated patient outcome measures following internal
fixation. These studies lend support for the use of internal fixation in selected patients with widely displaced
clavicle fractures in adults to decrease the incidence of nonunion and malunion. Surgery has proven to be safe
and effective with the most common complication being prominent hardware necessitating removal.
Most classification schemes for clavicle fractures divide them into three basic categories. Group I are middle third
fractures, Group II are lateral third fractures, and Group III are medial fractures. Neer et al. further subdivided
Group II fractures into three distinct subgroups based on associated soft-tissue and ligamentous injuries. In type I
injuries, the coracoclavicular ligaments remain intact; in type II injuries, this ligamentous complex is disrupted
allowing superior displacement of the lateral fragment; and type III injuries that involve the articular
P.2
surface of the acromial-clavicular joint. Several epidemiological studies show that approximately 80% of all
clavicle fractures occur in the middle one-third, 15% in the lateral third, and only 5% occur medially. The AO/OTA
classification of clavicle fractures is seen in Figure 1.1.
FIGURE 1.1 AO/OTA classification of clavicle fractures.

ANATOMY
A thorough knowledge of the osseous, soft-tissue, and neurovascular anatomy of the shoulder is important if
surgery is planned. The clavicle is an S-shaped bone and has an anterior convex to concave curvature when
viewed from medial to lateral. The lateral end of the clavicle flattens while the medial end remains cylindrical.
The midportion is densely cortical with a short and narrow medullary canal particularly in young adults (Fig. 1.2).
Laterally, the clavicle is anchored to the scapula by the relatively weak acromioclavicular ligaments and the more
robust coracoclavicular ligaments (conoid and trapezoid). Medially, the clavicle articulates with the sternum and
is supported by the thick and strong sternoclavicular, costoclavicular, and interclavicular ligaments. Although the
clavicle is predominately a subcutaneous structure, the deltoid muscle arises from the anterior-inferior portion of
the lateral clavicle while the trapezius muscle arises posterior and superior in its midportion. Several other upper
limb muscles take all or part of their origin from the clavicle including the subclavius, sternocleidomastoid, and
pectoralis major (Fig. 1.3).
From a mechanical point of view, the clavicle functions as a strut between the shoulder girdle and the thorax, and
it suspends the upper limb from the chest wall. The clavicle also provides significant protection to the subclavian
vessels and the brachial plexus that lie in close proximity (Fig. 1.4).

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

Most clavicle fractures in adults are managed nonoperatively. Nonsurgical treatment is indicated when fracture
displacement is <12 to 15 mm, angulation is <10 degrees, and translation is less than a bone diameter.
Treatment consists of support for the upper extremity in a sling, shoulder immobilizer, or figure-of-eight _clavicle
strap to relieve pain. In adolescents, teens, and young adults, a figure-of-eight sling is simple and well tolerated.
In adults, a sling or shoulder immobilizer is usually preferred. These treatment methods will not “reduce” a
clavicle fracture; rather, they are intended to support the upper limb during the healing process. Within 2 to 3
weeks, most patients are able to remove their sling for simple activities of daily living, bathing, and hygiene.
Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. External
support is discontinued when the patient has minimal pain and x-rays show progressive healing. Return to
activities is dictated by local symptoms. Most patients can return to full activities by 12 weeks if the fracture is
healed.
P.3

FIGURE 1.2 The clavicle viewed from above. Note the S-shaped anatomy of the bone.
FIGURE 1.3 Frontal view of the clavicle and associated soft-tissue structures.

P.4

FIGURE 1.4 Cross section of the anterior chest wall showing the relationship of the subclavian vessels to the
clavicle.

Until the turn of this century, the indications for internal fixation of clavicle fractures were very limited. Most major
orthopedic textbooks supported surgery for open fractures, those with vascular compromise or progressive
neurologic deficits, as well as in patients with scapulothoracic dissociation, or displaced pathologic fractures. Not
surprisingly, these conditions represent a small minority of clavicle fractures seen in clinical practice. Current
indications for clavicular surgery, based on recent randomized clinical trials, support the use of internal fixation in
adults when there is shortening, displacement, or translation >15 to 20 mm (Fig. 1.5). Other strong indications for
clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus, displaced group 2 type
2 lateral clavicle fractures, and symptomatic nonunion (Fig. 1.6).

FIGURE 1.5 X-ray of the clavicle showing a widely displaced fracture following a dirt bike accident. This is a
strong indication for internal fixation.

FIGURE 1.6 Radiograph of the clavicle showing a displaced Group II Type II distal clavicle fracture. This fracture
pattern has a high incidence of delayed union and nonunion and is another indication for surgery.

P.5
PREOPERATIVE EVALUATION
History and Physical Examination
Most clavicle fractures occur following a fall onto the upper extremity or by direct trauma to the shoulder region.
Due to pain and inability to comfortably move the extremity, most patients are seen in an emergency room shortly
after injury. In patients with clavicle fractures that occur following high-energy trauma such as motor vehicle,
motorcycle, or a fall from a height, a full trauma workup is essential. As with all injured patients, a detailed history
and thorough physical exam are necessary to accurately diagnose and treat the patient. Substantial trauma to
the shoulder girdle can be associated with injuries to anatomically adjacent structures such as the head, cervical
spine, chest wall, ribs, and lungs. In these patients, advanced imaging studies and consultation with other
medical or surgical specialists may be required.
Most patients with clavicle fractures complain of shoulder or clavicle pain that is exacerbated by movement.
Physical examination reveals swelling, tenderness along the clavicle, fracture crepitus, and deformity in
displaced fractures. Ecchymosis in the supraclavicular infraclavicular or chest wall often takes 12 to 36 hours to
develop (Fig. 1.7). In isolated shaft fractures, active range of shoulder motion is reduced while gentle passive
motion is uncomfortable but usually tolerated. With displaced fractures, a clinical deformity is often obvious. The
proximal fragment usually displaces upward and may tent the skin. The shoulder girdle is shortened and droops
downward and forward. When viewed from the back, the scapula appears prominent or “winged.” Due to the
close proximity of the clavicle to the subclavian vessels and brachial plexus, a careful neurologic and vascular
examination must be performed and documented.

Imaging Studies
A simple AP and oblique x-ray of the clavicle will confirm the diagnosis of fracture in the vast majority of cases.
To obtain an accurate evaluation of the fragment position, two projections of the clavicle are typically obtained:
anterior-posterior view and a (25 to 45 degrees) cephalic tilt view. The AP view should include the upper third of
the humerus, the shoulder girdle, and the upper lung fields, so that other fractures or a pneumothorax can be
identified. In the AP view, the proximal fragment is typically displaced superiorly and posteriorly, while the distal
fragment is inferior, shortened, and internally rotated. The cephalic tilt view brings the clavicle and acromial-
clavicular joint away from the overlying bony anatomy. CT and MRI scans may be useful in sternoclavicular
fractures and dislocations but are rarely necessary for diaphyseal fractures.

Treatment Paradigm
Most clavicle fractures in adults are managed nonoperatively. Nonsurgical treatment is indicated when fracture
displacement is <12 to 15 mm, angulation is under 10 degrees, and translation is less than a bone diameter.
Treatment consists of support for the upper extremity in a sling, shoulder immobilizer, or figure-of-eight clavicle
strap to relieve pain. In adolescents, teens, and young adults, a figure-of-eight sling is simple and well tolerated.
In adults, a sling or shoulder immobilizer is usually preferred. These treatment methods will not “reduce” a
clavicle fracture; rather, they are intended to support the upper limb during the healing process. Within 2 to
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3 weeks, most patients are able to remove their sling for simple activities of daily living, bathing, and hygiene.
Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. External
support is discontinued when the patient has minimal pain and x-rays show progressive healing. Return to
activities is dictated by local symptoms. Most patients can return to full activities by 12 weeks if the fracture is
healed.
FIGURE 1.7 Clinical appearance of the shoulder and chest wall following a motorcycle accident that fractured
the clavicle.

Until the turn of this century, the indications for internal fixation of clavicle fractures were very limited. Most major
orthopedic textbooks supported surgery for open fractures, those with vascular compromise or progressive
neurologic deficits, as well as in patients with scapulothoracic dissociation, or displaced pathologic fractures. Not
surprisingly, these conditions represent a small minority of clavicle fractures seen in clinical practice. Current
indications for clavicular surgery, based on recent randomized clinical trials, support the use of internal fixation in
adults when there is shortening, displacement, or translation <15 to 20 mm. Other strong indications for
clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus, displaced group 2 type
2 lateral clavicle fractures, and symptomatic nonunion.

Timing of Surgery
Whereas open clavicle fractures, and those with neurovascular compromise require immediate treatment, the
vast majority of closed displaced fractures that require surgery can be done electively during the first week after
injury. Patients with other injuries that require early surgery and who remain hemodynamically stable may benefit
from early internal fixation. However, in most seriously injured patients with a displaced clavicle fracture, internal
fixation should be delayed until the patient's condition has been optimized.

Surgical Tactic
There are two methods of internal fixation for clavicle fractures: intramedullary nailing and plate osteosynthesis.
The rationale for intramedullary nailing is the relative ease of the procedure with minimal soft-tissue stripping
leading to high rates of union and favorable functional outcomes. However, the S-shape curve in the clavicle, its
small medullary canal, and the presence of fracture comminution limit its use. By far, the most common method of
treatment for displaced clavicle fractures in adults is plate fixation. With this method of treatment, stable internal
fixation with restoration of length, rotation, and alignment can be achieved allowing early range of shoulder
motion and rehabilitation of the upper limb. Furthermore, recent advances in internal fixation using locking plate
designs may also improve results. Most manufacturers now make contoured clavicle-specific plates, which
further improve reduction and fixation (Fig. 1.8).
FIGURE 1.8 Synthes (Paoli, PA) precontoured clavicle plates.

P.7
SURGICAL TECHNIQUE
Setup, Positioning, Prep, and Drape
Before the patient is brought into the surgical suite, the operating table is rotated 180 degrees so that the
patient's head is at the foot of the table. This provides more space to accommodate the C-arm image intensifier,
which is brought in from the opposite side of the table. Due to significant swelling and skeletal distortion, regional
anesthesia is not recommended. Surgery is routinely done utilizing general anesthesia with an endotracheal tube
or a laryngeal mask airway, which is taped to the patient on the side opposite the fracture. In my experience,
surgery is greatly facilitated by the use of a Mayfield neurosurgical headrest (Fig. 1.9). The patient and the
headrest are positioned on the operating table with the affected side close to the table's edge. The Mayfield
headrest allows the patient's head and neck to be slightly extended and rotated to the nonoperative side giving
better access to the clavicle particularly in the medial one-third. The patient's head is further secured to the
Mayfield headrest by circumferentially wrapping it with a large Kerlix roll. The ipsilateral arm rests on a standard
arm board, which is adducted or rotated parallel to the OR table (Fig. 1.10). The head (foot) of the table is then
elevated 15 to 20 degrees. The C-arm image intensifier is brought in to ensure that the clavicle will be well
visualized during the procedure (Fig. 1.11). Because the metal supports in most operating room tables partially
obscure the field of view, it is often necessary to tilt or rotate the C-arm a few degrees to achieve satisfactory
images. Prior to the surgical prep, the upper chest wall and clavicular regions can be shaved if necessary. The
entire clavicle, shoulder, neck, chest wall, and upper extremity are prepped and draped. The image intensifier
must be sterilely draped and isolated as well. The sterile surgical field should encompass the entire upper
extremity including the clavicle and the ipsilateral acromial-clavicular and sternoclavicular joints (Fig. 1.12). At
this point in time, a surgical “time-out” is called, and all members of the surgical, nursing, and anesthesia teams
must concur with the patient's name, medical record number, and correct side and site of surgery, before the
procedure begins. Unless there are specific cardiopulmonary contraindications, the anesthesiologist is asked to
maintain the patient's systolic blood pressure below 100 mm Hg. This small but helpful step can reduce blood
loss during the case since a tourniquet is not employed.

Surgery
With a sterile marking pen, the superior and inferior borders of the proximal and distal fragments of the clavicle
are marked on the skin, and an appropriate length incision is centered over the fracture site (Fig. 1.13). In large,
obese, or very swollen patients, the clavicle may be difficult to palpate. In these cases, the C-arm image
intensifier can be used to localize the fracture site for the skin incision. A transverse incision is made parallel to
the clavicle and deepened through a subcutaneous tissues. Meticulous hemostasis is obtained with
electrocautery. Several sensory clavicular nerves cross the surgical field longitudinally. When possible, these
nerves
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should be preserved as they provide sensation to the infraclavicular portion of the chest wall. In many cases,
however, one or more of these nerves need to be divided to facilitate exposure and fixation. Patients should be
counseled that some numbness on the chest wall may occur after surgery.

FIGURE 1.9 Internal fixation and imaging are facilitated with the use of a Mayfield headrest.
FIGURE 1.10 Patient positioning for clavicle surgery.

FIGURE 1.11 The C-arm is brought into the operative field from the opposite side of the table.
The proximal clavicular fragment is exposed first (Fig. 1.14). It is usually quite prominent, subcutaneous, and is
relatively straight forward. At the fracture site, the soft tissues and thin periosteum are elevated several
millimeters to expose the bone end. There is a relatively avascular plane between the deltoid anteriorly and
trapezius posteriorly that can be developed down to bone. The soft tissues should only be elevated to
accommodate the plate medially.
P.9
The fracture site is now exposed, and the provisional hematoma is evacuated and copiously irrigated. The distal
fragment is visualized at the fracture site and is typically shortened and displaced downward and forward
beneath the proximal fragment. To better expose the distal fragment, a small Hohman retractor or serrated
reduction clamp is placed just distal to the fracture site, which elevates the bone into the wound for careful
subperiosteal dissection. In patients with comminuted fracture patterns, reduction and fixation of one or more
butterfly fragments may be necessary to achieve stable fracture fixation. In my experience, cortical fragments
measuring 15 to 20 mm in size usually need to be incorporated into the fixation construct. Care should be taken
to preserve the soft-tissue attachments to these fragments in order to avoid disruption of their blood supply. In
many patients, there is a large anterior butterfly fragment containing fibers of the deltoid muscle. Depending on
the fracture geometry, this fragment should be reduced and temporarily fixed to either the proximal or distal main
fragment with K-wires or a small pointed reduction clamp (Fig. 1.15A). Because these fragment(s) are relatively
small, 2.4-mm or more commonly, 2.7-mm interfragmentary cortical screws are used for definitive fixation (Fig.
1.15B). Comminution that is too small or not critical for mechanical stability are removed if they are devoid of soft
tissues and retained as “bone graft” if there are meaningful soft-tissue attachments. Other large butterfly
fragments are similarly reduced and fixed.

FIGURE 1.12 The patient is prepped and draped.

FIGURE 1.13 The surgical incision is marked with a sterile marking pen.
FIGURE 1.14 The proximal fracture fragment is exposed first.

Using small-reduction forceps on the main proximal and distal fracture fragments, the fracture is reduced by
distraction and translation. In simple noncomminuted transverse or short oblique fractures, reduction with
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restoration of cortical continuity often produces sufficient stability to allow removal or repositioning of the
reduction clamps to apply the plate. With stable fracture patterns, compression of the fracture through the plate
is desirable. In more unstable fracture patterns, a neutralization or spanning plate is preferred. In highly
comminuted clavicle fractures, bridging plates that restore length, alignment, and rotation, while preserving the
soft-tissue attachments, remain the treatment of choice (Fig. 1.16).
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FIGURE 1.15 Reduction and internal fixation of a large butterfly fragment.
FIGURE 1.16 Internal fixation at the completion of the procedure.

Implants
There are two distinct schools of thought regarding plate placement. The plate can be placed either anteriorly or
superiorly because biomechanical testing has not demonstrated an optimal position. Proponents of the anterior
plate argue that it is safer, since the screws are directed from anterior to posterior, thereby avoiding the lung and
the neurovascular structures. Furthermore, it reduces the number of patients who may require symptomatic
hardware removal. On the other hand, anterior plating requires additional dissection of the deltoid muscle,
particularly distally, and it is more difficult to fit the plate on the thin anterior surface of the distal fragment. With
anterior plating, the insertion angle for screws in the plate may be difficult to achieve in large patients or women
with generous breasts. Alternatively, surgeons who favor superior plating cite easier surgery and fixation with
possibly improved biomechanics. The disadvantages with this technique are a greater risk to the important
adjacent structures when drilling and the higher incidence of symptomatic hardware.
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FIGURE 1.17 Synthes (Paoli, PA) 3.5-mm plate used for clavicle fracture fixation.

Regardless of the plate position, a plate of adequate strength is required. One-third of tubular plates and
minifragment plates as “stand-alone” implants are rarely indicated in adults. Most studies support the use of
thicker small fragment plate with 3.5-mm screws (Fig. 1.17). In young patients with excellent bone, nonlocking
cortical screws are usually adequate. In older patients with compromised bone stock, or in any fracture with a
short proximal or distal segments, locking screws unequivocally improve strength of fixation. A minimum of three
screws (six cortices) should be placed in the major proximal and distal fracture fragments (Fig. 1.18). Frequently,
one or more screw holes in the plate are left empty at the level of the fracture. With fractures involving the distal
one-fourth of the clavicle, special precontoured periarticular clavicle plates may be helpful. These implants have
a flared or enlarged lateral end to the plate and accept four to six 2.7-mm locking screws. However, due to the
wide variation in clavicular morphology, these plates do not always fit well. For most middle third fractures, I
prefer to contour a straight pelvic reconstruction plate that allows me to precisely match the patient's anatomy
(Fig. 1.19). Invariably this requires a double bend to accommodate the S-shape of the clavicle
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and slight twist in the plate. However, many surgeons favor the precontoured plates for diaphyseal fractures.
Prior to closure, intraoperative fluoroscopy is used to assess the quality of the reduction as well as to ensure
screws are of appropriate length.
FIGURE 1.18 Postoperative x-ray demonstrating stable internal fixation.

FIGURE 1.19 A self-contoured pelvic locking plate.

In comminuted fractures when there are small residuals defects around the fracture site, 5 cc of demineralized
bone matrix putty is packed around the fracture site to augment healing. The wounds are copiously irrigated and
closed in layers. The deep soft-tissue closure should cover the plate. Drains are not routinely utilized. In all
patients, a careful subcuticular plastic closure is done. A firm pressure dressing is applied, and the affected arm
is placed into a sling.

Postoperative Management
In healthy patients with uncomplicated surgery whose pain is minimal or moderate can be sent home on the day
of surgery. In older patients, and those with complex fracture patterns, prolonged surgery, severe pain, or
medical comorbidities are admitted to the hospital overnight and discharged on post-op day 1. Hospitalized
patients receive two postoperative doses of an intravenous cephalosporin antibiotic (when there is no allergy).
Except for the rare open fracture, no additional intravenous or oral antibiotics are administered. Virtually all
patients require strong oral analgesics for the first week or two following surgery. Patients are seen in the out-
patient clinic approximately 7 to 9 days after their surgery. Sutures are removed, and a radiograph of the clavicle
is obtained and reviewed with the patient. The surgical incision is generally left open, and patients are allowed to
bathe or shower and get the incision wet. When stable internal fixation has been achieved, patients are allowed
to remove their sling for activities of daily living such as eating, grooming, and dressing. Most patients usually
wear a sling for 2 to 4 weeks and then discard it. Physical therapy is not routinely employed as the glenohumeral
joint is not affected, and most patients are moving their shoulder within the first 2 to 3 weeks. Patients with “office
jobs” are allowed to return to work within 2 or 3 weeks flowing surgery. On the other hand, return to work for
patients with physically demanding jobs must be delayed a minimum of 6 to 8 weeks and often up to 12 weeks.
After the first postoperative visit, patients are followed at monthly intervals until the fracture has healed
radiographically, which can range from 8 to 16 weeks. Patients are allowed to return to noncontact sports such
as walking, jogging, and cycling at 6 weeks. Participation in more vigorous sports such as soccer, tennis, and
baseball is delayed until 10 weeks postoperatively. Return to football, rugby, judo, hockey, etc. should be
delayed until the fracture is unequivocally united but not earlier than 12 weeks. All patients are asked to return 1
year after surgery for a discussion regarding the need for plate removal. Hardware removal is recommended for
adolescents, teens, and young adults. However, in all other patients, the plate is only removed if there are strong
clinical symptoms such as pain, prominence, or cosmetic issues. In my experience, approximately one-third of
patients eventually have their plate removed.

Complications
NEUROVASCULAR COMPLICATIONS
Complications following internal fixation of clavicle fractures are uncommon. Because of the close proximity
of the lung, the subclavian vessels, and brachial plexus, they are vulnerable to iatrogenic injury.
Nevertheless, with careful and meticulous surgery, injury to these important structures is rare. The use of a
sharp drill bit reduces drill time and the amount of pressure needed to advance the drill bit, thereby
decreasing the likelihood of sudden penetration of the far cortex. The danger to the lung and vessels is
greatest in the medial one-third of the clavicle necessitating increased vigilance. Placing a small Hohman
retractor along the inferior surface of the clavicle opposite, the hole in the plate to be drilled is both practical
and reassuring. Several orthopedic companies manufacture drills that have an oscillating mode in addition
to the standard forward and reverse, which minimize sudden “plunging” beyond the far cortex. Injury to the
lung leading to a pneumothorax or bleeding from a puncture in a major vessel can be extremely difficult to
control and may be life threatening. Prevention is the best treatment.
INFECTION
As with any surgical procedure, infection can develop following internal fixation. Infections in the first 2 to 3
weeks after surgery are treated with aggressive surgical irrigation and débridement, culture-specific
intravenous antibiotics, and retention of hardware if stable fixation has been achieved. In patients with
chronic infections and those presenting late usually require hardware removal as well as thorough operative
débridement and long-term antibiotics (Fig. 1.20).
MALUNION AND NONUNION
Malunion following internal fixation of acute clavicle fractures is rare. It is usually the result of technical
errors or fixation failure. On the other hand, nonunion after clavicular plating using modern techniques and
implants for internal fixation occurs in approximately 5% of patients. A nonunion is present when there are
no progressive signs of healing on radiographs taken between 3 and 5 months following surgery (Fig. 1.21).
Both local and systemic factors may contribute to the development of a nonunion. Local factors that have
been associated with fractures that fail to unite include excessive soft-tissue stripping, poor reductions, and
inadequate fixation. In adults, one-third tubular plates, 2.7-mm implants, or lag screws alone should not be
used. They have been
P.14
associated with high rates of loss of reduction and fixation failures. Systemic factors that may contribute to
the development of a nonunion include smoking, poor nutrition, diabetes, corticosteroids, and chronic
systemic disease.
FIGURE 1.20 Clinical photo showing infection after internal fixation.

FIGURE 1.21 Nonunion with hardware failure after unsuccessful internal fixation of a clavicle.

HARDWARE PROMINENCE
By far, the most “complication” following plate osteosynthesis of a clavicle fracture is late-symptomatic
hardware removal. Due to the relatively scant soft tissues around the clavicle, internal fixation devices may
be prominent particularly after the initial posttraumatic swelling resolves. Plate prominence can be
minimized but not entirely eliminated by a careful closure of the deep soft tissues over the plate following
the index procedure. When symptomatic, the plate can be safely removed after 1 year. Earlier plate removal
has been associated with a small incidence of refracture.

Outcomes and Results

In the past 15 years, numerous studies have reported improved radiographic and functional outcomes
following internal fixation of displaced clavicle fractures in adults when compared to nonoperative treatment.
Hill, McGuire, and Crosby were amongst the first group of investigators to report that closed treatment of
displaced middle third clavicle fractures was associated with poor results. They reported that 16 of 52
(31%) patients treated nonoperatively had an unsatisfactory result based on a questionnaire that they
developed (not statistically validated). Poor results were associated with brachial plexus symptoms,
cosmetic deformity, limb weakness, and nonunion in 15% of patients.
Robinson et al. in a work entitled “Estimating the Risk of Non-Union Following Non-Operative Treatment of
A Clavicle Fracture” reviewed 868 patients treated at a single institution. While the nonunion rate for the
entire group was only 6.2%, the nonunion rate more than tripled to 21% in a subgroup of patients with
 widely displaced fractures. Zlowodzki et al. in a systematic review of 2,144 clavicle fractures published in
the literature up to 2005 found that a nonunion developed in 15.1% of fractures after nonoperative
treatment, while the nonunion rate after internal fixation was only 2.2%. In a randomized control trial
comparing nonoperative versus plate fixation of displaced clavicle fractures, the Canadien Orthopedic
Trauma Society reported the results of treatment in 132 patients. There were less nonunions and malunions
as well as better Constant and Dash scores in the operative group.
In a nonrandomized prospective single surgeon study, 106 patients with a displaced clavicle fracture were
treated by the author with plate osteosynthesis between 2000 and 2008. One hundred three patients were
followed for an average of 12 months (range, 5 to 43). Indications for surgery were 100% displaced clavicle
fractures with shortening, translation, or displacement >15 mm. These were 74 males and 29 females with
an average age of 34 years (range, 14 to 73). The mechanism of injury included falls in 18 patients, motor
vehicle accidents in 22, motorcycle accidents in 32, and sports injuries in 31 patients. 88 (85%) of the
fractures were in the middle one-third, 14 (14%) were in the lateral one-third, and 1 (1%) was in the medial
one-third. All were closed injuries. Treatment consisted of conventional plate osteosynthesis in 15 patients
and locking plates in 82 patients. Alternative fixation techniques were utilized in six patients with extremely
distal clavicle fractures. Ninety-eight of the 103 patients (95%) healed primarily following the index
procedure at an average of 13.5 weeks (range, 6 to 28). Of the five patients who did not heal primarily, four
healed following revision surgery, while one patient failed to unite. Patient outcomes were evaluated using
the DASH score, a validated patient-oriented outcome measure for assessing upper extremity disability. A
zero score indicates a “perfect” extremity while a score of 100 means completely disabled. The mean DASH
score in this series was 16 (range,
P.15
3 to 58). Complications included one broken plate, seven reconstruction plates with minor deformation, and
eight patients with some loss of shoulder motion. There were no infections. The most frequent complication
was symptomatic hardware necessitating removal in 35 patients (34%). In conclusion, this study supports
the use of internal fixation of widely displaced clavicle fractures in adults. The method is both safe and
effective.

RECOMMENDED READING
Canadian Orthopaedic Trauma Society. Non-operative treatment campared with plate fixation of displaced
mid-shaft clavicular fractures. J Bone Joint Surg Am 2007;89:1-10.

Collinge C, Devinney S, Herscovici D, et al. Anterior-inferior plate fixation of middle-third fracture and
nonunions of the clavicle. J Orthop Trauma 2006;20:680-686.

Celestre P, Roberston C, Mahar A, et al. Biomechanical evaluation of clavicle fracture plating techniques:
does a locking plate provide improved stability? J Orthop Trauma 2008;22:241-247.

Duncan SFM, Sperling JW, Steinmann S. Infection after clavicle fractures. Clin Orthop 2005;439:74-78.

Hill JM, McGuire MH, Crosby L. Closed treatment of displaced middle-third fractures of the clavicle gives
poor results. J Bone Joint Surg Br 1997;79:537-541.

Huang JI, Toogood P, Chen MR, et al. Clavicular anatomy and applicability of precontoured plates. J Bone
Joint Surg Am 2007;89-A:2260-2265.

Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg 2007;15:239-248.

McKee MD, Pederson EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft
clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.

McKee MD, Wild LM, Schemitsch EH. Mid-shaft mal-unions of the clavicle. J Bone Joint Surg Am
2003;85:790-797.

Robinson CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion following nonoperative
treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86:1359-1365.

Smekal V, Irenberger A, Struve P, et al. Elastic stable intramedullary nailing versus nonoperative treatment of
displaced midshaft clavicular fractures—a randomized, controlled, clinical trial. J Orthop Trauma
2009;23:106-112.

Zlowodzki M, Zelle BA, Cole PA, et al. Treatment of mid-shaft clavicle fractures: Systemic review of 2144
fractures. J Orthop Trauma 2005;19:504-508.
 2
Scapula Fractures: Open Reduction Internal Fixation
Peter A. Cole
Babar Shafiq

INTRODUCTION
Scapula fractures are uncommon injuries. A recent epidemiological study from Edinburgh showed that only 52 of
6,986 (0.7%) fractures seen at their fracture clinic involved the scapula (1). It is estimated that scapula fractures
account for only 3% to 5% of all fractures about the shoulder girdle, with most occurring in the clavicle or
proximal humerus (2, 3, 4 and 5). The robust muscular envelope, the mobility of the scapula on the thoracic
cage, its oblique orientation to the chest wall, and the surrounding bones, which are more vulnerable to fracture,
protect the scapula making fracture of this bone infrequent.
In the past 25 years, several studies have documented poor results following nonoperative management of
displaced scapular fractures (6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18). With the development of modern
techniques in internal fixation, surgeons began repairing selected scapula fractures utilizing the AO principles of
restoration of articular reduction, alignment, and stable internal fixation leading to a renewed interest in the
operative management of both displaced intra-articular and extra-articular scapular fractures (6,10, 11, 12, 13,
14, 15, 16, 17 and 18). The surgical treatment of these fractures continues to evolve as our knowledge of
shoulder anatomy, surgical approaches, and implants has improved.
There is no universally accepted classification for scapula fractures. In 1984, Hardegger et al. (7) published a
series of 37 operatively treated scapula fractures and introduced a classification scheme that bears his name.
Additionally, Ada and Miller (19) proposed a comprehensive classification that was anatomically defined. Mayo et
al. (20) modified Ideberg's classification for intra-articular fractures (21,22), based on radiographs and operative
findings of 27 intra-articular glenoid fractures. This classification is also helpful in directing surgical decision
making, as it takes into account associated scapular body and process fractures, which frequently occur in
association with glenoid fractures (Fig. 2.1). The Orthopaedic Trauma Association (OTA) classification system is
an alphanumeric system that classifies both intra- and extra-articular fractures (Fig. 2.2). Its main weakness is
that it does not correlate fracture patterns or combinations of injuries with real fractures. Scapula fractures have
also been mapped from 3D reconstructions to better illustrate the true nature of fracture patterns and could serve
as a basis for a comprehensive classification scheme (Fig. 2.3). The main value of three dimensional mapping,
however, is to serve as a useful roadmap for surgical planning and a greater understanding of the muscular force
vectors acting on the scapula (16).

INDICATIONS AND CONTRAINDICATIONS

Open reduction and internal fixation of intra-articular glenoid fractures is indicated when there is more than 4 mm
of articular step-off and more than 20% of the glenoid is involved (2,7,20,21,23, 24 and 25). However, the
literature varies considerably with other authors advocating surgery for articular step-off ranging from 2 to 10 mm
(20,25, 26, 27 and 28). The decision for surgery as well as the amount or degree of articular step-off, gap, and
percentage of joint involvement should be correlated with the patient's job, age, activity level, physiologic status,
and hand dominance (Fig. 2.4A,B).
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FIGURE 2.1 This image depicts the Ideberg Classification as modified by Mayo et al. It is a classification specific
for intra-articular glenoid fractures and accounts for commonly associated fractures of the body and processes
and is helpful in determining surgical approach.

FIGURE 2.2 This figure is the AO/OTA classification for scapula fractures as modified in 2007. Though it
provides a systematic way of classifying scapula fractures, it has not been developed by correlating identified
patterns of injury or combined injuries. (Adapted from Marsh JL, Slongo TF, Agel J, et al. Fracture and
dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and
outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1-S133.)
 P.19

FIGURE 2.2 (Continued)

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FIGURE 2.3 This illustration shows maps of fractures about the glenoid with three common anatomical zones of
involvement in scapular fractures that required surgical treatment. These include (A) the lateral border just
inferior to the glenoid, (B) the spinoglenoid notch between the base of the acromion and the superior aspect of
the glenoid fossa, and (C) the glenoid cavity with the fracture tracking medially into the body of the scapula.
(From Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of scapular fractures with three-dimensional
computed tomography. J Bone Joint Surg Am 2009;91(9):2222-2228 [Fig 4] with permission.)

P.21
FIGURE 2.4 A: A 3D-CT image of the right scapula rotated to represent the scapula on its axis (scapular “Y”
view). The image demonstrates significant glenoid fracture displacement and comminution between the major
cephalad and caudad fragments. B: A 2D-CT axial image of a displaced intra-articular glenoid fracture that
extends coronally dividing the glenoid into anterior and posterior fragments.

The surgical indications for displaced extra-articular scapula fractures are controversial because there are no
randomized controlled studies comparing operative versus nonoperative treatment. Relative indications for
internal fixation of extra-articular scapular fractures include the following:
Lateral border offset (sometimes referred to as medialization) >20 mm on an anteroposterior (AP; Grashey)
view x-ray of the shoulder (Fig. 2.5A,B)
Angular deformity >45 degrees as seen on a scapular Y radiograph of the shoulder (Fig. 2.6A,B)
Lateral border offset >15 mm plus angular deformity >30 degrees
Glenopolar angle (GPA) <22 degrees as measured on a true AP Grashey view radiograph of the shoulder
(Fig. 2.7A,B)
Displaced double lesions of the superior shoulder suspensory complex (SSSC)
Both the clavicle and scapula fractures are displaced >10 mm (Fig. 2.8A,B)
Complete acromioclavicular dislocation and scapula fracture displaced >10 mm
We also advocate operative management of displaced scapular fractures in patients with complex ipsilateral
upper extremity injuries particularly in younger highly active patients, when two or more of the above criteria are
met (Fig. 2.9).
Contraindications to scapula surgery include extra-articular scapular fractures that are displaced <15 mm and
angulated <25 degrees because the outcomes of nonoperative treatment for even moderately displaced scapula
fractures are uniformly good (3 and 4,8,29, 30, 31 and 32). Active mobility of the elbow and wrist is encouraged
immediately, but a sling and rest are indicated for 10 to 14 days. Scapula fractures heal rapidly due to the rich
blood supply in the shoulder girdle. Active range of motion can be started by 4 weeks and advanced quickly.
Resistive exercises are begun by 8 weeks and restrictions lifted as symptoms allow by 12 weeks.
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FIGURE 2.5 A, B: 3D-CT (P/A view) and True A/P (Grashey) radiograph of left shoulder demonstrating Lateral
Border Offset (sometimes referred to as medialization). Note that the displacement is measured from “A” the
anatomic location of the lateral border (inferior and medial to the glenoid) to the tip of the displaced distal
fragment “B.” (Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic Measurement Technique for
Extra-articular Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371-3378, with permission.)
FIGURE 2.6 A, B: Scapular “Y” radiograph and 3D-CT rotated to “Y” view demonstrating angular deformity.
(Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic Measurement Technique for Extra-articular
Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371-3378, with permission.)

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FIGURE 2.7 A, B: 3D-CT (P/A view with acromion subtracted) and True A/P (Grashey) radiograph of right
shoulder demonstrating GPA. On the Grashey view, measured from inferior glenoid rim to superior glenoid rim to
most distal point of scapula inferior angle. (Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic
Measurement Technique for Extra-articular Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371-3378,
with permission.)
FIGURE 2.8 A, B: 3D-CT and AP shoulder demonstrate double lesion to the SSSC (clavicle fracture and
scapula neck fracture).

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FIGURE 2.9 Authors' preferred algorithm for the management of scapula fractures.

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FIGURE 2.10 This illustration depicts the SSSC, which is an osseoligamentous ring made up of the structures
along the dotted line. Goss theorized that if two structures in the ring were disrupted, then a “floating shoulder”
lesion would be present, implying that there would be no osseous or ligamentous continuity between the axial
skeleton and the forequarter. Figure 2.8 shows 3D-CT and AP radiographs of this lesion.

The term superior shoulder suspensory complex is the osseoligamentous relationship between the three scapula
processes, described by Goss in 1993 (33). Goss theorized that if there were two disruptions in this “ring,” made
up by the acromion, coracoid, and glenoid, as well as their capsule-ligamentous connections, then the
glenohumeral joint would be “floating,” a condition that describes discontinuity between the axial and
appendicular skeleton (Fig. 2.10). Though this theory has been challenged by some authors (34, 35 and 36),
Goss recommended surgery if two such disruptions occur simultaneously. We agree with Edwards et al. (34) and
Ramos et al. (36) that surgery is not indicated when each component of the double displacement is stable and
minimally displaced.
Isolated fractures of the acromion or coracoid process are uncommon. Fractures of the acromion process or
spine usually occur as a result of a direct blow to the superior shoulder region, whereas coracoid process
fractures result from violent traction injuries through the biceps and coracobrachialis. While indications for
operative management of these fractures have not been established, we use several criteria to aid in determining
the need for surgery. If either an acromion or coracoid fracture is displaced more that 10 mm, or there is an
ipsilateral scapula fracture or multiple disruption of the SSSC, then open reduction and internal fixation is
warranted (19,37, 38, 39, 40 and 41). When the acromion is displaced more than 5 mm, a supraspinatus outlet
view should be obtained and evaluated for acromial depression, which may contribute to an impingement
syndrome, much like a type III “hooked” acromion, and occasionally warrant internal fixation.
Outcomes following acromion and coracoid process fixation are good with high rates of union (13,40 and 41).
Anavian et al. reported the results of operative management of 14 coracoid and 13 acromion fractures treated
operatively. Most were treated with interfragmentary screw fixation and in selective cases with suture fixation.
Supplemental mini or small fragment plate fixation was used for coracoid fractures that extended into the glenoid
fossa or acromial spine. Similarly, 2.4- or 2.7-mm reconstruction plates were used when fixation of acromion
fractures extending into the scapular neck or base. Distal acromion fractures were treated with a tension band or
a mini fragment locking plate on the superior surface or along the anterior or posterior acromial edge.
Postoperatively, patients were treated with passive- and active-assisted range of motion for the first month,
progressing to resistance exercises after 2 months and full, unrestricted activity by 3 months. All patients were
pain free at rest and with upper extremity activities at the time of final follow-up (mean 11 months, range 2 to 42
months). Mean DASH score for those patients with functional assessments was 7 (0 to 26), better than that of
the uninjured population normative baseline DASH score 10. The only complications in this series were soft-
tissue irritation requiring hardware removal in two patients and removal of ectopic bone in one patient (14).
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PREOPERATIVE PLANNING
History
Fractures of the scapula occur as the result of blunt trauma with strong of forces applied to the shoulder. Partial
articular fractures, usually involving the anterior glenoid, are commonly associated with anterior shoulder
dislocations. These fractures are often referred to as bony Bankart lesions (42) and may be characterized by
anterior shoulder instability. If shoulder instability is present with subluxation of the humeral head on radiographic
examination, or clinical examination, then operative intervention, given an appropriate surgical candidate, is
recommended. Surgery is usually necessary when there is involvement of more than 20% of the articular
surface.
A second type of scapula fracture involves the glenoid neck and body with or without articular involvement, and
this pattern most commonly occurs following high-energy trauma. Associated injuries occur in up to 90% of
patients in this group, and a thorough physical examination is necessary to avoid overlooking serious
concomitant injuries (2,21,37). In the seriously injured patient, scapular fractures are often overlooked leading to
delays in treatment. It is a common misconception that scapulothoracic dissociation occurs following high-energy
blunt trauma, but this is not the case as this devastating injury results from a violent traction force to the upper
extremity.

Physical Examination
The physical examination must be thorough and complete as associated injuries are common particularly to the
spine, cranium, and thorax. When possible, the shoulder and upper extremity should be examined with the
patient sitting or standing to give good access to the posterior forequarter, which is difficult when the patient is
supine in bed or on a gurney. Medial and caudal displacement of the shoulder may be obvious producing marked
asymmetry, particularly if the patient is upright. Medialization may or may not be apparent on the initial
radiographic studies, but once the patient is upright and attempts to move the extremity, the shoulder medializes
as the scapula rotates forward over the thorax. In some patients with scapula and multiple rib fractures, the chest
wall fails to support the scapula and contributes to deformity (Fig. 2.11). Patients with highly displaced scapula
fractures, particularly when associated with multiple ribs or a clavicle fracture, are unable to forward elevate or
externally rotate their shoulders, even a few weeks after injury.
Skin integrity should be assessed as abrasions are common after the typical mechanism of a direct blow to the
shoulder. If surgery is indicated, it should be delayed until there is skin re-epithelialization around 7 to 14 days,
after injury (Fig. 2.12). Ipsilateral, concomitant, neurovascular injuries are common and require a very careful
assessment of the brachial plexus and peripheral pulses. Brachial plexus injury occurs in over 10% of patients
with scapula fractures (5,30). Axillary nerve sensation should be documented; however, motor function to the
deltoid is frequently impossible to determine with displaced fractures. The suprascapular nerve is vulnerable and
commonly
 P.27
injured in association with fractures that extend into the spinoglenoid notch at the base of the acromion, so-called
true scapula neck variants (18) (Fig. 2.13A). Based upon a review of 96 surgically treated scapula fractures, the
senior author identified 14 cases of suprascapular nerve injury almost exclusively associated with these fracture
patterns. Consequently, we recommend electrodiagnostic studies (electromyography and nerve conduction
studies— EMG/NCS) be performed in patients with fractures involving the suprascapular and/or spinoglenoid
notch. These studies are of little diagnostic value immediately after injury and should be performed at least 2
weeks after injury
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when fibrillations and positive sharp waves may be present indicating denervation (axonotmesis and
neurotmesis) (43,44). Every effort should be made to identify injury early and before surgical intervention, when
possible (45).

FIGURE 2.11 Clinical examination of a patient with a displaced scapula fracture. Appreciate the dramatic
depression and medialization of the forequarter. It is important to assess medialization clinically, and later,
postinjury, rather than on a supine injury radiograph or CT scan.
FIGURE 2.12 Note the scarring that resulted from abrasions that occurred at the time of impact of the patient's
shoulder following a bicycle crash. Surgery was delayed until the skin re-epithelialized in order to decrease the
chance of infection.

FIGURE 2.13 A. 3D-CT illustrating a “true scapula neck” fracture that extends through the spinoglenoid notch.
This fracture pattern is often associated with suprascapular nerve injury. B. Intraoperative photo illustrating the
lacerated suprascapular nerve and its proximity to the glenoid fragment. C. Intraoperative postreduction and
fixation. The glenoid fragment is off of the suprascapular nerve. A 4-0 Prolene stitch was utilized to tack the
lacerated nerve to an adjacent nerve branch and muscle.

Radiographic Studies
Because high-energy scapula fractures often present in an emergent setting in patients with concomitant chest
injuries, a chest x-ray and computed tomography (CT) scans are routinely acquired during the trauma evaluation.
If a scapula fracture is identified on the screening chest x-ray, dedicated scapular radiographs should be
obtained. These include an AP shoulder, scapula Y, and axillary views. Due to pain, the axillary view is often
difficult to obtain. One simple technique we have found helpful is to have the patient hold an IV pole that is slowly
abducted to 30 degrees. Another method is to forward elevate the patient's arm 15 degrees while the x-ray
gantry is directed toward the axilla from a caudal position next to the patient's hip. The AP x-ray of the scapula
should be taken 35 degrees off the sagittal plane to correspond with the same angular position of the scapula on
the thorax, the so-called Grashey view. The orthogonal scapular Y view is 90 degrees to the AP view. If there is
an intra-articular glenoid fracture detected on any x-ray view, then a 2D-CT scan with 1- to 2-mm axial cuts plus
coronal and sagittal reformation are helpful for the definition of articular displacement, comminution, and fracture
extension (Fig. 2.14). If there is more than 1 cm of fracture displacement at the scapular neck on any view, an AP
radiograph of the opposite shoulder is helpful to better define the fracture displacement. It is not uncommon to be
misled on the AP view of the injured shoulder because the glenoid may be angulated through the lateral border
fracture, eliminating the normal glenohumeral joint (clear space) on a technically correct radiograph. In these
circumstances, a 3D CT scan can be very helpful to assess the degree of angular deformity, as well as glenoid
displacement (see Figs. 2.5, 2.6, 2.7 and 2.8). Anavian et al. (15) described techniques to measure
medialization, angulation, GPA, and translation of scapula fractures and have established the clear superiority of
CT scans over plain x-rays for this purpose.
FIGURE 2.14 2D-CT with 1-mm cuts shows the comminution at the glenoid articular surface. 2D and 3D
reformats may miss this detail due to volume averaging. Obtaining an axial 2D-CT in addition to sagittal and
coronal reformats is important when intra-articular fractures are present. A. Axial cuts depicting anterior glenoid
comminution. B. Semicoronal cuts depicting anterior and inferior comminution.

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SURGERY
The scapula is part of the suspensory mechanism of the shoulder that attaches the upper extremity to the axial
skeleton through the clavicle. Eighteen muscles originate or insert on the scapula, which provides a stable base
for glenohumeral mobility. The goal of the surgery is to restore the relationship of the axial and appendicular
skeleton as well as length, alignment, rotation, and anatomic reduction of articular surfaces to allow early range
of shoulder motion and rehabilitation.
The majority of scapula fractures that require internal fixation can be approached through an anterior
deltopectoral or posterior Judet approaches. Additional approaches have been described for atypical fracture
patterns. In an effort to limit incisions and reduce potential surgical morbidity, we also use a minimally invasive
posterior approach for select cases (10).
Isolated anterior glenoid fractures, as well as associated transverse fracture extending through the glenoid and
into the base of the coracoid (Mayo type II fracture), are best treated through a deltopectoral approach. In most
other fractures involving the scapula including the scapular neck or body fracture with or without glenoid
involvement are done through a posterior approach. Combined anterior and posterior approaches are rarely
necessary. They are indicated with concomitant anterior articular fractures combined with scapula neck and
body variants or when there is a highly displaced coracoid and comminuted glenoid in addition to a scapular
body or neck fracture. Lastly, the clavicle or acromioclavicular joint may require its own approach to address
these injuries. Although clavicle fractures will be discussed in another chapter, it is important to point out that
they can be approached when the patient is either in the beach chair or in the lateral decubitus position.
From the posterior perspective, the scapula is a triangular flat bone, with a thin translucent body, surrounded by
borders that are well developed and thick and serve as points for muscular origins and insertions. The lateral
border of the scapula sweeps up from the inferior angle, forming the thickest condensation of bone that ends in
the neck of the glenoid process. The scapular borders and the glenoid neck provide the thickest and strongest
bone for reduction and fixation with plates and screws.
From the anterior perspective, the coracoid process is a curved osseous projection off the anterior glenoid neck
and serves as the origin for the short head of the biceps, pectoralis minor, and coracobrachialis. The glenoid
process, beneath the acromion, contains the pear-shaped glenoid fossa, which is approximately 40 mm in a
superior-inferior direction and 30 mm in an anterior-posterior direction in its lower half in adults (46).

SURGICAL APPROACHES
Posterior Approach
Surgery is performed under general or regional block anesthesia. The patient is positioned in the lateral
decubitus position, “flopping” slightly forward beneath a well-padded axillary roll. Bumps should be positioned on
an arm board to support the affected extremity. Prefabricated upper extremity positioners are very helpful to
support the affected extremity (Fig. 2.15). The entire forequarter is widely prepped and draped to allow for
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unrestricted motion of the shoulder. The bony landmarks around the shoulder are palpated and marked with a
sterile pen. The prominent posterolateral portion of the acromion is palpated and traced medially to the
superomedial angle of the scapula and turns distally along the vertebral border. “Shucking” the scapula with one
hand, as if to protract and retract the shoulder to create scapula-thoracic excursion, allows the surgeon to better
feel the bony landmarks in large or muscular patients.
FIGURE 2.15 This image demonstrates positioning of the patient when performing a posterior approach to the
scapula. Soft (BoneFoam) positioning wedges allow for a supportive working surface, while protecting the
downside arm. The body, positioned on a beanbag, should be allowed to fall forward. The entire arm should be
prepped free to allow for manipulation and motion of the glenohumeral joint during the procedure.

FIGURE 2.16 This image depicts a Judet posterior incision. It is planned along these landmarks: 1 cm caudal to
the acromion spine and 1 cm lateral to the vertebral border.

A Judet posterior incision is made 1 cm below the acromion spine and 1 cm lateral to the vertebral border.
This allows for lateral retraction of the flap with adequate coverage of the implants (Fig. 2.16). The incision is
developed onto the bony ridge of the acromial spine, splitting the interval between the trapezius and deltoid
insertions. The incision curves distally at an acute angle just under 90 degrees around the superomedial angle
and down the vertebral border. For access to the lateral border of the scapula, the incision must be extended to
allow for mobilization of the infraspinatus. Properly executed, the fascial incision along the acromial spine and
medial border should provide a cuff of tissue that can be sutured back to its bony origin at the end of the
procedure (Fig. 2.17).

FIGURE 2.17 A. This image shows the posterior Judet approach with the development of a flap from the
acromial spine and vertebral borders. This extensile exposure allows full visualization of the entire infraspinatus
fossa (the posterior scapula) from the vertebral border to the lateral border. The surgeon's fingers are reflecting
the entire flap en mass, and a Cobb elevator is used to dissect the flap off the flat posterior scapular surface.
This approach is best reserved for cases that surgery is delayed more than 10 days or for cases that are
severely comminuted with several displaced fracture lines exiting multiple scapular borders. It cannot be used
when the intra-articular inspection is required. B. Image of same patient in Figure 2.18A after flap elevation and
retraction. This patient has a fracture characterized by separation of the glenoid neck from the lateral border up
into the spinoglenoid notch. There is extension of another fracture line into the scapular body, which is apparent
in this image. What is not apparent is the severe lateral border offset and anteversion of the glenoid articular
surface. Note the location and vulnerability of the suprascapular neurovascular bundle exiting from just below the
acromion before it enters the infraspinatus muscle.

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FIGURE 2.18 Using the technique of accessing intermuscular windows, the most important window is between
the infraspinatus and teres minor to access the lateral border of the scapula and scapula neck. A-C illustrate
development of this interval as well as mobilization of the infraspinatus from the scapular spine for additional
exposure of the scapular body.

Based on the preoperative plan, the degree of exposure depends on the need for limited or complete exposure of
the posterior scapula. Working through limited intermuscular windows is favored to limit dissection and can be
used to access fracture intervals at the lateral border, acromial spine, and vertebral border (Fig. 2.18).
Alternatively, an extensile exposure can be performed by elevating all of the muscles from the infraspinatus fossa
exposing the entire posterior scapula. The flap can be elevated laterally as far as the lateral scapular border and
allows exposure to the glenoid neck. While the extensile approach exposes the entire posterior surface of the
scapular body, the entire subscapularis muscular sleeve on the anterior surface of the scapula is preserved,
maintaining the blood supply to the scapular body (Fig. 2.17B). Therefore, the extensile approach is biologically
respectful, with almost a 100% union rate. An extensile approach that elevates the deltoid, infraspinatus, and
teres minor in a single flap is usually reserved for fractures that are over 10 days old or for complex patterns with
four or more exit points around the ring of the scapular perimeter. This extensile exposure allows the surgeon
adequate control of the fracture at multiple points to allow mobilization and reduction of the fracture. It will not
allow for exposure of the articular surface of the glenoid due to the large flap, which cannot be retracted
sufficiently lateral for joint exposure. For adequate intra-articular exposure, an intermuscular dissection is
necessary over the posterior glenohumeral joint.
If limited intermuscular windows are utilized, the Judet fasciocutaneous flap is elevated, and tactically created
intermuscular intervals around the scapular perimeter are used to access specific fracture locations (Fig. 2.18).
The intermuscle plane at the spine of the scapula is between the trapezius and the deltoid. By subperiosteal
dissection, the inferior margin of the spine is uncovered to expose the rotator cuff muscles. The deltoid is
elevated off the muscular origin of the infraspinatus and tagged through its fascial cuff for reattachment to bone
through tunnels at the conclusion of the case. We have found that mobilization and careful retraction of the
deltoid allow the surgeon to work anteriorly at the lateral border and scapula neck without taking down the
deltoid. This technique is more tedious, but spares taking down the deltoid and the need for reattachment and
postoperative immobilization.
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FIGURE 2.19 Limited intermuscular window technique vertebral (medial) border.

FIGURE 2.20 This image depicts an extensile posterior approach with extension superiorly over the acromion
with exposure of the acromioclavicular joint to address an associated fracture of the acromion. There is also an
intra-articular glenoid fracture for which a capsulotomy has been performed to allow access to the glenohumeral
joint.

At the vertebral border of the scapula, the intermuscular interval is between the infraspinatus and the rhomboids
(Fig. 2.19). However, the most important window is between the infraspinatus and teres minor to gain access to
the lateral border of the scapula and scapular neck. Furthermore, the glenohumeral joint can be exposed to treat
intra-articular fractures. Knowledge of the correct intermuscular intervals is crucial to avoid denervation of the
infraspinatus, axillary nerve, or posterior humeral circumflex vessels. Once this interval is developed, the lateral
border of the scapula can be exposed, allowing restoration of glenoid version and lateral border offset (Fig.
2.18). If the glenoid articular surface must be visualized, a transverse capsulotomy is made allowing a retractor to
be placed on the anterior edge of the glenoid to retract the humeral head (Fig. 2.20). During the arthrotomy, the
capsule should be incised just distal to the labrum and is localized with an 18-gauge needle.
The lateral border can be reduced using small-pointed bone reduction clamps, small (4 mm) external fixation pins
as joy sticks, or a plate (Figs. 2.21 and 2.22). Large reduction tenaculums are difficult to apply because of
interference with the large muscular flap. In these cases, small external fixation pins in the proximal and distal
fragments can be secured in proper orientation with a small external fixator bar and clamps to line up the lateral
border for subsequent plating (Fig. 2.23). Alternatively, a 2.7-mm dynamic compression plate straddling the
lateral border of the scapula can be used to reduce the fracture (as well as definitive fixation) since it is applied
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without the need for contouring. If the reduction is not stable, a provisional 2.0-mm plate and screws placed
slightly more medial can be used to provisionally hold the lateral border aligned. Occasionally, a larger clamp can
be placed at the medial extent of the fracture at the scapula spinal or vertebral borders to help decrease stress
on the lateral border to improve the reduction.

FIGURE 2.21 Lateral border reduction with Shantz pins and clamp.
FIGURE 2.22 This image depicts a scapula fracture treated 2 weeks after injury with multiple fractures through
the “ring” of the scapula periphery. A Judet extensile approach was used and multiple pointed bone tenaculums
are applied at the periphery wherever there is a fracture exit point with displacement. The 2.7 reconstruction
plate is applied to the vertebral border of the scapula body extending to the scapular spine.

In our experience, 2.7-mm plates are well suited for the scapular borders and are of adequate strength to resist
breakage. These plates are lower profile than 3.5 plates, are easier to contour, and offer a greater number of
screws per centimeter. A 2.7-mm dynamic compression plate is used on the lateral border where stresses are
greatest, whereas 2.7-mm reconstruction plates are used for the scapular spine and vertebral borders of the
scapula, making plate contouring around the base of the spine and the vertebral border easier. Two pediatric
Kocher clamps are useful for bending and twisting the plates. We favor longer plates and more screws for added
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stress distribution since each screw is only 8 to 10 mm for the vertebral border. The use of locked small and
minifragment plates allows shorter plates given the better screw purchase over shorter working lengths.
FIGURE 2.23 This image depicts lateral border reduction accomplished with an external fixator applied to 4.0-
mm Schanz pins placed in the proximal (cephalad) and distal (caudad) segments. The 2.7-mm locking plate is
applied to the thick bone along the margin of the lateral border.

In the case of a posterior glenoid fracture with intra-articular or neck involvement where there is minimal
displacement or involvement of the scapular spine or vertebral border, a direct posterior approach can be
employed. In these cases, reduction and fixation can be accomplished solely through the interval between
infraspinatus and teres minor. If greater exposure to the glenoid fossa or superior glenoid is desired, an
infraspinatus tenotomy can be performed leaving a centimeter of cuff insertion at the greater tuberosity for repair.
This allows the slender musculotendinous portion of the infraspinatus to be retracted off the superior glenoid
region for better access to the glenohumeral joint. This maneuver is particularly helpful in large muscular patients
and can be used in conjunction with an extensile approach in which the whole infraspinatus and teres minor are
elevated. It is repaired with strong nonabsorbable sutures and requires protection from active external rotation for
6 weeks postoperatively.
Before wound closure, it is important that any adhesions or shoulder stiffness be released by manipulation of the
shoulder prior to waking the patient, especially in patients whose surgery has been more than 2 weeks
postinjury. We routinely use a suction drain under the flap and reattach the rotator cuff with strong
nonabsorbable suture through several drill holes at the scapular spine and vertebral border to improve fixation.
We prefer an absorbable subcuticular suture for the skin closure.

A Minimally Invasive Posterior Approach

Approximately three quarters of scapular fractures treated operatively are done through a posterior approach
(47). We have recently utilized a minimally invasive surgical technique with limited muscular dissection that
permits open reduction and internal fixation of selected scapula body and neck fractures (10). The use of small
incisions distant from the fracture site to introduce implants and apply fixation is a well-accepted technique in the
management of long bone fractures. We have applied this concept to fixation of the scapula. Because the
scapula is a triangular (ring-type) bone with predictable fracture exit points, incisions are made at each fracture
end, allowing the majority of the scapular body to remain unexposed (Fig. 2.24A,B). This approach allows for
direct reduction of the fracture at its margins without violating soft-tissue attachments along the majority of the
fracture across the scapular body.
Positioning is the same as for the previously described posterior approaches. Limited incisions are made as
necessary depending on the fracture pattern, usually placed laterally over the glenoid neck and lateral border
and also medially where the fracture exits at the spine or vertebral border (Fig. 2.24A,B). Through the lateral
incision, the dissection is developed to the fascia overlying the inferomedial margin of the deltoid. The deltoid is
retracted cephalad with a wide retractor, exposing the fascia overlying the external rotators. The fascia is
opened, exposing the teres minor and infraspinatus. The muscular interval between these muscles is developed
bluntly, exposing the fracture site as it exits the lateral scapular border. Care must be taken to avoid injury to the
axillary nerve and posterior circumflex humeral artery as they pass through the quadrilateral space, distal to the
infraspinatus muscle. Additionally, the infraspinatus is carefully retracted superiorly to avoid injury to the
suprascapular nerve as it exits at the spinoglenoid notch (48) (Fig. 2.25).
Through the medial incision, at the base of the scapula spine at its medial border, dissection is developed to the
fascia and then directly down to bone. Subperiosteal dissection is then extended along the vertebral border
distally as needed to expose the medial border fracture line for reduction and plate application. These two small
windows are usually adequate for reduction and plate application at the two most common sites of displacement,
the lateral and medial scapular borders. Once the lateral and medial incisions have been made and the fracture
exposed, a small external fixation pin (with small T-handled chuck) is placed in the cephalad fragment (glenoid
neck), and second external fixation pin is inserted into the caudal fragment (distal lateral border). The external
fixation pins are used as “joy-sticks” to reduce the fracture. Small-pointed bone reduction forceps may be used
laterally and medially to maintain reduction. The clamp may be applied through small pilot holes on either side of
the fracture. The external fixation pins and pilot holes must be strategically placed to avoid interference with plate
placement (Figs. 2.24B, 2.25, and 2.26).
Because longer plates are not feasible through these small windows, we recommend the use of 2.7-mm locking
plates. A 2.7-mm reconstruction plate is contoured to the medial border, and a 2.7-mm dynamic compression
plate is used for the straight lateral border. The fascia is closed with number 0 or 1 absorbable braided suture
and the subcutaneous tissue with 2-0 absorbable braided suture. The skin is closed with running 3-0 absorbable
subcuticular suture. Suction drains are not necessary.

Special Circumstances: Posterior Approach

Associated Spine Injuries
Cervical and thoracic spine injuries are associated with scapular fractures in over 20% of cases. Often times, the
orthopedic surgeon must coordinate patient care with a spine surgeon prior to positioning and induction of
anesthesia. Intraoperative positioning must be carefully executed. It is desirable to have the spinal injury
surgically stabilized first to insure protection of the spinal cord, if indicated. However, if the spine injury is
managed nonoperatively, intraoperative in-line traction with skeletal tongs is preferred. Caliper or tong traction is
easier to work around than a cervical collar, with regard to both safety and draping.
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FIGURE 2.24 A: Represents small incisions placed directly over the medial and lateral borders of the scapula at
the fracture ends. These windows are often adequate for affecting reduction and plate application at these two
common sites of displacement. (Adapted from Gauger EM, Cole PA. Surgical Technique: A Minimally Invasive
Approach to Scapula Neck and Body Fractures. Clin Orthop Relat Res 2011;469(12):3390-3399.) B: Deeper
exposure through these limited windows, retractor, and clamp placement, as well as plate positioning.

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FIGURE 2.25 A, B: Intraoperative photos showing minimally invasive limited incisions, deeper exposure, clamp,
and plate application. One can clearly see the division between the deltoid and infraspinatus muscles. What is
more difficult to discern is the interval between the infraspinatus and teres minor. Once this important interval has
been identified and developed, retractors can be placed to expose the lateral scapula border.

Suprascapular Nerve Injury

Suprascapular nerve injuries are commonly seen following highenergy displaced scapular fractures. An
electromyogram and NCS should be obtained before surgery in patients who present more than 2 weeks after
injury. Most injuries are contusions or neurapraxia. Lacerations to the suprascapular nerve occasionally occur in
patients where the fracture extends into the spinoglenoid or suprascapular notches. The nerve should be
visualized and protected at the base of the acromion during the posterior approach in these fracture patterns. If a
laceration is discovered, then repairing the lacerated nerve
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end or branches to the infraspinatus is useful and can promote some recovery of function. Suturing with a 6-0
nonabsorbable monofilament suture is recommended.
FIGURE 2.26 Postoperative AP radiograph of patient in Figure 2.25.

FIGURE 2.27 Photo of a patient in the beach chair position. The patient is positioned with an x-ray plate behind
the shoulder to allow for an intraoperative radiograph. Because this exposure allows excellent visualization of the
anterior glenoid, intraoperative fluoroscopy is rarely necessary. We also routinely place a towel roll under the
ipsilateral shoulder to improve shoulder extension and facilitate exposure. This patient has a clavicle malunion
with clavicle displacement and deformity.

Anterior Surgical Approach

The patient is placed in a beach chair position with an arm board attached to support the extremity. A small towel
roll is placed under the ipsilateral shoulder to help bring it forward. An x-ray cassette is positioned behind the
shoulder during the setup so an intraoperative film can be obtained obviating the need for intraoperative
fluoroscopy (Fig. 2.27). A classic anterior deltopectoral incision is made, and the cephalic vein is identified and
retracted laterally. The interval between the deltoid and pectoralis major is developed down to the clavi-pectoral
fascia, which is opened exposing the coracobrachialis and subscapularis. The upper and lower borders of the
subscapularis tendon are identified as they insert into the lesser tuberosity. At the inferior margin of the
subscapularis, muscles are the transversely running inferior humeral circumflex vessels, which should be ligated.
With the humerus in a neutral position, the subscapularis tendon is sharply released 1 cm from its insertion on
the lesser tuberosity leaving a cuff of tendon for later repair. Frequently adherent to the underlying joint capsule,
the subscapularis should be carefully separated from the underlying capsule for later closure in distinct layers.
Stay sutures are placed on each side of the subscapularis muscle to facilitate closure as well as to prevent
medial retraction. The joint capsule is incised longitudinally a few millimeters from the glenoid rim giving access
to the glenohumeral joint. Following irrigation of the joint, the glenoid fracture is identified and reduced (Fig.
2.28A).
Reduction can be obtained using a dental pick or small elevator and provisionally fixed with Kirschner wires (Fig.
2.28B). Fluoroscopy is not needed because the articular fracture reduction is directly visualized. Depending on
the size of the fragment or the degree of comminution, fixation is achieved with mini or small fragment screws.
When comminuted, a mini buttress plate is placed on the anteroinferior edge of the glenoid. Layered closure of
the capsule and subscapularis is done.

FIGURE 2.28 A: Anterior, deltopectoral approach. The subscapularis has been incised 1 cm from its insertion on
the lesser tuberosity, tagged with heavy stay sutures, and retracted medially. The joint capsule has been
separated from the undersurface of the subscapularis, tagged with stay sutures, and retracted laterally. B: With
the subscapularis and joint capsule retracted, excellent exposure and visualization of the glenoid and
anteroinferior glenoid fragment is obtained.

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FIGURE 2.29 A,B. Coracoid osteotomy. Postoperative AP and axillary lateral radiographs showing anterior
glenoid fixation and the coracoid osteotomy repaired with a 3.5-mm screw and washer placed with a lag
technique.
In cases where additional visualization is necessary due to a large or comminuted anterior glenoid rim that will
require a buttress plate, a coracoid osteotomy can be helpful to increase exposure. The coracoid is predrilled
with a 2.5-mm drill bit and completed with an osteotome or micro-oscillating saw. Once released, the conjoined
tendon and coracoid are reflected distally and medially, which gives excellent exposure of the anterior glenoid
and scapular neck. Because the musculocutaneous nerve penetrates the coracobrachialis approximately 5 to 6
cm from the tip of the coracoid, it is important to protect the musculocutaneous nerve during retraction (49). At
closure, the near cortex of the coracoid should be overdrilled with a 3.5-mm bit improve interfragmentary
compression with a 3.5-mm cortical screw (Fig. 2.29).

Postoperative Management
Rehabilitation following internal fixation of scapular fractures is based on the concept that stable internal fixation
of the fracture allows early passive range of shoulder motion. We often use a regional anesthetic block with an
indwelling interscalene catheter for the first 48 to 72 hours postoperatively to allow early range of motion.
Passive range of shoulder motion is started on the first or second postoperative day under the direction of a
physical or occupational therapist. Active-assisted range of motion is advanced as the patient's pain subsides.
The goal during the first 4 weeks after surgery is to regain and maintain shoulder motion rather than strength
training. Lifting and carrying with the affected shoulder is delayed at least 4 weeks and often longer. Following
hospital discharge, patients continue therapy as well as a home exercise program using pulleys and supine-
assisted motion with push-pull sticks. Ipsilateral elbow, wrist, and hand exercises including 3- to 5-pound weights
(on a supported elbow) are encouraged to prevent muscular atrophy and promote edema reduction.

Postoperative Protocol
A sling or shoulder immobilizer is worn for comfort
The drain is removed when output is <15 mL per 8-hour shift
Passive- and active-assisted range of shoulder motion starts on postoperative day 1 or 2
Hand, wrist, and elbow exercises (3 to 5 pounds) begin during the first week
Shoulder strengthening exercises are started at 4 weeks postoperatively
Advance the strengthening program at 8 weeks
Remove all restrictions at 12 weeks postoperatively if the fracture has healed

Follow-Up
Patients are followed in the clinic at 2, 6, and 12 weeks postoperatively and an AP, scapula Y, and axillary
radiographs are obtained. We recommend follow-up at 6 months and at 1 year with a single AP x-ray to
document radiographic and functional outcomes. Patients with associated injuries may warrant longer follow-up,
especially those with a brachial plexopathy.
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At the 6-week follow-up visit, shoulder strengthening exercises with weights are begun and advanced as the
patient's symptoms permit. If the patient has persistent loss of shoulder motion, a manipulation under anesthesia
should be considered. This is more common in patients who have a brachial plexus injury, head trauma, cervical
spine injuries, or complex-associated fractures of the ipsilateral extremity.

OUTCOMES
Mayo et al. (20), in a series of intra-articular glenoid fractures, documented 82% good or excellent results in
27 patients evaluated clinically and radiographically at 43 months postoperatively. Schandelmaier et al.
(28), in 2002, reported the results of 22 displaced intra-articular glenoid fractures treated operatively with
screw and plate fixation. Surgery was undertaken if the intra-articular displacement was >5 mm. With a
mean follow-up of 10 years, they found good, durable functional results based on the Constant and Murley
score in 18 of 22 patients. The operative shoulders had overall results of 94% (for strength, pain, ROM, and
function) as compared to the uninjured side. Four complications were reported, including one superficial
and one deep infection, one patient had shoulder stiffness, and one patient developed subacromial
impingement.
In another series of 33 intra-articular glenoid fractures, Anavian et al. reported the functional outcomes
including DASH score, strength, and range of motion following internal fixation. This single surgeon series
was notable in that 23 of 33 fractures were Mayo/Ideberg type IV or V, with 13 patients having a peripheral
nerve or brachial plexus injury and 30 patients having ipsilateral injuries. At follow-up of 25 months, 91% of
the patients had a DASH score of 10.8, and average ranges of motion were not significantly different from
the contralateral extremity. Although there were mild deficits in strength, 24 patients had no pain
whatsoever, and 90% of patients returned to preinjury work and recreational activity (12).
Scapula neck fractures should be treated operatively if significant displacement or angulation leads to
deformity with functional imbalance of the parascapular musculature. Ada and Miller (19) recommended
internal fixation when the glenoid is displaced medially more than 9 mm or there was more than 40 degrees
of angular displacement. This recommendation was based on a follow-up of 16 patients with scapular
fractures treated nonoperatively, of whom 50% had pain, 40% had exertional weakness, and 20% had
decreased motion at a minimum of 15 months' follow-up. Eight patients in this same study were treated
operatively, and all achieved a painless range of motion. Hardegger et al. (7) achieved 79% good or
excellent results in a series of 37 patients with scapular fractures treated operatively, although only five
cases were “severely displaced or unstable” scapula neck fractures, although these were not analyzed
separately. Nordqvist and Petersson (50) analyzed 68 scapula fractures at a mean 14-year follow-up and
found that 50% of nonoperated patients that healed with residual deformity had significant shoulder
symptoms. Armstrong and Van Der Spuy (8) noted that 6 of 11 patients with displaced scapula neck
fractures had residual stiffness at 6 months.
Herrera et al., in 2009, reported on the results of 22 patients with scapula fractures treated whose operative
management was delayed >3 weeks from injury. In all cases, surgery was delayed due to late referral or the
presence of concomitant injuries that precluded early operative intervention. Despite these challenges, the
authors reported marked improvement in radiographic alignment with surgery as well as maintenance of
reduction at follow up. Patients were followed for a mean of 26.4 months (12 to 72). Radiographic and
functional outcomes were obtained for 16 patients, and DASH scores were collected for 14 patients.
Patients had an overall DASH score of 14 (0 to 41) as compared to a mean DASH of 10.1 in the normal
population, and Short Form 36 (SF-36) scores were comparable to the normal population in all measured
parameters. The authors demonstrated that radiographic and functional outcomes were satisfactory even
when surgical treatment was delayed (13).
Recently, the senior author (PAC) reported the results of reconstruction of scapular malunions in five
patients treated at a mean of 15 months after injury. All patients were initially treated nonoperatively and
presented with debilitating pain, weakness, and were unable to return to work. Four of five patients had
associated injury to the chest wall and two had ipsilateral clavicle fractures resulting in a “floating shoulder”
or double disruption to the SSSC. All patients underwent osteotomy and reconstruction, followed by early
rehabilitation. Radiographic measurements, range of motion, strength testing, DASH, and SF-36
questionnaires were performed preoperatively and postoperatively with a mean follow-up of 39 months (18
to 101 months). All patients were pain free with regard to the shoulder, and all were united radiographically.
Mean DASH scores improved from 39 (27 to 58) to 10 (0 to 35). Mean ROM and strength improved in all six
measures and were significantly different from the contralateral, uninjured extremity in only external rotation
strength. There were no complications, and four of the five patients returned to their previous occupation
and recreational activities. One patient was unable to return to work as a truck driver and attributed this to a
lower back condition related to spine fractures (17).
Herscovici et al. (51) reported on internal fixation of seven clavicle fractures in patients with ipsilateral
scapula neck fractures. In this series, all patients achieved excellent functional results with no deformity at
48.5-month follow-up. Two other patients in this series treated nonoperatively had significant shoulder
drooping and decreased range of motion. Others have advocated internal fixation of just the clavicle as well
for restoration of
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length and sufficient stability (52). Leung et al. (53) treated 15 such patients with internal fixation of both the
fractures and reported good or excellent results in 14 patients 25 months after surgery.
Ramos et al. (36), on the other hand, reviewed 16 patients with ipsilateral clavicle and scapula neck
fractures treated conservatively. Ninety-two percent had good or excellent results at 7.5-year follow-up. A
significant shortcoming of the three former studies is that none documented the degree of displacement of
the scapula neck fracture, and in the latter, the radiologic outcome was noted to be good in all but one,
suggesting minimal original displacement. In a recent retrospective study by Edwards et al. (34), the
outcome of nonoperative treatment of ipsilateral clavicle and scapula fractures was assessed at a mean 28-
month follow-up. Nineteen of twenty healed uneventfully, with excellent range of motion and function, but
only 2 of 20 scapula fractures and 8 of 20 clavicle fractures were displaced more than 1 cm.

COMPLICATIONS
While stable, minimally displaced fractures usually result in good outcomes, patients with displaced
unstable fractures often have residual pain and decrease range of motion. Missed or delayed diagnosis of a
displaced fracture or nerve injury may result in malunion or nonunion, which may cause deformity,
dyskinesis, or weakness, leading to pain, glenohumeral instability, crepitance, rotator cuff dysfunction, and
glenohumeral degenerative joint disease (54, 55 and 56).
Fortunately, the rate of risk in ORIF for scapula fractures is quite low in the published literature. Peripheral
nerve injury inclusive of suprascapular, axillary, and musculocutaneous nerves all have injury potential
given their proximity to surgical approaches; however, the published incidence is rare, partly due to the
difficulty of determining whether neurologic injury is due to the injury. Scapula fracture patterns involving the
suprascapular and spinoglenoid notches are associated with an increased risk of suprascapular nerve
injury. The surgeon must command a thorough anatomical knowledge of the danger zones to avoid insulting
surgical forces. The greatest risk is for suprascapular nerve injury during a posterior approach, given the
excessive infraspinatus elevation that occurs from gaining exposure to the lateral border and glenoid neck.
Wijdicks et al. (18) described danger zones for the suprascapular nerve and circumflex scapular artery
based on dissection of 24 cadaveric specimens. Risks of iatrogenic nerve injury during anterior exposures
can be reduced by limiting retraction of the coracobrachialis where the musculocutaneous nerve traverses
approximately 6 cm inferior to the coracoid.
A well-reported complication is shoulder stiffness. This may be particularly true for patients who have been
mobilized for excessive periods either before or after surgery. Our policy is to manipulate the shoulder after
fixation and while the patient is still asleep to release all intrinsic and extrinsic contractures. This is salient
when the patient's surgery is delayed. Patients with cognitive delay, head injury, multiple extremity injuries
 are all vulnerable to stiffness, and occasionally if a patient is not progressing rapidly toward normal motion
by 6 weeks postoperatively, a manipulation under anesthesia should be arranged. To this procedure, we
always add an intra-articular steroid injection to prevent reoccurrence of scar tissue after intra-articular
fractures. It is rare that patients need this formal procedure, but is effective at giving them a “kick start”
when indicated.
There is a low rate of implant failure associated with ORIF of scapulas with plates and screws, and reported
malunion rates are almost nonexistent. Lantry et al. (47) reported a failure rate of 3.6% in their systemic
review of operatively treated scapula fractures. Our strategy to prevent hardware failure includes the use of
either locking plates or long plates with conventional screws to mitigate pullout and also provide stability to
the whole scapular perimeter with the use of vertebral border and scapula spine plates when fractures. This
approach reduces stress on any single implant and was associated with a 100% union rate in a recent
cohort of 84 patients by our group (11).
Due to the robust blood supply to the shoulder, both infection and nonunion should be rare occurrences if
principles are followed, and the complications that tend to occur are treatable, assisting the surgeon and
patient greatly with the decision to weigh the risks and benefits of operative management.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 22-year-old male was involved in a truck rollover accident and was ejected from the vehicle. He was initially
diagnosed with multiple bilateral rib fractures, bilateral pneumothorax, sternal fracture, complex spine fractures,
acromioclavicular dislocation, renal injury, as well as a traumatic brain injury. The patient required an exploratory
laparotomy and internal fixation of his spine fractures. He was subsequently transferred to our hospital for
additional care.
Physical examination at 5 weeks postinjury revealed that the left shoulder was significantly depressed with
diminished sensation in axillary nerve, and there was a profound loss of left shoulder of motion due to stiffness
and pain.
An AP radiograph of the shoulder showed a displaced glenoid neck fracture with a dislocated acromioclavicular
joint. In addition, there was significant angulation on the scapular Y view with 100% translation (Figs. 2.30 and
2.31). Due to the degree of displacement, a CT with 3D reconstructions was obtained for more accurate
measurements and preoperative planning.
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FIGURE 2.30 A-C: AP, scapular-Y, and axillary views of the left shoulder. There is a displaced glenoid neck
fracture with a decreased GPA on the AP view. Also seen on this view is a dislocated acromioclavicular joint.
Hundred percent displacement of the scapular body is seen on the Y view.

The CT scan revealed:

Lateral Border Offset: 38 mm
Angular Deformity: 45 degrees
Glenopolar Angle: 18 degrees
The fracture pattern was atypical in that there was a large segmental component of the lateral border. The
indications for surgery included a double disruption of the SSSC. Although there is no literature on glenoid
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version to suggest operative indications, the anteversion measured 32 degrees (Figs. 2.32 and 2.33). An EMG
was performed preoperatively because of sensory changes noted and verified the presence of a complete
axillary mononeuropathy. The suprascapular nerve was not tested due to patient intolerance of the exam.
FIGURE 2.31 Panoramic view of both clavicles demonstrating marked displacement of the acromioclavicular
joint. The malrotated position of the glenoid is clearly visible when compared to the contralateral shoulder in this
image.
FIGURE 2.32 A: 3D CT scan oriented in scapular Y position demonstrates angular deformity of 45 degrees. B:
3D CT scan oriented in PA view demonstrates medial-lateral displacement of the glenoid fragment (orange
dashed line) and lateral border (green dashed line) relative to the scapular body (blue dashed line). C: 2D axial
CT image depicting 32 degrees of glenoid anteversion relative to scapular body.

An extensile posterior Judet approach with elevation of the infraspinatus and teres flap was performed because
the fracture was 6 weeks old and required osteoclasis to mobilize the four major fragments. Furthermore, multiple
exit points of the fracture along the scapula perimeter were needed for reduction and fixation. Longer plates were
necessary for stable fixation of the segmental fracture at the lateral border, glenoid neck, and scapula spine (Fig.
2.34).
The patient was placed in the lateral decubitus position, leaning forward. During flap elevation, care was taken to
protect the neurovascular bundle. The callus was removed from the fracture site so that the reduction could be
visualized. External fixation pin joysticks (with T-handled chucks) were used in the glenoid neck and lateral
border to achieve fracture reduction. A provisional reduction was obtained with clamps at all borders including
the lateral border at two locations. A 10-hole 2.7-mm locking plate was placed on the lateral border, and a 16-
hole 2.7-mm recon plate was contoured to extend along the scapular spine, the superior angle, and down the
medial border. These long plates were favored over multiple small
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plates to create a stronger construct. A second plate was placed along the lateral border to reinforce this area,
which was under significant deforming force post reduction. The callus was used as bone graft. The
acromioclavicular joint was reduced and stabilized through a second incision using a tightrope technique
(Arthrex, Naples, Florida) (Fig. 2.35). Physical therapy was begun for full active and passive range-ofmotion
exercises.

FIGURE 2.33 A: 3D CT scan oriented in PA view. B: 3D CT with images manipulated such that the lateral
border is reduced to its normal, anatomic location (note that the lateral border is straight from the glenoid neck to
the inferior angle of the scapula). With the lateral border reduced, one can appreciate the true lateral border
offset (38 mm) of the glenoid relative to the anatomic position of the lateral border. C: 3D CT with glenoid and
lateral border reduced anatomically. The glenoid relative to the lateral border, increased GPA, restored glenoid
retroversion and repositioning of the acromion more vertically, decreasing the potential for rotator cuff
impingement.

At 6 months, the patient had significant improvement in both range of motion and strength. His range being
essentially equal and 60% strength compared to his opposite shoulder. His DASH score was 22 at this visit, and
we were optimistic for a full return in shoulder function in spite of his severe constellation of injuries. Radiographs
revealed a healed fracture.
FIGURE 2.34 Intraoperative photographs. Judet Flap. A: Marked displacement of the lateral border with
angulation. B: There is a bone void after the fracture has been disimpacted, reduced, and fixed in an anatomic
position. C: Callus removed at the time of exposure is used as bone graft before placing a drain and repairing
the Judet flap.

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FIGURE 2.35 A-C: Postoperative AP, scapular Y, and axillary radiographs showing restoration of anatomic
positioning of the scapula and AC joint.

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51. Herscovici D Jr, Fiennes AG, Allgower M, et al. The floating shoulder: ipsilateral clavicle and scapular
neck fractures. J Bone Joint Surg Br 1992;74(3):362-364.

52. Reudi T, Chapman MW. Fractures of the scapula and clavicle. In: Chapman MW, ed. Operative
orthopaedics. Philadelphia, PA: JB Lippincott; 1998:197-202.

53. Leung KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and
clavicle. J Bone Joint Surg Am 1993;7:1015-1018.

54. Curtis C, Sharma V, Micheli L. Delayed union of a scapular fracture-an unusual cause of persistent
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55. Kaminsky SB, Pierce VD. Nonunion of a scapula body fracture in a high school football player. Am J
Orthop (Belle Mead NJ) 2002;31(8):456-457.

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2008; 39(3):314-318.
 3
Proximal Humeral Fractures: Open Reduction Internal Fixation
John T. Gorczyca

INTRODUCTION
Fractures of the proximal humerus are common injuries and comprise approximately 4% of fractures seen in
clinical practice. They are the third most common extremity fracture in the elderly after the hip and distal radius.
The majority of these fractures are the result of lower-energy injuries in older patients, which occur following a
ground-level fall. Fortunately, most fractures are minimally displaced and are best treated nonoperatively.
However, with higher-energy mechanisms such as motor vehicle collisions, athletic injuries, or falls from a height,
the fracture is commonly multifragmentary, displaced or unstable, and surgery is often indicated. Displaced
proximal humeral fractures can present complex technical challenges, especially in elderly patients with
compromised bone. Over the past decade, there has been a dramatic increase in the number of patients with
proximal humerus fractures treated surgically. This is due to an aging population who are living longer and have
an increased expectation of improved shoulder outcome as well as significant improvement in the implants used
to treat these fractures. Traditionally, hemiarthroplasty was the most common procedure in the geriatric patient
with a displaced three- or four-part proximal humeral fracture. However, this procedure is associated with
unpredictable outcomes even in the hands of experienced shoulder surgeons. With the recent development and
widespread availability of periarticular locking plates for the proximal humerus, there has been a renewed
interest in internal fixation as an alternative treatment. While the early reports with locked plating were promising,
the technique is not a panacea and numerous problems have been described.
The most common classification of proximal humeral fractures was described by Neer (Fig. 3.1). Although inter-
and intraobserver reliability of this classification system is imperfect, its popularity stems from its relative
simplicity and its utility in guiding treatment.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

Regardless of the method of treatment, the great majority of proximal humerus fractures will heal. Nonoperative
treatment is indicated for all nondisplaced and most minimally displaced fractures in virtually all age groups.
Following injury, fracture healing takes 6 to 10 weeks, but functional recovery of shoulder motion and strength
takes much longer, and even fully compliant and motivated patients may fail to regain preinjury levels of function
and activity. Surgery is indicated for most patients with significantly displaced three- and four-part fractures and
dislocations of the proximal humerus. The nonoperative management of widely displaced fractures often leads to
symptomatic malunion, with painful loss of shoulder motion frequently due to impingement, muscle weakness,
and rotator cuff pathology. The goal of surgery is to restore the head shaft relationship and tuberosities with
stable fixation to allow early range of shoulder motion. This permits many patients to lift their arm above their
shoulder for activities of daily living. In many patients, the inability to perform this task may compromise a
geriatric patient's ability to live independently. However, many elderly and frail patients with multiple medical
comorbidities should be treated nonoperatively accepting some loss of function. Likewise, preexisting neuropathy
or stroke that compromises the expectation for functional benefit after surgery are strong indications for
nonoperative treatment.
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FIGURE 3.1 The Neer classification of proximal humeral fractures.

Less common indications for surgery include bilateral fractures, ipsilateral upper extremity injury (“floating elbow”
or “floating shoulder”), open fractures, fracture dislocations, polytrauma, and fractures with associated vascular
injury. Displaced fractures in adult patients should be reduced and stabilized. More than 40 years ago, Neer
recommended surgery for fractures of the proximal humerus with displacement of the head or either of the
tuberosities by 1 cm, or angulation >45 degrees, which we still follow today. Isolated fractures of the greater
tuberosity should be reduced and stabilized when displacement is >5 mm in any direction.
Not all proximal humeral fractures that require surgery are amenable to internal fixation. Strong indications for
hemiarthroplasty include head-splitting fractures (with the exception of some young patients with healthy bone)
anatomic neck fractures, and displaced three- and four-part fractures in patients with either comminution or
osteoporosis that would not support internal fixation. Preexisting chronic rotator cuff deficiency with arthropathy
is better treated nonoperatively or with shoulder arthroplasty.
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PREOPERATIVE PLANNING
History and Physical Examination
Seriously injured patients should undergo initial evaluation according to Advanced Trauma Life Support (ATLS)
protocols to ensure a thorough evaluation and to prevent missed injuries.
In the multiply injured patient with a shoulder fracture, injuries to the head, neck, chest wall, and upper extremity
commonly occur. Proximal humeral fractures that occur in elderly patients following lower energy falls may be
associated with injuries to the head, face, or wrist. When possible, a careful history may reveal substantial
medical comorbidities such as hypertension, coronary artery disease, or diabetes. The patient's medication
record should be scrutinized with particular reference to anticoagulation medication. Other important factors
include hand dominance, occupation, and living status, which may play an important role in decision making.
All patients should have a complete physical examination. The extremity should be examined for swelling,
ecchymosis, peripheral pulses, and neurologic impairment. Any questions regarding the vascular integrity
warrant further evaluation, with an ankle-brachial index, Doppler evaluation, or angiography. If any abnormality is
identified, vascular surgical consultation should be obtained. A thorough neurologic examination of the entire
upper extremity must be performed and documented. Evaluation of the axillary nerve can be difficult in a swollen
painful shoulder, but should be tested by asking the patient to contract the deltoid muscle whenever possible.
Range of motion of the shoulder is typically limited due to pain. It is also important to evaluate the elbow,
forearm, wrist, and hand performed in order to avoid missing a more distal injury.

Radiographic Evaluation
The proximal humerus consists of four parts: The humeral head, the greater and lesser tuberosities, and the
humeral shaft (Fig. 3.2). In order to optimally visualize these four parts, all patients with a shoulder injury should
have an anteroposterior view, a transscapular lateral (“Y”) view, and an axillary lateral view (Fig. 3.3A-C). The
axillary lateral, while challenging to obtain in the trauma setting, often provides crucial information. It is frequently
the best view to rule out a coronal plane head-splitting fracture, a glenoid rim fracture, as well as a glenohumeral
joint subluxation or dislocation. It is important to remember that if the x-ray beam is not orthogonal to the axis of
the humeral shaft (which is often the case), then any measurement of fracture angulation will be exaggerated.
Thus, the transscapular lateral radiograph provides a better view for accurately measuring fracture angulation. In
patients with complex fracture patterns, a computed tomographic (CT) scan can be helpful to evaluate fragment
size and displacement and can reveal nondisplaced fracture lines (Fig. 3.4A,B). The thickness of the humeral
head seen on the CT scan should be carefully assessed when considering internal fixation. If the head is too
small or thin, stable fixation may not be achieved and cut out of the screws is more likely. In addition to the axial,
sagittal, and coronal
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reconstructions, 3D imaging provides detailed topographic views which may allow a clearer appreciation of the
fracture geometry (Fig. 3.4C). In some cases, the scapula can be “subtracted” giving even more information
about the fracture morphology. Based on the physical exam, x-rays of the cervical spine, clavicle, ribs, elbow, or
forearm may be indicated.
FIGURE 3.2 The pathoanatomy of proximal humeral fractures.
FIGURE 3.3 A. Anterior-posterior view. B. Trans-scapula lateral view. C. Axillary lateral view.

Timing of Surgery
The majority of displaced proximal humerus fractures can be managed in a semielective fashion without
compromising the quality of the outcome. A patient with an isolated closed, proximal humeral fracture seen in the
emergency room can be discharged to home or to a suitable location if the pain is controlled and their social
circumstances permit. These patients are seen in the office or clinic several days later and scheduled for surgery
if indicated. On the other hand, if the pain is poorly controlled, the social circumstances are not optimal, or the
patient has other injuries, patients are typically admitted to the hospital for earlier surgery.
Fortunately, there are relatively few indications for emergent surgery. However, an open fracture, a fracture with
a vascular injury, an irreducible fracture with impending skin compromise, or an irreducible fracture dislocation
require immediate intervention. In these cases, surgery should be performed as soon as an operating room
becomes available and a surgical team can be assembled.
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FIGURE 3.4 A. The CT scan allows determination of the “thickness” of the humeral head available for fixation.
B. Axial CT cut of a valgus impacted fracture demonstrates displacement of the greater and lesser tuberosities.
C. A 3D CT image of a complex proximal humerus fracture.

Surgical Tactic
The most important step in preoperative planning is for the surgeon to carefully evaluate the x-rays and CT scan
and answer two questions. First, does this fracture require surgery, and second, what is the optimal implant if
surgery is required. Despite good preoperative planning, there is a small group of patients where the final
decision between internal fixation and arthroplasty cannot be made until the time of surgery. If any doubt exists,
the patient should be consented for both types of surgery, and the equipment and implants must be in the
operating room at the beginning of the case.
Surgery can be performed with the patient in either the beach chair position or supine on a flat-top radiolucent
table. There are advantages and disadvantages with each technique. In the supine position, the patient should
be
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positioned at the edge of the table with the arm supported on a hand board or a Mayo stand to allow shoulder
abduction. Properly positioned, this setup will not interfere with the use of the C-arm. The patient's head is
supported on a gel “donut” or a rolled-up stockinet, and the patient's eyes should be protected during the case
(Fig. 3.5).

FIGURE 3.5 Intraoperative setup for open reduction and internal fixation of a proximal humerus fracture with the
patient in the supine position. The patient's head is supported on a gel “donut” and the patient's eyes are
protected with plastic shields.

Prior to prepping and draping, the C-arm should be moved into position to ensure high quality anteroposterior
and axillary lateral images can be obtained (Fig. 3.6A-D). In most operating rooms, this is easiest if the surgical
table is rotated 90 degrees. I prefer the C-arm to come in from the cranial side, slightly oblique to allow
visualization of the entire humeral head and the edge of the glenoid when an axillary lateral view is obtained. It is
wise to rehearse these moves so that the radiology technician can change from an AP to an axillary lateral views
easily without the need to move the arm or shoulder. The spot for the C-arm is marked with tape on the floor in
order to re-create the intraoperative position of the fluoroscopy unit during surgery (Fig. 3.7).

Surgery
Surgery is most commonly performed under general anesthesia, which allows optimum control of the patient's
blood pressure and muscle paralysis. Regional nerve blocks are most useful for postoperative pain control. A
helpful technique is to position and tape the endotracheal tube on the side opposite the fracture. Maintaining the
mean arterial pressure close to 70 mm Hg helps minimize bleeding, and muscle paralysis or relaxation is helpful
to lessen the forces required for muscle retraction and fracture reduction. A cepholsoporin antibiotic is given for
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prophylaxis within 1 hour of surgery. A Foley catheter, arterial line, central venous pressure (CVP) monitoring, or
Swan-Ganz catheters are used when the patient's medical comorbidities or physiologic status dictates.
FIGURE 3.6 A. The patient is positioned with the involved shoulder at the edge of the table and the arm
supported in approximately 60 degrees of abduction with a Mayo stand. B. An AP fluoroscopic x-ray is obtained.

FIGURE 3.6 (Continued) C. The C-arm is rotated to obtain an axillary lateral view with abduction and mild
traction. D. An axillary lateral must show the entire head and the glenoid.

The entire upper extremity, shoulder, chest wall, and neck are prepped and draped in the usual orthopedic
fashion. A surgical time-out is called, and all members of the surgical, nursing, and anesthesia teams must agree
on the patient's name, medical record number, and correct side and site of surgery.

Techniques—Isolated Greater Tuberosity Fractures

The patient is positioned, prepped, and draped as outlined above. For isolated greater tuberosity fractures, I
prefer a deltoid-splitting approach rather than a deltopectoral incision. The challenge is to reduce and stabilize
the fracture through a small incision that must not extend more than 5 cm distal to the acromion to avoid injury to
the axillary nerve. For most greater tuberosity fractures, I do not identify the axillary nerve rather proceed in a
stepwise fashion to reduce and stabilize the greater tuberosity through the deltoid split.
The skin incision, and the deltoid muscle split, start proximally at the anterior-lateral edge of the acromion and
extend straight distally for 5 cm. The muscle is split through a relatively avascular plane in the deltoid raphe. A
loose suture can be placed through the deltoid muscle fibers 5 cm distal to the acromion to prevent further
muscle separation with injury to the axillary nerve.

FIGURE 3.7 The position of the C-arm base is marked on the floor with tape.

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Deep to the muscle is the hemorrhagic subdeltoid bursa, which should be evacuated and excised to improve
visualization. With internal and external rotation of the shoulder, the fracture lines will be appreciated. The
fracture should be mobilized to expose the undersurface of the greater tuberosity and the defect in the proximal
humerus. With the shoulder in internal rotation, a no. 2 or no. 5 heavy nonabsorbable suture is passed twice
through the supraspinatus tendon at its insertion on the tuberosity capturing bone and tendon. I prefer a no. 5
ethibond suture with a large cutting needle, which can be gradually worked through the hard cortical bone by
grasping the needle close to its point and rotating it back and forth like the tip of an awl. In younger patients with
hard bone, a small drill bit can be utilized. Due to the posterior and proximal displacement of the greater
tuberosity by the retracted supraspinatus and infraspinatus muscles, the first suture is often placed too far
anteriorly. If this is the case, the first suture is used to pull the greater tuberosity anteriorly and distally in order to
place two additional sutures in a better position. After this, the first suture can be removed. A curette is used to
remove clotted blood and debris from the cancellous underside of the greater tuberosity.
The greater tuberosity sutures are gradually pulled to reduce the greater tuberosity into the defect in the proximal
humerus. Two drill holes are made approximately 1 cm anterior and distal to the defect along the vector of the
sutures used to reduce the greater tuberosity. Following this, the needle end of each suture is passed from
within the fracture site out through the drill hole. The sutures are pulled tight is placed on the sutures to remove
slack, and the greater tuberosity is held with digital pressure or with a blunt probe and provisionally fixed with
one or two K-wires. Ideally, the guide wires for 3.5 or 4.0 mm partially threaded cannulated screws are used, and
passed obliquely to engage the medial cortex of the humeral shaft followed by an appropriate length screw (Fig.
3.8A-D).
It should be emphasized that in the soft bone of the proximal humerus, both internal fixation and suture
augmentation are necessary to prevent early fixation pull-out. The screw(s) ensure anatomic reduction of the
tuberosity, but are not strong enough alone to allow physiologic shoulder motion. The sutures provide a more
durable fixation of the greater tuberosity and resist tensile forces better. However, suture fixation alone can result
in a malunion of the tuberosity if positioned too distally, which can compromise shoulder strength and motion. On
the other hand, retraction of the cuff with posterior and proximal displacement of the tuberosity is also a risk
when suture repair is performed alone.
After placing one or two partially threaded screws across the fracture and into the medial cortex, the suture ends
are tightened and tied with a smaller, absorbable suture. In order to prevent loosening of the knot, the two ends
of suture above the knot can be tied together.
The fracture reduction and screw position is confirmed with fluoroscopy and stability is checked with gentle
shoulder motion. Finally, the rotator cuff is inspected for any sign of tear or deficiency. If a supraspinatus or
infraspinatus tear is present, it is carefully repaired with nonabsorbable sutures. The deltoid fascia is closed with
absorbable suture, the subcutaneous tissues are approximated, and staples or sutures are placed in the skin.
After application of a sterile dressing, the arm is placed in a shoulder immobilizer.

Techniques—ORIF of Two- to Four-Part Fractures in Adults

Virtually all displaced two-, three-, and four-part fractures of the proximal humerus that require suture ends are
approached through a deltopectoral incision. The incision starts just distal to the coracoid process and extends
12 to 17 cm toward the lateral side of the biceps tendon depending on how much exposure is needed. The
cephalic vein is identified, protected, and retracted. The deltopectoral interval is developed digitally, down to the
clavipectoral fascia, which is then incised as far proximally as its confluence with the coracoacromial ligament.
The space between the lateral aspect of the proximal humerus and the deltoid is developed by careful blunt
dissection, and a Hohman retractor is placed between the two. Abduction of the shoulder to 45 degrees or more
facilitates mobilization of the deltoid. Approximately one-third of the anterior deltoid insertion is released on the
shaft to improve exposure and space for the plate.
In three- and four-part fractures, the greater and lesser tuberosities are identified and tagged with two
nonabsorbable sutures passed through each of the tuberosities (i.e., total four sutures) where the cuff inserts
into the bone. As described in the description of isolated greater tuberosity fracture repair, the first suture in the
greater tuberosity is often used for traction that allows optimal placement of one or two additional sutures for
secure fixation. After the tuberosities are secured by the sutures, the sutures can be used to manipulate the
tuberosities into a reduced position.
Attention is now directed to the head fragment. In the uncommon event that the head fragment is dislocated, it
can be reduced using a thin periosteal elevator to lift the head over the edge of the glenoid. Alternatively, one or
two 2.0-mm terminally threaded K-wires can be drilled into the head fragment and used as joy sticks to help
manipulate and reduce the head fragment. In some cases, the head is impacted on the shaft. In most patients, it
should be disimpacted to allow reduction of the tuberosities using an osteotome or a thin periosteal elevator. The
fracture line between the impacted humeral head and the metaphysis can usually be recognized visually when
the split between the greater and lesser tuberosities is separated with an instrument or lamina spreader. It is
important to preserve bone stock on the head fragment by gradually freeing it around the periphery before
attempting to reduce it (Fig. 3.9).
In young patients with dense bone and large tuberosity fragments, the stability of the humeral head usually
improves after reduction of the tuberosities. Once the reduction has been verified fluoroscopically, the
tuberosities and head fragment are provisionally stabilized with K-wires, which do not interfere with subsequent
plate placement.
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FIGURE 3.8 A. AP radiographic showing a greater tuberosity fracture dislocation. B. Postreduction radiograph
demonstrates reduction of the glenohumeral joint with persistent displacement of the greater tuberosity. C. AP x-
rays show anatomic reduction of the tuberosity following internal fixation and tension band suture augmentation.
D. Axillary lateral radiograph.

P.56
FIGURE 3.9 Reduction of an impacted humeral head fragment. By placing an instrument in the fracture line
between the greater and lesser tuberosities, the surgeon first develops a plane between the head and the
tuberosities, then gently lifts the head from the metaphysis.

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FIGURE 3.10 A. The humeral head and shaft are reduced with the aid of a long thin periosteal elevator. The
elevator is used to lever the shaft posteriorly and laterally into a reduced position relative to the head. B.
Intraoperative fluoroscopic view shows the position of the elevator.

Unfortunately, most patients with displaced proximal humeral fractures are elderly and have soft osteoporotic
bone, which invariably has some component of crushing and comminution. In these patients, the ability to
maintain an adequate reduction of the humeral head by provisional fixation of the tuberosities alone is very
limited. In these cases, the greater tuberosity fragment should be carefully evaluated. If it is small or
multifragmentary, its reduction and stabilization should be postponed until after the head and shaft are reduced
and stabilized. On the other hand, if the greater tuberosity fragment is large, it should be reduced and
provisionally stabilized to the head using multiple K-wires outside the plane of the proposed plate. If the lesser
tuberosity is fractured and unstable, it is also reduced and held with K-wires. The humeral shaft, which is
typically displaced anteriorly and medially, is then reduced to the head with traction and the aid of a periosteal
elevator (Fig. 3.10A,B). The shaft is provisionally stabilized to the head with one or two oblique K-wires directed
from
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anterior-lateral-distal to posterior-medial-proximal (Fig. 3.11A). If the K-wires are able to hold the reduction,
fluoroscopy is used to assess the reduction prior to plate placement. The plate is positioned directly laterally so
that the anterior edge of the plate is located lateral to the long head of the biceps tendon (Fig. 3.11B).
FIGURE 3.11 A. Intraoperative photo shows heavy sutures placed in the greater and less tuberosities and the
head and shaft reduced and held with K-wires. B. The plate is placed on the lateral aspect of the proximal
humerus and fixed to the humerus under fluoroscopic control. The tuberosity sutures are tied to the plate.

Unfortunately, due to comminution and poor bone quality, K-wires and reduction clamps alone will not usually
hold the reduction in the poor bone of the humeral head. In this case, the greater and lesser tuberosities are
reduced to the humeral head, and the plate is fixed to the proximal fragment with K-wires through the perimeter
of the plate. Fluoroscopy is used to verify plate position and the overall reduction. The plate is reduced to the
shaft, thereby indirectly reducing the shaft to the head. Care must be taken to ensure that the superior aspect of
the greater tuberosity will end up 8 to 10 mm distal to the superior edge of the humeral head after final plate
positioning. With the plate pushed firmly against the bone, two locking screws are placed through the most
proximal holes into the humeral head. Screw position is checked on AP and lateral fluoroscopy. One or two
additional locking screws are placed more inferiorly into the humeral head, and the position is again confirmed
fluoroscopically. The next step is to fix the plate to the shaft. The plate is held against the shaft with direct
pressure, and the shaft is pushed proximally toward the head in an attempt to maximize bony contact and create
a load-sharing construct. There is a tendency for the shaft to displace anteromedially by the pull of the pectoralis
major muscle. This deformity should be corrected before the plate is fixed to the shaft. Typically, one or two
nonlocking screws are placed in the distal fragment to secure the plate against the bone with the remaining holes
filled with 3.5-mm locking screws.
Another scenario commonly encountered is the challenge of restoring the correct angular and rotational
relationships between the humeral head, shaft, and the glenoid. This generally occurs when there is significant
comminution of surgical neck allowing the head to collapse or rotate into varus or retroversion. The metaphyseal
defect will not support the head fragment in its normal alignment or version. This usually requires placement of
bone graft material (allograft, autograft, or substitute) into the metaphyseal void to buttress the head and provide
mechanical support for fracture reduction. Another alternative is to reduce and temporarily pin the humeral head
into the glenoid. If the greater tuberosity fragment is large (which is usually not the case in this scenario), it is
reduced to the head using traction sutures, and a plate is positioned laterally, held with K-wires, checked on
fluoroscopy, and fixed to the head and greater tuberosity with two proximal locking screws as described
previously. After confirmation of an adequate reduction and plate position fluoroscopically, two additional locking
screws are placed in the head, and the plate is reduced and fixed to the shaft. If the greater tuberosity fragment
is small or multifragmentary, the plate is positioned and provisionally secured to the head fragment with K-wires.
Reduction and plate position are verified fluoroscopically, as poorly placed screws in the humeral head that have
to be removed and replaced will further compromise fixation in the osteopenic humeral head. These are typically
the fractures with thin head fragments for which arthroplasty is often a treatment option.
The head and shaft are reduced and stabilized with screws. Locking screws are placed in any of the remaining
holes that will provide purchase into bone. No screw tip should be closer than 5 mm from articular surface. Next,
the sutures placed in the tuberosities are used to reduce them to the humeral head, and they are secured to the
plate. The sutures can be passed through one or more holes along the periphery of the plate or even as a
cerclage around the entire plate. Whatever technique is chosen, it is crucial that the tuberosities are anatomically
reduced and securely fixed. The sutures should not be passed through locking holes in the plate if possible, as
the threaded edge of the hole may abrade or transect the suture. Some surgeons prefer to pass the sutures
through the holes in the plate prior to positioning of the plate, which makes passage of the sutures easier. The
disadvantage with this technique is keeping the sutures out of the way during the remainder of the procedure,
and the preselected position of the sutures in the plate may not be at the ideal vector for tuberosity reduction or
fixation. Following internal fixation, the rotator cuff should be evaluated, and any tears should be repaired with
nonabsorbable suture. The wounds are copiously irrigated and meticulous hemostasis obtained with cautery.
The wound is closed in layers.

Postoperative Care
The surgical incision is inspected at 48 hours prior to hospital discharge When the wound is clean and dry,
pendulum exercises and gentle active range of shoulder motion is initiated. Patients are instructed in six
exercises they can perform at home independently:

1. Clockwise shoulder rotation—performed while leaning forward, starting initially with small rotations, and
gradually increasing the size of rotation as comfort improves.
2. 2. Counterclockwise shoulder rotation—as above, different direction of rotation.
3. Tight fist—the patient makes a tight fist, and then fully extends all fingers.
4. Thumb to shoulder—the patient flexes the elbow in an attempt to touch the anterior shoulder with the thumb,
and then gradually extends the elbow as far as possible, then repeats.
5. Front-assisted lift—the patient uses a 1 inch dia. wooden dowel (broomstick), and, grasping it with both hands
spaced 6 inches apart, slowly lifts it forward with the contralateral uninjured arm, while the injured arm follows
with minimal active contraction of the deltoid. The arm is lifted (shoulder flexed) to the point of mild discomfort,
at which point the arm is gently lowered to the resting position.
6. Side-assisted lift—the same dowel is used, the hands are placed a shoulder's width apart, and the uninjured
arm pushes the dowel to the opposite side, and the contralateral shoulder abducts with minimal active
contracture (i.e., active-assisted).

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FIGURE 3.12 Range of shoulder motion in a 30-year-old male 5 months following internal fixation of a displaced
proximal humerus fracture.

The patient performs 10 repetitions of each exercise and does these exercises three times per day. When not
performing exercises or bathing/showering, the patient protects his arm/shoulder in a sling or shoulder
immobilizer.
Patients are seen for follow-up at 2 weeks and at 6 weeks where AP and axially lateral radiographs of the
shoulder are obtained to confirm fracture reduction and to assess fracture healing. At 6 weeks, patients begin
independent range of motion exercises with gravity resistance. If at 6 weeks, the patient is unable to forward flex
the shoulder to 90 degrees independently, referral to a physical therapist is recommended. At 3 months, the
fracture should be healed, and the patient may perform passive stretching and resistive exercises without
restriction (Fig. 3.12). Once good shoulder motion has been restored, upper limb strengthening using
progressive weights or bands is instituted. Independent passive stretching can be performed by “walking the
fingers up the wall” anteriorly and at the side as well as external rotation using the dowel for terminal stretch. If
motion is not adequate, the patient should be referred to a physical therapist for assistance with the passive
stretching and resistive strengthening exercises.

Complications
The most common problem after a proximal humerus fracture is shoulder stiffness (Fig. 3.13). It is unusual
for a patient to regain normal shoulder motion after internal fixation of a displaced fracture. Fortunately,
most patients are able to perform activities of daily living with mild or moderate shoulder stiffness. In order to
minimize the risk of more significant shoulder stiffness, the surgeon must achieve stable fracture fixation
including the fixation of the tuberosities and initiate early motion. If the patient is unable to perform
independent exercises, or is not making progress independently, a physical therapist should be involved in
the rehabilitation
Screw cut-out or penetration through the subchondral bone into the glenohumeral joint occurs most
commonly in elderly patients, but it occurs in younger patients as well (Fig. 3.14). Methods to minimize this
risk are (a) placing screws into the subchondral bone without having drilled the entire screw path, (b)
checking the position of the screw tips with multiple fluoroscopic projections, to ensure that the screw tips
are at least 5 mm from the subchondral bone, and (c) manually pushing the shaft proximally prior to plate
fixation in order to increase bone contact and lessen the tendency for the humeral head to collapse. Some
authors recommend the use of a custom fit fibular allograft to mechanically support the humeral head.
Many forms of fixation failure can occur after open reduction and internal fixation of proximal humerus
fractures. Displacement of the tuberosities can occur due to failure of the suture or as a result of the suture
cutting through the tuberosity and cuff (Fig. 3.15). Proper positioning and placement of the suture at the
insertion
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of the rotator cuff, use of a heavy suture, passage of the suture through smooth holes in the plate (i.e.,
avoiding locking screw holes), and securing the suture with detailed attention to knot tying will minimize this
risk. Fixation failure by plate or screw breakage usually occurs as a result of fracture nonunion, but may
also occur if the patient is not compliant with postoperative activity restrictions.

FIGURE 3.13 Seven months following internal fixation of a three-part proximal humerus fracture, this 59-
year-old female still has significant loss of forward elevation and shoulder abduction.

FIGURE 3.14 A 61-year-old male referred to our institution for treatment of failed fixation and screw
penetration into the joint.

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 FIGURE 3.15 Loss of reduction of the greater tuberosity following internal fixation.

Aseptic necrosis may occur after a proximal humerus fracture (Fig. 3.16A,B). In the past, the fear of its
occurrence led many surgeons away from open reduction and internal fixation toward nonoperative
treatment or arthroplasty for these fractures. There is increasing recognition that when aseptic necrosis
occurs, it is not always associated with a poor result. In many cases, patchy aseptic necrosis occurs without
head collapse and relatively few symptoms. However, if aseptic necrosis with head collapse occurs and the
patient is symptomatic, they may benefit from shoulder arthroplasty. In order to reduce the risk of aseptic
necrosis, unnecessary soft-tissue stripping should be avoided. Intraoperative manipulation and reduction of
the head and shaft should be performed “from within” the fracture, taking care to use: (a) long periosteal
elevators to lever the shaft and head into position; (b) heavy sutures to assist with fracture reduction without
elevation of soft tissues; and (c) K-wires for provisional fixation whenever possible.

Results/Outcomes
Most studies report that 70% to 75% of patients obtain satisfactory outcomes following locked plating of proximal
humeral fractures. The reported 1-year mortality rate is elevated although it returns to the age-expected level
after the first year. Although there is a common belief that the results of internal fixation have improved since the
advent of locked plate fixation, this has not been clearly established. There are
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few randomized controlled trials comparing locked plating with nonoperative treatment or other treatment
modalities.

FIGURE 3.16 AP (A) and lateral (B) radiographs of a patient with avascular necrosis and collapse of the humeral
head following internal fixation of a proximal humerus fracture.

The use of locked plates to treat proximal humerus fractures has significantly increased in number over the past
decade. However, this is a challenging surgical procedure, fraught with potential complications, and the results
can be less than satisfactory. Proper and thorough evaluation of the patient and the fracture, preoperative
preparation, careful technique, and realistic expectations of surgical results remain essential in order to achieve
good results. Nevertheless, it is an important tool in the armamentarium of the fracture surgeon.

RECOMMENDED READING
Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures
treated with locking plates. J Orthop Trauma 2007;21:676-681.

Badman BL, Mighell M. Fixed-angle locked plating of two-, three-, and four-part proximal humerus fractures. J
Am Acad Orthop Surg 2008;16(5):294-302.

Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical
technique and prosthetic design. J Bone Joint Surg Br 1997;79:857-865.

Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14(3):183-190.
Fankhauser F, Schippinger G, Weber K, et al. A new locking plate for unstable fractures of the proximal
humerus. Clin Orthop 2005;430:176-181.

Gardner MJ, Boraiah S, Helfet DL, et al. Indirect medial reduction and strut support of proximal humerus
fractures using an endosteal implant. J Orthop Trauma 2008;22(3):195-200.

Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal
humerus fractures. J Orthop Trauma 2007;21(3):185-191.

Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg 2004;12(4):205-212.

Hernigou P, Germany W. Unrecognized shoulder joint penetration during fixation of proximal fractures of the
humerus. Acta Orthop Scand 2002;72(2):140-143.

Herscovici D, Saunders DT, Johnson MP. Percutaneous fixation of proximal humeral fractures. Clin Orthop
2000;375: 97-104.

Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of
the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427-433.

Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone
Joint Surg Am 1992;74:505-515.

Jakob RP, Miniaci A, Anson P, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone
Joint Surg Am 1991;73:295-298.

Kannus P, Palvanen M, Niemi S. Increasing number and incidence of osteoporotic fractures of the proximal
humerus in elderly people. Br Med J 1996;313:1051-1052.

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Koval KJ, Gallagher MA, Marsicano JG, et al. Functional outcome after minimally displaced fractures of the
proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.

Meier RA, Messmer P, Regazzoni P, et al. Unexpected high complication rate following internal fixation of
unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma 2006;20:253-260.

Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am
1970;52:1077-1089.

Olsson C, Petersson CJ. Clinical importance of comorbidity in patients with a proximal humerus fracture. Clin
Orthop Relat Res 2006;442:93-99.

Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin Orthop
Relat Res 2006;442:87-92.
Rietveld AB, Daanen HA, Rozing PM, et al. The lever arm in glenohumeral abduction after hemiarthroplasty.
J Bone Joint Surg Br 1988;70:561-565.

Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative
treatment. J Bone Joint Surg Am 2003;85:1647-1655.

Rowkles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus: an anatomic study. J
Bone Joint Surg Am 2001;83(11):1695-1699.

Soete PJ, Clayson PE, Costenoble VH. Transitory percutaneous pinning in fractures of the proximal
humerus. J Shoulder Elbow Surg 1999;8:569-573.

Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the
humeral head. Arch Orthop Trauma Surg 1984;100:249-259.

Sudkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with
use of the locking proximal humerus plate: results of a prospective, multicenter, observational study. J Bone
Joint Surg Am 2009;91:1320-1328.

Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures
of the proximal part of the humerus. J Bone Joint Surg Am 2002;84:1919-1925.

Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury
1998;29: 349-352.
 4
Proximal Humerus Fractures: Hemiarthroplasty
William H. Paterson
Sumant G. Krishnan

INTRODUCTION
Proximal humeral fractures are common injuries representing 4% to 5% of all fractures in clinical practice, but
they account for nearly half of all shoulder girdle injuries (1). After the hip and distal radius, fractures of the
proximal humerus are the third most common fracture in the elderly, with a strong female predominance (2). In
this age group, mechanical ground-level falls are the most common cause of fragility fractures of proximal
humerus, and there is a strong correlation with the presence of osteoporosis.
Early evaluation and management of these injuries is important in optimizing treatment and functional outcomes.
There are a bewildering number of treatment alternatives for managing proximal humeral fractures. Nevertheless,
there is universal agreement that nondisplaced and minimally displaced fractures are best managed
nonoperatively. Percutaneous fixation, plate osteosynthesis, intramedullary nailing, and arthroplasty are the most
common methods of treatment for displaced and unstable fractures in adults. A recent Cochrane database
review of interventions for treating proximal humeral fractures in adults showed that no single method of
treatment was preferable (3). This may be due to the limited number of patients stratified to individual techniques
as well as the wide variety of injury patterns and treatments.
Arthroplasty is most commonly advocated for the primary treatment of displaced three- and four-part fractures in
osteoporotic bone in the elderly. However, it is technically demanding, and numerous studies have documented
unpredictable outcomes (4). Notwithstanding, recent advances in surgical technique and prosthetic designs have
led to more successful outcomes (5, 6, 7, 8 and 9). Improved outcomes have been documented when soft-tissue
dissection is minimized and there is restoration of the “gothic arch” and anatomic reconstruction of the
tuberosities (5).

INDICATIONS AND CONTRAINDICATIONS

Age, bone quality, fracture pattern, and timing of surgery are important factors that influence the surgical
procedure, implant selection, and the functional and radiographic outcome. Utilizing these specific variables, we
have devised an “evidence-based” treatment algorithm (Table 4.1) (10).

Age
One of the most important considerations in selecting a method of treatment in proximal humeral fractures is the
chronological and physiologic age of the patient. Most female patients when they reach the sixth decade of life
have some degree of osteoporosis, and many have impaired neuromuscular control as well. These factors may
compromise osteosynthesis by increasing the risk of fixation failure, postoperative fracture displacement,
nonunion, and/or avascular necrosis (11). Fractures in patients aged 65 years or less appear to be more
amenable to humeral head preservation techniques.
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TABLE 4.1 Factors Affecting Treatment Choice

 Age Is the patient greater or less than 60 years old?

Bone quality Will the bone support fixation?

Fracture pattern Is the humeral head viable? Is the fracture pattern stable?

Timing of surgery Is the injury acute (<4 wk) or chronic (>4 wk)?

Bone Quality
Similar to age, a patient's bone quality can affect the success of humeral head preserving fixation techniques.
Despite improved fixation strength in osteoporotic bone afforded by locking plate technology, complications
continue to be higher in these patients after open reduction and internal fixation (12).

Fracture Pattern
Hertel et al. (13) investigating perfusion of the humeral head after an intracapsular fracture was able to
prospectively correlate radiographic fracture morphology with intraoperative humeral head vascularity.
Radiographic criteria predictive of humeral head ischemia included a posteromedial metaphyseal fragment
extending <8 mm below the articular surface and disruption of the medial hinge defined as displacement of the
humeral shaft >2 mm. When these two preoperative radiographic findings were present in conjunction with an
anatomic neck fracture, there was a 97% positive predictive value for humeral head ischemia.
Even when the humeral head is vascular and amenable to preservation, the ability to maintain adequate fracture
stability is necessary for successful fracture healing. The medial calcar of the humerus must be intact or restored
at the time of surgery for a “stable” reduction. Comminution in this region increases the risk of a varus fracture
reduction.

Timing of Surgery
The delay between injury and definitive surgery is the final variable that may affect functional outcomes following
surgical management of proximal humeral fractures. For example, a fracture amenable to percutaneous fixation
techniques may become impossible to reduce closed and pin percutaneously after 7 to 10 days or when early
callus forms that prevents closed reduction. It is also clear that the outcomes following early arthroplasty for
proximal humeral fractures are significantly improved compared to arthroplasty more than 4 weeks after injury
(14). We believe that optimal surgical timing for shoulder fracture arthroplasty is 6 to 14 days after injury to allow
for partial resolution of the soft-tissue swelling (assuming no acute neurovascular injury or other situation
necessitating an earlier intervention) (15).
Very rarely, glenohumeral arthritis may preexist in a patient with a displaced proximal humerus fracture. If the
degenerative changes are mild or moderate, conventional hemiarthroplasty is still indicated. If end-stage glenoid
arthrosis is present, a total shoulder arthroplasty with insertion of a glenoid component should be strongly
considered. As experience with reverse shoulder arthroplasty increases, the indications for utilizing this
prosthesis in the initial treatment of proximal humerus fractures have become better defined. We typically use a
reversed prosthesis when the patient is older than 75 years, when the greater or lesser tuberosity cannot be
reconstructed, or the patient has ipsilateral lower extremity fractures that require crutches or a walker. In the
infrequent situation in which a patient with a proximal humerus fracture has a concomitant irreparable rotator cuff
tear or cuff tear arthropathy, a reversed prosthesis should be considered.
Contraindications to shoulder fracture arthroplasty are typically related to severe medical comorbidities that
prevent surgical management in general. Nonoperative treatment may be a better treatment alternative for
geriatric patients with complex medical comorbidities, extremely low functional demands, and minimal pain at the
time of presentation. Other contraindications for arthroplasty are a history of infection, severe contracture of the
shoulder girdle, open epiphysis, or fractures amenable to other fixation techniques.

PREOPERATIVE PLANNING
Clinical Evaluation
Marked edema and ecchymosis, which can extend down the arm and into the chest, are often seen in patients
with proximal humeral fractures. Many elderly patients with these injuries are on anticoagulation therapy.
Evaluation for concomitant injuries or associated medical conditions is important in these elderly patients. A
cardiac or neurologic event may be the predisposing cause of the fall. Most of these patients require a careful
medical evaluation by an appropriate specialist particularly if surgery is contemplated.
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Subtle neurologic injury occurs in a large number of patients with proximal humeral fractures (15). Utilizing
electromyography, Visser et al. (15) documented neuropraxia of the axillary and/or suprascapular nerves in 50%
of patients. Clinical appreciation and documentation of this finding is important for both prognostic evaluation and
preoperative counseling, as eventual recovery may take up to 12 to 18 months after surgery (6). These may be
very difficult to identify clinically in a patient with a painful swollen shoulder following fracture.

Radiographic Evaluation
Radiographs should include anteroposterior, scapular “Y,” and/or axillary views. As part of our protocol, we
obtain full-length scaled radiographs of both humeri using a ruler of defined length for preoperative planning (Fig.
4.1). If plain radiographs do not allow a clear understanding of the fracture morphology, a computed tomography
scan with three-dimensional reconstructions may be a helpful.
Neer's classic four-part description of proximal humerus fractures has endured by virtue of its simplicity. Despite
this, interobserver reliability and intraobserver reproducibility have been reported to be only poor to fair (16). A
“comprehensive binary” description of these fractures based upon Codman's original concept of fracture planes
has also been described (Fig. 4.2) (13). In this classification, there are 12 possible fracture patterns: 6 patterns
resulting in 2 fracture fragments, 5 patterns resulting in 3 fracture fragments, and 1 pattern resulting in 4 fracture
fragments. In the original study by Hertel et al., ischemia was observed only in types 2, 7, 8, 9, 10, and 12. This
system has demonstrated improved interobserver reliability as well as better intraobserver reproducibility.

Restoring the “Gothic Arch”

Anatomic restoration of humeral height, correct prosthetic version, and tuberosity reconstruction play critical roles
in determining functional outcome (5). Many studies have shown that poor functional results correlate closely
with prosthesis and/or tuberosity malposition. Boileau et al. (4) described the “unhappy triad,” in which the
prosthesis is cemented “proud” and retroverted and the greater tuberosity has been positioned too low. This
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combination is associated with persistent pain and stiffness and poor function. Careful attention to the restoration
of the proximal humeral anatomy is crucial in obtaining good results following shoulder fracture arthroplasty.
FIGURE 4.1 A scaled ruler is placed on the patient's arm during the radiograph to calculate magnification.

FIGURE 4.2 Hertel's binary (LEGO) proximal humerus fracture description system. HH, humeral head; GT,
greater tuberosity; LT, lesser tuberosity. (Modified from Hertel R, Hempfing A, Stiehler M, et al. Predictors of
humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg
2004;13(4):427-433.)

We use the term “gothic arch” to describe the architectural anatomy of the proximal shoulder girdle as seen on
an anteroposterior radiograph (5). The arch is formed by tracing a line along the medial border of the proximal
humeral calcar to the articular surface and joining this with a line along the lateral border of the scapula to the
articular surface. The result is a classical “vaulted” or “gothic” arch shape seen in medieval period architecture
(Fig. 4.3). This simple concept allows for a highly reproducible surgical technique for restoration of proper
humeral height, which improves the potential for anatomic tuberosity reconstruction.
Using the scaled preoperative radiographs, we first measure the entire length of the intact contralateral humerus
from a line perpendicular to the medial epicondyle to the top of the humeral head (N) (Fig. 4.4A). On the injured
side, the length of the fractured humerus (F) (Fig. 4.4B) is determined by measuring from a line perpendicular to
the medial epicondyle to the fracture line at the humeral metadiaphysis. Humeral height for the prosthesis that
must be restored (H) is calculated by subtracting F from N (Fig. 4.4C). In addition, we measure the length of the
greater tuberosity fragment (G) (Fig. 4.4D), which should be within 5 mm of H to ensure that humeral prosthetic
height will allow for anatomic tuberosity reconstruction. These steps are vital and cannot be overlooked. Full-
length scaled radiographs of both humeri can even be done in the operating room immediately prior to surgery,
using digital radiography with markers for precise preoperative measurements.

FIGURE 4.3 The “gothic arch” of the normal shoulder is formed by (1) a line drawn along the medial humeral
shaft and calcar and (2) a line drawn along the lateral scapular border, which intersect at (3) the inferior articular
margin. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture:
restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

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FIGURE 4.4 A. Length of normal humerus (N) is the distance along the humeral shaft from a line perpendicular
to the medial epicondyle to the top of the humeral head, corrected for magnification. B. Length of fracture (F) is
the distance along the humeral shaft from a line perpendicular to the medial epicondyle to the fracture line at the
humeral metadiaphysis, corrected for magnification. C. The amount of humeral height to be restored (H) is the
value of N minus F. D. Greater tuberosity length (G) should be within 5 mm of humeral head height (H). (A
through D reprinted with permission from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder
arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66.)

As a final check, the preoperative value G is compared with the length of the greater tuberosity fragment
measured intraoperatively (Fig. 4.5). This is important because the greater tuberosity should be positioned 3 to 5
mm below the prosthetic head.

SURGICAL TECHNIQUE
General hypotensive anesthesia, without the use of a regional nerve block, is preferred. The patient is positioned
supine on the operating room table in a modified beach-chair position using a bean bag for scapula support (Fig.
4.6). The head of the table is elevated 20 to 30 degrees.
If desired, the table may now be turned 90 degrees to allow for a C-arm to be brought in directly perpendicular to
the patient. A sterile articulated arm holder is utilized (McConnell Arm Holder, McConnell Orthopedic
Manufacturing Company, Greenville, TX). The extremity, shoulder, chest wall, and neck are prepped and draped
with the affected arm free.
If there is no contraindication, appropriate preoperative and perioperative intravenous antibiotics are
administered (cephalosporin or vancomycin) for a 24-hour total duration. A 5- to 7.5-cm deltopectoral approach is
used. The incision is placed in the deltopectoral interval and starts at the medial tip of the coracoid paralleling
the path of the cephalic vein (Fig. 4.7). A mobile soft-tissue window will allow the procedure to be performed
through a relatively small incision. Prior to making the incision, the skin and subcutaneous tissue are infiltrated
with 0.25% bupivicaine with epinephrine. The cephalic vein is retracted medially with a small strip of the deltoid.
By blunt dissection, the deltopectoral interval is developed down to the clavipectoral fascia. Small Hohmann
retractors are placed under the deltoid proximally and over the coracoacromial ligament. A self-retaining retractor
is then placed beneath the deltoid and conjoint tendon (Fig. 4.8). The biceps tendon is identified in the
intertubercular groove, tagged, and divided at its insertion for later tenodesis. Typically, the fracture line can be
located with an elevator or osteotome between the tuberosities, just posterior to the bicipital groove. The greater
tuberosity is identified and mobilized. Four nonabsorbable horizontal mattress nonabsorbable sutures (No. 5
Ethibond, Ethicon, a Johnson and Johnson Company, New Brunswick, NJ) are placed separately in the greater
tuberosity at the bone-tendon junction (two in the infraspinatus and two in the teres minor). Similarly, the lesser
tuberosity is identified and mobilized. Two nonabsorbable sutures are placed around the lesser tuberosity at the
subscapularis bone-tendon junction (Fig. 4.9). The tuberosities are gently retracted to gain access to the
humeral head. Dissecting scissors are used to divide the rotator cuff in line with the tuberosity fracture plane.
The head fragment is carefully removed and measured with a caliper. If the humeral head measurement is
intermediate between sizes, the smaller size should be selected. The humeral head is saved and used to procure
three structural cancellous bone grafts, which will be placed into and around the humeral component (Fig. 4.10).
Loose bony fragments are removed from around the glenoid, and the joint is copiously irrigated and inspected for
signs of damage or arthrosis.
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FIGURE 4.5 Intraoperative measurement of greater tuberosity should be within 5 mm of humeral head height (H).
(Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture:
restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

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FIGURE 4.6 Modification of the beach-chair position.

FIGURE 4.7 Modified deltopectoral incision. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al.
Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66,
with permission.)
FIGURE 4.8 Retractor placement. (1) Over the coracoacromial ligament, (2) on top of the acromion, (3) self-
retaining retractor placed under the deltoid and conjoint tendon.

The humeral shaft is mobilized and delivered into the wound. The medullary canal is prepared by hand using
cylindrical reamers and fracture-specific trial implants of increasing diameter (Aequalis Fracture Prosthesis,
Tornier, St. Ismier, France) until the appropriate trial implant and head size are determined. The smallest reamer
that demonstrates cortical contact is chosen, and since we recommend a cemented stem, we do not attempt to
“ream up” to a larger implant stem diameter. If desired, a trial stem and head may now be placed into the
humerus. Fracture jigs are available to allow for stable trial implant height and retroversion during a trial
reduction. If a trial reduction feels too loose or tight, one must reassess whether the anatomy has been properly
restored using the “gothic arch” technique as described below. If the medial calcar is fractured, it is provisionally
stabilized using cerclage wire or heavy suture fixation with the last broach used in the medullary canal (Fig.
4.11).
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FIGURE 4.9 Four separate heavy nonabsorbable sutures are placed at the greater tuberosity bone-tendon
junction. Two temporary stay sutures are placed at the lesser tuberosity bone-tendon junction.

The next step is to restore the proximal humeral “gothic arch” anatomy. Unlike other described techniques, we
do not reference the reconstruction using the lateral humeral metadiaphysis. The appropriate diameter fracture-
specific prosthetic stem is opened, and the preselected size trial head is placed on the definitive implant with the
eccentric head offset rotated into the most lateral position (Fig. 4.12). We systematically place the humeral head
offset in this most lateral position as this decreases the amount of “medial overhang” of the humeral head and
increases the lateral room under the prosthetic head for bone graft and anatomic positioning of the greater
tuberosity.
Using the preoperative radiographic calculations as previously described, a mark corresponding to length H is
placed on the prosthetic implant by measuring from the top of the trial humeral head (see Fig. 4.4D). During
provisional placement of the prosthesis inside the medullary canal, the mark should be visible at the fracture line
of the humeral shaft. The line of the “gothic arch” (medial calcar of the humerus up to the inferior margin of the
anatomical neck down the lateral scapular border) should be unbroken (Fig. 4.13). This is confirmed visually and
by using an instrument such as a freer elevator to trace a smooth line from the top of the prosthetic humeral head
inferiorly to the medial calcar. Appropriate retroversion of the prosthesis is confirmed by rotating the forearm to a
neutral position and facing the prosthetic humeral head toward the glenoid (Fig. 4.14). This step ensures that the
patient's own retroversion is restored and is approximately 20 degrees relative to the transepicondylar axis of the
elbow.
The greater tuberosity is measured and noted to be within 5 mm of the measured humeral head height (H) (Fig.
4.5). The “gothic arch” anatomy of the proximal humerus is consistently recreated intraoperatively using this
method. If there is any concern, intraoperative fluoroscopy can be utilized to confirm restoration of the gothic arch
with the prosthetic stem and head.
If the arch is not “restored,” then either
1. Prosthetic height may be incorrect (it is usually too high)
2. Medial calcar is fractured and has not yet been restored
3. Head size is either too large or has not been rotated into the most lateral offset position (Fig. 4.12)
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FIGURE 4.10 This osteotome is included in the prosthetic instrumentation set and is used to fashion structural
bone graft from the humeral head.
FIGURE 4.11 A fractured medial calcar is stabilized using cerclage wire or heavy suture fixation.

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FIGURE 4.12 Appropriate prosthetic humeral head placement is in the most laterally offset position.

Once the arch has been established, the implant is removed, and two drill holes are placed in the proximal
humeral shaft on either side of the bicipital groove. Two heavy nonabsorbable sutures (No. 5 Ethibond, Ethicon,
a Johnson and Johnson Company, New Brunswick, NJ) are placed in a horizontal mattress fashion through
these holes to be used as “tension band” sutures during the final tuberosity fixation (Fig. 4.15). A cement
restrictor is placed 2 cm distal to the distal tip of the prosthesis. Taking care to ensure that the previous “gothic
arch” anatomy is restored (Fig. 4.16), the prosthetic stem is cemented into the canal in slight valgus using third-
generation cementation technique. The humeral canal is thoroughly irrigated, and a small diameter suction tube
is placed into the canal to vent blood during cementation. The cement is mixed using a vacuum centrifugation
device and injected into the humeral canal using a large syringe. Gentle pressurization of the cement is
performed using a separate wet glove, adding a small amount of cement each time. The vent tube is removed
during the third (final) pressurization. One to two centimeters of proximal cement is removed from the
intramedullary canal to allow for placement of bone graft. Final tightening of the wire or suture used to fix the
medial calcar fracture (if present) is performed. The final head of predetermined size is gently impacted into the
appropriate position. Three structural cancellous bone graft wedges (obtained from the humeral head) are then
placed as follows: (a) in the “window” of the fracture-specific prosthesis; (b) under the greater tuberosity at the
“lateral” fin of the prosthesis; and (c) under the anteromedial edge of the prosthetic head between the head and
neck of the implant (Fig. 4.17).
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FIGURE 4.13 With the prosthesis placed inside the medullary canal, the “gothic arch” is unbroken. Restoration
of humeral head height is confirmed with the ruler. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ,
et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg
2005;6(2):57-66, with permission.)
FIGURE 4.14 Appropriate version is determined by rotating the prosthetic humeral head to face the glenoid with
the forearm in neutral rotation at the patient's side.
FIGURE 4.15 Two heavy nonabsorbable sutures are placed through drill holes on either side of the
intertubercular groove.

FIGURE 4.16 Restoration of the “gothic arch” with the final prosthesis in place. (Reprinted from Krishnan SG,
Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech
Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

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With the humeral prosthesis reduced into the glenoid, tuberosity osteosynthesis is now performed. The medial
limbs of the sutures previously placed at the greater tuberosity bone-tendon junction are passed around the
prosthetic neck (Fig. 4.18). With the greater tuberosity in a reduced position, two of these sutures are tied over
the structural bone graft (Fig. 4.19). The remaining two greater tuberosity sutures (medial limbs) are placed
through the subscapularis bone-tendon junction from posterior to anterior and tied down while the lesser
tuberosity is held reduced (Fig. 4.20). Sutures previously placed through drill holes in the humeral shaft are then
used to create a vertical “tension band.” One suture is placed from anterior to posterior through the
subscapularis tendon, rotator interval, supraspinatus, and superior infraspinatus tendons (anterosuperior cuff).
The other is passed from posterior to anterior through the teres minor and infraspinatus, superior supraspinatus,
and leading edge of subscapularis tendons (posterosuperior cuff) (Fig. 4.21). The biceps is tenodesed within the
bicipital groove or rotator interval to soft tissue (Fig. 4.22). The shoulder is taken through a full range of motion,
to ensure there is no motion of the tuberosity fragments. Passive intraoperative range of motion should be at
least 160 degrees of elevation, 40 degrees of external rotation at side, 60 degrees of external rotation in 90-
degree abducted position, and 70 degrees of internal rotation in a 90-degree abducted position. Closure of the
wound is performed. Postoperative x-rays should demonstrate anatomic reconstruction of the proximal humerus
(Fig. 4.23).
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FIGURE 4.17 Three structural cancellous bone graft wedges are then placed: (a) in the “window” of the fracture-
specific prosthesis; (b) under the greater tuberosity at the “lateral” fin of the prosthesis; and (c) under the
anteromedial edge of the prosthetic head between the head and neck of the implant.
FIGURE 4.18 Medial limbs of sutures previously placed at the greater tuberosity bone-tendon junction are
passed around the prosthetic neck.
FIGURE 4.19 Two sutures previously placed at the greater tuberosity bone-tendon junction tied down around
the prosthesis.

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FIGURE 4.20 The two remaining sutures previously placed at the greater tuberosity bone-tendon junction are
placed through the lesser tuberosity bone-tendon junction and tied down.
FIGURE 4.21 Sutures placed through drill holes in the humeral shaft (gray, light blue) are used for vertical
“tension band” fixation. Additional simple sutures are used to reinforce rotator interval closure (purple).

FIGURE 4.22 Soft-tissue biceps tenodesis.

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FIGURE 4.23 A. Four-part proximal humeral fracture with broken “gothic arch.” B. Restoration of the “gothic
arch” and tuberosity anatomy. C. Two years after surgery. (A and B reprinted from Krishnan SG, Pennington
WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder
Elbow Surg 2005;6(2):57-66, with permission.)

POSTOPERATIVE MANAGEMENT
Patients are placed into a Smart Sling orthosis (Innovation Sports/Ossur, Foothill Ranch, CA) for 6 weeks (Fig.
4.24). Passive motion with the patient supine is begun the day after surgery. Passive supine limits of 90 degrees
of forward flexion and 30 degrees of external rotation are maintained for the first 4 postoperative weeks. During
weeks 5 to 6, passive supine forward flexion is full, and external rotation is maintained at 30 degrees. At 7 weeks
after surgery, active motion is allowed, and resistance exercises begin 10 weeks postoperatively.
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FIGURE 4.24 The Smart Sling orthosis.

COMPLICATIONS
Many complications can be avoided by proper patient selection, meticulous attention to detail, and careful
surgical technique.
1. Component Malposition. A prosthesis placed too high can over tension the superior rotator cuff, resulting
in pain and limited elevation. Incorrect prosthetic height or version also makes initial anatomic reduction
of the tuberosities difficult and will increase the risk of later tuberosity displacement and/or nonunion (6).
This can be avoided by following the criteria for restoring the “gothic arch” anatomy of the proximal
humerus as described.
2. Tuberosity Malposition. Even when the implant is placed correctly, fixing the tuberosities in a
nonanatomic position can result in a poor outcome. The proximal greater tuberosity should be 3 to 5 mm
below the top of the prosthetic head. Placing the greater tuberosity too low will have a similar effect to
placing the prosthesis too proud. An intraoperative AP radiograph should be obtained if there is any
question about the adequacy of reduction.
3. Failure of Tuberosity Fixation. A key technical point is passing the sutures used in tuberosity fixation
around the prosthetic neck. This provides superior stability by compressing the tuberosity to the
prosthetic neck (10).
4. Stiffness. In an effort to reduce the risk of early tuberosity migration, the surgeon may be concerned
about starting early postoperative shoulder motion. However, the excellent initial fixation afforded by this
technique allows for early protected motion as described. Other causes of stiffness include pain as the
result of poor prosthesis or tuberosity position or patient inability to participate in a structured therapy
program.
 5. Other. Less common complications include infection, intraoperative humeral fracture, heterotopic
ossification, nerve injury, complex regional pain syndrome, prosthetic loosening, rotator cuff failure, and
glenoid arthritis.

RESULTS/OUTCOMES
We performed a retrospective review of 170 consecutive patients treated by a single surgeon (SGK) with this
technique of proximal humeral hemiarthroplasty and tuberosity osteosynthesis between 2001 and 2006 (6). The
mean age was 72 years and follow-up was 24 to 56 months. Between September 2001 and March 2004, 58
standard humeral prosthetic stems (STD) were implanted. From April 2004 through May 2006, 112 fracture-
specific prosthetic stems (FX) were used. Differences between groups in age, mean time to surgery, and
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visual analog pain scores were not significant. The mean ASES score was higher in the FX group (72 vs. 55, p <
0.0001), and mean goniometric active elevation was better in the FX group (129.8 vs. 95.4, p < 0.0001). Overall,
127/170 (75%) greater tuberosities healed to the humeral shaft. Tuberosity healing was noted to be 89/112
(79%) in the FX group and 38/58 (66%) in the STD group ( p = 0.03). The FX group had a higher percentage of
patients 77/112 (69%) with active elevation >120 degrees when compared to the STD group 28/58 (48%), this
was significant ( p = 0.007). These results appear to support improved outcomes associated with the fracture-
specific stem compared to the standard stem.

REFERENCES
1. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J
Shoulder Elbow Surg 1995;4(2):107-112.

2. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin
Orthop Relat Res 2006;442:87-92.

3. Handoll HHG, Ollivere BJ. Interventions for treating proximal humeral fractures in adults. Cochrane
Database Syst Rev 2010;12: Art. No.: CD000434. DOI: 10.1002/14651858.CD000434.pub2

4. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes
after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg
2002;11(5):401-412.

5. Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the
“Gothic Arch”. Tech Shoulder Elbow Surg 2005;6(2):57-66.

6. Krishnan SG. Shoulder arthroplasty for fractures of the proximal humerus: where are we in 2010? AAOS
Instructional Course Lectures, New Orleans, March 2010.

7. Castricini R, De Benedetto M, Pirani P, et al. Shoulder hemiarthroplasty for fractures of the proximal
humerus. Musculoskelet Surg April 19, 2011 [Epub ahead of print].

8. Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop
Traumatol Surg Res 2010;96(6):683-694.
9. Esen E, Dogramaci Y, Gultekin S, et al. Factors affecting results of patients with humeral proximal end
fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients. Injury 2009;40(12):1336-
1341.

10. Lin K, Krishnan SG. Shoulder Trauma: Bone, Orthopaedic Knowledge Update 9. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2008.

11. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate
fixation of proximal humeral fractures. J Bone Joint Surg Am 2008;90(2):233-240.

12. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures
with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J
Bone Joint Surg Am 2009;91(6):1320-1328.

13. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture
of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427-433.

14. Sperling JW, Cuomo F, Hill JD, et al. The difficult proximal humerus fracture: tips and techniques to avoid
complications and improve results. In: Marsh JL, Duwelius PJ, eds. Instructional course lectures. Vol. 56.
Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:45-57.

15. Visser CP, Coene LN, Brand R, et al. Nerve lesions in proximal humeral fractures. J Shoulder Elbow
Surg 2001;10(5): 421-427.

16. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proximal humeral fractures. An
assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am
1993;75(12):1745-1750.
 5
Reverse Shoulder Arthroplasty for Acute Proximal Humerus
Fractures
Pascal Boileau
Adam P. Rumian
Xavier Ohl

INTRODUCTION
Although Neer reported favorable results following hemiarthroplasty for proximal humeral fractures in 1951, a
large number of subsequent studies have been unable to duplicate his functional and radiological outcomes. In
fact, most reports of shoulder hemiarthroplasty for fractures of the proximal humerus in the United States
document a high incidence of shoulder pain and stiffness (1,2). Many authors have documented that the results
of hemiarthroplasty are closely related to the accuracy of reduction and healing of the tuberosities, particularly
the greater tuberosity (3). If the greater tuberosity heals in a malunited position or migrates because of fixation
failure, a poor outcome is predictable. The critical role of the greater tuberosity is explained by the fact that three
of the four rotator cuff muscles insert directly onto it: the supraspinatus, infraspinatus, and teres minor. If the
greater tuberosity does not heal properly, then the function of these muscles will be compromised, leading to
shoulder dysfunction. Furthermore, malunion or nonunion of the tuberosity can lead to bony impingement with
decreased range of shoulder motion, pain, and stiffness.
In reverse shoulder arthroplasty (RSA), the center of rotation of the shoulder joint is medialized and the humerus
is lowered, resulting in an increased lever arm with improved function of the deltoid for abduction. The prosthesis
is designed to compensate for deficiencies of the rotator cuff, particularly the supraspinatus (4). A RSA is a
semiconstrained prosthesis, and insufficiency of the greater or lesser tuberosity will not cause instability of a
properly positioned prosthesis. This makes it an attractive option for arthroplasty in fracture cases where
successful reconstruction and osteosynthesis of the proximal humerus and tuberosities are problematic.
However, its use should be restricted to more elderly patients (i.e., over 70 years of age) as long-term results
with this implant are not available, and preliminary studies report deterioration of function after a few years (5).
Although RSA can compensate for cuff deficiency as described above, the surgical goal should include
reduction, fixation, and healing of the greater tuberosity to preserve the external rotation function of the shoulder
whenever possible (6).

INDICATIONS AND CONTRAINDICATIONS

RSA for fracture is reserved for comminuted osteoporotic fractures in elderly patients that are unsuitable for
osteosynthesis or conventional hemiarthroplasty. These include four-part fractures and fracture dislocations of
the proximal humerus, head-splitting fractures, some three-part fracture dislocations, and three-part fractures
without valgus impaction of the humeral head (7,8). Factors that would favor the use of a RSA rather than
hemiarthroplasty include age over 70 years, severe osteopenic bone or metabolic bone disease, marked
comminution of the fracture, preexisting rotator cuff disease, inflammatory arthritis, heavy smoking, and the use
of systemic steroid medication. Contraindications to RSA include age under 70 years, active infection, a
complete axillary
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nerve deficit, inadequate glenoid bone stock to support a glenoid implant, and inability or unwillingness of the
patient to comply with postoperative rehabilatation. RSA for fractures is a technically demanding procedure and
should not be performed by inexperienced surgeons without specialized training.
PREOPERATIVE PLANNING
Preoperative planning is essential to obtain a successful outcome after RSA for fracture and to prevent avoidable
complications. A detailed history should be obtained, and a careful physical examination should be performed.
The motor and sensory function of the axillary nerve must be accurately assessed because a significant number
of patients with proximal humeral fractures have subtle injuries to the nerve. While neurological dysfunction tends
to recover slowly, it may delay recovery and rehabilitation. This is especially important since RSA relies on the
deltoid muscle to be the prime driver of shoulder movement. In our opinion, RSA should not be performed in a
patient with a complete axillary nerve palsy. Radiographic evaluation should include anteroposterior (AP),
scapular Y, and axillary lateral views as well as a CT scan to classify the fracture, and determine fracture
displacement and evaluate the status of the tuberosities. The CT also allows some evaluation of the rotator cuff
as to the degree of fatty infiltration and muscular atrophy as well as the ability to assess the glenoid bone stock
to support a glenoid component (9).
We believe that the ideal timing of surgery is at 3 to 7 days after injury, which avoids operating through acutely
injured and edematous soft tissues and lessens the risk of wound complications. Surgery after a delay of more
than 3 weeks becomes technically difficult due to fracture callus that results in difficulty mobilizing the tuberosity
fragments and requires a more extensive soft-tissue dissection.
Preoperative radiographic planning is very important if successful outcome is to be consistently achieved. The
normal anatomical landmarks that are used as reference points to position the humeral prosthesis are displaced
or compromised as a result of the fracture. Correct positioning of the humeral prosthesis, especially in terms of
vertical height, is crucial as implanting the prosthesis too deep or too proud in the humeral canal can lead to a
poor result (10). In our opinion, it is not acceptable to rely on “eyeballing” the height of the prosthesis at the time
of surgery as this leads to unpredictable, unreproducible, and often unacceptable results. Scaled AP radiographs
of both humeri should be obtained. The length of the normal humerus is measured along the prosthetic axis as
shown in Figure 5.1. On the fractured side, the length of the remaining distal humeral shaft
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fragment is measured from the lateral edge of the fracture (Fig. 5.1). The difference between these two
measurements, adjusted for the magnification factor, gives the distance above the lateral edge of the distal
humeral shaft fragment that the top of the prosthesis needs to be implanted to achieve the correct humeral
length.
FIGURE 5.1 A,B. Evaluation of the humeral length on the fracture side and the controlateral side.

Patient Setup
Surgery can be performed under a general or regional anesthesia.
Antibiotic prophylaxis should be administered at the time of anesthetic induction according to local protocols. We
perform surgery in a laminar airflow room. A beach-chair position is used with the arm draped free. We routinely
perform a prescrub with diluted antiseptic scrub lotion before definitively prepping the arm as the patient has
often had their arm immobilized for a few days and has been unable to perform adequate hygiene in the axillary
region due to pain. The arm must be draped free to allow for intraoperative manipulation to aid in exposure and
prosthesis implantation. A sterile adhesive antimicrobial incise drape (Ioban, 3M) is applied to the surgical field
after marking the incision to lessen the risk of wound contamination.
We use the Aequalis Reversed Fracture Prosthesis (Aequalis RSAFx, Tornier, Inc.) system. This specifically
designed reverse fracture stem has a low-profile monobloc design, proximal hydroxyapatite coating to promote
bone healing, a fenestration to accept proximal bone graft, and a smooth polished neck to prevent abrasion of
sutures used for tuberosity osteosynthesis (Fig. 5.2). It is also modular as it can accept either a 36 or a 42
polyethylene cup.

Approach
Although we routinely use the deltopectoral approach for elective RSA, we utilise the superolateral deltoid-
splitting approach for fracture cases as it allows better access to the greater tuberosity fragments and improves
glenoid exposure. A vertical incision centered at the anterior edge of the acromion is made in Langer's lines, 1
cm medial to its lateral border (Fig. 5.3). Full-thickness skin flaps are raised, exposing the underlying deltoid
muscle and anterolateral acromion (Fig. 5.4). The deltoid is split in the avascular tendinous raphe between the
anterior and middle portions of the deltoid. This split should not extend more than 5 cm distally to avoid
damaging the axillary nerve. Proximally, the split is extended up over the superior surface of the anterior
acromion, and we detach 2 cm of the anterior deltoid muscle with a thin piece of bone to improve healing of the
deltoid after reattachment (Fig. 5.5). A deep self-retaining retractor is used for improved visualization.

FIGURE 5.2 Aequalis Reversed Fracture stem.

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FIGURE 5.3 Surgical approach.

FIGURE 5.4 Exposure of the deltoid muscle and anterolateral acromion.

Fracture Exposure
The hemorrhagic subacromial bursa and fracture haematoma are carefully removed, exposing the fracture site.
The key to understanding the anatomy is to identify the long head of biceps tendon, which lies between the
greater and lesser tuberosities and marks the rotator interval. The rotator cuff interval is opened or extended if
torn, and the biceps tendon is identified, tagged, and divided at its origin from the supraglenoid tubercle. We
excise its intra-articular portion to aid exposure, facilitate fracture reduction, and remove a source of
postoperative pain. A soft-tissue tenodesis below the rotator cuff interval of the remaining tendon is performed.
The fractured humeral head is now removed and saved to be used as bone graft in and around the definitive
prosthesis (Fig. 5.6).

Tuberosity Mobilization and Preparation

The supraspinatus tendon is identified and mobilized up to the glenoid rim. In many patients, its attachment to the
greater tuberosity is already torn, and any adhesions between the rotator cuff muscles and deltoid should be
freed. The greater tuberosity fragment is grasped with an atraumatic specifically designed grasping clamp to
allow suture placement (Aequalis, Tornier, Inc.; Fig. 5.7). We pass one green and one blue heavy nonabsorbable
braided sutures through the infraspinatus tendon and one green and one blue sutures through the teres minor
tendon (Fig. 5.8). These four strong nonabsorbable sutures (two green, two blue) will be used as horizontal
cerclages for tuberosity fixation and must be placed at the bone-tendon junction of the greater tuberosity.
Sutures of different colours are helpful to aid in suture management. We use a combination of Orthocord (Depuy
Orthopaedics, Inc.), Fiberwire (Arthrex, Inc.), or Force Fiber (Tornier Inc.). Likewise, two sutures are passed
around the lesser tuberosity fragment through the subscapularis tendon.
Using a shuttling suture or a crimping needle, two doubled-over lengths of suture are passed through the
superior portion and two of a different color through the inferior portion of the infraspinatus at its junction with the
bone. Sutures should not be passed through the bone itself to avoid causing comminution of the tuberosity
fragment. Once this step is completed, our attention is turned to the glenoid (Fig. 5.9).
FIGURE 5.5 Detachment of the anterior deltoid.

FIGURE 5.6 Removal of the fractured humeral head.

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FIGURE 5.7 Specific atraumatic grasping clamp is used to manipulate the greater tuberosity.
FIGURE 5.8 Four horizontal cerclages. One green and one blue through the infraspinatus tendon and one green
and one blue through the teres minor tendon.

Glenoid Exposure and Implantation

To expose the glenoid, a flat lever forked retractor (Kolbel retractor) is placed over the anterior glenoid neck to
retract the subscapularis muscle anteriorly. The anterior and inferior labrum is excised and an anterior
juxtaglenoid capsulotomy performed. Similarly, a forked retractor is placed posteriorly and the posterior labrum
excised and posterior capsulotomy performed. The glenoid exposure is completed by placing a retractor inferiorly
to depress the humeral diaphysis and expose the inferior rim of the glenoid.
The centerpoint of the glenoid is identified by the intersection of the superoinferior and mediolateral bisecting
lines. It is desirable to place the glenoid baseplate slightly inferiorly on the glenoid. The circular glenoid guide is
placed flush to the inferior rim of the glenoid and used to insert a threaded guide wire. In fracture cases without
glenoid wear, it is not necessary to correct glenoid version. The guide wire can be inserted in a neutral position
or with 10 degrees of inferior tilt (Fig. 5.10). Any superior tilt of the glenoid implant should be avoided to prevent
instability and inferior scapular notching.
Gentle reaming of the glenoid surface is performed using the cannulated reamers over the guide wire. The
reamer should be started before contacting the bone to lessen the risk of fracturing the glenoid (Fig. 5.11). The
aim of reaming is to provide a flat, smooth surface, but it is important to preserve most of the strong subchondral
bone to provide support for the glenoid implant. Depending on the size of the glenoid, a 25- or 29-mm baseplate
will be selected. Additional reaming with a second reamer is needed to accept the glenoid sphere. There are two
sizes of glenoid sphere: 36 and 42 mm. We tend to ream to accept the 42-mm implant in all but the smallest
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patients as this improves stability of the prosthesis. Finally, an 8mm hole is drilled over the guide wire to receive
the central peg of the glenoid baseplate, which is impacted until fully seated.
FIGURE 5.9 Technique for placement of the sutures.

FIGURE 5.10 Exposure of the glenoid with retractors and glenoid guide with wire inserted with 10 degrees of
inferior tilt.
FIGURE 5.11 Glenoid reaming.

Next, the baseplate is secured with screws (Fig. 5.12). The anterior and posterior conventional cortical screws
are positioned first to optimize compression of the baseplate. The anterior hole is drilled using a guide at a
trajectory that is superior and toward the middle of the baseplate, exiting through the posterior scapular cortex.
The hole is measured, and the screw is inserted although not yet tightened fully to avoid rocking the baseplate.
The posterior hole is then drilled at a trajectory that is inferior and toward the middle of the baseplate, exiting
through the anterior scapular cortex. The hole is measured, and the screw is inserted, and tightened fully, after
which the anterior screw is tightened. The aim of these screws is to achieve secure cortical fixation—the holes
should be redrilled in a different direction if this is not accomplished. The superior and inferior locking screws are
inserted next. The drill guide is positioned into the threaded holes of the baseplate and orientated to achieve the
desired trajectory. For the superior screw, this is approximately 20 degrees superior and 10 degrees anterior so
that the screw engages the cortical bone at the base of the coracoid process. For the inferior screw, this is
approximately 20 degrees inferior in the axis of the glenoid so that the screw engages the cortical bone of the
scapular pillar. The inferior screw is inserted and tightened first. The final position of the baseplate is verified,
which should be fully seated onto bone in a slightly inferior position, up to but not overhanging the inferior edge
of the glenoid, and with a neutral or slightly inferior tilt and correct version. Although we tend to impact and screw
the definitive glenoid sphere implant onto the baseplate at this stage, a trial implant can be screwed onto the
baseplate instead if desired (Fig. 5.13).

Preparation of the Humerus

The glenoid retractors are removed, and access to the medullary canal of the humeral shaft can be improved by
pushing up on the elbow, delivering it into the wound. The medullary canal is progressively reamed until the last
reamer used contacts cortical bone, which determines the size of the humeral stem. During reaming, one hand
should be positioned under the elbow during reaming to guide the direction of the reamers, control rotation, and
prevent excess traction on the tissues that could result in a neuropraxia (Fig. 5.14).

FIGURE 5.12 Baseplate secured with two standard-headed screws and two locking screws.
FIGURE 5.13 Implantation of the definitive glenoid sphere.

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FIGURE 5.14 Reaming of the humeral shaft.

Two holes are drilled lateral and posterior to the bicipital groove 1 cm below the fracture site. Two doubledover
strands of nonabsorbable suture of different colors are passed through the holes for use as vertical cerclage in
the tuberosity repair (Fig. 5.15).

Positioning the Trial Stem

It is important that the humeral stem be implanted in the correct retroversion and at the correct height above the
fracture site. A trial stem is mounted on the holder and introduced into the medullary canal.
The retroversion of the prosthesis is provided by the use of the alignment rod, which is inserted into the holder
and the stem is rotated until the retroversion rod is parallel to the patient's forearm with the elbow flexed to 90
degrees (Fig. 5.16). This will position the humeral implant at the desired 20 degrees of retroversion with respect
to the forearm (i.e., ∽10 degrees with respect to the epicondylar axis). Using electrocautery or sterile marker, a
mark is made on the bone adjacent to the lateral fin of the trial stem that will be used to guide the position of the
definitive implant.
The height of the prosthesis is determined by reducing the greater tuberosity around the humeral component
and onto the shaft. With proper reduction of the greater tuberosity, the most superior part of the trial implant will
be at or just above the top of the tuberosity. The height of the prosthesis can also be determined or confirmed
from the preoperative planning stage. The distance is set on the height gauge on the implant holder (Fig. 5.17).
The foot of the height gauge rests on the cortical rim on the lateral side of the humeral diaphysis, thus
positioning the implant at the correct height. If the trial stem is too loose in the medullary canal to allow sufficient
stability for the tuberosity reduction, then a larger-size trial stem should be used. If there is a disparity between
the preoperatively determined height and that required to achieve correct positioning of the implant relative to the
tuberosity, then the situation should be reassessed. If the greater tuberosity fragment is relatively intact and the
reduction verified to be anatomical with respect to the diaphysis, then the tuberosity should be used as the guide
for prosthesis height and a new measurement determined from the calibrated height gauge. Conversely, if
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the greater tuberosity is comminuted with some degree of bone loss, or anatomical reduction cannot be verified,
then the preoperatively templated height should be respected. If the trial stem is stable, a trial reduction can be
performed with a spacer; however, we do not routinely perform this step to avoid iatrogenic fracture.

FIGURE 5.15 Two sutures are passed through the humeral shaft under the fracture site.

FIGURE 5.16 Retroversion control with the trial stem.

FIGURE 5.17 Height control with the trial stem.

Humeral Stem Implantation

The definitive humeral implant is mounted on the holder. The bone graft cutting instrument provided with the set
is used to harvest shaped cancellous graft from the humeral head and is placed into the designated window in
the humeral stem (Fig. 5.18). The low-profile fracture stem combined with the bone graft increases the chance
for successful tuberosity healing.
A cement restrictor is placed in the humeral shaft 2 cm below the tip of the trial stem. The medullary canal is
irrigated and dried, and a small bore surgical drain is placed into the humeral canal and attached to suction.
Cement is injected using a large syringe, and the small drain is gradually withdrawn as the cement advances.
Very little cement is necessary as it is only needed for fixation of the distal prosthetic stem. The proximal canal
and prosthesis must be free of cement to allow for bony ingrowth. The definitive implant is inserted, using the
mark previously made on the bone to guide retroversion and height (Fig. 5.19). Excess cement is removed with a
curette. There should be no cement within 5 mm of the fracture. Any remaining space around the prosthesis in
this area is packed with more bone graft harvested from the humeral head to promote tuberosity healing.
The diameter of the polyethyelene humeral insert is determined by the size of the glenoid sphere. The thickness
of the humeral insert is determined by performing a trial reduction to ensure stability. If the glenoid and humeral
components have been implanted properly, a 6-mm humeral insert is usually appropriate. If pistoning of the
humerus is present on reduction, or deltoid tension is insufficient, then a thicker insert (9 or 12 mm) may
necessary. The prosthesis is dislocated, and the definitive insert is impacted into the humeral component.

Tuberosity Reduction and Fixation

Four doubled-over strands of suture previously passed through the bone-tendon junction of the infraspinatus and
teres minor are used for horizontal cerclage for the tuberosity repair. The ends emerging from the deep surface
of the tendon are passed around the neck of humeral implant (so-called lasso manoeuvre), which is polished to
prevent abrasion. The prosthesis is then reduced into the joint (Fig. 5.20).
FIGURE 5.18 Definitive humeral stem with the harvest cancellous autograft.

FIGURE 5.19 Implantation of the definitive humeral stem with height and retroversion control.

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FIGURE 5.20 Passage of the four horizontal cerclages around the neck of the prosthese: the “lasso” maneuver.
FIGURE 5.21 Reduction and fixation with two sutures of the greater tuberosity. Arm in external rotation.

At this point, it is crucial to place the arm in external rotation while the greater tuberosity is reduced onto the
prosthesis and the proximal humerus by pulling it anteriorly with the specific tuberosity grasper. A common
mistake is to try and reduce the tuberosity with the arm internally rotated, which will lead to the tuberosity being
fixed too far posteriorly, leading to loss of external rotation and posterior impingement. Two cerclages, one
superior (green) and one inferior (blue), are then tightened and tied to fix the greater tuberosity in position (Fig.
5.21). The use of doubled-over strands of suture enables the surgeon to use a specific sliding knot—the “Nice
knot”—which can gradually be adjusted and tensioned before being finally locked, thereby optimizing tuberosity
fixation (see Appendix). Gentle range of motion of the shoulder will verify that the greater tuberosity has been
fixed securely.
The remaining two cerclages emerging from around the neck of the prosthesis are now passed through the deep
surface of the subscapularis tendon—lesser tuberosity bone interface, one superiorly (blue) and one inferiorly
(green), using a crimping needle or suture shuttle. The lesser tuberosity is now reduced into position, with the
arm in internal rotation. The reduction is maintained with a clamp, and the cerclage sutures are again tied using
the sliding Nice knot. Thus, at the end of this step, both tuberosities are reduced and securely fixed to the
prosthetic neck (Fig. 5.22). The fixation is reinforced by the two vertical tension-band sutures (one
anterosuperior through the subscapularis tendon and one posterosuperior through the infraspinatus tendon)
previously prepared that provide solid fixation of the tuberosities onto the humeral diaphysis (Figs. 5.23 and
5.24).

Final Assessment
The arm is internally and externally rotated both at the side and in 90 degrees of abduction to check for security
of tuberosity fixation, prosthetic stability, and range of movement. The arm is abducted and forward elevated to
check range of movement and verify that there is no impingement against the acromion, and adduction is
performed to check that there is no impingement against the scapular pillar.
FIGURE 5.22 Reduction of the lesser tuberosity. Both tuberosities are perfectly reduced and stabilized.

FIGURE 5.23 Fixation of the tuberosities on the humeral shaft with two vertical tension-band (anterosuperior and
posterosuperior).

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FIGURE 5.24 Final aspect of the tuberosities reconstruction around the stem.
Closure
A surgical drain is placed in the subacromial space to prevent hematoma formation, which is common in fracture
cases. The anterior deltoid is reattached securely using interrupted nonabsorbable transosseous sutures, and
the skin is closed in a standard manner (Fig. 5.25).

POSTOPERATIVE REHABILITATION
If the soft tissues are of poor quality or there is any doubt about the security of the anterior deltoid repair, we
place the patient into an abduction splint for 4 weeks. During this period, the patient is allowed to take the arm
out of the splint to perform passive pendular exercises several times a day to prevent stiffness (5 minutes, five
times a day, as a rule). Otherwise, a standard broad arm sling in neutral rotation is used with passive- and
active-assisted exercises for 4 weeks. Full active and isometric strengthening exercises can be initiated after 6 to
8 weeks once a good passive range of motion has been obtained.

RESULTS
To date, few studies have been published of the results of RSA for fracture. Bufquin et al. (11) and Klein et
al.(12) reported good pain relief and range of motion of approximately 110 degrees of abduction, 120
degrees of forward elevation, and 10 degrees of external rotation with the arm at the side, which compares
favorably with the results of hemiarthroplasty in similar patients. Restoration of internal rotation is more
variable. Radiological follow-up has shown a high incidence of progressive radiolucent lines and notching
especially around the glenoid component, although frank loosening is uncommon, reinforcing again that use
of RSA should be reserved for the elderly (13). Patients should be counselled that improvement continues
for up to a year postoperatively and that some limitation in internal and external rotation is to be expected.
The most common complications are infection and instability (14). Instability of the prosthesis is often
related to technical errors of implantation, especially not adequately restoring the humeral length or
implanting the glenoid too high.

FIGURE 5.25 Transosseous repair of the anterior deltoid.

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Nonunion or fixation failure of the tuberosities after a Reversed Shoulder Arthroplasty for acute proximal
humerus fractures in elderly patients (>70 years) has been reported to occur in up to 50%. This is thought
to be related to severe osteopenia/osteoporosis as well as the bulky prosthesis, which impedes anatomic
reduction of the tuberosities. Based on the good results observed with the Aequalis Hemi-Arthroplasty
Fracture prosthesis, we have designed a novel RSA specifically designed for anatomic tuberosity
positioning, fixation, and bone grafting of the proximal humerus: the Aequalis RSAFx. We have evaluated
the radiological and early to midterm functional results of this prosthesis in a prospective cohort study of 38
patients (average age, 78 years) operated (Fig. 5.26). Radiographs and CT scan at last follow-up were
used to assess bone healing of the tuberosities and eventual radiolucent lines around the implants. Mean
follow-up was 12 months (6 to 34 months).
The tuberosities healed in anatomic position in 87% (33/38) of the cases (Fig. 5.27): three patients had
partial lysis of the greater tuberosity and two had migration with final malposition and a hornblower sign.
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No implant loosened, became infected, or dislocated, and no patient required reoperation. At the last follow-
up, the average forward elevation was 116 degrees (80 to 150 degrees), external rotation 26 degrees (0 to
50 degrees), and average internal rotation was L5 (buttock-D10; Fig. 5.28). The mean Constant score was
58 points (23 to 79 points), and the adjusted Constant score was 88% (33% to 118%). The subjective
shoulder value was 70%.

FIGURE 5.26 A-C. Case of a 72-year-old woman. Four-parts fracture of the right humeral head.
FIGURE 5.27 A-C. The same case than Figure 5.26. CT scan at 3 months shows union of the greater
tuberosity and integration of the allograft through the window of the stem. Radiographic control at 9 months
shows correct position of the greater tuberosity and good union.
 FIGURE 5.28 A-C. The same woman at 1 year. No pain, 140 degrees of forward elevation, 50 degrees of
external rotation, and she can reach the 12th dorsal vertebrae in internal rotation.

CONCLUSION
In conclusion, a specifically designed reverse shoulder prosthesis is an attractive option for treating complex
proximal humerus fractures in the elderly, because it allows (a) better tuberosity healing, (b) active external
rotation (useful for ADLs), and (c) reduces the risk of complications.
We have found a specifically designed RSA for fractures is a valuable option for treatment of difficult
proximal humeral fractures in the elderly where other options are likely to lead to a poor result. Strict
attention needs to be paid to the technical aspects of the surgery to optimize the outcome and prevent
complications.

REFERENCES
1. Neer CS II. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J
Bone Joint Surg Am 1970;52(6):1090-1103.

2. Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop
Traumatol Surg Res 2010;96(6):683-694.

3. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes
after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg
2002;11(5):401-412.

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4. Boileau P, Watkinson DJ, Hatzidakis AM, et al. Grammont reverse prosthesis: design, rationale, and
biomechanics. J Shoulder Elbow Surg 2005;14(1 Suppl S):147S-161S.

5. Guery J, Favard L, Sirveaux F, et al. Reverse total shoulder arthroplasty. Survivorship analysis of eighty
replacements followed for five to ten years. J Bone Joint Surg Am 2006;88(8):1742-1747.

6. Sirveaux F, Favard L, Oudet D, et al. Grammont inverted total shoulder arthroplasty in the treatment of
glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J
Bone Joint Surg Br 2004;86(3):388-395.

7. Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am
1970;52(6): 1077-1089.

8. Neer CS II. Four-segment classification of proximal humeral fractures: purpose and reliable use. J
Shoulder Elbow Surg 2002;11(4):389-400.

9. Goutallier D, Postel JM, Bernageau J, et al. Fatty muscle degeneration in cuff ruptures. Pre- and
postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;(304):78-83.

10. Ladermann A, Williams MD, Melis B, et al. Objective evaluation of lengthening in reverse shoulder
arthroplasty. J Shoulder Elbow Surg 2009;18(4):588-595.

11. Bufquin T, Hersan A, Hubert L, et al. Reverse shoulder arthroplasty for the treatment of three- and four-
part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term
follow-up. J Bone Joint Surg Br 2007;89(4):516-520.

12. Klein M, Juschka M, Hinkenjann B, et al. Treatment of comminuted fractures of the proximal humerus in
elderly patients with the Delta III reverse shoulder prosthesis. J Orthop Trauma 2008;22(10):698-704.

13. Cazeneuve JF, Cristofari DJ. Delta III reverse shoulder arthroplasty: radiological outcome for acute
complex fractures of the proximal humerus in elderly patients. Orthop Traumatol Surg Res 2009;95(5):325-
329.

14. Farshad M, Gerber C. Reverse total shoulder arthroplasty-from the most to the least common
complication. Int Orthop 2010;34(8):1075-1082.

Appendix
The Nice Knot
Introduction
Knot tying is an essential skill in both open and arthroscopic surgery. Traditionally, flat nonsliding knots, such as
surgeon's knots and square knots, have been used in open surgery, as they have been perceived to be more
secure than sliding knots, while the development of arthroscopic and endoscopic surgery has resulted in the
description of many “new” sliding knots, due to the technical challenges of tying intracorporeal flat knots. A knot
should be easy to learn and tie, have good loop and knot security, and allow accurate control of the tension
applied.

Technique
Pass a single doubled-over suture around the tissues to be opposed. This results in a doubled suture running
around the tissues, with two free ends on one side, and a loop on the other (Fig. 5.A1). Throw a simple half hitch
(Fig. 5.A2) and then pass the two free ends of the suture through the loop (Fig. 5.A3). Dress the knot that is now
ready to be tightened (Fig. 5.A4). Tighten the knot by pulling the two free ends apart from each other, which
results in the knot sliding down (Fig. 5.A5). Alternatively, to tighten the knot, the free ends can be pulled
alternatively, or the knot can be slid down as with other sliding knots. Finally secure the knot by throwing three
alternating half hitches (Fig. 5.A6).

FIGURE 5.A1
FIGURE 5.A2

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FIGURE 5.A3
FIGURE 5.A4

FIGURE 5.A5
FIGURE 5.A6

This knot has several specific characteristics:

First, it uses a doubled-over strand of suture. This immediately results in effective doubling of the strength of the
suture, as the tension in each strand is halved, so reducing the risk of breakage. The doubling of the suture also
results in increased internal friction, giving excellent loop and knot security.
Second, tightening the knot by pulling the free ends apart results in a very similar feel to when tying a flat
surgeon's or square knot, allowing accurate tensioning of the suture.
Third, the tightening process can be stopped and resumed at any stage as the good loop security of the knot
prevents it from slipping. Thus, when repairing any tissue under tension, two or more sutures can be placed in
position and the knots prepared on each suture. Provisional tightening can then be performed, and the tissue
repair can be adjusted as required before final tightening and locking of the Nice knots. This is in stark contrast
to when tying a flat knot, which either requires constant tension on the post strand or immediate locking of the
knot.
 6
Humeral Shaft Fractures: Open Reduction Internal Fixation
Bruce H. Ziran
Navid M. Ziran

INTRODUCTION
The humerus, like the femur, is a single large tubular bone protected by a large circumferential muscle envelope.
Fractures of the humerus are common injuries and account for 2% to 3% of all fractures seen in clinical practice.
They follow a classic bimodal distribution with lower-energy injuries in the elderly and higher-energy fractures in
younger patients. The humerus is designated as number 1 in the AO/OTA classification, with fractures of the
proximal, middle, or distal third assigned a second numeral one, two, or three, respectively. The classification is
further subdivided based on articular involvement or complexity into A, B, and C patterns (Fig. 6.1). Most
fractures of the humerus occur in the middle one-third and are managed nonoperatively with initial splinting and
conversion to a functional brace 10 to 14 days after injury. With nonoperative treatment, nonunion rates are <2%
for closed fractures and 6% for open fractures (1). Regardless of the method of treatment, the goals for the
surgeon and patient remain fracture union with good alignment and rotation along with restoration of shoulder
and elbow function. While there is broad consensus regarding many aspects of humeral fracture care, several
treatment controversies remain. These include the indications for nonoperative versus surgical management,
when to use a nail versus a plate, the use of conventional versus locked plating, the number of cortices required
for fixation, and the management of associated radial nerve palsies. This chapter discusses current concepts in
management as well as the surgical approaches to the humeral shaft.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

The majority of isolated lower-energy closed humeral shaft fractures are best managed nonoperatively.
Klenerman first established guidelines for nonsurgical management in 1966. These guidelines were based more
on the cosmetic appearance of the limb rather than functional outcomes. He proposed upper limits of 30 degrees
of varus, 20 degrees apex anterior angulation, 15 degrees of malrotation, and 3 cm of shortening as compatible
with good function. In general, malunions following nonoperative treatment of humerus fractures are well
tolerated due to the compensatory range of motion at the shoulder and elbow and are predominantly a cosmetic
issue. Additionally, the large muscle mass of the upper arm conceals moderate degrees of deformity (1).
Strong indications for surgical repair of displaced humeral shaft fractures include the following (Table 6.1).

Polytrauma
The multiply injured patient with a concomitant humeral shaft fracture may benefit from early surgical stabilization
to improve mobilization, facilitate nursing care, and decrease pain (2, 3 and 4). However, the optimal timing for
surgical fixation in these patients is unknown since many of these patients have other serious injuries, and
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early or ill-advised surgery may activate the systemic inflammatory response system leading to a “second hit”
phenomena. Most patients with closed fractures who are unable to undergo early surgery should be placed into
a well-padded coaptation splint. In patients with open fractures, temporary external fixation can be helpful
(damage-control orthopaedics) with conversion to internal fixation when the patient's overall condition permits
(5). If external fixation is performed, the pins should be placed away from the fracture zone to decrease the risk of
infection.
FIGURE 6.1 AO/OTA classification of humeral shaft fractures. The humerus is designated as number 1. The
second number refers to the location along the shaft (proximal = 1, middle = 2, distal = 3)—the humeral diaphysis
would be designated as 1 and 2. The letters A, B, and C refer to the type of the diaphyseal fracture (simple,
wedge, or complex) with further numeral classification (1, 2, 3) based on fracture group. Lastly, subgroup
classification further localizes the fracture to the proximal, middle, or distal zone (.1,.2, or.3, respectively). For
example, a simple, oblique midshaft humeral shaft fracture would be 12-A2.1.

TABLE 6.1 Indications for Surgical Fixation of Humeral Shaft Fractures

1. Polytrauma

2. Segmental fractures

3. Ipsilateral forearm fracture (“floating” elbow)

4. Pathologic fracture

5. Bilateral humeral shaft fractures

6. Concomitant vascular injury

 7. Concomitant brachial plexus injury

8. Unacceptable alignment (>15-20 degrees in coronal/sagittal plane)

9. Secondary radial nerve palsy

10. Open fractures

Segmental Fractures
Segmental fractures with significant fragment displacement or angulation are difficult to manage nonoperatively.
Intramedullary nailing or plate osteosynthesis may be indicated to prevent malunion or nonunion. Minimally
displaced segmental humeral shaft fractures can often be treated nonoperatively if alignment can be maintained.

Ipsilateral Forearm Fracture

Patients with both a displaced humeral shaft and ipsilateral forearm fracture—the so-called floating elbow—
often benefit from early internal fixation of both fractures to facilitate rehabilitation of the elbow. Nonoperative
treatment of the humeral fracture is associated with an increased risk of nonunion in this infrequent injury pattern
(6).

Pathologic Fracture
Impending and pathologic fractures of the humerus are usually the result of metastatic cancer, and patients often
benefit from internal fixation to relieve pain and improve function. Due to compromised bone and the possibility of
skip lesions, locked intramedullary nailing is the preferred method of treatment because of less surgical
dissection, technical ease, and satisfactory pain relief (7). In patients with very proximal and distal pathologic
lesions, locked plating with or without cement augmentation may provide better stability.

Bilateral Fractures
Simultaneous fracture of both humeri is uncommon and is usually associated with polytrauma. These patients
often benefit from fixation of either one or both fractures to improve rehabilitation, ease nursing care, and
decrease pain.

Vascular Injury
Combined vascular injury and humeral shaft fractures can be limb-threatening injuries. The order of treatment is
based on the ischemic state of the limb. When vascularization is the priority, a simple external fixation device
should be employed to stabilize the fracture out to length and prevent disruption of the vascular repair when
internal fixation is required. In a smaller number of cases, the use of a temporary vascular shunt allows more
definitive fracture treatment followed by vascular repair.

Ipsilateral Brachial Plexus Injury

There is very little literature on humeral shaft fractures with ipsilateral brachial plexus injuries. Brien et al. (8)
showed improved union rates following plate fixation of the humerus compared to external fixation or
intramedullary nailing.

Open Fractures
Open fractures of the humerus usually require prompt stabilization after irrigation and débridement. In lowergrade
open fractures, immediate internal fixation is safe and effective if the patient's overall condition permits. In high-
grade open injuries, if the wound is contaminated or there is a significant soft-tissue disruption, irrigation and
débridement with temporary external fixation should be strongly considered.

PREOPERATIVE PLANNING
History and Physical Exam
A careful history and physical exam should be performed on all patients with a humerus fracture. The history
should identify the mechanism of injury (low- vs. high-energy, ballistic injury, etc.), pertinent comorbidities
(diabetes mellitus, cardiac problems, etc.), pertinent past surgical history, medications, and drug allergies. hand
dominance with any upper-extremity injury should be established. The physical exam should evaluate and
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document objective findings such as swelling, ecchymosis, open wounds, neurologic status, and peripheral
pulses. A full trauma workup is necessary in patients with high-energy trauma, complex associated injuries and in
patients who are obtunded or have a closed-head injury.

Imaging Studies
In patients with suspected extremity injuries, anteroposterior (AP) and lateral radiographs should be obtained that
include the “joint above and below.” Frequently, due to significant pain, high-quality orthogonal radiographs are
difficult to obtain in the conscious patient. Traction films with light sedation can be helpful in a cooperative
patient. For some patients, optimal films cannot be obtained until the patient is under anesthesia in the operating
room. CT scans are not usually necessary and are most often used in humeral fractures with proximal or distal
fracture extension into shoulder or elbow joints.

Timing of Surgery
The timing of surgery with humeral shaft fractures depends on whether the fracture is open or closed. With open
fractures, irrigation and débridement should be performed as soon as the patient's condition and institutional
resources permit. Patients with Grade I and II open fractures who are also hemodynamically stable may benefit
from immediate internal fixation. In Grade III open fractures or in patients with highly contaminated wounds,
splinting or external fixation is preferred with delayed internal fixation. If there is a vascular injury, exploration,
repair, and external fixation should be performed urgently in collaboration with a vascular surgeon. Low-velocity
gunshot wounds without a neurovascular injury are treated with local wound care, antibiotic administration, and
fracture stabilization if indicated. For most closed fractures of the humerus, internal fixation can be performed
electively in the first few days.

Surgical Tactic
Part of the preoperative plan includes choosing an appropriate surgical approach based on the location of the
fracture or traumatic wound (Fig. 6.2). Fractures that are located in the proximal and midshaft of the humerus are
usually addressed through an anterior or anterolateral approach. The straight lateral approach has also been
advocated for midshaft fractures, but extensive mobilization of the radial nerve with this exposure increases the
chance of an iatrogenic injury. The posterior approach is most often used for fractures in the distal one half of
the humerus. However, patient positioning makes it more difficult in multiply injured patients. The distal
anterolateral approach was less useful in the past because contouring a plate to the anterolateral column was
difficult, and there was limited opportunity for fixation in the relatively narrow lateral pillar. However, newer locked
plating systems provide better fixation in “short” segment situations and now make the anterolateral approach a
more attractive option for selected distal fractures. A summary of the approach and plate placement based on
fracture location is shown in Table 6.2.
FIGURE 6.2 The surgical approach to humeral shaft fractures is frequently dictated by the location of the
fracture. Proximal fractures are usually approached by the anterior approach. Midshaft fractures can be
approached by anterior, anterolateral, medial, and posterior approaches. Distal third fractures can be
approached by lateral, anterolateral, or posterior approaches.

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TABLE 6.2 Surgical Approach and Plate Placement Based on Anatomic Fracture Location

Fracture Approach Plate Placement

Proximal one-
third Anterior Anterior/lateral

Midshaft Anterior/anterolateral/posterior/medial Anterior/anterolateral/lateral/posterior/medial

Distal one-
third Posterior/anterolateral/lateral Posterior/anterolateral/medial

In open fractures, some of the soft-tissue dissection may have occurred due to soft-tissue stripping at the time of
injury and may influence the surgical approach. Surgical “versatility” is important to minimize additional soft-
tissue injury by performing a separate approach through compromised soft tissues. If the soft-tissue lesion is
primarily on the medial aspect of the arm, the surgeon should be prepared to utilize a medial approach for
fixation.

RADIAL NERVE INJURY

The function of the radial nerve is critical, and its integrity must be carefully evaluated and documented in
patients with humeral shaft fractures. A radial nerve palsy that occurs at the time of fracture is seen in 6% to 15%
of cases (9, 10 and 11). A recent meta-analysis of more than 1,000 cases of humeral fractures documented an
average incidence of radial nerve lesions in 11.8% of patients (12). In closed fractures, these injuries are usually
a neuropraxia and are seen most commonly in fractures in the lower third of the humerus (13). Numerous studies
have shown that treatment is observation since spontaneous recovery occurs in the vast majority of cases (9, 10
and 11).
On the other hand, if the radial nerve palsy occurs in the presence of an open fracture, most authors favor nerve
exploration and fracture stabilization since the nerve is frequently damaged or interposed between fracture
fragments (14). If there is a clean transection of the nerve with minimal soft-tissue contamination, acute repair is
indicated. In patients with gross contamination or traumatic nerve loss, delayed reconstruction is preferable. In
nerve lesions that span several centimeters, shortening of the humerus by 2 to 3 cm may facilitate a tensionfree
nerve repair. In irreparable nerve lesions, cable grafting with or without tendon transfers may be indicated.
The management of a radial nerve palsy after closed reduction (secondary nerve palsy) is more controversial. In
a meta-analysis of over 1,000 humeral fractures, Shao et al. (12) demonstrated no significant difference in
recovery rate between primary (88.6%) and secondary (93.1%) nerve palsies (including those palsies after
closed reduction)—although the number of secondary nerve palsies from closed reduction was not quantitated in
this study.
The treatment of a radial nerve palsy includes functional splinting of the wrist and hand as well as range of
motion to prevent contractures. Electromyography/nerve conduction velocity studies should be performed
between 4 and 12 weeks after injury if there are no clinical signs of recovery. A positive prognostic sign of
recovery is an advancing Tinel's sign indicating the nerve regeneration. The brachioradialis is the first muscle to
recover, but wrist extension is easier to monitor.

SURGERY
For the majority of patients, we prefer general anesthesia with a muscle-paralyzing agent to facilitate fracture
reduction. Regional anesthesia can be used but marked swelling in the upper arm and shoulder often obscures
anatomic landmarks making this technique more difficult. If the surgery is likely to exceed 2 to 3 hours due to
fracture complexity, expected blood loss, or other planned procedures, a Foley catheter should be inserted. An
arterial line should be used in patients with cardiovascular comorbidities or potential hemodynamic instability.
Lastly, careful consideration should be given to patient positioning and the need to obtain high-quality
intraoperative fluoroscopic images. We prefer a completely radiolucent table that allows imaging from the elbow
to the shoulder. If a standard OR table, with a “hand table” is used, the surgeon should ensure that full imaging
of the entire arm is possible before the prep and drape. If the patient is positioned supine for an anterior or
anterolateral approach, the surgeon typically sits on the lateral side of the extremity, and the C-arm is brought in
from the medial (axillary) side (Fig. 6.3A). For a posterior approach with the patient in either the prone or lateral
position, fluoroscopic imaging is more difficult. In this case, a modified arm board or well-padded radiolucent
“block” is used to support the arm without interfering with C-arm access (Fig. 6.3B). The surgeon must rehearse
the maneuvers necessary to obtain high-quality images before the patient is prepped and draped. In all cases,
horizontal positioning of the arm is necessary to offset gravity and allow unimpeded elbow motion.
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FIGURE 6.3 A. Patient and C-arm positioning for an anterior or anterolateral approach to the humerus. B. Prone
positioning for a posterior approach.

SURGICAL APPROACHES
Anterior
The anterior approach (of Henry) to the humerus is used for anterior extensile exposure of the humerus and can
be utilized for most fractures of the humerus. Caution must still be taken to avoid injury to the radial nerve in the
middle and distal part of this exposure. The patient is positioned supine on the operating table with the arm
placed on a radiolucent table or abducted on a hand table. The affected extremity is prepped and draped from
the finger-tips to include the axilla, shoulder, and chest wall. The C-arm must be positioned to obtain
unobstructed AP and lateral views of the humerus. A tourniquet is not advised since it interferes with the surgical
exposure.
The landmarks for the anterior exposure of the humerus are the coracoid process proximally and the lateral
border of the biceps muscle and tendon. The internervous plane proximally is between the deltoid (axillary nerve)
and the pectoralis major (medial and lateral pectoral nerves). In the proximal part of the exposure, the
deltopectoral groove and cephalic vein are identified, and dissection is carried down through the clavipectoral
fascia. The deltoid and pectoralis major insertions as well as the biceps tendon are identified. A portion of the
pectoralis insertion can be released if needed, and the biceps muscle belly is elevated from the underlying
brachialis muscle and retracted medially. The brachialis muscle is divided in its midline to preserve its dual nerve
supply (musculocutaneous nerve-medial fibers, radial nerve-lateral fibers). In the distal aspect of the incision, the
radial nerve must be identified in the interval between the brachioradialis and brachialis muscles. It is critical to
identify the location of the radial nerve in fractures of the middle and distal humerus to avoid injury during
reduction and fixation. Figure 6.4 demonstrates patient positioning, superficial and deep dissections of the
anterior approach, and plate placement.
Anterolateral Approach for Fractures in the Distal Third
There is little difference between the anterolateral and anterior approaches except a slightly more lateral skin
incision (anterolateral) and the deep dissection being tailored for plate placement. The deep interval remains the
same in both approaches, but in the anterolateral approach, there is preferentially more laterally based
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dissection of the muscle from bone with less anterior and medial dissection. The skin incision is placed on the
lateral edge of the biceps muscle down to the flexion crease, at which point it crosses parallel or in the skin
crease to the mid-line and can continue down the forearm as the Henry exposure. The internervous and
muscular planes are the same as the anterior approach. The radial nerve is identified as previously described. At
this point, an extraperiosteal dissection of the brachialis and brachioradialis will expose the lateral column of the
humerus to the elbow joint, which can be opened to accurately visualize the distal and lateral aspects of the
humerus. The lateral ligamentous complex should not be detached. The anterolateral approach is useful for
distal third fractures of the humerus and can be extended proximally and distally. Figure 6.5 demonstrates the
deep dissection of the anterolateral approach for a distal fracture. Pre- and postoperative radiographs of
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an anterolaterally placed plate for a distal humerus fracture are shown in Figure 6.6. Skin incision is shown in
Figure 6.7.
FIGURE 6.4 Anterior approach to the humerus. A. The patient is positioned supine with the arm on a hand table
and skin incision. B. The belly of the biceps brachii with a tagged superficial vein. The biceps muscle is retracted
medially to reveal the underlying brachialis (C). The musculocutaneous nerve is found under the brachialis (D).
After the biceps is retracted medially, the brachialis is split in its midline (E-G) to reveal the fracture. The radial
nerve is located between the brachialis and brachioradialis (H). The fracture is first repaired with lag screws (I).
A 4.5-mm narrow LC-DCP plate is used as a protection plate (J,K). Note the plate was contoured slightly due to
a preexisting deformity. L-O. Pre- and postoperative radiographs.
FIGURE 6.4 (Continued)
FIGURE 6.4 (Continued)
FIGURE 6.4 (Continued)
FIGURE 6.5 A. The anterolateral exposure after splitting the brachialis. The radial nerve is identified by the
vessel loop (A,B), and a template was used as shown in (B). In this case, the fracture was distal, and the plate
was contoured (C) to rest on the anterolateral aspect of the distal humerus (D).

Posterior Approaches
The posterior approach is used for fractures in the distal one-half of the humeral shaft and is the approach of
choice in patients with distal periarticular or intra-articular humeral fractures. In this approach, the patient is
positioned in either the lateral decubitus or prone position. The prone position facilitates the use of fluoroscopy
for these fractures. As mentioned earlier, the arm can hang over either a radiolucent arm holder or a roll of
blankets on a radiolucent arm board. A sterile tourniquet can be used if it does not impede the surgical approach.
The landmarks are posterior acromion and olecranon. There is no internervous plane as dissection
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entails splitting the lateral and long heads of the triceps (radial nerve). The muscle is innervated proximally near
its origins, and a longitudinal dissection will not denervate the muscle. It is important to remember that the triceps
is composed of three heads: (a) the lateral head arising from the lateral lip of the spiral groove, (b) the long head
arising from the infraglenoid tubercle, and (c) the medial (deep) head, which rests along the posterior aspect of
the humerus from below the spiral groove to the distal one-quarter of the humerus. The radial nerve lies in the
plane between the lateral and long heads of the triceps. The position of the radial nerve on bone can also be
estimated by placing both hands along the back of the humerus with one small finger on the posterior acromial
edge and the other on the olecranon. The junction where the surgeon's thumbs meet in the mid-portion of the
arm is typically where the radial nerve is found on deep dissection. After the skin incision, the fascia over the
lateral and long head of the triceps should be split longitudinally in the midline, extending down to the triceps
tendon, if needed. The interval between the lateral and long head should be developed by careful blunt
dissection to prevent injury to the radial nerve and profunda brachii artery. The radial nerve and profunda brachii
artery should be identified superficial and proximal to the medial head of the triceps. Because a vascular leash
accompanies the radial nerve, excessive dissection around the nerve may result in injury to these delicate
vessels. The medial head of the triceps is then gently dissected off the humeral shaft to allow for bony exposure
and plate placement. Care should also be taken to avoid injury to the ulnar nerve in the distal humerus as it
passes from anterior to posterior, piercing the medial intermuscular septum and emerging distally from the
triceps. Figure 6.8 demonstrates the superficial and deep dissections of the posterior approach.
FIGURE 6.6 A-D. Pre- and postoperative x-rays demonstrating anterolateral plate placement for a distal one-
third humerus fracture.

FIGURE 6.7 A,B. Post-op clinical result and skin incision crossing the elbow flexion crease following
anterolateral plate placement for a distal onethird humerus fracture.

As an alternative to a triceps-splitting approach, a triceps-reflecting approach has recently been advocated as a

safer but equally effective means of accessing the posterior humeral shaft (15). In this approach shown in Figure
6.9, the skin incision remains posterior, but the deep exposure can be performed by one of two methods. In one
method, the triceps muscle is released from the lateral intermuscular septum and elevated along with the medial
head from the posterior aspect of the humerus. Using this approach, the radial nerve is easier to identify in the
lateral aspect of the posterior compartment, and most of the accompanying vessels have already arborized into
the muscle. In fractures with a more distal component, a second method mobilizes the triceps both medially and
laterally from their septum to provide access to the epimetaphyseal region. With either approach, the radial or
ulnar nerves must be safely identified and protected. With the para-tricipital approach, there is less trauma to the
triceps muscle and less bleeding since the muscle is elevated rather than split. The authors have now adopted
this approach as their preferred method when a posterior approach is indicated.

Lateral
The patient is positioned supine with the arm lying over the chest or on a hand table. The distal landmark is the
lateral epicondyle with proximal extension up the humeral shaft. There is no true internervous plane for this
approach because the radial nerve innervates the brachioradialis, triceps as well as the lateral half of the
brachialis. This approach is based on the description by Mills et al. (16) and shown in Figure 6.10. Sharp
dissection is carried down to the investing fascia of the posterior compartment. The posterior skin and
subcutaneous tissue over the fascia is developed. After triceps fascial incision, the surgeon gains access to the
posterior compartment. The triceps muscle is gently dissected off the overlying fascia until the lateral
intermuscular septum is identified. The lateral intermuscular septum separates the medial head of the triceps and
brachioradialis (distally) and the lateral head of the triceps and brachialis (proximally). The interval between the
triceps and the lateral intermuscular septum is developed from distal to proximal. The radial nerve pierces the
lateral intermuscular septum approximately 15 cm above the lateral humeral epicondyle. After identification of the
nerve, the lateral intermuscular septum can be divided. The nerve can then be tracked distally as it courses from
the posterior to the anterior compartment and passes between the brachialis and mobile wad. Proximally, the
nerve courses posteriorly toward the axilla with tight fascial bands of the lateral head of the triceps impeding
proximal dissection; these fascial bands can be released if necessary for proximal exposure. To summarize, the
main anatomic structures of the lateral approach are (a) the lateral head of the triceps posteriorly, (b) the
brachialis (inferior to the deltoid insertion and lying along the bone), (c) the biceps brachii (anteriorly), (d) the
radial nerve as it courses from posterior to anterior, and (e) the lateral intermuscular septum, which essentially
separates the triceps from the more lateral/anterior anatomic structures (brachioradialis and brachialis).
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FIGURE 6.8 The posterior approach to the humeral shaft. A. The positioning and skin incision (landmarks are
the posterior acromion and the olecranon process). After skin incision, the triceps fascia is identified as shown in
(B). The approximate location of the radial nerve can be estimated as shown in (C). After blunt dissection of the
lateral and long triceps heads, the medial head should be gently subperiosteally dissected to expose the fracture
(D,E).

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FIGURE 6.8 (Continued) In some cases, the medial head may be disrupted from the initial trauma. The fracture
is then repaired with lag screws and, in this case, a 4.5-mm narrow plate (F,G). The neurovascular bundle can
be seen in (G) coursing around the lateral aspect of the plate. Another case is shown in (H) with the bundle
coursing medial to lateral around the posterior aspect of the humerus. I,J. Pre- and postoperative radiograph
after posterior humeral plate fixation.

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FIGURE 6.8 (Continued)

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FIGURE 6.9 Paratricipital approach to humeral shaft. The patient is positioned prone with the skin incision
similar to the posterior approach. Instead of splitting the triceps, the medial and lateral aspects of the triceps are
released from the posterior humerus. Care is taken to avoid injury to the ulnar nerve medially (green arrow) and
the radial nerve laterally (yellow arrow). In this case, 3.5-mm reconstruction plates were used, and the lateral
plate was placed under the radial nerve.

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The anterior third of the deltoid insertion usually has to be released for placement of a lateral plate but due to its
large and expansile insertion, there is little morbidity to a limited release. If the plate is placed laterally, it usually
needs to be contoured due to the varied anatomy of the bone. During plate placement, the nerve has to be
inspected to ensure that it does not become entrapped beneath the plate. In some cases, there is significant
tension on the nerve; in such a case, the radial nerve can be transposed through the fracture site so that it is
away from the plate (17). While the soft-tissue dissection to perform this technique may be considerable, it may
be preferable to a tented or injured radial nerve. If a future surgery is necessary, the radial nerve is at less risk
because it is transposed away from the surgical exposure. Figure 6.10 demonstrates the lateral approach in a
cadaver. Radial nerve transposition through the fracture site is shown in Figure 6.11.

Medial
This approach is used most often when there is a vascular injury or a large medial wound associated with an
open fracture. The medial approach is uncommon and based on the need to access the brachial vessels. There
are numerous structures at risk but, with careful dissection, mobilization of the brachial artery and ulnar nerve
can be accomplished. The patient is positioned supine with the arm extended on a hand table. A tourniquet is not
commonly used because it interferes with the exposure. The landmarks are the medial epicondyle distally and
the posterior edge of the biceps brachii proximally. The skin incision is made along the posterior edge of the
biceps. The investing fascia is incised, and the neurovascular bundle is identified posterior to the biceps brachii.
The brachial artery, median nerve, basilic vein, and antebrachial cutaneous nerve are retracted anterolaterally.
The ulnar nerve is retracted posteromedially. Hemostasis should be meticulous due to many arterial and/or
venous branches. Once the neurovascular bundle is exposed and protected, the medial intermuscular septum is
identified and, if needed, can be dissected from the bone to improve exposure. The triceps can be elevated off
bone posteriorly and the coracobrachialis muscle anteriorly if needed. The medial aspect of the humerus should
now be exposed.
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FIGURE 6.10 Lateral approach to the humerus. The skin incision is demonstrated in (A). Note the radial nerve
(blue arrow) piercing through the lateral intermuscular septum proximally (green circle) and coursing over the
brachialis (green arrow) distally in (B). The lateral head of the triceps is shown posterior to the radial nerve (red
arrow). C. The radial nerve coursing around the fracture. The radial nerve (blue arrow) is gently freed up by
blunt proximal dissection (D). The plate is placed under the nerve (E). F-I. Lateral humeral plate placement with
accompanying radiographs. The radial nerve (blue arrow) is visualized distally between the brachioradialis and
brachialis (green arrow). Note that the anterior aspect of the deltoid was taken down to allow for plate placement
(yellow arrow).

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FIGURE 6.10 (Continued)

In cases of vascular injury, reperfusion is the priority; however, a laterally based external fixator (damage control)
that maintains length and alignment, followed by delayed internal fixation, as the patient's condition and soft
tissue permit. When using a medial plate, we recommend placing it in a more anterior position so if revision
surgery becomes necessary, it can be accessed through an anterolateral approach as opposed to a difficult
revision through the scarred medial approach. Figure 6.12 demonstrates an example of a humeral shaft fracture
with a medial open wound managed with ORIF.

IMPLANT SELECTION
Historically, large fragment plates (broad and narrow 4.5 mm) have been advocated for internal fixation of
humeral shaft fractures. More recently, 3.5-mm locking compression plates have been presented as a potential
option for fixation of humeral shaft fractures (4,18). Due to lack of supporting studies, the authors recommend the
use of 4.5-mm plates for most diaphyseal fractures and reserve 3.5-mm plates for small-stature patients or
fractures with epimetaphyseal extension.

FRACTURE FIXATION
Current concepts in fracture fixation have shifted dramatically to emphasize soft-tissue preservation techniques
that minimize excessive stripping or retraction of the tissues. Muscle attachments should be maintained
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whenever possible, and only the necessary amount of muscle should be stripped for fracture visualization and/or
implant placement. The periosteum should be maintained whenever possible. The surgeon should always strive
to respect both the fracture and the surrounding soft tissues.

FIGURE 6.11 Radial nerve transposition during the lateral approach. A-C. A more posterior-oriented view of the
radial nerve as it is transposed through the fracture site. The fracture with lateral plate placement (D,E) and the
radial nerve transposed.
FIGURE 6.12 A-E. Left humeral shaft fracture with open medial wound. External fixation was performed followed
by definitive fixation. B,C. Biceps retracted laterally with the median nerve (anterior), brachial artery (blue arrow),
and ulnar nerve (green arrow). C. Plate placement medially under the neurovascular bundle. D,E. The fracture
before and after medial plate placement, respectively.

Traditional teaching has emphasized the need to evacuate the fracture hematoma to allow better visualization for
fracture interdigitation and reduction. However, the fracture hematoma is rich in proteins and cytokines and plays
an important role in fracture healing (19,20). The hematoma should only be evacuated in simple fracture
patterns, where interfragmentary fixation or anatomic reduction and absolute stability are desired. In comminuted
fractures, where only alignment and relative stability are necessary, we believe that the hematoma should not be
disturbed.
A better understanding of the biomechanics of fracture fixation has improved our knowledge of construct stability
and stiffness. In general, absolute stability is best utilized when anatomic reductions can be achieved in two- and
three-part “simple” fractures. Absolute stability generally produces a “stiff” plate construct, which is best
achieved with lag screws and compression plating, in fractures with short working lengths. Comminuted fractures
that are treated with spanning plates produce relative stability. For example, a longer plate fixed proximally and
distally with screws away from the fracture zone allows for micromotion at the fracture site—the “working length”
of the plate. The surgeon can partially modulate the construct stiffness by altering the number and type of
screws as well as their position in the plate relative to the fracture site. Despite the improved stability that is
obtained with locking plates and screws, we strongly recommend engaging at least seven to eight cortices above
and below the fracture for nearly all patients.

Bridge Plating
In comminuted fractures, the surgeon can either perform a full exposure with bridge plating or consider minimally
invasive plating osteosynthesis (MIPO) to establish alignment, length, and rotation. With either approach, these
parameters can be difficult to determine intraoperatively. We frequently use radiographs of the contralateral side
as a template. With bridge-plating techniques, care should be taken to minimize soft-tissue and periosteal
stripping of the bone. The plate is then secured to either the proximal or distal fragment with cortical screws
away from the fracture zone. The goal in plating of these fractures is restoration of length, rotation, and
alignment as best as possible, and this portion of the procedure can be very challenging. Bone contour can aid
in establishing rotation, the plate can establish alignment, but length may need to be determined by comparison
to the contralateral side. Once these parameters are established, the plate is then fixed proximally and distally,
with screws outside the fracture zone. The bridge plate allows for motion around the fracture zone and may
stimulate osteogenesis. If the comminution is significant, placement of autogenous bone graft should be
considered. In some cases, the surgeon may decide to shorten the humerus a few centimeters. Alternatively, an
intramedullary nailing may be another good treatment option.

Future Directions
MIPO of the humeral shaft has recently been proposed to be an alternative to standard open plating. If the zone
of comminution is particularly long, MIPO may be preferred because of the extensive soft-tissue dissection and
possible stripping required for exposure and plate application. The technique takes advantage of locked screws
and long plate spans to create a “flexible but stable” construct. The plate is placed anteriorly because it avoids
the neurovascular structures. Figures 6.13, 6.14 and 6.15 demonstrate MIPO plating of the humerus. We often
use a temporary external fixator as a “mini-distractor” to hold gross alignment and length.
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The insertion/fixation portals are remote from the zone of injury and provide ample access to place three screws
on each end of the plate. Generally, a 9 to 12-hole narrow 4.5-mm plate is centered over the fracture zone, and
small incisions are placed just proximal and distal to the ends of the plate. Proximally, the biceps tendon serves
as an anterior landmark. The pectoralis insertion is released as needed. Two small Hohmann retractors are used
to center the plate on the humerus. Distally, the incision is based on the anterolateral exposure. The exposure
first finds the musculocutaneous cutaneous nerve along the biceps muscle. The biceps muscle and
musculocutaneous nerve are retracted medially, and the radial nerve is identified. With knowledge of the nerve
locations, the brachialis muscle is split, and two small Hohmann retractors are used to guide the plate over the
distal humerus. The plate is then inserted proximal to distal while the surgeon places a finger into the distal portal
to “receive” and guide the plate into the distal portal. Once the plate is centered over the fracture site and bone,
a unicortical nonlocking screw is placed into the second hole from the end to “pull” the plate to bone. The
fracture alignment is checked and adjusted before the opposite side of the plate is stabilized with another
unicortical screw into the second hole from the end of the plate. At this point, alignment is verified and the screws
are tightened. Bicortical locking screws are placed above and below the fracture. The initial unicortical screw can
be changed for a bicortical locking screw depending on the bone quality. Unicortical screws are used in case
adjustments to the plate require a new screw hole to be made. Using a unicortical screw spares the “far cortex,”
which is important for locked screw fixation. Figure 6.15 demonstrates pre- and postoperative x-rays after MIPO
plating. This technique invokes the principle of relative stability and is most useful in comminuted fractures but
has successfully been used in all fracture patterns.

FIGURE 6.13 Minimally invasive percutaneous osteosynthesis of the humerus. Fracture length is maintained by
an external fixator, and plate size is estimated using fluoroscopy.

FIGURE 6.14 MIPO of the humerus cont. The anterior aspect of the distal humerus is exposed after retraction of
both the radial and musculocutaneous nerves and splitting of the brachialis muscle. The plate is passed from
proximal to distal, and the surgeon's finger “catches” the plate through the distal exposure (A). Plate position is
confirmed using direct visualization (B) and fluoroscopy. A unicortical screw is placed in the second to last hole
on both sides of the plate to pull the plate to the bone—these screws can later be replaced by uni- or bicortical
locking screws. Final photo showing closure of the incisions (C).

POSTOPERATIVE CARE
Postoperatively patients are allowed to use their arm for activities of daily living if stable fixation has been
achieved. Range-of-motion exercises for the shoulder and elbow are started in the first week after surgery.
Patients are seen in clinic at 2 weeks for suture/staple removal with subsequent visits at 4, 8, 12, 24, and 48
weeks
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postoperatively with radiographs. Patients are not allowed to lift weight through the affected extremity until there
is radiographic evidence of bridging callus (three of four cortices). Complete healing of the humeral shaft usually
takes 12 to 16 weeks but can vary depending on the fracture pattern and the patient's health status.
FIGURE 6.15 Pre- (A) and postoperative radiographs (B,C) after MIPO plating of the humerus. Notice the
unicortical screw to pull the plate to the bone.

