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Master Techniques in Orthopaedic S urgery®

Fractures
Third Edition

MASTER
TECHNIQ UES
SURGERY®
Editor-in-Chief
Bernard F. Morrey , MD
Founding Editor
Roby C. Thompson Jr, MD
Volume Editors
Surgical Exposures
Bernard F. Morrey , MD
Matthew C. Morrey , MD
The Hand
James Strickland, MD
Thomas Graham, MD
The Wrist
Richard H. Gelberman, MD
The Elbow
Bernard F. Morrey , MD
The Shoulder
Edward V. Craig, MD
The Spine
David S. Bradford, MD
Thomas L. Zdeblick, MD
The Hip
Robert L. Barrack, MD
Reconstructive Knee Surgery
Douglas W. Jackson, MD

IN

ORTHOPAEDIC

Knee Arthroplasty
Paul Lotke, MD
Jess H. Lonner, MD
The Foot & Ankle
Harold B. Kitaoka, MD
Fractures
Donald A. Wiss, MD
Pediatrics
Vernon T. Tolo, MD
David L. Skaggs, MD
Soft Tissue Surgery
Steven L. Moran, MD
William P. Cooney III, MD
Sports Medicine
Freddie H. Fu, MD
Orthopaedic Oncology and Complex Reconstruction
Franklin H. Sim, MD
Peter F.M. Choong, MD
Kristy L. Weber, MD

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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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10 9 8 7 6 5 4 3 2 1

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.

Contents
Contributors
Series Preface
Preface
Acknowledgments

PART I UPPER EXTREMITY
CHAPTER 1

Clavicle Fractures: Open Reduction and Internal Fixation
Donald A. Wiss
CHAPTER 2

Scapula Fractures: Open Reduction Internal Fixation
Peter A. Cole and Babar Shafiq
CHAPTER 3

Proximal Humeral Fractures: Open Reduction Internal
Fixation
John T. Gorczyca
CHAPTER 4

Proximal Humerus Fractures: Hemiarthroplasty
William H. Paterson and Sumant G. Krishnan
CHAPTER 5

Reverse Shoulder Arthroplasty for Acute Proximal
Humerus Fractures
Pascal Boileau, Adam P. Rumian, and Xavier Ohl
CHAPTER 6

Humeral Shaft Fractures: Open Reduction Internal
Fixation
Bruce H. Ziran and Navid M. Ziran
CHAPTER 7

Humeral Shaft Fractures: Intramedullary Nailing
James C. Krieg
CHAPTER 8

Distal Humerus Fractures: Open Reduction Internal
Fixation
Daphne M. Beingessner and David P. Barei
CHAPTER 9

Intra-Articular Fractures of the Distal Humerus: Total
Elbow Arthroplasty
Elaine Mau and Michael D. McKee
CHAPTER 10

Olecranon Fractures: Open Reduction and Internal
Fixation
James A. Goulet and Kagan Ozer
CHAPTER 11

Radial Head Fractures: Open Reduction and Internal
Fixation
David Ring
CHAPTER 12

Forearm Fractures: Open Reduction Internal Fixation
Steven J. Morgan
CHAPTER 13

Distal Radius Fractures: External Fixation
Neil J. White and Melvin P. Rosenwasser
CHAPTER 14

Distal Radius Fractures: Open Reduction Internal Fixation
Andrea S. Bauer and Jesse B. Jupiter

PART II LO WER EXTREMITY
CHAPTER 15

Femoral Neck Fractures: Open Reduction Internal
Fixation
Dean G. Lorich, Lionel E. Lazaro, and Sreevathsa Boraiah
CHAPTER 16

Femoral Neck Fractures: Hemiarthroplasty and Total Hip
Arthroplasty
Ross Leighton
CHAPTER 17

Intertrochanteric Hip Fractures: The Sliding Hip Screw
Kenneth A. Egol
CHAPTER 18

Intertrochanteric Hip Fractures: Intramedullary Hip Screws
Michael R. Baumgaertner and Thomas Fishler
CHAPTER 19

Intertrochanteric Hip Fractures: Arthroplasty
George J. Haidukewych and Benjamin Service

CHAPTER 20

Subtrochanteric Femur Fractures: Plate Fixation
Michael J. Beltran and Cory A. Collinge
CHAPTER 21

Subtrochanteric Femur Fractures: Intramedullary Nailing
Clifford B. Jones
CHAPTER 22

Femur Fractures: Antegrade Intramedullary Nailing
Christopher G. Finkemeier, Rafael Neiman, and Frederick
Tonnos
CHAPTER 23

Femoral Shaft Fractures: Retrograde Nailing
Robert F. Ostrum
CHAPTER 24

Distal Femur Fractures: Open Reduction and Internal
Fixation
Brett D. Crist and Mark A. Lee
CHAPTER 25

Patella Fractures: Open Reduction Internal Fixation
Matthew R. Camuso
CHAPTER 26

Knee Dislocations
James P. Stannard
CHAPTER 27

Tibial Plateau Fractures: Open Reduction Internal
Fixation
J. Tracy Watson

CHAPTER 28

Extra-Articular Proximal Tibial Fractures: Submuscular
Locked Plating
Mark A. Lee and Brad Yoo
CHAPTER 29

Tibial Shaft Fractures: Intramedullary Nailing
Daniel S. Horwitz and Erik Noble Kubiak
CHAPTER 30

Tibial Shaft Fractures: Taylor Spatial Frame
J. Charles Taylor
CHAPTER 31

Tibial Pilon Fractures: Staged Internal Fixation
David P. Barei and Daphne M. Beingessner
CHAPTER 32

Tibial Pilon Fractures: Tensioned Wire Circular Fixation
James J. Hutson Jr.
CHAPTER 33

Ankle Fractures
Rena L. Stewart and Jason A. Lowe
CHAPTER 34

Talus Fractures: Open Reduction Internal Fixation
Paul T. Fortin and Patrick J. Wiater
CHAPTER 35

Calcaneal Fractures: Open Reduction Internal Fixation
Michael P. Clare and Roy W. Sanders
CHAPTER 36

Tarsometatarsal Lisfranc Injuries: Evaluation and
Management
Bruce J. Sangeorzan, Kyle F. Chun, Stephen K.
Benirschke, and Benjamin W. Stevens
CHAPTER 37

Pelvic Fractures: External Fixation
Enes M. Kanlic and Amr A. Abdelgawad
CHAPTER 38

Diastasis of the Symphysis Pubis: Open Reduction
Internal Fixation
David C. Templeman and Matthew D. Karam
CHAPTER 39

Posterior Pelvic-Ring Disruptions: Iliosacral Screws
Milton L. Chip Routt Jr
CHAPTER 40

Sacral Fractures
Jodi Siegel and Paul Tornetta III
CHAPTER 41

Acetabular Fractures: The Kocher-Langenbeck Approach
Berton R. Moed
CHAPTER 42

Acetabular Fractures: Ilioinguinal Approach
Joel M. Matta, Mark C. Reilly, and Hamid R. Redjal
CHAPTER 43

Acetabular Fractures: Extended Iliofemoral Approach
David L. Helfet, Milan K. Sen, Craig S. Bartlett,
Nicholas Sama, and Arthur L. Malkani

CHAPTER 44

Surgical Dislocation of the Hip for Fractures of the
Femoral Head
Milan K. Sen and David L. Helfet
CHAPTER 45

Periprosthetic Fractures: Evaluation and Management
Guy D. Paiement
CHAPTER 46

Soft-Tissue Coverage: Gastrocnemius and Soleus
Rotational Muscle Flaps
Randy Sherman and Wai-Yee Li
Index

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

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
Roy al 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 Sy stem
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-Presby terian Hospital
New York, New York

Daniel S. Horwitz, M.D.
Chief, Orthopaedic Trauma

Geisinger Health Sy stems
Danville, Pennsy lvania

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 Wy ss/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

Sumant G. Krishnan, M.D.
Director
Shoulder Fellowship
Bay lor 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-Presby terian 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-Presby terian
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

Kagan Ozer, M.D.
Clinical Associate Professor of Orthopaedic Surgery
The University of Michigan Medical School
The University of Michigan Health Sy stem
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 Phy sicians and Surgeons
Director, Orthopaedic Trauma Service
New York Presby terian Hospital
Director, Hand and Microvascular Service

New York-Presby terian 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
Roy al 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

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-Presby terian Hospital
Columbia University College of Phy sicians 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

Series Preface
Since its inception in 1994, the Master Techniques in Orthopaedic Surgery
series has become the gold standard for both phy sicians 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 y ears 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 y ears. 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 sty le and
vision. As I indicated in the preface to the second edition of The Hip volume,
the words of William May o 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 sy stems to
measure performance, analy ze 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 phy sicians 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 any one 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, y et 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 y ears 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, study ing, attending courses,
reviewing cases, analy zing data, and of course operating, try ing 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 y ears in the making. Any one 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 y ears. 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, my self, 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 y ears 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 y ou!
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 y et 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 every where who treat
patients with musculoskeletal trauma.
Donald A. Wiss, M.D.
Editor

PART I

UPPER EXTREMITY

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 y ears, 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 sy mptomatic 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 ty pe I injuries, the
coracoclavicular ligaments remain intact; in ty pe II injuries, this
ligamentous complex is disrupted allowing superior displacement of the
lateral fragment; and ty pe III injuries that involve the articular 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 cy lindrical. The midportion is densely cortical with
a short and narrow medullary canal particularly in y oung 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).

FIGURE 1.2
The clavicle viewed from above. Note the S-shaped anatomy of the bone.

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. . From a mechanical point of view.FIGURE 1.3 Frontal view of the clavicle and associated soft-tissue structures.4).

they are intended to support the upper limb during the healing process.4 Cross section of the anterior chest wall showing the relationship of the subclavian vessels to the clavicle. teens. and translation is less than a bone diameter. or figure-of-eight _​c lavicle strap to relieve pain. most patients are able to remove their sling for simple activities of . a figure-of-eight sling is simple and well tolerated. In adults. angulation is <10 degrees. INDICATIONS SURGERY AND CONTRAINDICATIONS FOR Most clavicle fractures in adults are managed nonoperatively. These treatment methods will not “reduce” a clavicle fracture. Nonsurgical treatment is indicated when fracture displacement is <12 to 15 mm. a sling or shoulder immobilizer is usually preferred. Within 2 to 3 weeks. Treatment consists of support for the upper extremity in a sling.FIGURE 1. rather. In adolescents. and y oung adults. shoulder immobilizer.

External support is discontinued when the patient has minimal pain and x-ray s show progressive healing. and hy giene.5 X-ray of the clavicle showing a widely displaced fracture following a dirt bike accident. or translation >15 to 20 mm (Fig. support the use of internal fixation in adults when there is shortening. 1. Other strong indications for clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus.5). these conditions represent a small minority of clavicle fractures seen in clinical practice. displaced group 2 ty pe 2 lateral clavicle fractures. Return to activities is dictated by local sy mptoms. 1.6). . Most major orthopedic textbooks supported surgery for open fractures. or displaced pathologic fractures. the indications for internal fixation of clavicle fractures were very limited. Until the turn of this century. Current indications for clavicular surgery. as well as in patients with scapulothoracic dissociation. Not surprisingly. displacement. FIGURE 1.daily living. bathing. those with vascular compromise or progressive neurologic deficits. Most patients can return to full activities by 12 weeks if the fracture is healed. and sy mptomatic nonunion (Fig. Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. This is a strong indication for internal fixation. based on recent randomized clinical trials.

In these patients. . chest wall. Due to pain and inability to comfortably move the extremity. a detailed history and thorough phy sical exam are necessary to accurately diagnose and treat the patient. In patients with clavicle fractures that occur following high-energy trauma such as motor vehicle. cervical spine. As with all injured patients.FIGURE 1. ribs.6 Radiograph of the clavicle showing a displaced Group II Ty pe II distal clavicle fracture. or a fall from a height. Phy sical examination reveals swelling. advanced imaging studies and consultation with other medical or surgical specialists may be required. Substantial trauma to the shoulder girdle can be associated with injuries to anatomically adjacent structures such as the head. motorcy cle. This fracture pattern has a high incidence of delay ed union and nonunion and is another indication for surgery . and lungs. 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. most patients are seen in an emergency room shortly after injury. Most patients with clavicle fractures complain of shoulder or clavicle pain that is exacerbated by movement. a full trauma workup is essential.

1. a careful neurologic and vascular examination must be performed and documented.7). In isolated shaft fractures. fracture crepitus. The proximal fragment usually displaces upward and may tent the skin. and deformity in displaced fractures. the scapula appears prominent or “winged. With displaced fractures. a clinical deformity is often obvious. . The shoulder girdle is shortened and droops downward and forward.” Due to the close proximity of the clavicle to the subclavian vessels and brachial plexus. Ecchy mosis in the supraclavicular infraclavicular or chest wall often takes 12 to 36 hours to develop (Fig. When viewed from the back.tenderness along the clavicle. active range of shoulder motion is reduced while gentle passive motion is uncomfortable but usually tolerated.

The AP view should include the upper third of the humerus. To obtain an accurate evaluation of the fragment position. Imaging Studies A simple AP and oblique x-ray of the clavicle will confirm the diagnosis of fracture in the vast majority of cases. and .FIGURE 1. two projections of the clavicle are ty pically obtained: anterior-posterior view and a (25 to 45 degrees) cephalic tilt view. the shoulder girdle.7 Clinical appearance of the shoulder and chest wall following a motorcy cle accident that fractured the clavicle.

and y oung adults. In the AP view. support the use of internal fixation in adults when there is shortening. The cephalic tilt view brings the clavicle and acromial-clavicular joint away from the overly ing bony anatomy. These treatment methods will not “reduce” a clavicle fracture. teens. Other strong indications for clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus. Current indications for clavicular surgery. while the distal fragment is inferior. the proximal fragment is ty pically displaced superiorly and posteriorly. Not surprisingly. Treatment consists of support for the upper extremity in a sling. and sy mptomatic nonunion. CT and MRI scans may be useful in sternoclavicular fractures and dislocations but are rarely necessary for diaphy seal fractures. so that other fractures or a pneumothorax can be identified. External support is discontinued when the patient has minimal pain and x-ray s show progressive healing. Nonsurgical treatment is indicated when fracture displacement is <12 to 15 mm. the indications for internal fixation of clavicle fractures were very limited. Return to activities is dictated by local sy mptoms. and hy giene. and translation is less than a bone diameter. In adults. these conditions represent a small minority of clavicle fractures seen in clinical practice. and internally rotated.the upper lung fields. Most patients can return to full activities by 12 weeks if the fracture is healed. Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. In adolescents. a figure-of-eight sling is simple and well tolerated. Until the turn of this century. Most major orthopedic textbooks supported surgery for open fractures. those with vascular compromise or progressive neurologic deficits. or translation <15 to 20 mm. they are intended to support the upper limb during the healing process. as well as in patients with scapulothoracic dissociation. rather. a sling or shoulder immobilizer is usually preferred. displacement. most patients are able to remove their sling for simple activities of daily living. bathing. Treatment Paradigm Most clavicle fractures in adults are managed nonoperatively. angulation is under 10 degrees. . shortened. shoulder immobilizer. displaced group 2 ty pe 2 lateral clavicle fractures. Within 2 to 3 weeks. based on recent randomized clinical trials. or figure-of-eight clavicle strap to relieve pain. or displaced pathologic fractures.

which further improve reduction and fixation (Fig. the most common method of treatment for displaced clavicle fractures in adults is plate fixation. Patients with other injuries that require early surgery and who remain hemody namically stable may benefit from early internal fixation. However. With this method of treatment. and the presence of fracture comminution limit its use. 1. stable internal fixation with restoration of length. and those with neurovascular compromise require immediate treatment. its small medullary canal. internal fixation should be delay ed until the patient’s condition has been optimized.Timing of Surgery Whereas open clavicle fractures. and alignment can be achieved allowing early range of shoulder motion and rehabilitation of the upper limb. However. the S-shape curve in the clavicle.8). the vast majority of closed displaced fractures that require surgery can be done electively during the first week after injury. Most manufacturers now make contoured clavicle-specific plates. recent advances in internal fixation using locking plate designs may also improve results. 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. Surgical Tactic There are two methods of internal fixation for clavicle fractures: intramedullary nailing and plate osteosy nthesis. . Furthermore. in most seriously injured patients with a displaced clavicle fracture. rotation. By far.

.

Positioning. The C-arm image intensifier is brought in to ensure that the clavicle will be well visualized during the procedure (Fig. and upper extremity are prepped and draped. the upper chest wall and clavicular regions can be shaved if necessary. surgery is greatly facilitated by the use of a May field neurosurgical headrest (Fig. In my experience. 1. Due to significant swelling and skeletal distortion. shoulder.12). Prep. which is adducted or rotated parallel to the OR table (Fig. and correct side and site of surgery.FIGURE 1. The head (foot) of the table is then elevated 15 to 20 degrees. chest wall. before the procedure begins.9). a surgical “time-out” is called. Prior to the surgical prep. and anesthesia teams must concur with the patient’s name. SURGICAL TECHNIQ UE Setup. Because the metal supports in most operating room tables partially obscure the field of view. The May field 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. and Drape Before the patient is brought into the surgical suite. The sterile surgical field should encompass the entire upper extremity including the clavicle and the ipsilateral acromialclavicular and sternoclavicular joints (Fig. which is brought in from the opposite side of the table. 1. and all members of the surgical. The patient’s head is further secured to the May field headrest by circumferentially wrapping it with a large Kerlix roll.8 Sy nthes (Paoli. Surgery is routinely done utilizing general anesthesia with an endotracheal tube or a lary ngeal mask airway. The image intensifier must be sterilely draped and isolated as well. At this point in time. The patient and the headrest are positioned on the operating table with the affected side close to the table’s edge. neck. 1. . PA) precontoured clavicle plates. This provides more space to accommodate the C-arm image intensifier. nursing.11). regional anesthesia is not recommended. The entire clavicle. the operating table is rotated 180 degrees so that the patient’s head is at the foot of the table.10). medical record number. which is taped to the patient on the side opposite the fracture. The ipsilateral arm rests on a standard arm board. 1. it is often necessary to tilt or rotate the C-arm a few degrees to achieve satisfactory images.

FIGURE 1.9 Internal fixation and imaging are facilitated with the use of a May field headrest. . This small but helpful step can reduce blood loss during the case since a tourniquet is not employ ed. the anesthesiologist is asked to maintain the patient’s sy stolic blood pressure below 100 mm Hg.Unless there are specific cardiopulmonary contraindications.

FIGURE 1.10 Patient positioning for clavicle surgery . .

11 The C-arm is brought into the operative field from the opposite side of the .FIGURE 1.

In these cases. Several sensory clavicular nerves cross the surgical field longitudinally. the superior and inferior borders of the proximal and distal fragments of the clavicle are marked on the skin. FIGURE 1. Meticulous hemostasis is obtained with electrocautery. however.table. 1. and an appropriate length incision is centered over the fracture site (Fig. the C-arm image intensifier can be used to localize the fracture site for the skin incision. these nerves should be preserved as they provide sensation to the infraclavicular portion of the chest wall. or very swollen patients. Surgery With a sterile marking pen. one or more of these nerves need to be divided to facilitate exposure and fixation. Patients should be . the clavicle may be difficult to palpate. When possible. In many cases. In large. obese.12 The patient is prepped and draped.13). A transverse incision is made parallel to the clavicle and deepened through a subcutaneous tissues.

At the fracture site. subcutaneous. the soft tissues and thin periosteum are elevated several millimeters to expose the bone end.13 The surgical incision is marked with a sterile marking pen. and is relatively straight forward.counseled that some numbness on the chest wall may occur after surgery . The proximal clavicular fragment is exposed first (Fig. The soft tissues should only be elevated to accommodate the plate medially . There is a relatively avascular plane between the deltoid anteriorly and trapezius posteriorly that can be developed down to bone. . 1.14). FIGURE 1. It is usually quite prominent.

FIGURE 1.14 The proximal fracture fragment is exposed first. .

Because these fragment(s) are relatively small. Care should be taken to preserve the soft-tissue attachments to these fragments in order to avoid disruption of their blood supply. a small Hohman retractor or serrated reduction clamp is placed just distal to the fracture site.7-mm interfragmentary cortical screws are used for definitive fixation (Fig. 1. 1. 2. In many patients. Other large butterfly fragments are similarly reduced and fixed. To better expose the distal fragment. there is a large anterior butterfly fragment containing fibers of the deltoid muscle. 2. reduction and fixation of one or more butterfly fragments may be necessary to achieve stable fracture fixation. cortical fragments measuring 15 to 20 mm in size usually need to be incorporated into the fixation construct. In my experience. this fragment should be reduced and temporarily fixed to either the proximal or distal main fragment with Kwires or a small pointed reduction clamp (Fig. and the provisional hematoma is evacuated and copiously irrigated. which elevates the bone into the wound for careful subperiosteal dissection.The fracture site is now exposed. Depending on the fracture geometry. 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. In patients with comminuted fracture patterns.15A). The distal fragment is visualized at the fracture site and is ty pically shortened and displaced downward and forward beneath the proximal fragment.4-mm or more commonly. .15B).

.

. while preserving the soft-tissue attachments. the fracture is reduced by distraction and translation.15 Reduction and internal fixation of a large butterfly fragment. reduction with restoration of cortical continuity often produces sufficient stability to allow removal or repositioning of the reduction clamps to apply the plate.16). 1. remain the treatment of choice (Fig. and rotation. bridging plates that restore length. In simple noncomminuted transverse or short oblique fractures. alignment.FIGURE 1. With stable fracture patterns. a neutralization or spanning plate is preferred. In highly comminuted clavicle fractures. compression of the fracture through the plate is desirable. In more unstable fracture patterns. Using small-reduction forceps on the main proximal and distal fracture fragments.

.

1. since the screws are directed from anterior to posterior. In y oung patients with excellent bone. The plate can be placed either anteriorly or superiorly because biomechanical testing has not demonstrated an optimal position. and it is more difficult to fit the plate on the thin anterior surface of the distal fragment. due to the wide variation in clavicular morphology. One-third of tubular plates and minifragment plates as “stand-alone” implants are rarely indicated in adults. Frequently.17). surgeons who favor superior plating cite easier surgery and fixation with possibly improved biomechanics. a plate of adequate strength is required. On the other hand. Most studies support the use of thicker small fragment plate with 3. In older patients with compromised bone stock. I prefer to contour a straight pelvic reconstruction plate that allows me to precisely match the patient’s anatomy (Fig. Invariably this .FIGURE 1.18).19). these plates do not alway s fit well. Implants There are two distinct schools of thought regarding plate placement. Furthermore. With fractures involving the distal one-fourth of the clavicle. it reduces the number of patients who may require sy mptomatic hardware removal. Proponents of the anterior plate argue that it is safer. Alternatively.5-mm screws (Fig. anterior plating requires additional dissection of the deltoid muscle. These implants have a flared or enlarged lateral end to the plate and accept four to six 2. nonlocking cortical screws are usually adequate. With anterior plating. The disadvantages with this technique are a greater risk to the important adjacent structures when drilling and the higher incidence of sy mptomatic hardware. or in any fracture with a short proximal or distal segments.7mm locking screws. For most middle third fractures. special precontoured periarticular clavicle plates may be helpful. locking screws unequivocally improve strength of fixation.16 Internal fixation at the completion of the procedure. 1. However. A minimum of three screws (six cortices) should be placed in the major proximal and distal fracture fragments (Fig. particularly distally. Regardless of the plate position. thereby avoiding the lung and the neurovascular structures. one or more screw holes in the plate are left empty at the level of the fracture. 1. the insertion angle for screws in the plate may be difficult to achieve in large patients or women with generous breasts.

Prior to closure. intraoperative fluoroscopy is used to assess the quality of the reduction as well as to ensure screws are of appropriate length. . However. many surgeons favor the precontoured plates for diaphy seal fractures.requires a double bend to accommodate the S-shape of the clavicle and slight twist in the plate.

PA) 3. .17 Sy nthes (Paoli.FIGURE 1.5-mm plate used for clavicle fracture fixation.

The wounds are copiously irrigated and closed in lay ers.19 A self-contoured pelvic locking plate.18 Postoperative x-ray demonstrating stable internal fixation.FIGURE 1. FIGURE 1. Drains . The deep soft-tissue closure should cover the 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.

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

prominence. with careful and meticulous surgery. injury to these important structures is rare. culture-specific intravenous antibiotics. Placing a small Hohman retractor along the inferior surface of the clavicle opposite. . or cosmetic issues. they are vulnerable to iatrogenic injury. Nevertheless. which minimize sudden “plunging” bey ond the far cortex. thereby decreasing the likelihood of sudden penetration of the far cortex. approximately one-third of patients eventually have their plate removed.20). In patients with chronic infections and those presenting late usually require hardware removal as well as thorough operative débridement and long-term antibiotics (Fig. Complications NEUROVASCULAR COMPLICATIONS Complications following internal fixation of clavicle fractures are uncommon. Infections in the first 2 to 3 weeks after surgery are treated with aggressive surgical irrigation and débridement. Because of the close proximity of the lung. 1. In my experience. INFECTION As with any surgical procedure. Several orthopedic companies manufacture drills that have an oscillating mode in addition to the standard forward and reverse. The danger to the lung and vessels is greatest in the medial one-third of the clavicle necessitating increased vigilance. Prevention is the best treatment. and retention of hardware if stable fixation has been achieved. 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. the subclavian vessels. infection can develop following internal fixation. the hole in the plate to be drilled is both practical and reassuring. The use of a sharp drill bit reduces drill time and the amount of pressure needed to advance the drill bit. and brachial plexus.

In adults. and chronic sy stemic disease. nonunion after clavicular plating using modern techniques and implants for internal fixation occurs in approximately 5% of patients.20 Clinical photo showing infection after internal fixation. Both local and sy stemic factors may contribute to the development of a nonunion. poor reductions. and inadequate fixation. It is usually the result of technical errors or fixation failure. . They have been associated with high rates of loss of reduction and fixation failures.7-mm implants.21).FIGURE 1. On the other hand. poor nutrition. or lag screws alone should not be used. Local factors that have been associated with fractures that fail to unite include excessive soft-tissue stripping. one-third tubular plates. MALUNION AND NONUNION Malunion following internal fixation of acute clavicle fractures is rare. A nonunion is present when there are no progressive signs of healing on radiographs taken between 3 and 5 months following surgery (Fig. corticosteroids. Sy stemic factors that may contribute to the development of a nonunion include smoking. 2. diabetes. 1.

McGuire. internal fixation devices may be prominent particularly after the initial posttraumatic swelling resolves. . When sy mptomatic. Poor results were associated with brachial plexus sy mptoms. HARDWARE PROMINENCE By far. 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. the most “complication” following plate osteosy nthesis of a clavicle fracture is late-sy mptomatic hardware removal. numerous studies have reported improved radiographic and functional outcomes following internal fixation of displaced clavicle fractures in adults when compared to nonoperative treatment. Outcomes and Results In the past 15 y ears. cosmetic deformity. Earlier plate removal has been associated with a small incidence of refracture. They reported that 16 of 52 (31%) patients treated nonoperatively had an unsatisfactory result based on a questionnaire that they developed (not statistically validated). Due to the relatively scant soft tissues around the clavicle.FIGURE 1. limb weakness. 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. and nonunion in 15% of patients. Hill. the plate can be safely removed after 1 y ear.21 Nonunion with hardware failure after unsuccessful internal fixation of a clavicle.

106 patients with a displaced clavicle fracture were treated by the author with plate osteosy nthesis between 2000 and 2008. Treatment consisted of conventional plate osteosy nthesis in 15 patients and locking plates in 82 patients. motorcy cle accidents in 32. The mechanism of injury included falls in 18 patients. 14 to 73). 6 to 28). Patient outcomes were evaluated using the DASH score.5 weeks (range. In a randomized control trial comparing nonoperative versus plate fixation of displaced clavicle fractures. 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. and sports injuries in 31 patients. Complications included one broken plate. while one patient failed to unite. 5 to 43). These were 74 males and 29 females with an average age of 34 y ears (range. the Canadien Orthopedic Trauma Society reported the results of treatment in 132 patients. While the nonunion rate for the entire group was only 6. translation. All were closed injuries. in a sy stematic review of 2. a validated patient-oriented outcome measure for assessing upper extremity disability. and eight patients with some loss of shoulder motion. Indications for surgery were 100% displaced clavicle fractures with shortening.Robinson et al.1% of fractures after nonoperative treatment. four healed following revision surgery. Ninety -eight of the 103 patients (95%) healed primarily following the index procedure at an average of 13. the nonunion rate more than tripled to 21% in a subgroup of patients with widely displaced fractures. The mean DASH score in this series was 16 (range. 14 (14%) were in the lateral one-third. while the nonunion rate after internal fixation was only 2. motor vehicle accidents in 22. In a nonrandomized prospective single surgeon study. or displacement >15 mm. seven reconstruction plates with minor deformation. There were no infections. and 1 (1%) was in the medial one-third.2%. One hundred three patients were followed for an average of 12 months (range.144 clavicle fractures published in the literature up to 2005 found that a nonunion developed in 15. Alternative fixation techniques were utilized in six patients with extremely distal clavicle fractures. The most frequent complication was . Of the five patients who did not heal primarily. Zlowodzki et al.2%. 88 (85%) of the fractures were in the middle one-third. 3 to 58). A zero score indicates a “perfect” extremity while a score of 100 means completely disabled. There were less nonunions and malunions as well as better Constant and Dash scores in the operative group.

20:680–686. Toogood P. Roberston C. Smekal V. Crosby L. J Orthop Trauma 2009. Devinney S. Zlowodzki M.23:106– 112. et al. Collinge C. RECOMMENDED READING Canadian Orthopaedic Trauma Society. Mahar A. Infection after clavicle fractures. J Bone Joint Surg Br 1997. Acute midshaft clavicular fracture. Clin Orthop 2005. et al. Schemitsch EH. J Bone Joint Surg Am 2007. In conclusion. Pederson EM. Deficits following nonoperative treatment of displaced midshaft clavicular fractures.86:1359–1365. et al.15:239–248.89-A:2260–2265. Jeray KJ.88:35–40. McKee MD. Clavicular anatomy and applicability of precontoured plates. J Orthop Trauma 2006. Treatment of mid-shaft clavicle . Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. Non-operative treatment campared with plate fixation of displaced mid-shaft clavicular fractures. Anterior-inferior plate fixation of middle-third fracture and nonunions of the clavicle. J Bone Joint Surg Am 2003. Court-Brown CM. Celestre P.89:1–10. et al. Sperling JW. McQueen MM. J Bone Joint Surg Am 2007. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures —a randomized. this study supports the use of internal fixation of widely displaced clavicle fractures in adults.439:74–78.22:241–247. Struve P. Irenberger A. McGuire MH. clinical trial. Hill JM. Duncan SFM. Wild LM. controlled. et al. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. Cole PA. Mid-shaft mal-unions of the clavicle. Robinson CM. The method is both safe and effective.sy mptomatic hardware necessitating removal in 35 patients (34%). Zelle BA. et al. Herscovici D. Jones C. J Bone Joint Surg Am 2004. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability ? J Orthop Trauma 2008. et al. McKee MD. J Bone Joint Surg Am 2006. Steinmann S.79:537–541. Chen MR. Huang JI.85:790–797. J Am Acad Orthop Surg 2007.

19:504–508. J Orthop Trauma 2005.fractures: Sy stemic review of 2144 fractures. .

A recent epidemiological study from Edinburgh showed that only 52 of 6. (20) modified . the mobility of the scapula on the thoracic cage. and implants has improved.10–18). surgical approaches. Additionally. protect the scapula making fracture of this bone infrequent. Hardegger et al. In the past 25 y ears. It is estimated that scapula fractures account for only 3% to 5% of all fractures about the shoulder girdle. and stable internal fixation leading to a renewed interest in the operative management of both displaced intra-articular and extra-articular scapular fractures (6. The surgical treatment of these fractures continues to evolve as our knowledge of shoulder anatomy . surgeons began repairing selected scapula fractures utilizing the AO principles of restoration of articular reduction. Cole and Babar Shafiq INTRODUCTION Scapula fractures are uncommon injuries. Ada and Miller ( 19) proposed a comprehensive classification that was anatomically defined. In 1984. With the development of modern techniques in internal fixation. with most occurring in the clavicle or proximal humerus (2–5). May o et al. its oblique orientation to the chest wall. (7) published a series of 37 operatively treated scapula fractures and introduced a classification scheme that bears his name. alignment. and the surrounding bones. several studies have documented poor results following nonoperative management of displaced scapular fractures (6–18).2 Scapula Fractures: Open Reduction Internal Fixation Peter A. There is no universally accepted classification for scapula fractures.986 (0.7%) fractures seen at their fracture clinic involved the scapula (1). which are more vulnerable to fracture. The robust muscular envelope.

2. . 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.1). 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). The main value of three dimensional mapping. 2.and extra-articular fractures (Fig.1 This image depicts the Ideberg Classification as modified by May o et al. The Orthopaedic Trauma Association (OTA) classification sy stem is an alphanumeric sy stem that classifies both intra. which frequently occur in association with glenoid fractures (Fig. however. based on radiographs and operative findings of 27 intra-articular glenoid fractures. is to serve as a useful roadmap for surgical planning and a greater understanding of the muscular force vectors acting on the scapula (16). as it takes into account associated scapular body and process fractures. FIGURE 2. 2.22).3). Its main weakness is that it does not correlate fracture patterns or combinations of injuries with real fractures. This classification is also helpful in directing surgical decision making.Ideberg’s classification for intra-articular fractures (21.

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J Orthop Trauma 2007.2 This figure is the AO/OTA classification for scapula fractures as modified in 2007. (Adapted from Marsh JL.21(10 Suppl):S1–S133.) . Though it provides a sy stematic way of classify ing scapula fractures. database and outcomes committee. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification. et al. it has not been developed by correlating identified patterns of injury or combined injuries.FIGURE 2. Slongo TF. Agel J.

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21.25–28). Tarkin IS.23–25).4A. (B) the spinoglenoid notch between the base of the acromion and the superior aspect of the glenoid fossa. . J Bone Joint Surg Am 2009. However.B).FIGURE 2. phy siologic status. The decision for surgery as well as the amount or degree of articular step-off. and (C) the glenoid cavity with the fracture tracking medially into the body of the scapula. age.91(9):2222– 2228 [Fig 4] with permission. Mapping of scapular fractures with threedimensional computed tomography . the literature varies considerably with other authors advocating surgery for articular stepoff ranging from 2 to 10 mm (20. and hand dominance (Fig. (From Armitage BM. These include (A) the lateral border just inferior to the glenoid. activity level.3 This illustration shows maps of fractures about the glenoid with three common anatomical zones of involvement in scapular fractures that required surgical treatment. et al.20. Wijdicks CA.7. and percentage of joint involvement should be correlated with the patient’s job. 2.) 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. gap.

4 A: A 3D-CT image of the right scapula rotated to represent the scapula on its axis (scapular “Y” view).FIGURE 2. Grashey ) view x-ray of the shoulder . 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. 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. The image demonstrates significant glenoid fracture displacement and comminution between the major cephalad and caudad fragments.

2.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. B: 3D-CT (P/A view) and True A/P (Grashey ) radiograph of left shoulder demonstrating Lateral Border Offset (sometimes referred to as medialization).” (Anavian J. 2.5A. et al. 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.469(12):3371–3378.6A.8A. Conflitti JM. Clin Orthop Relat Res 2011.B) Displaced double lesions of the superior shoulder suspensory complex (SSSC) • Both the clavicle and scapula fractures are displaced >10 mm (Fig. .(Fig. A Reliable Radiographic Measurement Technique for Extraarticular Scapular Fractures. 2. Khanna G.B) • Complete acromioclavicular dislocation and scapula fracture displaced >10 mm FIGURE 2. 2.B) Angular deformity >45 degrees as seen on a scapular Y radiograph of the shoulder (Fig.5 A.7A.

469(12):3371–3378. (Anavian J. Conflitti JM.) . et al. A Reliable Radiographic Measurement Technique for Extra-articular Scapular Fractures. Khanna G. Clin Orthop Relat Res 2011. with permission.with permission. B: Scapular “Y” radiograph and 3D-CT rotated to “Y” view demonstrating angular deformity .6 A.) FIGURE 2.

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

.8 A. B: 3D-CT and AP shoulder demonstrate double lesion to the SSSC (clavicle fracture and scapula neck fracture).9). We also advocate operative management of displaced scapular fractures in patients with complex ipsilateral upper extremity injuries particularly in y ounger highly active patients. when two or more of the above criteria are met (Fig. 2.FIGURE 2.

9 Authors’ preferred algorithm for the management of scapula fractures. .FIGURE 2.

then the glenohumeral joint would be “floating.29–32).10).” made up by the acromion. Active mobility of the elbow and wrist is encouraged immediately. ( 34) and Ramos et al. (36) that surgery is not indicated when each component of the double displacement is stable and minimally displaced. The term superior shoulder suspensory complex is the osseoligamentous relationship between the three scapula processes. as well as their capsule-ligamentous connections. coracoid. . 2. Resistive exercises are begun by 8 weeks and restrictions lifted as sy mptoms allow by 12 weeks. but a sling and rest are indicated for 10 to 14 day s.8. Scapula fractures heal rapidly due to the rich blood supply in the shoulder girdle. and glenoid.” a condition that describes discontinuity between the axial and appendicular skeleton (Fig. Though this theory has been challenged by some authors (34–36).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 (3–4. Goss recommended surgery if two such disruptions occur simultaneously. We agree with Edwards et al. Goss theorized that if there were two disruptions in this “ring. described by Goss in 1993 (33). Active range of motion can be started by 4 weeks and advanced quickly.

then open reduction and internal fixation is warranted (19. Fractures of the acromion process or spine usually occur as a result of a direct blow to the superior shoulder region. then a “floating shoulder” lesion would be present. a supraspinatus outlet view should be obtained and evaluated for acromial depression. 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. While indications for operative management of these fractures have not been established. which is an osseoligamentous ring made up of the structures along the dotted line. we use several criteria to aid in determining the need for surgery . which may contribute to an impingement sy ndrome. Isolated fractures of the acromion or coracoid process are uncommon.10 This illustration depicts the SSSC. imply ing that there would be no osseous or ligamentous continuity between the axial skeleton and the forequarter. When the acromion is displaced more than 5 mm. Goss theorized that if two structures in the ring were disrupted.8 shows 3D-CT and AP radiographs of this lesion. whereas coracoid process fractures result from violent traction injuries through the biceps and coracobrachialis.FIGURE 2. much like a .37–41). Figure 2.

Partial articular fractures. Anavian et al. Surgery is usually necessary when there is involvement of more than 20% of the articular surface.7-mm reconstruction plates were used when fixation of acromion fractures extending into the scapular neck or base. The only complications in this series were softtissue irritation requiring hardware removal in two patients and removal of ectopic bone in one patient (14).or 2. A second ty pe of scapula fracture involves the glenoid neck and body with . All patients were pain free at rest and with upper extremity activities at the time of final follow-up (mean 11 months. unrestricted activity by 3 months.ty pe III “hooked” acromion. or clinical examination. patients were treated with passiveand active-assisted range of motion for the first month. If shoulder instability is present with subluxation of the humeral head on radiographic examination. 2. Outcomes following acromion and coracoid process fixation are good with high rates of union (13. 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. given an appropriate surgical candidate.40–41). range 2 to 42 months). then operative intervention. Mean DASH score for those patients with functional assessments was 7 (0 to 26). Similarly. 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. progressing to resistance exercises after 2 months and full. PREOPERATIVE PLANNING History Fractures of the scapula occur as the result of blunt trauma with strong of forces applied to the shoulder. Postoperatively. reported the results of operative management of 14 coracoid and 13 acromion fractures treated operatively. and occasionally warrant internal fixation. usually involving the anterior glenoid. 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. better than that of the uninjured population normative baseline DASH score 10. is recommended.4.

37). scapular fractures are often overlooked leading to delay s in treatment. the chest wall fails to support the scapula and contributes to deformity (Fig. and thorax. Associated injuries occur in up to 90% of patients in this group. When possible. which is difficult when the patient is supine in bed or on a gurney. In the seriously injured patient. . and a thorough phy sical examination is necessary to avoid overlooking serious concomitant injuries (2. even a few weeks after injury . but once the patient is upright and attempts to move the extremity. the shoulder and upper extremity should be examined with the patient sitting or standing to give good access to the posterior forequarter. are unable to forward elevate or externally rotate their shoulders. Medialization may or may not be apparent on the initial radiographic studies. the shoulder medializes as the scapula rotates forward over the thorax. but this is not the case as this devastating injury results from a violent traction force to the upper extremity . Physical Examination The phy sical examination must be thorough and complete as associated injuries are common particularly to the spine. It is a common misconception that scapulothoracic dissociation occurs following high-energy blunt trauma.or without articular involvement. Patients with highly displaced scapula fractures. cranium. Medial and caudal displacement of the shoulder may be obvious producing marked asy mmetry. and this pattern most commonly occurs following high-energy trauma. particularly when associated with multiple ribs or a clavicle fracture. 2.21. In some patients with scapula and multiple rib fractures. particularly if the patient is upright.11).

It is important to assess medialization clinically . Based upon a review of 96 surgically treated scapula fractures. The suprascapular nerve is vulnerable and commonly injured in association with fractures that extend into the spinoglenoid notch at the base of the acromion. postinjury . we recommend electrodiagnostic studies (electromy ography and nerve conduction studies—EMG/NCS) be performed in patients with . 2.11 Clinical examination of a patient with a displaced scapula fracture. 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. 2. and later. it should be delay ed until there is skin re-epithelialization around 7 to 14 day s. Consequently. Appreciate the dramatic depression and medialization of the forequarter. after injury (Fig. Skin integrity should be assessed as abrasions are common after the ty pical mechanism of a direct blow to the shoulder.30). motor function to the deltoid is frequently impossible to determine with displaced fractures. Axillary nerve sensation should be documented. Ipsilateral. If surgery is indicated. concomitant. however. rather than on a supine injury radiograph or CT scan.FIGURE 2. so-called true scapula neck variants (18) (Fig. the senior author identified 14 cases of suprascapular nerve injury almost exclusively associated with these fracture patterns.12).13A).

.44).fractures involving the suprascapular and/or spinoglenoid notch. FIGURE 2. These studies are of little diagnostic value immediately after injury and should be performed at least 2 weeks after injury when fibrillations and positive sharp waves may be present indicating denervation (axonotmesis and neurotmesis) (43. Every effort should be made to identify injury early and before surgical intervention.12 Note the scarring that resulted from abrasions that occurred at the time of impact of the patient’s shoulder following a bicy cle crash. when possible (45). Surgery was delay ed until the skin re-epithelialized in order to decrease the chance of infection.

C. dedicated scapular radiographs should be obtained. This fracture pattern is often associated with suprascapular nerve injury .13 A. Radiographic Studies Because high-energy scapula fractures often present in an emergent setting in patients with concomitant chest injuries. . 3D-CT illustrating a “true scapula neck” fracture that extends through the spinoglenoid notch. If a scapula fracture is identified on the screening chest x-ray. Intraoperative postreduction and fixation. B.FIGURE 2. These include an AP shoulder. A 4-0 Prolene stitch was utilized to tack the lacerated nerve to an adjacent nerve branch and muscle. a chest x-ray and computed tomography (CT) scans are routinely acquired during the trauma evaluation. Intraoperative photo illustrating the lacerated suprascapular nerve and its proximity to the glenoid fragment. The glenoid fragment is off of the suprascapular nerve.

One simple technique we have found helpful is to have the patient hold an IV pole that is slowly abducted to 30 degrees. and axillary views. 2. angulation.8). . comminution. GPA. eliminating the normal glenohumeral joint (clear space) on a technically correct radiograph. the so-called Grashey view. In these circumstances.14). If there is an intra-articular glenoid fracture detected on any x-ray view. and translation of scapula fractures and have established the clear superiority of CT scans over plain x-ray s for this purpose.5–2. a 3D CT scan can be very helpful to assess the degree of angular deformity. 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.to 2-mm axial cuts plus coronal and sagittal reformation are helpful for the definition of articular displacement. 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 orthogonal scapular Y view is 90 degrees to the AP view. 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. (15) described techniques to measure medialization. Anavian et al. an AP radiograph of the opposite shoulder is helpful to better define the fracture displacement. and fracture extension (Fig. as well as glenoid displacement (see Figs. then a 2D-CT scan with 1. the axillary view is often difficult to obtain.scapula Y. 2. Due to pain. If there is more than 1 cm of fracture displacement at the scapular neck on any view.

FIGURE 2. SURGERY The scapula is part of the suspensory mechanism of the shoulder that attaches the upper extremity to the axial skeleton through the clavicle. A. Axial cuts depicting anterior glenoid comminution. B. which provides a stable . Semicoronal cuts depicting anterior and inferior comminution. Obtaining an axial 2D-CT in addition to sagittal and coronal reformats is important when intra-articular fractures are present. Eighteen muscles originate or insert on the scapula.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.

and coracobrachialis. Additional approaches have been described for aty pical fracture patterns. are best treated through a deltopectoral approach. The goal of the surgery is to restore the relationship of the axial and appendicular skeleton as well as length. rotation. forming the thickest condensation of bone that ends in the neck of the glenoid process. 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. contains the pear-shaped glenoid fossa. Combined anterior and posterior approaches are rarely necessary. The scapular borders and the glenoid neck provide the thickest and strongest bone for reduction and fixation with plates and screws. 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. . From the anterior perspective. The lateral border of the scapula sweeps up from the inferior angle. 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. the scapula is a triangular flat bone. The majority of scapula fractures that require internal fixation can be approached through an anterior deltopectoral or posterior Judet approaches. the clavicle or acromioclavicular joint may require its own approach to address these injuries. 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). Although clavicle fractures will be discussed in another chapter. In an effort to limit incisions and reduce potential surgical morbidity. surrounded by borders that are well developed and thick and serve as points for muscular origins and insertions. alignment. beneath the acromion. as well as associated transverse fracture extending through the glenoid and into the base of the coracoid (May o ty pe II fracture).base for glenohumeral mobility. Lastly. and anatomic reduction of articular surfaces to allow early range of shoulder motion and rehabilitation. The glenoid process. Isolated anterior glenoid fractures. with a thin translucent body. pectoralis minor. we also use a minimally invasive posterior approach for select cases (10). 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.

as if to protract and retract the shoulder to create scapula-thoracic excursion.SURGICAL APPROACHES Posterior Approach Surgery is performed under general or regional block anesthesia. 2. “Shucking” the scapula with one hand. Prefabricated upper extremity positioners are very helpful to support the affected extremity (Fig. The patient is positioned in the lateral decubitus position. The bony landmarks around the shoulder are palpated and marked with a sterile pen. Bumps should be positioned on an arm board to support the affected extremity.15). The entire forequarter is widely prepped and draped to allow for unrestricted motion of the shoulder. . 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. allows the surgeon to better feel the bony landmarks in large or muscular patients. “flopping” slightly forward beneath a well-padded axillary roll.

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 .FIGURE 2.

It is planned along these landmarks: 1 cm caudal to the acromion spine and 1 cm lateral to the vertebral border.16). positioned on a beanbag.body .16 This image depicts a Judet posterior incision. The entire arm should be prepped free to allow for manipulation and motion of the glenohumeral joint during the procedure. splitting the interval between the trapezius and deltoid insertions. 2. FIGURE 2. A Judet posterior incision is made 1 cm below the acromion spine and 1 cm lateral to the vertebral border. The incision is developed onto the bony ridge of the acromial spine. should be allowed to fall forward. The incision curves distally at an acute angle just under 90 degrees around the . This allows for lateral retraction of the flap with adequate coverage of the implants (Fig.

This image shows the posterior Judet approach with the development of a flap from the acromial spine and vertebral borders.17).superomedial angle and down the vertebral border. Image of same patient in Figure 2. B. 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. It cannot be used when the intra-articular inspection is required. Note the location and vulnerability of the suprascapular neurovascular bundle exiting from just below the acromion before it enters the infraspinatus muscle. This patient has a fracture characterized by separation of the glenoid neck from the lateral border up into the spinoglenoid notch. which is apparent in this image. What is not apparent is the severe lateral border offset and anteversion of the glenoid articular surface.17 A. There is extension of another fracture line into the scapular body . FIGURE 2. For access to the lateral border of the scapula. This approach is best reserved for cases that surgery is delay ed more than 10 day s or for cases that are severely comminuted with several displaced fracture lines exiting multiple scapular borders. the incision must be extended to allow for mobilization of the infraspinatus. . 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.18A after flap elevation and retraction. 2. This extensile exposure allows full visualization of the entire infraspinatus fossa (the posterior scapula) from the vertebral border to the lateral border. Properly executed.

Therefore. This extensile exposure allows the surgeon adequate control of the fracture at multiple points to allow mobilization and reduction of the fracture. the entire subscapularis muscular sleeve on the anterior surface of the scapula is preserved. The flap can be elevated laterally as far as the lateral scapular border and allows exposure to the glenoid neck. an intermuscular dissection is necessary over the posterior glenohumeral joint.17B). 2. an extensile exposure can be performed by elevating all of the muscles from the infraspinatus fossa exposing the entire posterior scapula. Working through limited intermuscular windows is favored to limit dissection and can be used to access fracture intervals at the lateral border.Based on the preoperative plan. For adequate intra-articular exposure. and vertebral border (Fig.18). acromial spine. the extensile approach is biologically respectful. Alternatively. An extensile approach that elevates the deltoid. It will not allow for exposure of the articular surface of the glenoid due to the large flap. 2. the degree of exposure depends on the need for limited or complete exposure of the posterior scapula. with almost a 100% union rate. maintaining the blood supply to the scapular body (Fig. and teres minor in a single flap is usually reserved for fractures that are over 10 day s old or for complex patterns with four or more exit points around the ring of the scapular perimeter. which cannot be retracted sufficiently lateral for joint exposure. . While the extensile approach exposes the entire posterior surface of the scapular body. infraspinatus.

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 . The deltoid is elevated off . the inferior margin of the spine is uncovered to expose the rotator cuff muscles. the most important window is between the infraspinatus and teres minor to access the lateral border of the scapula and scapula neck. and tactically created intermuscular intervals around the scapular perimeter are used to access specific fracture locations (Fig. If limited intermuscular windows are utilized. 2.18). The intermuscle plane at the spine of the scapula is between the trapezius and the deltoid.18 Using the technique of accessing intermuscular windows.FIGURE 2. By subperiosteal dissection. the Judet fasciocutaneous flap is elevated.

2. the most important window is between the infraspinatus and teres minor to gain access to the lateral border of the scapula and scapular neck. allowing restoration of glenoid version and lateral border offset (Fig.20). At the vertebral border of the scapula. If the glenoid articular surface must be visualized. the capsule should be incised just distal to the labrum and is localized with an 18-gauge needle. or posterior humeral circumflex vessels. the lateral border of the scapula can be exposed. However. Furthermore. the intermuscular interval is between the infraspinatus and the rhomboids (Fig. . 2. This technique is more tedious.19).the muscular origin of the infraspinatus and tagged through its fascial cuff for reattachment to bone through tunnels at the conclusion of the case.18). During the arthrotomy. Once this interval is developed. a transverse capsulotomy is made allowing a retractor to be placed on the anterior edge of the glenoid to retract the humeral head (Fig. Knowledge of the correct intermuscular intervals is crucial to avoid denervation of the infraspinatus. the glenohumeral joint can be exposed to treat intra-articular fractures. 2. axillary nerve. but spares taking down the deltoid and the need for reattachment and postoperative immobilization. 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.

19 Limited intermuscular window technique vertebral (medial) border.FIGURE 2. .

FIGURE 2. small external fixation pins in the proximal and distal fragments can be secured in proper .21 and 2. Large reduction tenaculums are difficult to apply because of interference with the large muscular flap. 2. The lateral border can be reduced using small-pointed bone reduction clamps. In these cases. There is also an intra-articular glenoid fracture for which a capsulotomy has been performed to allow access to the glenohumeral joint.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.22). or a plate (Figs. small (4 mm) external fixation pins as joy sticks.

23).21 Lateral border reduction with Shantz pins and clamp. 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.7-mm dy namic 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 without the need for contouring.0-mm plate and screws placed slightly more medial can be used to provisionally hold the lateral border aligned. a provisional 2. Alternatively. If the reduction is not stable. .orientation with a small external fixator bar and clamps to line up the lateral border for subsequent plating (Fig. Occasionally. FIGURE 2. a 2. 2.

FIGURE 2.22 This image depicts a scapula fracture treated 2 weeks after injury with .

7-mm plates are well suited for the scapular borders . The 2.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.23 This image depicts lateral border reduction accomplished with an external fixator applied to 4. In our experience.7-mm locking plate is applied to the thick bone along the margin of the lateral border. FIGURE 2.0-mm Schanz pins placed in the proximal (cephalad) and distal (caudad) segments. 2.7 reconstruction plate is applied to the vertebral border of the scapula body extending to the scapular spine. The 2.

We prefer an absorbable subcuticular suture for the skin closure. whereas 2. The use of locked small and minifragment plates allows shorter plates given the better screw purchase over shorter working lengths.5 plates. We favor longer plates and more screws for added stress distribution since each screw is only 8 to 10 mm for the vertebral border. In these cases. an infraspinatus tenotomy can be performed leaving a centimeter of cuff insertion at the greater tuberosity for repair. Two pediatric Kocher clamps are useful for bending and twisting the plates. 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 . it is important that any adhesions or shoulder stiffness be released by manipulation of the shoulder prior to waking the patient. These plates are lower profile than 3.and are of adequate strength to resist breakage. reduction and fixation can be accomplished solely through the interval between infraspinatus and teres minor.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. are easier to contour. especially in patients whose surgery has been more than 2 weeks postinjury.7-mm dy namic compression plate is used on the lateral border where stresses are greatest. If greater exposure to the glenoid fossa or superior glenoid is desired. We have recently utilized a . 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. 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. and offer a greater number of screws per centimeter. This allows the slender musculotendinous portion of the infraspinatus to be retracted off the superior glenoid region for better access to the glenohumeral joint. Before wound closure. A 2. A Minimally Invasive Posterior Approach Approximately three quarters of scapular fractures treated operatively are done through a posterior approach (47). a direct posterior approach can be employ ed.

B). 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. incisions are made at each fracture end. 2. allowing the majority of the scapular body to remain unexposed (Fig.minimally invasive surgical technique with limited muscular dissection that permits open reduction and internal fixation of selected scapula body and neck fractures (10).24A. 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 . Because the scapula is a triangular (ring-ty pe) bone with predictable fracture exit points. .

FIGURE 2.24 A: Represents small incisions placed directly over the medial and lateral .

Through the lateral incision. the dissection is developed to the fascia overly ing the inferomedial margin of the deltoid. exposing the teres minor and infraspinatus. The deltoid is retracted cephalad with a wide retractor. 2. the infraspinatus is carefully retracted superiorly to avoid injury to the suprascapular nerve as it exits at the spinoglenoid notch (48) (Fig.B). Positioning is the same as for the previously described posterior approaches.25). The muscular interval between these muscles is developed bluntly.) B: Deeper exposure through these limited windows. Cole PA. distal to the infraspinatus muscle. The fascia is opened. These windows are often adequate for affecting reduction and plate application at these two common sites of displacement. . usually placed laterally over the glenoid neck and lateral border and also medially where the fracture exits at the spine or vertebral border (Fig. (Adapted from Gauger EM. Care must be taken to avoid injury to the axillary nerve and posterior circumflex humeral artery as they pass through the quadrilateral space.24A. Limited incisions are made as necessary depending on the fracture pattern. exposing the fascia overly ing the external rotators. Additionally.469(12):3390–3399.borders of the scapula at the fracture ends. Clin Orthop Relat Res 2011. as well as plate positioning. and clamp placement. exposing the fracture site as it exits the lateral scapular border. Surgical Technique: A Minimally Invasive Approach to Scapula Neck and Body Fractures. 2. retractor.

a small external fixation pin (with small T-handled chuck) is placed in the cephalad fragment (glenoid neck). and plate application. retractors can be placed to expose the lateral scapula border. What is more difficult to discern is the interval between the infraspinatus and teres minor. dissection is developed to the fascia and then directly down to bone. at the base of the scapula spine at its medial border. Through the medial incision. One can clearly see the division between the deltoid and infraspinatus muscles. deeper exposure. Once the lateral and medial incisions have been made and the fracture exposed.FIGURE 2. Once this important interval has been identified and developed. clamp. These two small windows are usually adequate for reduction and plate application at the two most common sites of displacement. B: Intraoperative photos showing minimally invasive limited incisions.25 A. the lateral and medial scapular borders. . Subperiosteal dissection is then extended along the vertebral border distally as needed to expose the medial border fracture line for reduction and plate application.

25. FIGURE 2.26 Postoperative AP radiograph of patient in Figure 2. A 2. .26).7-mm dy namic compression plate is used for the straight lateral border. we recommend the use of 2. The clamp may be applied through small pilot holes on either side of the fracture.and second external fixation pin is inserted into the caudal fragment (distal lateral border).7-mm reconstruction plate is contoured to the medial border. 2. Suction drains are not necessary . and a 2.25. The external fixation pins are used as “joy -sticks” to reduce the fracture.7-mm locking plates.24B. The fascia is closed with number 0 or 1 absorbable braided suture and the subcutaneous tissue with 2-0 absorbable braided suture. Because longer plates are not feasible through these small windows. and 2. The skin is closed with running 3-0 absorbable subcuticular suture. Small-pointed bone reduction forceps may be used laterally and medially to maintain reduction. 2. The external fixation pins and pilot holes must be strategically placed to avoid interference with plate placement (Figs.

2.Special Circumstances: Posterior Approach Associated Spine Injuries  Cervical and thoracic spine injuries are associated with scapular fractures in over 20% of cases. The nerve should be visualized and protected at the base of the acromion during the posterior approach in these fracture patterns. At the inferior margin of the subscapularis. intraoperative in-line traction with skeletal tongs is preferred. It is desirable to have the spinal injury surgically stabilized first to insure protection of the spinal cord. However. A classic anterior deltopectoral incision is made. Most injuries are contusions or neurapraxia. A small towel roll is placed under the ipsilateral shoulder to help bring it forward. Caliper or tong traction is easier to work around than a cervical collar. Lacerations to the suprascapular nerve occasionally occur in patients where the fracture extends into the spinoglenoid or suprascapular notches. The interval between the deltoid and pectoralis major is developed down to the clavi-pectoral fascia. If a laceration is discovered. and the cephalic vein is identified and retracted laterally. the orthopedic surgeon must coordinate patient care with a spine surgeon prior to positioning and induction of anesthesia. with regard to both safety and draping. which is opened exposing the coracobrachialis and subscapularis. Suprascapular Nerve Injury  Suprascapular nerve injuries are commonly seen following high-energy displaced scapular fractures. Intraoperative positioning must be carefully executed. An electromy ogram and NCS should be obtained before surgery in patients who present more than 2 weeks after injury. Often times. then repairing the lacerated nerve end or branches to the infraspinatus is useful and can promote some recovery of function. if indicated. Suturing with a 6-0 nonabsorbable monofilament suture is recommended. muscles are the transversely . The upper and lower borders of the subscapularis tendon are identified as they insert into the lesser tuberosity . 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. Anterior Surgical Approach The patient is placed in a beach chair position with an arm board attached to support the extremity. if the spine injury is managed nonoperatively.27).

The joint capsule is incised longitudinally a few millimeters from the glenoid rim giving access to the glenohumeral joint. Because this exposure allows excellent visualization of the anterior glenoid. which should be ligated. intraoperative fluoroscopy is rarely necessary . Frequently adherent to the underly ing joint capsule. With the humerus in a neutral position. Stay sutures are placed on each side of the subscapularis muscle to facilitate closure as well as to prevent medial retraction.28A). Following irrigation of the joint. 2. The patient is positioned with an x-ray plate behind the shoulder to allow for an intraoperative radiograph. the glenoid fracture is identified and reduced (Fig. FIGURE 2. We also routinely place a towel roll under the ipsilateral shoulder to improve shoulder extension and .running inferior humeral circumflex vessels. the subscapularis tendon is sharply released 1 cm from its insertion on the lesser tuberosity leaving a cuff of tendon for later repair. the subscapularis should be carefully separated from the underly ing capsule for later closure in distinct lay ers.27 Photo of a patient in the beach chair position.

B: With the subscapularis and joint capsule retracted. Depending on the size of the fragment or the degree of comminution. The subscapularis has been incised 1 cm from its insertion on the lesser tuberosity . deltopectoral approach. tagged with stay sutures. Fluoroscopy is not needed because the articular fracture reduction is directly visualized. and retracted laterally . excellent exposure and visualization of the glenoid and anteroinferior glenoid fragment is obtained.28B). Lay ered closure of the capsule and subscapularis is done. This patient has a clavicle malunion with clavicle displacement and deformity . When comminuted. Once released. The joint capsule has been separated from the undersurface of the subscapularis. 2. The coracoid is predrilled with a 2.28 A: Anterior. which gives excellent exposure of the anterior glenoid and scapular neck. At .5-mm drill bit and completed with an osteotome or micro-oscillating saw. FIGURE 2. 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. a mini buttress plate is placed on the anteroinferior edge of the glenoid. it is important to protect the musculocutaneous nerve during retraction (49). Reduction can be obtained using a dental pick or small elevator and provisionally fixed with Kirschner wires (Fig. fixation is achieved with mini or small fragment screws. the conjoined tendon and coracoid are reflected distally and medially. tagged with heavy stay sutures. and retracted medially . Because the musculocutaneous nerve penetrates the coracobrachialis approximately 5 to 6 cm from the tip of the coracoid.facilitate exposure.