COMPLICATIONS
The most common complications following internal fixation of the humerus are infection, nonunion, and
iatrogenic radial nerve palsy. Infections are more common after open fractures. A patient with a
postoperative infection should undergo irrigation and débridement with culture-specific intravenous
antibiotic therapy. If the fracture fixation is stable, we advocate aggressive débridement, use of antibiotic
delivery depots (bone cement or calcium sulfate), and systemic antibiotic suppression. Once the fracture
has healed, early hardware removal and external bracing are utilized until the fracture strengthens enough
to withstand physiologic loads. If the fracture fixation is loose or unstable, then treatment consists of
hardware removal, débridement, and external fixator or a brace followed by delayed reconstruction. A recent
study of 121 patients who developed deep
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infection after internal long bone fracture fixation demonstrated that 71% went on to fracture union with
operative débridement, retention of implants, and antibiotic therapy (21).
Nonunion rates following internal fixation of the humerus are reported to be 6% (22). The etiology of the
nonunions may be related to (a) comminution with extensive soft-tissue damage, (b) vascular injury, (c)
fracture instability, (d) significant fracture displacement with interposed soft tissue, (e) infection, and (f)
pathologic fracture. There is a significant risk to the radial nerve during revision or nonunion surgery - thus,
adding increased importance to the initial surgery (17). For atrophic nonunions, revision plating with bone
grafting remains the treatment of choice. If the nonunion is hypertrophic, then improving stability is usually
successful. Conversion from plating to nailing for nonunions has not been as successful.
Iatrogenic radial nerve palsy after internal fixation has been reported to occur in 5% to 10% of cases. These
palsies are best treated with observation for 4 months—since most recover in 3 to 6 months (23).

SUMMARY
The majority of humeral shaft fractures can be treated nonoperatively. Common indications to perform
internal fixation include polytrauma, “floating” elbow injuries, open fractures, radial nerve palsy after closed
reduction, concomitant vascular injury, and unacceptable alignment. Fracture location frequently dictates
surgical approach. The majority of midshaft fractures can be addressed through the anterior or anterolateral
approach. Distal fractures can be repaired via the posterior approach. Highly comminuted fractures are
amenable to bridge plating or anterior submuscular MIPO plating. Four point five (4.5) mm narrow plates are
recommended for most fractures, although 3.5-mm plates can be used in simple fractures and those with
epimetaphyseal extensions. Primary nerve palsies are typically observed for 4 to 6 months while the
treatment of secondary radial nerve palsies following closed reduction remains controversial. Internal
fixation of humeral shaft fractures has a high union rate and relatively few complications with careful, well-
planned surgery.

ACKNOWLEDGMENTS
The authors would like to acknowledge Maria Christina Bouchard for providing assistance in obtaining the
references for this chapter.
REFERENCES
1. Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral
diaphysis. J Bone Joint Surg Am 2000;82:478-486.

2. Bell MJ, Beauchamp CG, Kellam JK, et al. The results of plating humeral shaft fractures in patients with
multiple injuries. The Sunnybrook experience. J Bone Joint Surg Br 1985;67(2):293-296.

3. Tingstad EM, Wolinsky PR, Shyr Y, et al. Effect of immediate weightbearing on plated fractures of the
humeral shaft. J Trauma 2000;49:278-280.

4. Idoine JD, French BG, Opalek JM, et al. Plating of acute humeral diaphyseal fractures through an anterior
approach in multiple trauma patients. J Orthop Trauma 2012;26(1):9-18.

5. Suzuki T, Hak DJ, Stahel PF, et al. Safety and efficacy of conversion from external fixation to plate fixation
in humeral shaft fractures. J Orthop Trauma 2010;24(7):414-419.

6. Rogers JF, Bennett JB, Tullos HS. Management of concomitant ipsilateral fractures of the humerus and
forearm. J Bone Joint Surg Am 1984;66(4):552-556.

7. Dijkstra S, Stapert J, Boxma H, et al. Treatment of pathologic fractures of the humeral shaft due to bone
metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone
cement. Eur J Surg Oncol 1996;22(6):621-626.

8. Brien WW, Gellman H, Becker V, et al. Management of fractures of the humerus in patients who have an
injury of the ipsilateral brachial plexus. J Bone Joint Surg Am 1990;72(8):1208-1210.

9. Garcia A Jr, Maeck BH. Radial nerve injuries in fractures of the shaft of the humerus. Am J Surg
1960;99:625-627.

10. Kettelkamp DB, Alexander H. Clinical review of radial nerve injury. J Trauma 1967;7:424-432.

11. Pollock FH, Drake D, Bovill EG, et al. Treatment of radial neuropathy associated with fractures of the
humerus. J Bone Joint Surg Am 1981;63:239-243.

12. Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated with fractures of the shaft of the
humerus: a systematic review. J Bone Joint Surg Br 2005;87(12):1647-1652.

13. Holstein A, Lewis GB. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am
1963;45:1382-1388.

14. Foster RJ, Swiontkowski MF, Bach AW, et al. Radial nerve palsy caused by open humeral shaft
fractures. J Hand Surg Am 1993;18:121-124.

15. Gerwin N, Hotchkiss RN, Weiland AJ. Alternative exposures of the posterior aspect of the humeral
diaphysis with reference to the radial nerve. J Bone Joint Surg Am 1996;78(11):1690-1695.

16. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for
fracture treatment. J Ortho Trauma 1996;10:81-86.

17. Olarte CM, Darowish M, Ziran BH. Radial nerve transposition during humeral fracture fixation: preliminary
results. Clin Orthop Relat Res 2003;413:170-174.

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18. Catanzarite J, Alan R, Baig R, et al. Biomechanical testing of unstable humeral shaft plating. J Surg
Orthop Adv 2009;18(4):175-181.

19. Street J, Winter D, Wang JH, et al. Is human fracture hematoma inherently angiogenic? Clin Orthop
Relat Res 2000;378:224-237.

20. Kloen P, Di Paola M, Borens O, et al. BMP signaling components are expressed in human fracture callus.
Bone 2003;33(3):362-371.

21. Berkes M, Obremskey WT, Scannell B, et al. Maintenance of hardware after early postoperative infection
following fracture internal fixation. J Bone Joint Surg Am 2010;92(4):823-828.

22. Gregory Jr RG. Fractures of the shaft of the humerus. In: Bucholz R, Heckman J, eds. Rockwood and
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humeral shaft fractures. J Trauma 2009;66(3):800-803.
 7
Humeral Shaft Fractures: Intramedullary Nailing
James C. Krieg

INTRODUCTION
Humeral shaft fractures are relatively common injuries and are estimated to account for up to 3% of fractures
seen in clinical practice. The majority of fractures occur as isolated injuries; however, a small but significant
number occur as part of a more complex constellation of upper extremity trauma or occur in a multiply injured
patient.
There is a classic bimodal pattern of injury, with older patients sustaining fractures following low- and
intermediate-energy falls. On the other hand, injuries may be due to high-energy mechanisms, such as motor
vehicle or motorcycle accidents, falls from heights, industrial injuries, gunshot wounds, etc. in younger patients.
Depending on the mechanism of injury, fractures range from fairly simple patterns, such as spiral or transverse,
to complex ones, which can be segmental or comminuted. Fracture patterns commonly seen in the humeral shaft
are illustrated in the OTA/AO classification (Fig. 7.1).
Historically, isolated lower-energy humeral shaft fractures have been treated nonoperatively, with excellent
results. Numerous authors have shown union rates of 95% to 98% with this method of treatment (1,3). However,
in patients with higher-energy or displaced fractures, nonoperative treatment is less successful, and most of
these patients benefit from internal fixation.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

The goals of treatment following a humeral shaft fracture are union of the fracture, with minimal deformity that
does not impair function or become a cosmetic issue. Treatment must allow early functional restoration of
shoulder and elbow motion and recovery of muscle strength.

NONOPERATIVE TREATMENT
Nonoperative management is indicated for most closed, isolated, lower-energy humeral shaft fractures. The
functional fracture brace method of Sarmiento remains the treatment method of choice for closed management.
The patient is initially placed in a plaster coaptation splint until the acute swelling and pain have diminished.
Most patients can be safely placed into a Sarmiento functional fracture brace a week following injury. Today,
these braces are prefabricated, come in numerous sizes, and are easily adaptable to individual patients. The
brace consists of polyethylene anterior and posterior shells. The margin of one shell fits inside the other. The
halves are secured with velcro straps, allowing for continuous adjustment. Patients are encouraged to wear it
snugly, adjusting daily (1).
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FIGURE 7.1 AO/OTA classification of humeral shaft fractures.

Slings are discontinued after a few weeks to minimize shoulder or elbow stiffness. Patients are instructed in
shoulder pendulum exercises and active and passive range of elbow motion. The brace is worn for 8 to 12
weeks, until healing is seen radiographically and arm motion is pain free. Success rates with this method of
treatment are very high, with union rates >95% reported (1).

SURGICAL TREATMENT
There is a large group of patients in whom closed, nonoperative functional humeral bracing is not indicated. In
these patients, surgery is required to restore limb alignment, provide access to the soft tissues, mobilize the
extremity, or permit weight bearing through the extremity when lower extremity function is impaired.
There are several consistent indications for internal fixation of humeral shaft fractures using either plate
osteosynthesis or intramedullary nailing. These include pathologic or impending pathologic fractures in order to
relieve pain, improve stability, and facilitate cancer chemotherapy or radiation. Open fractures of the humerus
typically benefit from early fracture stabilization to improve the treatment of the open wounds, thereby reducing
the risk of infection. Similarly, humeral fractures associated with arterial injuries are best treated with early
fixation to protect the brachial vessel repair. Another strong indication for surgery is the patient with ipsilateral
fractures of the humerus and forearm. Stabilization of both fracture sites allows for early range of elbow motion.
In patients with bilateral humerus fractures, at least one, and often both, should be fixed surgically to
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decrease morbidity and facilitate activities of daily living. Lastly, in patients with an ipsilateral brachial plexus
injury, surgery is typically indicated to reduce the risk of nonunion and facilitate early therapy.
Relative indications for operative management of humeral shaft fractures include displaced segmental fractures.
These fractures are difficult to control in a fracture brace, increasing the relative risk of nonunion or malunion (2).
In polytraumatized patients, internal fixation of a humeral shaft fracture may improve pain control, allow activities
of daily living, and facilitate patient mobilization.
Operative treatment is also indicated in patients in whom an acceptable reduction cannot be obtained or
maintained in a fracture brace. Surgery may be indicated in a patient with closed humeral fracture and softtissue
injuries or abrasions that preclude brace application. Other patients do not tolerate bracing due to persistent pain
or fracture instability due to their body habitus. Social considerations, such as job impairment, family needs, self-
care, etc., may lead some patients to request operative treatment, which should be individualized.
In the critically ill or multiply injured patient, most closed fractures of the humerus are best treated initially with a
coaptation splint. Once the patient's overall condition has improved, internal fixation, when indicated, can be
performed.

Implants: Plate Versus Nail

Several prospective randomized trials have shown comparable outcomes in patients with humeral shaft fractures
treated with a plate or nail. Nevertheless, plate osteosynthesis remains the standard in surgical treatment of the
majority of operative fractures of the humeral shaft in North America. Advantages of plating include anatomic
reduction and compression fixation of noncomminuted fracture patterns. In addition, open surgery allows for
exposure and protection of the radial nerve. In comminuted fracture patterns, bridge plating with restoration of
length, alignment, and rotation is usually possible. With the advent of periarticular, anatomic specific plates,
fixation can be performed for fractures that extend proximally or distally into the epimetaphyseal regions.
Nevertheless, there are a number of disadvantages with plating, generally related to the large surgical exposure
through the zone of injury. This carries with it the risk of fragment devascularization, iatrogenic nerve injury, and
infection. In addition, it often leaves a long unsightly scar along the length of the arm.
Intramedullary nailing of the humerus, while used less frequently than plate osteosynthesis, has several
mechanical and biologic advantages. Mechanically, intramedullary nails are strong implants, which can
effectively share load. They are inserted using “minimally invasive” closed techniques. This eliminates direct
exposure of the fracture site, reducing blood loss and decreasing the risk of infection. Intramedullary nails are
ideally used to stabilize fractures in the middle three-fifths of the humerus. Many fractures that extend above the
humeral diaphysis can be treated with either a plate or a nail. In the past decade, advances in nail design have
improved fixation stability by the addition of multiplanar interlocking screws that often lock into the nail. This has
expanded the range of fractures that are amenable to intramedullary nailing (Fig. 7.2).
Antegrade nailing with the patient in the supine position is used for the vast majority of patients. Retrograde nails
are rarely used because of the risk of insertion portal comminution or fractures in the distal humerus. In addition,
there is a need for the patient to be in the prone position. Numerous studies support the preferential
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use of a reamed antegrade intramedullary nail, rather than a plate, in the following circumstances: (a) pathologic
or impending pathologic fractures, (b) segmental fracture patterns, (c) severe osteoporosis, (d) long zones of
comminution (Fig. 7.3), or (e) compromised soft tissues.
FIGURE 7.2 A fixed angle, spiral blade interlock can help with proximal interlock stability. The blade is locked to
the nail, reducing risk of loosening.

FIGURE 7.3 Humerus fracture due to gunshot wound, stabilized with a humeral nail.

It is important to emphasize that closed humeral nailing is contraindicated when the status of the radial nerve
cannot be determined preoperatively. This occasionally occurs in patients with head injuries, altered
consciousness from drugs or alcohol, mechanical ventilation, or polytrauma. In these circumstances, either open
nailing with visualization of the nerve or plate fixation is safer. In patients with an open fracture as well as a radial
nerve palsy, it is recommended that the nerve be explored. In these patients, plating seems preferable to nailing,
since the majority of the exposure has been done at the time of nerve exploration. Intramedullary nailing is
inferior to plating in treating humeral nonunion, and should not be used (11). The main disadvantages of
antegrade humeral nailing are postoperative shoulder pain and higher incidence of hardware removal. This may
be a significant consideration in patients whose work or avocations include significant overhead activity.

PREOPERATIVE PLANNING
There are a number of fracture-related, as well as patient-related, issues that must be analyzed when developing
a treatment plan for a patient with a humeral shaft fracture. Fracture-related issues, such as the location of the
fracture, the geometry or morphology of the fracture, associated soft-tissue condition, and the magnitude of
displacement must be considered. In addition, patient-related issues such as medical comorbidities, body
habitus, functional demands, the bone quality, as well as concomitant injuries, either in the same limb or
elsewhere in the body, affect the choice of treatment.

HISTORY AND PHYSICAL

The history should include not only the mechanism of injury, hand dominance, occupation, and recreational
activities, but the health status of the patient as well. Medical comorbidities, such as cardiovascular disease,
diabetes, or a history of cancer, may influence diagnosis or treatment. The patient's social history may provide
useful information about their ability to cooperate with a rehabilitation program.
The patient and the injured limb must be carefully and systematically examined. Most patients have localized
swelling, pain with palpation, or movement of the arm, and decreased range of motion of their shoulder and
elbow. The skin must be examined to rule out an open fracture, which may be subtle. The brachial, radial, and
ulnar pulses should be symmetrical with the opposite limb. Diminished or absent pulses or a cool hand after
reduction require a vascular workup. The neurologic exam should include specific testing of the motor and
sensory function of the radial, ulnar, and median nerves. Approximately 10% of patients with displaced humeral
shaft fractures present with a radial nerve injury. Careful evaluation and documentation of the neurovascular
status have both medical and legal significance. The vast majority of patients with a closed humeral fracture who
present with a radial nerve palsy have a neuropraxia. These have an excellent prognosis, and the vast majority
recover spontaneously. The indication for surgery is based more on the fracture status rather than
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the radial nerve lesion. The management of a patient with a humerus fracture whose radial nerve function is lost
after reduction and splinting is controversial. Various studies support both observation and early surgery. On the
other hand, there is wide consensus that a radial nerve injury that occurs in the presence of an open fracture
should undergo nerve exploration at the time of irrigation and débridement of the open fracture.

Imaging Studies
In a patient with a suspected humeral shaft fracture, a full-length AP and lateral x-ray of the humerus should be
obtained. If the fracture extends into the proximal or distal epimetaphyseal areas, dedicated shoulder and elbow
radiographs should also be obtained. It is imperative to understand the proximal and distal extent of the fracture if
an intramedullary nail is to be used. The nail can only be inserted to the lowest extent of the medullary canal,
which ends several centimeters above the olecranon fossa in most individuals.
In the painful arm, it can be difficult to obtain an axillary lateral of the shoulder. This is obtained by placing the x-
ray cassette at the base of the neck with the x-ray beam directed from distal to proximal, through the axilla. This
requires only a small amount of abduction, combined with forward elevation, of the shoulder. Occasionally, a CT
scan may be necessary to completely understand the fracture.
Timing of Surgery
Open humeral fractures are surgical urgencies and require irrigation, débridement, and stabilization as soon as
the patient's condition and institutional resources allow. Intravenous antibiotics using a cephalosporin should be
started upon admission. In highly contaminated open fractures, an aminoglycoside or penicillin is added.
Fractures that occur in conjunction with a vascular injury should be treated emergently in coordination with a
vascular surgeon. The timing of stabilization in a polytrauma patient should take into account the overall relative
risk to the patient. In critically injured or unstable patients, the fracture is splinted and definitive surgery is
delayed until the patient's overall condition improves.
Internal fixation for most isolated, closed fractures is done during daylight hours with an experienced and rested
team, usually within the first 3 to 5 days. Following reduction and splinting, many patients can be discharged
home from the Emergency Department, seen in the clinic, and have their surgery scheduled within a few days.
Exceptions include patients who are in too much pain to be discharged, and those patients whose social
situations preclude independent living with an immobilized arm.

SURGICAL TECHNIQUE
Anesthesia
General anesthesia is preferred with the endotracheal tube secured to the side opposite the injury. The proximity
of the surgery to the patient's head, and the positioning required, make the use of regional anesthesia more
difficult. However, postoperative nerve blocks can be helpful, if the neurologic status of the extremity is known. A
Foley catheter and arterial lines may be indicated in polytrauma patients, but are not necessary for most isolated
humeral shaft fractures.

Positioning and Imaging

Nailing is done in the supine position with the patient either in the “beach chair” or flat on a radiolucent table.
The chief advantage of the beach-chair position is gravity assistance with the reduction, which may be helpful
when a skilled scrubbed assistant is not available. The disadvantage with this position, however, is the ability to
obtain intraoperative biplanar images without moving the limb. The need to move the arm to check different C-
arm views may lead to a loss of reduction. If a beach-chair position is used, it is very important that shoulder can
extend beyond neutral to facilitate the correct starting point. With the beach-chair position, the C-arm is placed
alongside the patient's head on the affected side.
I prefer to position the patient supine on a flat-top radiolucent table. With this position, there must be no metal
rails on the side of the table, a common feature of standard operating tables. This position facilitates
intraoperative imaging, by moving the C-arm to the opposite side of the table, and minimizes movement of the
limb to obtain appropriate fluoroscopic views.
The patient is positioned supine at the edge of the table that allows shoulder motion, and a “bump” is placed
under the affected side, from shoulder to hips using a few folded blankets. This is designed to roll the affected
side of the body up 15 to 25 degrees from the table. This allows the shoulder to easily extend past neutral and
facilitates the use of biplanar fluoroscopy. The unaffected arm should be padded and tucked at the patient's side.
It is important to avoid using an arm board to support the unaffected limb as it can impede the position of the
image intensifier (Figs. 7.4, 7.5 and 7.6).
Prior to prepping and draping, numerous preliminary fluoroscopic images are obtained. The arm is held in neutral
rotation, and the shoulder is extended slightly to better visualize the starting point for the nail. The AP
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view is obtained by “rolling back” the arc of the fluoroscopy machine approximately 30 to 40 degrees. This is
done to compensate for the elevation caused by the bump under the patient's side as well as the relationship of
the shoulder girdle to the thorax. Without moving the limb, a transscapular Y-lateral view can be obtained by
rolling the C-arm over the arc toward the surgeon (Fig. 7.7). In addition, an axillary lateral of the proximal
humerus can easily be obtained with minimal movement of the limb. The shoulder is slightly abducted, while the
C-arm is tilted in a manner typically used to obtain an inlet view of the pelvis.

FIGURE 7.4 A completely radiolucent table is used. The patient is positioned in a semisupine position. Folded
blankets elevate the affected side. The C-arm is brought in from the opposite side, unimpeded by a contralateral
arm board. The AP image obtained by rolling back the C-arm is seen.

Surgery
All patients should receive prophylactic antibiotics within 30 minutes of the skin incision. Unless an allergy is
known or suspected, a first-generation cephalosporin is recommended. The neck, chest wall, shoulder girdle,
and the entire injured limb are prepped and draped into the field. This allows for intraoperative manipulation of
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the limb for reduction and nailing. In large patients, a metallic object can be used with fluoroscopy to localize the
correct site for the skin incision (Fig. 7.8). The incision starts at the anterior tip of the acromion, just lateral to the
AC joint and extends distally 5 cm (Fig. 7.9).
FIGURE 7.5 Rolling the C-arm over the top allows for a transcapular Y-view. The arm has not been moved.

FIGURE 7.6 An axillary view can be obtained by tilting the C-arm sideways. The assistant extends the shoulder
slightly. This can be most helpful in proximal fracture as seen in this x-ray. Please note that the image has been
vertically flipped, so that the anterior humerus is at the top of the view.

The advantages of an anterolateral incision include better access to the ideal starting point (4) since the humeral
head is largely anterior to the acromion. Dissection is carried through the deltoid in the natural raphe between
the anterior and middle thirds of the muscle (Fig. 7.10). The subdeltoid bursa is excised and the supraspinatus
tendon is exposed. A 2.0-mm terminally threaded guidewire is placed on the superior aspect of the proximal
humerus and adjusted fluoroscopically on the AP and transcapular views to identify the correct
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starting point. Most commercially available nails have a slight proximal lateral bend. The correct starting point is
just medial to the sulcus between the margin of the articular cartilage and the greater tuberosity. It enters the
edge of articular cartilage, but avoids the insertion of the supraspinatus tendon (Fig. 7.11). The guide wire is
advanced into the bone, and the supraspinatus tendon is carefully incised, in line with the fibers, around the
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guide wire. The edges of the tendon are tagged with large, nonabsorbable sutures to protect the tendon during
reaming and nail passage as well as for later repair (Fig. 7.12).

FIGURE 7.7 AP radiograph of the humerus in a 20-year-old multiply injured female with splenic and liver
lacerations, a pelvic fracture, and multiple lower extremity injuries.

FIGURE 7.8 Localization with a guidewire helps ensure appropriate incision placement.
FIGURE 7.9 The humeral head is anterior to the tip of the acromion. The skin incision begins at the anterior tip
of the acromion and courses anterolaterally.

FIGURE 7.10 Cross-sectional anatomy demonstrates the raphe between anterior and middle thirds of deltoid as
well as the orientation of supraspinatus fibers over humeral head.
FIGURE 7.11 Radiographic identification of starting point. This should be done before cuff incision to ensure the
approach is centered at starting point.

FIGURE 7.12 Sutures retract the edges of the supraspinatus tendon.

Once the guide wire is correctly positioned and verified fluoroscopically, a cannulated reamer or awl is used to
open the entry point in the proximal humerus. A ball-tipped guide rod is then passed down the medullary to the
fracture site. The fracture is then reduced with traction, translation, or direct pressure under fluoroscopic control,
and the surgeon or the assistant advances the ball-tipped guide wire into the distal fragment. The reduction is
verified on the AP view, and the C-arm is then rotated “over the top” to get a lateral, without moving the arm.
Single plane corrections are performed, one after the other, until a satisfactory reduction is achieved, and the
guide wire is successfully passed into the center of distal fragment. The nail length is determined by measuring
the length of the guide wire or can be estimated by holding a radioopaque ruler next to the arm while fluoroscopic
views are obtained at the shoulder and elbow.
The nail should span the entire length of the humeral canal. Preoperative and intraoperative assessment of
length are critical for two reasons. The first is that the anatomy of the humeral medullary canal tapers distally and
stops 2.0 to 2.5 cm above the olecranon fossa. This leaves virtually no room to advance the nail if it is too long.
Nails that are too long may fracture the distal humerus when trying to countersink the nail proximally or, more
commonly, will distract the fracture site, increasing the risk of nonunion. If left prominent at the entry site, the nail
will often be painful with shoulder motion. Thus, proper nail length is critical.
Rotation can often be determined radiographically. In simple fracture patterns, the irregular edges of the fracture
ends will match up when the alignment is correct. This is best checked after the guide wire has been passed
across the fracture, providing some stability. In comminuted fractures, a true AP image of the shoulder should
show the sulcus of bone between the articular surface and greater tuberosity at its deepest. Once this view has
been obtained, the forearm and the distal fragment can be rotated to the neutral position. When the distal
segment is neutral, the forearm, with the elbow flexed, should be parallel to the x-ray beam.
The radial nerve is always a concern when performing an intramedullary nailing of the humerus. To avoid
iatrogenic injury, some surgeons recommend exposure of the fracture site to ensure that the radial nerve is not
entrapped during reduction, reaming, and nail passage. Other strategies to avoid iatrogenic nerve injury include
not reaming through the zone of injury in comminuted fractures. The reamer is stopped at the proximal end of the
zone of injury, pushed across the comminuted zone while the reamer head is not spinning, and then reaming
resumes once the distal canal is engaged. In simple fractures, ensuring an anatomic reduction prior to reaming
and nail passage can minimize the risk of nerve injury (Fig. 7.13). Because the risk of nail incarceration is greater
in narrow bones, such as the humerus, it is prudent to ream the canal prior to nail insertion. The canal is reamed
until “cortical chatter” is encountered throughout the diaphysis. The nail selected should be 1 mm smaller in
diameter than the final reamer size to minimize the risk of iatrogenic comminution or incarceration. It also permits
impaction of the fracture ends in length stable fractures. A full-length humeral nail is chosen but must not be
prominent at the entry site to reduce the risk of shoulder impingement. To avoid irritation of the rotator cuff
tendon, the nail should be countersunk 3 to 5 mm into the proximal fragment. Distally, the nail should reach the
end of the medullary canal.
Length assessment can be difficult in comminuted fractures. A preoperative x-ray of the unaffected side allows
precise determination of nail length. Unlike the lower extremity lengthening is more of a potential
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problem than shortening. Distraction should be avoided in comminuted fractures because of an increased risk of
nonunion.
FIGURE 7.13 Reduction prior to reamer or nail passage helps prevent soft-tissue damage at fracture site in this
simple fracture pattern.

FIGURE 7.14 Distal locking is done in an anterior to posterior direction with a small open technique. Use of
retractors can reduce risk to neighboring structures.

To improve stability and prevent loss of reduction, all humeral nails should be statically locked. In length stable
fracture patterns, such as a transverse or short oblique fractures, distal interlocking is done first in order to allow
for compression at the fracture site by “back slapping” the nail. In comminuted or segmental injuries, or in cases
of impending pathologic fracture with cortical contact, proximal interlocking may be done first. Proximal
interlocking is done through an outrigger attached to the nail that allows several multiplanar screws to be
inserted in the humeral head. Another technique uses a fixed angle blade, which passes through the nail and
may be of benefit in poor bone.
Distal interlocking is typically done using a “free hand” technique. This is essentially the same procedure used in
placing femoral or tibial nail interlocking screws. For virtually all humeral nails, the distal screws are inserted from
anterior to posterior, rather than from lateral to medial. This places the brachial artery and median nerve at risk,
especially if the nail is rotated and the interlocks are from anteromedial to posterolateral. A “miniopen” technique
for screw insertion is recommended. After localizing the distal screw holes fluoroscopically, a 2-cm incision in the
skin is made followed by blunt dissection to the anterior humeral cortex. A drill sleeve or two small retractors may
be used to protect the adjacent soft-tissue structures (Fig. 7.14). An oscillating drill can also reduce the risk of
soft-tissue injury. The anterior cortex of the distal humerus is acutely sloped, and the bone in younger patients is
quite dense, and a sharp drill bit or one with a “brad” tip can be helpful.
At the conclusion of the case, the supraspinatus tendon is carefully repaired, and the deltoid fascia is closed
prior to skin closure. The arm is placed in a sling for comfort.

FIGURE 7.15 A freehand technique, with fluoroscopy, can facilitate distal interlock placement.

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FIGURE 7.16 Once the nail is locked distally, it can be used to compress the fracture site. This can be done by
impaction of the bone segments, use of a compression device on the instrumentation, or tapping the handle of
the nail with a magnet.
FIGURE 7.17 After successful nailing of the humerus. Surgery performed 5 days after injury, with closed
reduction in supine position.

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With careful surgical technique, using the correct entry point, fracture reduction, and proper nail placement,
favorable outcomes can be achieved in most patients (Figs. 7.15, 7.16 and 7.17).

POSTOPERATIVE MANAGEMENT
Intravenous antibiotics are continued for 24 hours. If the patient's condition allows, and secure fixation was
achieved in surgery, physical therapy can be started on the first or second postoperative day. Codman's
pendulum exercises and passive range of motion of the shoulder are begun first. Patients are encouraged to
wean from the sling as pain decreases. Typically, this is done within 2 to 3 weeks. Activities of daily living are
encouraged, and lifting is limited to light objects. If lower extremity fractures are present, weight bearing on
crutches or walker is permitted.
Sutures are removed in the clinic at 10 to 14 days. At 6 weeks, follow-up x-rays are obtained and reviewed for
signs of fracture healing. If callus is present, the patient is instructed in rotator cuff strengthening exercises.
Outpatient physical therapy can be quite helpful in this regard. Lifting can be increased, and activity is generally
increased.
By 12 weeks, most patients will have sufficient healing and should have recovered enough motion and strength
to return to most activities, except for heavy lifting and prolonged overhead activities. Continued strengthening
exercises should result in near normal activity levels in most patients by 6 months after surgery. x-rays are taken
every 6 weeks to monitor healing until full union is observed. Implant removal is not routinely recommended. In
the occasional patient in whom prominent hardware is symptomatic, elective removal can be undertaken
following union.

OUTCOMES
 Union rates following humeral nailing range from 90% to 95% in published series. This compares favorably
to open reduction and plate fixation (5, 6 and 7). In comparative studies between intramedullary nailing and
plating, the nail patients had more shoulder pain (up to 31%) and loss of shoulder motion. However, the
functional outcome measures (including ASES scores and return to activity) failed to show significant
differences on longer-term follow-up.
In these same studies, the incidence of reoperation was higher in the nail group than in the plate fixation
group. The majority of the reoperations were for hardware removal. Intramedullary nailing of the humerus is
an operation with a high union rate and a relatively low incidence of complications (8). Outcomes compare
favorably to plate fixation (8, 9 and 10). It is imperative that the surgeon be familiar with the technique to
achieve an optimal outcome.
Complications
Shoulder Pain and Stiffness
Some degree of shoulder pain and stiffness is common after humeral shaft fractures. These problems are
more prevalent after antegrade intramedullary nailing than other methods of treatment. What remains less
clear is the cause of shoulder pain and its effect on functional outcome. Regardless of the cause, initial
treatment should consist of regular, supervised therapy. Manipulation under anesthesia, with or without
arthroscopic débridement, can be considered for recalcitrant cases. Persistent rotator cuff dysfunction can
be challenging to evaluate. The presence of the nail may preclude a diagnostic MRI. In such cases, there
may be an indication for hardware removal after healing, followed by MRI to evaluate the rotator cuff.
Alternatively, an arthrogram can be helpful.
Radial Nerve Issues
Radial nerve palsy after nailing of the humerus fortunately is uncommon. Very little literature exists to guide
treatment. In most patients, the nerve recovers, and observation is appropriate during the first 4 months
(12). However, some surgeons recommend exploring the nerve earlier to rule out a structural injury.

REFERENCES
1. Sarmiento A, et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint
Surg Am 2000;82(4):478-486.

2. Castella FB, et al. Nonunion of the humeral shaft: long lateral butterfly fracture—a nonunion predictive
pattern? Clin Orthop Relat Res 2004(424):227-230.

3. Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento) bracing of humeral shaft fractures. J
Shoulder Elbow Surg 2002;11(2):143-150.

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4. Riemer BL, et al. The anterior acromial approach for antegrade intramedullary nailing of the humeral
diaphysis. Orthopedics 1993;16(11):1219-1223.

5. Chapman JR, et al. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails
versus plates. J Orthop Trauma 2000;14(3):162-166.

6. Stannard JP, et al. Intramedullary nailing of humeral shaft fractures with a locking flexible nail. J Bone Joint
Surg Am 2003;85-A(11):2103-2110.

7. McCormack RG, et al. Fixation of fractures of the shaft of the humerus by dynamic compression plate or
intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br 2000;82(3):336-339.

8. Rommens PM, et al. Humeral nailing revisited. Injury 2008;39(12):1319-1328.

9. Heineman DJ, et al. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop
2010;81(2):216-223.

10. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for
humeral shaft fractures in adults. Cochrane Database Syst Rev 2011;6:CD005959.

11. Lin J, Chiang H, Hou SM. Open exchange locked nailing in humeral nonunions after intramedullary
nailing. Clin Orthop Relat Res 2003;(411):260-268.

12. Wang JP, et al. Iatrogenic radial nerve palsy after operative management of humeral shaft fractures. J
Trauma 2009;66(3):800-803.
 8
Distal Humerus Fractures: Open Reduction Internal Fixation
Daphne M. Beingessner
David P. Barei

INTRODUCTION
Intra-articular fractures of the distal humerus in adults are uncommon but complex and challenging injuries. They
typically occur in young people as the result of high energy trauma and occur more commonly in males. As life
expectancy grows, the incidence of distal humerus fractures in the elderly has increased, particularly in women.
In this group of patients, fractures often occur as the result of a ground-level fall. Fixation in these patients with
osteopenic bone may be difficult, and surgical tactics and newer implants continue to evolve to accommodate
this challenge.
Historically patients did poorly with surgical management of this injury, but in the past 25 years, modern fixation
techniques have dramatically improved outcomes. Today, the majority of patients experience only mild to
moderate residual impairment and regain approximately 75% of their elbow motion and strength. Union rates
between 90% and 100% have been reported. However, stable internal fixation that allows early range of elbow
motion is mandatory to achieve such outcomes.
The elbow joint functions to position the hand in space. Restoration of elbow motion is essential to perform most
activities of daily living. A range of motion between 30 and 130 degrees of flexion (100-degree arc) is necessary
to perform most activities of daily living. Recent series of distal humerus fractures have demonstrated restoration
of motion arcs of up to 112 degrees when repaired with contemporary fixation techniques.
The surgeon must have a thorough knowledge of the complex anatomy around the elbow prior to embarking on
surgery of the distal humerus. The osseous anatomy can make plate contouring difficult, and precontoured
periarticular plates have been developed to facilitate fixation. The flat posterolateral surface of the humerus is an
ideal place for plate placement while the distal medial humerus invariably requires plate contouring for placement
around the medial epicondyle. Virtually all surgical approaches involve identification and protection of the ulnar
and radial nerves during exposure and hardware placement.
The most common classification used for distal humerus fractures is the OTA/AO classification system. Type A
fractures are extra-articular, type B fractures are partial articular (such as isolated condyle fractures, coronal
shear fractures, or epicondyle fractures), and type C fractures are complete articular injuries. Thirty-nine percent
of fractures are type A, twenty-four percent type B, and thirty-seven percent type C. (Fig. 8.1)

INDICATIONS AND CONTRAINDICATIONS

Nonoperative treatment of displaced distal humerus fractures in adults leads to a high rate of nonunion,
malunion, and elbow stiffness. It is typically reserved for low-demand elderly patients with significant medical
comorbidities who cannot tolerate surgery. Such patients, particularly those with minimally displaced fractures or
lowarticular injuries/shear injuries, can be treated with immobilization in a long arm cast for 3 weeks followed by
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early range of elbow motion. For patients with significant displacement of the metaphysis, the soft tissues must
be carefully monitored to be sure that there is no skin compromise secondary to displaced fragments.
FIGURE 8.1

Comminuted intra-articular fractures in geriatric patients with significant osteopenia may be better treated with
total elbow arthroplasty. In particular, fractures with significant shear components, articular comminution, and
fractures that are below the olecranon fossa may be difficult to repair in osteopenic bone. However, arthroplasty
should be reserved for low-demand patients as the long-term outcomes have shown a high incidence of implant
loosening.
The vast majority of open and closed displaced intra-articular fractures in adults are best treated with open
reduction and stable internal fixation that allows early range of motion to optimize elbow function. Distal humerus
fractures continue to be challenging injuries to manage but with improved fixation techniques and implants, good
outcomes are possible.

PREOPERATIVE PLANNING
History and Physical Examination
A complete history including mechanism of injury, preinjury condition, medical issues, and handedness should be
obtained. Physical examination should identify open wounds, skin tenting, significant abrasions or contusions,
nerve function (particularly ulnar and radial nerve), and associated injuries. A thorough vascular examination
including peripheral pulses should be performed. If the peripheral pulse on the affected extremity is decreased,
then noninvasive vascular studies should be performed, and any significant abnormalities should prompt a
vascular surgery consultation. Although vascular injuries are uncommon, they can be missed due to the excellent
collateral blood flow in the upper extremity. The patient should be medically optimized prior to surgical
intervention, which is often lengthy.

Imaging Studies
Typically, plain radiographs are sufficient to diagnose and develop a treatment plan. Radiographs should include
the entire length of the humerus and the forearm. Traction radiographs are helpful to further delineate the
fracture geometry (Fig. 8.2). With adequate analgesia, gentle traction is applied to the arm in the radiology suite,
and an anteroposterior and lateral radiograph of the elbow is obtained. These radiographs should be studied to
identify all components of the fracture. It is important to determine if there is continuity of the trochlear fragment
to the medial epicondylar fragment as this can influence hardware choice. Unlike plateau or pilon fractures,
computed tomography scanning is not usually needed but can be helpful when coronal plane injuries such as
shear fractures of the capitellum and trochlea are suspected.
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FIGURE 8.2 Anteroposterior radiograph of a comminuted distal humerus fracture (A). A traction view better
delineates the fracture lines and extent of joint injury (B).

Timing of Surgery
Fractures should be immobilized in a long arm splint in a position that takes pressure off the skin. This position
may vary according to fracture configuration but is often with the elbow semiextended. A hyperflexed position
should be avoided to prevent development of a compartmental syndrome. In the absence of soft-tissue
compromise or open injuries, the fracture should be treated on an urgent, but not emergent, basis. It is essential
to have a complete and detailed preoperative plan to be sure that all required implants are available. The patient
should be medically optimized since the surgery can be lengthy. Open fractures or those with significant soft-
tissue compromise should be treated on an emergent basis. If the patient is not well enough for a prolonged
procedure, an irrigation and débridement of the open wound may be performed followed by replacement of a
well-padded splint and fixation when the patient's condition permits. A spanning external fixator and staged
fixation protocol is rarely necessary but may be useful for grossly contaminated open injuries or those with a
vascular injury and repair.
The goal of treatment is anatomic and rigid fixation of the articular component of the injury and either absolute or
relative stability of the metaphyseal component depending on the degree of comminution. A variety of implants
may be required for provisional and definitive fixation of these fractures, and their availability should be confirmed
preoperatively. These implants include 3.5-mm LCDC plates, 2.7- and 3.5-mm reconstruction plates,
precontoured periarticular distal humerus nonlocking and locking plates, minifragment plates and screws (2.0,
2.4, and 2.7 mm), and Kirschner wires in various sizes (1.25, 1.6, and 2.0 mm). A variety of clamps including
small and large Weber clamps, a small saw and osteotomes for an osteotomy, and bipolar cautery should also
be available.

SURGERY
After appropriate medical evaluation, the patient is brought to the operating room, general anesthesia is induced,
and preoperative antibiotics are administered. Because these fractures often require prolonged operating time,
regional techniques of anesthesia are used less frequently. Advanced monitoring (i.e., arterial or central lines) is
performed at the discretion of the anesthesiologist based on the patient's physiologic status as well as
comorbidities. A Foley catheter is routinely placed. The lateral decubitus or prone position allows for good
visualization of the fracture as well as proper positioning of the C-arm. We prefer a lateral
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position on a foam mattress with a radiolucent armboard since it decreases the potential risks of prolonged prone
positioning such as eye injuries (Fig. 8.3). All pressure points must be carefully padded with particular care taken
to avoid compression of the peroneal nerve at the knee or the lateral femoral cutaneous nerve at the hip. The
prone position is useful for selected patients with spine injuries or fractures in their contralateral extremities. The
lower arm is supported on a well-padded plexiglass armboard. Sequential compression devices are placed on
the legs and used for the duration of the case. The C-arm is brought in from the head of the table. Prior to
prepping and draping test, images should be obtained to ensure high-quality images during the procedure (Fig.
8.4A,B). The entire arm from shoulder to hand is prepped and draped (Fig. 8.5). A sterile tourniquet may be used
but is not often necessary and may be in the way of a more extended incision. Injecting the proposed incision
with Marcaine with Epinephrine helps with hemostasis during the exposure (Fig. 8.6).
FIGURE 8.3 The patient is placed in the lateral decubitus position with the affected side over a radiolucent
armboard. The lower arm is placed on a plexiglass armboard and is well padded. The C-arm is positioned from
the top of the bed, and the positioning allows for anteroposterior and lateral imaging (A). Prone positioning also
allows for adequate imaging and access to the fracture (B).

A posterior midline incision is made, and full-thickness medial and lateral fasciocutaneous flaps are raised. It is
important to elevate the deep fascia in order to more easily identify the ulnar and radial nerves (Fig. 8.7). The
fracture is then exposed using a triceps-sparing approach (Fig. 8.8) or an olecranon osteotomy. We prefer these
approaches since they are extensile and allow for excellent visualization of the joint. The preoperative plan
should indicate which approach will be required. The triceps-sparing approach is the first step of the olcranon
osteotomy approach and can easily be converted to an osteotomy should increased visualization be required. On
the medial side, the ulnar nerve is identified proximal to the elbow joint under the medial triceps (Fig. 8.9). It is
dissected approximately 15 cm proximal to the joint and distally to the level of its first motor branch into the flexor
carpi ulnaris (Fig. 8.10). It can be fully elevated for transposition or left in situ and protected throughout the
procedure depending on the fracture and fixation requirements. The triceps is then elevated from the posterior
aspect of the humerus on the medial side by lifting it directly from the humerus and medial intermuscular septum
(Fig. 8.11). Distally, the posterior band of the medial collateral ligament is elevated, and the posterior joint
capsule is entered to visualize the trochlea. On the lateral side, the sensory branch of the radial nerve is
identified in the fascia and followed proximally to the radial nerve proper, which typically lies just anterior to it
(Fig. 8.12). The radial nerve
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is identified as it crosses the posterior humerus proximally and distally as it travels anterior the intermuscular
septum. If the fracture is distal and will not require long plates, the radial nerve does not need to be exposed, and
dissection should remain posterior to the septum. The triceps is then elevated from the posterior humeral shaft.
Distally, the anconeus may be divided or dissected on its lateral side to be elevated with the triceps (Fig. 8.13).
The joint capsule is opened laterally and the fracture exposed. The visualization afforded by this approach is
typically adequate for fractures with a simple articular split, particularly if it is lateral to the midpoint of the
trochlea (Fig. 8.14). Fractures with three articular fragments may be converted to two fragments by reducing the
middle segment to the medial or lateral joint fragment first and then reducing the remaining fracture.

FIGURE 8.4 Fluoroscopy is brought in prior to draping to ensure that adequate images can be obtained in both
the anteroposterior (A) and lateral (B) views.

If the fracture is more complex, including multiple intra-articular fragments or coronal shear fragments, then this
approach should be extended into an olecranon osteotomy (Fig. 8.15). Similarly, if a simple articular fracture
cannot be adequately visualized for anatomic reduction, an osteotomy should be performed as well. We try to
avoid using an osteotomy in elderly patients that might require conversion to a total elbow arthroplasty if the
fixation fails or a nonunion develops. The triceps-sparing approach described above allows visualization to the
proximal ulna. If an olecranon osteotomy is needed, the bare area of the proximal ulna in the greater sigmoid
notch is identified on the medial and lateral side. The ulnar nerve is carefully protected. I prefer plate fixation of
the osteotomy. The plate is positioned on the ulna prior to the osteotomy and drill holes are placed, one at the tip
of the plate and a second in the shaft for improved reduction and fixation at
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the conclusion of the case (Fig. 8.16A). A small sponge may be placed around the proximal ulna to distract it from
the distal humerus to avoid articular damage during the osteotomy. Fluoroscopy is used to confirm the location of
the osteotomy (Fig. 8.16B), and a shallow chevron with the apex pointing distally is cut using a saw to the
subchondral bone and then completed with an osteotome (Fig. 8.16C,D). Care must be taken not to cut to far
distally and enter the coronoid or to proximal which compromises visualization and is difficult to repair. The
olecranon together with the triceps tendon is reflected proximally and the fracture is exposed (Fig. 8.16E). The
reflected triceps and olecranon are wrapped in a saline-soaked sponge and kept moist for the duration of the
procedure.

FIGURE 8.5 The entire arm from shoulder to hand is prepped and draped.

FIGURE 8.6 Injecting the proposed incision with Marcaine with Epinephrine helps with hemostasis during the
exposure.
FIGURE 8.7 A posterior midline incision is made, and full-thickness medial and lateral fasciocutaneous flaps are
raised. It is important to elevate the deep fascia in order to more easily identify the ulnar and radial nerves.

The goal of surgery is to obtain an anatomic reduction of the articular surface together with restoration of
alignment of the humerus. Stable fixation must be obtained to allow for early range of elbow motion. The fracture
fragments are carefully irrigated, and care is taken not to disrupt any remaining soft-tissue attachments. The
articular surface is typically reduced first. However, if the metaphyseal injury is not comminuted, reducing one
column at the metaphysis may aid in reduction of the articular surface by creating a stable
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platform on which to build the joint. Kirschner wires are helpful to provide provisional fixation of the joint surface.
Shear fragments may be secured with strategically placed countersunk minifragment screws (Fig. 8.17).
Minifragment plates (2.0 mm) can be helpful to hold the metaphyseal reduction if the wires are not secure (see
Fig. 8.14E). For more transverse metaphyseal fractures, a drill hole can be made with a 2.5-mm drill in each
segment, and a modified small-pointed reduction clamp with two straight ends can be placed to hold the
reduction. A large-pointed Weber clamp can be placed across the joint to provide articular compression.
However, care must be taken to avoid overcompression of the joint in comminuted fractures. After reduction and
provisional fixation with a combination of K-wires, clamps, and minifragment plates, both columns of the distal
humerus should be plated. One plate should be a 3.5-mm LCDC plate or equivalent strength precontoured
periarticular plate (Fig. 8.18). This plate typically is used on the lateral side (Fig. 8.19). With significant
metadiaphyseal comminution, the plate may need to be long, and the position of the plate in relation to the radial
nerve must be verified. The surgeon should make note of where the nerve crosses the plate and document it in
the operative report in the event that hardware removal is necessary in the future. On the medial side, a 2.7- or
3.5-mm reconstruction plate is usually sufficient. This type of plate is more flexible and easier to contour around
the medial epicondyle and trochlea. Alternatively, a precontoured periarticular plate may be used (Fig. 8.20). The
plates can be oriented at 180 or 90 degrees to each other depending on the fracture configuration (Fig. 8.21).
Both
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constructs are of sufficient strength to allow early motion. When necessary, the lateral plate can be placed either
posteriorly or laterally, and the medial plate can be placed directly medially or posteromedial. When possible,
interfragmentary compression of the articular surface should be achieved with screws placed through one or
both plates, and fixation strength may be increased by interdigitating these screws. If comminution is present,
one must be careful to avoid narrowing the trochlea during fixation, and “position screws” rather than “lag
screws”
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are used. If the trochlear fragment is separate from the medial epicondyle, a plate that extends down onto the
trochlea is necessary to adequately capture the trochlear fragment (Fig. 8.22). Retrograde column screws may
also enhance fixation of the articular segment to the shaft. Locking plates may be used in osteopenic patients but
are not required for fixation in the younger trauma age group. They are also useful for coronal shear fractures of
the capitellum. If the fracture is distal to the olecranon fossa (transcondylar), smaller caliber plates may be
sufficient (Fig. 8.23).

FIGURE 8.8 Posterior view of the arm demonstrating a triceps-sparing approach (A). The incision is curved
laterally around the tip of the olecranon so the patient will not lean directly on the incision, and an olecranon
plate will not be directly under the incision. The ulnar nerve is protected on the medial side. The triceps is
reflected medially and laterally for exposure of the fracture and joint (B).
FIGURE 8.9 On the medial side, the ulnar nerve is identified proximal to the elbow joint under the medial triceps.

FIGURE 8.10 The ulnar nerve is dissected approximately 15 cm proximal to the joint and distally to the level of
the first motor branch into the flexor carpi ulnaris. It can be fully elevated for transposition or left in situ and
protected throughout the procedure depending on the fracture and hardware configuration.
FIGURE 8.11 The triceps is then elevated from the posterior aspect of the humerus on the medial side by lifting it
directly from the humerus and medial intermuscular septum.

FIGURE 8.12 On the lateral side, the sensory branch of the radial nerve is identified in the fascia and followed
proximally to the radial nerve proper, which typically lies just anterior to it.
FIGURE 8.13 The triceps is then elevated from the posterior humeral shaft. Distally, the anconeus may be
divided or dissected on its lateral side to be elevated with the triceps.
FIGURE 8.14 Anteroposterior and lateral radiographs of a 40-year-old male with a distal humerus fracture and a
simple articular split (A,B). The fracture was addressed through a tricepssparing approach. Adequate
visualization with this approach allowed for an anatomic reduction of the articular fracture (C,D). Note the
minifragment plate placed in the metaphysis to hold the reduction during placement of the main implants (E).
FIGURE 8.14 (Continued)
FIGURE 8.15 Posterior view of the arm demonstrating a chevron osteotomy of the olecranon (A). The osteotomy
is made with the apex pointing distally to maximize the size of the fragment to repair (B,C). This technique allows
for excellent visualization of the fracture and the articular surface.

FIGURE 8.15 (Continued)

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FIGURE 8.16 The plate is positioned on the ulna prior to the osteotomy, and pilot drill holes are placed, one at
the tip of the plate and a second in the shaft for ease of reduction at the conclusion of the case (A). With
fluoroscopy to confirm the location of the osteotomy (B), a shallow chevron with the apex pointing distally is cut
using a saw to the subchondral bone of the bare area and then completed with an osteotome (C,D). The
olecranon together with the triceps insertion is then reflected proximally, and the fracture is then exposed (E).

After internal fixation of the humerus is complete, the olecranon osteotomy is repaired. The osteotomy is clamped
from the medial and lateral side with pointed reduction clamps on each side (Fig. 8.24). A drill hole in the shaft is
used to hold the clamp distally, and the curved portion of the clamp is placed at the tip of the olecranon out of the
path of the plate. The previously drilled plate is then replaced, and screws are applied (Fig. 8.25A,B) The elbow
is then taken through a full range of motion to ensure that there are no blocks to elbow motion and that the
fixation is secure. Final radiographs are obtained to be sure that the reduction is anatomic, all hardware is safely
placed, and all screws are of appropriate length. The wound is copiously irrigated with saline and the arm
cleaned with chlorhexidine. The ulnar nerve is then inspected. If it is stable in
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the cubital tunnel with no contact with the medial hardware, it may be left in situ. If it is in contact with metal or
has a tendency to dislocate, then we recommend a subcutaneous transposition. Excellent hemostasis must be
obtained to avoid a postoperative hematoma. A drain may be placed as needed. The subcutaneous layer is
closed with 2-0 absorbable sutures to take the tension off the skin. At the tip of the olecranon, the deep dermis
may be sutured to the fascia to decrease the chance of fluid collecting in the olecranon bursa (Fig. 8.26). The
skin is closed with 3-0 nylon suture and ¼ inch steristrips are applied (Fig. 8.27). Sterile dressing with a longarm
bulky splint incorporating the hand is then applied with the elbow at approximately 70 degrees of flexion (Fig.
8.28).

FIGURE 8.16 (Continued)

FIGURE 8.17 This fracture had a shear component in the coronal plane. Strategically placed screws are placed
into the articular surface and countersunk to repair these fragments (A). The remaining hardware may then be
placed around these screws (B, C). Note the retrograde column screws placed from each plate for added
stability.
FIGURE 8.17 (Continued)
FIGURE 8.18 Anteroposterior and lateral views of the distal humerus showing a medial 2.7-mm reconstruction
plate and a lateral LCDC plate.

FIGURE 8.19 A 3.5-mm LCDC plate positioned laterally.

POSTOPERATIVE CARE
The patient receives 24 hours of intravenous antibiotics. At 48 hours, the splint is removed and the patient is
placed into a light dressing with a tubigrip sleeve, and a compression glove and range of motion exercises are
initiated. If an osteotomy has been performed, the patient may do active and active-assisted flexion and
extension for the first 6 weeks but should avoid active extension against gravity or resistance. Otherwise, they
are
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permitted to do active motion against gravity without restrictions. There are no restrictions to rotation. Hand and
shoulder motion are also encouraged. The patient is seen in clinic at 2 weeks for suture removal and clinical
evaluation. Radiographs are obtained at 6 weeks at which point a gentle strengthening program is started. At 3
months, radiographs are obtained, and a more aggressive strengthening protocol is instituted if the fracture is
healed.

FIGURE 8.20 Precontoured periarticular plate.

FIGURE 8.21 Plates may be oriented at 180 or 90 degrees to each other depending on the fracture
configuration.

COMPLICATIONS AND OUTCOMES

Distal humerus fractures are complex injuries, and a discussion about the potential complications and outcomes
should be discussed with the patient preoperatively. Risks inherent to all surgical care should be discussed
including the risk of infection and nerve injury.
FIGURE 8.22 Anteroposterior view of the distal humerus showing a medial 2.7-mm reconstruction plate that
wraps around the medial epicondyle onto the trochlea. This plate contour is useful when the trochlea and medial
epicondyle are separate fragments.

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FIGURE 8.23 Anteroposterior and lateral radiographs of a 30-year-old female with a low fracture with the
majority of the fracture below the olecranon fossa (A,B). Provisional fixation with wires and clamps is completed
(C,D).

Paresthesias in the ring and small fingers are not uncommon following distal humerus fracture surgery.
Controversy still exists with regard to the treatment of the ulnar nerve intraoperatively. The only current clear
indication for anterior transposition is preoperative ulnar nerve symptoms. There is no clear indication for ulnar
nerve transposition in the setting of normal preoperative function. If the nerve is unstable in situ after exposure or
has significant contact with the medial implant, transposition may be beneficial.
Heterotopic ossification may occur after elbow trauma with current reported rates of about 8% after distal
humerus fractures. It is difficult to predict which patients will develop this problem, and routine prophylaxis is not
warranted. A recent study demonstrated an increased rate of nonunion in patients treated with indomethacin for
prophylaxis after distal humerus fractures. Furthermore, compliance rates with taking the drug are often low. If
prophylaxis is considered, for example, in head-injured patients, risks such as nonunion or medication side
effects must be carefully weighed against the potential benefits.
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FIGURE 8.23 (Continued) Smaller implants are placed and are sufficient for fixation of injuries at this level and
can actually allow for more screws per segment than a larger plate (E,F). The fracture went on to union
uneventfully (G,H).

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FIGURE 8.24 After fixation is complete, the osteotomy is repaired. The osteotomy is clamped from the medial
and lateral side with a straight-curved pointed clamp on each side.

FIGURE 8.25 The osteotomy is performed with a saw. The fracture is then reduced and provisionally wired and
clamped (A). The osteotomy is then repaired with a plate with screws placed through predrilled holes (B).
FIGURE 8.26 The subcutaneous layer may be closed with several 2-0 absorbable sutures to take the tension off
the skin. At the tip of the olecranon, the deep dermis may be sutured to the fascia to decrease the chance of fluid
collecting in the olecranon bursa.

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FIGURE 8.27 The skin is closed with 3-0 nylon suture and ¼ inch steristrips are applied.

FIGURE 8.28 Sterile dressing with a long-arm bulky splint incorporating the hand is then applied with the elbow
at approximately 70 degrees of flexion.
The incidence of nonunion of distal humerus fractures is low with reported rates <5%. Stable internal fixation and
avoiding excessive soft-tissue stripping improve the rate and the time to union. Similarly, malunion can be
avoided by proper surgical technique. In patients with open fractures and large bone defects, bone grafting
should be performed approximately 6 weeks after the index procedure to promote fracture healing prior to implant
failure. In patients with symptomatic nonunions, revision of fixation with bone grafting and elbow release may be
indicated.

RECOMMENDED READINGS
Barei DP, Hanel DP. Fractures of the distal humerus. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds.
Green's operative hand surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2009.

Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intra-
articular fractures of the distal humerus. J Orthop Trauma 2006;20(3):164-171.

Nauth A, McKee MD, Ristevski B, et al. Distal humeral fractures in adults. J Bone Joint Surg Am
2011;93(7):686-700.

Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin 2008;39(2):187-200.

Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg
1999;8:85-97.

Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal
humerus. J Orthop Trauma 1994;8(6):468-475.

Schildhauer TA, Nork SE, Mills WJ, et al. Extensor mechanism-sparing para-tricipital posterior approach to
the distal humerus. J Orthop Trauma 2003;17:374-378.

Vasquez O, Rutgers M, Ring DC, et al. Fate of the ulnar nerve after operative fixation of distal humerus
fractures. J Orthop Trauma 2010;24(7):395-399.
 9
Intra-Articular Fractures of the Distal Humerus: Total Elbow
Arthroplasty
Elaine Mau
Michael D. McKee

INTRODUCTION
Total elbow arthroplasty (TEA) for the management of displaced and comminuted intra-articular fractures of the
distal humerus in the elderly is a relatively new but attractive alternative to open reduction and internal fixation
(ORIF) or nonoperative treatment in this subgroup of patients. Traditionally, displaced distal humeral fractures
are treated with internal fixation; however, obtaining and maintaining the reduction through healing and
rehabilitation in osteoporotic bone can be extremely challenging. These injuries typically occur in elderly patients
with compromised bone stock secondary to osteoporosis following a mechanical ground level fall. Fractures of
the distal end of the humerus are classified in the AO/OTA system as type 13-C fractures and involve both the
articular surface and a metadiaphyseal region (Fig. 9.1).
In the past 15 years, several studies have reported the results of TEA as the primary treatment of selected distal
humeral fractures, documenting favorable outcomes compared to open reduction internal fixation (1, 2, 3 and 4).
At the same time, there has been renewed interest in distal humeral hemiarthroplasty as an alternative treatment
method, but this has not been well described in the literature. The results of primary arthroplasty versus
secondary TEA following failed fixation remain unclear. While primary arthroplasty is considered technically
easier with a lower complication rate (19), Prasad and Dent (5) recently reported that secondary elbow
arthroplasty following failed internal fixation had similar outcomes to primary TEA, with only a marginally higher
complication rate.

INDICATIONS AND CONTRAINDICATIONS

Primary TEA for distal humerus fractures is largely limited to the elderly (>70 years of age) patient population
with displaced and comminuted intra-articular fractures (Fig. 9.2A,B). Within this population, other factors
favoring TEA include complex articular fractures in patients with preexisting elbow arthritis (6), advanced age
with reduced life expectancy, severe osteoporosis, or pathologic bone. Occasionally, younger patients (<70
years of age) with advanced and symptomatic degenerative changes in the elbow joint, with an intra-articular
distal humerus fracture, may be a candidate for an elbow replacement procedure. Because older patients with
simple fracture patterns do well with ORIF (7,8), age alone should not dictate the method of treatment.
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FIGURE 9.1 AO/OTA classification of type 13C fractures.

FIGURE 9.2 AP (A) and lateral (B) radiographs of an elderly patient who subsequently sustained a fracture-
dislocation injury resulting in a comminuted intra-articular elbow fracture of the AO/OTA 13C type.

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Fracture extension into the diaphysis past the olecranon fossa or flare of the condyles can be treated with
arthroplasty, within certain limits. For example, the Coonrad-Morrey system has a revision humeral component
with a long anterior flange that is designed for bone loss of up to 8 cm from the joint surface. Fracture extension
into the diaphysis should be treated with internal fixation.
There are several absolute contraindications to TEA and include flaccid paralysis of the upper extremity, severe
cognitive impairment, a neuropathic joint, or the presence of an active infection. Relative contraindications to
primary elbow replacement for fracture include anticipated noncompliance with activity restrictions, high-grade
open fractures, soft-tissue compromise that would prevent adequate wound closure, and limbs with vascular
compromise. It is important to remember that the vast majority of patients with a displaced intraarticular distal
humerus fracture under the age of 70 years should be treated with ORIF.

PREOPERATIVE PLANNING
History and Physical Examination
A complete history and thorough physical examination should be performed. The history should include
information on the mechanism of injury, preinjury levels of function, and medical comorbidities such as
rheumatoid arthritis, diabetes, or stroke that may influence the method of treatment. In patients with high energy
injuries, or in the multiply injured patient, airway management and hemodynamic stability should always take
priority and should include a careful assessment of the head, chest, and abdomen prior to further treatment of
the injured extremity.
On physical examination, the elbow is invariably swollen, tender, and motion is decreased. The entire upper limb
must be evaluated and the soft tissues inspected for abrasions, blisters, or open wounds (typically posterior). If
an open fracture is identified, intravenous antibiotics should be started. We use cefazolin for grade I or II open
fractures, and an aminoglycoside is added for grade III injuries. A detailed neurovascular examination is
performed including evaluation of the brachial and radial pulses, as well as the capillary refill. The function of the
radial, median, and ulnar nerves should also be determined and documented as these structures are susceptible
to damage, particularly, the ulnar nerve. The forearm should be carefully assessed to rule out a compartment
syndrome. In the absence of neurovascular compromise or a compartment syndrome, a closed reduction with
correction of any obvious angulation or deformity is performed (which decreases tension on the soft tissues) and
a long-arm splint applied.

Imaging
Standard anteroposterior (AP) and lateral radiographs of the elbow are obtained. Film quality should be
adequate for assessment of bone quality, fracture displacement, and the extent of intra-articular comminution. In
displaced fracture patterns, traction radiographs that use ligamentotaxis to restore length and alignment can
provide additional information. A CT scan of the elbow can improve the assessment of articular fragments but is
best done following a preliminary closed reduction with some restoration of length and alignment (Fig. 9.3). On
occasion, when the fracture pattern is unclear, a CT scan can provide detailed information about the fracture
geometry, especially intra-articular comminution or associated fractures. This can help in surgical decision
making
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regarding the ideal procedure (i.e., TEA vs. ORIF). We have not found MRI scans to be helpful in the acute
setting. Additional upper extremity radiographs should be obtained based on the history and physical
examination.
FIGURE 9.3 CT scan with 3D reconstruction of the patient in Figure 9.1. Based on the imaging studies, a
decision was made to treat the injury with a TEA.

Timing of Surgery
The treatment of choice for most displaced, intra-articular distal humerus fractures is ORIF with TEA reserved for
complex articular fractures in the elderly low demand patient. We believe that the best results occur when
surgery is performed by experienced surgeons working with a knowledgeable operating room staff, and we rarely
perform this complicated surgery at night or on the weekends. We proceed with surgical intervention as promptly
as logistical preparations can be made, typically within a few days of injury. The role of primary TEA in patients
with an open fracture remains highly controversial. If the patient has a minor, grade I puncture posteriorly, there
is no gross contamination, and a prompt (<12 hours) thorough débridement is performed, it is probably safe to
proceed with primary TEA. In the absence of any of these conditions, or if there is soft-tissue compromise,
irrigation/débridement and temporary stabilization should be performed followed by elbow arthroplasty at a later
date. If a decision regarding open reduction internal fixation versus elbow replacement cannot be made
preoperatively with the available imaging studies, an intraoperative fluoroscopic assessment should be done,
and implants for both ORIF and TEA should be available and the patient consented for either procedure. It is
important to inform the operating room staff regarding the equipment required.

SURGERY
Approach
The management of the triceps muscle and tendon as well as the olecranon is crucial to achieving consistently
good outcomes following TEA. We prefer to perform TEA after resection of the fractured humeral condyles using
a triceps-sparing approach, which has many advantages although it is technically more difficult, and the
exposure is more limited. For surgeons who do not regularly perform elbow arthroplasty, the triceps-splitting
approach is most commonly used. An alternative approach is the triceps-reflecting (Bryan-Morrey) technique
involving a medial-to-lateral peel of the triceps to gain adequate exposure. However, given the small but definite
risk of triceps detachment with these approaches, our preferred exposure is the triceps-sparing method. The
medial and lateral borders of the triceps muscle are incised, and the triceps muscle is freed from the distal
humeral shaft. The medial and lateral collateral ligaments (LCLs) are elevated along with the soft tissues as a
sleeve during the exposure and later reattached to the triceps at the conclusion of the case. Concomitant
fractures of the proximal ulna and olecranon are relative contraindications to successful primary TEA, as they
jeopardize the stability of the ulnar component (9,10). Similarly, the use of an olecranon osteotomy for exposure
is contraindicated if a TEA is anticipated. Regardless of which surgical approach is chosen, there must be
adequate exposure of the distal humerus to visualize the fracture, allow removal of all of the fracture fragments,
and allow proper implantation of the prosthesis.

Implant Selection
In general, total elbow prostheses are available as unlinked with separate humeral, ulnar, and occasionally radial
components or linked where the ulnar and humeral components are physically joined. A few models may be
converted between the two depending on the requirements of the case. Among the linked systems, they are
further subdivided into fully constrained and semiconstrained models. These differ in that the latter allow a small
amount of varus-valgus and rotational movement, the so-called sloppy hinge, in addition to the full extension and
flexion movement at the elbow joint. These semiconstrained implants have a lower loosening rate than the
traditional fully constrained, with the rationale being that the looser hinge allows for some accommodation of the
stresses seen at the prosthesis-cement and cement-bone interfaces, and this results in lower rates of loosening.
Both the semiconstrained and constrained systems are linked, and thus, in contrast to the unlinked systems, are
ideal for TEA in the fracture setting since they do not rely on intact ligaments or bony alignment to convey
stability to the elbow joint.
Due to the bone loss and loss of ligament attachment that is incurred in acute fracture patterns where a TEA is
indicated—namely, OTA/AO type 13 C2-C3—a linked, semiconstrained implant is typically the implant of choice.
Examples of this include the Coonrad-Morrey (Zimmer, Warsaw, IN) and Discovery (Biomet Orthopaedics,
Warsaw, IN) systems.

SURGICAL TECHNIQUE
Surgery is performed when logistical preparations can be made, usually in the first few days after injury. It is not
necessary or desirable to perform this procedure emergently at night or on weekends without skilled staff. Either
a general or regional anesthetic technique can be used. The patient is positioned on a “bean bag” in the
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lateral decubitus position with the affected side up (Fig. 9.4). A tourniquet is used in all cases, nonsterile or
sterile depending on the morphology of the arm. The injured extremity is supported on a padded bolster before
prepping and draping. Alternatively, surgery can be performed in the supine position with the injured arm draped
free on a sterile bolster across the patient's chest. A sterile stockinette and flannel or an adherent wrap is placed
on the hand. A first-generation cephalosporin is given intravenously prior to inflation of the tourniquet.
Intraoperative imaging is necessary only if a decision has to be made on whether to perform an ORIF or TEA.
Fluoroscopy is not usually necessary when performing a TEA.
FIGURE 9.4 The patient is placed in the lateral decubitus position on a “bean bag,” and the extremity is
supported over a bolster.

The bony landmarks are drawn on the skin with a sterile-marking pen (Fig. 9.5A). A 15-cm midline incision is
made posteriorly centered over the elbow joint, and a full thickness medial and lateral subcutaneous flap is
created above the fascia. The next step is to identify and protect the ulnar nerve in the cubital tunnel. It should
be mobilized both proximally and distally to avoid injury. The distal dissection should extend to the first motor
branch to the flexor carpi ulnaris (FCU) muscle. The ulnar nerve is protected with a small Penrose drain or
vessel loop (Fig. 9.5B).
Once the ulnar nerve has been identified and protected, the medial and lateral borders of the triceps are
identified and incised, and the triceps elevated from the distal humeral shaft, exposing the fractured condyles
(Fig. 9.6A). Progressive subperiosteal and capsular release of soft tissues on the medial side of the elbow is
performed, preserving the medial collateral ligament (MCL) along with the flexor-pronator origin as a continuous
sleeve for later repair and reattachment. Similarly, on the lateral side, the LCL is released along with the muscle
of the common extensor-origin in a continuous flap, which will allow repair and reattachment of these soft tissues
at the conclusion of the procedure. The distal humeral fracture fragments are now completely excised (Fig.
9.6B). It is not usually necessary to repair the condyles or minimal metaphyseal fracture extension in the
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shaft. If there is extensive proximal fracture extension, that is, 5 to 6 cm past the end of the olecranon fossa, it
may be necessary to repair this fracture extension (without compromising the intramedullary canal) to enhance
stability of the humeral component (in addition to using a longer prosthesis). The Coonrad-Morrey system has an
8-inch revision humeral component with a log anterior flange that is designed to accommodate for distal humeral
bone loss and may be useful in this situation. Any residual rough edges on the humeral shaft should be trimmed
away with an oscillating blade or rongeur.
FIGURE 9.5 A. The bony landmarks are identified and marked on the skin and a posterior midline incision is
made. The fascia is exposed and (B) the ulnar nerve is mobilized distally to the branch of the FCU and tagged
with a Penrose drain.

FIGURE 9.6 Once the ulnar nerve has been protected, the distal humerus medial to the triceps is exposed
followed by the (A) lateral side of the distal humerus. B. The fracture fragments are excised.

The humeral shaft is “delivered” either medially or more commonly lateral to the triceps tendon and stabilized
with small Hohmann retractors. Once the shaft of the humerus is accessible, the medullary canal is opened and
enlarged using hand broaches or rasps in the arthroplasty tray until cortical resistance is encountered (Fig.
9.7A). A trial humeral prosthesis is inserted and firmly seated with the anterior flange against the cortical bone of
the anterior distal humerus of the residual olecranon fossa (Fig. 9.7B). This serves as a landmark for the proper
height of the prosthesis and in turn, the location of the flexion-extension axis for the arthroplasty. The retractors
are removed, and the elbow is flexed and externally rotated to expose the olecranon. The tip of the olecranon is
removed with a high speed burr or small rongeur to allow direct access down the ulnar canal. This start point
should be in line with the intramedullary canal of the ulna, centering the
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fulcrum of the prosthesis with that of the greater sigmoid notch. The posterior cortex of the ulna is used as a
guide for rotational alignment. A starting awl is used to identify the ulnar intramedullary canal. Progressively
larger reamers, broaches or rasps are then used to prepare the proximal ulna (Fig. 9.7C,D ). Great care should
be taken to avoid penetrating the far cortex of the ulna to minimize the risk of an iatrogenic fracture during
insertion of the ulnar component. A trial ulnar component is inserted and seated so that its center of rotation is
the intersection of the midline of the coronoid process in the horizontal plane and the middle third of the
olecranon fossa in the vertical plane.

FIGURE 9.7 A. The humeral canal finder is inserted followed by (6a) rasps of increasing size. B. A humeral trial
is inserted. Similarly, on the ulnar side, the (C) entry point for the ulnar component is identified, and (D) rasps of
increasing size are inserted until the ulnar trial can be placed for a trial reduction (E).
FIGURE 9.7 (Continued)

The trial components are reduced, and elbow range of motion is tested for extension and flexion and signs of
impingement (Fig. 9.7E). Areas of potential impingement include the olecranon posteriorly and the coronoid
process anteriorly. The trial reduction should ensure proper fit and stability prior to cementing the definitive
implants. Range of motion between 0 and 140 degrees is ideal, but is not always possible. If more extension is
required, the components often need to be seated more deeply. Also, it is better to leave the elbow with a small
(10 to 20 degrees) deficit in extension than to have the prosthesis hyperextend. A slight loss of terminal
extension is usually well tolerated in the older patient, but hyperextension can be painful and may lead to
instability, which increases stress on the prosthesis and the potential for loosening. The depth of insertion of the
trials is noted and marked for insertion of the definitive implants. We typically use a 4- or 6-inch humeral
component and a 3.5-inch ulnar component, depending on the size of the patient. Sizes of components available
for trialing depend on the system used. For the Coonrad-Morrey (Zimmer, Warsaw IN) trial, humeral components
are available with 4-, 6-, or 8- inch stems, with the latter usually used more for revision cases where a longer
stem is required. Both humeral and ulnar prostheses are available in extra-small, small, and regular sizes. Once
the appropriate size trial has been identified, and maximal range of motion can be achieved without impingement,
and the stems fill their respective canals, the trials are removed. The intramedullary canal is lavaged, and a
cement restrictor with either a plastic plug or impacted cancellous bone from the condyles is placed in the
humeral medullary canal. The canals are suctioned dry, and cement is injected with the use of a narrow-nozzle
cement gun. The use of antibiotic-impregnated cement has been shown to decrease infection rates in TEA. If
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cement premixed with antibiotics is not available, it is possible to add antibiotics to the cement mix. The current
preference of the authors is to use a tobramycin-cement mix. Prior to cementing the humeral component, a thin
wedge of bone graft obtained from the fractured condyles is placed between the anterior humeral flange and
anterior humeral cortex: once this heals, it helps to reduce stress on the humeral component. The definitive
components are cemented into the humerus and ulna and reduced (Fig. 9.8A,B). The humeral and ulnar sides
are inspected simultaneously for extruded cement, which is completely removed without disturbing the cement
mantle around the prosthesis. Once the excessive cement is removed, the humeral and ulnar components are
coupled together with the locking mechanism (Fig. 9.8C). The elbow is extended until the cement hardens to
ensure complete seating of the components. The wounds are irrigated and the joint reexamined for loose
cement. The elbow is carried through a range of motion and tested for stability: the usual 5 to 8 degrees of
“toggle” with the semiconstrained prosthesis are expected.
FIGURE 9.8 After the canals are cleaned and dried, a cement restrictor is placed on the humeral side and
antibiotic-impregnated cement is injected with a cement gun. A. Humeral and (B) ulnar components are placed,
excess cement is removed, and the (C) locking mechanism with connecting axle placed. The arm is held in
extension until the cement hardens. D. The ulnar nerve is left in a tension free position medially.

The tourniquet that was used during surgery is released and meticulous hemostasis obtained. The triceps fascia
is closed and reapproximated with the edges of the medial (MCL, flexor pronator mass, forearm fascia) and
lateral (LCL, common extensor origin, forearm fascia) soft-tissue sleeves. If a triceps splitting or reflecting
approach had been used, transosseous nonabsorbable sutures are required to reattach the triceps tendon
attachment to the olecranon through drill holes. The ulnar nerve is left in a tension-free position medially (Fig.
9.8D). Subcutaneous closure using 2-0 absorbable sutures is performed followed by skin closure with staples. A
plaster splint is placed anteriorly to immobilize the arm in full extension for the first 24 to 48 hours postoperatively
(Fig. 9.9). We do not routinely use suction drains after a TEA. Postoperative radiographs are obtained (Fig.
9.10A,B).
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FIGURE 9.9 The wound is irrigated with saline, and the medial and lateral soft-tissue sleeves are
reapproximated and sutured together. The incision is closed in layers. An extension splint is applied for 24 to 48
hours.

POSTOPERATIVE CARE
The arm is initially splinted in extension for the first 24 to 48 hours postoperatively, and the limb is elevated on
pillows to decrease swelling. On postoperative day 3, the splint is removed. Postoperative antibiotics are
administered for 24 hours, but DVT prophylaxis is not used routinely for this procedure. If a triceps-sparing
approach was used, unrestricted active and passive range of motion exercises of the elbow are started, including
exercises for the shoulder and wrist. For elbow arthroplasty done through a triceps reflecting or split approach,
active elbow extension exercises are restricted for 4 to 6 weeks to protect the triceps repair. In these patients,
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gravity-assisted extension exercises are used during the first 4 to 6 weeks to prevent stiffness at which time
active extension is permitted. In terms of weight bearing for patients with associated lower extremity injuries,
patients are allowed to use crutches or a walker if needed. Lastly, TEA patients are allowed to return to activities
of daily living with a (life-long) 5 to 10 pounds weight restriction. We strongly advise that patients refrain from
participating strenuous activities such as tennis or golf because of the substantial forces applied to the elbow,
which may lead to aseptic loosening. Patients are seen for clinical follow-up in 2 weeks for inspection of incision
and monitoring of adequate wound healing, followed by another 4-week follow-up when radiographs of the elbow
are obtained. Patients are then followed once every few months until the 1-year postoperative mark, after which
annual radiographs are obtained for signs of loosening.
FIGURE 9.10 Postoperative radiographs showing AP (A) and lateral (B) views of the TEA.

RESULTS
Outcomes following total elbow replacement for displaced intra-articular distal humerus fractures are
generally good to excellent. Functional outcomes as measured by the Mayo Elbow Performance Score
(MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores have shown improved outcomes
compared to internal fixation in clinical studies. Successful outcomes after TEA for fracture have been
reported in patients that have been followed up to 5 years after surgery. Despite extension deficits of 20 to
30 degrees, most patients have a functional arc of elbow flexion averaging 110 degrees and good or
excellent functional scores at 1 and 3-year follow-up (11, 12 and 13). Mckee et al. (4) in a randomized,
controlled clinical trial comparing TEA to ORIF in older patients (mean age 79 years) found higher MEPS
and DASH scores in the TEA group. Additionally, 5 patients (of 20) randomized to internal fixation were
found to have irreparable fractures and were treated with arthroplasty. A comparative study by Frankle et al
showed poor results in 4 of 12 patients treated with ORIF versus 12 good or excellent results in 12 patients
treated with primary TEA. The revision rates following elbow arthroplasty for fractures are low in most
series, although they do increase over time (5 revisions in 43 index cases at a mean of 7 years
postoperatively in one series) (14). Moreover, studies show that resection of the humeral condyles during
TEA for distal humerus fractures does not result in substantial decreases in forearm, wrist, or hand strength,
when these parameters are individually measured (15).
 COMPLICATIONS
Deep infection is the most feared early complication of elbow arthroplasty and is seen in approximately
5% of primary arthroplasties for fracture (15,16). The most common organisms are Staphylococcus
aureus and Staphylococcus epidermidis. Early deep infection is treated with urgent operative
intervention. This consists of disassembly of the prosthesis, obtaining deep cultures for proper
bacterial identification, radical débridement, thorough irrigation, and component reassembly and
closure. Although it is unsupported by currently available evidence, the authors augment this with
locally implanted antibiotics (i.e., 2 g vancomycin in powder form), followed by 6 weeks of intravenous
antibiotics. If this is unsuccessful, then either chronic suppressive therapy or staged revision
arthroplasty is required. Factors that may reduce deep infection rates include the use of preoperative
antibiotics, meticulous attention to draping of the extremity and surgical technique, and the use of
antibiotic-impregnated cement. Additionally, a careful preoperative plan, the availability of proper
equipment, and surgical experience all help to minimize surgical time, an important factor in decreasing
infection rates. Aseptic loosening is the most common cause of late failure following TEA (17). The use
of semiconstrained linked implants may reduce the incidence of aseptic loosening by allowing 7
degrees of varus-valgus laxity and 7 degrees of axial rotation. If the prosthesis becomes loose, the
ulnar component is affected more frequently, although the anterior cortex of the distal humerus is an
area prone to osteolysis. The goal of arthroplasty is to reproduce physiologic kinematics as closely as
possible to minimize the amount of stress that can accelerate implant loosening. Proper alignment of
the prosthesis with the release of any preexisting soft-tissue contractures minimizes the long-term
strain on the components. Late loosening that is clinically symptomatic usually requires revision
arthroplasty (20).
Although uncommon, the polyethylene and bushings can experience locking mechanism disassociation
and wear. Gill and Morrey (17) described a method of identifying bushing wear radiographically by
drawing a line perpendicular to the axis of the bushing and measuring the angle to another line drawn
along the longitudinal axis of the component stem on an AP radiograph. As 7 degrees of varus-valgus
laxity is built into the implant, they defined partial bushing wear as an angle between 3.5 and 5
degrees on either side of the shaft and complete wear as an angle more than 5 degrees on either side
of the shaft. If there is radiographic evidence of bushing wear and the patient has symptoms of pain,
squeaking, or palpable crepitus, then revision of the bushings and or polyethylene may be indicated.
Periprosthetic humeral fractures have been reported and may be a result of additional trauma,
osteoporosis, surgical technique, implant positioning, patient compliance, stress shielding, or aseptic
loosening. O'Driscoll and Morrey (18) classified these fractures into the Mayo Classification of
Periprosthetic Fractures of the Elbow. Although rare, they usually require revision with a long-stem
revision implants and strut allograft augmentation.
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Complications related to triceps dysfunction have been significantly decreased by the use of a triceps
sparing approach and the use of a linked prosthesis. Finally, heterotopic ossification following elbow
arthroplasty is rare, and the literature contains little evidence in favor or against prophylaxis after TEA
(10). We do not routinely use heterotopic ossification prophylaxis when performing TEA for fracture.

CONCLUSION
 Semiconstrained TEA is an effective and safe technique for the treatment of selected comminuted intra-
articular fractures of the distal humerus in elderly (>70 years) patients. There is increasing evidence that
this procedure is superior to ORIF in this subgroup of patients and reliably produces good to excellent
outcomes with a functional arc of motion without the need for prolonged therapy. Complications, although
rare, are significant and require careful patient selection, meticulous surgical technique, and postoperative
care to optimize patient outcome.

REFERENCES
1. Cobb T, Morrey B. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly
patients. J Bone Joint Surg Am 1997;79(6):826-832.

2. Frankle MA, Herscovici D Jr, DiPasquale TG, et al. A comparison of open reduction and internal fixation
and primary total elbow arthropalsty in the treatment of intraarticular distal humerus fractures in women older
than age 65. J Orthop Trauma 2003;17:473-480.

3. Melhoff TL, Bennett JB. Distal humeral fractures: fixation versus arthroplasty. J Shoulder Elbow Surg
2011;20:S97-S106.

4. McKee MD, Veillette CJ, Hall JA, et al. A multicenter, Prospective, randomized, controlled trial of open
reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures
in elderly patients. J Shoulder Elbow Surg 2009;18:3-12.

5. Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a
comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone
Joint Surg Br 2008;90(3): 343-348.

6. Jost B, Adams RA, Morrey BF. Management of acute distal humeral fractures in patients with rheumatoid
arthritis: a case series. J Bone Joint Surg Am 2008;90:2197-2205.

7. Srinivasan K, Agarwal M, Matthews SJ, et al. Fractures of the distal humerus in the elderly: is internal
fixation the treatment of choice? Clin Orthop Relat Res 2005;434:222-230.

8. Huang TL, Chiu FY, Chuang TY, et al. The results of open reduction and internal fixation in elderly
patients with severe fractures of the distal humerus: a critical analysis of the results. J Trauma 2005;58:62-
69.

9. Morrey BF, Sanchez-Stotelo J. Approaches for elbow arthroplasty: how to handle the triceps. J Shoulder
Elbow Surg 2011;20:S90-S96.

10. Nauth A, McKee MD, Rivstevski B, et al. Distal humeral fractures in adults. J Bone Joint Surg Am
2011;93:686-700.

11. Lee KT, Lai CH, Singh S. Results of total elbow arthroplasty in the treatment of distal humerus fractures
in elderly Asian patients. J Trauma 2006;61(4):889-892.
12. Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total
elbow arthroplasty as a primary treatment. J Bone Joint Surg Br 2002;84(6):812-816.

13. Gambirasio R, Riand N, Stern R, et al. Total elbow replacement for complex fractures of the distal
humerus. An option for the elderly patient. J Bone Joint Surg Br 2001;83(7):974-978.

14. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone
Joint Surg Am 2004;86(5):940-947.

15. McKee MD, Pugh D, Richards R, et al. Effect of humeral condylar resection on strength and functional
outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 2003;85:805-807.

16. Wolfe SW, Figgie MP, Inglis AE, et al. Management of infection about total elbow prostheses. J Bone
Joint Surg Am 1990;72:198-212.

17. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid
arthritis: A ten to fifteen-year follow-up study. J Bone and Joint Surg Am 1998;80(9):1327-1335.

18. O'Driscoll SW, Morrey BF. Periprosthetic fractures about the elbow. Orthop Clin North Am 1999;30:319-
325.

19. Frankle MA, Virani N, Fisher D, et al. Immediate total elbow arthroplasty for distal humerus fractures.
Tech Orthop 2006;21(4):363-373.

20. Brownhill JR, Ferreira JM, Pichora JE, Johnson JA and King GJ. Defining flexion-extension axis of the
ulna: implications for intra-operative elbow alignment. J Biomech Eng. 2009;131(2):021005.
 10
Olecranon Fractures: Open Reduction and Internal Fixation
James A. Goulet
Kagan Ozer

INTRODUCTION
Fractures of the olecranon constitute approximately 10% of fractures that occur about the elbow. They vary in
complexity from relatively simple transverse fractures to highly comminuted and unstable fracture dislocations.
Due to the wide spectrum of fracture patterns, no single method of treatment is applicable to all fractures.
Olecranon fractures occur in all age groups with a bimodal injury pattern. Peaks occur in younger adults
following higher injury trauma and in older patients with poor bone quality following ground-level falls. The goal
of treatment in displaced fractures is to achieve stable internal fixation that allows early range of elbow motion.
The critical element in treatment of a proximal ulnar fracture is restoration of the size and shape of the trochlear
notch. Small areas of comminution and minor incongruities in the transverse groove are well tolerated, since this
portion of the olecranon is responsible only for limited load transmission. Although olecranon fractures frequently
occur as isolated injuries, failure to recognize concomitant bone or soft-tissue injuries associated with ulnar
fractures often preclude restoration of normal elbow function. Careful attention to associated injuries with repair
of the lateral ligament complex, repair of the anterior capsule and coronoid process, and repair or replacement of
the radial head when these structures are injured is critical for restoration of elbow function. Evaluation of
fracture displacement, comminution, and ulnohumeral instability determines the method of surgery to be used to
treat olecranon fractures.
There are a large number of classifications for olecranon fractures that have been described. Colton devised a
simple descriptive system that is still widely employed. Both the Schatzker and Mayo classifications are
descriptive based on the fracture pattern and a consideration of the type of internal fixation required (2,4,15).
The AO/OTA classification is probably the most widely used in North America (Fig. 10.1).

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

Nondisplaced and very minimally displaced fractures (<2 mm) can be treated nonoperatively if the triceps
mechanism remains intact. Patients who can actively extend their elbow against gravity can usually be treated
nonoperatively. These injuries are treated in a well-molded long arm cast, which is converted to a removable
splint, and gentle active motion is initiated 2 to 3 weeks after injury.
Most displaced olecranon fractures require surgical treatment (Fig. 10.2). Treatment alternatives include simple
tension band wire fixation, fixation with plates (with or without locking screws), and olecranon excision with
triceps advancement (1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11). Treatment is influenced by the size of the olecranon
fragment, the degree of comminution, and the bone quality. Because the olecranon and proximal ulna are
subcutaneous in location, low-profile implants are important to reduce the incidence of painful prominent
hardware.
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FIGURE 10.1 AO/OTA classification of olecranon fractures.

FIGURE 10.2 A displaced olecranon fracture with disruption of the extensor mechanism and articular surface.
This is a very strong indication for surgery.

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FIGURE 10.3 Radiographic appearance of a properly done tension band wire construct.

Tension band wire fixation is reserved for simple transverse fractures and most noncomminuted injuries, which
constitute the majority of olecranon fractures (Fig. 10.3). Tension band wiring is contraindicated in comminuted
fractures as it cannot preclude shortening with this technique. In these fractures and those associated with
ulnohumeral instability, plates and screws often provide better fixation (Fig. 10.4). Conventional nonlocking
plates are adequate for fractures in younger patients with good bone quality and no fracture gaps. Comminuted
length-unstable fractures, in patients with poor bone quality, and olecranon fractures associated with radial head
or coronoid fractures are treated with locked plates. In the past decade, precontoured periarticular proximal
ulnar-locking plates have been developed and can be very helpful.
Olecranon excision with triceps advancement is used occasionally in patients with small comminuted fractures
that do not affect elbow stability (5,12,13). Most are elderly patients with significant osteoporosis (Fig. 10.5A,B).
Olecranon excision is contraindicated for fractures distal to the semilunar notch or for fractures
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associated with ligamentous instability. In young patients, avulsion of the triceps tendon from the olecranon or
contaminated open fractures with crush injury of the proximal olecranon are best treated with excision and
reattachment of the triceps tendon.
FIGURE 10.4 A comminuted length unstable olecranon fracture treated with a plate and screws.

FIGURE 10.5 A,B. An 87-year-old female with multiple medical comorbidities fell, sustaining an olecranon
fracture. She was treated by excision and triceps tendon repair.

PREOPERATIVE PLANNING
History and Physical Exam
A careful history and physical exam should be performed on all patients with an elbow injury. The history should
identify the mechanism of injury (low vs. high energy, ballistic injury, etc.), pertinent comorbidities (diabetes
mellitus, cardiac problems, etc.), pertinent past surgical history, medications, and drug allergies. Hand
dominance should also be established. The physical exam must evaluate and document objective findings such
as swelling, ecchymosis, open wounds, neurologic status, and peripheral pulses. Patients with minimally
displaced olecranon fractures should be evaluated to determine if active elbow extension is present, because it
is an important criterion for nonoperative treatment. A full trauma workup using Advanced Trauma Life Support
(ATLS) protocols is necessary in patients with high-energy trauma, patients with complex associated injuries,
patients who are obtunded, and patients who have a head injury.

IMAGING STUDIES
In patients with suspected elbow injuries, an anteroposterior (AP) and lateral radiographs should be obtained.
Due to pain associated with positioning of the elbow, high-quality orthogonal radiographs are often difficult to
obtain in the conscious patient. Traction films with light sedation can be helpful for evaluation of complex
fractures in a cooperative patient. In some patients, optimal films cannot be obtained until the patient is
anesthetized in the operating room. Based on the physical examination, x-rays of the entire humerus or forearm
may be indicated. Computed tomography scans are not usually necessary for isolated olecranon fractures and
are most often used for olecranon fractures associated with articular impaction, radial head or coronoid fractures,
or fracture dislocations. There are very few indications for magnetic resonance imaging scans.

TIMING OF SURGERY
The timing of surgery for olecranon fracture fixation is determined by the status of the soft tissues. With open
fractures, irrigation and débridement should be performed as soon as the patient's condition and institutional
resources permit. Immediate internal fixation may be beneficial for Grade I and II open fractures, in patients who
are hemodynamically stable. In patients with highly comminuted fractures associated with grossly contaminated
wounds, splinting or external fixation is preferred with sequential débridements followed by delayed
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internal fixation. If a vascular injury is present, exploration, repair, and external fixation should be performed
urgently in collaboration with a vascular surgeon. Low-velocity gunshot wounds without a neurovascular injury
are treated with local wound care, antibiotic administration, and fracture stabilization if indicated. For closed
olecranon fractures, internal fixation is performed electively when the soft tissues permit. Because the olecranon
is a subcutaneous bone, soft-tissue abrasions may require local skin care prior to internal fixation.

SURGICAL TACTIC
Following a careful preoperative assessment of the patient and a critical review of the injury radiographs, a
treatment plan is developed. This determines what should be available in the operating room if surgery is
required. For simple, noncomminuted transverse fractures, the surgeon should plan to have 18-gauge stainless
steel wire, Kirschner (K) wires, and/or 4.5- or 6.5-mm cannulated screws for intramedullary fixation, a battery-
powered drill, and a no. 14 gauge angiocath to pass the wire beneath the triceps tendon. Small and medium
pointed reduction clamps should also be available.
More complex fractures require a wider array of equipment. Standard “small fragment” implants and instrument
sets are requested for plate fixation of fractures distal to the semilunar fossa. Fracture-specific periarticular
olecranon-locking plate sets should also be available for comminuted olecranon fractures or when bone quality is
poor. With high levels of comminution, provision should be made for “minifrag” 2.0-, 2.4-, and 2.7-mm plates and
screws.
A proximal radial prosthesis should also be available when a displaced radial head or neck fracture is present.
Suture anchors are indispensable when ligamentous instability is suspected.

SURGERY
Either regional or general anesthesia can be utilized. The patient is placed in a supine position. A nonsterile
tourniquet is applied to the upper arm. To facilitate visualization and stability, the table is tilted obliquely toward
the patient's noninjured side. Surgery is performed with the forearm placed across the chest, with a supportive
bolster placed beneath the proximal forearm (Fig. 10.6A). When an assistant is not available, the wrist may be
secured with a sterile Kerlex (Kendall Healthcare Products, Mansfield, MA) and attached to a weight on the
patient's contralateral side. When an assistant is available, it is their job to support the arm. Flexion of the elbow
can be adjusted by varying the height of the support under the proximal forearm. For simple fractures, fracture
reduction
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often can be achieved with the elbow in 90 degrees of flexion, but most complex fractures require the freedom to
freely flex and extend the elbow. Some surgeons prefer placing the patient either in a lateral or in a prone
position. However, supine positioning minimizes setup time, limits the complexity of anesthetic monitoring, and
accommodates management of patients with multiple injuries who cannot be positioned either lateral or prone.

FIGURE 10.6 A. The patient is positioned supine on the table with the arm across the chest. A towel or bolster is
used to support the forearm. B. A curved incision is drawn on the skin with a sterile marking pen.

One gram of cefazolin is administered at the beginning of the case. In case of allergy, vancomycin is used. When
the fracture is open, an aminoglycoside or penicillin or both are also administered. The entire arm from fingertips
to the tourniquet is carefully prepped and draped. A C-arm intensifier is essential and must be positioned to
provide high-quality intraoperative images.
The incision starts on the subcutaneous border of the ulna and extends proximally around the tip of the
olecranon, 4 to 5 cm (Fig. 10.6B). Curved incisions are helpful in obtunded patients who are subject to pressure
from casts and splints and allows the skin incision an offset from the deeper fascial incision when the soft-tissue
envelope is compromised (14,15).
The incision is deepened to the level of the fascia, and a full-thickness subcutaneous flap is elevated over the
olecranon medially and laterally. The ulnar nerve is identified medially, but is not routinely mobilized. The fracture
site is identified, and 2 to 3 mm of periosteum is elevated along the length of the fracture to improve visualization
and subsequent reduction. The forearm muscles are minimally reflected from the ulnar diaphysis as needed for
visualization. Debris and clot are removed from the fracture site. The proximal fracture fragment is reflected
proximally, allowing the joint to be inspected for chondral damage, loose bodies, and articular impaction.
With simple two-part fracture, the fracture is reduced and held with a large pointed reduction tenaculum (Fig.
10.7). Reduction can be facilitated by extending the elbow to reduce the pull of the triceps. Another helpful tip is
to drill a 2.5-mm unicortical hole on the dorsal surface of the ulna in the distal fragment so that the point of
reduction forceps does not slip. In more complex cases, particularly those with fracture comminution and/or
articular impaction, the reduction may be challenging (Fig. 10.8). Depressed osteoarticular fragments must be
elevated, and if the resulting defect creates an unstable void, it should be bone-grafted. Multiple small 1.25- or
1.6-mm K-wires are used for provisional fixation, which may be augmented with minifragment screws. The
remaining fracture is then reduced and provisionally stabilized with one or sometimes two-pointed reduction
forceps. The fracture reduction is checked radiographically, with the C-arm.
A tension band wire construct is used as definitive fixation in noncomminuted transverse olecranon fractures.
Strategically placed pointed reduction forceps are used to achieve and maintain fracture reduction. Either a 1.6-
or 2.0-mm K-wire is advanced through the tip of the olecranon on each side of the reduction tenaculum, just
beneath the subchondral bone, and directed into the anterior cortex of the proximal ulna (Fig. 10.9). The position
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of the wires must be confirmed with an AP and lateral image with the C-arm (Fig. 10.10). To avoid excessively
long pins through the anterior cortex, the K-wires should be backed out of the anterior cortex for a few millimeters
after the anterior cortex has been penetrated. This allows the K-wires to be bent, advanced, and countersunk at
the end of the procedure.
FIGURE 10.7 A schematic illustration of an olecranon fracture reduced and held with a large pointed reduction
forceps.

FIGURE 10.8 Articular impaction in a 22-year-old female after a fall onto her elbow.
FIGURE 10.9 The K-wires are placed that engage the anterior cortex of the proximal ulna.

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FIGURE 10.10 The reduction must be confirmed radiographically using the C-arm.

A 2.0-mm drill bit is then used to create a transverse drill hole, 2 to 3 cm distal to the fracture site midway
between the posterior and anterior cortex. The ulnohumeral joint should lie roughly midway between the tip of
the olecranon and the drill hole. An 18-gauge stainless steel wire is then placed through the drill hole. A 14-
gauge angiocath is used to create a path for placement of the wire. It is inserted through the triceps tendon deep
to the K-wires. The stylet is removed leaving the latex angiocath in place. The tension band construct can be
created using either one of two wires. Placing one wire proximally through the angiocath (which is then removed)
and one wire distally is a simple and effective technique. The wires are crossed posteriorly and are then
tightened by twisting the proximal wire to the distal wire both medially and laterally (Fig. 10.11). Alternatively, a
single wire can be used, twisting the ends of the wires on one side to simply create a loop to apply tension on
the side opposite the free wire ends (Fig. 10.12).
All of the slack should be “removed” from the wire(s), which are then tensioned and slowly tightened. A variety of
wire tighteners are commercially available, or it can be done with two heavy needle drivers. The exact amount of
tightening is done by “feel.” Excessive tightening can easily break the wire necessitating
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repeating the process. After the wires are tightened, excess wire is clipped and bent to minimize wire
prominence. Lastly, the K-wires are bent 180 degrees and crimped with pliers before they are impacted over the
proximal wire loop, completing fixation (Fig. 10.13).

FIGURE 10.11 A schematic drawing illustrating a tension band wire construct using two crossed stainless steel
wires.
FIGURE 10.12 An illustration showing the use of a single wire for the tension band that is passed beneath the
triceps tendon with the help of an angiocath.

Alternatively, definitive fixation of a transverse noncomminuted olecranon fractures can be achieved using a 4.5-
or 6.5-mm intramedullary screw, which is used as a proximal anchor for the tension band wire(s). It is critical that
the fracture is anatomically reduced prior to screw insertion (Fig. 10.14A-D). Equally important is
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to ensure that the screw is perfectly in line with the intramedullary canal. Failure to follow these steps may lead
to fracture translation, gapping, or poor fixation (Fig. 10.15).
FIGURE 10.13 Completed tension band fixation. The ends of the wire should be bent 180 degrees and impacted
over the wire into bone.
FIGURE 10.14 A,B. Preoperative radiographs demonstrating a displaced transverse olecranon fracture. C,D.
Tension band fixation with an intramedullary screw. Before tightening the figure-of-eight wire, two loops are
made to tension both sides equally.

In some patients with a large proximal fracture, a plate contoured around the proximal end of the olecranon after
reduction can be an effective treatment method. Precontoured plates may be used, or a 3.5-mm one-third tubular
plate may be modified for this purpose (Fig. 10.16A,B). Typically, the plate is applied with a 3.5-mm lag screw
placed through the proximal end of the plate to allow for compression at the fracture site. Securing the distal end
of the plate to the proximal ulnar diaphysis completes the fixation.
I prefer to use a locking plate for simple large olecranon fractures when bone quality is poor (Fig. 10.17A- C). A
second or third locking screw placed through the plate and into the proximal fragment significantly improves
fixation stability. Comminuted fractures and fractures with instability of the ulnohumeral joint require a more
detailed approach to fracture reduction and fixation. Small bone fragments may preclude simple piece-by-piece
reassembly of the fragments and risk devascularizing of the pieces. In these cases, indirect reduction and plating
can be helpful. Commercially available “minidistractors” can be used, although pins and connecting bars
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from a small external fixator set are equally effective. Temporarily anchoring the proximal olecranon fragment to
the distal humerus with a fixation pin provides a stable platform in which to work and is a key first step. The
fracture can then be distracted out to length (Fig. 10.18A,B). With indirect reduction, small fracture fragments can
be teased into place, followed by definitive fixation, with one or more plates. Sometimes, a single locking plate
can replace the need for two nonlocking plates. Even with improved posterior plates, however, a supplementary
medial buttress plate may prove helpful.

FIGURE 10.15 If the intramedullary screw is not placed perfectly, it can lead to translation or gapping at the
fracture site.

Recognizing injuries associated with olecranon fractures is essential to obtaining consistently good functional
results. Radial head fractures and coronoid fractures and/or capsular avulsion injuries may present as part of a
complex elbow injury pattern known as a “terrible triad.” Operative management consists of radial head
replacement and capsular repair in addition to reconstruction of the proximal ulnar fracture (Fig. 10.19A-D).
After fracture fixation is complete, the tourniquet is released, and final radiographs are obtained. The fracture is
examined through a full range of motion to confirm fracture stability. The wound is irrigated and closed in layers.
A drain is not usually placed if adequate hemostasis has been obtained. The arm is placed in a posterior splint.

POSTOPERATIVE CARE
Uneventful wound healing and institution of early motion are the goals following open reduction and internal
fixation of an olecranon fracture. Antibiotics are continued for 24 hours postoperatively. Patients with simple
transverse fractures are usually discharged on the day of surgery. In these patients, a single postoperative
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intravenous antibiotic dose is given. We prefer to use an inexpensive custom-made removable splint for
protection for 3 or 4 weeks following internal fixation of simple transverse fractures and for up to 6 weeks
following fixation of comminuted fractures. Hinged elbow braces are used rarely postoperatively, but may be
necessary in the setting of ligamentous instability.
FIGURE 10.16 A,B. Fixation of a large but osteoporotic olecranon fracture with a locking hook plate.

FIGURE 10.17 A-C. A comminuted olecranon fracture treated with a contoured locking plate using biplanar
fixation.

For most patients, the elbow is placed into the precontoured, heat-molded splint set at 90 degrees of flexion, on
the day following surgery. The splint is secured to the arm with Velcro straps. The patient is instructed to remove
the splint for active assisted range-of-motion exercises three to four times each day. The splint remains in use
until adequate motor control is achieved, typically between 3 and 4 weeks postoperatively. Patients who do not
rapidly regain their range of motion are referred to a physical therapist. We allow patients to use their arm for
activities of daily living. Active and active assisted motion exercises are encouraged. Patients are advised to
avoid lifting objects heavier than 5 pounds until fracture healing is evident radiographically.
At 6 weeks if the fracture is healing uneventfully, the strengthening phase of rehabilitation is initiated. A
progressive resistance program is employed to strengthen the entire upper extremity. For manual workers, work-
hardening programs are utilized, and functional capacity evaluations are administered prior to the employee's
return to work.

RESULTS
High rates of fracture union, ranging from 76% to 98%, with good to excellent functional results should be
anticipated with surgical management of olecranon fractures (4, 5, 6 and 7,9,16,17). Some loss of motion is
common,
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with loss of terminal extension of about 10 degrees the most frequently reported complication. Patients
should be advised that motion and strength may be diminished compared to their preoperative status,
although these changes are rarely significant functionally.
FIGURE 10.18 A,B. A schematic drawing illustrating the use of indirect reduction of the proximal ulna using
a minidistractor.

COMPLICATIONS
The most common complication following olecranon fracture fixation is discomfort associated with
prominent implants. As noted previously, careful attention to operative technique may reduce implant
prominence and reduce the need for implant removal. Even so, more than most fractures, implant
removal is necessary in many patients following internal fixation. Prominent hardware has been
reported in 20% to 80% of patients in published series, and implant removal has been reported in 34%
to 66% of olecranon fractures (1,4,6, 7 and 8,16, 17 and 18). Tenderness at the operative site may be
treated successfully in some patients using a variety of elbow pads available in sporting goods or
gardening stores. If these measures fail and implant removal is required, removal is delayed until at
least 8 months after fracture fixation and is followed by an additional 6 weeks of protected activity.
Complications with more serious implications include soft-tissue compromise, infection, elbow stiffness,
and malunion or nonunion. Infection has been reported to occur in 0% to 6% of cases. Infections are
more common after open fractures. The risk of infection is decreased with the use of preoperative
antibiotics and
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careful handling of the soft tissues. A patient with a postoperative infection requires irrigation and
débridement with culture-specific intravenous antibiotic therapy. If the fracture fixation is stable, we
recommend aggressive débridement and systemic antibiotic suppression. Once the fracture has
healed, early hardware removal and external bracing are utilized until the fracture strengthens enough
to withstand physiologic loads. If the fracture fixation is loose or unstable, the hardware should be
removed and appropriate antibiotics utilized followed by delayed reconstruction.

FIGURE 10.19 A-D. A 45-year-old male was brought to the emergency room following a high-speed
motor vehicle collision. Initial radiographs showed a complex fracture dislocation of the elbow. AP and
lateral radiographs show reconstruction of the proximal ulna with a locking plate and a radial head
replacement.

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 FIGURE 10.20 A,B. An olecranon nonunion with hardware loosening 9 months after initial fixation.
Following compression plating, the fracture has healed.

Nonunion is uncommon following internal fixation of simple transverse fractures, but increases in
frequency with fracture complexity (19). Considerable consolidation of small fracture fragments often
occurs even when an olecranon fracture fails to heal, often leaving a single ununited fracture line. After
infection has been ruled out as a cause of nonunion, implant removal and repeated fixation are
recommended (Fig. 10.20A,B). Compression across the fracture line is desirable, so far as this can be
achieved without creating articular incongruity.
Ulnar neuropathy has been reported in 2% to 12% of cases following internal fixation. To limit the risk
of ulnar neuritis, the nerve should be identified and protected during open reduction and internal
fixation. Postoperative ulnar neuritis is usually transient, and in most patients, it spontaneously
resolves. Anterior interosseous nerve injury has also been noted in association with operative
management of olecranon fractures (20). Exploration may be considered when it does not resolve
spontaneously.

REFERENCES
1. Bailey CS, MacDermid J, Patterson SC, et al. Outcome of plate fixation of olecranon fractures. J Orthop
Trauma 2001;15:542-548.

2. Chin KR, Ring D, Jupiter JB. Double tension-band fixation of the olecranon. Tech Shoulder Elbow Surg
2000;31:61-66.

3. Colton CL. Fractures of the olecranon in adults: classification and management. Injury 1973;5:121-129.

4. Erturer RE, Sever C, Sonmez MM, et al. Results of open reduction and plate osteosynthesis in
comminuted fracture of the olecranon. J Shoulder Elbow Surg 2011;20(3):449-454.

5. Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures: excision or open reduction
with internal fixation. J Bone Joint Surg Am 1981;63:718-721.

6. Horne J, Tanzer T. Olecranon fractures: a review of 100 cases. J Trauma 1981;21:469-472.

7. Hume MC, Wiss DA. Olecranon fractures: a clinical and radiographic comparison of tension band and
plate fixation. Clin Orthop 1992;285:229-235.

8. Johnson R, Roetker A, Schwab J. Olecranon fractures treated with AO screw and tension bands.
Orthopedics 1986;9: 66-68.

9. Mullett JH, Shannon F, Noel J, et al. K-wire position in tension band wiring of the olecranon: a comparison
of two techniques. Injury 2000;31:427-431.

10. Quintero J. Complex elbow injuries. In: Ruedi TP, Murphy WM, eds. AO principles of fracture
management. New York, NY: Thieme Medical Publishers; 2000:338-339.

11. Wilson J, Bajwa A, Kamath V, et al. Biomechanical comparison of interfragmentary compression in

transverse fractures of the olecranon. J Bone Joint Surg Br 2011;93(2):245-250.

12. Didonna ML, Fernandez JJ, Lim TH, et al. Partial olecranon excision: the relationship between triceps
insertion site and extension strength of the elbow. J Hand Surg Am 2003;28:117-122.

13. Inhofe P, Howard T. The treatment of olecranon fractures by excision of fragments and repair of extensor
mechanism: historical review and report of 12 fractures. Orthopedics 1993;16:1313-1317.

14. Patterson SD, Bain GI, Mehia JA. Surgical approaches to the elbow. Clin Orthop 2000;370:19-33.

15. Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation
of olecranon fractures. J Trauma 1969;9:594-602.

16. Murphy D, Greene W, Dameron T Jr. Displaced olecranon fractures in adults. Clinical evaluation. Clin
Orthop Relat Res 1987;224:215-223.

17. Wolfgang G, Burke F, Bush D. Surgical treatment of displaced olecranon fractures by tension band wiring
technique. Clin Orthop Relat Res 1987;224:192-204.

18. McKee MD, Jupiter JB. Trauma to the adult elbow and fractures of the distal humerus. In: Browner BD,
Jupiter J, Levine AM, et al. eds. Skeletal trauma. Philadelphia, PA: WB Saunders; 1992:1455-1522.

19. Papagelopoulos J, Morrey BF. Treatment of nonunion of olecranon fractures. J Bone Joint Surg Br
1994;76:627-635.

20. Parker JR, Conroy J, Campbell DA. Anterior interosseus nerve injury following tension band wiring of the
olecranon. Injury 2005;36(10):1252-1253. Epub March 19, 2005.
 11
Radial Head Fractures: Open Reduction and Internal Fixation
David Ring

INTRODUCTION
The advent of techniques and implants for internal fixation of small fractures (1) coincided with an increasing
appreciation of the important contributions of the radial head to the stability of the elbow and forearm (2, 3, 4 and
5). In conjunction with the inadequacy and problems associated with the silicone rubber radial head prostheses
(2,6, 7 and 8), it became popular to attempt to save even the most complex fracture of the radial head by
operative fixation (9). Early reports of open reduction and internal fixation of fractures of the radial head were
very positive, perhaps due to the prevalence in these early series of isolated partial head fractures for which
good results would be expected (10, 11, 12, 13, 14 and 15). Some subsequent reports have found that complex
fractures of the radial head are prone to early failure, nonunion, and poor forearm rotation after operative fixation
(9,16, 17 and 18). Combined with increased availability and use of more predictable metal radial head prosthesis
for complex fractures of the radial head (19,20), most surgeons reserve open reduction and internal fixation for
fractures with three or fewer large articular fracture fragments of good bone quality with no fragmentation or bone
loss (21).

INDICATIONS AND CONTRAINDICATIONS

Historical Background
For most of the last century, excision of the radial head was the only commonly used treatment for fractures of
the radial head (22,23) and decision making was simple: excise or do not excise. If excision was elected, the
entire head was resected because the results of partial head excision were usually poor (24, 25, 26 and 27).
Open reduction and internal fixation became a more viable option with the advent of techniques and implants for
the fixation of small fractures and articular fracture fragments in the 1980s (1).
The incidence, severity, and consequences of proximal migration of the radius after excision of isolated fractures
of the radial head have long been a source of debate (25). On the other hand, there is agreement on the value of
retaining the fractured radial head in the setting of complex combined injury with instability of the forearm or
elbow such as an Essex-Lopresti injury (23,28) (radial head fracture and rupture of the interosseous ligament of
the forearm) or a terrible triad injury (posterior dislocation of the elbow with fractures of the radial head and
coronoid process) (29, 30, 31 and 32). The radial head is increasingly recognized as an important stabilizer of
the forearm and elbow (2, 3, 4 and 5,23,29, 30, 31, 32, 33 and 34). Some authors even suggest that ulnohumeral
arthrosis after elbow fracture dislocation is accelerated in the absence of a radial head (35).
The initial reports of open reduction and internal fixation of fractures of the radial head focused primarily on
isolated fractures involving only part of the radial head (10, 11, 12, 13, 14 and 15). The good results in these
series, the popularity
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of the new techniques for internal fixation of small fractures, and the increasing recognition of the importance of
the radial head led many to emphasize the importance of preserving the native radial head. Unfortunately,
subsequent study have reported unpredictable results after internal fixation of more complex fractures of the
radial head (9,16, 17 and 18), particularly very comminuted fractures with greater than three articular fragments
(9).
Combined with recent improvements in radial head prostheses, the decision making for radial head fractures
associated with instability of the forearm or elbow now focuses on fixation versus prosthetic replacement (21).
Problems have been reported related to the articulation of a metal radial head implant with native capitellar
cartilage, although the majority of these are related to an oversized prosthesis (36). In general, results of
prosthetic replacement of the radial head have been quite favorable (19,20,37), making it a useful alternative to
open reduction and internal fixation.

Goals of Treatment
Fracture of the radial head can restrict forearm rotation, compromise the stability of the forearm or elbow, and—
although relatively uncommonly—cause radiocapitellar arthrosis.
The primary goal of treatment is to ensure forearm rotation. Incongruity of the radial head in the proximal
radioulnar joint causes loss of rotation. Painful arthrosis of the proximal radioulnar joint is not usually observed.
Long-term data from Sweden support the contention that partial fractures of the radial head that do not restrict
forearm rotation are usually consistent with excellent elbow and forearm function no matter the radiographic
appearance (38), although some data are at odds with this (13).
Operative fixation can restrict forearm rotation via implant prominence, scarring, or heterotopic bone formation.
Some patients with healed, apparently well-aligned fractures of the radial head after operative fixation have
substantial loss of motion that is not attributable to implant prominence (9). This may be due to articular
incongruities, but—based on observations of my own patients, and some similar observations in the literature
(39)—I suspect that many fractures of the radial head are impacted in a way that expands the diameter of the
radial head. Healing of the radial head with this deformity might contribute to loss of forearm motion. Loss of
ulnohumeral motion is usually related to capsular contracture and only rarely related to interference from
displaced fracture fragments.
When the interosseous ligament of the forearm has been torn [the so-called Essex-Lopresti lesion (28) and
variants (40,41)], the initial treatment must include restoration of contact between the radial head and capitellum
to prevent marked proximal migration of the radius. Although restoration of the radial head does not guarantee
good function in this complex injury, failure to restore the radial head will result in a chronic forearm instability
that currently had no good solution (42). Attempts to save the radial head at all costs might be unwise in this
setting. For instance, many chronic Essex-Lopresti lesions result from failure of attempted operative fixation of
the radial head. In this circumstance where the radial head is essential, tenuous fixation of a complex radial head
fracture may be inadequate and prosthetic replacement might be preferable.
The circumstance is similar for elbow fracture dislocations. Particularly for unstable elbow injuries such as the
terrible triad pattern of elbow fracture dislocation (30), secure reconstruction of the radial head is requisite. If the
fracture is too complex to achieve this, then radial head replacement may be preferable. Many partial head
fractures are difficult or impossible to repair securely and should also be considered for prosthetic replacement
(43). The part of the radial head that is fractured is the critical anterolateral buttress resisting posterior
displacement of the elbow (44).
Although radiographic criteria for acceptable alignment of the radial head articular surface are frequently offered
(25,32,45,46), there are few data to support them. The oft-repeated 2-mm limit for acceptable articular alignment
derived from Knirk and Jupiter's (47) study of intraarticular distal radius fractures may not apply to the
radiocapitellar joint. Although displaced fractures of the radial head are extremely common, radiocapitellar
arthritis is an uncommon presenting complaint about which very little has been published (48).

Treatment Rationale According to Injury Pattern

Isolated Partial Radial Head Fractures
Slightly displaced fractures involving part of the radial head do relatively well with nonoperative treatment
(38,46,49,50). They rarely block motion, cause pain, or lead to arthrosis. Although radiographic criteria for
operative treatment have been suggested, they lack scientific support.
One generally accepted indication for operative treatment of an isolated partial fracture of the radial head is a
fracture that blocks forearm rotation. Because it can be difficult to assess forearm rotation in the setting of an
acute painful elbow hemarthrosis, it can be useful to aspirate the hemarthrosis and place a local anesthetic in the
elbow joint. Alternatively—perhaps preferably—if the patient is evaluated in the office at least 4 or 5 days after
injury, there is usually sufficient pain relief to allow a reliable examination. Crepitation with forearm rotation does
not seem predictive of problems, provided there is no block to motion, although this deserves further study.
Given that few problems arise with nonoperative treatment [a minimum of 75% good results in long-term follow-
up according to a very strict rating scale (50)], the surgeon should not take too much credit for good elbow
function after operative treatment of isolated partial fractures of the radial head. Since operative treatment
represents an opportunity for several complications, it should be undertaken with care (51).
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Isolated fractures of the radial head that are more than slightly displaced are relatively uncommon (approximately
6% to 15% of all radiographically visible partial radial head fractures) and unreliably diagnosed (52). Among this
small group of patients, it is uncommon to observe a block to forearm rotation. The surgeon should therefore
approach the management of the patient with an isolated partial fracture of the radial head with the
understanding that these fractures rarely benefit from operative treatment (53,54).

Partial Radial Head Fracture as Part of a Complex Injury

The treatment rationale for partial radial head fractures that are part of a complex injury pattern is entirely
different. Such fractures are usually displaced and unstable with little or no soft-tissue attachments and
occasionally some fragments are lost (55). Even a relatively small fracture can make an important contribution to
the stability of the elbow and forearm. Usually, the anterolateral aspect of the radial head is fractured, with
resultant loss of the anterior buttress of the ulnohumeral joint (44).
While such fractures would seem to be obvious candidates for open reduction and internal fixation because the
majority of the head remains intact, they can be very challenging to treat due to fragmentation, the small size of
the fragments, lost fragments, poor bone quality, limited subchondral bone on the fracture fragments, and
metaphyseal comminution and bone loss (43). Early failure of fixation of these fractures is potentially problematic,
particularly in the setting of an Essex-Lopresti injury or a terrible triad fracture dislocation of the elbow.
Therefore, many partial head fractures associated with complex injuries may be best treated with prosthetic
replacement even though this means removing a substantial amount of uninjured radial head. Open reduction
and internal fixation is indicated when stable, reliable fixation can be achieved.
Displaced, partial head fractures are common among patients with posterior olecranon fracture dislocations—the
majority of whom are older, osteoporotic women. Some authors believe that radial head excision is acceptable in
this setting provided that the ulnohumeral joint is stable (56). In some cases, I have neglected or excised a small
partial radial head fracture in this setting, with good results, but I favor retaining the stability and support of
radiocapitellar contact in most cases. I believe that a low-energy injury in an older patient is a relatively favorable
setting in which to consider neglecting or resecting the radial head, but that retention of the radial head, either
with operative fixation or prosthetic replacement, would be preferable in healthy, active patients injured in high-
energy injuries.

Fractures Involving the Entire Head of the Radius

Fractures involving the entire head of the radius [type 3 according to the system of Mason (22)] are almost
always part of a more complex injury. Some older, low-demand patients are best treated with resection of the
radial head without prosthetic replacement, but only if the elbow and forearm are stable. The rare younger
patient with an isolated injury involving the entire radial head can also be considered for excision without
prosthetic replacement, but retention of the radial head may improve the function and durability of the elbow,
particularly with forceful use, although it can be debated whether a metal prosthetic articulating with capitellar
cartilage is better than no articulation at all in the long run.
When treating a fracture dislocation of the forearm or elbow with associated fracture involving the entire head of
the radius, open reduction and internal fixation should only be considered a viable option if stable, reliable
fixation can be achieved. There is a definite risk of both early failure and later nonunion, both of which can
contribute to recurrent instability (9). Other factors such as loss of fragments, metaphyseal bone loss, impaction
and deformity of fragments (39), and the size and quality of the fracture fragments may make open reduction and
internal fixation a less predictable choice. In particular, if there are more than three articular fragments, the rates
of early failure, nonunion, and poor forearm rotation may be unacceptable (9). The optimal fracture for open
reduction and internal fixation will have three or fewer articular fragments without impaction or deformity, each of
sufficient size and bone quality to accept screw fixation, and little or no metaphyseal bone loss.

PREOPERATIVE PLANNING
Plain radiographs are useful for determining the overall pattern of injury. In my experience—both in patient care
and research—fractures of the radial head can occur either in isolation or in association with one of several
discrete injury patterns including (a) fracture of the radial head and rupture of the interosseous ligament of the
forearm [Essex-Lopresti and variants (28,40,41)] (Fig. 11.1A); (b) fracture of the radial head and rupture of the
medial collateral ligament complex and/or fracture of the capitellum (Fig. 11.1B); (c) fracture of the radial head
and posterior dislocation of the elbow (57,58); (d) posterior dislocation of the elbow with fractures of the radial
head and coronoid process (18,30,58) [the so-called terrible triad (59)] (Fig. 11.1C); and (e) posterior olecranon
fracture dislocations (posterior Monteggia pattern injuries) (29,60, 61 and 62) (Fig. 11.1D). As has been
emphasized by Davidson et al. (39), complex fractures of the radial head are nearly always associated with a
complex injury. If there is at least one fracture fragment with no contact with the intact radial neck on radiologic
studies, then an associated fracture or dislocation is very likely (55). Intraoperative evidence of ligament injury
should always be sought (63), particularly if simple excision is being considered (23).
Plain radiographs frequently underestimate the complexity of a radial head fracture (Fig. 11.2). Computed
tomography—particularly three-dimensional reconstructions with the distal humerus removed (Fig. 11.2B)—is
very useful for characterizing the fracture and planning surgery (64). In the setting of a complex injury pattern, the
surgeon should always be prepared for prosthetic replacement of the radial head in case operative fixation
proves unfeasible or unwise (Fig. 11.2C,D).
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FIGURE 11.1 When evaluating a fracture of the radial head, one should consider the possibility of one of the
following complex injury patterns: A. An Essex-Lopresti lesion or variant. B. Fracture of the radial head and
medial collateral ligament injury. C. An elbow fracture dislocation. D. An olecranon fracture dislocation. (All parts
Copyright David Ring, MD.)

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FIGURE 11.2 Computed tomography can help characterize a fracture of the radial head. A. This radiograph of a
terrible triad fracture dislocation suggests that the radial head fracture is partial and relatively small. B. A
computed tomography scan demonstrates that at least one half of the radial head is involved, and the fracture
has created complex comminution. C. The fragments were not repairable. D. Because this portion of the radial
head is critical to stability in the setting of a terrible triad injury, a metal prosthesis was used with a good result.
(All parts Copyright David Ring, MD.)

SURGERY
Patient Positioning
The majority of radial head fractures are treated with the patient supine on the operating table, under general or
regional anesthesia, with the arm supported on a hand table. A sterile tourniquet is preferred to a nonsterile
tourniquet in order to improve access to the elbow. Posterior olecranon fracture dislocations are often best
treated in a lateral decubitus position with the arm supported over a bolster.
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Techniques
Operative Exposures
The most popular interval for the exposure of fractures of the radial head is between the anconeus and extensor
carpi ulnaris (Kocher exposure) (65,66) (Fig. 11.3). This interval is fairly easy to define intraoperatively. It
represents the most posterior interval and provides good access to fragments of the radial head that displace
posteriorly. It also provides greater protection to the posterior interosseous nerve. On the other hand, attention
must be paid to protecting the lateral collateral ligament complex. The anconeus should not be elevated
posteriorly, and the elbow capsule and annular ligament should be incised diagonally, in line with the posterior
margin of the extensor carpi ulnaris (67).
A more anterior interval protects the lateral collateral ligament complex, but places the posterior interosseous
nerve at greater risk (23). Some authors recommend identifying the nerve if dissection onto the radial neck is
required (23). Kaplan described an interval between the extensor carpi radialis brevis and the extensor digitorum
communis (65), whereas Hotchkiss (23) recommends going directly through the extensor digitorum communis
muscle (Fig. 11.3). I find these intervals difficult to define precisely based upon intraoperative observations. A
useful technique for choosing a good interval and protecting the lateral collateral ligament complex was
described by Hotchkiss (23): starting at the supracondylar ridge of the distal humerus, if one incises the origin of
the extensor carpi radialis, elevates it, and incises the underlying elbow capsule, it is then possible
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to see the capitellum and radial head. The interval for more distal dissection should be just anterior to a line
bisecting the radial head in the anteroposterior plane.
FIGURE 11.3 Several lateral muscle intervals have been described. The most commonly used interval is that of
Kocher (between the anconeus and extensor carpi ulnaris). This is particularly good for retrieving posterior
fracture fragments. Kaplan's interval more anteriorly places the lateral collateral ligament at less risk and
provides good exposure to the more anterolateral aspects of the radial head that are typically fractured, but puts
the posterior interosseous nerve at greater risk.

In my practice, the vast majority of fractures of the radial head that merit operative treatment are associated with
fracture dislocations of the elbow. In this context, exposure is greatly facilitated by the associated
capsuloligamentous and muscle injury (9,29,68). When the elbow has dislocated, the lateral collateral ligament
has ruptured, and the injury always occurs [or nearly always according to some authors (68)] as an avulsion from
the lateral epicondyle. Along with a variable amount of muscle avulsion from the lateral epicondyle (68, 69, 70,
71 and 72), these injuries leave a relatively bare epicondyle (Fig. 11.4). There is often a split in the common
extensor muscle that can be developed more distally.
FIGURE 11.4 The vast majority of complex radial head fractures are associated with an elbow dislocation. Elbow
dislocation results in avulsion of the origin of the lateral collateral ligament and a variable amount of the common
extensor musculature from the lateral epicondyle resulting in a relatively bare epicondyle. This damage should
be used to enhance exposure to the radial head. (Copyright David Ring, MD.)

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In the setting of a posterior olecranon fracture dislocation (posterior Monteggia pattern injury), the radial head
often displaces posteriorly through capsule and muscle. In such cases, the surgeon will usually extend this
posterior injury in order to mobilize the olecranon fracture proximally to expose and manipulate the coronoid
fracture through the elbow articulation. This usually provides adequate access to the radial head as well (Fig.
11.5). Slight additional dissection between the radius and the ulna is acceptable, given the usually extensive
injury in this region, but extensive new dissection in this area has been suggested to increase the risk of proximal
radioulnar synostosis.
When treating a complex fracture of the radial head with the lateral collateral ligament complex intact (for
instance an Essex-Lopresti injury), it may be difficult to gain adequate exposure without releasing the lateral
collateral ligament complex from the lateral epicondyle. This can be done either by directly incising the origin of
the lateral collateral ligament complex from bone or by performing an osteotomy of the lateral epicondyle
(1,11,17,73,74) (Fig. 11.6). In either case, a secure repair and avoidance of varus stress (shoulder abduction) in
the early postoperative period are important.

FIGURE 11.5 A. Posterior olecranon fracture dislocations (very proximal posterior Monteggia injuries) create
posterior muscle injury that can be used to expose a fracture of the radial head. B. Companion drawing to clarify
technique in (A).

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FIGURE 11.5 (Continuted) C. Mobilizing the olecranon fracture fragment proximally as one would do for an
olecranon osteotomy exposure of the distal humerus provides access to the joint. D. Companion drawing to
clarify technique in (C). E. Recreating the posterior subluxation of the radial head that occurred at the time of
injury provides good exposure to the radial head. F. Companion drawing to clarify technique in (E). (Parts A, C,
and E Copyright David Ring, MD.)

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FIGURE 11.6 In the uncommon circumstance that a complex fracture of the radial head is not associated with
injury to the lateral collateral ligament (e.g., Essex-Lopresti injury), it may be necessary to take down the origin of
the ligament in order to obtain satisfactory exposure of the radial head. This can be done by releasing the soft-
tissue attachment or via an osteotomy of the lateral epicondyle.

The posterior interosseous nerve wraps around the radial neck, directly adjacent to the neck in some patients,
and separated by some muscle fibers in others. It is at risk during open reduction and internal fixation. It can be
protected by pronating the forearm, dissecting the supinator bluntly with or without identifying the nerve, and
avoiding the use of retractors placed over the radial neck (23). One study showed that, with pronation, the
posterior interosseous nerve is an average of 3.8 cm distal to the articular surface of the radius (75).

Implants and Implant Placement

Small (1.0 to 2.4 mm) headed or headless screws (such as the Herbert screw) can be used. Standard screws
placed in the articular area of the radial head should be countersunk below the articular surface. Some authors
recommend using long screws from the head to the neck for radial neck and simple articular fractures (76). Some
small fragments can only be repaired with small Kirschner wires. Threaded wires are usually used because of
the tendency for smooth wires to migrate and potentially travel to various parts of the body (77). Absorbable pins
and screws are being developed for similar uses (78,79), but are still somewhat brittle and associated with an
inflammatory response.
Small plates are available for fractures that involve the entire head. Plate types include T- and L-shaped plates
with standard screws, small (condylar) blade plates, and new plates designed specifically for the radial head
(many of which incorporate angular stable screws—screws that thread directly into the plate). The use of plates
that are placed within the radial head or countersunk into the articular surface has also been described (73).
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The majority of the radial head articulates with either the proximal ulna or the distal humerus. Implants can be
placed on the small nonarticular area without impinging during motion, but implants placed in other areas must
be countersunk below the articular surface. The articular surface of the radial head with the proximal ulna can be
difficult to distinguish from the nonarticular surface with simple visual inspection, particularly when the radial
head is fractured. Smith and Hotchkiss (80) characterized the nonarticular portion of the radial head based upon
reference points made in the operative wound. If the radial head is bisected in the anterior-posterior plane with
the elbow in neutral, full pronation, and full supination, the safe zone can be defined as half the distance
between the middle and posterior marks and half the distance plus a few millimeters (roughly two-thirds the
distance) between the middle and anterior marks (80). Caputo et al. (81) have approximated this zone according
to landmarks on the distal radius as lying between the radial styloid and Lister's tubercle. Finally, a study in
which small plates were applied to the radial head with the forearm in neutral rotation did not result in
impingement (82).

Operative Techniques for Specific Fracture Types

ISOLATED PARTIAL RADIAL HEAD FRACTURES (FIGS. 11.7, 11.8, 11.9, 11.10, 11.11, 11.12, 11.13, 11.14,
11.15, 11.16, 11.17, 11.18, 11.19 and 11.20)
A Kocher or Kaplan exposure is used taking care to protect the uninjured lateral collateral ligament complex. The
anterolateral aspect of the radial head is usually fractured and is straightforward to expose through these
intervals (Fig. 11.7A,B). The fracture is usually only slightly displaced. In fact, it is usually impacted into a stable
position (Fig. 11.9A,B). The periosteum is usually intact over the metaphyseal fracture line. Every attempt is
made to preserve this inherent stability by using a bone tamp to reposition the fragment (Figs. 11.10A,B and
11.11A,B). After the fragments have been realigned, one or two small screws are used to secure each fragment.

PARTIAL RADIAL HEAD FRACTURE AS PART OF A COMPLEX INJURY

Exposure of fractures of the radial head that are part of an elbow fracture dislocation is straightforward due to the
associated capsuloligamentous and muscle injury (see above). In the absence of this soft-tissue injury, most
partial radial head fractures can be treated through a Kocher or Kaplan exposure. Reduction and screw fixation
is usually used, but if there is any metaphyseal bone loss or comminution, a plate may be preferable (Fig. 11.21).
FIGURE 11.7 Open reduction and internal fixation of an isolated fracture of the radial head. A. This impacted
partial head fracture blocked forearm rotation. B. There were no other apparent injuries. (Both parts Copyright
David Ring, MD.)

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FIGURE 11.8 A. A lateral skin incision in line with the muscle interval is used. B. Companion drawing to (A)
showing anatomy under incision. (Part A Copyright David Ring, MD.)

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FIGURE 11.9 A. In this case, the interval between the anconeus and the extensor carpi ulnaris was used, and
the elbow capsule and annular ligament were incised anterior to the lateral collateral ligament. B. Companion
drawing to clarify technique in (A). (Part A Copyright David Ring, MD.)

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FIGURE 11.10 A. This patient had two large impact fragments. The periosteum was intact, and the position of
the fragments was quite stable. B. Companion drawing to clarify technique in (A). (Part A Copyright David Ring,
MD.)

FIGURE 11.11 A. A bone tamp was used to realign them without disrupting soft-tissue attachment and to attempt
to preserve some of the inherent stability of this impacted fracture. B. Companion drawing to clarify technique in
(A). (Part A Copyright David Ring, MD.)

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FIGURE 11.12 A. A 1.5-mm drill was used initially. B. Companion drawing to clarify technique in (A). (Part A
Copyright David Ring, MD.)
FIGURE 11.13 Careful screw size measurement with a depth gauge is important. B. Companion drawing to
clarify technique in (A). (Part A Copyright David Ring.)

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FIGURE 11.14 A. To provide interfragmentary compression, the near hole is overdrilled with a 2.0-mm drill. I
often skip this step in poor-quality bone. B. Companion drawing to clarify technique in (A). (Part A Copyright
David Ring, MD.)

FIGURE 11.15 A. A countersink is used to diminish screw prominence. B. Companion drawing to clarify
technique in (A). (Part A Copyright David Ring, MD.)

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FIGURE 11.16 A. It is particularly important to place the screw below the articular surface when it is within the
area that articulates with the proximal ulna. B. Companion drawing to clarify technique in (A). (Part A Copyright
David Ring, MD.)

FIGURE 11.17 A. The annular ligament and elbow capsule are sutured. B. Companion drawing to clarify
technique in (A). (Part A Copyright David Ring, MD.)

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FIGURE 11.18 A. In most cases, I suture this along with overlying fascia. B. Companion drawing to clarify
technique in (A). (Part A Copyright David Ring, MD.)
FIGURE 11.19 In this patient, a subcuticular suture is used. (Copyright David Ring, MD.)

FIGURE 11.20 Steri-Strips were applied. (Copyright David Ring, MD.)

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FIGURE 11.21 Partial radial head fractures associated with more complex injuries are usually displaced and
much less stable. A. This is a terrible triad injury with the coronoid fragment visible anterior to the coronoid. B. A
lateral radiograph after manipulative reduction shows both coronoid and radial head fragments. C. The radial
head fracture was a single small fragment that was repairable with a screw. D. The coronoid was repaired with
sutures through drill holes, and the lateral collateral ligament was reattached to the lateral epicondyle. (All parts
Copyright David Ring, MD.)

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FRACTURES INVOLVING THE ENTIRE HEAD OF THE RADIUS
Excellent exposure is requisite, and the surgeon should not hesitate to release the origin of the lateral collateral
ligament complex to improve exposure in the unusual situation where it is not injured (Fig. 11.22). In many cases,
it will prove useful to remove the fracture fragments from the wound and reassemble them outside the body (on
the “back table”). Sacrificing any small residual capsular attachments in order to do this seems an acceptable
trade off in order to achieve the goal of stable, anatomical fixation. This reconstructed radial head is then
secured to the radial neck with a plate. Consideration should be given to applying bone graft to metaphyseal
defects—sufficient bone can often be obtained from the lateral epicondyle or olecranon.

FIGURE 11.22 Complex fractures of the entire head are very challenging to repair. A. This patient had a fracture
dislocation playing hockey. The majority of the radial head is dislocated posteriorly. B. The complexity of the
fracture is apparent on the anteroposterior radiograph.C. A 2.0-mm blade plate and screws were used to repair
the fracture, which consisted of two large head fragments and substantial metaphyseal comminution. D. The
lateral collateral ligament was also repaired. (All parts Copyright David Ring, MD.)

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RESULTS
We reviewed the results of open reduction and internal fixation of a fracture of the radial head in 56 patients
(9). The 15 patients with isolated partial fractures of the radial head had excellent results. Among the 15
patients with displaced fractures of the radial head as part of a complex injury, 4 (27%) recovered fewer
than 100 degrees of forearm rotation and were considered unsatisfactory. Thirteen of the 14 (93%) patients
with Mason type 3 comminuted fractures of the radial head comprising more than three articular fragments
 had unsatisfactory results. Three had early failure of fixation requiring radial head excision, six had painful
nonunion treated with excision, and four had 70 degrees or less of forearm rotation. In the 12 patients with a
type 3 fracture in whom the radial head was split into two or three simple fragments, there were no early
failures, two had nonunion, and all achieved an arc of forearm rotation of 100 degrees or more.

POSTOPERATIVE MANAGEMENT
The elbow is prone to stiffness and is best managed with active exercises as soon as possible after injury and
surgery. Furthermore, elbow stability is enhanced by early active elbow motion. For these reasons, the goal of
surgery should be a situation stable enough to allow active motion after a very short period of immobilization for
comfort.
If the lateral collateral ligament has been repaired, shoulder abduction should be avoided for about 6 weeks (so-
called varus stress precautions). I have not found hinged braces or continuous passive motion useful or worth
the added expense, and there are no data to support their use.

COMPLICATIONS
Laceration or permanent injury to the posterior interosseous nerve during open reduction and internal
fixation of a radial head fracture is unusual. Most commonly, this complication is experienced as a palsy
related to retraction or exposure that resolves over weeks to months. To limit the potential for this
complication, retractors should not be placed around the anterior part of the radial neck, the forearm should
be pronated during exposure of the radial neck, and consideration should be given to identifying and
protecting the nerve when more distal dissection and internal fixation are needed, particularly when a more
anterior muscle interval is used for exposure.
Injury to the lateral collateral ligament complex leading to posterolateral rotatory elbow instability is an
uncommon complication related to injury or inadequate repair of the lateral collateral ligament complex.
Awareness of this potential complication and the anatomic landmarks used to prevent it should help limit its
occurrence. This complication is treated by reconstruction of the lateral collateral ligament complex (83).
Stiffness after radial head fracture is usually related to the hemarthrosis and perhaps inadequate early
elbow movement. This could be exacerbated by the trauma of the operative dissection, particularly if the
fixation achieved was tenuous and the surgeon opted to immobilize the elbow and forearm. Heterotopic
ossification— usually in the form of anterior heterotopic bone blocking flexion or a proximal radioulnar
synostosis blocking forearm rotation—is also risk of operative treatment. Stiffness, with or without
heterotopic bone, is treated with exercises, dynamic, or static-progressive splinting, or operative release
(84).
Early failure of fixation is not infrequent, particularly with complex fractures (Fig. 11.23). In a recent series, 3
of 14 fractures involving the entire radial head and creating greater than three articular fragments had
failure of fixation within the first month (9). Because this can contribute to instability of the forearm or elbow,
unstable or unpredictable fixation is undesirable, and such fractures should probably be treated with
prosthetic replacement.
Radial head fractures are also associated with nonunion (Fig. 11.24). Nonunions of partial head fractures
are usually asymptomatic, and therefore the true incidence is unknown (Fig. 11.25). Among fractures of the
entire radial head, 6 of 11 in one series (17) and 8 of 26 fractures in another series (9) (including 2 of 12
fractures with three or fewer fragments and 6 of 14 fractures with greater than three articular fragments) had
nonunion.
Delayed resection of the radial head has usually been performed to improve forearm rotation and not for
painful arthrosis of the radiocapitellar joint (85,86). Incongruity of the proximal radioulnar joint presents as
stiffness rather than pain or arthrosis and incongruity of the radiocapitellar joint inconsistently and
unpredictably leads to radiocapitellar arthrosis, which seems to be an uncommon problem.
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FIGURE 11.23 Early failure of fixation is not uncommon when treating a complex fracture of the radial head.
A. This fracture of the entire head created several small fragments. B. There was an associated elbow
dislocation.C. The radial head was repaired with a plate and screws. D. Within 3 weeks, some of the
screws were loose, and a few fragments had escaped from the fixation. There was crepitation and a block
to forearm rotation. E. The radial head was excised. F. The elbow remained stable and the elbow regained
good function; however, it would be unwise to go without radiocapitellar contact if there was also a coronoid
fracture. (All parts Copyright David Ring, MD.)

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FIGURE 11.24 Nonunion is a frequent complication of complex fractures of the entire head of the radius. A.
After reduction of fracture dislocation of the elbow, a fracture of the entire head of the radius is apparent. B.
The elbow remains well aligned. C. Operative fixation with a plate and screws was performed. D. The
lateral collateral ligament was reattached to the epicondyle with sutures through drill holes.

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FIGURE 11.24 (Continued) E. Six months later, the plate is broken, and the fracture remains ununited. F.
The patient has near full forearm rotation with crepitation and some pain. (All parts Copyright David Ring,
MD.)

FIGURE 11.25 Partial radial head fractures can also fail to heal. This seems to be more common in
 association with complex injury patterns and metaphyseal bone loss. (Copyright David Ring, MD.)

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85. Goldberg I, Peylan J, Yosipovitch Z, et al. Late results of excision of the radial head for an isolated closed
fracture. J Bone Joint Surg 1986;68A:675-679.

86. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg
1986;68A: 669-674.
 12
Forearm Fractures: Open Reduction Internal Fixation
Steven J. Morgan

INTRODUCTION
Fractures of the diaphyseal portion of the forearm usually result from a fall on an outstretched arm or an axially
directed force from higher energy injuries such as motor vehicle or motorcycle accidents. The forces generated
can result in a fracture in either both bones of the forearm or an isolated fracture of the radius or ulna. Fractures
in the distal one-third of the radius with disruption of the interosseous membrane leading to subluxation or
dislocation of the distal radioulnar joint (DRUJ) are commonly known as Galeazzi fractures. Fractures in the
proximal one-third of the ulna with an associated radial head dislocation are known as Monteggia fractures.
These injuries lead to instability of the wrist or elbow joint that can only be resolved by anatomic reduction and
stable internal fixation of either the radius or ulna.
Direct trauma to the forearm can also result in extra-articular fractures of the radius or ulna. With this mechanism
of injury, the interosseous membrane is not grossly disrupted allowing a small number of these patients to be
managed nonoperatively. With higher energy trauma, substantial fracture displacement and disruption of the soft
tissues can lead to a compartment syndrome. In general, diaphyseal fractures of the forearm can be classified as
a both-bone fracture, an isolated fracture of the radius or ulna, or complex injuries such as Galeazzi or
Monteggia fractures. These broad descriptive terms can be further codified more scientifically using the AO/OTA
Comprehensive fracture classification for descriptive and research purposes (Fig. 12.1).
The vast majority of diaphyseal fractures of the forearm require surgery because they are very difficult to reduce
and maintain through healing in a cast. Strong deforming forces often lead to loss of reduction, and slow
consolidation in diaphyseal bone requires prolonged immobilization. This often leads to loss of motion in the
elbow, forearm, and wrist joints. Internal fixation avoids these issues allowing restoration of length and alignment
and allows early functional motion of the extremity. However, even with properly done surgery, some residual
deficits and functional disability may occur. Many patients lose some strength and forearm rotation. DASH scores
and general health assessments reflect these deficits (1,2).

INDICATIONS AND CONTRAINDICATIONS

The radius and the ulna form a complex articulation. Loss of normal alignment results in a loss of forearm
supination and pronation (3,4). Open reduction internal fixation of displaced forearm fractures in the skeletally
mature patient remains the standard treatment for this injury. Internal fixation restores length, alignment, and
rotation while allowing early functional range of motion of the extremity. Multiple studies have documented
excellent outcomes with this method of treatment (5, 6, 7, 8, 9 and 10).
On the other hand, in a small number of patients with isolated fractures of the ulna resulting from a direct blow,
nonoperative treatment can be successful. The “night stick” fracture, as it is commonly referred to, does not have
the degree of soft-tissue injury that is seen in other fractures of the forearm decreasing the likelihood of
associated instability of the distal or proximal radioulnar articulations. Isolated fractures involving the distal one-
third of the ulna can usually be managed in a cast or brace if angulation is <10 degrees and there is no
significant translation or shortening that can result in significant functional impairment at the DRUJ.
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Internal fixation of isolated ulna fractures, regardless of injury mechanism, is recommended in open fractures,
injuries with angulation >10 degrees, and in fractures with significant comminution or shortening (11).
FIGURE 12.1 AO/OTA fracture classification. (Reprinted from J Orthop Trauma 2007;21(10 suppl), with
permission.)

Preoperative Planning
History and Physical Examination
A thorough history and physical examination and high-quality radiographs of the forearm, elbow, and wrist are
necessary to develop a treatment plan. The history should provide information as to the mechanism of injury,
hand dominance, occupation, previous injury, and associated medical problems. The entire extremity should be
examined for associated injuries. Circumferential inspection of the extremity is necessary to identify the presence
of an open fracture as well as to assess the extent
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and severity of the soft-tissue injury. Any violation of the skin in proximity to the fracture site should be
considered an open fracture until proven otherwise. Ecchymosis, fracture blisters, and swelling suggest
significant soft-tissue injury and the index of suspicion for compartment syndrome should be high. The forearm
should be palpated for tenderness, and the elbow, wrist, and carpus should receive special attention as injuries
to these anatomic structures are not uncommon. The neurologic examination should document the integrity of
the motor and sensory status of the radial, posterior interosseous, ulnar, and median nerves. Vascular
examination should focus on limb perfusion, and the brachial, radial, and ulnar pulses must be assessed.

Imaging Studies
Full-length anterior posterior and lateral radiographs of the forearm that include the elbow and wrist should be
obtained. Dedicated x-rays of the elbow or wrist joints may be necessary based on the clinical exam or
preliminary x-rays. In the multiply injured patient, or in patients with severe soft-tissue injury or neurologic or
vascular compromise, a provisional reduction and splint should be applied prior to obtaining radiographs. In
comminuted fractures, traction x-rays can be very helpful to better define the extent of injury. Difficult to obtain
without adequate analgesia, these radiographs are best obtained in the operating room following induction of
anesthesia prior to surgery. Occasionally, stress x-rays of the elbow or wrist can reveal subtle or gross instability
that may influence treatment.

Timing of Surgery
Surgical timing is largely dependent on the condition of the soft tissues and the general condition of the patient.
For most isolated closed fractures without neurovascular compromise, internal fixation should be done within 24
to 48 hours of injury. In patients with a compartment syndrome, I favor immediate internal fixation following
fasciotomy with few exceptions. Other indications for emergent surgery are widely displaced Galeazzi or
Monteggia fractures or patients with acute carpal tunnel syndrome. For most Grade I, II, and IIIA open fractures,
thorough irrigation and debridement with immediate fracture stabilization has been shown to be safe and
effective. For some Grade IIIA and Grade IIIB high-energy open fractures, particularly in the multiply injured
patients, irrigation and debridement and delayed internal fixation are warranted. In these cases, simple temporary
spanning external fixation can be helpful.
In the emergency room, a coaptation or long arm splint is applied. Temporary immobilization of the fracture
controls pain and restores gross alignment to prevent further soft-tissue injury while awaiting definitive fracture
fixation. In a Monteggia fracture with a radial head dislocation, gentle traction and supination using conscious
sedation or regional anesthesia (bier block) will often reduce the dislocation, allowing splint application of the
extremity. Following any manipulation of the forearm, the neurologic and vascular status of the extremity should
be reevaluated and documented.

Surgical Tactic
A thorough understanding of the soft-tissue injury and fracture pattern is necessary to make a surgical plan. This
is based on the overall condition of the patient, the location of an open wound (if present), the degree of fracture
comminution, and the quality of the bone. The location of an open wound will influence the surgical approach.
We frequently incorporate the traumatic wound into the surgical exposure for internal fixation and thoroughly
debride the wound in the zone of injury. For example, a large dorsally based wound over the radius may dictate a
dorsal (Thompson) exposure as opposed to the more familiar volar approaches. Certainly not every open
fracture lends itself to a surgical approach that allows wound debridement and internal fixation with one incision.
In open fractures where both the radius and ulna are involved, the sequence of the surgical approach is
determined by which bone is associated with the open wound. Once the fracture site and soft-tissue injury are
debrided, the order of fixation is based on the fracture pattern rather than the open injury.
Internal fixation of a forearm fracture should restore length, rotation, and alignment using implants that provide
stable fixation that allows early functional rehabilitation. When length is reestablished in one of the two bones,
the other bone is often indirectly reduced by the surgical actions taken on the first, simplifying the second
reduction. With noncomminuted fractures of the forearm, I prefer to fix the radius first. This tactic is selected
because it allows the arm to remain extended on the arm table and facilitates exposure and reduction of the
radius. Once the radius is fixed, the elbow can be flexed facilitating exposure and fixation of the ulna.
In the situation where there is comminution of one fracture and a simple fracture pattern exists in the other bone,
the noncomminuted fracture should be reduced and fixed first. This helps to reestablish the correct length of the
more comminuted fracture indirectly. When both bones are comminuted, the least comminuted fracture is
approached first. If there is no significant difference in the two bones, the radius is generally approached first for
the reasons previously stated.
The surgical exposure, reduction, and fixation of each bone are performed sequentially. Exposing both of the
bones of the forearm prior to reduction and internal fixation is indicated only in cases where surgery has been
delayed (3 weeks). However, the incisions should not be closed until the fracture reduction and fixation of both
bones are satisfactory. By leaving the wounds open and closing both at the end of the case, access to both sites
is available if difficulty is encountered.
In open fractures, irrigation and debridement with immediate plate fixation has been shown to be both safe and
effective (8,12). In the critically ill multiply injured patient with an open forearm fracture, temporary external
fixation following irrigation and debridement with delayed internal fixation can be helpful. In comminuted
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fracture patterns, the use of bone graft at the completion of the procedure remains controversial. If indirect
reduction techniques with bridge plating are utilized, then bone grafting is not necessary. However with Grade III
open fractures, bone loss, or long zones of comminution where the fracture site is dissected, bone grafting is
strongly recommended. Autogenous bone grafts or bone graft substitutes should be used on an individualized
basis.

Implant Selection
The implant of choice for virtually all diaphyseal forearm fractures in adults is a 3.5-mm dynamic compression
plate and is available in full contact and limited contact design in either titanium or stainless steel. In theory, a
limited contact dynamic compression (LCDC) decreases devitalization of the underlying bone, and titanium
implants may decrease stress shielding. In practice, excellent results can be achieved with either implants and
carefully executed surgery. Plates with locking screw options have become available in the past decade;
however, the indications for its use remain undefined. Most authors recommend its use in elderly patients with
osteoporosis and selected metadiaphyseal fractures (13,14).
Implant selection and plate length should be determined preoperatively. Overlay implant templates are available
and should be part of the surgical tactic. Digital PACS templating has become more common, and the technology
continues to evolve. In noncomminuted fractures, a minimum of six cortices in each fragment are recommended.
For comminuted fractures, six to eight cortices of fixation in each fragment should be employed. In these cases,
one or more holes in the zone of comminution are left empty. If locking screws are utilized, bicortical fixation
significantly improves mechanical strength. The ideal plate length and construct stiffness for optimal fracture
healing remain unknown. The use of longer plates, spaced screws, and a combination of conventional and
locking screws may influence fracture healing.

SURGICAL TECHNIQUE
The patient is positioned in the supine position, and the extremity is supported on a hand table. A nonsterile
tourniquet is applied to the upper arm. C-arm access is often facilitated by rotating the table 45 or 90 degrees so
the operative extremity is centered in the room. The image intensifier is brought in from the end of the hand table
obviating the need for the surgeon or his or her assistant to move (Fig. 12.2). Cefazolin 1 to 2 g should be
administered at the beginning of the case. Patients with a penicillin allergy or a history of MRSA are given
vancomycin as an alternative. In closed fractures, patients receive one or two additional doses of antibiotics
postoperatively. In open fractures, the duration of antibiotics is individualized based on the severity of the wound
and the degree of contamination.
Surgery can be performed using general or regional anesthetic techniques. Regional anesthesia with long-acting
pharmacologic agents is contraindicated in most patients with diaphyseal forearm fractures due to the risk of
masking a postoperative compartment syndrome (15).
In comminuted diaphyseal fracture patterns, if there is any question regarding the fracture geometry or
morphology, traction radiographs should be obtained under anesthesia prior to prepping and draping. The
extremity is prepped and draped from fingertips to the tourniquet. In patients with open fractures, the tourniquet is
not inflated, to prevent further ischemic injury to the traumatized soft tissue. In closed fractures, surgery is
routinely performed under tourniquet control. In large or swollen arms, the C-arm is used to identify the location
of the surgical incisions that are drawn on the extremity using a sterile marking pen. Loop magnification is
recommended to improve visualization and dissection and to control bleeding. Bipolar cautery and small ligature
clips are utilized liberally during the dissection.

FIGURE 12.2 The surgeon and assistant are seated on either side of the hand table, and the C-arm is brought
directly in line with the extremity.

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SURGICAL APPROACHES
Flexor Carpi Radialis Approach
For fractures involving the distal one-fourth of the radius, a volar approach based on the flexor carpi radialis
(FCR) muscle and tendon is utilized. A skin incision of appropriate length is made just radial to the tendon (Fig.
12.3). Following the skin incision, the FCR tendon sheath is split longitudinally and the FCR tendon is retracted
ulnarly. The floor of the tendon sheath is then incised. The flexor pollicis longus (FPL) is identified and retracted
ulnarly, which protects the median nerve. The pronator quadratus is elevated from the radius and retracted
ulnarly exposing the distal one-fourth of the radius (Fig. 12.4). This exposure avoids a direct dissection of the
radial artery.

Volar Henry Approach

The extensile volar approach of Henry is utilized for most fractures of the radius (16). Adequate exposure can be
obtained from the biceps tuberosity to the distal radial articular surface. The surgical skin incision extends from
the lateral aspect of the biceps tendon to the radial styloid, generally following the lateral aspect of the FCR (Fig.
12.5). In the distal aspect of the incision, the radial artery is in close proximity to the volar fascia and must be
identified and protected. Proximally the plane of dissection is between the brachioradialis (BR) and the FCR (Fig.
12.6). The radial artery is usually retracted ulnarly, but can be mobilized and retracted radially as dictated by the
soft tissues or fracture. Loop magnification is helpful when dissecting the radial artery for better recognition of the
small vascular branches. The superficial radial nerve is identified on the undersurface of the BR proximally
where it pierces the fascia and emerges on the superficial surface of the BR distally. The pronator quadratus is
released from the distal radius and retracted ulnarly along with the FPL (Fig. 12.7).
In the middle of the forearm, the pronator teres can either be detached by pronating the forearm and releasing its
tendinous attachment or it can be preserved in some cases (Figs. 12.8 and 12.9). Proximally, with the arm in full
supination, the supinator muscle is elevated from the periosteum and retracted radially, while the flexor digitorum
superficialis (FDS) is elevated and retracted ulnarly exposing the biceps tuberosity (Fig. 12.10).

Dorsal or Thompson Approach

The dorsal approach can also expose the length of the radius from the radial head to the distal articular surface
(17). Because of the risk to the posterior interosseous nerve and irritation of the soft tissues caused by a
prominent dorsal plate, this approach is used less frequently. I use this approach mainly for open fractures with a
dorsal wound, or fractures that require exploration of the posterior interosseous nerve. The skin incision extends
from the lateral humeral epicondyle to the ulnar aspect of Lister's tubercle (Fig. 12.11). The safe interval is
between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC) proximally. The
interval between these muscles is more easily recognized more distally in the forearm (Fig. 12.12). Once this
interval is developed, the posterior interosseous nerve is localized as it emerges from the mid substance of the
supinator muscle. The nerve must be dissected within the supinator being careful to protect the branches of the
nerve to the supinator muscle itself (Fig. 12.13). As with the volar approaches, loop magnification can be
beneficial. The arm is then supinated to expose the attachment of the supinator and the pronator teres, both of
which are detached and subperiosteally elevated toward their origin. As the approach is developed distally, the
abductor pollicis longus (APL) and the extensor pollicis brevis cross the radius obliquely (Fig. 12.14). The
muscles are elevated from the underlying periosteum and retracted either radially or ulnarly to facilitate exposure.
In the most distal aspect of the approach, the interval between the ECRB and the extensor pollicis longus is
developed. As with all approaches to the forearm, the extent of dissection is selected based on the fracture
location and the length of the plate fixation to be utilized.
FIGURE 12.3 The surgical incision is based just radial to the FCR tendon.

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FIGURE 12.4 A. The floor of the tendon sheath is incised. The FPL is encountered and retracted ulnarly. This
exposes the pronator quadratus. B. The pronator quadratus is elevated from the radial side of the radius and
transversely at the distal insertion. C. The pronator quadratus is fully retracted ulnarly exposing the volar distal
radius ulnarly. D. In this particular longitudinal fracture pattern, the approach facilitates placement of small
reduction clamps to reduce the longitudinal split in the radius.

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FIGURE 12.5 The surgical incision is based just radial to the FCR tendon.

FIGURE 12.6 The volar fascia is opened to expose the BR and the FCR muscles. The interval between these
muscles is developed bluntly. The sensory branch of the radial nerve courses beneath the BR and pierces the
volar fascia in the distal third.
FIGURE 12.7 The distal third of the radial shaft is exposed with retraction of the BR radially and FCR ulnarly.
The radius is relatively flat in this zone, and the plate generally needs minimal contouring.

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FIGURE 12.8 The pronator teres has been elevated sharply to expose the middle third of the radius.
FIGURE 12.9 The pronator attachment can be preserved, and the tendon can be elevated from the volar surface
of the radius allowing submuscular/tendinous placement of a plate.

FIGURE 12.10 The Henry approach can be extended to the proximal third of the radius if needed. The probe
shows the insertion of the bicipital tendon.

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FIGURE 12.11 The dorsal approach to the radius is marked along a line from the lateral humeral epicondyle to
the ulnar side of Lister's tubercle.

FIGURE 12.12 The dorsal investing fascia is examined to define the interval between the ECRB and the EDC.

FIGURE 12.13 The forearm is pronated, which brings the posterior interosseous nerve (PIN) closer to the
operative field and may increase the risk for injury.
FIGURE 12.14 The dorsal fascia is incised along this interval. The APL crosses the dorsal surface of the radius
obliquely in the distal portion of the exposure.

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Approach to the Ulna
The subcutaneous nature of the ulna allows a direct dorsal approach to the entire length of the ulna. The elbow
is flexed on the hand table to provide access to the ulna (Fig. 12.15). The dissection is in the interval between
the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris (FCU). To avoid subcutaneous placement of internal
fixation, the ECU is retracted and the dorsal aspect of the ulna is exposed (Fig. 12.16).
The subcutaneous nature of the ulna also allows percutaneous plate placement. Following indirect reduction of
the ulna by either plate fixation of the radius or provisional ulnar reduction utilizing an external fixator, two small
incisions are made along the subcutaneous border of the ulna and the overlying skin is mobilized from the deep
tissue with an elevator directed toward the fracture. The plate is then inserted along the bone until it is visualized
in the opposite incision. The process is done using an image intensifier. The plate is then secured to the bone
with screws in the two small incisions and strategically placed stab incisions along the subcutaneous border of
the ulna (Fig. 12.17). Plates placed percutaneously on the subcutaneous border can be prominent and often
require removal after healing.

REDUCTION AND PLATE FIXATION TECHNIQUES

The fracture pattern dictates the technique for reduction and internal fixation. Soft tissues are retracted with right
angle retractors or strategically placed small Hohmann retractors placed extraperiosteally. Broad retractors
should be avoided to minimize soft-tissue stripping (Fig. 12.18). In transverse and short oblique fracture patterns,
direct reduction, interfragmentary compression with lag screws, and compression plating techniques are utilized.
Pointed reduction forceps or serrated reduction forceps are used to distract the bone, restoring length. The
fracture is reduced under direct visualization (Fig. 12.19). Oblique fracture patterns are reduced by placing the
small reduction clamps perpendicular to the fracture line. Depending on the orientation of the fracture,
compression should then be obtained with a lag screw outside or through the plate. For most diaphyseal radial
fractures, small amounts of plate “contouring” are necessary. In transverse fracture patterns, the plate is secured
to the bone held with a small forceps and fixed with a bicortical screw in one end of the plate. Opposite the
fracture, an additional bicortical screw is placed eccentrically promoting compression of the fracture when it is
tightened. Prior to final tightening, the clamps anchoring the plate to the bone should be loosened or removed to
allow the plate to slide in relationship to the compressing screw. Two or three additional screws are placed in the
“neutral” position on either side of the fracture. In poor-quality bone, a minimum of six to eight cortices of fixation
should be obtained on either side of the fracture or use of a locked plate device should be considered.
FIGURE 12.15 A. The subcutaneous approach to the ulna is marked with the elbow flexed and the forearm in
neutral rotation. The fracture site should be palpated to determine the midpoint of the incision. B. The ECU is
identified, separated from the periosteum, and retracted dorsally and radially.

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FIGURE 12.15 (Continued) C. The fracture site is exposed, yet the careful dissection has left the periosteum
intact and soft-tissue attachments to the comminuted segments. D. The fracture is reduced with judiciously
placed clamps and reduction aids to minimize soft-tissue dissection and destruction, the reduction is maintained
by a plate provisionally fixed with clamps. E. Final fixation with a plate resting under the ECU.

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FIGURE 12.16 A. The plate along the subcutaneous border of the ulna should be placed so that it lies beneath
the ECU and is recessed dorsal to the subcutaneous border of the ulna. B. This reduces painful symptoms
related to a prominent plate that most frequently occur when the forearm is placed on a rigid surface.

FIGURE 12.17 An incision measuring 2 cm is made over the subcutaneous proximal ulna and carried down to
the periosteum. The subcutaneous tissue is elevated from the periosteum by pushing a plate along the
subcutaneous border of the ulna. With the plate inserted, a separate 2-cm incision is made over the plate at the
distal ulna. The plate is then centered on the bone at both ends and screws are placed. If additional screws are
required closer to the fracture, stab wounds are made over the plate and screws are inserted percutaneously.
FIGURE 12.18 Exposure is facilitated through the use of small Hohmann retractors. Extensive dissection of soft
tissue was required in this case of a 3-week-old fracture. Despite the wide dissection, note that the callus and
comminuted bone segments have been peeled away from the fracture site and soft-tissue attachment preserved.

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FIGURE 12.19 A. Pointed reduction forceps or serrated reduction forceps are used to grasp the bone and draw
it out to length. B. When gross length has been reestablished, a plate can be utilized to maintain length and
alignment. The plate is provisionally fixed to the bone with two Verbrugge or plate holding forceps. Length can be
fine-tuned by applying distal traction and loosening the proximal clamp to gain additional length before the clamp
is retightened. C. The plate is then fixed to the bone both proximally and distally. Once two screws are placed in
each segment, the associated clamp can be removed.

Comminuted fractures should be fixed utilizing indirect reduction techniques and application of a bridge plate
whenever possible. In this situation, dissection of the comminuted fragments in the fracture zone is avoided.
Correct restoration of length and alignment can be obtained by several methods. The fracture can be brought out
to length by manual traction using reduction forceps on opposite sides of the fracture and clamping the plate to
the bone to maintain length while screws are inserted. A more reliable method for restoring length and alignment
is to fix the plate on one side of the fracture with one or two screws. At the other end of the plate, a screw is
inserted 1 to 2 cm beyond the end of the plate. This “push-pull” screw is used to indirectly reduce the fracture by
inserting a small lamina or bone spreader between the plate and the “push-pull” screw with controlled distraction.
Under fluoroscopic control, length and alignment are restored and confirmed. Screws are then placed in the plate
to maintain the reduction. During this process, two loosely applied clamps placed perpendicular to one another
around the plate will control alignment during the distraction process (Figs. 12.20 and 12.21). Utilizing indirect
reduction techniques, and respecting the biology of the soft tissues, bone grafting is not usually required even in
comminuted fractures (18) (Figs. 12.22 and 12.23).
Following plate fixation of forearm fractures, range of motion and stability of both the proximal and distal
radioulnar articulations should be carefully checked. In the case of a Galeazzi fracture, if the DRUJ is stable
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through a full range of motion, no postoperative immobilization is required. On the other hand, if the DRUJ is
unstable but reducible, the arm can be splinted or casted in supination for 4 to 6 weeks or the joint can be
pinned. If the DRUJ is unstable and irreducible, the joint should be opened, explored, and repaired. The
extremity should be immobilized for 4 to 6 weeks in a cast. With Monteggia fractures, the radial head reduces
>90% of the time with anatomic reduction and stable fixation of the ulna. If the radial head does not reduce, the
most common cause is malreduction of the ulna. Less common is interposition of the annular ligament. If the
radial head is reduced and stable, then no additional immobilization is required. If the radial head is unstable, it
should be reduced into a stable position usually with supination of the forearm. In both bone forearm fractures,
failure to achieve full range of motion intraoperatively is usually the result of residual shortening or malalignment.
In all cases, full-length radiographs should be obtained prior to leaving the operating room to ensure accurate
fracture reduction. The tourniquet should be deflated prior to closure and meticulous hemostasis obtained. The
deep structures such as the pronator teres, supinator, and pronator quadratus are placed back in their anatomic
location but do not require repair. The fascia on both the volar and dorsal exposures are left open, to decrease
the likelihood of a postoperative compartment syndrome following closure. The subcutaneous tissues and skin
are closed in layers.
FIGURE 12.20 Indirect reduction of the ulna is depicted. A compression distraction device and screw are used
for distraction of the fracture. The dental pick is used to tease the wedge fragments into better but not anatomic
position. One length is established, the plate is secured proximally. The compression distraction device is then
removed.

FIGURE 12.21 Alternatively, a lamina spreader can be utilized as is depicted here to push the fracture out to
length. During this process, two loosely applied clamps placed perpendicular to one another around the plate will
control alignment.
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FIGURE 12.22 A,B. An open both-bone forearm fracture. The figures demonstrate a comminuted radius and
segmental comminuted ulna fracture. C,D. The radius is least comminuted and is plated with a bridge plate
technique first. Minimal screw fixation is utilized. Following reduction of the radius, the ulna has been
provisionally reduced by restoration of length and alignment of the radius.

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FIGURE 12.22 (Continued) E,F. Bridge plate fixation of the radius and ulna is demonstrated. Both bones have
been treated with a bridge plate technique. The segmental nature of the ulna fracture necessitated a longer
plate. Locking fixation was utilized secondary to the bridge plate application and the advanced age of the patient
and presumed osteopenia. Minimal screw insertion was utilized to minimize bone devitalization.

POSTOPERATIVE CARE
Assuming there is no instability in the proximal or distal radioulnar joints, the surgical incision sites are dressed,
and a volar forearm splint is applied with the wrist extended 30 degrees. Splinting is designed to support the soft
tissues and increase patient comfort in the immediate postoperative period. The splint is discontinued at the first
postoperative visit, and active assisted range of motion of the upper extremity is initiated at that time. In addition,
the patient is encouraged to begin using the extremity for activities of daily living, with restrictions against lifting
objects >10 to 15 pounds. The lifting restriction is eased at 6 to 10 weeks depending on clinical and radiographic
signs of fracture healing. Typically all restrictions are removed by 3to 4 months. Return to sedentary work is
allowed 7 to 10 days following surgery, but return to sport is restricted for 4 to 6 months following injury. Clinical
and radiographic follow-up is obtained 6 weeks following injury and then on a 4- to 6-week basis thereafter until
union. Hardware removal is uncommon and should not be done for at least 18 months because of the risk of
refracture. Patients should be carefully counseled regarding the inherent risk of nerve injury or refracture after
elective hardware removal (19,20).

COMPLICATIONS
Compartment Syndrome
Fortunately complications following forearm fracture fixation are infrequent. The most significant early
complication with forearm fracture fixation is the development of acute carpal tunnel syndrome or forearm
compartment syndrome. If a compartment syndrome is diagnosed, the carpal tunnel as well as the
superficial and deep compartments of the forearm up to the level of the biceps aponeurosis should be
released.
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An intraoperative decision and determination for further releases of the mobile wad and posterior
compartment are made based on the clinical exam or compartment pressures. The soft tissue over the
carpal tunnel should be closed. The remainder of the incision should be left open for delayed primary
closure or split-thickness skin grafting.

FIGURE 12.23 A,B. A closed both-bone forearm fracture treated with compression plating of the radius and
bridge pate fixation of the ulna is demonstrated.

Malunion
Malunion is generally the result of residual shortening or malalignment of the fracture. Malalignment is more
frequent in comminuted fractures when indirect reduction techniques are not utilized. Careful preoperative
planning and the use of comparative radiographs may be helpful in obtaining a satisfactory reduction. At the
completion of every case, the extremity should be checked for range of motion in flexion extension and most
importantly in
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 supination and pronation. When full restoration of motion cannot be achieved, the reduction should be
scrutinized for error and corrected. In patients who present weeks or months after surgery with a malunion,
a corrective osteotomy can be considered. In many cases, release of the interosseous membrane is
necessary to improve outcomes.
Nonunion
In approximately 5% of cases, a nonunion develops. In these cases, the possibility of a low-grade infection
should be considered, particularly if there is scalloping of the canal or radiolucency around the screw holes.
A CBC, ESR, and CRP should be part of the preoperative workup. I have not found nuclear medicine scans
to be reliable or sensitive. In general, when fixation failure occurs and revision surgery is undertaken, bone
and tissue cultures should be obtained. If the nonunion is atrophic, iliac crest bone graft or allograft
combined with demineralized bone matrix or BMP should be utilized. The current literature continues to
support the use of autogenous bone graft in these situations with high rates of success (21,22).
Synostosis
Synostosis can occur following fixation of the forearm as a result of the initial trauma or aggressive
dissection around the interosseous membrane. Regardless of the etiology, loss of range of motion is the
end result. Once the synostosis has fully matured, it can be resected in selected symptomatic patients. The
exposed bone that remains after the resection is covered with bone wax to prevent the formation of
hematoma and decrease the risk of recurrence of the synostosis. Interposition grafts, radiation, and
nonsteroidal anti-inflammatory medications may play a role (23).

REFERENCES
1. Droll KP, Perna P, Potter J, et al. Outcomes following plate fixation of fractures of both bones of the
forearm in adults. J Bone Joint Surg Am 2007;89(12):2619-2624.

2. Goldfarb CA, Ricci WM, Tull F, et al. Functional outcome after fracture of both bones of the forearm. J
Bone Joint Surg Br 2005;87(3):374-379.

3. Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and the ulna on
supination and pronation. J Bone Joint Surg Br 2002;84(7):1070-1074.

4. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of both
bones of the forearm in adults. J Bone Joint Surg Am 1992;74:1068-1078.

5. Anderson LD, Sisk TD, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the
radius and ulna. J Bone Joint Surg Am 1975;57:287-297.

6. Burwell HN, Charnley AD. Treatment of forearm fractures in adults with particular reference to plate
fixation. J Bone Joint Surg Br 1964;46:404-425.

7. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation in acute diaphyseal fractures of the
radius and ulna. J Bone Joint Surg Am 1989;71:159-169.

8. Duncan R, Geissler W, Freeland AE, et al. Immediate internal fixation of open fractures of the diaphysis of
the forearm. J Orthop Trauma 1992;6:25-31.

9. Mih AD, Cooney WP, Idler RS, et al. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop
1994;299: 256-258.

10. Moed 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;68:1008-1017.

11. Mackay D, Wood L, Rangan A. The treatment of isolated ulnar fractures in adults: a systematic review.
Injury 2000;31(8):565-570.

12. Jones JA. Immediate internal fixation of high-energy open forearm fractures. J Orthop Trauma
1991;5(3):272-279.

13. Henle P, Ortlieb K, Kuminack K, et al. Problems of bridging plate fixation for the treatment of forearm
shaft fractures with the locking compression plate. Arch Orthop Trauma Surg 2011;131(1):85-91. Epub 2010
Jun 3.

14. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression
plate with the point contact fixator for forearm fractures. J Bone Joint Surg Am 2003;85(12):2343-2348.

15. Davis ET, Harris A, Keene D, et al. The use of regional anaesthesia in patients at risk of acute
compartment syndrome. Injury 2006;37(2):128-133. Epub 2005 Oct 26.

16. Henry WA. Extensile exposures. 2nd ed. New York, NY: Churchill Livingstone; 1973:100.

17. Thompson JE. Anatomical methods of approach in operations on the long bones of the extremities. Ann
Surg 1918;68:309.

18. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm
fractures: a retrospective review. J Orthop Trauma 1997;11(4):288-294.

19. Beaupre GS, Csongradi JJ. Refracture risk after plate removal in the forearm. J Orthop Trauma
1996;10:87-92.

20. Langkamer VG, Ackroyd CE. Removal of forearm plates: a review of complications. J Bone Joint Surg Br
1990;72:601-604.

21. Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop
Trauma Surg 2010;130(12):1439-1445. Epub 2010 Mar 9.

22. 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;86(11):2440-2445.

23. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint
Surg Am 1998;80(2):248-257.
 13
Distal Radius Fractures: External Fixation
Neil J. White
Melvin P. Rosenwasser

INTRODUCTION
Despite increased focus on injury prevention, as well as osteoporosis identification and management, distal
radius fractures continue to be one of the most common injuries in clinical practice. They occur in a bimodal
fashion with predictable peaks in the young and elderly. Many lower-energy nonarticular fractures and most
epiphyseal fractures in children can be treated with closed reduction and casting with excellent outcomes. On the
other hand, comminuted fragility fractures of the distal radius secondary to osteoporosis in the elderly may be
easy to reduce but difficult to maintain in a cast after closed reduction. Similarly, fractures in younger patients as
the result of higher-energy injuries often result in unstable fracture patterns that require surgery.
All displaced distal radius fractures should be reduced and splinted to correct gross deformity and improve the
neurovascular status and relieve pain. Postreduction radiographs should be critically assessed for signs of
instability. Lafontaine et al. (1) proposed five factors that correlated with fracture instability: (a) initial dorsal
angulation >20 degrees, (b) dorsal comminution, (c) radiocarpal intra-articular involvement, (d) associated ulnar
fractures, and (e) age >60 years. In these authors' experience, patients with three or more of these factors had a
high incidence of loss of reduction with cast treatment alone. Nesbitt et al. (2) used the Lafontaine et al. criteria
and determined that age was the only significant risk factor in predicting instability. In patients over the age of 58
years, there was a 50% risk for secondary displacement, while patients over 80 years had a 77% increased risk.
More recently, MacKenney et al. (3) prospectively evaluated 4,000 distal radius fractures and identified age,
metaphyseal comminution, and ulnar variance as risk factors for early or late instability. In addition to the loss of
reduction, carpal malalignment and postreduction joint incongruity (articular step-off or fracture gap) have been
shown to have a negative impact on functional outcome (4, 5 and 6).

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

Closed reduction and casting is utilized for the majority of patients with fractures of the distal radius.
Nonoperative management is indicated if after reduction the radial length is within 3 to 4 mm of uninjured wrist,
the radial inclination is 22 degrees or more and articular step-off or gap is <2 mm. The carpus must be aligned
with the radial shaft. Loss of the volar tilt should be no more than 10 degrees (Table 13.1). Our philosophy has
been to accept less deformity in younger, highly active patients, and to accept more deformity in the lower
demand elderly osteoporotic patients. Minor degrees of shortening or angulation usually do not adversely affect
clinical outcomes (7, 8 and 9). After closed reduction follow-up, x-rays are obtained in the clinic every 7 to 10
days for the first 3 weeks to ensure maintenance of reduction and to assess the need for surgical intervention.
The cast should not block full metacarpal phalangeal joint flexion and is continued for 6 weeks followed by a
removable prefabricated splint. If finger motion is maintained, occupational therapy is not usually required. If
stiffness or swelling persists, then supervised therapy is recommended.
Unstable and displaced fractures of the distal radius usually require surgical repair due to the latent instability of
even well-reduced fractures. We believe that there is a subset of patients with acceptable initial reductions that
might benefit from early surgery based on LaFontaine's criteria who have a high likelihood of
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redisplacement. In general, early surgery is recommended for most patients with volarly displaced fractures and
in most patients with severe initial displacement, shortening, and dorsal comminution. Treatment decisions in this
group of patients are individualized.

TABLE 13.1 Normal and Acceptable Postreduction Radiographic Values

Acceptable Postreductiona

Measurement Normal Literature Author's opinionb

Volar tilt 11 degrees 0-15 degrees dorsal 10-degree dorsal

tilt

Ulnar variance EQual to other sidec or ± 2 2 to 4 mm 3-mm shortening

mm shortening

Radial inclination 22 degrees 10-17 degrees 15 degrees

Articular Congruous 1-2-mm step or gap 2-mm step

displacement 1-mm gapd

aNote thatthe goal of surgical intervention is anatomic restoration of the distal end of the radius. The
acceptable postreduction values vary widely by report and opinion and are also related to the functional
demands of the individual patient. This is most noted by recent literature that shows increased tolerance
to malunions in the elderly. The author's preferences are outlined in bold. (Reprinted from Schwartz AK,
Rosenwasser M, White NJ, et al. Fractures of the forearm and distal radius. In: Schmidt AH, Teague
DC, eds. Orthopaedic knowledge update 4: trauma. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2010, with permission.)
bPredicting fracture stability is more important than minding any specific parameters. If the fracture is
unstable, no cast will maintain reduction.
cLunate facet of radius to ulnar head, as compared to contralateral side.
dWhile preventing pointcontact is important, containing the lunate is paramount for achieving a good
outcome. As such, only 1 mm of gap is acceptable.

In the past decade, locking plates for internal fixation of unstable distal radius fractures have become widely
available. These include anatomically designed plates for the volar, radial, and dorsal aspects of the radius,
which are low profile and can be locked. The ability to lock the screws into the plate dramatically increases
fixation stability even in patients with severe osteopenia. Both fixed angle and variable angle screw trajectories
allow the surgeon to target and stabilize displaced articular facets. This has led to a dramatic and rapid change
in surgical indications for unstable distal radius fractures. Locked plating of the distal radius fractures has
virtually replaced the previous standard of spanning external fixation in North America. However, modern external
fixation with either spanning or nonjoint spanning frames can achieve satisfactory outcomes when combined with
K-wire augmentation and metaphyseal bone grafting, which supports the articular reduction in similar fashion to
the subchondral screws of a volar locked plate.
In our practices, we have shifted almost completely to plating of distal radius fractures. However, there still are
indications for augmented external fixation utilizing supplemental K-wire fixation for the highly comminuted distal
radius fractures that are not amenable to internal fixation or when trying to prevent or treat infection or significant
soft-tissue injury.

Strong Indications for External Fixation Include:

Highly comminuted and, at times, very distal intra-articular distal radius fractures not amenable to internal
fixation
Contaminated grade II and III open fractures of the distal radius
Can be used as temporary or definitive fixation
Open fractures associated with bone loss

Generally as a temporary measure

Open or closed fractures associated with neurovascular injuries requiring repair or massive soft-tissue injury
Highly unstable fractures associated with extrinsic ligament injuries such as volar lip-shearing type or ulnar
translocation of carpus

Relative Indications for External Fixation Include

Widely displaced fractures with significant soft-tissue swelling, abrasions, or blisters
Multiply injured patients
Complex ipsilateral limb injuries
Infected wrist or forearm fractures

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PREOPERATIVE PLANNING
History and Physical Examination
A thorough history and physical examination is essential with particular attention focused on the soft-tissue
integrity and neurocirculatory examination of the extremity. The brachial, radial, and ulnar pulses should be
palpated and/or dopplered. A careful neurologic exam of the extremity should assess the motor and sensory
integrity of the radial, median, and ulnar nerves. This must be clearly documented. The skin should be inspected
for the presence of open wounds including small wounds on the ulnar side of the wrist. Furthermore, the forearm
and elbow should be checked for swelling and tenderness to rule out an associated Galeazzi, Monteggia, or an
Essex-Lopresti injury. The forearm musculature should be palpated to rule out a frank or evolving compartment
syndrome. The hand should also be examined for pain or deformity, which might indicate a combined injury such
as a carpal or metacarpal fracture or dislocation. Patient-specific information, hand dominance, occupational
requirements, medical comorbidities, and expectations often guide treatment recommendations. Once the
physical examination has been completed, a closed reduction of the fracture and a sugar-tong or long-arm splint
should be applied. The wrist should not be placed in a “hyper-flexed” posture that might increase pressure in the
carpal canal. Any signs or symptoms of increasing pain or paresthesias mandate that any splints or cast be
loosened or removed for a more precise evaluation and treatment. Osteoarthritic fingers are especially
vulnerable to postfracture swelling and pain. Acute tendon injuries are rare following closed distal radius
fractures.
Imaging Studies
High-quality anteroposterior (AP) and lateral radiographs of the wrist and entire forearm must be obtained. In
some cases, comparative contralateral wrist films are helpful. Postreduction radiographs often clarify the fracture
pattern and help determine fracture stability. In comminuted or complex fracture patterns, CT scans with axial,
coronal, and sagittal reconstructions can be useful to better clarify the fracture pattern and morphology. CT
scans should only be obtained after the fracture has been reduced and splinted. Scans done with the fracture
shortened, displaced, and angulated rarely provide useful information and waste health care resources. For
selected unstable fractures, fluoroscopic traction views can also provide useful information about facet
displacement and may determine or alter the surgical approach. Traction films can also reveal subtle, combined,
carpal bone, and/or ligamentous injury.

Timing of Surgery
Unstable closed fractures of the distal radius without neurovascular compromise require timely but thoughtful
intervention. Surgery should be scheduled semielectively following reduction and splinting. Open fractures, on
the other hand, require urgent irrigation, débridement, and stabilization. All patients with compartment syndromes
or acute carpal tunnel syndrome require emergent decompression.
In a subset of patients following closed reduction, there is redisplacement on follow-up radiographs. Patients
treated nonoperatively should be followed weekly for 21 days to monitor this potential redisplacement. We
caution against a “slippery slope” phenomenon whereby a small amount of displacement is accepted at 1 week
and a bit more at 2 weeks followed by a grossly unacceptable reduction at 3 or 4 weeks. If there is more than 2
to 3 mm of displacement on follow-up radiographs, surgery is recommended.

Treatment Paradigm
The definitive treatment plan is based upon fracture stability, patient expectations, functional requirements, and
medical comorbidities. Significant alterations in radial length, radial inclination, and reversal of palmar tilt have
been correlated with less favorable results. These outcomes are worsened with articular incongruity and carpal
subluxation (4, 5 and 6). However, mild or even moderate degrees of deformity do not preclude a satisfactory
result, increasing the importance of individualizing treatment. All patients with a displaced distal radius fracture
should have a closed reduction and application of a sugar-tong splint or split long-arm cast. We use either an
intravenous Bier block or a fracture hematoma injection. If a hematoma block is used, it is important to also inject
the ulnocarpal joint to improve patient comfort when there is an ulnar styloid fracture or concomitant ligament
injury. Unstable fractures are treated with surgery. In most cases, it is better to perform primary osteosynthesis
rather than corrective osteotomy.
Unstable distal radius fractures should not be treated with joint-spanning external fixation alone (Fig. 13.1).
Outcomes are improved with adjunctive techniques such as Kapandji dorsal intrafocal pinning, transradial
styloid-intramedullary pinning, and metaphyseal grafting with allograft or calcium phosphate bone cement (10,11)
(Fig. 13.2). In minimally comminuted fractures, with sufficient distal fragment bone stock, nonspanning external
fixation may be preferable, as it allows better control in restoring radial length, inclination, and palmar tilt (12).
Dorsal or volar shear fractures, such as Smith's and dorsal or volar Barton's, should be treated with a locked
buttress plate. Occasionally, in highly comminuted fractures, a bridging frame is used as an adjunct to an open
reduction and internal fixation (Fig. 13.3). This can be helpful with the small volar or dorsal pericapsular shear
fractures associated with carpal instability. Scaphoid or lunate die-punch injuries should be treated with elevation
of fragments and subchondral bone grafting stabilized with K-wire fixation. This can be performed with
arthroscopic assistance or via fluoroscopic guidance (10) (Fig. 13.4).
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FIGURE 13.1 A. Thirty-three-year-old right-hand-dominant male sustained an intra-articular left distal radius
fracture after a fall from a height. The fracture was reduced by traction and manipulation and spanned with a
bridging external fixator (B). Unstable intra-articular fractures require adjunctive fixation, K-wires with and without
bone graft, to achieve and maintain reduction. Despite initial satisfactory reduction, fracture fragment subsidence
occurred despite the spanning frame. Three months postinjury, the wrist is malunited (C). Assessment of the
lateral view of the reduction is critical, and in this case, the connecting bars obscure the image. This can be
prevented by placing the bars more dorsally or utilizing radiolucent material.

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FIGURE 13.1 (Continued)

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FIGURE 13.1 (Continued)

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FIGURE 13.2 Fifty-seven-year-old right-hand-dominant female sustained this distal radius fracture (A). A closed
reduction was unsatisfactory, and the recommended technique of augmented external fixation with K-wires was
employed successfully (B). The frame is a neutralization device that allows the wrist to be placed in a neutral
position aiding finger rehabilitation and reducing swelling. Most fractures are protected for 6 weeks, and pin
removal can be done under local anesthesia in the clinic (C). This patient made an excellent functional recovery.

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FIGURE 13.2 (Continued)

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FIGURE 13.3 Sixty-seven-year-old right-hand-dominant female with comminuted intra-articular left distal radius
fracture (A). External fixation was used as a reduction tool during a planned open reduction and locked volar
plating (B). The frame which was for neutralization only with no excessive traction applied. The frame is secured
with the wrist in a neutral position (B,C). Rehabilitation can begin immediately. This technique is especially
useful when the surgeon has few assistants to maintain traction during fracture reassembly and plating.
Depending on the intra-operative assessment of the quality of internal fixation, the frame can be removed in the
OR, as early as 2 weeks post-operative, or maintained for a full 6 weeks.

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FIGURE 13.3 (Continued)

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FIGURE 13.3 (Continued)

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Ulnar styloid fractures occur in more than one half of all distal radius fractures. Stability of the important
triangular fibrocartilage complex (TFCC) attachment is more important than the size of the ulnar styloid fragment
(13, 14 and 15). Following fixation of displaced distal radius fractures, the distal radioulnar joint (DRUJ) should
be manipulated for signs of instability. If unstable, the TFCC or the ulnar styloid should be repaired.
When not injured, the carpus will follow the reduction of the distal radius fracture and maintain a collinear
alignment. Residual angular or rotational instability, or the pattern of dorsal intercalated segment instability,
indicates a laxity of the extrinsic capsular ligaments, which occurs secondary to radial shortening from fracture
impaction or gross angular deformity or from ligament disruption of the extrinsic radiocarpal ligaments.
Periarticular shear fractures, either dorsal or palmar, are primarily ligamentous injuries that require surgical
fixation. Carpal alignment should be assessed by scrutinizing the radiocarpal and the proximal and distal carpal
arches (15).
FIGURE 13.4 Fifty-three-year-old right-handed male fell sustaining a distal radius articular facet impaction
fracture (A). This is the ideal indication for an arthroscopic-guided reduction. B. Visualization through the
arthroscope allows precise fragment elevation using joystick K-wires and confirmation with the image intensifier
(C). To protect the reduction and fill the subchondral metaphyseal void, cancellous allograft was impacted
through a dorsal incision at the fracture site. In most cases, to prevent late subsidence, this reduction should be
protected by a spanning external fixator until early consolidation has occurred at 6 weeks.

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We reported a randomized clinical trial comparing external fixation, locked volar plating, and locked radial column
plating for displaced distal radius fractures. There were no differences in patient outcomes for any of the
techniques (16, 17 and 18). However, plating permitted a quicker functional recovery because of accelerated
mobilization than is possible with external fixation (16). Despite the widespread enthusiasm for volar plating of
the distal radius, external fixation can result in equivalent long-term outcomes and should be part of the
surgeon's armamentarium.
SURGERY
Positioning and Setup
Surgery is performed under general or regional anesthesia. Regional anesthesia provides full muscle relaxation
and postsurgical pain relief for 8 to 12 hours. The patient is placed supine on the operating room table, and the
arm is abducted and placed on a radiolucent arm board to accommodate the C-arm image intensifier. A first-
generation cephalosporin is given intravenously prior to the inflation of the arm tourniquet, which is used in
virtually all cases. If a penicillin allergy exists, vancomycin or clindamycin is substituted. We routinely use the
mini-C-arm for distal radius fractures. A standard C-arm fluoroscopic unit is an acceptable alternative, but
produces about 10 times the exposure to x-ray.
The arm is prepped and draped, and the tourniquet is inflated to 250 mm Hg. The tourniquet is only used for
exposure, identification, and protection of tendon intervals and most importantly the adjacent cutaneous nerves
while placing the external fixation pins. It should be released after the pins have been safely inserted. When
arthroscopy is used to assist fracture reduction, the equipment is positioned near the foot of the bed.
Arthroscopic assessment of the radiocarpal joint provides an exacting of the reduction and facet realignment and
is more accurate than fluoroscopic images. This is particularly helpful in dorsal lunate die-punch injuries. After
arthroscopic-assisted articular facet realignment and stabilization with percutaneous K-wires, possibly
supplemented with metaphyseal void bone grafting, a spanning external fixation frame is placed. This neutralizes
deforming forces and protects the reduction.

Implant Selection
Radiolucent connecting bars should be used whenever possible. If these are not available, then two connecting
bars are offset volarly and dorsally to not obstruct obtaining high-quality lateral radiographs.
External fixation 3-mm half-pins are utilized for insertion in the radius and second metacarpal. Although the pins
are self-drilling and tapping, we prefer predrilling pilot holes to minimize the possibility of iatrogenic fracture or
eccentric placement and allow drilling to be manual. For nonspanning frames, we do not predrill the distal radial
metaphysis as this bone is usually less dense.

Adjunctive Techniques
One or more percutaneously placed K-wires introduced through the radial styloid can help prevent a translational
deformity at the fracture site after application of the frame especially when using a nonspanning external fixator.
However, bridging or spanning external fixation frames are neutralization devices and cannot reduce displaced
intra-articular fracture fragments. When the articular facets are impacted and cannot be reduced by traction
alone, strategically placed intrafocal (Kapandji) K-wires can be helpful to manipulate and reduce the articular
facets before frame application. Once these osteoarticular fragments are reduced as assessed by the image or
via arthroscope, the K-wire is advanced from distal to proximal to engage the volar cortex to prevent
redisplacement. In osteoporotic bone, this may be inadequate to maintain the reduction throughout the course of
bone healing and should be supplemented by allograft bone or calcium phosphate cement placed into the
metaphysis. Grafting is done through a 3-cm dorsal incision at Lister's tubercle between the third and fourth
dorsal compartments. The fracture site is opened with an elevator, and the bone graft or cement is impacted to
fill the void up to the subchondral margin, which will prevent subsidence when the intrafocal pins and external
fixator are removed (11). Additionally, restoration of the normal volar tilt is impossible with a spanning frame
because of the symmetric dorsal and palmar soft-tissue tensioning via ligamentotaxis (19). The ability to dial in
the volar tilt is an advantage of the non joint spanning frame.

Arthroscopically Assisted Articular Reduction

Several studies have shown that wrist arthroscopy can improve the quality of reduction and placement of pins
(20). In addition, wrist arthroscopy allows a thorough inspection of the articular surfaces and the intercarpal
ligaments and TFCC, which may be injured following distal radius fractures. Arthroscopy is performed with the
wrist vertically distracted on a traction tower that accommodates both the image intensifier and working room for
the placement of adjunctive K-wires.
There are no absolute indications for wrist arthroscopy of distal radius fractures. It should be employed only by
surgeons experienced with the technique and adds minimal additional surgical time or morbidity. It is most
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useful to visualize the joint in partial articular fractures such as the radial styloid or Chauffeur's fracture type.
Occasionally when treating a very distal fracture using a volar locking plate, it may be helpful to ensure that the
screws are not intra-articular.

FIGURE 13.5 Operating room set up for arthroscopically guided distal radius reduction and fixation. There is
adequate room for scope tower and miniimage intensifier around the injured extremity.

Ten pounds (4.5 kg) of traction is applied through sterile finger traps attached to the index and long fingers with
the shoulder abducted and the elbow flexed to 90 degrees (Fig. 13.5). Care is taken to pad and protect the
elbow from the adjacent tower. The arthroscopy portals are marked on the skin and coincide with the dorsal
compartment intervals. The workhorse portals are the 3-4 and 4-5 dorsal compartments, but any may be used.
The 1-2 portal is helpful in reducing radial styloid fractures, and the six radial and six ulnar portals are necessary
to visualize and, if necessary, repair the TFCC. Finally, the midcarpal portals can be used to assess the stability
of the scapholunate and lunotriquetral ligaments when indicated.
Arthroscopy is optimally performed under tourniquet control. The joint is distended with 3 to 5 mL of normal
saline injected through the 3-4 portal. Portal placement and orientation are checked with an 18-gauge needle. A
2- to 3-mm incision is made with an 11 blade, and then a small, curved hemostat is used to penetrate the dorsal
joint capsule. Utilizing a 2.7-mm blunt trocar and cannula, the arthroscope is inserted into radiocarpal joint.
Clotted blood in the joint often obscures initial visualization but is rapidly cleared with pressurized joint lavage or
a synovial shaver. In many patients, there is an articular cartilage injury on both the radial and carpal side of the
joint from axial loading and impaction. Careful inspection and palpation of the intercarpal ligaments and TFCC
are performed with a probe (20). Extra-articular placement of joystick reduction K-wires as well as limited open
exposure at the fracture site is useful to reduce impacted articular fragments. The fracture is stabilized with
subchondral K-wires and neutralized by a spanning external fixator and a metaphyseal void bone graft or filler as
indicated.

APPROACH
Nonspanning External Fixation
Nonspanning external fixation is used less frequently in North America than Europe because of its unfamiliarity
and the limited number of fractures where it is applicable. However, several published series have documented
the efficacy with this method of treatment (5,7). A nonbridging external fixator is a powerful tool for direct
fragment manipulation to restore the volar articular tilt since it does not require ligamentotaxis to effect a
reduction. It requires a distal segment of bone at least 7 mm to place the 3-mm half-pins. The technique can still
be used even with intra-articular extension. After the articular fragments are reduced and stabilized with
provisional K-wires, the half-pins are placed just proximal to the articular facets. Half-pins are placed between
the extensor compartments to avoid tendon injury (Fig. 13.6). However, if the bone quality is poor or the distal
segment is <7 mm, a nonspanning fixator is not employed.
The greatest benefit of a nonjoint spanning frame is its ability to reduce and maintain the volar tilt by controlling
the articular facet fragments with the half-pins acting as power joysticks. Numerous authors have shown that a
nonbridging external fixation is the most effective way to reestablish radial length, inclination, and palmar tilt
(5,7). This cannot be accomplished with a joint bridging construct because of the symmetric tensioning of the
palmar and dorsal capsule created by joint distraction. Simply put, ligamentotaxis alone cannot realign
osteoarticular fragments devoid of soft-tissue attachment, which often results in a nonanatomic V-shaped
articular malunion rather than the normal articular concavity (Fig. 13.7A, B).
If the fracture is amenable to a nonbridging external fixator, half-pins should be placed lateral and medial to
Lister's tubercle using fluoroscopy. Many intra-articular distal radius fractures have a split between the scaphoid
and lunate facets. The two distal half-pins are placed on either side of the fracture line through small longitudinal
incisions. For a nonbridging frame, the distal radial pins are placed 90 degrees to the long axis of the radius. The
medial pin in the lunate facet fragment is the most important as the lunate facet reduction controls carpal
alignment and restoration of the DRUJ. It is always placed first and should be oriented parallel to the
subchondral surface as viewed from the sagittal image. The scaphoid facet pin is then placed subchondral and
parallel as viewed from the lateral image. Either the C-arm or the wrist is elevated to obtain a lunate facet 20-
degree tilted lateral view to assess the pin placement. The pins are then manipulated proximal to distal, which is
the reduction maneuver. The extensor tendons especially the extensor policis longus (EPL) must be identified
and protected prior to pin placement. Self-drilling 3-mm half-pins are placed under fluoroscopic guidance by hand
so that the half-pins engage the palmar cortex. The EPL tendon excursion is checked after pin placement.
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FIGURE 13.6 Placement of half-pins between the extensor compartments to avoid tendon injury.
FIGURE 13.7 A. Ligamentotaxis; axial force applied through intact capsuloligamentous structures. Note that with
symmetrical pull of the volar and dorsal ligamentous strucutres not more than neutral volar tilt can be obtained.
Over distraction or flexion of the wrist joint should not be employed to obtain volar tilt. It will not work, and may
promote finger stiffness and severe post-oprative pain. B. V-shaped malreduction of the joint surface resulting
from the inability of bridging to gain volar tilt.

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Prior to reducing the fracture using the half-pins in the distal fragment as joysticks, a radial styloid K-wire (1.6
mm) should be inserted into the medullary canal of the radius. This prevents excessive palmar translation of the
distal fragment when the nonbridging fixator is secured. If the palmar cortex is fractured, this translation K-wire is
essential.
The frame is assembled with pin to rod connectors and a radiolucent bar. The reduction maneuver is performed
with the surgeon gently pushing the half-pins distally, which distracts and corrects the length, inclination, and tilt
and can be fine-tuned under image control. Fluoroscopy is used to visualize the fracture, and the
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half-pins are used to guide the reduction. Since they enter the bone parallel to the subchondral articular facets,
they are very successful in restoring volar tilt (Fig. 13.8).
FIGURE 13.8 The lateral half-pin is placed. Identification of the EPL is mandatory. The radial pin is placed at the
same level and angle as the medial half-pin and again is bicortical into the volar column. The reduction is
performed with gentle distal pressure of both thumbs on the distal half-pins. It is at this time that a critical
assessment is made of the lateral view to ensure that there has not been overtranslation of the articular
fragments. This can occur when the volar distal radial column is also fractured, and the direction of reduction
force may promote a malreduction. This can be prevented by placing a transradialstyloid intramedullary K-wire to
control this palmar translation. This powerful reduction device does not require excessive longitudinal traction to
effect a reduction and permits a more exacting restoration of radial inclination and volar articular tilt.
FIGURE 13.9 Metacarpal pin-placement site using a limited open incision.

BRIDGING FIXATION
Bridging external fixation is utilized when the bone quality or fracture comminution precludes a nonbridging
construct. Regardless of type of frame, the pins are placed through a limited open approach to minimize injury to
the tendons and cutaneous nerves (21) (Fig. 13.9). It also optimizes pin placement in the midaxis of the radius
and metacarpals. The angle of insertion of the pins for a bridging external fixator is 45 degrees to
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the long axis of the radius and metacarpal (Fig. 13.10). It is important to always place percutaneous K-wires to
realign and support intra-articular fragment reduction regardless of the type of spanning external fixation frame
employed. The distal pins are placed in the second metacarpal at 45 degrees to the long axis of the bone.
Metacarpal pin placement should be done through a limited open approach, using either a single incision or two
smaller incisions. The pins are placed in the proximal half of the metacarpal in the bare area between the
extensor tendons and the first dorsal interosseus muscle. Placing the pin proximally may allow pin fixation into
the base of both the second and third metacarpals enhancing fixation stability. More distal pin placement may
encroach on the metacarpal phalangeal joint, which can lead to finger stiffness. The index finger should be
flexed fully at all joints during pin placement to minimize tethering of the extensor mechanism. To avoid a pin
portal fracture, the 3-mm half-pins must be placed in the center of the cylindrical metacarpal shaft. The
orientation of these pins should be 45 degrees to the long axis of the bone to permit full abduction and extension
of the thumb (18). As noted previously, the pins must engage both cortices.
FIGURE 13.10 Pin placement at 45 degrees to the long axis of the radius and metacarpal.

The two most common pitfalls when using bridging external fixation are excessive pronation of the distal fragment
that can produce a malunion of the lunate facet and DRUJ resulting in loss of supination. The other common
error is futile excessive distraction of the carpus to reduce impacted fragments, which invariably leads to finger
stiffness and in some cases may be a prime factor in the initiation of complex regional pain syndrome (CRPS).
The small incisions should be closed after pin placement and before assembling the frame. The skin closure
should be adjusted around the pins to minimize skin tension leading to necrosis and pin track infection, which is
a leading cause of premature pin loosening. A loose skin closure is better as it will allow some movement around
the pins following final reduction and tightening of the frame. The pin clamps and connecting radiolucent bars are
placed two finger breadths (2.5 cm) from the skin to reduce the frame profile and improve stability. It is important
to avoid excessive wrist flexion and/or ulnar deviation (Cotton-Loder). The wrist and forearm should be in neutral
rotation before tightening the frame. If the metacarpal pins have been properly placed at 45 degrees to the long
axis, then the thumb will be able to fully abduct and extend. A single spanning bar is usually sufficient but a
second may be added if the fracture is complex or very unstable. It is important to check the stability of the DRUJ
after frame application. Testing for instability should be performed in neutral, pronation, and supination. If
unstable, fixation or immobilization of the styloid fracture or TFCC tear is required, which can be performed
arthroscopically or open. Another option is to pin the joint with a trans radioulnar K-wire with the DRUJ reduced
and protected by a long-arm splint.
AP, lateral, and tilted lateral radiographs should be obtained in the operating room at the conclusion of the case
to confirm the adequacy of reduction as well as pin or wire placement. The surgical incisions are infiltrated with a
local anesthetic.

Proximal Pin Placement

Proximal pin placement is similar for both external fixation constructs. The radial shaft pins are placed 10 cm
proximal to the tip of the radial styloid and always at least 5 cm proximal to any fracture lines. They are inserted
at the “bare” interval between the brachioradialis and the extensor carpi radialis longus muscles, which will not
impede tendon excursion. Pin placement is done through a limited open approach to ensure identification and
protection of the radial sensory and lateral antebrachial cutaneous nerves (22) (see Fig. 13.10). We prefer self-
drilling pins that are bicortical. We do however routinely drill a pilot hole to aid with precise pin placement. Note
that although not absolutely necessary it is easier to assemble the frame if the proximal pin trajectory matches
the distal pin trajectory. In other words, we put the pins at 45 degrees to long axis of the bone to match
metacapal pin in a spanning fixator and at 90 degrees to match the distal radial pins in a non joint spanning
construct. Prestressing to load the pins during the assembly of the frame is unnecessary and may lead to
osteolysis around the pins and premature loosening.

TIPS AND TRICKS

1. If the surgical plan is to start with a fixator frame of any type, then the proximal and distal pins should be
placed first. For a right-handed surgeon, it is easiest to work left to right and avoid having to work with the
right elbow awkwardly over previously placed pins.
2. For spanning frames, the surgeon should sit facing the patient's axilla improving access to the second
metacarpal and to the radial styloid for adjunctive K-wires. For a nonspanning frame, it is imperative to work
sitting over the patient's shoulder. This allows easy acquisition of lateral x-rays while placing pins in the distal
metaphysis of the radius. It is best to rely on the lateral view and keep the pins parallel to the hand table.
3. It is imperative to protect the dorsal sensory branch of the radial nerve. Care and time should be taken with
proximal pin insertion, and all drilling should be done under direct visualization and by using drill sleeves. We
generally place these pins between ECRL and brachioradialis, but it is certainly acceptable to use the interval
between ECRL and ECRB.
4. Patient education before surgery including the necessity of finger motion and pin care should be performed.
5. Overdistraction may be used intra-operatively when using a joint spanning frame to help obtain reduction. No
patient should leave the operating room with the joint over-distracted. This technique will not work, but
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more importantly, it will promote finger stiffness and regional pain syndromes. Over distraction can be seen on
a standard AP X-ray by assessing radio-carpal spacing.

AFTERCARE
As finger stiffness is one of the most common and serious complications of wrist fractures, mobilization of the
digits early is critical. The index finger motion may be limited because of pain and the proximity of the metacarpal
pins. Unless the ulnar styloid or TFCC has been injured or surgically repaired and immobilized, institution of
forearm rotation exercises should also begin within the first few days.
Hand therapy is often required to teach and guide the initial rehabilitation especially if the ability to grasp is
impaired by swelling, apprehension, or pain. This is continued until certain milestones are met such as a full
grasping fist and full supination. The remainder of strengthening and mastery of activity of daily living skills (ADL)
can be achieved with a home exercise program and periodic supervision. The patient is seen at 2 weeks for
suture removal and x-rays and then again at 6 weeks for assessment of fracture tenderness and radiographic
healing. Generally, the external fixator is removed between 6 and 8 weeks after surgery in the outpatient setting.
A removable wrist splint is provided, and wrist motion and function are encouraged. Clinical and radiographic
follow-up are done at 3 and 6 months.

COMPLICATIONS
The most common complication with external fixation is pin-track infection. Most can be managed by local
 pin care with cleansing and oral antibiotics. If the pins loosen prematurely, they must be replaced to ensure
a stable frame construct and to maintain reduction. Modern external fixation frames are mechanically sound,
and the connecting joints usually remain snug after surgery. However, it is important to check all frame
articulations for tightness at each postoperative visit.
Some patients present with significant swelling and stiffness postoperatively. They should be aggressively
treated to avoid arthrofibrosis with loss of wrist or hand motion. It is imperative to ensure that the frame itself
or overdistraction is not contributing to the stiffness. This may be a factor in the initiation of CRPS. If a
CRPS develops, a multidisciplinary team approach should be employed and may require regional blocks,
pain management, and even manipulation under anesthesia to maintain joint motion.
Loss of reduction following pinning and external fixation of the distal radius is uncommon. If it occurs,
revision surgery is often necessary.