5-mm bit improve interfragmentary compression with a 3. 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.5-mm cortical screw (Fig.29 A. The goal during the first 4 weeks after surgery is to regain and maintain shoulder motion rather than strength training.B. 2. Lifting and carry ing with the affected shoulder is delay ed at least 4 weeks and often longer.29). Postoperative AP and axillary lateral radiographs showing anterior glenoid fixation and the coracoid osteotomy repaired with a 3. patients continue therapy as well as a home exercise program using pulley s and supine-assisted motion with pushpull sticks. wrist. 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. Coracoid osteotomy .5-mm screw and washer placed with a lag technique. and hand exercises including 3. Passive range of shoulder motion is started on the first or second postoperative day under the direction of a phy sical or occupational therapist. Active-assisted range of motion is advanced as the patient’s pain subsides. Ipsilateral elbow.to 5- . Following hospital discharge. the near cortex of the coracoid should be overdrilled with a 3.closure. FIGURE 2.

head trauma. in a series of intra-articular glenoid fractures. a manipulation under anesthesia should be considered. wrist. cervical spine injuries. and axillary radiographs are obtained. At the 6-week follow-up visit. 6.pound weights (on a supported elbow) are encouraged to prevent muscular atrophy and promote edema reduction. in 2002. 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. OUTCOMES May o et al. shoulder strengthening exercises with weights are begun and advanced as the patient’s sy mptoms permit. and 12 weeks postoperatively and an AP. Schandelmaier et al. scapula Y. especially those with a brachial plexopathy . documented 82% good or excellent results in 27 patients evaluated clinically and radiographically at 43 months postoperatively. This is more common in patients who have a brachial plexus injury. If the patient has persistent loss of shoulder motion.and active-assisted range of shoulder motion starts on postoperative day 1 or 2 Hand. 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. Surgery was undertaken if the intra-articular displacement was >5 mm. or complexassociated fractures of the ipsilateral extremity . We recommend follow-up at 6 months and at 1 y ear with a single AP x-ray to document radiographic and functional outcomes. ( 28). reported the results of 22 displaced intra-articular glenoid fractures treated operatively with screw and plate fixation. Patients with associated injuries may warrant longer follow-up. With a mean follow-up of 10 . (20).

40% had exertional weakness. In another series of 33 intra-articular glenoid fractures. Anavian et al. The operative shoulders had overall results of 94% (for strength. strength.8. Nordqvist and Petersson (50) analy zed 68 scapula fractures at a mean 14y ear follow-up and found that 50% of nonoperated patients that healed with residual deformity had significant shoulder sy mptoms. although these were not analy zed separately. and range of motion following internal fixation. they found good. and average ranges of motion were not significantly different from the contralateral extremity .. At follow-up of 25 months. (7) achieved 79% good or excellent results in a series of 37 patients with scapular fractures treated operatively. Four complications were reported. one patient had shoulder stiffness. including one superficial and one deep infection. of whom 50% had pain. in 2009. reported on the results of 22 patients with scapula fractures treated whose operative management was delay ed >3 weeks from injury. reported the functional outcomes including DASH score. with 13 patients having a peripheral nerve or brachial plexus injury and 30 patients having ipsilateral injuries. 24 patients had no pain whatsoever. and function) as compared to the uninjured side. Armstrong and Van Der Spuy (8) noted that 6 of 11 patients with displaced scapula neck fractures had residual stiffness at 6 months. Eight patients in this same study were treated operatively. In all cases. although only five cases were “severely displaced or unstable” scapula neck fractures. ROM. Although there were mild deficits in strength. and 90% of patients returned to preinjury work and recreational activity (12). Hardegger et al. Scapula neck fractures should be treated operatively if significant displacement or angulation leads to deformity with functional imbalance of the parascapular musculature. pain. and one patient developed subacromial impingement. This recommendation was based on a follow-up of 16 patients with scapular fractures treated nonoperatively. surgery was delay ed due to late referral or the presence . and 20% had decreased motion at a minimum of 15 months’ follow-up. durable functional results based on the Constant and Murley score in 18 of 22 patients. This single surgeon series was notable in that 23 of 33 fractures were May o/Ideberg ty pe IV or V.y ears. Herrera et al. and all achieved a painless range of motion. 91% of the patients had a DASH score of 10. 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.

Herscovici et al.5month follow-up. strength testing. and DASH scores were collected for 14 patients. There were no complications. and four of the five patients returned to their previous occupation and recreational activities.of concomitant injuries that precluded early operative intervention. Others have advocated internal fixation of just the clavicle as well for restoration of length and sufficient stability (52). All patients underwent osteotomy and reconstruction. and Short Form 36 (SF-36) scores were comparable to the normal population in all measured parameters. Despite these challenges. Mean ROM and strength improved in all six measures and were significantly different from the contralateral. Patients had an overall DASH score of 14 (0 to 41) as compared to a mean DASH of 10. (53) treated 15 such patients with internal fixation of both the fractures and reported good or excellent . The authors demonstrated that radiographic and functional outcomes were satisfactory even when surgical treatment was delay ed (13). the senior author (PAC) reported the results of reconstruction of scapular malunions in five patients treated at a mean of 15 months after injury. Radiographic and functional outcomes were obtained for 16 patients. Radiographic measurements. and were unable to return to work. the authors reported marked improvement in radiographic alignment with surgery as well as maintenance of reduction at follow up. In this series. All patients were pain free with regard to the shoulder. DASH. and all were united radiographically. Mean DASH scores improved from 39 (27 to 58) to 10 (0 to 35).4 months (12 to 72). uninjured extremity in only external rotation strength. followed by early rehabilitation. All patients were initially treated nonoperatively and presented with debilitating pain. and SF-36 questionnaires were performed preoperatively and postoperatively with a mean follow-up of 39 months (18 to 101 months). all patients achieved excellent functional results with no deformity at 48. (51) reported on internal fixation of seven clavicle fractures in patients with ipsilateral scapula neck fractures. Leung et al.1 in the normal population. Recently. Two other patients in this series treated nonoperatively had significant shoulder drooping and decreased range of motion. weakness. range of motion. 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). Patients were followed for a mean of 26. 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.

A significant shortcoming of the three former studies is that none documented the degree of displacement of the scapula neck fracture. given the excessive infraspinatus elevation that occurs from gaining exposure to the lateral border and glenoid neck. axillary. dy skinesis. Risks of iatrogenic nerve injury during anterior . glenohumeral instability. suggesting minimal original displacement. (34). Ramos et al. Ninety -two percent had good or excellent results at 7. with excellent range of motion and function. the rate of risk in ORIF for scapula fractures is quite low in the published literature. Scapula fracture patterns involving the suprascapular and spinoglenoid notches are associated with an increased risk of suprascapular nerve injury . Nineteen of twenty healed uneventfully. Missed or delay ed diagnosis of a displaced fracture or nerve injury may result in malunion or nonunion. 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. Wijdicks et al. the outcome of nonoperative treatment of ipsilateral clavicle and scapula fractures was assessed at a mean 28-month follow-up. and glenohumeral degenerative joint disease (54–56). crepitance. which may cause deformity. patients with displaced unstable fractures often have residual pain and decrease range of motion. minimally displaced fractures usually result in good outcomes. Peripheral nerve injury inclusive of suprascapular. partly due to the difficulty of determining whether neurologic injury is due to the injury. and in the latter.results in 14 patients 25 months after surgery . however. rotator cuff dy sfunction. leading to pain. (36). the radiologic outcome was noted to be good in all but one. (18) described danger zones for the suprascapular nerve and circumflex scapular artery based on dissection of 24 cadaveric specimens. the published incidence is rare.5-y ear follow-up. Fortunately. reviewed 16 patients with ipsilateral clavicle and scapula neck fractures treated conservatively. but only 2 of 20 scapula fractures and 8 of 20 clavicle fractures were displaced more than 1 cm. In a recent retrospective study by Edwards et al. and musculocutaneous nerves all have injury potential given their proximity to surgical approaches. on the other hand. or weakness. COMPLICATIONS While stable.

A well-reported complication is shoulder stiffness. acromioclavicular dislocation. He was initially diagnosed with multiple bilateral rib fractures. sternal fracture. This may be particularly true for patients who have been mobilized for excessive periods either before or after surgery. To this procedure. renal injury. as well as a traumatic brain injury. The patient required an exploratory laparotomy and internal . but is effective at giving them a “kick start” when indicated. multiple extremity injuries are all vulnerable to stiffness. It is rare that patients need this formal procedure. and the complications that tend to occur are treatable.exposures can be reduced by limiting retraction of the coracobrachialis where the musculocutaneous nerve traverses approximately 6 cm inferior to the coracoid. There is a low rate of implant failure associated with ORIF of scapulas with plates and screws. both infection and nonunion should be rare occurrences if principles are followed. ILLUSTRATIVE CASE FOR TECHNIQ UE A 22-y ear-old male was involved in a truck rollover accident and was ejected from the vehicle. Our policy is to manipulate the shoulder after fixation and while the patient is still asleep to release all intrinsic and extrinsic contractures. assisting the surgeon and patient greatly with the decision to weigh the risks and benefits of operative management. and occasionally if a patient is not progressing rapidly toward normal motion by 6 weeks postoperatively. Lantry et al. complex spine fractures. a manipulation under anesthesia should be arranged. 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. bilateral pneumothorax. (47) reported a failure rate of 3. and reported malunion rates are almost nonexistent. we alway s add an intraarticular steroid injection to prevent reoccurrence of scar tissue after intraarticular fractures. Patients with cognitive delay.6% in their sy stemic review of operatively treated scapula fractures. head injury. Due to the robust blood supply to the shoulder. 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). This is salient when the patient’s surgery is delay ed.

He was subsequently transferred to our hospital for additional care. Due to the degree of displacement.30 and 2. . a CT with 3D reconstructions was obtained for more accurate measurements and preoperative planning. 2. and there was a profound loss of left shoulder of motion due to stiffness and pain. In addition.31).fixation of his spine fractures. An AP radiograph of the shoulder showed a displaced glenoid neck fracture with a dislocated acromioclavicular joint. there was significant angulation on the scapular Y view with 100% translation (Figs. Phy sical examination at 5 weeks postinjury revealed that the left shoulder was significantly depressed with diminished sensation in axillary nerve.

and axillary views of the left shoulder. Hundred percent displacement of the scapular body is seen on the Y view.FIGURE 2. Also seen on this view is a dislocated acromioclavicular joint.30 A–C: AP. scapular-Y. . There is a displaced glenoid neck fracture with a decreased GPA on the AP view.

31 Panoramic view of both clavicles demonstrating marked displacement of the acromioclavicular joint. Although there is no literature on glenoid version to suggest operative indications. The suprascapular nerve was not tested due to patient intolerance of the exam. The CT scan revealed: Lateral Border Offset: 38 mm Angular Deformity : 45 degrees Glenopolar Angle: 18 degrees The fracture pattern was aty pical in that there was a large segmental component of the lateral border.33). the anteversion measured 32 degrees (Figs. 2. The indications for surgery included a double disruption of the SSSC.FIGURE 2.32 and 2. . An EMG was performed preoperatively because of sensory changes noted and verified the presence of a complete axillary mononeuropathy. 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 .

FIGURE 2. B: 3D CT with images manipulated such that the lateral border is reduced to its normal. C: 3D CT with glenoid and lateral border reduced anatomically . increased GPA. C: 2D axial CT image depicting 32 degrees of glenoid anteversion relative to scapular body . glenoid neck. decreasing the potential for rotator cuff impingement. The glenoid relative to the lateral border. Longer plates were necessary for stable fixation of the segmental fracture at the lateral border.dashed line). and scapula spine (Fig.33 A: 3D CT scan oriented in PA view. one can appreciate the true lateral border offset (38 mm) of the glenoid relative to the anatomic position of the lateral border. Furthermore. With the lateral border reduced. anatomic location (note that the lateral border is straight from the glenoid neck to the inferior angle of the scapula). 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. restored glenoid retroversion and repositioning of the acromion more vertically . 2. multiple exit points of the fracture along the scapula perimeter were needed for reduction and fixation.34). .

care was taken to protect the neurovascular bundle. B: There is a bone void after the fracture has been disimpacted. and fixed in an anatomic position. A provisional reduction was obtained with clamps at all borders including the lateral border at two locations. and down the medial border. The callus was removed from the fracture site so that the reduction could be visualized. Judet Flap. The patient was placed in the lateral decubitus position. the superior angle.35). During flap elevation.34 Intraoperative photographs. External fixation pin joy sticks (with T-handled chucks) were used in the glenoid neck and lateral border to achieve fracture reduction. Naples. A 10-hole 2. A: Marked displacement of the lateral border with angulation. and a 16-hole 2.7-mm locking plate was placed on the lateral border. reduced. C: Callus removed at the time of exposure is used as bone graft before placing a drain and repairing the Judet flap.7-mm recon plate was contoured to extend along the scapular spine. The acromioclavicular joint was reduced and stabilized through a second incision using a tightrope technique (Arthrex. which was under significant deforming force post reduction. The callus was used as bone graft. Phy sical therapy was begun for full active and passive range-of-motion exercises. leaning forward. A second plate was placed along the lateral border to reinforce this area. Florida) (Fig.FIGURE 2. These long plates were favored over multiple small plates to create a stronger construct. . 2.

His DASH score was 22 at this visit. scapular Y. At 6 months. the patient had significant improvement in both range of motion and strength.FIGURE 2. .35 A–C: Postoperative AP. His range being essentially equal and 60% strength compared to his opposite shoulder. and we were optimistic for a full return in shoulder function in spite of his severe constellation of injuries. Radiographs revealed a healed fracture. and axillary radiographs showing restoration of anatomic positioning of the scapula and AC joint.

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Displaced proximal humeral fractures can present complex technical challenges. However. hemiarthroplasty was the most common procedure in the geriatric patient with a displaced threeor four-part proximal humeral fracture. or falls from a height. Traditionally. the fracture is commonly multifragmentary.3 Proximal Humeral Fractures: Open Reduction Internal Fixation John T. most fractures are minimally displaced and are best treated nonoperatively. Over the past decade. athletic injuries. They are the third most common extremity fracture in the elderly after the hip and distal radius. there has been a renewed interest in internal fixation as an alternative treatment. which occur following a ground-level fall. However. Fortunately. this procedure is associated with unpredictable outcomes even in the hands of experienced shoulder surgeons. While the early reports with locked plating were promising. With the recent development and widespread availability of periarticular locking plates for the proximal humerus. The majority of these fractures are the result of lower-energy injuries in older patients. 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. especially in elderly patients with compromised bone. the technique is not a . and surgery is often indicated. there has been a dramatic increase in the number of patients with proximal humerus fractures treated surgically. Gorczyca INTRODUCTION Fractures of the proximal humerus are common injuries and comprise approximately 4% of fractures seen in clinical practice. displaced or unstable. with higher-energy mechanisms such as motor vehicle collisions.

panacea and numerous problems have been described. its popularity stems from its relative simplicity and its utility in guiding treatment.and intraobserver reliability of this classification sy stem is imperfect. Although inter. . 3. The most common classification of proximal humeral fractures was described by Neer (Fig.1).

.

many elderly and frail patients with multiple medical comorbidities should be treated nonoperatively accepting some loss of function. More than 40 y ears ago. and rotator cuff pathology. Likewise. poly trauma. but functional recovery of shoulder motion and strength takes much longer. This permits many patients to lift their arm above their shoulder for activities of daily living. Isolated fractures of the greater tuberosity should be reduced and stabilized when displacement is >5 mm in any direction. Neer recommended surgery for fractures of the proximal humerus with displacement of the head or either of the tuberosities by 1 cm. the great majority of proximal humerus fractures will heal. ipsilateral upper extremity injury (“floating elbow” or “floating shoulder”). Less common indications for surgery include bilateral fractures. Displaced fractures in adult patients should be reduced and stabilized. open fractures. the inability to perform this task may compromise a geriatric patient’s ability to live independently. INDICATIONS SURGERY AND CONTRAINDICATIONS FOR Regardless of the method of treatment.and four-part fractures and dislocations of the proximal humerus.FIGURE 3. muscle weakness. fracture healing takes 6 to 10 weeks. The goal of surgery is to restore the head shaft relationship and tuberosities with stable fixation to allow early range of shoulder motion. which we still follow today. . Nonoperative treatment is indicated for all nondisplaced and most minimally displaced fractures in virtually all age groups.1 The Neer classification of proximal humeral fractures. fracture dislocations. In many patients. and fractures with associated vascular injury. and even fully compliant and motivated patients may fail to regain preinjury levels of function and activity . However. or angulation >45 degrees. Surgery is indicated for most patients with significantly displaced three. The nonoperative management of widely displaced fractures often leads to sy mptomatic malunion. preexisting neuropathy or stroke that compromises the expectation for functional benefit after surgery are strong indications for nonoperative treatment. Following injury. with painful loss of shoulder motion frequently due to impingement.

If any abnormality is identified. Strong indications for hemiarthroplasty include headsplitting fractures (with the exception of some y oung patients with healthy bone) anatomic neck fractures. Doppler evaluation. A thorough neurologic examination of the entire upper extremity must be performed and documented. with an ankle-brachial index. wrist. coronary artery disease. Any questions regarding the vascular integrity warrant further evaluation. ecchy mosis. or wrist. and hand performed in order to avoid missing a more distal injury . Range of motion of the shoulder is ty pically limited due to pain. injuries to the head. When possible. 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. The extremity should be examined for swelling. . occupation. Evaluation of the axillary nerve can be difficult in a swollen painful shoulder. chest wall. and displaced three. a careful history may reveal substantial medical comorbidities such as hy pertension. All patients should have a complete phy sical examination. which may play an important role in decision making. face. In the multiply injured patient with a shoulder fracture. and upper extremity commonly occur. Preexisting chronic rotator cuff deficiency with arthropathy is better treated nonoperatively or with shoulder arthroplasty . or angiography. neck. and living status. but should be tested by asking the patient to contract the deltoid muscle whenever possible.Not all proximal humeral fractures that require surgery are amenable to internal fixation. peripheral pulses. and neurologic impairment. forearm. or diabetes. Proximal humeral fractures that occur in elderly patients following lower energy falls may be associated with injuries to the head. vascular surgical consultation should be obtained. It is also important to evaluate the elbow. Other important factors include hand dominance. The patient’s medication record should be scrutinized with particular reference to anticoagulation medication.and four-part fractures in patients with either comminution or osteoporosis that would not support internal fixation.

x-ray s of the cervical spine. the greater and lesser tuberosities. then any measurement of fracture angulation will be exaggerated. and the humeral shaft (Fig. stable fixation may not be achieved and cut out of the screws is more likely.B). and an axillary lateral view (Fig. The thickness of the humeral head seen on the CT scan should be carefully assessed when considering internal fixation. while challenging to obtain in the trauma setting. Based on the phy sical exam. a transscapular lateral (“Y”) view. Thus. 3. In order to optimally visualize these four parts. a computed tomographic (CT) scan can be helpful to evaluate fragment size and displacement and can reveal nondisplaced fracture lines (Fig. In some cases.Radiographic Evaluation The proximal humerus consists of four parts: The humeral head. as well as a glenohumeral joint subluxation or dislocation. ribs. The axillary lateral. 3D imaging provides detailed topographic views which may allow a clearer appreciation of the fracture geometry (Fig. It is frequently the best view to rule out a coronal plane head-splitting fracture.3A–C).4 A. or forearm may be indicated. 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). In addition to the axial. elbow. sagittal. 3. clavicle. 3. . 3. the transscapular lateral radiograph provides a better view for accurately measuring fracture angulation. often provides crucial information. In patients with complex fracture patterns. all patients with a shoulder injury should have an anteroposterior view. If the head is too small or thin. and coronal reconstructions. the scapula can be “subtracted” giving even more information about the fracture morphology. a glenoid rim fracture.2).4C).

.FIGURE 3.2 The pathoanatomy of proximal humeral fractures.

Axillary lateral view. Anterior-posterior view. . C. B. Trans-scapula lateral view.3 A.FIGURE 3.

Axial CT cut of a valgus impacted fracture demonstrates displacement of the greater and lesser tuberosities.4 A. C. The CT scan allows determination of the “thickness” of the humeral head available for fixation. B. Timing of Surgery .FIGURE 3. A 3D CT image of a complex proximal humerus fracture.

surgery should be performed as soon as an operating room becomes available and a surgical team can be assembled. Surgical Tactic The most important step in preoperative planning is for the surgeon to carefully evaluate the x-ray s and CT scan and answer two questions. If any doubt exists.5). In these cases. 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. and the equipment and implants must be in the operating room at the beginning of the case. a fracture with a vascular injury. what is the optimal implant if surgery is required.The majority of displaced proximal humerus fractures can be managed in a semielective fashion without compromising the quality of the outcome. or the patient has other injuries. an open fracture. A patient with an isolated closed. However. does this fracture require surgery. this setup will not interfere with the use of the C-arm. the patient should be positioned at the edge of the table with the arm supported on a hand board or a May o stand to allow shoulder abduction. patients are ty pically admitted to the hospital for earlier surgery . the social circumstances are not optimal. an irreducible fracture with impending skin compromise. These patients are seen in the office or clinic several day s later and scheduled for surgery if indicated. the patient should be consented for both ty pes of surgery. In the supine position. The patient’s head is supported on a gel “donut” or a rolled-up stockinet. Properly positioned. . 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. Surgery can be performed with the patient in either the beach chair position or supine on a flat-top radiolucent table. On the other hand. Fortunately. there are relatively few indications for emergent surgery. or an irreducible fracture dislocation require immediate intervention. if the pain is poorly controlled. 3. First. and the patient’s ey es should be protected during the case (Fig. There are advantages and disadvantages with each technique. and second.

In most operating rooms.6A–D). 3.FIGURE 3. I prefer the C-arm to come in from the cranial side. this is easiest if the surgical table is rotated 90 degrees. . 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 C-arm should be moved into position to ensure high quality anteroposterior and axillary lateral images can be obtained (Fig. Prior to prepping and draping. 3. 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.7). The patient’s head is supported on a gel “donut” and the patient’s ey es are protected with plastic shields. slightly oblique to allow visualization of the entire humeral head and the edge of the glenoid when an axillary lateral view is obtained.5 Intraoperative setup for open reduction and internal fixation of a proximal humerus fracture with the patient in the supine position.

. D. B. An AP fluoroscopic x-ray is obtained. C. An axillary lateral must show the entire head and the glenoid.FIGURE 3. The C-arm is rotated to obtain an axillary lateral view with abduction and mild traction.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 May o stand.

Surgery Surgery is most commonly performed under general anesthesia.FIGURE 3. and neck are prepped . which allows optimum control of the patient’s blood pressure and muscle paraly sis. A helpful technique is to position and tape the endotracheal tube on the side opposite the fracture.7 The position of the C-arm base is marked on the floor with tape. The entire upper extremity. chest wall. A Foley catheter. and muscle paraly sis or relaxation is helpful to lessen the forces required for muscle retraction and fracture reduction. or Swan-Ganz catheters are used when the patient’s medical comorbidities or phy siologic status dictates. central venous pressure (CVP) monitoring. Regional nerve blocks are most useful for postoperative pain control. A cepholsoporin antibiotic is given for prophy laxis within 1 hour of surgery. Maintaining the mean arterial pressure close to 70 mm Hg helps minimize bleeding. shoulder. arterial line.

With internal and external rotation of the shoulder. A curette is used to remove clotted blood and debris from the cancellous underside of the greater tuberosity . the fracture lines will be appreciated. After this. nursing. the first suture can be removed. Deep to the muscle is the hemorrhagic subdeltoid bursa. medical record number. which should be evacuated and excised to improve visualization. I prefer a no. 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. A surgical time-out is called. 5 heavy nonabsorbable suture is passed twice through the supraspinatus tendon at its insertion on the tuberosity capturing bone and tendon. . The fracture should be mobilized to expose the undersurface of the greater tuberosity and the defect in the proximal humerus. prepped. a small drill bit can be utilized. and draped as outlined above. For most greater tuberosity fractures. and the deltoid muscle split. The skin incision. In y ounger patients with hard bone. With the shoulder in internal rotation. 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. start proximally at the anterior-lateral edge of the acromion and extend straight distally for 5 cm. and anesthesia teams must agree on the patient’s name. Techniques—Isolated Greater Tuberosity Fractures The patient is positioned. For isolated 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.and draped in the usual orthopedic fashion. the first suture is often placed too far anteriorly. 5 ethibond suture with a large cutting needle. I prefer a deltoid-splitting approach rather than a deltopectoral incision. and all members of the surgical. 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. and correct side and site of surgery . Due to the posterior and proximal displacement of the greater tuberosity by the retracted supraspinatus and infraspinatus muscles. If this is the case. The muscle is split through a relatively avascular plane in the deltoid raphe. 2 or no. a no. the first suture is used to pull the greater tuberosity anteriorly and distally in order to place two additional sutures in a better position.

3. Following this. 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. the guide wires for 3. and passed obliquely to engage the medial cortex of the humeral shaft followed by an appropriate length screw (Fig.5 or 4. the needle end of each suture is passed from within the fracture site out through the drill hole. .0 mm partially threaded cannulated screws are used.8A–D).The greater tuberosity sutures are gradually pulled to reduce the greater tuberosity into the defect in the proximal humerus. Ideally. and the greater tuberosity is held with digital pressure or with a blunt probe and provisionally fixed with one or two K-wires. The sutures are pulled tight is placed on the sutures to remove slack.

FIGURE 3.8 .

AP radiographic showing a greater tuberosity fracture dislocation. AP x-ray s show anatomic reduction of the tuberosity following internal fixation and tension band suture augmentation. The screw(s) ensure anatomic reduction of the tuberosity. the subcutaneous tissues are approximated. it is carefully repaired with nonabsorbable sutures. retraction of the cuff with posterior and proximal displacement of the tuberosity is also a risk when suture repair is performed alone. the suture ends are tightened and tied with a smaller. protected. After placing one or two partially threaded screws across the fracture and into the medial cortex. Postreduction radiograph demonstrates reduction of the glenohumeral joint with persistent displacement of the greater tuberosity . the two ends of suture above the knot can be tied together. which can compromise shoulder strength and motion.A. and four-part fractures of the proximal humerus that require suture ends are approached through a deltopectoral incision. After application of a sterile dressing. both internal fixation and suture augmentation are necessary to prevent early fixation pull-out. and staples or sutures are placed in the skin. If a supraspinatus or infraspinatus tear is present. Techniques—ORIF of Two. However. Axillary lateral radiograph. absorbable suture. three-. but are not strong enough alone to allow phy siologic shoulder motion. The sutures provide a more durable fixation of the greater tuberosity and resist tensile forces better. It should be emphasized that in the soft bone of the proximal humerus. The deltoid fascia is closed with absorbable suture. the arm is placed in a shoulder immobilizer. and . Finally. B. In order to prevent loosening of the knot. D. On the other hand. C. 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 rotator cuff is inspected for any sign of tear or deficiency. suture fixation alone can result in a malunion of the tuberosity if positioned too distally.to Four-Part Fractures in Adults Virtually all displaced two-. The fracture reduction and screw position is confirmed with fluoroscopy and stability is checked with gentle shoulder motion. The cephalic vein is identified.

The space between the lateral aspect of the proximal humerus and the deltoid is developed by careful blunt dissection. Approximately one-third of the anterior deltoid insertion is released on the shaft to improve exposure and space for the plate.and four-part fractures.e. one or two 2. Abduction of the shoulder to 45 degrees or more facilitates mobilization of the deltoid. 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. It is important to preserve bone stock on the head fragment by gradually freeing it around the periphery before attempting to reduce it (Fig. down to the clavipectoral fascia. The deltopectoral interval is developed digitally. 3.. As described in the description of isolated greater tuberosity fracture repair. the sutures can be used to manipulate the tuberosities into a reduced position. In the uncommon event that the head fragment is dislocated. the greater and lesser tuberosities are identified and tagged with two nonabsorbable sutures passed through each of the tuberosities (i. which is then incised as far proximally as its confluence with the coracoacromial ligament. In most patients.9). it can be reduced using a thin periosteal elevator to lift the head over the edge of the glenoid. After the tuberosities are secured by the sutures. . Alternatively. Attention is now directed to the head fragment. In some cases. total four sutures) where the cuff inserts into the bone.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. and a Hohman retractor is placed between the two. The fracture line between the impacted humeral head and the metaphy sis can usually be recognized visually when the split between the greater and lesser tuberosities is separated with an instrument or lamina spreader.retracted. it should be disimpacted to allow reduction of the tuberosities using an osteotome or a thin periosteal elevator. the head is impacted on the shaft. In three.

9 .FIGURE 3.

3. On the other hand.11B). the ability to maintain an adequate reduction of the humeral head by provisional fixation of the tuberosities alone is very limited.10A. the stability of the humeral head usually improves after reduction of the tuberosities. which do not interfere with subsequent plate placement. If it is small or multifragmentary. In y oung patients with dense bone and large tuberosity fragments. it should be reduced and provisionally stabilized to the head using multiple K-wires outside the plane of the proposed plate. In these patients. If the lesser tuberosity is fractured and unstable. Unfortunately. 3. it is also reduced and held with Kwires. the tuberosities and head fragment are provisionally stabilized with K-wires. 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. Once the reduction has been verified fluoroscopically. the greater tuberosity fragment should be carefully evaluated. the surgeon first develops a plane between the head and the tuberosities.11A). By placing an instrument in the fracture line between the greater and lesser tuberosities. most patients with displaced proximal humeral fractures are elderly and have soft osteoporotic bone. The shaft is provisionally stabilized to the head with one or two oblique K-wires directed from anterior-lateral-distal to posteriormedial-proximal (Fig. its reduction and stabilization should be postponed until after the head and shaft are reduced and stabilized. The humeral shaft. fluoroscopy is used to assess the reduction prior to plate placement. If the K-wires are able to hold the reduction. then gently lifts the head from the metaphy sis. which invariably has some component of crushing and comminution. which is ty pically displaced anteriorly and medially.B). if the greater tuberosity fragment is large. In these cases. 3.Reduction of an impacted humeral head fragment. is then reduced to the head with traction and the aid of a periosteal elevator (Fig. .

The elevator is used to lever the shaft posteriorly and laterally into a reduced position relative to the head. The plate is placed on the lateral aspect of the proximal humerus and fixed to the .11 A. B. FIGURE 3. Intraoperative fluoroscopic view shows the position of the elevator.FIGURE 3. Intraoperative photo shows heavy sutures placed in the greater and less tuberosities and the head and shaft reduced and held with K-wires. The humeral head and shaft are reduced with the aid of a long thin periosteal elevator. B.10 A.

thereby indirectly reducing the shaft to the head. The plate is held against the shaft with direct pressure. One or two additional locking screws are placed more inferiorly into the humeral head.humerus under fluoroscopic control. and the plate is fixed to the proximal fragment with K-wires through the perimeter of the plate. and the position is again confirmed fluoroscopically. This usually requires placement of bone graft material (allograft. This deformity should be corrected before the plate is fixed to the shaft. Fluoroscopy is used to verify plate position and the overall reduction. If the greater tuberosity fragment is large (which is usually not the case in this scenario). the greater and lesser tuberosities are reduced to the humeral head. due to comminution and poor bone quality. shaft. 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. and the glenoid. and the shaft is pushed proximally toward the head in an attempt to maximize bony contact and create a load-sharing construct. Screw position is checked on AP and lateral fluoroscopy. two locking screws are placed through the most proximal holes into the humeral head. and . it is reduced to the head using traction sutures. autograft. In this case. There is a tendency for the shaft to displace anteromedially by the pull of the pectoralis major muscle. K-wires and reduction clamps alone will not usually hold the reduction in the poor bone of the humeral head. Another alternative is to reduce and temporarily pin the humeral head into the glenoid. The metaphy seal defect will not support the head fragment in its normal alignment or version.5-mm locking screws. Another scenario commonly encountered is the challenge of restoring the correct angular and rotational relationships between the humeral head. The plate is reduced to the shaft. 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. Unfortunately. The tuberosity sutures are tied to the plate. Ty pically. This generally occurs when there is significant comminution of surgical neck allowing the head to collapse or rotate into varus or retroversion. The next step is to fix the plate to the shaft. or substitute) into the metaphy seal void to buttress the head and provide mechanical support for fracture reduction. With the plate pushed firmly against the bone.

and any tears should be repaired with nonabsorbable suture. held with K-wires. 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. The disadvantage with this technique is keeping the sutures out of the way during the remainder of the procedure. as poorly placed screws in the humeral head that have to be removed and replaced will further compromise fixation in the osteopenic humeral head. checked on fluoroscopy. Patients are instructed in six exercises . After confirmation of an adequate reduction and plate position fluoroscopically. and the preselected position of the sutures in the plate may not be at the ideal vector for tuberosity reduction or fixation. No screw tip should be closer than 5 mm from articular surface. The head and shaft are reduced and stabilized with screws. The sutures should not be passed through locking holes in the plate if possible. two additional locking screws are placed in the head. Reduction and plate position are verified fluoroscopically. These are ty pically the fractures with thin head fragments for which arthroplasty is often a treatment option. and they are secured to the plate. If the greater tuberosity fragment is small or multifragmentary. and the plate is reduced and fixed to the shaft.a plate is positioned laterally. The wounds are copiously irrigated and meticulous hemostasis obtained with cautery. pendulum exercises and gentle active range of shoulder motion is initiated. Whatever technique is chosen. The wound is closed in lay ers. Next. as the threaded edge of the hole may abrade or transect the suture. the sutures placed in the tuberosities are used to reduce them to the humeral head. Postoperative Care The surgical incision is inspected at 48 hours prior to hospital discharge When the wound is clean and dry. the rotator cuff should be evaluated. which makes passage of the sutures easier. and fixed to the head and greater tuberosity with two proximal locking screws as described previously . Following internal fixation. Locking screws are placed in any of the remaining holes that will provide purchase into bone. it is crucial that the tuberosities are anatomically reduced and securely fixed. Some surgeons prefer to pass the sutures through the holes in the plate prior to positioning of the plate. the plate is positioned and provisionally secured to the head fragment with K-wires.

and the uninjured arm pushes the dowel to the opposite side. the patient protects his arm/shoulder in a sling or shoulder immobilizer. 4. If at 6 weeks. at which point the arm is gently lowered to the resting position. and gradually increasing the size of rotation as comfort improves. 3. and the contralateral shoulder abducts with minimal active contracture (i. then repeats.they can perform at home independently : 1. The arm is lifted (shoulder flexed) to the point of mild discomfort.12). At 3 months. and the patient may perform passive stretching and resistive exercises without restriction (Fig. Side-assisted lift—the same dowel is used. Counterclockwise shoulder rotation—as above. Once good shoulder motion has been restored.e. 2. while the injured arm follows with minimal active contraction of the deltoid. slowly lifts it forward with the contralateral uninjured arm. starting initially with small rotations. patients begin independent range of motion exercises with gravity resistance. the fracture should be healed. Front-assisted lift—the patient uses a 1 inch dia. referral to a phy sical therapist is recommended. Clockwise shoulder rotation—performed while leaning forward. grasping it with both hands spaced 6 inches apart. Independent passive stretching can be performed by “walking the fingers up the wall” anteriorly and at the side . 6. upper limb strengthening using progressive weights or bands is instituted. When not performing exercises or bathing/showering. the hands are placed a shoulder’s width apart. At 6 weeks. Thumb to shoulder—the patient flexes the elbow in an attempt to touch the anterior shoulder with the thumb. wooden dowel (broomstick). 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.. and then fully extends all fingers. The patient performs 10 repetitions of each exercise and does these exercises three times per day. Tight fist—the patient makes a tight fist. different direction of rotation. and then gradually extends the elbow as far as possible. and. the patient is unable to forward flex the shoulder to 90 degrees independently. 5. active-assisted). 3.

as well as external rotation using the dowel for terminal stretch. If motion is not adequate. the patient should be referred to a phy sical therapist for assistance with the passive stretching and resistive strengthening exercises. .

.

3. Fortunately. It is unusual for a patient to regain normal shoulder motion after internal fixation of a displaced fracture. If the patient is unable to perform independent exercises.12 Range of shoulder motion in a 30-y ear-old male 5 months following internal fixation of a displaced proximal humerus fracture. the surgeon must achieve stable fracture fixation including the fixation of the tuberosities and initiate early motion. a phy sical therapist should be involved in the rehabilitation .13). Complications The most common problem after a proximal humerus fracture is shoulder stiffness (Fig.FIGURE 3. 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. or is not making progress independently.

13 Seven months following internal fixation of a three-part proximal humerus fracture. this 59-y ear-old female still has significant loss of forward elevation and shoulder abduction.FIGURE 3. .

3. 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. to ensure that the screw tips are at least 5 mm from the subchondral bone. (b) checking the position of the screw tips with multiple fluoroscopic projections.Screw cut-out or penetration through the subchondral bone into the glenohumeral joint occurs most commonly in elderly patients.14). Some authors recommend the use of a custom fit fibular allograft to mechanically support the humeral head. Methods to minimize this risk are (a) placing screws into the subchondral bone without having drilled the entire screw path. . but it occurs in y ounger patients as well (Fig.

Fixation failure by plate or screw breakage usually occurs as a result of fracture nonunion. . avoiding locking screw holes). but may also occur if the patient is not compliant with postoperative activity restrictions.. 3. Proper positioning and placement of the suture at the insertion of the rotator cuff.e. 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.FIGURE 3. passage of the suture through smooth holes in the plate (i. use of a heavy suture.14 A 61-y ear-old male referred to our institution for treatment of failed fixation and screw penetration into the joint. Many forms of fixation failure can occur after open reduction and internal fixation of proximal humerus fractures.15). and securing the suture with detailed attention to knot ty ing will minimize this risk.

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B). it is not alway s associated with a poor result. taking care to use: (a) long periosteal elevators to lever the shaft and head into position. and (c) K-wires for provisional fixation whenever possible. the fear of its occurrence led many surgeons away from open reduction and internal fixation toward nonoperative treatment or arthroplasty for these fractures. patchy aseptic necrosis occurs without head collapse and relatively few sy mptoms. they may benefit from shoulder arthroplasty.16A. if aseptic necrosis with head collapse occurs and the patient is sy mptomatic. unnecessary soft-tissue stripping should be avoided.15 Loss of reduction of the greater tuberosity following internal fixation. In the past. However. In order to reduce the risk of aseptic necrosis. Intraoperative manipulation and reduction of the head and shaft should be performed “from within” the fracture. There is increasing recognition that when aseptic necrosis occurs. FIGURE 3. (b) heavy sutures to assist with fracture reduction without elevation of soft tissues. In many cases.16 AP (A) and lateral (B) radiographs of a patient with avascular necrosis and . Aseptic necrosis may occur after a proximal humerus fracture (Fig.FIGURE 3. 3.

Implications for surgical technique and prosthetic design. Clin Orthop 2005. and realistic expectations of surgical results remain essential in order to achieve good results. this is a challenging surgical procedure. The use of locking plates in fracture care. J Bone Joint Surg Br 1997. Results/Outcomes Most studies report that 70% to 75% of patients obtain satisfactory outcomes following locked plating of proximal humeral fractures. et al. The three-dimensional geometry of the proximal humerus.16(5):294–302. Badman BL. et al. Fankhauser F. Analy sis of efficacy and failure in proximal humerus fractures treated with locking plates. Proper and thorough evaluation of the patient and the fracture. preoperative preparation. Walch G. There are few randomized controlled trials comparing locked plating with nonoperative treatment or other treatment modalities. and fourpart proximal humerus fractures. J Am Acad Orthop Surg 2006. fraught with potential complications. Boileau P. it is an important tool in the armamentarium of the fracture surgeon. Schurmann M. Cantu RV. The reported 1-y ear mortality rate is elevated although it returns to the age-expected level after the first y ear.collapse of the humeral head following internal fixation of a proximal humerus fracture. J Am Acad Orthop Surg 2008. Koval KJ. Schippinger G. However.14(3):183–190. Although there is a common belief that the results of internal fixation have improved since the advent of locked plate fixation. The use of locked plates to treat proximal humerus fractures has significantly increased in number over the past decade.79:857–865. RECOMMENDED READING Agudelo J. Mighell M. J Orthop Trauma 2007. this has not been clearly established. Nevertheless. Stahel P. Fixed-angle locked plating of two-.430:176– . careful technique. three-. and the results can be less than satisfactory.21:676–681. A new locking plate for unstable fractures of the proximal humerus. Weber K.

Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. Haidukewy ch GJ. Gallagher MA. The importance of medial support in locked plating of proximal humerus fractures. Unrecognized shoulder joint penetration during fixation of proximal fractures of the humerus. Johnson MP.313:1051–1052. Helfet DL. Rozing PM. J Orthop Trauma 2008. Neer CS. et al. Percutaneous fixation of proximal humeral fractures. et al. Regazzoni P.442:87–92. Jaberg H. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. Weil Y. Niemi S. Petersson CJ. Innovations in locking plate technology .20:253–260. Kannus P. Functional outcome after minimally displaced fractures of the proximal part of the humerus. Increasing number and incidence of osteoporotic fractures of the proximal humerus in elderly people. Update in the epidemiology of proximal humeral fractures. Gardner MJ. Saunders DT. Boraiah S. Marsicano JG.181. Displaced proximal humeral fractures.442:93–99. Palvanen M.74:505–515. et al.72(2):140–143. Stiehler M. J Bone Joint Surg Am 1997. Daanen HA. Clin Orthop Relat Res 2006.375:97–104. Koval KJ. Clin Orthop Relat Res 2006. et al.52:1077–1089. et al.79:203–207. et al. Classification and evaluation.22(3):195–200. J Bone Joint Surg Am 1970.73:295–298. Hertel R. Messmer P. J Bone Joint Surg Am 1991. Clin Orthop 2000. Gardner MJ. Br Med J 1996. I. Herscovici D.13(4):427–433. Niemi S. Percutaneous stabilization of unstable fractures of the humerus. J Orthop Trauma 2006. Rietveld AB. Acta Orthop Scand 2002. J Bone Joint Surg Am 1992. J Shoulder Elbow Surg 2004. Warner JJ. The lever arm in glenohumeral . et al. J Orthop Trauma 2007. Miniaci A. Olsson C. Meier RA. Hempfing A. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. Germany W.21(3):185–191. Kannus P. J Am Acad Orthop Surg 2004. Hernigou P. Four-part valgus impacted fractures of the proximal humerus. Barker JU. Jakob RP. Palvanen M. Clinical importance of comorbidity in patients with a proximal humerus fracture.12(4):205–212. et al. Anson P. Jakob RP.

Clay son PE. Robinson CM. J Bone Joint Surg Br 1988. et al. Patt TW. Severely impacted valgus proximal humeral fractures. Jakob RP. Wijgman AJ. Page RS.84:1919–1925. Fornaro E. Injury 1998. J Bone Joint Surg Am 2009. J Bone Joint Surg Am 2002.83(11):1695– 1699.70:561–565. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: results of a prospective. Zy to K. Rowkles DJ.8:569– 573.91:1320–1328. . Results of operative treatment. Arch Orthop Trauma Surg 1984. J Shoulder Elbow Surg 1999. Sudkamp N. Hepp P.abduction after hemiarthroplasty . Bay er J. Costenoble VH. et al.85:1647–1655. Transitory percutaneous pinning in fractures of the proximal humerus. Results of surgical treatment of multifragmented fractures of the humeral head. J Bone Joint Surg Am 2001. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Roolker W. observational study. Soete PJ. multicenter. Sturzenegger M. Percutaneous pinning of the proximal part of the humerus: an anatomic study. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus.29:349–352. McGrory JE. J Bone Joint Surg Am 2003.100:249–259.

mechanical ground-level falls are the most common cause of fragility fractures of proximal humerus. However. recent advances . Percutaneous fixation. Paterson and Sumant G. Arthroplasty is most commonly advocated for the primary treatment of displaced three. it is technically demanding. and arthroplasty are the most common methods of treatment for displaced and unstable fractures in adults. plate osteosy nthesis. there is universal agreement that nondisplaced and minimally displaced fractures are best managed nonoperatively . Notwithstanding. and there is a strong correlation with the presence of osteoporosis. with a strong female predominance (2). fractures of the proximal humerus are the third most common fracture in the elderly. After the hip and distal radius. and numerous studies have documented unpredictable outcomes (4). 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. Nevertheless. In this age group.and four-part fractures in osteoporotic bone in the elderly. but they account for nearly half of all shoulder girdle injuries (1). intramedullary nailing. Krishnan INTRODUCTION Proximal humeral fractures are common injuries representing 4% to 5% of all fractures in clinical practice. There are a bewildering number of treatment alternatives for managing proximal humeral fractures.4 Proximal Humerus Fractures: Hemiarthroplasty William H. Early evaluation and management of these injuries is important in optimizing treatment and functional outcomes.

and many have impaired neuromuscular control as well. Most female patients when they reach the sixth decade of life have some degree of osteoporosis. nonunion. a patient’s bone quality can affect the success of humeral head preserving fixation techniques. INDICATIONS AND CONTRAINDICATIONS Age. Fractures in patients aged 65 y ears or less appear to be more amenable to humeral head preservation techniques.1) (10). TABLE 4. and/or avascular necrosis (11).in surgical technique and prosthetic designs have led to more successful outcomes (5–9). Bone Q uality Similar to age. bone quality. Utilizing these specific variables. implant selection. fracture pattern. and the functional and radiographic outcome. we have devised an “evidence-based” treatment algorithm (Table 4.1 Factors Affecting Treatment Choice Age One of the most important considerations in selecting a method of treatment in proximal humeral fractures is the chronological and phy siologic age of the patient. These factors may compromise osteosy nthesis by increasing the risk of fixation failure. postoperative fracture displacement. Despite improved fixation strength in osteoporotic bone afforded by locking plate technology. Improved outcomes have been documented when softtissue dissection is minimized and there is restoration of the “gothic arch” and anatomic reconstruction of the tuberosities (5). and timing of surgery are important factors that influence the surgical procedure. complications .

When these two preoperative radiographic findings were present in conjunction with an anatomic neck fracture. a total shoulder arthroplasty with insertion of a . If the degenerative changes are mild or moderate. there was a 97% positive predictive value for humeral head ischemia. For example. The medial calcar of the humerus must be intact or restored at the time of surgery for a “stable” reduction. Radiographic criteria predictive of humeral head ischemia included a posteromedial metaphy seal fragment extending <8 mm below the articular surface and disruption of the medial hinge defined as displacement of the humeral shaft>2 mm. a fracture amenable to percutaneous fixation techniques may become impossible to reduce closed and pin percutaneously after 7 to 10 day s or when early callus forms that prevents closed reduction. Very rarely.continue to be higher in these patients after open reduction and internal fixation (12). We believe that optimal surgical timing for shoulder fracture arthroplasty is 6 to 14 day s 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). glenohumeral arthritis may preexist in a patient with a displaced proximal humerus fracture. conventional hemiarthroplasty is still indicated. Even when the humeral head is vascular and amenable to preservation. If end-stage glenoid arthrosis is present. 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. the ability to maintain adequate fracture stability is necessary for successful fracture healing. (13) investigating perfusion of the humeral head after an intracapsular fracture was able to prospectively correlate radiographic fracture morphology with intraoperative humeral head vascularity. Comminution in this region increases the risk of a varus fracture reduction. Fracture Pattern Hertel et al. 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).

which can extend down the arm and into the chest. Most of these patients require a careful medical evaluation by an appropriate specialist particularly if surgery is contemplated. open epiphy sis. (15) documented neuropraxia of the axillary and/or suprascapular nerves in 50% of patients. when the greater or lesser tuberosity cannot be reconstructed. or fractures amenable to other fixation techniques. as eventual recovery may take up to 12 to 18 months after surgery (6). Subtle neurologic injury occurs in a large number of patients with proximal humeral fractures (15).glenoid component should be strongly considered. A cardiac or neurologic event may be the predisposing cause of the fall. 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. Evaluation for concomitant injuries or associated medical conditions is important in these elderly patients. a reversed prosthesis should be considered. PREOPERATIVE PLANNING Clinical Evaluation Marked edema and ecchy mosis. and minimal pain at the time of presentation. extremely low functional demands. Nonoperative treatment may be a better treatment alternative for geriatric patients with complex medical comorbidities. Many elderly patients with these injuries are on anticoagulation therapy. Utilizing electromy ography. Other contraindications for arthroplasty are a history of infection. are often seen in patients with proximal humeral fractures. We ty pically use a reversed prosthesis when the patient is older than 75 y ears. Contraindications to shoulder fracture arthroplasty are ty pically related to severe medical comorbidities that prevent surgical management in general. or the patient has ipsilateral lower extremity fractures that require crutches or a walker. Clinical appreciation and documentation of this finding is important for both prognostic evaluation and preoperative counseling. In the infrequent situation in which a patient with a proximal humerus fracture has a concomitant irreparable rotator cuff tear or cuff tear arthropathy . Visser et al. These may be very difficult to identify clinically in a patient with a painful swollen . severe contracture of the shoulder girdle.

scapular “Y.” and/or axillary views. Radiographic Evaluation Radiographs should include anteroposterior.1).shoulder following fracture. . we obtain full-length scaled radiographs of both humeri using a ruler of defined length for preoperative planning (Fig. a computed tomography scan with three-dimensional reconstructions may be a helpful. If plain radiographs do not allow a clear understanding of the fracture morphology. As part of our protocol. 4.

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.1 A scaled ruler is placed on the patient’s arm during the radiograph to calculate magnification. Despite this.FIGURE 4. Neer’s classic four-part description of proximal humerus fractures has endured by virtue of its simplicity. .

there are 12 possible fracture patterns: 6 patterns resulting in 2 fracture fragments. In the original study by Hertel et al. Stiehler M.. Hempfing A. and tuberosity reconstruction play critical roles in determining functional outcome (5).13(4):427–433. et al. LT. (Modified from Hertel R. 7. and 1 pattern resulting in 4 fracture fragments. In this classification. 10. Many studies have shown that poor functional results correlate .2 Hertel’s binary (LEGO) proximal humerus fracture description sy stem.2) (13). J Shoulder Elbow Surg 2004. FIGURE 4. and 12. correct prosthetic version. lesser tuberosity .4. 9. This sy stem has demonstrated improved interobserver reliability as well as better intraobserver reproducibility . GT. ischemia was observed only in ty pes 2. 8. HH. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. greater tuberosity .) Restoring the “Gothic Arch” Anatomic restoration of humeral height. 5 patterns resulting in 3 fracture fragments. humeral head.

closely with prosthesis and/or tuberosity malposition. Boileau et al.” in which the prosthesis is cemented “proud” and retroverted and the greater tuberosity has been positioned too low. .3). which improves the potential for anatomic tuberosity reconstruction. This combination is associated with persistent pain and stiffness and poor function. The result is a classical “vaulted” or “gothic” arch shape seen in medieval period architecture (Fig. We use the term “gothic arch” to describe the architectural anatomy of the proximal shoulder girdle as seen on an anteroposterior radiograph (5). This simple concept allows for a highly reproducible surgical technique for restoration of proper humeral height. 4. (4) described the “unhappy triad. Careful attention to the restoration of the proximal humeral anatomy is crucial in obtaining good results following shoulder fracture arthroplasty . 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.

3 .FIGURE 4.

4A).) Using the scaled preoperative radiographs.4D). Burkhead WZ.4C). In addition. . 4. 4. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch. which intersect at (3) the inferior articular margin. These steps are vital and cannot be overlooked.4B) is determined by measuring from a line perpendicular to the medial epicondy le to the fracture line at the humeral metadiaphy sis. we measure the length of the greater tuberosity fragment (G) (Fig. (Reprinted from Krishnan SG.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. et al. we first measure the entire length of the intact contralateral humerus from a line perpendicular to the medial epicondy le to the top of the humeral head (N) (Fig. with permission. which should be within 5 mm of H to ensure that humeral prosthetic height will allow for anatomic tuberosity reconstruction. On the injured side.6(2):57–66. Pennington WZ. Humeral height for the prosthesis that must be restored (H) is calculated by subtracting F from N (Fig. the length of the fractured humerus (F) (Fig.” Tech Shoulder Elbow Surg 2005. 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. 4. 4.

FIGURE 4. corrected for magnification.4 A. D. B. corrected for magnification. Length of normal humerus (N) is the distance along the humeral shaft from a line perpendicular to the medial epicondy le to the top of the humeral head. C. Greater tuberosity length (G) should be within 5 mm . Length of fracture (F) is the distance along the humeral shaft from a line perpendicular to the medial epicondy le to the fracture line at the humeral metadiaphy sis. The amount of humeral height to be restored (H) is the value of N minus F.

6(2):57–66. is preferred.5 Intraoperative measurement of greater tuberosity should be within 5 mm of humeral head height (H).6). Pennington WZ.) SURGICAL TECHNIQ UE General hy potensive anesthesia.” Tech Shoulder Elbow Surg 2005. (Reprinted from Krishnan SG.6(2):57–66. Burkhead WZ. the table may now be turned 90 degrees to allow for a C-arm to be brought in directly . Burkhead WZ. FIGURE 4.” Tech Shoulder Elbow Surg 2005. (A through D reprinted with permission from Krishnan SG. This is important because the greater tuberosity should be positioned 3 to 5 mm below the prosthetic head. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch. The head of the table is elevated 20 to 30 degrees. The patient is positioned supine on the operating room table in a modified beach-chair position using a bean bag for scapula support (Fig. Pennington WZ.of humeral head height (H). without the use of a regional nerve block. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch. 4.) As a final check. the preoperative value G is compared with the length of the greater tuberosity fragment measured intraoperatively (Fig. with permission. et al. et al. If desired. 4.5).

and neck are prepped and draped with the affected arm free.perpendicular to the patient. TX). The cephalic vein is retracted medially with a small strip of the deltoid. 4. Greenville. the skin and subcutaneous tissue are infiltrated with 0.6 Modification of the beach-chair position. McConnell Orthopedic Manufacturing Company. A 5. A self-retaining retractor . the deltopectoral interval is developed down to the clavipectoral fascia. Prior to making the incision. A mobile soft-tissue window will allow the procedure to be performed through a relatively small incision. chest wall. The extremity. By blunt dissection. A sterile articulated arm holder is utilized (McConnell Arm Holder.7).25% bupivicaine with epinephrine. appropriate preoperative and perioperative intravenous antibiotics are administered (cephalosporin or vancomy cin) for a 24-hour total duration. shoulder. If there is no contraindication.to 7. FIGURE 4. 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. Small Hohmann retractors are placed under the deltoid proximally and over the coracoacromial ligament.5-cm deltopectoral approach is used.

Four nonabsorbable horizontal mattress nonabsorbable sutures (No. 4. the smaller size should be selected. and divided at its insertion for later tenodesis. . The head fragment is carefully removed and measured with a caliper. 4. and the joint is copiously irrigated and inspected for signs of damage or arthrosis. Similarly.9). Ethicon. tagged. 4. which will be placed into and around the humeral component (Fig. Two nonabsorbable sutures are placed around the lesser tuberosity at the subscapularis bone-tendon junction (Fig. The tuberosities are gently retracted to gain access to the humeral head. If the humeral head measurement is intermediate between sizes. just posterior to the bicipital groove. the fracture line can be located with an elevator or osteotome between the tuberosities. a Johnson and Johnson Company.8). NJ) are placed separately in the greater tuberosity at the bone-tendon junction (two in the infraspinatus and two in the teres minor).is then placed beneath the deltoid and conjoint tendon (Fig. The humeral head is saved and used to procure three structural cancellous bone grafts. New Brunswick. Dissecting scissors are used to divide the rotator cuff in line with the tuberosity fracture plane. The greater tuberosity is identified and mobilized. 5 Ethibond. the lesser tuberosity is identified and mobilized. Loose bony fragments are removed from around the glenoid.10). Ty pically. The biceps tendon is identified in the intertubercular groove.

7 Modified deltopectoral incision.6(2):57–66. et al.FIGURE 4.) . with permission. (Reprinted from Krishnan SG.” Tech Shoulder Elbow Surg 2005. Pennington WZ. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch. Burkhead WZ.

(2) on top of the acromion. (3) self-retaining retractor placed under the deltoid and conjoint tendon.FIGURE 4.8 Retractor placement. . (1) Over the coracoacromial ligament.

.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.FIGURE 4.

Tornier. The medullary canal is prepared by hand using cy lindrical reamers and fracture-specific trial implants of increasing diameter (Aequalis Fracture Prosthesis. we do not attempt to “ream up” to a larger implant stem diameter. it is provisionally stabilized using cerclage wire or heavy suture fixation with the . If a trial reduction feels too loose or tight. The humeral shaft is mobilized and delivered into the wound.10 This osteotome is included in the prosthetic instrumentation set and is used to fashion structural bone graft from the humeral head. one must reassess whether the anatomy has been properly restored using the “gothic arch” technique as described below. St. The smallest reamer that demonstrates cortical contact is chosen.FIGURE 4. and since we recommend a cemented stem. a trial stem and head may now be placed into the humerus. If the medial calcar is fractured. Fracture jigs are available to allow for stable trial implant height and retroversion during a trial reduction. Ismier. France) until the appropriate trial implant and head size are determined. If desired.

11). 4.last broach used in the medullary canal (Fig. .

Unlike other described techniques. 4. We sy stematically 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 . .11 A fractured medial calcar is stabilized using cerclage wire or heavy suture fixation. and the preselected size trial head is placed on the definitive implant with the eccentric head offset rotated into the most lateral position (Fig. we do not reference the reconstruction using the lateral humeral metadiaphy sis.FIGURE 4.12). The appropriate diameter fracturespecific prosthetic stem is opened. The next step is to restore the proximal humeral “gothic arch” anatomy.

The line of the .FIGURE 4. the mark should be visible at the fracture line of the humeral shaft. a mark corresponding to length H is placed on the prosthetic implant by measuring from the top of the trial humeral head (see Fig. During provisional placement of the prosthesis inside the medullary canal. Using the preoperative radiographic calculations as previously described. 4.4D).12 Appropriate prosthetic humeral head placement is in the most laterally offset position.

14).“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. Pennington WZ. FIGURE 4. 4.6(2):57–66.” Tech Shoulder Elbow Surg 2005. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.13 With the prosthesis placed inside the medullary canal. Restoration of humeral head height is confirmed with the ruler. 4. et al.) . the “gothic arch” is unbroken. Burkhead WZ. This step ensures that the patient’s own retroversion is restored and is approximately 20 degrees relative to the transepicondy lar axis of the elbow. (Reprinted from Krishnan SG.13). with permission. 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. 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.

The greater tuberosity is measured and noted to be within 5 mm of the .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.

The cement is mixed using a vacuum centrifugation device and injected into the humeral canal using a large sy ringe.17). a Johnson and Johnson Company. The final head of predetermined size is gently impacted into the appropriate position. Ethicon. the prosthetic stem is cemented into the canal in slight valgus using third-generation cementation technique. the implant is removed. A cement restrictor is placed 2 cm distal to the distal tip of the prosthesis. Head size is either too large or has not been rotated into the most lateral offset position (Fig. New Brunswick. The vent tube is removed during the third (final) pressurization.measured humeral head height (H) (Fig. 5 Ethibond. Medial calcar is fractured and has not y et been restored 3. and (c) under the anteromedial edge of the prosthetic head between the head and neck of the implant (Fig. 4. If there is any concern. The “gothic arch” anatomy of the proximal humerus is consistently recreated intraoperatively using this method. . The humeral canal is thoroughly irrigated. 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. One to two centimeters of proximal cement is removed from the intramedullary canal to allow for placement of bone graft. (b) under the greater tuberosity at the “lateral” fin of the prosthesis. Two heavy nonabsorbable sutures (No.” then either 1. Prosthetic height may be incorrect (it is usually too high) 2.16). 4.12) Once the arch has been established. intraoperative fluoroscopy can be utilized to confirm restoration of the gothic arch with the prosthetic stem and head. and a small diameter suction tube is placed into the canal to vent blood during cementation. and two drill holes are placed in the proximal humeral shaft on either side of the bicipital groove. Final tightening of the wire or suture used to fix the medial calcar fracture (if present) is performed.15). 4. 4. If the arch is not “restored. 4. adding a small amount of cement each time. NJ) are placed in a horizontal mattress fashion through these holes to be used as “tension band” sutures during the final tuberosity fixation (Fig. Gentle pressurization of the cement is performed using a separate wet glove. Taking care to ensure that the previous “gothic arch” anatomy is restored (Fig.5).

15 Two heavy nonabsorbable sutures are placed through drill holes on either side of the intertubercular groove.FIGURE 4. .

Shoulder arthroplasty for fracture: restoration of the “Gothic Arch. Burkhead WZ. with permission. Pennington WZ.16 Restoration of the “gothic arch” with the final prosthesis in place.” Tech Shoulder Elbow Surg 2005.) . et al.FIGURE 4. (Reprinted from Krishnan SG.6(2):57–66.

.

With the greater tuberosity in a reduced position. and leading edge of subscapularis tendons (posterosuperior cuff) (Fig.FIGURE 4. .21). and superior infraspinatus tendons (anterosuperior cuff). 4. 4. rotator interval.” One suture is placed from anterior to posterior through the subscapularis tendon. supraspinatus. and (c) under the anteromedial edge of the prosthetic head between the head and neck of the implant. The medial limbs of the sutures previously placed at the greater tuberosity bone-tendon junction are passed around the prosthetic neck (Fig.19). superior supraspinatus. 4. With the humeral prosthesis reduced into the glenoid. two of these sutures are tied over the structural bone graft (Fig. tuberosity osteosy nthesis is now performed. (b) under the greater tuberosity at the “lateral” fin of the prosthesis. Sutures previously placed through drill holes in the humeral shaft are then used to create a vertical “tension band.18). 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. The other is passed from posterior to anterior through the teres minor and infraspinatus.20).17 Three structural cancellous bone graft wedges are then placed: (a) in the “window” of the fracture-specific prosthesis.

18 Medial limbs of sutures previously placed at the greater tuberosity bonetendon 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.FIGURE 4. .

.FIGURE 4.20 The two remaining sutures previously placed at the greater tuberosity bonetendon junction are placed through the lesser tuberosity bone-tendon junction and tied down.

FIGURE 4. Additional simple sutures are used to reinforce rotator interval closure (purple). light blue) are used for vertical “tension band” fixation. .21 Sutures placed through drill holes in the humeral shaft (gray.

to ensure there is no motion of the tuberosity fragments.22 Soft-tissue biceps tenodesis.The biceps is tenodesed within the bicipital groove or rotator interval to soft tissue (Fig. 4. 40 degrees of external rotation at side.23). Passive intraoperative range of motion should be at least 160 degrees of elevation. and 70 degrees of internal rotation in a 90-degree abducted position. 4. Closure of the wound is performed. . FIGURE 4.22). 60 degrees of external rotation in 90-degree abducted position. Postoperative x-ray s should demonstrate anatomic reconstruction of the proximal humerus (Fig. The shoulder is taken through a full range of motion.

Four-part proximal humeral fracture with broken “gothic arch. et al.23 A. Two y ears after surgery . C. Restoration of the “gothic arch” and tuberosity anatomy . (A and B reprinted from Krishnan SG. Burkhead WZ.FIGURE 4. Shoulder arthroplasty for fracture: restoration of the “Gothic . Pennington WZ.” B.