SUMMARY
In summary, we believe that external fixation properly performed is a viable alternative to internal fixation of
distal radius fractures and produces equivalent outcomes to open reduction and plating. In the global
treatment of distal radius fractures, both cost and infection risks make external fixation a valuable tool in the
treatment of unstable distal radius fractures (23).

REFERENCES
1. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20(4):208-
210.

2. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg
[Am] 2004;29(6):1128-1138.

3. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg
Am 2006;88(9):1944-1951.

4. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a
prospective randomised comparison of four methods of treatment. J Bone Joint Surg Br 1996;78(3):404-409.

5. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular
distal radius fractures. J Hand Surg [Am] 1994;19(2):325-340.

6. Batra S, Debnath U, Kanvinde R. Can carpal malalignment predict early and late instability in
nonoperatively managed distal radius fractures? Int Orthop 2008;32(5):685-691.

7. Synn AJ, et al. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop
Relat Res 2009;467(6):1612-1620.

8. Anzarut A, et al. Radiologic and patient-reported functional outcomes in an elderly cohort with
conservatively treated distal radius fractures. J Hand Surg Am 2004;29(6):1121-1127.
9. Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is
increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am
2007;32(7):962-970.

10. Trumble TE, Wagner W, Hanel DP, et al. Intrafocal (Kapandji) pinning of distal radius fractures with and
without external fixation. J Hand Surg [Am] 1998;23(3):381-394.

11. Chapman C, Rosenwasser MP. Treatment of unstable distal radius fracture with cancellous allograft and
external fixation. J Hand Surg 1999;24A(6):1269-1278.

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12. McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of
bridging versus non-bridging external fixation. J Bone Joint Surg Br 1998;80(4):665-669.

13. Zenke Y, et al. The effect of an associated ulnar styloid fracture on the outcome after fixation of a fracture
of the distal radius. J Bone Joint Surg Br 2009;91(1):102-107.

14. Souer JS, et al. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-
screw fixation of a distal radial fracture. J Bone Joint Surg Am 2009;91(4):830-838.

15. Kim JK, et al. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial
fracture? J Bone Joint Surg 2010;92(1):1-6.

16. Wei DH, et al. Unstable distal radial fractures treated with external fixation, a radial column plate, or a
volar plate. A prospective randomized trial. J Bone Joint Surg Am 2009;91(7):1568-1577.

17. Egol K, et al. Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked
plating for unstable fractures of the distal radius: a randomised, prospective trial. J Bone Joint Surg Br
2008;90(9):1214-1221.

18. Xu GG, et al. Prospective randomised study of intra-articular fractures of the distal radius: comparison
between external fixation and plate fixation. Ann Acad Med Singapore, 2009;38(7):600-606.

19. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius: a cadaveric study to determine if
ligamentotaxis restores radiopalmar tilt. J Hand Surg [Am] 1990;15(1):18-21.

20. Wolfe SW, Easterling KJ, Yoo HH. Arthroscopic-assisted reduction of distal radius fractures. Arthroscopy
1995;11(6):706-714.

21. Seitz WH, Putnam MD, Dick HM. Limited open surgical approach for external fixation of distal radius
fractures. J Hand Surg [Am] 1990;15(2):288-293.

22. Sarmiento A, Pratt GW, Berry NC, et al. Colles' fractures. Functional bracing in supination. J Bone Joint
Surg [Am] 1975;57(3):311-317.
23. Wei D, Poolman R, Bhandari M, et al. External fixation versus internal fixation for unstable distal radius
fractures: a systematic review and meta-analysis of comparative clinical trials. J Orthop Trauma 2011
(forthcoming).
 14
Distal Radius Fractures: Open Reduction Internal Fixation
Andrea S. Bauer
Jesse B. Jupiter

INTRODUCTION
Recent epidemiological studies show that the operative treatment of distal radius fractures continues to increase.
Koval et al. (1) reviewed the cases submitted by candidates for Part II of the American Board of Orthopaedic
Surgery and found that the proportion of distal radial fractures treated with open surgical treatment had
increased from 42% in 1999 to 81% in 2007. Some of this increase is related to the large number of internal
fixation devices now available in the marketplace, which is heavily promoted. These commercially available volar
locked plates are specifically designed for fixation of distal radius fractures (Fig. 14.1). Additionally, the advent of
locking plate technology allows improved fixation in osteoporotic bone when compared to conventional plating
and has led to increased use in elderly patients (2).
While advances in technology have facilitated internal fixation of the distal radius, the surgeon must still be
aware of the structure and biomechanics of the distal radius. The column theory of the distal radius, as described
by Rikli and Regazzoni in 1996, continues to be a useful guide in understanding and treating distal radius
fractures (3) (Fig. 14.2). The radial column consists of the radial styloid and the scaphoid facet of the distal
radius. This area serves to buttress the carpus radially and is the origin of important intracarpal stabilizing
ligaments. The intermediate column consists of the lunate facet of the distal radius as well as the sigmoid notch
and functions in load transmission from the carpus to the distal radius. The entire distal ulna and triangular
fibrocartilage complex is considered the ulnar column, which stabilizes the distal radioulnar joint (DRUJ) as well
as the ulnar carpus. Whether or not “fragment-specific” implants are used, it is important to understand the roles
of each column in restoring anatomy and biomechanics of the distal radius.

INDICATIONS AND CONTRAINDICATIONS

The decision for operative fixation of a distal radius fracture is based on a combination of fracture and
patientspecific factors. The type of fracture, associated soft-tissue and neurovascular injuries, associated
fractures (of the ipsilateral limb or distant sites), and the overall medical condition of the patient must all be taken
into account. However, with the advent of fixed-angle locking screw-plate constructs, underlying osteopenia is no
longer a contraindication to internal fixation.

Definite Indications for ORIF

Some fracture patterns are inherently unstable, such as those involving dislocation or subluxation of the
radiocarpal joint, and require open reduction internal fixation (ORIF) to restore stability. Other fracture patterns,
such as articular fractures with a displaced, rotated lunate facet fragment, cannot be reduced by closed
maneuvers
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and require ORIF. Finally, fractures with unacceptable amounts of displacement that present 3 weeks or more
after injury can rarely be reduced closed and require ORIF (Table 14.1).
FIGURE 14.1 A few of the many implants constructed specifically for the volar distal radius.

Relative Indications
Many factors specific to the fracture type and the patient are relative indications for ORIF of the distal radius.
These include bilateral displaced fractures, fractures associated with ipsilateral limb trauma or in the setting of a
polytrauma, some fractures with associated progressive swelling or nerve dysfunction, open fractures, fractures
associated with DRUJ instability, and unstable fractures not reduced after closed reduction and cast
immobilization (Table 14.2). There are several agreed-upon radiographic indications of fracture instability (4, 5
and 6). These include dorsal comminution >50% of the width on a lateral radiograph, any palmar metaphyseal
comminution, initial dorsal tilt >20 degrees, initial fragment translation >1 cm, initial radial shortening >5 cm, intra-
articular disruption, associated ulna fracture, and severe osteoporosis (Table 14.3).

Relative Contraindications
Patients with medical conditions that prohibit the use of anesthesia, with poor compliance, or with local softtissue
problems, such as active infection or complex regional pain syndrome, may not benefit from internal fixation of
their fracture (Table 14.4). Additionally, low-demand elderly patients with fracture displacement but good
alignment of the carpus on the forearm may not achieve functional improvement with ORIF, despite radiographic
improvement (7). The surgeon must keep in mind that anticipated functional loading, rather than chronological
age, should be used to guide treatment decisions.
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FIGURE 14.2 The column theory of the distal radius.

TABLE 14.1 Definite Indications for ORIF

Radiocarpal subluxation or dislocation

Displaced fracture of the radial styloid
Rotated fracture of the volar lunate facet
Displaced intra-articular fractures seen late (after 3 wk)

TABLE 14.2 Relative Indications for ORIF

Bilateral displaced fractures

Fractures associated with ipsilateral limb trauma
Fractures in the setting of polytrauma
Fractures associated with excessive swelling or nerve dysfunction
 Open fractures
Fractures associated with DRUJ instability
Unstable fractures that failed cast immobilization

TABLE 14.3 Radiographic Signs of Instability

Dorsal comminution >50%

Palmar metaphyseal comminution
Dorsal tilt >20 degrees
Fragment translation >1 cm
Radial shortening >5 cm
Intra-articular disruption
Associated ulna fracture
Severe osteoporosis

TABLE 14.4 Relative Contraindications to ORIF

Patients with medical conditions that prohibit anesthesia use

Poor patient compliance
Poor local soft-tissue conditions or complex regional pain syndrome

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PREOPERATIVE PLANNING
As with any musculoskeletal injury, a careful evaluation of the patient's overall condition, as well as that of the
involved limb and hand, must be made before a decision is rendered to proceed with operative intervention. The
fracture characteristics are not always easily appreciated before the fracture is reduced and repeat x-rays are
taken. Furthermore, additional x-ray views, including oblique views that focus on the articular surface or
computed tomography (CT) scanning, may further influence the decision about treatment (8).
A thorough evaluation of the imaging studies preoperatively helps in determining which reduction maneuvers
may be necessary, and whether fixation of the fracture will require a special exposure or additional equipment.
For particularly complex fractures, a preoperative template may be useful (Fig. 14.3).
When the fracture involves impacted articular fragments and/or extensive metaphyseal comminution, the
potential for autogenous, allogeneic, or bone-substitute grafts should be noted in the preoperative plan. In these
cases, the patient should also be informed that bone grafting may be necessary.
OPERATIVE TECHNIQUES
ORIF of the distal radius is generally performed as outpatient surgery with regional anesthesia, pneumatic
tourniquet control, and the involved limb extended on a hand table. A parenteral antibiotic, usually cefazolin, is
given at least 30 minutes prior to incision as prophylaxis against surgical site infection. A surgeon-operated mini-
C-arm fluoroscopy unit is used throughout the procedure to confirm fracture reduction and hardware placement.
Distal radius fractures may be operatively approached through several different exposures, which will be
highlighted here with emphasis on the pearls and pitfalls of each.

Volar Approach
The uncomplicated volar shearing, as well as the extra-articular, volar-displaced Smith's, and many dorsally
displaced fractures may be approached through the modified Henry approach to the distal radius (Fig. 14.4).
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An advantage of a volar approach is the surgeon's ability to judge rotational alignment as well as length by
reducing the volar cortical fracture lines as this area is not usually comminuted even in impacted, dorsally
displaced fractures. The modified Henry approach exploits the interval between the radial artery and the flexor
carpi radialis (FCR). The incision is marked out directly over the FCR, which is almost always palpable,
beginning approximately 5 cm proximal to the distal wrist crease.

FIGURE 14.3 Preoperative template for ORIF of a distal radius fracture.

FIGURE 14.4 A-C. Volar modified Henry approach to the distal radius.

At the distal wrist crease, the incision is angled ulnarly to avoid crossing the crease at a 90 degrees. The skin
and volar sheath of the FCR are incised, the FCR tendon is retracted, and the dorsal sheath of the FCR is
incised.
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Then the muscle belly of the flexor pollicis longus is retracted to expose the pronator quadratus. The pronator is
sharply elevated in an L fashion to expose the distal radius and the fracture site, with the longer limb generally
from the radial aspect of the radius and the shorter limb just proximal to the radiocarpal joint. A needle placed
into the radiocarpal joint can help define exactly where the shorter limb should lie. Whenever possible, the
proximal pedicle of the anterior interosseous artery should be preserved to maintain muscle viability and limit the
potential for a pronation contracture that develops due to ischemia of the pronator quadratus (Fig. 14.5).
FIGURE 14.5 An unstable fracture in a 54-year-old woman. A. Initial radiographs of the wrist demonstrate an
intra-articular fracture of the distal radius. B. Planned incision. C. The approach is carried out directly onto the
FCR tendon. D. Exposure of the pronator quadratus. E. Exposure of the fracture site.

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FIGURE 14.5 (Continued) F. A K-wire can be inserted into the radiocarpal joint. G. Reduction of the fracture
using an osteotome to elevate the distal fragment. H. A locked plate is applied to the volar distal radius and held
in position with K-wires. I. Mini-C-arm fluoroscopy is used to check the positioning of the plate. J. Fluoroscopy
imaging demonstrates excellent positioning of the plate.

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FIGURE 14.5 (Continued) K. The initial screw is placed in the proximal oval hole. L. Final appearance of the
plate and screws. M. The pronator quadratus is repaired, if possible, using 2-0 Vicryl suture. N. Postoperative
radiographs.

Relatively complex fractures associated with high-energy trauma or those involving a small, displaced volar
lunate facet fragment are better exposed through an extended ulnar-based incision that creates an interval
between the ulnar nerve and artery and the flexor tendons. Extending this incision distally to release the
transverse carpal ligament will further facilitate exposure (Fig. 14.6).
Orbay (9) developed an extensile approach to the volar distal radius. By extending the Henry approach more
distally, the surgeon releases the fibrous septum overlying the FCR and step cuts the insertion of the
brachioradialis tendon, which permits further displacement of the distal fragment and allows for exposure of the
dorsal surface of the distal fragment (Fig. 14.7).
Irrespective of the approach, the vast majority of fractures can be reduced intraoperatively using longitudinal
traction and direct digital manipulation of the distal fracture fragment(s). The locked-screw application of implants
contoured to the specific anatomy of the volar surface of the distal radius increases the stability of fixation. The
distal screws, if placed in the subchondral position, further enhance the stability of fixation, especially in
osteopenic bone.
Proper intraoperative fluoroscopy is essential to avoid inadvertent penetration of the articular surface during
volar plate fixation of the distal radius (10,11). One way to accomplish this is to always place the distal ulnar
screws first and check their placement on fluoroscopy (with the beam 20 degrees inclined from distal to proximal
to visualize the articular reduction) before proceeding with placement of the radial-sided screws. This allows an
unobstructed fluoroscopic view of the initial screw placement.
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FIGURE 14.6 A. Extensile volar ulnar approach for complex high energy articular fractures. B. Approach to the
transverse carpal ligament and interval between the ulnar artery and nerve and flexor tendons seen in
crosssection. C. Release of the pronator quadratus from the ulna.
FIGURE 14.7 A-E. The extensile FCR exposure developed by Orbay involves distal release of the FCR septum,
which permits wide exposure of the anterior surface as well as the ability to gain access to the dorsal surface of
the distal fragment.

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FIGURE 14.7 (Continued)

Whenever possible, the pronator quadratus should be reapproximated, which provides muscle coverage over the
implant. The wound is irrigated and closed, and a bulky postoperative dressing is placed, which incorporates a
light volar wrist splint with the fingers left free.
Several specific fracture patterns have potential pitfalls that may lead to loss of reduction or problems with
internal fixation via a volar approach:
1. When approaching the displaced volar fracture in the older patient, one must suspect an element of dorsal
cortical comminution, even if it is not apparent on the lateral x-ray. In the presence of dorsal comminution, an
implant applied as a buttress to push up the displaced volar distal fragment has the potential to translate the
fragment dorsally. This may cause loss of the normal volar tilt of the distal articular surface (Fig. 14.8).
2. The volar shearing radiocarpal fracture subluxation (Barton's fracture) most often has two or more distal
fracture fragments. In some, the volar ulnar component may be relatively small. Failure to support this
fragment can result in postoperative volar subluxation of both the small fragment as well as the carpus (Fig.
14.9). Anatomically, the very distal articular rim of the radius dips anteriorly both at the radial styloid as well as
at its most ulnar aspect. Therefore, one implant may be unable to support the entire distal articular rim
adequately (12).
3. When stabilizing a three- or four-part articular fracture through an volar approach, the radial styloid (column)
component may not be protected against shearing forces when a single volar implant is utilized. In these
instances, an additional small contoured radial implant can be applied through the same exposure by step-
cutting the brachioradialis insertion (Fig. 14.10). In addition, the volar lunate articular facet fragment may be
found to be rotated with minimal subchondral bony support (13). One option is to loop a wire through the volar
capsular attachments to the fragment and through a hole drilled transversely in the distal radius metaphysic
(Fig. 14.11) (14).

DORSAL APPROACH
Although the use of contoured locking plates has enabled many fracture patterns to be treated with volar plating,
there remain several indications for dorsal plating of the distal radius. These include shear fractures of the radial
styloid with associated articular impaction, some complex four-part intra-articular fractures in which the dorsal
lunate facet fragment cannot be reduced from a volar approach, fractures with associated intercarpal ligament
disruptions, and some dorsally displaced fractures that present >3 weeks postinjury.
Several surgical approaches can be used to access the dorsal aspect of the distal radius. For fractures of the
radial styloid, a dorsal radial incision can be used to create exposure between the first and second extensor
compartments. Care must be taken to avoid injury to the branches of the radial sensory nerve. For a broader
approach to the dorsal aspect of the distal radius, the incision should be placed more dorsally. The extensor
retinaculum is opened between the third and fourth extensor compartments. The fourth extensor compartment is
elevated subperiosteally toward the ulnar fragment. The second extensor compartment can also be elevated
subperiosteally. The exposure to the dorsoradial and intermediate columns can also be made through two
incisions in the extensor retinaculum. One is between the first and second compartments, and the other is
between the fourth and fifth compartments.
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FIGURE 14.8 A. A complex articular fracture in an older age patient. B. Loss of volar tilt due to unstable fixation.

For the most part, fracture reduction can be accomplished by longitudinal traction and direct manipulation of the
fracture fragments. A central articular impaction, however, may be ineffectively reduced with traction alone. In
this case, the impaction is directly elevated through the fracture site, and an arthrotomy of the radiocarpal joint is
needed to directly visualize the articular reduction. Direct visualization of the articular surface is also advisable in
cases of intercarpal ligament injury.
For difficult reductions, the use of either an external fixator or finger traps for traction can be considered. This is
especially useful for fractures seen late or those associated with soft-tissue swelling. Additionally, provisional
fixation with smooth Kirschner (K) wires is important with unstable articular fractures. This helps control the
reduction when using intraoperative image intensification.
There are a number of options for internal fixation via the dorsal aspect of the distal radius. The concept of
“fracture-specific fixation” guides fixation by using small, strategically placed implants to support the specific
fracture fragments. These include anatomically shaped plates, pins, and wire forms.
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FIGURE 14.9 Postoperative volar subluxation of the radiocarpal joint. A. Shearing radiocarpal fracture
subluxation with small lunate facet fragment. B. Immediate postoperative radiographs.

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FIGURE 14.9 (Continued) C. Subluxation of the radiocarpal joint noted at 2 weeks caused by failure to support
the lunate facet fragment. D. Clinical appearance.
FIGURE 14.10 Complex articular fractures involving both the radial and intermediate columns can be stabilized
from the volar approach using a radial column plate and volar surface plate.

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FIGURE 14.11 Fixation of a displaced, rotated, volar, ulnar, lunate-facet fragment can be done using a small
gauge wire looped through the volar capsule and radius in a figure-of-eight fashion. A. Preoperative x-ray and
CT scan reveal a displaced, volar, lunate facet. B. The radial styloid and dorsal lunate facet could be reduced
and held with K wires, but the volar lunate facet required open reduction and wire loop fixation.

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FIGURE 14.11 (Continued) C. Healed fracture at 1 year. D. Clinical wrist motion.

A metaphyseal defect underlying an articular fragment and/or concerns for the stability of the internal fixation
necessitates additional support. This can be done with either autogenous bone graft, bone substitute, or
allograft. A bone substitute such as Norian (Synthes, West Chester, PA) works well.
Following anatomic reduction and stable fixation, the extensor retinaculum is closed, leaving the extensor pollicis
longus free outside of the retinacular closure. Then, as with fractures treated via a volar approach, the wound is
irrigated and closed, and a bulky postoperative dressing is placed, which incorporates a light volar wrist splint
with the fingers free.

FIXATION OF DISTAL RADIOULNAR JOINT INSTABILITY

At the conclusion of any operation for a fracture of the distal radius, stability of the DRUJ must be confirmed.
This is done by taking the forearm through a full range of pronation and supination while palpating the ulnar
styloid for any gross movement. True instability of the DRUJ is rare following stable fixation of the distal radius,
but if present is best treated by operative fixation. If an ulnar styloid fracture is present, this can be accomplished
by fixation of the ulnar styloid. If not, then operative repair of the triangular fibrocartilage complex may be
warranted. An additional exposure is necessary to address fractures of the distal ulna. A longitudinal incision is
created along the diaphysis of the ulna. Remember that the ulnar styloid lies relatively anterior to the ulnar
diaphysis.
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POSTOPERATIVE MANAGEMENT
Postoperatively, the wrist is supported in a bulky postoperative dressing with a volar plaster splint incorporated
for the first 7 to 10 postoperative days. During this period, the patient is encouraged to mobilize the upper limb,
regain digital mobility, and incorporate the hand and limb in activities of daily living. In those patients in whom
DRUJ instability is present, the forearm is also immobilized for 14 to 21 days. During this initial recovery period,
antiedema measures are encouraged, including elevation, digital mobilization, and elastic wrapping as needed.
The avoidance of excessive digital swelling and early range of motion of the fingers are key to a successful initial
recovery.
After 7 to 10 days the postoperative dressing and splint are removed and the patient is encouraged to begin
active wrist and forearm range of motion, generally under the guidance of an occupational or physical therapist.
Resistive activities are begun once healing is assured, generally around 6 to 8 weeks. Patients often need
exercises for strength and motion for at least 3 months postoperatively, with a functional end point often reached
only after 12 to 18 months.

COMPLICATIONS
Complications following operative treatment of distal radius fractures are well recognized. These include
loss of fixation, infection, nerve compression, complex regional pain syndrome, and digital and/or wrist
stiffness (15, 16 and 17). With the increasing popularity of volar plating of the distal radius, there is
increasing recognition of complications specifically associated with this approach. There have been
numerous reports of flexor tendon irritation and rupture since volar plating has become more widely used,
presumably related to impingement of the volar plate on the flexor tendons (18, 19, 20, 21, 22 and 23).
Similarly, screws that protrude out of the dorsal cortex of the distal radius may lead to irritation and rupture
of extensor tendons (24,25).
Additionally, the inadvertent retention of angled drill guides is a complication unique to locked plating
(26,27). There is some debate over the proper course of action following this complication. Certainly the
patient must be informed of the risk of flexor tendon rupture. Then, the patient and surgeon together can
decide whether and when to return to the operating room for removal.
Careful patient selection, preoperative planning, technical care in fixation, and careful postoperative
management will help minimize these adverse outcomes.

REFERENCES
1. Koval KJ, Harrast JJ, Anglen JO, et al. Fractures of the distal part of the radius. The evolution of practice
over time. Where's the evidence? J Bone Joint Surg Am 2008;90(9):1855-1861.

2. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial
fractures in the elderly. J Bone Joint Surg Am 2009;91:1868-1873.

3. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early
function: a preliminary report of 20 cases. J Bone Joint Surg Br 1996;78(4):588-592.

4. Fernandez DL. Fractures of the distal radius. Operative treatment. Instr Course Lect 1993;42:73-88.

5. Ruedi TP, Murphy WM, eds. AO principles of fracture management. New York: Thieme; 2000:362.

6. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg
Am 2006;88(9):1944-1951.

7. Synn AJ, Makhni EC, Makhni MC, et al. Distal radius fractures in older patients: is anatomic reduction
necessary? Clin Orthop Relat Res 2009;467(6):1612-1620.

8. Arona S, Grover SB, Batra S, et al. Comparative evaluation of postreduction intra-articular distal radial
fractures by radiographs and multidetector computed tomography. J Bone Joint Surg Am 2010;92(15):2523-
2532.

9. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5(2):103-
112.

10. Tweet ML, Calfee RP, Stern PJ. Rotational fluoroscopy assists in detection of intra-articular screw
penetration during volar plating of the distal radius. J Hand Surg Am 2010;35(4):619-627. Epub 2010 Mar 3.

11. Soong M, Got C, Katarincic J, et al. Fluoroscopic evaluation of intra-articular screw placement during
locked volar plating of the distal radius: a cadaveric study. J Hand Surg Am 2008;33(10):1720-1723.

12. Harness N, Jupiter J, Fernandez D, et al. Loss of fixation of the volar lunate facet after volar plating of
distal radius fracture. J Bone Joint Surg Am 2004;86:1900-1908.

13. Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop
1986;202:103-111.

14. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J
Hand Surg Am 1999;24(3):525-533.

15. Cooney WP III, Dobyns JH, Linscheid RL. Complications of Colles' fractures. J Bone Joint Surg Am
1980;62(4): 613-619.

16. Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome,

disturbance in the distal radio-ulnar joint and impairment of nerve function: a clinical and experimental study.
Acta Orthop Scand 1967;108:5- 153.

17. Jupiter JB, Fernandez D. Complications of distal radius fractures: instructional course lectures. J Bone
Joint Surg 2001;83:1244-1265.

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18. Lifchez SD. Flexor pollicis longus tendon rupture after volar plating of a distal radius fracture. Plast
Reconstr Surg 2010;125(1):21e-23e.

19. Adham MN, Porembski M, Adham C. Flexor tendon problems after volar plate fixation of distal radius
fractures. Hand 2009;4(4):406-409. Epub 2009 Mar 13.

20. Yamazaki H, Hattori Y, Doi K. Delayed rupture of flexor tendons caused by protrusion of a screw head of
a volar plate for distal radius fracture: a case report. Hand Surg 2008;13(1):27-29.

21. Cross AW, Schmidt CC. Flexor tendon injuries following locked volar plating of distal radius fractures. J
Hand Surg Am 2008;33(2):164-167.

22. Duncan SF, Weiland AJ. Delayed rupture of the flexor pollicis longus tendon after routine volar placement
of a T-plate on the distal radius. Am J Orthop 2007;36(12):669-670.

23. Valbuena SE, Cogswell LK, Baraziol R, et al. Rupture of flexor tendon following volar plate of distal radius
fracture. Report of five cases. Chir Main 2010;29(2):109-113. Epub 2010 Feb 6.

24. Bianchi S, van Aaken J, Glauser T, et al. Screw impingement on the extensor tendons in distal radius
fractures treated by volar plating: sonographic appearance. AJR Am J Roentgenol 2008;191(5):W199-W203.

25. Hattori Y, Doi K, Sakamoto S, et al. Delayed rupture of extensor digitorum communis tendon following
volar plating of distal radius fracture. Hand Surg 2008;13(3):183-185.

26. Lucchina S, Fusetti C. Is early hardware removal compulsory after retention of angled drill guides in
palmar locking plates? The role of pronator quadratus reconstruction. Chin J Traumatol 2010;13(2):123-125.

27. Bhattacharyya T, Wadgaonkar AD. Inadvertent retention of angled drill guides after volar locking plate
fixation of distal radial fractures. A report of three cases. J Bone Joint Surg Am 2008;90(2):401-403.
 15
Femoral Neck Fractures: Open Reduction Internal Fixation
Dean G. Lorich
Lionel E. Lazaro
Sreevathsa Boraiah

INTRODUCTION
Approximately 50% of all hip fractures involve the intracapsular femoral neck (1,2). The total number of hip
fractures is projected to increase from approximately 1.5 million in the year 1990 to 6 million by 2050 (3, 4 and 5).
The United States has the highest incidence of hip fracture rates worldwide, with an age-adjusted annual
incidence of 725 per 100,000 population (4,6). On a per-person basis, hip fractures are the most expensive
fracture to treat (7, 8 and 9), with annual estimate hospital cost per hip fracture patient of $25,000 and rising
(7,8,10,11).
Femoral neck fractures are periarticular injuries where anatomic reduction and normal hip function are often
sacrificed to maximize the potential for fracture healing. Traditionally internal fixation has utilized with either a
sliding hip screw and side plate or multiple cannulated parallel lag screws (12) (Fig. 15.1). Although there is
evidence documenting the superiority of parallel lag screw placement compared with other implants (13, 14, 15
and 16), controversy remains as to the optimal treatment of choice (17). Implants that allow sliding permit
dynamic compression at the fracture site during axial loading, but some shortening of the femoral neck invariably
follows. Until recently, a healed femoral neck fracture without implant failure or the development of avascular
necrosis (AVN) was considered a success (Fig 15.1). Healing, however, comes at the expense of a shortened
femoral neck. This impacts the biomechanics of the hip joint, which is either accepted or overlooked. The
negative impact of altered hip mechanics following fracture has been studied and reported. Femoral neck
shortening was shown to be associated with significantly lower physical function on SF-36 subscores (18). It has
also been shown to correlate with decreased quality of life (19).
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This leads us to believe that anatomic reduction and internal fixation, which is maintained through fracture
healing, is critical for successful outcomes. With an increased emphasis on preservation of hip function,
understanding the pathomechanics and preservation of hip anatomy is imperative to restore in order to maximize
the chance of a successful outcome. Anatomic reduction with intraoperative compression using length-stable
devices to maintain the reduction can lead to high union rates with minimal shortening and better functional
outcome.
FIGURE 15.1 AP radiographic view demonstrating two sliding constructs that healed in a shortened fashion.

There is a large body of literature that documents high complication and reoperation rates following internal
fixation of intracapsular femoral neck fractures (20). This may be related to both mechanical and biological
problems related to femoral neck fracture healing. The femoral neck is intracapsular, is bathed in synovial fluid,
and lacks a periosteal cambium layer that is necessary for callus formation. From a structural standpoint, the
bone screw interface is strongest immediately after surgery and weakens over time. Restoring anatomic fracture
reduction often requires direct visualization prior to fixation. The most widely used classification for femoral neck
fractures is the Garden classification. However, this classification scheme is based on the anteroposterior (AP)
radiographs alone and does not consider the lateral or sagittal plane alignment. Recent studies have shown
posterior roll off or angulation of the femoral head leads to increased reoperation rates (21, 22 and 23) (Fig.
15.2).
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The authors report a 56% reoperation rate if the posterior tilt is >20 degrees (21). If anatomic reduction is the
goal, it is important to address malalignment in all planes. We believe that the best and most consistent approach
to achieve an anatomic reduction of this difficult fracture is through open reduction, direct visualization, and
fixation of the fractures.
FIGURE 15.2 A. Anterposterior radiographic view demonstrating a valgus impacted femoral neck fracture.
Lateral radiographic view (B) and axial CT view (C) demonstrating posterior roll-off of the femoral head not
appreciated on the AP radiographic view.

INDICATIONS AND CONTRAINDICATIONS

The indications for open reduction and internal fixation (ORIF) of femoral neck fractures continue to expand. It is
important to distinguish between low-energy fragility fractures in elderly patients and younger patients with high-
energy femoral neck fractures since the approach to treatment and methods of fixation vary. For geriatric patients
with mechanical ground level falls, a complete assessment of the patients' status is helpful in selecting surgical
options. In this group of patients, our treatment algorithm is as follows: (a) ORIF is indicated for most patients
<65 years of age, regardless of fracture pattern, (b) patients aged 65 to 85 years receive ORIF for Garden I and
II fractures, and selected physiologically younger patients are also treated with ORIF for displaced fractures
(Garden III and IV), and (c) patients >85 years with a Garden I or II fractures should also be considered for ORIF.
Garden III and IV fractures in this age group are treated with arthroplasty.
When assessing the physiological age of a patient, one should consider multiple factors including, but not limited
to, chronological age, preinjury activity level, preinjury ambulatory status, and potential patient compliance.
Regardless of the fracture pattern, in patients presenting with significant medical comorbidities, advanced
physiologic age, degenerative changes of the femoral head, or pathological fractures, hip arthroplasty should be
considered. There is a large body of literature that supports the use of hemiarthroplasty or total hip arthroplasty
in these situations (24). These are only guidelines for treatment, and the surgical treatment must be
individualized to every patient.
For nondisplaced and Garden I femoral neck fractures, we usually perform in situ fixation using a percutaneous
approach to relieve pain, permit mobilization, and decrease the small chance of further fracture displacement.
There are several randomized controlled trials comparing closed reduction and screw fixation with arthroplasty
for displaced femoral neck fractures in the elderly. These studies report fewer complications and better outcomes
with arthroplasty. However, there are no studies that we are aware that compare open reduction and length-
stable internal fixation to arthroplasty for comparable fractures.

PREOPERATIVE PLANNING
History and Physical Examination
A thorough history and physical examination is essential. In geriatric hip fracture patients, a complete medical
assessment and risk stratification should be performed with the assistance of an internal medicine specialist. On
physical exam, the affected leg is usually externally rotated and shortened. Movement of the limb is painful, and
range of hip and knee motion is resisted by the patient secondary to pain. A thorough neurovascular examination
and assessment of the soft tissue and the skin should be made. Cutaneous bruises indicate that the patient may
be anticoagulated. Traction has not shown to be of any benefit. A knee immobilizer may be helpful to immobilize
and relieve pain.
In younger patients (<50 years) with a displaced femoral neck fracture, urgent reduction and fixation of the
femoral neck is indicated. Ipsilateral femoral neck fractures are seen in 3% to 5% of patients with high-energy
femoral shaft fractures.

IMAGING STUDIES
A radiographic series for a patient with a suspected hip fracture should consist of an AP and cross-table lateral
radiographs of the affected hip, an AP pelvis x-ray and full-length femur films of the ipsilateral side. We prefer a
cross-table or Clayton-Johnson lateral, because a frog lateral position is difficult to obtain secondary to pain. If
any uncertainty exists as to the fracture pattern, a traction internal rotation view can be very helpful. As stated
earlier, the Garden classification of femoral neck fractures is based solely on the AP view of the hip.
Valgusimpacted fractures, which are typically amenable to in situ percutaneous pinning, may have posterior roll
off of the femoral head. Unfortunately, the Garden classification does not take into account posterior
displacement or angulation of the femoral head best seen on the lateral x-ray. When anatomic reduction of the
fracture is planned, a three-dimensional assessment of the fracture should be obtained.
Computed tomography (CT) is helpful in determining displacement of the femoral head and the degree of femoral
head comminution in some patients. In patients with suspected femoral neck stress fractures, where a fracture
line is not visible on plain radiographs, magnetic resonance imaging (MRI) can be very beneficial. Unfortunately,
bone scans and MRI have not been helpful in reliably assessing the viability of the femoral head immediately
after fracture and cannot be used in selecting patients either for arthroplasty or ORIF.
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SURGICAL TECHNIQUE
General or spinal anesthesia may be used. The choice of anesthesia depends on the patient's general health
and consultation with the surgeon and internal medicine specialist. For most patients, we prefer spinal
anesthesia. Patients are positioned supine on a fracture table against a well-padded peroneal post. The
unaffected limb is positioned in one of two ways. It can be flexed, abducted, and externally rotated and supported
on a lithotomy holder or “scissored” using the opposite strut on the fracture table. With either position,
unobstructed high-quality AP and lateral images must be obtainable. Before prepping and draping, the surgeon
should ensure that adequate AP and lateral images can be obtained. A prophylactic first-generation
cephalosporin is given.
For the vast majority of patients, an open reduction is performed. In patients with minimally displaced fractures, a
limited anterior Smith-Petersen approach is utilized to facilitate palpation of the neck to access displacement and
reduction as well as to introduce instruments to assist with reduction. The entire hip joint and ilium can be
reached using the Smith-Petersen approach. For most patients, only the inferior limb of the approach is needed.
A 10-cm skin incision is made beginning just distal to the anterior inferior iliac spine. After incising the deep
fascia, the interval between sartorius and tensor fascia lata is developed. External rotation of the thigh
accentuates this dissection plane. The lateral femoral cutaneous nerve is identified and retracted medially with
the sartorius. Once this interval is developed, the tendinous portion of the rectus femoris is identified and is
carefully elevated off the hip capsule. The capsule is opened to visualize the femoral neck.
In younger patients with displaced fractures, a Watson-Jones surgical approach is used to gain complete
exposure to the femoral neck. A skin incision is made approximately 2 cm posterior and distal to the anterior
superior iliac spine down toward the tip of the greater trochanter. The incision is then curved distally and
extended 10 cm along the anterior portion of the femur. After incising the deep fascia, the interval between the
tensor fascia lata and gluteus medius is developed. The anterior part of the gluteus medius and minimus is
retracted posteriorly to visualize the anterior capsule. To avoid damage of the femoral head blood supply, the
capsule is sharply incised in Z-shaped fashion along the anterolateral axis of the femoral neck in the manner
described by Ganz et al. (25) (Fig. 15.3). The capsulotomy must remain anterior to the lesser trochanter at all
times to avoid injury to the medial femoral circumflex artery, which extends superior and posterior to the lesser
trochanter (25,26). After the femoral neck has been exposed, the hematoma is evacuated. A 5-mm Schanz pin
(external fixation pin) is placed laterally in the trochanter/proximal femur. In valgus displaced femoral neck
fractures, two 3.2-mm terminally threaded guide wires are placed just superior to the greater trochanter directed
to the fracture line. This is then used as a joystick to correct the coronal plane deformity. A ball spike pusher is
used with posteriorly directed forces to correct the sagittal plane deformity (Fig. 15.4).
With varus displaced femoral neck fractures, a weber clamp is applied through the Watson-Jones interval in line
with the inferior femoral neck for fracture reduction and compression across the calcar. Sagittal plane deformity
is corrected using a ball spike pusher. After the reduction has been achieved, attention is then turned toward
creating a true length and angle stable fixation construct.
In femoral neck valgus fractures with posterior displacement of angulation of the head, the following sequence of
fixation is used. A 7.3-mm partially threaded screw is inserted in the inferior portion of the femoral neck and head
on the AP view (central on lateral view) to compress the fracture and correct the deformity (Fig. 15.5). Then, a
7.3- or 6.5-mm fully threaded screw is placed in the center of the femoral head as seen on the AP view. An
allograft fibula is burred to a core diameter of 10 to 11 mm. A 10- to 11-mm cannulated drill is used to create a
track for the fibula. The fibula is then gently tapped to the subchondral bone. A triangulated 3.5-mm compression
screw is directed from the greater trochanter through the fibula to the calcar to create a length and angle stable
construct (Fig. 15.6). The initial partially threaded screw is then exchanged for a fully threaded screw.
In varus deformities of the femoral neck, the fixation sequence is changed. A 7.3-m partially threaded screw is
used to fix the fracture and create fracture compression. The rest of the sequence of screw placement is the
same as before. The 7.3-mm partially threaded screw is then replaced with fully threaded screw. The allograft
fibula acts as a “biologic screw.” The strength of the allograft and host bone interface increases over time, unlike
the bone screw interface that decreases over time. The benefit of this configuration has been described (27).
After the fracture has been stabilized, the wounds are carefully irrigated. The capsule is loosely reapproximated
in abduction, and layered closure of the wounds is then performed.

POSTOPERATIVE MANAGEMENT
Patients are mobilized from bed on the first or second postoperative day. Routine DVT prophylaxis is utilized.
Antibiotics are continued for 24 hours. Patients are kept non-weight bearing for 8 to 12 weeks. Early range of hip
motion is encouraged. Hip muscle strengthening is emphasized beginning at 6 weeks postsurgery. The patients
are gradually advanced to full-weight-bearing status. Patients are seen in the outpatient clinic at 2 weeks for
suture removal. They are seen at 4- to 6-week intervals for x-rays to assess fracture healing.
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FIGURE 15.3 A,B. Illustrations demonstrating the Watson Jones approach with the Z-shaped caspulotomy.

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FIGURE 15.4 From left to right, AP and lateral radiographic views demonstrating unreduced fracture, followed by
radiographic views after fracture reduction. These views also showed K-wires in the proximal fragment serving
as a joystick and ball spike pusher to further control alignment and reduction.

FIGURE 15.5 Following reduction, the K-wires were advanced to the subchondral bone in the femoral head and
then partially threaded cannulated screws and washers were then placed to achieve compression at the fracture
site.
FIGURE 15.6 The partially threaded cannulated screws and washers are replaced with fully threaded
cannulated screws. In order to stabilize the fibula allograft a 3.5 cortical screw inserted from the greater
trochanter across the fibula allograft in the direction of the calcar. Final fluoroscopic images illustrate an
acceptable reduction and placement of fibula allograft and hardware.

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COMPLICATIONS
Femoral neck nonunion and AVN are the two most significant long-term complications following ORIF of
femoral neck fractures. These adverse events are considered to be secondary to mechanical failure of
fixation and biological failure to heal. In displaced femoral neck fractures, there is an increased risk for
fracture nonunion, with an incidence that has been reported to reach 30% in older patients (28). Contrary to
the belief that nonunion occurs more frequently in younger patients, no correlation has been found among
age, gender, and rate of nonunion (29). The literature reports nonunion in younger patients with an
incidence ranging from 0% to 86%. Swiontkowski et al. (15) reported a 100% union rate in 27 patients and
attributed this favorable result to emergent ORIF including anatomic reduction and compressive fixation.
Tian et al. (30) performed a comparison of different reduction methods and surgical timing in 240 displaced
femoral neck fractures and concluded that reduction method has a more pronounced effect on healing than
surgical timing. Poor reduction has been demonstrated to increase nonunion rates. Haidukewych et al. (31)
reported a 4% rate of nonunion in patients for whom a good to excellent fracture reduction was obtained,
compared to an 80% nonunion rate in patients with poor reductions. Barnes and Dunovan (32) reported that
quality of reduction has a direct association with fracture union and that the rate of union correlates
inversely to patient age and degree of osteoporosis. Boraiah et al. (33,34) reported a 94% union rate with
minimal shortening in 54 patients that underwent ORIF of femoral neck fracture using intraoperative
compression and length-stable fixation. A nonunion resulting from a femoral neck fracture can be treated
with arthroplasty, valgus osteotomy (converting shearing forces into compression forces at the fracture site),
or revision internal fixation.
The incidence of AVN in all femoral neck fractures, irrespective of patient demographics, has been reported
as high as 25%, with an average rate of 45% in young adults (35). The rate of revision surgery following
AVN of the femoral head is 11% to 19%, with arthroplasty performed for the majority of revisions (28).
Swiontkowski et al. (15) showed a prevalence of AVN in 25% of patients for 27 patients aged 15 to 49
years, citing emergent reduction of the fracture as the main factor associated with successful treatment.
Jain et al. (36) supported these findings and reported an AVN rate of 16% for 38 young patients treated >12
hours following the fracture and 0% when treated within 12 hours of the fracture. However, more recent
studies in the literature fail to demonstrate an association (between time to fracture reduction and
subsequent AVN). A meta-analysis including 18 retrospective case series with patients between the ages of
15 to 50 years noted an overall AVN rate of 22.5% for displaced femoral neck fractures with no difference
between patients who were treated within 12 hours following their fracture and those treated after 12 hours
following their fracture (37). In a prospective study of 92 patients, an overall AVN rate of 16% was reported
with no difference in patients treated before or after 48 hours at 2 years follow-up (38). Patients with AVN
do not always develop major symptoms. Haidukewych et al. (31) reported that 29% of patients with AVN did
not need additional surgical interventions.
One of the theories proposed to explain the development of AVN related to femoral neck fractures is
disruption of the vascular supply to the femoral head. Some authors have suggested that there is a direct
association between amount of fracture displacement and disruption of femoral head vascularity.
Nonetheless, this theory fails to explain the occurrence of AVN in nondisplaced femoral neck fractures, as
noted in 20% of cases (35). Also, the femoral head vascularity is probably not as tenuous as has been
taught. There is a rich intraosseous anastomosis, and it receives contribution from the medial femoral
circumflex artery and inferior gluteal artery (39).
Following a femoral neck fracture, the femoral head vascularity depends on preservation of the remaining
vascular supply, revascularization, and repair of area of necrosis prior to collapse of the subchondral bone
and overlying articular surface. An anatomic reduction and stable internal fixation are thought to be critical
factors in helping to preserve the remaining blood supply and providing the stability required for these
revascularization buds to grow into the area of necrosis (40,41).

OUTCOMES
High union rates with minimal femoral neck shortening and improved functional outcomes can be expected
when length-stable fixation, stable calcar pivot, and intraoperative compression are achieved during
reduction of femoral neck fractures. In our experience, a 94% union rate and 93% recovery of limb function
(single limb stance) were obtained when the above-mentioned principles were used as guidelines (Figs.
15.7 and 15.8).
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FIGURE 15.7 A. AP and lateral radiographic views demonstrating a Garner IV femoral neck fracture in 60-
year-old female. B. AP and lateral radiographic views demonstrating immediate postoperative images with
the use of side plate length-stable construct. C. AP and lateral radiographic views 6 months after surgical
intervention that demonstrate a healed femoral neck fracture, maintaining length, no radiographic signs of
AVN and bone incorporation of the fibula allograft.

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FIGURE 15.8 A. AP and lateral radiographic view demonstrating failure (screw penetration) of a sliding
construct. B. Coronal and axial CT scan view demonstrating screw penetration into the joint.

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 FIGURE 15.8 (Continued) C. AP and lateral radiographic view 7 months after revision ORIF with a length-
stable construct that demonstrate a healed femoral neck fracture, maintaining length with development of
Heterotopic Ossification (HO) over the anterior aspect of the hip. D. AP and lateral radiographic view 14
months after revision ORIF and 6 months after removal of hardware and excision of the HO demonstrating a
healed femoral neck fracture, maintaining length, bone incorporation of the fibula allograft, and no
radiographic signs of AVN.

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displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am 2003;85:1673-1681.
18. Tidermark J, Ponzer S, Svensson O, et al. Internal fixation compared with total hip replacement for
displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br
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19. Gurney B, Mermier C, Robergs R, et al. Effects of limb-length discrepancy on gait economy and lower-
extremity muscle activity in older adults. J Bone Joint Surg Am 2001;83:907-915.

20. Tidermark J, Zethraeus N, Svensson O, et al. Quality of life related to fracture displacement among
elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma 2002;16:34-38.

21. Palm H, Gosvig K, Krasheninnikoff M, et al. A new measurement for posterior tilt predicts reoperation in
undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1
year. Acta Orthop 2009;80(3):303-307.

22. Conn KS, Parker MJ. Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients.
Clin Orthop Relat Res 2004:249-254.

23. Bjorgul K, Reikeras O. Outcome of undisplaced and moderately displaced femoral neck fractures. Acta
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24. Hedbeck CJ, Enocson A, Lapidus G, et al. Comparison of bipolar hemiarthroplasty with total hip
arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone
Joint Surg Am 2011;93(5):445-450.

25. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the
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graft. J Bone Joint Surg Br 1986;68:387-391.

28. Lu-Yao GL, Keller RB, Littenberg B, et al. Outcomes after displaced fractures of the femoral neck. A
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fractures. 138 patients followed for 2 years. Acta Orthop Scand 1993;64:175-177.

30. Tian W, Cui Z, Kan S. Comparison of cannulated screws fixation with different reduction methods at
different time points for displaced femoral neck fractures in terms of fracture healing. Zhongguo Xiu Fu
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31. Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in
patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;86:1711-1716.

32. Barnes B, Dunovan K. Functional outcomes after hip fracture. Phys Ther 1987;67:1675-1679.

33. Boraiah S, Paul O, Gardner MJ, et al. Outcomes of length-stable fixation of femoral neck fractures. Arch
Orthop Trauma Surg 2010;130:1523-1531.

34. Boraiah S, Paul O, Hammoud S, et al. Predictable healing of femoral neck fractures treated with
intraoperative compression and length-stable implants. J Trauma 2010;69:142-147.

35. Nikolopoulos KE, Papadakis SA, Kateros KT, et al. Long-term outcome of patients with avascular
necrosis, after internal fixation of femoral neck fractures. Injury 2003:525-528.

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36. Jain R, Koo M, Kreder HJ, et al. Comparison of early and delayed fixation of subcapital hip fractures in
patients sixty years of age or less. J Bone Joint Surg Am 2002;84:1605-1612.

37. Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. A
meta-analysis of 18 published studies involving 564 fractures. Injury 2005;36(1):131-141.

38. Upadhyay A, Jain P, Mishra P, et al. Delayed internal fixation of fractures of the neck of the femur in
young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br
2004;86:1035-1040.

39. Boraiah S, Dyke JP, Hettrich C, et al. Assessment of vascularity of the femoral head using gadolinium
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41. Garden RS. Reduction and fixation of subcapital fractures of the femur. Orthop Clin North Am
1974;5:683-712.
 16
Femoral Neck Fractures: Hemiarthroplasty and Total Hip
Arthroplasty
Ross Leighton

INTRODUCTION
Displaced femoral neck fractures in elderly patients with osteoporotic bone provide unique challenges in
treatment. Controversy continues regarding the optimal method of treatment (1). In displaced femoral neck
fractures, most studies support replacement of the femoral head in older patients (2, 3, 4 and 5). Numerous
authors have documented high rates of osteonecrosis, fixation failure, and nonunion when these fractures have
been treated with internal fixation (6). Economic analyses indicate that the cost of treating such complications is
immense (7, 8, 9 and 10). A long-term follow-up study of patients treated with open reduction of the displaced
femoral neck fracture, evaluated 13 years after fracture fixation, found that the functional outcome deteriorated
even among patients with a healed fracture and no osteonecrosis (11).
In contrast, arthroplasty allows rapid, safe mobilization of the patient without concern about fixation failure or
fracture union (2, 3 and 4,12). Replacement arthroplasty is routinely done in patients most at risk for
complications after internal fixation. These patients include elderly patients with compromised bone quality and
fracture comminution. Over the last 10 years, prospective randomized trials have demonstrated the superiority of
arthroplasty compared with internal fixation in this group of patients over the age of 60. The indications for
hemiarthroplasty versus a total hip replacement are less clear (4,13).
Despite substantial limitations, the Garden classification is probably the most frequently cited classification in
North America. Garden I and II describe undisplaced fractures, while Garden III and IV are displaced femoral neck
injuries. In the comprehensive AO/OTA classification scheme, femoral neck fractures are categorized as 31-B
(Fig. 16.1A,B).

INDICATIONS AND CONTRAINDICATIONS

Internal Fixation
Internal fixation remains the treatment of choice for the majority of femoral neck fractures in patients <60 years of
age. In patients >60 years of age, internal fixation using cannulated screws is reserved for nondisplaced Garden
I and II fractures. The details and techniques of internal fixation are covered in Chapter 15.
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Bipolar or Modular Hemiarthroplasty
The bipolar or modular hemiarthroplasty is the most commonly used implants to treat displaced femoral neck
fractures in the elderly. It can be used with a fixed head (unipolar) or bipolar head and provides a relatively easy
conversion to a total hip arthroplasty (THA), if required in the future.
Strong indications for hemiarthroplasty are
1. Displaced femoral neck fracture in patients over 60 to 65 years of age without antecedent hip arthritis (Fig.
16.2).
2. Patients >60 years of age with minimally displaced femoral neck fractures but whose bone is too poor for
internal fixation (Fig. 16.3).
3. Failed internal fixation without associated acetabular damage (Fig. 16.4).
Comparisons between cemented bipolar and unipolar hemiarthroplasty have shown similar outcomes in terms of
dislocation rates, postoperative pain, and recovery of ambulatory status (14, 15 and 16). Fluoroscopic evaluation
after 1 year has shown that many bipolar prostheses placed for fractures act as a unipolar implant.
A cemented femoral stem is considered the standard treatment in the elderly osteopenic patient population (Fig.
16.5). The cement provides immediate stability and permits early weight bearing. The prevalence of
postoperative acetabular pain or arthritis is uncommon with this method of treatment. Hemiarthroplasty should be
modular to allow for changes in offset, length adjustment, and tensioning of the hip girdle muscles (17,18). The
use of a Moore or Thompson prosthesis is of historical interest and is not recommended (Fig. 16.6). A modular
head with a well-fitted cemented or occasionally uncemented femoral component is our preferred implant in
elderly patients with displaced subcapital neck fractures (19).

Total Hip Arthroplasty

Total hip arthroplasty (THA) is an attractive treatment modality for selected elderly patients with displaced
femoral neck fractures (Fig. 16.7). It is a technique known to most orthopedic surgeons. When used to treat hip
arthritis, it has very predictable long-term results. Initial studies using total hip arthroplasty for fractures showed
an increased rate of dislocation plus an increased amount of blood loss (20, 21 and 22). The initial cost is
increased compared to a unipolar or bipolar arthroplasty; however, proponents of the technique (THA) argue that
it may reduce the overall costs due to its theoretically improved long-term survival (23, 24, 25, 26, 27, 28, 29, 30,
31 and 32). It is not indicated for most geriatric femoral neck fractures. The slightly higher dislocation rates
combined with the difficulty in this frail patient population following the usual postoperative THA protocols has
limited its use. However, in younger highly active patients (age 60 to 75 years) with little or no cognitive
impairment and increased longevity of life, well-controlled studies have shown improved outcomes after THA
(23,29).
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FIGURE 16.1 A. The Garden classification of femoral neck fractures.
FIGURE 16.1 (Continued) B. The AO/OTA classification of femoral neck fractures.
FIGURE 16.2 A displaced subcapital femoral neck fracture in an elderly female.

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FIGURE 16.3 A minimally displaced femoral neck fracture in a patient with hemiplegia and poor bone stock.
FIGURE 16.4 Failed internal fixation of a femoral neck fracture.

FIGURE 16.5 A cemented bipolar hemiarthroplasty.

FIGURE 16.6 An Austin-Moore prosthesis. It is no longer used for treatment.

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FIGURE 16.7 AP radiograph of an uncemented total hip replacement.

FIGURE 16.8 A basicervical hip fracture in a frail osteoporotic geriatric patient.

Strong indications for the use of THA in the management of acute femoral neck fractures in the elderly include
(30,31):

1. Femoral neck fractures with associated hip joint disease.

2. Significant symptomatic contralateral hip disease.
3. Advanced osteoporosis with poor bone quality (Fig. 16.8).
4. Failure of internal fixation of a femoral neck fracture in patients over 60 years of age with acetabular damage
(Fig. 16.9).
5. Failure of a hemiarthroplasty.
 FIGURE 16.9 Failure of a sliding hip screw to treat a femoral neck fracture.

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FIGURE 16.10 A,B. A 62-year-old male fell off a ladder sustaining a displaced femoral neck fracture, treated
with a primary total hip replacement.

Relative Indications for Total Hip Arthroplasty include

Healthy active patients over the age of 60 with a displaced femoral neck fracture (Fig. 16.10A,B).
 Older cooperative patient with normal cognition and statistical survival rates >10 years.
Fractures secondary to metastatic disease with acetabular involvement.
In our center, an elderly patient with a displaced subcapital femoral neck fracture is most commonly treated with
a cemented bipolar hemiarthroplasty (4). Uncemented stems are utilized in patients with excellent bone quality
and canal diameters <16.5 mm. Uncemented stems are also preferred in patients with significant risk factors for
cardiovascular disease (32) (approximately 3% to 5% of patients) (Fig. 16.11). In patients that are over the 60
years of age with osteoporotic bone that have a displaced femoral neck fracture, it is rare to regret doing a
bipolar or modular unipolar hemiarthroplasty; however, it is very common to regret doing an ORIF in this
particular group (Fig. 16.12).

Preoperative Planning
Preoperative planning is important to the success of the procedure. Leg length, offset, femoral head size, and the
stability of the hip have to be carefully planned prior to surgery.
Preoperative templating of the contralateral side can be used as an alternate to templating the fractured hip and
is strongly recommended.

History and Physical

A well-performed and documented history and physical should be performed on every patient. This includes
determining important medical comorbidities such as cardiovascular disease, hypertension, and diabetes (the
Charlson comorbidity index). The patient's current list of medication must be known as many elderly patients are
on anticoagulants, antihypertensive medications, or corticosteroids, which may impact anesthesia or the timing of
surgery. Most elderly patients with a hip fracture benefit from internal medicine and cardiology consultation,
which have been shown to improve outcome and reduce hospital stay (33). Confirmation, with family members,
of the drug history, medical and surgical history, and the presence of drug sensitivities and allergies can be very
helpful in this population. The medical evaluation should proceed as quickly and safely as possible. Most
patients should be ready for surgery within 24 hours of admission.
The vast majority of hip fractures in the elderly occur as a result of a mechanical ground-level fall. Physical
examination reveals a tender and painful hip. The leg is shortened and externally rotated if the fracture is
displaced. Range of motion of the hip is decreased or impossible secondary to pain. The peripheral pulses and
neurologic examination should be carefully evaluated and documented.
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FIGURE 16.11 An uncemented bipolar hemiarthroplasty utilized in a healthy 71-year-old female following a
displaced femoral neck fracture.
FIGURE 16.12 Avascular necrosis of the femoral head following internal fixation of a femoral neck fracture.

Imaging Studies
Radiographs should include an anteroposterior (AP) of the pelvis, an AP of the affected hip including 50% of the
femoral shaft, and a lateral of the hip joint (shoot-through lateral). This allows the fracture to be classified as
undisplaced Garden I or II or displaced Garden III or IV. A Clayton-Johnson lateral should be obtained, as
opposed to a frog-leg lateral because it provides more information about acetabular version and possible
posterior comminution in the femoral neck. High-quality imaging is essential both to understand the fracture
morphology and allow for preoperative templating. As a general rule, templating is done on the uninjured hip to
help reproduce the patient's normal offset and height relative to the lesser trochanter.

Timing of Surgery
To achieve the best outcomes, surgery should be performed within 24 hours of admission for most patients with
a displaced femoral neck fracture. If the patient has multiple medical comorbidities (e.g., pulmonary, cardiac,
metabolic), a delay of 48 hours may be required to optimize the patient. The sooner the surgery is completed the
lower the immediate complications.

Surgical Tactic
The steps in preoperative planning for a femoral head replacement procedure for a patient with a femoral neck
fracture are based on templating the injured but more importantly the noninjured hip. Identify the planned femoral
neck cut measuring from the lesser trochanter. Measure the offset of the nonfractured hip to reproduce the
patient's normal offset. Measure the acetabular diameter if a total hip is being contemplated. A larger femoral
head may reduce early dislocations. The head size is usually based on cup size but patient characteristics (age
and quality of the bone) may be a factor (34).
If a low femoral neck fracture is present, a longer neck length may be required to replace the excised neck.
When a THA is performed, consideration should be given to an offset liner to replace the neck length and offset.
This also has the benefit of allowing more polyethylene thickness and thus may permit the potential use of a
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larger femoral head size for stability (Fig. 16.13). If the fracture extends to the level of the lesser trochanter, a
calcar replacement component should be available. Cables around the lesser trochanter area may be indicated
to prevent fracture extension distally (Fig. 16.14). Careful pre-op planning helps ensure that the correct size hip
implants are available at the time of surgery.
FIGURE 16.13 Stability was increased by adding a 4-mm offset liner, a 10-degree lip, and a 36-mm head.

In some medical centers, the decision to perform a hemiarthroplasty or a THA may determine which surgeon or
service will perform the procedure. Most orthopedic surgeons are comfortable performing a hemiarthroplasty;
however, if a calcar replacement is required or a total hip is indicated, a total joint arthroplasty surgeon is
sometimes consulted. This makes it imperative that the indications for a THA are clearly understood so that the
correct procedure is performed by the right surgeon.
FIGURE 16.14 Total hip replacement utilizing a calcar component with cables for a low-comminuted basicervical
femoral neck fracture.

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SURGERY
Anesthesia
Unless there are specific medical contraindications such as concurrent use of anticoagulant medications, we
prefer to perform the surgery using spinal anesthesia. This has been shown to significantly reduce early
postoperative confusion in this population. Other invasive monitoring may be indicated in patients with labile
blood pressure or significant cardiac risk factors. A Foley catheter is routinely used to assist with fluid
management and postspinal anesthetic bladder paralysis. Antibiotic prophylaxis with a first-generation
cephalosporin is given within 1 hour of the procedure and continued for three doses postoperatively, which
reduces the perioperative infection rate to <2% in most studies.

Patient Positioning
Hip arthroplasty can be done with the patient in the supine (anterolateral) or lateral position (Hardinge and
posterior approach). When using the lateral position, the use of a patient positioner that allows the placement of
strategically padded bolsters to secure the patient and stabilize the pelvis is very helpful (Fig. 16.15). All
pressure points should be well padded including the unaffected limb. The lower abdomen, pelvis, hip, and the
entire lower extremity are prepped and draped into the surgical field. At this point in the case, the surgical team
should reverify the patient's name, medical record, and correct side and site of surgery before initiating the
procedure.
Surgical Approaches
Three surgical approaches will be described. A hemiarthroplasty or total hip replacement can be done utilizing
any of the three approaches. All have distinct advantages and disadvantages. The selection of approach is
based primarily on surgeon preference and experience.

The Hardinge Approach

The Hardinge is a direct lateral approach to the hip and can be done with the patient in the supine or lateral
position. The anterior-superior iliac spine, greater trochanter, and outline of the proximal femur should be
identified and marked with a sterile pen. A longitudinal incision beginning 5 cm above the tip of the greater
trochanter, which extends down the shaft of the femur for 8 cm, is created (Fig. 16.16). Once the skin and
subcutaneous tissue are divided, hemostasis is obtained with electrocautery. The fascia latae is opened in line
with its fibers exposing the abductors as they attach anterior and superior to the greater trochanter. Develop an
anterior flap that consists of the anterior part of the gluteus medius muscle with the underlying gluteus minimus
and the anterior part of the vastus lateralis (Fig. 16.17). Most authors have recommended detaching and splitting
only
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the anterior one-third of the gluteus medius muscle to reduce the risk of damage to the superior gluteal nerve,
which passes 4.5 cm above and 2 cm behind the tip of the greater trochanter. A reported 33% functional deficit in
gluteus medius muscle was noted when this modification was not utilized (27). Develop this anterior flap
following the contour of the femoral neck until the anterior hip joint capsule is exposed. The rectus femoris
tendon is dissected off the capsule, and the lesser trochanter is palpated posterior-medial. Once the anterior wall
of the acetabulum is reached, a “T”-shaped capsulorrhaphy is created, and the upper and lower capsular flaps
are tagged with a heavy suture (Fig. 16.18).

FIGURE 16.15 Positioning and draping for a hip arthroplasty with the patient in the lateral position.
FIGURE 16.16 The skin incision for the Hardinge approach.

It is important that the lesser trochanter and the tip of the greater trochanter are exposed. This allows adequate
exposure for visualization of the femoral neck fracture as well as to make the femoral neck cut. An oscillating saw
is used to make the femoral neck cut about (2 to 2.5 cm) above the lesser trochanter. The femoral head is
removed with the help of an osteotome, elevator, or skid, and a T-handle corkscrew (Fig. 16.19).
Once the femoral head has been removed, the acetabulum is exposed with a right angle retractor posteriorly and
a narrow Hohmann retractor anteriorly. The fovea is identified, and the ligamentum is excised exposing the floor
of the acetabulum. The cartilage of the acetabulum should be examined for defects or damage. If there is no
significant articular surface damage and limited arthritic changes, a hemiarthroplasty is the procedure of choice.
FIGURE 16.17 Develop an anterior flap that includes the anterior one-third of the gluteus medius, and release
the gluteus minimus and the anterior portion of the vastus lateralis.

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FIGURE 16.18 Through a T-shaped capsulorraphy, the fracture is exposed.

FIGURE 16.19 The femoral neck and head are removed with a corkscrew.

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FIGURE 16.20 A box osteotome is used to enlarge and lateralize the opening in the proximal femur.
FIGURE 16.21 The femur is prepared with a rasp.

The femur is externally rotated and adducted with the lower leg hanging at 90 degrees (bent at the knee) over
the side of the bed in a sterile “leg bag.” If a premade product is not available, a leg bag can be created by
double folding a large sheet so the inside stays sterile even at a low height. Using the lesser and greater
trochanter, calcar shape, and epicondyles of the knee, the correct hip version is established for femoral canal
preparation. A small curette is used to open the femoral canal. A box osteotome or chisel is used to enlarge the
opening in the femoral neck as well as to lateralize the entrance site (Fig. 16.20). A blunt trochanteric reamer is
utilized to further lateralize the opening. Finally, the proximal femur is prepared with a reamer or rasp taking care
to ensure adequate anteversion and open the medullary canal to the predetermined size (for cemented or
noncemented component) (Fig. 16.21). The final femoral rasp is left in place and used as a trial stem. The head
and neck trials are snapped onto the rasp using a high or low offset neck based on the preoperative plan. The
previously excised femoral head is measured and compared to the preoperative size. Neck length is adjusted to
allow appropriate tensioning of the soft tissues but should be consistent with the template of the opposite hip
preoperatively. If a monopolar component is utilized, the head and neck length will be chosen together. If a
bipolar component is used, the femoral head size is predetermined by the cup size, but the femoral neck length
can be independently selected (Fig. 16.22).
The hip is reduced and stability as well as leg length is clinically assessed. If the reduction is difficult, tight, or the
limb appears too long, residual femoral neck length should be reassessed. If it is too long, the head and neck
trials are removed, the femoral rasp is advanced a few millimeters, and the neck is shortened with a calcar
reamer. If the hip is either unstable or the leg is too short, there are several treatment options. To increase hip
stability without adding length, add offset first by using a high offset neck. If shortening is the problem, increase
the length of the trial neck. Go up gradually, as a few millimeters can greatly alter the tissue tension. The optimal
size is an implant that recreates stability, length, and offset. Once the proper components have been identified,
the trials are removed and the femur and acetabulum irrigated. If a cementless femoral stem is to be used, it is
carefully placed in the canal, and the predetermined neck offset, along with the proper-sized femoral
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head, is attached to the femoral component. The hip is reduced and checked for stability in flexion and internal
rotation, plus extension and external rotation.
FIGURE 16.22 The bipolar components are in place, and the hip is ready to be reduced.

FIGURE 16.23 Closure of the anterior flap and the anterior one-third of the gluteus medius.

If a cemented femoral stem is chosen, the medullary canal is plugged distally with an appropriate size canal plug
ensuring that it is 2 cm beyond the tip of the anticipated femoral component. The canal is thoroughly irrigated
and dried to minimize fat emboli during cement insertion. One or two bags of cement are prepared and placed
into the medullary canal using contemporary cementing techniques. The femoral component is then inserted
taking great care to recreate the anteversion, valgus, and stem height.
Once the cement has hardened, the head, neck, and cup are assembled and placed on the femoral stem, and
the hip is reduced. Stability is checked as noted above. Once the surgeon is satisfied that the hip is stable and
the limb length is correct, the incision is closed. The capsule is closed utilizing the tagged sutures from the
exposure. The abductor layer is carefully reapproximated to the soft tissue on the trochanter and abductor
medius. Occasionally, this layer may be sutured directly to the bone through separate bone drill holes (Fig.
16.23).
If a drain is used, it should be placed below the tensor fascia, which is then closed with figure-of-eight no. 1
absorbable suture. The subcutaneous tissue is closed with number 2-0 absorbable suture and the skin
approximated with skin staples.

The Anterior-Lateral Approach

Surgery can be performed with the patient in the lateral position as described above or in the supine position
with a bump beneath the ipsilateral hip to bring the greater trochanter into greater relief and move the tensor
fascia latae anteriorly, and it is helpful to flex the knee 30 degrees and adduct the hip. A 15-cm longitudinal
lateral incision is made centered on the tip of the greater trochanter (Fig. 16.24). Once the skin and
subcutaneous tissue are divided, any bleeders should be cauterized. Divide the fascia latae in line with its fibers
superiorly,
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heading proximally and anteriorly in the direction of the anterior superior iliac spine (Fig. 16.25). Extend the
fascial incision distal to expose the vastus lateralis. This is where the anterior lateral approach differs from the
Hardinge approach. The anterolateral approach exploits the intermuscular plane between the tensor fascia latae
and the gluteus medius. Retract the gluteus medius posteriorly and the tensor fascia latae anteriorly and bluntly
develop this plane to expose the capsule of the hip joint (Fig. 16.26). The tendon of the rectus femoris is
dissected off the capsule allowing placement of a retractor above and below the femoral neck. With the hip
externally rotated, the anterior portion of the vastus lateralis is released, and the soft tissues to the level of the
lesser trochanter are visualized (Fig. 16.27). Frequently, the anterior one-third of the gluteus medius must be
released from the greater trochanter (Fig. 16.28). Incise the anterior capsule of the hip joint longitudinally and
develop this in a “T”-shaped manner. The superior and inferior capsule should be tagged with heavy suture for
repair at the end of the case. The fracture and the femoral head should be easily visualized at this time. The
femoral neck and head are removed with a corkscrew. In subcapital fractures, the femoral neck is cut 2.0 to 2.5
cm above the lesser trochanter. If posterior comminution is present, the osteotomy can be made slightly lower to
improve bone contact in which to seat the femoral component. In low femoral neck fractures, a cerclage wire or
cable may be used to prevent fracture extension during preparation of the femur. One cable should be placed
above the lesser trochanter and one below if there are linear fracture lines extending from the femoral neck.
Alternatively, a calcar replacement component can be used to maintain length and offset of the hip. With the leg
externally rotated, the posterior capsule is released from the femoral neck, and the gluteus minimus is detached
to the mid portion of the greater trochanter. These steps significantly improve access to the femoral canal. The
hip capsule must be divided up to the anterior border of the acetabulum so that excellent exposure of the hip joint
is possible. The femur is now retracted posterior-laterally to gain access to the acetabulum. The ligamentum
teres is resected to expose the floor of the acetabulum. The articular surface is inspected for damage or
significant arthritis. Occasionally, this examination leads to a decision to perform a total hip rather than a
hemiarthroplasty (Fig. 16.29).
FIGURE 16.24 The skin incision for an anterolateral approach to the hip.

FIGURE 16.25 The fascia latae is opened.

Attention is then turned to the femur. The hip and knee are flexed to 90 degrees, and the hip is externally rotated.
The lower leg is placed into a sterile leg bag and hung over the side of the bed. In this position, exposure of the
femoral medullary canal is usually possible. This can be difficult in heavy patients so a Hardinge exposure (as
described above) may be preferred. Once this exposure has been obtained, the steps for preparation of the
femoral canal are the same as described above. Trial components are used to determine the correct length,
offset, and stability. The definitive femoral stem is then implemented with or without cement according to the
preoperative plan. The wounds are carefully closed in layers.
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FIGURE 16.26 The interval between the tensor fascia latae and the gluteus is identified.
FIGURE 16.27 The tendon of the rectus femoris is levated and released exposing the hip capsule.

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FIGURE 16.28 The anterior one-third of the insertion of the gluteus medius tendon is released to improve
exposure.

The capsule should close easily over the prosthesis. If the closure is tight or cannot be performed using the
tagged capsule edges, the head may not seated in the acetabulum correctly. If there is any question, then an
intraoperative x-ray should be done to ensure proper fit and reduction. The capsule is reapproximated with the
tagged sutures plus one or two more sutures as required to achieve tight closure and good coverage of the
femoral head.
If a drain is to be used, it should be inserted below the fascia, which is closed with figure-of-eight no. 1
absorbable sutures. The subcutaneous tissue is closed with a 2-0 absorbable sutures and the skin
reapproximated with staples.
FIGURE 16.29 Positioning the acetabular component.

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FIGURE 16.30 The skin incision for the posterior approach to the hip.

THE POSTERIOR APPROACH

Patient Setup and Surgical Technique
The patient is positioned in the lateral decubitus position with the affected side upward using a patient stabilizer
that places bolsters anterior and posterior on the pelvis. It is very important to stabilize the pelvis so that it does
not roll forward or backward during the procedure. If the torso is not stable, errors in cup positioning may occur.
A 12- to 15-cm skin incision is centered over but slightly posterior to the greater trochanter (Fig. 16.30). The
tensor fascia latae is divided longitudinally above and below the trochanter, and the muscle fascia of the gluteus
medius is opened. The hip is flexed and externally rotated exposing the short external rotators (Fig. 16.31). The
sciatic nerve should be palpated to make sure that it is out of harm's way. Some surgeons expose the nerve and
place a vesi-loop around it so it can be identified at the end of the procedure. The piriformis tendon is identified
superior to the femoral neck and tagged with a heavy suture and divided for repair at the end of the procedure.
The remaining external rotators (superior and inferior gemellus) as well as the obturator internus are then
divided, and the quadratus femoris muscle is dissected off the proximal femur to the level of the lesser trochanter
but above the insertion of the gluteus maximus (Fig. 16.32). A “T”-shaped capsulorrhaphy is done preserving the
capsular attachments to the acetabular rim (Fig. 16.33). The femoral neck is shortened leaving 2.0 to 2.5 cm of
bone above the lesser trochanter or at the highest level of intact posterior femoral neck. The femoral neck and
head are removed using an osteotome and a T-handle corkscrew.
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FIGURE 16.31 Exposure of the short external rotators.

FIGURE 16.32 The short external rotators are taken down from the back of the trochanter exposing the hip
capsule.

FIGURE 16.33 A T-shaped casulorraphy exposes the fracture site.

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FIGURE 16.34 Acetabular reamer.

FIGURE 16.35 A fully porous cup with screw holes.

The acetabular cartilage is inspected, and a decision is made whether to utilize a hemiarthroplasty or total hip
replacement.

Technique for a Total Hip Arthroplasty (Acetabular Preparation)

Removal of the femoral head exposes the acetabulum. The acetabulum is exposed circumferentially by
dissecting the capsule inferiorly and extending this exposure posterior and superior to allow excision of the
labrum and later repair of the capsule. The fovea is cleared down to the inferior medial wall of the acetabulum. If
a total hip is planned, reaming of the acetabulum usually begins with a 44-mm reamer to obtain the proper depth.
The acetabulum is reamed in 2-mm increments until the reamer meets the superior dome. The posterior wall and
the dome must be carefully observed during reaming particularly in older osteoporotic bone to prevent fracture or
medial penetration. When reaming is complete, a trial cup should be used to confirm fit and fill in the acetabulum
(Fig. 16.34). If any questions exist, an intraoperative radiograph should be obtained to assess cup position.
Important landmarks are the position of the pelvis, posterior wall inclination, dome position, and the position of
the potential screw holes in the cup. If the screw holes are easily visible, the cup is usually too vertical.
A cup 1 to 2 mm greater than the final reamer size should be selected when using a press-fit acetabular
component. If the quality of the bone is good or there is concern regarding the possibility of creating a fracture,
reaming to within 1 mm of the planned cup size may reduce hoop stresses (Fig. 16.35). One or two screws in the
acetabular component are used to increase stability particularly in the elderly patient (Fig. 16.36). Initial testing
for stability is done with a 32-mm liner. In this age group, a 36-mm liner (if the cup is larger than 54 mm) or a 40-
mm liner (if the cup is larger than 56 mm) is a very reasonable approach and has been demonstrated to reduce
early dislocation.

FIGURE 16.36 A screw used to fix the acetabular component.

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Femoral Preparation and Implantation (THR or Hemiarthroplasty)
Attention is then turned to the femur. The femur is internally rotated and adducted as well as flexed to almost 90
degrees. A right angle retractor is used posteriorly, a narrow Hohmann retractor is placed over the trochanter,
and a retractor/elevator under the anterior aspect of the femoral neck is used to lift the proximal femur up and out
of the wound. If the femur will not elevate out of the wound easily, the iliopsoas tendon or the superior
attachment of the gluteus maximus is released for better exposure. Once adequate visualization is achieved, a
curette is utilized to locate the canal. A small box osteotome is then used to prepare the proximal femur in the
correct anteversion. A blunt T-handle reamer confirms the location of the medullary canal, and a lateralized
reamer is used to ensure correct reaming, trials, and implants.
The proximal femur is prepared using a power reamer and/or a hand rasp to enlarge the canal to the
preoperatively chosen amount depending on the type of femoral component to be implanted. A cemented or
cementless femoral component can be used in geriatric patients with a femoral neck fracture. The femoral
component should be inserted with appropriate anteversion (Fig. 16.37). It should be advanced with steady
controlled strikes with a mallet until seated on the calcar or seated at the correct level if a tapered component is
utilized.
Once the femoral component trial is in place, a femoral neck of appropriate length and offset is inserted to allow
reproduction of the original offset and length (Fig. 16.38). If stability, offset, and length are optimal, then head
size can be selected depending on cup diameter. If the length is correct but stability is not achieved, increasing
the offset will usually help without adjusting length. Offset can be altered with an offset liner or an offset neck.
The next variable to examine is head size. With geriatric hip fracture patients, I favor placing in a large head with
an ultrahigh molecular weight polyethylene (UHMWP) liner. The head size is usually limited by the amount of
polyethylene available based on cup diameter. If the hip is still unstable, a small increase in neck length is
another option. Excessive length (>1 cm) will cause a significant and predictable limp, and this age group does
not compensate for leg length discrepancies as well as a younger population. Once component size has been
determined, the trials are removed. UHMWP should be used if a head size >36 mm is chosen; however, a
regular HMWP cup can be used if a 32 or 28 mm head has been selected. Once the permanent components
have been implanted, a final trial with the selected head and neck length can be performed before the final head
and neck are implanted. Following reduction, hip stability, and leg lengths are checked one last time. To be
slightly long in leg length by design is professionally acceptable. To be long by happenstance is not acceptable.
Wound closure is very important. The posterior hip capsule should be closed to cover the femoral head. This
helps decrease dead space and has been shown to reduce the rate of dislocations. The piriformis tendon along
with the gemellus muscles and obturator internus is repaired to the back of the trochanter or the abductor tendon
in a pants-over-vest repair. The sciatic nerve should be examined or palpated to make sure it is intact and
uninjured. If a drain is used, it should be inserted beneath the fascia latae. The tensor fascia latae is closed with
heavy interrupted figure-of-eight sutures. The subcutaneous layer is closed with number 2-0 absorbable suture
and the skin approximated with skin staples.

Postoperative Care
Patients are allowed to be weight bearing as tolerated using a walker or crutches immediately after surgery.
Balance is a major problem in this age group, and the use of walking aids is necessary until muscle rehabilitation
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and balance have been reestablished. This is a very different group from the elective total hip population. Drains,
if utilized, should be removed at 24 to 48 hours. At 6 weeks, most patients can progress to a single or quad cane.
By 12 weeks, most patients can be permitted to ambulate without assistive devices if they were able to do so
before their fracture. Patients are seen in the clinic at 2 weeks for wound inspection and suture removal. Clinical
follow-up is done at 3, 6, and 12 months postoperatively. Chemical deep vein thrombosis (DVT) prophylaxis
(CHEST or AAOS guidelines) is started on the first postoperative day and continued as an outpatient for 14 to 28
days following discharge.

FIGURE 16.37 Seating of the femoral component.

FIGURE 16.38 The head and neck trial used to ensure proper length, offset, and stability.

Complications
Complications can be divided into disease-specific and general complications. Hip fracture patients are
more prone to confusion and delirium in the postoperative period. Supplemental nasal oxygen has been
shown to reduce the potential for patient confusion during the first 48 hours postoperatively. General
complications such as pneumonia, cardiac failure, DVT, pulmonary embolism, atrial fibrillation, and urinary
tract infections require prompt diagnosis and treatment in collaboration with medical specialists. Prevention
of dislocation of the hip is a team responsibility and involves the surgeon, orthopedic nurses,
physiotherapist, occupational therapist, and the family.

Postoperative Wound Infection

Streptococcus and Staphylococcus account for almost 85% of postoperative wound infections. Gram-negative
and mixed microbial infections account for the remaining 15%. Presentation is usually with fever, redness around
the wound, drainage, or pain with motion of the affected joint. The diagnosis is confirmed with blood tests (high
ESR, CRP, and WBC) and a positive joint aspiration. Immediate surgical débridement of the joint combined with
6 weeks of culture-specific intravenous antibiotics has a 60% to 65% chance of success. For infections that
occur in the first few weeks, we usually perform a liner exchange as well. Subacute and chronic infections
invariably require removal of the prosthesis and an antibiotic spacer with staged reconstruction.

Hip Dislocation
Hip dislocation is an uncommon event following arthroplasty, and prevention is the key. A hip dislocation is more
common in patients that are treated with THA compared with those receiving a hemiarthroplasty. The initial
reports of patients having a total hip replacement for fracture reported dislocation rates as high as 10%;
however, more recent reports documented dislocation rates of <2%, which is similar to an elective THA.
Hemiarthroplasty has a very low rate of dislocation (<1%). Once diagnosed, reduction under conscious sedation
or light general anesthesia is recommended. Some studies suggest that an abduction brace may be helpful for
the initial 6 weeks following closed reduction; however, this may be not well tolerated in the elderly. If a closed
reduction is unsuccessful, then an open reduction with or without revision of the components is required. The
reason for dislocation should be determined whenever possible. The most common causes include a short neck
(particularly a negative neck length), incorrect anteversion, incorrect offset, or head size that does not optimize
the head-to-neck ratio for a given cup size.

Heterotopic Bone Formation

Significant heterotopic bone formation following arthroplasty for femoral neck fractures is very uncommon.
Prophylaxis is not recommended for this population as they are not high risk. Brooker Grade I and II heterotopic
ossification is not clinically significant. Grade III can lead to hip stiffness while grade IV is clinically fused. A strong
indication for surgical management would be a very severe case of heterotopic bone formation (Grade IV) when
no movement of the hip is present.

CONCLUSIONS
The recommendations for treatment of a femoral neck fracture include the following:
1. Nondisplaced as well as displaced femoral neck fractures in patients <60 years of age are usually treated
by internal fixation.
2. In displaced femoral neck fractures in patients over the age of 60, the literature supports arthroplasty
over internal fixation.
3. Nonmodular unipolar Moore or Thompson prosthesis should no longer be used.
4. Cemented modular unipolar or bipolar hemiarthroplasty has the most reliable and predictable outcome
and remains the procedure of choice for elderly patients with displaced femoral neck fractures.
5. An uncemented fully porous modular hemiarthroplasty should be considered preferentially in patients with
significant cardiovascular risk factors.
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6. Total hip arthroplasty is a viable alternative treatment in the highly “active elderly patient.” The use of
large femoral heads (>32 mm) with or without the addition of an offset neck or liner, plus meticulous
capsular repair techniques, have reduced the early dislocation rate (23,35,36). This has also permitted
more predictable excellent long-term functional outcomes in this specific subgroup of displaced femoral
neck fractures.

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 17
Intertrochanteric Hip Fractures: The Sliding Hip Screw
Kenneth A. Egol

INTRODUCTION
Hip fractures in the elderly are associated with significant morbidity and mortality and will continue to burden the
health care system as the population continues to age (1). Intertrochanteric hip fractures represent approximately
half of the fractures that occur in the proximal femur, with a strong female preponderance throughout all age
groups (2). Mortality rates for extracapsular hip fractures are comparable with those of femoral neck fractures,
with 1-year mortality rate of 20% to 30%.
While several classification systems exist, intertrochanteric fractures are best classified as stable or unstable
based upon the integrity of the posteromedial cortex. The Orthopaedic Trauma Association (OTA) classification
is useful both to determine the stability of the fracture pattern and to guide treatment (4). Intertrochanteric
fractures are classified as 31-A fractures and further subdivided into 31-A1, 31-A2, and 31-A3 fractures (Fig.
17.1). The 31-A1 simple fracture is a stable fracture with a single fracture line extending along the
intertrochanteric line (A1.1), through the greater trochanter (A1.2), or below the lesser trochanter (A1.3). The 31-
A2 fracture is multifragmentary and is subdivided into progressively more unstable patterns with a loss of medial
support: A2.1 fractures are simple fractures with one additional fragment, progressing to several fragments (A2.2)
and fracture extension >1 cm below the lesser trochanter (A2.3). Most A2 fractures are considered unstable with
the exception of the 31-A2.1 pattern. In the most unstable pattern, 31-A3, the fracture enters the lateral cortex of
the femur distal to the vastus ridge. This pattern can manifest as a reverse oblique intertrochanteric fracture
(A3.1), a simple transverse fracture (A3.2), or a multifragmentary fracture (A3.3).

ANATOMICAL CONSIDERATIONS
The intertrochanteric region of the hip is the area between the greater and lesser trochanters and represents a
zone of transition from the femoral neck to the femoral shaft. This area is characterized primarily by dense
trabecular bone that serves to transmit and distribute stress, similar to the cancellous bone of the femoral neck.
The orientation of the trabeculae in the intertrochanteric and greater trochanteric region acts to resist highly
compressive forces (5). The greater and lesser trochanters are the sites of insertion of the major muscles of the
gluteal region: the gluteus medius and minimus, the iliopsoas, and short external rotators. The calcar femorale, a
vertical wall of dense bone extending from the posteromedial aspect of the femoral shaft to the posterior portion
of the femoral neck, forms an internal trabecular strut within the inferior portion of the femoral neck and
intertrochanteric region and acts as a strong conduit for transfer of load. This region is extracapsular and is less
prone to many of the healing complications seen with femoral neck fractures.

INDICATIONS AND CONTRAINDICATIONS

Virtually all patients who sustain an intertrochanteric hip fracture with any displacement should be considered for
surgical repair. The goals of treatment are stable internal fixation of the fracture that will allow early mobilization
and protected weight bearing with uncomplicated healing. Patient factors that are important in the decision-
making process are associated with medical comorbidities, preinjury level of function, and bone quality.
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Extremely frail patients deemed too “sick” for surgery or who were nonambulatory prior to their fracture may be
treated nonoperatively with a short period of bed rest and gradual mobilization to a chair. Bone quality may also
affect the surgeon's choice of implant (nail vs. plate) or the length or the device. In a small group of patients with
symptomatic preexisting hip arthritis or severe osteoporosis due to systemic medical condition such as renal
failure or metastatic disease may be candidates for primary hip arthroplasty instead of fracture fixation.

FIGURE 17.1 The AO/OTA classification of intertrochanteric hip fractures.

PREOPERATIVE PLANNING
History and Physical Examination
The vast majority of hip fractures occur in the elderly following a fall from standing height. Geriatric hip fracture
management requires a treatment algorithm that takes into account the complex medical and social needs of this
patient population. Patients with multiple medical problems pose a dilemma. Many of these patients are taking
anticoagulation medication that must be reversed prior to surgery. In a small but substantial number of patients, a
cardiac, neurological, or metabolic event was the inciting event that led to the fall. Consultation with specialists in
internal medicine, cardiology, pulmonary, etc., is frequently required. Surgery should be performed as soon as it
is safe but often requires 24 to 48 hours of medical optimization.
On physical examination, the affected leg is usually shortened and externally rotated. There is marked
tenderness to palpation around the hip and proximal thigh. Any movement of the limb is painful and resisted by
the patient. The neurovascular status of the extremity should be carefully assessed and documented.

Imaging Studies
An anteroposterior (AP) pelvis and an AP and lateral radiograph of the hip should be obtained in all patients with
a suspected hip injury. This usually allows the physician to establish the diagnosis; however, important details
regarding the fracture geometry may be difficult to interpret if the x-rays were obtained with the leg shortened
and externally rotated. If there is any doubt about the fracture morphology, a traction radiograph with the leg
internally rotated should be obtained. This should be done with appropriate analgesia in the radiology suite or in
the operating room prior to surgery.
In patients with no obvious fracture following a mechanical fall, the x-rays should be scrutinized for a pelvic ring
injury or an occult femoral neck fracture. If none are identified and the patient is unable to bear weight, a CT
scan or MRI should be obtained. Bone scans are rarely used.
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Timing of Surgery
Most patients with an intertrochanteric hip fracture should have surgery when medically optimized, if possible
within 24 hours of admission to the hospital. These injuries are deemed urgent rather than emergent. Surgery is
best done during the daytime or evening and late night surgery is rarely indicated. Early surgery avoids the
problems of prolonged recumbency and minimizes the risk of decubiti, atelectasis, urinary tract infections,
pulmonary infections, and thrombophlebitis, which can be fatal in the frail geriatric patient. Prompt medical and
anesthesia consultation also facilitate timely surgery. Occasionally, surgery must be delayed beyond 24 hours
due to severe medical comorbidities. Patients who are admitted over the weekend with a hip fracture should not
wait until Monday for their procedure to be completed for surgeon convenience.

Surgical Tactic
There are two main categories of implants that are used in the treatment of intertrochanteric fractures: the
cephalomedullary nail and the sliding hip screw and side plate (6, 7, 8, 9 and 10). There is a large body of
literature that supports the use of a sliding hip screw for stable intertrochanteric fracture patterns (Fig. 17.2). On
the other hand, several randomized controlled trials support the use of both an intramedullary nail and a hip
screw in unstable fracture patterns. The one fracture where the use of a sliding hip screw is contraindicated is a
reverse obliquity fracture pattern due to the risk of excessive shortening and medialization of the shaft
postoperatively. This fracture pattern is more appropriately treated with a cephlomedullary implant or fixed angle
implant.
FIGURE 17.2 A stable intertrochanteric hip fracture. A. AP radiograph. B. Cross-table lateral radiograph. C.
Traction/internal rotation view.

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FIGURE 17.3 Positioning with the unaffected limb in the “well leg” holder in the lithotomy position.

SURGERY
Positioning and Reduction
Surgery can be preformed under general or spinal anesthesia. Both anesthetic types have advantages and
disadvantages that should be discussed with the anesthesiologist. For many elderly sick patients, an arterial line,
central venous catheter, and an indwelling Foley catheter are necessary to improve patient care. A
cephalosporin antibiotic is administered intravenously and continued for 24 hours postoperatively. Once the
patient is stable, they are placed supine on a fracture table with a padded peroneal post placed between the
legs. The affected foot and ankle is padded and placed in the boot or stirrup of the fracture table. The unaffected
or well leg must be positioned in a manner that allows for high-quality intraoperative imaging. There are two
ways this can be accomplished. Most often, the well leg is placed in a lithotomy positioner with hip flexed,
externally rotated, and abducted (Fig. 17.3). If there is arthritis or a contracture of the nonaffected hip, the
decreased hip motion may not allow the C-arm to be positioned between the legs. In this scenario, another
option is to “scissor” the legs, with the nonaffected limb lowered and the hip extended (Fig. 17.4). This position is
best accomplished by lowering the nonaffected limb and raising the injured limb. The fracture is reduced by
longitudinal traction on the fracture table against the peroneal post with the leg in external rotation, followed by
gradual internal rotation to neutral or just beyond. Reduction must be confirmed radiographically, in two views
prior to prepping and draping. These images should be saved for later reference.
The hip, pelvis, lower abdomen, and extremity are prepped and draped. Draping may be performed with an
isolation drape (shower curtain) or using conventional split sheets. The C-arm image intensifier is sterilely
draped when appropriate.
FIGURE 17.4 Positioning on the fracture table with the unaffected leg “scissored.”

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FIGURE 17.5 The hip prepped and draped demonstrating the incision over the lateral aspect of the femur distal
to the vastus ridge.

Surgical Approach
A direct lateral approach to the proximal femur is utilized through an incision parallel to the femoral shaft. The
incision starts at the vastus lateralis ridge and extends distally depending upon fracture pattern (Fig. 17.5). The
incision is carried down through the subcutaneous tissue and fat to the iliotibial band (ITB) ensuring that all small
bleeding points are cauterized (Fig. 17.6). The ITB is incised in line with the skin incision exposing the vastus
lateralis muscle belly. The vastus can be split longitudinally; however, this results in substantial bleeding and
unnecessary damage to the muscle. I prefer to elevate the vastus lateralis off the lateral intermuscular septum. It
is very important to identify and coagulate or ligate the relatively large arterial perforators to minimize blood loss.
With the lateralis elevated and retracted anteriorly, one or two narrow Hohmann retractors are placed. It is not
necessary to strip the vastus extensively off the femur (Fig. 17.7).

Fixation
The vastus lateralis ridge is palpated, and a drill guide (usually 130 or 135 degrees) is placed approximately 2.5
cm distal to this point. A drill guide should always be used to accurately place the wire into the neck and head of
the femur. It is applied directly to the lateral cortex of the femur parallel to the floor. Based on the previously
saved reduction C-arm fluoroscopic views, the amount of anteversion/retroversion in the proximal femur is noted,
and the angle of the drill guide is “fine-tuned.” A terminally threaded guide pin is advanced under fluoroscopic
control through the lateral cortex into the central portion of the femoral head in both the AP and lateral views.
This is a crucial step, and the surgeon should not accept poor pin position (Fig. 17.8). If the pin is too superior in
the head, the starting point should be moved distally. If the pin is either too anterior or too posterior on the lateral
view, it is repositioned accordingly. Baumgaertner et al. (11) have shown a higher complication rate when the
guide pin is malpositioned. He defined the tip-apex distance (TAD), which is the summation of the
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distance from the tip of the pin from the center of the femoral head in the AP and lateral views. These authors
have shown that the TAD should be <25 mm (11) (Fig. 17.9).

FIGURE 17.6 The skin incision is carried down to the ITB.

FIGURE 17.7 The vastus lateralis is elevated off the intermuscular septum exposing the femur shaft.
FIGURE 17.8 The guidewire is advanced from the lateral cortex using a fixed angle guide. The wire is placed in
a center-center position as see on the AP (A) and lateral (B) views.

Once the position of the guide pin has been confirmed fluoroscopically to be center-center, the wire length is
measured with the manufacturers' depth gauge (Fig. 17.10). An adjustable cannulated triple diameter reamer is
“set” and used to prepare the proximal femur for the compression hip screw (Fig. 17.11A). The 3 diameters of the
reamer account for 1. the lag screw core diameter, 2. the plate barrel, and 3. recessing the femoral cortex to
allow the plate to sit flush with the femur (Fig. 17.11B). In patients with good quality bone, it is advisable to tap
the screw path before inserting the compression hip screw. In patients with poor quality bone, this step is not
usually necessary. Once tapped, the lag screw is inserted over the guide pin with a sleeve to the depth
previously reamed (Fig. 17.12A,B). This step should be checked with frequent fluoroscopic images to ensure that
the guide pin does not inadvertently advance through the femoral head. Once the screw has been seated, the
side plate is inserted. The length of side plate is determined based upon the fracture pattern, fracture stability,
and bone quality (12). Most surgeons use side plates with two to four screw holes.
If a “keyed” system was used, the final turn of the lag screw may need to be parallel or perpendicular to the shaft
of the femur to accommodate side plate application. The side plate is slid over the guidewire attachment onto the
lag screw, gently pushed, and then impacted into the femoral neck and alongside the shaft (Fig. 17.13A,B). The
plate is fixed to the femur with 4.5-mm bicortical screws (Fig. 17.14). The guide pin is then removed. A “set”
screw may be placed into the lag screw through the end of the barrel to increase compression at the fracture
site. I rarely use this screw and prefer to allow some hip impaction by releasing the traction on the fracture table.
Final AP and lateral radiographs with the C-arm should be obtained in the operating room to confirm fracture
reduction and adequacy of implant placement (Fig. 17.15).
The wound is thoroughly irrigated and closed over a suction drain. The vastus is allowed to fall back into its
anatomic position over the implant. The ITB is closed with interrupted heavy, absorbable sutures (Fig. 17.16).
The subcutaneous tissues are closed with an absorbable suture, and the skin is closed with nylon (Fig. 17.17).
The drain is attached to suction.
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FIGURE 17.9 Demonstrates the concept of “Tip-Apex” distance.

FIGURE 17.10 The lag screw length is indirectly measured over the guidewire.
FIGURE 17.11 The triple diameter reamer (A) is used to prepare the proximal femur for the lag screw. B.
Reamer depth is monitored on image intensification.

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FIGURE 17.12 The lag screw is inserted over the guidewire (A). Fully inserted (B).
FIGURE 17.13 The side plate is inserted over the lag screw extension in the proper “keyed” position (A).
Radiographs demonstrate the side plate fully seated.

FIGURE 17.14 Screws are drilled and placed to secure the plate to the bone.

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FIGURE 17.15 Final radiographs demonstrate implant placement for a stable intertrochanteric hip fracture. A. AP
radiograph and (B) lateral radiograph.

Postoperative Care
Deep venous thrombosis (DVT) prophylaxis is started on the first postoperative day. Unless there is a specific
contraindication, we use a mechanical compression device and a pharmacologic anticoagulation medication that
is continued for 6 weeks. Physical and occupational therapy are initiated on the first postoperative day,
beginning with mobilization from bed to chair. If the patient is unable to tolerate this transfer, they are assisted
into a dangling position in their bed. Gait training with a walker is started on the second postoperative day. The
patient's therapy program should be tailored to his or her preoperative level of function and physical,
psychological, and social situation. Occupational therapy should focus on assisting patients to regain
independence in activities of daily living. This includes helping the patient regain perceptual, motor, and adaptive
skills including toileting,
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dressing, bathing, and cooking. Most elderly patients who sustain an intertrochanteric fracture benefit from 7 to
10 days of inpatient rehabilitation. For this reason, we obtain a rehabilitation consult on the first postoperative
day for disposition planning. Coordination between a social worker, case manager, physiatrist, and the patient's
family is invaluable to determine the optimal setting for each patient. Following discharge, arrangements are
made for continued outpatient physical and occupational therapy. Patients are seen in the clinic at monthly
intervals for clinical and radiographic follow-up until the fracture has healed, usually within 3 to 4 months.
FIGURE 17.16 Following irrigation, the wound is closed in layers beginning with the ITB.

FIGURE 17.17 Final skin closure prior to dressing placement.

Complications
Complications following internal fixation of an intertrochanteric hip fracture can be divided into medical and
orthopedic. The most common medical complications include pneumonia, urinary tract infection, DVT, and
constipation. All require thorough evaluation and treatment in conjunction with the medical specialists.
Most orthopedic complications are preventable. Wound drainage that persists for more than a few days is
aggressively treated with irrigation and débridement, deep wound cultures, and intravenous antibiotics.
Malunion is most commonly the result of excessive limb shortening following controlled collapse in unstable
fracture patterns.
A leg-length discrepancy >2 cm can lead to hip pain and a limp. Nonunion following internal fixation using a
sliding hip screw is rare. If symptomatic, they often require revision fixation with or without bone grafting or
complex revisions to joint arthroplasty.

REFERENCES
1. Morris AH, Zuckerman JD. National Consensus Conference on Improving the Continuum of Care for
Patients with Hip Fracture. J Bone Joint Surg Am 2002;84(4):670-674.

2. Johnston AT, Barnsdale L, Smith R, et al. Change in long-term mortality associated with fractures of the
hip: evidence from the Scottish hip fracture audit. J Bone Joint Surg Br 2010;92(7):989-993.

3. Kesmezacar H, Ayhan E, Unlu MC, et al. Predictors of mortality in elderly patients with an intertrochanteric
or a femoral neck fracture. J Trauma 2010;68(1):153-158.

4. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and
Classification. J Orthop Trauma 1996;10(Suppl 1):36-40.

5. Skuban TP, Vogel T, Baur-Melnyk A, et al. Function-orientated structural analysis of the proximal human
femur. Cells Tissues Organs 2009;190(5):247-255.

6. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of
practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am
2008;90(4):700-707.

7. Park SR, Kang JS, Kim HS, et al. Treatment of intertrochanteric fracture with the Gamma AP locking nail
or by a compression hip screw—a randomised prospective trial. Int Orthop 1998;22(3):157-160.

8. Crawford CH, Malkani AL, Cordray S, et al. The trochanteric nail versus the sliding hip screw for
intertrochanteric hip fractures: a review of 93 cases. J Trauma 2006;60(2):325-328; discussion 8-9.

9. Aros B, Tosteson AN, Gottlieb DJ, et al. Is a sliding hip screw or im nail the preferred implant for
intertrochanteric fracture fixation? Clin Orthop Relat Res 2008;466(11):2827-2832.

10. Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of
ten randomised trials. Int Orthop 1996;20(3):163-168.

11. Baumgaertner MR, 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;;77(7):1058-1064.

12. 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 Orthop Trauma 1999;13(1):5-8.
 18
Intertrochanteric Hip Fractures: Intramedullary Hip Screws
Michael R. Baumgaertner
Thomas Fishler

INTRODUCTION
The number of hip fractures in the United States is estimated to be approximately 400,000 per year and will
increase 50% by the year 2025. These fractures typically occur in elderly osteoporotic females, with 90% of
fractures occurring in patients older than 65 years of age (1). The cost burden exceeds 20 billion dollars
annually, which does not include care beyond 1 year from injury. Approximately one in four hip fracture patients
requires long-term placement in an assisted care environment, and nearly 50% of these patients do not regain
preinjury levels of activity. The 1-year mortality following surgery for a hip fracture remains around 20%.
There are numerous classifications for hip fractures. All attempt to distinguish between stable and unstable
fracture patterns. Unstable fracture patterns are marked by significant disruption of the posteromedial cortex,
subtrochanteric extension, or reverse obliquity in the main fracture line. The AO/OTA classification of these
fractures incorporates each of these features, classifying intertrochanteric fractures along a spectrum from most
(31A1.1) to least (31A3.3) stable (Fig. 18.1).
Stable two-part and some three-part fractures, once reduced, will resist medial and compressive loads and can
be treated with either a compression hip screw and side plate or an intramedullary nail. On the other hand,
unstable three- and four-part intertrochanteric fractures invariably collapse into varus and shorten, and this is
only partially prevented by a sliding hip screw. Even when healing is successfully achieved, limb shortening >2
cm and medialization of the shaft can lead to poor outcomes.

INDICATIONS AND CONTRAINDICATIONS

There are two broad categories of implants for the treatment of intertrochanteric hip fractures: a sliding hip screw
and side plate and a cephalomedullary nail. A sliding hip screw and side plate remains the implant of first choice
for stable two-part fractures, and multiple studies have shown no advantage with the use of an intramedullary
device in this subgroup (2, 3, 4 and 5). Cephalomedullary nailing is indicated in unstable intertrochanteric hip
fractures, particularly those with subtrochanteric extension and reverse oblique fracture patterns (AO/OTA 31A3).
An additional indication for nailing is an impending or pathologic fracture of the proximal femur.
Contraindications to the use of a cephalomedullary nail include fractures of the femoral neck, deformities within
the femoral shaft including preexisting implants, and hip ankylosis. A relative contraindication is the young trauma
patient because of concerns regarding removing substantial bone from the trochanteric block in order to
accommodate these large implants.
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FIGURE 18.1 The AO/OTA classification of intertrochanteric hip fractures.

Cephalomedullary nails direct a screw(s) or a triflanged blade into the femoral neck and head through a variable
length intramedullary nail. Implant insertion can be performed in a closed, percutaneous manner, minimizing
surgical trauma at the fracture site, and reducing intraoperative blood loss. The device functions as an
intramedullary buttress, maintaining length and alignment while restoring the mechanical support of the
posteromedial cortex, preventing shaft medialization.

PREOPERATIVE PLANNING
History and Physical Examination
Elderly patients typically present after a mechanical ground level fall and are unable to stand or walk. It is
important to obtain a thorough medical and social history, which includes associated medical history and the
patient's ambulatory status. On physical examination, the affected extremity is usually shortened and
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externally rotated. There is exquisite tenderness to palpation around the hip and proximal thigh, and any
movement in the extremity is painful. It is important to assess and to document the neurovascular examination as
well as to rule out any associated injuries. Consultation with an internal medicine specialist is recommended to
optimize the patient for surgery. Dehydration and associated metabolic abnormalities are common and should be
corrected preoperatively. Diabetic patients must have good perioperative glucose control. Patients on
anticoagulation therapy require temporary normalization of their clotting parameters prior to surgery. Prophylaxis
against venous thromboembolism should take into account the relative risks of pulmonary embolism and bleeding
complications. The choice of pharmacologic agent remains contoversial, but mechanical prophylaxis is indicated
for all patients. Antiplatelet agents are usually stopped preoperatively but restarted shortly after surgery (6).

Imaging Studies
The diagnosis of an intertrochanteric hip fracture is generally confirmed with standard anteroposterior (AP) and
cross-table lateral radiographs of the hip. Additional x-rays, including an AP pelvis, centered over the pubic
symphysis and full-length radiographs of the entire femur, should be obtained because deformities in the shaft
may preclude the use of an intramedullary device. Internal rotation and traction radiographs are invaluable for
understanding the fracture anatomy as well as the success of the anticipated closed reduction. Occasionally, x-
rays of the unaffected hip and femur are useful for preoperative planning. Computed tomography is not usually
necessary but is obtained in complex fractures on a case-by-case basis.

Timing of Surgery
In all cases, medical optimization should be expeditious, as mortality is increased when surgery is delayed
beyond 48 to 72 hours from admission (7). Surgery is ideally performed during daylight hours with a rested team,
7 days a week. On the other hand, optimization efforts can and should be performed through the nighttime hours;
as a result, we most commonly perform the procedure on the day following hospital admission. Occasionally, this
timetable is altered by the need to correct coagulopathy or perform more involved preoperative medical studies.

Surgical Tactic
Careful examination of the preoperative radiographs as well as x-rays of the unaffected hip are important parts of
the preoperative plan and help guide implant selection with respect to the neck-shaft angle, diameter, and screw
length. The nail-screw angle of the device should match the neck-shaft angle of the desired reduction. The most
common configuration is a 135-degree neck angle with a 95-mm lag screw. It is important to note that the nail is
not designed to fill the canal. Although first-generation short-stem implants were associated with an unacceptably
high rate of subsequent femoral fracture, a recent meta-analysis showed no increased relative risk for this
complication when intramedullary devices were compared to side plates (8). We use a full-length intramedullary
nail in pathologic fractures and in patients with subtrochanteric extension. For the majority of patients, we use a
short nail that facilitates distal locking through a nail mounted jig. Other authors advocate the use a full-length
implant to protect the entire femur for all cases.

Surgical Technique
Surgery is performed under a general or spinal anesthetic. While general anesthesia allows for complete muscle
relaxation, it carries a higher risk of perioperative morbidity and mortality, particularly in the elderly hip fracture
patient with multiple medical comorbidities. A decision on the method of anesthesia should be made in
collaboration with the surgeon, anesthesiologist, and consulting internal medicine specialist. The preoperative
prophylactic antibiotic of choice is a first-generation cephalosporin. In cases of penicillin allergy, a suitable
alternative, typically vancomycin or clindamycin, is given.
We prefer to use an orthopedic table that allows for balanced traction to be applied to both lower extremities, but
a fracture table may be used as well. A well-padded post is placed in the perineum. Both lower extremities are
secured to the table, and traction is applied. The operative side is adducted and slightly flexed at the hip and the
unaffected leg abducted and extended to allow for lateral plane fluoroscopic imaging (Fig. 18.2B,C). “Scissoring”
the extremities in such a way prevents the pelvis from rotating on the perineal post as traction is applied to the
fractured limb, which can lead to a varus reduction (Fig. 18.3).
Once the patient has been securely positioned on the table, the fracture is reduced. There are two goals, the
first of which is to gain access to the starting point in the proximal femur, the second being anatomic reduction of
the fracture. Most stable fracture patterns will reduce with longitudinal traction and internal rotation of the limb.
However, unstable intertrochanteric fractures may require different maneuvers, such as slight external rotation. A
particularly troublesome deformity is subsidence of the proximal fragment into the intramedullary
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canal of the distal fragment. The hallmark radiographic sign of a triangular double density, representing the
overlap between the fragments, must be recognized, as this deformity is not reducible by manipulative means;
here, a percutaneous intrafocal reduction aid as described by Carr is helpful (Fig. 18.4A-E) (9). Prior to prepping
and draping the field, we confirm that we can see the following areas with fluoroscopy: the anterior cortex of the
proximal femur, the fracture zone, the anterior neck, the entire circumference of the femoral head, the posterior
neck, and the greater trochanter.

FIGURE 18.2 A. In the typical position, the patient is supine on the orthopedic table with the torso windswept
and the lower extremities in balanced traction. B. The C-arm is positioned on the contralateral side of the patient.
C. “Scissoring” of the lower extremities allows for unimpeded lateral fluoroscopic imaging.

In considering the reduction, we determine an acceptable neck-shaft angle to be 130 to 145 degrees. Increased
valgus is permissible because it reduces the bending forces on the implant and may offset limb shortening that
occurs with fragment impaction. Loss or gain of femoral anteversion >15 degrees, as seen on the lateral view, is
unacceptable.
Once a provisional reduction has been achieved, the surgical field is prepped and draped in a standard sterile
fashion. It is important to prep below the level of the knee in the event that a long nail is used that requires a
distal interlocking screw. We use a sterile shower-curtain-type drape but add an extra sterile layer proximally to
protect against puncture hole contamination from the instruments. If the closed reduction is inadequate, a
number of percutaneous maneuvers may be attempted, utilizing such tools as the ball spike pusher, collinear
clamp, and cerclage wire to improve the reduction (Fig. 18.5A-C).
The tip of the trochanter and the femoral shaft axis is marked in both planes with a sterile skin marker under
fluoroscopy (Fig. 18.6). This provides a visual aid for the correct insertion of the guide pin and the nail. In
addition, it helps reduce fluoroscopy time. Prior to instrumenting the proximal femur, the reduction should be
verified with biplanar imaging. Using a freehand technique, a 3.2-mm guide pin is inserted percutaneously
approximately 5 cm proximal to the greater trochanter, engaging the bone at a point in line with the intramedullary
canal, typically just medial to the tip of the greater trochanter. This location will counteract the tendency toward
varus and increased neck-shaft offset as well as minimize any damage to the gluteus medius insertion. On the
lateral fluoroscopic view, the guide pin should be centered in line with the medullary canal, and on the AP, it
should be aimed slightly medial (Fig. 18.7A-B).
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FIGURE 18.3 With the application of unopposed traction, the pelvis rotates around the perineal post. The hip
abducts, hampering access to the starting point.
FIGURE 18.4 A,B. A double density of the medial cortex corresponds to an intussusception of the neck into the
shaft, seen on the lateral x-ray.

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FIGURE 18.4 (Continued) C. Traction will not correct the apparent apex posterior deformity, but an intrafocal
pin will. D. A levering action disengages the fragments and allows for a line-to-line anterior cortical reduction. E.
On the AP view, the medial cortex is restored.
FIGURE 18.5 Percutaneous reduction aids include the (A) ball-spike pusher to correct flexion deformity of the
proximal fragment.

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FIGURE 18.5 (Continued) B. Colinear clamp with Hohmann-style arm attachment, inserted percutaneously and
used to correct varus in a reverse-oblique fracture. C. A small cerclage wire, passed atraumatically, can be a
powerful reduction aid, provisional fixation, and adjunctive definitive fixation in fracture patterns with a long
subtrochanteric spike.

The skin is infiltrated with local anesthetic containing epinephrine, and a 2-cm incision is made along the guide
pin, through fascia, and directly onto the greater trochanter (Fig. 18.8). Once the guide pin is properly placed, the
proximal femur is opened with a large cannulated drill. We do not use the soft-tissue protector sleeve but rather
minimize soft-tissue trauma by advancing the reamer in reverse until it reaches bone. We ream until the widest
part of the drill has reached the lesser trochanter (Fig. 18.9A). It is unnecessary to ream to the isthmus unless
the medullary canal is exceptionally narrow. In these cases, we employ flexible medullary reamers. It is important
that the reamer cuts a channel for the implant rather than displacing the fracture fragments as it passes into the
canal (particularly if the guide pin is in the fracture line). Placing firm medial-directed
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pressure on the trochanteric mass as well as pushing the reamer medially as it is advanced will ensure
appropriate canal preparation (Fig. 18.9B). An incorrect entry site is more problematic than generous reaming in
this patient population.

FIGURE 18.6 Marking of the femoral shaft axis and the tip of the trochanter.

The nail is assembled on the driving/targeting device and pushed into the intramedullary canal. Only hand force
should be required, forcing the nail with a hammer risks iatrogenic fracture (Fig. 18.10). The nail can be inserted
with or without a guide pin. Biplanar fluoroscopy should be checked at this point to ensure that the nail is not
exiting the canal through the fracture and that the nail is seated to the correct depth. If the nail does not fully
advance but does not appear “tight” on the AP image, the surgeon should check the lateral image to see if the tip
of the nail is impinging on the anterior cortex, because many nail systems do not incorporate a sagittal bow. Also,
the soft tissues should be checked to ensure that they are not restricting the entrance site. A combination of
expanding the entry portal, soft-tissue release, isthmic (flexible) reaming, or implant downsizing usually solves
the problem.
The correct position for the lag screw is estimated on the intraoperative fluoroscopic views, and a 2-cm skin
incision is made in the proximal lateral thigh. It is important to split the deep fascia lata so that the drill sleeve can
be placed flush against the lateral cortex of the femur. Taking into account the anteversion of the femoral neck,
the surgeon should advance the appropriate guide pin through the jig and nail into the femoral neck and head.
FIGURE 18.7 A. Appropriate guide pin location on the AP view. B. Appropriate guide pin location: centered on
the lateral view.

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FIGURE 18.8 By keeping the bevel of the blade in contact with the guide pin, a perfectly placed, minimally
invasive path is cut for atraumatic passage of the reamer and implant.

At this point, we confirm and, when necessary, “fine tune” the reduction. Manipulation of the insertion handle
connected to the nail can improve the “sag” or translation on the lateral view. On the AP view, the guide pin acts
as an excellent reference because it is 135 degrees to the shaft. If it is parallel to the neck but too superior or
inferior in the head, the neck-shaft angle is acceptable. The guide pin is removed, the nail is advanced or backed
out slightly, and the pin is reinserted. However, if guide pin is not parallel with the femoral neck, the fracture is
usually in varus. The reduction can often be improved (after removing the guide pin) with increased traction as
well as abduction of the extremity. It is very helpful to remember that once the nail is seated in the femur, the
adduction necessary to access the entry site is no longer needed. Significant valgus can be achieved by simply
abducting the extremity at this point. With the nail seated to the appropriate depth, a 3.2-mm guide
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pin is inserted centrally and deep into subchondral bone using both the AP and lateral fluoro images for guidance
(Fig. 18.11A,B). The pin should be directed toward the apex of the femoral head, defined as the point where the
subchondral bone is intersected by a line parallel to and in the center of the femoral neck. The aim is to minimize
the tip-apex distance (TAD), defined as the sum of the distances measured on AP and lateral fluoroscopy
between the tip of the screw and the apex of the femoral head. This necessitates both central and deep
placement. The known length of the guide pin's threaded tip can serve as a reference when estimating TAD that
effectively controls for magnification (Fig. 18.11C). A partially radiolucent aiming jig can make placement of the
pin along the axis of the neck on the lateral view considerably easier.

FIGURE 18.9 A. Firm medial pressure is placed to prevent lateral fracture displacement and to assure that a
channel for the implant is created. B. Insertion of the proximal reamer so that the widest part is at the level of the
lesser trochanter.
FIGURE 18.10 The nail is fully seated in the canal.

Once satisfied with the reduction and the position of the guide pin, an auxiliary stabilizing pin for all unstable
fractures is placed (Fig. 18.12A,B). This auxiliary pin is directed through the jig such that it avoids the path of the
lag screw and locks the jig to the head-neck fragment. The auxiliary pin serves as an antirotation device during
screw insertion as well as an independent fracture stabilizer should the guide pin be inadvertently removed while
the surgeon is reaming for the lag screw.

FIGURE 18.11 A. Appropriate guide pin placement on the AP x-ray. B. Appropriate guide pin placement on the
lateral x-ray.

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FIGURE 18.11 (Continued) C. The technique to measure TAD.

With the guide pin seated deep into the subchondral bone of the femoral head, we ream 3 to 5 mm short of the
subchondral bone. Reamer progress is monitored with spot fluoroscopic images to identify inadvertent binding or
advancement of the guide pin as well as to prevent joint penetration. An obturator should be used during removal
of the reamer to prevent inadvertent removal of the guide pin. We seldom use a tap because of the bone quality
typically seen in this patient population.
FIGURE 18.12 A. Certain implant systems provide a targeting attachment to place the auxiliary stabilizing pin. B.
An auxiliary stabilizing pin is added to help control rotation. It is placed out of the path of the lag screw.

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FIGURE 18.13 A. The lag screw is seated to the appropriate depth. Image was taken prior to centering of sleeve
insertion. B. The centering sleeve is advanced through the lateral cortex and into the nail using the sleeve
pusher.

The lag screw length is selected so that the distal aspect of the fully seated screw is recessed 5 to 8 mm into the
centering sleeve, exactly as one would do when using a sliding hip screw and side plate. For a 135-degree nail,
a 95-mm screw is the most common size. The lag screw is then inserted over the guide pin with the centering
sleeve. Once the lag screw has reached the appropriate depth (Fig. 18.13A) and the reduction is verified, the
centering sleeve should be advanced though the lateral cortex and into the nail using the sleeve pusher (Fig.
18.13B).
The head-neck fragment is typically torqued somewhat as the screw is seated into the dense subchondral bone.
In right hips, screw tightening tends to extend the proximal fragment, which often helps correct the common mild
extension deformities at the fracture. However, for left-side fractures, the clockwise seating of the screw flexes
the hip and worsens such a deformity. We scrutinize the fracture on the lateral fluoroscopic image while slightly
rotating the screw insertion handle back and forth (which controls the head-neck fragment) to identify the
optimum reduction (Fig. 18.14). The reduced position is then maintained while an AP image is
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obtained to confirm the reduction. The sleeve is locked to the nail when it is tightened with the set screw. This
locks the rotational reduction but allows unimpeded sliding of the screw within the sleeve.

FIGURE 18.14 A. Lag screw insertion in a left hip showing worsening of extension deformity. B. Rotation of the
screw results in fracture reduction.
FIGURE 18.15 A-C. A demonstration of compression screw insertion. Note how the fracture reduces with the
applied compression.

For most cases, we insert a compressing screw to initiate sliding and increase the immediate stability of the
fracture (Fig. 18.15). This also prevents the rare but catastrophic complication of proximal disengagement of the
screw from the nail. For length-stable fractures, traction should be released from the extremity prior to
considering a distal interlocking screw. We then assess rotational stability by securing the distal extremity and
gently rotating the insertion jig. If the fracture fragments move as a unit, we consider distal interlocking optional
(Fig. 18.16A,B). If there is any question of motion, a single screw is placed in the dynamic slot using the
alignment jig. For length-unstable fractures, two distal interlocking screws are placed through the insertion jig, or,
with full-length nails, by a freehand technique.
The abductor fascia proximal to the trochanter at the nail insertion site is closed with a heavy absorbable suture.
The subcutaneous tissue and skin are closed in layers. The proximal wound is at risk of contamination from a
disoriented elderly patient's wandering fingers (Fig. 18.17). A dry sterile dressing is applied with care in
consideration of the elderly patient's fragile skin.
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FIGURE 18.16 A,B. AP and lateral postoperative radiographs.

FIGURE 18.17 The two small skin incisions with staple closure.

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POSTOPERATIVE MANAGEMENT
Patients receive antibiotic prophylaxis for 24 hours, generally with a first-generation cephalosporin. Prophylaxis
against deep venous thrombosis is carefully considered with a combination of sequential compression devices
and pharmacologic medication. Patients are mobilized from bed to chair and are gait trained with a physical
therapist on the first or second postoperative day, weight bearing to tolerance. Patients are typically discharged
to a short-term rehabilitation facility on postoperative day 3 or 4. Patients are seen in the outpatient clinic at 10 to
14 days for suture removal and at 6 and 12 weeks to confirm clinical and radiographic union. All patients who
sustain a low-energy fracture of the hip should be evaluated and treated for osteoporosis.

COMPLICATIONS
The soft-tissue envelope surrounding the proximal femur is redundant, well vascularized, and forgiving. For
these reasons, as well as the low-energy mechanisms that most often cause these fractures, soft-tissue
necrosis, wound dehiscence, and surgical site infection are rare following internal fixation. When it occurs,
treatment ranges from oral or intravenous antibiotics to surgical débridement, depending on the extent of
process.
Screw cutout has historically been the primary mode of failure for both compression hip screws and
cephalomedullary nails. It may be avoided entirely by appropriate reduction and implant placement. A varus
neck-shaft angle universally leads to an increased TAD and an increased offset when an intramedullary
device is used. The absolute importance of TAD in predicting screw cut-out with intramedullary devices has
been recently confirmed (10).
Stiffness of the hip following fixation is commonly encountered but rarely limits function. Excessive collapse
of the sliding hip screw, however, does lead to limb length discrepancy and reduced femoral offset, both of
which contribute to an asymmetric gait with a limp. It is here where intramedullary nails, which collapse less
than a sliding hip screws, provide a superior maintenance of anatomy, particularly in unstable fracture
patterns (11).
Nonunion is rare in this highly vascularized, metaphyseal, and extracapsular anatomic region. When it
occurs, it can be attributed, like screw cut-out, to malreduction or poor implant placement. Additional
complications include femoral shaft fracture, fractures below the implant, and painful hardware. A number of
techniques, such as conversion to a hip replacement, revision osteosynthesis with a long-stem implant, or
open reduction and internal fixation, can be used to address these problems. Fortunately, these
complications are uncommon with proper surgical technique and new generation devices (12).

REFERENCES
1. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related
fractures in the United States, 2005-2025. J Bone Miner Res 2007;22(3):465-475.

2. Parker MJ, Handoll HH. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database
Syst Rev 2006;3:CD004961.

3. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary
implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2008;(3):CD000093.

4. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-
analysis of 24 studies involving 3,279 fractures. Int Orthop 2006;30(2):69-78.

5. Saudan M, Lübbeke A, Sadowski C, et al. Pertrochanteric fractures: is there an advantage to an

intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and
proximal femoral nail. J Orthop Trauma 2002;16(6):386-393.

6. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed). Chest
2008;133(6 Suppl):299S-339S.

7. Moran CG, Wenn RT, Sikand M, et al. Early mortality after hip fracture: is delay before surgery important?
J Bone Joint Surg Am 2005;87:483-489.

8. Bhandari M, Schemitsch E, Jönsson A, et al. Gamma nails revisited: gamma nails versus compression hip
screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma
2009;23(6):460-464.

9. Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a
stable reduction. J Orthop Trauma 2007;21(7):485-489.

10. Geller JA, Saifi C, Morrison TA, et al. Tip-apex distance of intramedullary devices as a predictor of cut-
out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop 2010;34(5):719-722.

11. Hardy DC, Descamps PY, Krallis P, et al. Use of an intramedullary hip-screw compared with a
compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of
one hundred patients. J Bone Joint Surg Am 1998;80(5):618-630.

12. Utrilla AL, Reig JS, Munoz 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
design of the gamma nail. J Orthop Trauma 2005;19(4):229-233.
 19
Intertrochanteric Hip Fractures: Arthroplasty
George J. Haidukewych
Benjamin Service

INTRODUCTION
The number of patients treated for intertrochanteric hip fractures continues to increase and represents a
significant financial and societal impact. The vast majority of intertrochanteric hip fractures treated with modern
internal fixation devices heal. However, certain unfavorable fractures patterns, fractures in patients with severely
osteopenic bone, or patients with poor hardware placement can lead to fixation failure with malunion or
nonunion. Randomized prospective studies of displaced femoral neck fractures in elderly osteoporotic patients
treated with internal fixation have shown high complication rates. For this reason, most surgeons favor
arthroplasty, which has fewer complications and offers the advantage of early weight bearing. This has led some
surgeons to consider the use of a prosthesis in the management of selected, osteoporotic, unstable,
intertrochanteric hip fractures. In theory, this may allow earlier mobilization and minimize the chance of internal
fixation failure and need for reoperation. The use of arthroplasty in this setting, however, poses its own unique
challenges including the need for so-called calcar replacing prostheses, and it raises questions regarding the
need for acetabular resurfacing and the management of the often-fractured greater trochanteric fragment. The
purpose of this chapter is to review the indications, surgical techniques, and specific technical details needed to
achieve a successful outcome. Also addressed are the potential complications of hip arthroplasty for fractures of
the intertrochanteric region of the femur.

INDICATIONS
The overwhelming majority of intertrochanteric hip fractures, whether stable or unstable, will heal
uneventfully when the procedure is performed correctly, using modern internal fixation devices. Both
intramedullary nails and a compression screw and side plate have proven safe and effective. Several
European studies have found that hip arthroplasty can lead to successful outcomes; however, there is a
higher perioperative mortality rate among these patients compared to those who undergo internal fixation. In
North America, the indications for hip arthroplasty for peritrochanteric fractures include patients with
neglected intertrochanteric fractures (>6 weeks) when attempts at open reduction and internal fixation
(ORIF) are unlikely to succeed; pathologic fractures due to neoplasm (primarily metastatic disease); internal
fixation failures or established nonunions where the patient's age or proximal-bone stock precludes revision
internal fixation; and in patients with severe preexisting, symptomatic osteoarthritis of the hip with an
unstable fracture pattern. Recent studies have documented that hip arthroplasty for salvage of failed
internal fixation provides predictable pain relief and functional improvement.

PATIENT EVALUATION AND PREOPERATIVE PLANNING

Because these patients are typically elderly and frail with multiple medical comorbidities, a thorough medical
evaluation is recommended. Preoperative correction of dehydration, electrolyte imbalances, and anemia is
important. In acute cases, surgery is performed within 48 hours of injury to avoid prolonged recumbency
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following medical consultation. When done as a reconstruction procedure, it is scheduled as an elective
procedure similar to a total hip.
Plain anteroposterior (AP) and lateral radiographs of the hip, femur, and pelvis are important for preoperative
planning. If the surgeon has any concern regarding the possibility of a pathologic fracture, computed tomography
(CT) or magnetic resonance imaging (MRI) scanning can be helpful. If a pathologic fracture due to metastasis is
diagnosed, full-length femur radiographs are critical to rule out distal femoral lesions that would impact treatment.
Appropriate imaging of the proximal fragment is important to allow templating of the femoral component for length
and offset as well as to determine whether a proximal calcar augmentation will be necessary to restore the
anatomic neck-shaft relationship. Careful scrutiny of the hip joint is necessary to determine whether a total hip
arthroplasty is needed rather than hemiarthroplasty. A final decision is often made intraoperatively after visual
inspection of the quality of the remaining acetabular cartilage. If previous hardware from internal fixation is
present, implant-specific extraction equipment and a broken screw removal set, with or without the use of
fluoroscopy, are invaluable. Obtaining the original operative report can assist the surgeon in determining the
implant manufacturer if it is not recognized from the radiographs. Templating cup size and femoral component
length and diameter is an important part of the preoperative plan.
It is often difficult to determine preoperatively whether hemiarthroplasty or total hip arthroplasty is appropriate,
and whether a cemented or uncemented femoral component fixation is necessary. I prefer to have a variety of
acetabular resurfacing and femoral-component fixation options available intraoperatively. Although having such a
large inventory of implants available for a single case is cumbersome, it is wise to be prepared for unexpected
situations that arise during these challenging reconstructions.
To evaluate infection as a possible contributing factor in a patient with failed internal fixation, a complete blood
count with differential, a sedimentation rate, and a C-reactive protein should be obtained preoperatively. I have
not found aspiration to be predictable in the setting of fixation failure and rely on preoperative serologies and
intraoperative frozen section histology for decision making.

SURGICAL TECHNIQUE
The exact surgical technique will vary, of course, based on whether the reason for performing the arthroplasty is
an acute fracture, a neglected fracture, a pathologic fracture, or a nonunion with failed hardware. However, many
of the surgical principles are similar regardless of the preoperative diagnosis.
General or regional anesthesia is utilized. The patient is placed in lateral decubitus position using a commercially
available positioner on the operating room table. An intravenous antibiotic, typically a first-generation
cephalosporin, is given. Antibiotics are continued for 48 hours postoperatively until the intraoperative culture
results are available and then stopped or continued if the culture is positive. We carefully pad the down side,
insert an axillary roll, protect the peroneal nerve area, and ankle to minimize the chance of neurological or skin
pressure problems due to positioning. A stable vertical and horizontal position allows the surgeon to improve
pelvic positioning, which facilitates proper acetabular-component implantation when necessary. Several
commercially available hip positioners are available that provide accurate and stable pelvic positioning.
Consideration should be given to the use of intraoperative blood salvage (cell saver), as these surgeries can be
long with significant blood loss.
The leg, hip, pelvis, and lower abdomen are prepped and draped in the usual fashion. If possible, the previous
surgical incisions are used. If no previous incision is present, then a simple curvilinear incision centered over the
greater trochanter is recommended. The fascia is incised in line with the skin incision, and the status of the
greater trochanter is evaluated. If the greater trochanter is not fractured, either an anterolateral or posterolateral
approach can be used effectively based on surgeon preference. In the acute fracture situation, it is always
preferable, if possible, to leave the abductor-greater trochanter-vastus lateralis complex intact in a long sleeve
during the reconstruction.
In nonunions or neglected fractures, the trochanter may be malunited and preclude access to the intramedullary
canal. In this situation, the so-called trochanteric slide technique may be useful (Fig. 19.1). The technique of
preserving the vastus-trochanter-abductor sleeve may minimize the chance of so-called trochanteric escape and
should be used whenever possible.
If hardware is present in the proximal femur, I have found it helpful to dislocate the hip prior to hardware removal.
The torsional stresses on the femur during surgical dislocation can be substantial, especially in these typically
stiff hips, and iatrogenic femur fracture can occur with attempted hip dislocation. Whether removing an
intramedullary nail or sliding compression hip screw and side plate, having implant-specific extraction tools is
extremely helpful. The principles of reconstruction are similar regardless of whether a nail or plate was used. If
previous surgery has been performed, intraoperative cultures and frozen section pathology are obtained from the
deep soft tissues and bone. If there is evidence of acute inflammation or other gross clinical evidence of
infection, the hardware is removed, all nonviable tissues are débrided, and the proximal femoral-head fragment is
resected with placement of an antibiotic-impregnated polymethacrylate spacer. Reconstruction is delayed 6 to 12
weeks or longer while the patient receives organism-specific intravenous antibiotics based on the intraoperative
cultures.
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FIGURE 19.1 A. Trochanteric slide technique, initial exposure: the sleeve of abductors and vastus lateralis are in
continuity. B. Trochanteric slide technique, deep exposure. Note continuity of the musculotendinous sleeve with
mobilization of the greater trochanter.

With the hip dislocated either anteriorly or posteriorly, the proximal fragment is excised, and the acetabulum is
circumferentially exposed. The quality of the remaining acetabular cartilage is evaluated. If the cartilage is well
preserved, then a hemiarthroplasty is most commonly utilized. Appropriate attention to head size with
hemiarthroplasty is important as an undersized component can lead to medial loading, instability, and pain, while
an oversized component can lead to peripheral loading, instability, and pain as well. If preexisting degenerative
change is seen on radiographs or the acetabular cartilage is damaged from prior hardware cutout, a total hip
replacement is strongly recommended. Of course, even in the setting of normal-appearing acetabular cartilage,
an acetabular component may provide more predictable pain relief, and this decision should be made at the time
of surgery. The acetabulum is carefully reamed because these hips do not have the thick, sclerotic subchondral
bone commonly found in patients with osteoarthritic hips. The acetabulum is reamed circumferentially until a
bleeding bed is obtained. I prefer uncemented acetabular fixation due to the versatility it allows with the liner,
bearing surface, and head size options. I also typically augment the cup fixation with several screws.
Attention is then turned to the femur. It should be emphasized that the femoral side of the reconstruction is
typically more challenging than the acetabular side in this setting. The general principles of femoral
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reconstruction are summarized diagrammatically in Figure 19.2. It is important to carefully evaluate the level of
bony deficiency medially. Typically, bone loss from the fracture or a nonunion results in a bony deficit well below
the standard resection level for a primary total-hip arthroplasty. Therefore, a calcar prosthesis is almost always
necessary to restore leg length and hip stability. Femoral components with modular calcar augmentations are
available and allow intraoperative flexibility in restoring the hip mechanics. Occasionally, a large posteromedial
fragment may be reduced and stabilized with cerclage wires or cables, which helps in determining femoral
component height. In the acute fracture situation, reduction by wire or cable can potentially result in bony
healing, thereby restoring medial bone stock.

FIGURE 19.2 A. Illustration summarizing the general principles of femoral reconstruction for intertrochanteric
fracture or salvage of failed internal fixation. Note the restoration of appropriate femoral-component height using
a calcar-replacing stem. Referencing the tip of the greater trochanter as a guide to restoring the center of
rotation. Secure fixation of the greater trochanter has been obtained as is typical: with a cable through and a
cable below the lesser trochanter. Note the stem length chosen to bypass all cortical stress risers by a minimum
of two diaphyseal diameters. B. Preoperative nonunion and hardware cutout after ORIF of an intertrochanteric
fracture. Note the acetabular erosion superiorly from the lag screw. C. Postoperative reconstruction with a total
hip arthroplasty with particulate bone grafting of the superior acetabular cavitary defect.

Sclerotic hardware tracks, fracture translation, callus, etc., can alter the morphology of the proximal femur
increasing the technical difficulty. These alterations can deflect reamers and broaches, leading to intraoperative
fracture or femoral perforation. I have found it useful to use a large diameter burr to provisionally shape the
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funnel of the proximal femur. Once these sclerotic areas have been opened, standard reamers and broaches can
be used to prepare the canal more safely.
If a compression screw and side plate are present, I recommend that the femoral stem bypasses the most distal
screw hole in the shaft by at least two cortical (diaphyseal) diameters. Because most adult femoral shafts are
approximately 30 mm in diameter, templating for 6 cm of bypass is a good general guideline for stem length.
Either cemented or uncemented femoral-component fixation can be effective in this type of reconstruction and is
based on the preoperative as well as the intraoperative assessment of bone quality. If an uncemented femoral
component is chosen, I use an extensively coated design that can achieve distal diaphyseal fixation. This
strategy allows the surgeon to bypass stress risers effectively yet not rely on proximal bony support for implant
stability. Cemented fixation may be advantageous for elderly patients with capacious, osteopenic femoral canals.
Regardless of whether cemented or uncemented fixation is used, intraoperative radiographs are recommended
to assure appropriate alignment and length as well as to rule out iatrogenic fracture or extravasation of cement.
Extravasated cement can be a cause of late periprosthetic fracture, and it if it occurs, it should be carefully
removed. Small, medial, screw-hole extravasations can usually be ignored as long as they are bypassed
sufficiently by the femoral component.
A helpful guide to the proper height of the calcar reconstruction is the relationship between the center of the
femoral head and the tip of the greater trochanter: It should be essentially coplanar. Although this may be difficult
to assess in the presence of a trochanteric fracture, usually, the greater trochanteric fragments are still
somewhat attached and can be used as a gross guide for evaluating the appropriate level of calcar buildup. A
trial reduction is performed, and leg lengths and hip stability are assessed. Again, intraoperative radiographs
should be obtained. The author typically obtains an intraoperative radiograph after the permanent acetabular
component and the trial femoral component are in place, and then once again, after the definitive femoral
components are implanted, and the greater trochanteric fragment fixation, if necessary, is complete.
Intraoperative fluoroscopy can be very useful and is used routinely.
Regardless of the method of femoral fixation, it is wise to use local bone graft obtained from the resected
femoral-head fragment to fill any lateral cortical defects from prior hardware as well as the interface with the
greater trochanter and the femoral shaft, if necessary. Countless methods of greater trochanteric fixation have
been described; however, most surgeons now use multiple wires or a cable claw technique. Commercially
available “claw plates” may be advantageous, but their lateral bulk can be problematic in thin patients.
Regardless of the method chosen, the greater trochanteric fixation should be stable through a full range of
motion of the hip. Liberal autogenous bone graft from reamings is applied around the interface of the greater
trochanter and the femoral shaft. The fascia, subcutaneum, and the skin are in layers. Representative cases
emphasizing these principles are shown in Figures 19.2 to 19.5.
FIGURE 19.3 A. Preoperative failed ORIF with proximal fragment translation and screw cutout. B. Postoperative
reconstruction with a total hip arthroplasty with calcar augmentation to restore appropriate femoral-component
height, thereby restoring leg length and hip stability.

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FIGURE 19.4 A. Preoperative failed ORIF of a reverse obliquity fracture. Note the difficulty in managing the
greater trochanter in this situation. B. Postoperative reconstruction with calcar-replacing bipolar hemiarthroplasty
through a trochanteric slide technique.

FIGURE 19.5 A. Preoperative failed ORIF with screw cutout. The acetabular joint space is well preserved. B.
Postoperative radiograph demonstrating a cemented calcar-replacing bipolar hemiarthroplasty.

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REHABILITATION
In general, weight bearing can progress as tolerated after surgery; however, the surgeon should individualize the
rehabilitation regimen based on patient compliance, quality of intraoperative component fixation achieved, and,
most importantly, the status of the greater trochanter. If trochanteric fixation is required, the selective use of an
abduction orthosis, partial weight bearing for 6 weeks, and avoidance of abductor strengthening until
trochanteric union has occurred is recommended. Sutures are typically removed at 2 weeks, and periodic
radiographs are obtained to evaluate component fixation and trochanteric healing. Clinical and radiographic
follow-up is performed at 6 weeks, 12 weeks, and 1, 2, and 5 years postoperatively, then every 2 years
thereafter. For asymptomatic elderly patients with transportation difficulties, the follow-up periods are modified to
6 weeks, 3 months, 1 year, and then every 5 years thereafter.

RESULTS
There are several reports of arthroplasty for intertrochanteric fracture in the literature. They generally
document the efficacy of arthroplasty as an alternative treatment for the acute fracture; however,
complications still remain concerning. Most reports using arthroplasty for intertrochanteric fractures are for
salvage of failed internal fixation. Haidukewych and Berry reported on 60 patients undergoing hip
 arthroplasty for salvage of failed ORIF. Overall, functional status improved in all patients, and the 7-year
survivorship free of revision was 100%. Pain relief was predictable. Dislocation was not a problem;
however, persistent trochanteric complaints and problems obtaining bony trochanteric union were common.
Both bipolar and total hip arthroplasties performed well. Calcar-replacing designs and long stem prostheses
were necessary in the majority of cases.

COMPLICATIONS
Medical complications are common due to elderly, frail patients undergoing complex, prolonged
surgery. Thromboembolic prophylaxis, perioperative antibiotics, and early mobilization are
recommended. If a long-stem cemented implant is used, intraoperative embolization and
cardiopulmonary complications can occur. It is important to lavage and dry the canal thoroughly prior to
cementing longer stems in these frail patients, and little, if any, pressurization should be used. Infection
and dislocation are surprisingly rare after such reconstructions in which modern techniques and
implants are used. The principles of treatment of an infected arthroplasty are beyond the scope of this
chapter. Dislocations are managed with closed reduction and bracing as long as the trochanteric
fragment fixation remains secure. Problematic recurrent dislocations due to trochanteric (abductor)
insufficiency in patients with well-positioned components can be effectively managed with constrained
acetabular liners.
Trochanteric complaints, including bursitis, hardware pain, and nonunion, are the most common
complications after reconstruction. Patients should be counseled preoperatively that such chronic
complaints are very common. Bony union will occur in many but not all trochanteric fragments. Stable
trochanteric fibrous unions in good position will often be asymptomatic and not require treatment.
Displaced trochanteric escape, if symptomatic, is typically treated with a repeat internal fixation attempt
with some form of bone grafting. The best treatment is prevention, with extremely secure initial
trochanteric fixation, the use of the trochanteric slide technique if mobilization of the trochanter is
required, liberal use of autograft bone at the trochanter-femur interface, and careful postoperative
rehabilitation and bracing. Problematic high Brooker grade heterotopic ossification is rare after these
reconstructions, and the senior author does not use routine prophylaxis.

SUMMARY
Hip arthroplasty is a valuable addition to the armamentarium of the surgeon treating intertrochanteric hip
fractures. In general, it is reserved for neglected fractures, pathologic fractures due to neoplasm, salvage of
internal fixation failure and nonunion, and (rarely) for fracture in patients with severe, symptomatic,
preexisting degenerative change. Attention to specific technical details is important to avoid complications
and provide a durable reconstruction. Trochanteric complications are common, but functional improvement
and pain relief are predictable.

RECOMMENDED READING
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Orthop 2003;371: 206-215.
Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed
intertrochanteric femur fracture fixation. Orthopedics 2010;33:721.

Choy WS, Ahn JH, Ko JH, et al. Cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures
in elderly patients. Clin Orthop Surg 2010;2:221-226.

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D'Arrigo C, Perugia D, Carcangiu A, et al. Hip arthroplasty for failed treatment of proximal femoral fractures.
Int Orthop 2010;34:939-942.

Eschenroeder HC Jr, Krackow KA. Late onset femoral stress fracture associated with extruded cement
following hip arthroplasty. Clin Orthop 1988;236:210-213.

Geiger F, Zimmermann-Stenzel M, Heisel C, et al. Trochanteric fractures in the elderly: the influence of
primary hip arthroplasty on 1-year mortality. Acta Orthop Trauma Surg 2007;127:959-966.

Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable
intertrochanteric hip fractures in the elderly. Clin Orthop 1987;224:169-170.

Grimsrud C, Monzon RJ, Richman J, et al. Cemented hip arthroplasty with a novel cerclage cable technique
for unstable intertrochanteric hip fractures. J Arthroplasty 2005;20:337-343.

Haentjens P, Casteleyn PP, DeBoerk H, et al. Treatment of unstable intertrochanteric and subtrochanteric
fractures in elderly patients: primary bipolar arthroplasty compared with ORIF. J Bone Joint Surg Am
1989;71(8):1214-1225.

Haentjens P, Casteleyn PP, Opdecam P. Primary bipolar arthroplasty or total hip arthroplasty for the
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1994;60:124-128.

Haentjens P, Casteleyn PP, Opdecan P. Hip arthroplasty for failed internal fixation of intertrochanteric and
subtrochanteric fractures in the elderly patient. Arch Orthop Trauma Surg 1994;113:222-227.

Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures.
J Bone Joint Surg Am 2003;85:899-905.

Haidukewych GJ, Berry DJ. Revision internal fixation and bone grafting for intertrochanteric nonunion. Clin
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Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity of fractures of the intertrochanteric region of the
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Hammad A, Abdel-Aal A, Said HG, et al. Total hip arthroplasty following failure of dynamic hip screw fixation
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treatment of unstable intertrochanteric fractures in the elderly. Orthopedics 1990;13:1131-1136.

Kim Y-H, Oh J-H, Koh Y-G. Salvage of neglected unstable intertrochanteric fractures with cementless
porous-coated hemiarthroplasty. Clin Orthop 1992;277:182-187.

Knight WM, DeLee JC. Nonunion of intertrochanteric fractures of the hip: a case study and review. Orthop
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Kyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the femur. Instr Course Lect
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Lifeso R, Younge D. The neglected hip fracture. J Orthop Trauma 1990;4:287-292.

Mariani EM, Rand JA. Nonunion of intertrochanteric fractures of the femur following open reduction and
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Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures.
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Sarathy MP, Madhavan P, Ravichandran KM. Nonunion of intertrochanteric fractures of the femur. J Bone
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 20
Subtrochanteric Femur Fractures: Plate Fixation
Michael J. Beltran
Cory A. Collinge

INTRODUCTION
Subtrochanteric femur fractures are challenging injuries to manage, and no single method of treatment is
applicable to all fracture patterns. Following a fracture, powerful hip muscle forces often lead to complex but
predictable deformities (Fig. 20.1). Intertrochanteric extension, fracture comminution, and poor bone quality
increase the difficulty in treatment and require careful preoperative planning. The goal of surgery is to restore
length, alignment, and rotation using an implant that provides stable internal fixation and allows early mobilization
and protected weight bearing. Subtrochanteric fractures are usually treated with an intramedullary nail or a fixed
angle plate; however, the choice of implant depends on the fracture pattern, host factors, and the surgeon's
experience and resources (1, 2, 3, 4, 5, 6, 7 and 8). Several classification schemes have been proposed to
categorize subtrochanteric fractures. The comprehensive classification of the AO/OTA is predominately
descriptive while the Russell-Taylor classification attempts to guide treatment with either a nail or plate. The
purpose of this chapter is to discuss the rationale for plating of the proximal femur and highlight proven
techniques that are necessary to achieve a quality reduction and place appropriate, stable internal fixation.

INDICATIONS AND CONTRAINDICATIONS

Virtually all subtrochanteric femur fractures in adolescents and adults require surgery. Given the substantial and
serious risks associated with nonoperative care, including deep vein thrombosis, pressure decubiti, urinary tract
infections, and pneumonia, traction and casting should only be considered in patients with extremely serious
medical comorbidities that preclude surgical intervention. There is widespread agreement that the benefits of
correctly done surgery far exceed the risks. For any surgery in the proximal femur, the surgeon must be familiar
with the anatomy around the hip to achieve consistently good outcomes. Furthermore, a working knowledge of
fracture fixation principles, both mechanical and biologic, is necessary. Proximal femoral plating is
contraindicated in any circumstance where the surgeon is unfamiliar with these techniques.
For most subtrochanteric fractures, an intramedullary nail is the treatment of choice. There is a large body of
literature documenting successful outcomes following nailing of these difficult injuries (1,2,4,8). Plating is
reserved for a subset of fractures where nailing would be challenging and place the patient at an increased risk
for complication or failure.
Open reduction and plate fixation of a subtrochanteric femur fractures is indicated in the following situations:
1. The use of an intramedullary implant is precluded by distal implants (i.e., stemmed total knee prosthesis).
2. A preexisting implant that must be removed through an open approach.
3. Comminution of the lateral wall or fracture extension into the greater trochanter or piriformis fossa that makes
the use of an intramedullary device difficult or impossible.
4. For internal fixation after corrective osteotomies for malunion or nonunion of the proximal femur.
The advantage of plating, compared with nailing, is that it reduces the risk of injury to the hip abductors and
short external rotators, minimizing the incidence of heterotopic ossification, especially in patients with head
injuries.
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FIGURE 20.1 Muscle attachments around the proximal femur lead to predictable deformity pattern after
displaced subtrochanteric fracture.

PREOPERATIVE PLANNING
History and Physical Examination
While subtrochanteric femur fractures are seen in all age groups, they most commonly occur in two age clusters.
The first group is elderly osteoporotic patients with fractures that occur following low energy falls or
bisphosphonate-related stress fractures. Recent studies have shown a correlation between prolonged
bisphosphonate use and atypical fractures of the femur (9,10). In older patients, a history of malignancy should
also be sought, as the subtrochanteric region of the femur is a common site for bony metastasis. The second
group of patients is younger individuals whose fracture occurs after high-energy trauma (e.g., motorcycle or
motor vehicle collisions and falls from a height).
A thorough history and physical examination is mandatory prior to treatment. Advanced Trauma Life Support
protocols are used in all seriously injured patients. Virtually all patients present with a painful swollen thigh and
are unable to stand or walk. The leg is externally rotated and shortened. Motion in the leg is reduced and very
painful. The physical examination should clearly document the neurovascular status. Abnormal or asymmetric
distal pulses warrant further studies (i.e., ankle-brachial indices) to rule out a vascular injury. ABIs <0.90 require
a vascular consultation and workup (11).
Once life and limb-threatening injuries have been appropriately addressed, the secondary and later tertiary
surveys should identify all other musculoskeletal injuries, particularly in the polytraumatized patient with a head
or chest injury. Concomitant injuries often impact the timing of surgery and patient positioning and may alter the
surgical approach or type of implant to be used. While uncommon, open fractures of the proximal femur often
involve small anterior or anterolateral wounds secondary to an inside-out mechanism. All open fractures require
early and thorough surgical débridement with fracture stabilization.

Imaging Studies
Initial radiographs should include an AP and lateral of the femur and hip, an AP pelvis, as well as knee films to
rule out associated injuries. Traction views with intravenous sedation of the femur are very helpful, as shortening
and external rotation are typically present and often obscure the true fracture geometry. Computed tomography
(CT) is not typically required for subtrochanteric fractures below the level of the lesser
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trochanter. However, a CT scan may be useful if plain radiographs suggest or show involvement of the femoral
neck, greater trochanter, or piriformis fossa. Imaging studies must be critically reviewed to determine the integrity
of the proximal fragment, since extensive comminution here may preclude the use of an intramedullary nail.
Subtrochanteric fractures secondary to low energy falls should also be assessed to rule out a pathologic lesion
or an atypical fracture secondary to prolonged bisphosphonate use. The latter typically involve a simple
transverse or short oblique fracture associated with cortical beaking and thickening (9,10).

Timing of Surgery
Subtrochanteric femur fractures should be considered an urgent orthopedic injury particularly following high-
energy trauma because of the inability to mobilize patients until definitive stabilization has been performed. In a
patient who is stable and cleared for surgery, internal fixation with a plate or nail should be done as soon as
possible, preferably within 24 hours. In the polytraumatized patient in extremis and borderline patients with head
and/or chest trauma, damage control surgery using a spanning external fixator may be indicated. Open fractures
require emergent débridement and irrigation. We prefer to treat Gustilo and Anderson type I and II fractures with
a first-generation cephalosporin and type III open fractures with the addition of an aminoglycoside. Grossly
contaminated wounds are uncommon in the proximal femur, but when present the addition of penicillin is
advisable.

Surgical Tactic
When surgery is planned, a surgical tactic should be developed to enhance efficient surgery and minimize
surgical errors (Fig. 20.2). The surgical tactic outlines whether a direct or indirect reduction is required, whether
a traditional fixed angle device or a proximal locking plate is necessary, and whether a percutaneous technique
can be employed. Tracing out the fracture on paper may help the less-experienced surgeon understand the
fracture geometry and the reduction steps better. In circumstances where hospital inventory is limited, a
preoperative plan also ensures that all necessary implants are available, especially longer plates, which may
require special order. With the use of a 95-degree blade plate, the length of the blade should be determined
preoperatively, because intraoperative removal of a wrong-sized implant is difficult and fraught with problems.
FIGURE 20.2 A preoperative plan allows the surgeon to review the important concepts for repair of these
complex fractures, mobilize necessary resources, and potentially make any errors on paper instead of in surgery.

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The preoperative plan should also take into consideration how intraoperative imaging will be obtained, because
the flexed, abducted, and externally rotated position of the proximal fragment makes obtaining standard
orthogonal AP and lateral projections difficult. High-quality intraoperative imaging is absolutely critical for fracture
reduction and screw placement into the femoral head. Prior to draping, the C-arm should be positioned to confirm
that correct views can be consistently obtained, unhindered by overlap of the contralateral thigh.
Two methods of plate fixation for subtrochanteric femur fractures are presented with clinical and radiographic
images to demonstrate specific points. First is the “classic” example of a 95-degree angled blade plate (see Fig.
20.10), and the second uses a “modular” fixed angled implant (see Fig. 20.11). Patient positioning and reduction
and fixation strategies are similar for both implants.

IMPLANT SELECTION
Compared to plates, nails have a biomechanical advantage given their intramedullary location that decreases
bending stresses, varus angulation, and prevents shaft medialization. Contemporary intramedullary nails allow
for trochanteric or piriformis entry and enhanced proximal fixation with one or two screws inserted into the
femoral neck and head. As a result of these advances, recent studies of subtrochanteric femur fractures fixed
with intramedullary nails have demonstrated high union rates and a low incidence of complications (1,4).
Despite their mechanical advantages, intramedullary nailing of subtrochanteric fractures can be technically
difficult and fraught with problems. Virtually all nails have an enlarged upper portion to accommodate the
proximal interlocking screws designed for femoral head placement. This requires reaming with removal of
substantial amounts of bone from the proximal femur (Fig. 20.3). Furthermore, injury to the abductor mechanism
has been reported leading to gait disturbances, persistence of pain, or difficulties if revision surgery is required.
Occasionally, fracture extension from the entry portal may occur during reaming or insertion of the nail and may
cause fracture displacement or varus malalignment.
The Russell-Taylor classification system was devised to help guide implant selection (Fig. 20.4). Type IA and IB
fractures are easily managed with nails placed through either a piriformis or trochanteric starting point at the
discretion of the surgeon. Type 2A fractures, due to fracture extension into the piriformis fossa, preclude use of a
piriformis starting point but are often still well treated with trochanteric nails. Type 2B fractures, particularly those
complicated by lateral wall comminution, are perhaps the best indication for plating of the proximal femur. Fixed
angle plates have been successfully used to treat selected subtrochanteric fractures and avoid many of the
problems encountered during nailing. Classically, these fractures were treated with a 95-degree blade plate or a
dynamic condylar screw (DCS) and side plate and recently with periarticular locking plates.
The use of these implants allows either direct anatomic reduction with internal fixation or indirect reduction and
bridge plating techniques. Simple two- or three-part fractures can be reduced anatomically and fixed leading to
absolute stability and primary bone healing. Plate tensioning and fracture compression allow the bone to share
load with the plate, increasing mechanical stability and reducing implant fatigue. More complex and comminuted
fracture patterns are better treated with indirect reduction and bridge plating (relative stability). In either case,
fracture reduction in terms of axial alignment, rotation, and length must be restored if optimal healing and return
of function are to be achieved.

FIGURE 20.3 Intraoperative fluoroscopy during revision surgery shows significant amount of bone removed
during cephalomedullary nailing (arrowheads).

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FIGURE 20.4 Russell-Taylor classification of subtrochanteric factors attempts to predict which subtrochanteric
fractures may be well treated with nailing. Type I versus II addressed involvement of piriformis fossa/greater
trochanter where a nail may propagate or deform fractures. Types A versus B addresses involvement of lesser
trochanter and posteromedial buttress.

Fixed angle plates minimize injury to the abductor mechanism, which may be particularly important in younger
patients, and can be used as a reduction aid, when applied properly. However, plating the proximal femur carries
its own set of disadvantages. Bridge plating of unstable fractures creates a load bearing rather than load-sharing
implant and is mechanically inferior to a nail. The risk of failure increases in patients with poor bone quality
treated with conventional plates and screws. In this setting, the substantial forces across the subtrochanteric
region may lead to implant failure.
Currently, plating of the proximal femur is most commonly performed with either a 95-degree angled blade plate,
a 95-degree DCS (Synthes, Paoli, PA), or newer proximal femur locking plates. All of these implants are fixed
angle devices that improve stability in the proximal femur. Historically, the 95-degree blade plate (Fig. 20.5) was
the most commonly used implant for the internal fixation of proximal femur fractures, and there is a large body of
literature supporting its use (6,7,12, 13 and 14). However, outside academic medical centers, it is not commonly
utilized due to technical complexity and surgeon inexperience. The 95-degree DCS (Fig. 20.6) was developed to
address some of these technical issues, but requires removal of significant amounts of proximal bone and has
never gained widespread acceptance.
Newer locking plates anatomically contoured to fit the proximal femur have recently been developed (Fig. 20.7).
These plates improve mechanical stability using multiple screws that are locked into the plate creating a
construct with multiple “fixed angle” screws. Additionally, these locking plates were manufactured to facilitate
submuscularly insertion using smaller and potentially more biologically sparing approaches. Finally, a locking
proximal femur plate, while still technically challenging, may be more “user friendly” compared to a traditional 95-
degree blade plate. Despite these apparent benefits, locking plates for the proximal femur are not a panacea for
this difficult injury. Thoughtful and technically proficient surgical techniques are important because implant
failures are not uncommon (15).

SURGERY
Positioning and Setup
General or spinal anesthesia is utilized in consultation with the anesthesiologist. We prefer general anesthesia
as it allows complete muscle paralysis that helps overcome the powerful deforming muscle forces in the proximal
femur necessary to obtain a reduction. For polytraumatized patients and those with serious medical
comorbidities, central lines should be considered and blood products made readily available because blood loss
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500 mL or more is common. For closed fractures, we recommend 1 to 2 g of cefazolin (Ancef) administered within
an hour of skin incision and continued for 24 hours postoperatively. For patients with a penicillin allergy and
previous methicillin-resistant Staphylococcus aureus infection and for high-risk patients, alternatives such as
clindamycin or vancomycin may be indicated.

FIGURE 20.5 Case example x-rays of a subtrochanteric fracture in a 35-year-old man above a preexisting plate
(healed fracture) repaired using a 95-degree angled blade plate.
FIGURE 20.6 Case example radiographs of a 26-year-old man with multisegmental femur fractures repaired with
shaft nailing and use of a 95-degree DCS device for the proximal fractures.

FIGURE 20.7 Case example x-rays of a 45-year-old man with a subtrochanteric femur fracture 2 years after
acetabular reconstruction with osteotomy, subsequently repaired using a proximal femur locking plate.

The patient can be positioned supine or lateral, either on a radiolucent flattop or fracture table, based on
surgeon preference and experience. Traditionally, most of these surgeries have been done with the patient
positioned supine on a fracture table. Most surgeons are comfortable with this position, and it allows for strong
sustained longitudinal traction, which may be important in nonteaching hospitals where qualified assistants are
not available. An additional benefit of the supine position is in the polytraumatized patient with pulmonary injury
because it avoids a “dependent” lung. The supine position also allows other injuries to be addressed without the
need to reposition the patient. However, supine positioning on the fracture table does not consistently eliminate
reduction problems such as posterior sag or varus malalignment. Strong and sustained traction can also lead to
pudendal nerve palsies. Adducting the limb against the perineal post often increases the varus deformity
particularly in large or obese patients.
When using a fracture table with the patient in the supine position, reduction and imaging are improved by
“scissoring” the legs up and down. The injured leg is elevated while the unaffected leg is lowered. The use of a
well leg lithotomy holder is less attractive because the pelvis cannot be fully stabilized against the peroneal post,
comparison views of the opposite hip are not possible, and compartment syndromes have been described
(16,17). We prefer the lateral decubitus position on a radiolucent table, because it improves fracture reduction
and exposure by relaxing the abduction force of the gluteus medius and neutralizes the posterior sag commonly
encountered with supine positioning. The pelvis, hip, and entire lower limb are prepped and draped free to allow
for traction and manipulation of the extremity as well as aiding intraoperative fluoroscopy.
A thorough aseptic prep (e.g., alcohol- and chlorhexidine-based solution) is applied to the skin. We routinely use
an iodine impregnated adhesive (Ioban, 3M, Minneapolis, MN) to isolate the surrounding skin and perineum from
the operative field and to secure draping.

Imaging
Whether using a fracture table or a flat-top radiolucent table, optimal anteroposterior (AP) and lateral imaging of
the proximal femur including the head and neck are mandatory and must be confirmed preoperatively. With the
patient positioned supine, AP views are easily obtained, but obtaining a good lateral view generally requires that
the C-arm be rotated “off axis” to account for the typical external rotation deformity seen as well as to can be
obtained clear the well leg. Accurate AP imaging requires the C-arm to be rolled beyond neutral to accommodate
rotational deformities, and a slight cranial tilt often improves visualization of the flexed proximal fragment. If the
patient is positioned laterally, “AP” views of the hip and femur are easily obtained with a “shoot-thru”
posteroanterior view (Fig. 20.8). A true lateral of the femoral neck is obtained with a dual roll over view, which
tilts the beam 25 degrees caudad in order to profile the femoral neck and 10 degrees of posterior rollover to
account for anteversion of the hip. The imaging sequence should be rehearsed prior to prepping and draping to
ensure optimal AP, and lateral visualization of the proximal femur can be obtained during the procedure.
Whenever possible, leg length and limb rotation should to compared to the opposite side.

FIGURE 20.8 Clinical photographs of patient with a subtrochanteric femur fracture (A) in lateral position on a
radiolucent flat top table. The limb is draped free (B) to allow manipulation and a direct lateral approach to the
proximal femur is planned.

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Surgical Approach
A direct lateral approach to the proximal femur is used for open reduction and plate osteosynthesis of
subtrochanteric fractures (Fig. 20.9). The incision begins a few centimeters proximal to the tip of the greater
trochanter and extends distally in line with the femoral shaft as far is needed. After incising the skin and
subcutaneous
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tissue, the iliotibial band is incised in line with the skin incision. The vastus ridge on the lateral wall of the
trochanter, if not fractured, is easily identified and represents an important landmark for orienting a blade plate or
proximal locking plate. If this area is fractured, direct reduction and lag screw fixation is usually required to
restore the lateral wall, especially if a blade plate is to be utilized.

FIGURE 20.9 Lateral approach to the proximal femur is diagrammed. A. The greater trochanter and lateral femur
can usually be palpated and the skin incision follows this longitudinal line. B. The tensor fascia lata is divided
longitudinally in line with the skin incision. C. The vastus lateralis is elevated anteriorly and the lateral aspect of
the proximal femur is exposed without extensive soft-tissue stripping. Perforating vessels are identified and
ligated.

The muscle belly of the vastus lateralis is carefully elevated from the lateral intermuscular septum and retracted
anteriorly, exposing the lateral aspect of the femoral shaft. Care must be taken to avoid periosteal stripping in
this area, which is already prone to slow healing and subject to significant mechanical forces that may limit the
longevity of implants. The dissection usually begins proximally and is carried distally. The approach exposes
multiple perforating femoral vessels, which should be identified and cauterized or ligated to avoid significant
bleeding. Soft-tissue elevation should be confined to the lateral femur, with minimal or no dissection medially to
limit further devitalization. Comminuted fracture fragments should be left in situ.

Minimally Invasive Techniques

In addition to traditional open approaches, plates may also be applied using minimally invasive, submuscular
techniques. Using these methods, surgeons make smaller incisions, and plates are placed submuscularly in an
effort to minimize the “surgical footprint.” The ultimate goal of these approaches is to maintain the fracture
biology by minimizing the amount of additional soft-tissue trauma and maintaining the fracture environment.
These are technical procedures that require thoughtful and vigilant usage of fluoroscopy to restore alignment, as
direct visualization of the fracture is precluded using these approaches. Finally, when using minimally invasive
techniques, the surgeon must adhere to the mechanical principles of modern fracture management (i.e., planning
for absolute or relative stability and long plates, according to preoperative plan) and executing the plan that
carries out these principles.
Some fixation systems dedicated to repair of proximal femur fractures have features to aid in minimally invasive
insertion of plates and screws, including radiolucent targeting devices, calibrated, and/or cannulated drill and
screw guides.
For minimally invasive plating of subtrochanteric fractures, the “working” incision is proximally based: a
longitudinal skin incision is centered laterally over or just inferior to the vastus ridge. The tensor fascia lata is
incised in line with the skin incision. The origin of the vastus lateralis muscle contains dense Sharpey's fibers,
which must be released for optimal plate application. The plate is inserted through the incision using the
attached handle/targeting device. The plate is slid along the shaft of the femur between muscle and periosteum
keeping the distal tip of the plate against bone. Plate position is confirmed fluoroscopically in the AP and lateral
projections.

Reduction
Subtrochanteric femur fractures are associated with characteristic deformities. The proximal fragment is usually
flexed, abducted, and externally rotated by the pull of the iliopsoas, gluteus medius, and the short external
rotators of the hip, respectively (Fig. 20.1). The femoral shaft is usually medialized by the pull of the adductors
and sags posteriorly and collapses into varus. Deformity correction involves longitudinal traction to restore length
and can be accomplished by manual traction, the use of a fracture table, a universal distractor (Synthes, Paoli,
PA), or temporary external fixation. Large pointed reduction clamps (i.e., Weber clamps) or a carefully applied
serrated clamp can help reposition and reduce the proximal fragment to the femoral shaft. When simple
correction of abduction or flexion is necessary, the use of a ball-spike pusher on the anterior cortex or a Schanz
pin with a T-handled chuck anchored in the proximal fragment can be very effective at fine-tuning the reduction.
Finally, a well-placed small or minifragment “tacking” plate can aid in maintaining an unstable reduction, but must
be considered carefully if it will significantly affect the local biology at the fracture site or impede definitive
fixation.
When correctly applied, anatomically contoured proximal femoral plates can improve the reduction by reducing
the fracture to the plate. For simpler fracture patterns where reduction is relatively straightforward, we often
reduce the fracture first and then apply the plate and screws. This may be done most easily with a proximal
femoral locking plate, where the construct capturing the proximal segment is modular and can be applied without
forceful manipulation. For fractures that are comminuted and displaced, applying a well-contoured plate, (either
the 95-degree blade plate or proximal femur locking plate) proximally, and using it as a reduction aid can be very
helpful. With the plate properly secured to the lateral aspect of the proximal fragment, the construct can be
reduced to the distal fragment and confirmed fluoroscopically.
We recommend direct reduction with minimal soft-tissue stripping for simple, noncomminuted fracture patterns
and those fractures with one or two large butterfly fragments amenable to lag screw fixation. Interfragmentary lag
fixation of large comminuted fragments in this region should only be attempted if an anatomic reduction without
soft-tissue stripping can be achieved; otherwise, an indirect reduction should be performed. If medial cortical
contact has been restored, compression of the fracture can be performed using an articulated tensioning device
attached to the end of the plate. By tensioning the plate and creating a load-sharing environment with the bone,
fracture healing with a low incidence of nonunion and hardware failure has been reported (14).
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When comminution precludes the use of direct reduction techniques or when a submuscular plate application is
planned, indirect fracture reduction using a bridge plate technique should be performed. In this situation, no
attempt is made to expose the fracture fragments distal to the head-neck segment after proximal plate
application. After length has been restored, distal screws are inserted using multiple small incisions or a short
open lateral approach distally. In this setting, a longer plate is desirable to increase mechanical stability and
minimize dissection in the zone of injury. With submuscular plate application, the use of a universal distractor is
necessary to regain length and indirectly reduce some of the cortical fragments via ligamentotaxis. If proximal
plate application is correct, mechanical alignment of the limb should be restored once the plate is fixed distally.
Longer plates with well-spaced screws are thought to be advantageous during bridge plating, especially when
locking screws are used. It is important to have at least six to eight screw holes available below the fracture site.
With longer working lengths, spacing rather than clustering screws in the shaft may be an effective means of
modulating implant stiffness. The use of shorter plates in comminuted fracture patterns is not advised, because
stress concentration occurs at the level of the fracture, increasing the chance of implant failure or nonunion
(18,19).

Fixation
95-Degree Angled Blade Plate: (Fig. 20.10)
The use of a blade plate is technically demanding but provides excellent stability in the proximal femur and has a
strong clinical record. Most of the technical challenge lies in positioning the cutting chisel for blade placement, as
this process must be precise simultaneously in three planes or a malreduction will occur. To facilitate accurate
placement, alignment wires and the 95-degree alignment guide can be used before cutting the blade's path with
the seating chisel. One guide wire is placed along the anterior femoral neck and helps recreate femoral
anteversion: errors in wire placement here will lead to rotational malalignment. Anatomically, the femoral neck
originates from the anterior one-half of the greater trochanter, and a common mistake is to place a wire centrally
within the trochanter, which may lead to external rotation deformity. Proper blade placement requires that the
seating chisel enters in the anterior half of the greater trochanter, just proximal to the vastus ridge. The blade
should pass about 10 mm below the superior face of the basicervical femoral neck. The next guide wire is
inserted to control coronal plane alignment. Using a preset alignment guide, this wire is placed through the
superior portion of the trochanter at an angle of 95 degrees relative to the femoral shaft. When inserted properly,
this wire should approach the inferomedial femoral head: errors in placement of this wire may lead to varus
malalignment and may predispose to implant failure and nonunion. With both guide wires in place, the chisel can
be inserted using the 95-degree alignment guide. A channel is created in the lateral cortex by predrilling with a
linear triple drill guide before chisel insertion. The slotted hammer is used to guide the chisel and make minor
corrections as it is inserted. In younger patients with dense cortical bone, the chisel should be backed out
frequently to minimize the risk of incarceration. Constant attention to the appropriate positioning of the chisel, in
concert with frequent AP and lateral fluoroscopic imaging, will minimize technical errors and ensure proper
preparation for the blade.
After chisel placement into the inferomedial femoral head is confirmed fluroscopically, the appropriate length
blade as templated from preoperative and intraoperative radiographs is inserted. The blade cannot be assumed
to follow the natural path cut by the chisel, and continued diligence in blade placement is necessary.
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Chisel placement does not remove bone from the femoral head and neck, so slight adjustments in blade
positioning are possible but technically difficult. After successful blade placement, additional screw fixation into
the proximal fragment and calcar femorale should be done.

FIGURE 20.10 Case example of a 72-year-old woman with a subtrochanteric femur fracture after a fall. A. Injury
radiographs.
FIGURE 20.10 (Continued) B. Intraoperative positioning is on the fracture table and incision is marked. C.
Intraoperative fluoroscopy images show use of summation pins to aid in correct insertion of chisel and 95-degree
blade plate. D. The chisel is placed along the axis of the femoral neck.
FIGURE 20.10 (Continued) E. The 95-degree blade plate is inserted and fixed with an additional point of screw
fixation proximally (F) before the fracture reduction is finalized, compression achieved, and shaft fixation applied.
Postoperative and 6-month follow-up (G) radiographs are shown.

Locking Proximal Femur Plate (Demonstrated in Fig. 20.11)

Locked plating has advanced the treatment of unstable periarticular fractures, including subtrochanteric and
peritrochanteric femur fractures. While clinical data regarding outcomes following locked plating of the proximal
femur is limited, correct application of locked plates using biologically friendly techniques has been shown to
improve results in other areas. An anatomically contoured plate applied to the proximal fragment may help
restore coronal, sagittal, and axial plane alignment when the plate is fixed proximally and then distally. Careful
attention to detail is necessary to minimize the tendency for varus malalignment. Proper reduction of the fracture
and alignment of the plate relies on placing guide wires within the femoral head. Because virtually no bone is
removed during guide wire insertion, it allows for incremental adjustment in the plate position prior to definitive
screw placement. Furthermore, because final plate position is dependent on guide wire position in the femoral
head and the lateral wall, an intact vastus ridge is not critical for proper implant placement.
Proximal femoral periarticular locking plates are now available from a variety of orthopedic implant
manufacturers. We describe the use of the Peri-Loc Proximal Femur Locking Plate (PFP, Smith and Nephew,
Memphis, TN),
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which is a 316-L stainless steel plate reinforced in the subtrochanteric area to resist fatigue failure. The PFP
allows up to six screws to be directed into the femoral head. It uses guide wires strategically directed into the
femoral neck and, when confirmed to be correctly placed fluoroscopically, allows cannulated screws to be
precisely inserted. The plate is positioned against the lateral aspect of the proximal femur and adjusted under C-
arm control until an “optimal fit” is confirmed. Prior to fixation, plate position should be centered distally on the
shaft as well. K-wires or a narrow clamp may be useful to stabilize the plate. A 3.2-mm guide pin is placed into
the “Alpha” hole of the plate, which serves as the designated reference point for correct plate and pin position
within the proximal fragment. The drill guides can also be used as handles to aid in positioning the plate. AP and
lateral C-arm radiographs must be obtained to ensure that guide wire placement is properly placed. The optimal
guide pin position (Alpha) is just superior to the calcar (AP view) and in line with the femoral neck axis (AP and
lateral views). The guide pin should be inserted deep within the femoral head, but should not penetrate the
subchondral bone. If the guide wire is not in the correct position in the femoral head, it should be removed, the
plate
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repositioned slightly, and the pin reinserted. The authors recommend that at least two guide pins be inserted into
the proximal femur and alignment confirmed on AP and lateral x-rays before proceeding with screw insertion.
Screw lengths are determined by measuring the guide pin with a calibrated depth gauge. We recommend that a
nonlocking screw be inserted into the “Alpha” hole first. Subsequent screws can be either nonlocking or locking
depending on the bone quality or fracture pattern. It is very important to avoid stripping the screws when using a
powered drill, and final tightening should always be done by hand. The modularity of modern locking plates
allows for more flexibility in when and how reduction is achieved. Combining standard nonlocked screws to lag
the bone to the plate followed by locked screws to improve construct stability is very helpful. Remember that if a
combination of nonlocking and locking screws is used, the nonlocking cortical screws must be inserted first
before any locking screws are inserted (lag before you lock), or the fixation of those screws can be
compromised.
FIGURE 20.11 Case example of a 43-year-old woman with a subtrochanteric femur fracture (A) with
peritrochanteric extension treated with a proximal femoral locking plate. B. In this case the patient was positioned
lateral and the leg draped free for ease of reduction and visualization. C. Reduction was achieved with a small
buttress plate and a pointed reduction clamp before plate application.
FIGURE 20.11 (Continued) D. The plate is centered along the lateral femur to gain an “optimal” fit and the
guide pin is placed through the Alpha hole, along the calcar and centrally to ensure that fixation will be suitable.
Additional fixation is applied according to the preoperative plan. Postoperative (E) and 6-month follow-up (F) x-
rays show an aligned and ultimately healed proximal femur.

Tips and Tricks

1. These are not everyday cases for ANY surgeon. The preoperative plan allows for a more efficient and less-
stressful surgical experience and can decrease the risk for surgical failure. Preoperative drawings are a useful
exercise, particularly for surgeons unfamiliar with the techniques or those in training. This practice helps
ensure that the proper equipment and implants are available as determined before surgery.
2. In order to obtain high-quality fracture reductions, the surgeon must have a clear understanding of the
deformity affecting both the proximal and distal fragments. The proximal fragment is typically flexed, abducted,
and externally rotated, while the distal segment sags posteriorly and may be deformed by the pull of the
adductor complex.
3. Intraoperative assessment of alignment is discussed in several parts of this chapter, including a
comprehensive method of achieving this critical component for “successful” surgery. An organized, step-by-
step assessment should be a part of the preoperative plan.
4. The fracture hematoma is biologically valuable, and while it may be entered to facilitate reduction in cases
where open reduction and internal fixation with absolute stability is used, it should be preserved whenever
possible.
5. Minifragment or small fragment plates can be applied to effectively counteract deforming forces and
functionally simplify a fracture pattern (Case 2). These plates should be placed with caution, so as not to
impede the path of future screws or further devitalize bone.
6. Large AO bone forceps should be available when open reduction is planned. The large serrated reduction
clamps are useful for holding the major bone fragments, and the Verbrugge clamp is useful for aligning the
plate to bone (or vice versa) or applying compression with a push-pull screw. The articulated tensioner is also
useful for applying compression in a similar manner.
7. The femoral neck and head are anterior to the shaft, thus any implant (plate or nail) that is desired to follow
their axis must begin relatively anterior on the lateral aspect of the proximal femur.

POSTOPERATIVE MANAGEMENT
A cephalosporin antibiotic is used for 24 hours after fixation of closed fractures, and an aminoglycoside is added
for open fractures and continued for 48 to 72 hours, until wound closure is achieved. Patients are mobilized on
the first or second postoperative day depending on associated injuries. Quadriceps and abductor stretching and
strengthening are initiated during the first week, because weakness in these muscles has been documented at
1-year postinjury and may influence long-term functional outcomes (20,21). Thromboembolic chemoprophylaxis
is routinely employed and is strongly recommended. Because most plate constructs are load bearing, touchdown
weight bearing is employed until there is radiographic evidence of callus formation. As healing progresses,
patients are allowed to increase weight bearing. In cases where anatomic reduction has been achieved and
compression has created a load-sharing construct, earlier weight bearing may be allowed. We typically follow
these patients with AP and lateral radiographs at 6-week intervals after the initial postoperative visit until the
fracture is healed.

COMPLICATIONS
Complications related to plate fixation of subtrochanteric femur fractures can be divided into those
secondary to technical errors and those secondary to host factors. Technical errors include angular and
rotational malalignment, screw penetration into the hip joint, fracture shortening, and improper or
inappropriate implant selection and application. The most common technical error is residual varus
malalignment. Hip joint violation is avoidable with careful analysis of the intraoperative fluoroscopy views.
When direct reduction of the fracture is utilized, gapping at the fracture site should be avoided because it
increases the likelihood of implant failures and nonunion (22). Eight cortices of fixation distally are
recommended to provide the necessary implant strength to prevent early torsional and axial failure. A
common technical error encountered during indirect reduction and bridge plating is an overly stiff implant.
The use of longer plates with fewer but well-spaced cortical screws may limit implant stiffness and
encourage callus formation. With locked plating, an implant of sufficient length is necessary to allow for
spacing the screws to prevent stress concentration and premature implant breakage.
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Newer techniques to modulate locking plate stiffness have recently been reported. Far cortical locking,
slotting of near cortical holes, and threaded screw head inserts are all new methods designed to give
surgeons control of implant stiffness with some modulation of the healing environment (23, 24 and 25).
Despite well-performed surgery using modern operative techniques, some subtrochanteric femur fractures
fail to unite. Smokers and immunocompromised patients are particularly prone to these complications.
Implant failure is more likely to occur in elderly patients with osteoporotic bone (especially varus cutout),
although this complication is theoretically reduced with use of locking screws. In osteoporotic bone where
varus cutout is a concern, the use of an intramedullary device may be advisable to decrease stress across
the fracture and implant.
Postoperative Infection
Postoperative infection is relatively uncommon, but when it occurs is potentially devastating. Persistent
wound drainage after surgery should be monitored carefully. A wound hematoma is much more common
than infection and generally much easier to treat. A timely I&D of a draining hematoma before it becomes
infected is usually straightforward and successfully treated with primary wound closure as long as the
wound appearance and serum infection markers are benign, and intraoperative Gram stain is inconsistent
with infection. If a true infection is present, a more aggressive approach is mandated. If deep infection is
obvious or highly suspected, wide surgical débridement and treatment with intravenous antibiotics are
obligatory. The hardware should be carefully assessed for loosening, and, if fixation is lost, implants should
be removed. The patient may benefit from a brief vacation from hardware in skeletal traction or stabilization
with an antibiotic-coated intramedullary nail in cases of chronic infection. A recent study suggests that a
successful outcome is possible with retained implants for acute deep infections (26). The wound bed may
be well addressed with antibiotic beads or a negative pressure dressing. Once the infection is controlled,
revision internal fixation may be appropriate.
Delayed Union/Nonunion
The subtrochanteric area has correctly been labeled as a problem area in terms of healing. Under normal
circumstances, the area is under high mechanical stress, and nonunion is more common. This may be
especially true if there is residual malalignment or the stability is compromised. Biologically, the
subtrochanteric area is presumed to be a vascular watershed, where additional insult after a high-energy
injury or aggressive surgical dissection may not allow adequate local biology for healing. If there is no
progression toward healing 12 or 14 weeks postoperatively, autogenous bone grafting should be
considered. We still favor iliac crest autograft, which remains the gold standard, although reamer irrigator
aspirator grafting from the contralateral femur or bone morphogenic proteins are alternatives in some cases.
Alternatives to autogenous iliac crest bone graft are considered in high risk patients such as obesity,
diabetes, and steroids. Bone grafting of a well-stabilized fracture may be a lesser surgical burden than
hardware removal and intramedullary nailing. Suffice it to say that mechanical, biologic, and infectious
factors may play a role in nonunion, and any or all of these may need to be addressed. In some comminuted
fractures that have failed to unite, much of the fracture will have healed, leaving a simpler “pattern” of
nonunion to address. For a symptomatic subtrochanteric nonunion requiring revision fixation, we favor
hardware removal and cephalomedullary nailing. If the nonunion is very proximal, then revision plating may
be preferable.
Malalignment
Unfortunately, malalignment is common after plating (or nailing) of subtrochanteric femur fractures. These
commonly involve varus, flexion, external rotation, or a combination of these. As more biologic approaches,
including minimally invasive approaches have become more popular, the rates of malunion appear to have
increased as direct visualization is avoided. Virtually all of the assessment must be done radiographically,
and vigilance during this part of surgery is mandatory if these problems are to be avoided. If unsuitable
alignment is recognized at any step during surgery, the appropriate steps should be taken to correct the
problem(s). Many of these problems are successfully avoided through the process of preoperative planning.
 OUTCOMES
Outcomes after traditional blade plate fixation of subtrochanteric femur fractures are generally good,
especially when biologic principles are followed (6). Kinast et al. (6) demonstrated superior outcomes after
indirect reduction of subtrochanteric femur fractures compared to direct reduction, with no nonunions
reported in their series. Like other technically challenging orthopedic procedures, a learning curve exists,
and improved outcomes can be expected with experience. If direct reduction of a comminuted fracture is
performed, stripping of individual fragments is ill-advised, as this has been associated with unfavorable
results. Indirect reduction and submuscular plating, while theoretically attractive, must be tempered by a
lack of clinical evidence, especially given recent reports of early plate breakage (15,27). A recent series of
31 complex peritrochanteric fractures treated with a proximal femur plate has shown a high union rate and a
low incidence of complications (28).

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REFERENCES
1. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric
fractures with use of an intramedullary nail or a 95 degree screw-plate: a prospective, randomized study. J
Bone Joint Surg Am 2002;84:372-381.

2. Wiss DA, Brien WW. Subtrochanteric fractures of the femur: results of treatment by interlocking nailing.
Clin Orthop Relat Res 1992;283:231-236.

3. Kang S, McAndrew MP, Johnson KD. The reconstruction locked nail for complex fractures of the proximal
femur. J Orthop Trauma 1995;9:453-463.

4. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric
fractures caused by low-energy trauma. J Bone Joint Surg Am 2005;87:2217-2226.

5. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg 2007;15:663-671.

6. Kinast C, Bolhofer BR, Mast JW, et al. Subtrochanteric fractures of the femur: results of treatment with the
95 degree condylar blade plate. Clin Orthop Relat Res 1989;238:122-130.

7. Yoo MC, Cho YJ, Kim KI, et al. Treatment of unstable peritrochanteric femoral fractures using a 95 degree
angled blade plate. J Orthop Trauma 2005;19:687-692.

8. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the
femur. J Bone Joint Surg Am 2001;83:643-650.

9. Goh SK, Yang KY, Koh JS, et al. Subtrochanteric insufficiency fractures in patients on alendronate
therapy: a caution. J Bone Joint Surg Br 2007;89:349-353.

10. Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on
long-term alendronate therapy. J Bone Joint Surg Am 2009;91:2556-2661.
11. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after
knee dislocation: a prospective study. J Trauma 2004;56:1261-1265.

12. Celebi L, Can M, Muratli HH, et al. Indirect reduction and biological internal fixation of comminuted
subtrochanteric fractures of the femur. Injury 2006;37:740-750.

13. Schatzker J, Wadell JP. Subtrochanteric fractures of the femur. Orthop Clin North Am 1980;11:509-520.

14. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery. Berling, Germany:
Springer-Verlag; 1989.

15. Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop
Trauma 2011;25:76-83.

16. Anglen J, Banovetz J. Compartment syndrome in the well leg resulting from fracture-table positioning.
Clin Orthop Relat Res 1994;301:239-242.

17. Mathews PV, Perry JJ, Murray PC. Compartment syndrome of the well leg as a result of the
hemilithotomy position: a report of two cases and review of the literature. J Orthop Trauma 2001;15:580-583.

18. Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad Orthop Surg
2009;17:647-657.

19. Sommer C, Babst R, Muller M, et al. Locking compression plate loosening and plate breakage: a report of
four cases. J Orthop Trauma 2004;18:571-577.

20. Helmy N, Jando VT, Lu T, et al. Muscle function and functional outcome following standard antegrade
reamed intramedullary nailing of isolated femoral shaft fractures. J Orthop Trauma 2008;22:10-15.

21. Archdeacon M, Ford KR, Wyrich J, et al. A prospective functional outcome and motion analysis
evaluation of the hip abductors after femur fracture and antegrade nailing. J Orthop Trauma 2008;22:3-9.

22. Perren SM. Physical and biological aspects of fracture healing with special reference to internal fixation.
Clin Orthop Relat Res 1979;138:175-196.

23. Bellapianta J, Dow K, Pallotta NA, et al. Threaded screw head inserts improve locking plate
biomechanical properties. J Orthop Trauma 2011;25:65-71.

24. Bottlang M, Doornink J, Fitzpatrick DC, et al. Far cortical locking can reduce the stiffness of locked
plating constructs while retaining construct strength. J Bone Joint Surg Am 2009;91:1985-1994.

25. Sellei RM, Garrison RL, Kobbe P, et al. Effects of near cortical slotted holes in locking plate constructs. J
Orthop Trauma 2011;25:S35-S40.
26. Berkes M, Obremskey WT, Scannell B, et al. Maintenance of hardware after early postoperative infection
following fracture internal fixation. J Bone Joint Surg Am 2010;92:823-828.

27. Floyd JC, O'Toole RV, Stall A, et al. Biomechanical comparison of proximal locking plates and blade
plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma 2009;23:628-633.

28. Mitchell E, Kregor P. Submuscular locked plating for pertrochanteric femoral fractures: early experience
in a consecutive one-surgeon series. Annual Meeting of the Orthopedic Trauma Association, Phoenix,
Arizona, 2006.
 21
Subtrochanteric Femur Fractures: Intramedullary Nailing
Clifford B. Jones

INTRODUCTION
Subtrochanteric femur fractures are much less common than hip or shaft fractures. They are usually associated
with high-energy trauma in young adults or with lower-energy falls in the elderly. The subtrochanteric region of
the femur is an area of high compressive stresses medially along the lesser trochanter and calcar and
correspondingly high distraction forces laterally along the greater trochanter and proximal femur. Successful
treatment methods require neutralization of these forces while maintaining the blood supply to enhance healing.
Intramedullary nailing of the proximal femur has become the standard method of treatment for most
subtrochanteric femur fractures. Contemporary femoral nails are categorized by their screw orientation and nail
design. Standard antegrade femoral nails have a radius of curvature or anterior bow to facilitate its insertion into
the femoral canal. Their proximal screw insertion pattern is either transverse or oblique and directed from the
greater to the lesser trochanter. Reconstruction nails are similar to standard antegrade nails but are reinforced
proximally to accommodate large oblique interlocking screws that are directed into the femoral head. Currently,
nails are labeled as piriformis or trochanteric entry nails. Distally, interlocking screw insertion can be performed
transversely from lateral to medial or are multidirectional. Either combination can be utilized for reconstruction
nailing of subtrochanteric fractures. With these options, a full-length statically locked reconstruction nail of
sufficient diameter can be utilized to treat fractures extending from the greater trochanter to the distal femoral
metaphysis.

INDICATIONS AND CONTRAINDICATIONS

The OTA/AO fracture classification describes subtrochanteric fractures as 31-A (1) (Fig. 21.1). This subgroup of
fractures includes intertrochanteric, pertrochanteric, and subtrochanteric, which can be confusing because of
conflicting terminology and regional differences. For this reason, Russell and Taylor based their classification on
the integrity or compromise of the greater trochanter/piriformis fossa region and the lesser trochanter/medial
calcar region (2) (Fig. 21.2). Not surprisingly, fracture extension into the greater trochanter and piriformis fossa
creates problems with nailing and increases the risk of comminution and instability. Fracture extension into the
lesser trochanter and medial buttress creates problems with sagittal alignment and varus angulation.
A reconstruction nail can be utilized for virtually all acute subtrochanteric femur fractures. This implant can also
be utilized for some ipsilateral femoral neck and shaft fractures. Since the reconstruction nail protects the entire
femur, it is an excellent implant to treat a wide variety of fracture types. It can be also used for prophylactic
nailing of impending and pathologic femur fractures. With screw(s) directed into the femoral head, a
reconstruction nail is often used to treat patients with osteoporotic femoral shaft fractures who may be at risk for
a femoral neck fracture around their nail should another fall occur. It is also useful in treating atypical
(bisphosphonate) femoral fractures (3, 4 and 5). The implant can be inserted through a trochanteric entry site for
selected proximal femoral fractures in adolescents. Reconstruction nails are useful in the treatment of malunions,
nonunions, and failed plate fixation of selected proximal femur fractures. Whenever possible, closed nailing is
preferred over an open procedure to decrease the risk of infection and improve healing. However, the goals of
fracture reduction with proper alignment and healing are more important than nailing technique.
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FIGURE 21.1 OTA/AO proximal femoral fracture classification.
FIGURE 21.2 Components of the Russell-Taylor IB subtrochanteric pattern with greater trochanter intact and
lesser trochanteric fracture.

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There are several contraindications to nailing of subtrochanteric fractures. The first and foremost
contraindication is surgeon skill. These are complex injuries and there is long learning curve that must be
mastered for successful nailing. Significant comminution and displacement of the greater trochanter or fracture
extension into the femoral neck are relative contraindications to nailing. A preexisting femoral diaphyseal
deformity, femoral implant, or stemmed total knee arthroplasty are also contraindications to nailing.

PREOPERATIVE PLANNING
Subtrochanteric fractures occur with a bimodal frequency (6). Young adults usually sustain high-energy fractures
with associated injuries and fracture patterns. Older elderly patients sustain lower-energy fractures with falls
through osteoporotic bone. A patient with a femur fracture following high-energy trauma mandates a thorough
trauma evaluation for other life- or limb-threatening injuries. Subtrochanteric fractures usually present with a limb
shortening, external rotation, and pain. The proximal femur is exquisitely tender, and any motion in the limb is
painful. Fortunately, nerve and vascular injuries are uncommon.
Preoperative imaging consists of a low anterior-posterior (AP) radiograph of the pelvis and AP and lateral
radiographs of the hip (Fig. 21.3). The entire femur must be imaged to evaluate for preexisting deformities,
retained hardware, or a distal prosthesis that could impede intramedullary nailing. We often obtain contralateral
femoral radiographs to serve as a template for neck-shaft angulation, neck-shaft transition, medullary diameter,
anterior femoral bow, and limb length. This is especially important when there is comminution or bone loss.
Furthermore, in some small stature people and races, nail insertion may be impossible secondary to a relatively
short neck-shaft transition, short neck width, and small medullary diameter. Traction radiographs are obtained
with gentle and gradual traction of the limb in a neutral rotation. These radiographs are helpful to evaluate the
fracture morphology, pattern, and extent. In the past, oblique radiographs have been used to evaluate the
femoral neck but have been replaced by computed tomography (CT) imaging. CT scans with axial, coronal,
sagittal reconstruction are the best modality to evaluate the femoral neck, piriformis fossa, and greater
trochanteric anatomy (Fig. 21.4). It is best performed with some traction and the leg in neutral rotation. Fracture
extension into the piriformis fossa and/or greater trochanter with a coronal split complicates femoral nailing. If the
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integrity of the proximal femoral canal is compromised, the stability of the nailing construct may be impaired.
Therefore, an open or semiopen nailing technique may be required for reduction and subsequent nailing.
Alternatively, a periarticular proximal femoral-locking plate may be indicated.

FIGURE 21.3 Injury radiographs of AP pelvis (A), AP hip (B), Lat hip (C), and AP femur (D) of subtrochanteric
femoral fracture in 63-year-old female after a low-energy fall.
FIGURE 21.3 (Continued)

For most patients, fixation within 24 hours of admission is necessary because of pain, continued blood loss, risk
of deep vein thrombosis, and pressure sores. Patients should be aggressively resuscitated, have routine blood
chemistries, and be typed and cross-matched for surgery. A metabolic panel including calcium, vitamin D,
parathyroid, and thyroid stimulating hormone should be obtained in elderly patients with lower-energy fractures.
Deep vein thrombosis prophylaxis with sequential compression devices and/or chemical methods should be
initiated postoperatively. Depending on the fracture pattern, associated injuries, and surgeon preference, traction
should be started to maintain length and reduce blood loss and reduce pain.
FIGURE 21.4 Coronal CT cut through the proximal femur demonstrating comminution and displacement of the
greater trochanter in a 47-year-old female after a MVA.

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PERIOPERATIVE EVALUATION
Nail selection is dependent on surgeon experience, fracture pattern, proximal femoral geometry, and femoral
diaphyseal anatomy. Inexperience, failure to understand the deforming forces, and inadequate imaging studies
greatly increase the chance of fracture malreduction. Some ethnicities and races of small stature have relatively
narrow femoral necks, short neck-shaft transition, and small medullary canals, making reconstruction nailing very
difficult or impossible. If the fracture anatomy is not clear, contralateral femoral radiographs may help with
preoperative planning, measurements, and templating.
Reconstruction nails are available in many lengths and diameters (Fig. 21.5). Depending on the manufacture, the
nail has the ability to be utilized in left or right femurs only or interchangeably for both left and right based on the
screw configuration proximally. Most reconstruction type nails are expanded or thickened in the upper end to
accommodate the proximal screws and high mechanical forces in the proximal femur. The transition from the
thickened proximal portion to the diaphyseal portion is variable depending on the manufacturers. Trochanteric
entry nails typically have a 4 to 10 degrees bend or angulation in the coronal plane compared to standard
reconstruction nails that are designed for piriformis fossa entry and have no angulation. The proximal interlocking
screws are usually angled anteriorly (8 to 15 degrees) to accommodate the anteversion of the femoral neck and
cephalad (120 to 135 degrees) to accommodate the neck-shaft angulation. Despite the nail anteversion,
excessive posterior nail entry can compromise screw insertion into the femoral neck and head. Failure to restore
the normal neck-shaft angle can severely compromise screw insertion into the femoral head. Proximal screw size
varies from 5.0 to 8.0 mm and spread is 1.5 to 2 cm. With varus reductions or atypical anatomy, screw insertion
can be suboptimal or impossible. The proximal screws are either partially or fully threaded. Only full-length
femoral nails should be utilized to distribute force from proximal to distal and protect the entire femur in elderly
osteoporotic bone. In younger patients with more comminuted fracture patterns, larger diameter nails are
recommended. For older more osteoporotic fractures, nail diameter has to be tailored to the patient's anatomy to
avoid distal cortical penetration. In these situations, I prefer nails with a smaller anatomic radius of curvature or
smaller nail diameters (<11 mm) that allow for more central nail position distally and lessen the risk of the anterior
cortex penetration. Because of inherent fracture instability, all reconstruction nails should be locked distally with
either one or two screws.
Secondary to the proximal deforming forces, devices that realign the proximal femur in both the sagittal and
coronal planes are beneficial (Fig. 21.6). Large and small tenaculum clamps (Weber Clamp, large
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and small, 1 to 2 each) can be inserted through small strategically applied incisions directly over the fracture site
to anatomically reduce spiral fractures or translate transversely oriented fractures (Fig. 21.7). Ball-tipped spike
pushers (3,7) can translate and reduce large fracture fragments (Fig. 21.8). Schantz pins (2.5 and/or 5.0 mm)
inserted percutaneously or openly can help realign, reduce, translate, and derotate fracture fragments. The
Schantz pins can be inserted in a bicortical fashion temporarily for the initial reduction maneuver and then
converted to a unicortical position after the ball-tipped guide wire has been inserted (Fig. 21.9). Anterior to
posteriorly directed Schantz pins can act as pollar-blocking pins to narrow the metaphysis and correctly direct
reaming and subsequent nail insertion. Kirschner wire insertion (0.62 mm) anteriorly or posteriorly to the entry
portal proximally can aid in reconstruction of complex, multiplanar fracture patterns, and solidify a tubular
construct proximally for reaming and nailing without displacing the fracture (Fig. 21.10).

FIGURE 21.5 The two types of reconstruction IMN are trochanteric reconstruction IMN (curved, trochanteric, or
universal start site) and standard reconstruction IMN (straight, anterior piriformis start site).
FIGURE 21.6 Assistive reduction devices for proximal femoral fracture reduction: small and large Weber clamp,
2.5- and 5.0-mm Schantz pins, Shoulder Hook, Universal Chuck, and Ball-Tip Spike Pusher.

FIGURE 21.7 Large and small Weber clamps.

PATIENT POSITIONING
The patient can be positioned either supine or lateral on a fracture table. The supine position is more common
since it is familiar to surgeons and staff, and patient positioning is faster and the fracture reduction may be
improved (Fig. 21.11). Furthermore, the supine positioning facilitates intraoperative visualization of the proximal
femur with the C-arm, which is critical for successful fracture reduction and nailing (Fig. 21.12). The
disadvantage of the supine position is longitudinal traction on the extended limb often exacerbates multiplane
proximal femoral fracture deformity. Some of these difficulties can be overcome by lateral nailing on a fracture
table. However, the lateral position is less familiar to younger surgeons and OR staff. It also requires different
equipment to accommodate the patient and extremities while on the fracture table.
Intraoperative traction can be accomplished with a boot or skeletal pin traction. Boot traction can be performed in
the majority of patients if surgery is performed within the first 48 hours. If surgery is further delayed, skeletal
traction may be necessary to restore leg length. If this is required, the traction should be periodically reduced or
released during the case to minimize the risk of a pudendal or sciatic nerve injury. The use of paralyzing agents
during surgery also facilitates fracture reduction. Intraoperative or manual traction on a regular operating room
table is not recommended due to the difficulty of consistently restoring length with this method and the need for a
dedicated leg holder or skilled assistant. In a small percentage of patients with high-energy trauma, particularly
those with a “dashboard” mechanism of injury, an occult knee ligament injury may be present. Therefore, in a
patient with a painful swollen knee, skeletal traction through a distal femoral pin may be a safer alternative until
the knee injury is better clarified.
High-quality AP and lateral radiographs of the hip, with the patient on the fracture table, are essential to
determine the fracture reduction and femoral neck anteversion angle. Usually, the x-ray beam has to be angled
about
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10 to 25 degrees from the floor to obtain a true lateral view. AP visualization may require a slight rollover and
cephalad tilt of the beam to accommodate the neck flexion and abduction. The monitor should be placed at the
end of the fracture table so that both surgeon and fluoroscopy technician can easily see the screen. If the patient
is lateral on the fracture table, AP visualization is accomplished with the beam parallel to the floor while the
lateral image is obtained with the beam upright but tilted cephalad 30 to 45 degrees to better visualize the
femoral neck.

FIGURE 21.8 Unstable subtrochanteric fracture with flexion and abduction deformity (A) corrected with
percutaneously inserted ball-tip spike pusher (B) that corrects deformity, improves proximal start site accuracy,
and maintains reduction during reaming and nail insertion.
The opposite uninjured leg is a good template to assess limb rotation, length, and alignment preoperatively. In
the supine position, the fracture should be reduced as well as possible before beginning the procedure. First,
externally rotate (not internally rotate as with intertrochanteric fractures) the secured limb through the boot
holder. Second, apply traction through the peroneal post and foot piece. Third, flex the foot traction device about
15 to 20 degrees. Fourth, provide about 10 to 15 degrees of adduction to improve nail insertion trajectory. Once
the above steps are performed, begin fluoroscopic assessment of the reduction and provide small incremental
changes in the above parameters to “fine-tune” the reduction. The contralateral leg can be positioned in a
scissored or hemilithotomy position. Scissoring can accommodate longer procedures but can interfere with
lateral visualization. Hemilithotomy positioning facilitates lateral visualization but may be of concern with
extended length cases (increased compartmental pressures) and patients with limited hip motion. With either
method, persistent intraoperative monitoring of the uninvolved leg for pressure areas and compartments is
necessary.
A cephalosporin antibiotic is administered intravenously within 1 hour of skin incision and continued for 24 to 48
hours postoperatively. The prep and drape must extend from the ipsilateral lower chest wall to the midcalf.
Following irrigation and débridement of open fractures, I routinely reprep and drape.

FRACTURE REDUCTION
Whenever possible, fracture reduction should be performed and confirmed fluoroscopically before the surgical
incisions are made. Since the fracture may be in relative flexion initially, reduction of the flexion redirects the skin
incision anteriorly and aids in proper entry site selection. Remember that correct fracture reduction requires
restoration of length, rotation, and alignment in both coronal and sagittal planes (Fig. 21.13). AP, lateral, and
oblique (roll over or roll under) images will assist in the assessment of fracture reduction.
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FIGURE 21.9 Imaging demonstrate injury pattern (A) and then two percutaneously inserted 5.0-mm Schantz pins
that translate, derotate, and realign (B) an oblique proximal femoral fracture in an 85-year-old male. While
holding the reduction, the Schantz pins were backed-up to the lateral cortex to allow for reaming and nail
insertion.

FIGURE 21.10 Percutaneously inserted posterior and anteriorly directed Kirschner wires and derotational
Schantz pins are utilized to maintain the proximal femoral reduction during reaming and nail insertion with AP (A)
and LAT (B) images.

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FIGURE 21.11 Patient is positioned in a supine position on an OSI fracture table with boot traction of the
ipsilateral leg in slight external rotation and adduction and hemilithotomy position of the contralateral limb.
FIGURE 21.12 C-arm setup.

FIGURE 21.13 Intraoperative imaging of incorrect (A) and correct (B) rotation of a spiral fracture.

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When the fracture is persistently flexed and in varus, the proximal segment should be reduced with either a ball-
tipped spike pusher or Schantz pin placed through a small skin incision. Usually, this will be performed through a
small anterolateral incision that counters the flexion and abduction yet is out of the plane of image intensifier.
With the fracture aligned, the entry site should be more easily obtained by bringing the trochanter and piriformis
fossa more in line with the axis of the femoral shaft. For spiral fracture patterns, a combination of both a ball
spike pusher and Weber tenaculum clamps can efficiently reduce and maintain the fracture reduction (8). Again,
through a 3- to 4-cm anterolateral incision, spread the vastus in line with its fibers and insert the Weber clamp
(i.e., perpendicular to the diaphysis in both planes). Once the location of the fracture is confirmed on fluoroscopy,
the clamp is opened enough to slide it over the cortex and then closed to reduce the fracture (Fig. 21.14).
Loosening the footplate prior to tightly clamping the fracture often helps to improve rotational alignment before
final tightening. If the fracture does not reduce, it is usually malrotated or flexed, which is
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best seen on the lateral view (Fig. 21.15). Utilizing a ball spike pusher (anteriorly to posteriorly) on the flexed
proximal segment with the fracture reapproximated but not compressed often facilitates translation of the flexed
proximal segment allowing reduction (Fig. 21.16).

FIGURE 21.14 For a spiral fracture pattern, a 4-cm incision is created, and a large Weber clamp is inserted
parallel to the muscle fibers done to the bone (A). Once against the bone and parallel to the fracture plane, the
clamp is rotated 90 degrees (B), slided alongside the bone, and compresses the fracture utilizing the tines only
(C).
FIGURE 21.15 This is a lateral view of the Weber clamp compression but with flexion deformity still present.

For segmental fractures, I often use a unicortical Schantz pin in the central fragment along with the ball-tipped
spike pusher to correct varus as well as a distal shoulder hook to correct translation (Fig. 21.17). Another less
common method for reduction is application of a bicortical Schantz pin along the anteromedial calcar femorale
area to derotate, realign, and translate the proximal segment (Fig. 21.18). Furthermore, patterns of apex
posterior sag or angulation can be corrected with an inferiorly applied mallet and manual downward pressure
applied anteriorly.

FIGURE 21.16 Through the same anterolateral incision, a ball-tip spike pusher is inserted along the proximal
segment (A,B). With gentle loosening of the clamp, anterior to posteriorly directed force through the pusher
translates the fragment until perfect. The clamp is then retightened allowing for anatomic, keyed-in reduction for
stability and reaming (C,D).

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FIGURE 21.16 (Continued)

FIGURE 21.17 An injury AP radiograph of a displaced unstable segmental subtrochanteric fracture with
diaphyseal extension (A). With proximal spike-pusher control, segmental 5.0-mm Schantz pin translation and
derotation, and distal segment translation with a shoulder hook, the unstable pattern is realigned to create a
conduit for guide pin, reamer, and nail insertion (B).

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FIGURE 21.18 A translated and malrotated fracture imaged with AP (A) and LAT (B) fluoroscopy has a
combination utilization of percutaneous inserted 2.5-mm Schantz pins, 5.0-mm Schantz pins, and Weber Clamp
stabilize deforming forces for entry site terminally threaded guide pin (C,D), reaming (E), and nail insertion (F,G).

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FIGURE 21.18 (Continued)

NAIL ENTRY SITE

The skin incision should be placed in line with the femoral diaphysis (7). To confirm this, a guide pin is placed
along the skin in both the AP and lateral planes to confirm a convergent skin site proximal to the hip (Fig. 21.19).
Make an incision just distal to the iliac crest and direct it toward the greater trochanter (Fig. 21.20). Avoid short
incisions placed over the greater trochanter or using an awl to gain entry as this potentiates varus deformities.
With obese and muscular patients, very proximal incisions for nail entry are crucial to avoid varus reductions
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(9, 10 and 11). Once the guide pin is placed percutaneously through the skin, continue to palpate the trochanter
to triangulate the direction of the pin and confirm this with fluoroscopy.
FIGURE 21.19 With the aid of an externally referenced guide pin with AP and LAT images, skin marks are
applied to the skin (A). The percutaneous start site is created at the confluence of the skin marks (B,C).

For reconstruction nailing in the supine position, my preferred starting point is 10 to 15 mm anterior to the
standard piriformis starting point (Fig. 21.21). This must be confirmed on both an AP and lateral image
documenting no overlap of the guide pin on the femoral neck. With traditional piriformis nailing, the guide pin
“appears” to be about 10 to 15 mm distal to the femoral neck on the AP radiograph. On the lateral view, the
guide pin should parallel or be just posterior to the femoral neck. If the start site is too posterior, it will make
screw insertion into the femoral neck and head difficult or mechanically suboptimal. If the start site is too anterior,
it will create an excessive anterior-to-posterior screw insertion angle and increase proximal
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hoop stresses for nail insertion, which increases the risk of proximal femoral blow out. Once the entry site is
confirmed on both the AP and lateral images, insert the terminally threaded guide pin to the level of the lesser
trochanter in line with the femoral diaphysis in both planes. Once the guide pin is advanced and the entry site is
confirmed, make a 2 to 3 cm incision around the guide pin to allow for mobility of the soft tissues around the
guide pin as well as create space for the reaming and nailing instruments (Fig. 21.22).
FIGURE 21.20 The central aspect of the greater trochanter is palpated with the off-hand (left) as a reference,
and the guide pin is inserted percutaneously (right) utilizing cerebral tactile triangulation.
FIGURE 21.21 The incorrect start point is at the tip or lateral to the tip of the greater trochanter (A). The correct
start point is the “universal start site,” which corresponds to a direct line down the diaphysis on the AP (B) and
LAT (C) images.

I prefer to open the proximal femoral cortex with a cannulated (usually 8- to 9-mm) drill instead of the larger (12-
to 16-mm) drills found in most sets to avoid splintering, widening, and/or displacing the proximal fragment (Fig.
21.23). Once opened, insert a ball-tipped guide wire with or without a bend at the tip (Fig. 21.24). Advance the
guide wire down the medullary canal to the distal femoral physeal scar under fluoroscopic control maintaining the
wire in the middle of the medullary cavity (Fig. 21.25). Advance the ball tip into the dense
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subchondral bone without penetrating the chondral surface to decrease the chance the guide wire will be
withdrawn during reamer insertion and removal.
FIGURE 21.22 A 2- to 3-cm incision is created around the guide pin allowing for mobility and cannulated
instrument insertion. The pin should not be entrapped by skin or fascia superficially.

REAMING
With the fracture reduced, ream proximally across the fracture site and distally in 0.5 mm increments (Fig. 21.26).
Eccentric reaming is minimized when the fracture is well reduced and the entry portal is correct. Eccentric
reaming most commonly occurs during reamer insertion and extraction and is exacerbated by varus
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start sites, soft-tissue pressure from medial to lateral, obesity, and muscularity. Final reaming size is dependent
upon canal diameter, bone quality, surgeon experience, and nail availability. It is important to ream the canal, 1.5
to 2.0 mm larger than final nail size to reduce hoop stress upon insertion and allow for small rotational adjustment
of the nail after insertion to fine-tune the screw insertion angle into the femoral neck and head (12,13). If utilizing
a straight nail in osteoporotic bone, utilize a nail size of 10 to 11 mm to allow for adequate stability at the fracture
site and yet avoid anterior distal cortical penetration. Reaming proximally is dependent upon specific proximal
nail dimensions. Usually, reaming 1.0 to 1.5 mm greater than the measured nail size is adequate. Attention to
detail is necessary to avoid reaming away the posterior cortex or lateral wall.
FIGURE 21.23 An 8-mm rigid end-cutting reamer is utilized to open proximal femur to the level of the lesser
trochanter.

FIGURE 21.24 The ball-tipped guide rod is bent to facilitate intramedullary insertion.
FIGURE 21.25 The ball-tipped guide rod is inserted deep into the cancellous bone of the central femoral
condylar area.
FIGURE 21.26 The fracture is held reduced with clamp assistance while sequential reaming is performed.

FIGURE 21.27 The subtraction method of nail length is determined.

NAIL LENGTH
Nail length can be determined by several different methods. The most accurate method is the subtraction
method. Many systems allow for a cannulated ruler to be inserted over the guide wire to the level of the greater
trochanter or femoral neck (Fig. 21.27). This ruler compensates for the known guide pin length and is
manufacturer dependent. A “poor man's” version of this is to apply a guide pin parallel to the inserted guide pin
to the level of the greater trochanter or femoral neck. The residual length nonoverlapped will be equal to the
length of the nail. Some systems utilize an external “premagnified” ruler applied parallel to the femur and
touching the skin. This method is dependent on guessing the correct magnification and is usually less accurate
than the guide wire or subtraction method. In situations of marked comminution or bone loss, premeasuring the
contralateral uninjured limb may be helpful.

NAIL INSERTION
Before inserting the nail, confirm the correct nail rotation and orientation is paired with the correct proximal
targeting device including drill sleeves. Place a drill through both drill sleeves and confirm central position within
the holes of the nail (Fig. 21.28). Also, confirm that the bow is anterior not posterior. Nail insertion is performed
over the guide wire. Check to ensure that the diameter of the ball-tip guide wire is smaller than the inner diameter
of the nail to avoid incarceration. If the ball tip is bigger than the inner nail diameter, exchange the ball-tip guide
wire for a smaller nonbeaded guide wire through a radiolucent exchange tube after reaming. Again, impact the
guide wire into the dense subchondral bone distally to avoid inadvertent guide wire migration.
Percutaneously, place a 3.2-mm “anteversion pin” from lateral to medial, which parallels the anterior femoral
neck, and confirm it with AP and lateral images (Fig. 21.29). Prior to insertion, the femoral nail is internally
rotated 90 degrees and inserted in that position for the first 5 or 6 cm. The nail is gradually externally rotated as
the nail is advanced down the shaft. Following nail insertion, the nail-mounted external proximal screw insertion
guide should be positioned parallel to the “anteversion pin” to ensure central position of proximal interlocking
screws into the femoral head (Figs. 21.30 and 21.31). Nail insertion should be smooth with minimal resistance. If
there is significant resistance to nail advancement, it may be caused by, too large of a nail (in comparison to the
final reaming diameter), incorrect entry portal (increasing hoop stresses) or an incarcerated fracture fragment.
When this occurs, remove the nail and reassess the situation. Rereaming another 0.5 to 1.0 cm larger may be
helpful. Also check to ensure there are no comminuted fracture fragments trapped in the medullary canal. Insert
the nail distally to the level of the distal epiphyseal scar. Final nail depth is dependent on the nail position
proximally that ensures that both proximal screws will be directed into the central portion of the femoral neck and
head. Some nail systems deploy external guides to overlay the femoral neck to confirm nail depth but are
dependent upon a true perpendicular beam to the femoral neck. Reconfirm fracture reduction quality and central
position of the nail within the femoral condyles before proceeding further.
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FIGURE 21.28 The guide arm and sleeve position is confirmed to correlate with proper nail orientation and
drill/screw insertion angle.
FIGURE 21.29 A 3.2-mm guide pin is inserted percutaneously paralleling the femoral neck orientation on the AP
(A) and LAT (B) views.

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FIGURE 21.30 A. The external reference guide pin and guide arm parallel reference confirms correct nail
insertion rotation.B. The external reference guide pin, guide arm, and drills are parallel and therefore centrally
inserted into the femoral neck and head. C. The final screw position is centrally located within the femoral neck
and head.

Obesity can impede or preclude nail insertion when using the external guide arm attached to the nail leading to
errant drilling and screw placement (Fig. 21.32). If the targeting guide is blocked by soft tissues, extend and
deepen the skin incision through the adipose tissue to allow for the guide to be inserted with less deforming
forces (Fig. 21.33).
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FIGURE 21.31 The trochanteric nail (4-degree bend) is inserted 90 degrees (A) to facilitate nail insertion and
proximal femoral anatomy confirmed with imaging (B).

PROXIMAL INTERLOCKING SCREW INSERTION

Once the nail is seated to the desired depth, proximal screw insertion can be performed. First, remove the central
guide wire inside the nail. Within the proximal nail guide, insert the obliquely oriented drill sleeves through small
skin incisions down to the lateral cortex. In order to avoid misguided proximal screws, several steps must be
accomplished in order. Confirm that the targeting guide is firmly attached to the nail. It is important to avoid
hammering the drill sleeve against the femoral cortex to prevent changes in drill angulation. To diminish this risk,
gently insert the drill sleeves with the inner trochar and carefully advance it to bone. Insert a drill bit through the
caudad (lower) sleeve until it reaches the lateral cortex. Then retract the drill bit about 1 to 2 cm, start the drill,
and advance it slowly through the lateral cortex and then the interlocking holes in the nail. If resistance is
encountered, the drill may be above or below the nail holes or hitting the anterior or posterior cortex of the
femoral neck. Because the proximal nail guide obscures true lateral imaging, oblique views are required during
this step. Once the initial caudad drill is inserted, confirm the drill position by looking
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“above” and “behind” the proximal nail guide (Fig. 21.34). Both views should confirm placement within the
femoral neck and head. Also, the “above” view should parallel the preexisting anterior femoral neck guide pin
(anteversion pin). If the initial drill is placed along the inferior neck and preoperative planning confirmed
appropriate screw spread to be within the anatomic width of the neck, the second cephalad drill should be safe
and accurate. Once drilled, again confirm the depth (5 mm within subchondral bone) and position (central) within
the femoral neck and head. With a depth gauge or calibrated drill, determine the screw length.
FIGURE 21.32 Percutaneously inserted reconstruction nail with guide arm wide enough to accommodate
muscular and obese thigh and insert cephalomedullary screws without guide deformation.

FIGURE 21.33 Obese girth of patient's thigh impedes guide arm insertion without deformation (A). This guide
arm width-thigh width mismatch is accommodated with skin incision to appropriate depth (B) to allow for guide
arm insertion (C).
Once satisfied with the drill position, keep one drill in position to stabilize the targeting device and the nail
construct. Tapping the screw holes is dependent on bone quality. I prefer partially threaded cancellous screws
rather than fully threaded cortical screws. Place the screw deep into the subchondral bone to ensure optimal
stability and then insert the second screw to the desired depth. Confirm screw position “above” and “below” the
attached guide (Fig. 21.35). If the screw stops advancing within the nail, the partial screw threads cannot capture
the cortical bone and the screw will just spin without advancing. Gently tapping or pushing the screw while slowly
advancing the screwdriver can be helpful. The proximal nail guide and anteversion pin can now be removed.
Again, confirm correct nail and screw position proximally. Some surgeons favor retaining the proximal guide
locked to the nail until distal screws have been inserted.

DISTAL INTERLOCKING SCREW INSERTION

In length-stable fractures, release some or all of the traction to minimize distraction at the fracture site and allow
some impaction at the fracture site. For successful distal interlocking, the beam of the fluoroscopy machine must
be perfectly perpendicular to the nail. Move the machine base to accommodate the position of the leg. The nail is
usually slightly externally rotated because of the anteversion required for proximal screw insertion. Do not rotate
the leg to accommodate fluoroscopic visualization. I prefer to bring the fluoroscopy head close to the distal femur,
apply magnification on the machine (one- or twofold), and then fine-tune position of the
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C-arm under fluoroscopic control. “Perfect circles” must be obtained for consistent and reproducible distal screw
insertion with a freehand technique. Place a knife blade parallel to the skin until centered within the perfect circle
(Fig. 21.36). Make a 2-cm skin incision through the skin and deep fascia and spread the deeper tissues with a
hemostat. The freehand drilling technique can be performed in several different ways. I prefer to place the tip of
the drill bit within the center position of the perfect circle (Fig. 21.37). Advance the drill bit parallel to the
projected line of the C-arm beam. Once advanced, confirm drill bit orientation. The drill can then be drilled
through the nail or gently tapped with a mallet through the nail. Drill through the far cortex. Measure screw length
with a calibrated drill guide or depth gauge and insert the screw. Confirm proper screw insertion within the nail
with a perfect lateral position again (Fig. 21.38). Avoid long screws projecting medially as they can be a source
of pain postoperatively.
FIGURE 21.34 Confirmation of central guide pin insertion or correct nail rotation is confirmed with AP (A) and
LAT images of the guide pin insertion above (B) and below (C) guide arm interference.

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FIGURE 21.35 Confirmation of correct nail rotation and cephalomedullary screw insertion with above (A) and
below (B) LAT images.

POSTOPERATIVE MANAGEMENT
The wounds are closed in layers. While the patient is still anesthetized in the operative suite, remove the drapes
and traction boot or pin and check limb alignment, rotation, and length in comparison to the contralateral
uninvolved leg. If there is a major discrepancy in length, rotation, or alignment, the fixation should be revised, if
the patient's condition will permit. If the deformity is minor or the patient is too sick for additional surgery, a
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postoperative CT scan is indicated. Obtain full-length femoral radiographs postoperatively to confirm fracture
reduction and correct nail and screw position (Fig. 21.39). Antibiotics should be continued for 24 hours
postoperatively in closed fractures. Deep vein thrombosis prophylaxis should be begun on the first postoperative
day if there are no contraindications. Partial weight bearing (10 to 15 kg) with crutches or a walker in younger
individuals should be initiated in the first several days. The goal in older individuals is to advance with full weight
bearing as tolerated to facilitate rehabilitation. If the bone quality is good, the fracture reduction is anatomic, and
minimal comminution is present, the patient can advance weight-bearing status to tolerance over the next several
weeks. Gentle range of motion of the hip and knee are started during the first week postoperatively. In elderly
patients, calcium citrate and vitamin D3 supplementation should be considered.
FIGURE 21.36 Confirmation of perfect circle distal screw hole reference to imaging and skin insertion site with
scalpel reference.

FIGURE 21.37 Confirmation of correct lateral cortex start site is performed with drill tip.
FIGURE 21.38 Lateral imaging confirms correct interlocking screw insertion.

Sutures are removed at 2 weeks. Regular clinical visits and radiographic evaluation of healing should be
obtained at 4- to 6-week intervals. Once callus appears radiographically, patients are allowed to advance weight
bearing and strength training. Once extremity strength is restored and the limp is resolved, the crutches or walker
can be discontinued. Patients should be followed for at least 1 year to ensure uncomplicated healing.

OUTCOMES
Surprisingly, there are few long-term outcome studies following intramedullary nailing of subtrochanteric
femoral fixation. Radiographic healing has been reported in 85% to 100% of the fractures (14, 15, 16, 17
and 18). Pain-free ambulation without an assistive device begins at about 3 months. By 6 months, return to
function in terms of gait, endurance, and strength is usually present. Function does not always correlate
with fracture healing. If varus and shortening are avoided, full-unrestricted function should be expected. In
elderly patients with subtrochanteric fractures, 1-year mortality of 25% has been reported (19). With
uneventful healing, more than 50% of elderly patients are able to regain activities of daily living.

COMPLICATIONS
Malreduction
Malreduction secondary to powerful deforming forces, incorrect entry portals, and eccentric reaming
unfortunately are common but avoidable. The usual deformity is varus, flexion, and external rotation of the
proximal fragment (Fig. 21.30). Anatomic fracture reduction or alignment is critical to reduce deformities (8).
Obese and muscular patients increase nail insertion difficulty and residual deformity (9, 10 and 11). Very
proximal start sites in line with the femoral diaphysis reduce eccentric reaming and nail insertion errors (7). If
the fracture cannot be reduced and closed, some authors advocate cerclage wiring of fracture fragments to
maintain reduction and restore the cortical tube anatomy of the femoral canal (8).
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FIGURE 21.39 Final postoperative AP and LAT images of complex multifragmentary subtrochanteric femur
fracture successfully treated with reconstruction nail (A-D).

Proximal Screw Placement Errors

The most common cause of proximal screw insertion errors is malreduction. A varus malreduction will
prohibit or complicate screw insertion into the femoral head. The caudad screw is usually inserted deep
enough while the cephalad screw is too short (Fig. 21.40). Posterior nail insertion or retroversion of the nail
will potentiate posterior screw insertion errors. In-out-in, acutely anteriorly angled screws, or posteriorly
short screws are usually the result. Severely osteoporotic fractures treated with a reconstruction nail and
two proximal interlocking cephalomedullary screws can result in reciprocal compression and displacement
of the screws in a “Z” pattern (Fig. 21.41).
Distal Nail Problems
Distal nail problems occur with a radius of curvature mismatch between the nail (straight) and the femur
(curved, especially with osteoporosis). Radiographic confirmation in two planes that the ball-tipped guide
wire is located in the central position of the medullary canal and distal femoral condyles is very important
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before reaming or nail insertion is performed. This problem is diminished with smaller radius of curvature
nails. Furthermore, downsizing the nail size to a 10 to 11-mm diameter nail may better accommodate the
curvature of the femur and avoid penetration of the anterior cortex. If anterior cortical nail penetration
occurs, the nail should be removed (Fig. 21.42). Rarely, removing and “bending” and reinserting the nail
may be helpful. Another strategy is to insert a lateral to medial blocking screw to redirect the nail posteriorly
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if performed in conjunction with additional reaming to create an alternative nail pathway. If the cortical
violation is very distal, inserting a smaller diameter nail may be an option. If the anterior cortical hole is large
and distal, one may consider plate augmentation of the distal femur to diminish stress and potential fracture.

FIGURE 21.39 (Continued)

FIGURE 21.40 Varus malreduction initiated with poor reduction, eccentric reaming, and too lateral start site.
Note unequal screw length and nonparallel screw insertion in comparison to femoral neck anatomy.
FIGURE 21.41 Reciprocal screw compression of reconstruction cephalomedullary screws in the setting of
osteoporosis can result in hardware failure and “Z” pattern of screw loosening.

Infection
Postoperative infection is uncommon following intramedullary femoral nailing. If an early infection does
occur, an aggressive irrigation and débridement in conjunction with high-dose intravenous antibiotics is
required. If this fails to control the infection, we advocate removal of the nail, reaming of the medullary
canal, insertion of a temporary antibiotic nail, with or without traction. Once the infection resolves and the
inflammatory markers return to normal, renailing should be performed to promote union and avoid deformity
and disability. Loss of Fixation Loss of fixation can occur if healing is delayed or bone quality is
compromised. In patients with good bone quality, we usually perform an exchange nailing and redirect the
screws deep into the femoral head. If loss of fixation is related to osteoporotic bone with reciprocal screw
migration or “Z” effect, I remove the nail and convert the fixation to a single large cephalomedullary screw
and nail design.
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FIGURE 21.42 Anterior cortical distal femoral penetration caused by femoral osteoporosis, increased
anterior femoral bowing, and a relatively stiff and straight femoral nail.

Nonunion
Nonunion occurs in 0% to 15% of fractures. Fixation failure, nail breakage, or varus angulation may be
present on radiographs. Exchange nailing with a larger size nail is usually successful. One may consider
removing a straight nail and insert a trochanteric entry nail (4 to 6 degrees) (Fig. 21.43). The additional
amount of valgus may facilitate fracture compression and minimize shearing forces. If fully threaded screws
were initially inserted, these are changed to partially threaded screws to enhance fracture site compression
(Fig. 21.44). Atrophic nonunions are usually related to high-energy forces (especially open fractures) and
delayed healing and require an infection workup. If infection is ruled out, treatment consists of exchange
nailing with or without autogenous bone grafts.
Atypical Femoral Fractures Associated with Prolonged Bisphosphonate Administration
Recently, a number of studies have been published regarding patients with atypical subtrochanteric or
proximal femoral fractures following prolonged bisphosphonate use (4,20). The fracture pattern is typically
transverse or short oblique and is often associated with thickened cortices, which should alert health care
providers to inquire
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about bisphosphonate usage (Fig. 21.45). These patients require careful preoperative planning because
these patients often have very thick cortices and increase bowing of the femur and exhibit delays in healing.
Since there is a high incidence of bilaterality, radiographs of the contralateral femur should be obtained.

FIGURE 21.43 An oligotrophic nonunion (A) with broken fully threaded screws and a standard
reconstruction nail is successfully treated to union (B) with reamed exchange trochanteric start nail and
partially threaded screws.

Functional Impediments
Leg-Length Discrepancy
With femoral shortening, more than 15 to 20 mm patients frequently complain of pain, a limp, and weakness
with activity.
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FIGURE 21.44 An oligotrophic nonunion (A) is successfully treated to union (B) with a larger reamed
exchange nail and partially threaded screws.

Pain
Pain present at 9 to 12 months usually is associated with a nonunion, malrotation creating hip or knee pain,
prominent hardware, or leg-length discrepancy.
Malrotation
Internal rotation deformities are more frequent than external rotation problems. If diagnosed early in the
postoperative period (<2 weeks), removal of the distal interlocking screws, derotation of the distal segment,
and reinsertion of the distal interlocking screws can be performed. Redrilling in close proximity to the prior
screw holes can be difficult. In patients who present later, a rotational CT scan is helpful to document the
degree of deformity. If the patient has sufficient symptoms to warrant further treatment, management
consists of nail removal, a closed intramedullary derotational osteotomy, and revision static nailing.
Malreduced and Shortened Greater Trochanter
Trochanteric migration usually occurs when coronal fractures of the greater trochanter are overlooked or
compromised during reaming or nailing. If diagnosed early in the postoperative period, tension band wiring
or suturing the greater trochanter distal to the proximally interlocking screws can be performed. When
diagnosed, late treatment is very difficult. Trochanteric hook plates proximally to capture the posterior and
cephalad migrated trochanter is difficult and can be attached with a screw inserted posterior to the nail
proximally (Fig. 21.46).
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FIGURE 21.45 An atypical femoral fracture with shortening and displacement (A) is treated with a
reconstruction nail (B).
 FIGURE 21.46 A complex multifragmentary pertrochanteric femoral fracture treated with a reconstruction
nail had a subsequent displacement of the greater trochanter (A) and hip dysfunction. This problem was
successfully treated with open reduction internal fixation of the greater trochanter with a hook plate placed
outside the retained nail (B).

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REFERENCES
1. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007:
Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma
2007;21(10 Suppl):S1-S133.

2. Russell TA, Taylor AJ. Subtrochanteric fractures. In: Browner BD, ed. Skeletal trauma. 1993.

3. Collinge C, Liporace F, Koval K, et al. Cephalomedullary screws as the standard proximal locking screws
for nailing femoral shaft fractures. J Orthop Trauma 24;12:717-722.

4. Neviaser AS, Lane JM, Lenart BA, et al. Low-energy femoral shaft fractures associated with alendronate
use. J Orthop Trauma 2008;22(5):346-350.

5. Patton JT, Cook RE, Adams CI, et al. Late fracture of the hip after reamed intramedullary nailing of the
femur. J Bone Joint Surg Br 2000;82(7):967-971.
6. Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients. J Trauma 1979;19(8):582-
592.

7. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the
Gamma nail. Clin Orthop Relat Res 2000;375:30-42.

8. Afsari A, Liporace F, Lindvall E, et al. Clamp-assisted reduction of high subtrochanteric fractures of the
femur. J Bone Joint Surg Am 2009;91(8):1913-1918.

9. Ostrum RF. A greater trochanteric insertion site for femoral intramedullary nailing in lipomatous patients.
Orthopedics 1996;19(4):337-340.

10. Ricci WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry portal for the treatment of
femoral shaft fractures. J Orthop Trauma 2006;20(10):663-667.

11. Tucker MC, Schwappach JR, Leighton RK, et al. Results of femoral intramedullary nailing in patients who
are obese versus those who are not obese: a prospective multicenter comparison study. J Orthop Trauma
2007;21(8):523-529.

12. Johnson KD, Tencer AF, Sherman MC. Biomechanical factors affecting fracture stability and femoral
bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations. J
Orthop Trauma 1987;1(1):1-11.

13. Ovadia DN, Chess JL. Intraoperative and postoperative subtrochanteric fracture of the femur associated
with removal of the Zickel nail. J Bone Joint Surg Am 1988;70(2):239-243.

14. Kregor PJ, Obremskey WT, Kreder HJ, et al. Unstable pertrochanteric femoral fractures. J Orthop
Trauma 2005;19(1): 63-66.

15. Min WK, Kim SY, Kim TK, et al. Proximal femoral nail for the treatment of reverse obliquity
intertrochanteric fractures compared with gamma nail. J Trauma 2007;63(5):1054-1060.

16. Park SY, Yang KH, Yoo JH, et al. The treatment of reverse obliquity intertrochanteric fractures with the
intramedullary hip nail. J Trauma 2008;65(4):852-857.

17. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric
fractures caused by low-energy trauma. J Bone Joint Surg Am 2005;87(10):2217-2226.

18. Shukla S, Johnston P, Ahmad MA, et al. Outcome of traumatic subtrochanteric femoral fractures fixed
using cephalomedullary nails. Injury 2007;38(11):1286-1293.

19. Ekstrom W, Nemeth G, Samnegard E, et al. Quality of life after a subtrochanteric fracture: a prospective
cohort study on 87 elderly patients. Injury 2009;40(4):371-376.
20. Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women
taking alendronate. N Engl J Med 2008;358(12):1304-1306.

21. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric
intramedullary femoral nailing. J Orthop Trauma 2005;19(10):681-686.

22. Streubel PN, Wong AH, Ricci WM, et al. Is there a standard trochanteric entry site for nailing of
subtrochanteric femur fractures? J Orthop Trauma 2011;25(4):202-207.
 22
Femur Fractures: Antegrade Intramedullary Nailing
Christopher G. Finkemeier
Rafael Neiman
Frederick Tonnos

INTRODUCTION
Diaphyseal femur fractures are classified according to the AO/OTA classification (Fig. 22.1). The diaphysis is
defined as the area remaining when subtracting the areas formed by a box around the proximal and distal
metaphyseal areas of the femur (1). Intramedullary nailing is the most common form of diaphyseal femur fracture
fixation performed in the United States. The modern pioneer of nailing was Gerhard Kuntscher, who developed
this technique in 1939 and performed it regularly in the 1940s (2). Since that time, many steps in the evolution of
the technique have occurred, and nail design continues to evolve. Nevertheless, controversies remain regarding
patient position, direction of nailing (retrograde vs. antegrade), nail design, the role of reaming, and the ideal
starting point. Most authors recommend static cross-locking of the nail as studies have shown that this does not
inhibit fracture healing (3). Intramedullary nailing using a piriformis fossa starting point has been the classic
approach to femoral nailing. Due to its difficulty in the supine position, many surgeons are now using a
trochanteric starting because it is easier in the supine position. Today there are implants specifically designed for
trochanteric entry that accommodate the complex proximal femoral osseous anatomy (4). There are no significant
differences in outcome between trochanteric and piriformis starting points (5,6).
Intramedullary reaming has both advantages and disadvantages in a patient with a femur fracture. Reaming
allows the surgeon to “sound” the canal, which allows a better assessment of nail diameter. However, the main
reason to ream a femur is to allow larger diameter implants, which decreases hardware failure and improves
union rates (2,7). An unproven but theoretically attractive advantage of reaming is to deposit finely morselized
autogenous bone graft at the fracture site. The disadvantages of reaming are its potential negative physiologic
effects, which include acute respiratory distress syndrome and systemic inflammatory response syndrome (8).
The role and timing of reaming remain highly controversial (9). Advances in reamer design and techniques, such
as “minimal reaming,” minimize the number of passes and may decrease the embolic load. Reamers with sharp,
deep flutes have replaced previous generations of shallow reamers, thereby diminishing the “plunger” effect of
reaming. More recently, reamers have been designed to decrease the pressure and heat within the canal by
using a suction/irrigation system to cool and clear the products of reaming. Most North American surgeons use
reaming when nailing diaphyseal femur fractures, because the risk/reward ratio is still very favorable.

INDICATIONS AND CONTRAINDICATIONS

Most diaphyseal fractures can be nailed, regardless of the degree or amount of comminution, angulation, or
shortening. Metaphyseal extension is not a contraindication to nailing, although special attention to reduction is
required. Nailing is also indicated for pathologic or impending fractures in patients with bone pain or lytic lesions
from metastasis.
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FIGURE 22.1 OTA classification of femur fractures.

Intramedullary nailing can be successfully performed antegrade (piriformis or trochanteric entry) or retrograde
(through the knee). Although some surgeons may routinely perform retrograde nailing, most surgeons prefer to
reserve retrograde nailing for special circumstances such as bilateral femur fractures, ipsilateral femur and tibia
(floating knee) fractures, femur fracture in an obese patient, ipsilateral femoral neck/shaft fractures or ipsilateral
femur, and pelvis or acetabulum fractures.
There are several contraindications to nailing and include patients of small stature with narrow intramedullary
canals who may be at an increased risk for nail incarceration or iatrogenic fracture. They may require excessive
reaming to allow safe passage of the nail. Pediatric and adolescent patients with open epiphysis may be better
treated with flexible nails that avoid the growth plates. Severe systemic or local infections are also
contraindications to nailing. Alternate methods such as external fixation or plating should be considered in these
cases. Patients with severe lung injury and long bone fractures often require damage control with a temporary
external fixator prior to intramedullary nailing. This allows for improvements in their physiologic state prior to
definitive care. An open femur fracture is not a contraindication to primary nailing (10). Most open femur fractures
can be safely nailed after the initial irrigation and débridement. However, in highly contaminated femur fractures
that would require a “second look” or in cases of prolonged delay (in the authors' opinion this would be >12
hours) to irrigation and débridement, the surgeon should place an external fixator for temporary stabilization. This
will allow the surgeon to reexpose the bone ends at the next operation and gain thorough access to the open
fracture zone of injury. Once the zone of injury is deemed thoroughly irrigated and débrided, the definitive
intramedullary nail can be inserted.
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PREOPERATIVE PLANNING
History and Physical Examination
When planning surgery for intramedullary nailing, careful evaluation of the patient is essential. Age,
comorbidities, and concomitant injuries are essential parts of the evaluation. An isolated femur fracture from a
high-energy mechanism is a diagnosis of exclusion. The entire axial and appendicular skeleton, as well as the
chest and abdomen, must be thoroughly examined to rule out additional injuries. The surgeon should check for
open wounds, abrasions, blisters, and swelling not only in the injured thigh but also in all the extremities. A large
hemarthrosis of the ipsilateral knee may indicate a patella or tibial plateau fracture or cruciate injury. The
peripheral pulses should be carefully documented, and an ankle-brachial index should be calculated if pulses are
diminished or not palpable. The surgeon should document a detailed neurological exam looking for deficits in the
deep peroneal, superficial peroneal, and tibial nerve distributions. Femoral nerve function will be nearly
impossible to ascertain, but careful observation of the patient may give information of quadriceps function if the
patients move involuntarily due to pain.
Older patients with osteoporosis and bowing of their femurs require special consideration to prevent an
iatrogenic fracture during nailing. Comorbidities are important and may influence patient positioning, direction of
nailing, nail type, and the role of reaming. Morbidly obese patients may be better treated with a retrograde nail. If
antegrade nailing is required, a lateral position rather than supine position may be helpful. Multiply injured
patients with spine fractures or solid organ injuries such as the liver or spleen are more safely nailed in the
supine position. In patients with lung injuries and multiple long bone fractures, nailing without reaming or with
modified suction-irrigation reamers may minimize fat embolization. Metastatic disease to bone may influence the
surgeon to stabilize the entire femur, including the femoral head and neck, to prevent fractures in these locations.

Imaging Studies
High-quality radiographs should be obtained for accurate preoperative planning. A full-length anteroposterior and
lateral radiograph is essential. If fracture comminution precludes adequate determination of canal diameter and
length, x-rays of the contralateral femur are helpful. Frequently these measurements can be taken
intraoperatively from landmarks on the contralateral femur using fluoroscopy.
Dedicated radiographs of the hip and knee, as well as a computed tomography (CT) scan, may help identify
fractures of the knee joint or femoral neck (11). A thin-section CT through the femoral neck will identify many, but
not all, nondisplaced femoral neck fractures ipsilateral to a femoral shaft fracture (11, 12 and 13). The authors
recommend asking for and evaluating the thin cuts (2 mm) through the femoral necks as part of the trauma pelvis
CT in patients with femoral shaft fractures. High vigilance for femoral neck fractures is still required for all
patients with femur fractures in the perioperative period.

Timing of Surgery
Once the patient has been evaluated and treated for concomitant injuries, the timing of nailing must be
considered. Nailing within 24 hours is preferred for those patients without complex medical comorbidities and
who are stable for surgery. If an operating room is not available or the patient has a full stomach, the surgeon
may have to delay treatment for a few hours. The surgeon should treat the femur fracture as soon as the patient,
the operating room resources, and the surgeon are fully ready for surgery. There is no need to operate in the
middle of the night by a tired surgeon and hospital crew. However, if surgery will be delayed more than several
hours, the surgeon should place the patient in skeletal traction to hold the femur out to length. This is usually
more comfortable for the patient and may decrease blood loss. The surgeon should also consider a femoral
nerve block or indwelling femoral nerve catheter while the patient waits for surgery (14). For multiply injured
patients who require resuscitation, some form of traction is recommended as their physiologic state may
deteriorate rapidly. If surgery is delayed >8 to 12 hours, skeletal traction is preferred. A Kirschner wire should be
placed in the distal femur or proximal tibia and attached to a tensioned traction bow. This can often be done in
the emergency department or intensive care unit under local anesthesia. In the unstable polytrauma patient,
damage control orthopedics using external fixation may be preferable to skeletal traction if the patient is going to
be in the operating room for life-saving procedures. An external fixator can be applied in the intensive care unit,
but this is not ideal. Single-stage conversion of an external fixator to a nail should be done early (ideally within 14
days) to minimize the risk of infection (15). Scannell et al. (16) showed no apparent difference in morbidity or
outcome between patients treated with skeletal traction or external fixation in the severely injured patient.

Surgical Tactic
Prior to surgery, the surgeon should develop a surgical plan based on the findings of the physical exam and
imaging studies. This plan must be shared with the operating room staff to make sure all the personnel work
efficiently. The surgeon should decide patient positioning, whether a fracture table will be used and whether the
patient will need damage control techniques (external fixator) or definitive treatment. If the patient is going to be
treated
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definitively with an intramedullary nail, will the surgeon place the nail retrograde or antegrade? If antegrade
nailing is chosen, will the surgeon use a piriformis or trochanteric entry? The surgeon will also need to decide if
he/she will ream or not ream. Other key decisions that will need to be determined before the case are the
location of the C-arm and if any ancillary reduction devices such as Shanz pins, a crutch, bolsters, etc. will be
needed. All of these decisions need to be made before the case starts to be sure the appropriate equipment and
resources available. Once the surgical tactic is completed, the surgeon is now ready to execute the plan and
perform the operation.

Surgery
For the most part, the anesthesiologist will determine whether a regional or general anesthetic will be most
appropriate for the patient and the planned operation. Absolute contraindications for regional anesthetic are
head injury, a large blood loss, and coagulopathy.
The trauma surgeon and/or anesthesiologist will most likely determine whether an arterial and/or central line will
be needed. In general, unstable patients with a large blood loss or patients with cardiopulmonary comorbidities
will require arterial and central venous access. A foley catheter is usually indicated to help monitor volume
status.
Prophylactic antibiotics should be given based on the patients' drug allergies and soft-tissue status. An antibiotic
with staphylococcus and streptococcus coverage such as a first-generation cephalosporin is recommended for
closed fractures. An alternative antibiotic such as clindamycin should be given if the patients have a significant
penicillin allergy. Routine antibiotic prophylaxis is typically given for 24 hours post-op. Patients with open
fractures should receive antibiotics as soon as possible to cover gram-positive organisms (first-generation
cephalosporin) for small skin wounds with little to no contamination. If the open wound is more extensive or
contaminated, then additional antibiotics should be given to cover gram-negative organisms (gentamycin) and
possibly anaerobic organisms (penicillin) if there is significant soil contamination. The appropriate duration of
postoperative antibiotics after an open femur fracture is not clearly defined. Continuing antibiotics for 1 to 3 days
after the last washout is reasonable based on initial wound contamination.

Patient Positioning
There are several ways to position a patient for femoral nailing, and each has its advantages and disadvantages.
Classically patients are positioned either supine or lateral on a fracture table. Traction through the leg extension
or using a skeletal traction pin is almost always necessary to restore length and alignment of the shortened
femur. Alternatively, nailing on a flat-top radiolucent table can be done, but usually requires a scrubbed assistant,
traction with weights off the end of the table, or a femoral distractor to maintain length during the procedure.
Kuntscher (2) originally described femoral nailing with the patient in the lateral position on a fracture table (Fig.
22.2). The chief benefit of lateral positioning is that it provides easier access to the piriformis fossa
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and facilitates nailing of fractures in the proximal portion of the femur as well as in large or obese patients.
Disadvantages of lateral nailing include limitations in patients with multiple injuries and the difficulty judging
proper rotation of the extremity. Lateral decubitus nailing on a fracture table is used much less frequently today.

FIGURE 22.2 Lateral decubitus operative position. Access to the proximal femur is facilitated by increased hip
flexion, which minimizes interference of the insertion instrumentation with the patient's torso. A drawback to this
technique is that pulmonary function is slightly compromised, the setup is time consuming, and venous
congestion can be caused from the peroneal post compressing the medial thigh and femoral vessels.
FIGURE 22.3 Supine positioning for antegrade femoral nailing on a fracture table. Both lower extremities are
secured in traction boots. The injured femur may require a traction pin if the fracture is particularly short or there
has been a delay to surgery with prior traction applied.

Supine nailing on a fracture table (Fig. 22.3) is the most commonly utilized technique for femoral nailing in North
America. Benefits include a relatively straightforward setup, familiarity by the operating room staff, improved
ability to assess limb length and rotation when both legs are in extension, and it can often be performed without a
scrubbed assistant. The major drawback with this method is difficulty gaining access to the piriformis fossa,
particularly in large patients.
Supine or floppy lateral positioning on a radiolucent table has recently become more popular due to its simple
setup and accommodation of patients with multiple injuries. Multiple procedures can be performed on the same
patient without a position change when this method is chosen. The major disadvantage with this technique is
accurate restoration of length and alignment that requires a scrubbed assistant for reduction and traction,
especially in delayed cases or in patients with large muscle mass. Because most femoral nailings are done
supine on a fracture table and it is currently the most universal method of femoral nailing, the rest of the chapter
focuses on this technique.
Once the patient has been placed on the fracture table, it is helpful to “bend” the patient's torso away from the
injured side (Fig. 22.4) to improve access to the starting point in the proximal femur. The upper extremity
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on the injured side is secured across the chest and held on bolsters, a Mayo stand, or pillows (see Fig. 22.4).
With isolated femur fractures, the injured leg is placed into the boot of the fracture table. If a skeletal traction pin
is required or is already in place, it is incorporated into the fracture table. A distal femoral traction pin must be
strategically placed to avoid interfering with the nailing process. If there are no injuries to the knee joint, many
surgeons prefer a proximal tibial pin. We routinely place the noninjured extremity in the contralateral traction boot
with the hip and knee in extension so that modest counter traction can be applied through this limb as well (see
Fig. 22.4). This stabilizes the pelvis and prevents rotation of the pelvis around the perineal post when traction is
applied to the injured limb. Another benefit of nailing with both legs in extension is the excellent ability to assess
length and rotation by using the uninjured femur as a guide. Although many surgeons prefer to flex, abduct, and
externally rotate the uninjured leg in a well-leg support, we have found this to be less reliable for stabilizing the
pelvis and assessing length and rotation.
FIGURE 22.4 The patient's torso should be gently angled away from the injured limb to allow freer access to the
proximal end of the femur. The upper extremity should be brought over the chest and secured so that it will not
interfere with the ball-tipped guide rod and reamer when placing them into the proximal end of the femur. The
noninjured limb should have a small amount of counter traction so it will prevent the pelvis from rotating around
the perineal post. When both limbs are in positioned in this manner, length and rotation can be determined fairly
accurately.

Once the patient is positioned and secured to the fracture table with both lower extremities in extension, gentle
traction is applied to the noninjured injured extremity to keep it from sagging. The next step is to apply traction to
the injured extremity to restore the length, alignment, and correct the rotation. For simple and minimally
comminuted femur fractures, this is relatively easy to accomplish. However, in patients with comminuted unstable
fractures, we use the uninjured side as a reference.

Imaging
The C-arm is brought in perpendicular to the patient from the opposite side, and a posterior-anterior (PA) image
of the hip on the injured side is taken. This image is saved to the second screen of the C-arm monitor. A PA
image is then taken of the hip on the uninjured side. The uninjured extremity is rotated (usually slightly external)
until the PA profile matches the hip from the injured side. Once the two hips match, a PA image of the knee on
the uninjured extremity is taken and saved. The injured extremity is then rotated until the knee image on the
injured side matches the knee image on the uninjured side. Once the two knee images match, the rotation of the
femurs should be correct. The C-arm can now be centered over the fracture site, and traction can be applied or
released as needed to restore the length of the injured femur. If the fracture is a simple pattern, rotation and
length can be fine-tuned based on matching up the fracture lines like a puzzle. If there is significant comminution,
length can be determined by measuring the uninjured femur with a long ruler using the image intensifier (Fig.
22.5). The injured femur can be pulled out to the desired length as needed with the traction boot or traction pin.
The most difficult situation is when both femurs are fractured, and there are no normal landmarks to judge length
and rotation. In this infrequent scenario, the surgeon takes a lateral image
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of the least injured extremity's hip and rotates the C-arm until a lateral projection of the hip is obtained with about
10 to 15 degrees of femoral neck anteversion. The C-arm is then moved down to the knee, and the knee is
rotated (usually slight external rotation is required) until a perfect lateral of the knee is obtained. At this point, the
femur should have acceptable rotational alignment. Length should be restored as best as possible using the
ligamentotaxis of the fractured fragments as guides to length. Once one side is fixed, then the other side can be
matched using the technique described above so that both extremities have symmetric length and rotation. One
important technical point to emphasize is that a direct lateral of the hip is difficult to obtain in large patients due to
the need to image through the entire pelvis. However, rotating the C-arm 10 to 15 degrees off the true lateral
allows adequate visualization in most patients. Once length and rotation have been restored, the two extremities
are scissored by lowering the uninjured extremity toward the floor (Fig. 22.6).

FIGURE 22.5 When the fracture is comminuted and there are no intact edges on the proximal and distal
fragments from which to judge length, a ruler can be used to measure the noninjured side to guide how much
traction to apply to restore the length of the injured extremity.
FIGURE 22.6 Scissor the legs, dropping the uninjured lower extremity toward the floor to allow lateral
fluoroscopic views of the injured lower extremity.

Entry Point
Antegrade femoral nailing can be done via entry through the piriformis fossa (trochanteric fossa) or the tip of the
greater trochanter (trochanteric entry). The choice between piriformis fossa or trochanteric entry is mainly based
on surgeon preference and experience. The trochanteric portal may be easier to locate in larger patients. There
has been concern that trochanteric entry nails may damage the gluteus medius and lead to hip dysfunction.
However, randomized controlled trials show no difference in outcome between the two approaches (4,5). If a
trochanteric entry portal is to be used, the surgeon must use a nail designed for trochanteric entry and insert the
nail in the location recommended by the manufacturer. Small deviations from the recommended entry portal may
cause malalignment in more proximal fractures. A 4 to 6-cm incision is made several centimeters proximal to the
tip of the greater trochanter. A skin incision made well above the trochanter improves the trajectory for guide wire
insertion, reaming, and nailing. Be sure that the insertion handle will be able to accommodate the soft tissue
distance when using a more proximal skin incision. The incision is deepened through the subcutaneous tissue
down to the gluteal myofascia, which is incised in line with the incision. Blunt finger dissection through the
muscle allows identification of the tip of the greater trochanter.
The piriformis fossa is located medial and slightly posterior to the base of the femoral neck. An AP image of the
hip with a guide pin or awl placed in the fossa should appear as being slightly “inside the bone” (Fig. 22.7). If the
tip of the guide pin or awl appears perched directly on the cortex of the femoral neck, it is too anterior. It is
important to avoid anterior entry portals as this may cause iatrogenic comminution due to large hoop stresses
created by an eccentric nail trajectory and pathway. The surgeon must also avoid starting the nail lateral to the
piriformis fossa in the greater trochanter as this will result in varus malreduction with proximal femur fractures.
The guide pin should be adjusted so that it is projected to be down the center of the medullary canal on both the
AP and lateral fluoroscopic views. Once the guide pin is in the piriformis fossa and in line with the femoral canal
on the PA and lateral views, it is advanced to the level of the lesser trochanter. The staring point in the proximal
femur is opened with the cannulated drill or end-cutting reamer. Meticulous attention to detail in regard to
obtaining a “perfect” starting point cannot be overemphasized.
With a trochanteric entry site, the guide pin should be placed on the tip of the greater trochanter as seen on the
AP view (17) and in the middle or slightly posterior in the greater trochanter on the lateral view. If the surgeon is
using a nail that he/she is not familiar with, the manufacturer's technique guide should be reviewed to verify the
recommended entry site on the greater trochanter. Anterior placement of a trochanteric entry nail can lead to
malalignment of the proximal femur (18). It is important to use a femoral nail designed specifically for trochanteric
entry with this approach. If a “straight” nail designed for piriformis entry is placed through a trochanteric entry
portal, a varus malreduction can occur.

Guide Wire Passage

To facilitate passage of the guide wire, it is helpful to place at slight bend in the wire 1 or 2 cm from the tip (Fig.
22.8). This bend helps passing the guide wire into the distal segment when there is mild residual displacement.
With greater degrees of fracture displacement, manual manipulation of the fracture with an intramedullary
reduction tool can be helpful (Fig. 22.9). Most modern nail sets have a cannulated reduction tool that can be
inserted over the guide wire and advanced just proximal to the fracture site. In patients with small medullary
canals, reaming of the proximal fragment may facilitate insertion of this device. The proximal fragment can then
be manipulated to allow passage of the guide wire into the distal fragment. It is important that the guide wire be
centered in the middle of the medullary canal on the AP and lateral view using the C-arm prior to reaming.
Occasionally, the proximal or distal fracture fragments can be “pushed or pulled” into better alignment with a
crutch or a lifting pad attachment that is part of some fracture tables. If these maneuvers are also not successful,
then direct manipulation of the proximal or more commonly the distal fracture can be done using a
percutaneously inserted terminally threaded 2.5-mm pin or external fixation pin (Shanz pin) attached to a handle
(Fig. 22.10). By manipulating the fragment(s), alignment can usually be improved allowing passage of the ball-
tipped guide wire (Fig. 22.11). Schantz or external fixation pins should be placed eccentrically or in a unicortical
fashion to allow easy passage of the ball-tipped guide wire. In many cases, one or more of these “tricks” will
need to be employed simultaneously to allow successful guide wire passage.
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FIGURE 22.7 A. The guide pin should sit in the piriformis fossa on the AP view of the proximal femur. The pin
should look like it is inside the bone a short distance instead of being perched on the anterior cortex. If the tip
does not appear slightly into the bone on the AP view, then it is too anterior, being perched on the anterior cortex
of the femoral neck. B. X-ray image example of what is presented in (A).
FIGURE 22.8 A slight bend placed near the end of the guide rod will facilitate passage of the guide rod across a
mildly displaced fracture.

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FIGURE 22.9 Fracture reduction with small-diameter nail or reducing tool. A more powerful reducing force may
be applied with the use of a small-diameter nail or reducing tool. When proximal diaphyseal fractures are
encountered, this instrument can be used to control the flexed, externally rotated, and abducted proximal
fragment during reduction.

If closed or percutaneous reduction methods are unsuccessful after a reasonable period of time (20 to 30
minutes), an open reduction with direct passage of the ball-tipped guide wire should be done. An open reduction
should not be considered a treatment failure. A seriously injured patient may be better off with a small open
incision and shorter operation than a prolonged procedure with multiple failed attempts at closed reduction that
increase the risk of fat embolism, pudendal nerve palsy, and heterotopic ossification.

Reaming
After C-arm confirmation of satisfactory placement of the ball-tipped guide wire in the femur (central and
advanced to the epiphyseal scar; Fig. 22.12), the surgeon prepares to ream the intramedullary canal. To avoid
inadvertent contamination, the work area above the insertion site and adjacent to the patient's abdomen and
chest should be inspected. Not uncommonly, an overhead light or IV pole at the head of the table can create
potential obstructions and need to be moved. At this time, we often add an additional sterile sheet near the head
of the table. Ideally, sharp reamers with narrow drive shafts, small heads, and deep cutting flutes are utilized.
Based on the estimated canal width determined preoperatively, an end-cutting reamer at least 1 mm smaller than
the medullary canal diameter is introduced. The reamer is passed slowly down the intramedullary canal until the
reamer head reaches 1 to 2 cm from the end of the guide wire. Whenever possible, a skin protector is utilized to
avoid damage to the skin and soft tissues at the entry site (Fig. 22.13). Reamer size is increased in
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0.5 to 1.0 mm increments until the cortical chatter is encountered. Thereafter, it is advisable to increase size by
0.5 mm increments to avoid nail incarceration and thermal necrosis. The femur should be “overreamed” 1.0 to
1.5 mm greater than the planned nail diameter. When using a trochanteric entry portal, reaming the proximal
fragment at least 2 mm larger than the desired nail diameter will make passage of the nail easier in the proximal
femur and decrease the chance for iatrogenic comminution.

FIGURE 22.10 2.5-mm terminally threaded guide pins can be used as percutaneous reduction aids. One or two
pins placed into a bone fragment can be used to steer or direct the fragment into alignment with the proximal
fragment allowing the ball-tipped guide rod to be placed into the intramedullary canal. Larger Schanz pins can be
equally effective.
Nail length is determined by specific measurement tools found in most nailing sets. This step can be done prior
to reaming if the surgeon desires. The most important factors in determining nail length are reduction of the
fracture and confirmation that the guide wire has not backed out during the reaming process. The surgeon
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should ensure that the fracture is reduced radiographically. Length can be fine-tuned and adjusted using the
fracture table as needed. If the surgeon is using a nailing system without a length measurement tool, then the
“two-wire” technique can be used. Keeping the original ball-tipped guide wire in place, a second guide wire of
the same length can be placed adjacent to it down to the entry site. The length of the wire above the tip of the
original guide wire is the correct length of the nail to be inserted.

FIGURE 22.11 The surgeon must be cognizant not to block passage of the guide rod with the pins. The pins
should be placed unicortically or above or below the passage of the proposed path of the guide rod.
FIGURE 22.12 Fluoroscopic AP image showing the ball-tipped guide wire centered in the distal femur at the level
of the epiphyseal scar.

Nail Insertion
The nail should always be inserted over a ball-tipped guide wire. Most modern nail designs allow the guide wire
to be removed through the nail eliminating the need to exchange the ball-tipped guide wire for a smooth
nonbeaded wire through an exchange tube. The nail with its attached insertion handle nail is then manually
pushed down the intramedullary canal until it stops. It is then advanced with light blows using a mallet or
hammer. If back slapping is needed to overcome distraction at the fracture site, the nail should be inserted
slightly deeper into the femur so that after the fracture is compressed, the nail will be at the proper level, just
below the tip of the greater trochanter. When inserting a trochanteric or a piriformis entry nail, it may be helpful to
rotate the nail 90 degrees toward the patient to facilitate nail passage through the proximal femur. Once the nail
tip is past the lesser trochanter, the surgeon slowly rotates the nail back to its normal position while the nail is
being tapped into place. The nail is advanced taking periodic spot views with the C-arm. During passage of the
nail across the fracture, the surgeon should utilize any reduction “techniques” previously used to reduce the
fracture. If at any time, the nail does not advance smoothly with each tap of the mallet, the C-arm images should
be scrutinized to ensure that the nail is not stuck on a bone fragment or fracture edge (Fig. 22.14). It is important
to remember that an intramedullary nail can only realign fractures in the middle third of the femur, but cannot
predictably realign metadiaphyseal injuries due to nail size and medullary canal mismatch.
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If the fracture is malreduced after nailing, the implant should be removed and length, rotation, and frontal and
sagittal plane alignment reassessed. Occasionally, with comminuted infraisthmal fractures, blocking screws may
be necessary. Once the nail is placed into the correct position, the guide wire is removed. If the fracture is at its
proper length, then the surgeon proceeds with cross-locking. If back slapping is needed to compress or shorten
the fracture, the distal cross-locks need to be placed first.
FIGURE 22.13 A skin protection instrument will protect the skin edges from burning or abrasion during reaming.
A lap-pad strap is tied to the protector to prevent it from falling on the floor.

FIGURE 22.14 The surgeon should not hesitate to image the nail if smooth passage of the nail is interrupted. In
some cases, the nail may get hung up on a bone fragment or the edge of a fracture fragment.
Blocking Screws
Not uncommonly, it is difficult to obtain or maintain coronal or sagittal plane alignment in fractures proximal or
distal to the isthmus due to comminution, muscle forces, or a mismatch of the canal diameter and the nail. If
closed reduction maneuvers fail to overcome malalignment, then blocking screws can be helpful. Blocking
screws are designed to narrow the canal within metaphyseal bone and direct the nail in a preferential direction
by “blocking” its passage down a less optimal path. In general, the blocking screw is placed on the side of the
fracture “concavity” in the fracture fragment where the canal is wider than the nail (Fig. 22.15). The blocking
screw is most effective if placed closer to the fracture site than farther away from it. The surgeon should be
careful to look for nondisplaced fracture lines extending away from the primary fracture in the proposed area of
the blocking screw to avoid iatrogenic comminution. Once the blocking screw is placed, the guide wire is
reinserted into the new path and then reamed to assist with nail passage. Care must be taken when reaming
near the blocking screw to prevent jamming or reamer head damage. The nail can now be reinserted and
statically locked. In most cases, the blocking screw should be left in place after nail placement (Fig. 22.16).

Proximal Locking
The most important aspect to successful proximal cross-locking is verifying that the insertion jig handle is still
fully tightened onto the nail. If the handle is tight, most modern proximal cross-locking jigs work very well. The
surgeon should verify with the C-arm that the proposed cross-locking screws will not enter
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the fracture site. A common pitfall with proximal locking is making the incisions for the drill sleeves too small. The
drill sleeves need adequate room to slide smoothly down to the bone to avoid entrapment by the skin, muscle,
and fascia, which could affect drilling and subsequent screw placement. Because most current nail systems use
the drill sleeves to measure the screw length, it is critical that the sleeves are placed firmly against bone. After
placing the proximal cross-locking screw(s), their position should be confirmed fluoroscopically.
FIGURE 22.15 If proper coronal or sagittal plane alignment is difficult to achieve by indirect methods, blocking
screws placed on the concave side of the deformity in the proximal fragment can help align the fragments into a
satisfactory position.

Some nail designs allow proximal cross-locking screws to be placed into the femoral head (historically referred to
as reconstruction nails). The surgeon should consider placing cross-locking screw into the femoral
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head if the fracture is at the level of the lesser trochanter or higher where standard transverse or oblique (greater
trochanter to lesser trochanter) cross-locking screws will not be above the proximal fracture. The other reason to
use cross-locking screws into the femoral head is to stabilize a femoral neck fracture ipsilateral to a femoral shaft
fracture. Using a single device to stabilize an ipsilateral femoral neck and shaft fracture is controversial, and the
modern trend is to fix both fractures with separate implants (i.e., cannulated screws for the neck fracture and a
retrograde nail or plate for the shaft fracture.) Despite this controversy, some surgeons currently advocate
routine placement of cephalomedullary screws into the femoral neck for all patients with a femoral shaft fractures.
These surgeons advocate this approach because of the significant risk of missing a nondisplaced femoral neck
fracture even with CT scanning to screen for these fractures (19).
FIGURE 22.16 Example of a blocking screw placed to prevent varus malalignment of a distal femoral fracture.

Distal Locking
Whereas proximal locking is done with a jig, distal locking is most commonly accomplished using a freehand
technique. Distal locking jigs have been developed, but for the most part have been abandoned as unreliable.
Other attempts at simplifying distal locking have included radiolucent drill attachments, handheld radiolucent drill
guides, navigation, and an intramedullary radiofrequency probes. While these devices can be helpful, they are
expensive and not widely available. The vast majority of distal cross-locking is still done freehand.
Freehand distal locking is predicated on obtaining “perfect circles” of the distal locking holes with the C-arm (Fig.
22.17). Having both of the patient's lower extremities in extension and scissored as described above facilitates
freehand distal locking. Once the C-arm has been positioned to project perfect circles, the surgeon localizes the
spot on the skin overlying the center of the intended cross-locking hole with a drill bit or tip of a knife blade. A
1.5-cm skin incision is made through the skin and iliotibial band and spread down to bone. A calibrated drill bit is
placed on the lateral aspect of the femur and moved in small increments until the sharp tip of the drill bit is within
the projected image of the center of the cross-locking hole. The position of the drill bit should be clearly
visualized on several projections. Once the tip is confirmed to be in the center of the cross-locking hole, the drill
is adjusted to be “in line” with the x-ray beam. Pressure should be kept on the drill bit so that it does not “walk” or
slip off the rounded cortex. The lateral cortex is opened with the drill, and an x-ray image at this point must
confirm that the drill is still pointing toward the center of the locking hole, and if not, what adjustments should be
made to the angle of insertion. If at anytime, the surgeon loses his direction or encounters unexpected
resistance, a spot image with the C-arm should be obtained. If the drill bit has deviated from its intended course,
the steps listed above should be repeated until the drill bit has successfully traversed the nail. Once the drill bit
penetrates the far cortex, the length of the screw can be determined from the calibrations on the drill bit. Of
course, length can be measured with a standard depth gauge. If more than one cross-locking screw is planned, it
may be helpful to leave the first drill bit in place to provide a visual guide for insertion of the second drill bit and
screw. The C-arm should be used to confirm that the drill bit(s) are through the holes in the nail prior to placing
the cross-locking screws. After the screws have been tightened into place, the C-arm is used to confirm that the
locking screws are through the nail, are of appropriate length, and flush with the lateral cortex. For length stable
fractures in the middle one-third of the femur, one cross-locking screw is sufficient (20). However, for
comminuted fractures and infraisthmal injuries, at least two distal cross-locking screws are necessary to avoid
rotation or toggling of the distal fragment (Fig. 22.18). Virtually all femur fractures should be statically locked to
prevent loss of reduction, which has been reported to occur in up to 10% of femur fractures (21). Brumback et al.
(2) has shown that statically locked femur fractures do not have higher rates of nonunion.

Final Details
At the completion of the nailing, the surgeon should reassess the hip region to rule out a missed femoral neck
fracture. The C-arm can be rotated 180 degrees around the femoral neck taking spot images. With the patient
still under anesthesia, the patient is moved off the fracture table and limb length, and rotation is compared to the
opposite side. Ligamentous evaluation of the knee should also be performed, as this may be painful once awake.
If gross malalignment is detected, the problem should be corrected before leaving the operating room. If the
deformity is small or the patient is too sick, a post-op CT scan should be obtained.

POSTOPERATIVE MANAGEMENT
The early postoperative phase, or hospital phase, should focus on patient monitoring, deep vein thrombosis
(DVT) prophylaxis, pain control, antibiotics, surgical site care, and early physical therapy. In patients with other
injuries, variations from the routine management are often necessary. It is not uncommon to see a drop in the
patient's hemoglobin and hematocrit after closed nailing and should be followed closely for several days although
blood transfusions are uncommon. We strongly recommend mechanical and chemical prophylaxis for DVT
prevention, which is initiated within 24 hours in the absence of any contraindications.
Physical therapy focuses on early mobilization, and patients are encouraged to be full weight bearing if there is
good cortical contact or otherwise partial weight bearing with crutches or a walker. Hip, knee, and ankle motion
is stressed along with isometric strengthening exercises. The incision is kept covered with clean,
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dry dressings until oozing stops. Prolonged drainage usually may be due to an underlying seroma, hematoma, or
anticoagulation therapy. This occasionally warrants surgical evacuation.
FIGURE 22.17 The C-arm should be positioned to obtain an optimal lateral view of the distal femur. The goal is
to pass the beam exactly in line with the axis of the screw holes. When the C-arm is properly aligned, the holes
appear as perfect circles. An elliptical appearance of the holes suggests malalignment of the beam. Malalignment
of the beam in the coronal plane makes the holes appear as vertical ellipses. Malalignment in the sagittal plane
makes holes appear as horizontal ellipses.

After hospital discharge, patients are continued on DVT prophylaxis for 2 weeks and pain medications as
needed. Follow-up 10 to 14 days postoperatively is recommended for suture/staple removal and wound
evaluation. Physical therapy is continued to assist with early functional recovery. Radiographs are obtained at
follow up and at 4 to 6-week intervals to assess fracture healing. Once fracture callus is evident on radiographs,
weight bearing is advanced, and the patient weaned from external supports.
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FIGURE 22.18 Cross-locking a fracture in the distal third of the femur with a single screw permits the short distal
fragment to toggle or rotate on the axis of the screw.

Return to preinjury function can be prolonged after a femoral shaft fracture. Up to 20% of people fail to return to
full-time preinjury employment after 3 years (22). With union rates ranging from 97% to 99% in most series, there
is a significant discrepancy between fracture healing and functional recovery. Abnormal gait, hip abductor
weakness, knee extensor weakness, knee pain, and hip pain are all common postoperative issues. Soft-tissue
damage from the trauma can be a significant cause of disability as well. All these factors support the need for
early, focused rehabilitation, and a long-term exercise programs (23).

COMPLICATIONS
With careful technique, complications are uncommon. Patients commonly experience mild hip and knee pain
as well as loss of motion. Hip abductor and knee extensor weaknesses typically occur and contribute to a
limp that may persist for several months. Malunion is more common than nonunion.
Post-Op Wound Infection
Postoperative wound infection occurs in fewer than 1% of patients. Early infections can be effectively
treated with irrigation and débridement of the infected wound and hematoma. Deep cultures should be
obtained to direct antibiotic choice. Antibiotics will usually be administered for several weeks due to the
presence of hardware. If the infection is delayed more than several weeks and involves the intramedullary
canal, the existing nail should be removed and the intramedullary canal reamed to remove infected tissue.
The Reamer Irrigator Aspirator (Synthes, Paoli, PA) is a useful device to ream the canal and irrigate and
aspirate the intramedullary contents at the same time. An intramedullary nail made of
polymethylmethacrylate and antibiotic (tobramycin and/or vancomycin) is a simple way to deliver high-dose
local antibiotics to the intramedullary canal. This antibiotic nail is not stable so the femur should be
temporarily stabilized with an external fixator or KAFO for a few days to allow maximal antibiotic elution.
After a few days to a few weeks, the antibiotic nail can be exchanged for a standard interlocking nail. For
intramedullary infections, antibiotics will usually be given for several weeks based on the organism, its
sensitivities to various antibiotics, and host factors.
Malunion/Delayed Union/Nonunion
Typically, malunions result from improper alignment at the time of fixation. Surgeons treating these fractures
must have a system in place to be able to assess the length, angulation, and rotational components
intraoperatively. Angular malunion is seen most commonly with fractures that are near the proximal or distal
shaft region and also with unstable, comminuted fracture patterns (i.e., AO/OTA types 32-B and 32-C) (21).
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Malrotation is the most common type of malunion and > 15 degrees of malrotation has been reported to
occur in 28% of cases in one study. Functional limitations were greater in patients that were externally
rotated (24). Another series reported an average of 16 degrees of malrotation (25).
Typical pitfalls contributing to malunion include improper starting point, failure to obtain adequate reduction
prior to reaming, and not critically assessing length and rotation prior to cross-locking. With newer
generation nails, the trochanteric starting point may be inadvertently “lateralized,” even after appropriate
guide pin placement. As the proximal femur is opened, the reamer will follow the path of least resistance and
be pushed laterally by the tension of the soft tissues, reaming a path, which is eccentric and lateral to that
which is intended. This results in a varus malalignment and can be challenging to correct, even if
recognized intraoperatively.
The overall nonunion rate with the use of reamed, statically locked nails is 2% to 3% as compared to 7.5%
with nonreamed nails (21). Dynamization, the technique of removing the proximal or distal interlocking
screws to allow fracture compression with during weight bearing, should be considered for length stable
fractures that have not healed within 3 to 4 months. However, dynamization may be successful in only 50%
of cases (26). The ideal fracture would have a gap <1 cm and showing some callus. Delayed unions in the
proximal or distal thirds for the femoral shaft should have the cross-locking screws removed farthest from
the fracture site. Because the canal width in proximal and distal ends of the femur are wider than in the
middle third, this will prevent secondary malalignment from the smaller segment rotating or angulating
around the nail. If the nail has a “dynamic slot,” this should be used to help prevent loss of rotational and
angular alignment. For aseptic nonunion within the diaphysis and without bone loss, reamed, exchanged
nailing is successful in 70% to 100% of cases (27). If exchange nailing is not successful, a second attempt
is warranted as many nonunions will go on to heal after the second procedure. Exchange nailing may not be
as successful in nonunions associated with high-energy comminuted fractures (28). In these cases, as well
as cases of bone loss, bone grafting should be considered in addition to exchange nailing. Whether BMP
(bone morphogenic protein) can be used to substitute for autologous bone in this setting is not settled. The
authors recommend following the FDA recommendation for use of BMP in nonunions. The FDA has
approved the use of BMP-7 for nonunions when autologous bone graft is not feasible. Plating has a limited
role in femoral diaphyseal nonunion. For proximal or distal femoral shaft fractures within or near the
metaphysis, plating is an excellent treatment option for nonunion. Plating is also a good option for
nonunions with deformity or in refractory nonunions that require open bone grafting. In select cases, the
surgeon can consider adding a plate to a femoral shaft nonunion with an existing nail in place (29). One
scenario where this may make sense is when a retrograde nail was used to treat the initial injury, and the
surgeon may not wish to go back through the knee to exchange or remove the nail. A plate may also be
added to a nail when simple exchange nailing has not worked, and the surgeon is concerned about
torsional stability. Combined plating and nailing may provide the advantage of direct nonunion compression
with the plate and early weight bearing afforded by the nail.
 Missed Femoral Neck Fracture
A femoral neck fracture ipsilateral to a femoral shaft fracture is rare, occurring in 3.2% of cases (13).
Because many of these femoral neck fractures are nondisplaced and difficult to see on radiographs in the
acute trauma setting, up to 25% of ipsilateral femoral neck fractures are missed (13). Surgeons treating
femoral shaft fractures should remain vigilant before, during, and after treatment of the femoral shaft
fracture for a femoral neck fracture. If the neck fracture is identified intraoperatively, the treatment depends
on whether the fracture is displaced and whether the nail has been inserted prior to diagnosis. Displaced
fractures will most likely require an open reduction. Open reduction can be difficult if the nail is not removed.
Stabilization of a reduced femoral neck fracture ipsilateral to a diaphyseal fracture can be accomplished in
several ways: reconstruction-type nail, partially threaded screws placed around the nail after reinsertion of
the nail, partially threaded screws and a plate or partially threaded screws and a retrograde nail. If the
patient is on a fracture table, moving the patient off the fracture table to a radiolucent table is not practical
so one of the other methods should be used. If the femoral neck fracture is nondisplaced and identified after
the nail has been inserted, partially threaded screws can be placed either anterior or posterior to the nail to
secure the fracture. If the neck fracture is nondisplaced and identified prior to nail insertion, then the neck
fracture can be provisionally secured with heavy K-wires inserted anterior to the point of entry of the nail to
prevent displacement. The surgeon can then place partially threaded screws around the nail or choose a
reconstruction-type nail with screws directed into the femoral head. Regardless of the method chosen to
stabilize the femoral neck fracture, the surgeon should make every attempt to anatomically reduce the neck
fracture as anatomic reduction seems to be the only significant factor for successful treatment.

REFERENCES
1. AO/OTA classification—Marsh JL. Fracture Classification Compendium-2007: Orthopedic Trauma
Association Classification, Database, and Outcomes Committee. J Orthop Trauma 2007;21:S31-S42.

2. Kuntscher G. The Marrow Nailing Method. Switzerland: Stryker Trauma GmBH, 2006:2. (Original work
published 1947).

3. Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary nailing of femoral shaft fractures. Part II:
Fracture-healing with static interlocking fixation. J Bone Joint Surg Am 1988;70:1453-1462.

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4. Russel T. Third generation nailing. J Orthop Trauma 2008;22:S1.

5. Ricci WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry portal for the treatment of
femoral shaft fractures. J Orthop Trauma 2006;20(10):663-667.

6. James P, Stannard MD, Larry Bankston MD, et al. Functional outcome following intramedullary nailing of
the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals. J
Bone Joint Surg Am 2011;93(15):1385-1391.

7. Moed BR, Watson JT, Cramer KE, et al. Unreamed retrograde intramedullary nailing of fractures of the
femoral shaft. J Orthop Trauma 1998;12:334-342.
8. Pape H-C, Auf'm'Kolk M, Paffrath T, et al. Primary intramedullary femur fixation in multiple trauma patients
with associated lung contusion—a cause of posttraumatic ARDS? J Trauma 1993;34(4):540-548.

9. Wolinsky P, Tejwani N, Richmond JH, et al. Controversies in intramedullary nailing of femoral shaft
fractures. J Bone Joint Surg Am 2001;83:1404-1415.

10. Brumback RJ, Ellison PS Jr, Poka A, et al. Intramedullary nailing of open fractures of the femoral shaft. J
Bone Joint Surg Am 1989;71:1324-1331.

11. Tornetta P III, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft
fracture. Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.

12. Yang KH, Han DY, Park HW, et al. Fracture of the ipsilateral neck of the femur in shaft nailing. The role
of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

13. Cannada LK, Viehe T, Cates CA, et al. Southeastern Fracture Consortium. A retrospective review of
high-energy femoral neck-shaft fractures. J Orthop Trauma 2009;23:254-260.

14. Mutty C, Jensen EJ, Manka MA, et al. Femoral nerve block for diaphyseal and distal femoral fractures in
the emergency department. Surgical technique. J Bone Joint Surg Am 2008;90:218-222.

15. Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of external fixation to intramedullary nailing for
fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am 2000;82:78.

16. Scannell BP, Waldrop NE, Sasser HC, et al. Skeletal traction versus external fixation in the initial
temporization of femoral shaft fractures in severely injured patients. J Trauma 2010;68:633-640.

17. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric
intramedullary femoral nailing. J Orthop Trauma 2008;22:S25-S30.

18. Prasarn ML, Cattaneo MD, Achor T, et al. The effect of entry point on malalignment and iatrogenic
fracture with the Synthes Lateral Entry Femoral Nail. J Orthop Trauma 2010;24:224-229.

19. Collinge C, Liparace F, Koval K, et al. Cephalomedullary screws as the standard proximal locking screws
for nailing femoral shaft fractures. J Orthop Trauma 2010;24:717-722.

20. Hajek PD, Bicknell HR, Bronson WE, et al. The use of one compared to two distal screws in the
treatment of femoral shaft fractures with interlocking intramedullary nailing: a clinical and biomechanical
analysis. J Bone Joint Surg Am 1993;75:519-525.

21. Brumback RJ, Reilly JP, Poka A, et al. Intramedullary nailing of femoral shaft fractures, part I: decision
making errors with interlocking fixation. J Bone Joint Surg Am 1988;70:1441-1452.

22. Bednar DA, Pervez A. Intramedullary nailing of femoral shaft fracture: reoperation and return to work. Can
J Surg 1993;36:464-466.

23. Paterno MV, Archdeacon MT. Is there a standard rehabilitation protocol after femoral intramedullary
nailing? J Orthop Trauma 2009;23:S39-S46.

24. Ricci WM, Bellabarba C, Lewis R, et al. Angular malalignment after intramedullary nailing of femoral shaft
fractures. J Orthop Trauma 2001;15:90-95.

25. Jaarsma RL, Pakvis DFM, Verdonschot N, et al. Rotational malalignment after intramedullary nailing of
femoral fractures. J Orthop Trauma 2004;18:403-409.

26. Lynch JR, Taitsman LA, Barei DP, et al. Femoral nonunion: risk factors and treatment options. J Am
Acad Orthop Surg 2008;16:88-97.

27. Brinker MR, O'Connor DP. Current concepts review exchange nailing of ununited fractures. J Bone Joint
Surg Am 2007;89:177-188.

28. Banaszkiewicz PA, Sabboubeh A, McLeod I, et al. Femoral exchange nailing for aseptic non-union: not
the end to all problems. Injury 2003;34:349-356.

29. Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken
inter-locking nail. J Trauma 1998;45:747-752.
 23
Femoral Shaft Fractures: Retrograde Nailing
Robert F. Ostrum

INTRODUCTION
Femoral shaft fractures are one of the most common injuries following blunt or penetrating trauma to the lower
extremity. Closed reamed intramedullary nailing remains the gold standard of treatment for the vast majority of
patients following fracture. Femoral nailing has been shown in multiple studies to be a highly effective method of
treatment with high union rates and low complications but recovery times of 6 to 9 months are not uncommon.
Over the last 60 years, the techniques for intramedullary nailing have been refined to include newer nail designs,
insertion sites, metallurgy, and interlocking options. What has remained unchanged is that intramedullary nailing
of the femur is still a highly technical procedure regardless of the implant employed.
Femoral shaft fractures are classified by the AO/OTA as 32 A, B, and C depending on the degree of
comminution. In this location, intramedullary nailing can be accomplished with either an antegrade or retrograde
nail. On the other hand, distal or supracondylar fractures (AO/OTA 33) are less commonly treated with a
retrograde nail because recent advances in locked plating of the distal femur improve outcomes in very distal
fractures, particularly those with complex articular injuries (Fig. 23.1).

INDICATIONS AND CONTRAINDICATIONS

Retrograde nailing is indicated for selected diaphyseal femur fractures located 5 cm distal to the lesser
trochanter extending down to the supracondylar region 7.5 cm above the knee joint. There are several strong
indications for retrograde nailing. First, in multiply injured patients with ipsilateral or contralateral lower extremity
fractures, supine retrograde nailing on a radiolucent table allows either simultaneous or sequential fixation of
other fractures, saving valuable operating time. Furthermore, polytraumatized patients with multisystem injuries
and a femur fracture often benefit from rapid positioning on a radiolucent table allowing access to the pelvis and
abdomen for simultaneous treatment by other surgical disciplines. Second, ipsilateral fractures of the femur and
tibia, the so-called floating knee, can often be managed through a single, small knee incision with placement of a
retrograde femoral nail and an antegrade tibial nail. Third, in patients with ipsilateral hip, acetabular, or pelvic
fractures, most authors recommend independent fixation of each injury. This approach allows for the best
possible treatment of each fracture without compromising the surgical approach or fixation of either one. Fourth,
bilateral femoral shaft fractures are optimally treated with a retrograde nailing on a radiolucent flat-top table.
There are several relative indications for retrograde nailing. These include femoral shaft fractures in the obese or
very muscular patients or in individuals with trochanter lipodystrophy where antegrade nailing may be difficult. In
patients with an associated vascular injury, a retrograde nail done acutely or following initial treatment with an
external fixator may be an excellent treatment option. Another relative indication for a retrograde nail is a femur
fracture above a total knee replacement. If the femoral component has an “open box” configuration, nailing is a
viable treatment alternative if the prosthesis is not loose. If the femoral component is “closed” and will not accept
a nail, a locked plate is a better and more suitable option.
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FIGURE 23.1 OTA classification of distal femur fractures.

Contraindications to retrograde nailing include adolescents with open growth plates; patients with a previous
anterior cruciate ligament reconstruction; and those with preexisting femoral hardware that would prohibit
retrograde nailing. The use of a retrograde nail acutely in contaminated grade IIIA and IIIB open femur fractures
remains controversial due to the risk of infection in the knee joint. In many patients, bridging external fixation and
delayed nailing may be a safer approach. The presence of a total hip prostheses may not allow for an fixation
with a retrograde femoral nail and should only be used with very distal fractures that allow for adequate
diaphyseal nail fit and fill with meticulous preoperative planning.

PREOPERATIVE PLANNING
History and Physical Examination
A detailed history and physical examination should be performed. Many patients with femur fractures have
serious associated limb or life-threatening injuries. Patients with femoral shaft fractures should be evaluated
using the Advanced Trauma Life Support (ATLS) protocols to ensure that shock and other critical injuries are
identified and treated. A multidisciplinary approach is required in the multiply injured patient to optimize patient
care. Virtually all patients with an acute femur fracture have a very painful leg that is swollen. The limb is usually
shortened and externally rotated. Motion of the affected hip and knee is resisted secondary to pain. The
condition of the soft tissues and limb compartments as well as the neurovascular status should be evaluated and
clearly documented. If orthopedic surgery is delayed >12 hours, a skeletal traction pin through the distal femur or
proximal tibia is indicated to relieve pain and restore limb length. Isolated femoral shaft fractures should be
treated within 12 to 24 hours whenever possible. Open fractures require emergent irrigation and débridement
with fracture stabilization with a nail or temporary external fixator.
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Imaging Studies
Full-length AP and lateral radiographs of the entire femur are mandatory. Dedicated x-rays of the hip and knee
are often required to rule out intercondylar extension or an ipsilateral femoral-neck fracture based on the clinical
exam and initial x-rays. Computerized tomography (CT) of the knee is recommended in patients with
supracondylar femur fractures to rule out an unrecognized intercondylar split or coronal plane fracture of the
femoral condyle (Hoffa fracture). Most trauma patients undergo CT scanning of their abdomen and pelvis as part
of the ATLS protocol. These scans should be carefully reviewed to assess the integrity of the hip and rule out an
occult femoral neck fracture. In comminuted and displaced fractures, traction views or fluoroscopic radiographs in
the operating room, with the patient anesthetized, may be helpful in clarifying the fracture geometry or to identify
subtle injuries to the hip or knee joint.

Surgical Tactic
Full-length films are necessary to allow measurement of the length and diameter of the femur. Patients of small
stature, persons of Asian descent, and those with developmental problems often have very narrow canals. Most
manufacturers do not make retrograde nails smaller than 9 or 10 mm in diameter. This must be recognized prior
to surgery so that either a nail of appropriate diameter is available or other surgical options are considered. It is
important to ensure that there is a full complement of nails available at the time of surgery. Many studies have
shown that the best results following retrograde femoral nailing are achieved when a full-length canal fill nail is
utilized.
The decision to use a percutaneous or limited open approach for nail insertion is dictated by the status of the
distal femoral fragment. When it is intact, a percutaneous approach is preferred. If the distal fragment is
displaced with fracture extension into the knee joint, a more extensile approach is usually necessary.
Occasionally, a nondisplaced split between the femoral condyles can be treated with independent cannulated
screws inserted through small stab incisions laterally. The presence of an intra-articular split in the femoral
condyles should be a major priority when planning the approach. Visualization and fixation of the articular surface
may be compromised by an incorrectly placed incision. Cannulated screws of similar metallurgy to the retrograde
nail should be used as well as any hardware if an associated hip fracture is present. In a patient with an
ipsilateral femoral-neck fracture, important decisions must be made prior to surgery about the type of table and
patient position for this combined injury. In patients with other extremity fractures, preoperative planning is
necessary for positioning and draping to optimize resources.

SURGERY
Patient Positioning and Setup
Intramedullary nailing is usually performed under general anesthesia, but in isolated injuries particularly in the
elderly with medical comorbidities, a spinal may be preferable. We prefer general anesthesia because it allows
predictable muscle paralysis for fracture reduction and fixation. Preoperative antibiotics, usually a first-generation
cephalosporin, are administered and continued for 24 hours postsurgery. Vancomycin or clindamycin is used in
patients with penicillin allergies. Arterial lines, central venous catheters, and the need for a Foley catheter are
inserted on a case-by-case basis.
Retrograde femoral nailing is performed with the patient supine on a radiolucent table. Some surgeons prefer a
bolster beneath the torso, but care must be taken to avoid excessive pelvic obliquity that can lead to rotational
errors. The optimal position for nailing is with the patient supine and the patella pointing straight upward. The
limb is sterilely prepped and draped from the toes to the iliac crest. It is important to have the entire leg exposed
to allow for evaluation of length and rotation as well as for placement of the proximal anterior-posterior locking
screws (Fig. 23.2).
The ability to flex the knee between 40 and 50 degrees is very important. Too little knee flexion does not allow
correct position of the guide pin or passage of the reamers and nail. Furthermore, inadequate knee flexion risks
damage to the tibial plateau from contact with the instruments (Fig. 23.3). Too much knee flexion makes
radiographic visualization of the distal-femoral entry site difficult and puts the patella in the way of the insertion,
which can lead to articular damage. Protection sleeves should always be used to minimize injury to the patellar
tendon or tibial plateau. We favor the use of sterile radiolucent triangles to maintain precise knee flexion during
the case. If this is not available, a sterile bolster can be used.

Surgery
For the percutaneous approach, a 2- to 3-cm incision is made just medial to the patellar tendon. Alternatively, a
patellar tendon-splitting approach can be used. The joint capsule is opened, and the fat pad and synovium are
bluntly dissected in the intercondylar region with a scissors or long hemostat. With the C-arm in the anterior-
posterior and tilted 20 degrees cephalad, a trochar-tipped guide pin is positioned in the center of the
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intercondylar notch. On the lateral view, the guide pin is centered just anterior to the tip of the inverted V formed
by Blumensaat's line and the femoral groove (Fig. 23.4A,B). The guide pin is then advanced 4 to 5 cm into the
distal femoral metaphysis under fluoroscopic control to ensure that the pin is centered in both projections. The
distal femur is then opened with a cannulated 12-mm straight reamer while the patellar tendon is protected with
retractors or a sleeve (Fig. 23.5). The guide pin is then removed.
FIGURE 23.2 Preoperative radiograph showing a middiaphyseal femoral shaft fracture.

A 3.2-mm ball-tipped guide wire with a slight bend at the tip is inserted into the opening in the distal femur. The
fracture is reduced by strong longitudinal traction with muscle paralysis. Once the length is restored, alignment
can be improved by positioning sterile bolsters under the thigh or using external devices to apply force. When
traction alone does not reduce the fracture, percutaneous insertion of 5-mm self-drilling Schanz pins proximally
and distally is a simple and expedient technique of reduction that restores length and allows passage of the
guide wire (Fig. 23.6A,B). Alternatively, a strategically placed femoral distractor may be helpful in comminuted
fractures to maintain length during reaming and nail placement or when a scrubbed assistant is unavailable.
When a distractor is used, the most distal pin is placed distal and anterior in the distal fragment at the level of the
epiphyseal scar to allow unimpeded passage of the reamers and the nail. The proximal pin is placed as proximal
as possible, usually
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just proximal to the lesser trochanter, to allow unimpeded reamer and nail passage (Fig. 23.7). The femoral
distractor should be placed with the distraction rod anterolateral to allow for distal interlocking with the distractor
in place. Another technique for reduction is to place an intramedullary reduction device over the guide rod in the
distal fragment, manipulate the fracture, and pass the guide rod retrograde to the intertrochanteric region of the
femur.
FIGURE 23.3 Right knee flexed over triangle at 40 to 50 degrees. A 3-cm incision through the skin and patellar
tendon is made. A retractor is used to protect the patellar tendon. A guide pin is inserted just anterior to the V on
the lateral radiograph made by the intersection of Blumensaat's line and the femoral groove and centered on the
AP x-ray.

FIGURE 23.4 A. Lateral fluoroscopic view showing proper insertion site just anterior to the V formed by
Blumensaat's line and the femoral groove. B. AP fluoroscopic view of centered guide pin.

There are several methods to determine femoral length. One way is with a radiopaque ruler placed on the
anterior surface of the leg with the fracture out to length. The nail should span from 5 mm deep to the articular
surface of the knee joint to a level just above the lesser trochanter. Full-length nails provide a longer working
length and better fit in the isthmus and prevent nail toggle within the intramedullary canal. Full-length canal fit
nails inserted to the level of the lesser trochanter should be employed regardless of the location of the femur
fracture. This decreases the potential for a stress riser at the tip of the nail and minimizes the windshield-wiper
effect in the distal femoral metaphysis. Another method to determine nail size is to use a calibrated ruler that can
directly measure length from the guide pin. An AP and lateral fluoroscopic view should be used to ensure that the
measuring device is 2 to 3 mm inside the intercondylar notch (Fig. 23.8A,B).
Determination of nail length in comminuted fractures can be difficult. In these cases, careful preoperative
planning using the intact femur is the best method to avoid leg length discrepancies. In patients who are brought
to the operating room urgently, both limbs can be prepped and draped, and limb length can be assessed
intraoperatively using a radiopaque ruler placed on the anterior surface of the uninjured limb if not fractured.

FIGURE 23.5 Reaming with the opening reamer to make the entry hole in the distal femur. The cartilage and the
patellar tendon are protected by a reaming sleeve.

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FIGURE 23.6 A. Passage of the ball tip guide rod into the intramedullary canal. A 5-mm Schanz pin has been
inserted into the distal fragment percutaneously to assist with the reduction. Once the guide rod is passed across
the fracture site, the Schanz pin is removed. B. Schanz pin inserted in the distal fragment with mallet as external
reduction aid to pass ball tip guide rod.
FIGURE 23.7 Placement of ball tip guide rod into proximal femur, the retrograde nail tip should be above the
lesser trochanter.

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FIGURE 23.8 A. Measuring from the insertion hole in the distal femur to determine the appropriate length for the
retrograde IM nail. B. End of measuring guide against the intercondylar notch insertion site.

Reaming is routinely performed using modern, sharp, flexible medullary reamers. Nail diameter is determined
based on the preoperative plan. Reaming is usually performed to 1.0 to 1.5 mm greater than cortical chatter and
a nail 1 mm less in size than the final reamer is inserted (Fig. 23.9A). It is very important that the femur is reduced
during reaming to avoid eccentric reaming, which may lead to iatrogenic comminution or malalignment following
nail placement (Fig. 23.9B). The insertion and targeting guide is attached to the nail on the back table with the
outrigger for the distal screws aligned laterally. The nail is inserted by hand until resistance is encountered and
then advanced with light blows with a hammer (Fig. 23.10A).

FIGURE 23.9 A. Reaming of the intramedullary canal. Reaming should continue up to 1 mm greater than when
“chatter” is encountered. B. Intraoperative fluoroscopy view showing reaming being performed with the femur
fracture reduced.

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FIGURE 23.10 A. Insertion of the retrograde IM nail over the ball tip guide rod. Careful attention to rotation of the
limb is necessary as the patella should be straight anterior. The IM nail should be inserted with the aiming arm
parallel to the floor to prevent rotation of the nail. B. Notice difficulty in determining the location of the end of the
nail on the AP view. C. Lateral view may be easier to determine where the end of the retrograde nail is with
relation to the cartilage. D. Retrograde IM nail inserted, note slight gapping of the lateral cortex. This can be
corrected after distal interlocking.

Recognition of nail insertion depth, femoral length, and rotation is a critical step prior to final nail seating and
locking (Fig. 23.10B,C). Rings on the insertion jig that delineate the nail/targeting junction are visualized
fluoroscopically. The most reliable way to ensure that the nail is at least 3 to 5 mm deep to the articular surface is
to place the distal locking sleeves through the outrigger and fluoroscopically confirm that they will be placed at or
just above the epiphyseal scar. With most retrograde nails, the most distal screw hole is 15 mm from the tip of
the nail. For many nailing systems, the best way to ascertain the depth of the nail in relation to the articular
cartilage is on the lateral C-arm view. However, it is important to obtain a true lateral of the distal femur by
superimposing the femoral condyles for a more accurate assessment of the contour and anatomy of the distal
femur.
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FIGURE 23.11 Once the nail has been determined to be at the appropriate depth, distal interlocking is performed
by using the insertion jig and measuring the screw length off the sleeve and drill bit.

For minimally comminuted femoral shaft fractures with at least 50% cortical contact, one distal locking screw is
usually sufficient. In elderly patients with compromised bone stock or in any patient where distal screw fixation is
questionable should have a second screw inserted. Comminuted and spiral fractures that do not have axial
stability require at least two distal locking screws (Figs. 23.11 and 23.12A,B). Infraisthmal distal femur fractures
should also have a minimum of two distal locking screws to limit nail toggling with flexion and extension of the
knee.
New generation retrograde nails now have sites for multiple distal interlocking screws at oblique angles to give
multiplanar distal fixation improving stability. However, if there is excessive rotation of the nail, the oblique screws
may enter the patellofemoral joint. A distal interlocking blade is also available that improves purchase in distal
fragments and osteoporotic bone. The addition of a locking end cap changes this nail into a fixed angle
construct. Other screw designs allow for better purchase in cancellous bone, and some are locked to prevent the
screw from backing out.
Prior to proximal locking, final determination of length must be determined. Proximal locking is most commonly
done using a free-hand technique. Screws are directed from anterior to posterior. Similar to distal locking, one
screw is sufficient in minimally comminuted and length stable fractures. For all other injuries, two screws should
be employed.
FIGURE 23.12 A. Insertion of the distal interlocking screw through the sleeve on the insertion jig handle. One
screw distally can be used for axially stable fractures while two screws can be used for unstable fractures and
distal fractures. B. Distal interlocking screw inserted through the sleeve on the insertion handle.

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FIGURE 23.13 After distal interlocking of the retrograde IM nail, since there was distraction of the fracture, the IM
nail is hammered in to compress the fracture. If the fracture was shortened, the IM nail would be slapped
backward to lengthen the femur.

Pitfalls, Errors, and Complications

When nailing distal fractures, it is imperative that the starting point is in the center-center position to prevent
varus-valgus deformities. If malalignment does occur after nail insertion, the implant should be removed leaving
the guide wire in place. A “blocking screw” is placed percutaneously immediately adjacent to the guide wire on
the concave side of the deformity from anterior to posterior. The retrograde nail is reinserted using the “blocking
screw” to narrow the path for the nail and guide it up the intramedullary canal correcting the deformity. The
locking screws from the nail set can be used for this purpose or another small fragment screw.
For the occasional fracture that was distracted during nailing, correction can be obtained by placing the distal
interlocking screws and then tapping on the insertion handle to close the gap (Figs. 23.10D and 23.13). More
commonly, comminuted fractures tend to shorten during the nailing process. To help restore femoral length, the
nail is “back slapped” after insertion of the distal interlocking screws to restore length. Light blows in a reverse
direction with the slap hammer will not usually result in over distraction due to the intact iliotibial band.
Fluoroscopy should be used to confirm that the tip of the nail is 3 to 5 mm deep to the articular surface (Fig.
23.14A,B). The nail should not be prominent by even 1 mm at the notch because this may adversely affect the
patellofemoral joint.

FIGURE 23.14 A. After IM nail insertion handle removal, a finger is placed into the distal femur to check the
retrograde nail placement and to assure that the inserted end is deep to the distal femoral articular cartilage. B.
Proper seating of retrograde IM nail a few millimeters deep to the articular cartilage.

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FIGURE 23.15 A. Using a perfect circle technique after removal of the triangle, a 1- to 2-cm incision is made, the
quadriceps fascia is opened, and a trocar tip drill bit is inserted. The drill is centered on the visible nail hole,
drilled through the anterior cortex, the drill handle is removed, the drill bit is tapped through the hole in the IM
nail, the drill handle is reassembled on the drill bit, and the posterior cortex is drilled. B. Drill point inserted in the
middle of the dynamic hole after obtaining perfect circles, and this site will allow for some compression of the
fracture site in a stable fracture.

Proximal Interlocking
With the limb in neutral rotation and the knee bolster removed, the proximal interlocking screws are inserted. The
perfect circle technique of rotating the C-arm until round holes are obtained is essential to successful interlocking
(Fig. 23.15A,B). A 1- to 2-cm anterior incision is made over the screw hole as determined by fluoroscopy. The
quadriceps fascia is opened sharply with a knife, and a hemostat is used to spread down to the bone. A trochar,
tipped, short, drill bit is inserted at a 45-degree angle onto the anterior femoral cortex such that the tip of the drill
is centered in the hole. For nails with a dynamic oblong hole, insertion of the proximal screw can be done in the
upper or lower portion of the hole depending on the fracture morphology. For axially stable fractures, a dynamic
screw can be placed at the top of the hole to allow for compression with weight bearing. For unstable fractures,
the screw can be placed in the bottom portion of the hole to prevent further shortening. The drill is inserted
through the proximal cortex perpendicular, and the image intensifier is used to evaluate the position of the drill bit
in relation to the hole. Minor adjustments to the drill bit can then be made, and once it is centered in the hole and
drilled through the proximal cortex, it is tapped through the nail with a mallet. The posterior cortex is then drilled
taking care not to plunge too deeply with the drill bit to avoid injury to the sciatic nerve. A depth gauge is used to
determine screw length, and a bicortical screw is inserted. With some systems, a screwdriver that locks the
screw onto the tip is very helpful and prevents the screw from disengaging deep within the soft tissues of the
proximal thigh. If a locking screwdriver is not available, then an absorbable suture tied around the neck of the
screw can be used to retrieve the screw should it become dislodged during insertion (Fig. 23.16A-C). Final screw
seating should be checked with a crosstable lateral of the leg to assure that the screw is fully seated. Often the
screw tightens significantly when it enters the dense far cortex giving the false impression that the screw is
seated. One screw is sufficient for most fractures, but with very proximal fractures, and those with extensive
comminution, the addition of a second screw is recommended. The small wounds are irrigated with saline and
carefully closed in layers. Sterile dressings are applied, and a compression bandage is applied from toes to
groin. With the drapes removed but the patient still under general anesthesia, length, angulation, and rotation of
both limbs are compared. The ipsilateral knee is also examined for ligamentous instability (Fig. 23.17A,B).

POSTOPERATIVE MANAGEMENT
Active range of motion is encouraged in the early postoperative period. Continuous passive motion machines are
reserved for multiply injured patients or in those with head injuries. Full extension and flexion >90 degrees
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should be obtained between 6 and 8 weeks postoperatively. Weight bearing can be initiated early in axially
stable fractures but is usually delayed 6 to 10 weeks until callus forms in unstable fractures. Most fractures heal
between 3 and 6 months. Low molecular weight heparin and mechanical prophylaxis with sequential
compression hose are routinely used. Patients are seen in the clinic at 2 weeks postoperatively to remove
sutures and assess knee motion. Follow-up visits are scheduled at 6, 10, 16, and 20 weeks or longer until union
occurs. Weight bearing is increased based on clinical and radiographic healing. Once there is firm bridging
callus, full weight bearing can be initiated without restrictions.
FIGURE 23.16 A. After depth gauging the hole, the screw is inserted. A captured screwdriver or a suture around
the screw head should be used so that the screw is not lost in the quadriceps muscle during insertion. B. Screw
for proximal interlocking inserted in the middle of the dynamic slot. C. A lateral fluoroscopic view should be
obtained after proximal interlocking by placing the leg in a figure 4 position to assure that the proximal screw has
been fully inserted.

COMPLICATIONS
Soft Tissue/Infection
Fortunately, infections following retrograde nailing are uncommon and rarely lead to a septic knee joint.
Localized infection can be treated with an incision and drainage with maintenance of hardware if the
infection is in the early postoperative period. Suppressive antibiotics can be continued until union. Most of
these patients
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benefit from late removal of the nail with reaming of the intramedullary canal. Early knee motion is
encouraged to prevent arthrofibrosis.

FIGURE 23.17 A. Final A-P fluoroscopy view with C-arm demonstrating fracture alignment after retrograde
intramedullary nailing. B. AP radiograph showing fracture reduction and proper placement of retrograde
intramedullary nail.

Stiffness and Knee Motion

Most patients regain their knee motion by 8 to 12 weeks. Continuous passive motion machines may be
considered for obtunded patients or those with multiple injuries that require prolonged bed rest. Several
studies comparing antegrade and retrograde nailing of femoral shaft fractures have not shown a difference
in knee motion, strength of the quadriceps, or knee scores. Leaving the nail prominent at the intercondylar
notch can lead to patellar impingement and should be revised as soon as it is recognized. Quadriceps
adhesion to the suprapatellar pouch is common in supracondylar fractures. Active assisted knee motion
should be encouraged and supervised in the early postoperative period. In patients with limited knee
motion, we recommend an aggressive physical therapy program for limb rehabilitation. Full extension and
flexion to 120 degrees should be expected with a well-placed, retrograde, femoral nail. If by 4 months, a
patient has not achieved 90 degrees of knee flexion, manipulation under anesthesia should be considered.
Nonunion/Malunion
Nonunion is more frequent when small diameter, noncanal filling nails are employed. Reamed canal-sized
implants have been shown to achieve union rates >90%, which compare favorably to antegrade nailing. In
patients with delays in union, dynamization can be performed if the fracture is axially stable. This is
beneficial in fractures that have some callus but have a gap at the fracture site with a well-fitting nail. Almost
always, the proximal screw is removed to allow the nail to move in a proximal direction with compression of
the fracture site and not toward the knee joint. With bilateral fractures, nailing the less comminuted fracture
first and then using the same length nail on the more complex contralateral side decreases the risk of leg
length discrepancy. Fractures at the tip of the implant have been reported in osteoporotic bone with the use
of short nails. For this reason, full-length nails are recommended for all fractures, including those in the
supracondylar region. Most malunions that have been reported with the use of retrograde nails for fractures
 occur in the proximal and distal ends of the femur.
Knee Pain/Symptomatic Hardware
Pain caused by prominent distal screws is common and is usually caused by screws that are too long. The
most distal locking screw is inserted into the trapezoidal distal femur, and screws that appear with their tips
just outside the medial femoral cortex are usually too long. Sometimes the screw heads are prominent or
click or snap under the iliotibial band in thin patients. Symptomatic distal screws can be removed as an
outpatient procedure
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once union has occurred, or a painful screw may be removed once abundant callus is visible on
radiographs. Long-term knee pain is uncommon with proper operative technique. Residual anterior knee
pain is occasionally seen and is most common secondary to original injury or with residual weakness in the
quadriceps muscle.

RECOMMENDED READING
Daglar B, Gungor E, Delialioglu OM, et al. Comparison of knee function after antegrade and retrograde
intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation. J Orthop Trauma
2009;23(9):640-644.

Gregory P, DiCicco J, Karpik K, et al. Ipsilateral fractures of the femur and tibia: treatment with retrograde
femoral nailing and unreamed tibial nailing. J Orthop Trauma 1996;10(5):309-316.

Herscovici D, Whiteman KW. Retrograde nailing of the femur using an intercondylar notch approach. Clin
Orthop Relat Res 1996;332:98-104.

Moed BR, Watson JT. Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in
multiply injured patients. J Bone Joint Surg Am 1995;77:1520-1527.

Ostrum RF. Treatment of floating knee injuries through a single percutaneous approach. Clin Orthop
2000;375:43-50.

Ostrum RF, Agarwal A, Lakatos R, et al. Prospective comparison of retrograde and antegrade femoral
intramedullary nailing. J Orthop Trauma 2000;14:496-501.

Ostrum RF, DiCicco J, Lakatos R, et al. Retrograde intramedullary nailing of femoral diaphyseal fractures. J
Orthop Trauma 1998;12:464-468.

Ostrum RF, Maurer JP. Distal third femur fractures treated with retrograde femoral nailing and blocking
screws. J Orthop Trauma 2009;23(9):681-684.

O'Toole RV, Riche K, Cannada LK, et al. Analysis of postoperative knee sepsis after retrograde nail insertion
of open femoral shaft fractures. J Orthop Trauma 2010;24(11):677-682.

Ricci WM, Bellabarba C, Evanoff B, et al. Retrograde versus antegrade nailing of femoral shaft fractures. J
Orthop Trauma 2001;15:161-169.

Sears BR, Ostrum RF, Litsky AS. A mechanical study of gap motion in cadaveric femurs using short and long
supracondylar nails. J Orthop Trauma 2004;18:354-360.

Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J
Bone Joint Surg Br 2000;82:652-654.
 24
Distal Femur Fractures: Open Reduction and Internal Fixation
Brett D. Crist
Mark A. Lee

INTRODUCTION
The treatment of distal femur fractures is challenging due to disruption of the joint surface, metaphyseal
comminution, bone loss in open fractures, and limited space for fixation in fractures with small articular segments.
Most distal femur fractures in adults are managed operatively due to poor outcomes with nonoperative
management even in elderly patients. High-energy fractures typically occur in younger patients and are
associated with open fractures, diaphyseal extension, and intra-articular comminution. Lower-energy fractures
usually occur in elderly females secondary to ground-level falls and may be extra-articular or intra-articular.
Periprosthetic femur fractures above a total knee or below a total hip arthroplasty create unique problems in
treatment. For all of these reasons, fixed-angle devices (including locking plates) and indirect reduction
techniques for the nonarticular fracture components have been developed to decrease the need for bone
grafting, prolonged external fixation, or medial plating. For the most of these fractures, plate osteosynthesis is the
implant of first choice.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

While the vast majority of distal femur fractures in adults are managed surgically, there are a few indications for
nonoperative treatment. These include truly nondisplaced fractures that can be managed for a short period of
time in a cast or hinged knee brace. Occasionally, an impacted stable supracondylar fracture in an elderly patient
can be managed without surgery. Similarly, adolescents with open epiphysis and minimally displaced fractures
are often well managed in a cast. Lastly, in extremely frail patients with multiple medical comorbidities who do not
walk, nonoperative management should be considered.
On the other hand, displaced distal femur fractures that occur in adults are primarily managed surgically to
restore stability and allow early range of knee motion and rehabilitation. Even in elderly patients, nonoperative
management of displaced fractures is associated with poor outcomes because of an increased risk of
pneumonia, deep vein thrombosis, pressure ulcers, and knee stiffness (1).

PREOPERATIVE PLANNING
History and Physical Examination
As with all patients that sustain trauma, a complete history and physical should be performed. Critical factors
include mechanism of injury and associated medical comorbidities that might increase the risk of intra- or
postoperative complications. These include underlying cardiovascular disease, diabetes mellitus, osteoporosis,
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tobacco use, a preexisting surgical history (particularly arthroplasty), and preinjury ambulatory and functional
status. A complete physical should include evaluation of the patient, their extremity, pelvis, and spine to avoid
missed injuries. Typically the affected lower extremity is shortened and externally rotated. Careful skin inspection
and neurovascular exam should be done to avoid missing an open fracture wound posteriorly or neurovascular
compromise including compartment syndrome. Ecchymosis and swelling develop rapidly and should be noted. If
there is diminished or absent pulses, gentle longitudinal traction should be applied to the lower extremity, and
reexamination should be performed to see if the vascular status improves. This often distinguishes whether the
difference in the pulse is secondary to fracture displacement or due to an arterial injury that requires vascular
consultation. Once the physical examination is complete, either a well-padded long-leg splint or knee immobilizer
is applied to relieve pain and provide support to the injured limb. If surgery is delayed, frequent skin and
neurovascular checks should be performed. When the fracture is significantly shortened or the patient is not
comfortable in a splint or brace, proximal tibial skeletal traction should be considered.

FIGURE 24.1 A,B. Initial injury AP and lateral knee radiographs.

Imaging Studies
Anteroposterior (AP) and lateral radiographs of the knee and femur are crucial and provide valuable information
about the injury and treatment alternatives (Fig. 24.1A,B). Since the fracture is typically shortened and rotated,
traction, radiographs can be obtained following appropriate sedation. Full-length femur films are required to avoid
missing a more proximal fracture or hip injury. Additionally, bone quality can be assessed on plain films on the
basis of the cortical diaphyseal thickness and intramedullary diameter. This information helps guide the choice of
implants particularly in the elderly. Computed tomographic (CT) scans with 2D and increasingly 3D
reconstructions are obtained for many fractures and virtually all injuries with intra-articular extension.
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FIGURE 24.2 The AO/OTA classification of distal femoral fractures. 33A fractures are extra-articular and can be
treated with plates or medullary implants. 33B fractures are articular injuries that are best treated with open
reduction and compression across the fracture; locked implants are not indicated for these fractures. 33C
fractures require restoration of the articular surface as well as the relationship of the distal articular segment to
the shaft of the femur.

The AO/OTA classification is useful to guide treatment including the surgical approach and fracture implants
(Fig. 24.2). The distal femur region is designated as 33 in the comprehensive classification of fractures. Type
33A fractures are extra-articular distal femur injuries and can be fixed with a variety of implants, frequently
dictated by surgeon preference. 33B fractures are partial articular injuries and may involve either the medial or
lateral femoral condyle. It is mandatory to rule out a coronal plane fracture (B3 component or Hoffa fracture) with
even simple supracondylar/intercondylar patterns. This fracture can occur in up to 38% of fractures and if missed
leads to poor outcomes (2). It is best seen on the sagittal reconstruction of the CT scan. Type 33C fractures
involve both the articular surface and metadiaphysis and range from fairly simple splits to highly comminuted
fracture patterns.
We use both plain radiographs and CT scans for preoperative planning. The AP and lateral radiographs of the
distal femur are helpful to determine plate length. Many of the high-energy distal femoral fractures with
comminution and femoral shaft extension require a total plate length that is two to three times the length of the
zone of comminution. It is critical to have a plate of proper length, as short plates are a common cause of fixation
failure. Digital imaging software can be used for preoperative planning and to ensure that adequate distal fixation
can be achieved with the implant. Finally, we frequently obtain a comparison image of the contralateral femur (if
not injured) to determine femoral length when either significant comminution or bone loss exists. This radiograph
also determines the normal lateral distal femoral angle (LDFA). Once this is known, the frontal plain reduction
angle for the injured side is determined and is used to determine our 95-degree reference path for our implant of
choice. Almost all contemporary implants include a 95-degree reference screw or wire to assist in frontal plane
reduction and restoration of the LDFA.
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FIGURE 24.3 Sagittal reconstruction CT scan showing coronal plane fracture of the lateral condyle (Hoffa).

CT scans are very important in preoperative planning for two reasons. First, the CT may reveal unrecognized
coronal plane fractures (Fig. 24.3; Hoffa fracture) that usually require independent interfragmentary screw
fixation and may affect implant fixation, selection, and location. Second, detailed information is gained regarding
the distal extent of the fracture to determine whether or not internal fixation is technically feasible. Current implant
designs have increased our ability to gain fixation in increasingly distal fracture patterns, and primary distal
femoral replacement arthroplasty is rarely performed today.

Timing of Surgery
To allow for early mobilization, most supracondylar fractures should be surgically repaired as soon as the
patient's overall condition permits, usually within the first 48 hours. Open fractures require urgent irrigation and
débridement as soon as operating room resources are available, and the patient is physiologically stable. In
patients with open fractures, definitive fixation may be delayed for appropriate imaging, implant availability, and
preoperative planning. Staged surgery should also be employed if the soft tissues or patient status or hospital
resources preclude early definitive fixation. For most closed fractures in noncritically ill patients, we do not utilize
temporary spanning external fixation for distal femur fractures, even for higher energy articular patterns. We favor
simple splinting and early definitive internal fixation. This stands in marked contrast to high-energy proximal tibial
fractures, where soft-tissue complications are more frequent with early internal fixation (3). Urgent but thoughtful
intervention is required, and a detailed preoperative plan remains important especially with intra-articular fracture
patterns as this can influence implant selection.

Temporary Spanning External Fixation

The indications for temporary spanning external fixation have increased over the past 10 years to manage
complex extremity fractures in the seriously injured patient. The benefits of temporary external fixation include
decreased pain, improved mobilization of the patient, and easier access to the soft tissues when compared to
splinting or traction. Furthermore, in complete articular fractures, preoperative planning is improved when
radiographs and a CT scan are obtained after closed reduction and external fixation due to ligamentotaxis (Fig.
24.4A,B). The external fixator can also be used intraoperatively as a reduction device.
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FIGURE 24.4 A,B. AP and lateral radiographs of a distal femur fracture placed in temporary knee-spanning
external fixator.

The indications for temporary knee joint spanning external fixation include
Polytrauma patients with multiple orthopedic injuries who are too unstable to undergo definitive fixation
Open contaminated fractures that will require multiple débridements
 Closed fractures with significant soft-tissue trauma that precludes early definitive fixation
Complex articular fractures that would benefit from CT imaging after external fixation due to ligamentotaxis
Femoral and tibial external fixation pins should be placed outside of the zone of injury and away from future
definitive surgical approaches. Typically, 150- to 200-mm Schantz pins are used in the femur, and approximately
150-mm pins are used in the tibia. Femoral pins can be placed anteriorly, laterally, or anterolaterally. However, if
the external fixator is going to be used intraoperatively, a configuration that uses anterior pin placement in the
femur is recommended to avoid interfering with plate placement. Furthermore, anterior femoral pin placement
avoids any potential contamination of the lateral surgical approach to the distal femur. In order to improve
radiographic visualization of the distal femur after external fixation, the bar-to-bar clamps should be strategically
placed distal or proximal to the articular surface. The knee should be flexed 10 to 20 degrees to decrease the
hyperextension deformity of the distal fragment and relax the posterior neurovascular structures. Standard
external fixator pin care should be used. In order to minimize the risk of infection, definitive internal fixation should
be performed within 2 weeks whenever possible (4).

Preoperative Surgical Tactic

Once the x-rays and CT scan have been obtained and carefully reviewed, a surgical plan can be developed.
Using the tracing technique popularized by the AO or digital templating software, a formal plan should be
formulated that includes identifying each fracture fragment that needs reduction and the steps necessary to
accomplish it (5). The surgical tactic should describe in detail the procedure from beginning to end. For less
experienced surgeons and residents in training, this should include the surgical approach, the equipment
required, and the sequence of the procedure including operating room set up, patient positioning; fracture
exposure, reduction, and fixation; wound closure and postoperative course. We recommend including specific
fracture reduction steps with specific techniques and clamps utilized, provisional fixation, and sequence and
location of internal fixation with the specific implants. This ensures that all of the necessary equipment will be
available at the time of surgery.
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FIXATION DEVICES
Implant selection is dictated primarily by the fracture location and pattern. Extra-articular AO/OTA 33A fractures
can be managed with intramedullary nails, traditional fixed-angle implants, or periarticular locking plates. The
choice between these implants is largely dictated by surgeon experience and preference as there is little Level I
evidence supporting one implant over another. However, a recent study concluded that locking implants may
function better in osteoporotic bone than other techniques due to improved fixation in the distal fragment as well
as better control of angular stability under physiologic loading (6). Advances in intramedullary nail designs have
also improved performance in osteoporotic bone because angular stability is improved by multiplaner fixation with
locking options in the distal fragment (Fig. 24.5). Another implant uses a bone-sparing spiral blade in the distal
fracture segment with subsequent submuscular plate passage of a plate that is attached to the blade. This type
of implant provides the bone-sparing benefit of the first-generation angled blade plates with the submuscular
plate techniques seen with modern periarticular locking plates (Fig. 24.6).
Isolated partial articular or AO/OTA 33 type B fractures are uncommon injuries that require internal fixation when
displaced conventional nonlocking contoured or traditional buttress techniques are highly effective except in the
extremely osteoporotic patients. In this small subgroup, a locking plate is indicated (Fig 24.21A-F).
In North America, the anatomically contoured periarticular locking plates have become the treatment of choice for
most intra-articular distal femoral fractures (AO/OTA type C). These systems combine the ability to use both
locking and nonlocking screws (hybrid technique) that have addressed many of the major limitations and
concerns about the first-generation locking plates such as the Less Invasive Surgical Stabilization (LISS;
Synthes, West Chester, PA). The multiple fixed angle screw design provides secure fixation in the distal articular
block that can be advantageous in osteoporotic bone or short articular segments. Additionally, multiple points of
angular stability can provide fixation around independent articular lag screws. Newer generation multidirectional
locking plates allow screws to be directed through an arc of up to 20 degrees in each direction and precisely
direct screws around other distal fixation (Fig. 24.7A,B). This has been shown to provide reliable angular stability
in bridging constructs (7). Most of the current generation of locking implants includes insertion handles and
aiming arms that facilitate percutaneous screw placement along the femoral shaft.

FIGURE 24.5 AP radiograph of a femoral shaft fracture managed with a retrograde femoral nail with fixed-angle
blade fixation distally.
FIGURE 24.6 AP knee radiograph showing comminuted intra-articular distal femur fracture managed with a
modular blade plate.

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FIGURE 24.7 A,B. AP and lateral knee fluoroscopy views showing multidirectional locking screw fixation used to
avoid lag screws placed across the articular fragments.
Surgical Technique
The patient's condition and medical comorbidities often influence whether a general or spinal anesthetic is
recommended. We prefer general anesthesia to ensure reliable and sustained muscle paralysis that is required
for fracture reduction and fixation. Standard antibiotic prophylaxis is utilized. Appropriate blood products should
be available, and an arterial line should be considered in unstable patients or if a prolonged procedure is
expected. A Foley catheter is utilized in most patients.

Patient Positioning
Internal fixation of distal femur fractures is done on a radiolucent table that allows for unobstructed imaging from
the pelvis to the foot. The patient is placed supine on the operating table with a small bump placed beneath the
ipsilateral hip to allow the leg to lie in neutral rotation (Fig. 24.8A).

FIGURE 24.8 A. The patient is positioned in the supine position with a bump under the ipsilateral hip to position
the femur in neutral rotation. Surgical drapes should allow for access to the ipsilateral hemipelvis. Custom
positioning pads (A) or radiolucent triangles and towel bumps (B) can be used to flex the knee to aid with
fracture reduction in the sagittal plane.

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FIGURE 24.9 A. Supine patient position with both lower extremities draped into surgical field to allow for better
visualization of the proximal femur and intraoperative assessment of limb length and alignment. B. The
nonoperative extremity can be flexed above the C-arm to be able to visualize the proximal femur.

The entire lower extremity should be prepped and draped from the iliac crest to the toes to allow for accurate
intraoperative assessment of length, alignment, and rotation. In fractures with significant comminution or bone
loss, we often include the contralateral extremity in the operative field for comparison and easier fluoroscopic
access to the proximal femur for the lateral view (Fig. 24.9). Sterile bumps or towels, custom ramps, or
radiolucent triangles can be used to help position the leg (Fig. 24.8B). In very distal fractures, a sterile tourniquet
can be used, but for most fractures, it is not applicable.
Fluoroscopy is a vital component for internal fixation of a distal femur fracture and is utilized in all cases. It is
important that the C-arm has the ability to easily rotate around the operating table to provide high-quality lateral
imaging. Typically, the C-arm is placed on the opposite side of the surgical approach.

SURGICAL APPROACHES
Several surgical approaches can be used for internal fixation of the distal femur. The surgical approach selected
depends on the fracture location and pattern, the degree of articular involvement, the soft-tissue injury, and
planned implants.

Direct Lateral Approach

The most common approach for extra-articular fractures (33A) and some intra-articular fractures (33C) is the
direct lateral approach (Fig. 24.10). With modification to incorporate a lateral patellar arthrotomy, this approach is
used for most intra-articular fractures that do not have medial articular comminution. The benefits of this
approach include ease of plate application, the ability to reduce the metaphyseal component of the fracture, and
its extensile nature. The inability to completely visualize the medial articular surface significantly limits its use in
most type C2 and C3 fracture patterns that involve the medial condyle.
The transarticular approach and retrograde plate osteosynthesis (TARPO) are used to address complex articular
fractures and allow for lateral submuscular plating (8). Through a midline total knee incision, a
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lateral parapatellar arthrotomy is performed. Subluxating the patella medially allows for excellent visualization of
the articular surface for joint reconstruction (Fig. 24.11A). Following reconstruction of the distal articular block,
the epimetaphysis is attached to the shaft with a plate passed submuscularly beneath the vastus lateralis along
the lateral femoral cortex, and diaphyseal screw placement is done percutaneously (Fig. 24.11B).

FIGURE 24.10 Direct lateral approach to the distal femur that allows for an extensile approach to the entire
femur.

The extended TARPO approach is used for complex medial articular fractures with medial retraction of the
quadriceps to address the joint surface and the metadiaphyseal fracture component as well (9). Through a
lateral parapatellar arthrotomy, the vastus lateralis fascia is elevated from the muscle belly that allows for easier
mobilization of the muscle anteromedially without injuring the perforating vessels. Extending the approach
proximally provides visualization of the metaphysis for direct reduction and internal fixation.
FIGURE 24.11 TARPO surgical approach to the distal femur (A) articular visualization and (B) plate application
using a percutaneous aiming arm.

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FIGURE 24.12 Medial subvastus approach to address medial articular comminution with the vastus medialis
retracted anteriorly.
FIGURE 24.13 Medial femoral condyle coronal fracture reduced with a pointed reduction clamp perpendicular to
the fracture line.

Occasionally, a medial subvastus approach to the distal femur is required to address medial articular involvement
in complex distal femur fractures or for isolated medial condyle fractures (Fig. 24.12). The incision is centered
over the medial condyle and extends proximally anterior to the adductor tubercle. A medial arthrotomy is done to
visualize the articular surface. If a lateral arthrotomy has already been performed through another approach,
caution should be used to minimize the risk of devascularizing the patella. If proximal extension is necessary, the
vastus medialis is elevated anteriorly. However, the femoral vessels limit proximal extension beyond the
metadiaphyseal region.

SURGICAL TACTIC
Articular Reduction
Typically, the articular fracture fragments are more displaced than they appear on radiographs, especially the
intercondylar split, and an adequate articular exposure is required to accurately reduce the fracture. Because
anatomical reduction is the goal for articular fractures, we do not recommend percutaneous reduction and
fixation techniques for distal femoral fractures with articular involvement. Any coronal plane fractures (Hoffa
fragment) are addressed first. Carefully placed pointed reduction clamps applied from within the exposure are
necessary to achieve the appropriate reduction vector (Fig. 24.13). Following anatomical reduction, the fracture
is provisionally fixed with Kirschner wires (K-wires) placed perpendicular to the fracture. To control rotational
forces, a minimum of two anterior to posterior interfragmentary compression screws are placed obliquely across
the frontal plane fracture from the articular margin and away from the weight-bearing articular surface whenever
possible. To avoid patellar impingement, these screws must be countersunk below the articular surface. If the
coronal fragments are displaced, multiple 1.6- or 2.0-mm smooth or terminally threaded wires placed into the
fragment allow for multiplanar manipulation and reduction. Once the coronal articular fragments have been
reduced, the medial and lateral condyles are reduced. Each condylar segment is derotated and reduced using
multiple wires as joysticks to hold the rotational aspect of the reduction (Fig. 24.14). Since comminution is less
common along the central fracture line in the intercondylar notch, interfragmentary compression can usually be
achieved with the use of colinear or periarticular specialty clamps. Due to the trapezoidal nature of the distal
femur, the reduction may look anatomic at one point, but can be malreduced in the sagittal plane or gapped at
another point. Once an anatomical articular reduction is verified, the condyles are reduced and compressed with
screws placed anteriorly and/or posteriorly (Fig. 24.14), which allows for future plate placement. Occasionally,
we insert screws from medial to lateral when a medial parapatellar approach for articular reduction has been
utilized. A minimum of two, but frequently several, 2.7-mm or larger screws are used to stabilize the intercondylar
split.

Reduction of the Articular Surface to the Femoral Shaft and Minimal Invasive Reduction
Techniques
Once the articular surface is anatomically reduced and rigidly fixed, it is reduced and fixed to the femoral shaft. A
variety of methods can be used, but the goals should be to restore the length, rotation, and sagittal and coronal
plane alignment of the femur. Traditional open techniques require direct visualization and manipulation of the
metadiaphyseal fracture fragments. These techniques are used for simple fracture patterns where primary
fracture healing is the goal and lag screw fixation or compression plating can be utilized. Standard reduction
forceps are used to manipulate the fragments and maintain fracture reduction (Fig. 24.15). Schantz pins or K-
wires can also be used as joysticks to manipulate the fragments prior to compression with the reduction forceps.
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FIGURE 24.14 A. Medial and lateral condyle separated with coronal fracture lines provisionally K-wired. B.
Medial and lateral condyles derotated, reduced with a pointed reduction clamp, and held with K-wires. C.
Accompanying AP fluoroscopic view of provisional K-wire fixation of figure (B). D. Intercondylar lag screw fixation
in place (two screws noted with arrows).

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FIGURE 24.14 (Continued) E. Diagram showing potential intercondylar lag screw positions that will avoid
impeding plate positioning.

However, in comminuted fractures, direct reduction techniques can cause devascularization of the fracture
fragments leading to delayed union and implant failure. With comminuted fractures, bridge-plating techniques are
commonly used with the goal of restoration of length, alignment, and rotation rather than anatomic reduction of
the individual fracture fragments. Indirect reduction techniques avoid direct exposure and manipulation of the
metaphyseal fracture fragments. They minimize disruption of the blood supply to the fracture fragments, reducing
the risk of nonunion and hardware failure. These indirect techniques can be used in a minimally invasive fashion.
First and foremost, minimally invasive reduction of the articular surface is not recommended. However, the
techniques for minimally invasive reduction of the reconstructed articular segment to the femoral shaft are
reliable and reproducible for most fracture patterns.
Indirect reduction techniques utilize ligamentotaxis and manipulation of the fracture fragments remote from the
fracture site to regain the alignment of the femur. Following a distal femur fracture, muscle forces lead to
predictable deformities that must be recognized and addressed in order to achieve a satisfactory reduction. The
gastrocnemius muscles cause fracture extension, and the hamstrings and quadriceps cause fracture shortening.
The first step in reducing the articular surface to the shaft is to regain leg length with the use of manual traction
or a femoral distractor or external fixator. While shortening can usually be corrected with manual traction, the
need for sustained traction while addressing other planes of deformity is better facilitated with the use of a
femoral distractor or external fixator. Although a knee-spanning external fixator can be useful, it is not as
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effective at correcting the sagittal plane deformity as using an “all-femur” external fixator (Fig. 24.16A). First,
image the distal femoral articular block and try to match rotational alignment with the preoperatively captured
image of the uninjured femur to appreciate a perfect AP projection. A 5.0-mm Schantz pin is placed near the
patella in the proximal edge of the distal fragment perpendicular to the bone (Fig. 24.16B). This pin is then used
to correct fracture extension and shortening (Fig. 24.16C). Once the alignment is corrected, the pin is connected
to a second Schantz pin in the femoral shaft proximal to the fracture site with a single rod. Surgical bumps and/or
radiolucent triangles can be used to help correct posterior translation. Manipulating the two pins can also correct
residual rotational deformity. However, it is very difficult to reduce coronal plane malalignment with an anteriorly
placed external fixator or distractor. If the alignment can be corrected in all planes, additional temporary K-wire
fixation can be placed across the metaphyseal fracture line to maintain the reduction.

FIGURE 24.15 Lateral fluoroscopic view showing large reduction forcep reducing the shaft component of the
distal femur fracture with lag screw in place.
FIGURE 24.16 A. An “all-femur” external fixator can be used as an intraoperative reduction aid placing a Schantz
pin in the articular block and the femoral shaft. B,C. The metaphyseal fracture component can be reduced by
using the pin in the articular block to correct the sagittal plane deformity and length.

Coronal plane alignment is usually corrected by an anatomically precontoured implant. Once the overall length
and sagittal plane alignment are restored, the plate is inserted via the articular surgical approach or occasionally
through a separate lateral approach. The plate is centered on the femur using AP and lateral fluoroscopy (Fig.
24.17). The plate should be placed along the anterolateral surface of the distal femur in line with the axis of the
femoral shaft. Placing the plate posterior to the axis of the femur can lead to a malreduction. A guide wire is
placed through the 95-degree fixed-axis hole of the plate parallel to the knee joint on the AP view to create 5
degrees of valgus when the bone is drawn toward the plate (Fig. 24.17A). Next, temporary proximal fixation is
done with provisional wires, plate reduction instruments, or clamps. If a percutaneous aiming arm is utilized with
the plate, it is helpful to center the plate proximally by positioning the leg or the C-arm to visualize the aiming arm
superimposed on the plate to determine screw trajectory (Fig. 24.17B).
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FIGURE 24.17 A. AP fluoroscopic view with the 95-degree axis wire with a periarticular clamp in place. B.
Lateral fluoroscopic view with the percutaneous aiming arm superimposed on the plate to insure that the plate is
centered. A proximal wire is in place to hold the plate position. C. Oblique lateral fluoroscopic view showing that
the posterior cortex is reduced. D. AP fluoroscopic view showing the cortical screw being placed proximal to the
fracture to use the plate to restore coronal plane alignment.

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FIGURE 24.17 (Continued) E. Once the cortical screw is placed, the coronal plane reduction is complete. F. It is
important to verify that the sagittal plane reduction has not changed on the oblique lateral view that shows the
posterior cortex reduced.

The plate is either compressed to the bone or within proximity of the periosteum with either a plate reduction
instrument or a cortical screw. Prior to placing the screw proximal to the fracture site, the plate must be perfectly
positioned and compressed to the distal femur with a periarticular reduction forceps to avoid plate prominence or
subsequent malpositioning of the distal screws (Fig. 24.21). We prefer to use a cortical screw to “draw” the bone
toward the plate to obtain coronal plane reduction (Fig. 24.17D,E). Once the plate is secured to the bone, the
lateral view should be checked to ensure that the sagittal plane alignment has not changed (Fig. 24.17F). It is
important to emphasize that the plate can only correct coronal plane alignment; it does not correct length or
sagittal plane alignment. The use of both cortical and locking screw fixation is termed “hybrid” fixation. If only
locking screw fixation is desired in the diaphysis, the plate can still be used as a coronal plane reduction aid as
described by utilizing plate reduction devices included in the plate instrument set.
Overall fracture alignment is verified with fluoroscopy and intraoperative long-cassette radiographs. Oblique
lateral fluoroscopic views help verify the sagittal metaphyseal reduction by avoiding the obstruction of the aiming
arms typically used with precontoured locking plates (Fig. 24.17C). Fluoroscopy has a relatively small field of
view; therefore, intraoperative long cassette radiographs should be obtained in fractures with comminution to
ensure that overall alignment is restored (Fig. 24.18C). The posterior cortex can often be used as a reduction
reference even when there is significant metaphyseal comminution (Fig. 24.18D).
Although optimal plate length and the number of diaphyseal screws are controversial, there are several general
guidelines that are useful. If comminution exists in the metadiaphyseal region, it is common to use a plate length
that spans three times the length of comminution. If bridge-plating techniques are utilized, the initial screw placed
for coronal plane reduction with a precontoured plate is placed close to the fracture site. If this technique is used,
it is important to verify that the reduction has not changed in the sagittal plane during screw placement and that
the proximal end of the plate is also reduced to the bone prior to placing locking screws in the diaphysis. Once
coronal plane alignment is restored, the periarticular locking screws are placed with fluoroscopic assistance.
Since the medial condyle is sloped 25 degrees (Fig. 24.19), it is important to avoid placing screws that are too
long or penetrate the medial cortex.
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FIGURE 24.18 In comminuted fractures, especially with bone loss (A,B), it is important to get intraoperative
alignment views both AP (C) and lateral views (D) to verify reduction. Postoperative radiographs show that the
overall length and alignment were restored (E,F).

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FIGURE 24.18 (Continued)

Periprosthetic Fractures
Although periprosthetic fractures do not have an articular component, they present unique challenges. The
overall technique for reduction and plate application is the same as with standard fractures, but hardware
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placement may need to be adjusted or nonstandard techniques utilized to gain adequate fixation around the
femoral component. Locking screw technology has vastly improved the ability to manage these fractures with
open reduction internal fixation instead of revision arthroplasty.
FIGURE 24.19 The distal femoral anatomy as it relates to plate applications. The lateral metaphysis is angulated
10 degrees from the sagittal plane; the medial metaphysis is angulated 25 degrees from the sagittal plane. To
avoid a medial translational deformity of the articular surface, lateral plate applications should follow the sloped,
lateral, metaphyseal surface. To ensure that screws are contained within the distal femur, the anterior location of
the metaphysis must be appreciated. Anterior implants are shorter than those angulated or placed more
posteriorly.

The critical question that needs to be answered for any fracture around a prosthesis is whether the components
are well fixed or loose. In distal femur fractures around a total knee arthroplasty, the type of femoral component
should be determined (cruciate retaining vs. stabilizing) to determine if there is enough bone available for distal
fixation. A traction view often provides additional information regarding bone stock. The level of the fracture and
the amount of bone available for distal fixation may influence the method of treatment with either an
intramedullary nail or plate osteosynthesis.
Although fixed angle and multiplanar locking options exist in several of the current intramedullary nail systems,
use of a retrograde intramedullary nail can be challenging when there is limited bone available distally. Therefore
retrograde intramedullary nail fixation is more likely to be considered when the fracture is well above the femoral
component, in patients that have an “open box” femoral component that can accommodate a nail.
If there is limited distal bone, either unidirectional or multidirectional locking screws can be used to improve
fixation when a distal femoral locking plate is chosen. Occasionally, in patients with significant comminution or
unstable arthroplasty components, revision arthroplasty may be a better option especially in low-demand
patients. In patients with ipsilateral knee and hip arthroplasties and a periprosthetic fracture, plate fixation must
bypass both arthroplasty components to avoid creating a stress riser for future fractures. Combinations of
unicortical, bicortical locking screws, specialty attachment plates, and cables may be required for adequate plate
fixation in these complex cases. It is important to gain length stabilization by obtaining screw fixation proximal and
distal to the fracture and avoid cable fixation alone to avoid postoperative fracture displacement.

Open Fractures
Open fractures are typically associated with higher energy injury patterns, fracture comminution, and bone loss.
Gustilo and Anderson type I or II open fractures with a simple fracture pattern may undergo early definitive
fixation after urgent irrigation, and débridement is adequately performed. In complex type III open fractures with
significant contamination and fracture comminution, urgent thorough irrigation and débridement and temporary
knee-spanning external fixation is our preferred approach. Once the patient's overall condition has improved,
appropriate imaging studies have been obtained, a surgical tactic developed, and the soft tissue and fracture
bed is clean, healthy, and stable, definitive internal fixation may be performed. When there is significant bone
loss, we often use an antibiotic cement spacer as a void filler at the time of definitive fixation to create a sterile
space for staged bone grafting. In these fractures, either a second medial plate or a medial cortical substitution
plate as described by Mast et al. (5) may reduce the incidence of hardware failure (Fig. 24.20). Bone grafting is
performed approximately 4 to 6 weeks later when the acute inflammatory phase has resolved. The choice of graft
material remains controversial but it is helpful to use material that is osteogenic, osteoinductive, and
osteoconductive. When bone grafting is performed, the biomembrane that forms around the antibiotic spacer
should be left in place because of its favorable biological properties as described by Masquelet (10).

FIGURE 24.20 AP radiograph showing a medial cortical substitution plate used in an open fracture with bone
loss.

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In fractures with large bony defects, it is not uncommon to have slow fracture consolidation leading to plate
failure and nonunion at the junction between the femoral shaft and the bone graft. It is often difficult to verify
complete healing with plain radiographs. These patients should be followed clinically and radiographically for
several years.

Unicondylar Fractures
AO/OTA type 33B (unicondylar) fractures are approached with direct exposure, open reduction, and rigid fixation.
The surgical approach is determined by the fracture pattern and location. For lateral condyle fractures, both in
the sagittal and coronal (Hoffa) planes, a direct lateral approach provides adequate visualization unless there is
intercondylar comminution seen on the CT scan. If there is comminution that extends into the intercondylar notch,
a lateral parapatellar arthrotomy should be used to adequately visualize and reduce the fracture. With very
posterior fractures, a posterolateral approach to the distal femur is indicated for reduction and fixation (11).
Medial condylar fractures in the sagittal and coronal (Hoffa) planes are typically approached through the medial
subvastus approach with arthrotomy as previously described.
Articular reduction is accomplished with the use of joysticks, pointed reduction clamps, and provisional K-wire
fixation. It is critical to ensure that both the intercondylar, articular, and cortical fracture exit points are
anatomically reduced prior to fixation. It is common to have the articular surface reduced but have the other
areas malreduced, especially in the sagittal plane. Intercondylar notch comminution needs to be reduced prior to
reduction of the main condylar fragment to avoid malreduction of the entire condyle. Lag screw fixation can be
performed with either standard or cannulated screws with the screw diameter dependent upon the size of the
fragments and patient. For coronal plane fractures, it is important to start the screws as peripherally as possible
and countersink the screw heads to avoid injury to the patella with knee motion. We have found “headless”
screws in this area to be very useful. It is important that the screws do not penetrate the articular surface
posteriorly. If there is comminution at the epicondylar exit point or if the fracture line is very vertical with a high
risk of shear forces, an antiglide plate can be helpful (Fig. 24.21).

FIGURE 24.21 A. AP knee radiograph showing the comminuted lateral condyle fracture. B. Lateral radiograph,
(C) axial CT scan image, (D) sagittal reconstruction CT image, (E) postoperative AP knee radiograph, and (F)
postoperative lateral radiograph.

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FIGURE 24.21 (Continued)

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POSTOPERATIVE MANAGEMENT
For extra-articular fractures, patients are kept toe-touch weight bearing (25 pounds) for 6 weeks and then
progress to weight bear as tolerated. For intra-articular fractures, toe-touch weight bearing is continued for a
total of 10 to 12 weeks, and weight bearing is progressed based on radiographic evidence of healing. Lower
extremity range-of-motion exercises and gait training are begun on postoperative day 1. For most patients, a
hinged knee brace or knee immobilizer is utilized for the first 6 weeks during ambulation. In closed fractures,
antibiotics are administered for 24 hours. In open fractures, the duration of antibiotics is typically 48 to 72 hours.
Deep vein thrombosis prophylaxis, including sequential compression devices and low molecular weight heparin,
are routinely employed. Continued anticoagulation after hospital discharge is determined on a case-by-case
basis. Sutures are removed 2 to 3 weeks postoperatively. Patients are seen in the clinic at 6 weeks for clinical
examination and radiographs. Range-of-motion exercises are continued, and strengthening protocols are
instituted. Weight bearing is advanced in patients with extra-articular fractures. For patients with intra-articular
distal femur fractures, radiographs at 10 to 12 weeks postoperatively help determine if weight bearing can be
progressed. Thereafter, patients are seen at 2- to 3-month intervals until the fracture is clinically and
radiographically healed. Physical therapy is continued until knee range of motion and quadriceps function has
improved to allow the patients to transition to a home exercise program. Patients with bone loss are followed
yearly until union is certain.

RESULTS
Outcomes following internal fixation of distal femur fractures continue to improve. Indirect reduction
techniques have significantly decreased the need for acute bone grafting and decreased the rate of
hardware failure. Locking plates have decreased the technical challenge for plate application. Zlowodzki et
al. (12) systematically reviewed the literature for operative treatment of distal femur fractures from 1989 to
2005 (majority case series) and showed that operative management significantly decreased the rate of poor
outcomes. However, there were no significant differences in outcomes (nonunion, deep infection, fixation
failure, and secondary surgery) between antegrade intramedullary nailing, retrograde femoral nailing,
compression plating, submuscular locked plating (primarily LISS), and external fixation. Submuscular locked
plating showed a significant decrease in deep infection but a higher rate of fixation failure and secondary
surgeries when compared to compression plating.

COMPLICATIONS
Intraoperative
Major intraoperative complications are uncommon during fixation of distal femur fractures. The most
common intraoperative complication is incomplete multiplanar fracture reduction. Length and coronal
plane restoration are more readily achieved; however, sagittal plane (with apex posterior deformity)
and rotational malreduction can be difficult to recognize. Maintenance of the sagittal plane reduction
can be optimized with an “all femur” external fixation reduction frame or provisional wire fixation of the
metaphyseal reduction. Rotational reduction requires use of comparison views of the uninjured limb,
and intraoperative imaging can help identify radiographic landmarks.
Plate Application Errors
Plate malposition leads to several errors that are avoidable. Placing the plate too posteriorly on the
distal fragment can lead to medialization of the condyles in relation to the shaft as the plate is fixed to
the femoral shaft. It will also lead to anterior translation and extension of the condyles when using
fixed-angle devices in order to get the plate to fit along the femoral shaft. This error can be avoided by
insuring that the plate sits along the anterolateral surface of the distal femur in line with the lateral axis
of the femoral shaft. Placing the plate too anterior along the femoral shaft can lead to fixation failure
especially when using unicortical locking screws in the diaphysis (13). This can be avoided with
careful plate application using intraoperative lateral plane imaging or with the use of a more generous
lateral approach to the femur proximally that allows for tactile evaluation of plate position.
Intra-articular screw penetration can occur in both the knee joint and the patellofemoral joint (Fig.
24.22). This can be avoided by compressing the distal end of the plate to the anterolateral distal femur
with a periarticular reduction forceps prior to screw insertion into the articular block. In addition, intra-
articular screw placement is avoided by placing the plate anterior to Blumenstaat's line on the lateral
view. If screws must be placed posterior to Blumenstaat's line, they should be unicondylar. Internally
rotating the plate to fit along the anterolateral surface of the distal femur also minimizes the risk of plate
prominence causing iliotibial band irritation.
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FIGURE 24.22 Axial CT scan shows that the lateral locking plate is externally rotated with locking
screws placed into the patellofemoral joint.

Nonunion/Malunion
The incidence of malunion and nonunion is not known with the current generation of locking implants.
Early series of first-generation locking plates reported very low rates of nonunion but contemporary
experience describes a higher rate of nonunion (12). There are also new concerns regarding the
stiffness of these implants in osteoporotic bone, and whether a stiffness mismatch may lead to poor
callus formation and delayed union (14). Our experience is that many nonunions are related to an
inadequate biologic responses and suboptimal fracture reduction. For some nonunions, plate fixation is
required to correct residual malalignment and provide compression at the nonunion site, which is
important for the nonunion repair. Retrograde intramedullary nails may be used for selected
metaphyseal nonunions when the alignment is acceptable.
Knee Stiffness
The goal of surgery is to restore the range of motion of the knee for activities of daily living. However,
loss of knee motion is common after distal femur fractures. Although loss of flexion is more common,
loss of extension is more problematic because it is very difficult to regain. One of the chief benefits of
internal fixation is that it allows for early range of knee motion that is started within the first few days
after surgery. To avoid a flexion contracture, either a hinged knee brace that can lock in full extension
or a knee immobilizer can be worn when the patient is not performing range-of-motion exercises.
If therapeutic exercises fail, surgical management including arthroscopic lysis of adhesions in
combination with knee manipulation should be considered for mild contractures. For more severe or
late contractures, an open lysis of adhesions and quadricepsplasty may be necessary. An extensile
direct lateral approach or incorporation of the previous incision should be used with an arthrotomy to
release the intra-articular adhesions—typically in the suprapatellar pouch and the medial gutter. The
most common area of extra-articular adhesions involves the quadriceps along the anterior
metadiaphyseal region, especially if there was prior comminution or bone loss. This is best treated with
a quadricepsplasty with careful elevation of the vastus musculature from the anterior femur leaving the
periosteum intact. Once the quadriceps is elevated from the anterior femur, careful manipulation of the
 knee should be performed to stretch the contracted quadriceps muscle, but avoid iatrogenic fracture or
avulsion of the patellar tendon. If knee flexion has not been restored, V-Y quadriceps lengthening or
release of the rectus origin should be considered. Deep drains should be used to minimize the risk of a
postoperative hematoma. Perioperative regional anesthesia and a continuous passive motion machine
should be considered to maintain knee motion. Aggressive physical therapy should be continued
postoperatively up to 5 days per week to try to maintain the range of motion.

CONCLUSION
Distal femur fractures present technical challenges secondary to articular comminution, deforming muscle
forces, a short articular segment, osteoporosis in elderly patients, and bone loss in open fractures. While
several implant options exist, precontoured periarticular locking plates have become the most commonly
used method to address these fractures. Careful preoperative planning, anatomical reduction of the articular
surface, and accurate restoration of length and alignment is required to successfully treat these fractures.
As with all articular fractures, early range of motion and rehabilitation is important for joint function.

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REFERENCES
1. Crist BD, Della Rocca GJ, Murtha YM. Treatment of acute distal femur fractures. Orthopedics
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2. Nork SE, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal
plane fractures. J Bone Joint Surg Am 2005;87(3):564-569.

3. Egol KA, et al. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a
prospective, standardized protocol. J Orthop Trauma 2005;19(7):448-455; discussion 456.

4. Della Rocca GJ, Crist BD. External fixation versus conversion to intramedullary nailing for definitive
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No.):S131-S135.

5. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery. 1st ed. Berlin,
Heidelberg, New York: Springer-Verlag; 1989.

6. Higgins TF, et al. Biomechanical analysis of distal femur fracture fixation: fixed-angle screw-plate construct
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8. Krettek C. et al. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal
supracondylar femoral fractures. Injury 1997;28(Suppl 1):A31-A41.
9. Starr AJ, Jones AL, Reinert CM. The “swashbuckler”: a modified anterior approach for fractures of the
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10. Masquelet AC. Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone
reconstruction. Langen-becks Arch Surg 2003;388(5):344-346.

11. Taitsman LA, et al. Osteochondral fracture of the distal lateral femoral condyle: a report of two cases. J
Orthop Trauma 2006;20(5):358-362.

12. Zlowodzki M, et al. Operative treatment of acute distal femur fractures: systematic review of 2
comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20(5):366-371.

13. Button G, Wolinsky P, Hak D. Failure of less invasive stabilization system plates in the distal femur: a
report of four cases. J Orthop Trauma 2004;18(8):565-570.

14. Lujan TJ, et al. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus
formation. J Orthop Trauma 2010;24(3):156-162.
 25
Patella Fractures: Open Reduction Internal Fixation
Matthew R. Camuso

INTRODUCTION
The patella is the largest sesamoid bone in the body and is a key component of the extensor mechanism, adding
a distinct mechanical advantage for optimal knee function. Between the massive quadriceps muscle and the
sturdy patellar tendon (ligament), the patella transmits three to seven times body weight through the
patellofemoral joint during deep knee flexion. In the absence of a patella, the extensor mechanism loses nearly
60% of its strength during terminal extension. The surrounding retinacular tissues are also a key component of
the extensor mechanism complex; when intact, they can transmit loads to the leg even in the presence of a
displaced patella fracture (Fig. 25.1).
The patella has two chondral facets, each articulating with the patellofemoral groove of the distal femur. The
thickest portion of cartilage is in the central third; the patella thins out near its periphery both medially and
laterally. Between two-thirds and three-fourths of the undersurface is covered with articular cartilage, with the
distal most portion being nonarticular. Understanding the dimensions of the patella will help the surgeon avoid
penetration of the articular surface with implants during surgery (Fig. 25.2).
Fractures of the patella are commonly the result of an eccentric load to the knee. An extreme tensile moment
results in failure of the patella in the form of a transverse fracture. The injury continues both medially and
laterally, tearing the retinaculum, causing a complete disruption of the extensor mechanism (Fig. 25.3). In this
setting, fracture fixation is relatively straightforward and is combined with repair of the retinaculum. Alternatively,
the patella can fracture when a direct force is applied to its surface, such as when the knee strikes the
dashboard in a vehicle crash (Fig. 25.4). Associated injuries are common, and these stellate multifragmentary
impacted patella fractures can be very difficult to manage.

CLASSIFICATION
Patella fractures are classified in many ways. The AO/OTA classification groups the fractures into three types.
Type A fractures are extra-articular and are associated with disruptions of the extensor mechanism. These
require surgery to restore the continuity of the extensor mechanism. However, articular reconstruction is not
necessary. Most commonly, these are fractures of the inferior pole of the patella (Fig. 25.5).
Type B fractures are partial articular fractures. These vertically oriented fractures can often be confused with
bipartite patellae. When significant articular displacement is present, operative treatment is recommended to
reduce the risk of patellofemoral arthrosis. In these injuries, the extensor mechanism remains intact and therefore
does not require repair (Fig. 25.6).
Type C fractures are complete articular fractures, often resulting in displacement of the articular surface with
disruption of the extensor mechanism. These fractures occur from a direct fall or blow to the patella, causing a
more complex comminuted fracture pattern. Simple fractures are considered C1 fractures. Comminution of one
segment of the patella is termed C2. When both poles are comminuted, the fracture is categorized as C3.
These injuries require realignment of the articular surface and repair of the extensor mechanism, making them
the most challenging to treat (Figs. 25.4 and 25.7).
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FIGURE 25.1 Anatomy of the patella and associated extensor mechanism.

FIGURE 25.2 Anatomy of the chondral surface of the patella.

INDICATIONS AND CONTRAINDICATIONS

Regardless of the mechanism of injury, a disruption of the knee extensor mechanism leaves the lower limb
severely disabled. Surgery is necessary to restore active leg extension and to repair the articular surface of the
patella.
A displaced fracture of the patella usually indicates that a significant disruption of the extensor mechanism has
occurred. For this reason, surgical treatment should be considered for most displaced patella fractures.
Nondisplaced fractures and those with an intact extensor mechanism can be managed nonoperatively in a knee
immobilizer, hinged knee brace, or cylinder cast for 4 to 6 weeks.
The goals of surgery are twofold: to repair the extensor mechanism and to restore the articular surface.
Restoration of extensor mechanism is necessary for normal gait and independent ambulation. Articular congruity
is important to reduce the risk of patellofemoral arthrosis, a condition that is difficult to treat. For this reason,
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patella fractures with articular displacement of more than 1 to 2 mm in adults should be considered for repair.
The multiply injured patient with a patella fracture, even when minimally displaced, may benefit from internal
fixation to allow for early mobilization during rehabilitation.

FIGURE 25.3 Transverse patella fracture with associated retinacular tears.

FIGURE 25.4 Stellate patella fracture with articular impaction.

FIGURE 25.5 Type A: Extra-articular, inferior pole patella fracture with disruption of extensor mechanism.

FIGURE 25.6 Type B: Vertically oriented articular patella fracture with intact extensor mechanism.

Relative contraindications for patella fracture surgery include medically frail patients whose surgical risk is high,
severe osteoporosis, fractures in nonambulators, and soft-tissue injury or infection that would preclude safely
operating on the extremity.

PRE-OP PLANNING
History and Physical Examination
A thorough history is an important part of the initial patient evaluation. A patient with a suspected fracture of the
patella presents with pain over the anterior aspect of the knee. Understanding the mechanism of injury (direct
force vs. indirect load) gives important information as to the severity of the injury as well as the fracture pattern.
Medical history, prior activity level, and patient expectations are important factors that may affect decision
making.
Physical examination includes an evaluation of the entire extremity. Gentle palpation and rotation of the hip,
thigh, leg, and ankle are important to rule out associated fractures. A careful neurovascular examination with a
methodical evaluation of the lower leg compartments should be documented. Knee swelling and ecchymosis are
commonly present. Soft-tissue swelling can be significant due to the hemorrhage associated with the fracture
and its subcutaneous location. The soft tissues should be thoroughly inspected for abrasions, blisters, or
degloving injuries. All wounds around the knee must be appropriately investigated to rule out an open fracture or
traumatic arthrotomy, which requires urgent treatment (Fig. 25.8).

FIGURE 25.7 Type C: Articular patella fracture with associated disruption of extensor mechanism.

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FIGURE 25.8 Patella fracture with injured soft-tissue envelope.

In many patients, there is a palpable gap in the patella on examination; however, its absence does not rule out a
patella fracture. The hallmark of a patella fracture with disruption of the extensor mechanism is the inability to
actively extend the lower leg from a flexed position at the knee. Unfortunately, in most patients, this is difficult or
impossible to perform because of pain with displaced fractures. The ability to perform a straight leg raise may
suggest an intact extensor mechanism when it’s integrity is in question. Joint aspiration with instillation of local
anesthetic can aid in the physical examination for fractures that are not significantly displaced.

IMAGING
In a patient with a suspected patella fracture, radiographs of the knee, femur, and tibia should be obtained. Plain
films are usually sufficient to confirm the diagnosis of patella fracture. The anteroposterior (AP) view can be
difficult to interpret secondary to the overlying distal femur. The lateral projection provides the most information
regarding the magnitude of articular involvement and fracture displacement (Fig. 25.9A,B). Oblique images and
tangential views are rarely necessary but may add information about the extent of comminution. The axial or
sunrise view may diagnose a vertical fracture of the patella, which can be difficult to see on traditional views (Fig.
25.10). Comparison views may be helpful when a bipartite patellae is suspected. Other studies such as CT or
MRI scans are rarely indicated in isolated injuries to the patella, but may give a better understanding of the
extent of comminution in selected cases. In minimally displaced fractures where nonsurgical management is
being considered, a MRI scan may give useful information about the integrity of the retinaculum.

TIMING OF SURGERY
The timing of surgery varies depending on the patient’s medical condition or associated injuries. Open fractures
require early administration of intravenous (IV) antibiotics, tetanus prophylaxis, débridement of nonviable tissue
followed by thorough irrigation and fracture fixation. In closed fractures, fixation is delayed until all other life or
limb-threatening conditions have been addressed.
In nonmultiply injured patients, the status of the soft-tissue envelope determines surgical timing. If soft tissues are
good, fracture surgery is performed on a semielective basis, usually within the first week following injury. Timely
surgery allows for earlier mobilization of the limb and rehabilitation of the quadriceps mechanism. Unnecessary
delays in surgery should be avoided to minimize the potential for knee stiffness.
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Prolonged delays can result in proximal migration of the patella and shortening of the extensor mechanism
associated with spasm of the quadriceps, making reduction and fixation of the fracture more difficult. However, if
the soft-tissue envelope is compromised, delay in surgery is warranted to minimize the risk of infection.

FIGURE 25.9 Anteroposterior (A) and lateral (B) views of knee.

SURGICAL TACTIC
Patient positioning, the need for intraoperative fluoroscopy, reduction tools, and implants must be clearly
communicated to the operating room staff. Large-pointed reduction clamps are necessary for compression of the
major fracture fragments; medium and small clamps should be available for smaller fracture fragments.
Smalldiameter Kirschner wires (K-wire), size 1.25 to 2.0 mm, are often necessary to hold very small fragments of
comminution. In addition, small and minifragment screws (1.5 to 3.5 mm) and plates should be available. Double-
ended 1.6-mm K-wires can be helpful for accurate longitudinal wire placement when employing a modified
tension band technique with wires. Small fragment-cannulated screws (3.5 to 4.0) can also be used for a
modified tension band technique with screws when the fracture pattern allows. Stainless steel wire (16 to 20
gauge) for cerclage or tension band placement, wire tightening devices, and wire cutters are routinely required
for patella fracture surgery. Suture and wire passing devices, such as a Hewson suture passer or a 14-gauge
angiocatheter, facilitate suture passage through the soft tissues of the extensor mechanism and patella itself.
Bank bone graft should be available to support disimpacted articular surfaces. Mersilene tape and/or fiberwire
suture should be available if the surgeon believes that augmentation might be necessary.

SURGICAL TECHNIQUE
Anesthesia, Positioning, Imaging
Surgery can be performed using general, spinal, or regional anesthetic techniques. The patient is placed supine
on a radiolucent operating room table with the affected limb elevated slightly on a bump (Fig. 25.11). This allows
for unobstructed lateral fluoroscopy to be performed without interference from the contralateral limb while
bringing the injured limb closer to the surgeon’s view. A tourniquet should be positioned at the proximal end of
the thigh, so as not to interfere with draping or the surgical exposure. A towel bump is placed beneath the
ipsilateral flank to minimize external rotation of the leg and keep the patella facing upward (Fig. 25.12). A
cephalosporin antibiotic is given within 1 hour of the incision and prior to the inflation of the tourniquet.
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The entire limb from tourniquet to toes is prepped and draped free (Fig. 25.13). The leg is elevated and
exsanguinated with an Esmarch bandage, and the tourniquet is inflated. Care should be taken to ensure that the
quadriceps does not get bound up proximally in the tourniquet, preventing distal translation of the superior
patellar pole. The fluoroscopic unit is brought in from the opposite side of the patient (Fig. 25.14). Sterile half-
sheet drapes will be necessary to maintain sterility for lateral imaging (Fig. 25.15). Remaining in the lateral
position, the image intensifier can be moved toward the head of the table, allowing the surgeon to work on the
fracture and easily return the unit into position for repeated lateral fluoroscopic views as necessary (Fig. 25.16).

FIGURE 25.10 Sunrise view of patella

FIXATION
Type A Fractures
Type A fractures (Fig. 25.17A,B) require reattachment of the extensor mechanism to the adjacent patella. The
vast majority of these fractures occur at the inferior pole of the patella and represent an avulsion of the inferior
nonarticular pole of the patella. A much smaller number of cases involve avulsion of the quadriceps muscle from
the superior pole. They are often associated with tears in the retinaculum, which may require repair.
Repair strategies for type A fractures fall into two categories:

1. Securing the small avulsion fractures back to the patella with screw fixation. Screw fixation may be possible
when the avulsed fragment is large and noncomminuted. However, this technique may require
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supplemental fixation to reduce the tensile stress seen at the repair site during initial healing and rehabilitation.

FIGURE 25.11 Patient positioned with injured extremity elevated on a bump and contralateral limb secured
beside the bump, keeping it out of the operative field.

FIGURE 25.12 View of operative site with appropriate positioning aides.

 FIGURE 25.13 Tourniquet placed at proximal extreme end of thigh allows for full exposure of the operative
zone without interference from draping.

FIGURE 25.14 Fluoroscopic setup in anteroposterior plane.

2. Suturing the patellar tendon back to the patella through drill holes. Suture fixation, while maintaining the piece
of avulsed bone if possible, allows for bone-to-bone healing while securing fixation in the distal aspect of the
disrupted extensor mechanism. A heavy, nonabsorbable suture is used to resist the significant tensile forces
seen during knee extension.
With the knee in 5 to 10 degrees of flexion, an anterior approach to patella is performed, extending from 2 to 3
cm above the superior pole of the patella down to just above the tibial tubercle (Fig. 25.18). This allows access
to the entire length of the patellar tendon for suture fixation and easy access to the superior pole for knot tying.
Full-thickness flaps are created down to the extensor fascia, preserving vascularity to skin layers. The paratenon
is incised so that the medial and lateral borders of the patellar tendon are visible. Both medially and laterally, the
retinaculum is visualized and inspected for injury. The proximal pole of the patella may be everted to inspect the
articular surface. The corresponding trochlear groove of the distal femur is also inspected for articular injury. The
inferior pole of the patella is evaluated to determine if it is amenable to screw fixation versus suture repair. In
most cases, the inferior pole fracture fragment is too small or fragmented for screw repair alone and requires
suture fixation.

FIGURE 25.15 Lateral projection fluoroscopic positioning.

FIGURE 25.16 The fluoroscopic unit can remain in the lateral position and slide out of the way of the operating
surgeon, facilitating imaging as necessary.

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FIGURE 25.17 AP and lateral radiographs of type A patella fracture.

The joint should be thoroughly irrigated to remove intra-articular bony debris. The fractured end of the patella is
assessed for placement of drill holes. Placement of the drill holes too close to the dorsal surface will increase
patellofemoral joint forces and placement too close to the joint surface risks intra-articular penetration and edge
loading. Therefore, the central position is chosen (Fig. 25.19). Three retrograde drill holes (2.0 to 2.5 mm) are
made through the cancellous surface of the fractured patella, exiting the superior pole at the insertion of the
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quadriceps tendon. Care is taken to ensure there are adequate bone bridges between the drill holes. Through
each of the drill holes, a shuttle suture is placed using a suture passer. Each suture is clamped to later deliver a
limb of fiberwire repair suture from the patellar tendon. A total of three sutures are now positioned in the patella,
extending from distal to proximal.
FIGURE 25.18 Image of the midline incision with respect to the underlying structures of the extensor mechanism.

FIGURE 25.19 Three slightly diverging drill holes are placed into the superior segment of the patella, retrograde
from the inferior cancellous surface to the superior pole.

The distal end of the repair begins with identifying the tibial tubercle. Just proximal to the tubercle, a pair of
heavy, nonabsorbable sutures (no. 2 or no. 5 Fiberwire) are placed, creating a set of four strands that exit
proximally through the patellar tendon. Starting from near the tibial tubercle, the suture is run up the axis of the
ligament using a locking technique (such as a modified Krackow technique) for maximum security (Fig. 25.20). A
tapered needle with a small radius of curvature is used to minimize the risk of inadvertently cutting the suture or
injuring the tendon. One limb of suture is brought out through each edge of the tendon, medially and laterally,
while the two central limbs are brought out together in the midsubstance of the tendon (Fig. 25.21). The suture is
brought directly through the bony fragments of the inferior pole fracture, when possible, so that when
reapproximated, there is bone-to-bone apposition to maximize healing. Retaining these bony fragments reduces
the risk of significantly shortening the extensor mechanism, minimizing the risk of patellar baja. Once brought
through, the suture is tensioned to remove any slack that remains in the repair.
Using the shuttle sutures, the Fiberwire sutures are now delivered through the drill holes of the patella. The
medial and lateral limbs are brought through their corresponding drill holes, while the central limbs are together
pulled through the central drill hole. Each of the two central limbs are then paired with their respective sutures
both medially and laterally. Now the patellar tendon and inferior pole of the patella can be drawn together by
pulling the suture strands (Fig. 25.21). With the knee in full extension, the sutures are then tied directly over the
bone bridges in the proximal patella with multiple square knots (Fig. 25.22).
The retinaculum is repaired with no. 0 or no. 1 absorbable suture, using a simple, interrupted suture technique.
The retinacular repair is critical to decrease stress on the patellar repair. The tourniquet is deflated and
hemostasis is achieved. Range of knee motion is tested, using gravity to allow the knee to bend while watching
the repair for gapping or failure. The arc of motion is documented and used to help direct postoperative
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rehabilitation. A properly done repair should allow 90 to 100 degrees of knee flexion. Testing range of motion
with the tourniquet inflated may adversely stress the repair construct due to the binding of the quadriceps
proximally.

FIGURE 25.20 No. 5 Fiberwire suture placed with modified Krakow technique into the patellar tendon for
maximum security.
FIGURE 25.21 Fiberwire sutures are brought up through the drill holes using the shuttle sutures, drawing the
inferior pole of the patella and patellar tendon to the superior patellar segment. Each pair of sutures is then tied
using square knots over the bone bridge of the superior patella.

FIGURE 25.22 Final image of the repair with augmentation included.

Wounds are closed sequentially in layers. The extensor fascia and paratenon are closed (when possible). The
subcutaneous layers are reapproximated with inverted 2-0 Vicryl used sparingly, and skin is carefully closed. In
cases where the soft tissues are even moderately contused, skin closure with 3-0 nylon suture using Allgöwer-
Donati vertical mattress technique will maximize epidermal perfusion. Wounds are dressed with a sterile
nonadherent dressing and reinforced with sterile pads. A compression bandage is applied over a bulky layer of
cast padding to provide support. A knee immobilizer is applied with the knee in extension to protect the wound
and repair in the early postoperative stages. Postoperative radiographs are obtained (Fig. 25.23A,B).

Type B Fractures
By definition, type B fractures do not involve injury to the extensor mechanism. The purpose of repairing these
fractures is to anatomically reduce the articular surface to minimize the risk of patellofemoral arthrosis. These
fractures are typically oriented vertically and must be differentiated from a bipartite patellae (Figs. 25.6 and 25.24
A,B).
Through a midline surgical incision, the displaced patellar cortex can be visualized and exploited for evaluation of
the articular surface. When present, a tear in the retinaculum can be used to palpate and/or visualize the
retropatellar joint surface. It is important to first address articular impaction prior to reduction of the fracture, as
this may give the best access to the joint. Typically, the dorsal surface of the patella is used to judge the
reduction. It is important, however, to palpate the articular surface while doing so. When unrecognized impaction
is present, the reduction of the dorsal patellar surface may not reflect anatomic reduction of the articular surface.
Palpation of the joint surface through a rent in the retinaculum is most effective with the knee in full extension to
relax the extensor mechanism. It may be necessary to work directly through the primary fracture line.
Alternatively, the retinaculum may be incised to give access to the joint surface. Using a small osteotome or
elevator, the articular segment is elevated to match the adjacent levels of articular cartilage. When the impacted
segment is large, the defect is grafted and initially stabilized with K-wires and subsequently fixed with small or
minifragment screws. With smaller fragments, the K-wires alone are sufficient for fixation. Elevated segments
should be grafted with cancellous autograft or allograft to prevent collapse.
When satisfied with the alignment of the articular surface, the major fracture fragments are reduced and
compressed with pointed reduction forceps placed perpendicular to the fracture line. Temporary K-wires help
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control rotation of the segments from the torque applied during screw insertion. When the fracture pattern allows,
a series of interfragmentary lag screws are placed perpendicular to the fracture line in the patella (Fig.
25.25A,B). Preferably, the screw is begun in the smaller segment and lagged into the larger segment to maximize
screw purchase. When comminution or bone loss is present, lag screw fixation may be contraindicated. In this
case, screws are placed as position screws, so as not to overreduce the fracture fragments, resulting in loss of
articular reduction. A clear understanding of the “V” shape of the patella is necessary to avoid articular injury
during screw placement.
FIGURE 25.23 A,B. Type A fracture: postoperative radiographs.

FIGURE 25.24 A,B. AP and lateral radiographs of a type B patella fracture.

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FIGURE 25.25 A,B. Intraoperative fluoroscopic images of the vertically oriented patella fracture reduction and
interfragmentary lag screw fixation.

After definitive implants are placed, the preliminary fixation is removed, and the articular reduction is reassessed.
Without disruption of the extensor mechanism, additional fixation is rarely indicated. After deflation of the
tourniquet, the knee range of motion is evaluated and the fracture carefully visualized during flexion to ensure
that no displacement occurs. A safe range of motion is then documented, and the postoperative therapy program
tailored to these findings. Final radiographs should show safe implant position with an anatomically reduced
articular surface (Fig. 25.26A-C).

Type C Fractures
A disruption of the extensor mechanism combined with a fracture of the articular surface constitutes a type C
fracture of the patella (Fig. 25.7). Compression fixation of the articular surface combined with a tension band
construct for conversion of the tensile forces into compression forces at the joint surface is the most common
method of treatment. A modified tension band technique using K-wires or cannulated screws with a figure-ofeight
tension band wire can be used. When applied correctly, the tension band with cannulated screws has been
shown to provide improved biomechanical stability over the more traditional K-wires technique. However, any
method that combines stabilization of the articular surface with neutralization of the tensile forces of the extensor
mechanism (using suture, wires, plates, etc.) can be effective. The concept of fixation with absolute stability of
the articular surface protected by a construct that converts the tensile forces into compressive forces at the joint
surface is the key factor.
Setup, positioning, and approach are the same as for fractures previously described. With the fracture exposed,
the extent of the fracture comminution and impaction is assessed. Each pole of the patella is everted for
evaluation of the articular cartilage. Surgical extension of the retinacular tear may allow improved visualization of
the joint surface; however, this should be performed carefully to minimize injury to fragment vascularity. The
organized clot is removed, and the periosteum is elevated for 2 mm along the fracture edges. Areas of
comminution are assessed for the possibility of repair. Small fragments and fractures at the extreme periphery
are usually excised. Larger fragments should be repaired.
In simple two-part patella fractures, where there is no impaction nor comminution, the patella can be reduced
using a pair of large-pointed reduction clamps. Positioning the leg in full extension facilitates the mobility of each
fragment. Without impaction, reduction of the dorsal surface of the patella should indirectly reduce the articular
surface as well. This can be confirmed with direct visualization, palpation, or fluoroscopically. Once reduced, the
fracture is ready for stabilization.

Modified Tension Band Fixation with K-Wires

Classic patella fracture fixation combines longitudinal K-wire placement with a figure-of-eight tension band
applied to the dorsal patellar surface. This converts tensile forces into compression forces at the fracture site
with knee flexion. The two poles of the patella are everted to visualize the fracture surfaces (Fig. 25.27A,B).
Using a wire driver, two double-ended 1.6-mm K-wires are placed at the fracture site in the superior pole,
perpendicular to the fracture line, close to the articular surface, and parallel to one another. The trajectory must
be parallel to the articular surface so that the wires do not penetrate the medial nor lateral facets. The wires are
advanced from the fracture site in a retrograde fashion exiting through the proximal pole of the patella.
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The wire is advanced until it is just beneath the fracture surface. The fracture is then reduced to the adjacent
pole and held with one or two large-pointed reduction clamps. Anatomic reduction is judged using the dorsal and
(more importantly) articular fracture edges. Once an anatomic reduction is confirmed, the K-wires are advanced
across the fracture site into the distal pole and out of the bone. Slight knee flexion facilitates accurate wire
placement without displacing the fracture and helps avoid binding of the soft tissues both proximally and distally
during wire placement. Accurate placement is confirmed on an AP and lateral fluoroscopic image.
FIGURE 25.26 A,B,C. AP, lateral, and sunrise plain radiographs demonstrating anatomic reduction and safe
implant placement.

A 14-gauge angiocatheter is then placed deep to the K-wires directly adjacent to the superior and inferior poles
of the patella to facilitate passage of an no. 18-gauge wire (Fig. 25.28A,B). The two separate wires are then
brought over the top of the patella directly over the bone ensuring no soft-tissue entrapment. It is critical that the
tension band wire lay directly on bone for optimal function. This should be confirmed with fluoroscopy.
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The wires are then crossed over the dorsum of the patella in a figure-of-eight manner, creating two adjacent
wires that can twist with each other. Care should be taken to place the twist in a location that will minimize
irritation to the soft tissues. Using a wire tightener or heavy clamps, simultaneous gentle distraction with twisting
is performed until adequate tension is achieved. The pointed reduction clamps are removed, and the repair is
tested by flexing the knee. The stable arc of motion is documented to help guide postoperative rehabilitation.
The K-wires are cut and bent over the tension band wires and buried beneath the soft tissues. Care is taken to
close the soft tissues over the wires to minimize irritation and to prevent inadvertent migration. Final
intraoperative radiographs are obtained.

FIGURE 25.27 The displaced patella fracture ends are everted to inspect the articular surfaces.

FIGURE 25.28 Placement of 18-gauge tension band wire through angiocatheters at superior and inferior patellar
poles.

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FIGURE 25.29 K-wires from the inferior segment of the patella are advanced into the superior segment while
holding the fracture reduced with Weber clamps and securing the reduction with an additional antegrade K-wire.

Modified Tension Band Technique Using Cannulated Screws

Cannulated screw fixation has the advantage of providing compression at the fracture site while utilizing a
tension band wire construct to improve resistance to distraction. Either 3.5 cortical or 4.0 partially threaded
screws can be used. Fully threaded screws can be used in poor quality bone if screw purchase is a concern,
though it will not compress the fracture site. Guidewires for the cannulated screws are placed parallel to the
articular surface and perpendicular to the fracture plane. These may be placed before or after reduction of the
fracture. When placed before reduction, two parallel drill holes are made in the smaller patellar segment, using a
parallel drill guide. Guidewires are then passed with their blunt ends first through the bone, out the end of the
patella, and out through the soft tissue. Both wires are then retracted into bone to allow for the fracture to be
reduced. Each wire is then advanced from the shorter segment of the patella into the larger segment and placed
up to, but not through, the far cortex (Fig. 25.29). Their position is confirmed on AP and lateral plane fluoroscopy
(Fig. 25.30). Wire length is measured, making sure that the depth gauge is directly on bone for correct
measurement. Inaccurate measurements can lead to placement of excessively long screws, which may lead to
early breakage of the tension band wire.
FIGURE 25.30 A,B. Accurate wire positioning confirmed fluoroscopically will ensure safe placement of
cannulated screws.

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FIGURE 25.31 A,B. Partially threaded screws are placed for lag effect, keeping them well within bone.

After measuring length, the terminally threaded guide wire can be advanced into the far cortex, which minimizes
wire migration during drilling. The cannulated drill is placed over the guidewire and slowly advanced through the
length of the patella. The drill bit should be removed and cleaned several times since the hard bone of the
patella fills the shallow flutes quickly, causing thermal necrosis and making advancement of the drill difficult. The
length of screw should be 2 mm shorter than what is measured. This ensures that the screws remain within the
patella and not beyond the cortex so that the tension band wire contacts the patella and does not impinge on the
screw edge itself.
Partially threaded 3.5- or 4.0-mm screws are placed over each guide wire to provide compression across the
fracture site (Fig. 25.31A,B). It is important that the threads of the screws are completely in the far segment of
bone to provide compression. If this is not possible, then a fully threaded 3.5-mm lag screw should be used.
Reduction clamps are left in place during placement of the screws to prevent unrecognized distraction during
screw placement. With the patellar segments compressed, the fracture can be “locked in” by adding an
additional fully threaded screw in the midline. This may help prevent displacement of the fracture in patients with
poor quality bone.
Next, the tension band wire is applied. Through each of the two cannulated screws, a single 15-cm strand of 1-
mm (18 to 20 gauge) stainless steel wire is passed and brought out onto the dorsum of the patella. Straight
surgical wire may be easier to pass through the cannulations, but may not have the tensile strength of wire on a
spool. Sternal wires should be avoided because it has a lower tensile strength than annealed wire. The wire
should be handled carefully, minimizing kinks and bends that could result in premature failure during application
of tensile loads. A small incision near the quadriceps insertion at the exit point of the screw facilitates retrieval of
the wire. After passage, each end of the wire is then paired with its opposite strand from the other screw, making
a contiguous figure-of-eight between the two wires over the dorsum of the patella (Fig. 25.32). Care is taken to
be sure the edge of the wire contacts the edge of the patella and does not get “hung up” on the soft tissues,
reducing the effect of the tension band that could loosen over time (Fig. 25.33). In this way, the tension during
knee flexion is transmitted directly to the patella and not through the soft tissues. Once the wires are
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adequately positioned, two wires should come together on each side of the patella. The wires are then twisted
together in a clockwise manner, simultaneously, while gently pulling outward on the wire. A wire tightener is
effective for twisting the wire; without it, a pair of stout needle drivers will suffice. Stop twisting the wire when it
meets the surface of the patella (Fig. 25.34A,B).

FIGURE 25.32 Tension band 18-gauge wire is placed through the cannulation of the screws and brought out
over the dorsum of the patella in a figure-of-eight manner.

FIGURE 25.33 Long screws create edge loading and failure of the tension band (A); tension band wire that does
not contact the patella may not resist the tensile forces in flexion, also resulting in failure (B).
FIGURE 25.34 A,B. Using a jet wire tightener or a stout pair of needle drivers, the tension band is symmetrically
twisted until the wire twist meets the patella.

After deflating the tourniquet, the knee is put through a range of motion to assess fracture stability. The wires
may be retightened if any creep has occurred, taking care not to overtighten them. When satisfied with the
fixation, the wires may be cut short and folded flatly onto the peripheral soft tissues to minimize prominence (Fig.
25.35A,B). Closure and postoperative rehab is conducted as previously described.
In many instances, the patella fracture is not a simple two-part fracture. There may be articular impaction and/or
comminuted fractures that are not amenable to simple tension band fixation. In fact, tension band constructs are
only effective when an anatomical reduction has been achieved on the side opposite the tension band, which
can withstand compressive forces. Therefore, when articular comminution exists, one must consider alternative
methods of fracture fixation.
In this situation, my surgical strategy is to reconstruct the comminuted patellar fragments into a simple two-part
fracture, which can subsequently be repaired with traditional methods (outlined above). The larger fragments of
comminution are reduced to each pole of the patella, with the goal of creating a simple, transverse two-part
fracture. In a stepwise manner, each fragment is cleaned of hematoma and reduced and stabilized
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with clamps or K-wires. Areas of impaction are reduced, and bony voids are filled with small amounts of
cancellous allograft. Care is taken to pack this in tightly, so that no graft becomes a loose body within the joint.
The reduction should be judged with either direct inspection of an everted patella or by simple palpation with the
knee in extension. When a satisfactory reduction has been achieved, the fragments can be stabilized with
minifragment position screws (1.1 to 2.4 mm) that are countersunk. This is important to allow for anatomic
reduction of the opposite pole of the patella. These screws will become intraosseous screws after final fracture
reduction (Fig. 25.36A,B).
FIGURE 25.35 A,B. Final radiographs.

Once reconstruction of the comminuted superior and inferior poles is complete, they are reduced to one another
and held with large-pointed reduction clamps. At this point, multiple strategies exist to secure the final reduction,
depending upon how much “traffic” is present in the patella itself. Some intraosseous screws may interfere with
subsequent placement of cannulated screws for fixation of the two poles. With the knee in extension, a lateral
fluoroscopic image will show existing hardware, allowing the surgeon to avoid these implants during placement of
K-wires or guidewires for cannulated screws. This technique is an effective and efficient method for
reconstruction of comminuted patella fractures.
However, when the comminution of the patella requires numerous multiplanar screws within each patellar pole, it
may be impossible to place additional longitudinal (cannulated) screws perpendicular to the primary fracture
plane. In this case, and in cases where there is articular bone loss, dorsal plate fixation may be necessary. In
cases where there is bone loss, these implants function as neutralization plates. However, they can function as
tension bands in situations where the opposite surface has adequate bony contact, similar to the function of the
tension band wire.
I favor 2.0-mm plates that are contoured to fit the dorsal surface of the patella. Lengths are chosen to ensure
adequate fixation in each pole, extending from the most proximal to the most distal ends of the patella. Between
six- and eight-hole plates are most commonly utilized. Each end of the plate is secured using one or two
minifragment screws angled into quality bone for improved purchase. In the proximal pole, the screws are angled
caudad; in the distal pole, they are angled cephalad. In certain situations, these screws can extend back into the
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opposite pole and span the fracture site. Care is taken to be sure that they do not penetrate the articular surface.
In general, this technique is reserved for the most complex patella fractures (Fig. 25.37A,B).
FIGURE 25.36 A,B. Impacted joint surfaces must be elevated, reduced, and stabilized. In some cases, this may
require bone grafting or even the use of intraosseous screws for large articular fragments.

FIGURE 25.37 A,B. Final radiographs after reconstruction of complex type C patella fracture with impaction.
Augmentation
Some unstable fractures require supplemental fixation or augmentation. This may be necessary due to fracture
comminution, inadequate fixation, obesity, or concerns with patient compliance. Though rarely needed, one may
consider this technique anytime that the intraoperative exam suggests that the fixation is unstable or gapping
occurs at the fracture site during knee flexion. In this situation, augmentation of the repair may allow for more
aggressive rehabilitation and avoid prolonged immobilization. Several techniques exist to reduce the tensile
stresses upon the extensor mechanism. One such technique is described here.
Using a 2.5-mm drill bit, a drill hole is made through the anterior one-third of the tibial tubercle. A 5-mm Mersilene
tape is passed through the tubercle drill hole, and a second Mersilene tape is then placed through the
quadriceps tendon, just superior to the proximal pole of the patella (Fig. 25.38). Care is taken to place the tape
into good tissue to adequately capture the proximal segment of the injured extensor mechanism. Each limb of
Mersilene tape is then brought along the medial and lateral aspects of the patella, and with the knee flexed
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30 degrees (Fig. 25.39), the limbs are tied together, creating a “check reign.” Patellar baja can be created with
overzealous tightening of the backup fixation (Fig. 25.40).

FIGURE 25.38 Single limbs of 5-mm Mersilene tape is each placed through the quad tendon above the superior
pole of the patella and through a hole drilled in the tibial tubercle.
FIGURE 25.39 The two limbs of Mersilene tape are tied together with the knee flexed at 30 degrees to prevent
overtightening of the extensor mechanism.

In highly comminuted patella fractures, reconstruction of the joint surface may be impossible or ill-advised. In this
situation, the surgeon’s goal should be focused upon restoring the extensor mechanism. Simple cerclage of the
bony fragments with supplemental Mersilene tape or wire loop from quadriceps to tibial tubercle will restore leg
extension. Early range of motion is generally avoided until healing of the fragments and peripheral soft tissues
has occurred. Partial patellectomy is reserved for small polar fractures with significant comminution. Complete
patellectomy is uncommon acutely but may be indicated as a salvage procedure in chronic nonunions or infected
cases.

POSTOPERATIVE CARE
The knee is wrapped in a compressive dressing with a knee immobilizer or hinged knee brace locked in
extension. The knee is maintained in extension until the surgical incisions are dry. Rehabilitation begins on the
first day after surgery, and the progress is determined upon the stability of fracture fixation and the safe range of
motion determined during surgery. Full weight bearing as tolerated protected with crutches or a walker is allowed
in the immobilizer or knee brace. Straight leg raises in the brace are encouraged to minimize quadriceps
weakness and atrophy without stressing the repair.
In stable fractures, gentle knee range of motion is begun to minimize knee stiffness when the wounds have
healed, usually within the first 10 days after surgery. The brace may be removed during range-of-motion
exercises but should be worn at all other times. Active knee extension is avoided for the first 6 weeks to minimize
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the stress across the repair. With guidance from a therapist, active knee flexion and passive knee extension is
encouraged. Active and active-assisted flexions are allowed, starting with 0 to 30 degrees and advanced as
tolerated. The leg is extended passively, either with gravity assistance (prone positioning) or with assistance
from the therapist. Knee flexion of at least 90 degrees in the first 6 weeks should be the goal. Passive flexion is
avoided until there is clear evidence of fracture union.
FIGURE 25.40 Placement of the augment as shown can protect a tenuous repair/reconstruction of the extensor
mechanism and may allow more aggressive rehabilitation. Drawing of the augmentation used with Mersilene tape
through a drill hole in the tibial tubercle and over the patella.

In fractures with suboptimal fixation or stability, range of motion is delayed. The limb is left in an immobilizer in
extension for 4 to 6 weeks. Quad sets can be performed with the brace in place to reduce atrophy. Full weight
bearing in the brace is allowed. After 4 to 6 weeks, range of motion is begun utilizing both active and passive
modalities. In this setting, a therapist can be quite valuable to help maximize functional outcome.
When the tenderness over the repair is minimal and the quadriceps function has returned, it is safe to begin
ambulation with a knee brace, unlocked from 0 to 30 degrees to engage the extensor mechanism. As the gait
improves, the motion in the brace is increased and eventually discontinued. Stationary cycling and half squats
will improve quad strength and endurance as the knee range returns. Radiographs are evaluated at 6-week
intervals until fracture union is evident. The patella heals with intramembranous ossification as opposed to
callus; fracture lines can be expected to fill in by 3 to 6 months after repair.

COMPLICATIONS
Complications rates exceeding 20% have been reported following patella fracture surgery. Most can be
attributed to technical errors and/or patient compliance. Vigilance is recommended to identify these
problems early to ensure optimal outcome.
Knee stiffness is the most common complication following patella fracture surgery. Aggressive inferior pole
patellectomy can lead to patellar baja, causing stiffness and early arthrosis. Higher energy fractures with
associated soft-tissue trauma are more likely to develop arthrofibrosis. Retinacular scarring to the
surrounding soft tissues may also limit motion. Physical therapy with manual patellar mobilization is used to
minimize early adhesions. Early identification of the patient who is slow to regain motion is important so that
a physiotherapist can promptly intervene. In cases where prolonged immobilization is necessary,
physiotherapy is even more critical, and aggressive motion is begun as soon as it is safe. In patients with
less than 90 degrees of motion 8 to 12 weeks after surgery, a manipulation under anesthesia should be
considered. However, the surgeon must be confidant with the fixation stability before a manipulation is
performed. Knee manipulation should be performed under anesthesia using fluoroscopic control. When
manipulation is done after 12 weeks, it may be necessary to combine it with an arthroscopic lysis of
adhesions to reduce the risk of iatrogenic fracture. Most patients require at least 90 to 100 degrees of knee
flexion to get up from a seated position using both lower limbs.
Inappropriate surgical timing and poor handling of the soft tissues may lead to wound drainage, wound
breakdown, or infection. Prevention is the key to avoiding this potentially devastating complication. Surgery
should be delayed in patients with massive swelling, blisters, or abrasions. Gentle handling, meticulous
dissection, and careful wound closure are important. Drain placement will minimize hematoma formation and
may reduce the risk of infection.
Since the patella is a subcutaneous bone, infection requires early aggressive treatment. Wound cellulitis
may respond to simple antibiotics; however, deep infection must be treated with urgent return to the
operating room, formal open irrigation and débridement of necrotic material, washout of the joint (if
involved), sampling of the tissue for culture, and initiation of broad spectrum antibiotics. Antibiotic therapy is
tailored to the results of final cultures and their sensitivities, and an infectious disease consultant can be
very helpful. Typically, 6 weeks of IV antibiotics are recommended followed by suppression until
contaminated hardware can be removed. Fixation is left in place, if stable, to maintain fracture alignment,
but may require removal after the fracture is healed. Range of motion and therapy are stopped until the
infection is under control.
Fixation failure can occur as a result of poor surgical technique, severe fracture comminution, or a
combination of the two. Careful attention to detail and an understanding of the postoperative range-of-
motion limits will prevent most of these failures. When recognized early, salvage may still be possible.
Displaced fractures can be revised, and nondisplaced fractures can be immobilized. Unreliable patients may
require application of a cylinder cast to improve compliance. Fibrous union or nonunion can develop,
causing pain with stair climbing and kneeling. For symptomatic patients, this may be treated with revision
fixation or partial patellectomy. Extensor lags are usually the result of poor quadriceps rehabilitation, and a
focused therapy program will correct this.
Symptomatic hardware is common after patella fracture surgery. Careful attention during implant placement
is important to minimize this occurrence. Tension band wires should be folded back and into the soft tissues
when possible. Closure of the extensor fascia and prepatellar bursa in separate layers from the dermis will
provide a layer of cushion in most patients. Removal of hardware should be delayed until the surgeon is
certain that the fracture is healed. I require that the fixation remains in place for at least 1 year prior to
removal to be sure that the fracture is completely healed. If asymptomatic, the hardware is left in place.
Patella fractures occasionally result in patellofemoral arthrosis as a result of joint incongruity or cartilage
injury. Patients may be symptomatic with activities that require deep knee flexion, such as stair climbing or
kneeling. In mild cases, physiotherapy to strengthen the quadriceps can help, and injection therapy with
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corticosteroids or hyaluronic acids may be of some benefit. Arthroscopic débridement may be necessary for
large articular flaps or when severe fibrillation is present. A lateral release may be indicated when the lateral
facet is primarily involved. Other options such as microfracture, mosaicplasty, chondrocyte implantation, and
patellar realignment are controversial and have variable results. Patellofemoral arthroplasty may have some
role, but their results after patella fractures are unknown. Patellectomy can improve patellofemoral
symptoms but is associated with some extensor mechanism weakness.

OUTCOMES
Patients with isolated patella fractures can expect to walk brace free within the first 3 months after injury.
 However, regaining quadriceps strength for daily activities and sports may be prolonged. In the absence of
complications, most patients approach their baseline level of function within 1 year after surgery. Functional
results following internal fixation of patella fractures are generally good. The best results occur in patients
with anatomic reduction and early range of motion of the knee. Several studies have shown that patients
followed for more than 5 years have outcomes similar to an uninjured population cohort. Most are able to
return to work, with more than two-thirds returning to the same job. Those patients requiring limited fixation
due to poor bone quality or fracture comminution have suboptimal results. Articular incongruity with
subsequent arthrosis, weakness, and stiffness is the primary reason for poor long-term results.

RECOMMENDED READING
Benjamin J, Bried J, Dohm M, et al. Biomechanical evaluation of various forms of fixation of transverse
patellar fractures. J Orthop Trauma 1987;1:219-222.

Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring
through parallel cannulated compression screws. J Orthop Trauma 1997;11(8):573-576.

Burvant JG, Thomas KA, Alexander R, et al. Evaluation of methods of internal fixation of transverse patella
fractures: a biomechanical study. J Orthop Trauma 1994;8(2):147-153.

Carpenter JE, Kasman R, Matthews LS. Fractures of the patella. J Bone Joint Surg Am 1993;75:1550-1561.

Gardner MJ, Griffith MH, Lawrence BD, et al. Complete exposure of the articular surface for fixation of
patellar fractures. J Orthop Trauma 2005;19(2):118-123.

Marder RA, Swanson TV, Sharkey NA, et al. Effects of partial patellectomy and reattachment of the patellar
tendon on patellofemoral contact areas and pressures. J Bone Joint Surg Am 1993;75(1):35-45.

Melvin JS, Mehta S. Patellar fractures in adults. JAAOS 2011;19:198-207. Perry CR, McCarthy JA, Kain CC,
et al. Patellar fixation protected with a load-sharing cable: a mechanical and clinical study. J Orthop Trauma
1988;2(3):234-240.

Smith ST, Cramer KE, Karges DE, et al. Early complications in the operative treatment of patella fractures. J
Orthop Trauma 1997;11(3):183-187.

Weber MJ, Janecki CJ, McLeod P, et al. Efficacy of various forms of fixation of transverse fractures of the
patella. J Bone Joint Surg Am 1980;62(2):215-220.
 26
Knee Dislocations
James P. Stannard

INTRODUCTION
Dislocation of the knee is a relatively rare injury and occurs more commonly following high-energy trauma than
with athletic events. Knee dislocations are challenging to treat, requiring expertise in complex knee ligament
reconstruction in patients with compromised soft tissues and multisystem trauma. Recovery is prolonged, and
many patients require up to 2 years to reach maximum improvement following this injury, and most patients do
not regain preinjury levels of activity. In the past, knee dislocations were classified by the position of the tibia
relative to the femur. This classification while descriptive gave little information about pathoanatomy or treatment.
The anatomic classification initially proposed by Schenck is the most useful and commonly employed
classification (Table 26.1). This classifies the dislocation based on what structures are injured regardless of the
position of the tibia.
Surprisingly, one of the initial challenges in caring for these patients is making the correct diagnosis. Multiple
studies have shown that two-thirds to three-quarters of patients who sustain a knee dislocation present to the
trauma center with the knee reduced. This reduction may occur spontaneously following injury, or it may occur
as emergency medical services personnel splint the extremity and transport the patient. The diagnosis is very
straightforward and easy when the patient presents with the knee dislocated, but is more difficult to diagnose
when the knee is reduced, particularly in a patient with other injuries.

INDICATIONS AND CONTRAINDICATIONS

It is well established that nonoperative treatment of knee dislocations leads to poor results in active patients.
Therefore, surgery is indicated for the vast majority of patients with this injury. Patient factors such as obesity,
severe soft-tissue injuries, open knee dislocations, and multiple injuries often require staged management
protocols. This usually consists of temporary spanning external fixator, imaging studies, and delayed surgical
repair.
Contraindications to surgery include patients who are physiologically unstable for surgery, nonambulatory
patients or those with severe medical comorbidities that make them unsuitable for surgery. Some elderly patients
with a sedentary lifestyle and low demands may be considered for nonoperative management as well. However,
some of these patients benefit from temporary spanning external fixator to maintain the reduction for 3 to 4 weeks
followed by a brace. Because of poor outcomes associated with nonoperative care, as well as with spanning
external fixation as definitive treatment, most patients benefit from surgical repair.
There is considerable variability in the type, location, and number of soft-tissue injuries associated with knee
dislocations. Several authors have noted a higher incidence of vascular and neurologic injury in morbidly obese
patients following low-energy knee dislocations.

PREOPERATIVE PLANNING
History and Physical Examination
The first step in preoperative planning is recognition of the injury. Knee dislocations most frequently occur as a
result of high-energy trauma such as motor vehicle or motorcycle collisions, with concomitant injuries that may
draw attention away from the knee. Ipsilateral extremity fractures are very common and make performing a knee
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examination in the trauma room very difficult. The key to making the diagnosis is to have a high index of
suspicion. An effusion may or may not be present depending on the degree of damage to the joint capsule.
However, any knee with an effusion should be examined thoroughly. Similarly, abrasions and contusions around
the knee may indicate significant trauma to the joint. The condition of the soft-tissue envelope should be
documented because it may influence the timing of surgical repair. Additionally, radiographs of the knee may
demonstrate subtle clues such as avulsions of flecks of bone or asymmetry between compartments of the knee.
Finally, an examination under anesthesia (EUA) is the “gold standard” test to diagnose a knee dislocation and to
classify the torn structures.

TABLE 26.1 Anatomical Classification

Class Description

Knee dislocation I Cruciate intact knee dislocation

Knee dislocation II Both cruciates torn, collaterals intact

Knee dislocation III Both cruciates torn, one collateral torn Subset KD III Medial or KD III Lateral

Knee dislocation IV All four ligaments torn

Knee dislocation V Periarticular fracture dislocation

Patients who present with the knee dislocated should have the joint reduced as quickly as possible. Normally,
longitudinal traction on the lower leg produces a rapid and easy reduction. Occasionally, patients will present
with an irreducible knee, most frequently as a result of the femoral condyle “button holing” through the capsule or
muscle. This is frequently accompanied by puckering of the skin when a reduction is attempted. If the knee does
not reduce easily, the patient should be taken to the operating room for a reduction under anesthesia
expeditiously.
In a patient with a suspected ligamentous injury to the knee, a careful and gentle knee exam should be
performed. The anterior cruciate ligament (ACL) is best examined with the Lachman’s test with the knee in
approximately 30 degrees of flexion. The posterior cruciate ligament (PCL) should be examined with a posterior
drawer test. It is important to make certain the knee is not posteriorly subluxed prior to the examination, as that
can yield a false diagnosis of a torn ACL rather than a torn PCL. Varus and valgus laxity testing should be done
with the knee in full extension and 30 degrees of flexion. Instability in extension implies both the PCL and one of
the lateral collateral ligaments is torn. The dial test performed at both 30 and 90 degrees of flexion can identify a
posterolateral corner (PLC) tear with damage to the popliteus muscle unit. Finally, an anterior drawer that is
increased with the knee in external rotation can differentiate a torn posteromedial corner (PMC) from a simple
medial collateral ligament (MCL) tear.
It is critical to perform a careful neurologic and vascular examination of the leg, in addition to the assessment
knee stability. The vascular examination must include palpation of the distal pulses, which is the best marker of
clinically significant vascular injury. Popliteal artery injuries occur in 5% to 15% of patients with knee dislocations
and are limb-threatening injuries. There is strong support in the literature for a “selective arteriography” that uses
a careful vascular examination as the trigger for obtaining vascular imaging studies. If the vascular examination is
normal, the patient should be admitted for observation with serial clinical examinations. If the vascular status is
abnormal, vascular surgery consultation and additional studies are warranted. If there is any doubt regarding the
vascular status of the patient, a magnetic resonance angiogram (MRA) or classic contrast angiography should be
obtained. MRA is usually adequate and is preferred in stable patients who can undergo this procedure in the
acute setting. Otherwise, arteriography is utilized. If the imaging study documents an intimal tear, the patient
should be evaluated by a vascular surgeon. The contemporary treatment of a non-flow limiting intimal tears is
observation and careful serial vascular examinations. Additional physical examination tests such as ankle
brachial index may be performed in equivocal cases, but are not necessary in most patients.
A detailed neurologic examination of the extremity should also be performed and documented. Peroneal nerve
injuries due to traction at the fibular head occur in up to 20% of patients and are often a source of longterm
disability. It is important to document neurological injuries prior to surgical reconstruction. It may be beneficial to
perform a peroneal nerve neurolysis at the time of knee ligament reconstruction if there is a traction injury. While
much less common, tibial nerve injuries do occur, and the status of that nerve should also be documented prior
to surgical intervention.

Imaging Studies
In all patients with trauma around the knee, an anteroposterior (AP) and lateral radiograph should be obtained.
These should be studied carefully as they frequently yield subtle signs of a ligament knee injury such as bony
flecks or avulsions, asymmetry of the medial or lateral compartments, subtle subluxation, or rim fractures. If the
physical examination documents ligamentous instability, an MRI scan should be obtained when the patient is
stable as a supplement to the physical examination. The MRI scan helps identify the pathoanatomy,
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the location, and pattern of injury, provides a good evaluation of the menisci, and can confirm the exact location
of the neurovascular bundle relative to the knee joint.

Timing of Surgery
The timing of surgical repair in patients with a knee dislocation is controversial. Open dislocations require urgent
reduction, irrigation and débridement, and placement of a spanning external fixator. Similarly, patients with
irreducible dislocations should be taken to the operating room as soon as an operating room becomes available.
In patients with closed injuries without vascular embarrassment, the timing of definitive ligament repair is
debatable. The condition of the soft-tissue envelope as well as other associated injuries is a key factor in
determining the ideal timing for reconstruction. My preference is to treat associated fractures within 1 week of
injury and reconstruct the ligaments in the 3rd or 4th week following injury. I place the vast majority of patients in
a simple knee immobilizer prior to reconstructive surgery. The exceptions are open injuries and grossly unstable
knees where a spanning external fixator is employed for 3 to 4 weeks prior to reconstruction.

Surgical Tactic
Reconstruction of a dislocated knee is a complex procedure that requires careful preoperative planning in order
to maximize results. It is important to understand which structures are torn prior to surgery so that appropriate
equipment and allografts are available. An EUA is always performed at the beginning of the case to confirm the
findings on physical examination and correlate it with the results of the MRI. The sequence of the reconstruction
is important, particularly if a hinged external fixator will be used in conjunction with the reconstruction.
My surgical tactic includes a diagnostic arthroscopy at the outset of the case to document ligament injury and
assess the knee for meniscal and articular cartilage injury. After addressing those injuries, the notch is débrided
of torn ligament remnants, and the PCL reconstruction is performed when disrupted. Following repair of the PCL,
a reference wire for a hinged external fixator (if necessary) and the femoral pins must be placed prior to further
reconstruction. Next, the PMC and PLC are constructed. All tunnels are drilled and allografts placed prior to
tightening any of the PMC or PLC reconstructions. Normally, the PCL is tensioned first, followed by the two
corners. If a hinged external fixator is used, it is placed on the femoral pins after the skin is closed, and the three
tibial pins are drilled and placed as the final step of the procedure. I prefer to delay reconstruction of the ACL for
6 weeks or longer in the majority of cases. This allows rehabilitation to be focused on the PCL initially, shortens
an already long case, and allows the surgeon to “jump start” knee motion at the time of ACL reconstruction if the
patient is having difficulty with motion.
The surgical procedures described later in this chapter are my preferred techniques. I use an inlay double-
bundle PCL reconstruction in virtually all cases. If the patient has an adequate sized femur, I combine it with a
doublebundle ACL reconstruction 6 weeks later. There is no compelling clinical evidence that double-bundle
reconstructions are superior to their single-bundle counterparts. However, both seek to reconstruct the precise
anatomy and both provide additional rotational stability. This may be more important in a patient who has a PCL
injury as well as medial and lateral corner damage than in a patient with an isolated cruciate ligament injury.
However, in patients with complex multiligament knee injuries, there is limited bone stock available for tunnel
placement, and they must be placed perfectly when performing combined ACL and PCL reconstructions using
double-bundle techniques. I routinely use drill guides that improve tunnel placement as “free-hand techniques”
are often unreliable.
Another controversy is whether to repair the PMC and PLC primarily if adequate tissue is present. Recent
studies have shown that reconstruction is superior to primary repair for tears of the PMC and PLC. As a result, I
routinely reconstruct these areas. If the patient has reasonable tissue that might be amenable to repair, it is
repaired and then reconstructed in a belt and suspenders technique. The time necessary to complete a complex
multiligament knee injury is approximately 4 hours, and there is a long learning curve.

SURGERY
Anesthesia
General, spinal, or regional anesthesia can be utilized for reconstruction of a knee dislocation. These are lengthy
and painful procedures, and an indwelling epidural catheter or a femoral nerve block helps alleviate
postoperative pain and is strongly encouraged. Because these cases frequently take 3 to 4 hours to complete, a
Foley catheter is advisable. The need for arterial lines, central venous pressure (CVP) lines, or a Swan-Ganz
catheter is determined by the age, physiologic status of the patient, and associated injuries. Patients are given 1
to 2 g of a first-generation cephalosporin and are given an additional 1 g if the surgery takes longer than 4 hours.

Anatomic Posterior Cruciate Ligament Reconstruction

The PCL is the cornerstone of the knee and should be reconstructed and tightened prior to any of the other
ligaments in most cases. Historical results of PCL reconstructions have been very disappointing, with many
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patients having mild to moderate residual posterior laxity following reconstruction. There are two potential causes
for the unsatisfactory results associated with PCL reconstructions. The first is that the PCL has two functional
bundles: the anterolateral (AL) and the posteromedial (PM). They are named for their position on the femur and
tibia, respectively, when the knee is in extension. The AL bundle is tight with the knee in 70 to 80 degrees of
flexion, while the PM bundle is tight with the knee in approximately 15 degrees of flexion. Reconstructing both
ligaments may improve stability throughout the entire range of motion of the knee. The second potential cause of
postoperative instability following ACL reconstruction is the sharp angle the graft must turn around the back of
the knee when a transtibial reconstruction technique is used. The angle has been called the “killer turn,” and
may be responsible for graft stretching and/or failure. The anatomic PCL reconstruction I will detail below
addresses both of these issues and yields a consistently stable reconstruction.
The patient is positioned supine on the operating table. After an EUA confirms the diagnosis, standard
arthroscopy portals are created, and the knee is examined. Arthroscopic portions of the procedure are completed
by dropping the leg off the side of the table or using a lateral post if necessary. Particular care should be taken to
evaluate both menisci as well as both femoral condyles for articular cartilage injuries. Since many of these
injuries result from impact between a flexed knee and the dashboard of a vehicle, the femoral condyles are at
particular risk of articular cartilage damage. Once that assessment is complete and the articular cartilage and
meniscus have been addressed, attention is turned to the PCL. The notch is débrided of the remnants of the torn
ligament, while noting the femoral footprint of the native PCL.
The femoral tunnels are drilled using a guide that drills from the outside in through the medial femoral condyle.
Advantages of using the “outside in” guide include precise placement of the tunnel with no constraints based on
the patient’s anatomy and eliminating a “killer turn” at the femoral tunnel. The AL guidewire is drilled first and
should be placed high in the notch 8 to 10 mm back from the articular cartilage. After marking the skin with the
guide, a stab incision is made over the medial femoral condyle, and a drill tip-guide pin is drilled through the
condyle and into the notch. After confirming the position in the notch, the process is repeated for the PM tunnel.
The PM tunnel should be placed immediately inferior to the AL tunnel, with a minimum 4- to 5-mm bone bridge
between the two tunnels. The diameter of the two tunnels is determined by the graft, but is usually either 8 or 9
mm for the AL tunnel and 6 or 7 mm for the PM tunnel. Both tunnels are drilled to match the measured diameter
of the limbs on the graft (Fig. 26.1). Both tunnels are tapped if necessary for the interference screws used to
stabilize the graft. The arthroscope is now removed from the knee.
A nonirradiated Achilles tendon allograft is selected for the anatomic PCL reconstruction. The tendon is split into
a larger (about 60%) AL bundle and a smaller PM bundle. Locking stitches are placed into each of the limbs
using a strong suture to allow the graft to be passed into the knee and the respective tunnels. The bone block is
cut with an oscillating saw. The block should be trimmed to a size that is 15 to 20 mm long, 10 to 15 mm wide,
and at least 10 mm thick (Fig. 26.2). It is very important to leave the bone block a minimum of 10 mm thick, as a
thinner bone block can crack when the screw is tightened to secure it into the trough. Once the trimming has
been completed, a 4.5-mm hole is drilled through the bone block in a slightly oblique PM to AL direction.
The knee is now placed in a figure four position, and a PM approach is performed. The skin incision is identical
to the incision used for the PMC reconstruction. Carefully dissect down to the PM border of the tibia.
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The inferior landmark of the incision is the insertion of the pes anserinus tendons, and the exposure should
extend approximately 10 cm proximally. Once the PM border of the tibia is exposed, a Cobb elevator is used to
elevate the popliteus muscle from the back of tibia. This keeps the popliteus between the surgeon and the
neurovascular bundle, helping prevent vascular injury. The Cobb elevator is kept tightly against the posterior
tibia, and the popliteus is elevated all the way across the tibia. A blunt Hohmann retractor is then hooked over
the lateral aspect of the posterior tibia and used to keep the popliteus and neurovascular structures away from
the posterior tibia. The foot can also be turned to rotate the posterior tibia toward the surgeon, improving the
exposure of the posterior surface of the tibia.
FIGURE 26.1 The diameter of the two tunnels is determined by the graft (either 8 or 9 mm for the AL tunnel and
6 or 7 mm for the PM tunnel). Both tunnels are drilled to match the measured diameter of the limbs on the graft.

FIGURE 26.2 A nonirradiated Achilles tendon allograft is selected for the anatomic PCL reconstruction. The
tendon is split into a larger (about 60%) AL bundle and a smaller PM bundle. Locking stitches are placed into
each of the limbs using a strong suture to allow the graft to be passed into the knee and the respective tunnels.
FIGURE 26.3 A one-half-inch curved osteotome is used to create a trough in the back of the tibia.

FIGURE 26.4 A 4.5-mm cannulated screw and washer are used to stabilize the bone block into the trough.

A one-half-inch curved osteotome is used to create a trough in the back of the tibia (Fig. 26.3). The trough
should be <10 mm deep, so the graft is not countersunk creating a sharp turn. The top limb of the trough should
be approximately 5 to 10 mm below the joint surface. The dimensions of the trough are created so that the bone
block will fit into the trough. Once it has been completed, the bone block is inserted into the trough with the
tendon limbs on the proximal end of the trough. A 4.5-mm cannulated screw and washer are used to stabilize the
bone block into the trough (Fig. 26.4). A single screw is strong enough for fixation, as the shape of the trough
and the bone block provides stable fixation. When the screw has been tightened, a Kelly clamp is used to
penetrate the posterior capsule above the bone block to allow the graft to pass into the knee. In many cases of
acute injury, this is unnecessary as the capsule is disrupted from the trauma.
The arthroscope is then reinserted into the knee, and the hematoma that usually accumulates is evacuated. A
Hewson suture passer is inserted into the knee from the anterior and passed out the posterior capsule disruption
and into the PM exposure. The locked suture from the PM bundle is pulled into the knee, and an arthroscopic
grasper is placed in the PM tunnel. The grasper is used to retrieve the suture and pull it into the PM tunnel along
with the graft. Once that has been completed, the process is repeated with the AL bundle. Great care is taken to
make sure the AL bundle stays lateral to the PM bundle. Once both graft limbs have been pulled into their
respective tunnels, the graft is ready for fixation (Fig. 26.5).
FIGURE 26.5 The graft is ready for fixation once both graft limbs have been pulled into their respective tunnels.

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The knee is placed in approximately 15 degrees of flexion, and an interference screw is placed from outside in
through the medial femoral condyle while the PM bundle is tensioned. The knee is then placed in 70 to 80
degrees of flexion, while the AL bundle is tensioned. An interference screw is then placed through the medial
femoral condyle to secure the graft.

Posteromedial Corner Reconstruction

It is critical to differentiate between patients who have a torn MCL and a torn PMC. Patients with a torn PMC
have posterior oblique ligament (POL) damage in addition to a torn MCL. Patients with either injury will
demonstrate instability with a valgus stress with 30 degrees of knee flexion. A key physical examination test to
differentiate between the two is the anterior drawer with the foot in various positions. Initially, an anterior drawer
test is performed with the foot in a neutral position. Following that, the procedure is repeated with the foot in 10
to 15 degrees of external rotation. If the tibial plateau rotates out from under the femoral condyle to a greater
degree with the foot in external rotation than when the foot is in neutral, the test is positive, and the patient likely
has a torn PMC. Patients with an isolated MCL tear will frequently heal with nonoperative treatment that includes
a brace. Patients with a torn PMC frequently require surgery to regain stability.
PMC reconstruction can be performed with either a semitendinosis autograft or with allograft tissue. I will
describe my preferred technique that features the allograft reconstruction. The surgical approach is made using
a straight incision just posterior to the MCL from the femoral condyle to the insertion of the pes anserinus
tendons (Fig. 26.6). The isometric point on the medial femoral condyle is identified using fluoroscopy. This is
accomplished by obtaining a perfect lateral view of the knee joint and distal half of the femur. The isometric point
is determined by drawing a line from the anterior aspect of the posterior femoral cortex to the point where it hits
Blumensaat’s line. The intersection of those two lines is the isometric point (Fig. 26.7). A guide pin for a
biotenodesis screw (Arthrex, Naples, FL) is drilled into the distal femur at the isometric point (Fig. 26.8). There
are two options for allograft reconstruction that work well. The first is using a tibialis anterior allograft that is split
in half, yielding two grafts that are each 5 to 6 mm wide. The other option is to use two semitendinosis allografts.
In either case, both grafts are prepared with locking stitches in both ends. Both grafts are loaded onto the
biotenodesis screw and the size is measured.
The socket for the biotenodesis screw is drilled into the femur using a cannulated reamer over the guide pin
placed at the isometric point. Typically, this socket is drilled with an 8-mm reamer to a depth of 25 mm. The
biotenodesis screw and the two grafts are then placed into the socket and screwed into place (Fig. 26.9).
Excellent fixation is usually achieved. A 3.5-mm drill bit is then used to drill into the tibia at the proximal
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end of the insertion of the pes anserinus tendons. This drill hole is bicortical and is measured using a depth
gauge. A 4.5-mm screw of the appropriate length (usually around 50 mm) with a spiked ligament washer is then
inserted into the tibia. One of the two allografts is run from the socket in the femur directly down to the screw and
washer. This graft becomes the reconstructed superficial MCL. The second graft is routed posteriorly (Fig.
26.10A) under the direct head of semimembranosis (Fig. 26.10B) and then to the screw and washer on the tibia.
This forms a posterior sling and reconstructs the POL. The two grafts are then wrapped around the screw from
opposite directions (Fig. 26.11) and tensioned with the knee in 40 degrees of flexion in a figure four position. The
screw and ligament washer are then tightened down to the tibia, fixing the grafts in place under
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appropriate tension (Fig. 26.12). The knee is flexed to at least 90 degrees to check the security and tension of
the graft. The soft tissue and skin are then closed in layers, and dressings are placed over the incision. Patients
are allowed immediate weight bearing with the knee locked in extension and begin gentle range of motion the
following day. Motion is initiated at 0 to 30 degrees and advanced slowly over the next 6 weeks.