24). Passive motion with the patient supine is begun the day after surgery.” Tech Shoulder Elbow Surg 2005. active motion is allowed. meticulous .Arch. COMPLICATIONS Many complications can be avoided by proper patient selection. At 7 weeks after surgery.) POSTOPERATIVE MANAGEMENT Patients are placed into a Smart Sling orthosis (Innovation Sports/Ossur.24 The Smart Sling orthosis. and resistance exercises begin 10 weeks postoperatively . During weeks 5 to 6. passive supine forward flexion is full. with permission. Passive supine limits of 90 degrees of forward flexion and 30 degrees of external rotation are maintained for the first 4 postoperative weeks. FIGURE 4. Foothill Ranch.6(2):57–66. 4. CA) for 6 weeks (Fig. and external rotation is maintained at 30 degrees.

Tuberosity Malposition. nerve injury. fixing the tuberosities in a nonanatomic position can result in a poor outcome. Other. An intraoperative AP radiograph should be obtained if there is any question about the adequacy of reduction. the surgeon may be concerned about starting early postoperative shoulder motion. Component Malposition. 5 . Placing the greater tuberosity too low will have a similar effect to placing the prosthesis too proud. A prosthesis placed too high can over tension the superior rotator cuff. the excellent initial fixation afforded by this technique allows for early protected motion as described. 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). and careful surgical technique. This provides superior stability by compressing the tuberosity to the prosthetic neck (10). 3. The proximal greater tuberosity should be 3 to 5 mm below the top of the prosthetic head. However. 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 osteosy nthesis between 2001 and 2006 (6). Stiffness. 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. 2. and glenoid arthritis. Less common complications include infection. The mean age was 72 y ears and follow-up was 24 to 56 months. A key technical point is passing the sutures used in tuberosity fixation around the prosthetic neck. 1. Failure of Tuberosity Fixation. resulting in pain and limited elevation. 4. Between . complex regional pain sy ndrome. This can be avoided by following the criteria for restoring the “gothic arch” anatomy of the proximal humerus as described.attention to detail. intraoperative humeral fracture. Even when the implant is placed correctly. rotator cuff failure. prosthetic loosening. heterotopic ossification. In an effort to reduce the risk of early tuberosity migration.

Tinsi L. Boileau P. From April 2004 through May 2006.442:87–92. . et al. Handoll HHG. Nordqvist A. De Benedetto M. New Orleans. Petersson CJ.4. 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%).12: Art. Update in the epidemiology of proximal humeral fractures. Shoulder arthroplasty for fractures of the proximal humerus: where are we in 2010? AAOS Instructional Course Lectures. Kannus P.pub2 4. 112 fracturespecific prosthetic stems (FX) were used. p < 0. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. The mean ASES score was higher in the FX group (72 vs. Tuberosity healing was noted to be 89/112 (79%) in the FX group and 38/58 (66%) in the STD group (p = 0. Musculoskelet Surg April 19. Cochrane Database Syst Rev 2010. 2.0001). Krishnan SG.6(2):57–66. March 2010.11(5):401–412. No. J Shoulder Elbow Surg 2002. Palvanen M.September 2001 and March 2004. 127/170 (75%) greater tuberosities healed to the humeral shaft.8 vs.4(2):107– 112. Overall. mean time to surgery. Niemi S.0001). 3. Tech Shoulder Elbow Surg 2005.CD000434.007). Clin Orthop Relat Res 2006.1002/14651858. Differences between groups in age. 5. 7. REFERENCES 1. Pennington WZ. Incidence and causes of shoulder girdle injuries in an urban population.: CD000434. These results appear to support improved outcomes associated with the fracture-specific stem compared to the standard stem. and mean goniometric active elevation was better in the FX group (129. Krishnan SG. DOI: 10. 55. 95. Burkhead WZ.03). Shoulder hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 1995. Pirani P. 58 standard humeral prosthetic stems (STD) were implanted. 6. and visual analog pain scores were not significant. Interventions for treating proximal humeral fractures in adults. Ollivere BJ. p < 0. et al. this was significant (p = 0. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch”. et al. Krishnan SG. Castricini R. et al.

56. J Shoulder Elbow Surg 2004. Lin K. 8. et al. Brand R. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. An assessment of interobserver reliability and intraobserver reproducibility. IL: American Academy of Orthopaedic Surgeons. Hertel R.13(4):427–433. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. et al. Visser CP. In: Marsh JL. Results of a prospective. Stiehler M. Gultekin S. Sperling JW. et al. multicenter. eds. Hepp P. 9. The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results. Owsley KC. 15. observational study . et al. The Neer classification sy stem for proximal humeral fractures. Shoulder arthroplasty for acute proximal humerus fracture.75(12):1745–1750. Vol.2011 [Epub ahead of print]. Sidor ML.91(6):1320–1328. Cuomo F. Mole D. Duwelius PJ. Bay er J. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. Zuckerman JD.40(12):1336–1341. Roche O. Krishnan SG. Rosemont. Hempfing A. Südkamp N. et al. Shoulder Trauma: Bone. J Bone Joint Surg Am 2009. Orthopaedic Knowledge Update 9. 16. et al. Rosemont. 2008. J Shoulder Elbow Surg 2001. J Bone Joint Surg Am 2008. Sirveaux F.96(6):683–694. Instructional course lectures. Hill JD. Gorczy ca JT. 12. Esen E.10(5): 421–427. 13. Ly on T. 10. Orthop Traumatol Surg Res 2010. . 14.90(2):233–240. 2007:45– 57. Injury 2009. IL: American Academy of Orthopaedic Surgeons. Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty : a retrospective study in 42 patients. 11. Nerve lesions in proximal humeral fractures. Coene LN. Dogramaci Y. J Bone Joint Surg Am 1993.

infraspinatus. Adam P. The prosthesis is designed to compensate for deficiencies of the rotator cuff. A RSA is a semiconstrained prosthesis. pain. resulting in an increased lever arm with improved function of the deltoid for abduction. 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. If the greater tuberosity does not heal properly.5 Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Pascal Boileau. and insufficiency of the greater or lesser tuberosity will not cause instability of a properly positioned prosthesis. a large number of subsequent studies have been unable to duplicate his functional and radiological outcomes. Furthermore. and teres minor. Many authors have documented that the results of hemiarthroplasty are closely related to the accuracy of reduction and healing of the tuberosities. and stiffness.2). If the greater tuberosity heals in a malunited position or migrates because of fixation failure. then the function of these muscles will be compromised. 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. particularly the greater tuberosity (3). particularly the supraspinatus (4). malunion or nonunion of the tuberosity can lead to bony impingement with decreased range of shoulder motion. This makes it an attractive option for . a poor outcome is predictable. In fact. leading to shoulder dy sfunction. the center of rotation of the shoulder joint is medialized and the humerus is lowered. In reverse shoulder arthroplasty (RSA). and Xavier Ohl INTRODUCTION Although Neer reported favorable results following hemiarthroplasty for proximal humeral fractures in 1951. Rumian.

marked comminution of the fracture. RSA for fractures is a technically demanding procedure and should not be performed by inexperienced surgeons without specialized training. severe osteopenic bone or metabolic bone disease. its use should be restricted to more elderly patients (i. some three-part fracture dislocations. fixation. a complete axillary nerve deficit. it may delay recovery and . These include four-part fractures and fracture dislocations of the proximal humerus.8). Although RSA can compensate for cuff deficiency as described above. and healing of the greater tuberosity to preserve the external rotation function of the shoulder whenever possible (6).e. active infection. inadequate glenoid bone stock to support a glenoid implant. While neurological dy sfunction tends to recover slowly. over 70 y ears of age) as long-term results with this implant are not available.. Factors that would favor the use of a RSA rather than hemiarthroplasty include age over 70 y ears. and a careful phy sical examination should be performed. the surgical goal should include reduction. PREOPERATIVE PLANNING Preoperative planning is essential to obtain a successful outcome after RSA for fracture and to prevent avoidable complications. INDICATIONS AND CONTRAINDICATIONS RSA for fracture is reserved for comminuted osteoporotic fractures in elderly patients that are unsuitable for osteosy nthesis or conventional hemiarthroplasty . A detailed history should be obtained. 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. heavy smoking. preexisting rotator cuff disease. and inability or unwillingness of the patient to comply with postoperative rehabilatation. and preliminary studies report deterioration of function after a few y ears (5). Contraindications to RSA include age under 70 y ears. However. inflammatory arthritis. and three-part fractures without valgus impaction of the humeral head (7.arthroplasty in fracture cases where successful reconstruction and osteosy nthesis of the proximal humerus and tuberosities are problematic. head-splitting fractures. and the use of sy stemic steroid medication.

especially in terms of vertical height. 5. unreproducible. 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).1). 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. and determine fracture displacement and evaluate the status of the tuberosities. which avoids operating through acutely injured and edematous soft tissues and lessens the risk of wound complications. Radiographic evaluation should include anteroposterior (AP). . The difference between these two measurements. In our opinion. is crucial as implanting the prosthesis too deep or too proud in the humeral canal can lead to a poor result (10). and axillary lateral views as well as a CT scan to classify the fracture. RSA should not be performed in a patient with a complete axillary nerve palsy. it is not acceptable to rely on “ey eballing” the height of the prosthesis at the time of surgery as this leads to unpredictable. Scaled AP radiographs of both humeri should be obtained. scapular Y. The length of the normal humerus is measured along the prosthetic axis as shown in Figure 5. In our opinion. We believe that the ideal timing of surgery is at 3 to 7 day s after injury.1. Preoperative radiographic planning is very important if successful outcome is to be consistently achieved. the length of the remaining distal humeral shaft fragment is measured from the lateral edge of the fracture (Fig.rehabilitation. Correct positioning of the humeral prosthesis. 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. and often unacceptable results. 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. On the fractured side. This is especially important since RSA relies on the deltoid muscle to be the prime driver of shoulder movement.

Antibiotic prophy laxis should be administered at the time of anesthetic induction according to local protocols. 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 day s and has been unable to perform adequate hy giene in the axillary region due to pain. Evaluation of the humeral length on the fracture side and the controlateral side. A beach-chair position is used with the arm draped free. We perform surgery in a laminar airflow room.FIGURE 5. A sterile adhesive antimicrobial incise drape (Ioban.B.1 A. The arm must be draped free to allow for intraoperative manipulation to aid in exposure and prosthesis implantation. Patient Setup Surgery can be performed under a general or regional anesthesia. 3M) is .

2). This specifically designed reverse fracture stem has a low-profile monobloc design.) sy stem. and a smooth polished neck to prevent abrasion of sutures used for tuberosity osteosy nthesis (Fig. a fenestration to accept proximal bone graft.applied to the surgical field after marking the incision to lessen the risk of wound contamination. 5. We use the Aequalis Reversed Fracture Prosthesis (Aequalis RSAFx. . Inc. proximal hy droxy apatite coating to promote bone healing. Tornier. It is also modular as it can accept either a 36 or a 42 poly ethy lene cup.

.FIGURE 5.2 Aequalis Reversed Fracture stem.

Full-thickness skin flaps are raised. 5. 1 cm medial to its lateral border (Fig. the split is extended up over the superior surface of the anterior acromion. A vertical incision centered at the anterior edge of the acromion is made in Langer’s lines. exposing the underly ing deltoid muscle and anterolateral acromion (Fig.3). The deltoid is split in the avascular tendinous raphe between the anterior and middle portions of the deltoid. . FIGURE 5..Approach Although we routinely use the deltopectoral approach for elective RSA. A deep self-retaining retractor is used for improved visualization.3 Surgical approach. This split should not extend more than 5 cm distally to avoid damaging the axillary nerve.5). Proximally. we utilise the superolateral deltoid-splitting approach for fracture cases as it allows better access to the greater tuberosity fragments and improves glenoid exposure. 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.4). 5. 5.

FIGURE 5.FIGURE 5.5 Detachment of the anterior deltoid.4 Exposure of the deltoid muscle and anterolateral acromion. .

The key to understanding the anatomy is to identify the long head of biceps tendon. tagged. .6 Removal of the fractured humeral head. which lies between the greater and lesser tuberosities and marks the rotator interval. FIGURE 5.6). and the biceps tendon is identified. and divided at its origin from the supraglenoid tubercle. its attachment to the greater tuberosity is already torn. The fractured humeral head is now removed and saved to be used as bone graft in and around the definitive prosthesis (Fig. In many patients. 5. The rotator cuff interval is opened or extended if torn. facilitate fracture reduction. and any adhesions between the rotator cuff muscles and deltoid should be freed. A soft-tissue tenodesis below the rotator cuff interval of the remaining tendon is performed. exposing the fracture site. We excise its intra-articular portion to aid exposure. Tuberosity Mobilization and Preparation The supraspinatus tendon is identified and mobilized up to the glenoid rim.Fracture Exposure The hemorrhagic subacromial bursa and fracture haematoma are carefully removed. and remove a source of postoperative pain.

5.). two sutures are passed around the lesser tuberosity fragment through the subscapularis tendon. Tornier. Fig. 5. two blue) will be used as horizontal cerclages for tuberosity fixation and must be placed at the bone-tendon junction of the greater tuberosity. Inc. or Force Fiber (Tornier Inc.). Inc.7 Specific atraumatic grasping clamp is used to manipulate the greater tuberosity . We use a combination of Orthocord (Depuy Orthopaedics.7).).The greater tuberosity fragment is grasped with an atraumatic specifically designed grasping clamp to allow suture placement (Aequalis. FIGURE 5. Fiberwire (Arthrex. Likewise. Sutures of different colours are helpful to aid in suture management. These four strong nonabsorbable sutures (two green. 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.8). Inc. ..

Using a shuttling suture or a crimping needle.8 Four horizontal cerclages. One green and one blue through the infraspinatus tendon and one green and one blue through the teres minor tendon. our attention is turned to the glenoid (Fig.9).FIGURE 5. Sutures should not be passed through the bone itself to avoid causing comminution of the tuberosity fragment. 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. Once this step is completed. . 5.

The anterior and inferior labrum is excised and an anterior juxtaglenoid capsulotomy performed. a flat lever forked retractor (Kolbel retractor) is placed over the anterior glenoid neck to retract the subscapularis muscle anteriorly. a forked retractor is placed .9 Technique for placement of the sutures. Similarly.FIGURE 5. Glenoid Exposure and Implantation To expose the glenoid.

Gentle reaming of the glenoid surface is performed using the cannulated reamers over the guide wire. In fracture cases without glenoid wear. The centerpoint of the glenoid is identified by the intersection of the superoinferior and mediolateral bisecting lines. The .11). The guide wire can be inserted in a neutral position or with 10 degrees of inferior tilt (Fig. it is not necessary to correct glenoid version.posteriorly and the posterior labrum excised and posterior capsulotomy performed. The glenoid exposure is completed by placing a retractor inferiorly to depress the humeral diaphy sis and expose the inferior rim of the glenoid.10). The reamer should be started before contacting the bone to lessen the risk of fracturing the glenoid (Fig. 5. 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. 5. FIGURE 5.10 Exposure of the glenoid with retractors and glenoid guide with wire inserted with 10 degrees of inferior tilt. Any superior tilt of the glenoid implant should be avoided to prevent instability and inferior scapular notching.

an 8mm hole is drilled over the guide wire to receive the central peg of the glenoid baseplate. Additional reaming with a second reamer is needed to accept the glenoid sphere. The posterior hole is then drilled at a trajectory that is inferior and toward the middle of the baseplate. the baseplate is secured with screws (Fig. 5. Finally. Depending on the size of the glenoid.or 29-mm baseplate will be selected. The anterior and posterior conventional cortical screws are positioned first to optimize compression of the baseplate. exiting through the posterior scapular cortex. and the screw is inserted although not y et tightened fully to avoid rocking the baseplate. which is impacted until fully seated. The hole is measured.12). FIGURE 5. The anterior hole is drilled using a guide at a trajectory that is superior and toward the middle of the baseplate.11 Glenoid reaming. There are two sizes of glenoid sphere: 36 and 42 mm. smooth surface. but it is important to preserve most of the strong subchondral bone to provide support for the glenoid implant. We tend to ream to accept the 42-mm implant in all but the smallest patients as this improves stability of the prosthesis. exiting through the anterior scapular cortex. Next. The . a 25.aim of reaming is to provide a flat.

The drill guide is positioned into the threaded holes of the baseplate and orientated to achieve the desired trajectory. and with a neutral or slightly inferior tilt and correct version.13). The superior and inferior locking screws are inserted next. . 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. and the screw is inserted. 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. this is approximately 20 degrees inferior in the axis of the glenoid so that the screw engages the cortical bone of the scapular pillar.12 Baseplate secured with two standard-headed screws and two locking screws. For the superior screw. which should be fully seated onto bone in a slightly inferior position.hole is measured. The inferior screw is inserted and tightened first. Although we tend to impact and screw the definitive glenoid sphere implant onto the baseplate at this stage. 5. For the inferior screw. after which the anterior screw is tightened. and tightened fully. up to but not overhanging the inferior edge of the glenoid. a trial implant can be screwed onto the baseplate instead if desired (Fig. FIGURE 5. The final position of the baseplate is verified.

The medullary canal is progressively reamed until the last reamer used contacts cortical bone. which determines the size of the humeral stem. and access to the medullary canal of the humeral shaft can be improved by pushing up on the elbow. one hand should be positioned under the elbow during reaming to guide the direction of the reamers. control rotation.13 Implantation of the definitive glenoid sphere. and prevent excess traction on the tissues that could result in a neuropraxia (Fig. During reaming. .14). 5. Preparation of the Humerus The glenoid retractors are removed.FIGURE 5. delivering it into the wound.

. 5.14 Reaming of the humeral shaft. Two doubled-over strands of nonabsorbable suture of different colors are passed through the holes for use as vertical cerclage in the tuberosity repair (Fig.15).FIGURE 5. Two holes are drilled lateral and posterior to the bicipital groove 1 cm below the fracture site.

.e. 5.16). 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. 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.15 Two sutures are passed through the humeral shaft under the fracture site. . ~10 degrees with respect to the epicondy lar axis). This will position the humeral implant at the desired 20 degrees of retroversion with respect to the forearm (i. 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.FIGURE 5. A trial stem is mounted on the holder and introduced into the medullary canal. Using electrocautery or sterile marker.

The distance is set on the height gauge on the implant holder (Fig. 5. The height of the prosthesis can also be determined or confirmed from the preoperative planning stage. The foot of the height gauge rests on the cortical rim on the lateral side of the humeral diaphy sis. The height of the prosthesis is determined by reducing the greater tuberosity around the humeral component and onto the shaft. the most superior part of the trial implant will be at or just above the top of the tuberosity. then a larger-size trial stem should be used. If the greater tuberosity fragment is relatively intact and the reduction verified to be anatomical with . If the trial stem is too loose in the medullary canal to allow sufficient stability for the tuberosity reduction.17). With proper reduction of the greater tuberosity.16 Retroversion control with the trial stem. then the situation should be reassessed. If there is a disparity between the preoperatively determined height and that required to achieve correct positioning of the implant relative to the tuberosity.FIGURE 5. thus positioning the implant at the correct height.

FIGURE 5. 5. If the trial stem is stable. then the preoperatively templated height should be respected. 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. or anatomical reduction cannot be verified. a trial reduction can be performed with a spacer. however. The low-profile fracture stem combined with the bone graft increases the chance for successful tuberosity healing.respect to the diaphy sis.18). Conversely. if the greater tuberosity is comminuted with some degree of bone loss. then the tuberosity should be used as the guide for prosthesis height and a new measurement determined from the calibrated height gauge. Humeral Stem Implantation The definitive humeral implant is mounted on the holder.17 Height control with the trial stem. we do not routinely perform this step to avoid iatrogenic fracture. .

Cement is injected using a large sy ringe.19). 5. using the mark previously made on the bone to guide retroversion and height (Fig. Excess cement is removed with a curette. and a small bore surgical drain is placed into the humeral canal and attached to suction. The proximal canal and prosthesis must be free of cement to allow for bony ingrowth. Very little cement is necessary as it is only needed for fixation of the distal prosthetic stem.FIGURE 5. There should be no cement within 5 mm of the fracture. The definitive implant is inserted. 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 medullary canal is irrigated and dried. A cement restrictor is placed in the humeral shaft 2 cm below the tip of the trial stem.18 Definitive humeral stem with the harvest cancellous autograft. and the small drain is gradually withdrawn as the cement advances. .

. a 6-mm humeral insert is usually appropriate. If pistoning of the humerus is present on reduction. Tuberosity Reduction and Fixation Four doubled-over strands of suture previously passed through the bonetendon junction of the infraspinatus and teres minor are used for horizontal cerclage for the tuberosity repair. and the definitive insert is impacted into the humeral component.19 Implantation of the definitive humeral stem with height and retroversion control. If the glenoid and humeral components have been implanted properly. which is polished to prevent abrasion. The diameter of the poly ethy elene humeral insert is determined by the size of the glenoid sphere. The prosthesis is then reduced into the joint (Fig.FIGURE 5. The thickness of the humeral insert is determined by performing a trial reduction to ensure stability.20). The ends emerging from the deep surface of the tendon are passed around the neck of humeral implant (so-called lasso manoeuvre). then a thicker insert (9 or 12 mm) may necessary. or deltoid tension is insufficient. 5. The prosthesis is dislocated.

A common mistake is to try and reduce the tuberosity with the arm internally rotated. 5. are then tightened and tied to fix the greater tuberosity in position (Fig. Two cerclages.21). Gentle range of motion of the shoulder will verify that the greater tuberosity has been fixed securely .FIGURE 5. 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. At this point. . thereby optimizing tuberosity fixation (see Appendix). leading to loss of external rotation and posterior impingement.20 Passage of the four horizontal cerclages around the neck of the prosthese: the “lasso” maneuver. which will lead to the tuberosity being fixed too far posteriorly. one superior (green) and one inferior (blue). 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.

The lesser tuberosity is now reduced into position.23 and 5. and the cerclage sutures are again tied using the sliding Nice knot. 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.FIGURE 5. both tuberosities are reduced and securely fixed to the prosthetic neck (Fig. Arm in external rotation. 5. The reduction is maintained with a clamp. at the end of this step. Thus. using a crimping needle or suture shuttle.24).22).21 Reduction and fixation with two sutures of the greater tuberosity . one superiorly (blue) and one inferiorly (green). with the arm in internal rotation. 5. 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 diaphy sis (Figs. .

.23 Fixation of the tuberosities on the humeral shaft with two vertical tensionband (anterosuperior and posterosuperior). FIGURE 5.FIGURE 5. Both tuberosities are perfectly reduced and stabilized.22 Reduction of the lesser tuberosity .

25). and adduction is performed to check that there is no impingement against the scapular pillar. The arm is abducted and forward elevated to check range of movement and verify that there is no impingement against the acromion. prosthetic stability. which is common in fracture cases. and range of movement. 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. The anterior deltoid is reattached securely using interrupted nonabsorbable transosseous sutures. and the skin is closed in a standard manner (Fig. Closure A surgical drain is placed in the subacromial space to prevent hematoma formation. .24 Final aspect of the tuberosities reconstruction around the stem.FIGURE 5. 5.

During this period. Bufquin et al. POSTOPERATIVE REHABILITATION If the soft tissues are of poor quality or there is any doubt about the security of the anterior deltoid repair. (11) and Klein et al.FIGURE 5. and 10 degrees of external rotation with the arm at the side. RESULTS To date. . Full active and isometric strengthening exercises can be initiated after 6 to 8 weeks once a good passive range of motion has been obtained. few studies have been published of the results of RSA for fracture. 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.(12) reported good pain relief and range of motion of approximately 110 degrees of abduction.and active-assisted exercises for 4 weeks. which compares favorably with the results of hemiarthroplasty in similar patients. 120 degrees of forward elevation. as a rule). Otherwise. a standard broad arm sling in neutral rotation is used with passive. we place the patient into an abduction splint for 4 weeks. five times a day .25 Transosseous repair of the anterior deltoid.

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). which impedes anatomic reduction of the tuberosities. especially not adequately restoring the humeral length or implanting the glenoid too high. 78 y ears) operated (Fig. fixation. Based on the good results observed with the Aequalis Hemi-Arthroplasty Fracture prosthesis. although frank loosening is uncommon. This is thought to be related to severe osteopenia/osteoporosis as well as the bulky prosthesis. Patients should be counselled that improvement continues for up to a y ear postoperatively and that some limitation in internal and external rotation is to be expected. and bone grafting of the proximal humerus: the Aequalis RSAFx.Restoration of internal rotation is more variable. We have evaluated the radiological and early to mid-term functional results of this prosthesis in a prospective cohort study of 38 patients (average age.26). Instability of the prosthesis is often related to technical errors of implantation. reinforcing again that use of RSA should be reserved for the elderly (13). 5. Radiological follow-up has shown a high incidence of progressive radiolucent lines and notching especially around the glenoid component. Nonunion or fixation failure of the tuberosities after a Reversed Shoulder Arthroplasty for acute proximal humerus fractures in elderly patients (>70 y ears) has been reported to occur in up to 50%. we have designed a novel RSA specifically designed for anatomic tuberosity positioning. The most common complications are infection and instability (14).

27): three patients had partial ly sis of the greater tuberosity and two had migration with final malposition and a hornblower sign. Case of a 72-y ear-old woman. The tuberosities healed in anatomic position in 87% (33/38) of the cases (Fig. Four-parts fracture of the right humeral head.FIGURE 5. 5. No implant .26 A–C.

the average forward elevation was 116 degrees (80 to 150 degrees). and average internal rotation was L5 (buttock-D10. and no patient required reoperation. At the last follow-up. The mean Constant score was 58 points (23 to 79 points). and the adjusted Constant score was 88% (33% to 118%). external rotation 26 degrees (0 to 50 degrees).28). became infected. 5.loosened. . The subjective shoulder value was 70%. Fig. or dislocated.

FIGURE 5.27 .

CT scan at 3 months shows union of the greater tuberosity and integration of the allograft through the window of the stem. and she can reach the 12th dorsal vertebrae in internal rotation. CONCLUSION In conclusion. Radiographic control at 9 months shows correct position of the greater tuberosity and good union. 140 degrees of forward elevation. The same case than Figure 5. (b) active external . a specifically designed reverse shoulder prosthesis is an attractive option for treating complex proximal humerus fractures in the elderly. FIGURE 5.28 A–C. because it allows (a) better tuberosity healing.26. 50 degrees of external rotation. The same woman at 1 y ear.A–C. No pain.

52(6):1077–1089. Ladermann A. 10. Bernageau J. 2.(304):78–83. Postel JM. Shoulder arthroplasty for acute proximal humerus fracture. 9.52(6)1090–1103.and postoperative evaluation by CT scan. Four-segment classification of proximal humeral fractures: purpose and reliable use. II. Classification and evaluation. 7. Boileau P. Sirveaux F. Tinsi L. Survivorship analy sis of eighty replacements followed for five to ten y ears. Strict attention needs to be paid to the technical aspects of the surgery to optimize the outcome and prevent complications. Pre. 8. Melis B. Displaced proximal humeral fractures. Orthop Traumatol Surg Res 2010. Neer CS II. 6. Krishnan SG. 4. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 2006. REFERENCES 1. et al. 3. 5. and (c) reduces the risk of complications. Favard L. Watkinson DJ. et al.11(4):389–400. J Bone Joint Surg Am 1970. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. Displaced proximal humeral fractures. Sirveaux F. Guery J.14(1 Suppl S):147S–161S. 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. rationale. Neer CS II. et al. et al.rotation (useful for ADLs). Fatty muscle degeneration in cuff ruptures. Hatzidakis AM. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Boileau P. Grammont reverse prosthesis: design. Roche O. J Bone Joint Surg Br 2004. Clin Orthop Relat Res 1994. Results of a multicentre study of 80 shoulders. Favard L.86(3):388–395. I. et al. Sirveaux F. Mole D.11(5):401–412. Oudet D.96(6):683–694. Williams MD. J Shoulder Elbow Surg 2005. Reverse total shoulder arthroplasty. Goutallier D. and biomechanics. J Shoulder Elbow Surg 2002. Neer CS II. J Shoulder Elbow Surg 2002. et al. J Bone Joint Surg Am 1970.88(8):1742–1747. Objective evaluation of .

Throw a simple half hitch (Fig. while the development of arthroscopic and endoscopic surgery has resulted in the description of many “new” sliding knots. 11. due to the technical challenges of ty ing intracorporeal flat knots. Reverse shoulder arthroplasty for the treatment of three. Bufquin T. 5. Traditionally.A1). and a loop on the other (Fig. APPENDIX The Nice Knot Introduction Knot ty ing is an essential skill in both open and arthroscopic surgery. Klein M. 5. 12.22(10):698–704.95(5):325– 329. Cazeneuve JF. to tighten the knot. Farshad M. Delta III reverse shoulder arthroplasty : radiological outcome for acute complex fractures of the proximal humerus in elderly patients. 5. Hinkenjann B.A5). 5. J Bone Joint Surg Br 2007. and allow accurate control of the tension applied. the free ends can be pulled alternatively . which results in the knot sliding down (Fig.89(4):516–520.A2) and then pass the two free ends of the suture through the loop (Fig. Hersan A. J Orthop Trauma 2008. This results in a doubled suture running around the tissues. Reverse total shoulder arthroplasty -from the most to the least common complication. have good loop and knot security. with two free ends on one side. Cristofari DJ. 5. Gerber C. such as surgeon’s knots and square knots.34(8):1075–1082. Treatment of comminuted fractures of the proximal humerus in elderly patients with the Delta III reverse shoulder prosthesis. et al. et al. Hubert L. Technique Pass a single doubled-over suture around the tissues to be opposed.A3). J Shoulder Elbow Surg 2009. 13. Int Orthop 2010. A knot should be easy to learn and tie. flat nonsliding knots. Tighten the knot by pulling the two free ends apart from each other.lengthening in reverse shoulder arthroplasty.18(4):588–595. Alternatively. 14.A4). Juschka M.and four-part fractures of the proximal humerus in the elderly : a prospective review of 43 cases with a short-term followup. or the knot can be slid down as . as they have been perceived to be more secure than sliding knots. have been used in open surgery. Dress the knot that is now ready to be tightened (Fig. Orthop Traumatol Surg Res 2009.

5. Finally secure the knot by throwing three alternating half hitches (Fig.A6).A1 . FIGURE 5.with other sliding knots.

A2 .FIGURE 5.

A3 .FIGURE 5.

A4 .FIGURE 5.

FIGURE 5.A5 .

when repairing any tissue under tension. Thus. the tightening process can be stopped and resumed at any stage as the good loop security of the knot prevents it from slipping. allowing accurate tensioning of the suture. so reducing the risk of breakage. Provisional tightening can . Third. two or more sutures can be placed in position and the knots prepared on each suture.FIGURE 5. The doubling of the suture also results in increased internal friction.A6 This knot has several specific characteristics: First. as the tension in each strand is halved. giving excellent loop and knot security . This immediately results in effective doubling of the strength of the suture. it uses a doubled-over strand of suture. Second. tightening the knot by pulling the free ends apart results in a very similar feel to when ty ing a flat surgeon’s or square knot.

. This is in stark contrast to when ty ing a flat knot.then be performed. which either requires constant tension on the post strand or immediate locking of the knot. and the tissue repair can be adjusted as required before final tightening and locking of the Nice knots.

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

or distal zone (.3) based on fracture group. For example. middle.1. or complex) with further numeral classification (1. The letters A..1. oblique midshaft humeral shaft fracture would be 12-A2. The second number refers to the location along the shaft (proximal = 1. The humerus is designated as number 1.2. a simple.FIGURE 6.2. or. distal = 3)—the humeral diaphy sis would be designated as 1 and 2. B. and C refer to the ty pe of the diaphy seal fracture (simple.1 AO/OTA classification of humeral shaft fractures. Lastly . subgroup classification further localizes the fracture to the proximal. respectively ). wedge. middle = 2. INDICATIONS SURGERY AND CONTRAINDICATIONS FOR The majority of isolated lower-energy closed humeral shaft fractures are .3.

15 degrees of malrotation. the large muscle mass of the upper arm conceals moderate degrees of deformity (1). 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. facilitate nursing care. Strong indications for surgical repair of displaced humeral shaft fractures include the following (Table 6. and early or ill-advised surgery may activate the sy stemic inflammatory response sy stem leading to a “second hit” . However. In general. He proposed upper limits of 30 degrees of varus. TABLE 6. the optimal timing for surgical fixation in these patients is unknown since many of these patients have other serious injuries. Additionally. Klenerman first established guidelines for nonsurgical management in 1966.best managed nonoperatively.1). These guidelines were based more on the cosmetic appearance of the limb rather than functional outcomes. and decrease pain (2–4). 20 degrees apex anterior angulation. and 3 cm of shortening as compatible with good function.1 Indications for Surgical fixation of Humeral Shaft Fractures Polytrauma The multiply injured patient with a concomitant humeral shaft fracture may benefit from early surgical stabilization to improve mobilization.

and patients often benefit from internal fixation to relieve pain and improve function. Segmental Fractures Segmental fractures with significant fragment displacement or angulation are difficult to manage nonoperatively. Pathologic Fracture Impending and pathologic fractures of the humerus are usually the result of metastatic cancer. These patients often benefit from fixation of either one or . Nonoperative treatment of the humeral fracture is associated with an increased risk of nonunion in this infrequent injury pattern (6). the pins should be placed away from the fracture zone to decrease the risk of infection.phenomena. Due to compromised bone and the possibility of skip lesions. locked intramedullary nailing is the preferred method of treatment because of less surgical dissection. Bilateral Fractures Simultaneous fracture of both humeri is uncommon and is usually associated with poly trauma. Intramedullary nailing or plate osteosy nthesis may be indicated to prevent malunion or nonunion. Most patients with closed fractures who are unable to undergo early surgery should be placed into a well-padded coaptation splint. Minimally displaced segmental humeral shaft fractures can often be treated nonoperatively if alignment can be maintained. In patients with very proximal and distal pathologic lesions. 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. If external fixation is performed. technical ease. In patients with open fractures. and satisfactory pain relief (7). locked plating with or without cement augmentation may provide better stability . temporary external fixation can be helpful (damage-control orthopaedics) with conversion to internal fixation when the patient’s overall condition permits (5).

and drug allergies. PREOPERATIVE PLANNING History and Physical Exam A careful history and phy sical exam should be performed on all patients with a humerus fracture. irrigation and débridement with temporary external fixation should be strongly considered. The phy sical exam should evaluate and . (8) showed improved union rates following plate fixation of the humerus compared to external fixation or intramedullary nailing. etc. etc. In a smaller number of cases. When vascularization is the priority. hand dominance with any upper-extremity injury should be established.vs. ease nursing care. medications. a simple external fixation device should be employ ed to stabilize the fracture out to length and prevent disruption of the vascular repair when internal fixation is required. The order of treatment is based on the ischemic state of the limb. Open Fractures Open fractures of the humerus usually require prompt stabilization after irrigation and débridement. cardiac problems. Brien et al. ballistic injury. if the wound is contaminated or there is a significant soft-tissue disruption. Vascular Injury Combined vascular injury and humeral shaft fractures can be limbthreatening injuries. The history should identify the mechanism of injury (low. Ipsilateral Brachial Plexus Injury There is very little literature on humeral shaft fractures with ipsilateral brachial plexus injuries. high-energy.). and decrease pain.both fractures to improve rehabilitation. the use of a temporary vascular shunt allows more definitive fracture treatment followed by vascular repair. In lower-grade open fractures. pertinent comorbidities (diabetes mellitus. In high-grade open injuries. pertinent past surgical history. immediate internal fixation is safe and effective if the patient’s overall condition permits.).

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. optimal films cannot be obtained until the patient is under anesthesia in the operating room. antibiotic administration. splinting or external fixation is preferred with delay ed internal fixation.” Frequently. For some patients. With open fractures. internal fixation can be performed electively in the first few day s.document objective findings such as swelling. If there is a vascular injury. high-quality orthogonal radiographs are difficult to obtain in the conscious patient. repair. 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 . In Grade III open fractures or in patients with highly contaminated wounds. 6. Imaging Studies In patients with suspected extremity injuries. For most closed fractures of the humerus. neurologic status. and peripheral pulses.2). and fracture stabilization if indicated. open wounds. Patients with Grade I and II open fractures who are also hemody namically stable may benefit from immediate internal fixation. exploration. ecchy mosis. Timing of Surgery The timing of surgery with humeral shaft fractures depends on whether the fracture is open or closed. due to significant pain. anteroposterior (AP) and lateral radiographs should be obtained that include the “joint above and below. 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. Surgical Tactic Part of the preoperative plan includes choosing an appropriate surgical approach based on the location of the fracture or traumatic wound (Fig. irrigation and débridement should be performed as soon as the patient’s condition and institutional resources permit. Fractures that are located in the proximal and midshaft of the humerus are . Traction films with light sedation can be helpful in a cooperative patient.

The posterior approach is most often used for fractures in the distal one half of the humerus. but extensive mobilization of the radial nerve with this exposure increases the chance of an iatrogenic injury. The straight lateral approach has also been advocated for midshaft fractures. patient positioning makes it more difficult in multiply injured patients. A summary of the approach and plate placement based on fracture location is shown in Table 6. .usually addressed through an anterior or anterolateral approach. However. newer locked plating sy stems provide better fixation in “short” segment situations and now make the anterolateral approach a more attractive option for selected distal fractures. and there was limited opportunity for fixation in the relatively narrow lateral pillar. However.2. The distal anterolateral approach was less useful in the past because contouring a plate to the anterolateral column was difficult.

2 The surgical approach to humeral shaft fractures is frequently dictated by the location of the fracture. medial. Distal third fractures can be . anterolateral. Midshaft fractures can be approached by anterior. and posterior approaches. Proximal fractures are usually approached by the anterior approach.FIGURE 6.

If the soft-tissue lesion is primarily on the medial aspect of the arm. 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. acute repair is indicated. In closed fractures. Numerous studies have shown that treatment is observation since spontaneous recovery occurs in the vast majority of cases (9–11). TABLE 6-2 Surgical Approach and Plate Placement Based on Anatomic Fracture In open fractures.approached by lateral.000 cases of humeral fractures documented an average incidence of radial nerve lesions in 11. On the other hand. Surgical “versatility ” is important to minimize additional soft-tissue injury by performing a separate approach through compromised soft tissues. . In patients with gross contamination or traumatic nerve loss. anterolateral. if the radial nerve palsy occurs in the presence of an open fracture.8% of patients (12). A recent meta-analy sis of more than 1. delay ed reconstruction is preferable. the surgeon should be prepared to utilize a medial approach for fixation. If there is a clean transection of the nerve with minimal soft-tissue contamination. these injuries are usually a neuropraxia and are seen most commonly in fractures in the lower third of the humerus (13). or posterior approaches. most authors favor nerve exploration and fracture stabilization since the nerve is frequently damaged or interposed between fracture fragments (14). and its integrity must be carefully evaluated and documented in patients with humeral shaft fractures. RADIAL NERVE INJURY The function of the radial nerve is critical. A radial nerve palsy that occurs at the time of fracture is seen in 6% to 15% of cases (9–11).

Electromy ography /nerve conduction velocity studies should be performed between 4 and 12 weeks after injury if there are no clinical signs of recovery. the surgeon ty pically sits on the lateral side of the extremity. or other planned procedures. An arterial line should be used in patients with cardiovascular comorbidities or potential hemody namic instability. shortening of the humerus by 2 to 3 cm may facilitate a tension-free nerve repair. For a posterior approach with the patient in either the prone or lateral position. The treatment of a radial nerve palsy includes functional splinting of the wrist and hand as well as range of motion to prevent contractures. careful consideration should be given to patient positioning and the need to obtain high-quality intra-operative fluoroscopic images. The brachioradialis is the first muscle to recover. with a “hand table” is used.3A). In this case. we prefer general anesthesia with a muscleparaly zing agent to facilitate fracture reduction.In nerve lesions that span several centimeters. Regional anesthesia can be used but marked swelling in the upper arm and shoulder often obscures anatomic landmarks making this technique more difficult.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 . (12) demonstrated no significant difference in recovery rate between primary (88. If the patient is positioned supine for an anterior or anterolateral approach. and the C-arm is brought in from the medial (axillary ) side (Fig. SURGERY For the majority of patients. fluoroscopic imaging is more difficult. expected blood loss. Lastly. If a standard OR table. cable grafting with or without tendon transfers may be indicated. Shao et al. We prefer a completely radiolucent table that allows imaging from the elbow to the shoulder. In a meta-analy sis of over 1. A positive prognostic sign of recovery is an advancing Tinel’s sign indicating the nerve regeneration. In irreparable nerve lesions. If the surgery is likely to exceed 2 to 3 hours due to fracture complexity. the surgeon should ensure that full imaging of the entire arm is possible before the prep and drape. but wrist extension is easier to monitor.000 humeral fractures.6%) and secondary (93. a Foley catheter should be inserted. a . 6. The management of a radial nerve palsy after closed reduction (secondary nerve palsy ) is more controversial.

modified arm board or well-padded radiolucent “block” is used to support the arm without interfering with C-arm access (Fig.3 A. The surgeon must rehearse the maneuvers necessary to obtain high-quality images before the patient is prepped and draped. Prone positioning for a posterior approach. horizontal positioning of the arm is necessary to offset gravity and allow unimpeded elbow motion. In all cases.3B). FIGURE 6. B. 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. 6. Patient and C-arm positioning for an anterior or anterolateral approach to 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 .

the radial nerve must be identified in the interval between the brachioradialis and brachialis muscles. A tourniquet is not advised since it interferes with the surgical exposure. and the biceps muscle belly is elevated from the underly ing brachialis muscle and retracted medially . The C-arm must be positioned to obtain unobstructed AP and lateral views of the humerus.a hand table. In the proximal part of the exposure. . The brachialis muscle is divided in its midline to preserve its dual nerve supply (musculocutaneous nerve– medial fibers. and chest wall. Figure 6. and dissection is carried down through the clavipectoral fascia. A portion of the pectoralis insertion can be released if needed. 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. The affected extremity is prepped and draped from the fingertips to include the axilla.4 demonstrates patient positioning. shoulder. The deltoid and pectoralis major insertions as well as the biceps tendon are identified. and plate placement. radial nerve–lateral fibers). In the distal aspect of the incision. superficial and deep dissections of the anterior approach. The internervous plane proximally is between the deltoid (axillary nerve) and the pectoralis major (medial and lateral pectoral nerves). 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 deltopectoral groove and cephalic vein are identified.

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The lateral ligamentous complex should not be detached.5-mm narrow LC-DCP plate is used as a protection plate (J. The anterolateral approach is useful for distal third fractures of the humerus and can be extended proximally and distally.6. The musculocutaneous nerve is found under the brachialis (D). A 4. which can be opened to accurately visualize the distal and lateral aspects of the humerus.5 demonstrates the deep dissection of the anterolateral approach for a distal fracture. Pre. The radial nerve is identified as previously described. The internervous and muscular planes are the same as the anterior approach. The radial nerve is located between the brachialis and brachioradialis (H). Figure 6. The biceps muscle is retracted medially to reveal the underly ing brachialis (C). After the biceps is retracted medially . .FIGURE 6. but in the anterolateral approach. The patient is positioned supine with the arm on a hand table and skin incision. 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. Skin incision is shown in Figure 6. B. The deep interval remains the same in both approaches.and postoperative radiographs. At this point. The skin incision is placed on the lateral edge of the biceps muscle down to the flexion crease.and postoperative radiographs of an anterolaterally placed plate for a distal humerus fracture are shown in Figure 6. The belly of the biceps brachii with a tagged superficial vein. A. The fracture is first repaired with lag screws (I). Note the plate was contoured slightly due to a preexisting deformity . there is preferentially more laterally based dissection of the muscle from bone with less anterior and medial dissection.7. 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.K). L–O. Pre. an extraperiosteal dissection of the brachialis and brachioradialis will expose the lateral column of the humerus to the elbow joint. the brachialis is split in its midline (E–G) to reveal the fracture.4 Anterior approach to the humerus.

The anterolateral exposure after splitting the brachialis. In this case. The radial nerve is identified by the vessel loop (A. and a template was used as shown in (B). and the plate was contoured (C) to rest on the anterolateral aspect of the distal humerus (D). the fracture was distal. .B).FIGURE 6.5 A.

FIGURE 6. Pre.and postoperative x-ray s demonstrating anterolateral plate placement for a distal one-third humerus fracture. .6 A–D.

The prone position facilitates the use of fluoroscopy for these fractures. the arm can hang over either a radiolucent arm holder or a roll of blankets on a radiolucent arm board. The muscle is innervated proximally near its origins. The landmarks are posterior acromion and olecranon. and a longitudinal dissection will not denervate the muscle. In this approach.7 A. A sterile tourniquet can be used if it does not impede the surgical approach. (b) the long head arising from the infraglenoid tubercle. As mentioned earlier. 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. and (c) the medial (deep) head. Post-op clinical result and skin incision crossing the elbow flexion crease following anterolateral plate placement for a distal one-third humerus fracture.B. The radial nerve lies in the plane between the lateral and long . 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. which rests along the posterior aspect of the humerus from below the spiral groove to the distal one-quarter of the humerus. There is no internervous plane as dissection entails splitting the lateral and long heads of the triceps (radial nerve).FIGURE 6. the patient is positioned in either the lateral decubitus or prone position.

piercing the medial intermuscular septum and emerging distally from the triceps. extending down to the triceps tendon. excessive dissection around the nerve may result in injury to these delicate vessels. if needed.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. Because a vascular leash accompanies the radial nerve.8 demonstrates the superficial and deep dissections of the posterior approach. Figure 6. . the fascia over the lateral and long head of the triceps should be split longitudinally in the midline. 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 medial head of the triceps is then gently dissected off the humeral shaft to allow for bony exposure and plate placement. The radial nerve and profunda brachii artery should be identified superficial and proximal to the medial head of the triceps. The junction where the surgeon’s thumbs meet in the mid-portion of the arm is ty pically where the radial nerve is found on deep dissection. After the skin incision. Care should also be taken to avoid injury to the ulnar nerve in the distal humerus as it passes from anterior to posterior.

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The fracture is then repaired with lag screws and.E). the radial or ulnar nerves must be safely identified and protected. The approximate location of the radial nerve can be estimated as shown in (C). there is less trauma to the triceps muscle and less bleeding since the muscle is elevated rather than split. the triceps fascia is identified as shown in (B). With either approach. In some cases.FIGURE 6.and postoperative radiograph after posterior humeral plate fixation. In one method. In fractures with a more distal component.J. With the para-tricipital approach. Pre. and most of the accompany ing vessels have already arborized into the muscle. The positioning and skin incision (landmarks are the posterior acromion and the olecranon process). . the radial nerve is easier to identify in the lateral aspect of the posterior compartment. a second method mobilizes the triceps both medially and laterally from their septum to provide access to the epimetaphy seal region.8 The posterior approach to the humeral shaft. The neurovascular bundle can be seen in (G) coursing around the lateral aspect of the plate. a triceps-reflecting approach has recently been advocated as a safer but equally effective means of accessing the posterior humeral shaft (15). A. The authors have now adopted this approach as their preferred method when a posterior approach is indicated. After blunt dissection of the lateral and long triceps heads. 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.9. I. the skin incision remains posterior.5-mm narrow plate (F. After skin incision. in this case. a 4. As an alternative to a triceps-splitting approach. Another case is shown in (H) with the bundle coursing medial to lateral around the posterior aspect of the humerus.G). In this approach shown in Figure 6. the medial head should be gently subperiosteally dissected to expose the fracture (D. the medial head may be disrupted from the initial trauma. but the deep exposure can be performed by one of two methods.

Care is taken to avoid injury to the ulnar nerve medially (green arrow) and the radial nerve laterally (yellow arrow). The distal landmark is the lateral epicondy le with proximal extension up the humeral shaft. This approach is based on the description by Mills et al. There is no true internervous plane for this approach because the radial nerve innervates the brachioradialis. the medial and lateral aspects of the triceps are released from the posterior humerus. Sharp dissection is carried down to the investing fascia of the posterior compartment. The lateral intermuscular .FIGURE 6. and the lateral plate was placed under the radial nerve. Lateral The patient is positioned supine with the arm ly ing over the chest or on a hand table. 3.10. Instead of splitting the triceps. (16) and shown in Figure 6. The patient is positioned prone with the skin incision similar to the posterior approach. triceps as well as the lateral half of the brachialis. the surgeon gains access to the posterior compartment. The triceps muscle is gently dissected off the overly ing fascia until the lateral inter-muscular septum is identified. After triceps fascial incision. The posterior skin and subcutaneous tissue over the fascia is developed.5mm reconstruction plates were used. In this case.9 Paratricipital approach to humeral shaft.

the radial nerve is at less risk because it is transposed away from the surgical exposure. the nerve courses posteriorly toward the axilla with tight fascial bands of the lateral head of the triceps impeding proximal dissection. If the plate is placed laterally. 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. If a future surgery is necessary. After identification of the nerve. In some cases. these fascial bands can be released if necessary for proximal exposure. To summarize. Figure 6. The interval between the triceps and the lateral intermuscular septum is developed from distal to proximal. Radial nerve transposition through the fracture site is shown in Figure 6. it usually needs to be contoured due to the varied anatomy of the bone. the lateral intermuscular septum can be divided. (c) the biceps brachii (anteriorly ). the main anatomic structures of the lateral approach are (a) the lateral head of the triceps posteriorly. there is significant tension on the nerve. While the softtissue dissection to perform this technique may be considerable. During plate placement. in such a case. and (e) the lateral intermuscular septum. The radial nerve pierces the lateral intermuscular septum approximately 15 cm above the lateral humeral epicondy le.septum separates the medial head of the triceps and brachioradialis (distally ) and the lateral head of the triceps and brachialis (proximally ). it may be preferable to a tented or injured radial nerve. (d) the radial nerve as it courses from posterior to anterior. . there is little morbidity to a limited release.11. (b) the brachialis (inferior to the deltoid insertion and ly ing along the bone). the nerve has to be inspected to ensure that it does not become entrapped beneath the plate. 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.10 demonstrates the lateral approach in a cadaver. Proximally. which essentially separates the triceps from the more lateral/anterior anatomic structures (brachioradialis and brachialis). the radial nerve can be transposed through the fracture site so that it is away from the plate (17).

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Note that the anterior aspect of the deltoid was taken down to allow for plate placement (yellow arrow). The radial nerve (blue arrow) is gently freed up by blunt proximal dissection (D). The radial nerve coursing around the fracture.FIGURE 6. The lateral head of the triceps is shown posterior to the radial nerve (red arrow). Lateral humeral plate placement with accompany ing radiographs. .10 Lateral approach to the humerus. The plate is placed under the nerve (E). F–I. C. The radial nerve (blue arrow) is visualized distally between the brachioradialis and brachialis (green arrow). 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 fracture with lateral plate placement (D.E) and the radial nerve transposed. . A more posterior-oriented view of the radial nerve as it is transposed through the fracture site. A–C.11 Radial nerve transposition during the lateral approach.FIGURE 6.

a laterally based external fixator (damage control) that maintains length and alignment. The patient is positioned supine with the arm extended on a hand table. as the patient’s condition and soft tissue permit. The medial aspect of the humerus should now be exposed. it can be accessed through an anterolateral approach as opposed to a difficult revision through the scarred medial approach. followed by delay ed internal fixation.12 demonstrates an example of a humeral shaft fracture with a medial open wound managed with ORIF. The landmarks are the medial epicondy le distally and the posterior edge of the biceps brachii proximally. basilic vein. The investing fascia is incised. . if needed. Hemostasis should be meticulous due to many arterial and/or venous branches.Medial This approach is used most often when there is a vascular injury or a large medial wound associated with an open fracture. There are numerous structures at risk but. with careful dissection. and antebrachial cutaneous nerve are retracted antero-laterally. A tourniquet is not commonly used because it interferes with the exposure. Once the neurovascular bundle is exposed and protected. In cases of vascular injury. When using a medial plate. reperfusion is the priority . can be dissected from the bone to improve exposure. median nerve. mobilization of the brachial artery and ulnar nerve can be accomplished. and the neurovascular bundle is identified posterior to the biceps brachii. however. The triceps can be elevated off bone posteriorly and the coracobrachialis muscle anteriorly if needed. we recommend placing it in a more anterior position so if revision surgery becomes necessary. Figure 6. the medial intermuscular septum is identified and. The skin incision is made along the posterior edge of the biceps. The medial approach is uncommon and based on the need to access the brachial vessels. The ulnar nerve is retracted posteromedially. The brachial artery.

Left humeral shaft fracture with open medial wound.FIGURE 6. and ulnar nerve (green arrow).C. C. Biceps retracted laterally with the median nerve (anterior).12 A–E. B. External fixation was performed followed by definitive fixation. brachial artery (blue arrow). Plate placement medially under the .

the fracture hematoma is rich in proteins and cy tokines and play s an important role in fracture healing (19. where interfragmentary fixation or anatomic reduction and absolute stability are desired. The fracture before and after medial plate placement. and only the necessary amount of muscle should be stripped for fracture visualization and/or implant placement.18).5-mm plates for small-stature patients or fractures with epimetaphy seal extension. The surgeon should alway s strive to respect both the fracture and the surrounding soft tissues. we believe that the hematoma should not be disturbed. Due to lack of supporting studies. IMPLANT SELECTION Historically.5 mm) have been advocated for internal fixation of humeral shaft fractures. Absolute stability generally produces a “stiff” plate construct. More recently. In comminuted fractures. However. Muscle attachments should be maintained whenever possible. D.5-mm plates for most diaphy seal fractures and reserve 3. 3. 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. Traditional teaching has emphasized the need to evacuate the fracture hematoma to allow better visualization for fracture interdigitation and reduction. The periosteum should be maintained whenever possible. A better understanding of the biomechanics of fracture fixation has improved our knowledge of construct stability and stiffness.20).neurovascular bundle. where only alignment and relative stability are necessary. which is best achieved with lag screws and .and three-part “simple” fractures. respectively . large fragment plates (broad and narrow 4. In general.5-mm locking compression plates have been presented as a potential option for fixation of humeral shaft fractures (4.E. absolute stability is best utilized when anatomic reductions can be achieved in two. the authors recommend the use of 4. The hematoma should only be evacuated in simple fracture patterns.

and alignment as best as possible. these parameters can be difficult to determine intraoperatively. an intramedullary nailing may be another good treatment option. length. the plate is then fixed proximally and distally. If the zone of comminution is particularly long. placement of autogenous bone graft should be considered. Despite the improved stability that is obtained with locking plates and screws. Bone contour can aid in establishing rotation. the surgeon may decide to shorten the humerus a few centimeters. and this portion of the procedure can be very challenging. the surgeon can either perform a full exposure with bridge plating or consider minimally invasive plating osteosy nthesis (MIPO) to establish alignment. but length may need to be determined by comparison to the contralateral side. in fractures with short working lengths. Once these parameters are established. MIPO may be preferred because of the extensive soft-tissue dissection and . rotation.compression plating. If the comminution is significant. Bridge Plating In comminuted fractures. Comminuted fractures that are treated with spanning plates produce relative stability. For example. We frequently use radiographs of the contralateral side as a template. The goal in plating of these fractures is restoration of length. care should be taken to minimize soft-tissue and periosteal stripping of the bone. 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 bridge plate allows for motion around the fracture zone and may stimulate osteogenesis. the plate can establish alignment. With bridge-plating techniques. we strongly recommend engaging at least seven to eight cortices above and below the fracture for nearly all patients. With either approach. Alternatively. and rotation. In some cases. The surgeon can partially modulate the construct stiffness by altering the number and ty pe of screws as well as their position in the plate relative to the fracture site. with screws outside the fracture zone. The plate is then secured to either the proximal or distal fragment with cortical screws away from the fracture zone. Future Directions MIPO of the humeral shaft has recently been proposed to be an alternative to standard open plating.

FIGURE 6. and plate size is estimated using fluoroscopy . Figures 6. The plate is placed anteriorly because it avoids the neurovascular structures.13 through 6. We often use a temporary external fixator as a “mini-distractor” to hold gross alignment and length. Fracture length is maintained by an external fixator.possible stripping required for exposure and plate application.13 Minimally invasive percutaneous osteosy nthesis of the humerus.15 demonstrate MIPO plating of the humerus. The technique takes advantage of locked screws and long plate spans to create a “flexible but stable” construct. .

14 MIPO of the humerus cont. . Final photo showing closure of the incisions (C).FIGURE 6. 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. and the surgeon’s finger “catches” the plate through the distal exposure (A). The plate is passed from proximal to distal. The anterior aspect of the distal humerus is exposed after retraction of both the radial and musculocutaneous nerves and splitting of the brachialis muscle.or bicortical locking screws.

Notice the unicortical screw to pull the plate to the bone.(A) and postoperative radiographs (B.15 Pre. .C) after MIPO plating of the humerus.FIGURE 6.

the incision is based on the anterolateral exposure. The pectoralis insertion is released as needed. Proximally. and 48 weeks postoperatively with radiographs. POSTOPERATIVE CARE Postoperatively patients are allowed to use their arm for activities of daily living if stable fixation has been achieved.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. a 9 to 12-hole narrow 4. 8. 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.15 demonstrates pre.” which is important for locked screw fixation. Patients are not allowed to lift weight through the affected extremity until there is . Distally. Figure 6. the brachialis muscle is split. the biceps tendon serves as an anterior landmark. This technique invokes the principle of relative stability and is most useful in comminuted fractures but has successfully been used in all fracture patterns. and two small Hohmann retractors are used to guide the plate over the distal humerus. The exposure first finds the musculocutaneous cutaneous nerve along the biceps muscle. Bicortical locking screws are placed above and below the fracture. Two small Hohmann retractors are used to center the plate on the humerus. Using a unicortical screw spares the “far cortex. 12. 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. and small incisions are placed just proximal and distal to the ends of the plate. 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.and postoperative x-ray s after MIPO plating. 24. a unicortical nonlocking screw is placed into the second hole from the end to “pull” the plate to bone. Unicortical screws are used in case adjustments to the plate require a new screw hole to be made. alignment is verified and the screws are tightened. and the radial nerve is identified. The biceps muscle and musculocutaneous nerve are retracted medially. With knowledge of the nerve locations. The initial unicortical screw can be changed for a bicortical locking screw depending on the bone quality. Generally. Once the plate is centered over the fracture site and bone.5-mm plate is centered over the fracture zone.

radiographic evidence of bridging callus (three of four cortices). A recent study of 121 patients who developed deep infection after internal long bone fracture fixation demonstrated that 71% went on to fracture union with operative débridement. (b) vascular injury. If the nonunion is hy pertrophic. If the fracture fixation is loose or unstable. There is a significant risk to the radial nerve during revision or nonunion surgery – thus. Infections are more common after open fractures. we advocate aggressive débridement. A patient with a postoperative infection should undergo irrigation and débridement with culture-specific intravenous antibiotic therapy. COMPLICATIONS The most common complications following internal fixation of the humerus are infection. and external fixator or a brace followed by delay ed reconstruction. If the fracture fixation is stable. use of antibiotic delivery depots (bone cement or calcium sulfate). (c) fracture instability. 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. revision plating with bone grafting remains the treatment of choice. early hardware removal and external bracing are utilized until the fracture strengthens enough to withstand phy siologic loads. and antibiotic therapy (21). débridement. nonunion. Once the fracture has healed. (e) infection. then treatment consists of hardware removal. 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. and iatrogenic radial nerve palsy. (d) significant fracture displacement with interposed soft tissue. and (f) pathologic fracture. These palsies are best treated with observation for 4 months—since most recover in 3 to 6 months (23). and sy stemic antibiotic suppression. For atrophic nonunions. SUMMARY . then improving stability is usually successful. The etiology of the nonunions may be related to (a) comminution with extensive soft-tissue damage. Nonunion rates following internal fixation of the humerus are reported to be 6% (22). adding increased importance to the initial surgery (17). retention of implants.

French BG. Bell MJ. Beauchamp CG. Internal fixation of humeral shaft fractures has a high union rate and relatively few complications with careful. et al. The results of plating humeral shaft fractures in patients with multiple injuries. radial nerve palsy after closed reduction. well-planned surgery . Four point five (4. Sarmiento A. Zagorski JB. et al. Functional bracing for the treatment of fractures of the humeral diaphy sis. J Trauma 2000. Kellam JK.67(2):293–296. 5. Effect of immediate weightbearing on plated fractures of the humeral shaft. Wolinsky PR. 4. although 3. and unacceptable alignment. The Sunny brook experience.49:278–280. Common indications to perform internal fixation include poly trauma. Shy r Y.5-mm plates can be used in simple fractures and those with epimetaphy seal extensions. et al. J Orthop Trauma 2012. et al. et al. Hak DJ. Highly comminuted fractures are amenable to bridge plating or anterior submuscular MIPO plating. 2. Idoine JD. REFERENCES 1. Fracture location frequently dictates surgical approach.5) mm narrow plates are recommended for most fractures. “floating” elbow injuries. open fractures. Plating of acute humeral diaphy seal fractures through an anterior approach in multiple trauma patients. J Bone Joint Surg Br 1985. J Bone Joint Surg Am 2000. The majority of midshaft fractures can be addressed through the anterior or anterolateral approach. Opalek JM. 3. Safety and efficacy of conversion . Stahel PF. ACKNOWLEDGMENTS The authors would like to acknowledge Maria Christina Bouchard for providing assistance in obtaining the references for this chapter. Suzuki T. Zy ch GA.82:478–486. concomitant vascular injury.The majority of humeral shaft fractures can be treated nonoperatively. Distal fractures can be repaired via the posterior approach. Tingstad EM.26(1):9–18. Primary nerve palsies are ty pically observed for 4 to 6 months while the treatment of secondary radial nerve palsies following closed reduction remains controversial.