FIGURE 26.6 The surgical approach is made using a straight incision just posterior to the MCL from the femoral
condyle to the insertion of the pes anserinus tendons.
FIGURE 26.7 Fluoroscopy is used to identify the isometric point, which is determined by drawing a line from the
anterior aspect of the posterior femoral cortex to the point it hits Blumensat’s line. The isometric point is at the
intersection of those two lines.

FIGURE 26.8 A guide pin for a biotenodesis screw is drilled into the distal femur at the isometric point.
FIGURE 26.9 The biotenodesis screw and the two grafts are placed into the socket and screwed into place.

FIGURE 26.10 A second graft is routed posteriorly (A) under the direct head of semimembranosis (B) and then
to the screw and washer on the tibia.

Hinged External Fixation of the Knee

Knee dislocations have a broad spectrum of instability. Some have massive capsular disruptions and are
inherently unstable, while others have relative gross stability following reduction. Spanning external fixation may
be used in some cases prior to reconstruction of the ligaments to put the soft tissues at complete rest while
maintaining stability. Hinged external fixators may be used following reconstruction to maintain coronal and
rotational stability while allowing sagittal plane motion. My current protocol is to use hinged external fixators with
patients who have Schenck type 4 and 5 knee dislocations.
Placement of a hinged external fixator (Compass Knee Hinge, Smith & Nephew, Memphis, TN) must be initiated
prior to reconstructing the corners. The procedure begins with drilling a reference wire across the knee at the
isometric point (Fig. 26.13). The technique for finding the isometric point is the same as the technique for the
PMC reconstruction. The hinge is then mounted on the wire, and the femoral pins are placed. A one-hole
Rancho cube is placed on the medial side proximal to the 5/8 ring, with a three-hole cube on the lateral side.
Both cubes are placed at the hole that is furthest around the ring on the femoral side. A trochar system is used
after a stab incision is made on the skin. The trochar is centered on the femur, and the drill bit is placed through
it (Fig. 26.14). Six-millimeter Schantz pins are placed through the trochar achieving bicortical fixation from both
the medial and lateral sides. Once both pins have been placed and they are fixed to the Rancho cubes, the
reference wire is removed from the isometric point. The Rancho cubes and femoral pins are left in place, but the
hinge is removed to allow reconstruction of the PMC and PLC.
After completion of the knee reconstruction, the incisions are closed. The hinge is then mounted back onto the
two femoral pins and their Rancho cubes. That puts the hinge back at the center of rotation of the knee.
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Three tibial pins are then placed through three-, four-, and five-hole Rancho cubes that extend distally from the
inferior ring. One pin is placed from straight anterior, one from approximately three or four holes medially to the
first, and the final pin is placed at nearly a 90-degree angle from the lateral side. The tibial pins are 5 mm in size.
Once all the pins have been placed and tightened, knee motion is assessed (Fig. 26.15). If any pin sites are
tethered by soft tissue, the pin site is released using a scalpel. Sterile dressings are then placed around the pin
sites, and the procedure is complete.

FIGURE 26.11 Two grafts are wrapped around the screw from opposite directions.
FIGURE 26.12 The screw and ligament washer are tightened down to the tibia, fixing the grafts under the
appropriate tension.
FIGURE 26.13 The placement of a hinged external fixator begins with drilling a reference wire across the knee at
the isometric point.

FIGURE 26.14 A trochar system is used after a stab incision is made on the skin. The trochar is centered on the
femur, and the drill bit is placed through it.

Double-Bundle ACL Reconstruction with Achilles Tendon Allograft

For most patients, the anterior cruciate reconstruction is done as a planned second-stage procedure
approximately 6 weeks after injury. A nonirradiated Achilles tendon allograft is obtained and prepared on the
back table. The bone block is shaped to a 13-mm diameter for larger patients, 12 mm for smaller patients. The
anterior half of the bone should be marked with the surgical marker to assist in orientation of the bone when the
graft is passed into the tibial tunnel. The tendon is split into an 8-or 9-mm anteromedial (AM) bundle and a 6 or 7-
mm posterolateral (PL) bundle. If the patient does not have a large enough ACL footprint or if the graft is not
adequate, a single-bundle ACL reconstruction should be performed. Locking whip stitches are placed in both
bundles (Fig. 26.16). I use an outside in femoral guide, which allows precise placement of femoral tunnels
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with divergence between the two tunnels (Fig. 26.17). This allows interference fixation in the femur as well as the
tibia. I rarely perform a notchplasty as it is not necessary in most knees with anatomic placement of the two
bundles. The PL guidewire is drilled from the lateral femoral condyle to the notch at a location 8 mm back from
the articular cartilage and 5 to 6 mm up from the tibial surface (Fig. 26.18). This tunnel is reamed to 6 or 7 mm
from the femoral condyle toward the notch. The AM tunnel is placed at the back of the notch in the correct
anatomic position (low at 2 or 3 o’clock on a left knee or 9 or 10 o’clock on a right knee) just anterior (as you
view it during the arthroscopy with the knee flexed) to the posterior articular cartilage. The AM tunnel is drilled to
8 or 9 mm. The tunnels are tapped if necessary depending on the type of interference fixation selected.

FIGURE 26.15 Once all tibial pins have been placed and tightened, knee motion is assessed.

FIGURE 26.16 A nonirradiated Achilles tendon is split into an 8-mm AM bundle and a 6-mm PL bundle. Locking
whip stitches are placed in both bundles.
FIGURE 26.17 An outside femoral guide allows precise placement of femoral tunnels with divergence between
the two tunnels.

FIGURE 26.18 The PL guidewire is drilled from the lateral femoral condyle to the notch at a location 8 mm back
from the articular cartilage and 5 to 6 mm up from the tibial surface.

The tibial guide pin is drilled from a few centimeters below the joint surface on the medial side and exits in the
middle of the ACL footprint 7 to 9 mm anterior to the PCL. This is drilled to 12 to 13 mm to correspond to the
Achilles tendon bone block. It is important to elevate the periosteum on the tibia at the entrance to the tunnel, as
the bone block has a very tight fit, and the periosteum can prevent passage of the graft. An arthroscopic grasper
is used to take the sutures from the PL bundle and pass them into the knee. A second arthroscopic grasper is
passed from the lateral femoral condyle, through the PL tunnel, and into the notch. The PL graft sutures are
grasped in the notch and pulled through the PL tunnel, and the graft is pulled into the femoral tunnel (Fig. 26.19).
The process is then repeated with the two graspers for the AM bundle, taking care to orient the AM graft
anteriorly over the PL bundle using an arthroscopy probe. The two bundles are pulled completely into their
respective tunnels, and the bone block is pulled into the tibial tunnel. The orientation of the bone block
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should be maintained with the anterior portion that was marked with the surgical marker being kept anterior. The
fit is frequently remarkably tight, and it is not uncommon to use a bone tamp to fully seat the bone block into the
tibial tunnel. The block is left long and tamped up near the tibial joint surface. The tunnel is then tapped and a
10-mm interference screw is placed to secure the bone block. This screw usually gets very firm fixation in the
tibia.

FIGURE 26.19 The PL graft sutures are grasped in the notch and pulled through the PL tunnel, and the graft is
pulled into the femoral tunnel.
FIGURE 26.20 With the knee is placed in 40 degrees of flexion, a 7-mm bioabsorbable screw is placed through
the femoral condyle.

An assistant then pulls tension on the two bundles coming from their respective femoral tunnels while the knee is
put through a range of motion 20 times. This makes certain that the graft is pulled tightly through all tunnels and
pretensions the graft.
The PL bundles are tensioned by placing a guide wire into the PL tunnel and then moving the knee to 5 to 10
degrees of flexion. A 7- or 8-mm bioabsorbable screw is then placed through the femoral condyle from outside in.
The knee is then placed in 40 degrees of flexion, and an 8- or 9-mm bioabsorbable screw is placed through the
femoral condyle (Fig. 26.20). Incisions are then closed and the dressings placed over the surgical site.

Intraoperative Challenges
There are many technical challenges to overcome when performing a complex reconstruction following a knee
dislocation. As noted above, there multiple tunnels traversing the femur and great care must be taken to avoid
intersection of tunnels and damage to grafts. The combination of outside-in guides and great care in placing
PMC and PLC tunnels helps avoid this problem. However, it is important to pay attention to grafts that have
already been placed when drilling new tunnels. It is also important to delay tensioning the grafts until all tunnels
have been drilled. Another challenge is tensioning the ligaments and “balancing” the knee. If the PCL is
overtensioned, it can sublux the knee anteriorly in an unstable knee. In the worst cases, particularly with obese
or muscular patients, I use fluoroscopy to make certain the knee is appropriately reduced and the graft is not
overtensioned.
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POSTOPERATIVE REHABILITATION
There is little consensus regarding the optimal method of postoperative rehabilitation following surgery. Some
authors advocate non-weight bearing and splinting or casting for 4 to 6 weeks to allow early graft and softtissue
healing. This approach may minimize wound complications, but increases the risk of knee stiffness and
arthrofibrosis.
My postoperative protocol includes weight bearing on the first or second postoperative day with the knee locked
in extension in either a hinged knee brace or hinged external fixator. After 7 to 10 days, patients are allowed to
begin weight bearing without locking the knee in extension. Knee motion begins on the first postoperative day in
most of patients. Motion is initiated in the brace starting at 0 to 30 degrees and slowly advanced. The goal is to
achieve 90 degrees of knee flexion by 6 weeks following surgery. It is very important to make certain that full
passive extension of the knee is achieved and maintained, as flexion contractures can be very difficult to resolve.
Early knee motion may decrease the incidence of arthrofibrosis and improves chondrocyte nutrition potentially
preserving cells that have sustained some injury. Early rehabilitation concentrates on motion and quadriceps
strengthening using isometrics and limited motion exercises. If the patient has not achieved 90 degrees of flexion
within 6 weeks following reconstruction, a manipulation under anesthesia and arthroscopic lysis of adhesions is
recommended. I routinely utilize an epidural catheter for postoperative pain control, and patients are placed in a
continuous passive motion (CPM) machine. The CPM is set to replicate the flexion achieved in the operating
room immediately postoperatively. Patients are informed prior to the start of the reconstructive process that this
occurs in up to 20% of patients and is preferable to developing long-term motion problems.

RESULTS
Functional outcomes following knee dislocations are improving as surgery is increasingly able to restore
knee mechanics. It is important that PLC reconstructions address the popliteus, popliteofibular ligament,
and fibulacollateral ligament. Anatomic reconstruction of all three structures leads to good outcomes in up to
90% of patients. However, failure rates of 35% to 40% have been reported with primary repair alone.
Similarly, PMC reconstructions should be based on restoring both the MCL and the POL. Reconstruction
results with an anatomic PMC reconstruction are excellent, with only a 4% failure rate with 2-year follow-up
in contrast to failure rates for primary repairs which are 20%. Finally, PCL reconstruction using the anatomic
technique described in this chapter has yielded excellent results. Short-term failure rates were only 3% to
4%. Long-term results with a mean follow-up of nearly 5 years had failure rates of only 7%.

COMPLICATIONS
Motion
Arthrofibrosis with loss of knee motion remains a major challenge in patients following knee
dislocations. Twenty-five to thirty percent of patients develop a stiff knee and require additional
treatment following surgical repair.
Stability
A careful review of the published literature in the past 20 years shows that more than 40% of patients
have some residual instability following surgical repair. In many cases, a four-ligament knee
 reconstruction has three solid repairs while one ligament becomes loose during the early rehabilitation
phase. Revision of the lax structure can yield a stable knee with good function. Knee stability may be
improving as anatomic reconstructions are increasingly employed. If a lower demand patient has 1+ or
2+ laxity of a single side of the knee that does not impede activities of daily living, I often treat the
patient with a brace. Symptomatic instability is treated with revision surgery.
Neurovascular Injury
The incidence of popliteal artery injury following a knee dislocation varies from 5% to 40% in the
literature. Contemporary studies have reported an incidence of 5% to 15%. Approximately 20% of
patients sustain an injury to the peroneal nerve but there is no consensus on how to treat these
patients. My preference is to perform a neurolysis of the nerve at the time of PLC reconstruction,
making sure there is no scar tissue impeding nerve recovery. Patients are also fitted with an ankle foot
orthosis. Nerve recovery is unpredictable, and many patients have residual weakness or motor
impairment.
Wound Complications
Knee dislocation is usually a high-energy injury that impacts the skin and soft-tissue envelope. It is
important to use separate lateral and medial incisions to minimize dissection. It is also important to use
gentle soft-tissue
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handling techniques as well as perform layered closures. Despite these efforts, it is common to see
superficial or deep infections and wound dehiscence. This risk may be higher with early motion
rehabilitation protocols. It is difficult to determine the exact incidence of wound complications due to the
large number of variables in knee dislocation patients. However, the risk of some degree of wound
complication varies between 5% and 15%. I have a very low threshold for an irrigation and
débridement of worrisome incision or wound dehiscence. Intravenous antibiotics are employed in
conjunction with surgical débridement.

RECOMMENDED READING
Almekinders LC, Logan TC. Results following treatment of traumatic dislocations of the knee joint. Clin
Orthop Relat Res 1992;284:203-207.

Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner
injuries of the knee. Sports Med Arthrosc Rev 2006;14:78-83.

Fanelli GC, Stannard JP, Stuart MJ, et al. Management of complex knee ligament injuries. J Bone Joint Surg
Am 2010;92(12):2235-2246.

Levy BA, Fanelli GC, Whelan DB, et al. Controversies in the treatment of knee dislocations and multiligament
reconstruction. J Am Acad Orthop Surg 2009;17(4):197-206.

Montgomery TJ, Savoie FH, White JL, et al. Orthopedic management of knee dislocations. Comparison of
surgical reconstruction and immobilization. Am J Knee Surg 1995;8(3):97-103.
Sisto DJ, Warren RF. Complete knee dislocation. A follow-up study of operative treatment. Clin Orthop Relat
Res 1985;198:94-101.

Stannard JP. Medial and posteromedial instability of the knee: evaluation, treatment, and results. Sports Med
Arthrosc 2010;18(4):263-268.

Stannard JP. Anatomic posterior cruciate ligament reconstruction with allograft. J Knee Surg 2010;23(2):81-
87.

Stannard JP, Sheils TM, Lopez-Ben RR, et al. Vascular injuries in knee dislocations following blunt trauma:
evaluating the role of physical examination to determining the need for arteriography. J Bone Joint Surg Am
2004;86:910-915.

Stannard JP, McKean RM. Anatomic PCL reconstruction: the double bundle inlay technique. Oper Tech
Sports Med 2009;17(3):148-155.

Twaddle BC, Bidwell TA, Chapman JR. Knee dislocations: where are the lesions? A prospective evaluation
of surgical findings in 63 cases. J Orthop Trauma 2003;17:198-202.

Yeh WL, Tu YK, Su JY, et al. Knee dislocation: treatment of high-velocity knee dislocation. J Trauma
1999;46(4):693-701.
 27
Tibial Plateau Fractures: Open Reduction Internal Fixation
Tracy J. Watson

INTRODUCTION
Fractures of the tibial plateau involve a major weight-bearing joint covering a wide spectrum of injury, from
minimally displaced intra-articular fractures to complex fractures that present with severe articular impaction,
shaft extension, and soft-tissue compromise. In an effort to preserve normal knee function, the goals of treatment
are to restore joint congruity, preserve the normal mechanical axis, create a stable joint, and restore knee
motion. This may be a formidable task particularly in high-energy comminuted fractures with massive limb
swelling and variable bone quality.
In North America, the most widely used classification schemes for plateau fractures are the AO/OTA and
Schatzker classifications (1). These classifications are based on grouping fracture morphology such as condylar
splits, articular depression, comminution, and metadiaphyseal extension. Schatzker’s classification divided these
injuries into six distinct subtypes each with its own method of treatment (2). Additionally, dividing these into low-
energy versus high-energy fractures allows one to predict the initial degree of soft-tissue compromise (3) (Fig.
27.1). This is important when planning the timing of surgery.

INDICATIONS AND CONTRAINDICATIONS

Treatment decisions should include patient factors such as age, levels of activity, preexisting medical conditions,
and patient expectations as well as fracture factors such as the extent of articular involvement, fracture
comminution, associated injuries, and, most importantly, the condition of the soft tissues.
The method of treatment for lower-energy tibial plateau fractures varies widely among surgeons, and numerous
studies have reported satisfactory results using both nonoperative and surgical modalities particularly in the
elderly (4, 5 and 6). Low-energy tibial plateau fractures that do not result in joint instability or significant
malalignment of the mechanical axis can usually be treated nonoperatively. Minimally displaced fractures (<2
mm) in a patient with a stable knee joint and minimal angular deformity are usually managed without surgery
In the past 20 years, newer treatment algorithms have been developed to treat complex tibial plateau fractures
that occur in patients following high-energy trauma with soft-tissue compromise. Multiple studies have shown that
the ability to maintain the dynamic mechanical axis as well as an anatomic reduction correlates closely with
clinical outcomes (3,5,6). In these complex fracture patterns, there is little controversy regarding the need for
surgical treatment. Malunions following nonoperative treatment of displaced tibial plateau fractures are difficult to
treat, and often require complex corrective osteotomies or joint arthroplasty (7). Clinical outcomes following intra-
articular or extra-articular osteotomies are further compromised when posttraumatic arthritic changes have
developed (Fig. 27.2). On the other hand, outcomes following properly
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done initial surgery are superior to late reconstructive procedures adding increased importance to the index
procedure (7).
FIGURE 27.1 The Schatzker classification of tibial plateau fractures.

There is wide consensus that surgery is indicated for a tibial plateau fracture when there is
1. Varus or valgus instability of the knee >5 to 10 degrees with the knee examined in full extension (compared
to the uninvolved knee). This indicates significant axial instability caused by articular impaction or condylar
displacement (2,5,6).
2. A static or dynamic deviation of the mechanical axis, from longitudinal or axial displacement of a tibial
condyle, leading to excessive varus or valgus with weight bearing.
3. Any tilt, displacement, or impaction of the medial tibial plateau is poorly tolerated and requires fixation
(2,3,5,6).
Absolute indications for emergent surgery in tibial plateau fractures include open plateau fractures, fractures with
an associated compartment syndrome, and displaced fractures in the presence of a vascular injury. Relative
indications for surgery include lateral plateau fractures that result in axial joint instability, most displaced
bicondylar fractures, displaced medial condyle fractures, and coronal plane posterior condylar fracture
dislocations (2,3,8).
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FIGURE 27.2 A. Proximal tibial malunion with varus deformity and articular incongruency of lateral plateau,
resulting from malreduction of a posteromedial condylar fracture and failure to elevate impacted lateral articular
surface. B. Malunion of the medial condyle with chronic lateral dislocation of the patella.

The most common contraindication to emergent internal fixation of a tibial plateau fracture is a compromised soft-
tissue envelope, which can occur in either open or closed fractures. Following resolution of the soft-tissue injury,
definitive fracture surgery can be undertaken with the expectation of fewer complications (Fig. 27.3). The
spectrum of injuries to the tibial plateau is so great that no single method of treatment has proven uniformly
successful. However, by following sound surgical principles, a congruous knee joint that is functionally stable
can usually be achieved.

PREOPERATIVE PLANNING
History and Physical Exam
A patient with a tibial plateau fracture invariably presents with a painful, swollen knee and is unable to bear
weight on the affected extremity. The magnitude of force delivered to the knee determines not only the degree of
comminution of the fracture fragments and amount of articular impaction but also the degree of condylar and
shaft displacement. Therefore, it is important to determine whether the injury occurred as the result of a high- or
low-energy force.
FIGURE 27.3 A. A knee-spanning external fixator bridges an open tibial plateau fracture to facilitate soft-tissue
care and maintain length prior to definitive reconstruction. B. A closed tibial plateau fracture with multiple
lacerations that was initially treated with a spanning external fixator to allow for soft-tissue recovery.

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Most low-energy fractures have a common history of a ground-level slip and fall or occur following a twisting
moment resulting in a varus or valgus force to the knee and often occur in elderly patients. These are usually
isolated injuries, and the patient may not seek immediate medical attention. As the degree of articular impaction
increases, patients are unable to bear weight secondary to pain and instability.
High-energy fractures are the end result of a combined axial load with a rotational or angular force imparted onto
the knee that is stationary. Falls from a height, head on motor vehicle accidents, pedestrian versus vehicle, and
other direct impact loading mechanisms produce high-energy fracture patterns with associated soft-tissue
injuries. Not uncommonly, ipsilateral injuries to the hip or lower leg occur, and many patients present with
multiple system injuries.
The physical exam for all plateau fracture patterns, but especially for the high-energy plateau fractures, should
document the integrity of the peripheral pulses and nerve function. Close attention to the superficial peroneal
nerve is important as the inability to actively dorsiflex the foot with subjective paresthesias may be the first
clinical signs of a compartment syndrome. Gentle stress testing of the knee to assess any varus or valgus
instability is important, especially with lower-energy fracture patterns where instability of more than 5 degrees in
full extension compared to the uninjured knee is the major consideration for proceeding to surgical management.
Severe fracture patterns may occur in association with a fracture dislocation of the knee, and assessment of the
cruciate ligaments often influences treatment.
The evaluation of the surrounding soft-tissue envelope should be based on objective criteria. Superficial
abrasions, deep contusions, hemorrhagic blisters, and the lack of skin wrinkles all indicate a high-energy injury
with some component of internal degloving. The presence of some or all of these findings usually precludes early
internal fixation because surgical incisions through compromised soft tissues is associated with a significantly
increased risk of wound complications and infection. If open wounds are present, their relationship to the fracture
site and the knee joint must be determined (3,8, 9 and 10). Compartment pressure monitoring should be
performed in selected patients particularly those with significant soft-tissue swelling, painful paresthesias,
displaced medial plateau, bicondylar, and plateau fractures with shaft extension. In patients with head trauma,
altered mental status, or where the physical exam is equivocal, we strongly recommend measuring compartment
pressures.
In patients with absent or diminished pulses, longitudinal traction with gross realignment of the limb often
restores blood flow. If a pulse deficit remains, then an ankle/brachial indices (ABI) should be obtained. ABIs
consist of a systolic blood pressure obtained at the ankle over the posterior tibial artery and a systolic pressure
obtained at the elbow over the brachial artery. The ratio of ankle systolic pressure divided by brachial pressure
should normally be >0.9. Values <0.9 are predictive of arterial injury, and angiography with vascular surgery
consultation should be obtained.

Imaging Studies and Fracture Classification

Except for very subtle plateau fractures, anteroposterior and lateral radiographs of the knee usually demonstrate
the fracture. Routine radiographs should also include internal and external oblique views as well as a full-length
radiograph of the entire tibia and fibula. The oblique views often detect subtle degrees of joint impaction or
fracture lines not visible on the AP or lateral views.
In higher-energy displaced fractures, traction radiographs are useful in improving the understanding of the
fracture geometry and morphology when length is restored. Traction films may be painful to the patient and
usually require analgesics to obtain in the acute setting. Distraction radiographs are best obtained after
application of a bridging external fixator. Traction films aid in the preoperative planning for the location of surgical
incisions based on the orientation and size of the metaphyseal fragments and depth of articular impaction.
CT scans are obtained in virtually all patients with higher-energy fracture patterns (Schatzker VI, V, and VI)
where plain x-rays are often difficult to interpret because of displacement, impaction, and comminution. When the
plateau fracture results in axial shortening and displacement, CT scans should be performed after traction or
bridging external fixation has been applied. Properly interpreted, CT scans guide the choice of surgical approach
or the possibility of using percutaneous plates or screws (3,12) (Fig. 27.4).
Because of the high incidence of associated soft-tissue injuries that can occur in displaced fractures, MRI is an
important tool to evaluate soft-tissue pathology (11,12). In addition to delineating the fracture and possible
meniscal pathology, it can detect tears of the collateral or cruciate ligaments often seen with plateau fractures
(11,12) (Fig. 27.5). Obtaining an MRI acutely may be problematic in some institutions, especially in the multiply
injured patient and those with spanning external fixators. Although most contemporary external fixator
components are classified as “MR compatible,” the concerns of fixation pin image distortion and heat generation
may negate their use for the more complex fracture patterns, especially when spanning frames are used. Many
radiology departments still consider MRI to be contraindicated in patients with external fixators. This is especially
true for critically ill ICU patients.
MRI is most useful for low-energy fractures with equivocal knee stability and lesser degrees of articular
involvement. The decision to operate is based on the integrity of the meniscal and ligamentous structures, which
are easily defined by MRI. The MRI will also detail the extent of bony involvement much like a CT scan. We
preferentially obtain MRI scans for low-energy Schatzker I, II, and III fracture patterns in ambulatory
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patients when indicated. CT scans are preferred for higher-energy Schatzker IV, V, and VI injuries and in patients
with spanning fixators. Very rarely will both a CT scan and MRI be obtained.
FIGURE 27.4 A. AP, lateral, and oblique injury x-rays demonstrating a bicondylar fracture pattern. Because of
displacement and malalignment, the exact fracture morphology is not clearly seen. B. Radiographs and a CT
scan after application of a temporary external fixation device demonstrate the effectiveness of ligamentotaxis,
restoring length, and clarify the fracture components. Traction accomplished near anatomic alignment of medial
and lateral condyles, shaft axis alignment, and identified avulsion of the intracondylar eminence.
FIGURE 27.4 (Continued) C. A anteroposterior radiograph demonstrating a Schatzker IV (medial column) injury.
Intraoperative distraction demonstrating knee reduction and realignment of medial column. Distraction CT scan
reveals the orientation of medial column injury and the lateral column articular impaction.

CT angiography is now used to evaluate the integrity of the vascular system in patients where the ABIs are
equivocal or pulses are absent. These studies are less invasive than standard angiography and can be
performed quickly with less contrast. However, CT angiogram produces images that are slightly less detailed
than classic angiography, but it is accurate enough to diagnose arterial compromise in most patients (12). In
addition, threedimensional CT images have added another dimension in diagnostic accuracy and allows some
visualization of the surrounding soft tissues (12).
Alternatively, magnetic resonance angiography does not involve radiation and uses a dye that is less likely to
cause an allergic reaction or kidney damage. It is less useful in the trauma patient, particularly once a spanning
external fixator has been applied.
Preoperative planning is improved when the fracture can be categorized using a widely accepted classification
system. The Schatzker classification appears to be useful in categorizing lower-energy fractures (types I, II, and
III). However, for high-energy fracture patterns, this classification scheme has significant limitations. The
Schatzker classification was developed based on plain radiographs before CT scanning was available (Fig.
27.1). However, CT scans with axial, coronal, and sagittal reconstructions provide far greater understanding of
the anatomy as well as the extent and orientation of condylar fracture lines, the location, and depth of articular
impaction and comminution. Both 2D and 3D CT scans have demonstrated that many fracture patterns cannot
be classified or are erroneously classified by the AO/OTA or Schatzker classifications. These injuries include
posterior coronal plane fractures, articular rim fractures with joint impaction, or various combinations of these
injuries.
Luo et al. (13) proposed the Three Column Classification for tibial plateau fractures. This classification scheme
clarifies the diagnosis and pre-op planning as well as improving the choice for the surgical approach. According
to Luo classification, the transverse CT scan at the level of the plateau fracture is subdivided into three anatomic
areas: the lateral column, the medial column, and the posterior column (Fig. 27.6A).
Luo proposed that one independent articular depression with a break of the column wall (condylar fracture line)
is defined as a fracture of the relevant column. A pure lateral articular depression fracture is a Schatzker III injury.
Luo also defined this as a “zero-column fracture.” It has only articular impaction and does NOT have a break in
the lateral condylar region “column” (Fig. 27.5). Simple splits and split depression injuries such as Schatzker
type I and II fractures are considered a “one column (lateral column) fracture.” When there is a split depression of
the lateral condyle with an associated displaced coronal plane posteromedial condylar fracture traditionally
classified as a bicondylar or Schatzker V injury, this is defined as a “two-column (lateral and posterior column)
fracture.” The “three-column fracture” is defined as at least one independent articular fracture fragment in each
column. The most common three-column fracture is a traditional “bicondylar fracture” (Schatzker V or VI) with a
separate posterolateral articular fragment (Fig. 27.6B,C) (13).
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FIGURE 27.5 An AP x-ray showing a Schatzker III injury (“zero column”) fracture without a condylar fracture
demonstrating lateral articular impaction. The CT scan illustrates the orientation and depth of articular impaction.
The MRI demonstrates not only depth of articular impaction but denotes peripheral lateral meniscal tear (arrow).

Timing of Surgery
The timing of surgery for closed injuries is dependent upon many factors. These include the stability of the
injured knee joint, the condition of the soft tissues, availability of hospital resources, and a skilled OR team
familiar with the implants and instruments required for surgery. For most low-energy fractures, emergent surgery
is not indicated. Appropriate imaging studies should be obtained and a preoperative plan developed. The soft
tissues are not usually compromised in these fracture patterns, and aspiration of a tense hemarthrosis improves
patient comfort. Schatzker I, II, and III injuries are axially stable and do not shorten significantly when placed in a
well-padded compressive dressing and knee immobilizer. If the patient is comfortable and the neurovascular
status is intact, they can be discharged from the emergency room with clinic follow-up. If surgery is indicated, it
can be scheduled electively as soon as skin wrinkles appear, usually within 5 to 7 days. On the other hand, if the
patient has significant pain, is unable to ambulate with crutches or a walker, or has other injuries, admission to
the hospital is warranted.
High-energy fractures (Schatzker IV, V, VI) are not axially stable and shorten or displace when placed into a
splint or a knee immobilizer. Furthermore, these injuries frequently present with compromised soft tissues,
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abrasions, or skin blisters or have other associated injuries. Emergent open reduction and internal fixation is
contraindicated; however, restoration of length is crucial, and a closed reduction and application of a spanning
external fixator should be applied within 24 hours. The longer this procedure is delayed the less effective
reduction via ligamentotaxis becomes and makes subsequent surgery more difficult. These patients require
hospital admission following fixator application to monitor the neurovascular status and observe for any signs of
compartment syndrome. If definitive surgery will be delayed more than 5 days, postreduction CT scans have
been completed, and the patient is stable, they can be discharged if their social situation allows. Staged surgery
is performed once soft-tissue recovery occurs.

FIGURE 27.6 A. A transverse cut through the proximal tibia demonstrating the Luo column classification of tibial
plateau fractures. The tibial plateau is divided into three areas, identified as the lateral, medial, and posterior
columns. The columns are defined by three lines OA, OC, and OD. O is the center of the knee (midpoint of the
tibial spines). A represents the mid tibia (usually bisecting the tibial tubercle). D is the posteromedial ridge of the
proximal tibia; and point C is just anterior to the fibular head. Point B is the posterior sulcus of the tibial plateau
that bisects the posterior column into medial and lateral parts.
FIGURE 27.6 (Continued) B. A complex high-energy tibial plateau fracture. A spanning external fixator improves
alignment through ligamentotaxis and better identifies the column injuries. A displaced posteromedial fragment is
visualized as a lateral column injury. C. In addition to the transverse CT cuts, accurate classification is aided with
additional 3D reconstructions. The imaging demonstrates a two column injury. Lateral and posteromedial column
injuries are present.

Open plateau fractures invariably require emergent irrigation and débridement in the operating room with
application of a spanning fixator especially for high-energy injuries. Repeat débridements, negative pressure
dressings, or plastic surgical reconstruction may be required. Small open wounds can often be treated with
sterile dressings and appropriate prophylactic antibiotics until an operating room becomes available. If the open
wound communicates with the knee joint, then emergent irrigation and débridement is indicated to avoid late joint
sepsis.

Surgical Tactic
There is no universal agreement on the amount of articular depression or plateau step off that dictates
nonoperative or surgical treatment. Long-term studies with >20-year follow-up have indicated an inconsistent
relationship between residual osseous depression of the joint surface and the development of osteoarthrosis.
However, if joint deformity or depression produces knee instability, the likelihood of a poor outcome significantly
increases (2,5,6). The goals of surgery and thus the surgical tactic should address the four primary areas
specific to the fracture that ultimately determines prognosis. These include
A. The amount of articular depression
B. The extent of condylar displacement
C. The degree of metadiaphyseal comminution
D. Associated soft-tissue injuries MCL, ACL, etc.
A preoperative plan should address these factors and helps ensure that proper implants, reduction tools, bone
graft or bone graft substitutes, and fluoroscopic equipment are available for the surgical procedure.
The surgical tactic begins by analyzing the location of the major metaphyseal fracture fragments as well as
location of articular impaction. Specifically, the condylar fracture area identifies the “apex” exit point as the
primary determining factor where fixation hardware should be placed. Buttress and antiglide plates must be
centered over these apices’ to maintain the reduction and avoid late condylar displacement. This assessment
determines the placement and location of the surgical incisions. This may require posteromedial, direct posterior,
or posterolateral surgical approaches, in addition to the more common anterolateral and medial approaches. This
gives the surgeon 360-degree access to the entire proximal tibia.
The majority of plateau fractures involve the lateral condylar surface (lateral column), and an anterolateral
parapatellar incision is used. The length of incision depends on the specific fracture pattern and varies from
patient to patient.
With medial condyle and combined column fracture patterns, the preoperative CT scan determines the need and
location of a second incision (Schatzker IV, V, VI). Occasionally with a posterior column injury
(“fracturedislocation of the medial condyle”) (4), the apex of the fracture line is oriented directly posteriorly, which
requires a direct posterior approach for exposure and fixation (14,15).
Equipment requirements for most patients should include small fragment plates and screws (3.5/2.7 mm) as well
as proximal tibial precontoured plates. These are useful because they have a low profile and anatomically match
the proximal tibial. However, in very large or obese patients and those with substantial comminution, 4.5/5.0-mm
implants should be available (16).
In depressed fractures that require articular reduction but have minimal condylar displacement, an anatomic
precontoured nonlocking buttress plate is indicated, assuming that the bone quality is adequate. Bone on bone
apposition of the condyle provides an inherent buttress and resists axial displacement. A locking plate is not
required in length-stable fracture patterns.
Precontoured locking plates offer potential advantages in certain fracture patterns including increased holding
power in osteopenic bone, the ability to successfully bridge severely comminuted metadiaphyseal areas, and
most importantly prevent unwanted cantilever loading. Most preshaped plating systems allow for the use of both
locking and nonlocking screws.
A step-by-step written problem list with a simple drawing outlining the reduction and fixation tactic is very helpful
for residents and less experienced surgeons. This simple exercise summarizes the exposure, hardware
requirements, and fixation strategy PRIOR to the actual event, and facilitates the case by doing the surgery on
paper first.
A full complement of fracture-specific reduction clamps is necessary as these are designed specifically to apply
linear compression to both condyles. A femoral distractor and/or external fixator components should be available
to provide consistent ligamentotaxis throughout the case.
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SURGERY
Positioning
Unless there is a medical contraindication to general anesthesia, this is our anesthetic technique of choice.
General anesthesia provides more consistent muscle relaxation and facilitates better patient control when the
patient is positioned in a prone position. Additionally, it avoids masking an evolving compartment syndrome that
has been reported when long-acting regional anesthesia is used. Following the induction of anesthesia, the
patient is positioned either supine or prone, depending on the location of the fracture. I prefer a radiolucent
operating table with the involved leg elevated on a bean bag positioner (Fig. 27.7A). Once the patient is draped,
multiple sterile bolsters can be used to further flex the knee if necessary. Some surgeons prefer a table that can
“break” so that the knee can be flexed (Fig. 27.7B).
For some fractures, the patient is positioned in a “floating position,” with the patient primarily in a modified medial
or lateral decubitus position to allow for an initial anterolateral or posteromedial approach. By rotating the leg, a
second posterolateral or modified posterior incision can be accomplished (13) (Fig. 27.7C). The advantage of the
bean bag for use with the “floating position” is that once the initial procedure has been completed, the bean bag
can be deflated, and the leg rotated to accommodate a secondary approach.

Skin Prep and Drape

A tourniquet is placed on the upper thigh with a steridrape at the tourniquet margin (Fig. 27.7C). The limb is
prepped from toes to tourniquet. For more extensive approaches, the limb is prepped from toes to umbilicus, and
a sterile tourniquet is placed on the upper thigh.
The tourniquet is inflated for the primary exposure. Once completed, the tourniquet is deflated and hemostasis
achieved. The majority of the fixation and the bulk of the case is then performed without tourniquet control.

Imaging
The C-arm image intensifier should be brought in from the contralateral side. Preliminary images should be
obtained prior to prepping and draping to ensure that high-quality AP, lateral, and oblique fluoroscopic images
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are easy to obtain without interference from the table. The entire extremity is then prepped and draped as noted
above (Fig. 27.7A).
FIGURE 27.7 A. The patient is positioned supine on a radiolucent table with entire extremity elevated on a bean
bag positioner that allows flexion of the knee. A tourniquet is placed on the upper thigh and draped off with a
steridrape. B. Once prepped and draped the knee can be extended and elevated off the table surface as well as
fully flexed with the use of sterile bumps.
FIGURE 27.7 (Continued) C. Demonstration of a patient in a “floating lateral” position. The patient is positioned
on a bean bag in the lateral position to perform a posterolateral approach. The entire table can be rotated to the
patient’s right to facilitate this posterior exposure. D. Following the posterior exposure, the beanbag can be
deflated, and the patient rotated to his left to perform an anterolateral exposure.
FIGURE 27.7 (Continued) E. The ability to achieve 360-degree fluoroscopic visualization is mandatory by
elevating the limb with two sterile bolsters. The C-arm is positioned on the opposite side of the extremity. The
knee is elevated with a sterile bolster to obtain a lateral x-ray.

Reduction and Fixation of Specific Fracture Types

In order to successfully treat complex high-energy Schatzker IV, V, and VI injuries (multicolumn), it is helpful to
understand and gain experience treating lower-energy type I, II, and III (single column) fractures. The principals
of treating low-energy (single column) injuries are then brought together to treat the higher-energy complex
fractures by combining the individual exposures as well as fixation strategies specific to each fracture type
(column).

Lateral Column Injuries

Current concepts in treating low-energy lateral tibial plateau fractures are based on the ability to achieve a
congruent articular surface through a limited surgical exposure and fixation of the condyle. For most lateral
column injuries, Schatzker type I or II fractures, nonlocking plates are usually sufficient in normal healthy bone.
With comminution or significant osteoporosis, a locking plate is indicated.

Schatzker I/Isolated Lateral Column Fractures

Split condylar fractures (Schatzker I) without comminution can often be reduced and fixed with percutaneous
cannulated lag screws alone (17) (Fig. 27.8A). It is helpful to obtain a preoperative MRI to rule out a lateral
meniscus tear. If the meniscus is intact, it may be possible to perform a closed reduction and percutaneous
fixation with 3.5- or 4.5-mm conventional or cannulated screws (17). Reduction is achieved with longitudinal
traction and a varus force. Alternatively, a laterally based femoral distractor can assist with the reduction. If the
preoperative MRI demonstrates a peripheral meniscal tear or incarceration of the meniscus within the fracture
site, or if closed reduction fails to adequately reduce the fracture, an open reduction is indicated. When an
acceptable reduction is obtained, the fracture is compressed with large pointed forceps placed percutaneously
on the medial and lateral tibial condyles (Fig. 27.8B). Screw fixation is done through small stab incisions laterally
(16). The orientation of these screws should be determined preoperatively based either on the MRI or CT scan.
Evaluation of the “apex” of the lateral condylar fragment distally should be based on the preoperative CT or MRI
scan (12). If the apex of the fracture fragment is comminuted precluding bone on bone stability following
reduction, a precontoured buttress or antiglide plate (nonlocking or locking) is necessary to maintain the
reduction rather than screw fixation alone.
Schatzker II/Lateral Column with Articular Impaction Fractures
These injuries involve both a lateral condyle fracture combined with varying degrees of articular surface
depression. Preoperative imaging studies are important to determine the degree and location of articular
impaction
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as well as the orientation of the apex of the condylar fracture line (Fig. 27.9). In most cases, the depression is
anterior or central and is best approached through the utility anterolateral incision. The length of the incision is
determined by the individual fracture pattern. The articular surface is visualized through a transverse
submeniscal arthrotomy with elevation of the meniscus using several small traction sutures or small angled
retractors (Fig. 27.10A). A varus stress applied to the knee improves visualization.

FIGURE 27.8 A. A lateral column fracture without articular impaction also known as a Schatzker type I tibial
plateau fracture. Reduction was accomplished with distraction, valgus stress, and a percutaneous reduction
clamp through a small incision to elevate the fracture and meniscus. B. Guide wires are advanced
percutaneously, followed by 3.5-mm cannulated screws. The lateral ligament complex is reattached with suture
anchors.

Flexing the knee also improves visualization of the articular surface by distracting the joint by the weight of the
leg. Alternatively, a laterally based femoral distractor can be used to enhance joint visualization through
sustained distraction. Impacted articular fragments can be reduced by two different techniques.
In the first method, the split in the condyle is wedged open like a book. The articular depression is directly
visualized, and using an impactor, elevator, osteotome, or dental pick inserted from below, the osteoarticular
fracture fragments are disimpacted and elevated (Fig. 27.10B,C). Once the osteochondral
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fragments have been repositioned and the joint is congruent, temporary Kirschner wires (K-wires) are used to
provisionally stabilize the articular reduction. The defect created after elevating the joint surface is filled with
bank bone graft or alloplastic calcium substitutes (18, 19 and 20). Following graft placement, the split condyle is
reduced and held with a large reduction forceps, and intraoperative fluoroscopy is used to assess the reduction
(Fig. 27.10C,D).

FIGURE 27.9 A lateral column injury with articular impaction (Schatzker type II). Comminution and impaction of
the lateral articular surface occur with a large wedge fracture of the lateral tibial condyle. The CT images
demonstrate the depth and orientation of the articular impaction as well as comminution of lateral wall and apex
(arrows). This information is important to help determine the length of incision and plate placement.

Fixation is achieved with a precontoured lateral tibial plateau plate with multiple “raft screws” supporting the joint
surface. The plate now functions as an intact lateral cortical support (lateral I-beam). The screws extending
across the subchondral region provide support for the reconstructed surface and should engage the intact
medial cortex (medial I-beam). This twin I beam rafter construct supports the elevated joint surface preventing
late subsidence (14) (Fig. 27.10C,D) (9,10). In the elderly or in patients with osteoporosis, a locked plate is
indicated to improve fixation and resist axial load. Following column reconstruction care should be taken to repair
the meniscotibial ligament and any peripheral meniscal tears that may be present.
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FIGURE 27.10 A. An anterolateral incision is used. It begins 1 to 2 cm proximal to the joint line in the midline and
is carried distally over Gerdy’s tubercle and gently angled toward the lateral border of the tibial crest. The
incision can be extended proximally or distally when needed. The fascia lata is split in line with the skin incision,
and the anterior compartment muscles are reflected off the proximal tibia. The retractor in the proximal aspect of
the wound spreads the fascia exposing the capsule and meniscal-tibial ligament. B. The fascia is retracted
anteriorly and posteriorly to expose the major fracture line and capsular structures. The meniscal-tibial ligament
is incised horizontally to visualize the joint. The sagittal plane lateral column fracture line has been defined. C.
The major column fracture line has been “gapped open” with a lamina spreader to visualize and gain access to
the impacted articular fragments. The depressed osteoarticular fracture fragments are elevated from below using
a curved impactor under direct vision. The meniscal-tibial ligament has been incised below the level of the lateral
meniscus. The tibial attachment of the ligament is preserved to facilitate repair of the lateral meniscus (green
suture). An elevator is inserted into the joint to palpate the articular reduction. Following articular reduction, the
lateral column fragment is reduced and held with a large reduction forceps and adjunctive K-wires.

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FIGURE 27.10 (continued) D. (a) Condylar reduction maintained with K-wire and large reduction clamp. (b) A
curved impactor has been inserted through a subcondylar window to elevate the articular surface. (c,d) Bone
graft substitute has been inserted into the void to provide additional stability to the elevated articular surface. A
K-wire has been inserted to maintain the joint reduction. (e,f) A precontoured plate is applied and held with a
reduction clamp. “Raft” screws are placed through the proximal portion of the plate, capturing the intact medial
cortex providing additional support for the elevated articular surface.

A second method of reduction reduces the condylar split fracture first particularly when it extends distally, and it
is held with large pointed reduction forceps (Figs. 27.10D and 27.11). The impacted articular surface is then
reduced indirectly. Multiple 2-mm drill holes are placed in the subcondylar flare distal to the impacted articular
fragments, and a 1-cm cortical window is created by connecting the drill holes with a small osteotome. The cortex
is impacted directly into the metaphysis using a small curved impactor. Under fluoroscopic control, the impactor
is positioned to engage the depressed osteochondral fragments from below. It is important to disimpact and
elevate the fracture fragments en masse by placing graft material continuously beneath the fracture fragments.
The pressure from the impactor is distributed over a larger surface area preventing fragmentation or splitting of
the articular surface. The joint surface is slowly elevated and visualized with fluoroscopy or directly through the
submeniscal exposure. Once the articular surface has been reduced, provisional K-wire fixation is used to
maintain the reduction. Depending on the size of the incision, a periarticular lateral plateau plate can be placed
directly on the tibia or passed in a submuscular fashion with the distal screws inserted through small
percutaneous incisions (Figs. 27.10D, 27.11, 27.12 and 27.13 and 27.15).
Following internal fixation, the meniscotibial ligament is repaired along with any meniscal pathology, and the
fascia is closed. The anterior compartment fascia may be “pie crusted” by making multiple small incisions that
mesh the fascia to allow closure and decrease pressure in the anterior compartment. A drain is inserted and the
incision closed in layers avoiding skin tension (Figs. 27.13 and 27.14).

Schatzker III/Zero-Column Fracture

This injury usually occurs in older patients with osteoporotic bone after a low-energy fall with a valgus stress.
The articular surface of the lateral plateau is impacted without an associated lateral column fracture.
Preoperative
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MRI or CT scans are helpful to precisely locate the area of impaction and its orientation. Additionally, the MRI is
helpful in identifying a peripheral meniscal tear or incarceration of the meniscus within the depressed articular
surface.
FIGURE 27.11 A. The impacted joint is visualized through the submeniscal arthrotomy. The fascia has been
reflected anteriorly (clamp) and posteriorly (forceps) to expose the condylar fragment. B. The lateral column
fracture is reduced and held with a large and small percutaneous reduction forceps. At the inferior apex of the
major columnar fracture line (black arrow), a 1-cm bone window has been created. C. A small cortical window is
removed, and a curved impactor is used to elevate the impacted articular surface from below. D. The
metaphyseal defect is filled with an alloplastic bone graft substitute. The surface is continuously elevated until
congruency is achieved under direct vision and fluoroscopy.

With increased sophistication of arthroscopic techniques, this is one of the few tibial plateau fractures that are
amenable to arthroscopically assisted reduction and fixation (21). The fracture can be treated through small
incisions using either an image intensifier or arthroscopic visualization of the articular surface (Fig. 27.16). A
limited lateral incision is made over the metaphyseal region of the lateral condyle, and a small metaphyseal
cortical window is made below the depressed articular fragments. The window must be of sufficient size to allow
elevation and grafting of the fragments while assessing the reduced surface from above or arthroscopically.
Once reduction of the joint is confirmed, the reduction is stabilized by percutaneous cancellous or cannulated
screws placed in a subchondral location (21,22).

Schatzker IV/Medial and Posterior Column Fractures

Fractures of the medial column are usually caused by high-energy trauma and are often associated with
neurovascular injuries and significant fracture displacement. They can occur with other injuries such as knee
dislocations; therefore, a high index of suspicion is necessary to avoid overlooking a limb-threatening injury.
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In a few fractures with minimal comminution or displacement, closed reduction can be attempted with large
reduction forceps. If an anatomic reduction can be achieved, fixation with multiple percutaneous screws is
usually sufficient. With more complex medial condylar injuries, screw fixation alone is contraindicated when the
intercondylar eminence is avulsed with the anterior cruciate ligament or if comminution medially precludes bone
on bone reduction at the “apex” (Fig. 27.17A) (2,23). The energy required to produce a displaced medial
condylar fracture is substantially higher than what is required to produce a lateral condyle fracture and usually
requires a buttress plate to resist the deforming (varus) forces (Fig. 27.17B) (2,3).
FIGURE 27.12 A precontoured plate is advanced in a submuscular fashion along the lateral condyle and shaft.
A. The plate is held in place with a large pointed forceps and/or temporary K-wires while screws are inserted. B,
C, D. Following application of fixation hardware, the meniscaltibial ligament (sutures) is repaired to the capsule.

FIGURE 27.13 The submeniscal arthrotomy is closed by suturing the meniscal-tibial ligament.
FIGURE 27.13 (Continued)

FIGURE 27.14 A. The fascia lata is closed over suction drains. B. The anterior compartment fascia has been
“pie crusted” to allow closure without tension. C,D. Skin closure.
FIGURE 27.15 Radiographs and CT scan 1 year following repair. The CT scan shows maintenance of articular
congruity with complete incorporation of bone graft. Solitary “raft” screws placed in a subchondral location
continue to support the articular surface. The screws are supported by the reconstructed lateral cortex and the
intact medial cortex. Note the healed MCL avulsion fracture from medial femoral condyle.

FIGURE 27.16 A. A zero-column injury (Schatzker type III). This injury involves impaction and comminution of the
lateral articular surface without a condylar split. The CT scan demonstrates a central impaction of the lateral
articular surface and preservation of the intact lateral condylar rim. This particular pattern is often amenable to
arthroscopic-assisted fixation. B. A subchondral window is produced using a cannulated drill with the guide wire
localized using arthroscopy or fluoroscopy.
FIGURE 27.16 (Continued) C. The articular surface is elevated using a bone impactor followed by
percutaneous raft screw fixation. D. Follow-up x-rays demonstrate a healed fracture.

Not infrequently, the articular comminution extends across the midline into the lateral column, which is common
with fracture dislocation patterns. If the lateral plateau (column) articular involvement requires reduction, a lateral
approach may be required as well (Fig. 27.4C). Preoperative CT scans are critical in determining the location of
the apex of the medial column fracture lines. The location may be variable with the “apex” directed posterior,
posteromedial, directly medial, or anteromedial. The location and orientation of the “apex” determine the medial
column surgical approach. Very few fractures are amenable to a standard medial parapatellar incision. In order to
limit the surgical exposure, a thorough understanding of the CT scan is imperative to localize the incision to
maximize reduction and fixation of the condylar fragment (23).
Fixation is accomplished with a small fragment buttress plate located at the apex of the medial condylar fracture
line (Fig. 27.18). In most isolated medial column fractures, the apex of the medial condyle is noncomminuted
allowing direct bone on bone apposition. In these circumstances, a nonlocking buttress plate or antiglide plate is
sufficient for stabilization, and locking plates are not usually necessary for the medial fixation (5,8,10). Precise
positioning of the plate at the apex of the fracture line minimizes varus collapse with weight bearing. When there
is an anteromedial fracture, the anterior pes anserine as well as the superficial portion of the medial collateral
ligament must be reflected in continuity posteriorly (Fig. 27.19). This avoids soft-tissue entrapment by the plate
(Figs. 27.18 and 27.20). Alternatively, if the apex of the fracture is located at the posteromedial corner, or slightly
posterior to the corner, the inferior margin of the pes can be reflected anteriorly. The fascia of the gastrocnemius
muscle is incised to allow a plate to be positioned directly on the posteromedial aspect of the tibia (Figs. 27.21
and 27.22A,B).
When the fracture “apex” is located posteriorly or posterolaterally, a direct exposure of the posterior column is
accomplished through a posterior approach. The patient is placed prone and exposure is achieved with an
incision placed along the posteromedial border of the proximal tibia (Fig. 27.23A). The fracture is exposed by
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elevation and lateral retraction of the medial gastrocnemius, soleus, and popliteus muscles. This provides direct
visualization of the majority of the posterior aspect of the proximal tibia and facilities reduction and application of
a posterior plate (22) (Fig. 27.23B,D). Alternatively, the patient can be placed in a “floating position,” which
allows the patients’ limb to be rotated into the prone position yet allows an anterolateral approach without
repositioning (Fig. 27.7) (13,23). A transverse posterior L-shaped incision begins at the center of the popliteus
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and turns distally at the medial corner of the popliteal fossa (Fig. 27.23A). To avoid injury to the neurovascular
bundle in the popliteal space, the dissection should progress from medial to lateral under the soleus and
popliteus muscles in the proximal region. Through this approach, the medial column can be visualized along the
medial edge of this incision (Fig. 27.23C). The interval between the pes anserine tendons and medial
gastrocnemius can be developed. The pes can be released as noted above and the plate positioned anterior to
the medial collateral ligament. If the pes and semimembranous have been released, they should be repaired with
nonabsorbable sutures after fracture fixation (Fig. 27.23E).

FIGURE 27.17 A. Radiographs and CT scan showing a medial column fracture dislocation. This fracture is often
associated with intercondylar comminution and fragmentation. Arrows indicate apex comminution. B. A high-
energy medial column fracture dislocation with apex comminution. There is involvement of the tibial spine and
eminence and distal shaft extension. This degree of instability requires a medial buttress plate.

FIGURE 27.18 A medial column injury with the fracture apex directly medially, just anterior to midline (arrows).
Following disimpaction, the reduction is accomplished with large reduction forceps and K-wires used as joysticks
to manipulate the fracture. A contoured buttress plate is positioned directly over the apex with lag screws through
the plate.

FIGURE 27.19 A. The medial column exposure is directed to the apex of the medial condyle fracture; in this
case, the apex is at just anterior to the posteromedial border of the tibia. B. The pes fascia is identified (forceps)
and incised in line with the skin incision exposing the pes complex.

FIGURE 27.19 (Continued) C. In this case, the apex of the fracture is directly inferior to the pes insertion. The
pes is tagged, incised (elevator and scalpel), and reflected inferiorly revealing the apex of medial column
fracture. D. Apex comminution and impaction of medial condyle are identified following pes reflection.

FIGURE 27.20 A. The fracture is disimpacted with small cobb elevator. B. Reduction is achieved with a large
reduction forceps and a smaller tenaculum. C. The plate is positioned directly at the apex of the condylar
fracture, bridging the area of comminution. D. Following plate application, the pes (green tagged suture) is
repaired.

FIGURE 27.21 A. Through a posteromedial incision, the inferior edge of the pes is identified, and the interval
between it and the medial gastrocnemius is developed. B. The apex of the fracture is localized and reduced.
C,D. A contoured plate is placed along the posteromedial condylar flare in an extraperiosteal fashion. Following
screw application, the pes is allowed to cover the plate, and the wound is closed.

While most of the posterior aspect of the proximal tibia can be visualized through the posteromedial approach,
access to the posterolateral corner of the knee is problematic. It is not easily accessed from the anterolateral
approach either. The fracture fragments are often just posterior to the fibular head and covered by iliotibial band,
lateral collateral ligament, as well as the popliteus muscle and tendon. Several authors have described a direct
posterolateral approach to this area with or without a fibular osteotomy (14,15,24,25). Whenever possible, an
approach avoiding a fibular osteotomy is preferable. When a posterolateral exposure is necessary, we use a
longer, more laterally based incision, which still allows a submeniscal arthrotomy and anterolateral fixation if
necessary. Surgery in the posterolateral corner of the knee always requires identification and protection of the
peroneal nerve. Dissection between the biceps femoris tendon and lateral head of the gastrocnemius is
developed, and the peroneal nerve is identified and protected. The popliteus muscle is retracted medially
exposing the lateral aspect of the soleus muscle as it attaches onto the tibia and proximal fibula. The soleus is
detached from proximal to distal exposing the posterolateral aspect of the plateau. Fixation is achieved with small
implants to buttress this region; however, distal extension of the exposure is not possible because of the
neurovascular bundle.
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Shatzker V, VI/Multiple Column Injuries
These complex plateau injuries are usually the result of high-energy forces that are often associated with
compromise to the surrounding soft tissues. A staged approach is now widely accepted as the preferred method
of treatment (8, 9 and 10,26). This consists of early application of bridging external fixation to restore length and
knee stability (Fig. 27.3A,B). Distraction CT or MRI scans provide detailed information about the articular injury,
the degree of comminution, and the orientation of the fracture lines. When the soft tissues have recovered,
definitive internal fixation can be performed. For some high-energy fracture patterns, surgery should be delayed
for 2 or 3 weeks to allow sufficient time for the soft tissues to recover (Fig. 27.16).
Column-specific techniques regarding surgical exposure and fixation are combined to treat these difficult
fractures. For some fractures, stabilization of both the medial and lateral column injuries, Schatzker V patterns
can be achieved through a lateral approach using a solitary locking plate (27,28). The indications for this method
of treatment are based on the preoperative evaluation of the CT scan following ligamentotaxis reduction after
external fixation.
If the medial column in a bicondylar fracture is adequately reduced and there is no “apex” comminution and bone
on bone apposition exists, the fracture is often amenable to fixation with a laterally based locked plate. If
however, the medial condyle cannot be reduced indirectly, or there is apex comminution, then a separate
surgical approach with independent fixation is necessary. This is typically the case with coronal plane
posteromedial fractures (Fig. 27.24).
Fractures involving both columns are frequently comminuted, and there may be dissociation of the shaft from the
metaphysis (Schatzker VI; Fig. 27.25A). Articular impaction can often be elevated using cortical windows placed
in the subcondylar regions either medially or laterally. Large percutaneously applied
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reduction forceps may reduce or improve the position of the intercondylar fracture lines. Cannulated or 3.5
cortical screws can be used to secure the intercondylar reduction after which the condyles must be attached to
the tibial shaft. Using one or two femoral distractors, limb length and alignment can be restored allowing
placement of a submuscular-locked plate. Locking plates are used to “bridge” the zone of comminution at the
metadiaphyseal junction (29). Virtually all proximal tibial locking plate systems have outriggers to place screws in
the distal portion of the plate through small percutaneous incisions (27). Remember that if the condylar fracture
fragments are not comminuted and the condyles are well reduced, the medial condyle can usually be controlled
with a laterally based locking plate. However, if the apex of the medial condyle is comminuted, then this fragment
requires independent support to prevent late varus deformity. A locking plate on the medial side of a bicondylar
fracture using unicortical locking screws can be helpful. Typically hardware from a laterally based plate interferes
with medial condylar fixation making medial fixation problematic. Unicortical locking screws placed into the medial
condyle may prevent hardware “gridlock.” Care should be taken to limit dissection through the second incision
and avoid development of large skin flaps (Fig. 27.25B-D).
FIGURE 27.22 A. A CT scan reveals a posterior column fracture, with the fracture apex just lateral to
posteromedial corner. A comminuted coronal split divides the column injury (white arrow). The skin incision is
oriented posteromedially to gain access to the posterior aspect of the plateau. The pes is identified (elevator),
tagged, and reflected anteriorly. The gastrocnemius is reflected posteriorly exposing a highly comminuted
column fracture.
FIGURE 27.22 (Continued) B. The coronal split in the medial column (red line) is reduced with a horizontal rim
plate to maintain articular integrity. A posterior buttress plate is required to maintain the column reduction.

Occasionally, fracture comminution or soft-tissue injury is so extensive that surgical incisions may be
contraindicated, and a fine wire ring fixator is indicated. In a small subgroup of patients, the soft tissues do not
recover sufficiently during the first month to tolerate open reduction and internal fixation. These patients are
better treated with small tensioned wire or hybrid external fixation techniques.

Pitfalls and Tricks

One of the most common errors in tibial plateau fracture surgery is not placing the plates directly at the apex of
their respective condylar fracture fragments. This is primarily due to poor preoperative planning with incorrect
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placement of the surgical incisions. Thus, if the apex is not directly visualized, it is impossible to place the plate in
the correct location leading to axial displacement and condylar collapse with the development of a varus
malunion.
FIGURE 27.23 A. Patient positioned prone or floating lateral position. An “L” shaped incision is marked on the
skin that will be utilized to gain access to the posterior column. B. Through a direct posterior approach, the
medial head of gastrocnemius is retracted laterally, exposing the soleus and postmedial border of the tibia. C.
The soleus muscle is incised along the medial border of the tibia and then retracted laterally with the popliteus,
exposing the proximal posterior aspect of the tibia. Reflecting the pes anteriorly will also allow access to the
medial column (suction attachment).
FIGURE 27.23 (Continued) D. CT and x-ray studies show posterior and medial column fractures with significant
articular impaction. The joint is elevated through a posterior approach, and a buttress plate is applied directly to
the posterior tibia. The medial column injury is buttressed with a small antiglide plate. Post-op CT scans
document the articular and column reductions. E. The location of plates posteriorly and posterior medially prior to
wound closure. Inverted “L” incision at followup.

Numerous fracture-specific reduction clamps are available and are useful to help reduce these complex injuries.
Large hemispherical reduction forceps can apply substantial compressive forces in a linear fashion improving
intercondylar reduction. Reduction of the condyles can be facilitated using small external fixation pins (4 or 5 mm
diameter) placed into the displaced condylar segment and used as joy sticks to help with the reduction. When
used in conjunction with a large reduction forceps, displaced condyles can often be reduced avoiding large
surgical incisions with further soft-tissue stripping (Fig. 27.26A,B).
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FIGURE 27.24 A high-energy medial and lateral column injury with significant lateral articular impaction. A
distraction CT scan shows restoration of the medial column (black and white arrows). In this situation, a single
laterally based locking plate is used following articular reduction and subchondral grafting. Final image (right
lower) demonstrates no varus or articular collapse at 1-year follow-up.

Adjunctive rim fixation is useful to maintain reduction in very proximal cortical “rim” fractures. Eccentric rim or
peripheral margin fractures can displace the cortex at the level of the subchondral bone. If the cortex is not
reconstituted, the elevated joint surface has no “rim” to support the elevation leading to a loss of height and
subsequent subsidence. Precontoured buttress plates do not typically extend this far proximally. A horizontally
oriented cortical substitution “rim” plate positioned on top of the cortical rim fracture can be helpful. The plate
serves to reestablishing an intact rim and allows the subchondral elevation to be maintained (Figs. 27.27 and
27.28).
Tibial tubercle fractures occasionally occur with high-energy tibial plateau fractures. Fixation may be a problem if
the posterior cortex is also fractured preventing lag screw fixation from front to back. In some fractures, the tibial
tubercle region may be the only available bone in which to anchor fixation hardware. Fixation of the tubercle
fragment can be accomplished with an anterior hook plate or unicortical locking plate. Both maintain fixation to
the tubercle via the hook or locking screws (Fig. 27.29). The plate extends distally allowing fixation to the intact
posterior cortex at a site distal to the posterior comminution (15).

Postoperative Management
Postoperatively, the limb is placed into a bulky Jones dressing from the toes to groin. A cephalosporin antibiotic
is administered for 24 to 48 hours after surgery for closed fractures. Antibiotic coverage for open fractures
consists of a cephalosporin and aminoglycoside antibiotic given for 48 hours after the most recent surgical
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procedure. Prolonged use of antibiotics in open fractures is contraindicated unless culture-specific wounds with
antibiotic sensitivities have been identified. The suction drain remains for at least 24 hours or until drainage is
<30 mm per 8-hour intervals.
If the soft-tissue envelope was not significantly damaged at the time of injury and the wound closure was without
tension, a continuous passive motion (CPM) machine can be utilized. However, there is no Level I or II studies
documenting significant clinical benefit in terms of improved range of motion with its use in patients with tibial
plateau fractures. Its value may be more in terms of post-op comfort by mobilizing the muscular compartments
and reducing postoperative swelling and intracapsular adhesions. If there is tension on the suture line, CPM is
delayed until the incision line has sealed and is without drainage. The bulky dressing is removed at 48 hours,
and the limb is placed into a hinged knee brace that allows gradual increase in range of motion. If a meniscal tear
was present and required repair, range of motion is usually limited for the first 2 to 3 weeks with
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flexion stops at 60 degrees. This protects the peripheral meniscal rim and allows it to heal prior to advancing the
full, unrestricted range of motion.

FIGURE 27.25 A. CT images show a two-column fracture, with a split in the displaced posteromedial column and
articular impaction and comminution of the lateral column. Immediate application of a temporary external fixator
provides a ligamentotaxis reduction with gross realignment. B. Posteromedial exposure with arthrotomy identifies
a split in the medial column (a). A posteriorly applied buttress plate stabilizes the medial column. The medial
collateral ligament (forceps) is avulsed (b). The MCL is reattached with a ligament screw/washer following
column fixation (c). The lateral fascia is pie crusted following lateral column plating and joint elevation (d). C. (top
row) A temporary reduction plate is applied to stabilize the lateral column while definitive medial column fixation
is accomplished. A temporary Schantz pin is inserted into medial condyle to manipulate and achieve reduction of
the articular injury as well as a small pointed reduction forceps to compress the articular fracture. A medial
column plate is positioned posteriorly. (bottom row) Unicortical locking screws placed into the medial column to
achieve stability without blocking a laterally based raft plate and screws. One-year follow-up demonstrates
maintenance of articular reduction and mechanical axis.

FIGURE 27.25 (Continued)

FIGURE 27.25 (Continued) D. Wound closure.

Physical therapy is initiated during the first week for quadriceps strengthening as well as gait training with
crutches or a walker, non-weight bearing. Patients are seen at 2 weeks for suture removal and at monthly
intervals thereafter. Once the wound is healed, active and active-assisted range of motion is initiated. The goal is
to achieve at least 90 degrees of knee flexion by the 4th week after surgery. Weight bearing up to 50% of body
weight is initiated at 6 to 8 weeks depending on radiographic evidence of fracture healing.
In lower-energy injuries, patients can bear full weight by 10 to 12 weeks. The patient and surgeon alike can
expect a good, functional outcome for low-energy single column injuries. In high-energy multiple column injuries,
weight bearing should be delayed for 12 weeks or longer. Most patients can expect to resume simple activities
between 4 to 6 months. Running and vigorous athletic activities may require 1 year of rehabilitation.
Because of comminution and soft-tissue compromise at the metaphyseal/diaphyseal junction in the multicolumn
injuries, this area is often slow to consolidate. If union is not progressing, bone grafting is recommended before
initiation of weight bearing. The timing of grafting is based on the status of the soft tissues. High-energy injuries
often take 12 to 18 months before patients are able to resume many daily activities. Functional outcome for these
injuries is guarded, and patients rarely resume high-level athletics. Functional range of motion with painless
ambulation, normal alignment of mechanical axis, and the assumption of daily activities should be the goal.

Complications
Infection Poorly timed surgical incisions through traumatized soft tissues with extensive soft-tissue
dissection often contribute to early wound breakdown and infection. Careful timing of surgery and spanning
fixation techniques can minimize these complications. If wound breakdown does occur, irrigation and
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débridement of all the devitalized skin, muscle, and bone is mandatory. If the wound can be closed without
tension, then closure over suction drains is recommended. If a deep infection with purulence is
encountered, the wound should be left open with a negative pressure dressing in place and then redébrided
in 48 hours. Once a culture-negative wound has been obtained, secondary wound closure should be
accomplished. In most cases, especially if a wound VAC system has been utilized, delayed primary closure
can be accomplished. However, in some cases, closure will require a lateral or medial gastrocnemius
rotational flap. Occasionally, free tissue transfer is necessary.
FIGURE 27.26 A. (top row) Distraction radiographs and CT scans demonstrate a three-column injury with
lateral column articular impaction. A Schantz pin is inserted into the medial condyle to act as “joy” stick to
manipulate the medial column. Reduction is maintained with large reduction forceps and K-wires. The
posteromedial column has been stabilized with a posterior plate using unicortical locking screws proximally
to avoid interference from laterally based raft screws. The lateral articular surface is reduced using an
impactor placed through the fracture site. B. One-year follow-up showing maintenance of the mechanical
axis and the articular reduction.

FIGURE 27.27 (top) Anterior cortical rim fracture in conjunction with a lateral column fracture. In order to
maintain peripheral anterior cortical integrity, a horizontal “rim” plate is applied to buttress this region.
(bottom) A lateral cortical blowout requiring a small 2.5-mm horizontal rim plate at level of lateral joint line.

Hardware should be retained if it provides stability at the fracture site. If the hardware is loose, it should be
removed and the limb stabilized with a joint spanning external fixator. This often results in compromised
knee function or even a knee fusion as severe intra-articular sepsis combined with instability results in rapid
chondrolysis with destruction of the knee joint.
Nonunion Aseptic nonunion occasionally occurs in multicolumn fractures, particularly at the
metaphyseal/diaphyseal junction. As noted, these should be bone grafted early and fixation revised or
augmented (3,9,10). Nonunion can occur with late collapse of the articular surface or varus deformities. If
the mechanical axis is affected, then a corrective osteotomy may be required (7). If the patient is older,
revision to a total knee arthroplasty may be appropriate.
Knee Stiffness Knee stiffness often occurs in severe fractures when range of motion has been delayed
 (3,9,10). Arthroscopic lysis of adhesions combined with gentle manipulation under anesthesia may be
helpful in these patients who failed to achieve 90 degrees of knee flexion in the first 4 weeks after surgery.
Heterotopic ossification rarely occurs in tibial plateau fractures but does occur more frequently with fracture
dislocations of
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the knee and in patients with head trauma. The heterotopic bone should be removed if it impairs knee
motion. CT scans may help delineate the orientation and location of heterotopic bone if surgery is required.

FIGURE 27.28 (top) CT images demonstrating a three-column injury, with a widely displaced coronal plane
fracture through the medial column (arrows) and articular depression with comminution of lateral column.
(bottom) A rim plate is used to reduce the medial articular surface and restore the medial cortical rim. A
posterior approach is used to reduce and fix the posterior column. A lateral raft plate is applied following
articular reduction. The screws in the medial plate are placed last to avoid screw impingement. A fibular
head screw is used to reduce a displaced fibular head fracture. Follow-up at 1 year shows maintenance of
the articular surface and mechanical axis.

Surgical removal of this ossification can be performed in concert with knee manipulations. Although results
are encouraging, patients usually end up with some degree of residual knee stiffness.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 34-year-old man was involved in a motorcycle accident sustaining multiple injuries including a closed fracture
dislocation of his left knee (Fig. 27.30A). Significant swelling and soft-tissue contusions were present, and
compartment pressure measurements documented a compartment syndrome. An emergent fourcompartment
fasciotomy was performed and a spanning external fixator applied. Postoperative CT scans demonstrated a
three-column injury. The posterior column injury included a posteromedial fracture with a coronal split of the
medial column. A lateral column injury was also present with minimal impaction of the lateral articular surface and
a small lateral column fracture (Fig. 27.30B). The overall metaphyseal and shaft reduction was accomplished
with the spanning frame. The fasciotomy wound was treated with negative pressure dressings with two interim
washouts and was eventually closed on postinjury day 10. Following soft-tissue recovery (17 days postinjury), a
posteromedial approach was used to expose the posterior column and the metaphyseal shaft dissociation. Using
percutaneous joysticks and large reduction forceps, the medial column and joint were reduced and held
temporarily with K-wires. This fracture was stabilized with a back to front lag screw placed through the posterior
column plate. The reconstructed posterior column was then
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attached to the medial shaft fracture using an extension of the medial incision and percutaneous screws distally
(Fig. 27.30C). The proximal aspect of a standard lateral approach was used to reduce the lateral column injury. A
small fragment lateral periarticular locking plate was inserted using a minimally invasive submuscular approach
and stabilized with a unicortical locking screws (Fig. 27.30D). The plate was held to the lateral shaft with
bicortical screws. Follow-up films excellent alignment with maintenance of joint congruency at 1-year follow-up.
The patient was able to resume most of his daily activities and continue his occupation as a truck driver.

FIGURE 27.29 (top) A two-column injury with detachment of tibial tubercle (white arrows). Comminution of
posterior cortex prohibits simple lag screw fixation. Unicortical locking screws provide purchase in tubercle
segment with a plate spanning distally to allow fixation into intact shaft (black arrow).

Outcomes
In general, if the principles outlined above are followed, the clinical outcomes are very good for most
plateau fracture patterns. Several studies indicate that articular incongruity after tibial plateau fractures,
particularly lateral plateau injuries, is well tolerated and that the amount of articular congruity has little effect
in determining outcomes. Articular reductions with up to 2 mm of residual displacement are compatible with
a good clinical outcome. In some instances of severe high-energy fractures, the articular surfaces are so
damaged that a perfect articular reduction is impossible.
In our experience, poor functional and clinical results occur only when a combination of factors is present: a
central depressed lateral condylar fragment with articular incongruity >10 mm; any moderate instability of
the knee, and varus malreduction of the medial condylar segment. All of these factors lead to a dynamic
deviation of the mechanical axis with weight bearing. Rapid progression of posttraumatic arthritis in follow-
up is seen in patients who have undergone meniscal resection and those with residual tilt of the tibial
plateau. Surprisingly,
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little association between residual articular step-off and progressive degenerative changes has been found
in long-term studies assuming the dynamic mechanical axis has been maintained with minimal knee
instability (3,5,6,9).
FIGURE 27.30 A. Injury films demonstrate a fracture dislocation of the left knee. Intraoperative traction
fluoroscopic views reveal comminution and depression of the articular surface as well as metadiaphyseal
extension. The spanning external fixator restores length and alignment. B. Distraction CT images reveal a
three-column injury with a coronal split in the medial column producing an anteromedial and posteromedial
column injuries. There is joint depression in the lateral column injury. C. (top) Posterior and medial column
fixation was approached through a posteromedial approach. A posterior plate was applied to the posterior
fragment and the medial column reduced and fixed through the same exposure. (bottom left) Medial
approach. (bottom right) Lateral approach was limited to the proximal one half of the marked incision.
FIGURE 27.30 (Continued)
 FIGURE 27.30 (Continued) D. (top) The lateral column was reduced and the articular impaction elevated
through a small lateral incision. A lateral locking plate was used to provide fixation and subchondral joint
support with an oblique “kickstand” locking screw. (bottom) At 18-month follow-up, there is good joint
congruity and alignment.

Articular incongruities appear to be well tolerated, and many other factors are more important in determining
outcome rather than articular step-off alone, joint stability, retention of the meniscus, and coronal alignment.
Thus, in high-energy fractures in which severe comminution may prevent an anatomic articular
reconstruction, emphasis should be placed on optimizing the overall joint congruity and restoring the sagittal
and coronal plane alignment.

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 28
Extra-Articular Proximal Tibial Fractures: Submuscular Locked
Plating
Mark A. Lee
Brad Yoo

INTRODUCTION
Extra-articular fractures of the proximal tibial metadiaphyseal region are uncommon injuries and are typically
extensions of tibial plateau fractures. These fractures are technically challenging to treat due to the short
proximal fragment and significant muscular deforming forces. In the AO/OTA classification, these fractures are
classified as 31 and are geographically localized within a trapezoidal shaped area, whose dimensions equal the
epiphyseal width at its widest point and narrow distally (Fig. 28.1). These fractures are usually the result of high-
energy trauma such as motorcycle or pedestrian motor vehicle accidents in younger patients and fragility
fractures in the elderly. With high-energy trauma, associated soft-tissue injuries are common, and with displaced
and comminuted fracture patterns, the popliteal artery or trifurcation is at risk.
The management of extra-articular fractures of the proximal tibia depends upon a combination of patient-and
surgeon-dependent factors. Some issues to consider are the extent of the soft-tissue injury, the fracture pattern,
significant medical comorbidities or concomitant injuries, as well as the surgeon's level of expertise and the
hospital's ability to care for critically injured patients. A patient with a minimally displaced isolated transverse
fracture should be considered separately from the multiply injured patient with an open comminuted proximal
tibial injury (Fig. 28.2A,B).

INDICATIONS AND CONTRAINDICATIONS

There are three absolute indications for surgery, which include an open fracture, a concomitant compartment
syndrome, and fractures associated with a vascular injury. Furthermore, there are several relative indications for
surgery and include residual angulation >5 degrees in the coronal plane and 7 degrees in the sagittal plane (1),
patients with an ipsilateral femoral patellar or ankle fracture, and multiply injured patients. Other indications for
surgery include patients that would not tolerate prolonged immobilization of the knee or ankle if treated
nonoperatively.
Contraindications to internal fixation of an extra-articular proximal tibia fracture include a compromised soft-tissue
envelope acutely in closed fractures or contaminated wounds in open fractures. In these cases, temporary
bridging external fixation followed by delayed internal fixation has been shown to decrease the rate of deep
infection (2). Additional contraindications include active infection in the extremity and a subgroup of patients with
severe medical comorbidities that preclude a surgical procedure.
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FIGURE 28.1 OTA classification of proximal tibial fractures
FIGURE 28.2 Proximal extra-articular fractures demonstrate extreme variability from high energy, highly
displaced (A) to lower energy, minimally displaced patterns (B).

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History and Physical Examination
In the cooperative patient, a detailed history may provide important information regarding the mechanism of
injury, and important medical comorbidities such as diabetes, cancer, or autoimmune diseases should be noted.
The patient's medication list should be examined for items such as anticoagulants or immunosuppressive agents.
A history of prior fracture or previous orthopedic interventions is also important in preoperative planning.
The evaluation of the injured patient begins with the advanced trauma life support protocols, which proceeds
systematically with airway management, cardiopulmonary resuscitation, and spine precautions. Once life-
threatening issues have been addressed, a secondary survey of the musculoskeletal system is completed.
Although this evaluation includes an assessment of the spine, pelvis, and all four extremities, only the evaluation
of the lower extremity will be discussed.
The patient is fully exposed, and a visual inspection of the limb for open wounds, limb deformity, and degree of
soft-tissue damage is performed. Pulses are palpated, with particular attention to asymmetry between sides. The
posterior cortex of the proximal tibia is in close proximity with the popliteal artery and tibioperoneal trunk, and
displaced fractures in this region may cause a laceration, thrombosis, or traction injury to these structures (Fig.
28.3). If pulses are absent or asymmetric, gross realignment of the limb with gentle traction frequently improves
perfusion. Measurement of an ankle-brachial index (ABI) provides a rapid, objective assessment of vascular
impairment. An ABI lower than 0.9 alerts the surgeon to a potential vascular injury (3). If further investigation of
the arterial supply is warranted, angiography or computed tomography (CT) angiography should be performed. A
detailed neurological examination should also be performed and documented.
High-energy proximal tibial fractures are associated with an increased risk of compartment syndrome. Hallmark
signs include pain out of proportion to the injury, pain with passive stretch of the muscles within the
compartment, and a tense swollen leg. In some instances, an assessment of the patient's pain is not possible
due to sedation, intoxication, or a head injury. In these circumstances, direct measurement of intracompartmental
pressures should be performed. A difference of 30 mm Hg between the measured compartment pressure and the
diastolic pressure (delta p) has been shown to correlate closely with the need for fasciotomy (4). Since muscle
damage occurs as early as 2 hours, prompt diagnosis and surgical intervention may prevent long-term functional
disability. Displaced fractures in the proximal tibia are associated with an increased rate of compartment
syndromes, since most of the lower legs muscle mass is located proximally (5).
Because of the subcutaneous location of the tibia, open fractures are common and require timely operative
débridement and irrigation (6). Sterile dressings and a long leg splint or knee immobilizer should be applied until
an operating room becomes available. Both tetanus toxoid and a first-generation cephalosporin are indicated,
with the addition of penicillin in grossly contaminated wounds to prevent a clostridial infection. When the soft
tissues have absorbed a high amount of kinetic injury following fracture, microvascular damage and leg swelling
rapidly occur. This often results in serious or hemorrhagic fracture blisters (7). Surgical intervention should
proceed only after the soft tissues have recovered, heralded by the appearance of fine skin wrinkles as well as
improved mobility of the skin over the deeper dermal layers. Surgical intervention prior to soft-tissue recovery
has been associated with higher rates of wound complications and deep sepsis (8).
FIGURE 28.3 An angiogram demonstrating partial occlusion of the popliteal artery at the level of the knee with
reconstitution of the tibioperoneal trunk distally.

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Imaging Studies
Orthogonal anteroposterior (AP) and lateral radiographs are the basis for fracture characterization. High-quality
x-rays should be obtained of the tibia-fibula as well as separate films centered over both the knee and ankle
joints. The clarity of the image is greatly enhanced when the overlying splint material is removed. Traction
radiographs can help elucidate fragment morphology, and the quality of reduction performed through indirect
means; however, this maneuver is painful in the conscious patient. CT scans may detect the presence of an
intra-articular fracture but give detailed information about fragment morphology. While the presence of
concomitant injury to intra-articular soft-tissue structures (ACL, PCL) has been described in high-energy proximal
tibia fracture variants, these are usually addressed on a delayed basis after fracture reduction and fixation.
Exceptions are injuries to the cruciate or collateral ligaments with large bony avulsions. Magnetic resonance
imaging scan may be helpful in some patients with rim avulsion fractures or fracture dislocations of the knee.

Surgical Timing
In patients with displaced proximal tibial fractures and an acceptable soft-tissue envelope, definitive internal
fixation within 24 to 48 hours is safe and effective. In patients with higher energy injuries with significant
softtissue swelling and blistering are admitted for further evaluation and treatment. Immediate internal fixation in
this group of patients is ill advised because of the risk of wound problems and deep sepsis. In these patients, if
the fracture is not comminuted and length stable, a long leg splint or knee immobilizer can be used as temporary
stabilization while waiting for soft-tissue recovery. When fine skin wrinkles return, soft-tissue swelling resolves,
and the skin is mobile on the deeper structures, surgery can be performed. In many patients, this takes several
weeks. On the other hand, in patients with fracture blisters or severe open wounds or the fracture is comminuted
and unstable, application of a bridging external fixation is indicated. A spanning external fixator is used to
maintain length and permit circumferential soft-tissue care.

Surgical Tactic
The size of the proximal segment and the amount and location of fracture comminution influence the type of
implant and the method of insertion. There are two internal fixation devices that can be utilized for definitive
treatment of an extra-articular tibial fracture and include plate osteosynthesis or an intramedullary nail. There are
advantages and disadvantages with each of these implants, and the use of one device over another varies
among surgeons as there is little level I or II evidence supporting a specific technique.
Intramedullary nailing of proximal tibial fractures is a technically difficult procedure (10). Standard tibial nailing
often leads to a malreduction in valgus with an anterior apex. Semiextended or suprapatellar approaches have
been used to improve fracture alignment but the impact of these techniques on the periarticular soft tissues and
articular cartilage is not clear. The use of blocking screws has also been shown to minimize deformities with
nailing proximal fractures. When using an intramedullary nail, modern implants that provide multiple proximal axial
fixation options are important.
In the past decade, anatomically designed periarticular plates have been developed specifically for the proximal
tibia. These plates combine the use of conventional and locking screws with the ability for submuscular
placement. The enlarged upper end of the plate allows multiple screws to be placed in the short proximal
segment. The plate remains extra-articular minimizing a potential source of postoperative knee pain (Figs.28.4
and 28.5). Plate length should be determined before surgery as part of the preoperative plan. For fractures with
significant comminution, long plates may be required, and these may not be part of the normal inventory. It is
important to use preoperative conventional or digital templating to ensure that the plate will achieve three to four
bicortical points of fixation distal to the fracture.

SURGICAL TECHNIQUE
Operating Room Setup
Preoperative planning and proper operating room setup improve the surgical procedure. The patient is
positioned supine on a fully radiolucent table. The fluoroscopy machine is placed on the side opposite of the
injury. A bump is placed under the ipsilateral hip to internally rotate the knee to a neutral position, and a
tourniquet
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is place on the thigh. The leg is prepped from tourniquet to toes (Fig. 28.6). Except for very simple fracture
patterns, fluoroscopic images of the contralateral tibia are obtained and saved as these radiographs are
important for verifying length and rotation on the injured side. In comminuted fracture patterns with
metadiaphyseal extension or in cases with bone loss, we routinely drape both extremities into the surgical field to
allow for intraoperative determination of limb length.

FIGURE 28.4 Some implants are contoured lower on the metaphyseal flare and are best suited for fractures with
larger proximal segments.
FIGURE 28.5 Fracture implants designed to fit closer to the joint line are better for small proximal fracture
segments, especially when there are articular fracture extensions.

FIGURE 28.6 The patient is placed supine with the leg draped free. The C-arm is placed on the opposite side of
the table.
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Common Intraoperative Challenges
Restoration of length and rotational reduction are challenging in comminuted fracture patterns. One simple
technique is to position a cautery cord along the anatomic axis of noninjured tibia and to apply clamps at easily
reproducible proximal and distal radiographic landmarks. The clamped cord segment is maintained on the sterile
field until provisional reduction of the injured tibia is completed (Figs. 28.3B and 28.7A,B). The clamp and cord
construct are then placed along the anatomic axis of the injured tibia and aligned against the previously utilized
radiographic landmarks to determine correct restoration of length.
The lateral radiograph is more accurate for determining length intraoperatively and eliminates differences related
to the amount of knee flexion seen on the AP image. Lateral imaging is critical to accurately judge fracture
reduction but is frequently obstructed by the uninjured leg with single leg draping. The use of an elevated
platform below the injured extremity allows for unimpeded lateral imaging and allows the extremity to remain
stable during provisional reduction attempts (Fig. 28.8A-C).

Anesthesia
For acute fractures, general anesthesia is preferred to provide maximal muscle relaxation for fracture reduction
and evaluate the postoperative neurovascular status. In the absence of other severe injuries, arterial lines and
central venous pressure monitoring are not required. A cephalosporin antibiotic is administrated within 30 to 45
minutes of the skin incision and continued for 24 hours in closed fractures and longer in open injuries.

SURGICAL APPROACHES
An anterolateral approach is utilized for plating of proximal tibia fractures. Gerdy's tubercle provides a
reproducible and easily palpable landmark for the surgical incision; even in obese or large patients. A curvilinear
incision of variable length is made just caudal to Gerdy's tubercle from a point just lateral to the patellar tendon
curving proximally and posteriorly toward the tip of the fibular head (Fig. 28.9). Care should be taken to avoid
developing superficial flaps as the subcutaneous tissue is typically thin in this region. The fascia is divided in line
with the skin incision, and a full thickness flap is developed. The dissection should remain anterior to the fibular
neck to avoid injury to the common peroneal nerve. The proximal fascial flap over Gerdy's tubercle can be
delicate, and care must be taken to maintain its integrity to ensure that it is adequate to cover the head of the
plate. Placement of several heavy sutures in each flap allows retraction during plate insertion and ultimately can
be used for side-to-side fascial closure (Fig. 28.10). When an open reduction
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and internal fixation is planned, the anterior compartment muscles are then carefully elevated off the tibial
condyle. With indirect reductions and submuscular plating, the insertion of the anterior tibialis muscle is lifted off
the flare of the tibia. A submuscular path along the lateral surface of the tibia is created using a long blunt-tipped
soft-tissue elevator.
FIGURE 28.7 A bovie cord is clamped along the anatomic axis of the tibia at reproducible points (A) and (B) to
recreate the length based on the noninjured leg tibia.

FIGURE 28.8 Elevating the extremity on a radiolucent platform (A) allows for unimpeded AP (B) and lateral (C)
imaging.
FIGURE 28.9 The skin incision is oblique and just below Gerdy's tubercle.

FIGURE 28.10 Placing heavy suture in fascial flaps keeps them from getting trapped under plate during passage
and simplifies closure over head of plate.

FIGURE 28.11 Grade IIIB open proximal tibial fracture

Fracture Reduction
The use of direct and indirect reduction techniques is determined by both the fracture level and the condition of
the soft tissues. In high-energy injuries, the soft-tissue envelope can be severely compromised with deep
contusion, degloving, and open wounds (Fig. 28.11) (9). Compared with extensile approaches required for
articular reconstruction in tibial plateau fractures, the approach for submuscular plate placement for extra-
articular fractures is less extensile.
With very proximal fractures, direct reduction can be achieved using classic open techniques from within the
surgical exposure (Fig. 28.10). Noncomminuted fracture patterns can often be reduced with large-pointed
reduction clamps (Fig. 28.12A,B) and, when strategically placed, allow unimpeded access for lateral plating.
Another reduction technique involves placing screws anteriorly in the proximal and distal fragments and then
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applying a pelvic reduction clamp to manipulate, reduce, and compress the fracture. In some patients, the
fracture can be reduced closed and stabilized provisionally with multiple percutaneous 1.6 or 2.0 mm wires prior
to definitive fixation (Fig. 28.13).

FIGURE 28.12 A,B. A standard pointed bone reduction clamp and be applied anteriorly to reduce the fracture.
FIGURE 28.13 Percutaneous smooth wires can be used to maintain the reduction during plate insertion.

Comminuted fracture patterns are more safely treated with indirect reduction techniques (11). While
kneespanning external fixation can provide some degree of reduction and restoration of length, sagittal plane
displacement is rarely restored with longitudinal traction alone (Fig. 28.14). The leg is positioned in extension to
decrease the deforming forces of the extensor mechanism. Under fluoroscopic control, a 5.0-mm external fixation
pin is inserted perpendicular to the medial surface of the tibia (Fig. 28.15A,B). This “joystick” provides excellent
sagittal plane control of the proximal fragment and easily corrects the apex anterior fracture
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deformity. An additional external fixation half pin is placed perpendicular to the first half pin from anterior to
posterior in the proximal fragment to provide frontal plane reduction when necessary (Fig. 28.16A-C). These pins
can then be connected to a pin placed distally in the shaft using pin to bar clamps in the standard external fixator
set to maintain the reduction during fixation (Fig. 28.17).
FIGURE 28.14 Anterior knee spanning external fixation frames can sometimes maintain reduction during plate
insertion.

FIGURE 28.15 A frontal plane half pin (A) can easily correct apex anterior deformity (B).

Fixation
Simple fracture patterns are uncommon and are seen more commonly in younger patients. With anatomic
reduction and stable internal fixation, uneventful healing usually occurs. Following direct or indirect reduction, the
plate is inserted on lateral side of the tibia, and its position is confirmed fluoroscopically. Temporary K-wire
fixation is used to maintain plate position. A large linear or round periarticular clamp is used to compress the
plate against the lateral surface of the proximal segment (Fig. 28.18). Alternatively, nonlocking or conical head
screws can be placed into the plate to pull the plate against the bone. These can later be exchanged for locking
screws if necessary. Once several points of proximal fixation are placed, noncomminuted fractures should be
compressed with an articulated tension device or a “push-pull screw” (Fig. 28.19A,B). In the shaft, three or four
bicortical screws are necessary. In patients with good bone quality, conventional cortical screws are appropriate.
In osteoporotic bone, locking screws may be helpful. Short plates are typically used with simple fracture patterns
in patients with good bone quality. However, in patients with poor bone quality, substantially longer plates are
necessary to reduce the risk of frontal plane pullout on the shaft screws. In patients with higher energy injuries
with soft-tissue compromise and comminuted fracture patterns, minimally invasive submuscular bridge plating is
recommended. Most current plate designs include an outrigger for guided shaft screw insertion. The sequence of
screw placements in a plate depends on the fracture pattern. For comminuted fracture patterns, an indirect
reduction technique is typically utilized to maintain an optimal biologic environment for healing. Plate length
should be two to three times the length of the zone of comminution. Following indirect reduction, the plate is
passed submuscularly beneath the anterior compartment. Fluoroscopic imaging is utilized in the AP and lateral
planes to ensure proper plate position and maintenance of reduction. Correct positioning is important to avoid
lateral prominence at Gerdy's tubercle. Most contoured anatomic plates fit the proximal lateral tibial surface well.
Once the plate is properly positioned, provisional K-wires are placed through the plate proximal and distally to
maintain its position. A periarticular clamp or nonlocking screws are utilized to compress the proximal part of the
plate firmly against the bone. Often, the fracture may angulate into a slight valgus deformity or translate away
from the plate. This deformity is corrected with placement of a long nonlocking cortical screw or a specialized pull
reduction tool (whirley-bird) to reduce the shaft segment back to the plate. A distal cortical screw is placed at the
end of the plate to ensure provisional fracture stability. At this point, AP and lateral radiographs are obtained
using fluoroscopy or with a portable plain radiograph to verify the reduction. If the reduction is adequate,
additional locking screws are placed into the proximal fragment and conventional or locking screws distally. For
long-bridging fixation constructs, three to four well-spaced bicortical screws are necessary (Fig. 28.20A-F).
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FIGURE 28.16 A medial half pin (A) can control varus and valgus position (B) and (C) of the proximal fracture
fragment.

FIGURE 28.17 Half pins used for reduction can be connected to a temporary fixation frame.
FIGURE 28.18 A large periarticular or linear clamp is used to compress the head of the plate to the bone.

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FIGURE 28.19 A,B. External tensioning devices can be used to compress simple fracture patterns.

Another method of indirect reduction is using a push/pull technique. The plate is inserted submuscularly and
fixed to the proximal fragment as described previously. One or two nonlocking screws are placed in the head of
the plate to hold its position but allow for manipulation in the frontal plane. Length is restored using manual
longitudinal traction. Distally, the plate is aligned with the shaft of the tibia through a 4- to 8-cm open incision that
exposes the most distal part of the plate. K-wires or a reduction clamp can be used to maintain the sagittal plane
position. An articulated tensioning device or “push-pull screw” inserted distal to the plate is used to restore
correct length. Radiographic verification of alignment is then performed. A 5.0-mm medial Schanz pin allows for
some frontal plane manipulation and deformity correction. Once the reduction has been achieved, locking screws
can be placed proximally and distally to maintain the alignment.

POSTOPERATIVE MANAGEMENT
The incisions are closed in layers, and a posterior splint is used to maintain the foot in neutral dorsiflexion for a
few days. Weight bearing is based on bone quality and fracture configuration. In patients with good bone quality
and very stable fixation, partial weight bearing is allowed during the first 6 weeks following surgery and is then
progressed. In patients with long bridging constructs and limited bony contact must remain non-weight bearing
for 6 to 12 weeks. Weight bearing is progressed based on clinical examination and signs of radiographic healing.
Early active and passive range of knee motion is started on the first or second postoperative under the direction
of a physical therapist. While there is little evidence that continuous passive motion machines have long-lasting
benefit, selected patients with head injuries or multiple trauma may benefit from its use. Patients are seen in the
clinic at 2 weeks and their sutures removed. Clinical and radiographic follow-up is done at 4, 8, and 12 weeks.
Patients with complex fracture patterns are followed until there is complete fracture healing, which can take up to
a year.
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FIGURE 28.20 A high-energy proximal tibia fracture (A,B) is initially spanned (C). Indirect reduction is performed
with longitudinal traction (D) and then medial half pin to correct residual varus (E). Final construct is long plate
with multiple bicortical shaft screws (F).

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FIGURE 28.20 (Continued)

COMPLICATIONS
As with every surgical procedure, complications may occur following operative intervention. Common
complications include infection, delayed union or nonunion, and hardware prominence. Superficial and deep
sepsis may be difficult to differentiate clinically. The question is whether the hardware and fracture site are
involved. Acute superficial infections may be treated with local wound care and antibiotics for 2 weeks.
Close clinical monitoring is imperative to ensure that the pharmacologic intervention is effective. Deep
infections require operative irrigation and débridement, with deep microbial cultures and appropriate
intravenous antibiotics. If the hardware is stable, it should be retained. If the hardware is loose, it should be
removed. Screws without torsional resistance when tightened should be removed. Vancomycin- and
tobramycin-impregnated methylmethacrylate beads can be effective to obliterate dead space and provide
high local antibiotic concentration when bone has been resected. Long-term systemic antibiotics are tailored
based on intraoperative cultures. The erythrocyte sedimentation rate, C-reactive protein, and white blood
cell counts are used to follow the response to treatment. Once the antibiotic course is complete and the
serologic parameters have returned to normal revision, internal fixation may be indicated.
Knee arthrofibrosis is another common complication following treatment proximal tibia fractures. This
complication can be usually avoided by early supervised range of knee motion. If physical therapy fails to
improve knee motion, a manipulation under anesthesia with or without arthroscopy should be performed. A
small number of patients with persistent stiffness may benefit from a quadricepsplasty.
Loss of fracture reduction is uncommon with good surgical techniques. If it occurs in the early postoperative
period, the original fracture construct may have been inadequate. A history of noncompliance with the
weight-bearing precautions may also be a contributing factor. Infection should always be considered as a
causative factor and treated accordingly. A CT evaluation may aid in preoperative planning and help
determine the feasibility of revision fixation. Other modalities such as intramedullary fixation, fine-wire
fixation, or even cast treatment should be considered.
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Fracture malunion occurs along a wide spectrum. Minor degree of malalignment may be clinically
acceptable to the patient and require no further care. Symptomatic malunions often require operative
correction. Corrective osteotomies along the original fracture line will correct simple malunions. More
complex deformities are often associated with limb shortening and soft-tissue contractures. In these cases,
a circular fine wire distraction frame may be required for correction.
Fracture nonunion can occur due to infection, insufficient fracture stability, or a biologically deficient fracture
environment. A fracture construct that is too flexible and allows too much fracture motion usually results in a
hypertrophic nonunion. Treatment involves improving the stability of the fracture by revision internal fixation.
When the construct is too stiff, an atrophic nonunion with resorption at the fracture site may occur. These
are best treated by compression of the nonunion, stable internal fixation, and autogenous bone grafts.

OUTCOMES
A recent metaanalysis of outcomes following surgical treatment of extra-articular proximal tibia fractures has
an estimated complication rate between 8% and 23% (12). These authors recommended cautious
interpretation of these heterogeneous results. The majority of studies included were retrospective case
series with relatively small number of patients.
The estimated rate of malunion has been reported to be as high as 10% (11, 12, 13 and 14). Similarly, the
rate of nonunion has been cited to be 0.3% to 8% (12). Three publications on the use of locked plates for
proximal tibia fractures reported two nonunions in a total of 154 patients (11,13,14). Both of these
nonunions occurred in high-energy open fractures, but their precise fracture pattern is unknown (articular
vs. nonarticular pattern).
Injury to the superficial peroneal nerve has been documented with lateral plating of proximal tibial fractures
with long plates. The superficial peroneal nerve exits the crural fascia approximately 12.5 cm proximal to the
ankle joint. Screws inserted percutaneously in the distal leg may injure the superficial peroneal nerve at this
location. For the less invasive stabilization system plate (Synthes, Paoli, PA), screws inserted in the distal
portion of 13-hole plates are particularly prone to nerve injury. For patients of short stature, the nine-hole
plate has also been associated with this complication (15). To avoid iatrogenic nerve injury, it is
recommended that distal screws are inserted with a formal open incision, directly visualizing the recipient
screw hole as the screw in inserted.
Hardware prominence is a frequent cause of reoperation. This is particularly relevant for locking plates,
where construct stability is not reliant upon an intimate plate bone interface. The added thickness of the
proximal section of locking proximal tibial plates has the potential for iliotibial band irritation. Plate-induced
irritation is particularly bothersome with knee flexion (11,13,16, 17 and 18). Implant removal rates between
5% and 8% have been reported (13,16,19). By way of comparison, intramedullary devices used for
treatment of proximal tibia fractures had a 30% reduction in the rate of hardware removal compared with
lateral locked implants (19). Numerous reports have documented the difficulty of locked plate removal,
especially with titanium implants (18). Although the implants are inserted percutaneously, it is often
impossible to remove the plate in a similar fashion because of cold welding or stripping of the screws, which
significantly increased operative time for removal (18,20,21). If the screws cannot be removed, then a high-
speed carbide-tipped burr may be used to cut the plate around the stripped screws, which in turn may be
removed with pliers. Metal debris generated during this process adheres intimately with the soft tissues and
should be carefully removed at the conclusion of the procedure.
 Unfortunately, outcomes data following locked plating of extra-articular fractures of the proximal tibia is
embedded within studies that include both intra-articular and extra-articular fractures. Taken together,
postoperative range of knee motion averaged 122 degrees (11,13,14). In one study, the average Lysholm
knee score was 90 (range, 53 to 100). Poor outcomes were associated with ligamentous instability (11).
The average lower extremity measure score was 88 (range, 55 to 100), indicating that patients were
community ambulator's or better. Low scores were attributed to worker's compensation claims (14).

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2. Barei DP, et al. Complications associated with internal fixation of high-energy bicondylar tibial plateau
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6. Burgess AR, et al. Pedestrian tibial injuries. J Trauma 1987;27(6):596-601.

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9. Egol KA, et al. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a
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12. Bhandari M, et al. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma
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15. Deangelis JP, Deangelis NA, Anderson R. Anatomy of the superficial peroneal nerve in relation to fixation
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16. Boldin C, et al. Three-year results of proximal tibia fractures treated with the LISS. Clin Orthop Relat Res
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17. Phisitkul P, et al. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop
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Tibial Shaft Fractures: Intramedullary Nailing
Daniel S. Horwitz
Erik Noble Kubiak

INTRODUCTION
Tibial shaft fractures encompass a spectrum of injuries ranging from low-energy closed fractures to limb-
threatening open fractures. Intramedullary nailing is the treatment of choice for most displaced fractures in the
middle three-fifths of the tibia. Contemporary tibial nailing is performed with minimal medullary reaming using
cannulated locking nails for both closed and open fractures. Recent prospective studies have shown that
reaming is not associated with a statistically significant increase in infection rates for most open fractures (1, 2
and 3). Solid nails have largely been abandoned due to their inability to reduce the infection rate and difficulty
with insertion and removal.
The favorable mechanical and biologic characteristics of intramedullary nails as well as advances in nail design
have expanded the indications for nailing to include more proximal and distal tibial fractures. However, nailing of
proximal tibial fractures with conventional entry portals often leads to angular deformities. To minimize
malalignment following nailing, both a change in the approach (infrapatellar vs. suprapatellar) and the position of
the leg (flexed or extended) is required. Another recent technical advance in nailing is the introduction of angular
stable locking bolts or screws. This may improve stability following nailing in very proximal or distal fractures,
particularly in osteoporotic bone.
There are several widely used classifications for tibial fractures. The Gustillo and Andersen, as well as the
Tscherne classifications, are used to describe soft-tissue injury patterns associated with both closed and open
tibial fractures. The AO/OTA fracture classification of tibia fractures is a morphologic or geometric tool to
describe the location and pattern of bony injury (Fig. 29.1).

INDICATIONS AND CONTRAINDICATIONS

Numerous studies have shown satisfactory rates of healing and earlier weight bearing compared to other fixation
techniques when using an intramedullary nail. However, the advantages with this method of treatment must be
carefully weighed against the risks unique to tibial nailing such as chronic knee pain and infection.
Contraindications to nailing include patients who have isolated low-energy fractures with minimal shortening,
displacement, or angulation that can be treated in a cast. Sarmiento and others have shown that shortening up
to 12 mm and angulation up to 5 degrees in the frontal plane and 7 degrees in the sagittal plane are associated
with good outcomes following functional bracing (4,5). Nonoperative treatment of high-energy fractures with
substantial shortening, displacement, and angulation, particularly when there is associated soft-tissue injury,
makes cast or brace treatment inadvisable. Nailing is also contraindicated in young adolescents with open
epiphysis and in adults with very small medullary canals (<7 mm). The use of intramedullary nails in patients with
infected fractures and nonunions is controversial, and alternative fixation techniques are often more appropriate
in these patients.
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FIGURE 29.1 OTA classification for tibial shaft fractures.

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FIGURE 29.1 (Continued)

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FIGURE 29.1 (Continued)

Strong indications for intramedullary nailing include closed or open, displaced, and/or unstable fractures in the
middle three-fifths of the tibia that are not amenable to cast or brace treatment. Some tibial fractures with an
intact fibula can be difficult to reduce and hold in a cast and are better treated with an intramedullary nail. Other
strong indications for nailing are tibial fractures with complex ipsilateral injuries to the foot, ankle, knee, or femur.
Multiply injured patients with contralateral limb injuries and selected patients with pelvic, spine, and upper
extremity fractures usually benefit from surgical stabilization to improve mobilization of the patient and
rehabilitation of their limb. Relative indications for nailing include tibial fractures associated with compartment
syndromes or vascular injuries. In these cases, damage control orthopedics with initial external fixation followed
by delayed nailing may be preferable.
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The safety and efficacy of acute nailing of open tibial fractures has been evaluated in multiple prospective
studies (1, 2 and 3,6). Randomized controlled trials have not shown a statistically increased risk of infection
following acute primary nailing in these fractures. However, external fixation may be preferred in patients with
gross contamination, massive soft-tissue injury, extensive bone loss, or critically ill patients. In these challenging
cases, delayed nailing or conversion to circular ring external fixation may be preferable.
While there have been several reports of intramedullary nailing of proximal tibia fractures (i.e., 4 to 6 cm from the
joint), this remains a controversial topic (7,8). Specific reduction and nailing techniques are necessary in these
cases to avoid malalignment or fracture instability. Unless a surgeon is familiar with the use of blocking screws,
unicortical plating, and semiextended nailing methods, the use of a lateral locked plate should be considered. In
some comminuted fracture patterns, nailing and supplemental medial plating may be indicated.
A similar thought process can be applied to very distal tibial shaft fractures when there is room for only a single
distal interlocking screw. Unless the fracture is a simple pattern, and the fibula is either intact or can be axially
stabilized, strong consideration should be given to the use of distal tibial anatomic plating.

PREOPERATIVE PLANNING
History and Physical Examination
Preoperative planning begins with a careful evaluation of the patient. A complete evaluation should include the
Advanced Trauma Life Support protocols, obtaining a careful patient history and performing a detailed physical
exam. The physical exam must evaluate and document the neurovascular status of the affected limb, the status
of the compartments, and evaluation of active and passive toe motion. The soft-tissue envelope should be
inspected for contusions, blisters, or open wounds. It is important to remember that a compartment syndrome is a
clinical diagnosis, and pressure measurements are used primarily in borderline or questionable cases, and/or in
patients with head injuries or cognitive impairment secondary to drugs or alcohol. Following a detailed
assessment of the patient and his injury, the leg should be placed into a well-padded long leg splint prior to
definitive management.

Imaging Studies
Radiographs must include full-length anteroposterior (AP) and lateral views of the affected tibia, and AP and
lateral x-rays of the ipsilateral knee and ankle. Computed tomography (CT) scans of the knee or the ankle should
be obtained when there is an intra-articular fracture extension or high index of suspicion of joint involvement
based on the mechanism of injury or physical examination (Fig. 29.2).

TIMING OF SURGERY
Open Fracture Management
With open tibial fractures, high-dose intravenous antibiotics should be administered early. In Grade I, II, and IIIA
open fractures, a cephalosporin antibiotic is given for 24 to 48 hours, and an aminoglycoside is added in Grade
IIIB injuries. With farm injuries, penicillin is also administered. Tetanus toxoid should be given to all patients with
an open tibial fracture.
The timing of operative treatment for open tibia fractures remains controversial. Whenever possible, surgical
débridement should be done within 6 to 8 hours from the time of injury to lessen the risk of infection (9,10).
Grossly contaminated wounds are irrigated in the emergency department if delays in treatment are anticipated.
Patients with open fractures that are physiologically stable and have no other contraindications to surgery can be
safely nailed immediately following irrigation and débridement. Small clean wounds (<5 cm) are closed primarily,
if this can be done without tension. Larger wounds are packed open, closed over a bead pouch, or covered with
a wound vac. When there is deficient soft tissues, exposed hardware, or bone, microvascular surgery
consultation is obtained. Rotational flaps or a free tissue transfer may be necessary.

Closed Fracture Management

Isolated closed unstable tibial shaft fractures should be splinted and have their tibia nailed within 24 to 48 hours
whenever possible. In multiply injured patients, surgery is performed when the patient’s overall condition permits.

Surgical Tactics
The surgical setup includes a complete set of tibial nails and insertion equipment, medium and large-pointed
reduction clamps, a large femoral distractor or external fixation tray, and small fragment screws. The small
fragment set is useful to stabilize intra-articular extensions or when a unicortical plate or blocking screws are
needed. Radiolucent triangles of different sizes are very helpful when performing classic medial or lateral patellar
nailing with the knee flexed. The triangles also help reduce axial load and deforming forces on the tibial shaft
itself, making reduction easier to maintain.
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FIGURE 29.2 The preoperative lateral view of the distal tibia (A) raises suspicion of a posterior malleolus
fracture that was confirmed by a CT scan (B). This was addressed by placing an anterior-to-posterior small
fragment screw prior to reaming and nailing (C). If this fracture component is missed, it may displace during nail
placement.

SURGERY
Anesthesia
We strongly recommend general anesthesia when treating patients with acute tibial fractures. It allows full-
muscle paralysis for fracture reduction and allows careful postoperative monitoring for compartment syndrome.
While spinal and regional anesthetic techniques are attractive for postoperative pain control, the small but real
risk of masking a compartment syndrome makes this less appealing.
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Positioning
Patients are placed supine on a radiolucent table that provides wide access for an image intensifier that is
typically brought in from the opposite side. Fracture tables are rarely used when performing tibial nailing. A
“bump” is placed beneath the ipsilateral flank and hip to maintain the leg in a neutral position. The arm on the
affected side can be abducted on an arm board or placed and secured across the chest. A tourniquet is placed
proximally on the thigh if there is concern for intraoperative bleeding—usually related to vascular or soft-tissue
injuries.

Prep/Drape
Although a thigh tourniquet is routinely applied, it is not frequently inflated. It is useful in patients with a vascular
injury or significant bleeding associated with extensive soft-tissue injuries. We occasionally inflate the tourniquet
during the irrigation and débridement, but NEVER during intramedullary reaming or nailing. We use an initial
scrub with alcohol or chlorhexidine followed by an alcohol-based polymer product (Chloraprep/Duraprep). The
entire leg is prepped, and the toes are wrapped with an impervious sticky plastic drape and left visible in the
surgical field. Full access to the ankle and foot is essential to judge length, rotation, and alignment of the
extremity. When using an extended nailing technique, the calf is supported with sterile bath blankets or a foam
support beneath the drapes (Fig. 29.3).

Nail Selection
We strongly recommend cannulated tibial nails designed to be placed over a guide wire. The bend in the nail
should be very proximal rather than a long gradual curve, which can produce translational and angular
deformities especially in proximal fractures (Fig. 29.4). The nail should accommodate proximal and distal locking
screws that are at least 4 mm in diameter and are multiplanar. The ability to place locking screws in oblique
planes is especially helpful when stabilizing metadiaphyseal fractures. Newer nail designs allow placement of
angular stable (locked) screws, which may be desirable when treating metaphyseal fractures or fractures in
osteoporotic patients.

Approach
There are several surgical approaches utilized when performing intramedullary tibial nailing, each with distinct
advantages and disadvantages.

1. Medial tendon parapatellar. This is the most common starting point and is used for the majority of fractures in
the middle and distal thirds of the tibia. However, it can lead to valgus malalignment when used to treat
proximal tibial fractures.
2. Lateral tendon parapatellar. This approach aids in maintaining fracture reduction when nailing proximal one-
third of fractures but requires mobilization of the patellar tendon.
FIGURE 29.3 A foam support is used to facilitate the semiextended nailing technique. Note that the foam is
secured to the table with surgical tape to avoid intraoperative motion or loss of support.

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 FIGURE 29.4 Nails whose proximal bend is long and curved can produce anterior translation and extension
deformities when used to treat proximal tibial shaft fractures. For this reason, the authors prefer a more
proximal bend when nailing these proximal fractures.

3. Patellar tendon splitting. This gives direct access to starting point, but can inadvertently damage the patellar
tendon or lead to patella baja and is used less commonly.
4. Semiextended medial or lateral parapatellar. This approach is used to nail proximal tibial fractures.
Advantages include ease of positioning, imaging, and aid to fracture reduction.
5. Suprapatellar (transquadriceps tendon). This is an alternative approach for proximal tibial nailing but requires
special instruments. Inadvertent trochlear damage to the patella and femur is possible, and deposition of
reaming debris in knee is a concern.

STARTING POINT
We describe the two most commonly used approaches when nailing a tibial fracture: the medial parapatellar
tendon approach with the knee flexed (Fig. 29.5) and the lateral or medial parapatellar semiextended approach
(Fig. 29.6). Both approaches utilize a similar starting point for nail insertion, which has been described as the
“sweet spot,” referring to the flat extra-articular area just anterior to the joint and behind the patellar tendon (Fig.
29.7). This location has been well described in the literature (11) and is aligned with the lateral aspect of the
medial tibial spine on the AP radiograph and just below the articular margin on the lateral view. When a
parapatellar tendon approach is utilized, we prefer to remove soft tissues from the starting point using
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electrocautery in order to clearly visualize the entry portal. Great care should be taken to avoid entering the joint
or damaging the anterior aspects of the menisci. The starting point is localized and confirmed fluoroscopically
with either an awl or with a guide pin that can be enlarged with a cannulated drill or awl. Care must be taken to
avoid injury to the skin, meniscus, patella, and the cartilage of the femoral condyle during initial awl insertion and
instrumentation of the tibia.

FIGURE 29.5 A radiolucent triangle is used with the medial or lateral parapatellar approach. This allows the
surgeon to manipulate the tibial shaft, hold it with clamps, and obtain the correct starting point with minimal
assistance.

FIGURE 29.6 Intraoperative view of the parapatellar semiextended approach. In this case, a medial approach
was made. The synovium is preserved between the nail and the femoral condyle and can easily be inserted with
slight flexion of the knee.

For the medial parapatellar tendon approaches, a 3- to 4-cm skin incision is made between the inferior pole of
the patellar and the tibial tubercle along the medial border of the patellar tendon. The extensor retinaculum is
incised, and the sheath of the patellar tendon is identified, mobilized, and carefully preserved. The infrapatellar
fat pad is freed from the posterior surface of the tendon, which leads to the bare area just below the knee joint.
FIGURE 29.7 Lateral (A) and AP (B) views of the proximal tibia demonstrate the ideal starting point for a tibial
nail. This “sweet spot” is extra-articular, immediately behind the patellar tendon, on the anterior flat surface of the
tibia. Ideally, it should be slightly lateral to the central point of the tibial spine on the AP view. When nailing
proximal shaft fractures, this position should be carefully confirmed before entering the intramedullary space.

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The semiextended lateral or medial parapatellar approach utilizes a skin incision along the lateral or medial
border of the patella, extending from the superior pole of the patella to the upper third of the patellar tendon, with
the knee in relative extension (5 to 30-degree knee flexion). This approach can be made either medially or
laterally, based on the patient’s anatomy and which direction allows better access to the proximal tibia. For
example, if the patella naturally subluxes more easily to the medial side (more common), then the lateral
parapatellar approach is chosen. Through a 3- to 4-cm skin incision, the retinaculum and joint capsule are
opened to the level of the synovium, which should be kept intact. This allows the patella to be mobilized medially
or laterally without difficulty. The synovium is a thin layer and can be easily torn by insertion instruments or
reamers. If this occurs, it is carefully repaired with a 2-0 absorbable suture at the end of the case. The
retropatellar fat pad is freed from the posterior surface of the patellar tendon revealing the bare area of the
proximal tibia for nail entry. When using this approach, the bare area is palpated and visualized with fluoroscopy,
but is not generally visualized by the surgeon. When using the semiextended approach, the surgeon must be
vigilant to avoid anterior migration of the proximal starting point, intermeniscal ligament injury, and damage to the
articular surface of the knee during the approach, reaming, and instrumentation of the tibia.

FRACTURE REDUCTION
In our experience, the majority of tibial shaft fractures can be reduced closed with longitudinal traction and
correction of translational and angular deformities under general anesthesia. Unlike classic open reduction and
plating, the use of an intramedullary nail does not require a perfect anatomic reduction. It is predicated on the
concept of restoration of length, alignment, and rotation with stable fixation. For many fractures in the middle
one-third of the bone, the intramedullary nail is the ultimate indirect reduction tool! However, highly comminuted
fractures and those that are very proximal or distal often require adjunctive reduction techniques such as a
femoral distractor, percutaneously applied reduction clamps, blocking screws, unicortical plates, fibular fracture
fixation, and multiplanar locking screws.

CLAMP APPLICATION
Noncomminuted or minimally comminuted short oblique or spiral fractures, which do not reduce with traction
alone, can often be reduced with the application of percutaneous clamps. Understanding the three-dimensional
configuration of the fracture pattern and planning the skin incisions are the most difficult aspects of applying
percutaneous clamps (Fig. 29.8). The image intensifier is used to aid planning of the skin incision and clamp
application. A clamp has the greatest potential to reduce the fracture when it is placed perpendicular to the
fracture. Two or occasionally three clamps may be applied in spiral and oblique fractures, which allows for small
adjustments in length and rotation. However, care must be exercised to avoid injury to the soft tissues or
increasing fracture comminution. We prefer to initially reduce the fracture with traction or a distractor and use the
clamps to fine-tune the length and rotation.
Once the clamps have been applied and the reduction confirmed fluoroscopically, the clamps should be left in
place until the final locking screws have been inserted. Additionally, it is important to protect the skin from
prolonged compression beneath the clamps. Large bulky clamps should not be used to avoid damage to the
periosteum or soft tissues.

FEMORAL DISTRACTOR
The femoral distractor is the “tireless intern” of fracture reduction, and we employ it in length-unstable and
comminuted fractures as well as fractures in the metadiaphyseal regions of the tibia. The distractor is used to
maintain length, rotation, and alignment. Pins are placed medial to lateral in the proximal and distal tibia
metaphysis (Fig. 29.9). The proximal pin is placed 20 mm distal to the tibia articular surface, in line with the
posterior cortex of the tibia and parallel to the articular surface of the knee on the AP image of the knee (Fig.
29.10). The distal tibial pin is placed just proximal to the physeal scar, in line with the posterior cortex of the tibia
and parallel to the ankle joint as seen on the AP image. The fracture is slowly distracted until length is restored.
Fracture translation in the AP or lateral planes may be corrected manually or with percutaneous clamps. Valgus
or varus deformities can be corrected by releasing the distractor and making small adjustments at the Schanz pin
interface of the distractor. If a femoral distractor is not available, an external fixator can be used in the same
manner.
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FIGURE 29.8 The percutaneous application of clamps can significantly aid in reduction but this requires a
thorough understanding of the fracture planes. A complex spiral pattern may necessitate dual clamps (A) in order
to control and reduce the fracture, and when there is comminution present, the surgeon may choose to focus on
the major fracture plane only (B). Note the use of a distal fibular plate to assist with reduction of this comminuted
fracture and the confirmation of lateral reduction before seating the balled-tip guidewire (C).

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FIGURE 29.9 The use of a femoral distractor to aid in reduction necessitates the proper placement of the
threaded pins. Note the proximal posterior position (A) as well as the very distal and posterior position (B,C)
required in order to allow reaming and nail passage. Failure to place the half pins properly will create a situation
in which the tibia is reduced but the surgeon either cannot ream the canal or the fracture displaces during nail
passage due to interference with the distractor pins.

SMALL FRAGMENT PLATES AND SCREWS

A small fragment plate is occasionally used to supplement nailing of proximal tibial fractures, provide provisional
reduction of open fractures, and stabilize selected distal fibular fractures. A 3.5-mm unicortical plate is
occasionally used to improve stability during reaming and nail placement in open fractures. The plates are
typically removed after the locking screws have been placed and before wound closure (Fig. 29.11). Small
fragment plates are also used to supplement fixation in comminuted and unstable distal metadiaphyseal fractures
(Fig. 29.12). Occasionally, a simple tibial plateau fracture can be fixed prior to intramedullary nailing and distal
medial and lateral malleolar fractures can be fixed as well (Fig. 29.13). Internal fixation of the distal fibula may be
helpful in distal tibial fractures, particularly those with bone loss or extreme comminution. Nevertheless, the
lateral soft tissues must be able to tolerate this additional surgical trauma.
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FIGURE 29.10 Intraoperative views showing a femoral distractor in place. Note that the proximal and distal pins
are in the posterior aspect of the tibia, both parallel to the proximal and distal joint surfaces, and the frame sits
well out of the way of the tibial shaft, allowing further reduction maneuvers as necessary.
FIGURE 29.11 An intraoperative view of an open proximal tibial shaft fracture provisionally stabilized with a small
fragment plate. Note the preservation of the periosteum. Unicortical diaphyseal screws are usually sufficient to
maintain reduction during reaming and nail placement, but if poor bone quality requires bicortical screws, the
plate can be positioned more anteriorly, which will still permit reamer and nail passage.

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FIGURE 29.12 Significant medial and distal comminution can lead to residual instability following nailing, which
can be addressed with a percutaneous medial supplemental plate. Note the large medial butterfly fragment (A)
that has been buttressed with a medial plate (B), thus recreating a stable fracture/implant construct. It is crucial
that limited fixation be placed in the plate proximally, or else an overly rigid environment may be created,
increasing the chance of nonunion.
FIGURE 29.13 Associated malleolar fractures are best identified by either plain film or CT (A) and are addressed
by fixation of the malleolus followed by reaming and nail placement. If there is a vertical component to the
malleolus fracture, we favor the use of a medial antiglide plate (B). Sometimes, the interlocking screws can be
placed directly through the plate.

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FIGURE 29.14 Ideal distal placement of the bulb-tipped guidewire is especially crucial when nailing distal tibia
fractures. Note the slight bend at the tip of the wire, best seen on the lateral view (A) as well as the central and
fully seated position seen on the AP view (B). Reaming with the wire in an unacceptable position will result in
fracture displacement when the nail is placed.
BULB-TIPPED GUIDE WIRE
Once the fracture is reduced, a bulb-tipped guide wire is inserted under fluoroscopic control. We often place a
small bend at the tip of the guidewire to facilitate passage and ensure a central position in the medullary canal
(Fig. 29.14). The wire is advanced by hand or by gently tapping with a mallet under fluoroscopic control. The
guide wire should be placed in the center of the medullary canal and impacted into the hard bone of the distal
tibial metaphysis. Reaming of a fracture over an eccentrically placed wire may cause iatrogenic comminution or
lead to fracture malreduction. Measurement of nail size is determined using the manufacturers measuring device
placed over the guide wire. Alternatively, a second wire can be used to determine nail length. It is essential when
determining nail length that the surgeon confirms that the wire is fully seated in the distal tibia, and the fracture is
well reduced to avoid incorrect nail sizing.

REAMING
Tourniquets used during irrigation and débridement of an open fracture or for the initial approach, reduction, and
guide wire placement should be released prior to reaming and nail insertion. Reaming should be performed with
deep fluted, small core diameter sharp reamers. They should be advanced slowly at high speed, increasing in
0.5-mm increments until cortical chatter is encountered. For most adult patients, a 9.0- to 11.0-mm nail provides
enough mechanical strength to allow early, protected weight bearing. We routinely overream by 1.0 to 1.5 mm
greater than the anticipated nail size to facilitate nail insertion. Accurate fracture reduction and correct guide wire
placement must be confirmed fluoroscopically prior to reaming. Reaming a malreduced fracture often leads to
persistent deformities after nail passage. Eccentric reaming should be avoided and most commonly occurs where
there is deficient cortical bone secondary to fracture comminution. A percutaneously placed bone hook,
hemostat, or elevator can assist in centralizing the guide wire. Alternatively, turning off the reamer and advancing
it by hand past areas of significant comminution may prevent eccentric reaming. It is worth reemphasizing that
the tourniquet should be released prior to reaming to minimize thermal necrosis of the bone. Numerous studies
have documented that reaming destroys the endosteal blood supply, but this damage is balanced by increased
periosteal blood flow in the weeks following reaming (12,13).
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FIGURE 29.15 A lateral view showing imminent posterior cortical breach. In this case, the presence of a knee
arthroplasty necessitated a more anterior and distal starting point, increasing the entry angle of the nail and the
risk of posterior blowout. It is especially important to check this view in the osteoporotic patient.

NAIL INSERTION
The nail is inserted over the guide wire and advanced by hand or with gentle taps with a mallet in order to avoid
inadvertent damage to the posterior cortex. If resistance is met, it is important to check the lateral C-arm image to
ensure correct nail trajectory (Fig. 29.15). The nail should be inserted in slight external rotation, which moves the
insertion point for the distal interlocking screws anteriorly and minimizes the risk of injury to the posterior tibial
neurovascular bundle. Rarely, nail incarceration can occur during insertion. If this occurs, the surgeon should
carefully scrutinize the C-arm images to ensure that a cortical fragment has not “fallen” into the medullary canal
blocking nail advancement. If the nail does not advance with moderate force using a mallet, we VERY strongly
advise removing the nail and reaming an additional 0.5 to 1.0 mm to ensure a smooth nail insertion.

INTERLOCKING SCREWS
When, where, and how many proximal and distal interlocking screws should be placed remains a topic of debate.
As a general rule, we place two proximal and two distal interlocking screws in diaphyseal fractures with <50%
cortical contact. For proximal and distal metadiaphyseal fractures, we utilize the standard two proximal and two
distal interlocks plus at least one additional oblique plane interlocking screw from anteromedial to posterolateral.
For very unstable proximal metaphyseal fractures, or in patients with severe osteoporosis, we add an additional
anterolateral to posteromedial oblique locking screw. Similarly, in distal tibial fractures, we often place multiplanar
screws to enhance fixation stability.
Newer generation tibial nails allow the option of placing angular stable interlocking screws, which are
mechanically locked to the nail. To date, there is little clinical data to support their effectiveness. Theoretically,
they may increase the stability of metaphyseal fractures in patients with compromised bone quality secondary to
osteoporosis or extensive fracture comminution.
A common mistake associated with the interlocking screws is irritation of the pes anserine or anterior tibial
tendons secondary to not fully “seating” the large screw heads against bone. Another error is syndesmotic
irritation from excessively long distal interlocking screws. Both complications can be avoided by careful attention
to detail.

CLOSURE
The surgical wounds are closed in layers with interrupted absorbable sutures. The paratenon of the patellar
tendon sheath is repaired if has been opened as part of the approach. The skin is approximated with
nonabsorbable monofilament suture using 3-0 nylon or prolene.
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CASE EXAMPLES
Proximal Tibia
The deforming forces on the proximal tibia, combined with fracture comminution, often produce a valgus and
flexion deformity following nailing of proximal metaphyseal fractures. These fractures must be reduced before
reaming to avoid malreduction. With an oblique proximal fracture, a pointed reduction clamp can be used through
small stab incisions to reduce and hold alignment. It is important that the anterior soft tissues remain free of the
clamp and are not “crushed” for a significant length of time. With open fractures, clamp application is obviously
made easier, but in both cases, reduction must be maintained throughout canal preparation and nail placement
and locking (Fig. 29.16). If the reduction cannot be maintained with clamps alone, a unicortical plate or blocking
screws are recommended.
The use of a lateral or medial plate to obtain and maintain reduction of a proximal shaft fracture has application
in both open and closed fractures. The most common implants used are a 3.5-mm small fragment plate. While
the lateral aspect of the tibia offers better soft-tissue coverage, the medial side may be better for resisting valgus
deformity. The plate is usually placed anterior on the shaft so that screws do not interfere with guidewire
placement or reaming (Fig. 29.17). These plates should be placed extraperiosteally with essentially no stripping
at the fracture site. Unicortical screws are adequate in most patients (medullary canal is free and
anterior/posterior plate positioning becomes less important). The plate can often be removed once the canal has
been reamed, the nail placed, and the proximal interlocking screws inserted. If removal of the plate and screws
results in deformity at the fracture, then the plate should be reapplied or blocking screws inserted to correct the
deformity.
FIGURE 29.16 Intraoperative view showing loss of reduction in a proximal tibial shaft fracture. Note the presence
of a clamp, which initially had maintained anatomic reduction. After nail passage, a typical valgus deformity is
seen (A), and this is corrected by nail removal, placement of a blocking pin (B), reseating of the nail, placement
of multiple proximal interlocks, and exchanging the blocking wire with a blocking screw (C). Note the continued
tendency of the fracture to fall into valgus, even after maximal stabilization has been placed.

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FIGURE 29.17 Provisional anterior cortical plating of a complex tibial shaft fracture greatly aids in reduction and
nail placement. Note the “open” medullary canal seen on the lateral view (A), which permits passage of the
reamers and the nail with the plate in place. Once proximal and distal interlocking screws have been placed, the
plate is usually removed, as the nail provides adequate stability (B).

Blocking or “poller” screws are devices placed outside the path of the nail. They are intended to “block”
deformity by restricting the canal diameter available for the nail. For metadiaphyseal fractures, where the
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medullary canal does not “capture” the intramedullary device, there are two focal points that determine
alignment. For proximal tibial fractures, the entry portal site, as well as the cortical integrity of the proximal
fragment, influences the fracture reduction and alignment (Fig. 29.18). Unless a patient is very osteoporotic, the
bone quality of the proximal starting point is usually adequate to maintain the initial relationship to the nail. A
medial starting point for a proximal tibial fracture leads predictably to a valgus deformity (Fig. 29.19). Therefore,
the starting point should be more lateral for these fractures. The most effective application of blocking pins or
screws is at the second focal point, relatively close to the fracture. The valgus/flexion deformity seen in proximal
fractures is typically corrected with an AP blocking screw placed lateral to the proposed nail pathway and a
medial to lateral blocking screw placed posterior to the nail (Fig. 29.20). It is important to recognize that blocking
screws serve no function unless they are in contact with the nail. For situations in which a nail is already in
place, but there is residual malalignment, blocking screws can be placed around the nail to correct deformity and
add stability. Typically, this is done by aligning the drill bit so that it partially overlaps the nail, allowing the nail to
slightly deflect off the drill when placing the screw (Fig. 29.21). We use small fragment screws when using this
technique, as their smaller size allows for easier placement and less chance of fracturing one of the cortices
close to the fracture.

FIGURE 29.18 For distal fractures, the seated position of the tip of the nail—as well as cortical integrity at the
metaphyseal flare—influences reduction and alignment.
FIGURE 29.19 An excessively medial starting point has resulted in a valgus deformity of this proximal shaft
fracture. Note that even the addition of a lateral blocking screw at the metaphyseal flare cannot completely
correct this deformity. This emphasizes the importance of the correct starting point.

Midshaft Tibia
Midshaft tibial fractures may be easier to reduce than metadiaphyseal injuries but can still be difficult to nail.
Simple short oblique fracture patterns can be clamped in a percutaneous fashion, thereby restoring length and
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rotation. Transverse fractures make restoration of length and alignment straightforward. Yet, evaluation of
rotation can sometimes be difficult. Even in the setting of an intact fibula, up to 20 degrees of tibial malrotation
can occur. Therefore, it is crucial that the surgeon carefully evaluates the relationship between the proximal and
distal tibia on the injured extremity and compares it to the contralateral limb. This can be done by physical exam
and with fluoroscopy. Malrotation errors >5 to 10 degrees should be corrected before leaving the operating
room. This is most easily done by removing all interlocking screws, correcting rotation, and placing new
interlocking screws in new locations. If questions regarding rotational alignment remain, a postoperative
rotational CT scan should be obtained.
FIGURE 29.20 Placement of anterior-to-posterior blocking pins or screws to control valgus seen with proximal
shaft fractures. Note the presence of two pins on the initial intraoperative view, as the first, more lateral pin, was
not felt to be medial enough to adequately “block” the nail (A). During nail passage, it is confirmed that the pin
obtains contact with the nail (B) as the nail is gently tapped passed the blocking pin. After the nail is seated, and
all proximal interlocks have been placed, a blocking screw can be placed in a new position or through the
blocking pin site (C). In this case, a new site was chosen as it was felt that the pin was required to hold the
desired reduction during screw placement.

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FIGURE 29.21 Additional stabilization of acute fractures and nonunions can be achieved by the placement of
blocking screws around a well-positioned nail. The initial “overlap” of the drill and the nail (A) allows the nail
itself to deflect the drill and the subsequent screw, resulting in intimate contact (B). This added stability may be
crucial in the successful treatment of a hypertrophic nonunion (C).

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FIGURE 29.22 The distal (A) and proximal (B) views of a highly comminuted midshaft fracture reduced with the
aid of a femoral distractor. A straight wire placed on the anterior tibial crest confirms provisional alignment, prior
to placement of the bulb-tipped guidewire. Failure to judge this initial reduction can result in reaming in a
malreduced position, which will most likely produce final malreduction.

Reduction of axially unstable, highly comminuted midshaft tibial fractures can be challenging. The two most
common techniques to ensure correct length are the use of a femoral distractor and fixation of associated fibula
fractures. A femoral distractor placed on the medial side of the tibia is an invaluable tool when restoring length in
comminuted tibial fractures. The proximal half pin should be placed in the posterior aspect of the metaphysis,
approximately 2 to 3 cm below and parallel to the joint. The distal half pin should be placed just proximal to the
epiphyseal scar in the posterior one-third of the metaphysis and parallel to the ankle joint. With the patient
paralyzed, the threaded bar can be gently “dialed” out until length has been achieved. A guide wire or pin placed
over the anterior aspect of the limb can be used to confirm appropriate alignment of both proximal and distal joint
surfaces (Fig. 29.22). As discussed above, rotational alignment must also be carefully evaluated. In this setting,
the authors STRONGLY recommend use of intraoperative plain radiographs after initial interlocking screws are
placed, but before all interlock options have been utilized (Fig. 29.23).
If there is an associated fibula fracture that is amenable to fixation, restoration of the “lateral” column of the limb
can assist with overall alignment. It is important that any plate utilized be “flexible” in nature because final
adjustments are often needed on the tibia, and a more rigid dynamic compression plate (DCP) can easily “lock
in” a malreduction. Simple fibula fracture patterns can also be stabilized with an intramedullary implant. Rush
rods, flexible nails, and guide wires can be utilized. This technique typically requires an open reduction of the
fibula at the fracture site.

Distal Third Tibia

The distal aspect of the tibia shares the elements of a widened metaphyseal flare similar to proximal shaft
fractures, but is more often associated with a fibula fracture and loss of the “lateral” column support (Fig. 29.24).
When the fibula is fractured, open reduction and internal fixation is an effective technique to restore length and
alignment. This is generally done through a separate lateral incision and, as discussed above, can be done
using plates or an intramedullary device. As noted above, the authors recommend using “flexible” implants to
avoid malreduction of the tibia.
Percutaneous clamps and, on occasion, open minimally invasive plating may be indicated to reduce and hold
these unstable injuries. Blocking pins and screws also have an important role in providing stability in the distal
tibia. However, they are less useful in achieving initial reduction than in holding it. This is because the distal
fracture fragment is often extremely short (i.e., 3 to 4 cm), and the lever arm provided by blocking devices makes
angular correction more difficult. As a result, we prefer to achieve reductions using distractors or unicortical
plates and consider augmenting the fixation with blocking screws, if needed. It is worth reemphasizing that the
guide wire must be in the central portion of the distal fragment in both the AP and lateral views to avoid a
translational or angular deformity (Fig. 29.25).
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FIGURE 29.23 An intraoperative portable radiograph, prior to placement of all distal interlocking screws, confirms
acceptable alignment of the fracture. Fluoroscopy does not provide a large enough field of view.

Postoperative Care
Following nailing, the leg should be splinted with the ankle in neutral dorsiflexion. Early range of motion of the
knee is encouraged, and range of motion of the ankle is typically started when the splints are converted to a
“boot” at postoperative day 10 to 14. Postoperative weight bearing is dependent on the location and stability of
the reduced fracture. Most nailed midshaft fractures have adequate stability to permit early partial weight
bearing. Proximal and distal shaft fractures are generally permitted touchdown weight bearing (i.e., 20 to 30
pounds) for the first 6 weeks. Activity levels and therapy are advanced so that full weight bearing is permitted by
postoperative week 12.
We do not typically chemically anticoagulate patients following nailing of isolated tibial fractures. Anticoagulation
may be required in patients with associated injuries or those who have risk factors for thromboembolic disease.
Mechanical prophylaxis on the contralateral limb is utilized during the hospital stay. Once the patient has been
mobilized, they are discharged home or to a care facility, depending on their overall physical capabilities. Follow-
up is typically at 2 weeks for suture removal and then at 6 and 12 weeks for radiographic and clinical evaluation.
Formal physical therapy (i.e., gentle aerobic conditioning) does not begin until 6 weeks, and unless
complications present, we generally begin an aggressive strengthening program at 12 weeks.

COMPLICATIONS
Knee Pain
The etiology of knee pain after tibial nailing is not well understood (14, 15 and 16). Damage to the patellar
tendon, scar formation, and mild patella baja are considered possible contributing factors. Despite the lack
of a definitive cause, the authors believe that there are several steps that can be taken to minimize the risk
of knee pain. First, when using a parapatellar tendon approach, we carefully preserve, protect, and reclose
the tendon sheath. It is our belief that this layer advances the restoration of normal gliding characteristics
and prevents tendon adherence to the adjacent soft tissues. Second, we always perform a thorough
irrigation behind the patellar tendon and palpate the region to ensure that there is no residual reaming
debris. If this is not done, it is very easy to leave an irritating nidus directly behind the central portion of the
tendon. Third, we attempt to place our parapatellar tendon incision approximately 1 cm medial to midline so
that the resultant scar is not directly over the tubercle, that is, in a position of maximal contact when
kneeling. While none of these steps will guarantee a painless knee, our experience suggests that a majority
of the symptoms associated with tibial nailing are directly related to soft-tissue handling and surgical
technique.
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FIGURE 29.24 Initial nailing of a comminuted distal tibial shaft fracture, demonstrating the valgus deformity
that commonly occurs if the fibula, or lateral column, is not restored (A). Correction of this deformity requires
ORIF of the fibula, restoration of the lateral column, and revision nailing with multiple blocking screws (B).

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FIGURE 29.25 A 26-year-old female skier sustained a twisting injury to the lower extremity. She presented
complaining of severe pain in the left leg. AP and lateral images of the patient’s tibia (A,B) demonstrate a
distal diaphyseal tibia fracture with associated fibula fracture at the same level. The initial IM nail
stabilization was performed, and postoperative images demonstrate a valgus-extended malreduction of the
tibia (C,D). The intraoperative imaging from that procedure (E) demonstrates that the malreduction was
present during the operation. Note that the valgus alignment of the fibula is a sign that the reduction is not
correct. At the time of the revision surgery, the fibula was reduced and plated, restoring the lateral column of
the leg, and a blocking screw has been placed to maintain the correct central position of the new IM nail (F).
Final images demonstrate restoration of normal tibial anatomy (G,H).

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FIGURE 29.25 (Continued)

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FIGURE 29.25 (Continued)

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FIGURE 29.25 (Continued)

Infection
Acute postoperative wound infections are usually seen within 6 weeks of injury. These infections are
treated with irrigation and débridement and culture-specific antibiotics. Early postoperative wound infections
that involve the soft tissues around the surgical incisions may be aggressively treated with irrigation and
débridement, culture-specific antibiotics, and nail preservation. Unfortunately, infections that develop after 2
to 3 weeks usually involve the nail, medullary canal, and possibly the fracture site. Treatment options
include (a) serial débridements, nail removal, and application of a temporary, simple uniplanar external
fixator or (b) conversion to a circular ring fixator as definitive treatment. Choice of option a or b should be
based on surgeon experience, host characteristics, and the extent of infection. In both cases, repeat
débridements are performed until all nonviable tissue, including bone, has been removed. Consultation with
an infectious disease consultant may be helpful. Large bony defects that exist after débridement are
typically filled with an antibiotic impregnated methyl methacrylate spacer.
Revision nailing, following the acute treatment of infection, may involve a simple exchange with another
metal implant or the use of a custom “hybrid” nail made by coating a small diameter (8 to 9 mm) implant with
antibiotic impregnated methyl methacrylate (Fig. 29.26). While this is an “off-label” application of both the
implant and the cement, the authors have found it to be extremely useful in providing the early stability that
helps control infection, and at the same time delivering high concentrations of local antibiotic into the
intramedullary space. Since this construct allows for placement of all interlock options, it has been our
experience that, in the majority of cases, revision to a third nonhybrid nail is rarely required.
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FIGURE 29.26 Intraoperative view demonstrating the construction of a “hybrid” antibiotic nail (A). A small
diameter nail is used as the central core for a cement mantle created inside a 12.5-mm inner diameter
silastic tube. Following setup of the cement, the silastic tube is cut off, and the nail is introduced into the
tibia. Overreaming to 13 or 13.5 mm is recommended, and interlocks are placed through the cement-nail
hybrid structure (B).

Delayed Union and Nonunion

The treatment of a tibial nonunion following nailing is complex and beyond the scope of this chapter.
However, the incidence may be minimized by ensuring that the fracture is not nailed in distraction and that
fracture stability is maximized. When a hypertrophic nonunion occurs, we occasionally place blocking
screws to augment the nail construct. If the fracture anatomy does not allow augmentation with blocking
screws, or if the nail has been in for more than 8 to 10 months, our standard approach is a reamed,
exchanged nailing with or without a fibular osteotomy. If the fibula has healed, it is usually impossible to
close bony defects or gaps in the tibia without shortening the fibula.
Compression plating of the nonunion is utilized when revision nailing of a hypertrophic nonunion is
unsuccessful and in some atrophic nonunions. In most patients, the soft tissues have sufficiently recovered
to permit an open lateral approach and internal fixation with a large fragment plate. Care must be taken to
be sure that alignment is preserved as compression is applied. A fibular osteotomy is almost always
performed in this setting.
Simple dynamization of statically locked nails has been shown to have some effect on healing, especially if
done within 3 to 6 months of the initial nailing (17, 18 and 19). Our experience has been that this technique
is particularly effective if small gaps (i.e., 3 to 4 mm) are present. We recommend removing the interlocking
screws from the site furthest from the fracture. Dynamization is only indicated in length-stable fractures.
In any patient who develops a delayed union or nonunion, infection should be suspected, and a full workup
is indicated. If there is concern for infection, we recommend either a staged approach (initial reaming and
placement of an antibiotic nail followed by definitive nailing after 4 to 6 weeks of IV antibiotics), or, more
 recently, a single-staged treatment using a “hybrid” nail. Ultimately, if exchange nailing is not successful,
the nonunion often requires bone resection and transport using a ring fixator.

PEARLS
Leave all provisional fixation in place until the nail is inserted and statically locked.
Proximal and distal metaphyseal fractures require additional oblique plane fixation interlocking screws.
Do not nail in distraction.
Passage of the nail will not reduce a fracture that was reamed in a malreduced position.

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REFERENCES
1. Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary
nail fixation for distal tibia shaft fractures. J Orthop Trauma 2011;25:736-741.

2. Finkemeier CG, et al. A prospective, randomized study of intramedullary nails inserted with and without
reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 2000;14(3):187-
193.

3. Larsen LB, et al. Should insertion of intramedullary nails for tibial fractures be with or without reaming? A
prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18(3):144-149.

4. Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace.
Clin Orthop Relat Res 2004;428:261-271.

5. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg 1999;7(1):66-75.

6. Henley MB, et al. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective
comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma
1998;12(1):1-7.

7. Nork SE, et al. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma 2006;20(8):523-
528.

8. Lindvall E, et al. Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial
fractures: comparison of 56 cases. J Orthop Trauma 2009;23(7):485-492.

9. Tornetta P, III, et al. Intraarticular anatomic risks of tibial nailing. J Orthop Trauma 1999;13(4):247-251.

10. Pazzaglia UE. Periosteal and endosteal reaction to reaming and nailing: the possible role of
revascularization on the endosteal anchorage of cementless stems. Biomaterials 1996;17(10):1009-1014.

11. Pazzaglia UE, Andrini L, Di Nucci A. The reaction to nailing or cementing of the femur in rats. A
microangiographic and fluorescence study. Int Orthop 1997;21(4):267-273.

12. Vaisto O, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year
follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma
2008;64(6):1511-1516.

13. Leliveld MS, Verhofstad MH. Injury to the infrapatellar branch of the saphenous nerve, a possible cause
for anterior knee pain after tibial nailing? Injury 2011;

14. Keating JF, Orfaly R, O’Brien PJ. Knee pain after tibial nailing. J Orthop Trauma 1997;11(1):10-13.

15. Takeda T, Narita T, Ito H. Experimental study on the effect of mechanical stimulation on the early stage
of fracture healing. J Nihon Med Sch Nihon Ika Daigaku zasshi 2004;71(4):252-262.

16. Egger EL, et al. Effects of axial dynamization on bone healing. J Trauma 1993;34(2):185-192.

17. Larsson S, et al. Effect of early axial dynamization on tibial bone healing: a study in dogs. Clin Orthop
Relat Res 2001;388:240-251.

18. Tripuraneni K, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on
infection rate. Orthopedics 2008;31(12):1195.

19. Harley BJ, et al. The effect of time to definitive treatment on the rate of nonunion and infection in open
fractures. J Orthop Trauma 2002;16(7):484-490.
 30
Tibial Shaft Fractures: Taylor Spatial Frame
Charles J. Taylor

INDICATIONS AND CONTRAINDICATIONS

Tibial shaft fractures are serious injuries and are most commonly seen in adult and adolescent patients. Because
of its subcutaneous location anteriorly and medially, trauma to this area leads to a high percentage of open
fractures when compared to the femur or upper extremity. Even with closed fractures, severe soft-tissue injury
may be present, which may complicate treatment. Swelling, fracture blisters, and even full-thickness skin loss
may often occur with high-energy displaced fractures. Compartment syndrome can occur following both closed
and open tibial fractures. In addition to injuries caused by direct trauma, many fractures occur as the result of
torsional and bending forces. This most commonly occurs in the distal third of the tibia near the metadiaphyseal
junction.
Strong indications for treatment of a tibial fracture with a computer-assisted external fixation frame include (a)
open fractures with bone loss, (b) tibial shaft fractures with epimetaphyseal extension, (c) fractures with
significant loss of reduction (>3 weeks) following cast or brace treatment, and (d) infected fractures. Relative
indications for this technique include (a) selected complex open fractures, (b) unstable closed fractures with
significant soft-tissue compromise, and (c) some tibial fractures with a compartment syndrome following
fasciotomy. Although not specifically addressed in this chapter, delayed union, nonunion, and malunion of many
tibial fractures can be treated with the computer-assisted external fixation.
Historically, external fixation was reserved for patients with severe open fractures. Results from the last 10 to 20
years demonstrate the efficacy and safety of external fixation for fractures that may also be treated with
intramedullary nails. There are no absolute contraindications for its use as a primary method of treating acute
shaft fractures.

PREOPERATIVE PLANNING
History and Physical Exam
The severity of a tibial fracture can be distracting, but a thorough history must be obtained and a complete
physical exam performed. The patient’s general medical history should identify allergies to medicine, current
medications, current medical conditions being treated, and previous surgeries. The social situation, especially
support at home, may be important for patients in external fixation.
The specific mechanism of injury should be sought from the patient, witnesses, and first responders to
understand the energy involved, appreciate direct soft-tissue injury, and alert the medical team to other possible
injuries remote to the obvious tibial fracture. Significant bleeding at the accident scene or during transport
suggests an arterial injury as well. Fractures sustained from crushing injuries, during tornados, and in
association with electrical injuries alert the surgeon to the possible need for subsequent débridements and soft-
tissue procedures.
Patients with tibial fractures present in a variety of settings from level 1 trauma centers to outpatient offices. The
multiply injured patient, especially if unconscious, must be examined thoroughly and repeatedly. The c-spine
should be immobilized and the obvious extremity fractures splinted and wounds dressed. The patient should be
carefully log-rolled until the spine is cleared.
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Repeated neurologic and vascular assessments of the extremity should be made to identify a more proximal
injury or compartment syndrome. In the conscious patient, increasing pain and decreasing sensation are the
earliest signs and symptoms of compartment syndrome. The limb must be inspected for local tenderness,
ecchymosis, abrasions, fracture blisters, and open wounds. The knee and ankle joints are evaluated for
tenderness, swelling, stability, and range of motion if possible. A well-padded long-leg splint is applied following
gentle longitudinal traction to grossly realign the fracture.

Imaging Studies
Full-length anteroposterior (AP) and lateral radiographs of the tibia and fibula must be obtained. These
radiographs should include both views of the knee and ankle. Tall patients may require overlapping radiographs.
If there is fracture extension into the knee or ankle joints, or the physical examination suggests articular
involvement, a CT scan can be obtained to help delineate the fracture morphology and plan treatment.

Timing of Surgery
Considering the wide spectrum of presentations of tibial fractures, surgical timing varies greatly from emergent to
“elective.” In the multiply injured trauma center patient, surgical treatment of the tibia may follow more urgent
surgical treatments by general surgery and neurosurgery. Patients with open fractures should receive
therapeutic doses of Ancef and Tobramycin for 48 hours. Anaerobic coverage is considered for gross
contamination, and tetanus prophylaxis is given if appropriate. Open fractures should undergo débridement,
irrigation, and stabilization within a few hours of the injury when possible. Likewise, fractures with compartment
syndrome are addressed emergently with fasciotomy and stabilization.
Closed unstable low energy fractures may be splinted and seen in close follow up in an outpatient clinic.
Instructions should be given for ice, elevation, and signs of compartment syndrome. The patient should be non-
weight bearing on the injured extremity.
Patients with higher energy fractures, especially with crushing can be admitted for more careful monitoring prior
to urgent surgery.

Surgical Tactic
The Taylor Spatial Frame may be used in two modes, acute reduction or gradual reduction. In the simplest
mode, after fracture fragments are fixed, the frame can be acutely manipulated to reduce the fracture under
direct vision for Grade III open fractures or C-arm control for closed and Grades I and II open fractures. The
frame is then locked in position. No computer is necessary for this type of acute reduction. In its most versatile
mode, the frame may be gradually adjusted to reduce the fracture. This reduction is done gradually over the first
few weeks. Additional anesthesia is not necessary. This gradual reduction can be used for the entire reduction
process or after an initial acute reduction.
Prior to surgery, it is helpful to “size” the leg for ring diameter and to anticipate the number and approximate
placement of half pins and wires. Also, plan the approximate position and plane of steerage pins for oblique
fractures. A full-sized sketch or wax pencil markings of standard radiographs are helpful.

INTRODUCTION TO THE TAYLOR SPATIAL FRAME

The Taylor Spatial Frame fixator consists of two rings or partial rings connected by six telescopic struts with
special universal joints (Fig. 30.1). By adjusting only strut lengths, one ring can be repositioned with respect to
the other. Special FastFx struts have two modes of adjustment. In the unlocked position, they are free to slide
like a piston for an initial reduction in surgery (Fig. 30.2). In the locked mode, the struts may be gradually
adjusted allowing further reduction of the residual skeletal deformity in the clinic or patient’s home (Fig. 30.3).
The Spatial Frame fixator is capable of correcting all six axes of the deformity, three translations, two
angulations, and rotation by adjusting lengths of struts only.
The ability to make gradual adjustments to the frame after the surgical application allows the surgeon to separate
fracture fixation from reduction and even delay reduction for weeks. The surgeon should concentrate on stable
fixation of the major fragments during surgery. After stable fixation, the fragments can be further acutely reduced
with the fast fix struts in their unlocked position or gradually reduced in the locked position. This ability to achieve
delayed near anatomic reductions is the greatest strength of the Taylor Spatial Frame technique.
Frames may be tapered by using rings of different sizes to make them less cumbersome and safer while
descending stairs. Generally, one to two fingerbreadths clearance anterior between the ring and skin and two to
three posteriorly are adequate (Fig. 30.4). A 2/3 ring open posterior is frequently used for proximal tibial fractures
to allow full knee flexion. Complete and 2/3 rings range in size from 80 to 300-mm internal diameter in 25-mm
increments. Accessory rings and partial rings may be attached to extend the levels of fixation (Fig. 30.5).
Standard and short foot plates are available in 155- and 180-mm internal diameters. “U-Plates” are also used for
foot fixation (Fig. 30.6).
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FIGURE 30.1 One Spatial Frame ring can be repositioned with respect to the other by adjusting strut lengths.
(©J. Charles Taylor.)

The assembly drawing is shown in Figure 30.7. The open area of a 2/3 ring can be positioned based on
surgeon’s choice. Six identifier clips, uniquely colored and numbered 1 through 6, are provided with each frame.
Each numbered/colored clip is applied to a strut beginning with strut 1 (which is attached to a tab directly anterior
on the proximal ring) and progressing counterclockwise as viewed from the proximal end of the frame.
Hybrid frames may be used with ring to bar connectors to extend levels of fixation, especially with half pins. Hex-
Fix (trademark) and Jet-X (trademark) and other rod and rail fixators are designed for use with ring fixators and
are useful accessories and attachments to provide lower profile half pin fixation beyond the rings.

Adequate Fixation
The author strongly recommends predrilling for half pins and does not use self-drilling pins. Threaded titanium
half pins and/or tensioned 1.8-mm-diameter stainless steel wires are used with the Spatial Frame. To minimize
the number of pins and wires, their placement should be optimized to provide the greatest stability within
anatomic constraints. The entire length of the anterior/medial tibia is available for half-pin fixation. Four and 5-
mm titanium half pins are used for adolescents and small adults. Usually, 5-mm half pins are used in larger
patients. Long fragments are fixed with at least two and often three half pins in different planes. Pins should be
spread longitudinally along a significant portion of each fragment trying to stay out of the zone of soft-tissue
injury (Fig. 30.8). Obviously, this is not always possible. Shorter periarticular fragments are fixed with at least two
multiplanar half pins at approximately 70 degrees to each other. Adding a single olive wire in the coronal plane
adds significantly to the stability of a short fragment. Alternatively, three 1.8-mm olive wires can be used to
stabilize a short proximal or distal fragment (Fig. 30.9). The crossing angle of these wires must be optimized
within anatomic limits. Two “olives” should block the fragment from each side, and a third olive wire should block
the fracture obliquity. Stability for a very short proximal tibial fragment can be increased by transfixing the tibia
and fibula at the level of the fibular head with a tensioned wire. For very short distal tibial fragments,
transosseous wires can traverse the syndesmotic region. Intermediate length fragments may be fixed with a
combination of wires and half pins.

FIGURE 30.2 A Spatial Frame may be acutely adjusted by hand with all struts in the unlocked position. (© J.
Charles Taylor.)

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FIGURE 30.3 Fast Fx struts are free to slide in the unlocked position for acute fracture reduction. The locking
sleeve is advanced to lock the strut. The locked strut can still be gradually adjusted by rotating the nosepiece. (©
J. Charles Taylor.)

FIGURE 30.4 Spatial Frames may be tapered and eccentric. Allow sufficient soft-tissue clearance to prevent
frame impingement. (© J. Charles Taylor.)
FIGURE 30.5 A tapered frame consisting of a 180-mm-diameter 2/3 ring proximally connected to a 155-mm
Spatial Frame distally with Ilizarov threaded rods. The proximal 2/3 ring with the opening posteriorly allows full
knee flexion. (© J. Charles Taylor.)

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FIGURE 30.6 Additional skeletal stability and prevention of equinus deformity may be gained by fixing the foot to
a foot plate or U-plate. (© J. Charles Taylor.)
FIGURE 30.7 Each numbered/colored clip is applied to a strut beginning with strut 1 (which is attached to the
designated Master Tab anteriorly) and progressing counterclockwise as viewed from the proximal end of the
frame. The computer program assumes that the universal joints connecting strut 1 and strut 2 to the proximal ring
are aligned directly anterior with respect to the reference fragment. Different rotational alignments, especially for
more proximal femoral and humeral applications, can be accommodated by changing rotary frame offset. (© J.
Charles Taylor.)

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FIGURE 30.8 A. Do not limit mechanical stability by two sets of parallel pins. (© J. Charles Taylor.) B. Fracture
stability is significantly improved by extending the working length in each fragment. C. Stability is further
increased by inserting pins in different planes, achieving multiplanar fixation. (© J. Charles Taylor.)

The foot may be included temporarily for additional fracture stability, soft-tissue immobilization, and prevention of
equinus contracture. A distal shaft fracture with significant soft-tissue injury as well as in patients with peripheral
nerve injuries or head trauma should have the fixation extended to the foot in the beginning (Fig. 30.10). The foot
plate is attached to the distal ring of the Spatial Frame with threaded rods. Usually, a combination of olive wires
and half pins are placed in the calcaneus and two wires in the metatarsals (Fig. 30.11). Shorter frames may be
constructed with short body struts. Tapered and open section frames may be applied. Segmental fractures are
usually treated with a ring or 2/3 ring for each major fragment (Fig. 30.12A-C).
FIGURE 30.9 A. Short periarticular fragments can be stabilized with two to three multiplanar half pins. B. Stability
is improved significantly by at least one tensioned wire. C. Good stability is provided by three multiplanar
tensioned wires for short extra-articular fragments. Four multiplanar wires are used for intra-articular fractures
such as a bicondylar tibial plateau fracture. (© J. Charles Taylor.)

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FIGURE 30.10 The accessory foot plate or U-Plate is attached to the Spatial Frame with threaded rods. (© J.
Charles Taylor.)
FIGURE 30.11 Angled wires and/or pins are used in the calcaneus. Usually, two wires are used in the forefoot
(not shown) at the level of the metatarsal necks. (© J. Charles Taylor.)

Steerage Pin
Oblique fracture stability can be improved by using steerage pins on either side of the fracture (1). These pins
should be angled 15 to 20 degrees from the transverse plane along the plane of the fracture (Fig. 30.13). These
pins will cause dynamic interfragmentary compression with weight bearing and minimize fracture shear. It is still
beneficial if only one steerage pin is used.

FIGURE 30.12 A. Shorter struts allow more stable fixation when indicated. Accessory rings could be added to
extend the level of fixation. B. The component system permits custom frames such as this tapered open section
frame for distal femoral application. C. Each ring has six tabs and can serve as the intermediate ring for a
segmental application. Spatial Frames come preassembled or can be assembled from components. (© J. Charles
Taylor.)
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FIGURE 30.13 Steerage pins are angled 15 to 20 degrees approximating the major oblique fracture plane. They
are placed on each side of the fracture and are used with other pins and/or wires. Steerage pins increase
interfragmentary compression and reduce shear at the fracture site during ambulation. (© J. Charles Taylor.)

SURGERY
Positioning
General, spinal, or continuous epidural anesthetics may be used as indicated. Care must be taken when using
spinal or regional anesthesia to avoid masking a postoperative compartment syndrome. The patient is positioned
supine on a padded radiolucent table top. Whenever possible, tables that have no metal rails improve
visualization of the fracture with the image intensifier.

Imaging
The C-arm is positioned on the opposite side of the injury. The image monitor is usually best positioned at the
foot of the table.

Skin Prep and Drape

A tourniquet is placed on the proximal thigh, but is generally used only for débridement of open fractures or in
cases with substantial bleeding. The tourniquet should be deflated prior to pin and wire insertion. Longitudinal
traction through a calcaneal pin or wire may be useful to improve overall alignment but is not routinely employed.
A few folded towels are strategically placed to elevate leg segments as needed for frame application. The skin is
prepped with a Betadine Scub followed by Betadine Prep. Alternatively, DuraPrep may be used.

Fixation/Pin and Wire Technique

Pin and wire location and insertion technique are some of the most important factors for patient tolerance, frame
longevity, and minimizing additional surgery. Bayonet point wires with cutting relief are ideal for metaphyseal and
especially diaphyseal bone (Fig. 30.14). Wires are inserted percutaneously to the near cortex, then slowly drilled
across both cortices with frequent pauses to prevent overheating, and tapped through the far soft tissue. The
wire is irrigated with saline for additional cooling. It is important to achieve bicortical purchase with wires and pins
to enhance mechanical stability, decrease pin loosening, and minimize thermal necrosis. The small incision to
insert the drill sleeve or release the skin for the olive is closed with a simple suture.

FIGURE 30.14 Olive wire with close-up of cutting tip. (© J. Charles Taylor.)

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FIGURE 30.15 Determine the approximate position of one ring, usually on the shorter fragment, and mark the
skin. Place a second mark 18 cm from the first for fast fix struts or 15 cm for standard struts. These marks are the
approximate positions for the rings. (© J. Charles Taylor.)
FIGURE 30.16 Slide the frame over the leg. (© J. Charles Taylor.)

Frame Application
Assemble the Spatial Frame with two rings and six medium FastFx struts in their unlocked position (see Fig.
30.7). Choose the approximate level for one ring and mark the skin. Mark the skin 18 cm away for the position of
the second ring (Fig. 30.15). Slide the frame onto the leg (Fig. 30.16). The frame does not have to be centered
longitudinally over the fracture. Make a short longitudinal incision for a sagittal plane half pin. Using a five-hole
Rancho Cube as a drill guide (Fig. 30.17), drill a pilot hole for the half pin. Insert the half pin (Fig. 30.18) and
attach it to an appropriate length Rancho Cube maintaining the desired soft-tissue clearance (Fig. 30.19). Attach
the Rancho Cube to the Spatial Ring using the inner tier of holes at the anterior position (Fig. 30.20) on the
master tab, the junction of the number 1 and number 2 struts. Using as long a Rancho Cube as possible, insert a
half pin in the anterior/medial plane off the proximal face of the proximal ring (Fig. 30.21). Using a Rancho Cube
as a drill guide (Fig. 30.22), insert another half pin in the sagittal plane on the proximal portion of the distal
fragment (Fig. 30.23). Attach the Rancho Cube to this pin maintaining the 1 to 2 fingerbreadths soft-tissue
clearance (Fig. 30.24). Attach the Rancho Cube to the distal ring in the anterior hole (Fig. 30.25). Insert a second
half pin in the distal fragment in the anterior medial plane using as long a half pin as possible (Fig. 30.26).
Usually a third half pin is inserted in each fragment in a different plane and is attached to its respective ring with
a one-or two-hole Rancho Cube (Fig. 30.27).
Stability can be increased on longer fragments by extending the spread of fixation with an accessory ring
connected to one of the primary rings with threaded rods or posts (see Fig. 30.5) or with a hybrid frame
extension using a ring to rod connector.

FIGURE 30.17 Lay a long Rancho cube along the tibial crest for a sagittal pin. (© J. Charles Taylor.)
FIGURE 30.18 Using the cube as a drill sleeve guide, drill the appropriate pilot hole and insert a half pin by
hand. (© J. Charles Taylor.)

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FIGURE 30.19 Slide the cube along the pin to adjust anterior/posterior soft-tissue clearance and tighten the pin
to the cube with a set screw or short bolt. (© J. Charles Taylor.)
FIGURE 30.20 Attach the Rancho cube to the anterior hole of the ring using the inner tier of holes. See inset. (©
J. Charles Taylor.)

FIGURE 30.21 Insert a second half pin in the anterior medial plane using as long a Rancho cube as possible. (©
J. Charles Taylor.)
FIGURE 30.22 Lay a long Rancho cube along the tibial crest of the second fragment for a sagittal pin. (© J.
Charles Taylor.)

FIGURE 30.23 Using the cube as a drill sleeve guide, drill the appropriate pilot hole and insert a half pin by
hand. (© J. Charles Taylor.)
FIGURE 30.24 Slide the cube along the pin to adjust anterior/posterior soft-tissue clearance and tighten the pin
to the cube with a set screw or short bolt. (© J. Charles Taylor.)

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FIGURE 30.25 Attach the Rancho cube to the anterior hole of the ring using the inner tier of holes. See inset. (©
J. Charles Taylor.)

FIGURE 30.26 Insert a second half pin in the anterior medial plane using as long a Rancho cube as possible. (©
J. Charles Taylor.)

Reduction
With all struts unlocked, the distal ring is repositioned with respect to the proximal ring, thereby reducing the
fracture (Figs. 30.28 and 30.29). While the reduction is maintained, the struts are locked (see Fig. 30.3). After a
simple suture is placed to close the short incision, each pin or wire entry is covered by a piece of Xeroform or
Adaptic dressing and a gauze sponge. The leg is wrapped with a roll gauze dressing. The foot, if not included in
the frame, is supported in plantigrade position with a sling or post op shoe tied to the Spatial Frame.

Creating Temporary Deformity to Close Soft-Tissue Defects

It may be possible to minimize or eliminate the soft-tissue defect sometimes present in open fractures. After initial
stabilization, rather than trying to achieve anatomic reduction, the fragments can be positioned with a certain
amount of shortening and angulation allowing the muscle and skin to be apposed. This malreduction can be held
for weeks if necessary allowing the soft tissues to heal without tension. The fragments can then be gradually
reduced obviating more complex plastic coverage (Fig. 30.30).

FIGURE 30.27 Usually, a third half pin is inserted in each fragment in an intermediate plane. This third pin is
usually attached to the ring with a one or two-hole Rancho cube. (© J. Charles Taylor.)

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FIGURE 30.28 With struts unlocked, the frame is manipulated to reduce the fracture. Struts are then locked. (©
J. Charles Taylor.)

FIGURE 30.29 After pin and wire fixation of each major fragment, with all struts unlocked, the fracture is reduced
under C-arm control or direct vision for open fractures. Each strut is then locked, thereby securing the reduction.
(© J. Charles Taylor.)

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FIGURE 30.30 A. Open fractures may have a soft-tissue defect if anatomically reduced. (© J. Charles Taylor.) B.
With overriding and angulation the soft-tissue gap might be eliminated or at least significantly reduced. The
vascular status must be closely monitored. (© J. Charles Taylor.) C. Struts are applied in the malreduced
position, and the soft tissues are allowed to heal over 2 to 4 weeks. (© J. Charles Taylor.) D. The fracture is
gradually reduced. (© J. Charles Taylor.)

Bone Transport for Open Fractures with Segmental Bone Loss

Open fractures with significant bone loss are a strong indication for external fixation, remote osteotomy, and
bone transport into the defect. The Spatial Frame allows the transported fragment to be positioned accurately on
the docking site without reoperation (Fig. 30.31).

SPATIAL FRAME-SPECIFIC POSTOPERATIVE MANAGEMENT

By fully characterizing postoperative skeletal deformity, recording the proximal and distal ring diameters and the
six strut lengths and measuring the position of the frame on the limb, the surgeon can gradually reduce fractures
utilizing the Total Residual Deformity Correction Method.
Skeletal deformity is completely characterized by measuring six deformity parameters: the three projected angles
(rotations) and three projected translations between major fragments.
The frame parameters consist of proximal and distal ring diameters and the strut lengths.
Four mounting parameters are measured radiographically and clinically after surgery for acute fractures. They
are AP View, Lateral View, Axial, and Rotary Frame Offsets.
These parameters are input to a computer program that determines new strut lengths for the Spatial Frame
fixator that will completely correct the skeletal deformity. A structure at risk and a safe velocity may be selected
to precisely control a gradual reduction.

Choosing a Reference Fragment and the Origin

Orthopedic convention characterizes the deformity of the distal fragment with respect to the proximal fragment.
(The proximal fragment is the reference fragment, and the distal fragment is the moving or deformed fragment.)
Deformities can also be measured where the proximal fragment is characterized with respect to a reference distal
fragment. This characterization of the deformity by describing abnormal position of the proximal fragment is
especially useful in distal fractures with a short distal fragment. The location of the attachment of the distal ring
(using the joint surface as a landmark) will be more exactly determined in surgery and postoperative
measurement than the level of attachment of the proximal ring on the longer proximal fragment. It also allows the
surgeon to fully characterize the deformity even though the radiographs are too short to include the level of
attachment of the proximal ring. The distal fragment is the reference fragment, and the proximal fragment is the
moving fragment.
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FIGURE 30.31 A-C. The Spatial Frame can be used for bone transport. Usually the Spatial struts are used at the
docking site. Regular threaded rods or Spatial struts can be used for the osteotomy site. The foot may be
included for additional soft-tissue and bony stability. Antegrade or retrograde transport may be performed. (© J.
Charles Taylor.)

Either fragment could be the reference fragment. Ideally, the reference fragment should satisfy two criteria:
1. The reference fragment should be that fragment whose anatomic planes most closely match the planes of the
AP and Lateral radiographs.
2. AP and Lateral radiographs include the actual level of attachment of a ring to the reference fragment.
The patella provides a prominent landmark for distal femoral or proximal tibial fractures. The foot provides a
prominent landmark for distal tibial fractures. Frequently, the best choice for the reference fragment is the short
fragment in conjunction with the prominent landmark. The x-ray technician is more likely to successfully align with
the landmark (criteria 1), and if the joint line is included in the radiographs (as it should!), then the level of
attachment of a ring to that fragment is also included (criteria 2).
Obviously, the actual deformity is the same whether the physician characterizes the distal fragment with respect
to the proximal fragment or alternatively characterizes the proximal fragment with respect to the distal fragment.
However, the working measurements of even an oblique plane angular deformity will be different depending
upon which fragment is chosen for the reference fragment. Strangely enough, the final external fixation frames
for these different deformity characterizations (based on alternative reference fragments) are identical and will
effect the same complete correction. It is important that the same fragment be maintained as reference fragment
for AP and Lateral radiographs as well as clinical exam for malrotation.
Translation between fragments is measured from an Origin on the reference fragment to its Corresponding Point
on the moving fragment. The best choices for Origin and Corresponding Point are points that are coincident in
the anatomic (reduced) state. The tip of a spike on the reference fragment and the matching notch on the moving
fragment would be reasonable choices in posttraumatic deformity if these points are easily discerned on AP and
Lateral radiographs (Fig. 30.32).
However, the mechanical axis at the fracture site of the reference fragment and the mechanical axis at the
fracture site on the moving fragment are the most commonly used choices for Origin and Corresponding Point
(Fig. 30.33). The implied coordinate system on which these translational and rotational measurements are made
is the coordinate system of the reference fragment. Thus, imagine a grid aligned with the mechanical axes of the
reference fragment. The AP View translation, Lateral View translation, and Axial translation are measured along
these grid lines.
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FIGURE 30.32 A spike and its matching notch, if discernible on AP and Lateral films, is one possible choice for
Origin and Corresponding Point to measure translations at the fracture site. (© J. Charles Taylor.)

FRAME PARAMETERS
Proximal and Distal Ring Internal Diameters
The internal diameter is printed on each ring, partial ring, or foot plate (Fig. 30.34).

Strut Lengths
FastFx struts are available in xx-short, x-short, short, medium, and long sizes ranging in functional length from 75
to 284 mm. For a given size, the strut has a specific range from its shortest to longest length and a midposition
marked on each strut. Struts are marked with millimeter graduations with actual strut length printed every 10 mm.
The achievable length of struts overlaps by a few millimeters at each transition from one body to the next (Fig.
30.35). The strut length is read at the indicator (Fig. 30.36).

Deformity Parameters
Imagine a limb segment in anatomic position (Fig. 30.37A). The two fragments adjoin at the origin. With fracture
or deformity (Fig. 30.37B), the two fragments are angulated and translated. The translations are measured as
the separation of the adjacent (or corresponding) point from the origin. Translations are measured along the
coordinate axes of the reference fragment (actually the reference ring).
Select one fragment as the reference fragment (Fig. 30.38). Translation is measured between the origin and its
corresponding point on AP and Lateral views. Axial translation can be measured on either radiograph as the
distance between the interior ends of fragments measured along the reference fragment centerline. AP and
Lateral angulations are measured as the angles between respective centerlines; the axial angle is measured
clinically.

FIGURE 30.33 Measurements of translation and rotation are made along an imaginary grid aligned to the
reference fragment. (© J. Charles Taylor.)

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FIGURE 30.34 The Frame Parameters, the description of the frame, consists of the internal diameters of the
ring, which are printed on the rings, and the strut lengths, which are read at the indicator of each strut. (© J.
Charles Taylor.)

FIGURE 30.35 Struts are available in xxshort, xshort, short, medium, and long bodies. The achievable length of
struts overlaps by 5 to 10 mm from one body to the next in the series. (© J. Charles Taylor.)
FIGURE 30.36 Strut length is read directly at the indicator pin. (© J. Charles Taylor.)

FIGURE 30.37 A. When anatomically reduced, the Origin and Corresponding Point are coincident, and there is
no angulation or rotation between the fragments. (© J. Charles Taylor.) B. In general, there could be a six axes
deformity after initial fracture reduction, consisting of three translations and three angulations. (© J. Charles
Taylor.)

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FIGURE 30.38 Translation (displacement) is the perpendicular distance from the reference fragment to its
corresponding point on the moving fragment. To measure translations determine where the corresponding point
is with respect to the origin. (If a distal reference is chosen, the AP view and Lateral view translations will
generally be opposite those if a proximal reference is chosen.) Note: Angulation and rotation are determined by
the reference fragment’s view of the deformity in a traditional sense. For example, if a proximal reference is
chosen and the AP view along the reference fragment shows a varus deformity, then it is a varus deformity. If a
distal reference is chosen and an axial view is taken along the axis of the distal fragment (usually clinical exam)
that shows the distal fragment internally rotated with respect to the proximal fragment, it is an internal rotation
deformity. (© J. Charles Taylor.)

Mounting Parameters
There are four mounting parameters that describe the position of the reference ring with respect to the Origin.
Axial frame offset, Lateral view frame offset, and AP view frame offset are measured on postoperative films.
Rotary Frame Offset is generally assessed by clinical inspection.

Axial Frame Offset

Axial frame offset is the measurement of length parallel to the frame centerline from the origin to the reference
ring (Fig. 30.39). This can generally be measured on AP or Lateral films. This measurement in millimeters
partially specifies the orientation of the frame with respect to the origin.

AP View and Lateral View Frame Offset

If the tibia is significantly shifted from centered on AP view, measure the distance from the origin to the centerline
of the rings. This distance is AP view frame offset (Figs. 30.40A and 30.41). In most tibial mountings with circular
fixators, the tibia is located anterior to the geometric center of the ring. Measure the distance from the origin to
the centerline of the frame. This distance in millimeters is Lateral view frame offset (Figs. 30.40B and 30.41).

Rotary Frame Offset

The preferred (reference) rotational orientation of the Taylor Spatial Frame is with the proximal ring universal
joints (master universal joints) for strut 1 and strut 2 located exactly anterior on the proximal fragment (Fig.
30.42). When used for fractures, the frame may be inadvertently malrotated when applied. Simply enter the
angular position of the sagittal plane of the reference ring with respect to the reference fragment in rotary frame
offset (Figs. 30.7 and 30.43).
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FIGURE 30.39 The mounting parameter, Axial Frame Offset, measures the axial distance from the Origin to the
reference ring. (© J. Charles Taylor.)

FIGURE 30.40 A. AP View Frame Offset, one of the four mounting parameters, is measured from the Origin to
the centerline of the frame on AP view. (© J. Charles Taylor.) B. Lateral View Frame Offset, measured on Lateral
View, describes the distance from the Origin to the centerline of the frame. (© J. Charles Taylor.)
FIGURE 30.41 The AP and Lateral View Frame Offsets describe how the center of the reference ring is
positioned with respect to the Origin in a transverse plane. (© J. Charles Taylor.)

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FIGURE 30.42 The Spatial Frame computer program assumes that the Master Tab is always directly anterior on
the proximal ring. (© J. Charles Taylor.)
FIGURE 30.43 Rotary Frame Offset, one of the four parameters, is measured clinically as rotation of the sagittal
plane of the reference ring with respect to the sagittal plane of the reference fragment. (© J. Charles Taylor.)

Structure at Risk and Rate of Correction

It is incumbent upon the surgeon to be aware of the structures at risk on the concavity of the deformity. When
dealing with rotation about the longitudinal axis in addition to conventional angular correction, the risks may be
less or greater depending on the direction of axial rotation. For example, when correcting a
flexion/valgus/external rotation deformity of the proximal tibia, the peroneal nerve is at increased risk. However,
when correcting a flexion/valgus/internal rotation deformity, the axial rotation will tend to offset the stretch on the
peroneal nerve created during the correction of flexion/valgus.
The computer program allows the surgeon to input the coordinates of the structure at risk with respect to the
origin and set the maximum daily displacement of the structure at risk. The program creates a daily adjustment
schedule moving the structure at risk the prescribed amount each day until the deformity is eliminated (fracture is
reduced).

A Second Chance for Correction

Because of nonorthogonal initial radiographs, error in measuring radiographs, or excessive preload and bending
of wires and pins, there may still be residual skeletal deformity when the struts have reached their target lengths
at the completion of a total residual deformity correction. Simply measure the radiographs to determine new
deformity parameters and make a clinical exam for malrotation. Use the Total Residual Deformity Correction
Program again to determine new strut lengths to correct the residual deformity. New mounting parameters can be
entered if the original parameters were in error.
Alternatively, during any gradual correction, a total residual deformity correction may be undertaken by
measuring current parameters and noting current strut settings.

Internet-Based Software for Gradual Reduction of Fractures

A powerful Web-based program prepares an adjustment schedule to correct any residual skeletal deformity after
a Spatial Frame is applied. The surgeon first signs in on the Web-based site (Fig. 30.44).
Once in the site, the surgeon can select any previously saved cases that can be modified and saved under a
new name, select cases sent by colleagues, or create a new case (Fig. 30.45A). Patient and file information as
well as specific case notes can be saved to a secure international internet server.
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The physician can progress from tab to tab in the program only if sufficient information has been submitted at
each step. The program will prompt the surgeon for all necessary information.
To begin (Fig. 30.45B), enter patient information and graphically select the side and site of application. The user
also can represent the case as dowels as in previous versions or a more anatomic rendering of the bone. Also, in
this first window, the surgeon chooses “Operating Mode,” either Total Residual or Chronic. Case Name will
appear as the default title of the case when the case is finally saved.

FIGURE 30.44 Home Section for Web-based software used to prepare gradual schedule for deformity
correction, including residual skeletal deformity after fracture application. (© Smith & Nephew, Inc. 2001, 2003,
2012.)
 P.593

FIGURE 30.45 A. Cases Section to open, modify, and save a prior case; open cases sent by colleagues; or start
a new case. (© Smith & Nephew, Inc. 2001, 2003, 2012.) B. Cases Section, Case Info is used to identify the
patient and graphically select the side and site of application as well as the Operating Mode of the computer
software, Total Residual or Chronic. Surgeons notes can be entered which will be stored. (© Smith & Nephew,
Inc. 2001, 2003, 2012.)

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FIGURE 30.46 Define Deformity provides for the selection of the Reference Fragment and input of the deformity
parameters. As the deformity measurements are entered, a schematic representation of the deformity is
presented. Dowel or Bone view may be used. If using the “Dowel View,” the pointed end of the blue rod is the
Origin, and the pointed end of the green rod is the Corresponding Point. (© Smith & Nephew, Inc. 2001, 2003,
2012.)

In the next window (Fig. 30.46), select the proximal or distal reference fragment. Input the six skeletal deformity
parameters. As Deformity Parameters are entered, the software provides the surgeon with updated AP, Lateral,
and Axial views of the skeletal deformity. If using the “Dowel View,” the pointed end of the blue rod is the Origin,
and the pointed end of the green rod is the Corresponding Point.
Using the pull-down menu in the next window, select the type and diameter of the proximal and distal rings and
the strut body type (Fig. 30.47).
Next, the position of the reference ring with respect to the Origin is input into the mounting parameters. The
computer-generated views should confirm the position of the reference ring as seen clinically and
radiographically (Fig. 30.48).
Each of the six strut lengths is entered in the next window (Fig. 30.49). The computer then provides a graphical
representation of the initial crooked frame on crooked bone. After the final settings are calculated, the final strut
settings are displayed, and a graphical representation of the bone and frame is shown at the end of correction.
In the next window, the coordinates of the structure at risk and the maximum safe velocity are entered (Fig.
30.50). The computer determines the number of days required for the correction. The surgeon may also override
the number of days.
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FIGURE 30.47 Frame identifies the diameter of the rings used as well as the location of the open section of the
ring for 2/3 rings and foot plates. Also, the type of strut and body size is input for each of the six struts. (© Smith
& Nephew, Inc. 2001, 2003, 2012.)

The next window, Spatial Frame Prescription (Fig. 30.51A), is usually printed for the patient to use as an aid in
adjusting the frame. The prescription lists the daily strut adjustments as well as highlighting when struts need to
be changed out.
Within this same window is a tab to select the physician’s report that reiterates patient information (Fig. 30.51B).
The mounting parameters, initial and final strut settings, the coordinates of the structure at risk, as well as the
safe velocity are shown in table form. The daily adjustment schedule is also provided. Critical days when struts
need to be exchanged are highlighted and color coded and identified with a letter. The strut exchanges are listed
and explained in chronological order, and a list of necessary Spatial Frame parts is also given.
The Total Residual correction program can be used to prepare a daily schedule to reduce a fracture that is
significantly overlapped by using a waypoint correcting angulation, rotation, and length in the first step (Fig.
30.52 rows A-D) and correcting translation in a second step (Fig. 30.52 rows D-F). In the first step, only the
deformity parameters pertaining to angulation, rotation, and length are input to achieve the corresponding strut
lengths to get to the waypoint. Next, AP and Lateral view translation are entered as the only deformity
parameters to take the fragments from the waypoint to anatomic position.
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FIGURE 30.48 Mount is used to input the mounting parameters, the position of the reference ring with respect to
the Origin. The computer-generated views should confirm the position of the reference ring as seen clinically and
radiographically. (© Smith & Nephew, Inc. 2001, 2003, 2012.)

Within version 4.1 of the Web-based program under the “Deformity” tab, there is the option to correct axial
translation as the initial correction followed by the remainder of deformity parameters. If this option is chosen,
there is a reminder in the Prescription and Report at the end of axial translation correction.

GENERAL POST-OP MANAGEMENT

Patients are allowed to be partial weight bearing when their general condition allows. Cleaning of the pin skin
interface is usually commenced 5 to 7 days postoperatively, often in the outpatient clinic. If good AP and Lat
radiographs were not obtained in the hospital, they are taken at this first postoperative visit. These initial
radiographs need to be wide enough to include the full diameter of the ring so that Mounting Parameters can be
accurately measured. The patient is seen at 1- to 2-week intervals especially while the frame is being gradually
adjusted. Adjustments are usually performed over 1 to 2 weeks for fracture reductions. As many adjustments as
necessary can be performed. Usually, one or two adjustment schedules are run for fractures.
Oral antibiotics are used as needed during treatment. Fracture healing time averages 18 weeks and ranges from
7 to 24 weeks depending on a number of factors (10,11,15,22). Wires that suddenly become painful may have
lost tension and should be retensioned in the office.
As the fracture heals, the patient will increase weight bearing on the injured leg. Patients usually will go to a
single crutch by 8 to 10 weeks and full weight bearing by 12 weeks. When the patient is full weight bearing and
the fracture appears healed radiographically, one or two struts are removed in the office, and the patient walks
around the office for 30 minutes. If they experience no pain, they walk at home for a week with only four struts
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in place. If subsequent radiographs show no change in position of the fragments and the fracture still appears
healed, and the patient reports no increase in pain, the frame is removed. Most frames are removed in the office
with local anesthetic. More complex frames are removed in surgery under general anesthetic or intravenous
sedation. A prefabricated short leg walking brace is used for a few weeks in most cases.

FIGURE 30.49 Strut Settings (for fractures) is used to input each of the six strut lengths after the acute fracture
reduction. The computer then provides a graphical representation of the initial crooked frame on crooked bone.
After the Final Strut Settings are calculated, the settings are displayed, and a graphical representation of the
bone and frame is shown at end of correction. (© Smith & Nephew, Inc. 2001, 2003, 2012.)

In cases where foot plates or U-plates are used to augment bony stability, stabilize soft-tissue wounds, or
prevent equinus contracture, an accessory walking plate that attaches to the frame and allows weight bearing is
beneficial (Fig. 30.53). Shoes slotted to accommodate the fixation wires and pins in the foot have also been
used.
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FIGURE 30.50 Duration/Structure at Risk is used to input the location of the structure on the concavity of the
deformity that is to be protected by controlling the rate of correction. Also, the “Max Safe Distraction Rate” can
be selected. Alternatively, the “Correction Time” may be arbitrarily set. (© Smith & Nephew, Inc. 2001, 2003,
2012.)

COMPLICATIONS
Most complications are avoided by applying a mechanically stable frame with pins and wires properly
inserted. The surgeon should be vigilant and perform Total Residual Deformity Corrections of any skeletal
deformity remaining after initial operative reduction. Precautions should be taken to prevent equinus
contracture, including, sometimes, foot fixation. Strive for weight bearing.
An arterial Doppler is used pre- and post-op to access the arterial supply to the foot. An acute arterial injury
in surgery might be picked up by an absent pulse or continued bleeding from a pin or wire site. Late
bleeding from a pin or wire is usually from arterial erosion and often requires emergent surgical treatment.
Plantigrade position of the foot is very important. If the patient is able to actively extend the ankle above
neutral, a padded night splint or sling may be used to prevent equinus contracture. If the patient is unable to
actively dorsiflex the ankle to neutral because of swelling or pain the foot should be placed in a sling or post
op shoe with straps to the Spatial Frame. Alternatively, a Dynasplint may be used to prevent progression of
the equinus and to slowly bring the foot to neutral as swelling and pain subside postoperatively. As stated
earlier, distal tibial fractures, open injuries, and those patients with a peroneal nerve injury, or head trauma
or compartment syndrome, are at a greater risk of developing an equinus contracture and should have the
foot included in the frame even if the fracture is stable. Frequent periods of partial weight bearing are
beneficial to fracture healing and the prevention of ankle and foot deformities.
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FIGURE 30.51 A. Prescription is usually printed for the patient to use as an aid in adjusting the frame. The
prescription lists the daily strut adjustments as well as highlighting when struts need to be changed out. (©
Smith & Nephew, Inc. 2001, 2003, 2012.)

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FIGURE 30.51 (Continued) B. Within the Prescription window is a Report tab for the physician, which
reiterates essential patient and clinical information. The mounting parameters, initial and final strut settings,
the coordinates of the structure at risk, as well as the safe velocity are shown in table form. The daily
adjustment schedule is also provided. Critical days when struts need to be exchanged are highlighted and
color coded and identified with a letter. The strut exchanges are listed and explained in chronological order,
and a list of necessary Spatial Frame parts is also given. (© Smith & Nephew, Inc. 2001, 2003, 2012.)

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FIGURE 30.52 A Way Point Reduction, though rarely needed, may be performed by inputting the deformity
parameters in two separate steps. A first Total Residual Correction is run with AP View Angulation, Lateral
View Angulation, Rotation, and Length as the deformity parameters to get the fragments to the way point
position (A-D). Next, a second Total Residual Correction is run with AP View Translation and Lateral View
Translation as the deformity parameters to get the fragments to anatomic position (D-F). (© J. Charles
Taylor.)

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FIGURE 30.53 An accessory walking plate allows weight bearing when foot fixation is utilized for tibial
fractures. (© Smith & Nephew, Inc. 2001, 2003, 2012.)

Some equinus contractures that remain after fracture healing, especially if multiple transfixion wires were
used, will resolve with weight bearing and physical therapy following frame removal. Persistent contractures
can be treated with application of a spanning Spatial Frame across the ankle and gradual correction of the
equinus and 4 to 5 mm of distraction across the ankle.
Persistent symptomatic contractures can be addressed with the Spatial frame still on the tibial shaft fracture
by applying a foot plate and connecting it to the most distal tibial ring with Ilizarov hinges placed along the
ankle axis or, if space permits, applying Spatial Frame struts between the distal tibial plate and the foot
plate and performing a deformity correction.
Pin or wire skin interfaces should be cleaned daily with antibacterial soap and water beginning about day 5
if soft-tissue wounds allow. A light pressure gauze sleeve about wires emerging through muscles will
decrease soft-tissue motion along the pin. Antibiotics by mouth are frequently but not always needed in the
4.5 months average healing time of adult fractures treated with external fixation. A wire that suddenly
becomes painful is usually loose and can be retensioned in the office, usually with immediate relief of pain.
Pins or wires that develop redness or drainage are treated by oral antibiotics, increasing the dose, or
occasionally intravenous antibiotics. Pin or wire sites that do not respond to treatment should be removed
and replaced, if needed.
There is a spectrum of healing patterns seen with external fixation range from primary bone healing to a
more robust appearance with callus. In several series, the average time to healing for adult tibial fractures
treated with primary external fixation is approximately 4.5 months (10,11,15,22). Varus/valgus or
flexion/extension stress views with the struts removed or a CT scan can be performed to assess healing. If
fragments are well reduced and there are no signs of healing at 3 months, an autogenous bone graft should
be considered for delayed union. Also, the mechanical stability of the construct should be questioned. The
frame may need to be revised by adding pins, wires, or even an accessory ring to extend the level of
fixation.
Failure of the method is uncommon. Each case should be closely analyzed to determine a best course for
subsequent treatment. Treatment options include cast or brace, repeat external fixation, intramedullary (IM)
nail, or plate fixation with or without autogenous bone grafting.

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RESULTS
Results with Spatial Frame compare favorably to the results with other external fixation, IM nails, and plating
of tibial fractures. During its development, the Spatial system was thoroughly tested for theoretical accuracy
of the computer program, combined mechanical accuracy in correcting severe six axis deformities, and
frame stiffness. The computer program is mathematically accurate to within a millionth of an inch and a ten
thousandth of a degree. The combined mechanical accuracy of the program as applied to the frame by
hand is 1-mm translation and 0.6-degree angulation. The Spatial Frame is as stiff as the Ilizarov in axial
loading and twice as stiff in bending and torsion. Recent mechanical studies support the use of half pins
with the Taylor Spatial Frame noting improved torsional stiffness for all ring sizes and increased axial
stiffness as well in 155-mm rings. Half pins allow for axial micromotion as well (2).
The Spatial Frame has been used since approximately 1996. Although initially reported for fractures and
deformity correction (3), its early acceptance was for deformity correction and nonunions (4, 5, 6, 7, 8 and
9) and has gradually gained acceptance for primary treatment of fractures in adults and adolescents (6,10,
11, 12, 13, 14, 15 and 16). Historically, malunion was the most common complication of external fixation
reflecting the difficulty in making adjustments after the initial surgery and the reluctance to return to surgery.
Not only does repeat surgery pose a risk to the patient, but there is the real possibility that in an effort to
improve one aspect of fracture reduction, another could be lost.
The ability to make prescribed gradual adjustments to the Spatial Frame in the postoperative period is the
greatest strength of the system. The program provides a daily adjustment schedule for the struts that are
easy to adjust using the direct read indicator for each strut. MacFadyen and Atkins (11) demonstrated a
100% compliance of their patients adjusting the frame as prescribed. Near anatomic realignment and
repositioning of the externally fixed major fragments have been routinely achieved. Binski and Hutchinson
(10), MacFadyen and Atkins (11), and Whately (15) report a 95% to 100% rate of anatomic or near
anatomic restoration of alignment and position. Likewise, these same authors report a 96% to 100% rate of
primary union and remarkably low rates of reoperation, approximately 5%, for delayed union.
Chaudhary (16) also found accurate fracture reduction and deformity correction in 23 tibiae without tedious
analysis and postoperative frame alterations. Elbatrawy and Fayed (17) have reported similar success in 29
cases of fracture treatment and deformity correction. Manner et al. (18) compared their extensive results in
deformity correction and found the Taylor Spatial Frame (TSF) allowed for much higher precision compared
to conventional ring fixators.
Addressing the higher end in the spectrum of severity, Lovisetti et al. (19) reported the successful salvage
with Ilizarov and TSF fixators of seven tibiae sustaining thermal necrosis to bone and skin from injudicious
reaming for IM nailing. Several of these same authors have further proposed TSF for primary and definitive
 treatment of III C fractures of the distal femur noting initial frame and wound stability, elimination of the
“second hit,” and continuity of the original frame until union (20,21).
Eidelman and Katzman (22) have reported high success rates using the TSF in complex pediatric tibial
fractures, acute and delayed. Gessman et al. (23) and Nho et al. (24) have utilized the TSF to minimize the
soft-tissue defect in open fractures by malreducing bony fragments, allowing skin and soft tissues to heal
and subsequently gradually reducing the bony fragments.
Finally, in the most severe fractures with segmental bone loss, Rozbruch et al. (25) have shown the benefits
of circular fixation, remote osteotomy, and transport in reconstructing bone and soft-tissue defects in
patients who are not candidates for flap coverage. Transport is also an alternative to more extensive flap
and grafting procedures, regardless (26).

REFERENCES
1. Taylor JC. Dynamic interfragmentary compression in oblique fractures stabilized with half pin external
fixation: the steerage pin. Poster Exhibit Annual Meeting American Academy of Orthopaedic Surgeons,
February, 1994.

2. Khurana A, Byrne C, Evans S, et al. Comparison of transverse wires and half pins in Taylor Spatial Frame:
a biomechanical study. J Orthop Surg Res 201027;5-23.

3. Taylor JC. Complete characterization of a 6-axes deformity: complete correction with a new external
fixator, ‘The Spatial Frame’. Presented at the annual meeting of ASAMI North America 1997.

4. Rozbruch SR, Helfet DL, Blyakher A. Distraction of hypertrophic nonunion of tibia with deformity using
Ilizarov/Taylor Spatial Frame. Arch Orthop Trauma Surg 2002;122:295-298.

5. Taylor JC. The Taylor Spatial Frame. Invited Presidential Address at 1998 Annual Meeting of ASAMI North
America. New Orleans, Louisiana.

6. Taylor JC. The Rings first method for fractures and deformity correction. Presented at the Annual Meeting
of ASAMI North America 1999.

7. Taylor JC. The spatial frame as a reconstructive hinge: theoretical and practical considerations.
Presented at the Annual Meeting of ASAMI North America 2000.

8. Taylor JC. 6, 6 + 6, and 6 × 6 correction of ankle and foot deformities with the spatial frame. Presented at
the Annual Meeting of ASAMI North America 2003.

9. Taylor JC. Reconciliation of CORA and origin/corresponding point methods of deformity characterization.
Presented at the Annual Meeting of ASAMI North America 2004, Toronto, Canada.

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10. Binski JA, Hutchinson B. Treatment of tibial shaft fractures with the Taylor Spatial Frame, The
International Society for Fracture Repair, Bologna, Italy, November 2-6, 2004.
11. McFadyen I, Atkins R. The Taylor Spatial Frame in Limb Reconstruction: Review of 100 Cases.
Presented at the British Orthopaedic Association Annual Congress. September, 15-17, 2004, Manchester,
England.

12. Taylor JC. The last malunion with primary external fixation of fractures: the power of residual deformity
correction with the spatial frame. Presented at the Annual Meeting of ASAMI North America 2000.

13. Taylor JC. Skew parameters and the total residual deformity correction: a geometric method. Presented
at the Annual Meeting of ASAMI North America 2001.

14. Taylor JC. Complete correction of residual deformity following chronic deformity correction or fracture
external fixation: the total residual deformity correction. Presented at the Annual Meeting of ASAMI North
America 2002.

15. Whately C. The Taylor Spatial Frame for acute tibial fractures. Presented at the Annual Meeting of
ASAMI North America 2004, Toronto, Canada.

16. Chaudhary M. Taylor Spatial Frame—software-controlled fixator for deformity correction—the early Indian
experience. Indian J Orthop 2007;41(2):169-174.

17. Elbatrawy Y, Fayed M. Deformity correction with an external fixator: ease of use and accuracy?
Orthopedics 2009;32(2):82.

18. Manner HM, Huebl M, Radler C, et al. Accuracy of complex lower-limb deformity correction with external
fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator. J Child Orthop 2007;1(1):55-
61.

19. Lovisetti G, Sala F, Thabet AM, et al. Osteocutaneous thermal necrosis of the leg salvaged by
TSF/Ilizarov reconstruction. Report of 7 patients. Int Orthop 2011;35(1):121-126.

20. Sala F, Capitani D, Castelli F, et al. Alternative fixation method for open femoral fractures from a damage
control orthopaedics perspective. Injury 2010;41(2):161-168.

21. Sala F, Albisetti W, Capitani D. Versatility of Taylor Spatial Frame in Gustilo-Anderson IIIC femoral
fractures; report of three cases. Musculoskelet Surg 2010;94(2):103-108.

22. Eidelman M, Katzman A. Treatment of complex tibial fractures in children with the Taylor Spatial Frame.
Orthopedics 2008;31(10).

23. Gessmann J, Baecker H, Graf M, et al. Operative treatment of pediatric open fractures of the lower limb
using the Taylor Spatial Frame. Unfallchirurg 2010;113(5):413-417.

24. Nho SJ, Helfet DL, Rozbruch SR. Temporary intentional leg shortening and deformation to facilitate
wound closure using the Ilizarov/Taylor Spatial Frame. J Orthop Trauma 2006;20(6):419-424.
25. Rozbruch RS, Weitman AM, Watson TJ, et al. Simultaneous treatment of tibial bone and soft-tissue
defects with the Ilizarov method. J Orthop Trauma 2006;20(3):197-205.

26. Al-Sayyad MJ. Taylor Spatial Frame in the treatment of pediatric and adolescent tibial shaft fractures. J
Pediatr Orthop 2006;26(2):164-170.
 31
Tibial Pilon Fractures: Staged Internal Fixation
David P. Barei
Daphne M. Beingessner

INTRODUCTION
Pilon fractures continue to be challenging injuries due to their associated and often complex osseous and soft-
tissue injury components. Pilon fracture is a mechanistic term that is commonly applied to injuries of the tibial
plafond and describes an axial-loading injury similar to the interaction of a mortar and pestle. The energy
absorbed in these injuries often causes significant osseous comminution, fracture displacement, and axial
shortening. This, in turn, results in the significant swelling, abrading, and blistering of the surrounding soft-tissue
envelope (Fig. 31.1).
These fractures are typically the result of higher-energy mechanisms such as falls from a height, motor vehicle
collisions, motorcycle crashes, or industrial accidents in younger patients. They also may occur as the result of
lower-energy torsional injuries. Both groups may have significant soft-tissue compromise. A spectrum of injury
exists, but the combination of axial and rotational force is universal and results in a variety of fracture patterns
depending on the direction of force and position of the foot and ankle at the time of load application.
A variety of associated injuries may accompany pilon fractures. Some series have reported up to 51% of patients
with other fractures or major system injuries. The rate of open injuries has been reported to be as high as 56%.
However, compartmental syndrome is relatively uncommon with reported rates of up to 5%. Vascular injury at a
rate as high as 52% may occur but typically involves only one vessel and the patients are not clinically ischemic.
The AO/OTA classification system incorporates all fractures of the distal tibia including extra-articular fractures of
the distal tibial metaphysis. Tibial plafond fractures are categorized as extra-articular (43 Type A), partial articular
(43 Type B), or total articular (43 Type C). Each type is then further divided into one of three groups depending
on the amount of fracture comminution. Subgroups are identified by other characteristics of the fracture, such as
the direction, description, or location of a fracture line, the presence of metaphyseal impaction, and the location
and amount of comminution. Although the system can be unwieldy with 27 separate injuries described, for the
purposes of developing a surgical tactic, the authors find it useful to group the fractures according to the
AO/OTA system.
Ruedi and Allgower’s seminal English language article in 1969 described a principled technique for ORIF of the
tibial plafond that demonstrated a substantial improvement in functional outcome, complications from arthrosis,
and a minimal treatment complication rate compared to nonoperative management. This landmark article would
become the benchmark for the treatment of these injuries with only 3 of 84 consecutive patients that developed a
deep-wound infection. Subsequent to this publication, the history of open reduction and plate fixation of tibial
plafond fractures in North America demonstrated a high rate of deep-wound infection and complications with
associated poor outcomes. At least two major differences can be identified between Ruedi’s study and
subsequent studies with higher complication rates noted: (a) the time delay from injury to definitive surgery and
(b) the mechanism of injury. Though infrequently noted, 75% of Ruedi’s patients were definitively managed
surgically on the day of their injury. Fourteen patients were delayed for over 7 days secondary to “severe
swelling or doubtful skin conditions,” and the remaining six patients had been treated initially with casting
elsewhere but the exact time to their definitive procedure was not indicated. Furthermore, of the 84 fractures in
Ruedi’s manuscript, 60 fractures (71%) occurred from skiing injuries, 19 fractures (23%) occurred
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from a fall between 3 and 12 feet, and only 5 fractures (6%) occurred from higher-energy traffic accidents.
Comparatively, the subsequent North American literature describes a time delay between injury and definitive
treatment between 3 and 6 days. Additionally, a greater proportion of these patients sustained their injuries from
higher-energy motor vehicle collisions or other industrialized mechanisms. While other variables may also be
responsible for the differences in outcomes and complications, the difference in timing and injury mechanisms
remain key differences and have shaped the evolution of tibial pilon fracture care over the past 30 years.

FIGURE 31.1 Clinical photograph of a patient who sustained a high-energy tibial pilon fracture after falling from a
height. Because of other life-threatening injuries, he was unable to be brought to the operating room for
approximately 3 days. Note the significant hemorrhagic and serious fracture blisters that preclude definitive
operative treatment at this time.

Because of the problematic soft-tissue complications that became evident with open reduction and internal
fixation (ORIF), the optimal treatment for these injuries was reassessed and the development of staged ORIF
was developed. Specifically, this entails performing definitive ORIF only after a period of soft-tissue recovery.
Two separate reports by Sirkin and colleagues and Patterson and Cole in 1999 have led to its popularization and
concluded that the historically high rates of infection associated with ORIF of pilon fractures may have been due
to attempts at immediate fixation through swollen and compromised soft tissues.
There is still no consensus on the optimal treatment for these injuries; however, staged ORIF of high-energy
tibial pilon fractures has decreased wound complication rates commensurate with those seen in the initial Ruedi
and Allgower’s work. Overall, a deep-wound sepsis rate of approximately 2% to 5% for closed fractures is a
reasonable estimate, with higher rates likely in open fractures. Staged treatment requires the early application of
at least a spanning external fixator with or without fibular fixation. Key points for successful treatment are the
restoration of limb alignment, length, and rotation and placement of external fixator pins well outside the area of
surgical exposure or anticipated definitive implants. This strategy allows for more extensive approaches for
internal fixation in order to optimize articular reduction while decreasing the likelihood of soft-tissue compromise.
In addition, advances in minimally invasive-plating techniques, development, and familiarity of alternate
exposures and the availability of low-profile anatomic plates have given the surgeon more tools to address these
challenging injuries.

INDICATIONS AND CONTRAINDICATIONS

The vast majority of displaced pilon fractures should be treated with internal or external fixation with very limited
indications for nonoperative treatment. In displaced and comminuted fractures, nonoperative treatment often
leads to a malunion and occasionally a nonunion. However, some completely nondisplaced fractures may be
treated nonoperatively with cast immobilization until radiographic signs of union are present. This treatment is
followed with progressive weight bearing in a removable cast boot. In patients with significant medical
comorbidities who cannot tolerate surgery or in those that are bedridden or nonambulatory, a closed
manipulative reduction may be performed followed by cast immobilization. Alternatively, in those patients with
significant shortening, calcaneal traction for a short period of time (<2 weeks) followed by casting may be
performed.
Displaced pilon fractures are typically treated operatively. Although the optimal treatment method has not been
determined, there is general consensus that restoration of alignment and articular congruity and correction of
talar subluxation will improve outcomes.

PREOPERATIVE PLANNING
History and Physical
A complete history of the injury should be obtained. Understanding the mechanism of injury helps to determine
the presence of associated injuries as well as the anticipated soft-tissue disruption associated with the pilon
fracture. Other important factors include medical comorbidities, nicotine use, employment and hobbies, location,
and timing of the injury, as well as any preexisting ankle joint conditions. Since these injuries are often
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the result of an axial load, a complete musculoskeletal survey must be completed to assess for other extremity
fractures, spine, or pelvic injuries. Focused physical examination of the affected extremity should include
assessment of the soft tissues. The presence of abrasions, open wounds, fracture blisters, contusions, skin
tenting, and swelling should be noted. Gross deformities should be realigned during the physical examination.
Pulses should be documented as well as a complete peripheral nerve examination of the tibial and peroneal
(superficial and deep) nerves in both their sensory and motor distributions.

Imaging Studies
Radiographic evaluation of pilon fractures includes standard anteroposterior (AP), mortise, and lateral images.
Full-length radiographs of the tibia and fibula should also be included to evaluate for more proximal injuries.
Computed tomography (CT) with sagittal and coronal reformations provides more detail of fracture orientation to
allow for accurate preoperative planning. CT scanning, however, should be deferred until after a provisional
reduction (i.e., external fixator with or without fibular fixation) has occurred as it will provide more accurate
information about the fracture configuration (Fig. 31.2). If the plain radiographs demonstrate a relatively simple
fracture pattern without significant shortening in a patient with a minimal softtissue injury, acute CT scanning is
appropriate to plan for definite operative fixation.