Fractures of the humerus with radial nerve paraly sis. Boxma H. J Surg Orthop Adv 2009. 16. Tullos HS. 12. Dijkstra S. Management of fractures of the humerus in patients who have an injury of the ipsilateral brachial plexus. J Ortho Trauma 1996. J Hand Surg Am 1993.72(8):1208–1210. 13. Swiontkowski MF. J Orthop Trauma 2010. Weiland AJ.22(6):621–626. Bach AW. Bovill EG. Drake D.7:424–432. Hotchkiss RN. Radial nerve palsy caused by open humeral shaft fractures. et al. et al. J Bone Joint Surg Am 1984.from external fixation to plate fixation in humeral shaft fractures. Alan R. 8. et al. Stapert J. Management of concomitant ipsilateral fractures of the humerus and forearm. Grotz MR. Pollock FH.24(7):414–419. Radial nerve transposition during humeral fracture fixation: preliminary results. Eur J Surg Oncol 1996. 9. Catanzarite J. Lewis GB. 10. Foster RJ. Ziran BH. 17. 15. 18. Harwood P.99:625–627. Rogers JF. 14. Becker V. et al. Garcia A Jr. J Bone Joint Surg Br 2005. Clin Orthop Relat Res 2003.78(11):1690–1695.18(4):175–181. J Trauma 1967.413:170–174. Gerwin N. Radial nerve injuries in fractures of the shaft of the humerus. et al. J Bone Joint Surg Am 1981. 7. Baig R. Holstein A. Maeck BH.63:239–243.10:81– 86. Shao YC.18:121–124. Bennett JB. Mills WJ. Alexander H. Clinical review of radial nerve injury. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. Am J Surg 1960. J Bone Joint Surg Am 1990. Biomechanical testing of unstable humeral shaft plating. Brien WW. Radial nerve palsy associated with fractures of the shaft of the humerus: a sy stematic review.66(4):552–556. Treatment of pathologic fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosy nthesis with adjunctive bone cement. Olarte CM.45:1382–1388. Gellman H. Hanel DP. J Bone Joint Surg Am 1996. . Kettelkamp DB. et al. 6. Alternative exposures of the posterior aspect of the humeral diaphy sis with reference to the radial nerve. 11.87(12):1647–1652. J Bone Joint Surg Am 1963. Smith DG. Treatment of radial neuropathy associated with fractures of the humerus. Darowish M.

19. et al. BMP signaling components are expressed in human fracture callus. Scannell B. Obremskey WT. 2002:973–996. et al. Borens O. Street J. 22. et al. 23. J Bone Joint Surg Am 2010. 5th ed. Wang JP. Fractures of the shaft of the humerus. In: Bucholz R. Iatrogenic radial nerve palsy after operative management of humeral shaft fractures.92(4):823–828. Shen WJ. 21. Gregory Jr RG. Heckman J. Rockwood and Green’s fractures in adults .33(3):362–371. Bone 2003. et al. 20. J Trauma 2009. Di Paola M. Winter D. Kloen P. Maintenance of hardware after early postoperative infection following fracture internal fixation. Is human fracture hematoma inherently angiogenic? Clin Orthop Relat Res 2000. Wang JH.378:224–237. PA: Lippincott Williams&Wilkins. eds. Philadelphia.66(3):800–803. Chen WM. Berkes M. .

which can be segmental or comminuted. On the other hand. There is a classic bimodal pattern of injury. fractures range from fairly simple patterns. . falls from heights. however. Fracture patterns commonly seen in the humeral shaft are illustrated in the OTA/AO classification (Fig. Krieg INTRODUCTION Humeral shaft fractures are relatively common injuries and are estimated to account for up to 3% of fractures seen in clinical practice. in y ounger patients. The majority of fractures occur as isolated injuries.7 Humeral Shaft Fractures: Intramedullary Nailing James C. industrial injuries. injuries may be due to high-energy mechanisms. 7. etc. gunshot wounds. a small but significant number occur as part of a more complex constellation of upper extremity trauma or occur in a multiply injured patient. such as motor vehicle or motorcy cle accidents. with older patients sustaining fractures following low-and intermediate-energy falls. Depending on the mechanism of injury. to complex ones.1). such as spiral or transverse.

nonoperative treatment is less successful. isolated lower-energy humeral shaft fractures have been treated nonoperatively .1 AO/OTA classification of humeral shaft fractures. . and most of these patients benefit from internal fixation. with excellent results.FIGURE 7. Historically. 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.

. The functional fracture brace method of Sarmiento remains the treatment method of choice for closed management. Patients are encouraged to wear it snugly . There are several consistent indications for internal fixation of humeral shaft fractures using either plate osteosy nthesis or intramedullary nailing. provide access to the soft tissues. adjusting daily (1). The patient is initially placed in a plaster coaptation splint until the acute swelling and pain have diminished. lowerenergy humeral shaft fractures. with union rates >95% reported (1). The brace is worn for 8 to12 weeks. Treatment must allow early functional restoration of shoulder and elbow motion and recovery of muscle strength. until healing is seen radiographically and arm motion is pain free. with minimal deformity that does not impair function or become a cosmetic issue. The halves are secured with velcro straps. and are easily adaptable to individual patients. mobilize the extremity.INDICATIONS SURGERY AND CONTRAINDICATIONS FOR The goals of treatment following a humeral shaft fracture are union of the fracture. The brace consists of poly ethy lene anterior and posterior shells. come in numerous sizes. nonoperative functional humeral bracing is not indicated. allowing for continuous adjustment. or permit weight bearing through the extremity when lower extremity function is impaired. In these patients. isolated. SURGICAL TREATMENT There is a large group of patients in whom closed. Most patients can be safely placed into a Sarmiento functional fracture brace a week following injury. NONOPERATIVE TREATMENT Nonoperative management is indicated for most closed. these braces are prefabricated. Slings are discontinued after a few weeks to minimize shoulder or elbow stiffness. surgery is required to restore limb alignment. Patients are instructed in shoulder pendulum exercises and active and passive range of elbow motion. Today. The margin of one shell fits inside the other. Success rates with this method of treatment are very high.

surgery is ty pically indicated to reduce the risk of nonunion and facilitate early therapy . Lastly. Once the patient’s overall condition has improved. Social considerations. internal fixation of a humeral shaft fracture may improve pain control. humeral fractures associated with arterial injuries are best treated with early fixation to protect the brachial vessel repair. family needs. In patients with bilateral humerus fractures. at least one. Another strong indication for surgery is the patient with ipsilateral fractures of the humerus and forearm. These fractures are difficult to control in a fracture brace. and facilitate cancer chemotherapy or radiation. Implants: Plate Versus Nail Several prospective randomized trials have shown comparable outcomes in patients with humeral shaft fractures treated with a plate or nail. Operative treatment is also indicated in patients in whom an acceptable reduction cannot be obtained or maintained in a fracture brace. etc. such as job impairment. Similarly. Open fractures of the humerus ty pically benefit from early fracture stabilization to improve the treatment of the open wounds.. Surgery may be indicated in a patient with closed humeral fracture and soft-tissue injuries or abrasions that preclude brace application. . can be performed. most closed fractures of the humerus are best treated initially with a coaptation splint. may lead some patients to request operative treatment. internal fixation. which should be individualized. Stabilization of both fracture sites allows for early range of elbow motion. Other patients do not tolerate bracing due to persistent pain or fracture instability due to their body habitus. and facilitate patient mobilization. In poly traumatized patients. selfcare. when indicated. improve stability. In the critically ill or multiply injured patient. Relative indications for operative management of humeral shaft fractures include displaced segmental fractures. should be fixed surgically to decrease morbidity and facilitate activities of daily living. and often both. allow activities of daily living. in patients with an ipsilateral brachial plexus injury.These include pathologic or impending pathologic fractures in order to relieve pain. thereby reducing the risk of infection. increasing the relative risk of nonunion or malunion (2).

advances in nail design have improved fixation stability by the addition of multiplanar interlocking screws that often lock into the nail. reducing blood loss and decreasing the risk of infection. it often leaves a long unsightly scar along the length of the arm. In addition. and infection. In comminuted fracture patterns. bridge plating with restoration of length. Intramedullary nailing of the humerus. plate osteosy nthesis remains the standard in surgical treatment of the majority of operative fractures of the humeral shaft in North America. 7. Nevertheless. has several mechanical and biologic advantages. intramedullary nails are strong implants. Many fractures that extend above the humeral diaphy sis can be treated with either a plate or a nail. Advantages of plating include anatomic reduction and compression fixation of noncomminuted fracture patterns. Mechanically. With the advent of periarticular. This carries with it the risk of fragment devascularization. and rotation is usually possible. . Intramedullary nails are ideally used to stabilize fractures in the middle three-fifths of the humerus. alignment. iatrogenic nerve injury. there are a number of disadvantages with plating.Nevertheless. which can effectively share load. They are inserted using “minimally invasive” closed techniques. anatomic specific plates. In the past decade. while used less frequently than plate osteosy nthesis. fixation can be performed for fractures that extend proximally or distally into the epimetaphy seal regions. open surgery allows for exposure and protection of the radial nerve. In addition. generally related to the large surgical exposure through the zone of injury. This eliminates direct exposure of the fracture site.2). This has expanded the range of fractures that are amenable to intramedullary nailing (Fig.

.2 A fixed angle. The blade is locked to the nail. spiral blade interlock can help with proximal interlock stability . reducing risk of loosening.FIGURE 7.

rather than a plate. 7.Antegrade nailing with the patient in the supine position is used for the vast majority of patients. there is a need for the patient to be in the prone position. or (e) compromised soft tissues. Retrograde nails are rarely used because of the risk of insertion portal comminution or fractures in the distal humerus. in the following circumstances: (a) pathologic or impending pathologic fractures. Numerous studies support the preferential use of a reamed antegrade intramedullary nail. . (c) severe osteoporosis. (d) long zones of comminution (Fig. In addition. (b) segmental fracture patterns.3).

3 Humerus fracture due to gunshot wound.FIGURE 7. stabilized with a humeral nail. It is important to emphasize that closed humeral nailing is contraindicated .

it is recommended that the nerve be explored. may influence diagnosis or treatment. In addition. the geometry or morphology of the fracture. functional demands. This occasionally occurs in patients with head injuries. In patients with an open fracture as well as a radial nerve palsy. The patient’s social history may provide useful information about their ability to cooperate with a rehabilitation program. altered consciousness from drugs or alcohol. In these patients. or movement of the arm. This may be a significant consideration in patients whose work or avocations include significant overhead activity . HISTORY AND PHYSICAL The history should include not only the mechanism of injury. diabetes. and decreased range of motion of their shoulder and elbow. Fracture-related issues.when the status of the radial nerve cannot be determined preoperatively. In these circumstances. and should not be used (11). The patient and the injured limb must be carefully and sy stematically examined. pain with palpation. Most patients have localized swelling. as well as patient-related. PREOPERATIVE PLANNING There are a number of fracture-related. either in the same limb or elsewhere in the body . issues that must be analy zed when developing a treatment plan for a patient with a humeral shaft fracture. hand dominance. body habitus. plating seems preferable to nailing. as well as concomitant injuries. the bone quality. since the majority of the exposure has been done at the time of nerve exploration. or poly trauma. and the magnitude of displacement must be considered. occupation. either open nailing with visualization of the nerve or plate fixation is safer. which may . patient-related issues such as medical comorbidities. and recreational activities. Medical comorbidities. Intramedullary nailing is inferior to plating in treating humeral nonunion. such as the location of the fracture. The skin must be examined to rule out an open fracture. affect the choice of treatment. such as cardiovascular disease. or a history of cancer. The main disadvantages of antegrade humeral nailing are postoperative shoulder pain and higher incidence of hardware removal. associated soft-tissue condition. mechanical ventilation. but the health status of the patient as well.

The vast majority of patients with a closed humeral fracture who present with a radial nerve palsy have a neuropraxia. It is imperative to understand the proximal and distal extent of the fracture if an intramedullary nail is to be used. The brachial. The nail can only be inserted to the lowest extent of the medullary canal. ulnar. 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. Careful evaluation and documentation of the neurovascular status have both medical and legal significance. If the fracture extends into the proximal or distal epimetaphy seal areas. radial. On the other hand. and the vast majority recover spontaneously. In the painful arm. . Various studies support both observation and early surgery. Timing of Surgery Open humeral fractures are surgical urgencies and require irrigation. The management of a patient with a humerus fracture whose radial nerve function is lost after reduction and splinting is controversial. These have an excellent prognosis. 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.be subtle. and ulnar pulses should be sy mmetrical with the opposite limb. Diminished or absent pulses or a cool hand after reduction require a vascular workup. which ends several centimeters above the olecranon fossa in most individuals. The indication for surgery is based more on the fracture status rather than the radial nerve lesion. Occasionally. a CT scan may be necessary to completely understand the fracture. The neurologic exam should include specific testing of the motor and sensory function of the radial. it can be difficult to obtain an axillary lateral of the shoulder. of the shoulder. through the axilla. and median nerves. combined with forward elevation. a full-length AP and lateral x-ray of the humerus should be obtained. dedicated shoulder and elbow radiographs should also be obtained. This requires only a small amount of abduction. Approximately 10% of patients with displaced humeral shaft fractures present with a radial nerve injury.

Internal fixation for most isolated. usually within the first 3 to 5 day s.débridement. but are not necessary for most isolated humeral shaft fractures. and the positioning required. In highly contaminated open fractures. Exceptions include patients who are in too much pain to be discharged. The proximity of the surgery to the patient’s head. closed fractures is done during day light hours with an experienced and rested team. is the ability to obtain intraoperative biplanar images without moving the limb. and those patients whose social situations preclude independent living with an immobilized arm. Fractures that occur in conjunction with a vascular injury should be treated emergently in coordination with a vascular surgeon. seen in the clinic. The disadvantage with this position. many patients can be discharged home from the Emergency Department. if the neurologic status of the extremity is known. make the use of regional anesthesia more difficult. A Foley catheter and arterial lines may be indicated in poly trauma patients. however. Following reduction and splinting. However. and stabilization as soon as the patient’s condition and institutional resources allow. The timing of stabilization in a poly trauma patient should take into account the overall relative risk to the patient. SURGICAL TECHNIQ UE Anesthesia General anesthesia is preferred with the endotracheal tube secured to the side opposite the injury. Positioning and Imaging Nailing is done in the supine position with the patient either in the “beach chair” or flat on a radiolucent table. and have their surgery scheduled within a few day s. postoperative nerve blocks can be helpful. In critically injured or unstable patients. an aminogly coside or penicillin is added. the fracture is splinted and definitive surgery is delay ed until the patient’s overall condition improves. The need to move the arm to check different C- . The chief advantage of the beach-chair position is gravity assistance with the reduction. Intravenous antibiotics using a cephalosporin should be started upon admission. which may be helpful when a skilled scrubbed assistant is not available.

4–7. If a beach-chair position is used. With the beach-chair position. Folded blankets elevate the affected side. The patient is positioned in a semisupine position.arm views may lead to a loss of reduction. With this position. The AP image obtained by rolling back the C-arm is seen. 7. FIGURE 7. it is very important that shoulder can extend bey ond neutral to facilitate the correct starting point.6). there must be no metal rails on the side of the table. . This is designed to roll the affected side of the body up 15 to 25 degrees from the table. This position facilitates intraoperative imaging. The C-arm is brought in from the opposite side. This allows the shoulder to easily extend past neutral and facilitates the use of biplanar fluoroscopy .4 A completely radiolucent table is used. and minimizes movement of the limb to obtain appropriate fluoroscopic views. and a “bump” is placed under the affected side. from shoulder to hips using a few folded blankets. The unaffected arm should be padded and tucked at the patient’s side. by moving the C-arm to the opposite side of the table. a common feature of standard operating tables. the C-arm is placed alongside the patient’s head on the affected 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. I prefer to position the patient supine on a flat-top radiolucent table. The patient is positioned supine at the edge of the table that allows shoulder motion. unimpeded by a contralateral arm board.

The assistant extends the shoulder slightly . The AP view is . The arm is held in neutral rotation. and the shoulder is extended slightly to better visualize the starting point for the nail.5 Rolling the C-arm over the top allows for a transcapular Y-view. FIGURE 7.6 An axillary view can be obtained by tilting the C-arm sideway s. Please note that the image has been vertically flipped. numerous preliminary fluoroscopic images are obtained.FIGURE 7. so that the anterior humerus is at the top of the view. This can be most helpful in proximal fracture as seen in this x-ray . Prior to prepping and draping. The arm has not been moved.

In addition. a transscapular Ylateral view can be obtained by rolling the C-arm over the arc toward the surgeon (Fig.7).obtained by “rolling back” the arc of the fluoroscopy machine approximately 30 to 40 degrees. . The shoulder is slightly abducted. Without moving the limb. an axillary lateral of the proximal humerus can easily be obtained with minimal movement of the limb. 7. while the C-arm is tilted in a manner ty pically used to obtain an inlet view of the pelvis. 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.

.

and multiple lower extremity injuries.8 Localization with a guidewire helps ensure appropriate incision placement. and the entire injured limb are prepped and draped into the field. 7.9). chest wall. FIGURE 7. . The neck. 7. a metallic object can be used with fluoroscopy to localize the correct site for the skin incision (Fig.8). This allows for intraoperative manipulation of the limb for reduction and nailing. just lateral to the AC joint and extends distally 5 cm (Fig. a first-generation cephalosporin is recommended. In large patients. Unless an allergy is known or suspected. shoulder girdle.7 AP radiograph of the humerus in a 20-y ear-old multiply injured female with splenic and liver lacerations.FIGURE 7. Surgery All patients should receive prophy lactic antibiotics within 30 minutes of the skin incision. a pelvic fracture. The incision starts at the anterior tip of the acromion.

The skin incision begins at the anterior tip of the acromion and courses anterolaterally .11). The subdeltoid bursa is excised and the supraspinatus tendon is exposed. 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.10). The guide wire is advanced into the bone.FIGURE 7. The correct starting point is just medial to the sulcus between the margin of the articular cartilage and the greater tuberosity. Most commercially available nails have a slight proximal lateral bend.0mm 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 starting point. and the supraspinatus tendon is carefully incised. 7. 7. It enters the edge of articular cartilage. in line with . Dissection is carried through the deltoid in the natural raphe between the anterior and middle thirds of the muscle (Fig. A 2.9 The humeral head is anterior to the tip of the acromion. but avoids the insertion of the supraspinatus tendon (Fig.

FIGURE 7. . The edges of the tendon are tagged with large. around the guide wire.12). 7. nonabsorbable sutures to protect the tendon during reaming and nail passage as well as for later repair (Fig.the fibers.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. .

The fracture is then reduced with traction. or direct pressure under fluoroscopic control. The first .12 Sutures retract the edges of the supraspinatus tendon. A ball-tipped guide rod is then passed down the medullary to the fracture site. without moving the arm. Preoperative and intraoperative assessment of length are critical for two reasons. until a satisfactory reduction is achieved. one after the other.FIGURE 7. a cannulated reamer or awl is used to open the entry point in the proximal humerus. The nail should span the entire length of the humeral canal. Single plane corrections are performed. Once the guide wire is correctly positioned and verified fluoroscopically. and the guide wire is successfully passed into the center of distal fragment. and the C-arm is then rotated “over the top” to get a lateral. The reduction is verified on the AP view. 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. translation. and the surgeon or the assistant advances the ball-tipped guide wire into the distal fragment.

In comminuted fractures. proper nail length is critical. When the distal segment is neutral. will distract the fracture site. should be parallel to the x-ray beam. and nail passage. Nails that are too long may fracture the distal humerus when try ing to countersink the nail proximally or. The reamer is stopped at the proximal end of the zone of injury. 7. Once this view has been obtained. The radial nerve is alway s a concern when performing an intramedullary nailing of the humerus. Rotation can often be determined radiographically.is that the anatomy of the humeral medullary canal tapers distally and stops 2. a true AP image of the shoulder should show the sulcus of bone between the articular surface and greater tuberosity at its deepest. Because the risk of nail incarceration is greater in narrow bones. This is best checked after the guide wire has been passed across the fracture. In simple fractures. Distally . A fulllength humeral nail is chosen but must not be prominent at the entry site to reduce the risk of shoulder impingement. The nail selected should be 1 mm smaller in diameter than the final reamer size to minimize the risk of iatrogenic comminution or incarceration. the irregular edges of the fracture ends will match up when the alignment is correct. Thus. reaming. The canal is reamed until “cortical chatter” is encountered throughout the diaphy sis. such as the humerus. This leaves virtually no room to advance the nail if it is too long. If left prominent at the entry site.13). . pushed across the comminuted zone while the reamer head is not spinning. and then reaming resumes once the distal canal is engaged. To avoid irritation of the rotator cuff tendon. the forearm and the distal fragment can be rotated to the neutral position. it is prudent to ream the canal prior to nail insertion. Other strategies to avoid iatrogenic nerve injury include not reaming through the zone of injury in comminuted fractures. some surgeons recommend exposure of the fracture site to ensure that the radial nerve is not entrapped during reduction.0 to 2. It also permits impaction of the fracture ends in length stable fractures. To avoid iatrogenic injury.5 cm above the olecranon fossa. the forearm. with the elbow flexed. providing some stability. more commonly. the nail should reach the end of the medullary canal. increasing the risk of nonunion. the nail should be countersunk 3 to 5 mm into the proximal fragment. the nail will often be painful with shoulder motion. ensuring an anatomic reduction prior to reaming and nail passage can minimize the risk of nerve injury (Fig. In simple fracture patterns.

To improve stability and prevent loss of reduction. Length assessment can be difficult in comminuted fractures.13 Reduction prior to reamer or nail passage helps prevent soft-tissue damage at fracture site in this simple fracture pattern. all humeral nails should be statically locked. In length stable fracture patterns. Distraction should be avoided in comminuted fractures because of an increased risk of nonunion.FIGURE 7. Unlike the lower extremity lengthening is more of a potential problem than shortening. A preoperative x-ray of the unaffected side allows precise determination of nail length. such as a transverse or .

or in cases of impending pathologic fracture with cortical contact. A “miniopen” technique for screw insertion is recommended. After localizing the distal screw holes fluoroscopically. proximal interlocking may be done first. rather than from lateral to medial. Proximal interlocking is done through an outrigger attached to the nail that allows several multiplanar screws to be inserted in the humeral head. .short oblique fractures. 7. This places the brachial artery and median nerve at risk. A drill sleeve or two small retractors may be used to protect the adjacent soft-tissue structures (Fig. This is essentially the same procedure used in placing femoral or tibial nail interlocking screws. For virtually all humeral nails. Distal interlocking is ty pically done using a “free hand” technique. In comminuted or segmental injuries. a 2-cm incision in the skin is made followed by blunt dissection to the anterior humeral cortex. which passes through the nail and may be of benefit in poor bone. distal interlocking is done first in order to allow for compression at the fracture site by “back slapping” the nail. Another technique uses a fixed angle blade.14). the distal screws are inserted from anterior to posterior. especially if the nail is rotated and the interlocks are from anteromedial to posterolateral. and a sharp drill bit or one with a “brad” tip can be helpful. The anterior cortex of the distal humerus is acutely sloped. An oscillating drill can also reduce the risk of softtissue injury. and the bone in y ounger patients is quite dense.

Use of retractors can reduce risk to neighboring structures. 7. using the correct entry point. The arm is placed in a sling for comfort. and the deltoid fascia is closed prior to skin closure. . the supraspinatus tendon is carefully repaired.FIGURE 7.17).14 Distal locking is done in an anterior to posterior direction with a small open technique. and proper nail placement. At the conclusion of the case.15–7. fracture reduction. favorable outcomes can be achieved in most patients (Figs. With careful surgical technique.

16 Once the nail is locked distally . FIGURE 7.15 A freehand technique.FIGURE 7. it can be used to compress the fracture site. with fluoroscopy . This can be done by impaction of the bone segments. . can facilitate distal interlock placement. use of a compression device on the instrumentation. or tapping the handle of the nail with a magnet.

FIGURE 7. If lower extremity fractures are present. Codman’s pendulum exercises and passive range of motion of the shoulder are begun first. Ty pically. If the patient’s condition allows.17 After successful nailing of the humerus. Sutures are removed in the clinic at 10 to 14 day s. this is done within 2 to 3 weeks. phy sical therapy can be started on the first or second postoperative day. Activities of daily living are encouraged. the patient is instructed in rotator cuff strengthening exercises. At 6 weeks. weight bearing on crutches or walker is permitted. follow-up x-ray s are obtained and reviewed for signs of fracture healing. and secure fixation was achieved in surgery. Outpatient phy sical therapy can be quite helpful in this regard. POSTOPERATIVE MANAGEMENT Intravenous antibiotics are continued for 24 hours. Surgery performed 5 day s after injury . and lifting is limited to light objects. Lifting can be increased. Patients are encouraged to wean from the sling as pain decreases. By 12 weeks. most patients will have sufficient healing and should have recovered enough motion and strength to return to most activities. with closed reduction in supine position. and activity is generally increased. If callus is present. except for .

These problems are more prevalent after antegrade intramedullary nailing than other methods of treatment. It is imperative that the surgeon be familiar with the technique to achieve an optimal outcome. Implant removal is not routinely recommended. x-ray s are taken every 6 weeks to monitor healing until full union is observed. Manipulation under anesthesia. supervised therapy. Outcomes compare favorably to plate fixation (8–10). the nail patients had more shoulder pain (up to 31%) and loss of shoulder motion. Intramedullary nailing of the humerus is an operation with a high union rate and a relatively low incidence of complications (8). with or without arthroscopic débridement. The presence of the nail may preclude a diagnostic MRI. What remains less clear is the cause of shoulder pain and its effect on functional outcome. Persistent rotator cuff dy sfunction can be challenging to evaluate. Continued strengthening exercises should result in near normal activity levels in most patients by 6 months after surgery. Alternatively . there may be an indication for hardware removal after healing. However. In these same studies. can be considered for recalcitrant cases. In comparative studies between intramedullary nailing and plating. followed by MRI to evaluate the rotator cuff. an arthrogram can be helpful. This compares favorably to open reduction and plate fixation (5–7). . In the occasional patient in whom prominent hardware is sy mptomatic. the incidence of reoperation was higher in the nail group than in the plate fixation group. In such cases. initial treatment should consist of regular. Complications Shoulder Pain and Stiffness Some degree of shoulder pain and stiffness is common after humeral shaft fractures.heavy lifting and prolonged overhead activities. elective removal can be undertaken following union. Regardless of the cause. The majority of the reoperations were for hardware removal. OUTCOMES Union rates following humeral nailing range from 90% to 95% in published series. the functional outcome measures (including ASES scores and return to activity ) failed to show significant differences on longer-term follow-up.

Hou SM. Cochrane Database Syst Rev 2011. Functional bracing for the treatment of fractures of the humeral diaphy sis. Nonunion of the humeral shaft: long lateral butterfly fracture—a nonunion predictive pattern? Clin Orthop Relat Res 2004(424):227–230. et al. McCormack RG.81(2):216–223. Chapman JR. Chiang H. Kurup H. Sarmiento A. et al. Dy namic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. and observation is appropriate during the first 4 months (12). The results of functional (Sarmiento) bracing of humeral shaft fractures. J Bone Joint Surg Am 2000. 9. Fixation of fractures of the shaft of the humerus by dy namic compression plate or intramedullary nail. Stannard JP. randomised trial.85-A(11):2103–2110. 8. 5. REFERENCES 1. et al. In most patients. 4. 3. 11. Riemer BL. A prospective.16(11):1219–1223. Gerber C.Radial Nerve Issues Radial nerve palsy after nailing of the humerus fortunately is uncommon. Very little literature exists to guide treatment. 6.82(4):478–486. 2. J Orthop Trauma 2000. J Bone Joint Surg Am 2003. et al. et al. Plate fixation or intramedullary fixation of humeral shaft fractures. Open exchange locked nailing in humeral . Intramedullary nailing of humeral shaft fractures with a locking flexible nail. the nerve recovers. Injury 2008. Heineman DJ. However. Acta Orthop 2010.6:CD005959.14(3):162–166. et al. Lin J. Humeral nailing revisited. 7. Orthopedics 1993.11(2):143–150. Gross DF. Andrew JG. 10. The anterior acromial approach for antegrade intramedullary nailing of the humeral diaphy sis.39(12):1319– 1328. et al. Koch PP. Castella FB. Hossain M. Rommens PM. some surgeons recommend exploring the nerve earlier to rule out a structural injury . Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. et al.82(3):336–339. J Shoulder Elbow Surg 2002. J Bone Joint Surg Br 2000.

nonunions after intramedullary nailing. . Iatrogenic radial nerve palsy after operative management of humeral shaft fractures. Wang JP. 12. J Trauma 2009. Clin Orthop Relat Res 2003. et al. (411):260–268.66(3):800–803.

The . However. Restoration of elbow motion is essential to perform most activities of daily living. Union rates between 90% and 100% have been reported.8 Distal Humerus Fractures: Open Reduction Internal Fixation Daphne M. the majority of patients experience only mild to moderate residual impairment and regain approximately 75% of their elbow motion and strength. Today. The surgeon must have a thorough knowledge of the complex anatomy around the elbow prior to embarking on surgery of the distal humerus. They ty pically occur in y oung people as the result of high energy trauma and occur more commonly in males. Fixation in these patients with osteopenic bone may be difficult. and surgical tactics and newer implants continue to evolve to accommodate this challenge. Beingessner and David P. The elbow joint functions to position the hand in space. modern fixation techniques have dramatically improved outcomes. fractures often occur as the result of a ground-level fall. A range of motion between 30 and 130 degrees of flexion (100-degree arc) is necessary to perform most activities of daily living. Barei INTRODUCTION Intra-articular fractures of the distal humerus in adults are uncommon but complex and challenging injuries. In this group of patients. particularly in women. the incidence of distal humerus fractures in the elderly has increased. but in the past 25 y ears. Historically patients did poorly with surgical management of this injury. stable internal fixation that allows early range of elbow motion is mandatory to achieve such outcomes. Recent series of distal humerus fractures have demonstrated restoration of motion arcs of up to 112 degrees when repaired with contemporary fixation techniques. As life expectancy grows.

and elbow stiffness.1) FIGURE 8. (Fig. and precontoured periarticular plates have been developed to facilitate fixation. It is ty pically reserved for low-demand elderly patients with significant medical comorbidities who cannot tolerate surgery.osseous anatomy can make plate contouring difficult. malunion. 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 epicondy le. and thirty -seven percent ty pe C.1 INDICATIONS AND CONTRAINDICATIONS Nonoperative treatment of displaced distal humerus fractures in adults leads to a high rate of nonunion. coronal shear fractures. Such patients. Ty pe A fractures are extra-articular. and ty pe C fractures are complete articular injuries. twenty -four percent ty pe B. 8. or epicondy le fractures). ty pe B fractures are partial articular (such as isolated condy le fractures. particularly those . Thirty -nine percent of fractures are ty pe A. 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 sy stem.

Comminuted intra-articular fractures in geriatric patients with significant osteopenia may be better treated with total elbow arthroplasty. they can be missed due to the excellent collateral blood flow in the upper extremity . then noninvasive vascular studies should be performed. Imaging Studies Ty pically. which is often lengthy . medical issues. plain radiographs are sufficient to diagnose and develop a treatment plan. preinjury condition. good outcomes are possible. and any significant abnormalities should prompt a vascular surgery consultation. and associated injuries. If the peripheral pulse on the affected extremity is decreased. arthroplasty should be reserved for low-demand patients as the long-term outcomes have shown a high incidence of implant loosening. A thorough vascular examination including peripheral pulses should be performed. Phy sical examination should identify open wounds. Radiographs should include the entire length of the . Although vascular injuries are uncommon. fractures with significant shear components. significant abrasions or contusions. The patient should be medically optimized prior to surgical intervention. PREOPERATIVE PLANNING History and Physical Examination A complete history including mechanism of injury. nerve function (particularly ulnar and radial nerve). For patients with significant displacement of the metaphy sis.with minimally displaced fractures or low-articular injuries/shear injuries. and fractures that are below the olecranon fossa may be difficult to repair in osteopenic bone. can be treated with immobilization in a long arm cast for 3 weeks followed by early range of elbow motion. 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. and handedness should be obtained. the soft tissues must be carefully monitored to be sure that there is no skin compromise secondary to displaced fragments. However. skin tenting. Distal humerus fractures continue to be challenging injuries to manage but with improved fixation techniques and implants. articular comminution. In particular.