Timing of Surgery
There is a wide spectrum of presentations of pilon fracture, and surgical timing must be tailored to each
individual case. The key factor in determining timing of surgery is the condition of the soft-tissue envelope. Open
fractures should be treated emergently with irrigation and débridement followed by spanning external fixation or
definitive fixation. While not every tibial plafond fracture requires staged treatment, the authors have found this
treatment strategy to be successful in the management of the large majority of these injuries. Accordingly, if the
patient is going to be treated with staged ORIF, reestablishing limb length and alignment, and relieving the skin
of any areas of pressure should be done within the first 24 to 48 hours after appropriate medical clearance has
been obtained. The second stage is then performed when the swelling has sufficiently resolved, usually 1 to 2
weeks after the index procedure. The soft tissues at this point will demonstrate skin wrinkles, loss of “shininess,”
reepithelialization of fracture blisters, and a general pliability to the soft-tissue envelope.
FIGURE 31.2 This 45-year-old man sustained a closed tibial pilon fracture after falling from a ladder.
Radiographs (A and B) demonstrate significant articular comminution, anterior talar translation, and varus
malalignment. After fibular ORIF and biplanar spanning external fixation. (C and D), overall alignment is markedly
improved. Computed axial tomographic scanning with sagittal and coronal reformations (E-G) was performed
after placement of the external fixator, which allows the creation of a definitive surgical tactic. (E-G) was
performed after placement of the external fixator, which allows the creation of a definitive surgical tactic.

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FIGURE 31.2 (Continued)

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FIGURE 31.2 (Continued)

SURGERY: STAGED OPEN REDUCTION AND INTERNAL FIXATION

The authors treat the majority tibial plafond fractures with staged ORIF using the general principles outlined by
Ruedi and Allgower four decades ago. The goals are anatomic articular reduction and anatomic restoration of
length, alignment, and rotation of the distal tibia. Conceptually, pure isolated medial buttress plating, as originally
described by Ruedi and Allgower, is less important as choosing an implant, or implants, that are appropriate to
support the anticipated loads that the articular and diaphyseal fracture components may encounter. This
treatment method requires close attention to the creation of a surgical tactic at each intervention. Failure to do so
may compromise the final result and increase the risk of complications.

Stage 1: Fibular ORIF and Spanning Tibiotalar External Fixation

The goal of the initial operative stage is on the reduction and stabilization of the osseous component of the
fracture, particularly restoration of limb length, alignment, and rotation, but primarily as it relates to its effects on
soft-tissue stabilization. Specifically, this means the elimination of skin tenting, soft-tissue distortion, areas of
ischemia from displaced osseous fragments, and restoration of soft-tissue length. This first stage is typically
performed urgently as soon as the patient’s general condition permits. Critical elements of this stage include the
accurate placement of skin incisions, external pin placement, anticipation of where definitive tibial surgical
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incisions and implants will be placed, and the execution of optimal reduction of the fibula and tibial fractures. It is
the authors’ opinion that, if possible, the surgeon performing the initial stage should also perform the definitive
stage or share a similar management philosophy. Decisions and treatments that occur during this initial stage
can have significant impact on the final result. Furthermore, one should not be lulled into the assumption that this
stage is “simple” or only “provisional.”

Preoperative Planning
The key features of this stage include the anticipation of all skin incisions (for this and later stages), débridement
of any open wounds, ORIF of an associated fibular fracture, and closed manipulative reduction and temporary
spanning external fixation of the tibial plafond fracture. Close evaluation of the injury radiographs will help
determine whether an associated fibula fracture failed predominantly in compression, tension, or rotation and aid
in selecting optimal fibular fixation. It is infrequent that anything beyond fibular fixation and tibiotalar spanning
external fixation is performed in the first stage, but there are some exceptions. In a small subset of tibial plafond-
fracture patterns, extension of the fracture may propagate into the diaphysis. Occasionally, acute reduction and
stabilization of this fracture component during the initial stage may facilitate the subsequent stage of definitive
articular and axial reductions and fixations (Fig. 31.3). Similarly, widely displaced or rotated posterolateral
Volkmann fragments may also be addressed during the initial stage. While this is an infrequent occurrence, a
careful preoperative plan will allow the fibula fracture and posterolateral Volkmann fragment to be addressed via
the same posterolateral skin incision. It is imperative, however, that the surgeon refrain from overzealous open
tibial reductions during this initial stage.
FIGURE 31.3 A 32-year-old man sustained bilateral tibial pilon fractures and a tongue-type calcaneus fracture
after a fall from scaffolding. Plain injury radiographs of the left distal tibia (A and B) demonstrate a large posterior
plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. Note the
anterior and proximal talar displacement from the unstable posterior plafond fragment. Percutaneous,
fluoroscopically assisted clamp and lag-screw fixation were performed (C-E), followed by the application of a
biplanar external fixator (F and G).

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FIGURE 31.3 (Continued)

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FIGURE 31.3 (Continued)

Positioning and Draping

The patient is placed supine on a radiolucent operating table. A soft supportive bump or roll is placed beneath
the ipsilateral buttock, flank, and shoulder region to minimize the tendency for the entire limb to externally rotate.
A sturdy foam ramp or pillow is placed beneath the injured extremity to slightly flex the ipsilateral hip and knee
and elevate the leg, thereby allowing easier access to the posterolateral aspect of the fibula and to allow
unobstructed lateral fluoroscopic imaging of the foot, ankle, and tibia. The ipsilateral arm is placed across the
chest to avoid a traction injury to the brachial plexus. All bony prominences should be padded, particularly the
fibular head and lateral malleolar regions of the contralateral leg. A tourniquet is rarely used for this procedure.
The leg is shaved, aseptically prepared, and free-draped to the mid-thigh. A first-generation cephalosporin
antibiotic is administered within 60 minutes of the surgical incision. The image intensifier is brought in from the
contralateral side of table. When performing operative fixation of the fibula, the monitor is best viewed when it is
located at the foot of the bed. During the application of external fixation, particularly when applying traction to the
foot, the monitor is best positioned closer to the head of the bed.

Approach

FIBULA
While a straight lateral incision is typically performed for simple fractures of the fibula, the skin incision for fibular
fixation in the setting of a tibial plafond fracture should be performed in a relative posterolateral location;
specifically, slightly posterior to the palpable posterior border of the fibula. This allows for the use of
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the same incision if a posterolateral tibial approach is later chosen and increases the soft-tissue bridge if an
anterolateral exposure is required for tibial fixation. This posterolateral incision is also not directly located over
the subcutaneous fibula and therefore may help to minimize wound complications in this area (Fig. 31.4).

FIGURE 31.4 The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral
plate via a posterolateral surgical exposure. A. Note that the incision is largely over the peroneal musculature
rather than over the subcutaneous portion of the fibula. B. The incision is closed using the Allgower-Donati
suture technique to preserve skin vascularity and distribute the skin tension equitably. C. Final closure with
adjunctive adhesive strips.

The incision is longitudinal and centered over the fibula fracture. Dissection is carried directly through the
subcutaneous tissue, and the fascia of the lateral compartment is incised longitudinally along the entire length of
the skin incision. The anterior edge of the incised fascia is then retracted anteriorly, and the peroneal
musculature is retracted posteriorly. To preserve vascularity to the skin, care is taken to minimize the creation of
planes between the subcutaneous tissue and the fascia over the lateral compartment. Depending on the location
of the fracture, the superficial peroneal nerve may be encountered within the lateral compartment prior to exiting
the fascia and traveling within the subcutaneous layer.

TECHNIQUE
Fibular reduction and stabilization positively influence the initial management of these injuries in the following
ways:
1. Restoration of accurate fibular length, alignment, and rotation indirectly reduces the majority of tibial deformity
secondary to the ligamentous and other soft-tissue attachments between the two bones.
2. After fibular reduction and fixation, residual tibial displacement can be managed with an ankle joint spanning
external fixator using the reduced and stabilized fibula as a fulcrum.
3. Fibular reduction commonly neutralizes the tendency for valgus angulation and/or lateral translation of the
talus and associated tibial pilon fracture fragments.
4. Anatomic reduction of the fibula allows indirect reduction of the associated anterolateral (Chaput) and
posterior (Volkmann) tibial articular fragments via the anterior and posterior distal tibiofibular syndesmotic
ligaments, respectively.
Fibular malreduction, therefore, may result in the talus not being centered beneath the anatomic axis of the tibia
or may result in distal tibial metaphyseal malalignment. Notably, extension malreduction of the fibula is not
infrequent
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and results in anterior translation of the talus relative to the anatomic axis of the tibia and ultimately anterior talar
extrusion from beneath the tibial plafond. Fibula fractures that occur predominantly from rotational or tension
mechanisms are typically stabilized with one-third tubular plates. Unlike rotational ankle fractures, however, the
associated fibular fractures seen with high-energy tibial plafond fractures fail in compression or tension.
Compression failures frequently demonstrate comminution with transverse and oblique fracture plane
orientations. Tension failures are usually simpler, in terms of comminution, and generally occur in a relatively
distal location. While one-third tubular plates may occasionally be satisfactory, stiffer constructs are often
required. Stacked one-third tubular plates, precontoured distal fibular periarticular plates, and 2.7-mm or 3.5-mm
dynamic compression plates may be required. Manufactured, stiff precontoured periarticular distal fibular plates
are particularly advantageous, in that they provide satisfactory stability, while providing a reduction template by
virtue of their design.
The fibula is reduced using direct or indirect techniques or a combination thereof, and stabilizing implants are
typically applied to the posterolateral aspect of the bone. The placement of supportive bumps solely beneath the
posterior aspect of the hindfoot or ankle, as is commonly done for rotational ankle fractures, should be avoided
as this can result in an extension deformity of the fibula and tibia. If improved access to the fibula is required, the
entire leg should be elevated and supported on several bumps to avoid creating this common but avoidable
angulatory deformity.
While fibular reduction and fixation is typically performed prior to tibial reduction and external fixation, there are
occasions where reversal of this sequence may be advantageous. If limb shortening or instability is significant,
obtaining fibular reduction will be problematic. In these situations, external fixation of the tibial component is
performed initially to obtain provisional restoration of length, alignment, and rotation. Fibular reduction and
fixation is then performed. Similarly, in the setting of a comminuted fibula fracture, where a comparatively
minimally comminuted tibial fracture component exists, closed manipulative reduction and external fixation of the
tibia initially may more accurately restore length, alignment, and rotation of the limb and facilitate the subsequent
fibular reduction. In situations with significant fibular comminution, indirect reduction using a periarticular fibular
plate is very useful. Using an open approach, but with minimization of dissection in the zone of injury, the distal
portion of the plate is applied to the lateral malleolus in an anatomic position and held with Kirschner wires (K-
wire) and a small bone-holding clamp. Gradual restoration of fibular length is achieved with traction applied to
the foot and heel. Once length is achieved, the proximal portion of the plate is secured to the fibula proximal to
the fracture using another bone-holding clamp. The reduction is then adjusted until there is clinical and
fluoroscopic confirmation of restoration of length.

TIBIA
Very infrequently, the x-rays demonstrate a widely displaced or dislocated posterolateral Volkmann fracture
fragment. This injury pattern can be particularly challenging since definitive tibial plafond anterior exposures may
not allow adequate visualization or opportunity for satisfactory stabilization of this fragment. In these situations, a
posterolateral surgical approach to the tibia can be performed in conjunction with the initial stage and will simplify
the subsequent tibial reduction and fixation (Fig. 31.5).
The patient is positioned in the lateral decubitus position with the uninjured limb down and held there with a
deflated beanbag. The down limb is padded, particularly around the peroneal nerve at the knee and the lateral
malleolus. A ramp pillow or folded blankets are used to support the injured extremity. The skin incision is
performed halfway between the posterior border of the fibula and the lateral aspect of the Achilles tendon. Care
is taken to avoid injury to the sural nerve. The fascia overlying the peroneal musculature and tendons is incised
and the peroneals are retracted anteriorly. The underlying fascia is identified and incised longitudinally, exposing
the flexor hallucis longus (FHL) muscle and tendon. This unit is elevated from the posteromedial aspect of the
fibula and retracted posteromedially. During this dissection, the peroneal artery and accompanying veins may be
encountered immediately posterior to the fibula and require ligation. The posterior Volkmann fragment is then
identified, cleansed of organizing hematoma, and the posterior tibiofibular ligment is left intact if present. The
fibula can then be approached by now retracting the peroneals posteriorly. Fibular reduction often greatly aids in
the reduction of the posterior Volkmann fragment and is the first-reduction maneuver performed. In situations
where a poor ligamentotaxis effect on the fragment with fibular reduction occurs, reduction of the fibula helps to
bring the talus into a more centralized position beneath the tibia allowing easier manipulation of the Volkmann
fragment. One-third tubular, one-quarter tubular, or 2.0-mm plates are typically satisfactory for achieving stability.
It is imperative that unreduced anterior and central plafond fracture fragments not be secured with fixation that is
used to stabilize the Volkmann fragment to the posterior tibial metaphysis. Once the fibula and Volkmann
fractures are reduced and stabilized, the beanbag can be inflated, and the patient is allowed to roll backward to a
“sloppy lateral” position. This will allow the application of the external fixator.
FIGURE 31.5 The posterolateral approach is uncommon, but can be very useful for the treatment of substantially
displaced posterolateral (Volkmann) fracture fragments. A. The skin incision is at the midpoint between the
posterior border of the fibula and the lateral aspect of the Achilles tendon. B. Posterior retraction of the peroneal
musculature reveals the associated fibular fracture.

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FIGURE 31.5 (Continued) C. Anterior retraction of the peroneal musculature and incision of the muscular
investing fascia reveal the flexor hallucis longus and, often, the terminal portion of the peroneal artery. D.
Retraction of the FHL musculature posteromedially reveals the posterolateral aspect of the distal tibia. E.
Visualization of the fibular and posterior tibial fixation is seen.

TIBIAL EXTERNAL FIXATION

External fixation effectively stabilizes the tibial component of the injury, maintains neutral talar tilt, and resists the
tendency of the talus to displace anteriorly out of the ankle mortise. It is usually performed after fibular
stabilization and achieves these goals indirectly using ligamentotaxis. One of the most influential indirect
reduction methods for obtaining an accurate restoration of tibial length and alignment is the achievement of an
accurate and stable fibular reduction. Because this type of external fixation is only temporary, elaborate
constructs are not needed; however, the reduction must be rendered effectively stable as this provides a key
component to soft-tissue recovery.
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FIGURE 31.6 Medially based tibiotalar spanning external fixator viewed from the medial (A) and superomedial
(B) vantage points.

The authors use two main external fixation constructs for the staged management of tibial pilon fractures:

1. In the setting of an intact fibula or a surgically stabilized fibula, a medially based external fixator is typically
used (Fig. 31.6). A 5-mm Schanz pin is placed from anteromedial to posterolateral through the proximal tibial
diaphysis. A second 5 mm pin is placed from medial to lateral into the posterior aspect of the calcaneal
tuberosity and should avoid the numerous calcaneal sensory branches from the tibial nerve. The knee is then
flexed and supported with a radiolucent triangular support commonly used for tibial nailing. This position
allows placement and fluoroscopic imaging of a midfoot Schanz pin. This is a 4-mm Schanz pin placed from
medial to lateral across the three cuneiforms of the ipsilateral midfoot. To minimize the risk of septic
complications after definitive surgery, it is imperative that these pins are inserted out of the anticipated
location of plates, screws, and incisions. Talar neck pins are specifically avoided, as these will compromise
many anterior and anteromedial exposures of the distal tibia. Manipulation of the calcaneal Shanz pin performs
the vast majority of the reduction and is composed of (a) traction (restores tibial length); (b) varus or valgus
correction (to achieve a horizontal talus in the frontal plane); and (c) posterior translation (to reduce the
commonly seen anterior talar displacement). After these reduction goals are achieved, a radiolucent bar is
applied that connects the tibial pin to the calcaneal pin. Placement of this initial bar stabilizes the vast majority
of the reduction. At this time, the talus should be centered beneath the tibia on both the AP and lateral
fluoroscopic images, and the talar dome should be perpendicular to the longitudinal axis of the tibial shaft on
the AP view. Restoration of tibial length is estimated by reestablishing the normal relationship of the lateral
process of the talus with the distal tip of the fibula (i.e., the so-called dime sign). It is imperative that the tibia is
distracted to its normal length, with slight over distraction being preferred. Because the force vector between
the tibial pin and the calcaneal pin (represented by the radiolucent bar) is located posterior to the anatomic
axis of the tibia, the talus is held posteriorly beneath the tibial plafond, which minimizes anterior displacement.
 A second radiolucent bar connects the cuneiform pin to the tibial pin and maintains the tibiotalar articulation in
a neutral dorsi- and plantarflexion position. A third bar connects the calcaneal pin to the cuneiform pin
increasing the rigidity of the external fixation construct. A second 5 mm anteromedial to posterolateral Schanz
pin is then inserted into the tibial diaphysis just distal to the initial tibial Schanz pin and is typically connected
to both of the longitudinally oriented bars, completing the construct. Insertion of this last pin allows reduction
and stabilization of small amounts of angulation and translation of the proximal fragment.
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FIGURE 31.7 A biplanar tibiotalar spanning external fixator viewed from the lateral (A) and anterior (B)
vantage points.

2. There are several situations where the authors prefer a biplanar external fixator (Fig. 31.7). This includes (a)
an unstabilized fibula fracture; (b) tibial pilon fractures with a delayed presentation (>5 to 7 days postinjury);
(c) plafond fractures with substantial valgus angulation despite an intact or operatively reduced and stabilized
fibula; (d) marked displacement, particularly tibial shortening, with an intact fibula. This latter situation
presumes that there is talofibular capsuloligamentous disruption, and the fibula is no longer helpful in directing
the reduction of the talus, and hence, the fracture fragments of the tibial plafond. In these situations, a biplanar
calcaneal Schanz pin greatly assists in the restoration of tibial length and coronal plane talar alignment. The
key differences between this biplanar external fixator construct as compared with the medially based frame
described previously are (a) the use of a transcalcaneal Schanz pin and (b) the placement of tibial diaphyseal
pins in a more anterior to posterior direction rather than anteromedial to posterolateral. The reduction
sequence is identical to that outlined for the medially based external fixator; however, the calcaneal Schanz
pin can be manipulated from both the lateral and medial aspects, resulting in excellent control of the hindfoot
and the talus and distal tibia via ligamentotaxis. Medial and lateral radiolucent bars are used to secure the
tibial pin to the medial and lateral portion of the calcaneal pin, respectively. The remainder of the construct is
 similar to that described for the medially based frame.
At the conclusion of the procedure, the fibular skin incision is closed using a modified Allgower-Donati suture with
the knots tied posteriorly. Deep suture is rarely required. The limb is placed into a well-padded splint and a CT
scan of the distal tibia and fibula is then obtained to allow for the preoperative planning of the definitive tibial
fixation. Final tibial reduction and fixation is usually performed 7 to 21 days after this initial stage and only after
soft-tissue recovery has occurred.

POSTOPERATIVE CARE
Postoperatively, patients receive antibiotic prophylaxis for 24 hours, parenteral and oral analgesia, and the limb
is splinted with a removable posterior prefabricated support. Limb elevation, pin site care, and active motion of
the toes are encouraged. If there are no other significant injuries, the patient receives deep venous thrombosis
prophylaxis until they are mobilized and discharged home. As noted above, a thin-cut axial CT scan is obtained
with sagittal and coronal reformations prior to discharge. The patient returns to the outpatient clinic for an
assessment of soft-tissue swelling and to review the definitive operative plan at 1 week.
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Stage 2: Definitive Tibial Open Reduction and Internal Fixation
While restoration of the articular surface along with stable internal fixation that allows early motion is felt to be the
most important predictor of a satisfactory outcome, this remains controversial. Open management requires
meticulous attention to preoperative planning, soft-tissue handling, and the appropriate timing of intervention.
Avoidance of serious soft-tissue complications and an anatomic stable articular and metaphyseal reduction
provides the ideal environment for obtaining a satisfactory outcome.

Preoperative Planning
The vast majority of the surgical tactic is obtained from (a) a complete review and assessment of the
postspanned CT scan to assess the degree of articular surface involvement particularly noting the magnitude
and location of articular surface displacement, (b) the initial injury radiographs to determine the optimum location
for implants to stabilize the metadiaphysis, and (c) a clinical assessment of the soft-tissue envelope to determine
areas that are optimal or suboptimal for surgical incisions and implants. Because the ligamentous structures of
the ankle remain largely intact after a tibial pilon fracture, OTA C-Type injury patterns commonly demonstrate
three main fracture segments: the anterolateral (Chaput) fragment, the posterior (Volkmann) fragment, and the
medial malleolar fragment. Each of these fragments typically remains attached to the anterior tibiofibular
ligament, the posterior tibiofibular ligament, and the deltoid ligament, respectively. Infrequently, subtle areas of
comminution around the anterolateral and posterolateral fragments may represent detachment of the anterior
tibiofibular and posterior tibiofibular ligaments. The importance of this is that the ligamentotaxis effects on these
fragments may be much less than anticipated and may also result in syndesmotic incompetence despite fixation
of the posterolateral and anterolateral fracture fragments. Comminution and impaction are noted along the
intersection of the major fracture lines that separate the three major articular components described. These
areas of comminution and impaction are readily identified on the CT scan. The preoperative plan must include an
assessment of the major fracture components, and how their manipulation will allow access to the areas of
comminution while respecting their soft-tissue and ligamentous attachments. Ideally, stabilizing implants will
secure reduced articular fragments as well as neutralizing the major anticipated displacing forces that occur in
the metadiaphyseal region. A simple way to determine the likely direction of displacement is to review the injury
radiographs and assess the direction and displacement of the talus. A review of the fibula fracture and plafond
fracture will help determine the specific osseous areas that failed under tension, compression, rotation, or
combined mechanisms. This subsequently leads to an estimation of zones of articular impaction and areas that
are appropriate for implant placement to provide buttress, antiglide, or tension-band effects. All of this must be
done within the limitations of the soft-tissue injury and within the limits that the available surgical approaches
offer.
Precontoured periarticular distal tibial plates are extremely useful in the definitive management of these fractures.
Anterolateral, medial, and posterior distal tibial periarticular plates are now commonly available and provide the
surgeon with the ability to place multiple screws into the epiphyseal portion of the distal tibia, while allowing the
plate to facilitate indirect reduction of the metaphyseal component. Similarly, the stiffness of these plates is
particularly useful for unstable AO/OTA C-type injuries. More malleable implants, such as distal radius T-plates,
quarter tubular, third tubular, and minifragment plates, are occasionally useful, particularly in partial articular
injuries, where neutralization of the metadiaphysis is unnecessary, or in conjunction with stiffer implants when
meta-diaphyseal neutralization is required and the larger implant is insufficient for complete fracture stability.
Additional equipment often includes a universal distractor, Schanz pins, a large external fixation set, allograft or
bone graft substitute, headlamp illumination, K-wires, minifragment screws, osteotomes, dental picks, and a
variety of Freer elevators and bone clamps.

Positioning
The great majority of tibial plafond fractures are managed with anterior-based exposures, and therefore, the
patient is typically positioned supine and is similar to that used for the initial stage. Because the surgical
procedure may take several hours, a Foley catheter is inserted, and care is taken to pad all bony prominences. A
thigh tourniquet is commonly used to help with visualization of the articular surface. After the induction of
anesthesia and positioning of the patient, the limb is given a provisional scrub to remove loose skin and debris.
Provided the pin sites have been well maintained, the entirety of the preexisting external fixator is prepared and
draped into the surgical field. The surgeon is typically located at the distal end of the radiolucent table, and the
image intensifier is placed contralateral to the injured extremity. A first-generation cephalosporin or other
appropriate antibiotic is administered within 60 minutes of the surgical procedure.
As described above, in those unusual situations where a posterolateral approach is indicated, the patient is
placed in the lateral position, which facilitates a posterolateral exposure of the distal tibia. Externally rotating the
limb and tilting the operating table slightly can subsequently allow supplemental anterior or medial exposures.
The positioning for the posterolateral approach is given above.
Very uncommonly, a posteromedial exposure is required to adequately address the main components of the
injury. Radiographic clues that may suggest the need for a posteromedial approach include posteromedial
articular comminution and impaction, with posterior translation of the talus (unlike the typical anterior
displacement) and an intact or relatively intact anterior plafond. Rarely, tendinous and/or neurovascular
entrapment
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between posterior aspect of the medial malleolus and the posterior plafond, or tibial nerve dysfunction with
osseous debris or fragment displacement identified within the tarsal tunnel, may mandate a posteromedial
approach. The exposure can be performed with the patient in the supine or prone position. If the patient is in the
supine position, a small soft support is placed under the contralateral buttock and flank region, thereby
facilitating external rotation of the injured leg. Both legs are slightly elevated on ramp pillows or bumps with the
injured limb placed slightly higher than the uninjured limb. Occasionally, the prone position is used and allows an
easier trajectory for the insertion of screws and provisional stabilizing wires. In this situation, the patient is
positioned prone on padded bolsters. The injured limb is elevated on bumps or pillows to allow attainment of
lateral fluoroscopic images.

Surgical Approaches
The choice of surgical approach depends on the location and displacement of the major fragments and the local
soft-tissue conditions. Numerous surgical exposures for the operative treatment of tibial plafond fractures have
been described and include an anterolateral Bohler approach, a straight anterior approach, a classic and a
modified anteromedial approach, a straight lateral approach, a posterolateral approach, and a posteromedial
approach. Because of a greater understanding of tibial plafond fracture anatomy and the importance of soft-
tissue preservation, percutaneous adjuncts, limited arthrotomies, and indirect articular reductions have also been
described and clearly have a role in the treatment of these injuries. The authors utilize the modified anteromedial
or anterolateral exposures to manage the vast majority of tibial plafond fractures. Posterolateral and
posteromedial exposures are uncommonly required.

ANTEROMEDIAL APPROACH
The anteromedial approach to the distal tibia is a classic extensile exposure that allows adequate visualization of
a large percentage of the tibial plafond. It is particularly useful in medial-sided articular injury patterns as it allows
optimal visualization and management of the central and medial aspects of the tibial plafond, the medial
malleolus, and the subcutaneous portion of the distal tibial metadiaphysis. The approach can be extended
proximally to manage associated contiguous or noncontiguous fractures of the tibial diaphysis. The most
significant drawback from this exposure has been the creation of a large anteromedial skin flap that may already
be at risk from the injury.
Beginning in the distal diaphyseal region, the traditional anteromedial exposure begins approximately 1-cm
lateral to the tibial crest and follows the course of the tibialis anterior tendon. At the level of the ankle joint, the
skin incision continues distally and medially, ending at the distal tip of the medial malleolus. The skin and
subcutaneous tissue is elevated from the underlying deep fascia only to a point where the medial aspect of the
tibialis anterior tendon is identified. Immediately medial to the tibialis anterior tendon, a full-thickness incision
directly to the osseous surface of the anteromedial distal tibia is made. Ideally, the deep dissection should not
enter the tibialis anterior paratenon. The anteromedial skin, subcutaneous tissue, and periosteum are
subsequently elevated as a full-thickness flap, similar to that performed during the extensile lateral exposure for
calcaneal fracture management. Retraction of the anterior compartment laterally allows for limited visualization of
the lateral aspect of the distal tibia. As in all tibial plafond fracture exposures, the joint is entered by longitudinally
incising the capsule in the location of the major anterior fracture line.

MODIFIED ANTEROMEDIAL APPROACH

A subtle modification of the traditional anteromedial approach has been recently described by Assal, and is the
authors’ preferred anteromedial exposure (Fig. 31.8). This exposure allows visualization of the anterior and
medial aspects of the distal tibia, while improving visualization of the lateral distal tibial metaphysis and lateral
articular surface. The main drawback to this approach is similar to the standard anteromedial approach,
specifically, the creation of an anteromedial skin flap. Additionally, and unlike the traditional anteromedial
exposure, a relatively acute angle is created at the level of the ankle joint, and the skin of the tip of the
anteromedial flap may be more prone to superficial necrosis.
Similar to the previously described anteromedial exposure, the skin incision for the modified anteromedial
approach begins proximally approximately 1 to 2 cm lateral to the anterior crest of the tibia and over the anterior
compartment. This longitudinal component is continued distally to the level of the tibiotalar articulation, and then
the incision curves medially, creating an angle between the vertical and the horizontal limbs of approximately 105
to 110 degrees. The horizontal portion of the incision then extends to a point approximately 1 cm distal to the tip
of the medial malleolus and frequently terminates once the saphenous vein is identified. The medial edge of the
tibialis anterior tendon is identified and protected as the extensor retinaculum and periosteum immediately medial
to the tibialis tendon sheath are incised sharply. Similar to the traditional anteromedial exposure, a full-thickness
skin, subcutaneous, and periosteal tissue flap is then elevated from the distal tibial metaphyseal region. The
capsular incision is performed longitudinally between the major anterior fracture fragments.
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FIGURE 31.8 The modified anteromedial surgical approach for a tibial pilon fracture. A. The skin incision is
marked on the skin and viewed from the anterior aspect. The vertical limb is lateral to the palpable anterior tibial
crest and begins to curve medially at the level of the ankle joint. B. The distal extent of the incision is
approximately 1 cm distal to the tip of the medial malleolus adjacent to the saphenous vein. C. The superficial
exposure only elevated the skin and subcutaneous tissue just medial to the tibialis anterior tendon sheath. D.
The deep dissection occurs medial to the tibialis anterior tendon sheath with elevation of the medial flap to
include skin, subcutaneous tissue, and medial distal tibial periosteum. Retraction of the anterior compartment will
reveal the anterolateral aspect of the distal tibial plafond. E. Joint distraction allows visualization of the entire
distal tibial articular surface. F. The deep closure consists of reapproximation of the deep periosteal layer with
interrupted absorbable suture in a tension distributing fashion.

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FIGURE 31.8 (continued) G. The sutures of the deep layer have been sequentially tied and cut allowing for the
skin to be closed using an Allogower-Donati skin stitch.

ANTEROLATERAL APPROACH
The main advantage of the anterolateral approach is the avoidance of dissection over the tenuous anteromedial
soft-tissue envelope of the distal tibia (Fig. 31.9). It is an excellent alternative to the anteromedial exposures.
Unlike the anteromedial exposures, the anterolateral approach is mainly limited in the surgeon’s ability to
visualize and manipulate medial plafond comminution. The anterolateral approach otherwise allows excellent
access to a substantial amount of the tibial plafond, particularly the lateral, posterior, and central aspects. The
exposure relies on mobilizing and externally rotating the anterolateral (Chaput) fragment on the anterior
tibiofibular ligament. This maneuver allows access to the posterior and central aspects of the plafond.
Anterolateral plate application is simplified with this exposure because the anterior compartment is retracted
medially. This exposure, however, is nonextensile, and proximal screw fixations are typically made
percutaneously. If needed, medial implants can be placed percutaneously or through a separate medial malleolar
approach. The skin incision is oriented longitudinally and placed in line with the fourth ray. The incision travels
over the anterolateral aspect of the distal tibia and is usually centered over the anterolateral fracture fragment.
Because of the origin of the anterior compartment musculature, the maximum proximal extent of the incision is
limited to approximately 7 centimeters above the plafond. The variably located superficial peroneal nerve and/or
its arborizations are almost universally identified immediately within the subcutaneous fat. The nerve and its
branches are mobilized to allow retraction either medially or laterally. The distal extent of the fascia overlying the
anterior compartment and its confluence with the superior extensor retinaculum are identified. The superior and
inferior extensor retinaculae are incised longitudinally, immediately lateral to the course of the long toe extensor
tendons and peroneus tertius tendon. The longitudinal incision in the retinaculum is carried proximally through
the fascia of the anterior compartment. The entirety of the anterior compartment is retracted medially exposing
the underlying anterolateral aspect of the distal tibia (Chaput fragment) and the capsule of the ankle joint. A
longitudinal capsulotomy is performed at the medial extent of the Chaput fragment, thereby exposing the
tibiotalar articulation. Transversely oriented capsular vessels are often encountered and require cauterization.
Mobilization of the anterolateral Chaput fragment on its anterior distal tibiofibular ligament allows visualization of
the central and posterior tibial plafond.

POSTEROLATERAL APPROACH
The posterolateral approach is relatively uncommon but extremely useful exposure for the management of select
tibial plafond fractures. It is most useful for partial articular tibial plafond fractures where the unstable articular
segment is located posteriorly and there is no significant articular comminution. As noted earlier, it can be used in
conjunction with other anterior exposures to adequately reduce and stabilize the entire articular surface.
Complete articular fracture patterns that are most amenable to this adjunctive approach include (a) those with
complete dissociation of the posterolateral (Volkmann) fragment from the fibula, especially those that remain
substantially displaced despite anatomic reduction of any associated fibula fracture and (b) articular injury
patterns that demonstrate a large but minimally comminuted posterior plafond fragment that can be anatomically
reduced to the posterior metadiaphysis. Because of the orientation of the tibial plafond, once the posterior or
posterolateral portion of the tibial plafond is reduced, direct visualization of the articular surface is extremely
difficult if not impossible with this exposure. The articular reduction is achieved indirectly using any available
posterior cortical interdigitations, and is confirmed radiographically.
The posterolateral exposure is described above and can be performed with the patient in either the lateral or
prone position.
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FIGURE 31.9 A 48-year-old man was involved in a skiing accident. His injury plain radiographs and CT scan
demonstrate a spiral meta-diaphyseal tibial fracture with contiguous displaced anterolateral plafond fracture
(A-D). The surgical tactic included an anterolateral exposure of the distal tibial articular surface with adjunctive
percutaneous medial plating to stabilize the metadiaphyseal injury. (A-D). The surgical tactic included an
anterolateral exposure of the distal tibial articular surface with adjunctive percutaneous medial plating to stabilize
the metadiaphyseal injury. (E and F) The anterolateral skin incision is marked. The diaphyseal fracture
component is reduced and stabilized through a separate noncontiguous small anterior exposure. (E and F) The
anterolateral skin incision is marked. The diaphyseal fracture component is reduced and stabilized through a
separate noncontiguous small anterior exposure. (G) Immediately beneath the skin incision, the superficial
peroneal nerve and underlying superior extensor retinaculum are identified. (H and I) A universal distractor is
applied to the lateral aspect of the leg, with a Schanz pin placed into the lateral talar neck distally and the tibia
proximally. Satisfactory joint visualization is demonstrated. Initial stabilization of the metadiaphyseal component
has facilitated this approach. (J-L) The anterolateral articular surface is reduced and definitively stabilized with a
low-profile conventional implant with lag-screw fixation. The capsular incision has been closed. (M) A medial
distal tibial plate has been percutaneously inserted in a retrograde fashion. (N and O) Final immediate
postoperative AP and lateral images of the final reduction and fixation construct.

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FIGURE 31.9 (continued)

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FIGURE 31.9 (continued)

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FIGURE 31.9 (continued)

POSTEROMEDIAL APPROACH
The indications for the posteromedial approach to the tibial plafond are limited.
The longitudinal incision is placed just medial to the medial border of the Achilles tendon. Avoid disruption of the
paratenon overlying the Achilles tendon. Incise the fascia overlying the FHL musculature. Depending on the
location of the fracture fragments, the posteromedial aspect of the distal tibia is best approached in one of two
ways. Retraction of the FHL and the contents of the tarsal tunnel medially allows the most central and lateral
exposure of the posterior plafond. Because of the fibular origin of FHL, significant proximal dissection of the
distal tibial metaphysis is limited however. Mobilization of the FHL from the neurovascular bundle allows more
medial visualization at the joint level and also allows much more proximal medial visualization of the
metadiaphyseal area. In situations where a large posteromedial fragment spike can be reduced to the
metadiaphyseal region without the need for posteromedial articular visualization, a small longitudinal incision can
be made immediately posterior to the posteromedial distal tibial border and the digitorum musculature elevated
posterolaterally, immediately revealing the posteromedial surface of the tibia without directly disturbing the
neurovascular bundle.
The posteromedial exposure described can be performed with the patient in either the supine or the prone
position (Fig. 31.10).

Surgical Technique
The reduction and fixation sequence of any tibial pilon fracture varies according to the specific fracture pattern.
The authors regard the articular reduction as the most critical aspect of surgical care and, therefore, it remains
the priority of the surgical tactic. The reduction sequence, selected exposure(s), and location and type of
stabilizing implants are all directed toward achieving and maintaining an accurate articular reduction (Fig. 31.11).
Treatment of complete articular tibial plafond fractures (AO/OTA C-type) is among the most challenging fracture
patterns to operatively manage. While there are numerous possible fracture patterns, articular reduction of the
tibial plafond often begins with an assessment, reduction, and stabilization of the posterolateral (Volkmann)
fragment. Via the posterior tibiofibular ligament, an accurate fibular reduction begins the tibial reduction by
indirectly reducing the posterolateral Volkmann fragment relative to the proximal tibia and, of course, to the
reduced fibula. In some circumstances, however, despite an accurate fibular reduction, there remains residual
displacement, angulation, or articular impaction of the posterolateral Volkmann fragment. Whether further
reduction of the posterolateral fragment is performed via an anterior exposure, or directly using a posterolateral
exposure, depends on the degree of persistent displacement after the initial stage. For example, occasionally,
the posterolateral plafond exhibits a dorsiflexion impaction displacement that can be identified on the plain lateral
radiograph and more easily identified on the sagittal CT reformations. Subsequent reductions to the posterior
plafond therefore result in an extension deformity of the articular surface and a tendency to anterior talar
extrusion. Management of this residual deformity can usually performed through the anterior exposure. If
satisfactorily reduced, the reduction sequence commonly involves reducing the posterior aspect of the medial
malleolar fragment to the posterolateral fragment. Impacted central comminution is then reduced and secured to
the posterior plafond. The medial malleolar fragment is secured using the medial shoulder chondral
interdigitations, followed by reduction of the anterolateral (Chaput) fragment. This sequence, however, must be
flexible, and all strategies that achieve satisfactory articular and extraarticular reductions used. For example, a
useful technique for reduction of the articular segment as well as that of the metadiaphysis is to identify a
fracture fragment that contains some amount of articular surface distally while demonstrating a minimally
comminuted metaphyseal or metadiaphyseal proximal extension. An anatomic reduction of the proximal
metadiaphyseal component essentially converts the C-type tibial pilon fracture into a partial articular (B-type)
injury, greatly facilitating the reduction of the remaining articular surface, and providing a basis for reduction of
axial alignment. Large medial malleolar fragments, posterior osteochondral fragments, or large posterolateral
fragments are ideal for this reduction strategy. At each step of the reduction process, provisional fixation is
accomplished with the use of strategically applied clamps and small (0.045 inch) K-wires. Subchondral bone
defects are managed with morselized allograft cancellous chips or bone substitutes that provide stability, such as
some calcium phosphate materials.
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FIGURE 31.10 The posteromedial approach to the distal tibia can be performed in the prone or supine position.
The choice depends on a number of factors, including associated injuries and conditions that may make the
prone position hazardous and a fracture pattern that may necessitate anterior fracture manipulation, reduction, or
stabilization. Intraoperative photographs of the left leg of a patient in the prone position, viewed from the
posterior (A) and medial (B) vantage points. The planned surgical incision is adjacent to the medial border of the
Achilles tendon. In the same patient, a provisional reduction (C) and definitive fixation (D) of the distal tibial pilon
fracture are demonstrated. Note that the flexor hallucis longus (FHL) muscle (arrow) and the contents of the
tarsal tunnel are being retracted medially. E. Intraoperative photograph of the right leg of a different patient now
in the supine position. Note that a supple ipsilateral hip joint will aid in providing satisfactory visualization when
using the posteromedial exposure with a patient in the supine position. This position allows the posteromedial
approach to be used in conjunction with any required manipulation of other associated anterior distal tibial
fracture fragments (F). G. Intraoperative photograph of the same right leg demonstrating definitive fixation of a
posteromedial tibial pilon fracture. Note that because more proximal exposure was required in this fracture
pattern, the interval developed was between the neurovascular bundle and the FHL. The FHL (arrow) is
retracted laterally, and the neurovascular bundle is retracted medially.
 P.627

FIGURE 31.10 (continued)

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FIGURE 31.11 The operative sequence of stage 2: definitive ORIF of the distal tibial pilon fracture of the same
patient in Fig. 31.2. A review of the injury and spanned radiographs, and the CT scan (Fig. 2 A- G) demonstrate
C-type tibial pilon fracture with substantial medial metaphyseal osseous crush, articular comminution and
impaction (particularly central and anterior), and significant dorsiflexion deformity of the posterolateral
(Volkmann) fragment. The surgical exposure is the modified anteromedial. The external fixator was left in place to
maintain the talus in a distracted and posteriorly displaced direction allowing articular visualization. In this
situation, the articular reduction sequence begins with correction of the dorsiflexed posterolateral fragment ( A
and B). The posterolateral fragment is then reduced to the medial malleolus along the posteromedial fracture line
( C). K-wires are used to stabilize the reduction and are placed to minimize interference with the definitive
plate/screw implants. Reduction of the central, anterior, and lateral comminution is addressed next, using the
reduced posterolateral and medial fragments as a guide to reduction ( D and E). Notice the large cavitary defect
of the medial distal metaphysis. Residual posterior translation and flexion of the articular segment is noted and is
a consequence of the distraction maintained by the external fixator. An anterolateral distal tibial periarticular plate
is applied. An additional Schanz pin is placed into the distal aspect of the proximal segment, and a bone hook is
applied to the posterior aspect of the articular segment ( F). In conjunction with the precontoured periarticular
plate, they are used to reduce the axial alignment and angulation ( G). An additional precontoured periarticular
medial distal tibial plate is also applied given the anticipated instability of the distal tibial metaphysis and to
support the medial articular surface ( H). Final AP ( I), mortise ( J), and lateral ( K) immediate postoperative
radiographs demonstrate a satisfactory reduction. Note the presence of calcium phosphate bone substitute
material used to fill the medial metaphyseal defect. ( J), and lateral ( K) immediate postoperative radiographs
demonstrate a satisfactory reduction. Note the presence of calcium phosphate bone substitute material used to
fill the medial metaphyseal defect.

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FIGURE 31.11 (Continued)

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FIGURE 31.11 (continued)

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Articular visualization is greatly aided by the use of an external fixator or universal distractor with placement of a
Schanz pin directly into the talar neck. When an anteromedial exposure is performed, a medial to lateral talar
neck pin is inserted; conversely, when utilizing an anterolateral exposure, a lateral-to-medial talar neck pin is
inserted. By connecting the newly inserted talus pin to a preexisting tibial pin that was part of the initial spanning
external fixator or an additional tibial Schanz pin proximal to the fracture, distraction can be applied across the
ankle joint to aid in visualization. While visualization is improved with this type of distraction, occasionally, the
talus translates anteriorly and creates a paradoxical block to visualization and manipulation of articular
fragments. One method to minimize this is to utilize biplanar distraction via the tibial pins proximally, a
transcalcaneal pin distally, and the radiolucent bars from an external fixator set. Several advantages are
associated with this technique. (a) The talus remains posteriorly translated and distracted in the plafond allowing
easier manipulation of the articular fragments; (b) the distraction often achieves excellent overall metaphyseal
alignment, rather than inducing an angulatory malalignment as can be seen with a uniplanar distractor; (c) the
external fixation bars are posterior to the surgical exposure at the articular surface level and are not obstructive.
Provisional stabilizing implants are critical for the success of the procedure. Liberal use of small-diameter K-
wires, clamps, and minifragment plates and screws is very useful in maintaining a provisional reduction. These
devices should be placed out of the zone of definitive implants, and therefore, a preexisting knowledge of the
definitive implants, reduction sequence, and choices of surgical approaches is required.
Historically, implants used for tibial plafond fractures were placed on the anteromedial surface of the tibia. Their
size, poor design, and limited areas for strategic screw placement limited their usefulness and may have
contributed to wound problems. Current implants exhibit a more anatomical-based lower profile design and
simplify percutaneous and indirect plate reduction techniques. The goals of definitive internal fixation should
include absolute stability and interfragmentary compression of reduced articular segments, stable fixation of the
articular segment to the tibial diaphysis, and restoration of coronal, transverse, and sagittal plane alignments.
The location, rigidity, and number of these implants are based on each individual fracture. Important factors to
consider when choosing internal fixation for tibial plafond fractures include the degree of comminution, the ability
to achieve cortical contact and intrinsic fracture stability, the bone quality, the direction of the initial failure of the
bone (varus, valgus, flexion, extension), and the status of the soft-tissue envelope, any associated bone loss,
among others.
Ideally, the thickness of the plate should balance the need for an implant that has adequate stiffness to counter
the anticipated loads, while minimizing plate prominence and soft-tissue injury particularly along the anteromedial
surface of the tibia. Complete articular injuries (AO/OTA C-Type) typically require at least one stiff implant (e.g.,
3.5-mm compression plate) to maintain metadiaphyseal alignment. Partial articular injuries (B-type) can usually
be managed with lower profile implants that simply provide buttressing of the partial articular injury. The use of
locked plating remains poorly defined for intraarticular fractures of the distal tibia, and current evidence-based
recommendations are lacking. The majority of tibial pilon fractures at the authors’ institution continue to be
managed with nonlocking screw-plate devices.
Attention to wound closure is another critical component to successfully decrease soft-tissue complications. At
the conclusion of the surgical procedure, the joint capsule is closed with interrupted figure-8 absorbable suture.
Closure of the extensor retinaculum (anterolateral approach) and deep fascial layer (anteromedial approach) is
similarly done with interrupted figure-8 absorbable suture. The sutures are placed but not tied until the sutures
for the entire layer have been placed. Gentle traction is then applied to the suture ends, evenly distributing the
forces required for the deep closure. The sutures are then sequentially hand-tied and cut. The skin is closed with
nylon suture in an Allgower-Donati fashion. Steri-Strips are routinely applied over the skin incision to help
maintain reapproximation and minimize skin tension at the incision.

Postoperative Care
At the conclusion of the procedure, the injured limb is placed into a well-padded plaster splint with the foot in
neutral position. Pain is controlled with patient-controlled anesthesia devices. Peripheral nerve blocks, including
peripheral nerve catheters, are commonly used during the first 24 to 48 hours and are inserted at the conclusion
of the procedure while the patient is still under general anesthesia. Patients are discharged from the hospital on
a long-acting and a short-acting narcotic medication. The authors typically withhold nonsteroidal antiinflammatory
medications until approximately 3 months to minimize the theoretical risk of delayed or nonunion. The wound is
typically examined in the outpatient clinic area approximately 4 to 5 days postoperatively, and the limb is
subsequently splinted in a neutral position until the sutures are removed at 2 to 3 weeks. A supervised physical
therapy program consisting of active, active-assisted, and passive range of motion of the ankle, subtalar, and
metatarsophalangeal joints is then initiated. To avoid equinus contracture, a removable nighttime and resting
splint is recommended. Partial progressive weight bearing in a removable boot is initiated approximately 12
weeks after definitive surgery. The physical therapy focus at this point consists of maximization of motion,
strengthening, gait training, and the weaning of ambulatory devices such as crutches, canes, and external
supports. Postoperatively, edema may be substantial and persist for several months following injury. In addition
to patient education regarding this normal phenomenon, an elastic stocking is provided to help decrease
dependency-related swelling.
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COMPLICATIONS
Tibial plafond injuries are challenging injuries, and as such, complications may occur with surgical
management. The most common wound complication is partial thickness aseptic wound necrosis that
typically responds to careful observation after the patient develops a dry eschar and serial dressing
changes as needed. Full-thickness skin slough or surgical wound dehiscence may occur. In this setting, the
patient typically requires readmission to hospital for formal irrigation and débridement of the wound with
deep-wound cultures to accurately direct antibiotic treatment. Retention of stable hardware with antibiotic
suppression of the infection until fracture union is appropriate. However, loose implants should be removed,
and an external fixator may be required for stability. Large wounds that are not amenable to closure may
require flap coverage, and partnering with a plastic surgeon to develop a treatment plan is essential.
Chronic osteomyelitis may occur following tibial pilon fractures. If the fracture is healing, then antibiotic
suppression until union followed by removal of all implants and débridement of infected bone is appropriate.
Antibiotic treatment should be instituted and guided by an Infectious Diseases specialist. In the setting of
nonunion, osteomyelitis of the pilon is challenging to treat. Aggressive resection of all infected hardware
and tissue, including nonviable bone, is required. Antibiotic cement spacers may be used to fill defects, and
an external fixator is applied. After an appropriate course of antibiotics, reconstruction may be performed,
which may include both bone and soft-tissue procedures. Restoration of the distal tibia alignment is
paramount in order to facilitate potential arthrodesis procedures particularly if the articular surface has
degenerated following infection. In some settings, reconstruction is not possible and an amputation is the
best treatment for the chronic osteomyelitis.
The majority of tibial pilon fractures go on to union. However, nonunion rates of up to 16% have been
reported. Typically, the nonunion involves the extraarticular component of the fracture. A workup to exclude
infection is mandatory including a history of wound complications, physical exam, and blood work (WBC,
ESR, and C-reactive protein). Other causes of nonunion include medications, unstable fixation or technique
errors, avascular bone segments or general medical conditions such as vitamin D and calcium deficiency,
diabetes, or nicotine use. Principles of repair of aseptic nonunions include restoration of alignment, stable
internal fixation, and bone grafting of defects.
Posttraumatic arthritis may develop after pilon fractures, and many patients have at least some radiographic
findings of arthritis on their follow-up films. Early and minimally symptomatic arthritis may be treated with
rest, antiinflammatory medication, and occasional bracing. More severe arthritis may require arthrodesis.

OUTCOMES
The last decade has seen an improvement in outcomes when validated, patient-specific outcome tools have
been utilized; however, long-term outcome data and comparative studies are still lacking. While some of the
better quality studies are not specific to the staged ORIF of tibial pilon fractures, their data remain very
useful, particularly in demonstrating the residual injury burden that occurs with these fractures. Marsh
evaluated the intermediate term results of 56 tibial plafond fractures treated with external fixation and limited
 incision articular fixation. Thirty-five of these fractures were evaluated between 5 and 12 years postinjury.
Five of 40 ankles had undergone arthrodesis (12.5%). There was a long-term negative effect on the SF36
and Ankle Osteoarthritis Scale compared with age and gender-matched controls with 91% having x-ray
evidence of arthrosis demonstrated by osteophytes, joint space narrowing, or complete loss of joint space.
Eighty-seven percent of patients were unable to run. Injury severity and reduction quality correlated with
arthrosis but the presence of arthrosis had only weak correlations with functional outcomes. Importantly,
patients felt that they improved up to 2.4 years postinjury.
Pollak reviewed 80 patients treated with either external fixation or staged ORIF at a mean follow-up of 3.2
years. General health as per SF36 was significantly poorer than age and gender-matched controls. Thirty-
three percent of patients had ongoing pain. The use of external fixation and social factors (annual income
<$25,000 and a lack of a high-school diploma) were associated with a poorer outcome. Sixty-eight percent
reported that their fracture prevented them from working.
Williams evaluated 32 fractures treated with ankle-spanning external fixation and limited ORIF. Patients
were significantly lower in all but two SF36 categories compared with age and gender-matched controls.
Similar to Marsh’s study, radiographic arthrosis correlated with injury severity of the articular surface and
the quality of reduction, but clinical ankle scores and the SF36 correlated with preexisting patients
variables, such as gender, level of education, and the presence of a work-related injury.
Most recently, White and colleagues evaluated 95 fractures treated with acuteORIF. At 1-year follow-up, the
authors reported that 6% of patients had delayed or nonunions and a 1% arthrodesis rate. The SF36 also
demonstrated decreased physical and mental function compared with controls. Only 9% of patients reported
no pain, with 85% reporting mild or moderate pain. Forty-four percent were limited in their recreational
activity and 77% were restricted in their recreational or activities of daily living. Fifty-four percent had
employment changes including loss of job, change to a lighter duty job, or required permanent injury
benefits. Despite 90% of the initial reductions reported as anatomic, 78% had some evidence of arthrosis
on 1-year follow-up radiographs.
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Evidently, tibial pilon fractures have long-term effects on physical and mental function as determined by
patient-oriented functional and general health measurement tools. This translates into significant
detrimental effects on patients’ recreation, activities of daily living, and employment. Many of these
outcomes are driven by preexisting social factors such as level of education, gender, and the presence of a
work-related injury, and the degree of injury severity (such as fracture comminution). Unfortunately, factors
that are under the surgeon’s control, such as quality of reduction and method of stabilization, are not yet
strongly correlated with the final outcome and require further quality research to assess their impact. It is
likely that a slow improvement occurs over the first 2 to 3 years reaching a plateau at that time. The
arthrodesis rate within the first 10 years is likely 7% to 12%, but outcomes beyond this time frame are
largely unknown.

RECOMMENDED READING
Assal M, Ray A, Stern R. The extensile approach for the operative treatment of high-energy pilon fractures:
surgical technique and soft-tissue healing. J Orthop Trauma 2007;21(3):198-206.

Boraiah S, Kemp TJ, Erwteman A, et al. Outcome following open reduction and internal fixation of open pilon
fractures. J Bone Joint Surg Am 2010;92(2):346-352.
Howard JL, Agel J, Barei DP, et al. A prospective study evaluating incision placement and wound healing for
tibial plafond fractures. J Orthop Trauma 2008;22(5):299-305; discussion-6.

Marsh JL, Weigel DP, Dirschl DR. Tibial plafond fractures. How do these ankles function over time? J Bone
Joint Surg Am 2003;85(2):287-295.

Mehta S, Gardner MJ, Barei DP, et al. Reduction strategies through the anterolateral exposure for fixation of
type B and C pilon fractures. J Orthop Trauma 2011;25(2):116-122.

Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J
Orthop Trauma 1999;13(2):85-91.

Pollak AN, McCarthy ML, Bess RS, et al. Outcomes after treatment of high-energy tibial plafond fractures. J
Bone Joint Surg Am 2003;85(10):1893-1900.

Ruedi T. Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and
internal fixation. Injury 1973;5(2):130-134.

Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of
complex pilon fractures. J Orthop Trauma 1999;13(2):78-84.

Topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br
2005;87(5):692-697.

Tornetta P, III, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res 1996;323:273-
276.
 32
Tibial Pilon Fractures: Tensioned Wire Circular Fixation
James J. Hutson Jr.

INTRODUCTION
Circular tensioned wire fixation of periarticular fractures of the distal tibia is a well-established method of
treatment to manage selected pilon fractures as an alternative to internal fixation. Circular external fixation with
tensioned wires aligns and stabilizes these difficult and high-risk fractures with minimal additional soft-tissue
injury and few major complications. The chief advantage with this method of treatment is that it avoids the soft-
tissue dissection in the zone of injury required to place plates. Furthermore, the extensive metallic surfaces
inherent with internal fixation may increase the risk of bacterial colonization and subsequent infection. Despite
the advent of locked plating and “minimally invasive” surgical techniques, internal fixation of high-energy pilon
fractures is still associated with substantial risk. Increasing levels of soft-tissue damage, comminution of the
distal tibia, and bone loss create a zone of injury, which makes external fixation an attractive treatment
alternative. This chapter provides a comprehensive technique guide for application of circular fixation of pilon
fractures ranging from fixation of extra-articular distal tibial fractures to complex articular injuries with bone loss. A
bridging frame with limited internal fixation is a technique that surgeons with limited experience with circular ring
frames can learn to apply. For surgeons who treat complex pilon fractures not amendable to plating, the technical
drawings provided in this chapter may serve as a guide to address fractures with severe comminution, bone loss,
and complex soft-tissue injuries.
The Orthopedic Trauma Association’s Fracture Compendium that describes fractures in the distal tibia is seen in
Figure 32.1. Type A injuries are extra-articular fractures that spare the joint. Type B fractures are partial articular
injuries with an osteoarticular segment of the joint still intact and connected to the shaft. Type C fractures involve
the joint surface and adjacent metaphysis. They are further divided into three subtypes based on the severity of
articular and metaphyseal comminution. A C1 injury has a simple split, while C2 and C3 fractures have
increasingly complex joint disruption.

INDICATIONS AND CONTRAINDICATIONS

For many lower-energy injuries and in patients with a good soft-tissue envelope, internal fixation with low-profile
locking plates inserted using minimally invasive techniques is an attractive method of treatment. For example,
partial articular injuries (Type B) with an intact column of bone that maintains length are ideal for buttress plating
with low-profile plates. For many Type A and C1, fractures with mild to moderate soft-tissue injury can also be
treated with internal fixation or half-pin bridging frames with limited internal fixation.
However, as soft-tissue damage and bone comminution worsen, the indications to use circular tensioned wires
increase (1). Circular tensioned wire fixators are dynamic devices that allow the surgeon the ability to fabricate a
customized external fixator to treat complex distal tibial periarticular fractures. The fixators are
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constructed based on the position of the fracture fragments and the severity of injury to the soft tissues. Basic
principles are applied in sequence, which results in alignment and fixation of the fracture.
FIGURE 32.1 The AO/OTA classification of tibial pilon fractures. Type A distal tibial fractures have an intact joint
surface. Type B fractures have an intact portion of the metaphysis, and joint intact Type C fractures have varying
degrees of articular involvement and metaphyseal comminution.

Strong indications for circular tensioned wire external fixation of distal tibia periarticular fractures include
1. Grade II and III open fractures with soft-tissue injuries that would compromise an open approach for internal
fixation (Fig. 32.2). The most common is a large medial wound with partial edge necrosis that could not be
closed without a free flap (Fig. 32.3).
2. Closed fractures with soft-tissue injuries that would compromise an open approach for internal fixation
3. Complex fractures with severe comminution in which the fragments are too small to be fixed with locking
screws
4. Pilon fractures with bone loss (Fig. 32.4)
5. Pilon fractures with late presentation (>3 to 4 weeks)

FIGURE 32.2 Complex open wounds and crushing injuries are strong indications for circular fixation of a distal
tibia fracture. The frame has a modified foot ring to control the calcaneus and allow access to the medial skin for
local wound care.
FIGURE 32.3 A “classic” open medial wound with swelling and tissue loss that cannot be closed primarily. The
patient has diabetes and ischemic vascular disease. Acute shortening reduced the width of the open wound. The
minimal pathways of the tensioned wires avoid the dissection necessary to place plates. Because there is no
internal fixation to protect from bacteria, the wound was treated with local modalities with healing over several
months. This combination of risk factors creates a strong indication for circular fixation.

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FIGURE 32.4 A. A Grade IIIB open pilon with severe joint comminution and segmental bone loss. The patient
refused amputation. B. Reconstruction with bone transport for arthrodesis of the ankle after a free flap. C. The
reconstructed extremity with 13.5-cm transport and arthrodesis of the ankle.

Relative Indications
1. Pilon fractures with diaphyseal extension (Fig. 32.5).
2. Segmental tibial fractures
3. Patients with other fractures in the lower or upper extremity fractures that would enable mobilization and
earlier weight bearing
4. Obese patients who are unable to remain nonweight bearing for 3 months after plating
5. Pilon fractures associate with complex foot injuries
6. Psychiatric patients who will walk on their extremity against advice.
7. Patients with ischemic vascular disease/diabetes with tenuous skin that would not tolerate open incisions and
skin distraction necessary to place large locking plates

PREOPERATIVE EVALUATION AND PLANNING

History and Examination
Distal tibial periarticular fractures often occur in patients with other injuries. Multiply injured patients must be
evaluated for life and limb-threatening injuries using advanced trauma life support protocols. When the patient is
stable, the patient and his or her extremity are evaluated in detail. In the conscious patient, the mechanism of
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injury should be determined. This often gives important information about the amount of energy absorbed by the
limb and its impact on the soft tissues. The patient’s medical history should review important comorbidities such
as diabetes or peripheral vascular disease. Does the patient use alcohol or smoke tobacco? Is there a history of
mental illness? Is the patient employed? Does the patient have family support and financial resources for a
prolonged period of disability? These factors may influence the treatment recommendations.

FIGURE 32.5 A. A pilon fractures with shaft extension. B. The proximal stable-base fixation block is placed in the
proximal tibia, and the fracture is spanned with a distraction frame. A working length wire stabilizes the
comminuted section combined with limited internal fixation. C. Union of the fracture.

On physical exam, the entire limb from hip to toes should be exposed, inspected, and examined for signs of
injury. The soft-tissue envelope of the distal one half of the tibia should be carefully evaluated for abrasions,
blisters, or open wounds. In patients with skeletal deformity, gentle traction to grossly realign the limb should be
performed and the extremity supported. The dorsalis pedis and posterior tibial pulse are palpated. If undetectable
or asymmetric with the opposite side, a Doppler examination is performed. If there is compromise to the
circulation of the leg, consultation with vascular surgery is indicated. The lower leg and foot are evaluated for
compartment syndromes, which do occur but are seen less commonly than in patients with high-energy tibial
shaft fractures. A detailed neurologic exam with specific testing of deep and superficial peroneal, medial, lateral
and calcaneal plantar nerves, saphenous, and sural nerve function is recorded. It is essential to have an
accurate neurologic and vascular exam before surgery. If the patient has a postoperative loss of sensory, motor,
or vascular function, comparison with the preoperative evaluation is critical. Open wounds are observed for
extent of injury and degree of contamination. In patients with open fractures, intravenous cephalosporin or
vancomycin antibiotics are started immediately. Wounds with gross soil contamination receive additional
antibiotics that cover gram-negative organisms. With sterile gloves, the wound is lavaged with normal saline, and
a sterile dressing and splint are applied.

Imaging Studies
Essential radiographs include an anteroposterior (AP), lateral, and mortise view of the ankle, as well as full-
length films of the entire tibia. Dedicated x-rays of the foot should also be obtained. For the vast majority of
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pilon fractures, a computed tomography (CT) scan is obtained. It is an important adjunctive imaging study;
however, the scan should be delayed until the fracture has been preliminarily reduced and stabilized. If the scan
is acquired before the fracture is reduced, it is of little value. The scan defines the size and location of the
fracture fragments available for fixation. The orientation of the fragments, displacement of the joint surface, and
potential fixation pathways will be derived from the CT scan.

Surgical Tactic
Lower-energy closed fractures are placed into a well-padded short leg or coaptation splint. Open fractures,
fractures with vascular injuries, and patients with compartment syndrome require emergent surgery. Following
irrigation and débridement or compartment release, the fracture is temporarily stabilized with half-pin bridging
fixation using a transverse calcaneal pin and two half-pins in the tibia to create a delta frame (Fig. 32.6). Closed
fractures with comminution and displacement also are stabilized with an early bridging halfpin external fixator. If
these comminuted fractures are not reduced and stabilized early, massive edema and fracture blisters often
occur. Calcaneal pin traction on a Bohler-Braun frame or traveling traction with a transfixation pin in the
calcaneus and proximal tibia is an alternative if the patient cannot be taken to surgery (Fig. 32.7).
The goal of initial spanning fixation is to restore length and alignment of the fracture through distraction as well
as to align the dome of the talus with the central axis of the tibia shaft on both the AP and lateral views. The
second toe must be aligned with tibial tubercle to restore the correct rotational position of the extremity. The
forefoot is controlled with a metatarsal pin, and the foot is aligned in a plantar neutral position. It is essential that
excellent gross alignment be established with this initial bridging external fixation frame. However, it is important
to remember that indirect reduction through ligamentotaxis cannot reduce impacted osteoarticular fragments.
Failure to achieve these goals will compromise subsequent reconstruction. Repeat débridement, antibiotic bead
pouches, or negative pressure dressings are frequently utilized in selected open fractures.
FIGURE 32.6 An example of an acute or “resuscitation” distraction frame. A horizontal calcaneal transfixation pin
is used to distract through two connecting rods attached to a two-pin fixation block. The foot is controlled with a
first metatarsal pin to prevent equinus. In some lower-energy fractures, this frame is combined with limited
internal fixation as definitive treatment.
FIGURE 32.7 Traveling traction. A horizontal transfixation pin is placed through the proximal tibial and the
calcaneus. Distraction is maintained with connecting rods. The distal fragment can displace posterior if the heel
is not supported.

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FIGURE 32.8 A posterior fracture fragment can be forced into the posterior tibial neurovascular bundle
compromising blood flow and plantar sensation. This fragment requires early reduction to prevent permanent
damage to these essential structures.

A number of fractures will have further soft-tissue compromise or wound problems requiring repeat operative
débridement. Occasionally, a patient will have a fragment of the posterior tibia rotated and displaced against the
tibial nerve resulting in parasthesia or anesthesia of the plantar surface of the foot (Fig. 32.8). Reduction of this
fragment is urgently indicated to avoid permanent neurologic injury. A small number of Grade IIIB open fractures
prove to have unreconstructable limbs necessitating amputation (2). I have found it helpful to engage the patient
and family early in the course of treatment, particularly in severe cases involving limb salvage.
For the majority of closed and low-grade open fractures, improvement in the soft-tissue envelope occurs over 7
to 14 days. The status of the soft tissues determines the timing of definitive reconstruction of a pilon fracture.
When the edema has improved, the fracture blisters begin to reepithelialize, and the skin wrinkles return,
second-stage surgery can proceed.

Staged Reconstruction
Postreduction plain films and the CT scan are critically evaluated. The integrity of the lateral column is
determined by the presence or absence of a fibular fracture. If the lateral malleolus is fractured, the level of
fracture, amount of comminution, and separation of the fibula from the tibia are noted. The proximal extension of
the tibia fracture and comminution of the joint surface is evaluated. Fracture comminution and bone loss are
evaluated. The axial cuts on the CT scan help identify the ideal location for an incision if an open approach is
needed. A pilon fracture can be approached through anterior-medial, anterior-lateral, posterior-lateral, or
posteriormedial soft tissues based on the CT “windows” (Fig. 32.9). The condition of the soft tissues will be
compared to the fracture pattern to avoid an incision and dissection through compromised soft tissues. A
decision is made at this time as to the plan of treatment (a) open reduction and internal fixation, (b) bridging
external fixation with limited internal fixation, or (c) circular tensioned wire fixation. This chapter describes the
treatment strategies for tensioned wire fixation.
The goals of treatment in pilon fractures are to restore correct limb length, alignment, and rotation, reduce the
joint surface to match the contour of the dome of the talus, and reconstruct the ankle mortise and
metadiaphyseal bone. These goals are approached with cautious handling of the soft tissues. The strategy of
reduction for this injury is based on distraction. Because of the terminal location of pilon fractures, the tibial shaft
proximally is used as a fixation base to reduce the fracture. A fixation block is created with two half-pins in the AP
plane in an orthogonal position when using circular fixators. This fixation block is used as a base to support the
distal fixation rings, which are placed at the level of the plafond or calcaneus to distract and reduce the fracture.
The reduction of the fracture is initiated with application of a double-ring fixation block on the tibial shaft (Fig.
32.10). Distal fixation is determined by the configuration of the fracture and the soft-tissue injury. Type A, C1,
and C2 fractures with large fracture fragments are reconstructed with a fracture reduction ring at the level of the
tibial plafond (Fig. 32.11). If there is comminution of the joint, the frame will combine a distraction foot plate (ring)
and a plafond fracture reduction ring (Fig. 32.12). Pilon fractures amendable to limited internal fixation and
bridging distraction will have a foot plate (ring) applied to the calcaneus and talar neck without a ring at the level
of the plafond (Figs. 32.13 and 32.14).
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FIGURE 32.9 The surgical approaches to the distal tibia. A. Anterior lateral approach. Branches of the
superficial peroneal nerve must be carefully mobilized and protected. B. Anterior approach. Useful to place
anterior to posterior lag screws when using percutaneous reduction techniques. C. Anterior medial approach.
The anterior tibial tendon sheath should be kept intact with the approach located medial to the tendon. D.
Posterior lateral. Direct reduction and fixation of the posterior malleolus is accomplished through this portal. E.
Posterior medial approach. Applicable to complex medial malleolus fractures associated with pilon injuries.
FIGURE 32.10 Distal tibia/pilon fractures are treated with combinations of fixation blocks. The proximal tibial
fixation is applied in orthogonal alignment as a stable base in all fractures. A. Distal tibial fracture fixation ring. B.
Distal ring combined with a foot plate. C. Foot plate (ring) distraction across the fracture. The soft-tissue injury
and fracture pattern will determine the frame configuration.

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FIGURE 32.11 The basic distal tibial frame with an orthogonal tibia shaft fixation block and distal metaphyseal
fracture fixation ring. The safe zones for wire placement form a 60-degree arc in the medial lateral plane.
FIGURE 32.12 A foot plate is added to the basic frame to provide distraction of calcaneus to align the plafond
axially with the shaft of the tibia. Opposed olive wires in the calcaneus distract the pilon fracture and also
minimize equinus deformity of the foot.

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FIGURE 32.13 The circular ring fixator configured as a distraction frame. The foot plate has opposed olive wires
in the calcaneus, which are placed to avoid the posterior tibial nerve and artery. This frame configuration is used
with limited internal fixation and percutaneous fixation of some pilon fractures.

Distraction is the key to reduction. If the plafond or calcaneus (hindfoot) is distracted axially with correct rotation,
the distal tibial fracture will be spatially reduced with correct rotation, alignment, and length. This initial reduction
will facilitate the local alignment of the joint surface and the metaphysis by percutaneous or open techniques.
The better the alignment gained by accurate distraction, the easier the reduction of the joint and metaphysis. It is
almost impossible in complex pilon fractures to reduce the plafond if the dome of the talus is malaligned,
shortened, or rotated. This applies to any type of external fixator used to treat pilon fractures (monolateral, clamp
and rods, and circular tensioned fixators). The dome of the talus must be aligned correctly in distraction before
beginning the reduction of the fracture fragments.

FIGURE 32.14 A “by-pass” distraction frame. The foot plate is doubled to accommodate the large foot. The
frame has a stable a base with two AP half-pins and a medial halfpin. The hind foot is fixed with opposed olive
wires in the calcaneus and a talar neck wire.

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Anesthesia, Positioning, Imaging
General anesthesia is preferred. Postoperative nerve evaluation and the small chance of compartment syndrome
are relative contraindications to spinal anesthesia or regional nerve blocks. The patient is positioned on a
fluoroscopic flat-top table that allows easy access for a C-arm image intensifier, which is positioned on the
opposite side from the injured leg. A silicone bolster is placed under the buttock and flank to internally rotate the
leg to neutral. A tourniquet is placed on the thigh. Intravenous cefazolin or vancomycin is administered at least 1
hour before surgery. A foley catheter is placed as surgery often takes 3 to 6 hours.
The original or resuscitation fixator is removed before prepping. The resuscitation pins are never used for the
definitive fixator. Manual traction is maintained during the prep and drape to prevent angular displacement of the
fracture. The leg is scrubbed with soap and sterile water, and the pin sites are cleaned to remove dried skin and
debris. A formal prep and drape from tourniquet to toes is completed. It is essential to have the knee completely
exposed in the field to assess rotation of the fracture and limb. The rotation of the knee that centers the patella
image between the condyles is considered the AP alignment of the knee.

REDUCTION TECHNIQUE TYPE A AND TYPE C1 AND C2 FRACTURES

The level of the distal horizontal reference wire is determined by the fracture pattern. In Type A distal tibia
fractures, the joint surface is intact, while in some C1 and C2 fracture patterns, the articular fracture contains
large fragments. If a percutaneous or limited open reduction and fixation with subchondral lag screws will reduce
the joint surface anatomically and create a solid epimetaphyseal bone block, it is strongly recommended. The
reconstructed distal tibia can then be treated as a Type A fracture (Fig. 32.15).
The proximal ring block is aligned on the tibial shaft with two AP 5- or 6-mm half-pins (Fig. 32.16).
Hydroxyapatite-coated pins are always used because they bond to the bone reducing the incidence of pin track
infection. There should be at least 10 cm of spread between the half-pins to increase the fixator stiffness.
Mounting these pins with a Rancho Cube (Smith Nephew) facilitates alignment of the frame (Fig. 32.17). The
pins should be placed with their tips protruding just beyond the opposite cortex (Fig. 32.18). The distal halfpin is
placed 3 cm above the proximal extent of the fracture. Placing the half-pins distant from the fracture increases
the working length leading to frame instability. It is important to align the fixation block in an orthogonal position.
The frame should be parallel to the tibia on the AP and lateral views. The ring over the plafond must clear the
anterior soft tissues of the ankle, and the superior ring of the fixator block must not impinge on the posterior leg,
where the gastronemius and soleus muscles bulge posteriorly (Fig. 32.19).
If the fixation block on the tibia is orthogonal, then the joint surface of the plafond will be in anatomic alignment
when the joint forms a 90-degree (±2 degree) angle with the axis of the shaft. The joint line on the AP view forms
an angle of 90 degrees to the axis of the tibia. This anatomic fact allows the surgeon to accurately align distal
tibia fractures by placing a horizontal reference wire parallel to the epiphyseal scar and joint surface. The
horizontal reference wire is placed 10 mm above the plafond centered on the metaphysis in the lateral view (Fig.
32.20). The centered lateral view is used to place the reference wire (Fig. 32.21). This places the pin outside of
the joint capsule and prevents intra-articular pin placement (Figs. 32.22 and 32.23) (3,4). The plane of the
carbon fiber fracture reduction ring, which is connected to the proximal tibial ring, is 90 degrees to the shaft. The
horizontal reference wire in the distal tibia is attached to the distal side of a radiolucent carbon fiber fracture ring
and then manipulated under fluoroscopy to align the plafond axially and with correct rotation (Fig. 32.24). The
horizontal reference wire may need to be adjusted several times until an anatomic alignment is obtained (Fig.
32.25). Small angular corrections are done with washers on one side of the ring to improve alignment when
needed (Fig. 32.26). Once the wire is tensioned, distraction is placed across the fracture to reduce the
metaphysis.
FIGURE 32.15 A Type A distal tibia fracture. Reduction is gained by distraction to length, correction of rotation,
and axial alignment.

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FIGURE 32.16 The stable-base fixation block is placed 2 to 3 cm proximal to the fracture. The fixation block is
orthogonal to the tibia. Accurate alignment of the stable base facilitates fracture reduction.
FIGURE 32.17 The half-pins are connected to the rings on the stable base with universal fixation cubes. An 8-
mm bolt connects the Rancho Cube® (Smith Nephew) to a male hinge or post. These universal attachments
allow fine-tuning of the stable base and small corrections of the tibial shaft alignment with the plafond.
FIGURE 32.18 Half-pins are placed with 90-degree divergence in the midtibia. Care is taken not to insert or
leave the pins long.

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FIGURE 32.19 The anterior soft tissues at the ankle joint is more anterior than the skin on the subcutaneous
crest of the tibia. The treatment of pilon fractures with circular fixators requires that the frame be placed further
anterior to provide clearance for the ankle joint. The ring size may need to be increased in diameter to provide
adequate soft tissue for the front of the ankle and the bulging expansion of the gastronemius muscle.

FIGURE 32.20 A horizontal reference wire is placed parallel to the anterior joint. The wire is placed
approximately 10 mm above the joint.

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FIGURE 32.21 The horizontal reference wire is placed 10 mm above the joint parallel to the epiphyseal scar and
perpendicular to the axis of the tibia. The ankle joint is centered on the lateral fluoroscopic view to place the
reference wire accurately. If the fracture fragment is large enough, the wire is placed 12 mm superior to the joint.

FIGURE 32.22 A schematic illustration based on the anatomic study of Vora et al. of the capsular extension of
the ankle joint on the tibial plafond and fibula. The capsule has minimal overlap on the plafond medially and
posteriorly. The anterior-lateral extension requires the horizontal reference wire to be at least 10 mm above the
joint.

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FIGURE 32.23 The horizontal reference wire is placed 10 to 12 mm above the joint to avoid the anterior-lateral
proximal extension of the joint capsule. The posterior lateral fibula wire is placed on the superior surface of the
ring. The medial wire may be placed on either side of the ring depending on the fracture pattern of the pilon
fracture. A coronal plane wire is illustrated.

The alignment in the lateral view is examined next. Often the foot can be dorsiflexed to rotate the plafond around
the horizontal reference wire (Fig. 32.24). Arc wire, draw wire, and laminar spreader techniques (half-pin fixation
manipulation of distal fragment) are used to correct apex anterior or posterior malalignment (Figs. 32.27, 32.28
and 32.29). Occasionally, during this portion of the reduction, it will become obvious that the horizontal reference
wire needs to be adjusted anterior or posterior on the ring to align the plafond anatomically (Fig. 32.25). Once
the plafond is aligned, at least two additional divergent olive wires are placed across the fracture in the 60-
degree safe zone of wire pathways, and a fourth wire if space is available (Fig. 32.30). Two wires do not provide
adequate fixation, and at least three olive wires are required. If the distal tibial plafond fragment is large enough,
an AP half-pin can be added to the distal fixation ring (Fig. 32.31). If the distal fragment is too small, it will be
fixed with wires alone (Fig. 32.32). The wire configuration can be modified for fixation of epimetaphyseal
fragments as small as 2 cm (Fig. 32.33). The plafond wires must be placed in safe pathways to prevent joint
penetration or binding of the flexor or extensor tendons (Figs. 32.34, 32.35 and 32.36). A medial half-pin is added
to the proximal base ring (Fig. 32.16). A minimum of two AP half-pins and a medial half-pin are necessary
proximally. A fourth medial pin is placed in large patients.

Sequential Guide to Type A and C1-2 Distal Tibial Fractures

1. The more simple C1-2 articular fractures are reduced and fixed with 3.5- or 4.5-mm subchondral lag screws
 (Fig. 32.37).
2. A stable base ring is created and fixed to the tibial shaft with rings aligned parallel to the tibia on both the AP
and lateral views using two anterior to posterior half-pins on universal mountings.
3. A horizontal reference wire is placed 10 to 12 mm above the joint, and the distal tibial bone block is adjusted
and aligned on a radiolucent carbon ring aligning the fracture axially and with correct rotation (3,4).
4. The fracture is aligned in the lateral view, and frontal (coronal) plane deformities are corrected using
manipulation of the foot and specialized reduction techniques to reduce the fracture.
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FIGURE 32.24 The distal tibia is centered in the distal ring to align with the tibial shaft. Once aligned, the wire
is tensioned and the distal ring distracted. Bringing the foot into dorsiflexion often aligns the fracture in the
frontal plane as seen on the lateral image with fluoroscopy.
FIGURE 32.25 The plafond and horizontal reference wire is manipulated to correct rotation and translation.
The second toe is aligned with the tibial tubercle.

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FIGURE 32.26 Wire angular alignment is adjusted with washers, hinges, and posts allowing accurate axial
alignment of the ring with the tibia.
FIGURE 32.27 A draw wire technique is used to reduce a sagittal plane fracture. The olive wire bolt is not
tightened. The tensioner tool pulls the olive toward the tensioner. The bolt is tightened and the wire tensioned.

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FIGURE 32.28 The arc wire technique. A wire is arced to the fixation bolt on either side of the ring. When
tensioned, the arc flattens, reducing the posterior fragment. The AP half-pin resists the force of the reduction
(orange arrow). The metaphyseal bone block rotates around the tensioned horizontal reference wire (red
arrow).
FIGURE 32.29 The laminar spreader technique. A second cube is added to the half-pin and tightened. The
ring cube is loosened. The laminar spreader is opened, powerfully reducing the oblique fragment of a longer
Type A fragment (orange arrow—resisting fixation half-pin). The metaphysis rotates around the horizontal
reference wire.

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FIGURE 32.30 At least two additional divergent olive wires are added to the ring. Oblique fractures are fixated
with olive wires placed to improve fixation (orange arrow). The fracture is compressed. A third medial half-pin
is added to the stable base.

FIGURE 32.31 The resistance of the distal fixation block to rotation in the sagittal plane is greatly increased
with placement of an AP half-pin connected to the ring with a Rancho cube.

P.653
 FIGURE 32.32 If comminution of the reconstructed plafond prevents use of an AP half-pin, a drop wire placed
on long hinges or a post improves the stiffness of the fixation. Always use the available length of the distal
plafond fragment for fixation.

5. The plafond is fixed with three or four divergent olive wires in the 60-degree arc of safe wire placement. A third
medial face half-pin is added to the fixation block.
6. The fracture is compressed.
An alternative method to reduce distal tibia fractures (Type A and C1-C2 fractures) is the application of a Spatial
Frame (Smith Nephew) (Fig. 32.38). An orthogonal fixation block is placed on the tibial shaft, and the distal
plafond and the struts are manipulated using a computer-generated correction program to align the fracture. The
Spatial Frame can be used for the acute reduction of the fracture by calculating the deformity and mounting
parameters and applying the computer-generated correction while the patient is anesthetized. This consumes
valuable operating time. A better method is to place the Fast Fix Struts (Smith Nephew) in the loose position and
manually align the fracture with fluoroscopic imaging. The struts are locked in this “best” position obtainable by
manipulation. Residual malalignment is corrected in the postoperative period. The deformity and mounting
parameters are entered into a web-based computer correction program, and the frame is gradually aligned to
fine-tune the fracture reduction. Acute fractures can be reduced over several days to a week. Slowing the rate of
correction is indicated if the soft tissues will not tolerate more rapid correction.
FIGURE 32.33 Pilon fractures with limited plafond height can be fixed by crossing the wires from one side of the
ring to the other. The horizontal reference wire and a second wire elevated from the inferior side of the ring with
washers allow several wires to be placed on the same side of the ring. If the plafond height is greater, the wires
should be spaced over the width available to improve fixation stiffness.

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FIGURE 32.34 Safe wire pathways. Wires may be placed in the posterior calcaneus and talar head. Wires
placed anterior on the calcaneus can injure the posterior tibial nerve and artery. Green described a 60-degree
arc of safe wire placement at level of plafond to avoid tendon encroachment. Observe the wire placed from
posterior lateral to anterior-medial, which can be used to secure posterior malleolar fragment.

FIGURE 32.35 The posterior lateral wire is placed too far behind the lateral malleolus (black arrow) and may
penetrate the peroneal tendons. The olive is behind the lateral malleolus on the fluoroscopic view.
FIGURE 32.36 The posterior-medial wire placed too far around plafond and may penetrate the posterior tibial
and long flexor tendons. The AP fluoroscopic view will show the olive behind the plafond (black arrow).

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FIGURE 32.37 A C2 distal tibia fracture. A lag screw and fibula plate convert this to a Type A fracture.
Depending on the soft-tissue condition, the fracture is treated with internal or external fixation.

FIGURE 32.38 The Spatial Frame requires the tibial fixation block and the distal tibia plafond fracture reduction
ring to be mounted in orthogonal alignment. Malalignment of the rings will complicate the subsequent reduction.
The struts are manipulated with a computer-generated program, which aligns the fixation blocks in anatomic
alignment reducing the fracture.

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FIGURE 32.39 The tabs on the Spatial Frame rings must have clearance for the connection of the struts to the
ring. The horizontal reference wire (green wire) is easily applied to the ring. The anterior-medial half-pin on the
anterior side of the ring also has no clearance problems with the struts because the antimaster tab on the distal
ring has no struts attached. The fibula wire and the posterior-medial wire on the plafond (red wires) require
precise placement across the center of the tabs to prevent encroachment on the struts mounting points. The
posterior malleolar wire (blue wire) can also be placed without interfering with the struts.

The distal tibial reference ring must be placed with precision. The position of the Spatial Ring tabs presents a
problem when fixing the distal plafond fragment. The wires must be directed to cross the ring over the middle of
the tabs to prevent interference with the struts attaching to the ring on the tab (Fig. 32.39). A horizontal reference
wire is placed 12 mm above the plafond, and the plafond is aligned near the center of the ring and tensioned.
Washers are placed on either end of the wire to correct small angular malalignment by tensioning the wire again
if needed. The ring on the lateral fluoroscopic view is rotated around the wire until it is 90 degrees to the axis of
the shaft. To facilitate the alignment, a 100-mm rod is temporarily placed on the midportion of the ring and used
as a guide (Fig. 32.40). When the alignment rod is parallel to the metaphysis, the ring is square to the shaft and
a half-pin or wire is added to the ring to fix the position.
Precision in placing the two fixation blocks facilitates the computer-generated correction. The proximal tibial shaft
fixation block should be aligned orthogonally on the tibia (parallel to the shaft on the AP and lateral fluoroscopic
image and centered on the AP view) (Figs. 32.41 sand 32.42). When using Spatial Frames, the pin and wire
placement must avoid the strut pathways, which have mandatory connection points, the tabs on the Spatial Ring.
A fixation block constructed with two two-third rings separated by 120 or 150-mm threaded rods produces an
easy-to-use configuration. Two AP half-pins on Universal Rancho cubes are placed between the rings. The
inferior surface of the distal two-third ring has no pin wire connections that will interfere with the struts connecting
to the ring. The open two-third rings also keep the frame from rolling to either side when the patient is lying in
bed, and the open section is more comfortable for the patient. A third half-pin is placed medially in the proximal
fixation block to complete the fixation and is aligned orthogonally.
With the fixation blocks placed orthogonally, the fracture will be close to anatomically reduced when the ring
blocks are parallel. Spending time and effort to align the reference ring greatly improves the ease of calculating
and accomplishing the reduction.
Another valuable tool when using the Spatial Frame is the option for late reduction techniques. Often, critically ill
patients with multiple trauma with complex distal tibia fractures have significant delays in definitive treatment.
Malalignment of the fracture with early callus formation can be reduced using slow correction with the Spatial
Frame computer program. If there is more mature callus, a percutaneous osteotomy can be performed to mobilize
the distal metaphysis prior to reduction. The fibula must be controlled with a wire or screw across the
syndesmosis to prevent malleolar displacement as the correction progresses.
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FIGURE 32.40 A horizontal reference wire is placed approximately 10 mm above the plafond. The wire is placed
parallel to the epiphyseal line. A threaded rod is attached to the lateral Spatial ring adjacent to the horizontal
reference wire fixation bolt. On the lateral fluoroscopic image, the rod is used to rotate the ring until it is parallel
to the axial alignment of the distal tibia fragment. The second and third olive wires are applied to the ring, which
is held in alignment. The distal ring is now aligned orthogonally facilitating the computer-generated reduction for
the fracture.

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FIGURE 32.41 The tibial shaft Spatial Ring with the master tab is mounted on a universal Rancho cube. The ring
position on the tibia should allow approximately 150 mm separation from the distal tibia fracture ring for short or
medium Fast Fix (Smith Nephew) to be used. The ring is rotated on the tightened universal cube attached to the
AP half-pin until the guide rod is parallel to the shaft.

FIGURE 32.42 The ring in a similar technique is aligned with the shaft on the lateral fluoroscopic view. The ring
is adjusted for soft-tissue clearance. Additional AP and medial half-pins are placed to complete the ring fixation in
orthogonal alignment.

P.659
REDUCTION TECHNIQUE OF C3 PILON FRACTURES
Pilon fractures with comminution of the joint surface cannot be reduced without distraction across the joint (Fig.
32.43). With type C3 pilon fractures, the fibula must also be addressed (Fig. 32.44). The reduction technique
with circular fixators uses distraction between a stable proximal orthogonal base and a horizontal reference wire
placed into the calcaneus and tensioned on a foot plate (Fig. 32.45). The dome of the talus must be distracted
and aligned anatomically to reduce the joint surface (Figs. 32.46, 32.47, 32.48 and 32.49). If the limb is
shortened, the talar dome will physically occupy the space that the joint fragments need to be positioned to
reduce the plafond (Fig. 32.50). If the talus is translated anteriorly or posteriorly, the soft-tissue attachments
across the joint may tether the fracture fragments and prevent reduction. The posterior malleolar fragment, which
is attached to the talus by the posterior capsule, is impossible to reduce unless the talus is axially aligned with
the shaft.
The strategy of reduction is to apply distraction through a calcaneal horizontal reference wire to align the talus
axially with correct rotation. The talar dome is used as a template to align the crushed fragments of the plafond.
Reduction of the posterior fragment is the key to reduction. Distraction will reduce the fragment in many
fractures. Some fractures will have persistent posterior displacement, or the posterior malleolus will be rotated
and incarcerated in the posterior capsule. Through a small incision, the fragment is gently freed with a small
elevator. A threaded Steinman pin is then placed into the fragment. The fragment is rotated and pulled anteriorly
over the dome until it is in an anatomic position. It is pinned in place and used as a guide to reduce the mid and
anterior joint fragments. In low-energy fractures, there are usually large fragments to assemble with small screws
and wires. In high-energy fractures, there will be fragments of crushed cartilage, morselized subchondral bone,
and deformation of larger joint fragments from crushing of the cancellous bone. These fragments do not have
anatomic contours. In some cases, the cortex reduces anatomically, but the joint remains angulated or impacted.
These fragments may require small osteotomies and local bone grafting to regain alignment to match the talar
dome (Fig. 32.51). Cancellous allograft is used to fill in defects in the metaphysis. The fragments of the plafond
are reconstructed with multiple fixation methods depending on the size and orientation of the fragments (Figs.
32.52, 32.53, 32.54, and 32.55). With high-energy type C-3 pilon fractures, a level of joint comminution may be
encountered in which the articular fragments cannot be reassembled. In these cases, small Steinman pins are
used to “corral” the fragments into a “salvage joint” to support to the talus.
FIGURE 32.43 A C3 distal tibia pilon fracture. There is comminution of the joint with posterior subluxation of the
talus. The thick posterior capsule attaches to the large posterior malleolar fragment. The talar dome must be
aligned to reduce this essential fragment.

FIGURE 32.44 The three possible lateral malleolus fracture patterns: intact, simple, comminuted. The fracture
pattern of the fibula will influence the strategy of reduction of the plafond.
 P.660

FIGURE 32.45 A stable orthogonal base is applied to the tibia. Two posterior-threaded rods are connected to the
foot plate. The fracture reduction ring is placed into the frame in a proximal position to be used later in the
reduction. A horizontal reference wire is placed in the calcaneus. The foot is positioned to align the dome of the
talus with the long axis of the tibia. The posterior displacement of the foot must be corrected to reduce the joint
fragments. Notice how the posterior malleolus (yellow) is reduced by moving the foot anterior.
FIGURE 32.46 The foot is rotated on the foot plate until the second toe aligns with the tibial tubercule. Rotational
alignment has to be established at this point of the reduction.

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FIGURE 32.47 The horizontal reference wire in the calcaneus is placed 90 degrees to the axis of the ankle joint.
If the wire is placed in valgus or varus, or the talus does note reduce with traction, the wire can be adjusted away
from the foot plate on washers, hinges, and posts.
FIGURE 32.48 The foot is positioned, plantar neutral. A second opposed olive wire is placed superior to the foot
plate from posterior-medial to anterior-lateral. The threaded rods are placed posteriorly connecting the stable
base to the foot plate (orange nuts). Notice that the medial calcaneus has no wires placed anteriorly where they
could injure the posterior tibial nerve branches or artery.
FIGURE 32.49 With the two AP pins tightened, the foot plate is distracted until the dome of the talus pulls away
from the impacted plafond. Ten to 15 mm of distraction is applied by moving the nuts connecting the foot plate
rods to the stable base.

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FIGURE 32.50 Overdistraction is the key to reduction. Without distraction, the dome of the talus occupies the
space (green), which the plafond joint fragments occupy when reduced. If the posterior malleolar fragment does
not reduce with distraction, a threaded Steinman pin (yellow arrow), small bone hook, or pulling device is used to
pull the fragment anteriorly over the dome of the talus. The posterior malleolus is pinned in place (blue arrow)
and the anterior fragments reduced. The fracture reduction ring is positioned superior and will be moved inferior
after the joint reduction (black arrow).
FIGURE 32.51 High-energy pilon fractures have impaction of the osteocartilagenous fragments. Dense white
areas on the lateral view of the x-ray indicate crushed trabecular bone. The cortical fragments can be aligned
anatomically (yellow outline), but the joint fragments are still not reduced, impacted into the metaphysis (blue
arrow). These fragments are dislodged and reduced onto the dome of the talus and held in place with local bone
graft and small wires or screw fixation.
FIGURE 32.52 Small screws and wires are used to fix the fragments. Free wires protrude through the skin and
are removed at 6 weeks in patients with bridging distraction. Brad wires are bent over 180 degrees and tamped
into the bone. This prevents the pin from migrating. The anterior to posterior lag screw is used to control the
posterior malleolus when the anterior plafond is not crushed.

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FIGURE 32.53 Spring plates are useful to control unstable anterior fragments. In some fracture patterns, a plate
or multiple plates can be extended to the joint and the circular fixator used as a bridging frame for 3 to 4 months.

FIGURE 32.54 Internal fixation must be low profile. The retinaculum and capsule of the joint need to be closed
(yellow arrow). If there is swelling and large plates, the skin will be closed over a hematoma leading directly to
the hardware and fracture. Early wound dehisceince and infection may result from this tenuous closure.
FIGURE 32.55 The posterior malleolus can be fixated with the following techniques: (A) an olive wire placed
though the interval between the peroneal and Achilles tendon, (B) an anterior to posterior screw, (C) an anterior
buttress plate, (D) a posterior-locked plate placed through the posterior-lateral approach, or (E) a Steinman pin
(1.6 mm) can be drilled through the calcaneus and talus to pin the fragment to the dome and left in place for 6
weeks with the hind foot fixed by a distraction foot plate. The talar calcaneal pin is very useful to hold the initial
reduction during limited open reduction and then removed after screw fixation.

P.664
When impaction of the cancellous bone of the distal tibia superior to the joint fragments occurs, it creates a void
that should be filled with cancellous allograft. The graft is placed as a buttress to prevent the joint fragments from
displacing.
Small spring plates are occasionally used locally to control displaced anterior fragments, which are difficult to
control with tensioned wires. A combination of Steinman pins, small screws, bone graft, and local plates is used
to reduce the plafond. The fixation only needs to align the joint surface. The bridging external fixation maintains
axial alignment. This is the essential difference between external fixation and plating. Plating osteosynthesis
requires that the axial alignment is maintained by the plate construct, which must attach the compromised and
comminuted epimetaphysis with the shaft. Circular tensioned wire technique requires that internal fixation only
has to reduce and stabilize the joint. Axial stability and alignment are maintained by the external fixator and no
hardware traverses the comminuted metaphyseal zone of injury. This strategy is particularly valuable in treating
patients with compromised soft tissues (1,5).
Following reduction of the joint, an assessment is made of metaphyseal comminution. If there are larger
fragments, the metaphysis is fixed with a cluster of three or four divergent olive wires after closure of the
incisions used for the joint reconstruction (Fig. 32.56). If there is diaphyseal extension, a “working length ring” is
added to the frame to control the proximal extent of the fracture (Fig. 32.57). The fracture reduction ring is initially
placed in the frame but located superior to the ankle. After open reduction, the ring is moved over the plafond to
fix the fracture.
When there is severe comminution of the plafond and there is little or no bone for fixation, the fracture fixation
ring is not included in the frame, and the fixator is used as a distraction frame (Figs. 32.13, 32.14, 32.58, 32.59
and 32.60). If the preoperative CT scan indicates that the plafond is severely comminuted, the frame utilized will
be a “by-pass” frame, which is kept in place until the fracture heals. Unfortunately, this leads to subtalar joint
stiffness and requires prolonged physical therapy to recover. Patients can bear 50% of their weight with the
frame in place.
With classic open reduction and internal fixation of tibial pilon fractures, the first step is open reduction and
internal fixation of the fibula (Fig. 32.61). Anatomic reduction and fixation of the fibula requires that the plafond
must also be reconstructed to anatomic length. If there is residual shortening of the tibia, it often leads to a
predictable varus deformity (Figs. 32.62 and 32.63). When there is metaphyseal comminution, bone grafting is
indicated to reconstruct and fill the gap (Fig. 32.64).

FIGURE 32.56 After the open reduction with limited internal fixation (the fixation only maintains the alignment of
the joint), the carbon fiber fracture reduction ring is moved down the threaded rods and three to four olive wires
are placed. The olives are positioned to reinforce the internal fixation. Two threaded rods are added anteriorly
between the stable base and fracture reduction ring. A medial half-pin is added to the stable base.
FIGURE 32.57 A working length ring. Pilon fractures can have proximal extension. A ring is placed in the fixator
to place proximal wires or pins. The placement of this ring is determined during preoperative planning. In this
example, a draw wire technique is used to compress (red arrow) the shaft. Observe that a half-pin proximal
(black arrow) and olive wire distal (yellow arrow) are placed to resist the force of the reduction.

P.665
FIGURE 32.58 A schematic drawing of a C3 pilon fracture with severe comminution. The fragments are not
amendable to tensioned wire or internal plating.

FIGURE 32.59 The circular fixator is applied as a distraction frame aligning the joint. A medial to lateral olive wire
is placed through the talar neck to stabilize the hind foot in neutral plantar flexion. Small brad and free wires are
used to align the crushed joint using the dome of the talus as a mold. Once aligned, the talus is mildly shortened
to improve bone contact of the fragments.
FIGURE 32.60 Placement of the medial to lateral olive wire through the talar neck can impinge upon or enter the
medial extension of the talar navicular joint. The navicular wraps around the head of the talus. The wire is placed
posteriorly centered on the talar neck approximately where the dome of the talus intersects with the neck of the
talus.

FIGURE 32.61 The treatment options for the lateral malleolus in a pilon fracture: intact, no fixation, plate fixation,
intramedullary fixation, and comminuted.

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FIGURE 32.62 Plating the fibula to length demands that the distal tibia also be reconstructed to length. If the
plafond is not reconstructed and held distracted, a nonunion will occur. If the tibia fibula ligaments (yellow arrow)
are intact, the classic varus collapse will occur after frame removal.
FIGURE 32.63 If the fibula is plated and the tibia-fibular ligaments are disrupted (yellow arrow), the entire
plafond can shorten creating a fibula plus outcome where the lateral malleolus impinges on the calcaneus (green
arrow). Both columns always have to be reconstructed to the same length.

In contradistinction with plates, the use of a circular tensioned wire fixation distracts both the tibia plafond and
lateral malleolus fractures to length, and fixation of the fibula becomes elective. Pilon fractures with little-to-
moderate comminution are reconstructed to anatomic length, and the fibula is reduced and fixed with a plate or
an intermedullary pin (Fig. 32.61). If there is severe comminution, the surgeon has the option to slightly shorten
the tibia and fibula through the zone of comminution compressing the fragments to enhance union (Fig. 32.65).
Patients with ischemic vascular disease, osteopenic bone, and diabetes can have salvage reconstruction with
acute shortening. The tibial shaft can be compressed into the metaphyseal bone, which is molded over the dome
of the talus, and the lateral malleolus is shortened appropriately (Fig. 32.66). This can be improved by removing
a small segment of the fibula shaft to recreate a new mortise. This technique also improves soft-tissue coverage
when patients have open wounds and are poor candidates for free flaps. A proximal lengthening to equalize leg
length is combined with shortening in selected patients (Fig. 32.67).
In a few patients with Grade IIIA-B open pilon fractures, there is associated bone loss or gross disruption of distal
tibia, and the plafond cannot be reconstructed. Treatment options include a below-knee amputation or
reconstruction with intercalary bone transport (Fig. 32.68). The “frame time” is directly proportional to the length
of the reconstruction. Often, these fractures may need free-flap coverage and the use of antibiotic spacers to
manage the soft tissue. Large defects can be reconstructed and good function obtained for patients who will not
consider amputation (6).
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FIGURE 32.64 Metaphyseal bone loss and crushing are reconstructed with bone graft if the soft-tissue envelope
will permit. Compromised soft tissue with bone loss is reconstructed with an intercalary bone transport. Living
bone is transported into the zone of injury, and new bone is created proximally away from the injury.
FIGURE 32.65 Acute bone shortening is a salvage technique to gain bone on bone contact in distal tibia
fractures with bone loss and poor soft-tissue condition. The fracture ends are cut back as needed to allow stable
bone on bone contact. The fibula also will have a bone resection so the columns are equal length. Acute
shortening should not be >2 to 3 cm.

FIGURE 32.66 Oblique fractures without fixation can shorten but tend to displace (yellow). A lateral malleolus
with comminution may shorten with less displacement. If the plafond is comminuted and mild shortening can be
accepted, then oblique lateral malleolus fractures will need to have a section removed to allow shortening
without fibular malalignment.
FIGURE 32.67 Acute shortening is accepted in patients who are not candidates for lengthening. An elevated
shoe is prescribed. A proximal corticotomy with lengthening is used to regain length in patients who are
physiologically capable of bone transport.

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FIGURE 32.68 A. Type A distal tibia fracture with intact joint but segmental loss of the distal tibia. B.
Débridement results in a substantial segmental bone defect. The shaft is cut square with at least 75% of the
bone cross section exposed. Distally, the metaphysis is cut square. Posterior lateral bone spikes are left in place
to improve docking site union. The green fragments represent the removal of intact bone to facilitate the docking
of the reconstruction. The foot is controlled with a foot extension until the soft tissues have healed, and the
patient can place partial weight on the extremity. C. The transport is completed to docking. A revision bone graft
may be needed to heal the docking site. The foot plate is removed to allow ankle and hind foot motion as the leg
becomes more stable.
Technical Sequence for C3 Pilon Fractures
1. The stable proximal base is applied to the tibia with two AP half-pins on universal mounting cubes. The base
must be orthogonal.
2. A horizontal reference wire is placed in the calcaneus. The hind foot is aligned on the foot plate to center the
dome of the talus with the axis of the tibia on AP and lateral fluoroscopic images.
3. The fracture is distracted. If the fracture can be brought out to length, the fibula is fixed with a plate or pin.
When shortening of the comminuted metaphysis will be used to facilitate healing, the fibula is not fixed.
4. Distraction may produce anatomic alignment of the joint surface. Percutaneous screws and pins are placed to
stabilize the joint. Percutaneous screws are also used to align large proximal metaphyseal and shaft
fragments.
5. If distraction does not produce an acceptable reduction, the fracture is approached through the anteriormedial
or anterior-lateral interval (Fig. 32.9). The joint fragments are reduced and fixed with small screws, wires, and
small or minifragment plates. Bone graft is used to support the reconstructed articular surface.
6. The carbon fiber fracture ring is placed over the metaphysis, and at least three opposed divergent olive wires
are placed. An opposed olive wire is added to the foot fixation.
7. Olive wires are not placed in the metaphysis in two fracture patterns: (a) The comminution is so severe that
there are literally no fragments large enough for fixation or (b) the technique of bridging distraction with limited
internal fixation will be accepted as the definitive fixation technique. In this circumstance, a second opposed
olive wire in the calcaneus and a medial to lateral talar neck wire are added to the foot plate.
8. An additional medial half-pin is added to the proximal tibial stable base.
9. A bulky compressive dressing is placed around the ankle.
On rare occasions, a severe open pilon fracture with comminution and osteoarticular bone loss occurs. Salvage
arthrodesis is a possible alternative to a below-knee amputation (Figs. 32.69, 32.70, 32.71). If the fracture has
<3 cm of bone loss after débridement, an acute shortening can be applied to the arthrodesis. If the bone loss is
>3 cm, a delayed shortening (2 to 4 mm a day) is indicated, or an intercalary bone transport is applied
maintaining the leg to length. A proximal lengthening is combined with shortening in patients physiologically and
mentally capable of a bone transport. For larger defects involving loss of the plafond, an intercalary bone
transport is
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used to reconstruct the defect. The proximal fixation block is a five-eighth full-ring block (Fig. 32.72). Rods
connect to the foot fixation block with opposed olive wires in the talus. The midtibia transport ring has two AP
half-pins and a medial pin. The transport is lengthened 0.5 mm a day. Docking site revision is recommended for
transports more than 3 or 4 cm in length. Hind foot motion will be lost or severely restricted with this technique.
The patients have some forefoot circular motion and use a soft rubber rocker bottom shoe.
FIGURE 32.69 A C3.1 pilon fracture or trimalleolar fracture with open dislocation, fragment ejection, and gross
contamination was not reconstructible. The joint fragments were discarded, and a horizontal osteotomy of the
metaphysis and dome of the talus was created for arthrodesis of the joint.

POSTOPERATIVE CARE
Depending on the frame configuration, active-assisted range of motion of the ankle and hindfoot or/and forefoot
and toe therapy is started. The patients are encouraged to place partial weight on the leg using a sandal and
increase weight as tolerated. Patients should be placing 50% weight by the sixth week, and some will be full
weight before frame removal. If the patient had bridging distraction with wire fixation through the
plafond/metaphysis, the foot plate and calcaneal wires are removed in clinic 4 to 6 weeks after surgery. If the
patient had bridging distraction without wire fixation, the frame has to be maintained for at least 4 to 6 months.
Maintenance of the pin/wire interface with the skin is essential to reduce inflammation and subsequent pin/wire
infections. Once the surgical wounds are healed, the leg is washed in the shower with soap, removing all blood
and secretions where the pin/wire enters the skin. Skin that is tenting over wires is released with local
anesthesia. Gauze sponges are applied over wires that develop inflammation. Oral antibiotics are prescribed if
inflammation worsens.
Frame removal is indicated when callus has bridged the multiple fragments, and the patient can place 50% or
more weight on the extremity. If the patient is not bearing weight at 3 to 4 months, the fracture is not united.
Average frame time is 4 to 6 months for pilon fractures (Fig. 32.73). Outpatient frame removal with sedation or a
light general anesthesia is recommended. The ankle is casted for 2 weeks, and the patient is encouraged to
bear full weight in the cast. The cast is removed in the office, and a hinged ankle orthosis is placed, which the
patient uses until mature callus is observed at the fracture site. Physical therapy continues for an additional 6
months if funds are available. The functional result at 1 year postinjury will be the extent of recovery. The
patients rarely recover function comparable to their preinjury function (2).
COMPLICATIONS
Rarely, a patient will have purulent drainage and require wire removal and intravenous antibiotics. Deep
infection when using circular fixators for pilon fractures is uncommon, but does occur. This requires
irrigation and débridement and culture-specific antibiotics. In some patients, there is a dead bone fragment
that requires removal. Deep vein thrombosis (DVT) occurs infrequently. Rapid swelling in the frame
indicates the possibility of a venous obstruction, and swelling of the lower leg and thigh is often a deep clot.
Anticoagulation is required when a DVT has been diagnosed.
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FIGURE 32.70 The limb can be salvaged with acute shortening and compression arthrodesis. Proximal
lengthening is offered to appropriate patients to equalize length. The foot frame for smaller extremities is a
single ring using a post to place two talar body wires. For larger ankles, a double foot plate separated by 3-
cm hexagonal sockets provides improved frame stiffness. Five to 7 cm of the fibula is excised to improve
compression of the arthrodesis and prevent lateral impingement.

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FIGURE 32.71 Intercalary proximal to distal transport for arthrodesis. The proximal fixation block is a five-
eighth full ring. The midtibia transport ring has two AP half-pins and a medial half-pin. The foot fixation has
two opposed olive wires in the calcaneus and two opposed olive wires in the talus.

FIGURE 32.72 The five-eighth full-ring block has a horizontal reference wire and a smooth wire placed from
 the fibula head to the anterior-medial tibia on the proximal five-eighth ring. The full ring has a medial olive
wire and an AP half-pin.

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FIGURE 32.73 Frame removal time on 98 cases of distal tibia Type A and C fractures treated by the author.
Most fractures heal between 3 and 6 months. More complex fractures may need additional reconstructive
procedures and require many more months in the fixator.

A local bone graft is indicated if there is no callus formation after 3 to 4 months. Autograft is indicated
because an osteoinductive response is necessary to promote healing. The patients rarely recover function
comparable to their preinjury function (2). Nonunion is an infrequent complication that can be treated by
several methods (7).

REFERENCES
1. Watson JT, Moed BR, Karges DE, et al. Pilon fracture treatment protocol based on severity of soft tissue
injury. Clin Orthop 2000;375:78-90.

2. Pollak AN, McCarthy ML, Shay BR, et al. Outcomes after treatment of high-energy tibial plafond fractures.
J Bone Joint Surg [Am] 2003;85A:1893-1900.

3. Vora AM, Haddad SL, Kadakia A, et al. Extracapsular placement of distal tibia transfixation wires. J Bone
Joint Surg [Am] 2004;86A:988-993.

4. De Coster TA, Stevens MS, Robinson B. Safe extracapsular placement of proximal and distal tibial
external fixation pins. Annual meeting of Ortho. Trauma Assoc Poster #68:247-248, 1997.

5. Watson JT. Tibial pilon fractures. Tech Ortho 1996;11:150-159.

6. Hutson JJ, Dayicioglu D, Oltjen JC, et al. Treatment of Gustillo GIIIB tibia fractures with application of
antibiotic spacer, flap and sequential Ilizarov distraction osteogenesis. Ann Plast Surg 2010;64(5):541-552.

7. Hutsson JJ. Salvage pilon fracture nonunion and infection with circular tensioned wire fixation. Foot Ankle
Clin N Am 2008;13:29-68.

RECOMMENDED READING
Hutson JJ. Applications of Ilizarov fixators to fractures of the tibia: a practical guide. Tech Orthop 2002;17:1-
111.

An extensively illustrated monograph which will give the reader a basic understanding of Ilizarov technique to
treat tibia fractures. Recommended as a starting point for surgeons who would like to incorporate Ilizarov
technique into their trauma practice.

Murat B, Durmus AO, Mahmut U, et al. Tibial pilon fracture repair using Ilizarov external fixation,
capsuloligamentotaxis and early rehabilitation of the ankle. J Foot Ankle Surg 2008;47(4):302-306.

Papadokostakis G, Kontakis G, Giannoudis P, et al. External fixation devices in the treatment of fractures of
the tibial plafond. J Bone Joint Surg [Br] 2008;90B:1-6.

Seybold D, Gebman J, Ozokysy L, et al. Custom made Ilizarov ring fixator for fracture care in morbidly obese
patients. Langenbecks Arch Surg 2009;394:393-398.
 33
Ankle Fractures
Rena L. Stewart
Jason A. Lowe

INTRODUCTION
Ankle fractures are among the most common musculoskeletal injuries. These injuries span a spectrum from
simple closed fractures to complex open injuries. As a result, the orthopedic management is varied and can
range from nonoperative casting to staged surgery with a primary focus on damage control procedures followed
by definitive fixation. Treatment of ankle fractures is also dictated by patient-related factors. The presence of
diabetes and a growing population of geriatric patients, with osteoporotic, increase the complexity of ankle
fracture management.
These fractures typically result from a low-energy rotational force to the tibia about a planted foot but can also
present as a more complex, high-energy injury. The AO/Danis-Weber and Lauge-Hansen (Fig. 33.1) systems are
the most commonly used classifications to describe ankle fractures. The AO/Danis-Weber classification is an
anatomic system based upon the location of the fracture with regard to the tibiotalar joint (Weber A—below the
joint; Weber B—at the joint; Weber C—above the joint). Lauge-Hansen described four ankle injury patterns
based upon the mechanism of injury (Fig. 33.1). These patterns are determined by the foot’s position (supination
or pronation) at the time of fracture and the direction of applied force (external rotation, adduction, and
abduction).
Injury to the supinated foot begins anterior-lateral and moves around the osteoligamentous structures (posterior
then medial) as the force vector continues. If the foot is externally rotated from a supinated position, supination-
external rotation (SER), the anterior, inferior tibiofibular ligament (stage I) is the first structure to fail. With
continued external rotation, a classic fibula fracture (stage II) occurs. Fibula fractures resulting from an SER
injury will have a spiral pattern that moves from anterior-interior to posterior-superior. The long posterior-superior
spike of the distal fragment is a hallmark of SER injuries. Continued external rotation results in disruption of the
posterior-inferior tibiofibular ligament or fracture of the posterior malleolus (stage III). The most severe SER,
stage IV, injury pattern occurs as the rotational force tears through the deltoid ligament or fractures the medial
malleolus (typically a transverse fracture). Adduction of the supinated foot will lead to disruption of the lateral
collateral ligaments or a tension (transverse) fracture of the distal fibula. As more force is directed medial to the
supinated foot, the medial malleolus will fracture. An important distinction of this injury pattern is that the medial
column fracture is typically associated with articular impaction of the tibial plafond. In contrast to supination
fractures, injuries to the pronated foot begin at the medial malleolus/deltoid ligament to the anterior-inferior tibia-
fibula ligament before exiting laterally. Pronation-external rotation injuries are classically observed with a high
(suprasyndesmotic) fibula fracture, while pronation-abduction fractures are associated with comminution of the
fibula. Questions over the reproducibility and reliability of the Launge-Hansen schema have been raised;
however, it remains a useful classification when correlating the mechanism or injury and radiographs following
ankle injuries (1).

INDICATIONS AND CONTRAINDICATIONS

Making a decision to treat ankle fractures operatively or nonoperatively depends largely upon the fracture
personality: open versus closed, stable versus unstable, displaced versus nondisplaced, and the presence or
absence of articular impaction. Many of these injuries, such as isolated closed lateral or medial malleolar
fractures, can be successfully treated nonoperatively (2,3). Fibula fractures with displacement of 2 mm or less,
without ankle instability, can be managed conservatively in a walking cast or boot. Similarly, medial malleolar
fractures with
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up to 5 mm of displacement, with no mortise instability, or articular impaction can be successfully treated with
cast immobilization and regular radiographic follow-up (Fig. 33.2) (2). Nonoperative treatment is also
recommended for patients whose medical condition precludes operative intervention. Operative management is
recommended for open fractures and unstable fractures patterns, which include bimalleolar, bimalleolar
equivalent (fibula fracture with deltoid ligament disruption), and trimalleolar fractures (3,4).

FIGURE 33.1 The Danis-Weber (AO/ASIF) classification system is based on the level of the fibula fracture. The
Lauge-Hansen system is based on experimentally verified injury mechanisms. Type A Danis-Weber injuries are
usually Lauge-Hansen supination-adduction injuries. Type B can be either supination-external rotation or
pronation-abduction injuries. Type C injuries are usually pronation-external rotation injuries.

Determination of ankle stability is crucial during the initial evaluation and assessment of the fracture. If
unrecognized, ankle instability may alter the joint contact pressure and can result in abnormal loading of the
articular cartilage. Such changes can lead to posttraumatic osteoarthritis of the ankle joint (5, 6, 7 and 8). Since
physical exam findings including medial tenderness, with or without swelling and ecchymosis, do not consistently
correlate with disruption of the deep deltoid ligament, radiographic landmarks identified on high-quality anterior-
posterior (AP), mortise, and lateral radiographs are employed when determining ankle stability (discussed
below).
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FIGURE 33.2 A mortise radiograph of the left ankle with a nondisplaced medial malleolar ankle fracture, where
nonoperative treatment would be indicated.

PREOPERATIVE EVALUATION AND PLANNING

Good preoperative planning is essential for successful outcomes in all ankle fractures and begins with a
thorough history and physical exam. Medical comorbidities such as diabetes, obesity, and osteoporosis
negatively affect the patient’s functional outcome. Recognizing these illnesses in the preoperative period allows
modification of the operative plan (fixation scheme), rehabilitation protocol, and optimization of the medical
disease in the perioperative period.
A complete neurovascular physical exam of ankle fracture patients, particularly the medically ill and
polytraumatized patient, is required. We routinely do not evaluate ankle range of motion in patients with known
unstable fracture; however, we routinely assess for the presence of palpable pulses and intact motor function of
the ankle and toes. Additionally, peripheral nerves are evaluated for light touch sensation. In diabetic patients,
protective sensation is assessed with a 5.07 Semmes Weinstein monofilament. The location and condition of
preinjury chronic wounds or acute soft-tissue injury, including ecchymosis, fracture blisters, lacerations, and
abrasions, are documented.
An ankle fracture is assessed for stability using anatomic landmarks identified on radiographs. A clear symmetric
joint line along the medial, lateral, and superior joint should be observed. Disruption of the syndesmosis is a
marker of instability and can be observed on the AP or mortise radiograph by assessing the tibia-fibula overlap.
The distance between the medial fibular cortex and the fibular incisura should be <6 mm when measured 1 cm
proximal to the joint. Similarly, the tibia should overlap the fibula by >1 mm on a mortise view and 6 mm on a true
AP radiograph. Disruption of the syndesmosis will increase the clear space between the fibula and incisura as
well as decrease the tibia-fibula overlap either of which is a sign of instability. Another radiographic indication of
instability is disruption of the deep deltoid ligament, which can be assessed on the ankle mortise view. Disruption
of the deltoid is appreciated when there is asymmetry of the joint, talar tilt, or translation. The space between the
medial malleolus and talar dome (medial clear space) should measure <4 mm and the talocural angle 83 ± 4
degrees (Fig. 33.3). A medial clear space >4 mm indicates disruption of the deltoid ligament or a bimalleolar
equivalent fracture.
Ankle instability, however, may not be readily visualized on injury radiographs. SER injuries in particular do not
immediately reveal the full extent of the injury. In “apparent isolated” SER II fibular fractures, 38% to 65% of
fractures may also have disruption of the deltoid ligament (SER IV) (4,9). While a true SER II injury is stable and
can be treated nonoperatively, an SER IV injury represents an unstable fracture pattern and internal
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fixation is recommended. The dynamic instability present in these injuries can be better appreciated following an
external rotation stress radiograph (manual stress or gravity stress) (9, 10 and 11). During the stress test, it is
important that the foot be in either neutral or slight dorsiflexion so as to not falsely reduce the radiographic medial
clear space (12). Alternatively, a magnetic resonance imaging (MRI) can also show an occult deltoid ligament
injury (1,13). The cost difference between a MRI and stress radiograph is substantial, and the authors do not
recommend routine use of an MRI to determine injury to the medial deltoid complex.
FIGURE 33.3 Radiographic projection of fibula on tibia in standard AP radiograph. When measured 1 cm
proximal to the ankle joint, the distance between the medial border of the fibula and the incisura should be <6
mm on any view. On the AP view, the fibula should generally overlap the tibia (shaded area) by >6 mm or more
than 42% of the fibular width; however, individual variation and beam angle may affect individual measurements.
There should be more than 1 mm of overlap of the tibia and fibula on any view.

Contralateral films should be obtained when comminution of the fibula is present. These images aid in restoring
the correct fibular length and rotation thereby avoiding a malreduction. A CT scan is recommended if articular
impaction is present, or further delineation of the posterior malleolar fragment is needed (14).
Open wounds should be irrigated at the bedside but will need emergent, formal I & D in the operating room.
Initially, the fractures should be reduced and splinted. The majority of rotational ankle fractures are adequately
reduced with longitudinal traction and rotation opposite the deforming force. A well-padded, posterior and “U”
splint with the ankle in neutral dorsiflexion reduces pain and provides fracture immobilization. An adequate splint
combined with judicious elevation and cryotherapy helps reduce swelling. The immediate application of a
circumferential cast should be avoided. Even if nonoperative therapy is indicated, ongoing swelling can result in
dangerous constriction and may exacerbate the soft-tissue injury.
While most ankle fractures requiring surgery can be treated within the first 24 hours, they do not constitute a
surgical emergency. It is our practice that the isolated, closed, reduced, and splinted ankle fractures are sent
home with an office appointment and subsequent surgery within 5 to 7 days. In contrast, patients with significant
medical comorbidities, polytraumatized patients, or those with an emergent surgical indication (open/irreducible
fracture) are admitted and have definitive operative treatment as soon as their medical condition and soft-tissue
envelope allow.
It is important to ensure that the soft tissues will safely permit surgical intervention. Implementation of a staged,
“damage control” protocol is indicated when the soft-tissue envelope precludes early operative intervention (Fig.
33.4) or when a reduction cannot be maintained in a splint. We recommend application of a spanning external
fixator in patients with fracture blisters at the incision sites, open contaminated or degloving injuries that require
multiple débridements and soft-tissue coverage, or soft-tissue swelling that is preclusive of subsequent wound
closure. The external fixator stabilizes the fracture while allowing for management of soft-tissue wounds and
facilitates patient mobility. Definitive fracture fixation surgery is delayed until there is
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resolution of soft-tissue trauma. This is commonly judged by epithelization of fracture blisters and the presence
of wrinkles on the dorsum of the foot when in neutral dorsiflexion (wrinkle sign).

FIGURE 33.4 Clinical photographs of two ankles. (A) Trimalleolar fracture with blisters over the lateral malleolus.
(B) Bimalleolar fracture dislocation with abrasions over the medial malleolus.

We believe that many ankle fractures are regarded as “simple” fractures, and a lack of preparation can lead to
unnecessary errors or poor outcomes. A clear understanding of the patient’s condition and fracture morphology
is necessary for selection of correct patient positioning and operative approach.

SURGERY
Patient Positioning
Patients are most commonly positioned supine, and a general or regional anesthetic technique is utilized. A towel
roll placed beneath the ipsilateral hip allows the leg to lie in neutral rotation (Fig. 33.5). A pneumatic tourniquet is
applied to the upper thigh. The leg is shaved and prepped, and a sterile sheet is placed beneath the leg to
prevent inadvertent contamination of surgical gowns during draping. The leg is sterilely draped free, and the toes
are sealed with a plastic adhesive drape.
Prone positioning may be indicated for selected trimalleolar ankle fractures with a large, displaced posterior
malleolar fracture or posterior articular impaction. With chest rolls positioned from the shoulders to the anterior
superior iliac spines, care is taken to place the arms in a tension-free (90/90) position. Next, the anterior knees
are padded with a foam/gel pad and the legs placed in a tension-free position with the knees slightly bent. From
this position, the posterior malleolus and fibula may be fixed through a posterior-lateral approach (Fig. 33.6).
Reduction and instrumentation of the medial malleolus in the prone position may be more easily performed with
the knee flexed.
In closed fractures, a first-generation cephalosporin is used unless there is an allergic contraindication, in which
case an alternative antibiotic is chosen. In type II or III open fractures, an aminoglycoside is added to the pre-
operative antibiotic regimen.
FIGURE 33.5 Clinical photograph of right leg on a radiolucent ramp with the leg resting in neutral rotation
(patella facing the ceiling) after placement of a hip bump.

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FIGURE 33.6 Clinical photograph of a left trimalleolar ankle fracture positioned prone. Tibia is padded with
blankets that both flex the knee and elevate the ankle for lateral imaging.

Technique
Bony landmarks (medial/lateral malleoli and joint line) are localized and identified with a surgical marking pen.
The location of the fracture can also be marked based on palpation or, if needed, fluoroscopic imaging. Surgery
can be performed with or without a tourniquet. Meticulous homeostasis during the surgical approach should be
obtained and typically obviates the need for a tourniquet.
In bimalleolar ankle fractures, it is the author’s preference to fix the fibula first.

MEDIAL MALLEOLAR FIXATION

Our preferred medial approach is a straight incision just anterior to the midsagittal axis of the tibia (Fig. 33.7).
This incision allows inspection of distal medial tibia and the talar dome, while facilitating instrumentation of the
fracture. Some may favor a curved “J” incision for better access to the ankle joint. Care must be exercised when
placing the distal extent of this incision so as to not preclude access to the medial malleolus for instrumentation.
As with all approaches to the medial ankle, the saphenous vein and nerve should be preserved and protected
from inadvertent injury.
Adequate exposure is required to ensure an anatomic reduction. Because of the fracture orientation, anterior or
posterior malreductions may not always be appreciated when inspecting the medial cortical surface. We
therefore recommend exposure of the anterior articular aspect of the medial malleolus (the shoulder or axilla),
which aids in assessing the reduction. In addition, visualization of the anterior malleolus will facilitate inspection
of the joint surfaces. As small osteochondral abrasions or defects are not uncommon, distal retraction of the
fragment allows irrigation, débridement, and inspection of the joint (Fig. 33.8). Minimal dissection of the
periosteum (2 mm) is performed along the fracture edges to assess fragment interdigitation and cortical
reduction.
Reduction of the medial malleolus is performed with a bone tenaculum or small (1.6 mm) Kuntscher-wires (K-
wires). A small, pointed bone tenaculum can be placed on the medial malleolar fragment from anterior to
posterior and used to guide the reduction. Alternatively a 1.6-mm K-wire can be placed into the lateral cortex and
used as a joy-stick to guide reduction of the distal fragment. With either technique, a second pointed bone
tenaculum or Weber clamp is used to hold and compress the fragment. A drill hole (2.5 mm) is placed in the
intact distal medial metaphysis allowing insertion of one tine of the clamp while the other is placed around the
medial malleolar fragment (Fig. 33.9). A second K-wire may be inserted across the fracture to prevent fragment
rotation, at which point the first tenaculum/joy-stick can be removed.

FIGURE 33.7 Clinical photograph of a left ankle outlining the contour of the medial malleolus and planned
incision.

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FIGURE 33.8 Retraction of the medial malleolar fragment distally allows inspection and irrigation of the ankle
joint.

Large, one-piece, medial fragments are typically secured with two 4.0 mm, partially threaded, cancellous screws.
With the tenaculum centered on the fragment, a scalpel is used to split the superficial deltoid ligament in-line with
its fibers. With the foot slightly everted, a 2.5-mm drill bit is placed against the anterior colliculus and directed in-
line with long axis of the tibia. A second drill bit is placed in the intercollicular groove and directed parallel to the
first drill bit. While placing the second screw in the posterior colliculus has been common practice, it increases
the risk of injury to the posterior tibial tendon and can result in postoperative pain (15). If the size of the fragment
precludes placement of two 4.0-mm screws, then alternative methods of fixation should be considered. These
include a single lag screw with a K-wire, small diameter screws, or tension band wiring. Long 2.0, 2.4, and 2.7-
mm screws should be available and are well suited for small medial malleolar fragments. Alternatively, tension
band fixation can be performed by inserting 1.6-mm K-wires in a direction similar to the standard screw fixation.
Eighteen-gauge wire or a large nonabsorbable suture is passed around the K-wires and crossed in a figure-of-
eight fashion around a screw placed in the tibial metaphysis. The ends of the K-wires are then bent and
impacted.
Vertical medial malleolar fractures, as commonly seen with supination-adduction injuries, deserve special
attention. These fractures may be accompanied by marginal impaction of the anterior-medial plafond (16).
Reduction and fixation of the impacted distal tibia joint surface is mandatory. Small osteotomes and bone tamps
can facilitate anatomic restoration of the joint surface. The resulting cancellous bone void is filled with bone graft,
and the medial malleolus fracture is reduced (Fig. 33.10). While vertical, shear, medial malleolar fractures can be
stabilized with lag screws placed perpendicular to the fracture line, we recommend buttress plate fixation using a
1/3 tubular plate. Cortical screws can be inserted, using a lag technique through the plate for added stability
(17).
FIGURE 33.9 A pointed reduction tenaculum is used to provide provisional reduction of the medial malleolus.
One tine is placed in a drill hole placed in the medial tibial metaphysis, and the other tine is placed around the
distal aspect of the medial malleolus. Partially threaded, cancellous, lag screws are inserted anterior and
posterior to the tenaculum.

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FIGURE 33.10 (A) Radiograph of a vertical medial malleolar ankle fracture with subtle articular impaction of the
joint surface (white arrow). (B) Intraoperative radiograph with reduction of the depressed articular segment and
medial malleolus. A joy-stick wire is seen (black wire) in the fracture fragment. (C) A minifragment plate applied
as a buttress plate, and the fracture is lagged to the tibia with the distal most screw.

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FIBULAR FIXATION
The fibular incision is selected based upon both the fibular fracture personality and location of the soft tissue
injury. Minor adjustments in location of the incision may be needed due to associated soft-tissue abrasions or
fracture blisters. The fibula is classically approached through a straight lateral incision (Fig. 33.11). If a fracture
of the anterior-lateral tibia is present, the distal extent of the incision is curved anterior. This variation will allow
access to the anterolateral ankle (avulsion of the anterior, inferior, tibiofibular ligament) and fixation of the
Chaput-Tillaux fragment. Through this approach, the anterior-lateral plafond can be inspected. Any
osteochondral debris should be removed and articular impaction corrected. Alternatively, a longitudinal incision
just posterior to the fibula can be used to position a posterior antiglide plate. Here an undercontoured 1/3 tubular
plate may be placed with a 3.5-mm cortical screw at the apex of the fracture. Additionally, the plate frequently
allows lag-screw fixation through the plate. Regardless of the fibular incision, care is taken to preserve the
superficial peroneal nerve. This nerve may cross the surgical field at either the subcutaneous or fascial level,
and failure to protect it may result in a painful neuroma.
Periosteum at the fracture edge should be elevated to facilitate anatomic reduction, but further periosteal
stripping is kept to a minimum. Fracture reduction can be achieved by using one or more of the following
techniques: traction and rotation can be applied to the hind foot to assist with fracture reduction; a tenaculum
may be placed on the distal fragment and used to manually reduce the fragment; the bone reduction clamp may
be used to directly reduce and stabilize the fracture by placing the tines at a right angle to the fracture. Fracture
reduction is usually fairly easy in the acute setting, but becomes more difficult if the fibula has been left in a
foreshortened position for several days.
Simple, oblique, fibula fractures are usually reduced and fixed with an interfragmentary lag screw and 1/3 tubular
neutralization plate. Occasionally, long oblique fractures can be adequately fixed with interfragmentary lag
screws alone (18,19). The benefits of lag screw-only fixation include a smaller incision and less hardware
irritation. While this technique can be used in bi/trimalleolar fracture patterns, it should not be utilized in the
presence of fibular comminution or osteoporosis (18,19). While we typically use a 3.5-mm cortical screws
inserted in “lag” fashion, smaller diameter screws (2.0, 2.4, and 2.7 mm) are an alternative in smaller patients or
small fragments. In these circumstances, a smaller diameter screw helps reduce the risk of iatrogenic
comminution.
Comminution that precludes lag screw fixation is commonly seen in pronation-abduction injuries. In these
fractures, reduction and stabilization of the medial malleolus will reduce the ankle mortise and can be fixed
before the fibula however, the authors typically fix the fibula first. During fibular exposure, care is taken to remain
extraperiosteal through the zone of comminution (Fig. 33.12) (20). Maintaining the periosteal sleeve preserves
the blood supply and contains the comminuted fragments while the coronal and sagittal alignments are
corrected. If no bony “keys” are available to determine distal fibular rotation, the distal fragment may be reduced
to the talus and provisionally held with K-wires passed into the talar body. Fixation is achieved using a “bridge
plate,” spanning the zone of comminution (Fig. 33.13). While 1/3 tubular plates are useful in simple fibular
fractures, we recommend stronger reconstruction or precontoured fibular plates for these comminuted fractures.
Precontoured plates allow multiple screw hole options, which are also very helpful in small distal fragments (Fig.
33.13). These precontoured plates also allow locking screw fixation in the small distal fragment. It is the author’s
recommendation that locking screws be reserved for small distal fragments or patients with poor bone quality, for
example, osteoporosis, diabetes, or metabolic bones disease.

POSTERIOR MALLEOLUS FIXATION

Ankle fractures involving the posterior malleolus have a higher incidence of posttraumatic osteoarthritis than
bimalleolar fractures. The exact reasons for increased arthrosis following a posterior malleolar fracture are
unknown, but dynamic fracture models have shown that posterior, malleolar fractures are associated with a shift
in contact stress (anterior and medial) as opposed to an overall increase in the peak contact stress (7,21).
Associated chondral injury and residual joint instability may also be contributing factors to the increased
incidence of arthrosis following posterior malleolar fractures.
FIGURE 33.11 A clinical photograph of a direct lateral incision over the fibula. A pointed reduction clamp is seen
holding reduced a short oblique fibula fracture.

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FIGURE 33.12 Demonstrates technique of extraperiosteal plating of a comminuted fibula fracture. A. A clinical
photograph of the fibular plate fixed to the small distal segment. No periosteal dissection is performed through
the zone of injury. B. An intraoperative radiograph illustrating a push-pull screw and lamina (white arrow)
spreader is used to restore length and alignment of the fibula. C. A cortical screw (black arrow) is used to secure
the fibula proximally and finalize the coronal plane alignment.

FIGURE 33.13 Intraoperative mortise of a comminuted fibula fracture fixed with a precontoured plate applied as a
bridging construct and multiple points of fixation in the small, distal segment.

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FIGURE 33.14 Upper left image. Sagittal CT scan image demonstrates an incarcerated and rotated posterior
lateral articular fragment (white arrow). Bottom left. Sagittal CT image illustrates medial extension of the
posterior malleolus fracture as well as comminution of the medial malleolus that often accompanies this fracture
pattern. Right. A postoperative radiograph demonstrating reduction and stabilization of the comminuted medial
and posterior malleolus with minifragment plates.

Posterior malleolar fractures occur in three common patterns. Large posterior-lateral oblique fractures are the
most common, followed by fractures with medial extension and small posterior lip fractures (22). Classic
recommendations for posterior malleolar fixation have been based upon articular involvement of >25% of the
joint surface. While plain radiographs can reliably estimate size of the posterolateral fragment, they do not
reliably predict the presence of impacted articular fragments or posteromedial fracture extension (14). Fifty-
degree external rotation radiographs have been suggested as an adjuvant method of evaluating the posterior
fracture; however, this method has not been clinically verified in cases where the posterior malleolous fracture
personality is not clear, we recommend CT scans with two-dimensional reconstruction to evaluate for fracture
comminution, articular impaction, and medial extension as part of the preoperative workup (Fig. 33.14).
Small posterior-lip malleolar fractures frequently represent avulsion of the posterior, inferior tibiofibular ligament.
These fragments often reduce with fibular fixation and therefore are addressed after fibular fixation. The larger,
more common, posterior-lateral oblique and medial-extension fractures typically require fixation. For
noncomminuted, nonimpacted, minimally displaced fractures, fixation can be accomplished with a wellplaced
pointed tenaculum followed by percutaneous, anterior-to-posterior screws. One tine of the clamp is placed on the
posterior malleolar fragment, and one tine is placed through a small, separate incision on the anterior tibia.
Gentle dorsiflexion of the ankle or rotation of the clamp may facilitate final reduction, at which point
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an anterior-to-posterior, cannulated or noncannulated 3.5-mm screws will secure the fragment. These fractures
are similarly addressed after fibular fixation. For fractures with a large displaced posterolateral fragment, those
with posterior-medial extension and/or the presence of articular impaction, a direct surgical reduction is required.
When a formal surgical approach is selected for the posterior malleolus, it is the authors preference to stabilize
the posterior malleolus prior to fibular fixation so that the reduction can be radiographically visualized without
interference from fibular implants.

FIGURE 33.15 A clinical photograph of a patient positioned prone. The Achilles tendon is identified by the
diagonal lines, the fibula drawn laterally in black, and the posterior lateral incision (purple line).

Open reduction through a posterolateral approach is used to repair large displaced posterior-lateral oblique
fractures or fractures with impacted osteochondral fragments. With the patient in the prone position, a standard
posterolateral incision is made (Fig. 33.15). The peroneals are retracted laterally and the flexor hallucis longus
medially, which allows visualization of the posterior tibia metaphysis (Fig. 33.16). The posterior malleolar
fragment can be gently booked open to reduce incarcerated osteoarticular segments. Any cancellous defects are
bone grafted and fracture reduced. Fracture fixation is often achieved with two or three posterior-to-anterior
screws over washers. With large fragments, internal fixation may be achieved with a 1/3 tubular plate applied in a
buttress fashion. When articular impaction is present, we prefer to use a T-plate (3.5, 2.4, or 2.0 mm) and direct
the distal screws just above the articular fragment in a rafting fashion (Fig. 33.17).
Fractures with posterior-medial extension are often associated with articular comminution as well as a separate
posterior-medial fragment (Fig. 33.14). Subtle radiographic findings of this fracture pattern include a double
density of the medial tibia just above the medial malleolus; however, this finding is not always present. Fixation of
this fracture pattern frequently requires a combined posteromedial as well as a posterolateral approach (22,23).

SYNDESMOTIC ASSESSMENT AND FIXATION

Disruption of the ankle syndesmosis is traditionally observed with Weber Type C (pronation external rotation)
injuries. Injury to this ligamentous complex can occur with any rotational ankle fracture pattern and, if
unrecognized, will result in ankle instability. Transsyndesmotic fixation, however, is not always required.
Sequential rigid fixation of the distal fibula, medial malleolus, and when present posterior malleolus will often
restore ankle stability, provided the respective ligaments (AITFL, Deep Deltoid, and PITFL) are intact (24,25).

FIGURE 33.16 A. A clinical photograph demonstrating the surgical interval of the posterior lateral approach:
peroneal muscles (large white arrow) and the flexor hallucis longus (small white arrow). B. The muscular interval
is retracted revealing a 2.7-mm plate buttressing the posterior malleolus.

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FIGURE 33.17 Lateral radiograph of a trimalleolar fracture. The posterior malleolar fragment is fixed with the
distal screws directed just cephalad to the articular fragment.

Injury to the syndesmotic ligament complex (anterior tibiofibular, posterior tibiofibular, and the interosseous
ligament) cannot always be predicted based upon the fracture pattern (25). MRI imaging has been utilized as a
mechanism to assess ligament integrity; however, the added cost is substantial. We therefore recommend
careful intraoperative evaluation of the syndesmosis following fracture stabilization with a lateral stress test
(25,26). Following fracture fixation, a clamp or small bone hook is placed around the fibula, just proximal to the
syndesmosis, and a laterally directed force is applied while a fluoroscopic mortise x-ray is taken. Displacement of
the tibiofibular clear space >1 mm is suggestive of syndesmotic disruption. Alternatively an external rotation
stress test can be used to assess the integrity of the syndesmosis, but a laterally directed force has been shown
to be more predictive of ligament disruption (25,26).
Several controversies regarding syndesmotic fixation exist: screw diameter, screw number, number of cortices
engaged, timing of weight bearing, and timing of screw removal. To add further complexity, new fixation
techniques continue to emerge such as tight-rope fixation as well as locking syndesmotic screws.
Regardless of fixation type, the distal tibiofibular reduction must be anatomic. In one study, up to 52% of
syndesmotic reductions were shown by CT to be malreduced (27). We therefore recommend open reduction of
the tibia-fibula joint. This is accomplished through the fibular incision. With the foot held at 10-degree dorsi-
flexion, a periarticular reduction clamp is applied from the fibula to the medial tibia, parallel to the joint. The
reduction is visually and fluoroscopically inspected for any malrotation that may occur during clamp application. A
temporary K-wire may be placed to help maintain the reduction if needed, but is not standard practice.
Following reduction, syndesmotic fixation is accomplished by elevating the heel on a small bump. This position
affords a surgeon room to direct the drill in-line with the tibia-fibula axis (approximately 30 degrees) (Fig. 33.18).
The authors prefer to insert a single, tricortical 3.5-mm screw for syndesmotic fixation in noncomplicated patients.
For these patients, syndesmotic screws are typically removed 3 to 4 months postoperatively to facilitate early
rehabilitation progress and improve functional outcomes (28,29).
Syndesmosis disruption with a high fibula (Weber Type C) fracture, Maisonneuve fractures, is often closed
reduced and fixed with two syndesmotic screws (30), and the fibula fracture is not internally fixed. This technique
has been shown to result in a high incidence of tibiofibular malreduction. We recommend open reduction and
internal fixation of proximal fibula fractures prior to syndesmosis fixation in Maisonneuve injuries (31).
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FIGURE 33.18 Exposure of the anterolateral ankle joint may be performed by dissecting anterior to the fibula and
retracting soft tissues with a small right-angle retractor.

Large-fragment 4.5-mm screws, engaging four cortices, and multiple syndesmotic screws are reserved for
patients with osteopenia and diabetics with peripheral neuropathy. The combined increased screw diameter,
screw purchase in the far cortex, and multiple points of fixation provide added stability for patients with poor bone
biology or high risk noncompliance.
Utilization of two angularly stable tricortical syndesmotic screws through a locking 1/3 tubular plate has recently
gained support. Proponents of this technique suggest angularly stable screws prevent malreduction of the tibia-
fibula articulation compared to traditional cortical screws, which may malrotate the fibula if inserted off-axis (29).
When combined with open reduction of the tibiofibular joint, angularly stable screws are shown to decrease the
incidence rotational malreduction (52% to 16%); however, the clinical significance of this technique is still being
investigated (32).
Less rigid fixation with a fiber-wire tightrope is also an available option for syndesmotic fixation. Biomechanical
studies have demonstrated greater physiologic motion of the tibofibular joint with a tightrope compared to screw
fixation (33). Limited outcome data suggest a potential earlier return to function and work with a tightrope versus
screw fixation (34). However, concerns over the ability of a fiber wire to maintain syndesmotic reduction have
been raised in cadaver models (35), and granulomatous reactions have been reported (36).
POSTOPERATIVE MANAGEMENT
A nonadherent dressing and sterile gauze are applied to the incisions and held in position with sterile cast
padding. With the ankle held in neutral dorsiflexion, additional cast padding is applied followed by a short-leg,
posterior, and “U” splint. The splint is maintained until the patient can comfortably dorsiflex the injured ankle and
thus prevent equinus contracture. The leg is elevated postoperatively to minimize swelling. Patients with
adequate pain control and sufficient home care may be discharged following surgery, but many patients require
overnight observation for pain management.
Patients are seen in follow-up appointments between 10 and 14 days after surgery. The splint and sutures are
removed. Reliable patients are instructed in active ankle and subtalar range-of-motion and placed in a removable
short-leg “Cam Walker.”
Patients with simple fibular fractures are restricted from weight bearing for 6 weeks postoperatively. Repeat x-
rays are obtained at 6 weeks, and the patient’s weight bearing is at this time in the boot. Physical therapy is
typically initiated at this time to assist with range of motion, proprioception, and strengthening. When a
comminuted fibula is present, weight bearing is restricted until callus is observed at which point the patient is
placed on a partial progressive weight-bearing program.
Dependent swelling may persist for many months following ankle fractures and often require the use of
compression stockings or elastic wraps once the incision is healed. Patients are cautioned against returning to
sports until they have regained adequate strength and agility with a cross-training physical therapy program.
Patient’s return to driving is deferred for 9 weeks as braking time has been shown to be decreased until that time
(37).

SPECIAL CONSIDERATION
Diabetics/Osteoporosis
Successful, uncomplicated fracture union is more difficult patients with poor bone quality or complex medical
conditions. In particular, the geriatric patient with osteoporosis and the diabetic patient deserve special
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mention. Diabetic patients whose fractured extremity is complicated by peripheral neuropathy, vasculopathy, or
Charcot arthropathy are at a higher risk of wound-healing complications, infection, loss of fixation, and nonunions
than the general population (38,39). In the diabetic patient, a poor soft-tissue envelope with significant swelling
and fracture blisters that preclude early operative intervention are more commonly observed than in the general
population. As such, damage control protocols are employed with application of an ankle spanning external
fixator.
FIGURE 33.19 A Mortise radiograph illustrates three ways to improve stability in this osteoporotic and insulin-
dependent diabetic patient: bicortical medial malleolar screws, three tetracortical syndesmotic screws, and
locking screws at the proximal and distal extent of the fibular plate.

When the soft-tissue envelope allows definitive fracture fixation, standard fixation techniques may be inadequate,
and consideration is given to augmenting implant fixation. Like geriatric patients with osteoporosis, low bone
mineral density is commonly observed in the diabetic. Poor bone quality can lead to early loss of fixation,
hardware failure, and fracture collapse. The brittle bone encountered in both these patient populations is also
prone to iatrogenic comminution during fracture reduction or fixation. Meticulous care must be exercised during
fracture reduction and fixation so as to avoid propagation of existing fracture lines. Secure fixation of the medial
malleolus is augmented with bicortical screw fixation (Fig. 33.19) (40). When a vertical medial malleolus fracture
is stabilized, we recommend that lag screws are applied through a plate or a washer to prevent screws from
sinking through the metaphyseal cortex.
Fibular fixation can be augmented with precontoured, locked plating constructs in patients with osteoporotic
bone. The ankle mortise can be further stabilized by placing multiple (three or four) syndesmotic screws that
engage four cortices (Fig. 33.19). We recommend 3.5-mm plates and 3.5-mm cortical or 4.0-mm cancellous
syndesmotic screws (41). Supplemental stabilization with an external fixator or calcaneal-talar-tibial Steinmann
pins is occasionally employed for the neuropathic diabetic with poor bone stock.

COMPLICATIONS
 Many ankle fractures are “simple, standard” injuries that can be easily treated with the anticipation of an
excellent outcome. Complications, however, are inevitable with surgical treatment of any fractures. Surgeon
failure to appreciate the complexity of either the fracture pattern or the patient’s biology may result in higher
complication rates. In particular, preoperative appreciation of the posterior malleolar fracture size, presence
of articular impaction, intra-articular fragments, osteoporotic bone, or complicated diabetes are necessary to
select the appropriate surgical approach and implants. Patient-related factors that increase perioperative
complication
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rates that are beyond the surgeon’s control include open fractures, complicated diabetes, peripheral
vascular disease, and patient age >75 (42).

STIFFNESS
Loss of motion, especially dorsiflexion, can be problematic following ankle fractures. This complication is best
avoided with early patient-directed range-of-motion (active/active assist). If independent range-of-motion
exercises and stretching do not rapidly restore normal functional range of motion, an early referral to physical
therapy is recommended. Recalcitrant cases of stiffness may benefit from gastrocnemius recession, tendo
Achilles lengthening, and/or capsular release to improve restricted ankle dorsiflexion.

LOSS OF FIXATION
Screw purchase is often compromised in patients with osteoporosis and may result in loss of fixation.
Biomechanical studies have shown that three tetra-cortical syndesmotic screws improve fibula fracture stability
better than intramedullary K-wires (43). Utilization of locked-screw constructs can also improve fracture stability
in the setting of osteoporosis. Addition of a second plate (90/90 plating) can be considered; however, further
surgical dissection is required and that biologic insult must be balanced with fracture stabilization. Alternatively,
screw fixation may be augmented with an injectable composite graft placed into the screw holes (44).

INFECTION AND WOUND COMPLICATIONS

Postoperative infection usually presents with erythema as well as wound drainage or breakdown. Diabetics and
smokers have a higher risk of this complication (38,42,45). Operative débridement and culture-specific antibiotics
are usually required. Because of the risk of ankle joint involvement, careful clinical examination of the joint is
recommended. If indicated, ankle aspiration through a noncellulitic area is also suggested. If wound soft-tissue
swelling and débridement preclude skin closure, application of a negative pressure wound dressing can be
applied. Once the infection is under control, the soft tissue can be closed in a tension-free manner. Utilizing a
“pie-crust” technique can facilitate a tension-free closure (Fig. 33.16). Alternatively, soft-tissue coverage may
require a rotational muscle flap or a free tissue transfer.

POSTTRAUMATIC ARTHRITIS
The incidence of posttraumatic arthritis following ankle fractures is low, with reported incidence of <1% at 1 and
5 years (42). Trimalleolar ankle fractures, fractures with significant articular cartilage damage, open fractures,
and diabetes, are all associated with higher incidence of posttraumatic arthritis (42). Avoiding a fibular
malreduction (shortened/malrotated), widened ankle mortise, or failing to treat an impaction injury of the posterior
malleolus will minimize this complication.
Recent arthroscopic examination of ankle fractures has revealed a high (73%) incidence of chondral lesions with
ankle fractures (44). These lesions may contribute to poor functional outcomes or posttraumatic arthritis;
however, outcome studies are not presently available to examine the clinical implication of these lesions.
NONUNION/MALUNION
Nonunion following ankle fractures is uncommon. Patients with nonunion usually present with persistent pain
localized to the fracture site. Shortening and malrotation of the fibula can occur after operative and nonoperative
management of malleolar fractures (46,47). This can lead to ankle valgus and disruption of the talocrural
mechanics. Various lengthening osteotomies for the fibula can restore normal joint mechanics and alleviate
clinical symptoms (47,48).

HARDWARE PROMINENCE AND PAIN

Hardware prominence is fairly common in thin individuals following ankle fracture fixation due to the
subcutaneous location of the hardware (49). This most commonly involves lateral fibular hardware. While not
palpable beneath the skin, posterior fibular plates can also result in peroneal tendon irritation (50). Symptomatic
relief can be obtained with hardware removal. We typically delay hardware removal until 1 year from time of
surgery. Further, we recognize and educate our patients that hardware removal relieves pain in approximately
50% of patients (49). Patients are usually sent home the day of surgery, full weight bearing; however, they are
cautioned against activities requiring aggressive pivoting or activities that would cause significant torsional force
for 6 to 12 weeks following implant removal.
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Joint Surg Br 1990;72(4):709-713.

49. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional
outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 2001;15(4):271-274.

50. Ostrum R. Posterior plating of displaced Weber B fibula fractures. J Orthop Trauma 1996;10:199-203.
 34
Talus Fractures: Open Reduction Internal Fixation
Paul T. Fortin
Patrick J. Wiater

Talus fractures are uncommon, and most surgeons have limited experience within the management of this
challenging injury. These fractures usually occur as the result of high-energy trauma, which often produces
fracture comminution, displacement, and soft-tissue injury. The long-term consequences following a talus
fracture can be devastating often leading to significant lower extremity impairment.
Two-thirds of the talus is covered in articular cartilage, and all fractures are articular injuries affecting one or
more of the adjacent joints. The talus is divided into three major parts—head, neck, and body. The body of the
talus has five articular surfaces: superior, lateral, medial, posterior, and inferior. The neck of the talus has
multiple vascular foramina distributed along its longitudinal axis, which may compromise its strength by
increasing porosity making it more vulnerable to fracture. The head of the talus rests in a deep socket, similar to
the acetabulum, formed by the navicular, the anterior and middle calcaneal facets, the calcaneonavicular
component of the bifurcate ligament, superomedial calcaneonavicular ligament, and the plantar
calcaneonavicular ligaments. The relative displacements of the talar head, calcaneus, and navicular with weight
bearing are accommodated by the flexibility of this articulation that can adapt in form and size.
The extraosseous blood supply to the talus comes from three main arteries and their branches. These arteries,
in order of significance, are the posterior tibial, anterior tibial, and perforating peroneal (Fig. 34.1). The artery of
the tarsal canal (branch from the posterior tibial) and the artery of the tarsal sinus (perforating peroneal and
anterior tibial) form an anastomotic sling on the inferior neck of the talus. The main blood supply to the talus is
from the artery of the tarsal canal, which supplies the majority of the talar body. The posterior tibial artery also
provides anterograde flow through branches that penetrate the posterior tubercle of the talus. The anterior tibial
and the artery of the tarsal sinus supply the head and neck regions. Extensive intraosseous anastomoses within
the talus may contribute to its survival in complex fractures. Initial fracture displacement is believed to be the
most important factor affecting talar blood supply. Soft-tissue handling at the time of surgery also plays an
important role, and every effort should be made to preserve the deltoid ligament attachment on the talus and
avoid excessive soft-tissue stripping.
Because of the highly variable nature of talus fractures, classification of these fractures is difficult. Talar neck
fractures are classified into one of four types based upon initial fracture displacement and involvement of
adjacent joints (Fig. 34.2). The classification for fractures of the talar neck is based upon the radiographic
appearance at the time of injury. One important distinguishing characteristic among talar neck fracture types is
that type I fractures are truly nondisplaced. Any displacement is significant and precludes classification as a type
I injury. Hawkins type II fractures involve a talar neck fracture with subluxation or dislocation of the subtalar joint.
Hawkins type III fractures are characterized by a fracture of the neck with displacement of the body of the talus
from the tibiotalar and subtalar joints. Over half of type III fractures are open and are often associated with
neurovascular and/or skin tissue compromise. Type IV injuries involve subluxation or dislocation of the ankle,
subtalar, and talonavicular joints.
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FIGURE 34.1 The talus receives its blood supply from all three main arteries perfusing the foot. The posterior
tibial artery is the main contributor to talar body blood supply.

FIGURE 34.2 Hawkins classification of talar neck fractures. A. Type I. B. Type II. C. Type III. D. Type IV.
 P.693

FIGURE 34.3 Talar body fractures. A. Group I cleavage fractures (horizontal, sagittal, coronal). B. Group II
process or tubercle fractures. C. Group III crush with compression/impaction.

Talar body fractures can be classified into cleavage, crush, tubercle, or process fractures (Fig. 34.3). The Marti-
Weber classification system is less-commonly used but is a more comprehensive classification system that
incorporates nearly all types of talus fractures: type I fractures include talar head, process, and osteochondral
fractures. Type II fractures are nondisplaced head and neck fractures. Type III fractures include displaced neck
and body fractures with subluxation of either the ankle or subtalar joint. Type IV fractures are displaced neck or
body fractures with complete dislocation of the body as well as major crush injuries to the talus.
Unless substantially displaced, talus fractures are often difficult to visualize on plain radiographs and
uncommonly go unrecognized particularly in multiply injured patients (Fig. 34.4A-D). The late treatment of missed
talar injuries often results in suboptimal outcomes giving increased importance to initial diagnosis and treatment.
Of the bones in the foot and ankle, the talus is the most common site of missed injuries. Occult talar injuries
should always be suspected when swelling and ecchymosis of the foot and ankle are present, even when
radiographics appear normal.

INDICATIONS AND CONTRAINDICATIONS

Although implants for talus fracture fixation have been improved over the last decade to smaller more site-
specific designs, the principles of fracture management are the same. Displaced fractures require internal
fixation. Operative treatment is usually necessary to restore joint congruity and hindfoot mechanics. Disruption of
articular congruity and/or loss of talar length, alignment, and rotation are strong indications for operative
treatment. Even small amounts of fracture displacement can result in a significant compromise of subtalar, ankle,
or talonavicular function.
There are five major types of talus fractures: talar head, neck, body, process or tubercle, and osteochondral
fractures, and each type has site-specific indications for operative treatment. In general, talar neck and body
fractures should be treated operatively if the fracture is displaced more than 1 to 2 mm. The magnitude of
displacement is often difficult to properly evaluate with plain x-rays alone, and additional imaging studies such as
computed tomography (CT) scanning are typically required. Nonoperative treatment can be employed in a few
fractures that are displaced 1 mm or less. Some authors advocate operative treatment of even nondisplaced talar
neck and body fractures to allow early range of motion or prevent late fracture displacement. All open fractures
as well as fracture dislocations of the neck/body require immediate operative intervention. Regardless of fracture
type, talar neck and body fractures that result in skin compromise from fracture displacement should be treated
promptly with either an attempt at closed reduction or operative reduction and fixation to minimize the risk of soft-
tissue necrosis. Displaced talar neck and body fractures without joint dislocation, compromised skin, and/or
neurovascular compromise can safely be treated in a delayed fashion, usually within 24 to 48 hours.
Talar head fractures are often associated with disruption of the talonavicular joint and operative reduction and
fracture fixation are necessary to restore function to the joint (Fig. 34.5A-C). There are two types of talar head
fractures: shear fractures and compression or impaction fractures. Shear fractures may involve a locked
dislocation of the talonavicular joint where the fractured talar head becomes perched on the lateral portion of the
navicular. Failure to recognize and properly reduce these injuries can lead to permanent loss of midfoot and
hindfoot function. The other type of talar head injury is an impaction fracture usually in the medial portion of the
head. Minor degrees of compression are difficult to repair and should be treated nonoperatively. Larger areas of
talar head compression may benefit from elevation of the compressed region with bone grafting to restore
articular congruity. It is important to remember that talar head fractures can occur simultaneous with lateral
column injuries such as calcaneal or cuboid fractures, which may also need to be addressed.
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FIGURE 34.4 A,B. AP and lateral x-rays of a displaced talar neck fracture. C,D. Clinical photos of the same
patient 3 days later with soft-tissue compromise and impending full-thickness necrosis because of a delay in
diagnosis and failure to perform a timely reduction. (Copyright 2001 American Academy of Orthopaedic
surgeons, reprinted with permission from Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am
Acad Orthop Surg 2001;9(2):114-127.

Talar process or tubercle fractures typically involve the lateral talar process or posterior process (medial and/or
lateral tubercle). They can occur as an isolated injury or in combination with a talar body or neck fracture.
Although seemingly innocuous injuries, they often involve significant portions of articular cartilage and can
compromise ankle and/or subtalar joint stability if unrecognized. When these fractures are displaced and/or
compromise a significant portion of the articular surface, they should be treated surgically. This typically involves
open reduction and internal fixation but fragment excision may be appropriate if the fragment is small or when
comminution exists.
Osteochondral fractures of the talar dome can occur in conjunction with talar body fractures or as an isolated
entity. Acute displaced osteochondral fractures most commonly involve the anterolateral area of the talar dome
and can encompass significant portions of the dome with varying degrees of displacement. Large displaced
osteochondral fragments should be treated surgically with either fixation or excision depending upon the size or
amount of comminution.
Significant neuropathy, peripheral vascular disease, soft-tissue compromise, and limited ambulatory capacity are
relative contraindications to surgical management. Peripheral neuropathy is highly variable
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in severity, and many elderly patients have some degree of peripheral neuropathy that should not preclude
operative treatment. Loss of protective sensation, however, as judged by the ability to differentiate a 5.07
monofilament, is a sensitive indicator of significant neuropathy; therefore, failure to differentiate the monofilament
should be considered a relative contraindication to surgery. Even in patients with loss of protective sensation,
the decision to operate depends upon the fracture pattern, ankle stability, and presence of dislocation or
significant joint subluxation and should be made on a case-by-case basis. A minimally displaced talar body
fracture in a patient with significant neuropathy may be best treated nonoperatively, whereas a Hawkins III talar
neck fracture with posteromedial extrusion of the talar body should be treated surgically to relieve soft tissue
and/or neurovascular compromise regardless of the presence of neuropathy. Elderly patients with limited
ambulatory capacity, similarly, may be best treated nonoperatively if the joint is not significantly displaced or
dislocated.
FIGURE 34.5 A,B. AP and lateral ankle x-rays of a fracture dislocation of the talar head and talonavicular joint.
Note the subtle double density in the region of the talonavicular joint on the lateral radiograph. C. AP foot x-ray
taken several weeks lateral showing a locked fracture dislocation.

On occasion, poor soft-tissue conditions complicate the operative treatment of these fractures. For example, a
dual incision approach to a talar neck fracture may be contraindicated in situations where the anterolateral skin
is compromised (see Fig. 34.4A-D). Also, extensile exposures may be contraindicated in patients with marginal
perfusion of the extremity.

PREOPERATIVE PLANNING
History and Physical Exam
Knowledge of the mechanism of injury can be helpful in determining the energy imparted and the likelihood of
comminution, articular cartilage damage, and associated ligamentous injuries. When the injury is the result of
significant axial loading, there is an increased risk of irreversible cartilage damage that may lead to posttraumatic
arthritis. A thorough history should also include any comorbidities such as diabetes and peripheral vascular
disease that may adversely impact the decision to operate. The physical examination should document the
presence of dorsalis pedis and posterior tibial pulses, skin integrity, skin ulceration or tenting, sensory exam
(preferably with a 5.07 monofilament), and abnormal posturing of the toes that may indicate tethering/entrapment
of tendons. Type III and IV talar neck injuries are commonly associated with tibial nerve compromise from
posterior displacement of the talar body stretching the posterior tibial neurovascular bundle. Type II talar neck
injuries commonly involve medial displacement of the talar head segment resulting in prominence and skin
tenting over the anterolateral aspect of the talar body segment that can lead to soft-tissue compromise (Fig.
34.4A-D).
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FIGURE 34.6 Canale view can be helpful to assess talar neck length and alignment.

IMAGING STUDIES
The standard radiographic evaluation for ankle and foot injuries includes anteroposterior (AP), lateral, and
oblique views of the foot and ankle. The talus is both a foot and ankle bone, and fractures are commonly missed
with inadequate radiographs. The Canale oblique view is helpful to assess length and alignment of the talar neck
(Fig. 34.6). Shortening of the medial column of the foot secondary to impaction is common in talar neck fractures
and is best seen on the Canale view.
Because of the unusual shape of the talus, numerous articular surfaces, and variability of fracture patterns, CT
scans are an essential part of the radiographic evaluation of a talus fracture. CT is useful in defining the fracture
morphology and detecting occult fractures in the ankle and foot. Concomitant osteochondral fractures are
common with talar neck fractures and are not well visualized on plain x-rays.

TIMING OF SURGERY/REDUCTION
The urgency of reduction and timing of surgical intervention following talus fractures remain controversial. The
initial fracture displacement, amount of comminution, and presence of an open fractures are thought to be factors
associated with the development of posttraumatic osteonecrosis. Fractures that produce joint subluxation or
dislocation, as well as those with significant soft-tissue compromise due to fracture displacement, require
emergent reduction to avoid neurovascular compromise and/or skin necrosis. Because of the need for expedient
reduction in these circumstances, preoperative planning is invariably limited. If the peritalar joints are reduced
and fracture displacement is not significant, operative fixation can be performed when soft-tissue swelling and
bruising have recovered and proper imaging studies have been obtained. In most patients, a well-padded splint
provides adequate temporary support and pain relief. Provisional spanning external fixation to restore length and
stability may occasionally be necessary in unstable fracture patterns or when the soft-tissue injury precludes
early open reduction.
Knowledge of the fracture pattern and classification is very helpful when planning the surgical approach,
methods of reduction, and fixation techniques. For example, talar body fractures and type III talar neck fractures
with posteromedial extrusion of the talar body often require a transmalleolar exposure either through an existing
medial malleolar fracture or an osteotomy of the medial malleolus. Reduction aids such as a femoral distractor
may be necessary to reduce an extruded talar body. Chondral and osteochondral fractures that commonly
accompany talar neck and body injuries often necessitate small diameter subarticular screws or bioabsorbable
implants. Since talus fractures are articular injuries, it is helpful to have an assortment of small-diameter plates
and screws to facilitate anatomic restoration of the joint surface and rigid fracture fixation to allow early motion.

SURGICAL TECHNIQUE
Access to the talus for fracture surgery is limited, and extensile approaches are not recommended. Fracture
pattern and associated soft-tissue disruptions may indicate areas of potential compromised vascularity. The goal
of fracture surgery is to gain access to the bone for reduction and fixation without further insult to the remaining
blood supply. Unnecessary dissection should be avoided, and ligamentous attachments should be protected.
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FIGURE 34.7 A,B. Plain x-ray and CT image of Hawkins II talar neck fracture. C,D. Reconstruction images
demonstrate medial neck comminution and varus angulation of the talar neck and supination of the foot.

Imaging studies are carefully assessed to determine fracture pattern, areas of comminution, medial neck
shortening, and associated osteochondral fractures (Fig. 34.7A-D). The patient is positioned supine on a
radiolucent table with a bolster placed beneath the affected extremity. Intraoperative C-arm fluoroscopy is
essential and should enter from the opposite side of the table. A well-padded pneumatic tourniquet is placed on
the proximal thigh (Fig. 34.8). General anesthesia with muscle paralysis is preferred to regional techniques to
better counteract the strong deforming forces in the hindfoot. Spinal or regional anesthesia may be preferable in
a small number of patients with significant cardiopulmonary comorbidities but is not routinely employed because
it interferes with evaluation of the postoperative neurovascular status. This is particularly
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true in patients with other lower extremity injuries. A first-generation cephalosporin is given prior to the incision,
and two additional postoperative doses are administered. In patients with open injuries, the duration of antibiotics
is increased.
FIGURE 34.8 Patient position, showing pneumatic tourniquet placed proximally on thigh.

TALAR NECK FRACTURES

For most displaced talar neck fractures, we prefer a two-incision technique in which an anteromedial and an
anterolateral incision are utilized. Visualization of both the medial and lateral talar neck regions allows for more
accurate fracture reductions (Figs. 34.9A,B and 34.10A,B). Often times, the dorsal and medial talar neck are
comminuted while the lateral and plantar portions are not or visa versa.

FIGURE 34.9 A,B. Anterior medial approach to the talus.

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FIGURE 34.10 A,B. Anterior lateral approach to the talus.

Anteromedial Surgical Approach

The anteromedial incision extends from the anterior aspect of the medial malleolus to the medial cuneiform and is
centered midway between the tibialis anterior and tibialis posterior tendons (Fig. 34.11A,B) This approach
exposes the dorsomedial talar head and neck as well as the anteromedial body. Proximally, the greater
saphenous vein and nerve are identified and protected. The tibiotalar and talonavicular joints are exposed.
The remaining blood supply to the talus should be preserved. The arterial branches from the posterior tibial
vessels should be protected by avoiding plantar dissection along the medial neck. Similarly, the integrity of the
deltoid ligament must not be violated, and extensive dissection of the tibiotalar joint capsule should be avoided.
Frequently, the dorsal medial talar neck contains comminuted and/or impacted segments (Fig. 34.11B). The
dorsal soft tissues to these fragments must be respected. Only 1 to 2 mm of periosteum around the fracture site
is elevated so a cortical reduction can be adequately visualized.
FIGURE 34.11 A. Medial approach: incision in the interval between the anterior and posterior tibial tendons from
the medial malleolus to the navicular tuberosity. Proximal extension allows exposure for malleolar osteotomy (see
also Fig. 34.9A,B). B. Medial exposure showing medial neck comminution and shortening.

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FIGURE 34.12 A,B. Anterolateral approach. A. Incision from the anterolateral ankle joint in line with the fourth
ray. B. Superficial peroneal nerve is vulnerable in the superficial dissection.

Anterolateral Approach
The anterolateral incision parallels the fourth ray and is centered over the ankle joint (Fig. 34.12A). Proximally, it
is midway between the tibia and fibula, and distally it is directed toward the base of the fourth metatarsal. The
intermediate branch of the superficial peroneal nerve should be identified to avoid injury during the superficial
dissection (Fig. 34.12B). Once the nerve has been identified and protected, the extensor retinaculum is incised,
and the extensor tendons are retracted to improve visualization.
The anterior compartment contents are left as a unit and can be mobilized from lateral to medial by blunt
dissection. The extensor digitorum brevis is elevated and retracted distally and inferiorly. This exposes the
anterolateral body, lateral process, and lateral talar neck as well as the sinus tarsi.
To decrease the potential for flap necrosis, the skin and soft tissues between the two incisions should not be
undermined. The dorsalis pedis artery supplies this tissue flap as well as contributes some blood supply to the
talus through the dorsal soft-tissue branches. If more exposure is desired, the anterior joint capsule can be
released from the anterior tibia. The fat pad about the sinus tarsi can be excised so the lateral neck and lateral
process of the talus can be better evaluated. The subtalar joint is accessible through the lateral incision.
Longitudinal traction is applied through the calcaneus to distract the subtalar joint, and a pituitary rongeur is used
carefully to débride the joint.
Once the talus is exposed, reduction and fixation proceed in a stepwise fashion. A Kirschner (K)-wire can be
placed across the talar head fragment to act as a joystick and aid the reduction. Typically, the lateral talar neck
is not comminuted, and an anatomic cortical reduction is possible (Fig. 34.13). Length, alignment, and rotation
are corrected as the surgeon uses both incisions to judge the reduction. Smaller comminuted fragments are first
reduced to the larger intact segments and stabilized with K-wires (Fig. 34.14A-C). Once the gross reduction is
achieved, it is checked with C-arm fluoroscopy. Intraoperative axial alignment of the talar neck is best evaluated
using the Canale oblique view. The tibiotalar reduction is best seen on the mortise and lateral views, and the
subtalar joint is best assessed on the lateral and 45-degree mortise view. The radiographic reduction can be
compared to similar views of the uninjured taken preoperatively.
FIGURE 34.13 Anterolateral exposure showing displacement of the lateral talar neck.

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FIGURE 34.14 A. Provisional K-wire fixation. B,C. K-wire in the talar head used as a joystick to correct varus
angulation and to restore medial neck length.
Definitive fixation depends on fracture type, comminution, and bone quality. Small-fragment and minifragment
implants of adequate strength and variety are utilized. For noncomminuted talar neck fractures, longitudinal, 3.5-
mm, cortical, lag screws placed from the talar head into the body provide adequate fixation (Fig. 34.15). These
screws are placed in both the medial and lateral columns of the talus. The desired orientation of the screws
approximates parallel, but this is difficult to achieve because the navicular covers the talar head, and the forefoot
hinders a longitudinal trajectory. The medial column screw can be recessed using a burr or rongeur to allow a
slightly more lateral and longitudinal staring point and trajectory for the screw. When placing screws from an
articular staring point, the surgeon should countersink the screw head to minimize impingement or use headless
screws.
In many high-energy talar neck fractures, there is dorsomedial comminution. Longitudinal lag-screw fixation in
these cases results in fracture shortening, angulation, or displacement. To improve stability in these fractures
and prevent talar neck shortening, minifragment plates and screws are helpful. Recent advances in small site-
specific plate design including low-profile locking implants have improved the options for talar neck plating.
Plating along the lateral talar neck can be used for both comminuted and noncomminuted fractures. A fivehole
2.0-mm plate is contoured to fit the lateral talar neck and spans from the anterior surface of the lateral process,
along the lateral talar neck, to the head and neck junction. This plate is extra-articular, and it fits best when
positioned slightly plantar rather than directly lateral (Fig. 34.16A). Lateral fixation can often be supplemented
with a longitudinal cortical screw from the talar head into the body.
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FIGURE 34.15 Typical construct for talar neck fracture without significant medial comminution showing lateral
plating and medial set screw.

Medial talar neck comminution can also be addressed with plate fixation to prevent varus collapse. However, the
medial talar neck and tibiotalar joint anatomy limit options for plate placement. A 2.0-mm blade plate works well.
The blade is placed transversely across the distal talar neck from medial to lateral, just posterior to the medial
talar head articular surface. The plate is directed posteriorly to sit just plantar to the medial talar body articular
cartilage (Fig. 34.16B). Care must be taken to insure that the plate and screw heads sit below the level of the
articular surface. Intraoperative fluoroscopic images are used to assess the reduction and position of the screws
(Fig. 34.17A,B).
Closed fractures with deficient bone in the talar neck should be bone grafted. Autologous cancellous bone is
readily available from the ipsilateral distal tibia or calcaneal tuberosity. Crushed cancellous allograft is also
effective.

FIGURE 34.16 A. Lateral plate fixation. B. Medial plate fixation.

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FIGURE 34.17 A,B. Intraoperative fluoroscopic images for the assessment of reduction and position of screws.

TALAR NECK FRACTURE DISLOCATIONS

Talar neck fractures with associated posterior dislocation of the talar body present unique treatment challenges
for multiple reasons. First, reduction of the talar body into the ankle mortise in at timely manner is necessary to
diminish pressure on the skin and the neurovascular bundle. Second, timely closed reduction in an awake
patient is rarely successful. Third, formal fracture reduction, whether done closed or open, requires careful
planning.
The talar body usually extrudes posteromedially and pivots on the deltoid ligament (Fig. 34.18A-D). The talar
body segment is often incarcerated adjacent to or between the neurovascular and tendinous structures of the
tarsal tunnel. In our experience, closed reduction in the emergency department is rarely successful. However, a
single attempt under conscious sedation is reasonable. The knee is flexed to relax the gastrocnemius muscle,
countertraction is placed through the posterior femur, and longitudinal traction is applied by gripping the
calcaneus. The hindfoot is placed in equinus and valgus, and direct pressure over the talar body is applied
toward the ankle mortise. Repeated attempts should be avoided to prevent further compromise to the already
damaged soft tissues.
If the closed reduction attempt in the Emergency Department is unsuccessful, formal operative reduction is
necessary. General anesthesia with skeletal muscle paralysis is preferred. The patient is positioned supine, and
the affected extremity prepped and draped by sterile technique. Symmetric distraction across the ankle joint is
achieved by applying medial and lateral Association for Osteosynthesis (AO) “femoral” distractor. A centrally
threaded 6.0-mm Schanz pin is placed from lateral to medial across the proximal tibia metaphysis, and a second
pin is placed from medial to lateral across the calcaneal safe-spot in the tuberosity. Separate medial and lateral
distractors are applied to the pins to create adequate symmetric distraction across the ankle joint. Pressure on
the talar body toward the ankle mortise can often achieve a closed reduction. More direct manipulation of the
talar body fragment using a 4.0-mm half pin can be useful. A 1- to 2-cm longitudinal incision is made over the
talar body, and blunt dissection is carried down to the bone. The half pin should be placed manually into the talar
body fragment in a trajectory and to a depth that manipulation of the fragment will not cause further comminution.
If the closed reduction is successful and the provisional talar fracture reduction satisfactory, then the AO
distractor can be maintained or changed to standard medial and lateral external fixation frame components. The
talar fracture can then be treated by the same protocol as a closed fracture. A posterior talar body dislocation
that is irreducible by closed means requires open reduction. The medial and lateral AO distractors are used
along with the two exposures, anterolateral and anteromedial, described previously. The talar body is checked
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to ensure that there are no soft tissues blocking the reduction. The flexor tendons and neurovascular structures
are retracted gently, and the body segment directly manipulated with bone hooks or Schanz pins placed into the
nonarticular surface (Fig. 34.19A-C).

FIGURE 34.18 A-D. Clinical photographs and images of a patient with an irreducible talar neck fracture
dislocation. Note the flexed posture of the toes and the posteromedial prominence from the displaced talar body
fragment.

Should all efforts fail, a medial malleolar osteotomy can be added to facilitate the reduction although this is rarely
needed. Usually, inadequate symmetrical distraction between the tibial plafond and the calcaneus and/or soft
tissue blocks the reduction. After reduction, provisional multiplanar K-wire fixation is followed by definitive internal
fixation (Fig. 34.20A-C).
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FIGURE 34.19 A. Intraoperative appearance after anteromedial exposure of an irreducible talar neck fracture
dislocation. Note the talar body incarcerated behind the flexor tendons. B. Femoral distractor helps to facilitate
reduction of the body. Often, laterally applied distractor is also necessary to allow symmetric distraction between
the tibial plafond and calcaneus. C. Intraoperative appearance after reduction of the talar body fragment.

Talar Body Fractures

Displaced talar body fractures require a precise surgical approach. A portion of the anterior talar body is
accessible through both the anteromedial and anterolateral incisions. Simple sagittal fractures can be treated
using a single exposure, and the incision chosen is based on the fracture orientation seen on the CT scan. Joint
distraction using a femoral distractor can aid in exposure of the talar dome.
More complex talar body fractures including comminuted and coronal plane fractures, as well as associated body
and neck fractures, are best addressed using the dual incision technique. The anteromedial and anterolateral
exposures allow access to the anterior one-third to one-half of the talar body. For fractures that involve the
posterior half of the dome, an oblique medial malleolar osteotomy is usually necessary (Fig. 34.21A,B). The
anteromedial incision is extended proximally to the medial malleolus. The integrity of the deltoid ligament on the
malleolar bone should be confirmed prior to osteotomy. If the deltoid ligament is torn or avulsed, a medial
malleolar osteotomy is contraindicated, as the blood supply to the fragment will be inadequate for healing.
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FIGURE 34.20 A-C. Radiographic appearance after reduction with provisional K-wire fixation followed by
definitive internal fixation.

Fixation of the malleolar osteotomy should be planned preoperatively. Transverse lag screws with an antiglide
plate or lag screws directed up the medial malleolus parallel to the medial joint surface are adequate for fixation.
The two points of fixation are centered on the anterior and posterior colliculi and should be at 90 degrees to the
plane of the osteotomy. Otherwise, displacement of the malleolar fragment can occur when the screws are
tightened. The screw paths are drilled and tapped prior to osteotomy. The anteromedial joint capsule is incised
along the tibia to allow direct visualization of the shoulder of the medial ankle mortise.
The osteotomy is started proximally in the medial tibial metaphysis. It is inclined obliquely to enter the apex of the
medial ankle joint between the medial malleolus and the tibial plafond (Fig. 34.21A,B). Retractors are placed
posterior to the medial malleolus to protect the tendons and neurovascular bundle. A microsagittal saw is used to
cut through the cancellous bone to the subchondral bone just above the joint. A thin osteotome is then used to
complete the osteotomy and fracture the cartilage. The osteotomy is reflected distally to expose the medial talar
body.
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FIGURE 34.21 A. Medial malleolar osteotomy: fixation should be at 90 degrees to the line of osteotomy;
otherwise, displacement will occur from shear forces as screws are tightened. B. Medial malleolar osteotomy
allows visualization back to the posterior talar body.
A femoral distractor is used for joint distraction and dome visualization. Direct and indirect reduction techniques
are utilized for fracture reduction. Sagittal plane fractures can be fixed using medial to lateral lag screws.
Fragment size dictates the implant diameter. When placed across articular cartilage, smaller implants are
preferable and include 1.5-, 2.0-, or 2.4-mm, countersunk, cortical, lag screws. Medial to lateral lag screws can
also be placed extra-articularly through the deltoid fossa on the medial talar body. These screws should also be
countersunk to prevent impingement. As an alternative, headless subarticular screws can be used. Small
osteochondral fragments are stabilized with countersunk, minifragment, cortical, lag screws, or bioabsorbable
pins. Associated neck fractures are reduced and stabilized as described previously.
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TALAR HEAD FRACTURES
These injuries often occur in association with subtalar and/or transverse tarsal joint dislocations. When talar
head fractures occur as an isolated entity, rather than simultaneous with talar body or neck fractures, the
surgical approach is directly over the primary fracture line. For shear fractures of the talar head, a dorsal incision
is made just lateral to the tibialis anterior tendon. The interval between the tibialis anterior and extensor hallucis
longus is developed. In many patients with these injuries, a locked dislocation of the talonavicular joint is present.
The intact lateral portion of the talar head is locked on the lateral pole of the navicular. Distraction across the
talonavicular joint is necessary to facilitate reduction of the joint. Shear fractures without comminution or
significant joint surface impaction are amenable to screw fixation with subarticular screws (Fig. 34.22A-F).
Comminuted fractures, those with significant impaction, or joint instability may require temporary spanning medial
column external fixation. In patients with significant talar head impaction and joint incongruity, consideration
should be given to articular reduction and bone grafting of the subarticular defect. Crush injuries of the talar head
often involve the plantar medial portion of the talar head and are approached in the interval between the tibialis
anterior and tibialis posterior tendons.
FIGURE 34.22 A,B. Talar head fracture with locked dislocation of the talonavicular joint. C,D. Intraoperative
appearance after distraction of the medial column with a minidistractor. E,F. Final radiographs after reduction
and definitive fixation.

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FIGURE 34.22 (Continued)

TALAR PROCESS FRACTURES

Lateral Talar Process Fracture
Fragment size, amount of comminution, and degree of posterior facet involvement dictate the surgical treatment
strategy of these injuries. Lateral talar process fractures that occur in association with talar body and/or neck
fractures are exposed through an anteromedial or anterolateral surgical approach. Surgical exposure for
treatment of isolated lateral talar process fractures involves a longitudinal sinus tarsi incision extending from the
tip of the fibula distally in line with the fourth ray. Alternatively, the incision can extend toward the dorsum of the
foot to facilitate better visualization of the lateral talar neck region. Ligamentous attachments such as the anterior
talofibular and talocalcaneal ligament are preserved whenever possible. The fractured portion of the lateral
process is typically extruded laterally into the sinus tarsi. This fragment can be hinged open to visualize the joint
surface. Irreparable small fragments that may block reduction are excised. Inversion of the hindfoot and/or
distraction of the joint may be helpful to assess the posterior facet articular surface and to allow reduction of the
laterally extruded fragment. Solitary large lateral talar process fractures are often amenable to small-diameter
lag-screw fixation. Comminuted fractures or those with significant lateral extrusion may be best treated with a
small lateral buttress plate that runs from the lateral process along the inferior lateral talar neck (Fig. 34.23A-D).

POSTERIOR TALAR PROCESS FRACTURE

The surgical approach for posterior talar process fractures is dictated by the location of the primary fracture line
and amount of comminution. Isolated posteromedial talar tubercle fractures can be approached via a limited
posteromedial incision along the course of the flexor digitorum longus (FDL) tendon. Occasionally, these fracture
fragments can encroach upon the tibial neurovascular structures, and careful dissection should be performed.
The FDL tendon sheath is opened, and a limited arthrotomy is made through the floor of the FDL tendon sheath.
Once reduced, small-diameter lag-screw fixation is performed. Greater involvement of the posterior process
necessitates a more extensile exposure through a posterior longitudinal incision either medial or lateral to the
Achilles tendon (Fig. 34.24A-E). The decision to approach these fractures medial or lateral to the Achilles tendon
is based upon the location of the majority of talar body involvement. The investing fascia of the deep posterior
compartment is divided longitudinally exposing the flexor hallucis longus and posterior ankle
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and subtalar joints. The flexor hallucis longus tendon is retracted medially thereby protecting the tibial
neurovascular bundle. Larger fragments without comminution are amenable to lag-screw fixation but
comminution may necessitate use of a small buttress plate.

FIGURE 34.23 A,B. Lateral talar process fracture with significant posterior facet articular involvement. C,D.
Postoperative radiographs after plate fixation.

POSTOPERATIVE MANAGEMENT
Patients are placed in a bulky dressing with a posterior splint. Prophylactic antibiotics are administered for 24
hours following surgery. Once the wound is healed, patients are placed into a removable boot and begin active
range-of-motion exercises of the ankle, subtalar, and midfoot joints. Patients refrain from weight bearing for
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10 to 12 weeks or until the fracture is healed. The radiographic presence of osteonecrosis is not a
contraindication to weight bearing. Supervised physical therapy is instituted on a case-by-case basis depending
upon the patient’s ability to comply and progress with a self-directed home program.
Radiographic evaluation is performed at 6- to 8-week intervals to assess healing and to monitor for signs of
osteonecrosis. A “Hawkins sign,” which is a subchondral radiolucency beneath the talar dome, is usually visible
between 6 and 8 weeks after the injury. The presence of a Hawkins sign is a reliable indicator that the talus is
vascularized, and osteonecrosis is not likely to occur. The absence of a Hawkins sign does not, however,
reliably predict the development of osteonecrosis. The utility of magnetic resonance imaging (MRI) scanning for
monitoring of osteonecrosis is controversial. It is not practical or cost-effective to perform serial MRI scans on a
routine basis. It can occasionally be helpful in determining the extent of avascularity when subsequent
reconstructive surgical procedures are contemplated. Titanium implants have been suggested to cause less
interference with MRI visualization. CT scanning can be very helpful in assessing healing when plain x-rays are
equivocal.
FIGURE 34.24 A-C. Posterior talar body/process fracture with significant articular involvement. D,E.
Postoperative radiographs after plate fixation through a posteromedial approach.

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FIGURE 34.24 (Continued)

COMPLICATIONS
Soft-Tissue Compromise/Infection
Although the timing of surgical intervention for talar fractures is controversial, there is universal agreement
that fractures associated with joint dislocation and/or marked displacement should be treated with urgency.
Fracture displacement and/or joint dislocation can lead to excessive skin tension and soft-tissue and/or
neurovascular compromise. Expedient reduction is necessary to avoid the disastrous complication of full-
thickness tissue loss (Fig. 34.4). Delaying operative treatment can be preferable; however, when the
fracture is not significantly displaced and significant, swelling could compromise wound closure and healing.
The dual surgical approach for talar neck and body fractures necessitates careful soft-tissue handling and
proper timing to avoid wound edge necrosis. Superficial wound-edge necrosis can occur, and while it
usually responds to local wound care, it delays the initiation of range-of-motion exercises. Open injuries
require immediate and serial irrigation and débridement followed by the appropriate coverage or closure to
avoid deep infection. Early onset of deep infection necessitates irrigation and débridement with culture-
specific intravenous antibiotic therapy. Deep infection can result in septic destruction of all the peritalar
joints with significant bone loss that can be very difficult to salvage.

MALUNION OR NONUNION
Even small amounts of residual displacement or malalignment following talus fracture can lead to altered joint
mechanics and arthrosis. Shortening of the medial neck of the talus caused by comminution, impaction, and/or
malreduction can lead to a varus malunion. Varus malunion following talar neck fractures has been reported to
occur in up to 36% of patients who underwent open reduction and internal fixation. The dual incision approach
facilitates adequate visualization and proper restoration of talar length and alignment and therefore helps
minimize this complication. Apex dorsal malunion can occur when the body of the talus is left plantarflexed
relative to the neck, and the head fragment remains dorsal to the neck. This often leads to impingement of the
dorsal talus on the distal tibia with maximal ankle dorsiflexion. The talus is a common site of missed injury, and
malunion and nonunion can be the consequence of unrecognized fracture.
Treatment of symptomatic talar malunion can be extremely difficult and is dependent upon the integrity of the
peritalar joints. Long-standing varus malunion with peritalar joint arthritis typically can only be salvaged by
arthrodesis with realignment to obtain a plantigrade foot. Varus malunion typically leads to shortening of the
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medial column of the foot and needs to be addressed at the time of salvage arthrodesis. Malunion recognized
before the onset of significant arthritis can be treated by osteotomy with restoration of length, alignment, and
rotation (Fig. 34.25A-C). This may involve structural bone grafting to regain talar neck length.

FIGURE 34.25 A,B. Talar body fracture that was missed and resulted in malunion. C. Radiograph after
osteotomy and definitive fixation..
Osteonecrosis
Osteonecrosis is largely a consequence of the injury rather than a complication of surgical treatment. The
incidence of osteonecrosis following talar neck fractures is related to the initial fracture displacement and the
extent of comminution rather than the timing of reduction. Focal osteonecrosis without collapse is common
following talar neck and body fractures. It is often asymptomatic and does not necessarily doom the patient to a
poor result. Diffuse or global osteonecrosis can result in collapse of the talar dome and progressive
posttraumatic arthritis in the ankle and subtalar joints. In the past, the initial period in which weight bearing was
suspended was prolonged awaiting revascularization. This was believed to protect the talar dome from collapse.
However, this approach is largely unproven and impractical. Nonsurgical management of symptomatic
osteonecrosis includes bracing and shoe wear modification. Surgical salvage typically consists of arthrodesis of
the involved joints. As an alternative, in circumstances of completed fragmentation and collapse of the talar body,
a modified Blair fusion with removal of the nonviable body and fusion of the talar neck and head to the anterior
distal tibia can restore stability and lessen pain. With this procedure, patients retain more motion than with a
tibial-talocalcaneal fusion.
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POSTTRAUMATIC ARTHRITIS
Joint stiffness and posttraumatic arthritis are the most frequent consequences of talar body and neck fractures.
This often occurs with some degree of focal osteonecrosis. It can be the result of chondral damage at the time of
injury or from abnormal joint kinematics caused by malunion. Stable internal fixation that allows early motion may
minimize peritalar joint stiffness. When conservative measures are ineffective, arthrodesis of the affected joints(s)
is often necessary for pain relief. Proper imaging studies prior to any reconstructive salvage procedure are
necessary to define areas of osteonecrosis, available bone stock, and extent of arthritic involvement.

RECOMMENDED READING
Canale ST, Kelly FB. Fractures of the neck of the talus: long-term evaluation of seventy-one cases. J Bone
Joint Surg Am 1978;60:143-156.

Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 2001;9:114-127.

Kou JX, Fortin PT. Commonly missed peritalar injuries. J Am Acad Orthop Surg 2009;17:775-786.

Lindvall E, Haidukewych G, et al. Open reduction and stable fixation of isolated, displaced talar neck and
body fractures. J Bone Joint Surg Am 2004;86:2229-2234.

Marti R. Talus and Calcaneusfrakturen. In: Weber BG, Brunner C, Freuler F, eds. Die Frakturenbehandlung
bei Kindern und Jugendlichen. Berlin, Germany: Springer Verlag; 1978:373-384.

Miller AN, Prasarn MD, et al. Quantitative assessment of the vascularity of the talus with gadolinium
enhanced magnetic resonance imaging. J Bone Joint Surg Am 2011;93A:1116-1121.

Patel R, Van Bergeyk A, et al. Are displaced talar neck fractures surgical emergencies? A survey of
orthopaedic trauma experts. Foot Ankle Int 2005;26:378-382.
Rammelt S, Winkler J, et al. Anatomical reconstruction of malunited talus fractures. A prospective study of 10
patients followed for 4 years. Acta Orthop 2005;76:588-596.

Rammelt S, Zwipp H. Talar neck and body fractures. Injury Int J Care Injured 2009;40:120-135.

Tezval M, Dumont C, et al. Prognostic reliability of the Hawkins sign in fractures of the talus. J Orthop
Trauma 2007;8:538-542.

Vallier HA, Nork SE, Barei DP, et al. Talar neck fractures: results and outcomes. J Bone Joint Surg Am
2004;86:1616-1628.

Vallier HA, Nork SE, Benirschke SK, et al. Surgical treatment of talar body fractures. J Bone Joint Surg Am
2003;85: 1716-1724.
 35
Calcaneal Fractures: Open Reduction Internal Fixation
Michael P. Clare
Roy W. Sanders

INTRODUCTION
Fractures of the calcaneus are among the most challenging fractures for the orthopedic surgeon to effectively
manage. Approximately 60% to 75% of all calcaneal fractures are displaced intra-articular fractures, and up to
90% of calcaneal fractures occur in young adult males in their working prime, which underscores the economic
impact of these injuries (1,2). A thorough understanding of the relevant pathoanatomy and meticulous softtissue
handling is essential in maximizing patient outcomes.

Mechanism of Injury
Displaced intra-articular calcaneal fractures generally occur as the result of high-energy trauma, such as a motor
vehicle accident or a fall from a height. The mechanism of injury was first proposed by Essex-Lopresti (2) and
later confirmed by Carr (3). At the moment of impact, the lateral process of the talus impacts the calcaneus at the
crucial angle of Gissane as the subtalar joint is forced into eversion, which divides the lateral wall and body of
the calcaneus, and produces the primary fracture line laterally. The residual force dissipates medially into the
sustentaculum and, with continued force, extends into the anterior process or calcaneocuboid joint, producing an
anterolateral fragment. A secondary fracture line then results from increased force: with a posteriorly directed
force, the fracture line continues into and posterior to the posterior facet, producing a joint depression fracture,
and with a more inferiorly directed force, the fracture line extends inferior to the posterior facet, producing a
tongue-type fracture (Fig. 35.1A-C).
With displaced intra-articular calcaneal fractures, the loss of height through the calcaneus results in a shortened
and widened heel, typically with varus malalignment of the tuberosity. This loss of height is reflected by a
decreased tuber angle of Böhler, such that the normal downward tilt of the talus is diminished and the talus
becomes relatively more horizontal (Fig. 35.2A-C). As the superolateral fragment of the posterior facet is
impacted plantarward, the thin lateral wall explodes laterally just posterior to the crucial angle of Gissane. This
lateral wall expansion may trap the peroneal tendons against the lateral malleolus; in some cases, a violent
contracture of the peroneal tendons may disrupt the superior peroneal retinaculum from the fibula, resulting in an
avulsion fracture of the lateral malleolus and dislocation of the peroneal tendons. The anterior process typically
displaces superiorly, which directly limits subtalar joint motion by impinging against the lateral process of the
talus.
Clarification of fragment terminology is necessary to understand the pathoanatomy of displaced intra-articular
calcaneal fractures (Fig. 35.1A-C). The anterolateral fragment encompasses the lateral wall of the anterior
process, is typically pyramidal in shape, and may include a portion of the calcaneocuboid articular surface. The
anterior main fragment is the large fragment anterior to the primary fracture line, which usually includes the
anterior portion of the sustentaculum and anterior process. The superomedial fragment, also known as the
sustentacular or constant fragment, is the fragment of variable size found posterior to the primary fracture line;
this fragment almost always remains attached to the talus through the deltoid ligament complex and is therefore
stable. The superolateral fragment, also referred to as the semilunar or comet fragment, is the lateral portion of
the posterior facet that is sheared from the remaining posterior facet in joint depression fractures. The tongue
fragment refers to the superolateral fragment that remains attached to a portion of the posterior tuberosity
including the Achilles tendon insertion and is found in tongue-type fractures. The posterior main fragment
represents the posterior tuberosity.
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FIGURE 35.1 (A) Axial, (B) sagittal, and (C) semicoronal CT images demonstrating primary and secondary
fracture lines (black lines) and typical calcaneal fracture fragments: AL, anterolateral; AM, anterior main; PM,
posterior main; SL, superolateral; SM, superomedial; white arrow, lateral wall expansion.

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FIGURE 35.2 A. Normal lateral radiograph demonstrating normal tuber angle of Böhler (angle a) and crucial
angle of Gissane (angle b). B. Lateral injury radiograph with impaction of entire posterior facet; note decreased
tuber angle of Böhler angle, increased crucial angle of Gissane, and marked loss of calcaneal height with
relative horizontalization of talus. C. Lateral injury radiograph with impaction of superolateral fragment manifest
as “double density” sign (white arrows); note relative maintenance of tuber angle of Böhler and crucial angle of
Gissane.

INDICATIONS FOR OPERATIVE TREATMENT

Operative treatment is generally indicated for displaced intra-articular fractures involving the posterior facet.
Specific indications include fractures with intra-articular posterior facet displacement ≥2 mm, ≥20% loss of
calcaneal height, or significant lateral wall expansion. Surgical treatment allows restoration of calcaneal height,
width, and overall morphology, in addition to the posterior facet articular surface where possible, and allows
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for a late in situ arthrodesis as a means of salvage in the event of posttraumatic arthritis. The primary goal of
surgery is anatomic restoration of alignment and return of function without pain.
CONTRAINDICATIONS FOR OPERATIVE TREATMENT
Nonoperative management is reserved for intra-articular fractures that are truly nondisplaced (Sanders type I) on
computed tomography (CT) scan (4, 5 and 6). Other specific contraindications include fractures in patients with
severe peripheral vascular disease or insulin-dependent diabetes mellitus and peripheral neuropathy, other
medical comorbidities prohibiting surgery, and fractures in elderly patients who are minimal (household)
ambulators (7). Chronological age itself is not necessarily a contraindication to surgical treatment, as many older
patients are healthy and active well into their 70s (8). Although smoking itself is not a contraindication for
surgery, patients who are smokers are counseled as to the risks of wound complications and encouraged to quit
smoking; heavy smoking (>2 packs per day) is considered a relative contraindication to surgery. Similarly,
patients with non-insulin-dependent diabetes mellitus and intact protective sensation are counseled regarding
the importance of diligent blood glucose control but are still considered candidates for surgery.

PREOPERATIVE PLANNING
Clinical Evaluation
A patient with a calcaneal fracture typically experiences severe pain in the hind foot, which is related to bleeding
into the limited soft-tissue envelope surrounding the heel. The severity of fracture displacement and the extent of
soft-tissue disruption are proportional to the amount of force and energy involved in producing the injury—lower
energy injuries produce more mild swelling and ecchymosis, while higher energy injuries result in severe soft-
tissue disruption and may result in an open fracture.

Open Fractures
An open fracture of the calcaneus may present as a puncture wound medially from a prominent spike of bone
from the medial wall of the calcaneus or as a more substantial wound with significant soft-tissue disruption,
typically laterally or posteriorly. Open fractures are distinct injuries requiring different treatment and are generally
associated with higher complication rates relative to closed fractures.

Compartment Syndrome of the Foot and Skin Necrosis

Within a few hours following the injury, soft-tissue swelling in the hind foot is typically so severe that skin creases
in the area are no longer visible. In rare cases, severe swelling may produce a compartment syndrome of the
foot, which, if untreated, can result in clawtoe deformities, contracture, weakness, and loss of function. Thus, it is
important to ensure that pain associated with the fracture is not due to a compartment syndrome, particularly in
the calcaneal compartment, which is contiguous with the deep posterior compartment of the leg. With tongue-
type fractures, significant displacement of the tongue fragment may place excessive pressure on the posterior
skin, causing necrosis if left untreated.

Associated Injuries
A high index of suspicion must be maintained for other associated injuries, including lumbar spine fractures or
other fractures of the lower extremities, particularly with falls from a height. Up to 50% of patients with calcaneus
fractures may have other associated injuries—intuitively, these injuries are more common in higherenergy
trauma. Appropriate diagnostic evaluation should thus be completed where necessary.

Resolution of Soft-Tissue Swelling

Surgery is ideally performed within the first 3 weeks of injury prior to early consolidation of the fracture. Once
fracture consolidation ensues, the fragments become increasingly difficult to separate to obtain an adequate
reduction, and the articular cartilage may delaminate from the underlying subchondral bone. Surgery must be
delayed, however, until the associated soft-tissue swelling has adequately dissipated, which may require up to 3
weeks. We utilize a Jones dressing and supportive splint initially, combined with limb elevation. Once the initial
edema has begun to dissipate, the patient is converted to an elastic compression stocking and fracture boot.
Sufficient resolution of soft-tissue edema is indicated by a positive wrinkle test, in which the lateral calcaneal
skin is visually assessed and palpated with the foot positioned in dorsiflexion and eversion. The test is positive if
skin wrinkling is seen, and no pitting edema remains, indicating that surgical intervention may be safely
undertaken (5).
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RADIOLOGIC EVALUATION
Plain Radiography
With a suspected calcaneal fracture, plain radiographic evaluation should include a lateral view of the hind foot,
an anteroposterior view of the foot, an axial view of the heel, and a mortise view of the ankle.
A calcaneal fracture is most easily identified on the lateral view of the hind foot. With an intra-articular fracture,
there is a loss of height in the posterior facet—the articular surface is impacted within the body of the calcaneus
and usually rotated anteriorly up to 90 degrees relative to the remaining subtalar joint; a decreased tuber angle
of Böhler and an increased crucial angle of Gissane are seen in fracture patterns where the entire posterior facet
is separated from the sustentaculum and depressed (Fig. 35.2B); if only the lateral portion of the posterior facet
is involved, the split in the articular surface is manifest as a “double density,” in which case the tuber angle of
Böhler and crucial angle of Gissane may appear normal (Fig. 35.2C). The lateral view also allows delineation as
to whether the fracture is a joint depression or tongue-type fracture (2).
The anteroposterior view of the foot is helpful to identify if there is fracture extension into the calcaneocuboid
joint, anterolateral fragments, and widening of the lateral calcaneal wall. The Harris axial view of the heel shows
a loss of calcaneal height, increased width, and (typically) varus angulation of the tuberosity fragment, as well as
visualization of the articular surface. A mortise view of the ankle often demonstrates involvement of the posterior
facet.

Computed Tomography
If the plain radiographs reveal intra-articular extension of the calcaneal fracture, CT scanning is indicated.
Images are obtained in 2 to 3-mm intervals in the axial, sagittal, and 30-degree semicoronal planes.
The axial or transverse cuts reveal extension of fracture lines into the anterior process and calcaneocuboid joint
as well as the sustentaculum tali and anteroinferior margin of the posterior facet (Fig. 35.1A). The sagittal views
demonstrate displacement of the tuberosity fragment, extent of involvement of the anterior process including
superior displacement of the anterolateral fragment, anterior rotation of the superolateral posterior facet
fragment, and delineation of the fracture as a joint depression or tongue-type pattern (Fig 35.1B) (2). The 30-
degree semicoronal images show displacement of articular fragments in the posterior facet, the sustentaculum
tali, the extent of widening and shortening of the calcaneal body, expansion of the lateral calcaneal wall, varus
angulation of the tuberosity, and location of the peroneal tendons (Fig. 35.1C).

SURGICAL TECHNIQUE
Although a variety of surgical approaches have been described, we prefer the extensile lateral approach for
displaced intra-articular fractures, as it consistently allows reduction of the calcaneal body, restoration of
calcaneal height and width, even with severe comminution, as well as reduction of the intra-articular surface
where possible (6).

OPEN REDUCTION INTERNAL FIXATION: EXTENSILE LATERAL APPROACH

FOR JOINT DEPRESSION-TYPE FRACTURES
Patient Positioning/Draping/C-Arm
The patient is given preoperative prophylactic antibiotics and positioned on an operating table with a radiolucent
far end is utilized, preferably one with a “diving board” type attachment (i.e., without table legs distally) to
facilitate surgeon position and intraoperative fluoroscopy. The patient is placed in the lateral decubitus position
on a beanbag. The lower extremities are positioned in a scissor configuration, whereby the operative limb is
flexed at the knee and angles toward the distal, posterior corner of the operating table, while the nonoperative
limb is extended at the knee and lies away from the eventual surgical field. Protective padding is placed beneath
the contralateral limb to protect the peroneal nerve, and an operating “platform” is created with blankets or foam
padding to elevate the operative limb (Fig. 35.3).
A pneumatic thigh tourniquet is used in all cases. The procedure should be completed within 120 to 130 minutes
of tourniquet time, in order to minimize potential wound complications. A standard C-arm should be utilized rather
than a “mini” C-arm, because the arc of “C” is too small to fit around the operating table for a true lateral view.
The C-arm approaches the surgical field from opposite the surgeon and perpendicular to the table.

Approach
Soft-tissue complications following the surgical management of calcaneal fractures remain a major source of
morbidity with these injuries. Thus, careful attention to detail with respect to placement of the incision and gentle
handling of the soft tissues are of paramount importance. The vertical limb of the incision begins
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2 cm proximal to the tip of the lateral malleolus, immediately lateral to the Achilles tendon and thus posterior to
the sural nerve and the lateral calcaneal artery (9), and extends toward the plantar foot. The horizontal limb
continues at the junction of the skin of the lateral foot and heel pad, with a gentle curve connecting the two limbs
of the incision (Fig. 35.4A). Dissection is specifically taken “straight to bone” at the level of the calcaneal
tuberosity proximally and continues to the midpoint of the horizontal limb.

FIGURE 35.3 Intraoperative positioning for extensile lateral approach. Note scissor configuration of operative
and nonoperative limbs and operating platform.
FIGURE 35.4 Extensile lateral approach. A. Proposed incision. B. Full-thickness subperiosteal flap using “no
touch” technique.

A full-thickness subperiosteal flap is then raised starting at the apex, specifically avoiding the use of retractors
until a sizeable subperiosteal flap is developed, in order to prevent separation of the skin from the underlying
subcutaneous tissue (Fig. 35.4B). The calcaneofibular ligament is sharply released from the lateral calcaneal
wall, and the adjacent peroneal tendons are released from the peroneal tubercle through their cartilaginous
“pulley” (Fig. 35.4C). A periosteal elevator is used to gently mobilize the tendons in the distal portion of the
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incision, thereby exposing the anterolateral calcaneus. The peroneal tendons, sural nerve, and lateral calcaneal
artery are thus contained entirely within the flap, which minimizes devascularization of the lateral skin.
FIGURE 35.4 (Continued) C. Mobilization of peroneal tendons. D. K-wire retractors.

Deep dissection continues to the sinus tarsi and anterior process anteriorly and to the superior-most portion of
the calcaneal tuberosity posteriorly for “window” visualization of the posterior facet. Using a “no touch”
technique, three 1.6-mm Kirschner wires are placed for retraction of the subperiosteal flap: one into the fibula as
the peroneal tendons are slightly subluxed anterior to the lateral malleolus; a second wire is placed in the talar
neck; a third wire is placed in the cuboid as the peroneal tendons are levered away from the anterolateral
calcaneus with a periosteal elevator (Fig. 35.4D).

Mobilization of the Fragments

The expanded lateral wall fragment is mobilized and removed and preserved in saline on the back table. The
adjacent impacted superolateral articular fragment of the posterior facet is gently elevated with a small periosteal
elevator at the plantar margin of the fragment within the body of the calcaneus. The articular surface of the
fragment is assessed for chondral damage, and the fragment is débrided of residual hematoma and preserved in
saline on the back table. Removal of the articular fragment thereby affords exposure of the sustentacular
fragment, the tuberosity fragment, and the obliquely oriented primary fracture line medially (Fig. 35.5A).
A periosteal elevator is placed into the primary fracture line, and levered plantarward, which disimpacts the
tuberosity fragment from the sustentacular fragment, and helps restore calcaneal height and length along the
medial calcaneal wall (10,11) (Fig. 35.5B). A 4.5-mm external fixation pin is placed in the posterior-inferior corner
of the calcaneal tuberosity, and the tuberosity is further manipulated by longitudinal traction, medial translation,
and valgus angulation (12).

Reduction of the Articular Surface and Anterior Process

Attention is next directed to the articular fragment(s) of the posterior facet: with only one fragment (Sanders type
II fracture), 1.6-mm K-wires are placed parallel to the articular surface of the superolateral fragment to facilitate
reduction; with two separate fragments (Sanders type III fracture), the central articular fragment is first reduced to
the sustentacular fragment and provisionally held with 1.6-mm K-wires, which are exchanged for 1.5-mm
bioresorbable (poly-l-lactide acid) pins. The protruding ends of the pins are removed flush with the bony surface
with a handheld electrocautery unit (Fig. 35.6). The superolateral (lateral-most articular) fragment is then
reduced and provisionally stabilized to the central and sustentacular fragments. A minimum of two K-wires should
be placed across each fragment to prevent malrotation of the fragments. The articular fragment(s) must be
precisely reduced such that (superior-inferior) height, (anterior-posterior) rotation, and coronal plane (varus-
valgus) alignment are correct. Impingement from the tuberosity fragment against the articular fragment(s) may
preclude reduction. Thus, the surgeon may need to further disimpact the tuberosity with varus force or remove
excess bone from the tuberosity to facilitate the path for the articular fragment(s).
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FIGURE 35.5 Intraoperative views (A) following excision of lateral wall fragment and superolateral fragment. AL,
anterolateral; SM, superomedial; PM, posterior main. B. Mobilization with blunt periosteal elevator through
primary fracture line (white arrows).

The anterior process fragments are typically displaced superiorly from the intact interosseous ligament. The
fragments are pulled inferiorly with a dental pick and are provisionally secured with 1.6-mm K-wires. There is
often variability in anterior process fracture lines, particularly with higher energy patterns, such that there may be
three separate fragments. In this instance, as the anterolateral fragment is reduced, the surgeon must ensure
that the central fragment does not remain residually displaced superiorly. A lamina spreader may be used to
facilitate repositioning of the central fragment.
A transverse fracture line may be present through the crucial angle of Gissane, in which case the sustentacular
fragment may rotate anteriorly beneath the anterior main fragment. In this case, prior to the articular reduction,
the sustentacular fragment must be derotated, reduced, and provisionally stabilized to the anterior main fragment
to prevent malrotation of the entire posterior facet articular surface (Fig. 35.7).
Once the posterior facet articular fragments are reduced, the articular reduction is verified through “window”
visualization: the anterior and posterior corners of the superolateral fragment should align with the anterior and
posterior corners of the sustentacular fragment. Full visualization of the articular surface posteriorly may be
facilitated with a small retractor placed at the posterior margin of the joint surface. Failure to visualize the
posterior facet from both sides of the “window” may lead to malreduction of the fragment(s) in the sagittal plane
(Fig. 35.8A,B).
FIGURE 35.6 Stabilization of central articular fragment with bioresorbable pins (white arrows). The protruding
portion of the pins is removed flush with bone using handheld electrocautery unit.

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FIGURE 35.7 Articular intussusception. Sustentacular fragment (SM) is derotated, elevated (white arrow), and
reduced to anterior main fragment (AM). Note intra-articular (split) tongue fragment (SL) reflected on soft-tissue
hinge to facilitate reduction of primary fracture line.

At this point, the posterior edge of the anterolateral fragment should “key” into the anterior-inferior edge of the
superolateral fragment, which restores the crucial angle of Gissane; the lateral wall and the body of the
calcaneus should align with simple valgus manipulation of the external fixation pin; and the previously excised
lateral wall fragment should anatomically reduce, thereby confirming at the least that the lateral column is fully
restored.
FIGURE 35.8 Sagittal plane malalignment of superolateral fragment from inadequate “window visualization.” A.
Postoperative coronal CT image through more anterior portion of posterior facet—articular reduction appears
anatomic. B. Coronal image through more posterior portion demonstrating rotational malalignment.

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FIGURE 35.9 Intraoperative (A) lateral, (B) Broden’s, and (C) axial fluoroscopic images demonstrating
provisional reduction; note anatomic alignment of posterior facet articular surface (B) and restoration of
calcaneal height (C). Also note residual varus angulation of tuberosity (C), which corrects with simple
manipulation during definitive fixation (Fig. 35.11).

The reduction is confirmed by intraoperative fluoroscopy, including lateral, Brodén’s, and axial views. The lateral
view should be a true lateral view of the talus at the ankle joint in order to accurately assess the calcaneus (Fig.
35.9A). Next, the limb is externally rotated 45 degrees and foot dorsiflexed to obtain a mortise view of the ankle.
The beam is canted 10 degrees toward the foot of the bed to obtain a Brodén’s view, thereby revealing the
posterior facet. The entire facet is visualized under live fluoroscopy through dorsiflexion and
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plantarflexion of the foot (Fig. 35.9B). Lastly, the limb is externally rotated 90 degrees and the foot maximally
dorsiflexed through the midfoot. The beam is further angled 30 degrees toward the foot of the bed such that the
head of the fluoroscope is centered over the plantar midfoot, demonstrating a clear axial view of the calcaneus
(Fig. 35.9C).
Combined (Open/Closed) Techniques for Split Tongue Fractures
Although extra-articular tongue-type (Sanders type IIC) fractures are amenable to percutaneous reduction
techniques, intra-articular (split) tongue-type patterns (Sanders type IIA or B and III) require a formal open
reduction through an extensile lateral approach. In these patterns, the pull of the Achilles tendon often precludes
reduction of the lateral articular tongue fragment in proper sagittal plane rotation. We utilize the Essex-Lopresti
reduction technique on the tongue fragment in an open fashion, using a 4.5-mm external fixation pin placed
percutaneously into the tongue fragment (13). By levering the pin plantarly, the deforming force of the Achilles
tendon is neutralized, which allows anatomic reduction of the articular surface in the sagittal plane (Fig. 35.10).
The remainder of the procedure is completed (as described previously).

Definitive Fixation
A low-profile laterally based calcaneal plate is selected. Bending or contouring of the plate along the longitudinal
axis of the plate is strictly discouraged as it may result in varus malalignment of the tuberosity. As the screws are
tightened, it brings the plate to the bone, which narrows the width of the calcaneus.
The posterior facet is first secured with cortical lag screws (2.7 to 3.5 mm), typically one screw outside the plate
and one screw through the plate, and placed just beneath the articular surface angling distally and slightly
plantarly toward the sustentaculum to accommodate the slight lateral-to-medial downslope of the articular
surface. The plate is secured with 3.5-mm cortical or 4.0-mm cancellous screws, starting with the anterior
process. The distal-most screw holes in the plate are angled slightly posteriorly to accommodate the oblique
orientation of the calcaneocuboid joint.
The calcaneal tuberosity is next secured to the plate while maintaining a simultaneous lateral-to-medial force on
the plate (with the surgeon’s thumb) and a valgus-directed force on the undersurface of the tuberosity (with the
surgeon’s long and ring fingers; Fig. 35.11). The main components of the calcaneus (anterior process, posterior
tuberosity, and articular surface) are further stabilized to the plate such that two screws traverse each
component (Fig. 35.12A-C). In the event of poor patient bone quality, supplemental locking screws may be
placed beneath the posterior facet articular block to better support and maintain calcaneal height (Fig. 35.12D).
Final fluoroscopic images are obtained, confirming the final reduction and implant placement.
FIGURE 35.10 Essex-Lopresti technique for intra-articular split tongue pattern; note Schanz pin within tongue
fragment to neutralize pull of Achilles tendon.

FIGURE 35.11 Fixation of calcaneal tuberosity: simultaneous lateral-to-medial force on plate (applied by
surgeon’s thumb) and valgus-directed force on undersurface of tuberosity (applied by surgeon’s long and ring
fingers).

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FIGURE 35.12 Intraoperative (A) lateral, (B) Broden’s, and (C) axial fluoroscopic images demonstrating final
reduction and definitive fixation with nonlocking neutralization plate. D. Intraoperative lateral view showing use of
locking neutralization plate (different patient)—note locking screws (white arrows) placed beneath posterior facet
articular block as rafter support spanning bony defect.

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Open Reduction Internal Fixation/Primary Arthrodesis for Sanders Type IV Fractures
Open reduction internal fixation (ORIF) with primary subtalar arthrodesis is indicated only for highly comminuted
intra-articular (severe Sanders type III and all type IV) fractures (10), in which the articular surface is determined
at the time of surgery to be nonreconstructable (6). Standard ORIF techniques are utilized through an extensile
lateral approach to fully restore calcaneal height, length, and overall morphology. A primary subtalar arthrodesis
is included in the event of a poor intra-articular reduction, severe cartilage delamination, or absence of a
substantial portion of the joint surface (14).

Assessing the Peroneal Tendons

With removal of the K-wires, the peroneal tendons should reduce into the peroneal groove along the posterior
edge of the lateral malleolus. A Freer elevator is advanced within the peroneal tendon sheath on the
undersurface of the flap to the level of the lateral malleolus and levered forward while observing the overlying
skin to assess stability of the superior peroneal retinaculum and peroneal tendon sheath (Fig. 35.13A). If the
tendon sheath is detached from the lateral malleolus, the elevator will easily slide anterior to the fibula, in which
case a tendon sheath repair is required.
Following wound closure, a small (<3 cm) incision is then made along the posterior edge of the lateral malleolus,
exposing the peroneal tendon sheath, which is incised (Fig. 35.13B). One to two suture anchors are placed
along the posterolateral rim of the fibula. With the peroneal tendons held reduced in the peroneal groove, the
sutures are advanced in horizontal mattress fashion through the detached tendon sheath to tension the tendon
sheath toward the posterolateral rim of the fibula, thereby restoring the peroneal checkrein. Tendon stability is
then confirmed using a Freer elevator in the same manner (15).

Wound Closure
A deep drain is placed exiting proximally in line with the vertical limb of the incision, and deep no. 0 absorbable
sutures are placed in interrupted fashion, beginning with the apex of the incision and progressing to the proximal
and distal ends. The sutures are clamped until all sutures have been passed and then hand-tied sequentially,
starting at the proximal and distal ends and working toward the apex of the incision, so as to eliminate tension at
the apex of the wound. The skin layer is closed with 3-0 monofilament sutures using the modified Allgöwer-
Donati technique. The tourniquet is deflated and bulky splint placed (Fig. 35.14).

POSTOPERATIVE PROTOCOL
The patient is typically kept overnight in the hospital for pain control. Prophylactic antibiotics are continued for 24
hours following surgery. The patient is discharged in the same bulky splint and is seen at 2 weeks
postoperatively, at which point the patient is then converted to a compression stocking and fracture boot, and
early ankle joint range-of-motion exercises are begun. Nonstanding radiographs are obtained, and sutures are
removed when the incision is fully sealed and dry, typically at 4 to 5 weeks, at which point subtalar joint rangeof-
motion exercises are added. Weight-bearing radiographs are obtained at 10 to 12 weeks postoperatively, at
which point proprioception, eversion strengthening, and weight bearing are initiated.

FIGURE 35.13 Peroneal tendon dislocation. A. Assessment of superior peroneal retinaculum from undersurface
of flap with Freer elevator (black arrow). B. Superior peroneal retinaculum repair. Sutures passed in horizontal
mattress fashion through detached tendon sheath to advance sheath toward posterolateral rim restoring
peroneal checkrein.

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FIGURE 35.14 Wound closure using modified Allgöwer-Donati technique. Note skin bridge between vertical limb
of extensile lateral incision and incision for SPR repair.

We prefer that the patient sleeps in the boot at night until weight bearing is initiated, so as to prevent an equinus
contracture. The patient is gradually transitioned into regular shoe wear as weight bearing is advanced. Most
patients will have regained approximately 50% of normal hind-foot motion by the time weight bearing is begun;
thus, physical therapy is typically not necessary. Most patients are able to return to near full activity by
approximately 6 months postoperatively. The patient is evaluated, and repeat weight-bearing radiographs are
obtained at 4 months, 6 months, 9 months, and 1 year following surgery.

COMPLICATIONS
Wound Complications
The most common complication following surgical treatment of a calcaneal fracture is wound dehiscence,
which may occur in up to 25% of cases (6,12,16, 17, 18, 19 and 20). The majority of wounds will ultimately
heal, as deep infection and osteomyelitis develop in only 1% to 4% of closed fractures (16,18, 19 and 20). If
a wound breaks down, range-of-motion exercises are stopped and daily whirlpool treatments, damp-to-dry
dressing changes, and oral antibiotics are initiated. Once the wound seals, range-of-motion exercises are
reinstituted. For recalcitrant wounds, we prefer use of a negative pressure device to promote wound
healing.

LOSS OF SUBTALAR MOTION

As with most other intra-articular fractures, subtalar joint stiffness after a displaced intra-articular calcaneal
fracture is to some degree inevitable, in that the posterior facet articular surface is arguably never quite the same
following an intra-articular fracture. It is difficult to distinguish whether the stiffness is a consequence of the injury
or the extensile lateral approach or combination thereof. It has been our experience that patients typically regain
approximately 75% of normal subtalar motion following surgery, which should be sufficient to accommodate
activities on uneven ground.
In the event of subtalar arthrofibrosis, a capsular release and arthrolysis of the posterior facet are indicated. We
use the vertical limb of the extensile lateral incision to access the posterior facet. The orientation of the posterior
facet is identified, and the subtalar joint capsule is released (excised) with a no. 15 blade starting posteriorly and
working laterally and anteriorly. The remaining capsule can be released to the level of the crucial angle of
Gissane using the sharp end of a Freer elevator. The intra-articular adhesions are then carefully released with
the blunt end of a Freer elevator—care should be taken to avoid iatrogenic chondral damage. Aggressive
subtalar motion exercises are begun almost immediately following surgery.
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POSTTRAUMATIC SUBTALAR ARTHRITIS
Posttraumatic arthritis may still develop following ORIF, even in cases with an anatomic reduction, due to
cartilage damage at the time of injury (5). Because calcaneal height and morphology have already been
restored, implant removal and an in situ subtalar arthrodesis may be performed (5,21,22).

RESULTS/OUTCOMES
As with other complex periarticular fractures, it has been well established that surgical management of displaced
intra-articular calcaneal fractures, when properly executed by experienced fracture surgeons, is preferable to
nonsurgical management (23, 24, 25, 26 and 27).
Because of poor results with nonoperative management of displaced intra-articular calcaneal fractures, Crosby
and Fitzgibbons began treating these fractures surgically in the early 1990s and showed significantly better
results with operative treatment compared to their previous series of fractures treated nonoperatively (23).
Thordarson and Krieger (25) completed a randomized, prospective trial comparing operative treatment to
nonoperative treatment for displaced intra-articular calcaneal fractures and reported significantly better functional
results and outcome scores in those treated surgically.
Laughlin et al. (26) reported 78% good-excellent results in their series of displaced intra-articular calcaneal
fractures treated through an extensile lateral approach with a lateral neutralization plate and lag screws.
Similarly, Tornetta (27) reported 91% anatomic articular reduction and 77% good-excellent results in a small
series using an extensile lateral approach with minifragment neutralization plates and cortical lag screws.
Nonoperative management of a displaced intra-articular calcaneal fracture often results in a symptomatic
calcaneal malunion with significant long-term implications, including posttraumatic subtalar arthritis, loss of
calcaneal height, lateral subfibular impingement and associated peroneal tendon sequelae, and residual hindfoot
malalignment (28). Although patients can still develop posttraumatic arthritis following ORIF, in our experience,
patients in this instance have significantly better outcomes following late arthrodesis than those with calcaneal
malunions whose calcaneal height and morphology were not initially restored (28,29). These studies suggest
that restoration of calcaneal height, length, and morphology is indeed beneficial to outcome, regardless of the
fate of the articular surface long term.

REFERENCES
1. Coughlin MJ. Calcaneal fractures in the industrial patient. Foot Ankle Int 2000;21:896-905.
2. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg
1952;39: 395-419.

3. Carr JB, Hamilton JJ, Bear LS. Experimental intra-articular calcaneal fractures: anatomic basis for a new
classification. Foot Ankle 1989;10:81-87.

4. Crosby LA, Fitzgibbons T. Computerized tomography scanning of acute intra-articular fractures of the
calcaneus. J Bone Joint Surg Am 1990;72:852-859.

5. Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma
1992;6:252-265.

6. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal
fractures. Results using a prognostic computed tomography scan classification. Clin Orthop 1993;290:87-95.

7. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

8. Herscovici D Jr, Widmaier J, Scaduto JM, et al. Operative treatment of calcaneal fractures in elderly
patients. J Bone Joint Surg Am 2005;87:1260-1264.

9. Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop
Trauma 1999;13:73-77.

10. Burdeaux BD. Reduction of calcaneal fractures by the McReynolds medial approach technique and it’s
experimental basis. Clin Orthop 1983;177:87-103.

11. Eastwood DM, Langkamer VG, Atkins RM. Intra-articular fractures of the calcaneum. Part II: Open
reduction and internal fixation by the extended lateral transcalcaneal approach [see comments]. J Bone Joint
Surg Br 1993;75:189-195.

12. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of
calcaneal fractures. Clin Orthop 1993;291:128-134.

13. Tornetta P III. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma
1998;12:469-473.

14. Clare MP, Sanders RW. Open reduction and internal fixation with primary subtalar arthrodesis for
Sanders type IV calcaneus fractures. Tech Foot Ankle Surg 2004;3:250-257.

15. Clare MP. Acute and chronic peroneal tendon dislocations. Tech Foot Ankle Surg 2009;8:112-118.

16. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J
Orthop Trauma 2004;18:1-6.
17. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures:
analysis of 190 fractures. J Orthop Trauma 1999;13:369-372.

18. Harvey EJ, Grujic L, Early JS, et al. Morbidity associated with ORIF of intra-articular calcaneus fractures
using a lateral approach. Foot Ankle Int 2001;22:868-873.

19. Howard JL, Buckley R, McCormack R, et al. Complications following management of displaced intra-
articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with
nonoperative management. J Orthop Trauma 2003;17:241-249.

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20. Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop 2001;391:7-16.

21. Flemister AS Jr, Infante AF, Sanders RW, et al. Subtalar arthrodesis for complications of intra-articular
calcaneal fractures. Foot Ankle Int 2000;21:392-399.

22. Sanders R, Fortin P, Walling A. Subtalar arthrodesis following calcaneal fracture. Orthop Trans
1991;15:656.

23. Crosby LA, Fitzgibbons TC. Open reduction and internal fixation of type II intra-articular calcaneus
fractures. Foot Ankle Int 1996;17:253-258.

24. Laughlin RT, Carson JG, Calhoun JH. Displaced intra-articular calcaneus fractures treated with the
Galveston plate. Foot Ankle Int 1996;17:71-78.

25. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the
calcaneus: a prospective randomized trial. Foot Ankle Int 1996;17:2-9.

26. Tornetta P III. Open reduction and internal fixation of the calcaneus using minifragment plates. J Orthop
Trauma 1996;10:63-67.

27. Song KS, Kang CH, Min BW, et al. Preoperative and postoperative evaluation of intra-articular fractures
of the calcaneus based on computed tomography scanning. J Orthop Trauma 1997;11:435-440.

28. Clare MP, Lee WE III, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal
fracture malunions. J Bone Joint Surg Am 2005;87:963-973.

29. Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures:
does initial operative treatment matter? J Bone Joint Surg Am 2009;91:541-546.
 36
Tarsometatarsal Lisfranc Injuries: Evaluation and Management
Bruce J. Sangeorzan
Kyle F. Chun
Stephen K. Benirschke
Benjamin W. Stevens

INTRODUCTION
Injuries to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, are relatively uncommon
injuries, constituting approximately 0.2% of all fractures in the United States annually. Disruptions of any of the
TMT articulations are loosely defined as a Lisfranc injury, but the eponym is more specifically defined as the
articulation between the medial cuneiform and the base of the second metatarsal. This articulation is considered
the “keystone” to the midfoot, stabilizing both the longitudinal and transverse arches of the midfoot. Injuries can
be purely ligamentous, osseous, or both. Lisfranc-equivalent injuries can present in the form of contiguous
proximal metatarsal fractures, tarsal fractures, and combinations of both, the unifying factor remaining disruption
of the TMT joint complex and anatomic configuration of the midfoot. Many injuries are subtle, and a high index of
suspicion is required for timely diagnosis and treatment.
The mechanism of injury can be both high and low energy and usually occurs in a position of a plantarflexed
foot. A hyperflexion/compression/abduction moment is exerted on the forefoot and subsequently transmitted to
the TMT articulation. This results in a combination of the aforementioned soft-tissue and osseous injuries and
usually displaces the metatarsals in a dorsal-lateral direction. Variations to this pattern exist and vary depending
on the mechanism and energy of the injury (classification). Most injuries require surgical intervention and are
challenging to treat.
Recovery from TMT joint injuries is often prolonged and associated with varying amounts of long-term disability.
Missed injuries can result in progressive foot deformity and can lead to chronic pain, dysfunction, lost time from
work, and failure to regain preinjury activity levels.

INDICATIONS AND CONTRAINDICATIONS

The primary surgical indication for treatment of a tarsometatarsal injury is the knowledge that the injury will do
poorly with nonoperative treatment. Conceptually, tarsometatarsal injuries that lead to a loss of the arch or
significant foot deformity if treated conservatively should be treated surgically. These include both displaced
injuries and subtle injuries that have instability in two planes. The decision to treat a tarsometatarsal injury
surgically is based on both physical examination and radiographic studies.
The transverse and longitudinal arches of the foot depend on the tarsometatarsal joints to make the foot
sufficiently rigid to support the body, much as the apical blocks of ice support an igloo. Unstable tarsometatarsal
injuries that compromise this structural integrity may result in deformity of the foot. In the majority of displaced
injuries, the metatarsals displace dorsally and laterally on the tarsal bones, which produces pes planus with
forefoot abduction. As a result, when weight is borne on the foot, it collapses. During heel lift, further
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deforming forces that act on the midfoot tend to exacerbate the deformity. For the metatarsals to displace in this
direction, the plantar tarsometatarsal (Lisfranc) ligaments must be disrupted. Operative treatment is indicated
when an ambulatory patient has an injury that renders the foot mechanically unsound, deformed, or both.
Ambulatory patients with a displaced and unstable tarsometatarsal joint injury that is apparent on plain
radiographs are candidates for surgery. However, when the injuries are subtle or apparently nondisplaced,
operative treatment is indicated only when two-plane instability is detected on clinical examination or stress x-
rays. Because the foot functions in weight bearing, the integrity of the plantar ligaments is of greater importance
than that of the dorsal ligaments.
Contraindications to surgical intervention include nonambulatory individuals, patients with serious vascular
disease unlikely to heal a surgical incision but who have no significant deformity, severe peripheral neuropathy,
or an injury that is unstable in only the transverse plane. Lisfranc injuries with only bone injuries at the base of
the metatarsals can often be treated by casting or by closed reduction and percutaneous pinning. When
deformity and compromised circulation are found, the surgeon faces a dilemma. Leaving a deformity puts the
patient at risk for ulceration, while treating it surgically puts the patient at risk for wound-healing problems. In this
circumstance, vascular studies may be indicated to determine whether a revascularization procedure would be
beneficial prior to orthopedic intervention.
Neurologic impairment is also a cause for concern. The physician must decide whether sufficient energy
produced the injury or whether an underlying neuropathic condition exists. Trivial injuries that cause significant
displacement should stimulate an investigation into a possible neuropathic condition. A Charcot neuropathic foot
is a distinct clinical entity and requires different management techniques. The treatment of a Lisfranc injury in the
presence of peripheral neuropathy requires more fixation and a longer period of postoperative protection.

PREOPERATIVE PLANNING
History and Physical Examination
Lisfranc injuries are often missed, and it is one of the few injuries in orthopedics where the maxim “the eye
doesn’t see what the mind doesn’t search for” is most appropriate. Most injuries occur following high energy
trauma such as motor vehicle or motor cycle accidents or falls from heights. Many of these patients have
multisystem trauma and are managed with Advanced Trauma Life Support (ATLS) protocols. However, a small
but substantial number of injuries occur following a lower energy mechanism that occurs in sports such as
football, soccer, equestrian activities, etc. The physical examination should document the status of the dorsalis
pedis and posterior tibial pulses, the integrity of the skin, and the habitus of the foot. Tendon entrapment may be
demonstrated by an altered, uncorrectable position of the toes or midfoot. Intact or altered sensation should be
documented.
Instability can often be determined on physical examination. The physician grasps the metatarsal heads and
applies a dorsal force to the forefoot while the other hand palpates the tarsometatarsal joint. Dorsal subluxation
or dislocation of the bases of the metatarsals strongly suggests instability (Fig. 36.1). If the first and second
metatarsals can be displaced medially or laterally as well, global instability is present, and surgical treatment is
required. Lower energy injuries often interrupt the dorsal ligaments or medial capsule but do not disrupt the
strong structurally important plantar ligaments. When the plantar ligaments are intact, dorsal subluxation does
not occur with the stress examination. These injuries may be treated nonoperatively in a cast.
FIGURE 36.1 A-C. Diagrammatic representation of a dorsal view of the foot. The metatarsal bases are forced
laterally and dorsally.

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Imaging Studies
In a patient with pain and swelling in the foot an AP, oblique, and lateral radiograph should be obtained. Oblique
views are essential in evaluating midfoot injuries and should always be included. With ligamentous disruption of
the midfoot without fracture, non-weight-bearing radiographs may be deceptively benign. The ligaments are torn
with the initial injury displacement; however, when the deforming force is removed, the foot may “spring back”
into a reduced position, concealing gross instability.
Therefore, the physician should be suspicious whenever midfoot swelling and pain are present. In stable
patients, if a subtle midfoot injury is suspected, additional imaging should include a simulated weight-bearing AP,
lateral, and oblique view of the foot. If disruption of the tarsometatarsal joint is found on several radiographic
projections, a tarsometatarsal injury is likely. There are five critical radiographic signs that indicate or imply
midfoot instability. The first and most reliable radiographic sign is disruption in the continuity of a line drawn from
the medial base of the second metatarsal to the medial side of intermediate cuneiform on the anteroposterior
(AP) and oblique views (Fig. 36.2A). The second most reliable radiographic sign is widening of the interval
between the first and second ray. And the third important radiographic observation is the medial side of the base
of the fourth metatarsal should line up with the medial side of the cuboid on the oblique view. This is a “soft sign”
because the cross section of the metatarsal base is not equal to the cross section of the cuboid. As a result, a
step-off may be present if the angle of the beam is slightly misdirected. Fourth, on the lateral view, the
metatarsals should align with the cuneiforms at the dorsal cortex. When a ligament injury is present, the
metatarsals are usually dorsally displaced in relation to the cuneiforms. Finally, any disruption of the medial
column line (MCL), a line tangential to the medial aspect of the navicular and medial cuneiform, is highly
suggestive of a midfoot injury. The disruption will show on the intersection of the base of the first metatarsal on
an AP view taken during weight bearing.
If the presence, location, or degree of injury in a patient with a midfoot injury is uncertain, stress x-rays with or
without sedation or anesthesia should be taken in two planes. Typically, these are done using fluoroscopy to
make certain that the correct plane is achieved during imaging. When the index of suspicion is high, the stress
roentgenogram is performed in an operating room (OR), so that if the injury is confirmed, surgery can be done
under the same anesthetic. If x-rays are done in AP, lateral, and oblique planes, and stress views are obtained
when there is uncertainty, additional imaging modalities should not be necessary. Computed tomographic (CT)
scans of the midfoot are difficult to interpret. The role of the magnetic resonance imaging scan has not been
established.

TIMING OF SURGERY
Several factors must be considered when determining the timing of surgical intervention. These include the
amount of soft-tissue swelling, the availability of imaging studies, and the degree of displacement. Surgery
should be done emergently only in the presence of a compartment syndrome, open injury, an irreducible fracture
dislocations, or a deformity that threatens the integrity of the skin. Most open injuries should be irrigated,
débrided, and stabilized early.
Given the complexity of many tarsometatarsal injuries and their relative rarity, definitive management is best
delayed until experienced personnel are available. Aside from the circumstances discussed above, most Lisfranc
injuries can be scheduled electively for daytime surgery with a rested and experienced surgical team. The
extremity can be elevated until the swelling has resolved, and the fracture addressed on a more “elective” basis.
In some high-energy cases associated with significant soft-tissue injury and swelling, definitive management is
often delayed 2 or 3 weeks. In patients with grossly unstable injury patterns and significant soft-tissue
compromise, the foot should be temporarily stabilized with a splint or external fixator and definitive fixation
delayed until the soft-tissue envelope has improved.

SURGICAL TACTIC
Surgery requires a C-arm fluoroscopy unit and an appropriate radiolucent OR table, and positioning equipment
that facilitates patient positioning (i.e., positioning rolls, extremity ramp). Standard small fragment and
minifragment instrument trays that contain point-to-point reduction clamps, a dental pick small Homan retractors,
Freer and AO elevators, and Kirschner wire (K-wires) will suffice. A small battery powered drill is also necessary.
The implants needed to surgically treat TMT injuries include screws ranging in size from 2.0 to 3.5 mm. A
stronger 4.0-mm cortical screw is also used frequently at our institution. If external fixation is anticipated, the
appropriate external fixation pins, clamps, and bars should be available. Specialized modular foot implants and
plates may be helpful in difficult or complex fracture patterns.
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FIGURE 36.2 A. An AP x-ray demonstrating a subtle Lisfranc injury. The base of the second metatarsal is
displaced laterally. B. This lateral x-ray, taken under non-weight-bearing conditions, shows that the dorsal cortex
of the second metatarsal is subluxed dorsally relative to its cuneiform. C. A scout view is used to confirm that the
foot is in the correct position for assessing the tarsometatarsal joints. D. The stress x-ray reveals instability in the
first, second, and probably third tarsometatarsal joints.

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FIGURE 36.2 (Continued) E. An intraoperative fluoroscopic image taken after fixation reveals that the third
metatarsal is stable. F. Six weeks following surgery, the reduction appears anatomic and the clinical position of
the foot is good. G. Alignment of the metatarsal bases is restored in both planes.

SURGERY
Stress X-Rays
In some patients with foot trauma and clinical and radiographics signs suggestive of midfoot instability, stress
fluroscopic radiographs are indicated. In some patients, this can be done in the radiology department, while other
patients who probably require surgery are done in the OR. After appropriate IV sedation or a general anesthetic
is administered, the OR table is bent at the knees so the foot is relatively parallel to the floor. While wearing lead
gloves, the surgeon grasps the first and second metatarsal heads with one hand and the hind foot with the other.
With the thumb placed over the cuboid to act as a fulcrum, the forefoot is abducted, and an AP fluroscopic image
is obtained. Instability is present if a gap occurs on the medial side of the first or second tarsometatarsal joint, or
disruption of the MCL is produced (Fig. 36.2D). Stress views in the lateral plane are performed if any uncertainty
exists. With the knee extended, the surgeon grasps the midfoot with one hand and the forefoot with the other and
acutely plantarflexes the foot through the tarsometatarsal joint. A cross table lateral image is obtained. Although
the tarsometatarsal joints may angulate, they should not open asymmetrically. Subluxation indicates that the
joints are unstable.
Possible instability should be investigated at the intercuneiform level as well (Fig. 36.3). These injuries are
uncommon, out of the plane of standard x-rays, and are easily missed. Treatment follows the same principles
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as those at the Lisfranc level. Stress views in the AP plane are used to confirm the injury. Because little
movement is present in the intercuneiform joints, any significant motion is abnormal. If the instability is great
enough to allow subluxation of the midfoot, it should be treated. Displacement of the intercuneiform joints leads
to deformity that is poorly understood and difficult to treat.

FIGURE 36.3 A. An AP x-ray of a left foot with severe Lisfranc injury. All five metatarsals are displaced laterally.
B. The lateral view, taken under non-weight-bearing conditions, shows a dorsal dislocation.

Technique
After a preoperative time-out has been perfomed, the patient is given a general anesthetic. The decision to utilize
regional anesthetic techniques (i.e., popliteal/saphenous nerve blocks) should be made on a case-by-case basis.
If postoperative compartment syndrome of the foot or neurovascular compromise is a concern based upon the
mechanism of injury, soft-tissue injury, or fracture pattern, regional techniques should be avoided.
One to two grams of Cefazolin are given 30 minutes prior to the skin incision. Vancomycin is used in patients with
cephlosporin allergy and in patients with a history of methicillin-resistant staph aureus. The patient is positioned
supine with a roll beneath the greater trochanter to rotate the limb to a neutral position. A second roll is placed
beneath the popliteal fossa. A tourniquet is placed on the thigh. Knee flexion allows plantarflexion of the foot for
easier exposure and imaging. The C-arm is brought in from the opposite side of the table.
Under pneumatic tourniquet control, a longitudinal incision is made in the web space between the first and
second rays (Fig. 36.4B), avoiding damage to the dorsal cutaneous nerves. The first tarsometatarsal joint is
exposed between the long and short hallux-extensor tendons (Fig. 36.4C). Typically, there is hemorrhage in this
area, making identification of the structures somewhat difficult. The capsule may be enfolded into the joint and
should be removed and preserved for later reapproximation. The first metatarsotarsal joint is reduced first.
Typically, the first metatarsal is displaced dorsal and lateral and usually reduces with a plantar and medial force.
When the first metatarsal is anatomically reduced to the medial cuneiform and confirmed fluroscopically, a small
K-wire is placed across the joint at its periphery to prevent loss of reduction before definitive fixation (Fig. 36.4D).
The K-wire is placed in such a way as to not block definitive fixation.
Before reducing the second metatarsal, it is important to check for injuries between the medial and middle
cuneiforms. Although not as common as Lisfranc-level injuries, disruption of the medial/middle cuneiform
articulation is the most common of the intertarsal disruptions (Fig. 36.5A). If first-second intertarsal instability is
found, it should be addressed before the tarsometatarsal repair because it is difficult to secure the metatarsals to
the unreduced cuneiforms. Under direct vision, the cuneiforms are reduced and held together with a small
pointed reduction clamp. Through a small stab wound, a 3.5-mm cortical screw is placed from medial to lateral,
beginning in the middle of the dorsal one-third of the medial cuneiform. This starting position is necessary
because the middle cuneiform is smaller in its dorsoplantar and proximal-to-distal direction than is the medial
cuneiform (Fig. 36.5F). This approach also allows the surgeon to keep the screw out of the way of the
subsequent screws that will traverse the tarsometatarsal joints (Fig. 36.5C,D).
Next, the second metatarsal base is reduced into its mortise between the three cuneiforms. This is accomplished
by directly reducing the base of the second metatarsal against the intermediate cuneiform. If there is difficulty
reducing the dislocation, interposition of bone or soft tissue is frequently found plantarly. Occasionally, part of the
base of the second metatarsal is avulsed by the Lisfranc plantar ligament and blocks reduction of the second
metatarsal (Fig. 36.5A). A small elevator is used to push the fragment plantarly and medially. When it is reduced,
a large pointed reduction clamp is placed from the base of the second metatarsal to the middle of the medial
cuneiform and compressed. A K-wire is placed at the periphery of the joint to maintain the reduction. The dorsal
cortex of the second metatarsal is notched 12 to 15 mm distal to the joint, and a hole is prepared for a 3.5-mm
cortex screw with a 2.5-mm drill. Before advancing the drill, the surgeon should center it over the second toe and
advance it in a position almost parallel to the plantar surface of the foot. This is necessary because the
intermediate cuneiform is quite small in cross section, and if the screw is directed too plantarly, it may completely
miss the bone completely. To prevent subluxation as the screw is advanced across the joint, the drill hole can be
tapped before the 3.5-mm cortical screw is inserted. When the screw has been seated, the K-wire is removed.
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FIGURE 36.4 A. Idealized fixation. A small screw, usually 3.5 mm, transfixes the base of the metatarsal and
cuneiform. The screw should be directed from distal to proximal and begin approximately 15 mm from the joint or
a little farther in the first ray. If an intercuneiform injury is present, an additional screw is directed from medial to
lateral. B. The preferred position of the two dorsal incisions. C. This figure shows the intraoperative exposure
through the more medial of the two dorsal incisions. D. Intraoperative photograph showing the base of the
second metatarsal reduced into its mortise.

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FIGURE 36.4 (Continued ) E. The 3.5-mm screws bridge the first, second, and third tarsometatarsal joints and
the joint between the medial and intermediate cuneiform. The fourth and fifth tarsometatarsal joints are transfixed
by 0.062-inch K-wires. F. This oblique view shows that the base of the fourth metatarsal, on its medial side, lines
up with the medial side of the cuboid. G. A lateral x-ray of the same foot as in (F) shows that the dorsal cortex of
the metatarsal and tarsal bones are aligned. H. A postoperative photograph of the operated foot at 2 weeks after
surgery.

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FIGURE 36.5 A. An AP x-ray of a left foot with Lisfranc injury and intercuneiform disruption. Note the avulsion
fracture at base of second metatarsal. B. The lateral view, taken under non-weight-bearing conditions, shows
dorsal dislocation and cuneiform fracture. C. A postoperative AP view with intercuneiform fixation.
Tarsometatarsal fixation with 4.0-mm cortical screws and lateral K-wire fixation. D. Postoperative lateral view,
taken under non-weight-bearing conditions, shows dorsal placement of intercuneiform screw fixation, which
allows adequate room for crossed 4.0-mm cortical screw fixation in the first ray.

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FIGURE 36.5 (Continued) E. Oblique view confirms anatomical reduction of fourth and fifth metatarsal-cuboid
joints. F. Coronal weight-bearing CT cut at the level of the medial and middle cuneiforms demonstrates rapid
plantar tapering of the middle cuneiform. This relationship necessitates dorsal screw placement for
intercuneiform fixation.

Next, the position of the first metatarsal is reassessed relative to the medial cuneiform. If it has moved, it should
be repositioned and temporarily stabilized with K-wires. Definitive fixation is achieved with a 3.5-mm cortical
screw. This screw should start 15 to 20 mm distal to the joint, but it does not need to be as parallel to the plantar
surface of the foot because the shape of the medial cuneiform is greater in the dorsoplantar direction. This screw
should be approximately 40 mm in length. If the measured length is <30 mm, the starting hole was placed too
close to the joint, or the drill was directed obliquely out of the cuneiform. A short screw may not provide adequate
fixation in the cuneiform or provide the necessary support to resist dorsal subluxation.
The third tarsometatarsal joint should be directly evaluated. If it requires fixation but the fourth and fifth rays do
not, a full-thickness flap is developed through the original incision until the third tarsometatarsal joint is
visualized. It usually follows the second metatarsl into a reduced position. It is held in place with a reduction
clamp, and a screw is placed through a small stab wound. However, if the third and fourth metatarsal bases both
require reduction and fixation, a second incision is helpful. A longitudinal incision is made over the base of the
fourth ray parallel to the first incision (Fig. 36.4B). Depending on the size of the extensor brevis muscle, the
surgeon may be able to elevate the lateral border of the muscle. If it is too large, the muscle belly is split bluntly
in line with its fibers so that the tarsometatarsal joints are visualized. The third metatarsal base should
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be reduced first. Again, a K-wire is placed as provisional fixation. Definitive fixation is provided by a 3.5-mm
cortical screw.
Because the fourth and fifth tarsometatarsal joints are mobile, the goals of treatment are different than the first,
second, and third tarsometatarsal joints. These joints must be held in place only long enough for the patient to
develop sufficient soft-tissue healing. Screws may break because of the motion in these joints. The fourth and
fifth tarsometatarsals are typically reduced and pinned with 1.6-mm K-wires (Figs. 36.4E-G and 36.5C-E). The K-
wires may be inserted obliquely when the reduction is difficult or intertarsal injuries require fixation (Fig. 36.4A).
Lisfranc injuries may have a fracture component as well. When this occurs, it commonly presents as fractures
through the base of the metatarsals. When unstable, the fracture should be stabilized, and then the joint
evaluated. If fractures are present without concomitant ligament injuries, reduction and pinning may be adequate,
because the fractures should heal within 6 weeks. A common pattern includes a joint disruption at the first ray, a
fracture through the second metatarsal base, and a joint injury at the third. Because the second metatarsal is
recessed into a mortise between the cuneiform, it fractures and leaves the base attached to the ligaments. If the
first and third rays are stabilized across the joint, the second requires only reduction and sometimes pinning for 4
to 6 weeks. When fractures pass through the metatarsal bases and the adjacent joints are intact, treatment
consists of reduction and K-wire fixation. Unlike ligamentous injuries, fractures heal reliably in 6 weeks. The K-
wire can be left in place until the fracture becomes stable. Once the fracture is healed, mechanical stability is
restored.

ALTERNATIVE FIXATION TECHNIQUES

Early hardware failure and prominent hardware have resulted in the development of newer implant technology.
The 4.0-mm cortical screw is 15% stronger in bending than the 3.5-mm cortical screw (Table 36.1). The strength
advantage results primarily from the core diameter of 2.9 mm for the 4.0-mm cortical screw versus 2.4 mm for the
3.5-mm cortical screw. This newer screw has proven useful in crowded Lisfranc constructs while in theory, it also
reduces the incidence of hardware failure (Fig. 36.5C-E).
In a recent series, Thordarson et al. evaluated 3.5-mm absorbable screws in an attempt to minimize both the
incidence of symptomatic hardware and subsequent surgical procedures for their removal. The authors
concluded that the technique was safe at short-term follow-up. The efficacy of these implants has yet to be
tested for in longer-term follow-up.
In complex fracture patterns, specialized foot and ankle implants can be useful. Associated comminution of the
tarsal or metatarsal bones, especially with large articular fragments, may require fragment-specific buttress or
bridging techniques.

PRIMARY ARTHRODESIS VERSUS OPEN REDUCTION INTERNAL FIXATION

There is a subgroup of Lisfranc injuries that involve a purely ligamentous arch injury. Several authors have
suggested that this subgroup of patients may be better treated with primary arthrodesis. Recently, two short-term
studies compared primary arthrodesis and open reduction and internal fixation of this purely ligamentous
subgroup. Ly et al. demonstrated higher American Orthopaedic Foot and Ankle Society midfoot scores in the
arthrodesis group as well as higher self-reported postoperative levels of activity. Henning et al. also
demonstrated improved outcomes in the primary arthrodesis group based on the Short Musculoskeletal
Functional Analysis, although statistical signficance was not achieved. In both studies, secondary surgery was
significantly higher in the ORIF group because hardware removal was routinely included. Both studies suggest a
role for arthrodesis in the ligamentous Lisfranc subgroup, but long-term studies are needed. Also, arthrodesis as
a treatment strategy is predicated upon the notion that functional outcomes with fusion parallel that of internal
fixation.

TABLE 36.1 Comparison of 3.5-mm and 4.0-mm Cortical Screw Specifications and Bending
 Strength

Specifications (mm) 3.5-mm Cortical Screw 4.0-mm Cortical Screw

Thread diameter 3.5 4.0a

Thread pitch 1.25 1.25

Core diameter 2.4 2.9a

Screw lengths 10-110 14-100

Diameter of head 6.0 6.0

Glide-hole drill bit 3.5 4.0

Pilot-hole drill bit 2.5 2.9

Screws are from Synthes (Paoli, PA).

aSpecification results in 15% increase in bending strength of 4.0-mm screw.

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POSTOPERATIVE MANAGEMENT
Patients are placed in a short-leg posterior plaster splint at the end of the operation. The patient is discharged
when he or she safely masters ambulation with crutches or a walker, and pain control is achieved with oral
agents. The length of stay is dependent on associated injuries, the fragility of the patient, and the degree of
swelling. Sutures are removed 10 to 14 days after surgery. If the injury was isolated, the patient reliable, and
fixation secure, the splint is replaced with a removable brace. If any of these three factors is absent, a short-leg
non-weight-bearing cast is recommended for an additional 4 weeks.
Clinical examination and radiographs are taken at 6 weeks to assess alignment and fracture healing.
Postoperative imaging should include a simulated weight-bearing AP and lateral as well as an oblique view. For
most injuries, partial weight bearing is instituted with the patient wearing a removable protective boot at 6 weeks.
Self-directed physical therapy is begun at this time. Swimming is encouraged, and riding an exercise bike is
allowed. Depending on the stability and fixation, the patient is encouraged to gradually advance to full weight
bearing at 8 to 10 weeks. At this time, the patient can resume wearing a regular shoe if the foot is not too
swollen. The screws are left in place for a minimum of 16 weeks.
If the patient is asymptomatic and screws transfix only the first through third tarsometatarsal joints, they may be
left permanently in place. If the joint has become sufficiently stiff, the screws will not be symptomatic. However, a
small amount of motion frequently occurs, which causes the screws to loosen. If this happens, the screws can be
removed under local anesthesia in the office or outpatient surgery center.
Because swelling may persist for months, compression stockings may be beneficial. Initially, the patient may
begin by wearing athletic shoes. As activity level increases, a standard work shoe may replace the athletic shoe
for a few hours a day in increasing amounts until normal shoes can be tolerated. The process may be facilitated
by a custom-molded full-length insole of a nonrigid material.
Patients may return to work at 10 to 14 days if they work in a sedentary or semisedentary capacity. In patients
involved in heavy labor return to work is usually delayed for 4 to 6 months. Return to vigorous recreational
activities, such as basketball, volleyball, and running, is precluded for 9 to 12 months. Most patients experience
some symptoms in their foot for up to 2 years. Many will have lifelong symptoms. Only 12% of patients will
require a midfoot arthrodesis if the injuries are anatomically reduced and rigidly fixed. A slightly higher trend
toward midfoot arthrosis can be found in those patients with pure ligamentous injuries. If symptoms are
mechanical (i.e., midfoot pain during heel rise), a custom, full-length, semirigid insole may be beneficial.
Generally, this should be fabricated when the patient has returned to full weight bearing, and the swelling has
resolved.

COMPLICATIONS
Associated injuries following midfoot fractures and dislocations include intercuneiform injuries, tendon
entrapment, and vascular injury. The interval between the medial and intermediate cuneiform is the most
common associated intercuneiform joint injury. The tibialis anterior is the most commonly entrapped tendon.
The tibialis anterior tendon inserts in part on the base of the first metatarsal. As the first metatarsal is
displaced laterally, it takes the tendon with it. Once the deforming force is removed, the metatarsal moves
medially, and the tendon is trapped by the medial cuneiform. This often blocks reduction and is transposed
during open reduction.
The most common vascular injury is to the plantar branch of the dorsalis pedis, where it is tethered between
the first and second metatarsal. Damage to this vessel, however, is of little clinical significance because of
the rich blood supply to the foot. Injury to the dorsal cutaneous branches of the superficial peroneal nerve
also may occur. Because the tissues are edematous and displaced and hemorrhage is significant in the
subcutaneous tissue, identification of these small nerves is challenging. Care should be taken to preserve
the nerves, and patients should be warned preoperatively that nerve injury is possible. If one of these
nerves is divided during surgery, the proximal end can be tucked into the extensor brevis muscle belly or the
two ends can be reapproximated.
Soft-tissue problems are common, particularly after direct trauma. There is little muscle to absorb the load
or augment the blood flow. In some patients, an eschar may develop in areas that were injured and may
include the surgical incision. It is uncommon for these soft-tissue problems to require free tissue transfer,
but skin grafts
P.743
are common in direct injuries. Full-thickness wounds are managed with dressing changes or negative
pressure dressings until an adequate bed of granulation tissue develops to support a split-thickness graft.
Nonunion is uncommon in Lisfranc fractures, but when it occurs or is painful or leads to instability, treatment
may be required. In some low demand or elderly patients, symptoms are minimal, and surgical treatment is
not necessary. Incomplete reduction is a common problem that may lead to loss of the arch and abduction
of the forefoot. Great care should be taken to plantarflex and adduct the metatarsals adequately. To lessen
the likelihood of incomplete reduction, the surgeon must be certain that the first metatarsal is brought
medially and plantarly before trying to reduce the second metatarsal. A prominent cuneiform may be
observed on the dorsomedial aspect of the foot when the first metatarsal is incompletely plantarflexed and
adducted. At times this deformity may also be due to unrecognized intercuneiform injury.
RECOMMENDED READING
Arntz CT, Veith RG, Hansen ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint
Surg Am 1988;70(2):173-181.

Blair WF. Irreducible tarsal metatarsal fracture dislocation. J Trauma 1981;21:988-990.

Cross HS, Manos RE, Buoncristiani A, et al. Abduction stress and weightbearing radiography of purely
ligamentous injury in the tarsometatarsal joint. Foot Ankle 1998;19(8):537-541.

DeBenedetti MJ, Evanski PM, Waugh TR. The unreducible Lisfranc fracture. Clin Orthop 1978;136:238-240.

Foster SC, Foster RR. Lisfranc tarsal metatarsal fracture dislocation. Radiology 1976;120:79-83.

Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint: incidence,
classification and treatment. J Bone Joint Surg Br 1982;64(3):349-356.

Henning JA, Jones CB, Sietsma DL, et al. Open reduction internal fixation versus primary arthrodesis for
Lisfranc injuries: a prospective randomized study. Foot Ankle Int 2009;30(10):914-921.

Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of lisfranc joint
injuries. J Bone Joint Surg Am 2000;82(11):1609-1618.

Ly T, Coetzee JC. Treatment of primarily ligamentous Lisfranc injuries: primary arthrodesis compared with
open reduction internal fixation. A prospective, randomized study. J Bone Joint Surg Am 2006;88:514-520.

Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med 1994;13(4):719-730.

Sangeorzan BJ, Veith RG, Hansen ST Jr. Fusion of Lisfranc’s joint for the salvage of tarsometatarsal injuries.
Foot Ankle 1989;10(4):193-200.

Thordarson DB, Hurvitz G. PLA screw fixation of Lisfranc injuries. Foot Ankle Int 2002;23(11):1003-1007.
 37
Pelvic Fractures: External Fixation
Enes M. Kanlic
Amr A. Abdelgawad

INTRODUCTION
Injuries to the pelvic ring range from simple stable fractures as the result of low-energy forces to life-threatening
injuries with hemodynamic instability. Pelvic fractures account for 3% to 8% of all fractures seen in the
emergency room but are present in up to 25% of multiply injured patients. Mechanically unstable pelvic fractures
with hemodynamic instability represent approximately 10% of the pelvic injuries in level I trauma centers.
Bleeding from cancellous bone surfaces, the presacral venous plexus, or the arterial tree may cause hypotension
and shock. Associated injuries to the chest (15%), abdomen (32%), or long bone fractures can cause additional
bleeding in 40% of patients. Prolonged bleeding and shock with massive transfusions are the main cause of
multiple organ failure. Early diagnosis with control of hemorrhage is a critical factor in patient survival.
Exsanguinating hemorrhage is the main cause of death in the first 24 hours after a high-energy pelvic fracture in
a multiply injured patient. Injury severity score (ISS) correlates with whole body injury and is a better predictor of
mortality in polytraumatized patients with a pelvic injury than the specific type of pelvic fracture (1, 2, 3, 4, 5 and
6).
Of the several classification schemes for pelvic fractures, we favor the Tile classification (Fig. 37.1), which is
used to predict instability in the injured pelvic ring. Tile A injuries are stable fractures that can be managed
nonoperatively. Tile B injuries are rotationally unstable but vertically stable, and Tile C injuries are both
rotationally and vertically unstable (7). The Young and Burgess classification of pelvic fractures is also helpful
and widely utilized (Fig. 37.2).

INDICATIONS AND CONTRAINDICATIONS

External fixation is utilized primarily in the management of patients with hemodynamic instability following pelvic
fractures. The most common indication for external fixation is in a critically ill, unstable patient with a
translationally unstable pelvic injury (Tile C). A resuscitative anterior frame with ipsilateral supracondylar traction
is used when a C-clamp is unavailable or not applicable. Other indications for anterior external fixation include
some, rotationally unstable, Tile B1 and B2 pelvic fractures. We favor external fixation when the soft tissues in
and around the pelvis or abdomen are contaminated, such as with open fractures, diverting colostomies or when
a suprapubic urinary catheter must be placed. In addition, patients with concomitant visceral injuries, especially
injuries that could become more displaced or unstable when the abdomen is opened, are often treated with
pelvic external fixation as well. Lately, anterior-ring subcutaneous anterior external fixation (SAEF) is used more
often to augment posterior-ring fixation.
Contraindications to external fixation are stable pelvic-ring injuries (Tile A) or compromised soft tissues at
planned sites of pin insertion. External fixation should be avoided when internal fixation can be performed on a
stable patient in a safe and timely fashion.

PREOPERATIVE PLANNING
Patient Stabilization
In the field or emergency room, paramedics and primary responders trained in advanced trauma life support
(ATLS) play a critical role. A single attempt at reduction should be considered in patients with hemodynamic
instability and a potentially unstable pelvic-ring injury. Traction is applied to the lower extremity on the shortened
P.746
or deformed side of the pelvis with manual lateral compression on the iliac wings or greater trochanters. The
knees and ankles should be slightly flexed, internally rotated, and taped together, and the pelvis is supported
with a wrapped sheet or pelvic binder (Fig. 37.3). These measures may be life-saving when done at the scene of
an accident and followed by emergent transfer to an institution capable of treating pelvic trauma (8,9).

FIGURE 37.1 Modified Tile AO Müller Classification. Pelvic ring injuries may be classified as stable or unstable
depending on integrity of the posterior arch. Stable lesions have an intact posterior arch (A), whereas unstable
lesions can be divided into completely or rotationally unstable injuries with partial integrity of the arch or floor
(B1,B2) or completely unstable injuries with no part of the floor or posterior arch intact (C).

Hemodynamically unstable patients with pelvic-ring injuries require prompt evaluation and simultaneous
aggressive resuscitation. Initial measures include airway control and fluid resuscitation with 2 L of crystalloid
through two 14- to 16-gauge intravenous catheters in the upper extremities if there are no contraindications. If
the patient remains hypotensive, packed red blood cells, fresh frozen plasma, and platelets ideally in a 1:1:1 ratio
are started. Early transfusion of platelets as six packs to keep platelet counts above 100,000/μL has been shown
to improve survival. Patients should be kept warm during diagnostic and therapeutic measures (6,10).
FIGURE 37.2 Young and Burgess classification. A. Lateral compression force causing more vertical rami
fractures in the front. B. AP compression fractures. C. A vertically directed force or forces at right angles to the
supporting structures of the pelvis leading to vertical fractures in the rami and disruption of all the ligamentous
structures.

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FIGURE 37.3 Emergent temporary pelvic stabilization with a sheet tightened over iliac crests, the patient knees
flexed and held together with a bandage and supported on pillow.

History and Physical Examination

Whenever possible, a careful history should be obtained with particular emphasis on the mechanism of injury. A
history of high-energy trauma from motor vehicle or motorcycle collisions, falls from a height, or rollover motor-
vehicle crashes is often associated with an unstable pelvic injury. The physical examination should be directed to
look for signs of mechanical instability of the pelvis. Clinical signs of instability include a shortened and
malrotated extremity, asymmetric iliac spines, swelling or blood around the genitals and perineum, and contusion
or ecchymosis in the lower abdomen or pelvis. Gentle, manual, iliac-wing compression from lateral toward the
midline may reveal a mobile hemipelvis and mechanical instability. However, stressing the pelvic ring for stability
manually by multiple physicians is not warranted because it could dislodge early fragile blood clots in a
hemodynamically unstable patient. One-time manual testing, to exclude a situation in which the pelvis had been
unstable but has since been reduced, may be permissible by an experienced surgeon in cases where the x-rays
are equivocal (11,12). A neurological examination must assess the lower extremity for sensation and motor
function in the conscious and cooperative patient. If this is not possible, the physician should note whether there
is any movement in the extremities to painful stimuli. Vaginal and rectal exams with testing for occult blood may
help rule out an occult open fracture. If overlooked and not treated, a fracture hematoma that comes in contact
with a contaminated environment may cause a life-threatening pelvic infection.
The care of a hemodynamically unstable patient with a displaced pelvic fracture is the responsibility of a
multidisciplinary trauma team that includes a general (trauma) surgeon, orthopedic surgeon, interventional
radiologist, and anesthesiologist. Trauma protocols are helpful in evaluating and treating critically ill patients,
establishing priorities, and guiding treatment (10). Arterial blood gas with blood lactate levels and/or base deficit
analyses is a good indicator of the hemorrhagic state and tissue oxygenation and response to treatment (13, 14
and 15). Using an algorithm for the multiply injured patient with an unstable pelvic fracture (Fig. 37.4), Ertel et al.
(13) documented survival in 15 of 20 patients (75%) with an average ISS of 41.2 ± 15.3. Fifteen patients had
massive hemorrhage. Two patients required subdiaphragmatic clamping of the aorta to control exsanguination
(16).

Imaging Studies
As part of the primary survey, a focused abdominal sonogram for trauma (FAST) or computed tomography (CT)
scan (preferably with contrast) can be used to determine the presence of fluid in peritoneal cavity, retroperitoneal
space, as well as assess arterial contrast extravasation (11,13,14). A chest x-ray is an important part of the
trauma workup to rule out a pneumothorax, hemopneumothorax, tension pneumothorax, or flail chest as a cause
of hypotension or shock. A single anteroposterior (AP) radiograph of the pelvis can be used to diagnose a pelvic
fracture in approximately 90% of cases. X-ray signs of instability are (a) >5 mm of displacement of the sacroiliac
(SI) joint in any plane (inlet and outlet views will improve accuracy if circumstances allow), (b) a posterior fracture
gap, and (c) avulsions of the transverse process of fifth lumbar vertebra or the sacrospinous ligament.

Timing of Surgery
Damage control surgery to manage hemorrhage or severe contamination, with exploration and decompression of
the head, chest, and abdomen, as well as débridement of open fractures have been shown to improve survival.
Determination of the patient’s hemodynamic status and initial response to resuscitation place the patient into one
of three categories that dictate subsequent treatment (Fig. 37.4). The first category includes patients who are “in
extremis.” The second category includes patients who are hypotensive and in shock, and the third category
includes patients whose vital signs stabilize with appropriate resuscitation and treatment.
Patients who present “in extremis” (i.e., without measurable vital signs) usually require a crash laparotomy,
thoracotomy, and/or pelvic/abdominal packing with or without temporary aortic cross-clamping, in order to survive
(Fig. 37.5). Temporary occlusion of the infrarenal aorta is possible via percutaneous or open balloon catheter
techniques (17,18). Continued aggressive resuscitation therapy, a C-clamp (anterior or posterior), or an anterior
pelvic external fixator should be applied urgently. If bleeding continues, pelvic or abdominal packing against a
stabilized pelvis is more effective in controlling the bleeding.
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FIGURE 37.4 A damage-control algorithm for patients with a pelvic fracture. (From Ertel W. General assessment
and management of the polytrauma patient. In: Tile M, Helfet D, Kellam J, eds. Fractures of the pelvis and
acetabulum. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:71, with permission.)

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FIGURE 37.5 Aortic cross-clamping in a patient who was in “extremis.” A crash laparotomy was performed, and
bleeding was controlled by temporarily cross-clamping the aorta together with pelvic packing and application of a
C-clamp.

FIGURE 37.6 Laparotomy following application of an anterior external-fixation device. A C-clamp is covered by
sheets.

In another subset of patients whose shock persists despite adequate fluid replacement, blood transfusions, and
vasopressors, consideration should be given to replacing the resuscitation pelvic sheet or binder with an external
fixator or C-clamp. Numerous studies have shown that in patients with unstable pelvic injuries in which the
ligaments and fascial planes that support the pelvic floor have been disrupted, self-tamponade rarely occurs
(19). Huittinen and Slätis (20) estimated that up to 90% of bleeding following a pelvic fracture is the result of
disruption of the lumbosacral venous plexus or the cancellous bone surfaces from the fracture site, while only
10% have an arterial origin. The most common technique for controlling the diffuse bleeding (venous or smaller
arterial vessels) is by tamponade. In patients who require abdominal exploration, laparotomy may render the
pelvis more unstable because the muscle forces pulling on the iliac wings are diminished (21). A correctly applied
pelvic frame will improve pelvic stability without impeding the surgeon’s ability to perform a laparotomy (Fig.
37.6). If a patient with an unstable pelvic fracture requires a laparotomy for intraperitoneal injuries, exploration
with retroperitoneal packing to control bleeding may be accomplished simultaneously. Disruption of the soft
tissues in the pelvic floor allows direct access to both sides of sacrum and bladder for packing (22). Major vessel
injury to the external iliac and femoral artery or vein also requires repair. In massive retroperitoneal bleeding
caused by blunt trauma, Ertel et al. (13) recommended that the hematoma in the central zone be explored. This
method allows assessment of the posterior pelvic reduction by direct manual palpation from inside the pelvis.
Bone bleeding is better controlled when bony surfaces or the SI joints are directly opposed and compressed. If
significant residual displacement exists, loosening and adjusting the external fixator may improve the fracture
reduction and mechanical stability. If hemodynamic instability persists despite these measures including partial
closure of the distal abdominal fascia for better support of the packing, the patient should undergo a CT
angiogram of the abdomen and pelvis. The study is highly accurate in determining the presence or absence of
ongoing pelvic hemorrhage (23). Patients with contrast extravasation may be candidates for angiographic
embolization. Using a similar protocol, the Hannover Trauma Center was able to reduce mortality rate from 46%
to 25% (14,16,20,22,24).
In most North American trauma centers, a sheet or pelvic binder is applied to unstable patients with a possible
pelvic fracture during the initial evaluation and resuscitation. An ultrasound (FAST) of the abdomen and/or CT
scan of the head, chest, abdomen, and pelvis is obtained. If there is no free fluid in these areas and the patient
remains hemodynamically unstable, angiography with or without embolization is usually the next step. The
problem with angiography is that it does not address venous bleeding, is time consuming, requires specialized
personnel and equipment, and may cause gluteal muscle necrosis. In addition, only 10% of patients with pelvic
fractures have a bleeding source amenable to embolization (10,12,25, 26 and 27). Recently, several
investigators have popularized direct retroperitoneal packing below the pelvic brim after pelvic fracture
stabilization using an external fixator or a C-clamp. In one study using this approach, only 4 of 24 patients who
were hemodynamically unstable required subsequent angiography (10,28, 29 and 30).
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FIGURE 37.7 Unstable, complex pelvic, and bilateral acetabular fractures. A retrograde urethrogram is indicated
to assess the integrity of the urethra and bladder before placement of Foley catheter.
High-energy pelvic injuries with a major vessel injury such as the external or internal iliac or femoral artery or
vein, with critical ischemia to the extremity, and a profound neurologic deficit cause such persistent
hemodynamic instability that reconstruction attempts are usually futile. Fortunately, this is very rare, and survival
often requires a life-saving hemipelvectomy (25,31).
Open fractures with wounds in and around the rectum or vagina require irrigation and débridement, and when
large a diverting colostomy placed as far as possible from future incisions that will be used for definitive fracture
surgery. An immediate distal-rectal washout should be considered, and broad spectrum intravenous antibiotics
are mandatory (1, 2, 3, 4 and 5,9). In a closed pelvic injury with air present on CT in the pelvis, a rectal or colon
injury must be ruled out by colonoscopy (32,33).
Virtually all male patients with unstable pelvic injuries, with or without blood around the urethral meatus, require a
retrograde urethrogram before bladder catheterization (see Fig. 37.40). In our experience, a rectal exam cannot
reliably predict the position of the prostate and possible urethral injury especially in the trauma patient. If the
urethrogram shows extravasation of dye, a suprapubic catheter is inserted percutaneously or openly if a
laparotomy is necessary. Patients with hematuria and an intact urethra require a contrast study to rule out a
bladder rupture (Fig. 37.7). If no obvious source for the hematuria is identified, an abdominal CT or intravenous
pyelography should be obtained to investigate the upper urogenital tract. In a polytrauma patient, CT scans
without contrast can show kidney injuries, since contrast may be contraindicated in patients with renal damage or
poor function. If an emergent invasive radiology procedure is necessary, contrast studies (urological and
gastrointestinal) should be done after angiography (12,25,33).

PREOPERATIVE SURGICAL TACTIC

Pelvic Stabilization
Critically ill patients with unstable pelvic injuries require early pelvic stabilization to improve fracture stability,
provide a tamponade effect, improve clotting, and reduce pain. In patients with multiple injuries, including other
life-threatening conditions, the speed and safety of pelvic stabilization (Fig. 37.8 and Table 37.1) are more
important than the initial accuracy of reduction or sophistication of frame constructs.

Noninvasive Methods
Hemodynamically unstable patients with a suspected pelvic injury should be placed into some type of pelvic
circumferential compression device (PCCD). These devices lower transfusion rates and length of hospital stay
(8,34,35). PCCDs can be as simple as a bed sheet wrapped and secured with towel clamps or a hand-tied knot
placed around the pelvis and greater trochanter (Fig. 37.3). This method of stabilization is most effective when
applied after a simple reduction maneuver using traction on the shortened extremity that clinically does not
appear to be broken.
The knees are slightly flexed (muscles relaxed, supporting pillow), and the lower extremities are kept in internal
rotation by taping the feet and legs together (Fig. 37.9, 32.10, 32.11, 32.12 and 37.13). As part of the secondary
survey, the patient should be carefully “log rolled” onto their side for an examination of the spine and posterior
pelvis including a rectal examination. If surgery is delayed, it is important to take the patient off the spine board
onto a softer bed mattress to lessen the risk of pressure sores. Commercially available pelvic binders are easier
to apply and readjust when needed (Figs. 37.9 and 37.12). However, these devices may limit access
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to the abdomen and groin. If that is the case, the binder could be repositioned higher up to the iliac crests or
distally to the greater trochanters. Vacuum splints and beanbag positioners, while bulky, can be helpful and allow
better abdominal and inguinal access while providing pelvic immobilization (Fig. 37.13). PCCDs are temporary
measures (not more than couple of hours) that are used until an unstable pelvic injury has been excluded by
radiographs and CT scans, and hemodynamic stability has been restored or internal or external fixation
performed (34).

FIGURE 37.8 Schematic presentation of possible pelvic fixations.

TABLE 37.1 Methods of Pelvic Fracture Stabilization

▪ External fixation

• Noninvasive techniques (wrapped sheet, commercial pelvic binders, vacuum splint, or pneumatic
antishock garment)

• Invasive techniques

○ Anterior external fixator (w/wo skeletal traction)

- Iliac-crest external fixation (high route)

- Subcristal external fixation

- Supra-acetabular external fixation (low route)

- SAEF

- Supra-acetabular anterior C-clamp

 - Trochanteric C-clamp

○ Posterior external fixator (w/wo anterior fixator)

- Iliosacral posterior C-clamp

▪ Internal fixation

▪ Combination of external and internal fixation

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FIGURE 37.9 A trauma patient with the pelvis fracture stabilized with a pelvic binder. A right knee dislocation was
reduced and protected with knee immobilizer.
FIGURE 37.10 Pelvic AP x-ray from the patient from previous figure, indicating an unstable pelvic injury.

FIGURE 37.11 Radiographs of the same patient after application of a pelvic binder and positioning the feet in
internal rotation.
FIGURE 37.12 The use of pelvic binder in a mechanically unstable, open, pelvic fracture. It is easy to apply and
adjust as needed. Access to the abdomen and inguinal regions may be limited, and binder repositioning to the
trochanteric regions may be necessary.

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FIGURE 37.13 Vacuum splints apply pressure over a large area and provide good temporary fixation. They are
radiolucent and allow full access to the abdomen and inguinal areas.

External Fixation
Riemer et al. (36) reported a decrease in the mortality rate from 26% to 6% when external fixation was introduced
as a part of resuscitation protocol in hemodynamically unstable patients with a pelvic-ring injury. External fixation
improves fracture stabilization compared with noninvasive methods. The technique is minimally invasive and
relatively easy and safe to perform. External fixation also helps control pain and improves patient mobilization.
However, an anterior iliac-crest frame does not adequately stabilize posterior instability (Tile C fracture patterns).
Furthermore, the “upper route” frame may limit access to the abdomen and increase the fracture gap posteriorly
leading to greater instability and bleeding when the anterior frame is compressed. Distal femoral skeletal traction
with 25 to 30 pounds with the hip flexed may improve the posterior fracture reduction (37).
In most trauma centers, external fixation is used primarily as a temporary resuscitation frame until the patient’s
general condition improves to allow definitive internal fixation. When anterior frames are used as a definitive
fixation method for Tile C fractures, failure rates as high as 70% have been reported (12). While the optimal time
to convert from external to internal fixation is unknown, we prefer to wait at least 4 to 7 days to avoid activation of
the inflammatory system the so-called second hit phenomena. Earlier fixation may be feasible in patients in which
percutaneously placed iliosacral screws will produce adequate pelvic stabilization after reduction (see Figs.
37.19, 37.25, 37.29, 37.34, and 37.49). Combined posterior-internal fixation and anterior-external fixation provide
adequate stability to allow patient mobilization (see Figs. 37.14, 37.15, 37.20 and 37.21). However, discomfort,
pin tract problems, and loosening limit long-term frame application (16,24, 25, 26, 27, 28 and 29). External
fixation stability is determined by the (a) host factors (type of pelvic instability, patient size, and bone quality); (b)
frame characteristics (design and location, number, and size of pins); and (c) frame application (quality of
reduction and pin placement).

FIGURE 37.14 An anterior-superior iliac-crest, trapezoidal frame. This patient has a diverting colostomy,
suprapubic catheter, and significant soft-tissue defect on right upper thigh.

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FIGURE 37.15 External fixation frames should be placed to allow eventual mobilization and an upright position.

SURGERY
Anterior External Fixation
Iliac-Crest External Fixation
The frame is applied under general anesthesia with the patient in the supine position on a flat-top radiolucent
operating fracture table with traction attachments available, and, if time allows, C-arm control (Fig. 37.16). Except
in dire circumstances, a full prep and sterile technique is used for pin placement in either an open or
percutaneous approach. External fixation frames should be placed to allow eventual mobilization and an upright
position (Fig. 37.15). With the open technique, a 6- to 8-cm incision over the anterior third of the iliac crest is
started 2- to 3-cm posterior to the anterior-superior iliac spine (ASIS) (Figs. 37.17 and 37.18) to avoid damage to
the lateral femoral cutaneous nerve. To decrease the chance of skin stretching by the fixator pins, the incision
should be made after manual reduction and compression of iliac wings. This incision provides appropriate
orientation for the insertion point of the pins, and it could be incorporated into an internal fixation approach as
part of a staged reconstruction. Percutaneous incisions have also been advocated if later surgical approaches
might be necessary. In cases where prolonged external fixation is planned, 2-cm incisions directed toward the
umbilicus are less likely to cause soft-tissue necrosis and are used for a percutaneous approach after iliac-wing
reduction (Figs. 37.19 through 37.21).
FIGURE 37.16 A patient with a Tile C, unstable, open, pelvis fracture as well as an avulsed rectum, liver injuries,
and a right leg amputation. A previously applied C-clamp has been removed. Staged reconstruction with
percutaneous IS screws on the left side and an anterior external-fixator frame is planned. Both lower extremities
are secured to the traction attachments to facilitate fracture reduction.

FIGURE 37.17 An open approach to the right iliac crest. It starts 2 to 3 cm proximal to the ASIS (surgeon’s right
index finger is on ASIS).

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FIGURE 37.18 Separating the insertions of abdominal and gluteal muscles and incising the periosteum allow
visualization of the width of the iliac crest. If the iliacus muscle is not elevated from the inner table of iliac crest,
the danger of entering the retroperitoneal hematoma can be minimized.

FIGURE 37.19 Less invasive is to make two smaller incisions over iliac crest aiming toward umbilicus, in order to
avoid soft-tissue tension when more compression is needed. A guide wire placed along the inner iliac table helps
to direct pin position.

PIN PLACEMENT
The iliac crests normally overhang the iliac wings, and pins placed between the external and internal iliaccortical
table should be started between the medial third and half of iliac crest. Two pins should be placed in each ilium
for a resuscitation frame, and three pins should be placed when adequate time is available. The iliac crest has a
slight curvature, and the pins may not align in a straight line. The pins should be at least 1 cm apart. In the
supine position, the iliac-crest angles approximately 45 degrees toward the operating table, but the angle varies
from patient to patient (Fig. 37.22). The outer cortex is opened with an appropriate size drill bit inclined from
cranial toward the greater trochanter; aiming for the bone stock of anterior pillar above the acetabulum. The
surgeon manually advances 5-mm-diameter pins through the opening hole while trying to feel and avoid
penetration of the internal or external cortices. This procedure is not always easy, especially in obese patients.
FIGURE 37.20 The C-arm is used to confirm pin position and reduction.

FIGURE 37.21 Well-positioned pins, without irritation or infection at 2 weeks.

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FIGURE 37.22 A CT scan showing the orientation of the pelvis in the supine position. The ilium lies at an angle
of approximately 45 degrees. The surgeon must consider this orientation when placing the iliac-crest pins. (From
Rommens PM, Hesmann MH. External fixation for the injured pelvic ring. In: Tile M, Helfet DL, Kellam JF, eds.
Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:208, with
permission).

Several techniques can be used to improve the accuracy of pin placement. The surgeon can insert Kirschner (K)
wires on both sides of the iliac wing to serve as a guide (see Fig. 37.19). Some external fixation sets come with a
special guide where a long arm is rested on the inner table. In another technique, the C-arm is used to obtain an
obturator oblique view that shows the iliac wing in profile and pin position (see Fig. 37.20). Of course, elevation
of the gluteal and iliac muscles from both sides of the pelvis allows direct visual control of the iliac wing for pin
placement. However, extensive soft-tissue dissection on the inside of the iliac wings can inadvertantly enter the
retroperitoneal hematoma and should be avoided. Once inserted, the stability of the pins should be assessed by
in-line traction. When secure, the pins are captured by pin-to-bar clamps and attached to a connecting bar. The
same is done on the opposite side, and both independent bars are manipulated to improve the fracture
reduction.
For open book injuries (Tile B1), anterior compression alone will suffice. For “bucket handle,” lateral-
compression injuries (Tile B2), opening and external rotation of the compressed iliac wing is required.
Completely unstable, translational injuries (Tile C) require both anterior pins and some type of posterior fixation.
The bars are connected anteriorly with one or two transverse bars by bar-to-bar connectors that form a
trapezoidal frame (Fig. 37.21). The frame should be positioned to allow for a laparotomy if necessary (see Fig.
37.6) and additional soft-tissue swelling, yet allows the patient to assume an upright position in bed or in a
wheelchair (see Fig. 37.25). If there is any soft-tissue tension caused by the pins, they should be released by
small relaxing incisions to avoid pin tract discomfort, necrosis, and infection (Figs. 37.23 and 37.24). The fracture
reduction and pin placement are checked with the C-arm, patient condition and time permitting (see Fig. 37.20),
and final permanent radiographs are obtained as condition permits (12,14,38,39).
FIGURE 37.23 An example of soft tissues under tension around the pins. If the incision is not made in reduced
iliac-wing position and it is not perfectly above the medial half of the iliac crest, the soft tissue may be
compromised after pin placement. Such an outcome may cause significant discomfort, tissue necrosis, and
possible infection.

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FIGURE 37.24 A soft-tissue release by an incision perpendicular toward the direction of tension. The incision
can be closed avoiding tension.

Supra-Acetabular External Fixation

The bone above the acetabulum is thick and strong and holds pins well. Biomechanical studies have shown that
pins and frames in this “low route” provide better SI joint stability than “upper route” (iliac-crest) frames (40,41).
Some authors (25) feel that this route is ideal for emergent anterior-pelvic fixation because of the ease of
palpating this thick bone, quickly putting one pin at each side, reducing the pelvis, and connecting the frame with
a single anterior-transverse bar. However, for surgeons with limited experience with this technique, the risk of
penetrating the hip joint or damaging the neurovascular structures in the greater sciatic notch, especially in the
absence of the C-arm, is high (14,42,43). The setup for the low route is the same as for the iliac-crest procedure.
We recommend C-arm control of the surgical steps and computer navigation assistance if available.

Procedure
Under C-arm visualization, the anterior-inferior iliac spine (AIIS) is localized with a hemostat on the skin. Just
lateral to the AIIS, a 2-cm transverse skin incision is made. This will allow less skin-pin interference when
the patient is mobilized. The soft tissues are carefully separated down to bone in longitudinal fashion to
avoid damage to the lateral femoral cutaneous nerve (transient numbness in 1% to 13%). A protection
sleeve with an inner trocar is advanced to bone with an oscillating motion. Through the trocar, the outer
cortex is opened with a drill bit. A 5- or 6-mm diameter pin with threads of 50 to 70 mm and at least 180 mm
in length is advanced through the trocar (Fig. 37.25). The entry point should be at the level of the AIIS,
advanced toward the acetabular roof, checked on obturatory view (Fig. 37.26), and checked on an iliac
oblique C-arm view to avoid the sciatic notch (Fig. 37.27). The pin is directed toward the SI joint: 30
degrees medial in the sagittal direction and 20 degrees less than perpendicular (about 70 degrees) to the
caudocranial axis (Fig. 37.28). Another pin is placed on the opposite side, and after additional reduction
maneuvers, both pins are connected by a single bar (Figs. 37.29 and 37.30). The bar should be far enough
from the skin to allow for additional swelling. Correctly done, this low route will not obstruct a laparotomy
approach, and patients are usually able to sit without difficulties with a frame in place. Pin-site drainage
occurs in up to one-third of cases (43,44).

FIGURE 37.25 Supra-acetabular external-fixation pin placement under C-arm control. A 2-cm incision is
made, and the soft tissues are spread down to the bone. The external fixation pin with a soft tissue-
protecting sleeve should be utilized.

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FIGURE 37.26 Supra-acetabular pin placement. The iliac oblique view helps the surgeon ensure that the
pin does not penetrate the hip joint nor pass through the greater sciatic notch.

FIGURE 37.27 Supra-acetabular pin placement. The obturator oblique view helps the surgeon guide the
drill and pin toward the SI joint.

In order to avoid pin-site problems

Ensure that the skin around pins is not under tension (pain, necrosis, infection).
Provide enough space between the connecting bars and skin (allows for swelling without tissue
compression and necrosis).
Compression dressings around the pins to prevent bleeding and immobilizing tissues, lessening the pain.
 Use rather three than two pins whenever possible (upper route).
Pins and skin around them need to be cleaned daily.
Relaxing incisions around the pins should be done when there is soft-tissue tension present or when
there is fluid collection beneath the skin.
If erythema or cellulitis develops, oral antibiotic is indicated.
If pin is loose, it should be removed.

Computer Navigation and External Fixation

Virtual fluoroscopy was approved for clinical use in 1999. Images of the reduced pelvis are imported using the C-
arm (equipped with image modulator for distortion prevention) to the computer (registration process) in needed
projections (inlet, outlet, sacrum lateral, Judet views, and/or combination thereof). A C-arm is available and used
at the end of the procedure to confirm position of the pins in at least one projection. It is possible to have four
“live” images at the same time on the screen and monitor position of the guide sleeve or drill and its trajectory in
all four projections (Fig. 37.31). Patient anatomy, C-arm registered images, and the drill guide, “communicate”
via trackers and infrared rays to the camera and computer integrating software allowing for virtual reality
navigation (all elements are displayed on the screen). The result is reduced radiation exposure for the patient
and surgeon, higher precision, and less tissue damage in a significantly shorter time frame. The best
applications for navigation are for insertion of iliosacral screws, supra-acetabular pins or pedicle screws, and
anterior and posterior column acetabular screws (45,46).

Subcutaneous Anterior External Fixator or Internal Anterior External Fixator

These are pelvic fixation techniques that are placed beneath the skin. Instead of typical external fixation pins,
spinal pedicle screws are inserted in the supra-acetabular bone (Fig. 37.22) with or without navigation and
connected with one bar placed beneath the skin. Compression is possible with this technique, having one screw
firmly attached to the connecting bar while the other is tightened as the fracture is compressed (Fig. 37.33). The
main advantage with this technique is that the construct is more tissue tolerant, providing good fixation and
avoiding skin irritation and pin tract infections (Figs. 37.34 and 37.35) compared with classic external fixation
techniques. As a result, these subcutaneous frames can stay longer (3 months or more) than conventional
external pin fixators and improve healing with less discomfort to the patients. In the past several years, the
“subcutaneous anterior external fixation” has become our preferred method of anterior stabilization when
osteosynthesis (plate and screws) is contraindicated or problematic (47,48).
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FIGURE 37.28 Supra-acetabular pin placement angles.

FIGURE 37.29 Supra-acetabular frame from the front. One pin on each side is enough for resuscitation
purposes, but if longer use is planned or a higher degree of instability is present, then two pins and two
connected bars will provide better stability.

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FIGURE 37.30 AP radiograph with right SI screws and a supra-acetabular frame. This minimally invasive
combination of fixation was chosen to treat a patient with multiple injuries that include a Tile C pelvic fracture.

FIGURE 37.31 Operating room setup with computer camera and monitor at the foot of the radiolucent table. The
C-arm is removed after obtaining the images and their transfer to the computer. Position of navigation tool and its
virtual extension (guide sleeve, marked with green arrow) is visible on the monitor (blue arrow) simultaneously in
up to four needed projections.

Subcristal External Fixation

With subcristal external fixation, pins are placed from front to back in the anterior third of the iliac crest where
there is usually good bone present. Guiding landmarks are easily palpable. Through a small incision over the
ASIS, the anterior cortex is opened with a 4-mm drill bit, and a 150- to 180-mm-long 5-mm diameter pin is
introduced by hand, passing next to the medial wall of the ilium and aiming toward the most prominent part of
lateral ilium. After placement of bilateral pins, they are connected with a bar and tightened after the pelvic
fracture is reduced (Figs. 37.36, 37.37 and 37.38). Solomon et al. reported outcomes in 20 patients using these
techniques and described it as rapid and relatively easy. Four patients had pin tract infections without loosening
or need for premature pin removal. It was well tolerated (sitting, walking) and healing averaged 10.7 weeks (49).

FIGURE 37.32 Navigating position for placement of a supra-acetabular pedicle screw, simultaneously monitoring
the process on the iliac and obturator views.

FIGURE 37.33 Connecting rod for the opposite pedicle screws is placed subcutaneously, and compression is
achieved using a simple compression device.

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FIGURE 37.34 Lateral view at the completion of the procedure documenting no prominent hardware.

FIGURE 37.35 Postoperative x-ray with bilateral iliosacral screws and SAEF.

Anterior Frames Postoperative Management

The soft tissues around the pins are stabilized by split gauze sponges for light compression for 48 hours and
then are cleaned regularly to avoid crusting, fluid retention, and infection. Skin tension around the pins should be
identified and released under local anesthesia. The frame construct should allow the patient to assume an
upright position for pulmonary toilet.
FIGURE 37.36 Placement of subcristal external fixation pins from front to back, within the good quality bone of
the iliac crest.
FIGURE 37.37 C-arm confirming good pin position.

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FIGURE 37.38 AP x-ray with subcristal external fixator in place.

Rotationally unstable injuries with two pins in a “high-frame” configuration or one pin in a low-frame configuration
provide enough stability for patients to bear weight. In patients with unilateral posterior, iliac or sacral fractures
combined with an anterior injury stabilized with an external fixator are mobilized partial weight bearing. Pelvic x-
rays should be used to verify stability and assure that the reduction has not been lost after mobilization. It should
be emphasized that an anterior frame does not provide enough stability for weight bearing on bilateral posterior
injuries. Mechanical stability may be improved with good fracture reduction, posterior compression, large
diameter pins, a curved bar-bow fixator, and a combination of iliac-crest and supra-acetabular frames. Lateral
compression injuries typically heal in 6 to 8 weeks while symphyseal disruptions heal in 6 to 10 weeks.
Tile C translational injuries with complete instability cannot be sufficiently controlled with an anterior frame alone.
If a C-clamp is unavailable or not applicable (posterior iliac fracture), then in addition to an anterior frame,
supracondylar femoral traction with 25 pounds can be used to improve posterior and superior displacement.
These measures are utilized until the patient’s condition improves to permit definitive internal fixation of the
posterior pelvic ring (12,38,50).

C-Clamp, Posterior Fixation

The use of devices similar to the C-clamp was published in the German literature nearly 50 years ago, but the
modern era of these devices reemerged following reports by Ganz et al. in 1991 and Buckle et al. in 1994
(25,51,52). Biomechanical testing has shown that the C-clamp provides better fixation than other types of pelvic
external fixation in patients with unstable pelvic injuries (50). It improves the conditions for hemostasis by
compressing fracture surfaces, decreasing motion that may dislodge clots, and decreasing pelvic volume. It also
may enhance self-tamponade and provide better support for pelvic packing when needed. Many patients show
an immediate improvement of vital signs after frame application. The C-clamp produces direct posterior
compression and stabilization, yet leaves unobstructed access to the abdomen (see Figs. 37.44, 37.45 and
37.46) and perineum (see Fig. 37.47). It is indicated for an unstable pelvic injury with disruption of the posterior
pelvic ring in a hemodynamically unstable patient.
Absolute contraindications to the use of a C-clamp are
Hemodynamically stable patients
Posterior iliac-wing fractures because of risk of pelvic penetration with colon or bladder injury
Transiliac fracture dislocations of iliosacral joint because of the risk of pushing the hemipelvis inward
Relative contraindications for the use of a C-clamp include
Complex sacral fractures because of the risk of nerve damage with compression
Severe osteoporosis due to the risk of pin penetration through soft bone
Significant local soft-tissue damage at the site of pin placement (37,53)
The C-clamp set has a rectangular frame (Ganz) or two semicircular tubes connected by a central ratcheting
gear (Browner’s pelvic stabilizer). Both have large pins with sharp tips, and outside threads allow for connection
with the frame and additional controlled compression. Sets should be sterilely packed and available in the
emergency and operating rooms. Figure 37.39 illustrates the position of insertion of the posterior C-clamp pin at
the intersection of a line along the long axis of the femur and with a vertical line angled down from the ASIS. If
landmarks
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are obscured because of deformity and swelling, the C-arm should be used to localize the correct starting point.
The pin tip should be placed on the outside surface of the ilium at the level of the reduced, posterior SI joint,
where the bone is the thickest. The transition of the oblique and vertical portion of the iliac wings with the lateral
surfaces is presented in Figure 37.39. With the patient supine, the surgeon can identify the starting point on the
posterior ilium with a hemostat through a 2- to 3-cm longitudinal incision on the side of injury (Figs. 37.40 and
37.41). If there is any concern about an iliac wing fracture at the site of pin placement, extend the incision slightly
to ensure that the bone is intact (by palpation or direct visualization) and the pin position is safe. If the pins are
placed too anteriorly, where the iliac bone is very thin, the pins could penetrate into the pelvis. If the pin is too
posterior, it could slide into sciatic notch, which could cause bleeding from the gluteal vessels or damage to the
sciatic nerve (54).

FIGURE 37.39 The landmarks for placement of a pelvic posterior C-clamp. In the reduced position, the correct
entry point is the intersection of a line between the longitudinal axis of the femur and a vertical line from the ASIS.
FIGURE 37.40 AP pelvic x-ray shows a translationally unstable, open (ruptured rectum and perirectal tissue),
left-sided pelvic-ring injury with extravasation of contrast after urethrogram and right T-type acetabular fracture.
The patient also had a closed head injury, chest injury, right open-forearm fracture, and left proximal-humerus
fracture.

FIGURE 37.41 The incision location for C-clamp pin placement. If the patient’s hemodynamic status allows and
an operating room is available, C-arm control should be used because it improves pin placement and the
accuracy of reduction.

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FIGURE 37.42 C-clamp application. Compression pins are inside the frame, and the first pin is “walked” on the
lateral wall of iliac wing on the stable side. The pin is pushed hard into the bone and held in place until reduction,
and the opposite pin is placed. The clamp may be applied in the emergency room, intensive care unit, or
operating room. (This single image is from a different patient than the images in Figs. 37.40, 37.41, 37.42, 37.43,
37.44, 37.45, 37.46 and 37.47, all from another patient).

FIGURE 37.43 The C-arm view shows the first pin anchored on the intact side.

Compression pins are screwed into the threaded compression bolts and are attached to the arms connected with
the central ratcheted gear. The central gear is then released so the arms can be spread to accommodate the
patients size, and the compression pin attached to the fixator arm is “walked” on the lateral iliac wing until the
vertical portion is felt (Fig. 37.42). The sharp tip is pushed (or hammered) into the bone on uninjured side first
and held there until the same procedure is done with the other pin on the opposite side.
When both pins are firmly anchored into the bone, the fracture is reduced, the arms are compressed, and central
gear is tightened. Additional incremental compression is possible by screwing the pins centrally through the
compression bolts (Figs. 37.42, 37.43, 37.44, 37.45, 37.46, 37.47, 37.48 and 37.49). Overtightening should be
avoided in the case of transforaminal sacral fracture, which can cause sacral-nerve root damage. If the patient’s
condition does not improve (in the next 30 minutes) despite aggressive resuscitation efforts and pelvic
stabilization, pelvic packing with or without laparotomy (see Figs. 37.6 and 37.48) or angiography may be
indicated. Otherwise, the pins are sterilely covered, the frame supported by towels, and pin care is begun in a
day or two. Pelvic x-rays are obtained postoperatively.

FIGURE 37.44 A clinical picture of the C-clamp in place. Posterior stabilization is achieved, and the frame can be
rotated up or down to make space if additional procedures are necessary.

FIGURE 37.45 Posterior C-clamp and anterior iliac-crest frame in place.

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FIGURE 37.46 AP pelvis x-ray shows the pelvic ring temporarily reduced and fixed with the posterior C-clamp
and anterior iliac-crest fixator.

FIGURE 37.47 Pelvic fixation allows lithotomy position for surgery around the perineum.

C-Clamp, Anterior Fixation

The C-clamp can be applied anteriorly on the pelvis as well, in the area of thick supra-acetabular bone. Frosch
et al. (2007) applied it in 15 polytraumatized patients with pelvic fractures including 10 with multidirectionally
unstable Tile C-type fractures. Frame application was done on an average 54 minutes after admission, and the
procedure took an average of 15 minutes to perform. Richard and Tornetta (2009) used it in patients with B1—
open-book fractures. The tongs were inserted into the supra-acetabular bone, approximately three
fingerbreadths proximal to the greater trochanter (54) or in the gluteus ridge three fingerbreadths directly
posterior to the ASIS (55), with patients in supine position (Figs. 37.50 through 37.53). All procedures (56) were
done without C-arm, under local anesthesia and with minimal complications.

Contraindications to the Use of a C-clamp

Fracture at level of intended pin insertion
 Significant soft-tissue damage, open wounds, and internal degloving injuries—the so-called Morel-Lavallée
lesion, due to the risk of infection (55)

FIGURE 37.48 Clinical picture after surgeries showing stable, external, posterior, and anterior fixation. A rectal
injury was débrided and irrigated, and a suprapubic cystotomy and diverting left-sided colostomy were performed
as well.

FIGURE 37.49 AP pelvic x-ray showing reduction and iliosacral screw placement that were used to replace the
C-clamp 2 days after injury.

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FIGURE 37.50 Application of anterior C-clamp, for patient from Figs. 37.9, 37.10 and 37.11. Incision is about
three fingers breadths posterior to ASIS.

FIGURE 37.51 After manual compression and tightening, the connecting mechanism is used to produce
compression.
FIGURE 37.52 AP pelvis x-ray after application of anterior C-clamp. Fixation bolts are more proximal than desired
(must not be closer than 20 mm from hip joint), but as long as iliac wing bone is intact, the clamp will provide
enough compression and stability.

FIGURE 37.53 A clinical photo of a patient stabilized by insertion of chest tube, pelvic, and knee external fixators
and upper extremity splinting.

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FIGURE 37.54 Trochanteric C-clamp in patient with B2—open book injury. If there is no acetabular injury,
procedure is safe to perform and no C-arm is necessary. Integrated x-rays show injury (above right) and after
clamp application (below left, pelvic ring closed and stabilized).

C-Clamp, Trochanteric Fixation

The greater trochanters are at the level of the hip joint and coplanar with SI joint and symphysis and can be used
to anchor a C-clamp. Compression is applied after pelvic reduction and does not require a C-arm, and abdominal
access is not obstructed (Fig. 37.54). If perineal access and repairs are needed (for rectal or vaginal injuries),
trochanteric fixation should not be used. The main contraindications are acetabular fracture, proximal femur
fracture, and significant local soft-tissue injury. Dislodgement of the pins posteriorly could damage the sciatic
nerve while anterior displacement could damage the femoral nerve or vessels. The authors have also used this
technique to hold reductions for definitive osteosynthesis of the pelvic ring (57).

Postoperative Care
Prophylactic IV antibiotics are given within 1 hour of surgery and continued for 24 hours. In case of open
fractures, antibiotic therapy is extended depending of the wound situation. Patients with unstable pelvic-ring
injuries (type B and C) have a high risk for developing deep venous thrombosis and pulmonary embolism
(DVT/PE). When there are no injuries in lower extremities, venous compression boots or elastic stockings are
applied immediately (mechanical prophylaxis). If there are no contraindications, chemical prophylaxis is used as
well (58). In patients who develop a DVT despite prophylaxis or in high-risk patients for bleeding, retrievable
inferior vena cava filter should be considered (59).
The weight-bearing status is determined mostly by the posterior injury (full weight bearing on the site where
there is no posterior instability and toe touch or partial weight bearing where reduction and fixation was needed).
Routine pelvic x-rays (AP, inlet and outlet) are taken immediately after the surgery, than after mobilization and at
4- to 6-week time intervals (anterior external fixator is usually left in place for 6 to 10 weeks).

EXTERNAL FIXATION COMPLICATIONS

Aseptic Pin Loosening
Assuming that the pin was placed correctly, loosening is a consequence of increased stress on anterior pelvis
caused by premature weight bearing or residual instability of the posterior ring (or insufficient fixation). To
minimize pin loosening, attention to detail during pin insertion is crucial, using three pins rather than two pins on
each side, and early conversion to internal fixation is helpful. Loose pins should be removed in order to avoid risk
of pin-site infection.

Pin Infection
Infection can develop if there is skin tension with resulting necrosis of surrounding soft tissues. If recognized
early, relaxing incision should be done under local anesthesia.
Infected pins that do not respond to local pin care and oral antibiotics should be removed.

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Loss of Reduction
If follow-up x-rays show early loss of fracture reduction with stable external fixation pins, rereduction and
increasing the frame stability may be an option. If the pins are loose, they should be replaced in the operating
room. Increasing the number of pins and broadening the fixation construct can be effective.

Vascular or Nerve Damage or Intrapelvic Pin Penetration

Vascular or nerve damage following insertion of supra-acetabular or iliac-crest pins is rare. Pins should be
inserted by hand, and their position confirmed with multiple spotviews using fluoroscopy.
The use of a posterior C-clamp has a higher risk of complications because is often done in the emergency room,
without C-arm control and with limited radiographs. If compression pins are pushed through osteoporotic bone or
through unrecognized fractures in iliac wing, organ damage has been reported. Also, if the C-clamp pin is
inadvertently placed into sciatic notch, damage to the sciatic nerve or superior gluteal vessels can occur (54).
Hip joint penetration from an anterior C-clamp or supra-acetabular pins has been reported when pins are <15
mm from the acetabulum (54, 55, 56 and 57).

CONCLUSIONS
Patients with unstable pelvic injury (Tile B or C) and hemodynamic instability (systolic blood pressure < 90
mm Hg; 20% of all pelvic fractures) require
1. Initial noninvasive pelvic stabilization (sheet or binder), an accurate diagnosis and identification of the
source of bleeding, and aggressive resuscitation per ATLS protocols.
2. If the patient does not respond to this treatment, a pelvic external fixator using either the
a. “Upper route”—iliac-crest “two pins and two bars frame” for B fractures; additional supracondylar
femoral traction for C fractures or
b. C-clamp should be applied:
i. Posterior (C-fractures with intact posterior iliac wing)
ii. Anterior (B-fractures, “open book”)
iii. Trochanteric (when a C-arm is not available and there is no acetabular or femur fractures)
If the patient remains hypotensive and in shock, the next step is
3. Pelvic packing (extraperitoneal approach or with laparatomy) or
4. Pelvic angiography with embolization
5. When the clinical situation improves, conversion to internal fixation speeds healing and improves
 rehabilitation. If anterior internal fixation is problematic (compromised soft tissues, suprapubic catheter,
very lateral fractures requiring major incisions), our preference is to use a subcutaneous external fixation
or iliac-crest external fixation with three pins in each iliac wing until healing.

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 38
Diastasis of the Symphysis Pubis: Open Reduction Internal
Fixation
David C. Templeman
Matthew D. Karam

INTRODUCTION
Diastasis of the pubic symphysis is often part of a complex injury to the pelvic ring. The bony pelvis provides
protection to the lower abdominal and genitourinary tract as well as the great vessels of the pelvic floor and
lower extremity. High-energy trauma that leads to disruption and displacement of the pelvis may lead to
deformity, instability, and associated injuries to the surrounding visceral structures. In a small but not insignificant
number of patients, serious or life-threatening hemorrhage may occur. Inadequately diagnosed or treated, these
injuries can result in residual pain, leg length discrepancy, limp, sitting imbalance, and sexual or bladder
dysfunction.
Ligamentous symphyseal disruptions heal less predictably than parasymphyseal fractures and can be a source
of chronic pain if not appropriately treated. Due to the close proximity of the anterior pelvic ring and genitourinary
tract, injuries to the bladder and urethra occur in up to 25% of patients. These associated injuries increase both
the morbidity and mortality following pelvic fractures involving the anterior pelvic ring.
Several different classifications can be used to characterize pelvic injuries. Early classifications were based on
either the location of the fracture or the mechanism of injury. Most modern classifications, however, are based on
the degree of pelvic stability (1,2). The Tile classification of pelvic ring injuries is used to predict the mechanical
instability of the injured pelvic ring and is categorized as A, stable; B, rotationally unstable but vertically stable;
and C, rotationally and vertically unstable. Tile B and C injuries may have associated disruption of the symphysis
pubis (2). The Young and Burgess modification of the Tile classification is based on the mechanism of injury.
This system categorizes Tile B injuries that are rotationally unstable as APC I, which have a symphyseal
disruption of <2.5 cm and APC-II injuries with >2.5 cm of symphyseal diastasis, both of which have intact
posterior sacroiliac ligaments and are vertically stable. With more severe injuries and increasing external
rotation, the posterior ligaments are ruptured resulting in vertical and rotational instability, which is classified as
an APC-III injury or Tile C injury.

INDICATIONS AND CONTRAINDICATIONS

The pubic symphysis is a cartilaginous joint where the pubic bones meet. The articulation is composed of a
fibrocartilaginous disc that is reinforced by the superior and inferior pubic ligaments. The arcuate ligament forms
an arch between the two inferior pubic rami and is thought to be the major soft-tissue stabilizer of the symphysis
pubis (3).
Injuries to the pubic symphysis include diastasis, fractures into the symphysis, and fracture dislocations.
Following trauma, if the pubic symphysis is not disrupted, the anterior pelvic-ring injury commonly consists of
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pubic rami fractures. These fractures are usually vertically oriented but may be comminuted or horizontal (4).
Diastasis of the symphysis pubis rarely coexists with fractures of the pubic rami (5,6).
Open reduction and internal fixation (ORIF) is usually indicated when diastasis of the pubic symphysis exceeds
2.5 cm. Displacement of this magnitude is thought to be accompanied by injuries to the sacrospinous ligament
and the anterior sacroiliac ligaments, which allow the involved innominate bone to rotate externally; however,
recent cadaveric studies indicate that these ligaments often remain intact (7). Stable fixation of the symphysis is
sufficient to correct this instability (4). Internal fixation is performed to relieve pain and improve stability of the
anterior pelvic ring. The indications for surgery are based on the patient’s overall condition and the stability of
the entire pelvic ring.
In Tile C or Young-Burgess APC-III injuries, the symphysis pubis (or the anterior pelvic ring) is disrupted as is the
posterior pelvic ring, resulting in complete instability of the pelvis. Fixation of the anterior ring alone is insufficient
to restore pelvic stability and must be accompanied by reduction and fixation of the posterior pelvic injury (2,8).
The differential diagnosis of an APC-III versus an APC-II is therefore critical in deciding when to proceed with
fixation of the posterior pelvic ring. When the posterior sacroiliac ligaments are intact (APC-II Injury/Tile B), the
external rotation of the innominate bone is accompanied by inferior displacement of the pubic bone due to the
geometry of the sacroiliac joint. This inferior displacement helps to differentiate an APC-II injury from vertical
displacement of the pubic body that usually occurs with APC-III injuries. This sign has been verified by both
clinical observations and laboratory studies in cadaveric specimens. An additional clue to the presence of an
APC-III injury is cranial displacement of the ischial tuberosity on the injured side.
Contraindications to internal fixation of the symphysis pubis include unstable, critically ill patients; severe open
fractures with inadequate wound débridement; and crushing injuries in which compromised skin may not tolerate
a surgical incision. Suprapubic catheters placed to treat extraperitoneal bladder ruptures may result in
contamination of the retropubic space and are a relative contraindication to internal fixation of the adjacent
symphysis pubis. Obese patients (BMI > 30) who undergo pelvic fixation have a substantial increased risk of
complications including wound dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis
(DVT), pneumonia, and development of decubitus ulcers (9). Additional conditions that may preclude secure
fixation are osteoporosis and severe fracture comminution of the anterior pelvic ring.
When the diastasis of the symphysis pubis is <2.5 cm, internal fixation is seldom necessary. Patients may be
safely mobilized and allowed to exercise toe-touch weight bearing on the side of the externally rotated
hemipelvis. Radiographs are repeated within the first few weeks to ensure further displacement has not
occurred. By 8 weeks, the pelvis is usually healed enough to allow full weight bearing.
Chronic pelvic-ring instability may follow nonoperative treatment or unrecognized pelvic-ring injuries. This subset
of patients commonly presents with pain in the symphyseal or sacroiliac region when undergoing weight-bearing
activities. For this group of patients, single-leg-stance radiographs may be useful. The radiographs are taken as
standard anteroposterior (AP) pelvis x-rays, and the three-film series should include a standing AP pelvis as well
as an AP of the pelvis during left leg stance and an AP of the pelvis during right leg stance. Subtle instability may
manifest as a vertical displacement at the symphysis pubis with single leg stance on the unstable side (Fig.
38.1). These chronic instabilities may be approached with the same technique of fixation that one would use to
treat an acute injury, but retropubic scarring of the bladder to the posterior aspect of the pubic bones and
symphysis may be encountered.
FIGURE 38.1 AP pelvic radiographs in single leg stance show increased vertical displacement with weight
bearing on the unstable side (A) compared to the contralateral single-leg-stance radiograph (B).

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PREOPERATIVE PLANNING
History and Physical Examination
The mechanism of injury should be determined because the initial evaluation and treatment differ dramatically in
patients with lower-energy injuries that occur following a mechanical fall from those the result from high-energy
trauma such as motor vehicle or motorcycle accidents or falls from a height. Elderly patients with compromised
bone who sustain ground-level falls usually result in a hip fracture. However, a subgroup of these patients
sustain pubic rami fractures, which can be very painful. Alternatively, patients with high-energy trauma and pelvic
disruption require evaluation and treatment using Advanced Trauma Life Support (ATLS) protocols. Patients with
hemodynamic instability require urgent evaluation and resuscitation. A multidisciplinary team consisting of
general surgeons, orthopedists, urologists, and interventional radiologists is frequently required to treat patients
with multiple injuries (10, 11, 12 and 13).
Because the spectrum of injuries to the pelvis is so great, the physical examination ranges from mild focal
tenderness to massive swelling, skeletal distortion, and pelvic instability. The skin should be inspected for
abrasions, degloving injuries (Morel-Lavelle lesions), and open wounds. The integrity of femoral, popliteal,
dorsalis pedis, and posterior tibial pulses must be determined. A thorough neurologic examination should be
performed and documented. A rectal exam with evaluation of the prostate is necessary in complex fracture
patterns as is a vaginal pelvic examination in females. A one-time assessment of pelvic stability should be carried
out by a senior, experienced trauma specialist.

Imaging
After the patient has been stabilized, radiographic studies are obtained. To determine the direction and
magnitude of the symphysis pubis disruption and the relative position of the pubic bones, the surgeon should
obtain AP, 40-degree caudal and 40-degree cephalad views (Fig. 38.2A-C). Differences in the height of the pubic
rami usually indicate that the hemipelvis is displaced in more than one plane. The most common deformity
associated with disruption of the symphysis pubis is cephalad migration, posterior displacement, and external
rotation of one hemipelvis (1). This pattern indicates a posterior pelvic injury (Tile C/Burgess APC III) that
requires posterior reduction and internal fixation to achieve a stable pelvis (2,8,14). In addition to the plain films,
a computed tomography scan is recommended to assess the posterior pelvic anatomy. The anterior structures
are best studied with plain films (2,12).
Urologic injuries are common in patients with anterior pelvic trauma. In male patients, a retrograde urethrogram
should be obtained to ensure that the urethra is intact before passing a Foley catheter. Extravasation of dye
during the urethrogram is a contraindication to blind passage of a Foley catheter and requires consultation with a
urologist. The presence of blood at the tip of the penile meatus is frequently cited as a sign of urethral trauma;
however, it is not present in the majority of cases. When the urethra is intact, a Foley catheter is passed, and a
cystogram is obtained. Because the female urethra is short and less prone to transection, a retrograde
urethrogram is not required before inserting a Foley catheter (11).

FIGURE 38.2 A,B. An operating room table with a radiolucent extension. This table allows tilting of the
fluoroscopic unit to obtain cephalad (C,D) and caudad (E,F) images of the pelvis (B,C). The cephalad view
superimposes the symphysis on the sacrum; this makes the diastasis of the symphysis difficult to view. Many
operating room tables do not allow enough movement of the C-arm to obtain cephalad and caudal views.

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FIGURE 38.2 (Continued)

The bladder should be studied by cystography with an intravenous pyelogram or retrograde cystogram. External
compression of the bladder is frequently caused by a pelvic hematoma, and the magnitude of compression
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and shape of the cystogram are indirect clues to the extent of intrapelvic hemorrhage. The management of
extraperitoneal bladder ruptures in patients with pelvic fractures is controversial. Traditional Foley catheter
drainage of extraperitoneal ruptures avoids the need for a laparotomy and direct repair. Kotkin and Koch (11)
found that patients with extraperitoneal bladder ruptures and pelvic fractures have higher rates of complications,
and these authors stressed the need for adequate bladder drainage.
When an extraperitoneal bladder rupture exists, the patient is at an increased risk for infection due to seeding of
the pelvic hematoma from catheter infections. When internal fixation of the symphysis is planned, the risk of
infection from the ruptured bladder must be considered. We favor primary bladder repair, irrigation of the anterior
pelvic-ring injury, and the use of antibiotics. The timing of the bladder repair is determined on an individual basis
(11).
SURGERY
Position, Setup, Imaging
Surgery is performed under general anesthesia. A Foley catheter is required to decompress the bladder. The
patient is positioned supine on a radiolucent flat-top table that can accommodate a mobile C-arm image
intensifier (see Fig. 38.2A). Intraoperative imaging permits evaluation of the reduction, placement of the
hardware, and assessment of the remainder of the pelvis after the symphysis is reduced. Before prepping and
draping the surgical field, the surgeon should obtain AP, cephalad, and caudal views of the pelvis with the C-arm
to ensure adequate visualization (Fig. 38.2E,F). These views are particularly important if combined fixation of the
anterior and posterior pelvic ring is required (Fig. 38.2B-D). The cephalad projection provides the best image to
visualize screw length after internal fixation of the pubic symphysis.

Surgical Approach
There are two surgical approaches that can be used for reduction and fixation of the symphysis (Fig. 38.3). A
midline incision is used when an exploratory laparotomy has been performed by the general surgeons to address
intraabdominal injuries. More commonly, however, a Pfannenstiel approach is utilized. The incision begins 1 cm
above the symphysis and is approximately 10 cm in length. The subcutaneous tissues are divided exposing the
fascia of the rectus abdominus muscle. When marked disruption of the symphysis is encountered, detachment of
one head of the rectus abdominis is common. The linea alba is divided longitudinally between the two heads of
the rectus, with careful elevation of the insertion of the abdominis muscle laterally (Fig. 38.4). The rectus can be
released from the superior portion of the rami while maintaining its attachment anteriorly. Transverse incisions
that detach the rectus abdominis to the anterior rami should be avoided because it impairs subsequent repair
and healing of the abdominal wall (14).

FIGURE 38.3 Pfannenstiel incision to expose the linea alba, which is located in the midline.
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FIGURE 38.4 Division of the linea alba (A) and lateral retraction of the two heads of the rectus abdominis (B).
Further retraction reveals disruption of the right rectus abdominis muscle. The bone of the pubic body is visible
above the surgeon’s hand (C).

Reduction
Hohmann retractors are carefully placed in the obturator foramen, which enhances exposure and may assist in
partially reducing the displaced symphysis (Fig. 38.5A). Several methods can be used to achieve reduction. The
simplest method is to place large, pointed reduction clamps on each side of the symphysis (see Fig. 38.5B).
Because this clamp only allows a limited amount of control and torque, it works best in patients with lesser
degrees of displacement.
In patients with disruption of the symphysis and the posterior pelvic ring, a three-dimensional deformity is usually
present: posterior, cephalad, and external rotation of the innominate bone. Therefore, the reduction requires
manipulation of the entire innominate bone. Matta (15) popularized the technique in which a pelvic-reduction
clamp is secured to the pubis with 4.5-mm screws inserted into the pubic bodies in an anterior-to-posterior
direction (Fig. 38.6A,B). The screws are placed so they do not interfere with the subsequent application of the
symphysis plate. For an innominate bone that is displaced in a posterior direction, placement of a plate secured
with a screw and nut on the inner surface of the displaced hemipelvis prevents screw
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pullout when the clamp is used to manipulate the innominate bone anteriorly. Reduction of the symphysis often
improves alignment of the posterior injury, making its subsequent reduction and fixation easier.

FIGURE 38.5 A. Line diagram of Hohmann retractors and the use of pointed reduction clamps to reduce the
diastasis of the symphysis pubis. B. Intraoperative application of clamp with reduction of the pubic symphysis. C.
Application of plate on superior aspect of the pubic bodies. D. Cephalad view to confirm screw length.

Fixation
Several different implants may be used for fixation of the disrupted symphysis. Advocates of two-hole plate
techniques claim that the plate can act as a universal joint and slight implant loosening permits the return of
physiologic motion of the symphysis after fixation. This theoretically reduces the late problems of implant failures.
However, a large retrospective review comparing two-hole and multihole plates (minimum two screws on each
side of the symphysis) found that two-hole fixation was associated with a statistically significant increase in
fixation failures and malunions (16).
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FIGURE 38.6 Reduction of the displaced hemipelvis as recommended by Matta. A. The pelvis-reduction clamp is
anchored to the pubic bodies with 4.5-mm cortical screws directed in an anterior-to-posterior direction. The
placement of the screws requires protection of the bladder. The clamp allows multidirectional control of the
displaced hemipelvis. B. In addition to closing the diastasis of the pubic symphysis, posterior translation of the
pelvic ring can be partially corrected (arrows). This will not usually obtain an anatomic reduction of displaced
posterior injuries.

The most frequently used implants are pelvic reconstruction plates with either four or six holes. Precurved plates
(which are 3.6-mm thick and unlike straight plates of 2.8-mm thickness) provide additional stability. Plates that
use either 4.5- or 3.5-mm screws can be used at the discretion of the surgeon. We favor the use of the 3.5-mm
implants with three screws inserted on each side of the symphysis (Fig. 38.5C).
The use of locking plates is controversial. There are no published comparative studies, but observations of
several failures point to the benefits of allowing motion between the plate and the screw heads as symphyseal
motion returns with weight bearing (Fig. 38.7).
In addition to visualization of the reduction, palpation of the inner surface of the symphysis confirms the
adequacy of the reduction. Similarly, palpation behind each pubic body assists in accurately directing screws into
the distal space of the pubic body. In acute injuries, this space is readily accessible. After fixation with one or two
screws on each side of the symphysis, the C-arm is used to verify the reduction and position of the implants (Fig.
38.5D). If satisfactory, the remaining screws in the plate are filled in. When treating chronic injuries of the
symphysis, the surgeon should be cautious when developing the retropubic space because the bladder may be
adherent to the posterior aspect of the pubic bones and symphysis. The rectus fascia and the linea alba are
reapproximated with interrupted sutures. The wound is closed over a drain placed in the space of Retzius and
exiting proximal to the incision.
FIGURE 38.7 Acute plate failure after fixation with a locking screw construct.

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POSTOPERATIVE MANAGEMENT
The spectrum of injuries associated with disruption of the pelvic ring is diverse and prevents the use of rigid
postoperative protocols. However, several basic principles apply to most cases. Early patient mobilization
improves pulmonary care and decreases the risks associated with bed rest. An upright posture is usually
possible after surgery.
DVT occurs in 35% to 60% of patients with pelvic fractures and requires evaluation, prophylaxis, or treatment.
Proximal thromboses develop in 25% to 35% of these patients and are more likely to embolize than distal thrombi
(17,18). Routine screening is not helpful because of the high percentage of patients who develop DVT.
Screening is considered when surgery is delayed more than 48 hours from the time of the injury. The diagnosis
and treatment of thromboses that are identified preoperatively may help prevent an intraoperative pulmonary
embolism (19).
The ideal method of prophylaxis and treatment for venous thrombosis remains elusive. Pharmacologic agents
should be safe and easy to administer, monitor, and reverse. The use of pharmacologic anticoagulation in
trauma patients is further complicated when the patient presents with associated head injuries, retroperitoneal
bleeding, and thoracoabdominal injuries. Treatment cannot be started until bleeding is controlled (19).
Mechanical devices that increase venous blood flow by intermittent mechanical compression offer an alternative
to pharmacologic agents. However, when used as a sole form of therapy, they are ineffective. One study found
that combined use of mechanical compression and low-dose heparin was effective in reducing the incidence of
DVT (20).
With stable internal fixation, patients can be mobilized from bed to chair on the first or second day after surgery.
Ambulation depends on the specific injury. For isolated open-book injuries (Tile B/APC-II), we recommend
protected weight bearing on the injured side for 8 weeks. Follow-up radiographs at this time usually indicate
some new bone formation in the region of the symphysis. This is interpreted as sufficient healing and stability. In
patients with combined internal fixation of the anterior and posterior pelvic ring (Tile C), weight bearing should be
delayed for 8 to 12 weeks.
When weight bearing is initiated, physical therapy may be helpful. Most patients have muscle atrophy as a result
of injury and inactivity. Physical therapy, directed at increasing hip abductor strength and aerobic conditioning,
helps restore a normal gait. Lower back-strengthening exercises and work-strengthening programs may be
beneficial in patients who need to return to heavy labor. Discharge from the hospital is dependent on the
presence of associated injuries. Many patients can use crutches or are able to perform bed-to-chair transfers
within a week after surgery.
Matta and Tornetta (8) reported the results of open reduction for anterior fixation of pelvic-ring injuries. In a
series of 127 patients with pelvic-ring injuries, these authors noted that 88 of 105 fractures of the anterior pelvic
ring were not internally fixed, and none required subsequent treatment for nonunion or loss of reduction.
Based on this study, Matta (15) recommended that internal fixation of the anterior pelvic ring should be reserved
for symphysis pubis dislocations, and only a minority of pubis rami fractures that remain widely displace after
ORIF of the posterior pelvic ring.

COMPLICATIONS
Loss of Reduction or Fixation
Complications related to internal fixation of the symphysis pubis are uncommon. Loss of fixation anteriorly is
usually associated with inadequate reduction and fixation of the posterior pelvic ring. If this occurs, the
entire fixation construct, in both the anterior and posterior pelvic ring, usually requires revision
osteosynthesis.
Because of physiologic motion at the symphysis pubis, screw backout or plate failure is occasionally seen.
These events seldom become symptomatic, and late hardware removal is rarely indicated. This is verified
by a study that found that in 15 of 49 patients who developed motion of the anterior plate or screws, only 4
of the 15 required revision surgery due to symptoms. The other 11 patients with loose implants were
functioning as well as the large group of patients with successful fixation (21).
Infection
Wound dehiscence or infection is rare. Irrigation and débridement should include exposure of the plate and
retropubic space. Cultures and type-specific intravenous antibiotics are indicated for 3 to 6 weeks. When a
prior urologic injury has been treated, reevaluation of the urinary system is necessary. The procedure
should include urinalysis, urine cultures, and may even require imaging studies. A consultation with an
urologist is recommended.
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Sexual Dysfunction
Impotence may result from the initial injury, and drugs commonly used for erectile dysfunction have not been
successful. Because patients may be reluctant to discuss this issue, polite questioning in the private setting
of an examination room may identify those patients with sexual dysfunction.

REFERENCES
1. Bucholz RW. The pathological anatomy of Malgaigne fracture-dislocation of the pelvis. J Bone Joint Surg
Am 1981;63:400.

2. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988;70(1):1.
3. Hollinshead WH. Anatomy for surgeons. 3rd ed. Philadelphia, PA: Harper & Row; 1982.

4. Letournel E. Surgical fixation of displaced pelvic fractures and dislocations of the symphysis pubis. Rev
Chir Orthop 1981;67(8):771-782.

5. Gamble JG. The symphysis pubis: anatomic and pathological considerations. Clin Orthop 1986;203:261-
272.

6. Letournel E. Pelvic fractures. Injury 1978;10:145-148.

7. Doro C, Daren F, Hyunchul K, et al. Does 2.5 cm of symphyseal widening differentiate anteroposterior
compression I from anteroposterior compression II pelvic ring injuries? J Orthop Trauma 2010;24(10):610-
615.

8. Matta JM, Tornetta, P. Internal fixation of unstable pelvic ring injuries. Clin Orthop 1996;329:129-140.

9. Sems SA, Johnson M, Cole PA, et al. Elevated body mass index increases early complications of surgical
treatment of pelvic ring injuries. J Orthop Trauma 2010;24:309-314.

10. Dalai SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is
the key to pattern of organ injury: resuscitative requirements and outcome. J Trauma 1989;29(7):981-1000.

11. Kotkin L, Koch M. Morbidity associated with nonoperative management of extraperitoneal bladder
injuries. J Trauma 1995;38:895.

12. Tile M, Pennal GF. Pelvic disruption: principles of management. Clin Orthop 1980;151:56.

13. Geerts WH, Code KI. Thrombo-prophylaxis after major trauma: a double-blind study comparing LDH and
the LMWH enaparin [abstract]. Thromb Haemost 1985;73:284.

14. Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop 1989;242:83-97.

15. Matta JM. Indications for anterior fixation of pelvic fractures. Clin Orthop 1996;329:88-96.

16. Sagi HC, Papp S. Comparative radiographic and clinical outcome of two-hole and multi-hole symphyseal
plating. J Orthop Trauma 2008;22:373-378.

17. Geerts WH, Code K, Jay RM, et al. A prospective of DVT after major trauma. N Engl J Med
1994;331(24):1601-1606.

18. Montgomery KD, Geertz WH, Potter HG, et al. Thromboembolic complications in patients with pelvic
trauma. Clin Orthop 1996;329:68-87.

19. Montgomery KD, Potter HG, Helfet DL. Magnetic resonance venography to evaluate the deep venous
system of the pelvis in patients who have acetabular fractures. J Bone Joint Surg Am 1995;77(11):1639-
1649.

20. Stickney J, Delp SL. Deep venous thrombosis: prophylaxis. J Orthop Trauma 1991;227.

21. Putnis S, Pearc R,Wali U, Bircher M, Rickman M. Open reduction and internal fixation of traumatic
diastasis of the pubic symphysis- one year radiological and functional outcomes. J Bone Joint Surg Br
2011;93(1):78-84.
 39
Posterior Pelvic-Ring Disruptions: Iliosacral Screws
Milton L. Chip Routt Jr

Pelvic fractures and dislocations are uncommon injuries that usually result from a high-energy traumatic event
such as a motor vehicle or motorcycle accident, a fall from a significant height, or a heavy object crush. In elderly
patients with poor bone quality, even lower energy accidents can cause pelvic-ring instability. Mechanical
instability of the pelvic ring commonly occurs when normal physiological forces produce deformation at the pelvic
injury sites. Pelvic-ring instability is difficult to treat successfully for many reasons. The osseus anatomy is
complex, the injury sites can be numerous, the related soft-tissue injury is confusing, and most orthopedic
surgeons lack sufficient experience treating these injuries. Classification schemes have attempted to categorize
pelvic-ring injuries; however, the variety and complexity of these injuries has frustrated any grouping method.
Experienced clinicians realize that the most effective pelvic classification system is simply an anatomical
description of the injury sites and their displacements/deformities. An anatomical description is exact, easy to
remember, reproducible, reliable, and helps to guide accurate treatment. For the patient with an unstable pelvic-
ring injury, pelvic-related bleeding as well as the other organ system injuries due to the traumatic event can
cause hemodynamic instability. The physiologically unstable patient with a mechanically unstable pelvic-ring
injury therefore demands an early and coordinated management strategy. A multidisciplinary and dynamic team
approach facilitates an efficient resuscitation as well as definitive treatment that is tailored to the patient’s
specific injuries and evolving clinical course. Over time, many different treatments have been used to stabilize
pelvic-ring injuries without adversely affecting the overall patient condition. Modern treatment techniques have
improved patient care due to numerous factors including clinical experience, biomechanical research, implant
development, and imaging techniques. Despite these advancements, patients with unstable pelvic-ring injuries
continue to challenge clinicians as we seek even better methods to resuscitate, reduce, stabilize, and rehabilitate
these complex injuries and patients.

INDICATIONS AND CONTRAINDICATIONS

Iliosacral screw fixation is indicated for patients with unstable posterior pelvic-ring injuries including sacroiliac (SI)
joint dislocations, sacral fractures, certain posterior iliac “crescent” fracture-SI disruptions, and combinations of
these injuries. Iliosacral screw fixation is applied using osseus fixation pathways (OFP) within the upper-sacral
segments. The sacral osteology, pelvic instability severity, and specific injury patterns determine how many and
at what exact sites the screws are located. Iliosacral screws are used alone or in conjunction with other forms of
pelvic internal or external fixation. They can be resuscitative devices providing lag screw-dependant compressive
reductions and temporary as well as definitive fixation. The timing of internal fixation for displaced pelvic-ring
injuries depends on numerous factors such as the patient’s overall clinical condition, fracture pattern, local skin
condition, hemodynamic status, patient age and body habitus, and abdominal or urologic injuries.
The surgeon must meet certain criteria to insert iliosacral screws safely. The surgeon must completely
understand normal posterior pelvic anatomy, as well as its variations, especially the upper-sacral osseus
structure and the fluoroscopic imaging of these bony details. High-quality consistent fluoroscopic imaging of the
entire
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pelvis must be available during surgery. The surgeon must completely understand the specific injury and the
displacement patterns of the posterior pelvic ring and be able to correlate normal and altered pelvic pathologic
conditions as seen on radiographic images. Based on the preoperative plan, radiographs, and computed
tomography (CT) of the pelvis, the surgeon must be confident that the patient’s upper-sacral anatomy will allow
safe screw placement. Finally, the surgeon must possess the technical skill to reduce the posterior pelvic
deformity accurately by closed or open techniques. Iliosacral screws should not be used unless the injured area
is accurately reduced. Accurate reduction improves stability as well as the area available for the screws.
Dysmorphism of the upper sacrum is a relative contraindication for the insertion of iliosacral screws.
Dysmorphism is a common lumbosacral spinal segmentation variant. The dysmorphic upper-sacral segment
typically has a diminished and angular alar osseous area available for safe iliosacral screw passage into the
sacral body. The dysmorphic upper-sacral segment has obliquely oriented alar OFP. The distinct osseus
features of sacral dysmorphism are easily identifiable on the preoperative imaging studies. These upper-sacral
segment dysmorphic “abnormalities” occur in approximately 40% of patients and are best identified on the pelvic
outlet plain radiograph and CT scan. These abnormalities result from in utero segmentation variation and are
most often symmetrical, but can also have asymmetrical and even unilateral patterns in some patients. The
radiographic hallmarks of upper-sacral segment dysmorphism are best visualized on the pelvic outlet plain film
and include the following: (a) the lumbosacral disc space is essentially colinear with the iliac crests, (b) the
ventral foramen of the upper-sacral nerve root are not circular in appearance, (c) residual disc space is noted
between the upper and second sacral segments, (d) the dysmorphic ala decline acutely from the cranial-
posterior-medial upper-sacral body toward the SI joints in a caudal-anterior-lateral sloping in both the sagittal and
coronal planes, and (e) mamillary processes (underdeveloped transverse processes) are seen along the
dysmorphic ala. On the CT scan of the pelvis, sacral dysmorphism is noted by accentuated, undulating SI
surfaces; an obliquely oriented, anterior, alar cortex relative to the iliac cortical density (ICD); and a narrowed
alar zone available for screw insertion (Fig. 39.1A,B).
Obesity is a relative contraindication to iliosacral screw fixation for several reasons. Intraoperative fluoroscopic
imaging in obese patients is compromised by the excessive abdominal panniculus, which may obstruct inlet and
outlet images of the pelvis (Fig. 39.2A,B). Lateral pelvic flank obesity obstructs predictable true lateral sacral
imaging. Fluoroscopic detail in obese patients may be inadequate for safe screw placement. In addition, extra-
long instruments such as drills, taps, and screwdrivers are necessary for treating the obese patient.
In the recent past, fluoroscopic imaging of the pelvis was also complicated in some polytraumatized patients
because of contrast agents that were used during the initial abdominal evaluations. These agents and
techniques are rarely used today and should be avoided when possible. In patients with open fractures or
compromised posterior skin and soft tissues, iliosacral screw placement should be done percutaneously when
possible, rather than through an open approach. In a common mistake, the surgeon enters and inadvertently
decompresses a pelvic degloving injury during the process of iliosacral screw insertion. In such situations, the
screw is inserted, the degloving area irrigated and débrided, and the dead space closed over suction drains. In
severe cases, the dead space is packed open, or a vacuum-assisted closure device is selected (Fig. 39.3A,B).
FIGURE 39.1 3D pelvic scans demonstrate the variety of upper-sacral osseus anatomy that must be understood
for safe iliosacral screw insertion. A. This image represents a nondysmorphic upper-sacral segment. B. In
contrast, symmetrical sacral dysmorphism is noted on this outlet image. The lumbosacral junction is essentially
colinear with the iliac crests rather than recessed. A residual disc space is seen between the upper and second
sacral segments. The sacral ala are acutely sloped from midline-cranial-posterior to lateral-caudal-anterior.
Residual transverse processes form “mamillary bodies” along the ala bilaterally. The upper anterior
neuroforamen are ovoid instead of circular shaped. The dysmorphic upper-sacral OFP is obliquely oriented as a
result.

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FIGURE 39.2 A,B. Obesity complicates imaging both before and during pelvic surgery. A. This obese patient
has an unstable and displaced pelvic-ring disruption. The scout image underestimates the injury due to the
surrounding soft tissues. B. The reconstructed pelvic image identifies the injury severity.

PREOPERATIVE PLANNING
History and Physical Examination
In the hemodynamically unstable patient with an unstable pelvic-ring injury, resuscitation using advanced trauma
life support protocols has been shown to reduce morbidity and mortality rates. Large-bore intravenous access
allows rapid volume infusion, and the patient is kept warm. The potentially injured pelvis can be immobilized at
the accident scene before patient transport through use of a variety of simple techniques. In the past, vacuum
beanbags and military antishock trousers were used. More current and less complicated, a simple circumferential
pelvic sheet is recommended for initial temporary stabilization of the unstable pelvic-ring injury. Pelvic-wrapping
devices are also commercially available but are costly, and they often add to an overloaded inventory. Sheets
are readily available, inexpensive, and can be adjusted in width to fit any body habitus. They can be reused or
discarded, require no additional inventory, and can be positioned or trimmed to allow groin, perineal, flank,
abdominal, or combination access for other resuscitation or evaluation procedures. For some traumatic pelvic-
ring injury patterns, the circumferential pelvic sheet produces a perfect manipulative closed reduction when
applied snugly. When this occurs, an appropriately located and sized hole in the sheet is cut allowing iliosacral
screw insertion and pelvic external fixation pin applications as needed. The sheet is then removed once the
fixation devices are applied. Regardless of the technique chosen, pelvic overcompression should be avoided.
FIGURE 39.3 A. Percutaneous iliosacral screw fixation after irrigation and débridement was selected for this
patient’s pelvic fracture because of his grossly contaminated open lumbodorsal soft-tissue wound. B. Serial
débridements removed the necrotic tissues, and a vacuum-assisted closure device helped seal the region to
prevent ongoing fecal contamination. Careful application of the isolation bandage was required due to the anal
proximity. Fecal diversion was not needed. The wound was skin grafted 6 weeks after injury.

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The pelvic instability physical examination is a single mechanical and visual evaluation performed by an
experienced physician and then communicated to the rest of the treatment team. Repetitive examination of pelvic
mechanical instability is avoided because it produces pain and can potentially interfere with clot formation. A
detailed neurologic examination is documented in alert patients. During the examination of the pelvic area, the
surgeon identifies abrasions, contusions, degloving injuries, deformed skin, or open wounds. Obvious
contamination is removed, and sterile pressure dressings are applied to open pelvic wounds to diminish ongoing
bleeding. Packing an open pelvic wound decreases bleeding but the packing material should be sterile and
easily retrievable. Kerlix rolled sterile gauze allows the open wound to be packed, and a portion of the roll should
extrude from the wound so that it is easily identifiable. So that the pelvic packing material is always accounted
for, the ends of the Kerlix rolls are tied securely together if more than one roll is necessary to pack the open
wound. The lumbosacral palpation and visual, along with the digital rectal examinations, are performed during
the posterior spine assessment after the patient has been log rolled by a team of assistants.
The mechanical evaluation of the pelvis is ideally performed under fluoroscopic imaging. Pelvic-ring instability is
noted as gentle manual pressure is applied simultaneously toward the midline over each iliac crest. This
maneuver produces significant pain in alert patients with pelvic-ring instability, iliac fractures, and certain
acetabular fractures. Local pain during iliac manual compression can also be due to iliac area contusions in the
absence of pelvic-ring osseous injury. To prevent fracture-surface clot disruptions (among other potential
consequences), vigorous and repetitive, manual, pelvic examinations are not recommended. Digital rectal,
prostatic, and vaginal examinations are performed to test for both gross and occult blood. The vaginal and rectal
exams are initially done with the patient supine or log rolled into the lateral position. A more thorough speculum
vaginal exam is deferred until pelvic stability is achieved so the patient can be placed safely in the lithotomy
position.

Imaging Studies
The radiographic assessment begins with a screening, anteroposterior (AP), plain radiograph of the pelvis. A
complete radiographic series include orthogonal views (inlet/outlet), and a lateral sacral image should be
obtained especially in patients whose screening AP films show a “paradoxical inlet” of the upper-sacral area.
The “paradoxical inlet” appearance indicates either traumatic upper-sacral transverse fractures or normal yet
excessive lumbosacral lordosis. A CT scan of the pelvis is essential to further delineate the fracture anatomy.
The CT scan images of the pelvis indicate the patient’s body habitus, reveal related soft-tissue abnormalities,
such as hematoma, as well as degloving injuries and their extent, and also show contrast extrusions reflecting
bladder, vascular, or other injuries. The pelvic CT images also show the lumbosacral nerve-root positions as well
as sacral alar fractures. The iliac vessels and their relationship with displaced, superior-pubic ramus fractures
are often seen clearly on the images. With similar clarity, displaced inferior-ramus fractures can be identified as
they intrude on the vagina or are displaced anteriorly. The CT scan details subtle osseous injuries missed on the
plain films and shows the hemipelvic displacement patterns. Similar to the CT findings for an open pelvic wound,
an ipsilateral pneumothorax can often be seen on CT scans of the pelvis because the subcutaneous air extends
to the iliac area (Fig. 39.4).

FIGURE 39.4 A CT axial image has an obviously displaced sacral fracture, but when the image is carefully
examined shows fracture hematoma, body habitus, bone quality, comminution, left iliac fracture, local degloving
injury, and sacral nerve roots.

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Timing of Surgery
The timing of pelvic reduction and fixation is primarily dependent on the clinical condition of the patient,
institutional capabilities, and surgeon availability and expertise. Many patients with unstable pelvic-ring injuries
have other injuries that may require urgent surgery. For these patients, pelvic reduction and fixation should be
accomplished at the same anesthesia using a coordinated plan with the other surgical teams. Planning would
include patient positioning, operating table selection, necessary imaging, procedure prioritization and
sequencing, and other details. For example, if the urology consultants are planning urgent repair of the patient’s
bladder injury, the orthopedic surgeon could use the opportunity to reduce and stabilize the anterior and
posterior unstable pelvic-ring injuries when possible. Hemodynamically unstable patients with unstable pelvic-
ring injuries require some form of rapid pelvic stabilization. Anterior-pelvic external-fixation frames and posterior-
pelvic antishock clamps have been advocated to stabilize the pelvic ring rapidly. When possible, the pelvic
external-fixation system is applied through use of iliac crest or pelvic brim pins inserted after a closed reduction is
obtained and maintained by the circumferential pelvic wrap. Access holes are cut in the sheet overlying the iliac
crest. The skin is prepped, and the pins are inserted between the iliac cortical tables or within the pelvic brim
from the anterior inferior iliac spine. We recommend application of such external devices using the fluoroscopy
unit in the operating room when possible. The circumferential wrap can also be adjusted through use of the
same imaging unit to assess and adjust the pelvic closed-manipulation reduction (Fig. 39.5). If the reduction has
been achieved, iliosacral screws can also be inserted using access portals in the sheet. In selected
hemodynamically unstable patients, pelvic angiographic embolization is helpful in controlling pelvic arterial
bleeding.
Emergency, pelvic, open reduction and internal fixation induces the risk of bleeding and has a higher
complication rate, but for certain patients and injury patterns, the benefits may outweigh the risks. Percutaneous,
posterior-pelvic, internal fixation through the use of iliosacral screws minimizes the bleeding risk, is quick, and is
useful when an accurate closed-manipulated reduction of the posterior pelvic-ring injury can be accomplished.
For some injuries such as SI disruptions, the iliosacral lag screw is inserted as a reduction and fixation device
(Fig. 39.6).
Percutaneous iliosacral screws may be used in emergency resuscitation situations in combination with standard
anterior-pelvic external fixation. In patients who are hemodynamically stable, operative pelvic stabilization should
be done early. Before surgery, distal femoral traction improves the reduction and provides patient comfort.

Surgical Tactic
During the preoperative planning phase, the surgeon should consider the mechanism of injury, associated major-
system injuries, and the local soft-tissue conditions. Special attention is given to an analysis of the plain films and
CT scans. On occasion, iliac and obturator oblique radiographs of the pelvis are obtained in patients with
concomitant acetabular fractures. A two-dimensional (2D) CT scan further delineates the specific sites of injury
and direction of displacement. Just as important as detailing the injury and local anatomy, the 2D CT scan also is
used preoperatively to determine the number of screws that can be inserted, the upper-sacral anatomy, the
planned starting point on the lateral ilium, and the screw direction and length needed to achieve stable and
balanced fixation. The CT scan sagittal reconstructions demonstrate the specific upper-sacral anatomy
facilitating planning such as the amount of intraoperative tilt needed for inlet imaging (Fig. 39.7A,B).
Some clinicians prefer three-dimensional (3D) CT scans to improve their understanding of the osteology, fracture
details, and deformity patterns, but these should not be studied alone and instead must be correlated with the
axial images (Fig. 39.8A,B).
Based on the mechanism of injury, the physical examination, and the radiographic studies, the surgeon
formulates a plan. The preoperative plan includes all of the surgical details including timing, coordination with
other surgical treatment teams, equipment needs, patient positioning, prepping and draping, exposures,
reduction strategies, clamp application sites, fixation techniques, and treatment alternatives. Even the anticipated
rehabilitation goals are planned preoperatively; they are especially important for polytraumatized patients.
FIGURE 39.5 The use of a circumferential sheet provides an excellent technique for closed reduction in certain
pelvic-ring disruptions. In some patients, the reduction is maintained by the sheet, and the iliosacral screw is then
inserted through a “working portal” through the sheet as for this patient.

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FIGURE 39.6 A-D. A percutaneous iliosacral lag screw can be used urgently as a resuscitative device for certain
patients with pelvic-ring disruptions. A. This patient had persistent hemodynamic instability despite appropriate
resuscitation. B. He was taken to the operating room, and the initial iliosacral lag screw was positioned to
accurately compress the SI joint while accommodating the bony anatomy. The selected screw length accounted
for the SI-joint distraction. C. As the lag screw was tightened, the SI joint reduced. D. Fully threaded screws were
then added to supplement the posterior pelvic fixation construct. At the conclusion of the operation, he was
hemodynamically stable.

Not all posterior pelvic fractures, especially certain larger crescent iliac fractures, are amenable to iliosacral
screw fixation, and the surgeon should be familiar with various anterior-pelvic and posterior-pelvic operative
exposures and fixation techniques as well as percutaneous reduction and fixation strategies. The treatment plan
must be tailored to the individual patient. Insertion of iliosacral screws can be performed with the patient in the
supine, lateral, or prone position; each patient position has advantages and disadvantages. The lateral position
complicates both anterior-pelvic and posterior-pelvic surgical exposures and is not recommended for patients
with potential spinal injuries. Prone positioning allows posterior surgical exposures but denies the surgeon
simultaneous anterior-pelvic surgical access. Anterior-pelvic external-fixation frames further complicate prone
and lateral patient positioning for surgery.
If the supine position is selected, strict attention to detail during patient positioning, as well as skin preparation
and draping, is mandatory. For most and especially polytraumatized patients, the supine position is simple and
familiar; provides easy face-airway-chest-abdominal-perineal access; allows several teams to work
simultaneously on injured extremities if needed; and also provides anterior pelvic access. With the supine
approach, patient position adjustments and repeated drapings are avoided; thus valuable time is saved.
Computer guidance systems have been available for two decades and, like neurodiagnostic monitoring, are
intended to simplify the procedure by making it safer. Unfortunately, computer navigation systems are not a
substitute for the surgeon’s thorough knowledge of the sacral anatomy and radiology. Current navigation
systems are still being refined in attempts to help surgeons, but the surgeon’s knowledge should always be more
extensive than any artificial intelligence device.
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FIGURE 39.7 A. The midline sagittal sacral CT image is rotated to reflect a supine patient and then used
extensively during preoperative planning to demonstrate transverse fractures, determine the amount of C-arm
tilts anticipated for inlet and outlet imaging during screw insertion, and identify lumbosacral osteophytes. This
image alerts the surgeon and reveals the extent that the intraoperative C-arm inlet-outlet imaging will not be
orthogonal. The ideal inlet image superimposes the anterior cortical edges of the upper two sacral vertebral
bodies. The ideal outlet image superimposes the symphysis pubis on the second sacral segment and is rarely
orthogonal to the inlet image. B. Transverse sacral fracture and its associated displacement pattern are best
seen on the midline sagittal sacral CT image. This displacement pattern produces the “paradoxical inlet”
appearance noted on the screening AP pelvic plain film.

FIGURE 39.8 A,B. Critical information necessary for preoperative planning is not always available on the 3D
pelvic CT surface-rendered images. The routine 2D pelvic axial CT images reveal details beyond the bone
surface. A. This 3D pelvic image demonstrates the sacral fracture, lumbosacral disc injury, and displacement
pattern. B. The contrast-enhanced 2D axial image alerts the surgeon to the relationships between the sacral
fracture and both the iliac vascular and lumbosacral neural structures. The axial image also provides information
regarding the upper-sacral OFP’s size and orientation.

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SURGERY
Positioning
A general anesthetic is administered before the patient is moved onto the operating room table. Spinal
precautions protect the patient during transfer from the bed and positioning on a fluoroscopically compatible
operating table. Several strong assistants are needed to elevate the patient from the operating table so the
surgeon can position a soft, lumbosacral, spinal support. This support consists typically of two (or more) stacked
and folded operating-room blankets. Commercial sacral elevation products are available but folded blankets are
readily available, inexpensive, clean, and can be adjusted to fit any patient. Too much elevation causes the
patient to be unstable and therefore tilt to one side or the other. Elevating the patient’s pelvis from the operating-
room table is necessary to allow posterior-pelvic percutaneous access. If needed, distal-femoral pin traction is
continued through use of a pulley system attached to the operating table. Once the patient is positioned, a
cephalosporin antibiotic is intravenously administered preoperatively.
Some surgeons prefer to use varieties of neurodiagnostic monitoring during pelvic surgery. As for navigation
systems, neurodiagnostic monitoring is not a substitute for surgeon competence, a detailed preoperative plan,
accurate reduction, or adequate intraoperative fluoroscopic imaging. The surgeon must understand the posterior
pelvic anatomy and its fluoroscopic correlations. The surgeon should never use neurodiagnostic monitoring to
direct drill or screw insertions in a random manner while hoping to find a safe area for the screw.
Neurodiagnostic information may also be confusing, especially with regard to patients with preoperative
neurologic abnormalities, when information is falsely positive, and when clinical correlation is lacking.
Neurodiagnostic monitoring is in no way a safety net that will protect the surgeon from lack of knowledge
regarding sacral anatomy.
Imaging
The radiology technician and fluoroscope are positioned on the side opposite from the injured posterior
hemipelvis. If both sides are injured, the surgeon chooses the sequencing according to the injury pattern details.
The initial AP fluoroscopic image of the pelvis is used simply to assess proper patient positioning. Minor position
corrections are made and confirmed. The anterior pelvic inlet view is then used if preoperative mechanical
stability is to be assessed under fluoroscopy. Surprisingly, certain “nondisplaced” fracture sites thought to be
previously insignificant may show impressive instability under fluoroscopy. These “nondisplaced” fractures
should not be ignored. The pelvic inlet view is used because it demonstrates the instability yet allows the
surgeon to avoid being in the beam while performing the assessment.
The fluoroscope tilt is then customized for each patient until perfect inlet and outlet posterior-pelvic images are
obtainable. The ideal inlet image is estimated from the preoperative pelvic CT scan using the sagittal sacral
reconstruction midline image. This image reveals the patient’s specific upper-sacral osseus morphology and its
angular tilt relative to the horizontal plane. In the operating room using fluoroscopy, the C-arm unit is tilted
according to the preoperative plan and then adjusted so that the upper-sacral vertebral bodies are “stacked” by
superimposition as concentric circles.
Because of the upper-sacral morphological variations, the pelvic inlet view is the most difficult to reproducibly
obtain and therefore the least reliable view of the three standard images used intraoperatively. For dysmorphic
upper-sacral segments, anterior, cortical, alar indentations mark the anterior cortical-alar limits and are noted on
the inlet image. These are critical to note if upper-sacral segment screws are planned since the alar cortical
indentations mark the anterior alar cortical limits. If the surgeon ignores this important radiographic feature,
iliosacral screw safety is severely compromised (Fig. 39.9).
The ideal intraoperative outlet fluoroscopic image can also be estimated on the preoperative CT scan sagittal
reconstruction midline image. It is obtained when the superior aspect of the symphysis pubis is superimposed on
the second sacral-vertebral body. The surgeon should carefully examine this outlet image, which reveals the
corticated pathway of the upper-sacral nerve root. These bilateral pathways are osseous tunnels that begin
posteriorly, superiorly, and centrally at the spinal canal at the same level as the lumbosacral disc space. These
bilateral tunnels course anteriorly, caudally, and laterally from their spinal canal origin and end as the ventral
foramen of the first-sacral nerve root. The radiographic appearance on the outlet image of these bilateral
corticated pathways is like that of a small spica cast. Under the spica cast model, the body of the spica cast is
the spinal canal, while the thigh components of the spica cast are the sacral nerve-root tunnels passing from the
spinal canal to the ventral sacral foramen. The corticated edges of the nerve-root pathways/tunnels allow their
radiographic visualization in the operating room and on the plain preoperative radiographs. This spica cast
analogy lends a 3D quality to a 2D outlet image, giving a preoperative depth perception to the surgeon of the
upper-sacral nerve pathway. This is invaluable radiographic intraoperative information.
For dysmorphic upper-sacral segments, the C-arm unit tilt is adjusted to focus on the segment that will receive
the iliosacral screw. In some dysmorphic patients, iliosacral screws are inserted into the narrowed upper-alar site
and also into the second segment, which may be a more expansive area for screw insertions. If an upper-sacral
segment screw is chosen for a dysmorphic patient, the surgeon must understand that the anterior borders of the
sacrum at S1 and S2 are different, and therefore unique fluoroscopic markers highlight
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each specific site. The outlet view will predictably reveal the nerve-root tunnels for each segment. The true
lateral view will be disturbing with regard to the dysmorphic upper-segment screw insertion because the upper-
sacral segment is superiorly located relative to the superimposed ICDs. Therefore, this image looks as though no
lateral sacral-alar mass is safe for screw location. The preoperative plan will assure the surgeon that the screw
orientation will be directed from a posterior-caudal starting point with an anterior-cephalad directional aim.
Because of the unusual anatomy, these upper-sacral screws in dysmorphic sacra rarely extend beyond the
midline.

FIGURE 39.9 A. The anterior alar cortical limit for a dysmorphic upper-sacral segment has a notable indentation
on the pelvic inlet image. B. The surgeon therefore uses the pelvic inlet image intraoperatively to position the
iliosacral screw just posterior to this anterior alar indentation. C. On the 3D image, the dysmorphic segment alar
slope accounts for the indentation.

The inlet and outlet intraoperative fluoroscopic views of the pelvis are essential to visualize the upper sacrum.
Image enhancement and alternating negative images on the fluoroscope often improve imaging of the posterior
pelvis. The arc of rotation of the fluoroscope needed to obtain these “perfect” images varies for each patient and
depends upon the degree of lumbosacral lordosis and deformity due to the injury. For example, displaced U-type
sacral fractures produce a focal upper-sacral kyphosis that necessitates the inlet view be essentially in the AP
plane. The amount of tilt needed to obtain perfect inlet and outlet views is marked on the fluoroscope arm by the
technician, and the machine’s wheel positions on the floor are also marked to facilitate subsequent rapid
imaging. Minor rotational changes of the fluoroscope identify the tangential posterior-pelvic disruptions and may
be useful in certain sacral fractures. To assure consistent imaging, the C-arm and operating table heights are
also marked for consistency during the operation.
An “almost true” lateral sacral view is next obtained by adjusting the fluoroscope to superimpose the greater
sciatic notches. On the almost-true lateral sacral image, the ICDs are identified and correlated with the
preoperative CT scan once again so the surgeon understands where the anterior sacral ala are located. The
ICDs mark the alar locations according to the preoperative CT scan information. The safe sacral segment for
screw insertion is reconfirmed. Significant hemipelvis deformity causes this almost-true lateral sacral view to be
of little use. A “true” lateral sacral image is possible only after accurate posterior-pelvic fracture reduction or in
patients with minimal posterior-pelvic deformities.
Lumbosacral osteophytes among other upper-sacral osseus variants are confusing and complicate orthogonal
imaging, especially the inlet view of the pelvis. These osteophytes are best seen on the true-lateral sacral image.
The true lateral is also used to identify transverse sacral fractures and their displacements.
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Skin Preparation and Draping
The perineum is cleansed and isolated from the planned surgical field. The perineum in patients with pelvic-ring
injuries is typically contaminated and may have been soiled with feces while awaiting surgery. The perineum
requires thorough cleansing in order to achieve a sterile local surgical environment. The pubic and perineal hair
are shaved, and the skin is then scrubbed with isopropyl alcohol. The planned surgical field usually includes the
entire abdomen and bilateral flanks, and these skin areas are then prepared with iodine solution followed by
isopropyl alcohol. The scrotum, penis, and any urinary catheter are included in the operative field only when
combined urologic procedures are planned. Wide preparation of the posterolateral buttock skin is important and
facilitated by the lumbosacral elevation bump. Such access simplifies iliosacral screw insertion. Femoral vascular
catheters, enteral feeding tubes, suprapubic urinary catheters, and other essential anterior-abdominal lines are
prepared as skin. Ostomy sites are excluded from the surgical field. Chest tubes are positioned and isolated from
the planned operative field. The lower extremities can also be included in the sterile field if needed. For example,
if an anterior iliac surgical exposure is chosen for open reduction of the SI joint, the ipsilateral lower extremity is
included in the surgical field so that hip flexion (to relax the iliopsoas muscle for retraction) and other needed limb
manipulation can be easily performed during the exposure and reduction. The upper extremities are abducted at
the shoulders when possible to allow C-arm unit positioning. Upper extremity injuries may require splinting and
appropriate positioning to protect the injury while allowing necessary imaging.

Reduction
To facilitate safe screw insertion, promote osseus union, and diminish late pain and deformity, accurate
reduction and stable fixation of the posterior pelvic ring is the goal of surgery. Reduction of pelvic-ring fractures
can be accomplished using a variety of techniques. Anatomic reduction and stable fixation of the anterior pelvic
injury “indirectly” improve the posterior pelvic displacement, especially when supplementary manipulation
techniques are used. Reduction forceps are used temporarily to stabilize open reductions, whereas other
techniques are used to maintain closed manipulated reductions. Early surgical treatment improves the accuracy
of closed, manipulated, posterior-pelvic reductions. An anterior external-fixation device [or a femoral distractor-
pelvic compressor (Synthes, Paoli, PA) attached to the iliac fixator pins] can be used as a “pelvic compressor or
distractor” to produce and refine the closed reduction.
Distal femoral traction alone often improves posterior and cephalad deformities of the posterior pelvic ring. The
fluoroscopic inlet and outlet images of the pelvis confirm the reduction before iliosacral screw fixation. In some
situations such as pure sacral or SI joint distraction injury, a perfectly placed iliosacral lag screw is used to
reduce the posterior pelvic disruption. While iliosacral lag screws can be used to reduce certain distracted sacral
fractures, the procedure puts nerve roots at risk for injury (Fig. 39.10).
Open reductions are performed when closed-manipulation techniques fail to provide an accurate posterior-pelvic
reduction. Even after open reduction of the posterior pelvis, percutaneous iliosacral screws are used to provide
stability whenever possible (Fig. 39.11).
Fixation
After the reduction is accomplished, a smooth 0.62-mm Kirschner (K) wire is inserted under fluoroscopic control
from the lateral buttock onto the lateral ilium. This small-diameter smooth wire resists bending during insertion,
which allows accurate aiming yet causes minimal trauma to the local soft tissues, especially when several
attempts are needed to accurately locate the wire staring point and directional aim. In obese patients, the lateral
iliac starting point determination can be quite difficult. A predictable starting point on the skin is located in a
posterior cephalad quadrant that is formed by intersecting lines. One line parallels the femoral shaft, whereas the
perpendicular intersecting line is made from the palpable anterior-superior iliac spine (ASIS) toward the operating
table. The posterior-superior quadrant marks the sacrum.

FIGURE 39.10 When the sacral fracture is displaced through the nerve-root tunnels, the lower lumbar and sacral
nerve roots can be injured by the traumatic event, the reduction maneuver, and iliosacral lag screw fixation. The
iliosacral lag screw can injure the local nerve roots by incorrect positioning and overcompression. This axial CT
image demonstrates the first-sacral nerve-root displacement adjacent to the fracture.

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FIGURE 39.11 Open reductions for displaced sacral fractures are performed using a dorsal surgical exposure
when closed-reduction maneuvers fail and when sacral bone fracture fragments are to be removed from the
sacral nerve roots prior to reduction. The reduction clamps are applied dorsally from the intact sacrum to the
displaced fragment either at the posterior iliac spine or lateral sacral bone. Reduction clamp tine placement on
the anterior sacrum risks iatrogenic nerve-root and vascular injury.

According to the preoperative plan, the inlet and outlet images of the pelvis are used to direct the orientation of
the K-wire. Perfect wire direction and starting point may require several skin punctures with the smooth wire in
order to identify the exact skin insertion site that allows the optimal lateral iliac cortical starting point and
necessary osseus pathway direction. The perfect iliac bone starting point and wire direction are maintained by
either gently tapping or partially inserting the sharp wire several millimeters to engage the lateral iliac cortical
bone sufficiently. The skin is then incised around the wire, and the skin incision is made anticipating future screw
insertions. If the initial screw is to be located in the caudal anterior quadrant of the sacral osseus pathway, and a
subsequent screw is planned to be located cranial and posterior to the initial screw, then the incision should be
made accordingly. Next, a long drill guide is placed over the wire, and a 2-mm terminally threaded guide pin is
exchanged for the wire. The drill guide provides deep control of the guide pin and protects the deep soft tissues
from injury. The guide pin is inserted with a power drill into the lateral iliac cortex, and its direction is confirmed
through fluoroscopy. Because the guide pin is only slightly engaged in bone at this point, the surgeon can still
use the drill guide to make minor directional pin corrections. Frequent inlet and outlet images of the pelvis are
used as the pin is inserted from the ilium, across the SI articulation, and into the lateral aspect of the sacral ala.
The guide pin is halted within the ala when its tip is located just cephalad to the upper-sacral corticated tunnel
edge as seen on the outlet image. When carefully evaluated, the outlet image will identify the corticated edges of
the osseous tunnel of the upper-sacral nerve root that is immediately superior and medial relative to the ventral
foramen. Once identified, the nerve-root path is better understood. The surgeon must know that the nerve root
passes from posterior to anterior, midline to peripheral, and superior to inferior (Fig. 39.12).
As the guide pin reaches this site, the surgeon obtains a true lateral sacral image by fluoroscopically
superimposing the greater sciatic notches and ICDs of each reduced hemipelvis. If the posterior pelvic reduction
is accurate and no sacral dysmorphism had been identified in the preoperative plan, then the true lateral sacral
image identifies the guide pin tip and its relation with the ICD. The preoperative CT scan reflects the relation
between the ICD and the sacral ala. The correlation of this information, coupled with the intraoperative ICD,
indicates whether the pin tip is safely placed. The tip of the guide pin should be posterior to the anterior cortical
bone, caudal to the ICD that indicates the alar limit, and cephalad to the intraosseous path of the upper-sacral
nerve root, which is also visible on the true-lateral sacral image of some patients. The true lateral image should
show that the guide-pin tip is located within the midportion of the alar bone (Fig. 39.13).
The guide pin is then advanced into the upper-sacral vertebral body to (but not beyond) the midline. The guide-
pin depth is measured with the reverse ruler, and a cannulated drill is advanced over the guide pin. A cannulated
tap is used to prepare the pathway when necessary. A 7.0-mm cannulated cancellous screw of appropriate
length is inserted over the guide pin and tightened. For SI-joint disruptions, partially threaded cancellous screws
with 32-mm thread lengths are chosen when compression fixation is necessary. If the SI joint is distracted and
the lag screw is intended to compress the gap, then the screw length adjustment must be made to accommodate
the compression. Fully threaded 7.0-mm cancellous screws are used when compression fixation is not desired,
such as after accurate reductions of transforaminal sacral fractures. Fully threaded screws also are used when
needed to supplement previously applied compression-screw fixations.
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FIGURE 39.12 A. The intraoperative inlet image is obtained by superimposing the upper-sacral vertebral bodies
anterior cortical surfaces. The upper-sacral vertebral osseus varieties complicate reliable and consistent inlet
imaging. The surgeon must be aware that as a result of the sacral vertebral osseus variety, the inlet view is the
least reliable of the three routine images. In this situation, the narrow diameter guide pin was used to identify the
starting point and directional aim, and then the cannulated drill was inserted over the wire to prepare the screw
pathway. The drill appears to be located quite anteriorly within the sacral ala on the inlet image. B. The ideal
intraoperative pelvic outlet image is obtained when the cranial aspect of the symphysis pubis is superimposed on
the second sacral segment. This allows the ventral upper-sacral nerve tunnel exit points (foramen) to be best
seen. The outlet image is rarely orthogonal to the inlet image because the patient’s thigh girth usually obstructs
sufficient C-arm tilt. For this same patient, the outlet image demonstrates that the drill is located caudally within
the ala yet just cranial to the foramen. The drill is halted when located cranial and lateral to the first sacral
foramen. C. The true lateral sacral intraoperative image is then obtained by superimposing the reduced posterior
pelvis, ICDs, and greater sciatic notches. The drill tip is noted to be more posteriorly located than suggested by
the inlet image relative to the sacral vertebral ala and body anterior cortical limit. The drill is also noted to be
located caudally relative to the ICD and therefore the sacral ala and fifth lumbar nerve root and cranially
anteriorly relative to the first-sacral nerve-root tunnel. These three images confirm the safety of the drill location
and aim.
During cannulated drilling, tapping, and screw insertion, the surgeon obtains frequent fluoroscopic images to
assure no binding and inadvertent advancement of the guide pin. A 20- to 30-degree obturator oblique (rollover)
image is used to visualize the tangential posterior ilium as the screw is tightened. This amount of obliquity
needed to tangentially image the posterior lateral iliac cortical bone insertion site can also be planned using the
preoperative pelvic CT scan. With this image, the washer is noted to flatten as it contacts the ilium. As the screw
and washer are tightened and approach the lateral iliac cortical surface, the surgeon can
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also use a blunt-ended guide pin to palpate the washer gently and thereby assess the washer’s relationship to
the lateral iliac cortical surface. The surgeon can feel the washer’s movement around the screw neck until the
washer is applied finally onto the lateral iliac cortical bone surface. Using a washer, palpation of the washer with
the blunt-ended guide pin, and the appropriate rollover image, the surgeon can easily and predictably avoid
inadvertent screw-washer penetration into the posterior ilium. The surgeon should never overtighten the screw
and penetrate the lateral iliac cortex. This complication can occur in older patients with thin iliac-cortical bone
and in young patients when the screw is forcefully tightened. Intruded screws and washers have compromised
function.

FIGURE 39.13 The true lateral sacral image reveals the ICDs and therefore the sacral ala, the anterior sacral
cortical vertebral limit, the spinal canal, and the sacral nerve-root tunnel. In this example, the second sacral
osseus pathway is also demonstrated.

Next, the guide pin is removed manually. The fixation construct is stressed under fluoroscopic imaging. Additional
screws or supplementary fixation are used if residual instability is noted on the fluoroscopic stress examination.
The percutaneous wound is irrigated, and the skin is closed.
Transiliac, transsacral (TITS) iliosacral screws became possible recently when manufacturers produced screws
longer than 130 mm. These can be inserted in appropriate OFP. The upper OFPs are commonly horizontal in
nondysmorphic upper sacra. The obliquely angulated upper sacral OFP in a dysmorphic sacrum is not amenable
anatomically for TITS screws. The second segment’s OFP in a dysmorphic sacrum usually allows TITS screw
insertions. Using the preoperative pelvic CT scan, the TITS screw lengths and pathways can be planned. For
most adults, the TITS screw lengths range from 150 to 180 mm (Fig. 39.14).

Pitfalls and Tricks

Just like the operative nursing and anesthetic team members, a skilled and experienced radiology technician in
the operating room is an invaluable colleague. The technician must work diligently to provide reproducible pelvic
imaging. Positioning the fluoroscopic unit in the marked position for each view saves operative time and radiation
exposure. The technician should be informed and educated regarding the plan preoperatively and must provide
consistent quality images in order to make the procedure efficient and safe. Suboptimal imaging precludes safe
placement of percutaneous iliosacral screws. But like navigation systems and neurodiagnostic monitoring, the
radiology technician is not a substitute or surrogate for the surgeon’s knowledge of pelvic anatomy. The surgeon
must direct the technician early in the operation so that the desired quality images and C-arm positions needed
to obtain them are well understood and then can be delivered consistently. The surgeon must be patient with
and help to educate less-experienced technicians.

FIGURE 39.14 TITS iliosacral screws are placed when the additional screw length is necessary for stable
fixation. The screw starting point and directional aim must be perfect for these screws since they pass through
both alar areas.

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Table 39.1 The Differences Between Iliosacral Screws Used For Sacroiliac Joint Dislocations
And Sacral Fractures

Injury Screw Type Starting Point Direction Common SI

Length (mm) Cartilage

Sacroiliac

Lag or fully Caudal and Oblique 70-90 Spared

threaded posterior

Sacral

Fully threaded; Anterior and Horizontal 90-180 Violated

rarely lag cephalad

SI screws are usually obliquely oriented in order to be perpendicular to the articular joint surfaces while
sacral screws are more horizontally directed to both be perpendicular to the fracture surfaces but also to
increase the screw length for balance. Lag screws are used for SI joint compression while fully threaded
screws avoid overcompression of sacral fractures, particularly those involving the nerve-root pathways.
SI screw lengths for most adults if oriented perpendicular to the joint surfaces range from 70 to 90 mm in
 length. Sacral fracture screws should be longer because the pathology is more medial than for an SI
joint injury and to achieve a balanced implant. SI screws because of their oblique path usually avoid the
SI articular surfaces, whereas sacral screws typically pass through the SI joint surfaces because of their
orientation.

The initial iliosacral screw is positioned strategically to allow insertion of an additional ipsilateral screw or a
screw from the contralateral side if needed. The number of iliosacral screws necessary to sufficiently stabilize
each posterior-pelvic disruption depends on the degree of local instability as well as the quality of supplementary
fixation of the associated pelvic-ring injuries.
Screw orientation and type are very important. The “SI-joint” screw is different from the “sacral” screw in several
ways (Table 39.1). Compression lag screws are routinely used to treat SI-joint disruptions, but fully threaded
screws can be used if a perfect reduction has been achieved and no further compression is needed. Sacral
fractures may involve the sacral neuroforamina or alar area of the fifth lumbar nerve root; therefore, excessive
compression with a lag screw may produce nerve-root injury. For a transforaminal sacral fracture, either a very
carefully compressed lag screw or fully threaded noncompression cancellous screw is required.
Screws used to treat sacral fractures are usually longer than those used for SI joints because the sacral fracture
is more medially located. To obtain optimal stability through improved medial fixation, the sacral screw must be
oriented more horizontally and tends to cross the chondral SI surfaces. This “sacral style” screw is similar in
starting point and direction as those for TITS screws.
To increase the screw length, the screw orientation is slightly different for sacral screws than it is for SI-joint
screws. SI joint screws use a starting point that is more caudad and posterior on the ilium and are directed
cephalad and anterior to be perpendicular to the oblique SI articulation. Because of its direction, this “SI style”
screw usually avoids violation of the articular, SI-joint, cartilaginous surfaces.
The pathway of the fifth lumbar and first sacral nerve roots must be understood and respected. The nerves exit
the spinal canal and are directed anteriorly, laterally, and caudally. Because of this nerve orientation, the “safe”
zone for screw insertion becomes the elliptical area within the ala below the fifth lumbar nerve-root pathway on
the midalar cortical bone and above the first sacral nerve-root tunnel. A pelvic model and preoperative drawing
outlining the surgical tactic are helpful. A pelvic model also reveals the smaller area available for safe screw
placement in the second sacral segment.

POSTOPERATIVE MANAGEMENT
Intravenous antibiotics are administered for 24 hours after surgery. Sequential compression devices and
medications are used when possible attempting to diminish the risk of deep venous thromboses. Vena caval
filters are considered when routine anticoagulation is not possible or the patient has a history of venous
thrombosis or embolism. At our institution, a licensed physical therapist supervises the rehabilitation. The
rehabilitation schedule is dependent on the overall condition of the patient and associated injuries. The stabilized
hemipelvis is protected by partial weight bearing that the patient accomplishes with crutches or a walker for 6
weeks after the surgery. Progressive weight bearing follows, with a goal of crutch-free ambulation 3 months after
surgery. Inlet and outlet radiographs of the pelvis are obtained postoperatively and at the 6- and 12-week
postoperative clinic visits. A postoperative CT scan is used to assess the reduction and implant location. Patients
are seen in the clinic at 2, 6, and 12 weeks after the operation. Thereafter, patients are seen if needed.
Most adult patients can return to labor employment 4 to 6 months after surgery. Some patients with less
physically demanding jobs return much sooner, and others require job modifications. Heavy lifting and working
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at heights are avoided until the patient’s strength and conditioning goals are achieved. Vocational reeducation is
advocated for polytraumatized individuals with heavy job demands or those patients who are unable to return to
work. Nonimpact aerobic and water activities are allowed 6 weeks after the operation.

COMPLICATIONS
Iliosacral screw complications include screw malposition, iatrogenic nerve injury, fixation failure, and
infection. Screw malposition results from a poor understanding of the posterior pelvic anatomy or
fluoroscopic imaging or both, or posterior pelvic malreduction. Iatrogenic nerve-root injuries occur because
of erroneous reduction maneuvers, especially overcompression of transforaminal sacral fractures and
screw-placement errors. The sacral alar slope, inadequate imaging, sacral dysmorphism, a surgeon’s poor
understanding of the posterior pelvis, and posterior pelvic malreduction (among other factors) cause screw
misplacements. Surgeon knowledge of simple anatomical, imaging, and technical facts can dramatically
decrease the risk of screw malposition:
1. The upper-sacral alar area is an elliptically shaped passageway bounded above by the sloping sacral ala
and below by the upper-sacral nerve-root tunnel.
2. The boundaries of the upper-sacral alar area are identifiable radiographically after reduction. The outlet
images demonstrate the spica cast orientation of the upper-sacral nerve-root pathway, and the true-
lateral sacral image shows the superimposed ICDs, which reflect the alar orientation, and as a
consequence, the fifth lumbar nerve-root path is also revealed. The true lateral image is also frequently
used to visualize the corticated limit of the upper-sacral nerve-root path.
3. The iliac starting point, directional aim, and selected screw length all impact the safety of screw
placement.
4. Dysmorphic upper-sacral anatomy has predictable radiographic identifiers, and the surgeon should
recognize the narrowed safe zone available for screw insertion.
5. Obliquely oriented SI-joint screws must not extend beyond the midline because of the contralateral alar
anatomy.
6. On the inlet image, lumbosacral osteophytes accentuate the anterior sacrum, but they do not represent
the sacral body.
7. Neurodiagnostic monitoring and navigation systems do not offset insufficient knowledge of sacral
anatomy and its imaging. Iatrogenic nerve-root injuries occur because of screw placement errors and
erroneous reduction maneuvers, especially overcompression of transforaminal sacral fractures.
Fixation failures occur in patients with highly unstable posterior-pelvic injuries and/or insufficient stabilization
constructs, who are noncompliant or have suffered head injuries or have an associated infection. Increased
rates of fixation failure have been described in those patients treated with iliosacral screws alone or anterior
external fixation (Fig. 39.15). Initial malreduction of the posterior pelvic injury also increases the risk of
fixation failure. Iliosacral screw infections are exceedingly rare after manipulative reduction and
percutaneous insertion. Standard infection rates apply to open reduction via anterior SI exposures while
dorsal open pelvic surgical exposures have been associated with increased wound complications.
Treatment choices for fixation failure depend on numerous factors. In early failures, the unstable iliosacral
screws are either removed and replaced with alternative fixation constructs or supplemented by similar
according to their failure pattern. The treatment of late failures is based on the amount of posterior pelvis
displacement and healing. In rare situations, the overall condition of the patient or posterior pelvic soft-
tissue envelope prohibits further attempts at surgical fixation, and traditional management techniques, such
as traction, are chosen.
 FIGURE 39.15 Early postoperative iliosacral screw-bending failure is seen on this image. Supplemental
internal fixation was applied to improve stability and allow routine healing.

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OUTCOMES
Clinical outcomes are determined by a complex formula that includes factors such as the mechanism of the
injury, associated injuries, the patient’s preinjury condition and body habitus, quality of the reduction,
stability of fixation, timing of fixation, among others. The orthopedic surgeon can control some of these
factors. This may be as simple as enlisting an experienced colleague’s help or transferring the patient early
to an experienced management team/facility. Haphazard anterior pelvic external fixation devices or wayward
percutaneous fixation attempts that may or may not be indicated and applied using poorly planned surgical
wounds can adversely impact more effective treatments. Optimal results correlate with appropriate surgical
decision making, a good quality surgical plan, strategic surgical exposures, excellent reductions, and stable
fixations.
Some factors that impact clinical results are not within the orthopedic surgeon’s control. Traumatic
lumbosacral plexopathy, genitourinary system injuries, craniocerebral trauma, and severe lower extremity
injuries have all been shown to negatively affect outcomes in patients with pelvic-ring injuries. These
injuries are not a contraindication for appropriate surgical management of pelvic-ring injury. For example, a
patient with a traumatic urethral disruption should not be denied operative management of their pelvic-ring
injury because the urology consultants anticipate a poor outcome. A well-aligned and stable pelvic ring
facilitates future urethral reconstruction. The same holds true for lumbosacral nerve injuries in association
with posterior pelvic fractures and dislocations. Excellent sacral reduction with reconstitution of the sacral
nerve-root (foramenal) osseus pathways, including the removal of bone debris from these pathways, allows
the injured nerve roots an ideal recovery chance. High-quality outcomes are linked to accurate reductions
and stable fixations performed early after injury and without related surgical complications. The surgeon
must be available, knowledgeable, appropriately aggressive, and technically proficient.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 74-year-old active female fell down four steps at her home. She noted immediate anterior and posterior pelvic
pain. Her husband helped her to their car and transported her for evaluation at a local emergency facility. She
was discharged to home but had significant pelvic pain and was unable to walk without assistance from her
family members. She presented to our clinic 2 weeks after injury complaining of continued pelvic pain and
inability to ambulate. On physical examination, her vitals signs were stable, and her pelvis was grossly unstable
and painful to simple manual compression. She had diminished perineal sensation, but no other neurological
abnormalities. Her past medical and surgical histories were significant only for a long standing and functioning
left-sided colostomy. Her AP plain pelvic radiograph revealed osteopenia, a displaced right-sided parasymphy-
seal pubic ramus fracture, a minimally displaced right-sided sacral fracture, and a “paradoxical inlet” appearance
of the upper sacrum (Fig. 39.16).
The pelvic CT scan confirmed the prior findings and also demonstrated bilateral sacral fractures with
displacement causing decreased patency of the first sacral nerve-root pathways bilaterally (Fig. 39.17).
The sagittal pelvic reconstruction images identified the transverse sacral fracture and its displacement pattern
(Fig. 39.18). Her pelvic fractures were treated operatively with manipulative reduction and percutaneous fixation.
She was positioned supine, and the anterior pelvic deformity was reduced manually with distraction applied
between the iliac crests. The transverse sacral fracture anterior translational displacement was improved due to
supine positioning on the routine lumbosacral support. The sacral fractures were stabilized using TITS iliosacral
screws in the upper-sacral segment while the ramus fracture was secured with a medullary ramus screw (Fig.
39.19).

FIGURE 39.16 A 74-year-old active female’s AP plain pelvic radiograph revealing osteopenia, a displaced right-
sided parasymphy-seal pubic ramus fracture, a minimally displaced right-sided sacral fracture, and a
“paradoxical inlet” appearance of the upper sacrum.
FIGURE 39.17 Pelvic CT scan confirmed the prior findings and also demonstrated bilateral sacral fractures with
displacement causing decreased patency of the first-sacral nerve-root pathways bilaterally.

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FIGURE 39.18 The sagittal pelvic reconstruction images identified the transverse sacral fracture and its
displacement pattern.
FIGURE 39.19 The sacral fractures were stabilized using TITS iliosacral screws in the upper-sacral segment
while the ramus fracture was secured with a medullary ramus screw.

The postoperative pelvic CT scan axial image demonstrated the reduction, accurate location of the iliosacral
screws, and improved patency of the first-sacral nerve-root tunnels (Fig. 39.20). The sagittal reconstruction CT
image after surgery shows the sacral reduction and screw location (Fig. 39.21). After surgery, her pelvic pain
was relieved, and her perineal sensory abnormalities resolved gradually within 1 week after surgery. She used a
walker to decrease her right lower extremity load bearing for the initial 6 weeks after surgery and then added
progressive weight bearing over the subsequent 6 weeks. Her clinical course and fracture union were
uneventful, and she returned to her prior functional level.

FIGURE 39.20 The postoperative pelvic CT scan axial image demonstrated the reduction, accurate location of
the iliosacral screws, and improved patency of the first sacral nerve-root tunnels.
FIGURE 39.21 The sagittal reconstruction CT image after surgery shows the sacral reduction and screw
location.

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Clin Orthop 2004;422:201-207.

Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and
treatment protocols. J Trauma 1990;30:848-856.

Collinge C, Coons D, Tornetta P, et al. Standard multiplanar fluoroscopy versus a fluoroscopically based
navigation system for the percutaneous insertion of iliosacral screws: a cadaver model. J Orthop Trauma
2005;19:254-258.

Conflitti JM, Graves ML, and Routt Jr MLC. Radiographic quantification and analysis of dysmorphic upper
sacral osseous anatomy and associated iliosacral screw insertions. J Orthop Trauma 2010;24:630-636.

Farrell ED, Gardner MJ, Krieg JC, et al. The upper sacral nerve root tunnel: an anatomic and clinical study. J
Orthop Trauma 2009;23:333-339.

Gardner MJ, Farrell ED, Nork SE, et al. Percutaneous placement of iliosacral screws without
electrodiagnostic monitoring. J Trauma 2009;66:1411-1415.

Gardner MJ, Morshed S, Nork SE, et al. Quantification of the upper and second sacral segment safe zones
in normal and dysmorphic sacra. J Orthop Trauma 2010;24:622-629.

Gardner MJ, Routt Jr ML. The antishock iliosacral screw. J Orthop Trauma 2010;24:86-89.
Gardner MJ, Routt Jr ML. Trans-iliac, trans-sacral screws for posterior pelvic stabilization. J Orthop Trauma
2011;25: 378-384.

Goldstein A, Phillips T, Sclafani S. Early open reduction and internal fixation of the disrupted pelvic ring. J
Trauma 1986;26:325-333.

Griffin DR, Starr AJ, Reinert CM, et al. Vertically unstable pelvic fractures fixed with percutaneous iliosacral
screws: does posterior injury pattern predict fixation failure? J Orthop Trauma 2003;17:399-405.

Gruen GS, Leit ME, Gruen RJ, et al. The acute management of hemodynamically unstable multiple trauma
patients with pelvic ring fractures. J Trauma 1994;36:706-713.

Helfet DL, Koval KJ, Hissa EA, et al. Intraoperative somatosensory evoked potential monitoring during acute
pelvic fracture surgery. J Orthop Trauma 1995;9:28-34.

Kraemer W, Hearn T, Tile M, et al. The effect of thread length and location on extraction strengths of
iliosacral lag screws. Injury 1994;25:5-9.

Latenser B, Gentilello L, Tarver A. Improved outcome with early fixation of skeletally unstable pelvic
fractures. J Trauma 1991;31:28-31.

Matta J, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop 1989;242:83-87.

Oliver CW, Twaddle B, Agel J, et al. Outcome after pelvic ring fractures: evaluation using the medical
outcomes short form SF-36. Injury 1996;27:635-641.

Reilly MC, Bono CM, Litkouhi B, et al. The effect of sacral fracture malreduction on the safe placement of
iliosacral screws. J Orthop Trauma 2003;17:88-94.

Routt M, Simonian P, Inaba J, et al. Iliosacral screw fixation of the disrupted sacroiliac joint. Tech Orthop
1994;9:300-314.

Routt MLC Jr, Kregor PJ, Simonian PT, et al. Early results of percutaneous iliosacral screws placed with the
patient in the supine position. J Orthop Trauma 1995;9:207-214.

Routt MLC Jr, Meier M, Kregor P. Percutaneous iliosacral screws with the patient supine-technique. Tech
Orthop 1993;3: 35-45.

Routt MLC Jr, Simonian PT, Agnew S, et al. Radiographic recognition of the sacral alar slope facilitates
optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma 1996;10:171-177.

Routt MLC Jr, Simonian PT, Ballmer F. A rational approach to pelvic trauma: resuscitation and early
definitive stabilization. Clin Orthop 1995;318:61-74.
Schildhauer TA, Ledoux WR, Chapman JR, et al. Triangular osteosynthesis and iliosacral screw fixation for
unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma
2003;17:22-31.

Shuler T, Boone D, Gruen G, et al. Percutaneous iliosacral screw fixation: early treatment for unstable
posterior pelvic ring disruptions. J Trauma 1995;38:453-458.

Simonian PT, Routt MLC Jr, Harrington RM, et al. Anterior versus posterior provisional fixation in the
unstable pelvis: a biomechanical comparison. Clin Orthop 1995;310:245-251.

Simonian PT, Routt MLC Jr, Harrington RM, et al. Internal fixation for the transforaminal sacral fracture. Clin
Orthop 1996;323:202-209.

Yinger K, Scalise J, Olson SA, et al. Biomechanical comparison of posterior pelvic ring fixation. J Orthop
Trauma 2003;17:481-487.
 40
Sacral Fractures
Jodi Siegel
Paul Tornetta III

INTRODUCTION
Sacral fractures most commonly occur in association with a pelvic-ring disruption that can occur from high- and
low-energy trauma. Most sacral fractures are stable injuries and are treated nonoperatively. Unstable sacral
fractures are less common but are more challenging to treat. A small subset of these patients present with
hemodynamic instability, often with other injuries, requiring a multidisciplinary approach.
The classification of sacral fractures should start with use of one of the widely accepted classification schemes
of pelvic-ring disruption. The AO/OTA, Tile, and Young and Burgess classifications of pelvic fractures attempt to
describe the mechanism of injury and/or resulting instability. Sacral fractures have been sub-classified by Denis
into three zones, which describe the location of the fracture in relation to the adjacent sacral foramina (Fig. 40.1).
Denis Zone 3 sagittal plane injuries have been further characterized by Roy-Camille as modified by Strange-
Vognsen (1), and Isler added a classification that describes injuries to the facets at the lumbosacral junction.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY

The majority of sacral fractures are inherently stable injuries and are managed nonoperatively. Impacted sacral
fractures, often seen as a component of a lateral compression type 1 pelvic-ring disruption, with <20 degrees of
internal rotation deformity, are stable injuries and can be treated nonoperatively with immediate weight bearing
(2). Complete, nondisplaced, nonimpacted sacral fractures may also be treated nonoperatively; however, limited
weight bearing with close follow-up must be employed to ensure early detection of any displacement. Patients
are mobilized as soon as their overall condition allows. Pain levels are variable, and adequate pain medications
are provided. The increasing numbers of insufficiency fractures seen in elderly osteopenic patients after minimal
trauma are typically this fracture pattern and treated nonoperatively. A recent randomized controlled trail
evaluating parathyroid hormone use in this population revealed accelerated fracture healing and improved pain
scores and functional outcomes (3).
Most displaced sacral fractures that occur following higher-energy trauma are indicated for surgery. Typically,
these fractures have associated injuries to the anterior pelvis, which may require treatment. Posterior pelvic-ring
instability is present when there is vertical displacement of the hemipelvis, fracture displacement >1 cm, highly
comminuted fracture patterns, and injuries extending into the lumbosacral articulation. Additionally, some patients
with sacral fractures with disruption or displacement of the sacral foramina and neurologic dysfunction are
candidates for surgery.
The determination of pelvic stability in patients with comminuted fractures without significant displacement is
difficult. In these patients, two options have been recommended. One method is to perform a stress examination
under anesthesia in the operating room using a push-pull technique under fluoroscopy to determine the
presence or absence of instability. If substantial fracture displacement is demonstrated, surgery is typically
indicated. The other method to determine stability is to mobilize the patient and obtain follow-up radiographs to
assess fracture displacement (4).
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FIGURE 40.1 Denis 3-zone sacral fracture classification. Zone 1 fractures are transalar fractures lateral to the
foramen. Zone 2 fractures are transforaminal. Zone 3 fractures are central fractures, in the region between the
foramina.

PREOPERATIVE PLANNING
History and Physical Examination
Most unstable sacral fractures are the result of high-energy trauma such as motor vehicle and motorcycle
crashes, falls from height, and pedestrian-motor vehicle accidents. Many patients are critically ill with associated
injuries to the head, chest, and abdomen. A multidisciplinary approach using Advanced Trauma Life Support
protocols is recommended.
A careful and detailed physical examination should be performed. The pelvis and lower extremities should be
observed for asymmetry or deformity. The skin and soft tissues should be inspected for abrasions, contusions, or
open wounds. A closed internal degloving soft-tissue injury around the pelvis, the so-called Morel-Lavallee
lesion, must be identified and treated as it is associated with a 46% rate of bacterial colonization (5). Associated
long-bone fractures are common but ligamentous knee injuries and subtle injuries to the ankle and foot are often
overlooked.
A detailed neurovascular examination of both lower extremities—documenting the peripheral pulses as well as
motor and sensory function—is essential. Patients with displaced fractures and all patients with neurologic
injuries require a rectal examination. Similarly, some female patients with displaced pelvic fractures should have
a gynecologic evaluation.

Imaging Studies
Radiographic evaluation includes pelvic anteroposterior (AP), inlet, and outlet views, as well as obturator and
iliac oblique views (Judet). In virtually all patients with a displaced pelvic fracture, a computed tomography (CT)
scan should be obtained. Modern imaging techniques allow axial and reformatted sagittal and coronal views.
Correctly interpreted, these images provide a better understanding of the fracture, its deformity, soft-tissue injury,
and possible treatment strategies. Additionally, sacral dysmorphism may be identified on these films, which may
impact treatment. Finally, high-quality imaging can identify occult spina bifida, especially in the lower sacral
segments, which may be very important when surgery is indicated. Inadvertent clamp placement for reduction
can result in an iatrogenic nerve injury.
In physiologically stable patients who do not require ongoing resuscitation, no additional pelvic imaging studies
are required. In hemodynamically unstable patients with continued bleeding, a clinical decision must be made
regarding management. After other sources of bleeding have been excluded, two treatment methods exist for
attempts to control pelvic bleeding: external stabilization combined with an exploratory laparotomy and pelvic
packing or invasive angiography with potential therapeutic embolization. The optimal method of treatment
remains controversial, but clinical judgment, knowledge of the institution’s resources, and understanding
common injury patterns based on the pelvic imaging aid in appropriate decision making. Patients who respond to
initial resuscitation, but slowly deteriorate, may benefit from CT angiography to assist with diagnosis and location
of potential pelvic bleeding.
In hemodynamically unstable patients with an external rotation component to the deformity and increased pelvic
volume, a sheet or pelvic binder wrapped around the pelvis at the level of the greater trochanters is part of the
resuscitation. In patients going to the operating room for treatment of other injuries, the placement of a C-clamp
or external fixator may be beneficial. Prior to application of an external fixator, the surgeon must
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have a clear understanding of the injury and the deforming forces. Single-plane external rotation deformity can
be reduced and stabilized with a pelvic C-clamp or a supra-acetabular (Hannover-pin) external fixator. Vertical
displacement requires traction to reduce and stabilize the injury prior to placement of an external fixator (6).
Once the patient is stable, the genitourinary system must be thoroughly evaluated. Because of the intimate
location of the bladder to the pelvic ring, there is a relatively high incidence of bladder injuries. A urinalysis as
well as a retrograde urethrogram and cystogram should be obtained in most male patients.

SURGERY
Preoperative Planning
The steps necessary for reduction of most displaced unstable sacral fractures begin prior to the patient’s arrival
to the operating room. A careful analysis of the preoperative radiographs and CT scan clarifies the pathologic
anatomy. Posterior translation and internal and external rotation deformities can be identified on the pelvic inlet
radiograph (Fig. 40.2A-C). Flexion of the hemipelvis is best seen on the pelvic outlet x-ray. When flexion occurs
through the sacral fracture, the anterior pelvic ring will be displaced cephalad. This may be assessed by the
heights of the ischial tuberosities. Importantly, this should be differentiated from vertical displacement of the
hemipelvis as the displacement of the anterior ring is greater than the displacement of the posterior ring. When
there is true vertical displacement of the hemipelvis, the amount of anterior and posterior displacement is
approximately the same. Aside from lateral translation of the sacrum, most other deformities are correctable
preoperatively with skeletal traction and should be confirmed with a portable AP pelvis radiograph in traction
(Fig. 40.3). Initially, 15% to 20% of body weight is applied to the extremity through a distal femoral skeletal
traction pin. The need for additional weight is determined by the traction radiographs. The reduction achieved
preoperatively can be expected in the operating room and allows the surgeon to plan for a percutaneous
procedure with the patient in the supine position or an open procedure with the patient prone.
FIGURE 40.2 Injury AP pelvis radiograph demonstrating a lateral compression pelvic-ring fracture (A). The
posterior translation of the left hemipelvis through the sacral fracture is seen in the inlet view (B), and the flexion
is seen on the outlet view (C).

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FIGURE 40.3 The displaced sacral fracture was reduced with application of distal femoral skeletal traction.

Surgical Tactic
The anterior pelvic-ring disruption must also be addressed. A symphyseal dislocation is treated by open
reduction and internal fixation through a Pfannenstiel approach first. If displaced pubic rami fractures are present
instead, then surgery will typically begin posteriorly. In patients with good bone stock where a closed reduction
adequately aligns the anterior pelvis, iliosacral screws alone may be the only fixation that is necessary. In
patients with osteopenic bone or inadequate fixation with iliosacral screws alone, supplemental anterior fixation is
usually indicated.
When the CT scan shows severe sacral comminution, some surgeons fear that iliosacral screws placed in
compression may cause a neurologic injury. Also, bony fragments in the spinal canal or neural foramina may
warrant an open procedure with nerve decompression. H-type or U-type sacral fractures may also benefit from
open reduction and neural decompression (7). The CT scan also allows for precise evaluation of the
lumbosacral junction. Injury to the L5/S1 facet joint may require stabilization with lumbopelvic fixation. In these
circumstances, the patient should be positioned prone for open reduction and internal fixation of the sacrum with
screws or plates.

Surgery and Surgical Approaches

The authors prefer general anesthesia with chemical paralysis. Spinal or regional anesthetic techniques are not
commonly used. A Foley catheter is placed if a urologic injury is not present. Arterial lines, central venous
pressure monitoring, and Swan Ganz catheters are determined on a case-by-case basis.
A first-generation cephalosporin antibiotic is given intravenously within 1 hour of surgery. If the patient has been
in the ICU for a prolonged period of time, or has a positive screen for methicillin-resistant Staphylococcus
aureus, vancomycin is preferred.

Patient Positioning, Prep and Drape, Imaging

The reduction obtained with traction prior to surgery can usually be obtained intraoperatively. Adjustments can
be implemented under fluoroscopic control with a traction table and positioning tools.
The patient is positioned supine on a radiolucent flat-top table in traction through a distal femoral pin on the
affected side (Fig. 40.4A). The patient is positioned with the injured side close to the edge of the table to
facilitate drill, guidewire, and screw placement from slightly posterior to anterior. A bump is placed beneath the
ipsilateral lower thorax and flank to improve the trajectory for the screws placement in the supine patient. The hip
is slightly flexed, and the leg is supported with a sling. The uninjured side is attached to the table in a boot that
allows the leg to remain in full extension (Fig. 40.4B). Lifting the foot off the table allows the knee to go into slight
hyperextension, functioning as a countertraction post. The contralateral extremity must be rigid to allow for
adjustments to the reduction without displacing the patient when traction is applied. We routinely use bilateral
sequential compression devices during the procedure. A lateral padded positioner is secured to the table just
below the axilla on the injured side (Fig. 40.4C). This prevents the chest and torso from moving when traction is
applied. If this proximal lateral pad is not utilized, then traction on the affected side will not reduce the pelvis
distally but instead will rotate it around the intact, contralateral hip joint and pull the patient’s torso toward the
affected side of the table.
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FIGURE 40.4 The patient is positioned supine on a radiolucent operating table in skeletal traction on the
affected side (A). The uninjured side is placed in a boot with the knee in full extension to allow the extremity to
act as a stable post (B). A bump is placed under the ipsilateral upper buttock to allow for adequate hand
positioning during screw placement, and a pad is placed along the chest wall on the injured side to assist with
the closed reduction (C).

The C-arm is brought in from the noninjured side, opposite the surgeon. The monitor is placed at the foot of the
bed so that both the surgeon and the x-ray technologist can view the images. The C-arm is positioned over the
pelvis with its base perpendicular to the operating room table. The height of the table, the position of the C-arm
base, and the degree of the cephalad and caudad tilt needed for perfect inlet and outlet images are determined
and recorded prior to prepping and draping. Additionally, the surgeon should note if the pelvis is rotated to one
side by the position of the spinous processes of the lumbar spine as seen on fluoroscopy. This should be
corrected to an AP plane to ensure perfect intraoperative imaging, which is necessary to obtain perfect inlet and
outlet images to evaluate the reduction and to safely place screws.
Once perfect images are obtained, the reduction is evaluated. When necessary, additional traction is applied
using the fine adjustment function of the traction arm (Fig. 40.5A). A very precise reduction can usually be
obtained and visualized using this controlled traction setup (Fig. 40.5B). Since the acetabulum is an anterior
structure and the hip is flexed, when traction is applied to the femur, the injured hemipelvis will extend and
translate distally. The force from the traction will move the hemipelvis, but the remainder of the patient does not
move. The pad on the chest prevents the torso from translating laterally, toward the side of the traction; the
uninjured leg cannot translate distally as it is locked in an extended position and acts as a post to pull against
(Fig. 40.6A-D).
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FIGURE 40.5 The traction arm (A) will allow fine adjustments to the reduction (B). [This patient had a retrograde
nail placed for a femoral shaft fracture; therefore, in this situation, a proximal tibial skeletal traction pin was used.]
FIGURE 40.6 Closed reduction. With the contralateral extremity rigid, traction applied to the injured side will
cause the torso to translate (A,B). The pad along the chest wall will prevent the torso from moving and instead
allow the traction to reduce the pelvic deformity (C,D).

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FIGURE 40.6 (Continued)

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FIGURE 40.6 (Continued)

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FIGURE 40.6 (Continued)

Once the sacral fracture is reduced, the entire pelvis is prepped and draped; this will accommodate anterior
pelvic fixation as well, if necessary. The authors prefer to reduce and stabilize a symphysis diastasis prior to
sacral fixation. Most rami fractures do not require internal fixation before or after sacral fixation. In some patients,
supplemental external fixation, either above or below the skin, is added after sacral reduction and stabilization.

OPEN REDUCTION
If a satisfactory closed reduction cannot be obtained, the patient must be repositioned. This is uncommon as the
reduction is typically accomplished preoperatively with traction unless the fracture presents late. A radiolucent
flat-top table with traction is used. The patient is positioned prone (Fig. 40.7A). Chest rolls are used to allow for
adequate chest excursion, and specialized devices are used to support the head and endotracheal tube. The
bony prominences around the pelvis are left free. Pressure from the chest rolls on the anterior superior iliac
spine (ASIS) can contribute to unwanted posterior translation or impede fracture reduction. The upper extremities
are abducted to <90 degrees at the shoulders, and the elbows are flexed to 90 degrees. The injured extremity is
placed in traction. The hip is in neutral flexion, and the knee is flexed approximately 45 degrees to reduce
tension on the sciatic nerve and is held with a boot. Hyperextension of the lumbosacral junction may help reduce
a flexion deformity. The contralateral leg is positioned with the knee in slight flexion. Again, sequential
compression boots are applied. The C-arm is centered over the sacrum, and adequate imaging is confirmed prior
to skin preparation and draping. Excessive knee flexion impedes the C-arm from obtaining adequate inlet views
and must be corrected prior to draping.
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FIGURE 40.7 Open reduction. The patient is positioned prone on a radiolucent table in skeletal traction (A). A
wide area is draped, and a skin incision is planned 1 cm lateral to the PSIS (B). The origin of gluteus maximus at
the iliac crest and multifidus is visualized (C). The gluteus maximus is elevated off the iliac crest and multifidus as
far laterally as necessary; the dissection can be carried distally to the greater sciatic notch if necessary. Care
must be taken to protect the superior gluteal neurovascular bundle if the notch is exposed (D). Large Weber
tenaculums are then used to reduce the fracture (E).

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After a wide surgical field is prepared and draped, a vertical incision is made 1 cm lateral to the posterior superior
iliac spine (PSIS, Fig. 40.7B). The subcutaneous tissue is divided down to the fascia of the gluteus maximus
muscle. Large cutaneous flaps are avoided (Fig. 40.7C). The gluteus maximus is subperiosteally elevated off the
ilium and the underlying multifidus fascia as far laterally as necessary (Fig. 40.7D). The piriformis muscle is
identified and subperiosteally elevated from the sacrum and greater sciatic notch. In many cases, the reduction
can then be performed and evaluated from the dorsal landmarks of the sacrum, eliminating the need to expose
the greater sciatic notch. Should access to the anterior sacroiliac (SI) joint or ventral sacrum be necessary,
digital dissection through the notch must proceed carefully. The superior gluteal neurovascular bundle will be in
the lateral portion of the notch; caution must be exercised to protect it. After the erector spinae muscles are
elevated off the dorsal sacrum, the fracture will be exposed. The dorsal sacral cutaneous nerves will be visible
and are often injured. Clot and periosteum are removed from the fracture edges taking care not to remove any
bone. A lamina spreader inserted into the fracture can assist with cleaning the fracture site, visualization of the
ventral structures, and débridement of any neural impingement.
Once the sacral fracture is exposed, its displacement must be understood in order to reduce it effectively.
Cephalad and lateral displacement can be reduced with a large, pointed reduction clamp placed on the PSIS and
sacral spinous processes (Fig. 40.7E). Varying the position of this clamp on the ilium or the various spinous
processes can improve the leverage need for reduction. A large Schantz pin placed into the PSIS or posterior
inferior iliac spine (PIIS) can facilitate correction of anterior translation, flexion, or rotational deformities. Lateral
translation is corrected last so as not to impair correction of other deformities. In most cases, there is adequate
posterior cortical bone for an anatomic reduction. When comminution exists, then the reduction must be
confirmed with fluoroscopy in multiple planes.

FIXATION
Iliosacral Screws
Iliosacral screws placed for sacral fracture fixation are placed in a different plane when compared to fixation for
SI joint dislocations (Fig. 40.8A,B). Regardless of the reduction technique, most sacral fractures can be stabilized
with iliosacral screws. The trajectory of the screw should be as perpendicular to the fracture plane as possible to
assist with reduction and stability. This is typically parallel to the sacral endplate on the outlet view and parallel
to the axis of the bone on the inlet view. Careful preoperative planning will determine if a safe corridor exists for
placement of screws in this position. If the patient’s anatomy allows, correct positioning of the screw can allow for
transsacral placement and screw purchase in the contralateral ilium, providing theoretical increased resistance to
cephalad translation. The authors prefer to place a second screw for additional stability and to prevent rotation
around one screw. The second screw is placed either posterior and superior to the first screw in S1 or into S2,
depending on the patient’s anatomy.
FIGURE 40.8 Trajectory for iliosacral screw fixation on the inlet view for SI joint dislocation runs more posterior
to anterior (red) compared to more in-line with the sacrum for a sacral fracture (blue) (A). On the outlet view, the
trajectory for iliosacral screws for an SI joint dislocation is inferior to superior (red) while for a sacral fracture, it is
perpendicular to long axis of the sacrum (blue) (B).

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FIGURE 40.9 Schematic (A) and radiographic (B) position of an iliosacral screw in relationship to the bony
anatomy of the sacrum and the L5 and S1 nerve roots.

We prefer to use drill tip guidewires as they allow for better tactile appreciation of bony confinement and easier
redirection if necessary. Under fluoroscopic control, a guidewire is placed on the outer table of the ilium at a
position that will allow passage of the first screw low and anterior into S1 (Fig. 40.9A,B). This requires accurate
imaging of the sacral foramina on the outlet and the sacral promontory on the inlet view. Without precise imaging
and a thorough understanding of the three-dimensional anatomy of the pelvis, the L5 nerve root will be at risk. If
there is any question as to the correct starting position, a lateral image of the sacrum can be obtained so that the
iliac cortical density can confirm a safe position with the guidewire. The lateral view helps to ensure safety of the
path only if the path is perpendicular to the body, or if taken after the guidewire has been inserted and the
authors use this view only rarely. Sequential inlet and outlet images, along with tactile feedback from the drill tip
guide wire, confirm accurate positioning. The authors prefer to place a second guidewire before placing the first
screw to allow for ease of imaging. Partially threaded screws are used to produce compression across the
fracture, which adds stability to the fixation construct. Washers are also used to prevent penetration of the cortex
of the ilium and thus compromised fixation. When both screws are placed into or through S1, a double washer
can be used. Typically, a 46-mm threaded, 8.0-mm cannulated screw is placed as the primary screw. The
second screw may be 8.0 mm if it can fit; otherwise, a smaller diameter 6.5-mm screw can be used. The authors
do not use fully threaded screws even in comminuted fractures.

Spinal-Pelvic Fixation
When a sacral fracture occurs in association with an injury to the L5/S1 facet joint or there is severe comminution
or osteoporotic bone, spinal-pelvic fixation or triangular osteosynthesis to augment the fixation may be
necessary. The philosophy of this fixation is for the line of force transmission to bypass the sacral fracture with
fixation from the spine to the ilium (Fig. 40.10A,B). Pedicle screws are placed into L5 and/or L4, and a similar
designed screw is placed in the ilium, between the tables, starting distal to the PSIS and aiming cephalad to the
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greater sciatic notch. The raindrop, as seen on the obturator outlet image, is the optimal position for the screw
(Fig. 40.11). The iliac oblique image will confirm its position in relation to the greater sciatic notch. Since this
hardware can be prominent at the PSIS, recessing the screw beneath the overhang of the ilium can minimize
symptoms. The ilium screw is then connected to the pedicle screws with a 5-mm rod. It is important to note that
the fracture must be reduced and the iliosacral screw placed prior to final assembly of this construct, as once it is
in place, the fracture cannot be manipulated. This can be done percutaneously with minimally invasive spinal
instrumentation sets (Fig. 40.10B).
FIGURE 40.10 Normal force transmission in an intact pelvis (A). Force transmission after spinopelvic fixation in a
patient with a sacral fracture (B).

FIGURE 40.11 An obturator outlet view will reveal the shadow of a raindrop, which represents a corridor of bone
between the inner and outer tables of the ilium, cephalad to the acetabulum, inclusive of the sciatic buttress. This
corridor runs from the AIIS to the PIIS and is the ideal location for placement of iliac screws for spinopelvic
fixation or Hannover pins for anterior-inferior external fixation.

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Transiliac Bars/Posterior Sacral Plating
This fixation technique is rarely used today. Indications may be revision fixation after failed iliosacral screws,
cases of poor fixation, or when sacral dysmorphism does not permit standard iliosacral screw fixation.
The patient is positioned prone, as described for open reduction, and the fracture is reduced. Placement of
transiliac bars requires that the posterior superior iliac tubercles are intact and adequate in size to allow for the
implant. The most commonly used implants are threaded bars (6.3 mm) from a Harrington rod system. Placement
of the rods can occur either through the wound used to reduce the fracture or through percutaneous wounds.
Vertical incisions are made just lateral to the PSIS. A subfascial flap is elevated to allow passage of the bars in
order to maintain adequate blood supply to the flap and to have adequate soft-tissue coverage of the sacrum
and the implants. A gliding hole is then made through one iliac tubercle at the L5/S1 junction with a 6.5-mm drill
bit. Using a sharp trocar, a bar is passed over the dorsum of the sacrum, often resting on the sacral lamina, and
driven through the contralateral posterior iliac tubercle at the same level. A second bar is passed at the level of
S2, using the same technique. Washers and nuts are assembled to secure the rods in place. The rods are cut in
situ.
Similar to transiliac bars, posterior iliosacral plating can be placed through percutaneous wounds lateral to the
posterior iliac tubercles after a reduction is performed. Two 3.5-mm drill holes are made in the tubercles just
distal to the PSIS and approximately 1 cm lateral on each ilium. These holes are connected to allow for passage
of a 3.5-mm straight pelvic reconstruction plate. The plate is passed through these bony tunnels, over the
dorsum of the sacrum, and through the contralateral bony tunnel in the ilium. The plates are then contoured in
situ with a ball spike pusher and a mallet. Screws are placed in the lateral ends of the plate into the ilium;
typically, one of the screws can be oriented between the tables and achieve excellent bony purchase.

INTRAOPERATIVE CHALLENGES
Obstacles predictably occur in the operating room during the internal fixation of some pelvic fractures.
Inadequate imaging, especially when attempting percutaneous fixation, can result in poor reductions or
misguided fixation. Delaying the procedure for several days may be necessary if visualization is compromised by
residual contrast in the bladder or gastrointestinal tract. If imaging difficulties are encountered due to morbid
obesity or patient-related anatomic variations, placing a stack of towels in the midline at the lumbar spine can
restore the pelvic position toward normal to allow appropriate imaging. Bowel gas can sometimes be shifted by
slow, sustained pressure on the abdomen.
If a skin incision is made and a Morel-Lavallee lesion is encountered, the lesion should be débrided, allowing
safer placement of the iliosacral screws.
In the prone position, when significant longitudinal traction is necessary, the friction between the patient and the
table may not provide enough countertraction, causing the patient to shift distally on the table. One method to
overcome this problem is to fix the contralateral hemipelvis to the operating room table. Two Schantz pins, one
placed into the PSIS and one placed into the proximal femur, are attached to each other and then to the table
with standard external fixation components (8,9). The authors have no experience with this technique.
Although some pelvic-ring disruptions with sacral fractures can be treated with iliosacral screws alone, some
patterns have significant anterior ring instability that must be stabilized. Symphyseal disruptions require open
reduction and internal fixation. Significantly displaced rami fractures that impinge on urogenital structures may
require open reduction and fixation as well. Alternatively, when the posterior ring fixation is poor and the anterior
ring alignment is adequate, an external fixator may be used. The authors prefer supra-acetabular, two-pin
constructs as they produce a more anatomically correct vector for correction of external rotation injuries, and
they avoid the abduction deformity often created with iliac-crest frames. The pins are placed under fluoroscopic
guidance. The incision is two fingerbreadths below the ASIS. The C-arm is positioned to obtain an obturator
outlet view (Fig. 40.11), and the radiographic shadow of a raindrop of bone superior to the acetabulum is
identified (10). The raindrop represents the bony outline of the inner and outer tables of the ilium and the top of
the greater sciatic notch inferiorly. The center of the raindrop is the bony corridor inclusive of the sciatic buttress
that extends from the anterior inferior iliac spine (AIIS) to the PIIS. A frame constructed with 5- or 6-mm half pins
extending to the posterior pelvis in this thick bone is stiffer in resisting internal and external rotation forces than
iliac-crest frames and equal in resisting flexion and extension forces compared with iliac-crest frames (11,12).
Recently, surgeons have begun placing these frames beneath the skin. Multiaxial pedicle screws replace the 5-
mm half pins, and a standard 5-mm bar is passed superficial to the abdominal musculature, in the subcutaneous
fat of the anterior abdomen. This so-called internal fixator—or in-fix—avoids pin tract infections and patient
dissatisfaction (Fig. 40.12). Long-term results and complications are still unknown with this technique.

Postoperative Management
Postoperative management is often challenging due to the associated injuries. Patients with a pelvic-ring
disruption that includes a unilateral sacral fracture (with either unilateral or bilateral pubic rami fractures or a
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repaired symphysis diastasis) that is reduced and stabilized should remain non-weight bearing on the injured
side but can be allowed to bear weight on the noninjured side. When a formal open reduction internal fixation
has been performed, patients must be log rolled to avoid prolonged pressure on the posterior incision. Patients
should be mobilized from bed to chair as soon as their overall condition permits.

FIGURE 40.12 Postoperative radiograph of supplemental anterior pelvic-ring fixation with an internal fixator (in-
fix).

In percutaneous procedures with small lateral incisions, patients receive 24 hours of postoperative antibiotics. If
a patient requires a postoperative drain, as with open approaches or with a débrided Morel-Lavallee lesion,
antibiotics are continued until the drain is removed. A first-generation cephalosporin is used for most patients. In
the case of an allergy, vancomycin is substituted.
If there are no contraindications, patients are started on subcutaneous heparin on the first postoperative day and
are gradually transitioned to warfarin. If a patient has a contraindication to chemical deep venous thrombosis
(DVT) prophylaxis, an inferior vena cava (IVC) filter may be necessary. Sequential compression devices are used
throughout the hospital course.
In medically stable patients, formal AP, inlet, and outlet x-rays in the radiology suite are obtained on the first
postoperative day. The authors do not routinely obtain a postoperative CT scan unless there is concern
regarding the reduction, the fixation, or the postoperative neurologic examination.
Outpatient visits include an updated history and physical examination and AP, inlet, and outlet radiographs at 2
to 3 weeks, 6 weeks, 12 weeks, 4 months, 6 months, and 1 year. Weight bearing is usually advanced as
tolerated at 12 weeks, assuming that there is radiographic evidence of healing. If an external fixator is in place, it
is usually removed 8 weeks postoperatively if there is evidence of callus formation. The “in-fix” devices are
typically removed at 10 to 12 weeks, or later, once the rami fractures are healed.
Physical therapy is started in the hospital to teach patients safe transfers and crutch training. Additional therapy
is recommended once the fractures have healed and patients are full weight bearing. This is helpful for gait
training and improvement of lower extremity strength. Nonimpact activities, such as swimming and bicycling, are
encouraged. Patients are taught hip abduction strengthening exercises as well.

Complications
Traditionally, internal fixation of sacral fractures was associated with high complication rates due to poor
understanding of the fracture and incisions often placed through compromised posterior soft tissues. Wound
complications and deep infection rates after open treatment are reported as high as 25% (13);
percutaneous iliosacral screw fixation after closed reduction has dramatically reduced this rate. If a wound
hematoma or drainage occurs, early open débridement and negative pressure wound therapy over the
intact deep fascia can often salvage the fixation until union. Deep infection should be treated with
aggressive open treatment, not percutaneous drainage. Multiple débridements, removal of hardware if the
fracture is healed, or antibiotic beads may be necessary. Consultation with an infectious disease specialist
is recommended.
Given the location of sacral fractures and the local anatomy, iatrogenic nerve injury, especially to L5, has
been reported. A thorough understanding of pelvic anatomy and fracture deformity, as well as adequate
imaging, can reduce this risk. Careful documentation of the preoperative neurologic examination is vital. Any
postoperative alterations in the neurovascular examination compared with the preoperative findings in either
extremity warrants a CT scan to ensure that the hardware or reduction is not the cause of the neurologic
change. Aberrant hardware or a bone fragment in the neural canal may require reoperation. A neurologic
deficit without radiographic explanation should be observed. Overcompression of a sacral fracture is often
cited as a concern, and some surgeons prefer to place fully threaded screws to minimize this risk. However,
in our experience, this
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seems to be more of a theoretical concern and occurs most commonly following delayed posterior fixation.
With fixation of acute fractures, this is much less of a problem. The use of motor evoked potentials has been
recommended to decrease screw positioning errors (14), and newer methods may be helpful in monitoring
reduction maneuvers (15), but muscle paralysis cannot be employed, limiting its applicability.
Somatosensory evoked potentials are less useful as they are only a surrogate measure for motor nerves
and are less predictive of postoperative problems. Neurologic monitoring is not a substitute for lack of
knowledge of pelvic anatomy or surgical technique.
Massive intraoperative hemorrhage can be life threatening. Although several vessels in the area can be the
source, injury to the superior gluteal artery is the most common. If bleeding is encountered and cannot be
controlled, we recommend that the wound be packed and the patient transported urgently for angiographic
embolization. Continuous venous bleeding and coagulopathy can also put a patient at risk and may require
 the procedure to be aborted so that the patient can be resuscitated.
Loss of reduction can be due to infection, inadequate fixation, poor reduction, lack of compression, or
patient noncompliance. The cause must be identified before a treatment plan can be implemented. A full
series of pelvic radiographs and a CT scan can help identify the problem. Also, laboratory studies—
including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate—will assist in
determining the likelihood of infection and the response to treatment.
Malunion, either caused by malreduction or loss of reduction, can cause significant long-term disability. The
most common complaint is pain, including low back pain and sitting pain. Furthermore, pelvic obliquity,
sitting imbalance, leg-length discrepancy, and dyspareunia can occur. Nonunion, often the result of
inadequate fixation or fully threaded screws holding a fracture distracted, can also lead to chronic pain. The
treatment of a pelvic nonunion or malunion is challenging and correcting the deformity can be difficult.
There can be massive bleeding as well as neurologic injury. Accurate reduction of fractures acutely with
stable fixation is vital to prevent late deformity and disability.

Outcomes and Results

Over the past several decades, the outcomes of patients with pelvic fractures have improved as our
understanding of fractures and resultant deformities has improved. Adequate construct stability and care of
the associated soft-tissue injury have optimized surgical technique and patient mobilization. Despite this,
many patients still report chronic, long-term back, and posterior pelvic pain. And when an associated
neurologic injury is present, the outcome is worse.
Posterior pelvic-ring injuries that include sacral fractures have improved outcomes over pure SI joint
dislocations. This is presumably the result of bony healing to restore strength and stability over ligamentous
healing with scar tissue formation (16). Debate continues as to the definition of an adequate reduction and
the role that plays in functional outcomes.
Outcomes in multitrauma patients with pelvic fractures are likely multifactorial. The socioeconomic status of
trauma patients (17) and the associated neurologic, urologic, gynecologic, and orthopaedic injuries all play
a role. The prolonged recovery time and extensive rehabilitation necessary following pelvic fractures affect
employment and home life. Less than 50% of patient with severe pelvic fractures return to their previous
level of function and work status (18).

REFERENCES
1. Strange-Vognsen H, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma
1991;5(2):200-203.

2. Reilly M, et al. The treatment of minimally displaced fractures of the sacrum with immediate weight
bearing. Is there a role for prophylactic iliosacral screw fixation? OTA podium presentation, 2000.

3. Peichl P, Holzer L, Maier R, et al. Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of
elderly osteoporotic women. J Bone Joint Surg Am 2011;93(17):1583-1587.

4. Bruce B, Reilly M, Sims S. OTA highlight paper predicting future displacement of non-operatively managed
lateral compression sacral fractures: can it be done? J Orthop Trauma 2011;25(9):523-527.
5. Hak D, Olson S, Matta J. Diagnosis and management of closed internal degloving injuries associated with
pelvic and acetabular fractures: the Morel-Lavallée lesion. J Trauma 1997;42(6):1046-1051.

6. Dickson K, Matta J. Skeletal deformity after anterior external fixation of the pelvis. J Orthop Trauma
2009;23(5): 327-332.

7. Schildhauer T, Bellabarba C, Nork S, et al. Decompression and lumbpelvic fixation for sacral fracture-
dislocations with spino-pelvic dissociation. J Orthop Trauma 2006;20(7):447-457.

8. Lefaivre K, Starr A, Reinert C. Reduction of displaced pelvic ring disruptions using a pelvic reduction
frame. J Orthop Trauma 2009;23(4):299-308.

9. Matta J, Yerasimides J. Table-skeletal fixation as an adjunct to pelvic ring reduction. J Orthop Trauma
2007;21(9): 647-656.

10. Gardner M, Nork S. Stabilization of unstable pelvic fractures with supra-acetabular compression external
fixation. J Orthop Trauma 2007;21(4):269-273.

11. Archdeacon M, Arebi S, Le T, et al. Orthogonal pin construct versus parallel uniplanar pin construct for
pelvic external fixation: a biomechanical assessment of stiffness and strength. J Orthop Trauma
2009;23(2):100-105.

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12. Kim W, Hearn T, Seleem O, et al. Effect of pin location on stability of pelvic external fixation. Clin Orthop
Relat Res 1999;361:237-244.

13. Kellam J, McMurty R, Paley D, et al. The unstable pelvic fracture: operative treatment. Orthop Clin North
Am 1987;18(1):25-41.

14. Moed B, Ahmad B, Craig J, et al. Intraoperative monitoring with stimulus-evoked electromyography during
placement of iliosacral screws. J Bone Joint Surg Am 1998;80(4):537-546.

15. Lieberman J, Lyon R, Feiner J, et al. The efficacy of motor evoked potentials in fixed sagittal deformity
correction surgery. Spine 2008;33(13):E414-E424.

16. Cole JD, Blum D, Ansel L. Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop
Relat Res 1996;329:160-179.

17. Bosse M, MacKenzie E, Kellam J, et al. An analysis of outcomes of reconstruction or amputation after
leg-threatening injuries. N Engl J Med 2002;347(24):1924-1931.

18. Van den Bosch E, Van der Kleyn R, Hogervorst M, et al. Functional outcome of internal fixation for pelvic
ring fractures. J Trauma 1999;47(2):365-371.
 41
Acetabular Fractures: The Kocher-Langenbeck Approach
Berton R. Moed

INTRODUCTION
Fractures of the acetabulum are relatively uncommon injuries, usually resulting from high-energy trauma in young
adult patients. Open anatomic reduction with internal fixation is the recommended treatment for fractures causing
instability or incongruity of the hip joint. These fractures, which are often comminuted, are ideally treated by
experienced fracture surgeons at institutions proficient in the care of multiply injured patients. Despite the best of
care, however, these patients often have a protracted recovery and infrequently regain their preinjury level of
physical capability (1).
These fractures constitute an anatomically diverse group of injuries. Judet, Judet, and Letournel (2) proposed
the first systematic classification of acetabular fractures in 1961, which was based on the anatomic pattern of the
fracture, and over time, this classification was modified and improved by Letournel. The comprehensive fracture
classification systems of the Orthopaedic Trauma Association and the AO Foundation describe the alphanumeric
coding of this “Letournel” classification and offer no clinical advantage. Therefore, the Letournel acetabular
fracture classification continues to remain the international language of the majority of surgeons treating these
complex injuries. This classification has 10 distinct categories, which are divided into five elementary types and
five associated types (Fig. 41.1; Table 41.1).
The Kocher-Langenbeck, along with the extended iliofemoral and ilioinguinal, constitute the recommended
“standard” approaches for the surgical treatment of acetabular fractures (2). Despite the advent of many
alternatives, the Kocher-Langenbeck approach remains a mainstay in this regard (1).

INDICATIONS AND CONTRAINDICATIONS

As noted above, displaced fractures of the acetabulum resulting in joint incongruity or instability are best treated
by open reduction and internal fixation (ORIF). Contraindications to surgery are ill-defined and not absolute.
Important concerns include preexisting patient factors, such as poor general medical status and osteopenia, and
factors that relate to overall patient prognosis, such as advanced age and associated injuries. All of these
conditions must be considered with the knowledge that with nonoperative treatment in the face of joint
incongruity or instability or both, the prognosis for hip-joint function is poor.
In choosing the appropriate surgical approach, the surgeon has an objective to select the least extensive
exposure that allows sufficient bony access for anatomic joint reconstruction. The Kocher-Langenbeck approach
provides direct visualization of the entire lateral aspect of the posterior column of the acetabulum (Fig. 41.2) (2).
Indirect access to the true pelvis and to the anterior column can be attained by the palpating finger or through the
use of special instruments (Figs. 41.2, 41.3 and 41.4) (2). Therefore, the Kocher-Langenbeck approach is
applied in the treatment of fractures with the main displacement involving the posterior column. In the
classification of Letournel (Table 41.1), this group consists of six fracture types: posterior wall, posterior column,
posterior column plus wall, transverse, transverse plus posterior wall, and T-shaped. The Kocher-Langenbeck
approach is the surgical exposure of choice for the first three types, in which the fracture extent is limited to the
posterior wall or column or both. For the transverse, transverse plus posterior wall, and T-shaped fractures,
some decision making is required. All three of these fracture types have a transverse fracture line as a common
component. As a general guideline, if the fracture is <15 days old and the transverse component is located at
(juxta-) or below (infra-) the level of the roof (tectum) of the acetabulum (therefore not involving the weight-
bearing area of the acetabulum), the Kocher-Langenbeck approach is indicated (2). Otherwise, an alternative
exposure, such as the extended iliofemoral approach, should be used. For acute juxtatectal- and infratectal-level
transverse and T-shaped fractures, in which the major displacement occurs anteriorly at the pelvic brim and only
minor posterior displacement, the ilioinguinal approach is perhaps the best choice.
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FIGURE 41.1 Letournel acetabular fracture classification. (From Moed BR, Reilly M. Fractures of the
acetabulum. In: Rockwood and Green's fractures in adults. 7th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2009:1475, Figure 45.14.)

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TABLE 41.1 Acetabular Fracture Classification

Elementary fractures
 Posterior wall

Posterior column

Anterior wall

Anterior column

Transverse

Associated fractures

Posterior column plus wall

Anterior column or wall plus posterior hemitransverse

Transverse plus posterior wall

T-shaped

Both column

From Letournel E, Judet R. Fractures of the acetabulum. Berlin: Springer-Verlag; 1981, and Letournel
E, Judet R. Fractures of the acetabulum. 2nd ed. Berlin, Germany: Springer-Verlag; 1993.

FIGURE 41.2 Access provided by the Kocher-Langenbeck approach.

 P.820

FIGURE 41.3 A,B. Examples of available instruments for acetabular fracture reduction. Special instruments that
permit intrapelvic and anterior column access (A). Other useful reduction clamps, from left to right: large
reduction forceps with points; pelvic reduction clamp; large pelvic reduction forceps with pointed ball tips; straight
ball spike; Farabeuf reduction forceps; and serrated reduction forceps (B).

The status of the local soft tissues is an important additional consideration. Acetabular fracture surgery through a
compromised soft-tissue envelope is ill-advised because of the increased risk of infection. Open wounds usually
require débridement followed by delayed wound closure. Closed degloving soft-tissue injuries over the
trochanteric region associated with underlying hematoma formation and fat necrosis (the Morel-Lavallee lesion)
may be initially recognized by a fluid wave on palpation or may be later identified by the presence of a fluctuant,
circumscribed area of cutaneous anesthesia, and ecchymosis. These injuries, even when closed, can be
associated with the presence of pathogenic bacteria. Therefore, débridement followed by delayed wound closure
and, subsequently, delayed fracture fixation may be required (2). This delay, as noted previously, may
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preclude use of the Kocher-Langenbeck approach. More recently, a percutaneous method has been reported in
a small number of patients, using a plastic brush to débride the injured fatty tissue, which is then washed from
the wound with pulsed lavage (3). A medium closed-suction drain is placed within the lesion and removed when
drainage is <30 mL over 24 hours. Fracture fixation is deferred until at least 24 hours after drain removal.

FIGURE 41.4 A,B. Example of clamp application for fracture reduction with a bone model. (A: Copyright Berton
R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA. Permission granted.)

PREOPERATIVE PLANNING
In most cases, patients with an acetabulum fracture have sustained high-energy trauma. Therefore, examination
of the injured limb, even in those with an apparent isolated injury, should be just one part of a comprehensive
and systematic approach. Associated injuries can be life or limb threatening. The Advanced Trauma Life Support
evaluation sequence should be followed (4). As previously noted, soft-tissue injury has important implications
regarding subsequent surgery; therefore, the soft tissues should be evaluated carefully. The incidence of
preoperative, posttraumatic, sciatic nerve injury was reported as being as high as 31% (5). Other peripheral
nerves, such as the femoral and obturator nerves, also may be injured (6). A complete and clearly documented
neurologic examination is extremely important both for patient prognosis and for medical-legal concerns.
Preoperatively, this evaluation should be repeated periodically.
The initial anteroposterior (AP) x-ray of the pelvis can provide substantial diagnostic information regarding
fracture type as well as indicate a need for emergency treatment (Fig. 41.5). This x-ray must be supplemented by
further studies to define completely the acetabular fracture pattern. The three necessary additional plain x-rays
(Fig. 41.6) are centered on the affected hip and include an AP and two 45-degree oblique views (the internal or
obturator oblique view and the external or iliac oblique view) (2). Although these four plain x-rays usually provide
all the information needed to define the acetabular fracture type, the standard two-dimensional computed
tomography (CT) scan can supply important additional information and is indispensable for preoperative
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planning (Fig. 41.7). The eventual universal availability of high-quality three-dimensional CT reconstructions may
eliminate much of the mystery associated with the radiographic interpretation of acetabulum fractures (Fig. 41.8).
However, except for the AP hip x-ray, which in most cases provides the same information as the AP pelvis
examination, the plain and two-dimensional CT radiographic studies continue to be indispensable and should be
viewed concurrently to make the definitive fracture diagnosis (2).

FIGURE 41.5 Initial AP pelvis x-ray of a 20-year-old man involved in a motor vehicle accident. There is a
transverse fracture of the left acetabulum with a vertical fracture line through the ischium, suggestive of an
atypical T-shaped pattern. A double density just lateral to the femoral head suggests a displaced intra-articular or
wall-fracture component. The right hip is subluxed, but not dislocated, and there is widening of the right
sacroiliac joint.

After careful physical examination and radiographic study, the appropriate surgical approach can be determined.
The indications for emergency fracture fixation are uncommon (Table 41.2). Operative treatment is generally
delayed 3 to 5 days to allow stabilization of the patient's general status and for preoperative planning. My
preference is to use preoperative, skeletal, femoral-pin traction both to maintain an unstable hip in a located
position and to prevent further femoral head articular-surface damage from abrasion by the raw acetabular bony
fracture surfaces (Fig. 41.9). Significant intraoperative blood loss can occur. Approximately 2 units of blood
should be made available, depending on the extent of the fracture pattern. The use of an autologous blood
transfusion system may decrease the need for intraoperative, homologous, banked-blood transfusion.
FIGURE 41.6 A-C. Subsequent AP and 45-degree oblique hip x-rays visualize the atypical T-shaped acetabular
fracture more completely. However, the additional fracture components are not well delineated.

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FIGURE 41.6 (Continued)
FIGURE 41.7 Selected two-dimensional CT sections. In addition to the previously noted findings consistent with
an atypical T-type fracture, a posterior wall fracture fragment, and two osteochondral-free fragments (one intra-
articular and one displaced anterior to the femoral head) are evident.

P.824
FIGURE 41.8 A-D. Three-dimensional CT constructs formed as AP and 45-degree oblique views (A-C) and
created using the volume-rendering technique show very clearly the fracture as deduced by evaluation of the
plain x-rays and two-dimensional CT. An excellent overall appreciation of the fracture pattern is provided. A
three-dimensional construct subtracting the femur and oriented obliquely into the hip joint (D) shows the fracture
comminution; however, there is some loss of definition.

P.825

TABLE 41.2 Indications for Emergency Acetabular Fracture Fixation

Recurrent hip dislocation after reduction despite traction

Modifier: None
Progressive sciatic nerve deficit after closed reduction
 Modifier: None
Irreducible hip dislocation

Modifier: After open reduction (stable with traction), fracture fixation may be delayed
because of declining medical status of the patient or limitations of the surgical team
Associated vascular injury requiring repair

Modifier: When the fracture is directly related to the vascular injury and fracture
stabilization is an important adjuvant to the vascular repair, such as an anterior column Open
fracture associated with laceration of the femoral artery, urgent fracture fixation is required fractures

Modifier: Open fracture treatment principles require emergency irrigation, débridement, and
fracture stabilization. Fracture stabilization options include traction followed by delayed
ORIF or acute ORIF

From Tile M. Fractures of the pelvis and acetabulum. 2nd ed. Baltimore, MD: Williams &
Wilkins; 1995, with permission.

FIGURE 41.9 AP hip radiographs before and after the application of traction. A. Without traction, the femoral
head is medially subluxed, rubbing against the sharp corner of the superior acetabular fracture surface in this
displaced transtectal fracture. B. The hip joint is distracted with the application of traction pulling the articular
cartilage of the femoral head a safe distance away from the acetabular fracture surface.
 P.826

FIGURE 41.10 Lateral position for surgery on the right hip. The patient is supported on a beanbag on a
radiolucent operating room table. The down leg is padded, and an axillary roll and head supports are in position.
For this patient with an ipsilateral ankle fracture, the right leg is splinted and padded.

SURGICAL TECHNIQUE
Positioning
Acetabular fracture fixation using the Kocher-Langenbeck approach can be performed with the patient in either
the lateral or the prone position. Orthopedic surgeons from North America are more familiar with and perhaps
more comfortable using lateral positioning with the affected extremity draped free, as in hip arthroplasty surgery
(Fig. 41.10). However, although definitive study is lacking, the Kocher-Langenbeck approach is generally
thought to be most effective with the patient placed prone on a fracture table (1,7). The benefits of the prone
position are realized by maintaining the femoral head in a reduced position. Gravity becomes a help rather than a
hindrance in fracture exposure and reduction. The fracture table provides controlled traction and limb positioning,
further assisting in fracture reduction. Traction is applied through use of a distal femoral pin with the knee flexed
to approximately 90 degrees (Fig. 41.11). This angle of knee flexion places the sciatic nerve in a relaxed
position, minimizing the risk of intraoperative sciatic-nerve injury. An unscrubbed assistant is required for
intraoperative adjustment of the table.
FIGURE 41.11 Patient in the prone position for surgery on the right hip (A) with a detailed view of the affected
limb and femoral pin position (B).

P.827
FIGURE 41.12 The Judet fracture table. A small pad can be used to elevate the patient's head (A). A detailed
view (B) shows the padded perineal post and the padded support with perineal cutout for male patients. The
separation between the chest and padded perineal support serves to reduce abdominal pressure without
requiring additional padding or chest rolls. The currently available PROfx Fracture Table version (C)
manufactured by Mizuho OSI (Figure courtesy of Mizuho OSI, Union City, CA. Permission granted.)

With the patient placed prone, chest rolls should be used to elevate the head and to avoid excessive abdominal
pressure. The fracture table generates the added risk of injury (i.e., pudendal nerve palsy) from pressure against
the perineal post. The Judet fracture table adequately addresses these concerns. Although no longer being
manufactured, the original, Tesserit T3000 model (Figs. 41.11 and 41.12) continues to be available in
reconditioned form (Medrecon, Inc., Garwood, NJ). An updated version, which is also more practical for general
fracture table usage, is currently available (Fig. 41.12C; PROfx Fracture Table, Mizuho OSI, Union City, CA).

C-Arm
No matter what the patient position, use of a radiolucent operating table is advisable. Intraoperative C-arm
fluoroscopy can then be used to assess fracture reduction and hardware location (Fig. 41.13). Before the sterile
preparation and draping of the patient, the hip area should be quickly scanned with the C-arm to ensure
adequate fluoroscopic visualization.
 P.828

FIGURE 41.13 Intraoperative fluoroscopic views of a transverse with an associated posterior-wall fracture before
(A) and after (B) the transverse fracture component was reduced by using a pointed reduction forceps.

Draping
With the patient in the lateral position and the limb draped free, the sterile field is similar to that in hip arthroplasty
surgery but extended posteriorly to include the region of the posterior-superior iliac spine (Fig. 41.14). With the
patient prone on the fracture table, the sterile field consists of the buttock and the posterior and lateral aspects of
the thigh (Fig. 41.15).

Surgical Approach
An overview of the surgical approach is shown in Figures 41.16A-C. The skin incision (Fig. 41.17) is centered
over the greater trochanter. The proximal branch of the incision is directed toward the posterior-superior iliac
spine, ending approximately 6 cm short of this bony landmark. Distally, the incision extends approximately 15 cm
along the midlateral aspect of the thigh. This skin incision is carried through the subcutaneous tissue and
superficial fascia onto the fascia lata of the lateral thigh (the iliotibial tract) and the thin, deep fascia overlying the
gluteus maximus muscle (Fig. 41.18).
The fascia lata is then divided in line with the skin incision, beginning at the distal aspect of the wound,
continuing proximally toward the greater tuberosity, and ending at the first sighting of the gluteus maximus
muscle fibers as they insert into the iliotibial tract (Fig. 41.19). The trochanteric bursa of the gluteus maximus (a
large bursa between the tendon of this muscle and the posterolateral surface of the greater trochanter) is
incised, allowing clear visualization of the insertion area of the gluteus maximus muscle and access to the
undersurface of this muscle (Figs. 41.20 and 41.21). Beginning the deep dissection in this way, at the distal
branch of the Kocher-Langenbeck incision, the surgeon facilitates the next step: splitting of the gluteus maximus
muscle.
FIGURE 41.14 Patient from Figure 41.10 after sterile preparation and draping. The posteriorsuperior iliac spine
is marked with an “X.” The right leg is draped free.

P.829
FIGURE 41.15 A-H. Operative field (A), AP and 45-degree oblique x-rays radiographs (B-D); selected two-
dimensional CT sections through dome and columns of the acetabulum (E and F) and three-dimensional CT
views using the surface rendering technique (G and H) of a patient in the prone position on the Judet fracture
table after sterile preparation and draping for surgery on the right hip. The patient has an atypical T-shaped
fracture with intra-articular comminution. Please note that all subsequent intraoperative illustrations are oriented
as if the patient is in this position (i.e., prone having surgery on the right hip with the anatomically superior
direction on the patient located to the right and posterior located toward the top of the illustration).

P.830

FIGURE 41.15 (Continued)

P.831
FIGURE 41.16 The Kocher-Langenbeck approach. A.The skin incision. B. The fascia lata and gluteus maximus
have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the
quadratus femoris. The gluteus maximus tendon has been transected. C. The retroacetabular surface is exposed
by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic
notches. (From Moed BR, Reilly M. Fractures of the acetabulum. In: Rockwood and Green's fractures in adults.
7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:1490, Figure 45.33).

P.832
FIGURE 41.17 Skin incision for the Kocher-Langenbeck approach. The posterior-superior iliac spine is marked
with an “X.” The greater trochanter is outlined.

FIGURE 41.18 Incision through the skin and subcutaneous tissue onto the iliotibial tract and the deep fascia
overlying the gluteus maximus muscle.
 P.833

FIGURE 41.19 The iliotibial tract is incised, showing the underlying trochanteric bursa, and at the superiormost
aspect of the fascial incision, a few muscle fibers of insertion of the gluteus maximus.

The gluteus maximus muscle receives its blood supply from two major vessels: the superior gluteal artery
supplying the upper one-third of the muscle and the inferior gluteal artery supplying the lower two-thirds.
Although within the substance of the muscle multiple anastomotic connections are extant between these two
arteries, the upper one-third/lower two-thirds division in the muscle is a relatively avascular interval and is the
desired plane of dissection. This interval can often be identified by digital palpation of the undersurface of the
gluteus maximus. In addition, inspection of the superficial surface of the muscle frequently reveals a line of fat
marking the interval (Fig. 41.22). This intervascular interval may not correspond exactly with the line of the skin
incision that is directed toward the posterior-superior iliac spine. Often it is oriented in a more lateral direction (as
in Fig. 41.22), but it is well within the limits of the wound (see Fig. 41.22). Once the intervascular interval is
identified, incision in the gluteal fascia and blunt dissection, splitting the gluteus maximus muscle fibers, can
begin. Despite possessing a dual blood supply and potential for an intervascular plane of dissection, the gluteus
maximus muscle has innervation only from the inferior gluteal nerve. There is no internervous plane, and the
nerve branches of the upper one-third of the muscle cross the intended interval of dissection a little more than
halfway between the level of the greater trochanter and the posterior-superior iliac spine. Therefore, splitting of
the muscle fibers should stop as soon as the first nerve branch to the upper part of the muscle is encountered
(Fig. 41.23).
FIGURE 41.20 Trochanteric bursa is isolated before its incision.

P.834

FIGURE 41.21 View after incision of the trochanteric bursa.

FIGURE 41.22 Palpation of the undersurface of the gluteus maximus muscle after incision through the
trochanteric bursa. A fat line is noted at the tip of the scissors. The line of the scissors marks the upper one-
third/lower two-thirds division in the gluteus maximus muscle.

P.835
FIGURE 41.23 A. Gluteus maximus muscle fibers are split to the first nerve branch. A self-retaining retractor
holds the gluteus maximus muscle fibers apart. The nerve (located at the tip of the scissors) is crossing the split
in the gluteus maximus muscle fibers from posterior to anterior in the surgical field. B. Companion drawing to
clarify the exposure in (A).

P.836
FIGURE 41.24 Exposure deep to the iliotibial tract and the gluteus maximus muscle. The rake retraction places
tension on the gluteus maximus tendon of insertion into the femur, which is partially obscured by a subgluteal
bursa.

The deep muscles are now exposed. However, an additional subgluteal bursa often must be cleared to allow
visualization of the tendon of the deep, lower portion of the gluteus maximus muscle that inserts into the gluteal
tuberosity of the femur (Figs. 41.24 and 41.25). Release of this gluteus maximus insertion into the femur allows
adequate posteromedial retraction of the large mass of the gluteus maximus muscle without undue stretch on the
inferior gluteal nerve. The tendon is released, with care taken not to injure branches of the first perforating
branch of the profunda femoris artery, which run in close proximity (Fig. 41.26A,B).
The next step is to locate the sciatic nerve. The safest way to locate the nerve is along the posterior surface of
the quadratus femoris muscle. Variations in the musculature of the buttock are fairly common (8). However,
important variations in the quadratus femoris anatomy are virtually nonexistent. Furthermore, posterior injuries
that may disrupt the short external-rotator anatomy generally leave the quadratus femoris muscle unscathed.
Therefore, the relation between the sciatic nerve and the quadratus femoris muscle serves as a constant
reference point. The posterior surface of this muscle is usually obscured by residual bursal and areolar tissue
(Figs. 41.26A,B and 41.27A,B). This tissue must be incised to expose the nerve (Fig. 41.28A,B). Dissection of
these tissues may be accomplished through the use of either scissors or blunt dissection. Once the nerve is
visualized, it should be explored through its course to the greater sciatic notch (Fig. 41.29A,B). Any impinging
bone fragments should be removed, and any anatomic variations in the nerve noted. Direct manipulation of the
nerve should be avoided.
FIGURE 41.25 Thickened superior aspect of the gluteus maximus tendon is visualized after removal of the bursa
and is isolated with a right-angle clamp.

P.837
FIGURE 41.26 A. Gluteus maximus tendon has been released. B. Companion drawing to clarify the exposure in
(A).

P.838
FIGURE 41.27 A. Delineation of the tissue just superior to the released gluteus maximus tendon that obscures
the posterior surface of the quadratus femoris muscle. This tissue runs from posterior to anterior, covering the
sciatic nerve. B. Companion drawing to clarify the exposure in (A).

P.839
FIGURE 41.28 A. Tissue has been partially incised, revealing the sciatic nerve deep to it. The tip of the scissors
points to the remaining tissue over the quadratus femoris muscle. B. Companion drawing to clarify the exposure
in (A).

P.840
The dissection continues with the location of the tendons of the short external rotators of the hip. First, the
piriformis tendon is identified. It can be found running alongside the gluteus minimus muscle just under the cover
of the inferior aspect of the gluteus medius muscle as it inserts into the greater trochanter (Figs. 41.30A,B and
41.31A,B). If one is not careful, it is possible to mistake the posterior aspect of the gluteus medius muscle and its
tendon for the piriformis (Fig. 41.32) (9). Adding to the potential for confusion is the variability in the relation
between the sciatic nerve and the piriformis muscle. Typically (about 84% of the time), the sciatic nerve runs
deep to the piriformis muscle, appearing in the buttock at the inferior border of this muscle (see Fig. 41.30A,B)
(8). Three variations of this “normal” anatomy have been reported, and others probably exist (8). The most
common variation (12%) is for one part of the nerve (the peroneal division) to pass through the muscle and the
other part (the tibial division) to appear below the muscle. The entire nerve also may pass through the muscle
(1%). These two variations result in a split piriformis muscle with two tendons of insertion. The third variation is
passage of the peroneal division above the piriformis and the tibial division below it (3%). With enough operative
cases, one will eventually encounter one of these anatomic anomalies (Fig. 41.33). Knowledge of the anatomic
variability of this area and the prior identification of the sciatic nerve on the posterior surface of the quadratus
femoris muscle will prevent intraoperative confusion and decrease the risk of iatrogenic sciatic nerve injury. After
its identification, the piriformis tendon is isolated, tagged with a suture, and released from its insertion (Fig.
41.34). The anastomotic branch of the inferior gluteal artery (which participates in the cruciate anastomosis of
the thigh) runs in proximity to the piriformis muscle almost in parallel with the piriformis tendon (9). Failure to
locate this artery may result in its unintentional laceration, followed by troublesome intraoperative bleeding. This
vessel does not provide an important blood supply. Formal ligation is the easiest and best course of action.

FIGURE 41.29 A. Tissue has been completely incised, and the course of the sciatic nerve can be seen. The
sciatic nerve runs superficial to the obturator internus tendon and gemelli muscle bellies and then dives deep to
the piriformis muscle toward the greater sciatic notch. B. Companion drawing to clarify the exposure in (A).

P.841
FIGURE 41.30 Muscle relationships deep to the gluteus maximus (A) and deep to the gluteus medius muscle
(B).

The obturator internus tendon, with the superior and inferior gemelli muscles on either side, can be found just
inferior and slightly deep to the piriformis (see Fig. 41.30). The gemelli muscles insert onto the tendon of the
obturator internus, and the bellies of these two muscles may obscure this tendon (Fig. 41.35). If this situation
occurs, the tendon can be identified by palpation, with either a right-angle clamp or a finger placed deep to the
tendon. External rotation of the hip will relax the tendon, allowing easier access to its deep surface. Internal
rotation of the hip, placing the tendon under tension, will verify its position. In an alternative approach, the
overlying gemelli muscles can be teased away to reveal the obturator internus tendon (Fig. 41.36A,B). Once
located, the obturator internus tendon is isolated, tagged with a suture, and released from its insertion. To avoid
injury to the blood supply of the femoral head, both the piriformis and obturator internus tendons should be
incised approximately 1.5 cm from their insertion points into the greater trochanter (Fig. 41.37). A fascial layer
running from the undersurface of the gluteus maximus muscle to the posterior column of the acetabulum
separates the piriformis muscle from the obturator internus and gemelli muscles. This fascia is easily visualized
after the release of the piriformis and obturator internus tendons (Fig. 41.38A,B). The sciatic nerve lies directly
adjacent to the medial origin of this fascia (see Fig. 41.38A,B). Care must be taken not to injure the sciatic nerve
when this fascia is released during the clearing of the soft tissues from the posterior column (Fig. 41.39).
P.842
FIGURE 41.31 A. Isolation of the piriformis muscle. The gluteus maximus muscle (split) is held by the self-
retaining retractor. The posterior margin of the gluteus medius muscle is reflected anterosuperiorly by an Army-
Navy retractor to reveal the piriformis tendon, which is held by a right-angle clamp. The tip of the intraoperative
suction points to the gluteus minimus muscle. B. Companion drawing to clarify the exposure in (A).

P.843
FIGURE 41.32 Illustration from a patient different than that shown in Figure 41.31, showing a variation of the
gluteus medius muscle in which a deep fold creates an apparently separate posterior portion of the muscle and
tendon of insertion. A clamp reflects the more superficial portion of the muscle, revealing a portion of the gluteus
medius tendon that may be mistaken for the piriformis ( A). The actual piriformis tendon, now exposed by the
right-angle clamp, has a different orientation and configuration ( B).

P.844
FIGURE 41.33 Intraoperative photograph (A) and companion drawing (B) showing a split sciatic nerve with the
peroneal division above the piriformis muscle and the tibial division below the piriformis muscle.

P.845
FIGURE 41.34 The piriformis tendon is isolated and tagged with a suture.

FIGURE 41.35 Obturator internus tendon, obscured by the muscle bellies of the gemelli (X), is isolated with a
right-angle clamp. The sciatic nerve (sn) and piriformis tendon (p) can be seen.
 P.846

FIGURE 41.36 A. Muscle bellies of the gemelli have been dissected to reveal the obturator internus tendon. B.
Companion drawing to clarify the exposure in (A).

P.847
FIGURE 41.37 Obturator internus tendon is isolated and tagged with a suture. The stump of the previously
released piriformis tendon can be seen just cephalad to the obturator internus tendon as it inserts into the
greater trochanter.

The obturator internus muscle arises from within the true pelvis from the internal circumference of the obturator
foramen and the obturator membrane (10). The muscle fibers end in four or five tendinous bands that converge
and pass through the lesser sciatic notch. These bands turn a right angle around the grooved external surface of
the lesser sciatic notch, joining to form the single tendon of insertion. The bony surface is covered by cartilage
and is separated from the tendon by a bursa. Once the obturator internus tendon is released from its insertion
into the greater trochanter, it is elevated away from the hip capsule (along with the gemelli muscles) and followed
medially toward the lesser sciatic notch. The underlying bursa is opened, permitting access to (and palpation
through) the lesser sciatic notch (Fig. 41.40A,B). A specially designed sciatic nerve retractor can now be placed
with its tip anchored in the lesser sciatic notch (Fig. 41.41). Use of this instrument facilitates the bony exposure
by permitting controlled retraction of the sciatic nerve and the posterior soft tissues. The retractor is positioned
such that at the level of the lesser sciatic notch, the obturator internus tendons and gemelli muscles lie between
the retractor and the sciatic nerve, cushioning the nerve. However, the surgeon must realize that the sciatic
nerve retractor extends beyond the limits of this muscle cushion and directly contacts the nerve at the superior
and inferior aspects of the retractor (Fig. 41.42A,B). The relation between the sciatic nerve and the sciatic nerve
retractor must be such that the edges of the retractor do not impinge or place undue pressure on the nerve. The
surgical assistant in charge of maintaining position of the retractor must be cognizant of the importance of this
task. The position of the retractor should be checked frequently during the operative procedure.
Once the sciatic nerve retractor has been appropriately positioned, the posterior hip capsule and retroacetabular
surface of the posterior column are explored and cleared of debris. The dissection is carried from lateral to
medial, progressing from the fracture site superiorly toward the greater sciatic notch and inferiorly toward the
ischial tuberosity. Superiorly, the hip abductors are elevated from the external surface of the ilium and held with a
curved retractor (Fig. 41.43A,B).
As the dissection approaches the greater notch, care must be taken to prevent injury not only to the sciatic nerve
that is unprotected at this level, but also to the superior gluteal neurovascular bundle. The superior gluteal
neurovascular bundle exits the greater sciatic notch above the piriformis muscle, superior to the level of the
sciatic nerve. Its position can often be assessed by palpation of the superior gluteal arterial pulse at the level of
the greater sciatic notch. The superior gluteal neurovascular bundle tethers the abductor muscle mass. It can be
injured not only by direct laceration but also by traction from excessive retraction of the abductor muscle mass.
Inferiorly, the tendon of the obturator externus muscle may be encountered (Fig. 41.44). Release of this tendon is
not necessary and places the femoral head blood supply at risk (11).
P.848

FIGURE 41.38 A. Delineation of the fascia separating the piriformis muscle from the superior gemellus
muscle/obturator internus tendon/inferior gemellus muscle group. A right-angle clamp clearly shows the medial
margin of this fascia and its proximity to the sciatic nerve. The sciatic nerve can be seen running superficial to
the obturator internus tendon and gemelli muscles and then coursing deep to the piriformis muscle. B.
Companion drawing to clarify the exposure in (A).

P.849

FIGURE 41.39 This fascial band has been released.

In cases with fractures involving the ischial tuberosity or others requiring increased access to this area, more
extensive exposure may be obtained through the release of the quadratus femoris muscle. The quadratus
femoris muscle is extremely vascular. It should be released at its origin from the ischial tuberosity to avoid
excessive bleeding and damage to the branches of the medial circumflex artery.
The extent of the fracture pattern dictates the extent of the surgical approach. For fractures limited to the
posterior wall that do not require access to the true pelvis, the dissection is basically complete, as described up
to this point. Otherwise, the dissection must continue through the greater sciatic notch into the true pelvis and
onto the quadrilateral surface of the acetabulum. With the careful use of digital dissection and periosteal
elevators, the origin of the obturator internus muscle is elevated from the quadrilateral plate. Access is now
available for digital assessment of column fracture reduction and for the use of specialized reduction clamps (see
Figs. 41.3, 41.4, and 41.13). If necessary, this access can be enlarged by release of the sacrospinous ligament
(2).
To visualize the hip joint, a circumferential marginal capsulotomy is performed (Figs. 41.44 and 41.45A,B).
However, for fractures involving the posterior wall, capsular attachments to the posterior wall fracture fragment
must be maintained to minimize the risk of posterior wall devascularization. Marginal capsulotomy is performed
on either side of the posterior wall fracture fragment, which the remainder of the hip joint capsule. Incision of the
labrum is avoided unless needed to assess fracture reduction. Radial capsular incisions also should be avoided
to avoid injury to the blood supply to the femoral head.
P.850
FIGURE 41.40 A. Obturator internus tendon has been elevated, allowing access to the lesser sciatic notch. In
this photograph, the hemostat is directed toward, and its tip is inserted into the lesser sciatic notch. B.
Companion drawing to clarify the exposure in (A).

P.851
FIGURE 41.41 Sciatic nerve retractor (A) and its desired position in the lesser sciatic notch, as demonstrated in
a bone model (B).

The intra-articular surface of the hip joint is directly visualized through application of traction to the femur. This
can be accomplished easily and in a controlled manner with the use of the fracture table (Figs. 41.46A,B and
41.47A,B). Other methods include use of the femoral distractor (Fig. 41.48; Synthes, Paoli, PA), and manual
distraction by a surgical assistant using a traction pin in the distal femur or a Schanz screw in the greater
trochanter, or just pulling directly on the leg. Visualization of different aspects of the acetabular joint surface is
often improved by movement of the hip from the neutral position. Hip flexion facilitates access to the acetabular
fossa and the anteroinferior joint surface. This is helpful for the removal of loose bodies but places increased
stretch on the sciatic nerve.
Greater trochanteric osteotomy in an attempt to extend the access of the Kocher-Langenbeck approach farther
along the external surface of the anterior column is rarely required or indicated. The hip abductors remain
tethered by the superior-gluteal neurovascular bundle, limiting the effectiveness of this method in gaining
significant added exposure. Placing the hip in an abducted position, especially with the patient prone,
approximates the exposure gained by trochanteric osteotomy. If sufficient anterosuperior exposure cannot be
obtained by this maneuver, gluteus medius tenotomy and trochanteric osteotomy are available options. The need
for adjunctive tenotomy or greater trochanteric osteotomy usually means that an alternative to the standard
Kocher-Langenbeck approach should have been initially selected.
The closure of the Kocher-Langenbeck incision is straightforward. Released tendons of insertion of the gluteus
maximus and short external-rotator muscles are reattached through use of nonabsorbable suture. After the
placement of deep, closed suction drains, the fascia lata, gluteal fascia, subcutaneous tissues, and skin are
closed in layers (Figs. 41.49, 41.50, 41.51 and 41.52).

POSTOPERATIVE MANAGEMENT
Postoperatively, the patient is mobilized as quickly as the associated injuries will allow. Out of bed on the first
postoperative day, the patient subsequently begins formal physical therapy for muscle strengthening and active
range-of-motion exercises. Total hip arthroplasty precautions are not needed, as internal fixation has (or should
have) rendered the hip joint completely stable. Partial, toe-touch weight bearing with crutches or a walker is
required for 10 to 12 weeks. However, progression to full weight bearing must be individualized. Physical therapy
should continue until muscle strength and range of motion are regained or a plateau is reached. Multiple
elements must be factored into the recovery equation including the magnitude of the soft-tissue injury, the
fracture type, any associated injuries, and preexisting medical status. Therefore, the expected recovery time is
quite variable, ranging from approximately 6 to 12 months for returning to a fully ambulatory status.
P.852

FIGURE 41.42 A. Sciatic nerve is unprotected both below and above the obturator internus tendon and gemelli
muscles. B. Companion drawing to clarify the exposure in (A).

P.853
FIGURE 41.43 A. Sciatic nerve retractor (A) is placed in the lesser sciatic notch. Just superior to this retractor,
the greater sciatic notch (arrow) and the overlying piriformis muscle (p) can be seen. Two curved retractors (B)
reflect the hip abductors. The external surface of the posterior column, with its overlying soft-tissue debris, is well
visualized. B. Companion drawing to clarify the exposure in (A).

P.854
FIGURE 41.44 Obturator externus tendon is identified with a right-angle clamp. For orientation, sutures mark the
released piriformis and obturator internus tendons, the curved retractor reflects the hip abductors, and the
incised hip capsule reveals the femoral head. The surgeon's middle finger rests on the quadratus femoris muscle
just inferior to the obturator externus tendon as it heads toward the greater trochanter. The posterior column and
hip joint can be well visualized without release of this tendon.

COMPLICATIONS
Perioperative complications of acetabular fracture surgery may occur as a direct result of the surgical
approach selected for fracture fixation, or they may be related to the magnitude of the patient's overall injury
pattern. Major complications associated with the Kocher-Langenbeck approach include sciatic nerve injury,
infection, severe bleeding, and heterotopic bone formation. Thromboembolic disease (deep vein thrombosis
[DVT]/pulmonary embolism [PE]) is a serious problem associated with the trauma of acetabular fracture as
well as the subsequent surgery for fracture fixation.
The overall reported prevalence of posttraumatic, iatrogenic, sciatic-nerve palsy ranges from 2% to 16%
(12). Letournel (2) reported nerve palsy prevalence at 10% via the Kocher-Langenbeck approach.
However, he noted that one-fourth of these patients had not had complete documentation of their
preoperative status, leaving the actual cause of nerve injury in doubt. Whatever the actual number, risk of
sciatic nerve injury is substantial with the use of the Kocher-Langenbeck approach. Although intraoperative
nerve monitoring has been advocated as a method for decreasing this risk, it has not proven to be effective
(13). Management of sciatic nerve injury consists of observation and the use of an ankle-foot orthosis. The
prognosis for recovery of the tibial division is good despite severe initial damage. Recovery of the peroneal
division is more dependent on the severity of the initial injury.
Deep infection after fracture fixation by using the Kocher-Langenbeck approach has been reported in as
few as 1.5% of patients (2). However, the adverse effect of a deep postoperative intra-articular wound
infection cannot be minimized. Complete joint destruction can be expected in 50% of these cases (12).
Perioperative antibiotics and meticulous surgical technique are preventive measures. Once diagnosed,
infection requires urgent surgical débridement. Secure internal fixation should be maintained until the
fracture has united.
Bleeding from injury to the superior gluteal artery is a well-described complication of the Kocher-
Langenbeck approach, with a prevalence as high as 5% (14). Exposure and ligation of the vessel may be
required but is associated with iatrogenic injury to the superior gluteal nerve. The application of topical
thrombogenic agents and extended direct pressure with packing are often effective in obtaining hemostasis.
Continued excessive bleeding from retraction of the artery into the pelvis, requiring angioembolization or
retroperitoneal exposure for vessel control, is extremely rare.
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FIGURE 41.45 A. Hip capsule has been incised in a marginal, circumferential manner to reveal the femoral
head (arrow) and the hip joint. Fracture of the posterior column with a displaced, intra-articular, free
fragment is visualized. B. Companion drawing to clarify the exposure in (A).
Heterotopic ossification (HO) has been called the most widespread complication of acetabular fracture
surgery. However, HO after the Kocher-Langenbeck approach, resulting in significant loss of hip motion,
occurs in fewer than 10% of patients (2,15). Options for treatment include the use of perioperative
prophylactic agents or delayed excision after the maturation of functionally significant HO or both (16). The
advisability of using irradiation in a young fracture-patient population to suppress HO in <10% is subject to
debate.
DVT and resultant PE are potential life-threatening complications of acetabular fracture surgery. The risk of
DVT is high and PE occurs in approximately 2% of cases. Routine perioperative chemical and/or
mechanical prophylaxis is indicated. Despite the use of prophylactic treatment, the prevalence of
posttraumatic and postoperative thromboembolism approximates 11% (12).
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FIGURE 41.46 A. With a fracture table, the hip has been distracted to improve visualization and to unload
the hip joint for the facilitation of fracture reduction. B. Companion drawing to clarify the exposure in (A).

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FIGURE 41.47 A. Intra-articular, osteochondral, fracture fragment is reduced. B. Companion drawing to
clarify the exposure in (A).

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FIGURE 41.48 The application of a universal distractor, shown on a plastic bone model. (Copyright Berton
R. Moed, MD, St. Louis, MO; and Mark S. Vrahas, MD, Boston, MA.)
FIGURE 41.49 Intraoperative photograph of the reduction of the posterior column (previously seen
unreduced in Figs. 41.45, 41.46 and 41.47) and the fixation construct used.

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FIGURE 41.50 A-C. Postoperative x-rays of the case from Figs. 41.15 and the subsequent clinical photos
showing the anatomic reduction and fixation.

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 FIGURE 41.51 A,B. Postoperative two-dimensional CT sections corresponding to the levels of the
preoperative samples shown in Figure 41.15E and F showing the anatomic fracture reduction.

FIGURE 41.52 A,B. Postoperative surface-rendering technique three-dimensional CT showing the fracture
reduction with the fixation highlighted in red.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 47-year-old man was involved in a motor-vehicle accident, sustaining a transverse plus posterior wall fracture
of the right acetabulum with intra-articular comminution (Figs. 41.53, 41.54 and 41.55). ORIF was advised
because of the instability and incongruency of the hip joint. Surgery was performed 5 days after injury by using
the Kocher-Langenbeck approach (Figs. 41.56, 41.57, 41.58, 41.59, 41.60, 41.61, 41.62, 41.63 and 41.64).
Eight days later, the patient was discharged to home from the hospital with instruction to proceed with toe-touch
weight bearing with crutches.
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FIGURE 41.53 A-C. Preoperative AP and 45-degree oblique x-rays.

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FIGURE 41.54 A,B. Selected preoperative two-dimensional CT sections (A) just superior to the dome showing
an impacted osteochondral fragment (a) and a comminuted posterior wall (b) and (B) through the superior aspect
of the femoral head showing an osteochondral free fragment (a) and the main posterior wall fragment (b).

FIGURE 41.55 Three-dimensional CT views using the surface rendering technique showing the transverse
fracture line (a), the comminuted posterior wall fragment (b), the osteochondral free fragment (c), and the area of
marginal osteochondral impaction (*).

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FIGURE 41.56 A,B. Fracture reduction using the Kocher-Langenbeck approach. A. Intraoperative fluoroscopic
view showing the reduction of the transverse fracture component using a Farabeuf forceps applied through
screws inserted on each side of the fracture line in combination with an angled clamp placed through the greater
sciatic notch (as in Fig. 41.4). B. Plastic bone model showing this type of clamp application.

FIGURE 41.57 Intraoperative fluoroscopic view following clamp removal showing fixation of the transverse
fracture component with a short posterior plate and an anterior column lag screw.

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FIGURE 41.58 Intraoperative photograph showing the femoral head (f) and an impacted and slightly comminuted
articular surface with the underlying compressed cancellous bone (c). Copyright Berton R. Moed, MD, St. Louis,
MO.
FIGURE 41.59 Intraoperative photograph after elevation and temporary Kirschner-wire fixation of the impacted
intraarticular fragments. The residual underlying cancellous bone defect has been filled with freeze-dried
cancellous allograft bone. The Kirschner wires were subsequently exchanged for bioabsorbable pegs. Copyright
Berton R. Moed, MD, St. Louis, MO.

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FIGURE 41.60 The posterior wall fragments are sequentially reduced and held with the ball spike (instrument
shown in Fig. 41.3B). Screws are inserted while the reduction is maintained by the ball spike, eliminating the
need for temporary Kirschnerwire fixation. The accuracy of the reduction of the articular surface is inferred from
the reduction along the acetabular rim and that of the extra-articular cortical fracture lines. Copyright Berton R.
Moed, MD, St. Louis, MO.
FIGURE 41.61 Intraoperative fluoroscopic view after screw fixation of the comminuted posterior wall fragment.

FIGURE 41.62 The fixation construct is completed by the application of a second posterior plate to buttress the
posterior wall screw fixation.

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FIGURE 41.63 A-C. Postoperative AP and 45-degree oblique x-rays.

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FIGURE 41.64 A,B. Postoperative two-dimensional CT sections (A) through the dome and (B) at the level of the
posterior wall reduction.

REFERENCES
1. Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum: Surgical technique. J
Bone Joint Surg 2008;90-A(Suppl 2, Part 1):87-107.

2. Letournel E, Judet R. Fractures of the acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.

3. Tseng S, Tornetta P III. Percutaneous management of Morel-Lavallee lesions. J Bone Joint Surg Am
2006;88A:92-96.

4. Advanced Trauma Life Support for Doctors ATLS Student Course Manual. 8th ed. Chicago, IL: American
College of Surgeons; 2008.

5. Tile M. Fractures of the pelvis and acetabulum. 2nd ed. Baltimore: Williams & Wilkins; 1995.

6. Gruson KI, Moed BR: Injury of the femoral nerve associated with acetabular fracture. J Bone Joint Surg
2003;85A(3): 428-431.

7. Collinge C, Archdeacon M, Sagi HC. Quality of radiographic reduction and perioperative complications for
transverse acetabular fractures treated by the Kocher-Langenbeck approach: Prone versus lateral position. J
Orthop Trauma 2011;25:538-542.

8. Hollinshead WH. Anatomy for surgeons, volume 3: the back and limbs. 3rd ed. Philadelphia: Harper &
Row; 1982.

9. Henry AK. Extensile exposure. 2nd ed. Edinburgh: Churchill Livingstone; 1973.

10. Gray G. Anatomy of the human body. 28th ed. Philadelphia: Lea & Febiger; 1970.

11. Gautier E, Ganz K, Krügel N, et al. Anatomy of the medial femoral circumflex artery and its surgical
implications. J Bone Joint Surg Br 2000;82-B:679-683.

12. Moed BR, Reilly M. Fractures of the acetabulum. In: Bucholz RW, Heckman JK, Court-Brown CM, et al.,
eds. Rockwood and Green's fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins;
2009:1463-1523.

13. Moed BR, Dickson KF, Kregor PJ, et al. Surgical treatment of acetabular fractures. AAOS Instructional
Course Lectures, Rosemont, IL, 2009;59:481-502.

14. Letournel E, Judet R. Fractures of the acetabulum. Berlin: Springer-Verlag; 1981.

15. Matta J. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed
operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78A:1632-1645.

16. Moed BR, Israel H. Heterotopic ossification prevention and treatment: what is the best way to prevent
heterotopic ossification following acetabular fracture fixation? In: Wright JG, ed. Evidence-based
orthopaedics. Philadelphia: Saunders Elsevier; 2009:353-359.
 42
Acetabular Fractures: Ilioinguinal Approach
Joel M. Matta
Mark C. Reilly
Hamid R. Redjal

INDICATIONS AND CONTRAINDICATIONS

The ilioinguinal approach was developed by Letournel as an approach to the anterior column of the acetabulum
and the inner aspect of the innominate bone. It allows exposure of the entire, internal, iliac fossa, and pelvic brim
from the anterior aspect of the sacroiliac joint to the pubic symphysis. The quadrilateral surface of the innominate
bone and the superior and inferior rami are also accessible. Access to a portion of the external aspect of the ilium
also is possible (Fig. 42.1).
The ilioinguinal is the approach of choice for all fractures of the anterior wall and column. The majority of acute,
associated, anterior-plus-posterior, hemitransverse fractures may also be managed with the ilioinguinal
approach. If the fracture is older than 15 days, the ilioinguinal may still be used unless the posterior component
of the fracture is significantly displaced. In this circumstance, an extended iliofemoral approach is more
applicable.
The ilioinguinal approach may be used for the majority of associated both-column fractures. The presence of a
fracture involving the posterior wall does not necessarily preclude the use of this approach. If the posteriorwall
fragment contains a spike of ilium, the reduction may be possible through the exposure of the lateral ilium. The
ilioinguinal approach is not recommended for an associated both-column fracture with small or comminuted
posterior wall fragments or those with fracture involvement of the sacroiliac joint.
Certain transverse fractures also may be managed with the ilioinguinal approach. Specifically, fractures with
significant displacement at the pelvic brim but slight or no displacement posteriorly may be addressed in this
manner. In addition, the ilioinguinal may be used as a subsequent approach when incomplete reduction of the
anterior column portion of a T-shaped fracture has been obtained through a prior Kocher-Langenbeck approach
(Fig. 42.2).

PREOPERATIVE PLANNING
Initial radiographic evaluation of a patient with an acetabulum fracture should include an anteroposterior (AP)
pelvic radiograph and 45-degree oblique views of the pelvis. Although obtaining these views may be initially
uncomfortable for the patient, they are vital to fully understand the fracture pattern. Adequate analgesia should
be provided, and the physician may need to be onsite to ensure proper positioning. These films should be
obtained in the radiology department rather than as portable radiographs and with the patient out of traction. A
careful evaluation of the radiographs allows the fracture to be classified properly by determination of the exact
fracture pattern.
Computed tomography (CT) may add important additional information regarding the fracture configuration and
presence of incarcerated or impacted fragments within the acetabulum. Three-dimensional CT reconstructions
also can assist in providing a better understanding of complicated fracture patterns. Drawing
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the fracture on a dry bone or pelvic model (or drawing the innominate bone) helps ensure that the surgeon
understands the fracture configuration before embarking on surgical intervention.
The ilioinguinal approach proceeds through anatomic areas infrequently used by most orthopedic surgeons. In
addition, reduction of the fracture and proper placement of fixation require a thorough understanding of the
fracture pattern and the normal acetabular anatomy. Before undertaking the approach, the surgeon is strongly
advised to practice on a cadaver and to assist a surgeon who is familiar with the exposure, reduction, and
fixation of these difficult injuries.

FIGURE 42.1 Access to the innominate bone with the ilioinguinal approach. (Redrawn with permission from
Matta JM. Surgical approaches to fractures of the acetabulum and pelvis. Copyright Matta JM.)

SURGERY
Technique of Approach
The surgery is performed under general anesthesia with the patient positioned supine on the Pro-FX fracture
table (Fig. 42.3). The affected leg is positioned with the hip slightly flexed to relax the iliopsoas muscle, femoral
nerve, and external iliac vessels.
FIGURE 42.2 Fractures addressed through the ilioinguinal approach. (Redrawn with permission from Matta JM.
Surgical approaches to fractures of the acetabulum and pelvis. Copyright Matta JM.)

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FIGURE 42.3 Patient positioned on the Judet-Tasserit fracture table. The hip is flexed to relax the iliopsoas and
external iliac vessels. The lateral traction device is demonstrated.

If required during the surgery, a lateral traction device may be used through a traction screw placed into the
grater trochanter. Before surgery, a Foley catheter is introduced into the bladder. The incision begins at the
midline, 3 to 4 cm proximal to the symphysis pubis. It proceeds laterally to the anterior, superior, iliac spine, and
then along the anterior two-thirds of the iliac crest. The incision must extend beyond the most convex portion of
the ilium (Fig. 42.4). The periosteum is incised along the iliac crest, and the attachment of the abdominal muscles
and the origin of the iliacus are released. By subperiosteal dissection, the iliacus is elevated from the internal
iliac fossa as far posterior as the sacroiliac joint and medially to the pelvic brim (Fig. 42.5). The internal iliac
fossa is then packed for hemostasis. Through the lower portion of the incision, the aponeurosis of the external
oblique muscle and the external rectus abdominis fascia are exposed. These structures are sharply incised in
line with the cutaneous incision at least 1 cm proximal to the external inguinal ring. The aponeurosis of the
external oblique muscle is reflected distally. This unroofs the inguinal canal and exposes the inguinal ligament.
The spermatic cord or round ligament is visualized at the medial aspect of the incision. A Penrose drain is then
placed around the spermatic cord or round ligament and the adjacent ilioinguinal nerve. It may be used to
facilitate retraction during the procedure (Fig. 42.6).

FIGURE 42.4 Skin incision for the ilioinguinal approach. The incision begins 3 to 4 cm above the symphysis
pubis and must extend beyond the most convex portion of the ilium. (Redrawn with permission from Matta JM.
Surgical approaches to fractures of the acetabulum and pelvis. Copyright Matta JM.)

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FIGURE 42.5 Release of the insertion of the abdominal muscles and subperiosteal dissection of the internal iliac
fossa.
FIGURE 42.6 Inguinal canal has been unroofed, and the external oblique aponeurosis is reflected inferiorly. The
ilioinguinal nerve and the spermatic cord are protected by a Penrose drain. The inguinal ligament is identified.
(Redrawn with permission from Matta JM. Surgical approaches to fractures of the acetabulum and pelvis.
Copyright Matta JM.)

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FIGURE 42.7 Abdominal muscles and transversalis fascia have been detached from the inguinal ligament. A 1-
mm cuff of ligament remains for closure. (Redrawn with permission from Matta JM. Surgical approaches to
fractures of the acetabulum and pelvis. Copyright Matta JM.)
FIGURE 42.8 Directly beneath the inguinal ligament lie the external iliac vessels. Note how superficial the
external iliac artery and vein may lie beneath the ligament.

The inguinal ligament is sharply incised so that a 1- to 2-mm cuff of the ligament remains with the common origin
of the internal oblique and transversus abdominis muscles and the transversalis fascia (Fig. 42.7). Great care
must be taken to avoid injuring the underlying neurovascular structures. Immediately beneath the inguinal
ligament, the lateral femoral cutaneous nerve exits into the thigh. This nerve may be found adjacent to or up to 3
cm medial to the anterior, superior, iliac spine. It must be identified and protected throughout the operation.
Directly beneath the midportion of the incision lie the external iliac vessels (Fig. 42.8). Medial to these vessels,
the insertion of the conjoined tendon onto the pubis is incised. It may be necessary to incise a portion of the
rectus abdominis tendon as well; it is incised just above its insertion onto the pubis. The retropubic space of
Retzius is now accessible and is packed with moist sponges after evacuation of the fracture hematoma.
At this point, the anterior aspects of the femoral vessels and the surrounding lymphatics are exposed in the
midportion of the incision within the lacuna vasorum. The more laterally situated lacuna musculorum contains the
iliopsoas, the femoral nerve, and the lateral femoral cutaneous nerve. The iliopsoas sheath, or iliopectineal
fascia, separates the two lacunae (Fig. 42.9). The vessels and lymphatics are carefully dissected away and
retracted from the medial aspect of the fascia, and the iliopsoas muscle and femoral nerve are retracted from the
lateral aspect (Figs. 42.10 and 42.11). The iliopectineal fascia is sharply incised to the pectineal eminence (Fig.
42.12). The pulse of the external iliac artery should be palpated before this step to ensure that the vascular
bundle is protected from injury. The iliopectineal fascia is sharply detached from the pelvic brim (Fig. 42.13). In
certain individuals, this occasionally may be performed with finger dissection. Detaching the iliopsoas fascia
allows access to the true pelvis and subsequently the quadrilateral surface and the posterior column. A second
Penrose drain is placed around the iliopsoas; femoral nerve; and lateral, femoral, cutaneous nerve for retraction
purposes. A third Penrose is placed around the femoral vessels and lymphatics. Care should be taken to leave
undisturbed the fatty areolar tissue surrounding the vessels, as this contains the lymphatic vessels. Disrupting
the lymphatics may result in impaired postoperative lymphatic drainage and edema.
Before retraction of the external iliac vessels, the iliopectineal nerve and artery should be identified
posteromedial to the vessels. A search is made for an anomalous origin of the obturator artery from the inferior
epigastric artery or the presence of an anastomosis between the obturator and the external iliac vessels.
Whereas the presence of a venous anastomosis is relatively common, an arterial anastomosis is rare. If either of
these is present, the artery or vein or both should be clamped, ligated, and divided to prevent intraoperative
avulsion of the vessels and hemorrhage, which may be difficult to control.
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FIGURE 42.9 In this oblique section at the level of the inguinal ligament, the iliopectineal fascia separates the
lacuna musculorum and the lacuna vasorum. (Redrawn with permission from Matta JM. Surgical approaches to
fractures of the acetabulum and pelvis. Copyright Matta JM.)
FIGURE 42.10 External iliac vessels and lymphatics are dissected away from the medial aspect of the
iliopectineal fascia. The iliopsoas and femoral nerve have already been dissected away from the lateral aspect of
the fascia and are retracted by the surgeon's finger.

FIGURE 42.11 The iliopsoas and femoral nerve are retracted laterally, and the external iliac vessels are
retracted medially, exposing the iliopectineal fascia.

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FIGURE 42.12 This oblique section demonstrates the division of the iliopectineal fascia from the inguinal
ligament to the pectineal eminence. (Redrawn with permission from Matta JM. Surgical approaches to fractures
of the acetabulum and pelvis. Copyright Matta JM.)
FIGURE 42.13 Iliopectineal fascia is dissected free from its attachment to the pelvic brim. (Redrawn with
permission from Matta JM. Surgical approaches to fractures of the acetabulum and pelvis. Copyright Matta JM.)

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FIGURE 42.14 First window of the ilioinguinal approach. The internal iliac fossa is visualized. A Hohmann
retractor is placed on the anterior sacroiliac joint. (Redrawn with permission from Matta JM. Surgical approaches
to fractures of the acetabulum and pelvis. Copyright Matta JM.)

Subperiosteal dissection is used to expose the pelvic brim and superior pubic ramus. The periosteum also may
be elevated from the quadrilateral surface. Care should be taken when placing retractors near the greater sciatic
notch to avoid injury to the superior gluteal vein or branches of the internal iliac artery. The reduction and fixation
of the fracture may now be completed by working back and forth in the three visualization windows.
Medial retraction of the iliopsoas and femoral nerve allows visualization of the entire internal iliac fossa, the
sacroiliac joint, and the pelvic brim via the first window (Fig. 42.14). Lateral retraction of the iliopsoas and femoral
nerve, combined with medial retraction of the external iliac vessels, opens the second window (Fig. 42.15). This
window gives access to the pelvic brim, from the sacroiliac joint to the pectineal eminence, as well as access to
the quadrilateral surface for reduction of posterior column fractures. The pulse of the external iliac artery should
be frequently checked when working within this window. Medial retraction of the vessels gives access to the
superior ramus and symphysis pubis if required (Fig. 42.16). The spermatic cord or round ligament is retracted
medially or laterally as needed.
Limited access to the external aspect of the iliac wing may be obtained by detaching the sartorious and the
inguinal ligament from the anterior, superior, iliac spine, and elevating the tensor fascia lata muscle from the
ilium. This often facilitates placement of reduction clamps across the anterior innominate bone.
After internal fixation of the fracture, suction drains are placed in the retropubic space of Retzius as well as along
the quadrilateral surface and internal iliac fossa. The external aspect of the bone should also be drained if it has
been exposed. The abdominal fascia is sewn to the fascia lata with heavy suture. If the sartorious
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has been detached, it is repaired through a drill hole in the anterior, superior, iliac spine (Fig. 42.17). Muscular
relaxation should be used during closure, and continuous traction is required to prevent the abdominal fascia
from retracting proximally and posteriorly. If the abdominal muscles are not anatomically repaired, a sound repair
of the floor and roof of the inguinal canal is not possible. The tendon of the rectus abdominis is repaired, and the
transversalis fascia and the conjoined tendon of the internal oblique and transversus abdominis muscles are
reattached to the inguinal ligament (Fig. 42.18). The roof of the inguinal canal is repaired by closure of the
aponeurosis of the external oblique (Fig. 42.19). The iliopectineal fascia is not repaired.

FIGURE 42.15 Second window of the ilioinguinal approach. The pelvic brim and quadrilateral surface are
visualized.
Technique of Reduction and Fixation
The first objective in the treatment of an associated both-column injury is anatomically to reduce the fracture of
the anterior column. The iliac crest and wing are reduced first. The reduction of the fracture lines in the ilium
must be perfect if the articular surface is to be reduced. It is important to restore the normal concavity to the
internal iliac fossa, which is frequently greater than imagined. Often traction must be applied through the fracture
table to allow disimpaction of the iliac wing. Frequently, the iliac-wing fracture bifurcates to reach the iliac crest at
two points, creating a triangular fragment of the wing (Fig. 42.20). Because it facilitates the accurate reduction of
the anterior column, this fracture should be anatomically reduced and fixed first (Fig. 42.21). At the level of the
iliac crest, a 3.5- or 4.5-mm screw may be inserted between the tables of the ilium, which will fix the vertical or
triangular fractures (Fig. 42.22). Care must be taken when inserting these screws so reduction is not lost during
the final tightening. Alternatively, a 3.5-mm pelvic plate applied to the iliac crest may provide more reliable
fixation. This implant may be placed either in the internal iliac fossa just below the crest, or it may be located
directly on the iliac crest. Plates applied directly to the iliac crest allow the placement of long screws between the
two tables of the iliac wing. However, screws and plates in this location are a source of irritation, and this may
necessitate their removal.
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FIGURE 42.16 Third window of the ilioinguinal approach. The symphysis pubis and retropubic space of Retzius
are exposed. The spermatic cord or round ligament may be retracted medially or laterally as needed. (Redrawn
with permission from Matta JM. Surgical approaches to fractures of the acetabulum and pelvis. Copyright Matta
JM.)

FIGURE 42.17 Origins of the sartorius muscle and the abdominal muscles are secured through a drill hole in the
anterior, superior, iliac spine.

FIGURE 42.18 Inguinal ligament is repaired. Superior is the transversalis fascia and the conjoined tendon of the
internal oblique and transversus abdominis muscles. Inferior is the inguinal ligament.

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FIGURE 42.19 Aponeurosis of the external oblique is repaired, closing the roof of the inguinal canal.

FIGURE 42.20 A. Associated both-column fracture of the right acetabulum. View of the lateral aspect of the ilium.
B. Associated both-column fracture of the right acetabulum. Note the free triangular-fracture fragment at the iliac
crest. There is also a free fracture fragment at the pelvic brim. (Reprinted with permission from AO/ASIF. Both
column fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)
FIGURE 42.21 Farabeuf and Weber clamps are used in the reduction of the triangular iliac-crest fracture
fragment. (Reprinted with permission from AO/ASIF. Both column fracture through the ilioinguinal approach
[Video]. Copyright AO/ASIF Video, 1991.)

FIGURE 42.22 Screw is inserted between the tables of the ilium parallel to the iliac crest while the Weber clamp
maintains the reduction. (Reprinted with permission from AO/ASIF. Both column fracture through the ilioinguinal
approach [Video]. Copyright AO/ASIF Video, 1991.)

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FIGURE 42.23 Farabeuf and Weber clamps are used to reduce the anterior column fracture. Note that the
fracture fragment from the pelvic brim has been reduced and fixed with a single screw. The accurate reduction of
the anterior column is not possible unless the two extra-articular fracture fragments are accurately reduced and
stabilized. (Reprinted with permission from AO/ASIF. Both column fracture through the ilioinguinal approach
[Video]. Copyright AO/ASIF Video, 1991.)

FIGURE 42.24 Anterior column reduction is held with a screw placed from just lateral to the pelvic brim and
directed toward the sciatic notch. (Reprinted with permission from AO/ASIF. Both column fracture through the
ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)

Comminution of the anterior column fracture at the pelvic brim is common. Although these free cortical fragments
are extra-articular, it is imperative that they be reduced anatomically and fixed: The reduction of the anterior
column is impossible to judge without these pieces.
The anterior column fracture is then reduced. The reduction maneuver may be accomplished with the Farabeuf
clamp and ball spike (Fig. 42.23). Occasionally, clamps placed across the anterior border of the bone may be
useful. A screw placed from just lateral to the pelvic brim and directed toward the sciatic notch will hold the
reduction (Fig. 42.24). In addition, a screw may be placed between the tables of the ilium at the level of the iliac
crest (Fig. 42.25). A long-curved plate is then contoured to the superior aspect of the pelvic brim. Specialized,
precurved, pelvic plates are available with curvature radii of 88 and 108 degrees. These are designed to fit the
curvature of the typical male and female pelvic brims. This plate may extend anterior from the front of the
sacroiliac joint to the body of the pubis. The plate has a typical contour, which includes a concavity for the body
of the pubis, a convexity over the pectineal eminence, and a concavity for the internal iliac fossa (Fig. 42.26). In
addition, the plate must be twisted to match appropriately the contour of the ilium. Contouring of the plate is
frequently time-consuming. It is important that the plate fits the bone as perfectly as possible to avoid loss of
fracture reduction.

FIGURE 42.25 Additional 3.5-mm screw is placed between the tables of the ilium at the level of the iliac crest.
(Reprinted with permission from AO/ASIF. Both column fracture through the ilioinguinal approach [Video].
Copyright AO/ASIF Video, 1991.)

FIGURE 42.26 Curved pelvic plate is contoured to the innominate bone. Shown is the concavity at the superior
ramus, the convexity at the pectineal eminence, and the concavity of the internal iliac fossa. (Reprinted with
permission from AO/ASIF. Both column fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF
Video, 1991.)

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FIGURE 42.27 Posterior column fracture is reduced with the use of an angled reduction clamp placed entirely
within the second window of the approach. The iliopsoas and femoral nerve are retracted laterally, the external
iliac vessels are retracted laterally, and the external iliac vessels are retracted medially. One point of the
reduction clamp is on the anterior wall, and the other is on the quadrilateral surface. (Reprinted with permission
from AO/ASIF. Both column fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)

The posterior column is then reduced with the use of an angled reduction clamp, restoring the profile of the
greater notch. The reduction clamp is usually placed entirely within the second window of the approach (Fig.
42.27), but occasionally a large clamp placed across the anterior border of the bone is helpful. In most cases, the
quadrilateral surface is attached to the posterior column, and the accuracy of the posterior column reduction may
be assessed by inspecting the reduction of the quadrilateral surface to the anterior column. The posterior column
fixation is achieved by screws placed parallel to the quadrilateral surface (Fig. 42.28). These screws may be
placed either inside or separate from the pelvic brim plate and used to achieve fixation in the retroacetabular
surface (Fig. 42.29). In addition, a screw started on the anterior pillar of the lateral surface of the ilium and
directed obliquely toward the quadrilateral surface may be used. This screw may also be used in situations in
which a separate fragment of the quadrilateral surface requires fixation. Comminuted fragments of the
quadrilateral surface are frequently encountered, but these pieces usually make up a portion of the cotyloid
fossa and do not contribute to the direct articular portion of the joint or to hip stability. Plates contoured over the
pelvic brim and onto the quadrilateral surface are not routinely used.
FIGURE 42.28 Posterior column is held reduced with an angled reduction clamp. The screw is placed through
the plate and parallel with the quadrilateral surface. (Reprinted with permission from AO/ASIF. Both column
fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)

FIGURE 42.29 Posterior column fixation achieves purchase in the retroacetabular surface of the ilium. Tips of
the two screws inserted through the pelvic brim plate (red pointer). (Reprinted with permission from AO/ASIF.
Both column fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)

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FIGURE 42.30 Reduction of the articular surface is never directly visualized. (Reprinted with permission from
AO/ASIF. Both column fracture through the ilioinguinal approach [Video]. Copyright AO/ASIF Video, 1991.)

An extended posterior-wall fracture, if present, can be addressed by developing the exposure to the lateral
surface of the ilium. A large reduction clamp placed across the anterior innominate bone can be used to reduce
the posterior wall. This fracture can be fixed with obliquely orientated screws placed from just lateral to the pelvic
brim and directed posteriorly toward the superior extension of the ilium. However, it is imperative to use the
image intensifier to confirm an extra-articular screw location.
Impacted areas of articular cartilage are frequently encountered, especially with medial displacement of the
femoral head. The lateral traction device on the Judet-Tasserit table may be used to position the femoral head
beneath the intact segment of articular surface. The femoral head may then be used as a mold for the reduction
of the impacted segments. The disimpaction of such fragments is performed through the anterior column or
quadrilateral surface fracture lines.

TECHNICAL NOTE
Final reduction of the articular surface of the acetabulum cannot be directly visualized but is assumed to be
correct after anatomic restoration of the internal contour of the innominate bone (Fig. 42.30). The image
intensifier is a valuable adjunct to ensure both the proper orientation of screws near the acetabulum and the
perfect reduction of the articular surface. An AP pelvis radiograph should be obtained in the operating suite to
confirm the adequacy of reduction. Before the patient is discharged from the hospital, AP and 45-degree oblique
views of the pelvis are obtained to document reduction and fixation. If there is any suspicion that hardware may
be intra-articular, fluoroscopic examination can be a valuable tool. The x-ray beam may be directed exactly
parallel to any screw to document its location. Occasionally, a postoperative CT scan may give additional
information regarding the fracture reduction or hardware placement, but this is not routinely performed.

POSTOPERATIVE MANAGEMENT
Prophylactic antibiotic coverage with a first-generation cephalosporin and gentamicin is continued for 72 hours
after surgery. The suction drains are generally removed at 48 hours or when drainage has ceased.
Anticoagulation therapy follows a previously described protocol. All patients are screened with Doppler
ultrasound for possible deep venous thrombosis (DVT) at the time of admission. Those positive for DVT receive
a caval filter. If no DVT is present, mechanical sequential-compression devices are applied preoperatively and
left continually throughout the patient's hospital course. An adjusted-dose warfarin (Coumadin) regimen is begun
on the 2nd postoperative day and continued for 6 weeks.
A partial weight-bearing gait protocol is initiated, and weight bearing is limited to 30 pounds until 8 weeks after
the operation. Standing active-motion exercises of the hip are encouraged during this time. At 8 weeks after
surgery, weight bearing is advanced to full, and active-motion exercises against resistance are begun. An
emphasis is placed on strengthening the hip flexors and abductors. No heterotopic bone prophylaxis is
necessary.
After discharge, patients are seen in follow-up at 3 weeks, 3 months, 6 months, 1 year, and yearly thereafter. An
AP pelvis radiograph is obtained at each visit. If loss of reduction or early posttraumatic arthritis is suspected,
then Judet obliques may be obtained as well.
Patients are generally able to return to work in 4 to 6 months; if heavy labor is involved, they may return to work
in 6 months. They usually return to recreational activities by 6 months and to vigorous athletics by 1 year.
Although the majority of patients with acetabular fractures will report that their hip never feels entirely normal.
Seventy percentage are eventually able to return to their previous level of function.
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COMPLICATIONS
Complications with the ilioinguinal approach involve primarily neurovascular injuries. The lateral, femoral,
cutaneous nerve is the most frequently injured nerve, resulting in lateral thigh paresthesia or numbness.
Injuries to the femoral nerve are usually stretch injuries, attributable to vigorous retraction of the iliopsoas
and femoral nerve. Sciatic nerve injuries are due to either placement of retractors in the sciatic notch or
direct nerve injury by a drill. Lymphatic complications and postoperative thigh edema are avoidable if the
perivascular tissue surrounding the external iliac vessels is left undisturbed. The potential exists for direct
laceration of the external artery and vein. In addition, overzealous retraction of the vessels may produce an
intimal injury of the external iliac artery and subsequent arterial thrombosis. Careful palpation of the arterial
pulse throughout surgery is critical. Postoperatively, the peripheral pulses should be monitored for 24 hours
to identify any evolving vascular compromise.
In his early series, Letournel found a 30% incidence of surgical wound infections. With the routine use of
prophylactic antibiotics and closed suction drainage of the space of Retzius, however, surgical infection
rates have significantly decreased. With restoration of the internal contours of the innominate bone, the hip
joint is not immediately in direct connection with the infection. Routine exploration of the hip joint is not
performed unless clinical signs and symptoms lead one to suspect an intra-articular infection. Deep wound
infection, when encountered, is managed by repeated exploration of the wound, irrigation, débridement, and
closure over drains. Appropriate broad-spectrum antibiotic coverage is used until culture results are
obtained and direct coverage is possible.
Postoperative inguinal hernia may complicate incomplete or inadequate repair of the inguinal canal. Careful
dissection of the floor of the inguinal canal during exposure should leave sufficient tissue for a sound repair.
Letournel reported significant abdominal-wall hernias in only 1.1% of their patients.
FIGURE 42.31 A. AP pelvis, (B) obturator oblique, and (C) iliac oblique radiographs of an associated both-
column acetabulum fracture.

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 FIGURE 42.32 AP pelvis radiograph at 4-year follow-up. The fracture is healed, and the hip joint is rated
excellent based on both radiographic and clinic examination.

ILLUSTRATIVE CASES FOR TECHNIQUE

A 24-year-old woman was involved in a motor vehicle accident, sustaining an associated both-column fracture of
the acetabulum. AP pelvis and 45-degree oblique radiographs are shown in Figure 42.31. The patient underwent
open reduction and internal fixation of her fracture through the ilioinguinal approach. An AP radiograph at the 4-
year follow-up showed that the fracture healed with maintenance of the hip joint (Fig. 42.32). Her hip function
was normal.

RECOMMENDED READING
Fishman Al, Greeno RA, Brooks LR, et al. Prevention of deep venous thrombosis and pulmonary embolism in
acetabulum and pelvic fracture surgery. Clin Orthop 1994;305:10-19.

Gänsslen A, Krettek C. Internal fixation of acetabular both-column fractures via the ilioinguinal approach.
Oper Orthop Traumatol 2009;21(3):270-282.

Hessmann MH, Ingelfinger P, Dietz SO, et al. Reconstruction of fractures of the anterior wall and the anterior
column of the acetabulum using an ilioinguinal approach. Oper Orthop Traumatol 2009;21(3):236-250.

Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open
reduction. J Bone Joint Surg Am 1964;46:1615-1646.

Langford JR, Trokhan S, Strauss E. External iliac artery thrombosis after open reduction of an acetabular
fracture: a case report. J Orthop Trauma 2008;22(1):59-62.

Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop
1993;292:62-76.

Matta JM. Fracture of the acetabulum: accuracy of reduction and clinical results in patients managed
operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632-1645.

Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year
perspective. J Orthop Trauma 2006;20(1 Suppl):S20-S29.

Teague DC, Graney DO, Routt ML Jr. Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric
and clinical study. J Orthop Trauma 1996;10(3):156-159.
 43
Acetabular Fractures: Extended Iliofemoral Approach
David L. Helfet
Milan K. Sen
Craig S. Bartlett
Nicholas Sama
Arthur L. Malkani

INTRODUCTION
Over the past 30 years, advances in surgical approaches, reduction techniques, surgical implants, as well as the
preoperative and postoperative evaluation of acetabular fractures have led to a dramatic improvement in the
outcomes of these difficult injuries. Despite this, the management of these fractures continues to be a
challenging problem for the orthopedic surgeon, in part due to the complex anatomy of the pelvis and
acetabulum. The primary goal in the surgical treatment of acetabular fractures is an accurate reduction of the
articular surface in order to obtain a congruent hip joint, restoring normal joint mechanics. This is no different
from the management of other intra-articular fractures and is especially true for the weight-bearing joints. In the
case of the hip joint, malreduction leads to abnormal loading of the articular cartilage, eventually progressing to
painful posttraumatic arthrosis and loss of function.

INDICATIONS AND CONTRAINDICATIONS

The indications for operative fixation of acetabular fractures in general include displacement of the articular
surface, incongruence of the joint, unacceptable roof arc measurements, incarceration of an intra-articular
fragment within the joint, and subluxation of the femoral head. The timing of surgery is dependent upon several
factors including the availability of an experienced surgeon; management of associated visceral, skeletal, and
soft-tissue injuries; and completion of all imaging studies necessary for preoperative planning. Special situations
arise such as in the case of an incarcerated intra-articular fragment, an unreducible femoral head dislocation, or
a femoral head fracture, which mandate more urgent intervention to prevent further damage to the articular
cartilage or minimize the risk of avascular necrosis of the femoral head. Conversely, a Morel-Lavalle lesion
deserves special attention and may delay operative management of the acetabular fracture.
The selection of the proper surgical approach for acetabular exposure may not be straightforward and is largely
dependent on the particular fracture pattern and the experience of the surgeon. Mayo identified five factors that
affect the choice of surgical approach: (a) the fracture pattern, (b) the condition of the soft tissues, (c) the
presence of associated major systemic injuries, (d) the age and projected functional status of the patient, and (e)
the delay from injury to surgery. Although elaborate, the Letournel-Judet classification system is clinically useful
in this regard. Associated injuries to the pelvic ring must also be considered when determining the surgical
approach.
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FIGURE 43.1 The extended iliofemoral approach for exposure of a comminuted left both-column acetabular
fracture. (i ) Femoral head. (ii ) Abductor muscles and tensor fascia lata. (iii ) Schanz pin in greater trochanter
parallel with femoral neck.

Typically, extensile approaches are not the first choice for any fracture. However, they are necessary when
simpler approaches are inadequate. For example, infection rates with the ilioinguinal approach increase rapidly
in the presence of nearby suprapubic catheters, bladder ruptures, and colostomies. Similarly, an extensile
approach is preferred in selected associated complex fracture patterns or delayed surgical treatment of an
acetabular fracture. Complex fracture patterns often require exposure of both the anterior and posterior columns
for adequate visualization and reduction. In these cases, an extensile approach will provide adequate access to
the roof of the acetabulum in order to anatomically restore its articular surface. The extended iliofemoral
approach was developed by Letournel in 1974. It is one of the three most widely used surgical approaches used
to gain access to the acetabulum, the others being the Kocher-Langenbeck and the ilioinguinal.
The extended iliofemoral approach allows access to both columns of the acetabulum. This includes the lateral
aspect of the iliac wing, the internal iliac fossa, and the retroacetabular surface. It is an anatomic approach that
follows an internervous plane, reflecting anteriorly the muscles innervated by the femoral nerve and posteriorly
the muscles supplied by the superior and inferior gluteal nerves. The posterior flap is mobilized as a unit without
damaging its neurovascular bundles (Fig. 43.1).
There are three main stages to the dissection: (a) elevation of all the gluteal muscles with the tensor fascia lata,
(b) division of the external rotators of the hip, and (c) an extended capsulotomy along the lip of the acetabulum.
The end result is complete exposure of the outer aspect of the ilium and the whole posterior column inferiorly to
the upper part of the ischial tuberosity. Furthermore, the approach may be extended to allow a limited exposure
of the internal iliac fossa and the anterior column to the level of the iliopectineal eminence. This allows
simultaneous exposure of both columns and permits direct visualization of the reduction and fixation of the
anterior and posterior columns (Fig. 43.2). The articular surface of the acetabulum along with the femoral head
may also be visualized if this approach is combined with a surgical dislocation of the hip.
In addition to the approach described and popularized by Letournel, several authors describe alternative
approaches. Senegas et al. described a transtrochanteric approach that allows limited exposure of the anterior
column above the supraacetabular region. Mears and Rubash popularized the triradiate approach. These latter
two approaches require osteotomy of the greater trochanter that carries the risk of nonunion and has been
associated with an increased risk of heterotopic ossification (HO) by some authors. In addition, the triradiate
approach leaves in place a segment of gluteus maximus, preventing mobilization of the superior gluteal
neurovascular bundle. This hinders access to the sacroiliac joint and the posterior ilium adjacent to the posterior-
superior iliac spine. Thus, for most applications, the preferred and only truly extensile approach is the extended
iliofemoral. Another modification of this approach has been described by Reinert. It uses a T-shaped skin incision
with osteotomies of the iliac crest, greater trochanter, and the anterior-superior iliac spine (ASIS).
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Some authors have had success using this modification of the extended iliofemoral approach, claiming that it
improves the operative exposure in T-type, complex transverse, and both-column acetabular fractures and
malunions. Posterior extension of this exposure also allows for fixation of sacroiliac joint injuries. The
disadvantage is the extent of the bony osteotomies, often needed for fixation, and often unnecessary.

FIGURE 43.2 Access to the right pelvis via the extended iliofemoral approach. A. Lateral (outer) bony pelvis. B.
Medial (inner) bony pelvis.

Specific indications for the extended ilioinguinal approach include (a) high (transtectal) transverse and “T”-type
fracture patterns with the involvement of the weight-bearing dome (Fig. 43.3), (b) associated anterior column and
posterior hemitransverse fractures, (c) associated both-column fractures, with a posterior wall or a comminuted
posterior column, lateral dome involvement (Fig. 43.4), or extension into the sacroiliac joint, and (d) transverse or
associated fractures where treatment has been delayed. Matta also considers this approach in certain
transverse posterior wall fractures, such as those involving an extended posterior wall component where
disruption of the retroacetabular surface makes it difficult to assess reduction though a Kocher-Langenbeck
approach alone. Recently, this approach has also been adapted for use in acetabular revision arthroplasty.
With delays in the time from injury to surgery, the usefulness of approaches such as the ilioinguinal or Kocher-
Langenbeck diminishes because of limited joint visualization, organization of the hematoma, increased formation
and maturation of callus, and difficulty mobilizing and reducing the fracture lines. Technical problems escalate at
approximately 2 weeks after injury with the ability to obtain an anatomic reduction dropping from 75% to 62% of
cases by the 3rd week. This is due to the increasingly difficult task of meticulously taking down varying amounts
of callus, which progressively interfere with the anatomical reduction of all fractured segments of iliac crest and
acetabulum. Even in experienced hands, the results of late surgical reconstruction of acetabular fractures have
excellent or good results in only 65.5% of cases. Therefore, to improve the likelihood of achieving an anatomic
reduction, the extended iliofemoral approach is the preferred surgical approach for the most complex acetabular-
fracture cases in which surgery has been delayed more than 2 to 3 weeks. The major technical limitation of the
extended iliofemoral exposure is access to the lower portion of the anterior column (Figs. 43.2 and 43.5).
Dissection medial to the iliopectineal eminence becomes more difficult where the psoas muscle and iliopectineal
fascia block exposure. While a psoas tenotomy can increase visualization, the risk of injury to the femoral artery
and nerve must be considered.

FIGURE 43.3 A 28-year-old man with right transtectal ischial T-type acetabular fracture. A. Preoperative AP
pelvis. B. Postoperative AP pelvis.

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FIGURE 43.4 An 18-year-old woman with a both-column right acetabular fracture. A. AP pelvis. B. Iliac oblique
view. C. Obturator oblique view.

There are some relative contraindications to the extended iliofemoral approach. Blunt trauma to the gluteal
muscle mass and peritrochanteric region is probably the most common cause for concern. Contusions and
abrasions in this area are often associated with the Morel-Lavalle lesion, an area of fluctuance secondary to fatty
necrosis and a hematoma that develops under the degloved skin and subcutaneous tissues around the hip. The
Morel-Lavalle lesion requires surgical débridement and drainage before internal fixation and is associated with a
higher infection rate. Other relative contraindications to the extended iliofemoral approach include the presence
of a closed-head injury, which may lead to massive HO. Extensile approaches are generally avoided in the
elderly because of the prolonged operative time, extensive blood loss, prolonged rehabilitation, and increased
risk of infection and HO. Finally, the presence of a superior gluteal vascular injury makes this approach less
desirable because ligation of the lateral femoral circumflex artery during the dissection removes a major source
of collateral circulation to the abductor musculature, although this remains controversial.
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FIGURE 43.5 Maximal exposure of right acetabulum via the extended iliofemoral approach. (i ) Gluteus medius
muscle. (ii ) Gluteus minimus muscle. (iii ) Blunt Homan in lesser sciatic notch. (iv) Greater trochanter. (v) Tensor
fascia lata muscle. (vi ) Malleable retractor under the iliacus muscle. (vii ) Superior-gluteal neurovascular bundle.
(viii ) Piriformis muscle. (ix) Sciatic nerve. (x) Pointed Homan retractor over the anterior capsule of the hip. (xi )
Hip joint capsule.

PREOPERATIVE PLANNING
The preoperative evaluation begins with a thorough history and physical examination as well as an appropriate
trauma workup to identify any associated skeletal and visceral injuries. An accurate neurologic examination is
mandatory, as the incidence of sciatic nerve injury after acetabular fractures ranges from 12% to 38%. An
accurate diagnosis of the fracture and its subsequent classification can be accomplished with three basic
roentgenograms described by Judet et al. and include an anteroposterior (AP) view of the pelvis, an iliac oblique
view, and an obturator oblique view of the acetabulum. These three roentgenographic views provide sufficient
information to allow the surgeon to outline the fracture pattern on a pelvic model as part of the preoperative plan.
Conventional computed tomography (CT) scans with axial views provide additional information as to the extent of
injury to the acetabulum (Fig. 43.6A), especially identification of posterior-wall fractures, rotation of the columns,
the presence of intra-articular fragments or femoral head fractures, and the assessment of articular
displacement. Axial CT scans also can identify associated injuries to the posterior aspect of the pelvis such as a
sacroiliac-joint disruption and sacral fractures. Thin (1 to 2 mm) cuts should be used, along with sagittal and
coronal reformatting to thoroughly evaluate the fracture pattern preoperatively. Advances in imaging software
technology have led to the development of three-dimensional computerized tomography (3D CT), which provides
an even better understanding of the spatial relation of the fracture pattern relative to the pelvis (Fig. 43.6B).
Trauma patients, especially those with lower extremity/pelvic injuries, are at extremely high risk for developing
deep vein thrombosis (DVT), as high as 60% in some series. We screen all of our acetabular fracture patients for
DVT and treat them with compression boots and subcutaneous low-molecular weight heparin if a delay in
surgery is anticipated. Our preferred method of screening is magnetic resonance venography, which we had
found to be extremely sensitive and reliable. Patients with an increased risk of DVT or those with documented
DVT preoperatively are managed with a vena cava filter and intravenous heparin before surgery.
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FIGURE 43.6 CT of pelvis of patient in Figure 43.4. A. Axial view revealing significant dome comminution. B.
Three-dimensional reconstruction facilitating perception of configuration.

SURGERY
Surgical Anatomy
The physician performing an extended iliofemoral approach requires special training and a familiarity with the
complex anatomy of the pelvis, particularly the many neurovascular structures that are encountered. Those
structures that require identification are listed below.
Sciatic Nerve. The sciatic nerve is at risk during exposure of the posterior column and must be identified, as in
the Kocher-Langenbeck approach, along the belly of the quadratus femoris muscle. Traction along the nerve
should be minimized by maintaining the hip in extension with the knee flexed at all times.
Lateral Femoral Cutaneous Nerve. The lateral femoral cutaneous nerve is at risk during exposure of the ASIS. It
is also very susceptible to a traction injury during mobilization of the soft tissues. Patients should be warned
preoperatively of the significant risk of numbness, in the anterolateral thigh, after this exposure.
Superior Gluteal Neurovascular Bundle. The superior gluteal neurovascular bundle is at risk during exposure of
the greater sciatic notch and must be protected from undue traction or penetration by retractors.
Femoral Neurovascular Structures. The medial margin of the extended iliofemoral approach is the iliopsoas
muscle and the iliopectineal eminence. Further medial dissection without an ilioinguinal incision places the
femoral neurovascular structures at risk.
Pudendal Nerve. The pudendal nerve is at risk as it exits the pelvis through the greater sciatic notch, wraps
around the ischial spine, and travels back into the pelvis through the lesser sciatic notch.

Operating Room Preparation

General or spinal anesthesia is administered. We prefer the continuous epidural anesthesia as it provides
improved postoperative pain relief. The patient is supported on a beanbag and placed in the lateral decubitus
position on a radiolucent operating table or fracture table, depending on the surgeon's preference. Before
surgery, a Foley catheter is placed in the patient's bladder. Vascular access in two separate sites with large-bore
catheters is important for these lengthy procedures in which significant blood loss is common. The patient's age
and medical condition often dictate placement of an arterial or central line. We routinely use an intraoperative cell
saver to minimize transfusion requirements. This permits recycling of about 20% to 30% of the effective blood
loss and is best used when blood loss of more than 2 L is expected.
The hip is kept extended, and the knee flexed throughout the procedure to minimize sciatic nerve injury. In
addition, intraoperative sciatic nerve monitoring with spontaneous electromyography (EMG) and somatosensory
evoked potentials (SSEP) is used in all cases. The entire pelvis, hip, abdomen, and involved extremity are
prepped free, and sterile subdermal electrodes are inserted. The sensory electrodes are inserted adjacent to the
common peroneal and posterior tibial nerves and the motor adjacent to the tibialis anterior, peroneus longus,
abductor hallucis, and flexor hallucis brevis. The ground is inserted in the heel.
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FIGURE 43.7 Inverted “J” skin incision, right side.

Surgical Approach
The incision is in the form of an inverted “J” (Fig. 43.7) and begins at the posterior-superior iliac spine, extending
along the iliac crest toward the ASIS. From here, the distal arm of the incision proceeds along the anterolateral
aspect of the thigh for a distance of 15 to 20 cm (Fig. 43.8). There is a tendency for the surgeon to make this arm
more medial than desired. To avoid this, one should visualize a point 2 cm lateral to the superolateral pole of the
patella. With the leg held in neutral rotation, this location is generally in line with the desired incision.
Furthermore, a gentle curve posteriorly may be helpful in more obese patients.

FIGURE 43.8 Anterolateral view, right side. The inverted-J skin incision with distal extension for the extended
iliofemoral approach.

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FIGURE 43.9 Subfascial exposure of right iliac crest and anterior distal limb. (i ) Avascular white line. (ii ) Fascia
covering tensor fascia lata muscle. (iii ) Fascia covering sartorius muscle.

The fascial periosteal layer at the iliac crest is identified (Fig. 43.9) and divided sharply along its avascular “white
line,” where bleeding will be minimized. Often it is easiest to start in the area of the gluteus medius tubercle
where landmarks are more obvious and to progress posteriorly and anteriorly from this point. Posteriorly, the
strong fibrous origins of the gluteus maximus should be sharply released from the crista glutei. Depending on the
starting location, the tensor fascia lata muscle and the gluteus medius are subperiosteally released in a stepwise
fashion from the outer aspect of the iliac crest (Fig. 43.10). Using an elevator, the musculature along the external
surface of the iliac wing is released up to the superior border of the greater sciatic notch and anterosuperior
aspect of the hip joint capsule (Fig. 43.11). During this segment of the exposure, care must be taken to identify
the superior gluteal neurovascular bundle, which is at risk as it exits from the notch.
Attention turns next to the anterior portion of the approach (Fig. 43.9). The distal limb of the incision is carried
over the fascia covering the tensor fascia lata muscle and the muscle sheath entered. It is important to stay
within the bounds of the sheath, as this will keep the dissection lateral to the lateral femoral cutaneous nerve,
sparing the majority of its branches. It is often helpful to open the sheath from distal to proximal. Next, the tensor
fascia muscle is reflected off its fascia and retracted laterally and upward to expose the floor of the sheath and
fascia overlying the rectus femoris muscle (Fig. 43.10). Small vessels from the superficial circumflex artery are
divided and coagulated close to the bone between the superior and inferior spines. Distally, the incision must be
long enough to expose the inferior aspect of the muscle belly. This facilitates further release of the gluteal
muscles from the crest. The fascia overlying the rectus muscle is divided longitudinally and horizontally, and its
reflected head and direct heads retracted downward and medially to expose a very strong aponeurosis (the “no
name” fascia) over the vastus lateralis muscle (Fig. 43.10). When the rectus is retracted, a constant small
vascular pedicle reaching the lateral border of the muscle always requires coagulation. The aponeurosis can be
divided longitudinally to expose the ascending branches of the lateral circumflex vessels, which must be isolated
and ligated (Fig. 43.11). Should the upper portion of this exposure be unnecessary, these vessels can
occasionally be spared. Next, the thin sheath of the iliopsoas muscle is exposed and longitudinally incised. This
allows the use of an elevator to strip the fibers of the psoas from the anterior and inferior aspects of the hip
capsule. The exposure of the iliac wing is complete when the reflected head of the rectus femoris is sharply
released from its insertion. The gluteus minimus tendon is identified as it inserts into the anterior edge of the
greater trochanter and tagged and transected, leaving a 3- to 5-mm cuff for repair (Figs. 43.10 and 43.11). The
gluteus minimus muscle also has extensive attachments to the superior aspect of the hip capsule that may need
to be released. Posteriorly and superiorly, the gluteus medius tendon, measuring 15 to 20 mm in length, is also
isolated, tagged, and transected, leaving a 3- to 5-mm cuff (Figs. 43.11 and 43.12). It is important to transect and
tag these structures sequentially and carefully for subsequent reattachment. The tensor fascia lata and gluteal
muscles are held in continuity as a flap and reflected posteriorly to expose the external rotators and sciatic nerve
(Fig. 43.12).
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FIGURE 43.10 Subfascial reflection of tensor fascia lata and abductor muscle origins from right iliac crest. (i )
Avascular white line. (ii ) Tensor fascia lata muscle. (iii ) Gluteus medius muscle. (iv) Gluteus minimus muscle. (v)
Rectus femoris muscle. (vi ) Sartorius muscle. (vii ) No-name fascia covering vastus lateralis. (viii ) Ascending
branch of the lateral, femoral, circumflex artery.

FIGURE 43.11 Proximally, the abductor and tensor fascia lata muscles have been stripped subperiosteally from
the outer table of the right ileum. Distally, the ascending branch of the lateral circumflex artery has been ligated.
The abductor insertions have been marked for release. (i ) Tensor fascia lata muscle. (ii ) Gluteus medius muscle.
(iii ) Gluteus minimus muscle. (iv) Greater trochanter. (v) Piriformis muscle. (vi ) Hip joint capsule. (vii ) Two heads
of the rectus muscle. (viii ) Ligated ascending branch of the lateral, femoral, circumflex artery.

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FIGURE 43.12 Abductors of the right hip have been tagged and their insertions into the greater trochanter
released, allowing their muscle pedicle to be retracted to expose the sciatic nerve. The external rotators also
have been marked for release. (i ) Gluteus minimus tendon. (ii ) Gluteus medius tendon. (iii ) Gluteus maximus
tendon. (iv) Superior-gluteal neurovascular bundle. (v) Sciatic nerve. (vi ) Piriformis and conjoint tendons. (vii )
Hip joint capsule. (viii ) Greater trochanter. (ix) Quadratus femoris.

Alternatively, a trochanteric osteotomy may be performed. It is recommended to predrill and insert the
trochanteric fixation to facilitate later repair. When performing the osteotomy, it is important to remain superficial
to the piriformis fossa. Leaving a posterior shelf of bone just behind the osteotomy protects the deep branch of
the medial femoral circumflex artery. The tendons of the piriformis muscle, obturator internus muscle, and the
inferior and superior gemelli muscles are tagged and transected as in the Kocher-Langenbeck approach (Figs.
43.12 and 43.13). The tendinous femoral insertion of the gluteus maximus is identified, tagged, and released with
a cuff for repair (Fig. 43.13). It cannot be overemphasized that the quadratus femoris and its blood supply to the
femur via the ascending branch of the medial femoral circumflex artery must be preserved. The dissection is now
complete (Fig. 43.1).
The piriformis muscle can be followed toward the greater sciatic notch and the obturator internus muscle to the
lesser sciatic notch. A Hohmann or sciatic nerve retractor is then placed into the lesser notch, allowing complete
exposure to the posterior column of the acetabulum. The surgeon must ensure that the tendon of the obturator
internus maintains its position in the lesser notch between the sciatic nerve and the retractor. Should additional
retraction be required, a blunt Hohmann is gently placed into the greater sciatic notch, knowing that there is no
structure protecting the nerve. The distal portion of the posterior column can be visualized to the ischial
tuberosity, by using sharp dissection of the origin of the hamstring muscles proximally, if necessary.
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FIGURE 43.13 Retraction of right-hip external-rotator muscles and release of gluteus maximus insertion distally.
Medially, the anteriorsuperior and anterior-inferior iliac spines have been marked for either release or osteotomy.
(i ) Blunt Homan in lesser sciatic notch. The conjoint tendons have been positioned between the retractor and the
sciatic nerve. (ii ) Gluteus minimus tendon. (iii ) Gluteus medius tendon. (iv) Partial release of gluteus maximus
tendon. (v) Anterior-superior iliac spine and sartorius muscle origin. (vi ) Piriformis muscle. (vii ) Sciatic nerve.
(viii ) Anterior-inferior iliac spine and reflected head of rectus femoris muscle.

Although medial exposure of the anterior column is limited by the iliopsoas muscle and the iliopectineal fascia
(Figs. 43.2, 43.9, and 43.13), further access to the internal iliac fossa and acetabulum is possible. This is
obtained by subperiosteal dissection beneath the sartorius and direct head of the rectus or by osteotomizing the
superior and inferior iliac spines, which will, respectively, release these muscles (Figs. 43.5 and 43.13). The
insertion of the external oblique muscle onto the crest can also be subperiosteally released to reveal the inner
table of the pelvis, which is further exposed by stripping off the iliacus muscle with a periosteal elevator.
However, extensile exposure of the outer and inner tables of the iliac wing, especially in the presence of local
fractures, will create a risk of iliac-bone devascularization. Although devascularization of the iliac wing is rare,
Matta warned of its occurrence, especially in associated both-column fractures. To avoid devascularization of the
iliac bone in this case, he suggested leaving the direct head of the rectus femoris and anterior hip capsule
attached to the anterior column as a minimum. Also of concern with this exposure is the blood supply to the dome
of the acetabulum, which is at risk during dissection of the anterior-inferior iliac spine.
Displaced acetabular fractures often tear the hip joint capsule. If not present, exposure of the acetabular articular
surface can be obtained with a marginal capsulotomy, leaving a cuff of tissue for repair. Once the hip joint is
exposed, distraction with either a Schanz screw placed into the femoral head or a femoral distractor will facilitate
visualization (Figs. 43.1 and 43.14). This is important to evaluate the articular reduction, remove any
incarcerated osteochondral fragments, and rule out any intra-articular hardware. Once the exposure of the
extended iliofemoral approach has been completed, the fracture can be reduced according to the preoperative
plan. It is important to keep the soft-tissue flaps moist with wet sponges and periodic irrigation throughout the
procedure.
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FIGURE 43.14 Close-up of acetabular-joint exposure of patient in Figure 43.1. ( i ) Femoral head. ( ii ) Loose
articular fragments.

REDUCTION TECHNIQUE
Several regions of bone are optimal for screw placement. These include the iliac crest, the superogluteal ridge,
the greater sciatic buttress (above the sciatic notch and to the anterior-inferior iliac spine), the anterior column,
and the posterior column. Extra-long screws, ranging from 50 to 120 mm, should be available.
In a transverse fracture, there may be rotational malalignment of the inferior portion of the acetabulum. In the T-
type fracture patterns, the anterior and posterior fragments may be separate, and both columns become
displaced and malrotated. Usually, the anterior segment has medial displacement of its inferior portion so that the
radius of curvature of the acetabulum is greater than that of the femoral head. In both transverse and T-type
acetabular fractures, reduction is achieved with a pelvic-reduction clamp attached to 4.5-mm screws, placed
proximal and distal to the posterior-column fracture. The pelvic-reduction clamp initially allows distraction to
débride of the fracture surfaces and then facilitates manipulative reduction of the fracture. A bone spreader in the
fracture site can also facilitate exposure of the fracture or the joint (Fig. 43.15A). Additional control of rotation is
provided by a Schanz screw placed into the ischium and a pelvic clamp in the greater sciatic notch.
For the reduction of the T-type and more-comminuted variants, the anterior column should be reduced first with
respect to the residual acetabular “roof” portion of the ilium. The adequacy of reduction of the posterior column
can be visualized by direct assessment of the articular surface and also with digital palpation through the greater
and lesser sciatic notches. Before definitive reduction, a gliding hole can be inserted into the proximal aspect of
the posterior column from superior to inferior (Fig. 43.15B), assuring the position of the gliding hole in the middle
of the posterior column. A gliding hole can also be inserted from the lateral aspect of the iliac wing into the
anterior column, distal, and medial to the articular surface. Generally, this requires the insertion of a lag screw 6
cm proximal to the superior aspect of the articular surface and 2 cm posterior to the gluteal ridge. The lag screw
is then angled from posterosuperior to anteroinferior directly down the superior pubic ramus to secure the
anterior column of the acetabulum. In large individuals, this can be accomplished with a 4.5-mm cortical screw. In
women and small individuals, a 3.5-mm cortical screw is preferred. Care must be taken to assure that this screw
remains extra-articular and also does not penetrate the anterior aspect of the superior ramus in the area of the
iliopectineal eminence where the femoral vessels are in close proximity. The use of intraoperative fluoroscopy for
the insertion of this screw is highly recommended. Proper placement of pelvic-reduction forceps with respect to
the plane of the fracture and geometry of the osseous surfaces is crucial for an adequate reduction. A variety of
instruments are available to facilitate reduction. These include narrowcurved osteotomes, bone hooks, ball spike
pushers, “King-Tong” and “Queen-Tong” forceps, and the Farabeuf and pointed reduction clamps (Fig. 43.15C).
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FIGURE 43.15 Steps to fracture reduction of the right both-column acetabular fracture in Figures 43.4 and 43.6.
A. Laminar spreader in fracture site, exposing joint to allow débridement of loose intra-articular fragments and
callus. ( i ) Femoral head in joint. ( ii ) Superolateral dome fragment with capsular attachments. ( iii ) Greater
trochanter. ( iv) Intact iliac wing. B. Predrilling the gliding hole for the anterior-to-posterior column screw. C. Use
of a Farabeuf clamp affixed to screws to reduce the anterior column to the superolateral fragment and a pelvic
reduction clamp affixed to screws to reduce the anterior-to-posterior column (posterior-column portion not
shown).

To ensure an anatomic reduction of the acetabulum, the surgeon should work from the periphery toward the
acetabulum (Fig. 43.16), by reducing each fracture fragment sequentially. Once the iliac wing is stabilized with
lag screws, by 3.5-mm laterally applied reconstruction plates, or both, the posterior column is reduced to the iliac
wing with direct visualization of the acetabular articular surface. The posterior-column lag screw and 3.5-mm
reconstruction plate fixation is utilized for transverse and T-type fractures. The anterior column is then reduced to
the intact posterior column. This can be accomplished with anterior-to-posterior 4.5-mm lag screws inserted from
the anterior-superior spine into the sciatic buttress or anterior-column lag screws from the lateral aspect of the
iliac wing as described previously, or both. The adequacy of the reduction is assessed, both by direct
visualization of the acetabulum, with finger palpation of the greater and lesser sciatic notches and quadrilateral
plate, and, if necessary, in the internal iliac fossa. The use of fluoroscopy is essential to assure the adequacy of
reduction and the position of the fixation (Fig. 43.17).
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FIGURE 43.16 Reconstruction of comminuted left bothcolumn acetabular fracture shown in Figures 43.1 and
43.14. Reconstruction proceeds centripetally from the periphery. ( i ) Posterior-to-anterior column lag screw. ( ii )
Greater trochanter. ( iii ) Abductor muscles and tensor fascia lata.
FIGURE 43.17 Patient from Figures 43.4 and 43.6 at 1-year follow-up. Congruent reduction and maintenance of
joint space is shown. A. AP pelvis. B. Iliac oblique view. C. Obturator oblique view.

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CLOSURE
Because intra-articular hardware can lead to rapid chondrolysis, it is important to confirm hardware position
before closure. This is best achieved radiographically by using intraoperative fluoroscopic Judet views
(especially the obturator oblique) and clinically by rotating the hip back and forth while a finger is placed along
the quadrilateral surface to feel for any crepitus. At the completion of osteosynthesis, suction drains are placed
along the external surface of the iliac wing in the vicinity of the posterior column and vastus lateralis muscle. If
the internal iliac fossa has been exposed, a third drain is placed here. All drains should exit anteriorly.
The hip capsule is repaired first, followed by reattachment of the tendinous insertions of the short external
rotators to the greater trochanter through drill holes, and the femoral insertions of the gluteus maximus. Next, the
trochanteric insertions of the gluteus medius and minimus muscles are repaired, by using five or six sutures for
each tendon, as recommended by Letournel. Finally, the tensor fascia lata and gluteal muscles are reattached to
their origins on the iliac crest. If a medial exposure has been performed, then the origins of the sartorius and
direct head of the rectus femoris muscles are reattached through drill holes (or lag screws if osteotomies have
been performed). Finally, the fascia overlying the tensor fascia lata muscle is repaired, followed by placement of
a subcutaneous suction drain and skin closure.

POSTOPERATIVE MANAGEMENT
Postoperatively, patients are maintained on intravenous Cefazolin for 48 to 72 hours. Our postoperative
anticoagulation regimen includes 6 weeks of Warfarin in conjunction with compression boots. HO prophylaxis is
also mandatory, preferably with indomethacin 75 mg daily for 6 weeks. Drains are not removed until output has
tapered to 10 to 20 mL per 8-hour shift, and the patient has begun mobilizing, usually over the first 48 to 72
hours. We stress early mobilization during the postoperative period, allowing patients to sit at the edges of their
beds, dangle their legs, and progress to chairs within the first 24 to 48 hours after surgery. We do not use
continuous passive motion as we have not had difficulty regaining hip motion in this patient population. After
removal of the drains, patients are allowed toe-touch weight bearing up to 20 pounds with crutches.
Strengthening exercises along with gait training are initiated by the physical therapist. Weight bearing is not
advanced, and active abduction, any adduction, and flexion of the hip past 90 degrees are avoided for 6 to 8
weeks.
Acetabular fractures with a concomitant neurologic injury can pose a difficult rehabilitation problem because of
lack of muscle activity or neurogenic pain. These frequently require consultation with a neurologist and the pain
management service. We routinely obtain postoperative roentgenograms (AP pelvis and 45 degree oblique
“Judet” views) and a CT scan to critically assess the fracture reduction and hardware position. The CT scan is
usually obtained on postoperative day 5, just before discharge. At the time of discharge, home physical therapy
is arranged.
During the first follow-up visit at 2 weeks, staples or sutures are removed. At 6-week follow-up, new
roentgenograms are obtained, and generally, the abduction/adduction/flexion precautions are discontinued. The
patient returns at 8 to 10 weeks, and depending on the roentgenographic findings, progression to full weight
bearing is allowed, as tolerated, over the ensuing 4 weeks. An aggressive outpatient rehabilitation program
should be initiated at this stage. At 3 months postoperatively, the patient is reevaluated and is expected to be
weight bearing as tolerated with the assistance of a cane. In the absence of any contraindications, rehabilitation
becomes more aggressive with the initiation of strengthening exercises. At 6-month follow-up, the patient should
be back to full activity. Additional evaluation with radiographs is done at 1-year post-op and annually afterward.

RESULTS
The most important factor responsible for successful long-term clinical outcome following surgical fixation of
acetabular fractures is the quality of the reduction. Rowe and Lowell reviewed 93 acetabular fractures
treated nonoperatively and noted poor results for all 10 patients in whom the weight-bearing dome was not
anatomically reduced. After the pioneering work of Letournel and others, many investigators have shown
that long-term clinical outcomes correlate closely with the quality of reduction achieved during surgery. In
his review of 569 acetabular fractures treated within 3 weeks of injury, Letournel achieved an anatomic
reduction (a maximum of 1 mm of displacement on any of three views) in 74% of cases, with 82% of these
patients having very good clinical outcomes at a follow-up of as much as 33 years. Of the 26% with an
imperfectly reduced acetabulum, very good results were obtained in 54% of cases if the femoral head was
centered under the dome, and only 23% of cases where there was residual subluxation of the femoral head.
In patients treated within 3 weeks of injury, Letournel noted osteoarthritis in only 10.2% of those with perfect
reductions, as opposed to 35.7% with an imperfect reductions. Interestingly, when treatment was delayed
past this time, these rates were, respectively, 24% and 23%. Mears et al. retrospectively reviewed their
results in 429 acetabular fractures. They also found that clinical outcomes correlated well with the quality of
reduction. In their study, 89% of the patients with anatomic reductions had good or excellent clinical results
based on Harris Hip Scores. In 77% of patients with fair or poor results, at least one of the following
predisposing factors was present: femoral head or neck injury, acetabular impaction, marked displacement,
preexisting arthritis, or delayed presentation. In their study, 53% of their patients with morbid obesity also
had fair or poor clinical outcomes.
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The incidence of posttraumatic osteoarthritis is greatest in patients with articular surface incongruity or
residual subluxation of the hip joint. In Mears study, 12% of their patients underwent total hip arthroplasty or
arthrodesis at an average of 5 years 2 months postoperatively. Kebaish et al., in a retrospective review of
90 displaced acetabular fractures, showed superior long-term results in their patients when the articular
surface was restored to within 4 mm. In a similar retrospective study, Matta et al. demonstrated satisfactory
clinical outcome if the femoral head remained congruous within the weight-bearing dome and if articular
surface incongruity did not exceed 3 mm. However, in a subsequent prospective study, Matta suggested
that 3 mm is probably not acceptable. He reported that an anatomic reduction was achieved in 71% of 262
acetabular fractures, with 83% of these patients having good or excellent outcomes at an average follow-up
of 6 years. Of the 29% with an imperfectly reduced acetabulum, good or excellent results were obtained in
68% of cases if the defect measured 2 to 3 mm and only 50% if more than 3 mm. The most clearly
predictive initial factor for a poor result was damage to the femoral head.
In Matta's study of 106 patients treated with extended iliofemoral approaches, reduction was anatomic in
72%, imperfect in 22%, and poor in 6% of cases. Merle d'Aubigne and Postel scores were excellent in 23%,
good in 41%, fair in 19%, and poor in 17%. There was a significant correlation between the accuracy of
reduction and the clinical results, and at latest follow-up, there was a 31% incidence of posttraumatic
arthritis. Matta's results are in agreement with Helfet and Schmeling who previously noted that an articular
step-off of more than 2 mm or a gap of more than 3 mm was associated with a fourfold increase in joint
space narrowing at early follow-up. Alonso et al. noted an 81% rate of good or excellent results in 21
patients treated with an extended iliofemoral approach, which in all cases achieved a reduction within 2 mm.
Finally, Malkani et al. and Hak et al. used cadaver models to further support 2 mm or less as the criterion for
an acceptable reduction.
Loss of reduction can also occur during the postoperative period. This is more likely in elderly patients with
osteopenic bone where it is important to adequately buttress the fractures. The loss of accuracy of
reduction and the increased incidence of intra-articular damage in the elderly population further compromise
the outcomes in this population.

COMPLICATIONS
The overall incidence of complications following extensile exposures to the acetabulum ranges from
19% to 24%. Complications following operative treatment of acetabular fractures are best divided in
three groups: intraoperative, early, and late. Intraoperative complications include neurovascular injury,
malreduction, articular penetration of hardware, and death. Early postoperative complications include
DVT, pulmonary embolism (PE), skin necrosis, infection, loss of reduction, arthritis, and death. The
late group includes HO, chondrolysis, avascular necrosis, and posttraumatic arthrosis.
Sciatic Nerve Injury
Iatrogenic sciatic nerve injury or worsening of a preexisting deficit is a significant problem. In our
experience, patients at increased risk include those with preoperative sciatic nerve compromise and
those with fracture patterns that involve the posterior wall or column. Other authors have identified
patients treated via an ilioinguinal approach to be at increased risk, possibly related to indirect
reduction of the posterior column with the hip flexed. The peroneal nerve division is most commonly
involved. The most significant factor in reducing the incidence of iatrogenic sciatic nerve injury appears
to be the experience of the surgical team. Letournel initially reported an 18.4% incidence of
postoperative iatrogenic sciatic nerve injury using the Kocher-Langenbeck approach, which he
subsequently reduced to 3.3%. However, he also noted that none of his 114 patients treated with an
extensile approach developed this complication. Matta initially reported a 9% incidence of iatrogenic
nerve palsy. In his more recent study of 106 patients with extended iliofemoral approaches, there were
only four sciatic nerve palsies (3.7%). This was felt to be the result of improper placement of retractors
or excessive retraction. Alonso et al. found a postoperative sciatic nerve palsy in one of their 21
patients treated with an extended iliofemoral approach (4.8%). The incidence of iatrogenic nerve palsy
is greater when open reduction and internal fixation (ORIF) is delayed longer than 3 weeks, with an
overall incidence of 12%. The majority of these injuries also involved the sciatic nerve.
The use of intraoperative sciatic nerve monitoring by using SSEP monitoring remains controversial. In
Helfet's studies, intraoperative nerve monitoring reduced the incidence of iatrogenic sciatic nerve injury
to 2%. However, more recent studies have questioned the value of intraoperative SSEPs, failing to
demonstrate a reduction in the rate of iatrogenic nerve palsies. A high false-positive rate makes it
unclear to what extent intraoperative SSEP changes predict functional outcome. Intraoperative
monitoring of motor pathways with EMG allows for earlier detection of neurologic compromise and
removal of noxious stimuli, theoretically decreasing the risk of neurologic sequelae. In Helfet's study,
the addition of spontaneous EMG to intraoperative SSEP monitoring was superior to SSEP alone.
Given the significant learning curve that exists in the treatment of acetabular fractures, most authors
agree that intraoperative monitoring may prove most beneficial among less experienced surgeons.
Superior Gluteal Neurovascular Injury
Superior gluteal vessel injury is difficult to diagnose and is caused by either the fracture or an
iatrogenic insult during surgery. Letournel reported an incidence of 3.5% in his series. This potentially
lethal occurrence
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is more likely with severe displacement of the sciatic notch (e.g., high transverse fractures with marked
medial rotation). Acutely, hemodynamic instability with an arterial injury must be addressed during the
initial evaluation and resuscitation, usually with arteriography and embolization. However, once the
bleeding has been stopped, there may be concerns as to the viability of the muscle flap.
Because the extended iliofemoral approach completely detaches the gluteal muscles from the iliac
wing (Fig. 43.1), the superior gluteal vessels are the only blood supply to the flap. If this is
compromised, then complete ischemic necrosis in theory is likely. Mears and Rubash developed their
triradiate approach partly in response to reports of flap necrosis following the extended iliofemoral
approach; however, it has not been established whether the superior gluteal artery is to blame in these
cases. In fact, the incidence of this complication is relatively low. In over 400 acetabular fractures
addressed with an extended iliofemoral approach by Letournel, Matta, Mast, and Martimbeau, there
have been no reports of abductor flap necrosis. Alonso did not observe this complication using either
an extended iliofemoral or a triradiate approach in 59 cases of complex acetabular fracture. There
were no cases of abductor flap necrosis in Matta's series of 106 patients treated with an extended
iliofemoral approach.
There is some concern regarding the use of this approach in patients who have undergone
transcatheter arterial embolization of the internal iliac artery to control bleeding. A small series by
Yasumura, and another by Suzuki, have both described cases of gluteal muscle and skin necrosis
following embolization. It is not known if elevation of the abductor flap results in an increased risk of
muscle and skin necrosis in the setting of embolization by further compromising the blood supply to the
area. Necrosis may be the result of direct trauma and degloving of the area.
Furthermore, massive abductor necrosis resulting from a superior gluteal artery injury combined with
an extended iliofemoral approach was postulated based on early animal and cadaver studies alone.
Canine studies by Tabor et al. showed that although necrosis of muscle and loss of mass does occur
after the extended iliofemoral approach in the presence of gluteal vessel injury, this does not appear to
be functionally significant. In his study, none of the gluteal muscle flaps sustained complete ischemic
necrosis. Thus, some collateral flow to the abductor muscles must be present and appears to increase
in the presence of superior gluteal vessel injury.
Bosse had recommended a preoperative angiogram prior to performing an extended iliofemoral
approach to assess the integrity of the superior gluteal artery. However, a study by Reilly et al.
demonstrated only a 2.3% incidence of absent flow on the superior gluteal artery based on
intraoperative Doppler examination. No evidence of abductor muscle ischemia was found in any
patient. This study does not support the use of routine preoperative angiography in the management of
these injuries.
Deep Vein Thrombosis and Pulmonary Embolism
Letournel reported a 2.3% incidence of in-hospital death following operative fixation of acetabular
fractures with the majority of the deaths occurring in patients older than 60 years. Although DVT
probably plays a major role, its true incidence after an acetabular fracture is unknown. However,
patients with lower extremity trauma are particularly a risk. Kudsk et al. demonstrated a 60% incidence
of silent DVT by venography in patients with multiple trauma immobilized 10 days or more. In a
prospective study, Geerts et al. also demonstrated a 60% incidence of DVT in patients with primary
lower extremity orthopedic injuries. Letournel reported a 3% incidence of clinically evident DVT with
four fatal and eight minor pulmonary emboli in a series of 569 patients, despite the majority receiving
anticoagulant prophylaxis. Using a combination of perioperative mechanical prophylaxis and
postoperative anticoagulation prophylaxis, venous thrombosis and PE rates of <3% and 1%,
respectively, have been achieved. Improved detection of venous thromboembolism by using magnetic
resonance venography has also lead to a lower incidence of PE through aggressive treatment of
asymptomatic DVTs in the pelvis and proximal thigh. However, other data suggest that magnetic
resonance venography has a high false-positive rate for the detection of thrombi in the pelvic veins,
and its usefulness as a screening tool is still debated. Borer et al. reviewed 973 patients with pelvis or
acetabular fractures and found that the overall rate of pulmonary embolus was 1.7%, and the overall
rate of fatal pulmonary embolus was 0.31%. Routine preoperative screening for DVT had no effect on
the incidence of PE in this study.
Infection
The overall incidence of infection has been reported to be as high as 19% but probably lies between
4% and 5%. Matta noted a 5% incidence of postoperative wound infection in 262 patients with
acetabular fractures. In his more recent study of 106 patients treated with extended iliofemoral
approaches, 7 (6.6%) developed infections—3 superficial and 4 deep. There were 2 patients with
hematomas (1.9%) and one case of wound necrosis (0.9%). Mayo found a 4% overall infection rate,
which increased to 19% in 26 patients who underwent an extended iliofemoral approach. Letournel
reported 24 postoperative infections in 569 patients (4.2%) with 9 superficial, 10 early deep, and 5
delayed or late infections. Furthermore, he observed skin necrosis in 1.8% (10.2% of extended
iliofemoral approaches) and hematomas in 6.7% of cases. To minimize wound problems, he advocated
the use of prophylactic antibiotics, multiple suction drains in all recesses to prevent hematoma
formation, surgical evacuation of hematomas, and, if present, débridement of the
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Morel-Lavalle lesion over the greater trochanter. Other factors such as morbid obesity and burns must
also be taken into consideration as they may render the patient more susceptible to infection.

FIGURE 43.18 AP pelvis of patient in Figure 43.3 at 5 months after extended iliofemoral approach.
Significant (Brooker grade III) HO is present in the soft tissues of the right hip.

Heterotopic Ossification
The most common complication following the operative fixation of acetabular fractures is HO (Fig.
43.18), with an incidence ranging from 18% to 90%. However, functional limitation in patients with HO
occurs in only 5% to 10% of cases. Nevertheless, heterotopic bone formation is more common and
severe with the extended iliofemoral approach because of stripping of the external surface of the iliac
wing. Letournel reported its occurrence in 46% of his extended iliofemoral approaches performed
within 4 months of injury, as compared with a 21% incidence in 635 other approaches. Prior to his use
of prophylaxis, these rates were 69% and 24%, respectively. Matta noted a significant loss of motion in
20%, and Letournel observed severe HO (Brooker III and IV) in 35% of patients treated with this
approach within 3 weeks of injury. Both indomethacin and low-dose radiation therapy (single or
multiple fractions) have been shown to decrease the incidence and severity of HO in patients with
acetabular fractures. There remain concerns, however, about the cost and the long-term effects of
radiotherapy, particularly in the younger trauma population.
Despite prophylaxis with indomethacin, studies by Alonso, and by Johnson, have reported rates of HO
ranging from 86% to 88% in patients treated with an extended iliofemoral approach. Of these patients,
Brooker class III or IV ossification was present in 14% and 13%, respectively. In Johnson's study, the
majority of patients in the treated group had Brooker class 0-II ossification, with the untreated group
having mostly Brooker III and IV ossification. Another study by Moed et al. showed a 50% incidence of
HO after extensile exposures in patients treated with indomethacin. Only one patient in the treated
group had severe (Brooker class III-IV) ossification. Matta's study of 106 patients treated with extended
iliofemoral approaches did not use a uniform protocol for prophylaxis and demonstrated an overall
incidence of 59%—half of which were graded as severe (Brooker class III-IV). There was a correlation
 between the severity of the HO and lower Merle d'Aubigne and Postel scores, and nine patients (8.5%)
underwent excision to improve their range of motion. While it is clear that indomethacin does not
eliminate the occurrence of HO, it does significantly decrease its severity.
Avascular Necrosis
The incidence of avascular necrosis after operative treatment of acetabular fractures has generally
ranged from 3% to 9%, with the majority of cases identified between 3 and 18 months after surgery.
However, there is an increased incidence of avascular necrosis (AVN) of the femoral head in cases
presenting after 3 weeks and those associated with a posterior fracture/dislocation. In all probability,
the fate of the femoral head is determined at the time of the injury.

ILLUSTRATIVE CASE FOR TECHNIQUE

Case 1
A 23-year-old woman was involved in a motor vehicle accident, sustaining a right associated bothcolumn
acetabular fracture and extensive burns on the left side of her body. She also had a Morel-Lavalle degloving
injury involving her right thigh and buttock and a preoperative right sciatic nerve
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injury with a foot drop. AP pelvis and Judet view radiographs, and selected CT scan images, are shown in Fig.
43.19A-E. At 4.5 weeks postinjury, the patient underwent ORIF through an extended iliofemoral approach. Her
postoperative course was complicated by an infection of the iliac crest wound necessitating surgical débridement
and 6 weeks of intravenous antibiotics. Postoperative radiographs are shown in Figure 43.20. Her postoperative
CT scan shows congruent reduction of the hip joint (Fig. 43.21). At 5-month follow-up, she has a healed
acetabular fracture, is full weight bearing, and has progressively improving sciatic nerve function.
FIGURE 43.19 Both-column acetabular fracture. A. AP pelvis. B. Iliac oblique view. C. Obturator oblique view. D.
Axial CT scan image showing extensive comminution. E. Coronal CT scan image demonstrates subluxation of
the femoral head.

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FIGURE 43.20 Postoperative radiograph. A. AP pelvis. B. Iliac oblique view. C. Obturator oblique view.

FIGURE 43.21 Postoperative axial CT-scan image demonstrates congruent reconstruction of the hip joint.
FIGURE 43.22 Injury AP radiographs (left) and AP radiograph at 4.5 weeks (right) revealing a comminuted left-
sided both-column acetabular fracture.

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FIGURE 43.23 Obturator oblique (left) and iliac oblique (right) radiographs further demonstrate both-column
acetabular fracture.

Case 2
A 43-year-old female was involved in a high-speed motor vehicle accident and sustained multiple injuries
including a severe closed head and chest injuries and a comminuted left-sided both-column acetabular fracture
(Figs. 43.22, 43.23 and 43.24). An inferior vena cava filter and skeletal traction were placed. At 4.5 weeks
following the injury, she was medically stable, and acetabular fracture ORIF was performed through an extended
iliofemoral approach (Fig. 43.25). The fracture edges were carefully débrided of all fibrous tissue in order to aid
reduction, and multiple plates and screws were placed to reduce the columns (Figs. 43.26 and 43.27).
Radiotherapy was performed for HO prophylaxis, and she was also placed on a course of indomethacin. The
patient recovered very well from her head injury and returned for regular follow-up visits. At 4.5 years following
surgery, she was noted to have development of Brooker Grade III HO (Fig. 43.28). She was doing well and had
resumed all preinjury activities including her occupation as a physical therapist. She reported almost full
resolution pain, but with limitations in range of motion; to 110° of flexion. She elected not to have excision of HO
performed as she was able to perform her activities of daily living with little difficulty.
FIGURE 43.24 CT scan images further delineating the fracture pattern and quadrilateral plate involvement.

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FIGURE 43.25 Intraoperative image illustrates extensive early callus formation.

FIGURE 43.26 Intraoperative fluoroscopic images illustrate an acceptable reduction and extra-articular hardware
placement.

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FIGURE 43.27 Immediate postoperative AP and Judet radiographs.

FIGURE 43.28 AP and Judet radiographs at 4.5 years demonstrate a healed acetabular fracture, maintenance of
hardware, joint space, and development of Brooker Grade III HO.

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RECOMMENDED READING
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 44
Surgical Dislocation of the Hip for Fractures of the Femoral Head
Milan K. Sen
David L. Helfet

INTRODUCTION
Fractures of the femoral head are commonly seen in association with traumatic dislocation of the hip (1, 2, 3, 4, 5
and 6). Hip dislocations are usually high-energy injuries and are posterior in 82% to 94% of cases (3,7,8).
Classically, they are the result of a dashboard injury, with an axial load transmitted through the flexed hip (5,8, 9
and 10). The reported incidence of femoral head fractures in patients with posterior dislocations of the hip
ranges from 7% to 16% (1,4,10,11). Anterior hip dislocations are less common but can also be associated with
femoral head fractures, ranging from 15% (12) up to 77% in one series (3). These injuries are treated with
emergent reduction of the femoral head to decrease the risk of avascular necrosis secondary to ischemia caused
by tension on the blood supply of the femoral head (13, 14, 15 and 16). This is preferably done within 6 to 12
hours from the time of injury (4,13,17). Prior to attempting a closed reduction, it is important to exclude the
presence of a concomitant femoral neck fracture. Postreduction, an axial CT scan with 2-mm cuts is necessary to
ensure a concentric reduction that is free of intraarticular fragments (5,18,19). If a displaced femoral head
fragment is identified on the plain radiographs or CT scan, open reduction and internal fixation (ORIF) is usually
required (4). At the same time, the surgeon can address other associated musculoskeletal injuries, commonly
fractures of the acetabulum, and femoral neck and shaft (4).
The Pipkin classification was introduced in 1957 and includes four femoral head fracture subtypes. A Pipkin type
I fracture occurs below the ligamentum teres. The Pipkin type II fracture propagates above the ligamentum teres.
In the Pipkin type III fracture, the fracture is similar to a type I or II but is associated with a femoral neck fracture.
And the Pipkin type IV fracture is similar to a type I or II but with an associated acetabular fracture (Fig. 44.1).

INDICATIONS AND CONTRAINDICATIONS

As these injuries are often seen in the setting of high-energy trauma, it is important that the patient is evaluated
appropriately for associated abdominal, thoracic, and craniofacial injuries (8). In the presence of a femoral neck
fracture, postreduction hip joint asymmetry, progressive sciatic nerve injury, or an intra-articular fragment
displaced at least 2 mm or rendered the hip unstable, urgent open reduction and fixation of the fragments is
warranted (1,20, 21 and 22). For Pipkin type I or II femoral head fractures, free or nonreduced fragments that
remain after reduction must be excised or reduced and stabilized to avoid early posttraumatic arthrosis
(5,11,14,17). Historically, recommendations have included excision of large fragments, up to one-third of the
femoral head (2,4,5,21). However, because the entire acetabulum is involved in weight bearing (23), any
fragment that is
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amenable to fixation should be rigidly fixed. Smaller fragments may be excised (6,14,22,24, 25, 26, 27 and 28).
Small avulsion fractures of the ligamentum teres can be treated nonoperatively.
FIGURE 44.1 Pipkin classification for fractures of the femoral head.

In the past, much controversy existed in regards to the optimal surgical approach for fixation of femoral head
fractures. Initially, the Kocher-Langenbeck approach was used. It has the advantage of addressing fractures of
the posterior acetabular wall, but allowed only limited access to the articular surface of the femoral head for
fracture reduction and fixation. In addition, some studies identified an increased incidence of avascular necrosis
of the femoral head using this approach as compared to the Smith-Peterson approach (26,27). Alternatively, the
Smith-Petersen approach had the advantage of providing access to the anterior portion of the femoral head and
allowed for débridement of intra-articular debris. However, it did not allow complete visualization of the femoral
head, and it did not allow the surgeon to address posterior acetabular wall fractures. In addition, heterotopic
ossification has been shown to be a significant risk with the anterior approach (24,27). While combined anterior
and posterior approaches would improve visualization in the case of extensive femoral head fractures, there is an
increased risk of complication associated with such extensive dissection.
In 2001, Ganz et al. (29) described a technique for surgical dislocation of the hip. It involves a Kocher-
Langenbeck approach with a trochanteric osteotomy and anterior dislocation of the hip. The advantage of this
approach is that it allows visualization of the entire femoral head as well as the full circumference of the
acetabulum. Using this exposure, the surgeon can obtain anatomic reduction and rigid fixation of the femoral
head fragments, and a thorough débridement of the joint, without compromising the blood supply to the femoral
head (29, 30, 31, 32, 33 and 34).

PREOPERATIVE PLANNING
The preoperative evaluation and operating room preparation for this procedure are described in the section
“Acetabular Fractures: The Extended Ilio-Femoral Approach.”

SURGERY
The patient is placed in a lateral decubitus position. A standard Kocher-Langenbeck incision is made through the
skin, subcutaneous tissue, and tensor fascia lata (Fig. 44.2). The leg is then internally rotated to expose of the
posterior border of gluteus medius. Unlike the approach used in total hip arthroplasty, no attempt is made to
mobilize gluteus medius or expose the piriformis tendon. Electrocautery is used to mark the gluteus medius
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at the posterior edge of the greater trochanter. The posterior border of gluteus medius is then traced distally to
the posterior ridge of the vastus lateralis muscle, the point at which the deep branch of the medial femoral
circumflex artery (MFCA) becomes intracapsular.

FIGURE 44.2 Incision and division of the tensor fascia lata.

A 1.5-cm thick trochanteric osteotomy is then performed using an oscillating saw, following the line traced by the
electrocautery (Fig. 44.3). Care is taken to remain anterior to the most posterior insertion of the gluteus medius in
order to protect the deep branch of the MFCA. In addition, it is essential to keep
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a posterior shelf of bone just behind the osteotomy to protect the insertion of the short external rotators. At its
distal end, the osteotomy should exit at the level of the vastus ridge. The vastus lateralis is then released along
its posterior edge to the level of the gluteus maximus tendon, and greater trochanter is everted anteriorly.
Release of the remaining posterior fibers of gluteus medius allows free mobilization of the trochanteric segment.
Additional exposure can be obtained by elevation of the vastus lateralis and intermedius from the lateral and
anterior aspects of the femur, respectively. With anterior retraction of gluteus medius, the trochanteric fragment,
and vastus lateralis, the tendon of the piriformis and the gluteus minimus muscle should be visible. The gluteus
minimus is then carefully elevated off of the hip capsule. Gentle flexion and external rotation of the hip allows
visualization of the anterior, superior, and posterosuperior hip capsule.

FIGURE 44.3 A. Sliding trochanteric osteotomy. B. Retraction of trochanter, gluteus medius, and gluteus
minimus with exposure of joint capsule.

FIGURE 44.4 Variations in relationship of the sciatic nerve to the piriformis muscle. (From Agur AMR, Lee MJ.
Lower limb. In: Kelly PJ, ed. Grant's atlas of anatomy. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
1999:329, with permission.)

Attention must be paid at all times to the position and location of the sciatic nerve as it passes inferior to the
piriformis tendon. Flexion of the knee releases some of the tension on the nerve. In 12.7% of individuals, the
peroneal branch of the sciatic nerve passes either through the piriformis or superior to the piriformis (Fig. 44.4)
(35). In these individuals, the piriformis tendon should be released to prevent stretching of the nerve during
dislocation of the hip. In order to protect the ascending branch of the MFCA, the tendon should be released 1.5
cm from its insertion, rather than at its attachment to the femur.
The incision of the capsule begins on its anterolateral surface, parallel to the long axis of the neck. At the base of
the neck, the incision curves anteriorly and inferiorly, along the reflection of the anterior capsule (Fig. 44.5). The
main branch of the MFCA lies superior and posterior to the lesser trochanter; therefore, the capsular incision
must remain anterior to the trochanter to avoid injuring it. The proximal end of the anterolateral capsular incision
is extended to the acetabular rim. It then curves posteriorly, remaining parallel to the labrum, until one encounters
the retracted piriformis tendon. Care must be taken not to damage the labrum when doing the capsulotomy.
It is now possible to dislocate the hip anteriorly with flexion and external rotation of the hip. The leg is placed in a
sterile bag over the front of the table (Fig. 44.6). This allows visualization of the entire femoral head (Fig. 44.7). It
also allows for inspection of the labrum, and with carefully placed retractors, the entire articular surface of the
acetabulum (Fig. 44.8).
At this point, the surgeon may do a thorough irrigation and débridement of the femoral head and acetabulum.
The labrum and articular surfaces should be inspected. Small comminuted fragments that are not amenable to
fixation are excised. If a stump of the ligamentum teres remains attached to the femoral head, or if it has avulsed
a small fragment of the head, it is also excised.
Sizable fragments of the femoral head should be fixed (Fig. 44.9). The aim of fixation is to achieve rigid
subarticular fixation while leaving a smooth articular surface on the femoral head. Common strategies include
burying pins or screws or capturing the fragment by lag effect from a nonarticular entry point (25). Methods of
fixation have included countersinking screws (36), using headless screws (37,38), bioabsorbable pins or screws
(39), or suture fixation (21,22,27). Screws with threaded washers are contraindicated due to a significant
incidence of backing out of the hardware (26). Headless screws provide less compressive force across
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the cancellous bone of the femoral head than do standard small fragment screws (37). Therefore, it is our
preference to countersink bioabsorbable or small fragment screws with heads (Synthes, Inc, Paoli, PA) into the
fragment. We often augment the fixation of the fragment with the addition of a lag screw entering from
nonarticular regions to capture the fragment.
FIGURE 44.5 Outline of capsular incision.

While the articular surfaces are exposed, regular irrigation with Ringer's Lactate should be used to prevent
desiccation. Prior to reduction of the hip, a 2.0-mm drill hole is made in the femoral head to document
preservation of the blood supply. Previous studies have shown a high correlation between this and the presence
of a viable head (40) (Fig. 44.9). Laser Doppler flowmetry is another proven method for documenting the
vascularity of the femoral head prior to reduction (38). The hip is then reduced with manual traction on the flexed
knee, followed by internal rotation and extension.
When associated posterior wall acetabular fractures are present, they can be treated using the standard Kocher-
Langenbeck dissection. However, when the wall fragments are in a posterior-superior position, we have been
able to perform ORIF by direct exposure of these fragments after reduction of the hip and prior to repair of the
osteotomy. This alleviates the need for additional posterior dissection.
The wound is irrigated with 3 L of normal saline, and meticulous hemostasis is achieved. The capsulotomy is
then closed using 1-0 Vicryl suture. The greater trochanter is secured using two 3.5-mm cortical screws directed
toward the lesser trochanter. Two large Hemovac drains are placed deep to the tensor fascia lata.
 P.916

FIGURE 44.6 Positioning of patient for anterior dislocation: leg in flexion and external rotation suspended in a
sterile bag.

POSTOPERATIVE MANAGEMENT
Postoperatively, the patient is mobilized immediately. Crutch ambulation training with touch-down weight bearing
of 20 pounds is instituted for 6 to 8 weeks. Strengthening and motion exercises are instituted and encouraged
(22,41).
X-rays and a CT scan are done postoperatively to confirm fracture reduction, hardware placement, and
concentric hip reduction (Fig. 44.10).
Drains are not removed until output has tapered to 10 to 20 mL per 8-hour shift. In the hospital, patients are
maintained on intravenous Cefazolin for 48 hours. Our postoperative anticoagulation regimen includes 6 weeks
of Warfarin in conjunction with compression boots.
Heterotopic ossification prophylaxis is recommended (42), preferably with oral Indomethacin SR 75 mg daily for 6
weeks.
FIGURE 44.7 Dislocation of the hip with exposure of the articular surface of the acetabulum.

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FIGURE 44.8 Dislocation of hip with exposure of femoral head and Pipkin fragment.
FIGURE 44.9 Dislocation of femoral head and temporary fixation of Pipkin fragment with Kirschner wires (K-
wire). Active bleeding from the dislocated femoral head demonstrates that the blood supply remains intact.

RESULTS
Helfet et al. (43) reviewed five patients with Pipkin II fractures of the femoral head. All three were treated
with ORIF of the femoral head fractures using the surgical dislocation technique. Follow-up ranged from 11
to 24 months. At the time of their latest follow-up, all patients were ambulating without difficulty and without
a limp. None had pain with ambulation or range of motion of the hip, nor do they have any radiographic
evidence of avascular necrosis or degenerative changes. Tannast et al. (34) used this technique
successfully in 54 patients for ORIF of the acetabulum, 8 of whom had femoral head fractures. They were
able to successfully reduce and stablize the femoral head, and there were no cases of avascular necrosis.

COMPLICATIONS
Avascular Necrosis
The most significant potential complication related to this particular surgical approach is avascular
necrosis of the femoral head. The femoral head receives the majority of its blood supply from the deep
branch of the MFCA (4,44, 45, 46, 47 and 48). This branch of the MFCA is located at the proximal
border of the quadratus femoris muscle. It then courses superiorly, crossing anterior to the conjoined
tendon of the obturator internus and the superior and inferior gemelli muscles (Fig. 44.11). It then
perforates the hip capsule to supply the femoral head. Preservation of the quadratus femoris and the
short external rotators of the hip protects this branch of the MFCA, maintaining the critical blood supply
to the femoral head.
FIGURE 44.10 Postoperative x-ray illustrating placement of screws for the fixation of trochanteric
osteotomy.

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FIGURE 44.11 Blood supply to the femoral head and its relationship to the short external rotators.

Avascular necrosis is a well-described consequence of traumatic dislocation of the hip, with an

incidence ranging from 8.3% to 26.3% (8,10,14). It has also been established that duration of the
dislocation ≥6 hours greatly increases the risk of avascular necrosis (13). The Ganz approach uses a
controlled anterior dislocation of the hip for a short duration of time, minimizing the risk of injury to the
nutrient vessels. Ganz's study reviewed 213 patients treated with surgical dislocation of the hip for a
 variety of pathologies (29). At 2- to 7-year follow-up, no evidence of avascular necrosis of the hip has
been identified.
Further studies by Ganz et al. used a high-powered laser Doppler flowmeter to evaluate the changes
in blood flow to the head with this technique (31). They found that the dislocation resulted in some
impairment of blood flow, but that this reversed completely with reduction of the hip. They also found
that the anterior capsulotomy used in this approach did not alter the blood flow to the head, despite the
disruption of the anterior intra- and extracapsular anastomoses and the capsular branches of the
lateral circumflex artery. This indicates that the vessels on the anterior aspect of the femoral head are
less critical to its circulation. Rather, it is the preservation of the posterior extracapsular vessels that is
paramount.
Recent clinical studies have failed to identify any cases in which avascular necrosis occurred following
the surgical dislocation approach in the treatment of a variety of hip disorders and fractures (30,33,34).
Neurologic Injury
Neuropraxia of the sciatic nerve was seen in two patients in Ganz's study. Both patients recovered
within 6 months. Of note, both of these patients had had previous surgery, and scarring around the
sciatic nerve is thought to have contributed to the neuropraxia. In Sink's study of 334 hips, there was
one case of sciatic nerve palsy (0.3%), which partially resolved, and one transient sciatic neuropraxia
that resolved by 5 weeks postoperatively (33). One case of superior gluteal nerve palsy has also been
reported (34).
Trochanteric Nonunion
In Ganz's study, three patients required a second operation for failure of trochanteric fixation, a rate of
1.4%. Subsequent studies have demonstrated trochanteric nonunion rates of 1.8% to 1.9% (33,34).
These results compare favorably with the 98% union rate described in the literature for the extended
trochanteric slide osteotomy in total hip arthroplasty (49).
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Heterotopic Ossification
The incidence of heterotopic ossification at 1 year was 37% in Ganz's study. Most of the ectopic bone
formation occurred at the tip of the greater trochanter, and 86% were classified as Brooker grade I.
Two patients required excision of the ectopic bone to improve their range of motion. A more recent
study by Sink et al. found only a 5.4% incidence of heterotopic ossification, all of which were classified
as Brooker Grade I or II (33). None were symptomatic or required excision. However, this study looked
almost exclusively at elective procedures not related to trauma. In contrast, Tannast's study of 54
patients with acetabular fractures treated using the surgical dislocation approach found a 37% rate of
heterotopic ossification. The true incidence is likely influenced more by the traumatic event than the
approach itself (34).
Cosmesis
Seven of the patients in Ganz's study had “saddleback deformities” of the subcutaneous fat due to
insufficiency of the subcutaneous sutures. Five of these patients underwent plastic surgery to improve
the cosmetic appearance.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 64-year-old female was on vacation in South America and was involved in a high-speed motor vehicle
accident. She was ejected from the vehicle and lost consciousness and was revived and resuscitated upon
arrival at a local hospital. Her injuries included a right-sided femoral head fracture and posterior hip dislocation,
with an associated Posterior Wall Type acetabular fracture (Pipkin IV) and skin abrasions lateral to her right hip
(Fig. 44.12). Her hip dislocation was carefully reduced, traction was placed, and an Inferior Vena Cava filter was
placed for deep venous thrombosis prophylaxis. She was transferred to her home in the United States. ORIF was
performed through a Kocher-Langenbeck approach with a trochanteric flip osteotomy and a surgical hip
dislocation (the screw holes for repair of the trochanteric osteotomy were predrilled prior to the trochanteric
osteotomy) (Fig. 44.13). The femoral head fracture was reduced and fixed with two screws placed in the
subchondral bone. The posterior wall fracture was reduced and fixed with a spring plate and a five-hole pelvic
reconstruction plate and multiple screws. The fractures and osteotomy site healed uneventfully (Fig. 44.14 and
44.15). At 6 months following surgery, she has no hip pain, full range of motion, and has resumed her preinjury
activities.

FIGURE 44.12 Anteroposterior (AP), obturator oblique and iliac oblique radiographic pelvic views, and CT scan
images (counterclockwise from top) illustrating a right-sided femoral head fracture and associated posterior wall-
type acetabular fracture (Pipkin IV).

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FIGURE 44.13 Preoperative plan (left) and intraoperative photo (right) following surgical hip dislocation
illustrating excellent visualization of the femoral head and posterior wall fracture fragments.

FIGURE 44.14 Postoperative AP pelvic radiograph and CT scan images illustrating acceptable reduction and
position of the hardware.

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FIGURE 44.15 AP, obturator oblique and iliac oblique radiographic pelvic views (counterclockwise from top) at 6
months following surgery reveal maintenance of fixation and joint space.

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28. Yoon TR, Rowe SM, Chung JY, et al. Clinical and radiographic outcome of femoral head fractures: 30
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the hip. Monitoring by laser Doppler flowmetry. J Bone Joint Surg Br 2002;84:300-304.

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and accurate reduction of fractures of the acetabulum. J Orthop Trauma 2002;16:543-552.

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fractures. J Bone Joint Surg Br 2010;92:842-852.

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36. Swiontkowski MFT. Operative management of femoral head fractures. Orthop Trans 1989;13:51.

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Orthopedics 1986;9:1393-1397.

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39. Jukkala-Partio K, Partio EK, Hirvensalo E, et al. Absorbable fixation of femoral head fractures. A
prospective study of six cases. Ann Chir Gynaecol 1998;87:44-48.

40. Gill TJ, Sledge JB, Ekkernkamp A, et al. Intraoperative assessment of femoral head vascularity after
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42. Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of
heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg Am
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implications. J Bone Joint Surg Br 2000;82:679-683.

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Bone Joint Surg Br 1965;47:560-573.

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arthroplasty. J Bone Joint Surg Am 2000;82:197-206.
 45
Periprosthetic Fractures: Evaluation and Management
Guy D. Paiement

INTRODUCTION
Periprosthetic fractures are increasing in frequency as the numbers of patients with hip and knee arthritis
undergo total joint arthroplasty and life expectancy continues to rise. Epidemiological studies have shown that
the joint replacement population is growing faster than both the general and the geriatric populations. This
population is older, more osteoporotic, and less conditioned, takes multiple medications, and tends to have a
higher body mass index (knee replacement population). They are less at risk for higher energy trauma because
of their life style but more likely to sustain fractures from lower energy mechanical falls. Several risk factors have
been associated with periprosthetic fractures in the elderly; they include osteoporosis, female gender, advanced
age, osteopenia, inflammatory arthritis, metabolic bone disease, and alignment deformities (1). Recently, there
has been renewed interest in the mechanical and biological characteristics of the joint implants, which may be
possible risk factors (2).
The 1-year mortality following a periprosthetic femur fracture is approximately 11% compared to an acute hip
fracture mortality of 16.5%. By way of comparison, the mortality rate for primary hip replacement at 1 year is only
2.9% (3). The majority of periprosthetic fracture patients are elderly frail individuals with significant medical
comorbidities, and they behave clinically more like hip fracture patients than elective joint replacement patients.
While the need for medical optimization is similar in both groups, surgical planning can be more complicated and
difficult in the periprosthetic fracture group.

CLASSIFICATION
The most widely used classification for periprosthetic femoral fractures around the hip is the Vancouver
classification, which is based on three parameters: implant stability, bone stock quality, and fracture location. It
divides the femur in three regions: trochanter region (type A), proximal femur down to the tip on the implant (type
B), and diaphysis distal to the tip of the implant (type C) (Fig. 45.1). Type A fractures are subdivided into type AG
for greater trochanter fractures and type AL fractures that involve the lesser trochanter. Type B fractures
comprise a large majority of proximal periprosthetic femur fractures and are divided into three subtypes. In
subtype B1, the implant is stable whereas in B2 fractures, the stem is unstable, and in B3 fractures, the implant
is unstable and the bone stock is poor (Fig. 45.1B-D). Type C fractures are distal to the tip of a well-fixed stem
that complicates the fixation of the fracture (4).

INDICATIONS AND CONTRAINDICATIONS

Surgical indication is based on the effect of the fracture on the structural integrity of the bone-prosthesis
construct. An undisplaced or minimally displaced greater or lesser trochanter fracture (Vancouver type A) can be
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treated nonoperatively because it does not affect prosthesis stability (Fig. 45.2). Caution is required if the stem is
cemented because minimally displaced trochanteric fractures may have caused a cement mantle fracture that is
not always obvious. Oblique proximal femur or rotational stress radiographs may be indicated in these cases to
rule out cement mantle fractures that would require revision of the femoral stem.
FIGURE 45.1 The Vancouver classification is based on fracture location, implant stability, and bone quality. A.
Type A involves the greater or lesser trochanter with a solid implant and good bone stock. B. Type B1 is a
proximal femur fracture with a stable stem and good bone. C. Type B2 proximal femur fracture with an unstable
implant but adequate bone stock. D. Type B3 is a proximal femur fracture with a loose implant and poor bone
stock. E. Type C involves a fracture distal to prosthesis.

FIGURE 45.2 A 92-year-old man who was a community ambulatory fell and injured his right hip but was able to
stand and bear some weight. A Vancouver type AL fracture was diagnosed (A). The patient was treated
nonoperatively with protected weight bearing. Three months later (B), he was walking with no pain using a cane
when outside his home. The lesser trochanter fragment had displaced but there was no subsidence of the
implant.

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Femoral condyle fractures in knee replacement patients should be evaluated in the same fashion. An apparently
undisplaced medial condyle fracture on standard anteroposterior (AP) and lateral radiograph may be rotated and
will heal in a malposition that may change the joint line position or the flexion/extension gap. This can change the
prosthesis dynamics and accelerate polyethylene wear. Oblique and varus/valgus stress radiographs can be
helpful in making such a determination.
Unstable fractures require surgical treatment. On occasion in a very frail patient where the femoral stem has
subsided in a relatively stable position or the acetabular component has migrated medially because of the
fracture, nonoperative treatment may be indicated. Small degrees of limb shortening may be preferable to major
revision surgery.

PREOPERATIVE PLANNING
History and Physical Examination
Less than 10% of periprosthetic fractures occur following high-energy trauma, and the vast majority occurs after
a ground-level mechanical fall. A detailed history of the patient's preinjury level of function as well as any
symptoms related to their joint replacement is essential to determine whether the prosthesis was loose or
infected prior to their fracture. Knowledge of the patient's preinjury ambulatory status and the use of walking aids
are helpful. The patient should be questioned about preinjury discomfort or pain with activities of daily living as it
may indicate a loose prosthesis. Time, course, and progression of the pain are also helpful clues. Some patients
may report progressive instability that suggests implant loosening or bearing surface wear. Whenever possible,
prefracture radiographs should be reviewed to detect any changes in component position and axial alignment.
Past medical history, a thorough review of systems, and an accurate inventory of the patient's current
medications are important, because many will require internal medicine consultation preoperatively. Antiplatelet
medication, vitamin K antagonists, and immunosuppressive agents are common in this patient population and
may impact or delay the surgery. On physical examination, the leg is swollen, tender to palpation, and range of
motion is decreased or impossible to evaluate secondary to pain. The skin should be inspected for ulcers,
abrasions, lacerations, and ecchymosis particularly around the knee where soft tissues can be problematic. The
neurological and vascular status of the limb must be thoroughly evaluated and documented.

Imaging Studies
Full-length AP and lateral radiographs of the femur should be obtained as well as an AP pelvis. Radiographs of
the contralateral femur or knee can be useful when the fracture is comminuted making restoration of leg length or
alignment difficult. If the fracture involves the acetabulum, Judet views (obturator and iliac oblique views) are
required. A CT scan or even a CT-scan angiogram may be needed for some patients with protusio acetabuli to
minimize the risk of intraoperative injury to iliac or femoral vessels or to the ureter. A CT scan of the distal femur
may be helpful when there is a comminuted, osteoporotic fracture around the knee, because a hinged knee or
distal femoral replacement may be necessary. MRI, ultrasound, and nuclear scans are rarely needed in
evaluating periprosthetic fractures.

Laboratory Studies
A history of slow wound healing or drainage at the time of the original joint arthroplasty always raises the
possibility of a low-grade infection even years later. Biological markers such as ESR (erythrocyte sedimentation
rate) and CRP (C-reactive protein) are less reliable in the context of an acute fracture. A recent study of 204
periprosthetic fractures reported a false positive rate for infection of 43% based on the CRP levels and 31% for
the ESR (5). If an occult infection is suspected, an image-guided aspiration is recommended to obtain fluid for a
gram stain and cultures. Surgery should be delayed if possible until the cultures results are available. A positive
culture drastically changes the surgical treatment and the overall prognosis.
Timing of Surgery
Most periprosthetic fractures are caused by low-energy trauma and are rarely open or complicated by
neurovascular injury or a dislocation. The preoperative evaluation can be time consuming because of the need
to identify the prosthesis, obtain preinjury radiographs, or rule out an infection. The logistics of obtaining the
appropriate implants to cover all possibilities may also take time. Few surgeons are equally skilled at repairing
difficult fractures and performing complex prosthetic revisions. Collaboration with skilled arthroplasty colleagues
may be wise. It may be in the patient's best interest to postpone surgery until the preoperative evaluation is
complete, all necessary equipment is available, skilled operating personnel are on duty and experienced
colleagues ready to help.
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FIGURE 45.3 Proximal femur periprosthetic fractures. This simple treatment algorithm is based on four decisive
factors: infection, location, stability, and bone stock.

Surgical Tactics
Successful surgery requires a medically optimized patient, a knowledgeable and experienced surgical team, and
appropriate equipment and implants. Preoperative planning is crucial, and radiographs should be analyzed with
particular attention focused on the fracture location, implant stability, and bone quality. Periprosthetic proximal
femur fractures are traditionally classified according to the Vancouver classification since this has been shown to
correlate with treatment and outcomes. A simple treatment algorithm for these complex fractures is seen in Figure
45.3.
Although a type B1 fracture (stable stem) is the most common fracture pattern, it is not always easy to distinguish
it from a type B2 fracture (loose femoral component). Using the patient's history, prefracture radiographs of the
limb and current x-rays, the stability of the implant is estimated. For Vancouver type C fractures treated with plate
osteosynthesis, the plate must extend proximal to the tip of the prosthesis to avoid leaving an area of
unprotected bone between the proximal end the plate and the tip of the prosthesis. Failure to “overlap” the plate
and the femoral stem leaves an area of high stress concentration between the plate/bone distally and stem/bone
proximally. A fracture through such area can occur and is exceedingly difficult to treat. Table 45.1 lists 11
important considerations to address in the course of evaluating and treating these complex fractures. Addressing
each of the 11 considerations will improve the chance for a successful outcome. Table 45.2 lists the implants
that should be immediately available by likelihood of need for each type of fractures.

SURGERY
Monitoring
Periprosthetic fracture surgery can lead to substantial blood loss in many patients, and since the extent of
the surgery cannot be accurately predicted in advance, it is important to prepare preoperatively. Adequate
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intraoperative monitoring is very important, and adequate blood replacement must be available. In these
elderly frail patients, a Foley catheter, arterial line, and central venous catheters are routinely employed.
The use of a “cell saver” is strongly recommended.

TABLE 45.1 Considerations in Managing Type B Periprosthetic Fractures

1. Assess preinjury pain and function—stable noninfected implants do not hurt

2. Rule out infection preoperatively—easy to miss
3. Confirm stability intraoperatively if needed—arthrotomy and fluoroscopy
4. Use minimal dissection in reducing and fixing the fracture
5. Mixed use plate (locking and unlocking holes) are essential
6. Do not rely on cables alone for fixation
7. Bone stock often has to be assessed by direct inspection
8. Augment bone stock with cortical allograft only when the bone stock is poor
9. Fracture should be bypassed at both ends by two cortical diameters
10. Avoid stress risers; plate accordingly
11. Consider acetabular component revision if there is polyethylene wear or osteolysis

Positioning
Implant stability is the major determining factor in deciding patient position. Fracture fixation alone in the
presence of a loose implant invariably leads to a poor outcome. Fluoroscopic examination under anesthesia with
the patient supine on a radiolucent table may confirm the presence of a loose implant. If all clinical and
radiographic testing point toward a well-fixed implant without infection, the patient should be positioned supine
on a flat-top radiolucent table. The supine position facilitates fracture reduction as well as assessment of leg
length and alignment. Radiolucent sterile triangles are also useful to maintain reduction and alignment.
A fracture table is rarely needed; a femoral distractor or an external fixator can be helpful if there is substantial
shortening of the fracture, or skilled assistance unavailable. If there is any doubt about the stability of a hip
implant, the patient should be positioned in the lateral decubitus position. This allows femoral fracture fixation, as
well as assessment of the femoral or acetabular component stability, and facilitates revision at the same time if
necessary. We routinely use a patient positioning device (peg board) to ensure a stable patient position
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throughout the procedure. Furthermore, the table should rotate (backward or forward) in order to obtain a true
AP radiograph of the pelvis and obturator/iliac oblique views if needed.

TABLE 45.2 Periprosthetic Fractures Pre-Op Planning Check List

Fractures Necessary Likely Possible

Acetabulum Pelvic fixation set, large porous Trochanteric Acetabular cage Femoral
metal cups reattachment head allograft
device (TRD)

Proximal Mix use long plates Cables AND Plate bender K- Strut allograft Revision
femur B1 screws wires, bone forceps stem (see B2)

Proximal Mix use long plates, cables AND Plate bender, K- Strut allograft
femur B2 screws, revision stem straight wires, bone
and curved forceps, TRD

Proximal Mix use long plates, cables AND Plate bender K- Proximal femoral allograft,
femur B3 screws, revision stems straight wires, bone long cemented stem,
and curved Strut allograft forceps, TRD autograft/BMP

Proximal Long femoral mixed use plates— Long condylar Autograft/BMP, strut
femur C straight and curved cables AND femoral plates allograft
screws straight and curved

Distal Long condylar femoral plates Retrograde nailing Distal femoral

femur straight and curved, cables AND system, replacement with
screws autograft/BMP, strut constrained or hinged
allograft knee arthroplasty

Proximal Proximal tibial plate Revision tibial Proximal tibial

tibia prosthesis, replacement with
autograft/BMP constrained knee
arthroplasty

This table summarizes the equipment and implants needed to address different type of fractures,
 assuming there is no infection. The implants listed in the possible column should be available if the
bone stock is poor.

Imaging
C-arm fluoroscopic imaging is adequate in most cases but there are limitations due to the relative small size of
the visualized field. In complex fracture patterns where determination of length can be difficult often require full-
length intraoperative radiographs. Proper acetabular component positioning requires a true AP of the pelvis
showing both hips, which requires a standard radiograph and often tilting of the table. Leg length when revising
the femoral component can be better evaluated with a radiograph of both hips in the same field.

Skin Preparation and Draping

Skin preparation should follow the Center for Disease Control recommendations (6). Hair should not be removed
unless it will interfere with the procedure. If skin hair is removed, it should be shaved immediately before surgery
with electric clippers (category IA). Numerous studies support the use of 2% chlorhexidine gluconate (CHG)
formulations for surgical skin preparation. A recent study showed a 46% reduction in surgical site infections with
2% CHG compared with iodine-based preparations. Blood glucose should also be normalized for the same
reason (7).
Draping should allow the surgeon to extend incisions if needed. Sterile tourniquets can be used when repairing
many distal femur fractures.

Reduction
Open reduction and internal fixation of a Vancouver B1 fracture or a distal femur fracture is based on accepted
biological and mechanical fracture fixation principles. Indirect reduction and minimally invasive plating should be
attempted to preserve blood supply at the fracture site and minimize blood loss. If the fracture requires open
reduction, it is important to minimize soft-tissue stripping to improve fracture healing. A well thought out
combination of direct and indirect reduction techniques is often helpful. A femoral distractor or a temporary two-
pin external fixator may improve the reduction and decrease the extent of fracture exposure. However, pin
placement can be challenging in the presence of a hip or knee implant. Various radiolucent bumps and triangles
can also be used. A distal femoral skeletal traction is another option and can be attached to a fracture table or
hung over the end of the operating room table with weights.
Restoration of anatomic alignment is extremely important in these patients because axial misalignment that would
be less worrisome in other patients can cause accelerated polyethylene wear in a knee prosthesis or a stress
riser below a hip prosthesis. A well-fixed femoral stem has a modulus of elasticity 8 to 10 times higher than the
cortical diaphyseal bone below it. An anatomically reduced fracture treated with a femoral locking plate has a
modulus of elasticity many times higher than the cortical diaphyseal bone above it, depending on the construct
rigidity. The plate must extend proximally at least two femoral diameters above the tip of the prosthesis to
“average” the modulus of elasticity between the hip and knee. This decreases stress and minimizes future
catastrophic fractures.
Vancouver type B2 or B3 fractures (Fig. 45.4) are challenging because not only does the fracture need to be
fixed but the femoral stem needs to be revised. The patient is secured in the lateral position to allow safe tilting of
the table for imaging, so an extensile approach extending from the hip along the entire femur to the knee can be
performed. By combining a posterolateral hip approach (Kocher-Langenbeck or Gibson) with a standard lateral
femoral approach, the entire femur and the hip joint can be exposed with maximum flexibility and modest soft-
tissue disruption (Fig. 45.5). It allows internal fixation as well as revision of the femoral or acetabular component
if necessary. The lateral position also facilitates intraoperative imaging including Judet views (iliac and obturator
oblique) by tilting the table forward or backward. The uninvolved leg should be palpable through the drapes at
the knee and the ankle to help assess leg length in comminuted fracture patterns (types B2 and B3). If the
femoral component requires revision, the fracture site can be used to help to remove the prosthesis and the
cement if necessary. The fracture should be reduced anatomically and temporarily stabilized with clamps,
cerclage cables, plates, etc. The femur can then be prepared with flexible reamers and appropriate broaches.
Luque wires around a periprosthetic locking plate are useful for temporary fixation because they are easy to
apply and remove, inexpensive, and quite solid. A stable anatomic reduction must be maintained during the
entire preparation of the femur and during the insertion of the new femoral implant. Once the femoral implant is in
place, the Luque wires can be removed, and the plate is definitively fixed to the femur with cables and screws
proximally to control rotation and with screws distally (Fig. 45.6). One or two cables below the tip of stem are
applied to absorb hoop stresses and prevent crack propagation (2,8).
The surgery itself can be divided into seven stages

1. Surgical approach and exposure of the fracture site.

2. Removal of the loose stem and/or cement.
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FIGURE 45.4 A 72-year-old man fell on a staircase at home. A. An AP radiograph taken 2 weeks prior to the
 fall at a routine follow-up visit. His Harris Hip Score at that time was 92. B. Injury radiograph shows a femur
fracture proximal the tip of a stem that has subsided (Vancouver B2 fracture).

3. Anatomic reduction and temporary fixation of the fracture with a locking plate of appropriate length (from the
greater trochanter to at least four femur diameters distal to the tip of the fracture assuming that the tip of the
femoral prosthesis will be two femur diameters distal to the fracture end.
4. Preparation of the femur while maintaining anatomic reduction of the fracture—full femur x-rays should be
taken without the trial prosthesis to rule out fracture extension and/or with the trial prosthesis in place to rule
out perforation and verify the prosthesis length relative to the distal extension of the fracture.
5. Insertion of the femoral implant—full femur x-rays should then be taken to rule out fracture displacement or
extension during the stem insertion.
6. Definitive fixation of the plate with screws and cables above and below the tip of the stem: screws above to
control rotation and cables below to control hoop stresses.
7. Meticulous closure over drains.
Prosthetic Implants
The choice of a revision femoral implant in Vancouver B2 and B3 fractures is based on the following four factors
1. Location of the fracture
2. Comminution of the fracture
3. Stability of fracture fixation
4. Quality of the proximal femur bone
As a general rule, cemented implants should not be used because it is very difficult to pressurize the cement well
enough to obtain a solid mantle without pushing some of the cement into the fracture lines, which interfere with
fracture healing. Occasionally, a long cemented stem may be used in very elderly low demand patients to allow
earlier weight bearing. However, a construct with a stem well fixed only distally and loose proximally
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is at risk for catastrophic failure in cantilever mode. Figure 45.6 shows an example where the cement mantle
failed proximally leaving the stem solidly fixed distally with eventual stem fracture.
FIGURE 45.5 Vancouver type B2—Surgical exposure, fracture fixation, and femoral stem revision. With the
patient in the lateral decubitus position, the hip and femur have been exposed. The fracture is provisionally
stabilized, and the prosthesis is removed (A). The fracture is reduced with a combination of clamps and K-wires
and a periprosthetic fracture plate is applied and provisionally secured with wires (B). The femoral canal is then
prepared for a longer and usually bulkier femoral stem (C), and the implant is carefully inserted, making sure that
the fracture stays reduced and that the provisional fixation holds on (D). Finally, the plate is secured to the femur
with a combination of screws and cables (E).
FIGURE 45.6 This patient had a 6-month history of progressive thigh pain with weight bearing followed by 4
days of severe pain and then a fracture. The implant was loose proximally but solid distally. The fracture site was
used to remove the cement and the prosthesis. The fracture was reduced, and a long locking plate was used for
provisional fixation. The femur was prepared to allow the insertion of a long fully coated porous stem bypassing
the tip of the fracture by two cortical diameters. The locking plate spanned from the greater trochanter to two
diameters past the tip of the stem was then secured to the lateral femur with a combination of cables and screws
above and below the tip of the stem. One or two cables below the tip of stem are applied to absorb hoop
stresses and prevent crack propagation.

When there is no comminution and the fracture fixation is stable, a standard noncemented stem can be used as
long as it bypasses the fracture by two cortical diameters. A long fully coated noncemented stem is
recommended; straight or curved based on need length and the patient femoral curvature (9,10). Most
contemporary systems are modular allowing metaphyseal buildup, rotation, and offset adjustment.

PERIPROSTHETIC ACETABULAR FRACTURES

A pelvic ring injury in a patient with a hip prosthesis should be evaluated in the same way that a patient without a
hip prosthesis would be managed. Unstable fractures should undergo open reduction and internal fixation (ORIF)
when indicated. External fixation as a temporizing measure or as a definitive treatment should be avoided when
possible for fear of seeding the hip implant with the inevitable infected pin. Fractures of the acetabulum should
be evaluated by looking at four parameters
1. Implant mode of fixation (cement or cement less)
2. Implant stability
3. Fracture location and pattern
4. Bone quality
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Iliac and obturator views (Judet views) are essential, and in some cases, an inlet and outlet views may be useful.
A CT scan, with or without contrast, is advisable in cases with severe protusio to locate the neurovascular
structures and the ureter relative to the implant since it may alter the surgical approach or require the assistance
of a general or vascular surgeon. A periprosthetic acetabular fracture with a cemented implant usually implies
that the cement mantle is damaged and that the implant is unstable, requiring revision. One possible exception
would be an anterior column fracture where the dome and posterior cement mantle are intact. Nonoperative
treatment with protected weight bearing may be indicated especially in older low demand patients.
The same isolated minimally displaced anterior column fracture around a cementless implant can be treated like
a nondisplaced acetabular fracture with 6 to 8 weeks of limited weight bearing. A displaced posterior wall
acetabular fracture requires surgical stabilization to prevent dislocation.
Isolated column fractures are rare, the most common pattern being a transverse fracture going through both
columns with the implant appearing deceptively stable. Significant protusio may develop simply because of the
reaction forces across the joint even when the patient is non-weight bearing. These cases should be assessed
very carefully and followed closely when treated nonoperatively. Finally, the femoral component should be
evaluated for stability, malposition, and wear. The stability of the femoral stem should always be evaluated at the
time of the acetabular surgery, and the surgeon should be prepared to revise if needed.

PERIPROSTHETIC DISTAL FEMUR FRACTURES

Fractures around a total knee are the second most common type of periprosthetic fracture after the proximal
femur. They typically occur through fragile osteoporotic bone following low-energy trauma. Several mechanical
factors have been associated with this fracture including anterior cortical notching >3 mm, joint line
malalignment, joint stiffness and decreased range of knee motion. The goal in treatment is early restoration of
knee motion and protected weight bearing that allows uneventful fracture healing.
Treatment is based on four factors seen in Table 45.3.
1. Fracture location
2. Fracture displacement
3. Implant stability
4. Bone quality.

SURGICAL PLANNING
The knee prosthesis must be accurately identified (manufacturer, type, and size) before surgery especially if the
femoral component is unstable, and the tibial component is well fixed. A new or different polyethylene tray on the
tibia is frequently necessary. Once the implant has been identified, it is important to determine what “modularity”
or flexibility it offers for revision such as constraints, condylar femoral augments, metaphyseal supplementation,
and diaphyseal stem fixation. Some older-type prosthesis systems offer little flexibility, and revising both
components with a modern modular system may be necessary. Collateral ligaments are usually competent but a
constrained, mobile bearing, or hinged prosthesis may be necessary if there is extensive bone loss.
Periprosthetic fractures around a total knee are classified into three types: epicondylar, condylar, and
supracondylar (Table 45.3).
 TABLE 45.3 Distal Femur Periprosthetic Fractures Classification

Location Displacement Implant Stability Bone Quality

1-Epicondyle a—Non displaced Solid Sufficient for fixation

b—Displaced

2-Condyle (isolated) Rarely a factor Usually solid Usually sufficient for fixation

3-Supracondylar

A Rarely a factor Solid Sufficient for fixation

B Not a factor Loose Sufficient for fixation
C Not a factor Solid Insufficient for fixation
D Not a factor Loose Insufficient for fixation

This table summarizes the equipment and implants needed to address different type of fractures,
assuming there is no infection. The implants listed in the possible column should be available if the
bone stock is poor.

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The treatment goal for epicondylar fractures, type 1, is to ensure varus valgus stability. For most nondisplaced
and minimally displaced fractures, nonoperative treatment with a cast or brace is appropriate. On the other hand,
most displaced fractures will require ORIF. Occasionally, a more constrained tibial tray may help to protect
fracture healing.
For type 2 condylar fractures, treatment must restore fracture and implant stability using a condylar plate and
screws. If the femoral component requires revision, a stemmed implant is recommended to reduce stress at the
fracture site.
Type 3 fractures (supracondylar) can be challenging particularly if the implant is loose or the bone stock is poor.
Type 3A supracondylar fractures should be treated with either a locking femoral condylar plate or a retrograde
nail. Nailing requires precise knowledge regarding the size of the “box” in the femoral component. In the United
States, approximately half of the femoral components implanted are cruciate sacrificing implants that preclude
nailing.
Type 3B fractures should be treated with a stemmed revision femoral implant and internal fixation with a locking
distal femoral condylar plate for rotational stability. Types 3C and D require careful planning and consideration
for allograft or a distal femoral replacement prosthesis with a hinged articulation.

TECHNICAL CONSIDERATIONS
Epicondylar fractures can usually be repaired anatomically using partially threaded cancellous screws. The use
of washers or a short one-third tubular plate prevents the screw head from perforating the thin cortex.
Exact knowledge of the type of prosthesis is essential for several reasons. First, epicondylar fracture fixation can
be protected in some cases by changing the tibial plastic tray to a more constrained version that reduces varus
and valgus stresses. Second, if the femoral component is revised, it has to match the tibial polyethylene tray to
avoid accelerated wear. And third, if a supracondylar nail is planned, the femoral component needs to
accommodate nail insertion.

PERIPROSTHETIC PROXIMAL TIBIA FRACTURES

These fractures are rare but challenging because of the tenuous soft-tissue envelope. The same principles
apply; rule out infection, determine implant stability, localize exactly the fracture, and assess bone quality. The
same clinical sequence as proximal femur periprosthetic fractures apply. An infection can be investigated by a
knee aspiration if there is clinical suspicion. Surgery should be postponed until culture results are available, the
prosthesis is accurately identified, and soft tissues are healthier. Most fractures are around the implant that is
often unstable. Fractures located at a safe distance from the tibial component are unusual. A stable tibial implant
before the injury may be loosened by the impact, and both components may require revision to implant a more
constrained prosthesis. A stemmed tibial prosthesis may be necessary but the ligaments are still usually attached
to bone fragments. A more constrained prosthesis, however, is recommended to protect them.

PERIOPERATIVE MANAGEMENT
Periprosthetic fracture patients behave more like hip fracture patients postoperatively than elective joint
replacement patients in terms of complications and management. They are usually frail patients with significant
medical comorbidities, and medical specialists are usually consulted before and after surgery. If the surgery is
delayed for more than 24 hours, venous thromboembolic prophylaxis should be initiated with both mechanical
prophylaxis (foot or calf pumps) and with unfractionated or low molecular weight heparin. These anticoagulants
are safe until the night before surgery (11). Postoperatively, patients should be protected for at least 4 weeks
with a low molecular weight heparin or warfarin (INR between 2 and 3).
Noninfected periprosthetic fractures should receive the same antibiotic prophylaxis regimen as with elective joint
replacement (12). First-generation cephalosporin should be used for 24 hours unless the patient is a known or
likely (nursing home) MRSA carrier and then vancomycin should be considered. There is little evidence to
support continued antibiotics until the suction drains or bladder catheters are removed.
We routinely utilize regional and spinal anesthesia whenever possible because it reduces the risk of venous
thromboembolic disease, blood loss, and respiratory complications in patients over 75 years of age and carries a
lower morbidity and mortality in high risk patients (13).
Physical therapy should be started within 24 hours and is dictated by the fracture type and its fixation. Weight-
bearing status, range of motion, and hip precautions are adjusted on a case-by-case basis. Radiological and
clinical follow-up is determined by the fracture. Oblique or angled radiographs may be necessary to monitor
callus formation in presence of a revision prosthetic implant. Sutures are removed 10 to 14 days after surgery.
Patients are followed clinically and with radiographs at 4- to 6-week intervals until the fracture has healed.
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COMPLICATIONS
Periprosthetic fractures have a high complication rate especially when fixation of the fracture requires
revision of a prosthetic implant. Postoperative wound drainage increases with the amount of dissection and
the duration of the procedure. It often occurs even in the absence of infection. Future studies may
demonstrate a benefit for an incisional negative pressure dressing (“wound vac”) in selected patients.
Infections are catastrophic because of the presence of fracture implants, a prosthetic joint, and possibly an
allograft. As a general rule, they should be treated aggressively according to joint replacement infection
treatment guidelines. In patients with early postoperative wound infections (2 to 3 weeks), irrigation and
débridement and culture-specific intravenous antibiotics should be given. The threshold to remove the
 prosthetic implant should be lower than in elective hip arthroplasty, in order to increase the probability of
fracture healing.
The incidence of nonunion and delayed union exceed 10%. The etiology may be biological, mechanical, or
both. Fractures require stability in order to heal. The periprosthetic environment is difficult from a
mechanical standpoint because of the presence of multiple stress risers, materials of different modulus of
elasticity, poor bone quality and quantity, and a weight-bearing moving joint at both ends. If plate loosening
or screw failure is identified at follow up, it should be revised early to promote fracture healing and minimize
the risk of catastrophic failure.
The periprosthetic biological environment may be severely compromised due to the trauma of the injury and
multiple surgeries. The local environment may be further impaired by cement or polyethylene debris that
cause foreign body reaction and inflammation. At the time of surgery, soft-tissue preservation techniques
are required, but the chronic inflammatory material should be removed if the prosthesis is revised. The use
of bone morphogenic protein (BMP) and autogenous or allograft bone graft material should be
individualized. In patients with delayed unions or nonunions, an infection workup is mandatory.
Postoperative loss of knee motion is common after distal periprosthetic fractures, with or without revision of
the prosthesis, because of quadriceps scarring or intra-articular adhesions if the prosthesis is revised.
Meticulous and gentle surgical technique and proper ligament balancing if the prosthesis is revised are
critical. Postoperative epidural anesthesia, adequate pain management, continuous passive motion (CPM),
and skillful physical therapy have all been reported to help prevent stiffness. Manipulation under general
anesthesia should be considered early but performed cautiously.

REFERENCES
1. Cook RE, Jenkins PJ, Walmsley PJ, et al. Risk factors for periprosthetic fractures of the hip: a survivorship
analysis. Clin Ortho Relat Res 2008;466(7):1652-1656.

2. Pike J, Davidson D, Garbuz D, et al. Principles of treatment for periprosthetic femoral shaft fractures
around well-fixed total hip arthroplasty. J AAOS 2009;17:677-689.

3. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality after periprosthetic fractures of the femur. J Bone
Joint Surg Am 2007;89:2658-2662.

4. Brady OH, Garbuz DS, Masri BA, et al. The reliability and validity of the Vancouver classification of femoral
fractures after hip replacement. J Arthroplasty 2000;15:59-62.

5. Chevillotte CJ, Ali MH, Trousdale RT, et al. Inflammatory laboratory markers in periprosthetic hip fractures.
J Arthroplasty 2009;24:722-727.

6. Mangram AJ. Hospital Infection Control Practices Advisory Committee (HICPAC) and Centers for Disease
Control and Prevention (CDC). Guidelines for prevention of surgical site infection. Infect Control Hosp
Epidemiol 1999;24(4): 247-278. Available at: http://www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm

7. Darouiche R, Wall M, Itani K, et al. Chlorhexidine-alcohol vs. povidone-iodine for surgical-site antisepsis. N
Engl J Med 2010;362:18-26.
8. Zdero R, Walker R, Waddell JP, et al. Biomechanical evaluation of periprosthetic femoral fracture fixation.
J Bone Joint Surg Am 2008;90:1068-1077.

9. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic femoral fractures around well-fixed implants: use of
cortical onlay allografts with or without a plate. J Bone Joint Surg Am 2002;84:945-950.

10. Weeden SH, Paprosky WG. Minimal 11-year follow-up of extensively coated stems in femoral revision
total hip arthroplasty. J Arthroplasty 2002;17:134-137.

11. Recommendations for antithrombotic and thrombolytic therapy, 9th ed. ACCP Guidelines, Falck-Ytter Y,
Francis CW, Johanson NA et al. Chest 2012;141(2): suppl e2785-e3255.

12. Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty;
prophylactic antibiotics in clean orthopaedic surgery. www.aaos.org/about/papers/advistmt/1027.asp

13. Horlocker TT, Neal JM, Rathmell JP. Practice advisories by the American Society of Regional Anesthesia
and Pain Medicine: grading the evidence and making the grade. Reg Anesth Pain Med 2011;36:1-3.
 46
Soft-Tissue Coverage: Gastrocnemius and Soleus Rotational
Muscle Flaps
Randy Sherman
Wai-Yee Li

INTRODUCTION
Orthopedic trauma management continues to evolve into a technologically driven science as implants for fracture
fixation continue to improve. Less invasive surgical approaches for fracture reduction and fixation, 2D and 3D
imaging, and earlier and more aggressive rehabilitation continue to improve patient outcomes. However, in a
small but significant subset of orthopedic trauma patients, uncomplicated fracture healing can be seriously
compromised by complex soft-tissue injuries. Failure of the orthopedic surgeon to appreciate or underestimate
the magnitude of the soft-tissue injury may further complicate treatment. High-energy injuries are still associated
with a relatively high incidence of delayed union, nonunion, fixation failure, and infection. Early and repeated
débridement of open fractures and the surrounding soft tissues is one of the basic pillars of fracture
management. Unfortunately, many surgeons attempt to close small- and medium-sized wounds primarily leading
to wound breakdown or dehiscence. Early introduction of noninjured, well-vascularized soft tissue is a thoroughly
researched, well-documented alternative to maximize wound healing and minimize infectious complications after
fracture fixation. This chapter describes the use of the gastrocnemius and soleus rotational muscle flap for
coverage of soft-tissue defects in the lower leg.

INDICATIONS AND CONTRAINDICATIONS

A muscle, myocutaneous or fasciocutaneous flap, is indicated when vital structures such as bones, joints,
tendons, or hardware remain exposed after injury. Overlying skin and soft tissue that might initially appear viable
following injury can be further compromised after additional surgical exposure. Wounds that are closed under
tension may result in further ischemia to the skin. The treatment algorithm for soft-tissue reconstruction after a
tibial fracture traditionally divides the lower leg into proximal, middle, and distal thirds. For many wounds and
defects in the proximal third of the lower leg, a medial or lateral gastrocnemius flap is an excellent option. In the
middle third of the leg, small and medium-sized wounds can often be covered by a soleus rotational muscle flap.
With large defects in the distal one-third of the leg, ankle, and foot, a free tissue transfer is usually necessary.
When considering soft-tissue reconstruction following lower limb trauma, the ideal muscle flap should be well
vascularized, durable, easily harvested, and capable of a broad range of coverage options. Fortunately, of all of
the local rotational muscle flaps described, the gastrocnemius is one of the most reliable and is well
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situated to aid in the coverage of many proximal third defects. The gastrocnemius is a broad, two-headed muscle
with a single proximal vascular pedicle for each segment, the medial and lateral sural arteries, which either take
rise directly from the popliteal artery just above the articular line or result as a bifurcation of a single, more
proximal sural vessel. Each artery acts as the sole vascular supply for its muscle segment allowing for maximum
utilization of the flap in its elevation and arc of rotation. Consequently, the gastrocnemius muscle or a
myocutaneous rotational flap is the procedure of choice for soft-tissue coverage of complex open wounds about
the knee and proximal third of the tibia and fibula. The use of this flap is indicated in the following circumstances:
(a) coverage of acute, proximal third, grade III, open tibial fractures with or without hardware involving exposure
of the knee joint, capsule, fracture site, or cortex (Fig. 46.1); (b) obliteration of dead space and wound closure
after radical débridement of osteomyelitic wounds or infected nonunions in this region (Fig. 46.2); (c) coverage of
exposed total knee arthroplasties or prearthroplasty tissue augmentation in densely scarred wound beds (Fig.
46.3); (d) limb salvage and coverage of endoprostheses or allograft material after resection of musculoskeletal
neoplasms (Fig. 46.4); and (e) preservation of stump length in revision amputation surgery. The medial head of
the muscle is larger and longer than the lateral head. Each can be utilized to augment or replace defined tissue
defects on the ipsilateral side of the tibial surface. Anterior defects are better served by the medial gastrocnemius
flap. Distal cutaneous extensions of each flap allow for greater degrees of coverage but complicates donor site
closures.

FIGURE 46.1 Grade IIIB open tibial-plateau fracture with exposed knee joint after internal fixation and
unsuccessful attempt at primary wound closure.
FIGURE 46.2 Dead space involving skin, subcutaneous tissue, muscle, and bone in a proximal-third infected
nonunion.

The soleus muscle, without a myocutaneous correlate, has a much more limited arc of rotation and is primarily
used for small, medially based open wounds in the middle third of the leg. Parallel to and deep to the
gastrocnemius, the soleus muscle resides in the superficial posterior compartment of the lower leg and aids in
plantar flexion of the ankle and foot. It arises from the proximal tibia and fibula and inserts conjointly with the
gastrocnemius to form the Achilles tendon that inserts onto the calcaneous. It has a dual blood supply from both
the posterior tibial and peroneal arteries. Some authors contend that the muscle can be split longitudinally to
form a medial and lateral hemisoleus flap. Indications for its use include coverage of smaller, acute open
fractures, and chronic osteomyelitic wounds in the middle third of the lower leg (Fig. 46.5).
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FIGURE 46.3 Scarred, atrophic, prepatella skin in an elderly patient after removal of an infected total-knee
arthroplasty.
FIGURE 46.4 A 10-year-old girl immediately after tumor extirpation of a proximal tibial osteosarcoma and
placement of endoprosthesis after loss of anterior skin.

Contraindications to the use of the gastrocnemius flap include vascular compromise of the muscle itself by
disruption of the sural arterial pedicle, compromise of the popliteal artery from which it emanates, or occlusion of
the proximal arterial tree. Recipient site contraindications include a wound in the proximal third region whose size
and dimensions are too large for adequate coverage by the gastrocnemius muscle. Significant local trauma to
the muscle itself, although rare, prevents its successful rotation. The use of the soleus muscle for middle third
lesions is limited and often requires the possible transfer of a distant muscle or fasciocutaneous flap using
microvascular techniques. Similarly, injury to the substance of the soleus muscle will hinder its ability to be
transposed. Vascular compromise to the soleus muscle is extremely rare because of its segmental inflow.
Because of segmental minor arterial branches that exit from the posterior tibial and peroneal arteries distally, the
surgeon must take great care to assure adequate vascularity to the most distal aspect of the soleus muscle when
a complete transposition is planned. As with the gastrocnemius, a large anterior or laterally located wound in the
middle third of the leg may not be completely covered by the soleus muscle (Fig. 46.6), and free tissue transfer
may be a better option.
FIGURE 46.5 Middle-third grade IIIB open-tibial fracture with a bony sequestrum and loss of overlying soft tissue.

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FIGURE 46.6 Large, grade IIIB, open, middle-third tibial fracture cannot be closed by a local soleus flap and
requires free tissue transfer.

Before any muscle coverage procedure, it is critical that infection or tumor recurrence has been adequately
treated by débridement or excision before wound closure. No muscle flap will successfully combat ischemic, or
necrotic bone, sequestrum, or loose infected hardware, which may serve as a nidus for persistent infection.
A major advancement in modern open fracture management has been the introduction, dissemination, and now
wide use of vacuum-assisted dressings for wound care. The Wound VAC (vacuum assisted closure), registered
trademark by KCI for Negative Pressure Wound Therapy, is a simple, elegant dressing system that includes a
sterile porous sponge, a connecting tube, and a small machine capable of producing either intermittent or
constant vacuum. The sponge is cut to fit the size of the recipient wound and held in place by an occlusive,
adhesive transparent drape. A small aperture is cut into the drape to which the tube is easily attached. Finally,
the far end of the tube is connected to the vacuum source enabled with a canister to collect effluent materials.
This wound care system is designed to decrease local swelling, increase local tissue oxygenation by decreasing
intracellular hydrostatic pressure, and promote granulation tissue, thereby accelerating wound contraction and
closure by secondary intention. The VAC system is widely applicable and easily applied and managed. It can be
used in the operating room, the wards, clinics, and at home. It is highly adaptable to various wound sizes and
configurations. A constant reliable vacuum source is mandatory and is a keystone to the VAC therapy system.
The dressing need only be changed every 2 to 3 days. This has radically decreased nursing labor commitments
and dramatically improved patient care comfort during these very difficult perioperative periods. In the open tibial
fracture patient, the VAC device is most beneficial when used to prepare a wound for eventual closure using
either skin grafting or flap transfer techniques. It should not be seen as a substitute for operative débridement of
untidy wounds nor for definitive wound closure procedures. Its effect on how we treat complex extremity wounds
cannot be overestimated and continues to grow and adapt with extensive clinical experience.

PREOPERATIVE PLANNING
History and Physical Examination
Critical elements to the patient's history must include the circumstances and mechanism of injury, the time since
wounding and the interval treatments administered. The age and general health of the patient as well as any
previous injuries, surgeries, or medical treatments should be delineated. A history of peripheral vascular disease,
previous cardiac problems, deep venous thrombosis, pulmonary embolism, obesity, and/or smoking are
particularly relevant in perioperative planning and management.
A thorough physical examination of the patient is crucial when planning a muscle flap procedure. Clinical
inspection of the leg should be made, with particular attention paid to fracture and wound location. Most often,
but not always, these are interrelated. Wound length, width, and depth as well as tissue condition (viability, crush
component, maceration, foreign bodies) should be noted. Presence or absence, as well as quantification of pulse
strength and location, is mandatory. A detailed vascular examination with palpation of the dorsalis pedis and
posterior tibial pulses for arterial inflow, augmented by Doppler examination for venous outflow, should be
performed and documented. Sensory and motor examination prior to any planned surgical procedure is critical.
Other factors such as induration, discoloration, ecchymosis, and cellulitis must be considered. Any suspicion of a
degloving component to the wound should be highlighted and considered when planning further surgical
intervention. With acute open fractures, the surgeon should anticipate the need for subsequent soft-tissue
closure. If an external fixator is utilized, the frame should allow unrestricted
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transposition of the muscles from posterior to medial or anterior. The zone of injury at the fracture site may be
difficult to initially categorize, and serial débridement may significantly increase the size of the wound (Fig. 46.7).

FIGURE 46.7 Large amount of retained titanium from a previously removed, infected, totalknee arthroplasty.

The function of the posterior compartment muscles should be assessed whenever possible. Sensory
examination of the foot must be evaluated, with particular attention given to the posterior tibial, sural, saphenous,
and peroneal nerves both before and after each surgical intervention.

Imaging Studies
Radiographs should be viewed with particular attention directed to fracture location and the presence or absence
of internal or external fixation devices. Arteriography may be indicated if pulses are absent or diminished (Fig.
46.8). Magnetic resonance angiography may be a more appropriate imaging tool in certain circumstances.
Surgical incisions should be planned to address the need for additional débridement and internal or external
fixation of the fracture.

FIGURE 46.8 Angiogram demonstrating patency of the popliteal artery and continuity of the sural arteries despite
the fracture comminution and retained gunshot pellets.

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SURGERY
Gastrocnemius
Wound coverage using a muscle flap is undertaken only after definitive débridement of a traumatic or infected
wound has been completed or a tumor has been extirpated (Fig. 46.9). The entire involved extremity is prepped
and draped, and a sterile tourniquet is applied to the thigh. It is advisable to accurately mark the border between
the proximal and middle thirds of the tibia to ensure that there will be full muscle coverage. The entire operation
is performed under tourniquet control. The approach to the gastrocnemius muscle can be made through
perpendicular, oblique, or parallel incisions depending on the location and size of the defect. If a parallel incision
is used, the gastrocnemius muscle must be tunneled beneath the resulting bipedicled fasciocutaneous flap.
Whenever possible, tunneling the flap under a skin bridge should be avoided.
After incising the skin and subcutaneous tissue, the gastrocnemius muscle is identified by opening the deep
investing fascia of the leg longitudinally along the anterior border of the muscle (Fig. 46.10). The fascia should
be opened proximally toward the origin of the muscle and distally to its insertion on the Achilles tendon for
maximum exposure. The areolar plane between the gastrocnemius and soleus is entered by either sharp or
digital dissection. This plane is confirmed by visualizing the plantaris longus tendon, which lies adjacent to the
soleus at or near its medial border (Fig. 46.11). The white investing fascia on the posterior border of the soleus
and the deep border of the gastrocnemius assures recognition of this space. Occasionally, communicating
vessels between the soleus and gastrocnemius exist and must be divided. Superficially, the myofascia of the
gastrocnemius muscle is easily separated from the overlying deep investing fascia. One or two perforating
vessels from the muscle to the overlying skin must be saved if a myocutaneous flap is planned, otherwise they
are ligated. The gastrocnemius is separated at the median raphe into the medial and lateral heads. The raphe is
more prominent and easier to identify in the distal portion of the muscle (Fig. 46.12). The sural nerve and lesser
saphenous vein run along the raphe and should be preserved. These are constant landmarks that facilitate
separation of the medial from the lateral head. When the median raphe has been identified, dissection proceeds
from distal to proximal, with the surgeon working along the posterior midline while protecting the neurovascular
structures at all times. When both the posterior and anterior surfaces are freed, the gastrocnemius can be
released from its attachment to the Achilles tendon. The dissection continues proximally to the origin of the
gastrocnemius muscle from the femoral condyle (Fig. 46.13).
During the proximal dissection into the popliteal space, care must be taken to visualize and protect the medial
sural vascular pedicle (Fig. 46.14). Generous proximal exposure through a posterosuperior skin incision as well
as a release of the gracilis tendon if necessary will facilitate visualization. The muscle can be partially released
from the condyle by dividing the thick tendinous attachments, resulting in a 2- to 3-cm increase in the length of
the flap. The muscle can also be expanded significantly in both the transverse and longitudinal planes by
crisscross incisions made both anteriorly and posteriorly through its heavily fused bilaminar myofascia (Fig.
46.15). Furthermore, the gastrocnemius muscle can be split longitudinally in the distal portion so that part of the
muscle can be used to obliterate deep dead space, while the remainder of the muscle can be used for superficial
coverage.
The lateral gastrocnemius flap is raised in a similar fashion from the lateral cutaneous approach by using one of
the three incisions described. Of paramount importance is the identification and protection of the peroneal nerve
just below the head of the fibula as it penetrates from superficial to deep into the anterior compartment. After the
safety of this nerve is assured, raising the lateral gastrocnemius muscle is done in a fashion similar to that
described for the medial head. It should be noted, however, that the lateral gastrocnemius muscle is smaller than
the medial head and will not provide the same quantity of muscle for laterally based lesions. On rare occasions,
both heads of the gastrocnemius can be utilized.
FIGURE 46.9 Completed débridement of infected fracture of the knee with the removal of all nonviable soft-
tissue and bony sequestrum.

FIGURE 46.10 The gastrocnemius muscle is visible when the deep investing fascia is incised longitudinally.

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FIGURE 46.11 The plantaris longus tendon confirms the plane between the gastrocnemius and soleus muscles.
FIGURE 46.12 The median raphe separates the medial and lateral heads of the gastrocnemius and carries the
neurovascular structures, which must be protected.

FIGURE 46.13 Exposure of the muscle origin on the femoral condyle requires adequate muscle retraction and
sufficient proximal exposure.

FIGURE 46.14 When needed, the sural artery pedicle can be visualized on the deep surface of the
gastrocnemius in the popliteal fossa.

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FIGURE 46.15 Transverse and longitudinal myofascial release on both deep and superficial surfaces allows
significant expansion of muscle area to be used for coverage.

SOLEUS
The soleus muscle is almost always raised from a medial approach and is used to cover small medial and
anterior-based middle third wounds (Fig. 46.16). A curvilinear incision is made over the medial aspect of the calf.
The plane between the gastrocnemius and soleus muscles is easily identified and serves as an excellent starting
point. When raising the soleus, the gastrocnemius-Achilles musculotendinous unit must be preserved at all times.
Alice clamps are placed on the edge of the Achilles tendon to better demonstrate the area where the two merge.
The fascia that fuses the posterior soleus to the Achilles is divided (Fig. 46.17). Proceeding
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from proximal to distal, the surgeon dissects the muscle off the Achilles tendon with either a knife or Metzenbaum
scissors from medial to lateral. A pseudoraphe is encountered approximately three-fourths of the way through the
dissection. It is important to separate this and continue the dissection both posteriorly and laterally to include the
entire soleus muscle. The muscle is released distally to include as much length as possible (Fig. 46.18). The
plane between the deep side of the soleus and the deep flexor compartment is identified and can be digitally
dissected. Care must be taken to identify the distal segmental arterial branches arising from the posterior tibial
artery and vein. These can be very short and if inadvertently injured or cut, may retract beneath the deep fascia
making them extremely difficult to ligate. When these distal vessels have been identified, ligated, and divided, the
soleus attachments on the lateral side are dissected free under direct visualization. The muscle must be released
quite proximally, especially on its lateral side, to achieve any significant rotation of the muscle into the wound
(Fig. 46.19). Crisscross release of the soleus myofascia can be done on the deep or anterior surface of the
muscle to expand the size and dimensions of the flap (Fig. 46.20).

FIGURE 46.16 Ideal wounds for soleus coverage are small medial wounds located in the middle third of the leg.

FIGURE 46.17 The anterior border of the Achilles is identified and retracted with Alice clamps to aid dissection of
the posterior surface of the soleus from the tendon.

FIGURE 46.18 When freed from its anterior and posterior attachments, the soleus muscle is transected distally.
FIGURE 46.19 Because of the broad attachments on both the tibial and fibular sides, dissection must continue
proximally for any significant transposition to be achieved.

Each muscle, when transferred, is secured into place with absorbable sutures. It is worth emphasizing again that
the muscle, particularly the gastrocnemius, can be split longitudinally, with one slip obliterating dead space and
the remainder addressing the requirements of the open wound. Suction drainage is positioned prior to flap inset.
Finally, if a skin graft over the flap is necessary, it can be harvested from the ipsilateral calf, thigh, or buttock
after application of aerosolized thrombin. The thickness of the graft is usually 0.010 to 0.012 inches (Fig. 46.21).
Alternatively, a myocutaneous flap can be designed, based on perforators from the gastrocnemius, to include
skin and subcutaneous tissue (Fig. 46.22A,B). The skin overlying the muscle is used and can extend 5 cm
proximal to the medial malleolus. The ability to close the donor site must be considered before executing this
myocutaneous flap. This option does not exist with the soleus. A well-padded short-leg posterior splint is applied
with the foot and ankle in a neutral position (Fig. 46.23).

FIGURE 46.20 Scoring of the myofascia on the anterior surface of the soleus allows great dimensions for
coverage.
FIGURE 46.21 A split-thickness skin graft measuring between 0.010 and 0.012 inches can be placed
immediately after successful flap transposition. To improve recipient site aesthetics, we use sheet grafts as
opposed and with equal success to meshed grafts.

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FIGURE 46.22 A,B. A cutaneous paddle can be reliably transferred with the gastrocnemius muscle if it contains
at least one myocutaneous perforator.

POSTOPERATIVE MANAGEMENT
The Jackson-Pratt drain is removed when drainage is <30 mL per day. The dressings are changed between 3
and 5 days, and the skin grafts are inspected. At 1 to 2 weeks, the patient is allowed to place the leg in a
dependent position for short periods with progressive dependency increasing slowly to build tolerance over the
course of 3 to 5 weeks. Prolonged limb dependency is avoided for the first 6 to 8 weeks to avoid venous
congestion in the muscle. The timing of weight bearing depends primarily on the orthopedic injury, rather than on
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the muscle flap. The patient is seen weekly in the office until the wound is completely closed and dry. Patients
must be counseled preoperatively about the deformity caused by muscle rotation, including loss of natural
convexity in the proximal and middle third of the leg caused by rotation of the gastrocnemius muscle. It is well
documented that both the gastrocnemius and soleus muscles will atrophy over time after transposition. After a
gastrocnemius or soleus muscle flap is completed, range of motion of the knee and ankle is usually started
during the first week.

FIGURE 46.23 At the completion of the procedure, Jackson-Pratt drains are placed on suction, and the extremity
is secured in a well-padded posterior splint with the foot plantigrade.

Complications
Because of the rich blood supply and durability of both the gastrocnemius and soleus muscles, flap death is
rare. More common, however, is the development of postoperative hematoma, which requires surgical
evacuation, irrigation, and control of the bleeding site. Loss of power with plantar flexion is rarely a problem
if one head of the gastrocnemius or the soleus muscle is used alone.
A combined gastrocnemius and soleus muscle flap can lead to a greater incidence of muscle weakness and
gait abnormalities. Pain and dysesthesias at the donor site resulting from flap transposition should be
expected during the first 6 to 8 weeks and should not be considered a complication.
Occasionally, with dissection of the soleus muscle and loss of the middle and distal perforators, the distal
end of the soleus may become devascularized, and if this complication is recognized, it should be resected.
If unrecognized, it can lead to partial flap necrosis and subsequent wound infection with bone or hardware
exposure or both. Reversed or distally based soleus flaps, although described, should not be considered
reliable alternatives for muscle transposition.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 75-year-old female sustained a tibial plateau fracture as well as a Grade IIIB distal third lesion (Fig. 46.24)
involving loss of anteromedial soft tissues as demonstrated (Fig. 46.25). After ORIF of the plateau and
intramedullary nailing of the shaft fracture, there was exposed bone and hardware distally (Fig. 46.26). A
posteriorly based skin flap was raised to evaluate both the soleus muscle and the distal posterior tibial vascular
bundle in preparation for either a local rotation flap or free tissue transfer (Fig. 46.27). Fortunately, the soleus
muscle was of sufficient length and bulk to allow transfer and generous coverage of the fracture site (Fig.
46.28A,B). A thin, split-thickness skin graft was applied immediately after muscle inset (Fig. 46.29).
The fractures healed uneventfully.

FIGURE 46.24 Preoperative x-ray, closed disruption of the tibial plateau with GustiloType IIIB distal third lesion.

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FIGURE 46.25 Anteromedial soft-tissue injury.

FIGURE 46.26 Planning exposure

FIGURE 46.27 Vessel and muscle dissection.

FIGURE 46.28 A. Flap elevation. B. Flap transposition and inset.

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FIGURE 46.29 Skin graft coverage.

RECOMMENDED READING
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Beck J, et al. Reconsidering the soleus muscle flap for coverage of wounds of the distal third of the leg. Ann
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Dibbell DG, Edstrom LE. The gastrocnemius myocutaneous flap. Clin Plast Surg 1980;7:45.

Feldman SJ, Cohen BE, Mayo SW Jr. The medial gastrocnemius myocutaneous flap. Plast Reconstr Surg
1978;61:531.

Friedman J, Sherman R, Hollier L. Complex lower-extremity reconstruction in young children when free-tissue
transfer is not an option. J Reconstr Microsurg 2002;18(6):563.

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1978;62:15.
Pee L. Soft tissue coverage of our extensive mid-tibial wound with the combined medial gastrocnemius and
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Staunard J, et al. Surgical treatment of orthopedic trauma. New York: Thieme Medical Publishers; 2007.

Wong A, Sherman R, Pu L. Gastrocnemius flap. Reconstructive surgery of the lower extremity (Lee, Levine,
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