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.humerus and the forearm. It is important to determine if there is continuity of the trochlear fragment to the medial epicondy lar fragment as this can influence hardware choice. gentle traction is applied to the arm in the radiology suite. These radiographs should be studied to identify all components of the fracture.2). . With adequate analgesia. Unlike plateau or pilon fractures. and an anteroposterior and lateral radiograph of the elbow is obtained. Traction radiographs are helpful to further delineate the fracture geometry (Fig. 8.

Timing of Surgery Fractures should be immobilized in a long arm splint in a position that takes pressure off the skin. If . In the absence of soft-tissue compromise or open injuries.2 Anteroposterior radiograph of a comminuted distal humerus fracture (A). A traction view better delineates the fracture lines and extent of joint injury (B). Open fractures or those with significant soft-tissue compromise should be treated on an emergent basis. the fracture should be treated on an urgent. but not emergent. This position may vary according to fracture configuration but is often with the elbow semiextended.FIGURE 8. The patient should be medically optimized since the surgery can be lengthy. It is essential to have a complete and detailed preoperative plan to be sure that all required implants are available. A hy perflexed position should be avoided to prevent development of a compartmental sy ndrome. basis.

We prefer a lateral position on a foam mattress with a radiolucent armboard since it decreases the potential risks of prolonged prone positioning such as ey e injuries (Fig. and their availability should be confirmed preoperatively.4. The lateral decubitus or prone position allows for good visualization of the fracture as well as proper positioning of the Carm. A Foley catheter is routinely placed. Sequential compression devices are placed on the legs and used for the duration of the case. 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. and 2.5-mm LCDC plates. 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 patient is not well enough for a prolonged procedure. arterial or central lines) is performed at the discretion of the anesthesiologist based on the patient’s phy siologic status as well as comorbidities. The goal of treatment is anatomic and rigid fixation of the articular component of the injury and either absolute or relative stability of the metaphy seal component depending on the degree of comminution.6. The prone position is useful for selected patients with spine injuries or fractures in their contralateral extremities. The Carm is brought .0 mm). The lower arm is supported on a well-padded plexiglass armboard. 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. A variety of implants may be required for provisional and definitive fixation of these fractures.7 mm). 2. precontoured periarticular distal humerus nonlocking and locking plates.7.e.25. These implants include 3. SURGERY After appropriate medical evaluation. and preoperative antibiotics are administered. 2. and Kirschner wires in various sizes (1. 8. regional techniques of anesthesia are used less frequently. a small saw and osteotomes for an osteotomy .and 3.0. general anesthesia is induced. Because these fractures often require prolonged operating time. A variety of clamps including small and large Weber clamps. 1.. minifragment plates and screws (2. and 2. the patient is brought to the operating room. and bipolar cautery should also be available.3).5-mm reconstruction plates. Advanced monitoring (i.

4A.6). 8.B). 8. A sterile tourniquet may be used but is not often necessary and may be in the way of a more extended incision. . images should be obtained to ensure high-quality images during the procedure (Fig.in from the head of the table. The entire arm from shoulder to hand is prepped and draped (Fig. Injecting the proposed incision with Marcaine with Epinephrine helps with hemostasis during the exposure (Fig. Prior to prepping and draping test. 8.5).

The C-arm is positioned from the top of the .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.

Prone positioning also allows for adequate imaging and access to the fracture (B). 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. .bed. and the positioning allows for anteroposterior and lateral imaging (A).

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

10). the ulnar nerve is identified proximal to the elbow joint under the medial triceps (Fig. and full-thickness medial and lateral fasciocutaneous flaps are raised. 8. The preoperative plan should indicate which approach will be required. 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. 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.8) or an olecranon osteotomy. 8.7). We prefer these approaches since they are extensile and allow for excellent visualization of the joint. It is important to elevate the deep fascia in order to more easily identify the ulnar and radial nerves (Fig.9).6 Injecting the proposed incision with Marcaine with Epinephrine helps with hemostasis during the exposure. It can be fully elevated for transposition or . 8. The fracture is then exposed using a triceps-sparing approach (Fig. On the medial side. A posterior midline incision is made.FIGURE 8.

The visualization afforded by this approach is ty pically adequate for fractures with a simple articular split. 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.14).left in situ and protected throughout the procedure depending on the fracture and fixation requirements. Distally. . The joint capsule is opened laterally and the fracture exposed. and dissection should remain posterior to the septum.13). 8. 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. On the lateral side. Distally. particularly if it is lateral to the midpoint of the trochlea (Fig. The triceps is then elevated from the posterior humeral shaft. If the fracture is distal and will not require long plates.11). 8. and the posterior joint capsule is entered to visualize the trochlea. 8.12). 8. the radial nerve does not need to be exposed. which ty pically lies just anterior to it (Fig. the anconeus may be divided or dissected on its lateral side to be elevated with the triceps (Fig. the posterior band of the medial collateral ligament is elevated. the sensory branch of the radial nerve is identified in the fascia and followed proximally to the radial nerve proper. The radial nerve is identified as it crosses the posterior humerus proximally and distally as it travels anterior the intermuscular septum.

.7 A posterior midline incision is made. It is important to elevate the deep fascia in order to more easily identify the ulnar and radial nerves.FIGURE 8. and full-thickness medial and lateral fasciocutaneous flaps are raised.

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

9 On the medial side.FIGURE 8. . the ulnar nerve is identified proximal to the elbow joint under the medial triceps.

.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.

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. .

which ty pically lies just anterior to it. the sensory branch of the radial nerve is identified in the fascia and followed proximally to the radial nerve proper.FIGURE 8.12 On the lateral side. .

FIGURE 8. Distally . .13 The triceps is then elevated from the posterior humeral shaft. the anconeus may be divided or dissected on its lateral side to be elevated with the triceps.

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The fracture was addressed through a triceps-sparing approach.FIGURE 8. then this approach should be .B).D). Note the minifragment plate placed in the metaphy sis to hold the reduction during placement of the main implants (E).14 Anteroposterior and lateral radiographs of a 40-y ear-old male with a distal humerus fracture and a simple articular split (A. If the fracture is more complex. Adequate visualization with this approach allowed for an anatomic reduction of the articular fracture (C. including multiple intra-articular fragments or coronal shear fragments.

extended into an olecranon osteotomy (Fig.16A). I prefer plate fixation of the osteotomy. 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. an osteotomy should be performed as well. 8. If an olecranon osteotomy is needed. one at the tip of the plate and a second in the shaft for improved reduction and fixation at the conclusion of the case (Fig. The triceps-sparing approach described above allows visualization to the proximal ulna. 8. The plate is positioned on the ulna prior to the osteotomy and drill holes are placed. The reflected triceps and olecranon are wrapped in a saline-soaked sponge and kept moist for the duration of the procedure. Fluoroscopy is used to confirm the location of the osteotomy (Fig. Similarly. The ulnar nerve is carefully protected.D).15).16B). A small sponge may be placed around the proximal ulna to distract it from the distal humerus to avoid articular damage during the osteotomy. The olecranon together with the triceps tendon is reflected proximally and the fracture is exposed (Fig. if a simple articular fracture cannot be adequately visualized for anatomic reduction.16E). 8. . 8. 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 bare area of the proximal ulna in the greater sigmoid notch is identified on the medial and lateral side. 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.

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The osteotomy is made with the apex pointing distally to maximize the size of the fragment to repair (B. . This technique allows for excellent visualization of the fracture and the articular surface.C).FIGURE 8.15 Posterior view of the arm demonstrating a chevron osteotomy of the olecranon (A).

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5-mm reconstruction . reducing one column at the metaphy sis may aid in reduction of the articular surface by creating a stable platform on which to build the joint. With fluoroscopy to confirm the location of the osteotomy (B). 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. both columns of the distal humerus should be plated.18).7. care must be taken to avoid overcompression of the joint in comminuted fractures. However. 8. and the position of the plate in relation to the radial nerve must be verified. 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. The olecranon together with the triceps insertion is then reflected proximally .5-mm LCDC plate or equivalent strength precontoured periarticular plate (Fig. The fracture fragments are carefully irrigated.or 3. 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. A large-pointed Weber clamp can be placed across the joint to provide articular compression.17). 8.FIGURE 8.19). This plate ty pically is used on the lateral side (Fig.D). if the metaphy seal injury is not comminuted. Shear fragments may be secured with strategically placed countersunk minifragment screws ( Fig. Minifragment plates (2.5-mm drill in each segment. 8.16 The plate is positioned on the ulna prior to the osteotomy . On the medial side. Kirschner wires are helpful to provide provisional fixation of the joint surface. a drill hole can be made with a 2. The articular surface is ty pically reduced first. the plate may need to be long. and pilot drill holes are placed. 8. However. and the fracture is then exposed (E). and care is taken not to disrupt any remaining softtissue attachments. a 2.0 mm) can be helpful to hold the metaphy seal reduction if the wires are not secure (see Fig. and a modified small-pointed reduction clamp with two straight ends can be placed to hold the reduction. With significant metadiaphy seal comminution. For more transverse metaphy seal fractures. After reduction and provisional fixation with a combination of K-wires. and minifragment plates. One plate should be a 3.14E). one at the tip of the plate and a second in the shaft for ease of reduction at the conclusion of the case (A). clamps.

When possible. The plates can be oriented at 180 or 90 degrees to each other depending on the fracture configuration (Fig. 8. This ty pe of plate is more flexible and easier to contour around the medial epicondy le and trochlea. If the trochlear fragment is separate from the medial epicondy le. They are also useful for coronal shear fractures of the capitellum. and the medial plate can be placed directly medially or posteromedial. 8. . 8. Alternatively. and “position screws” rather than “lag screws” are used. 8. smaller caliber plates may be sufficient (Fig. When necessary. Locking plates may be used in osteopenic patients but are not required for fixation in the y ounger trauma age group. a precontoured periarticular plate may be used (Fig.20).21).23). Retrograde column screws may also enhance fixation of the articular segment to the shaft. a plate that extends down onto the trochlea is necessary to adequately capture the trochlear fragment (Fig. and fixation strength may be increased by interdigitating these screws.22). interfragmentary compression of the articular surface should be achieved with screws placed through one or both plates. If the fracture is distal to the olecranon fossa (transcondy lar). the lateral plate can be placed either posteriorly or laterally . one must be careful to avoid narrowing the trochlea during fixation. Both constructs are of sufficient strength to allow early motion. If comminution is present.plate is usually sufficient.

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FIGURE 8. Strategically placed screws are placed into the articular surface and countersunk to repair these fragments (A). . Note the retrograde column screws placed from each plate for added stability .17 This fracture had a shear component in the coronal plane. The remaining hardware may then be placed around these screws (B. C).

18 Anteroposterior and lateral views of the distal humerus showing a medial 2.7-mm reconstruction plate and a lateral LCDC plate. .FIGURE 8.

5-mm LCDC plate positioned laterally . .19 A 3.FIGURE 8.

20 Precontoured periarticular plate. .FIGURE 8.

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FIGURE 8.FIGURE 8. .22 Anteroposterior view of the distal humerus showing a medial 2.7-mm reconstruction plate that wraps around the medial epicondy le onto the trochlea.21 Plates may be oriented at 180 or 90 degrees to each other depending on the fracture configuration. This plate contour is useful when the trochlea and medial epicondy le are separate fragments.

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FIGURE 8. The fracture went on to union uneventfully (G.B).F).H). 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. Provisional fixation with wires and clamps is completed (C.23 Anteroposterior and lateral radiographs of a 30-y ear-old female with a low fracture with the majority of the fracture below the olecranon fossa (A.D). .

If it is in contact with metal or has a tendency to dislocate.24). Excellent hemostasis must be obtained to avoid a postoperative hematoma. then we recommend a subcutaneous transposition. If it is stable in the cubital tunnel with no contact with the medial hardware. 8. Final radiographs are obtained to be sure that the reduction is anatomic. The osteotomy is clamped from the medial and lateral side with pointed reduction clamps on each side (Fig. the deep dermis may be sutured to the fascia to decrease the chance of fluid collecting in the olecranon bursa (Fig. 8.27).26). the olecranon osteotomy is repaired. A drill hole in the shaft is used to hold the clamp distally. it may be left in situ. At the tip of the olecranon. The subcutaneous lay er is closed with 2-0 absorbable sutures to take the tension off the skin. . all hardware is safely placed. The previously drilled plate is then replaced.After internal fixation of the humerus is complete. 8. 3-0 ny lon suture and ¼ inch steristrips are applied (Fig. The wound is copiously irrigated with saline and the arm cleaned with chlorhexidine. The ulnar nerve is then inspected. splint incorporating the hand is then applied with the elbow at approximately 70 degrees of flexion (Fig. 8. 8.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. A drain may be placed as needed.25A. and screws are applied (Fig.28). and the curved portion of the clamp is placed at the tip of the olecranon out of the path of the plate. and all screws are of appropriate length.

The osteotomy is clamped from the medial and lateral side with a straight-curved pointed clamp on each side. the osteotomy is repaired. FIGURE 8. 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 8.25 The osteotomy is performed with a saw.24 After fixation is complete. .

FIGURE 8. the deep dermis may be sutured to the fascia to decrease the chance of fluid collecting in the olecranon bursa.26 The subcutaneous lay er may be closed with several 2-0 absorbable sutures to take the tension off the skin. . At the tip of the olecranon.

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28 Sterile dressing with a long-arm bulky splint incorporating the hand is then applied with the elbow at approximately 70 degrees of flexion. If an osteotomy has been performed. At 48 hours. POSTOPERATIVE CARE The patient receives 24 hours of intravenous antibiotics. and a compression glove and range of motion exercises are initiated. the patient may do active and activeassisted flexion and extension for the first 6 weeks but should avoid active .FIGURE 8. the splint is removed and the patient is placed into a light dressing with a tubigrip sleeve.27 The skin is closed with 3-0 ny lon suture and ¼ inch steristrips are applied. FIGURE 8.

If the nerve is unstable in situ after exposure or has significant contact with the medial implant. Furthermore. Controversy still exists with regard to the treatment of the ulnar nerve intraoperatively. in head-injured patients. Risks inherent to all surgical care should be discussed including the risk of infection and nerve injury . Otherwise. compliance rates with taking the drug are often low. they are permitted to do active motion against gravity without restrictions. Similarly. Paresthesias in the ring and small fingers are not uncommon following distal humerus fracture surgery.extension against gravity or resistance. The patient is seen in clinic at 2 weeks for suture removal and clinical evaluation. transposition may be beneficial. There are no restrictions to rotation. risks such as nonunion or medication side effects must be carefully weighed against the potential benefits. COMPLICATIONS AND OUTCOMES Distal humerus fractures are complex injuries. Heterotopic ossification may occur after elbow trauma with current reported rates of about 8% after distal humerus fractures. for example. radiographs are obtained. Radiographs are obtained at 6 weeks at which point a gentle strengthening program is started. A recent study demonstrated an increased rate of nonunion in patients treated with indomethacin for prophy laxis after distal humerus fractures. It is difficult to predict which patients will develop this problem. The only current clear indication for anterior transposition is preoperative ulnar nerve sy mptoms. and a more aggressive strengthening protocol is instituted if the fracture is healed. Hand and shoulder motion are also encouraged. malunion can be avoided by proper surgical technique. and routine prophy laxis is not warranted. If prophy laxis is considered. In patients with open fractures and large bone defects. There is no clear indication for ulnar nerve transposition in the setting of normal preoperative function. The incidence of nonunion of distal humerus fractures is low with reported rates <5%. At 3 months. bone grafting should be performed approximately 6 . Stable internal fixation and avoiding excessive soft-tissue stripping improve the rate and the time to union. and a discussion about the potential complications and outcomes should be discussed with the patient preoperatively.

Fate of the ulnar nerve after operative fixation of distal humerus fractures. RECOMMENDED READINGS Barei DP.. Philadelphia. Nork SE. Nork SE. J Orthop Trauma 2003.17:374–378. Athwal GS. Ristevski B. J Bone Joint Surg Am 2011. 2009.20(3):164–171. Tencer AF. 6th ed. Henley MB. Rutgers M.24(7):395– 399. Vasquez O. Schildhauer TA. PA: Elsevier Churchill Livingstone. In: Green DP. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Shoulder Elbow Surg 1999. J Orthop Trauma 2010. Complex fractures of the distal humerus and their complications. J Orthop Trauma 2006. The olecranon osteotomy : a six-y ear experience in the treatment of intra-articular fractures of the distal humerus. Schemitsch EH. Ring DC. Ring D. J Orthop Trauma 1994. Faber KJ. Jupiter JB. Mills WJ. et al. Orthop Clin 2008. et al. Distal humerus fractures.39(2):187–200. In patients with sy mptomatic nonunions. Hotchkiss RN.weeks after the index procedure to promote fracture healing prior to implant failure. . McKee MD.93(7):686–700. Pederson WC. Barei DP. et al. revision of fixation with bone grafting and elbow release may be indicated. Distal humeral fractures in adults. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. et al.8(6):468–475. Coles CP. Hanel DP.8:85–97. Nauth A. Fractures of the distal humerus. eds. Pollock JW. et al. Green’s operative hand surgery .

9 Intra-Articular Fractures of the Distal Humerus: Total Elbow Arthroplasty Elaine Mau and Michael D. displaced distal humeral fractures are treated with internal fixation. 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. obtaining and maintaining the reduction through healing and rehabilitation in osteoporotic bone can be extremely challenging.1). Fractures of the distal end of the humerus are classified in the AO/OTA sy stem as ty pe 13-C fractures and involve both the articular surface and a metadiaphy seal region (Fig. These injuries ty pically occur in elderly patients with compromised bone stock secondary to osteoporosis following a mechanical ground level fall. 9. Traditionally. however. .

FIGURE 9. severe . with only a marginally higher complication rate. 9. several studies have reported the results of TEA as the primary treatment of selected distal humeral fractures. In the past 15 y ears. INDICATIONS AND CONTRAINDICATIONS Primary TEA for distal humerus fractures is largely limited to the elderly (>70 y ears of age) patient population with displaced and comminuted intraarticular fractures (Fig. but this has not been well described in the literature. While primary arthroplasty is considered technically easier with a lower complication rate (19).B). Prasad and Dent (5) recently reported that secondary elbow arthroplasty following failed internal fixation had similar outcomes to primary TEA. documenting favorable outcomes compared to open reduction internal fixation (1–4). Within this population. At the same time.2A.1 AO/OTA classification of ty pe 13C fractures. advanced age with reduced life expectancy. there has been renewed interest in distal humeral hemiarthroplasty as an alternative treatment method. other factors favoring TEA include complex articular fractures in patients with preexisting elbow arthritis (6). The results of primary arthroplasty versus secondary TEA following failed fixation remain unclear.

osteoporosis. the Coonrad-Morrey sy stem 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. with an intra-articular distal humerus fracture. For example.8). Because older patients with simple fracture patterns do well with ORIF (7. within certain limits. may be a candidate for an elbow replacement procedure. Fracture extension into the diaphy sis should be treated with . y ounger patients (<70 y ears of age) with advanced and sy mptomatic degenerative changes in the elbow joint. Fracture extension into the diaphy sis past the olecranon fossa or flare of the condy les can be treated with arthroplasty. or pathologic bone. Occasionally. FIGURE 9. age alone should not dictate the method of treatment.2 AP (A) and lateral (B) radiographs of an elderly patient who subsequently sustained a fracture-dislocation injury resulting in a comminuted intraarticular elbow fracture of the AO/OTA 13C ty pe.

If an open fracture is identified. Relative contraindications to primary elbow replacement for fracture include anticipated noncompliance with activity restrictions. median. 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. The history should include information on the mechanism of injury. and an aminogly coside is added for grade III injuries. or open wounds (ty pically posterior). preinjury levels of function. particularly. and motion is decreased. The forearm should be carefully assessed to rule out a compartment sy ndrome. the elbow is invariably swollen. and ulnar nerves should also be determined and documented as these structures are susceptible to damage. In patients with high energy injuries. In the absence of neurovascular compromise or a compartment sy ndrome. A detailed neurovascular examination is performed including evaluation of the brachial and radial pulses.internal fixation. and limbs with vascular compromise. intravenous antibiotics should be started. airway management and hemody namic stability should alway s take priority and should include a careful assessment of the head. . high-grade open fractures. PREOPERATIVE PLANNING History and Physical Examination A complete history and thorough phy sical examination should be performed. It is important to remember that the vast majority of patients with a displaced intra-articular distal humerus fracture under the age of 70 y ears should be treated with ORIF. chest. We use cefazolin for grade I or II open fractures. The entire upper limb must be evaluated and the soft tissues inspected for abrasions. the ulnar nerve. There are several absolute contraindications to TEA and include flaccid paraly sis of the upper extremity. or the presence of an active infection. tender. and medical comorbidities such as rheumatoid arthritis. as well as the capillary refill. or in the multiply injured patient. a neuropathic joint. or stroke that may influence the method of treatment. severe cognitive impairment. and abdomen prior to further treatment of the injured extremity . diabetes. blisters. On phy sical examination. The function of the radial. soft-tissue compromise that would prevent adequate wound closure.

Additional upper extremity radiographs should be obtained based on the history and phy sical examination. a CT scan can provide detailed information about the fracture geometry. . On occasion. and the extent of intra-articular comminution.. TEA vs. This can help in surgical decision making regarding the ideal procedure (i. In displaced fracture patterns. 9. We have not found MRI scans to be helpful in the acute setting. especially intra-articular comminution or associated fractures. traction radiographs that use ligamentotaxis to restore length and alignment can provide additional information. fracture displacement. when the fracture pattern is unclear. Film quality should be adequate for assessment of bone quality.Imaging Standard anteroposterior (AP) and lateral radiographs of the elbow are obtained. 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. ORIF).3).e.

a decision was made to treat the injury with a TEA.FIGURE 9. Based on the imaging studies. 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. ty pically within a few day s of injury. grade . We proceed with surgical intervention as promptly as logistical preparations can be made.3 CT scan with 3D reconstruction of the patient in Figure 9. The role of primary TEA in patients with an open fracture remains highly controversial. If the patient has a minor. and we rarely perform this complicated surgery at night or on the weekends.1.

If a decision regarding open reduction internal fixation versus elbow replacement cannot be made preoperatively with the available imaging studies. which has many advantages although it is technically more difficult. An alternative approach is the tricepsreflecting (Bry an-Morrey ) technique involving a medial-to-lateral peel of the triceps to gain adequate exposure. allow removal of all of the fracture fragments. and the triceps muscle is freed from the distal humeral shaft. The medial and lateral borders of the triceps muscle are incised.10). there must be adequate exposure of the distal humerus to visualize the fracture. an intraoperative fluoroscopic assessment should be done. given the small but definite risk of triceps detachment with these approaches. We prefer to perform TEA after resection of the fractured humeral condy les using a triceps-sparing approach. or if there is soft-tissue compromise. as they jeopardize the stability of the ulnar component (9. the use of an olecranon osteotomy for exposure is contraindicated if a TEA is anticipated. and a prompt (<12 hours) thorough débridement is performed. 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. it is probably safe to proceed with primary TEA. Concomitant fractures of the proximal ulna and olecranon are relative contraindications to successful primary TEA. the triceps-splitting approach is most commonly used. irrigation/débridement and temporary stabilization should be performed followed by elbow arthroplasty at a later date. and allow proper . there is no gross contamination. and the exposure is more limited. For surgeons who do not regularly perform elbow arthroplasty. In the absence of any of these conditions. our preferred exposure is the triceps-sparing method. and implants for both ORIF and TEA should be available and the patient consented for either procedure.I puncture posteriorly. Regardless of which surgical approach is chosen. However. Similarly. 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.

and thus. Either a general or regional anesthetic technique can be used. A few models may be converted between the two depending on the requirements of the case.implantation of the prosthesis. IN) and Discovery (Biomet Orthopaedics. 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. total elbow prostheses are available as unlinked with separate humeral. semiconstrained implant is ty pically the implant of choice. Among the linked sy stems. The injured extremity is supported on a padded bolster before prepping and draping. the so-called sloppy hinge. in addition to the full extension and flexion movement at the elbow joint. Warsaw. they are further subdivided into fully constrained and semiconstrained models. usually in the first few day s after injury. Warsaw. It is not necessary or desirable to perform this procedure emergently at night or on weekends without skilled staff. in contrast to the unlinked sy stems. The patient is positioned on a “bean bag” in the lateral decubitus position with the affected side up (Fig. nonsterile or sterile depending on the morphology of the arm. ulnar. SURGICAL TECHNIQ UE Surgery is performed when logistical preparations can be made. IN) sy stems. Implant Selection In general. 9. Due to the bone loss and loss of ligament attachment that is incurred in acute fracture patterns where a TEA is indicated—namely. Examples of this include the Coonrad-Morrey (Zimmer. These semiconstrained implants have a lower loosening rate than the traditional fully constrained. OTA/AO ty pe 13 C2-C3—a linked. Both the semiconstrained and constrained sy stems are linked. These differ in that the latter allow a small amount of varus-valgus and rotational movement. A tourniquet is used in all cases.4). and this results in lower rates of loosening. with the rationale being that the looser hinge allows for some accommodation of the stresses seen at the prosthesiscement and cement-bone interfaces. Alternatively. surgery can be performed in the supine position with the injured arm draped . and occasionally radial components or linked where the ulnar and humeral components are phy sically joined.

and a full thickness medial and lateral subcutaneous flap is created above the fascia. The bony landmarks are drawn on the skin with a sterile-marking pen (Fig. Fluoroscopy is not usually necessary when performing a TEA. It should be mobilized both proximally and distally to avoid injury. A sterile stockinette and flannel or an adherent wrap is placed on the hand. FIGURE 9. The next step is to identify and protect the ulnar nerve in the cubital tunnel. A 15-cm midline incision is made posteriorly centered over the elbow joint. The distal dissection should extend to the first motor . A first-generation cephalosporin is given intravenously prior to inflation of the tourniquet.4 The patient is placed in the lateral decubitus position on a “bean bag.free on a sterile bolster across the patient’s chest. 9. Intraoperative imaging is necessary only if a decision has to be made on whether to perform an ORIF or TEA.” and the extremity is supported over a bolster.5A).

The distal humeral fracture fragments are now completely excised (Fig. It is not usually necessary to repair the condy les or minimal metaphy seal fracture extension in the shaft. The Coonrad-Morrey sy stem has an 8-inch revision humeral component with a log anterior flange that is designed to accommodate for . The ulnar nerve is protected with a small Penrose drain or vessel loop (Fig. The fascia is exposed and (B) the ulnar nerve is mobilized distally to the branch of the FCU and tagged with a Penrose drain. that is. on the lateral side. the medial and lateral borders of the triceps are identified and incised. 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). which will allow repair and reattachment of these soft tissues at the conclusion of the procedure. Once the ulnar nerve has been identified and protected. If there is extensive proximal fracture extension. Similarly.5B). 9.6B). the LCL is released along with the muscle of the common extensor-origin in a continuous flap. exposing the fractured condy les (Fig. preserving the medial collateral ligament (MCL) along with the flexor-pronator origin as a continuous sleeve for later repair and reattachment.branch to the flexor carpi ulnaris (FCU) muscle. 9. and the triceps elevated from the distal humeral shaft. 9. Progressive subperiosteal and capsular release of soft tissues on the medial side of the elbow is performed. The bony landmarks are identified and marked on the skin and a posterior midline incision is made. FIGURE 9.6A).5 A. 5 to 6 cm past the end of the olecranon fossa.

distal humeral bone loss and may be useful in this situation. 9. broaches or rasps are then used to prepare the proximal ulna . Progressively larger reamers.7A). centering the fulcrum of the prosthesis with that of the greater sigmoid notch. and the elbow is flexed and externally rotated to expose the olecranon. The posterior cortex of the ulna is used as a guide for rotational alignment. 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.6 Once the ulnar nerve has been protected. FIGURE 9. A starting awl is used to identify the ulnar intramedullary canal. This serves as a landmark for the proper height of the prosthesis and in turn. This start point should be in line with the intramedullary canal of the ulna.7B). The tip of the olecranon is removed with a high speed burr or small rongeur to allow direct access down the ulnar canal. Any residual rough edges on the humeral shaft should be trimmed away with an oscillating blade or rongeur. the medullary canal is opened and enlarged using hand broaches or rasps in the arthroplasty tray until cortical resistance is encountered (Fig. Once the shaft of the humerus is accessible. 9. The humeral shaft is “delivered” either medially or more commonly lateral to the triceps tendon and stabilized with small Hohmann retractors. the distal humerus medial to the triceps is exposed followed by the (A) lateral side of the distal humerus. The fracture fragments are excised. the location of the flexion-extension axis for the arthroplasty. The retractors are removed. B.

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. 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. 9. .(Fig.D ).7C.

9. on the ulnar side. The humeral canal finder is inserted followed by (6a) rasps of increasing size. and (D) rasps of increasing size are inserted until the ulnar trial can be placed for a trial reduction (E). The trial components are reduced. If more extension is required. the components often need to be seated more deeply. 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. A humeral trial is inserted. the (C) entry point for the ulnar component is identified. Areas of potential impingement include the olecranon posteriorly and the coronoid process anteriorly. Also. but is not alway s possible.7E). Similarly .7 A. it is better to leave the elbow with a small (10 to 20 degrees) deficit in extension than to have the prosthesis hy perextend. B. A slight loss of terminal extension is usually . and elbow range of motion is tested for extension and flexion and signs of impingement (Fig.FIGURE 9.

and maximal range of motion can be achieved without impingement. the trials are removed.or 6inch humeral component and a 3. The canals are suctioned dry. The definitive components are cemented into the humerus and ulna and reduced (Fig. which increases stress on the prosthesis and the potential for loosening. The use of antibiotic-impregnated cement has been shown to decrease infection rates in TEA. and a cement restrictor with either a plastic plug or impacted cancellous bone from the condy les is placed in the humeral medullary canal. For the Coonrad-Morrey (Zimmer. and regular sizes. . We ty pically use a 4.B). Prior to cementing the humeral component. The elbow is extended until the cement hardens to ensure complete seating of the components.8C).8A. 9. but hy perextension can be painful and may lead to instability. The depth of insertion of the trials is noted and marked for insertion of the definitive implants. which is completely removed without disturbing the cement mantle around the prosthesis. and cement is injected with the use of a narrow-nozzle cement gun. the humeral and ulnar components are coupled together with the locking mechanism (Fig. depending on the size of the patient. Once the appropriate size trial has been identified. If cement premixed with antibiotics is not available. The wounds are irrigated and the joint reexamined for loose cement. with the latter usually used more for revision cases where a longer stem is required. The humeral and ulnar sides are inspected simultaneously for extruded cement. or 8. 6-. Both humeral and ulnar prostheses are available in extra-small. Sizes of components available for trialing depend on the sy stem used.well tolerated in the older patient. Warsaw IN) trial. The intramedullary canal is lavaged. and the stems fill their respective canals. a thin wedge of bone graft obtained from the fractured condy les is placed between the anterior humeral flange and anterior humeral cortex: once this heals. 9. humeral components are available with 4-. it helps to reduce stress on the humeral component. it is possible to add antibiotics to the cement mix. The current preference of the authors is to use a tobramy cin-cement mix. small.5-inch ulnar component. 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. Once the excessive cement is removed.inch stems.

The arm is held in extension until the cement hardens. The triceps fascia is closed and reapproximated with the edges of the medial (MCL.FIGURE 9. and the (C) locking mechanism with connecting axle placed. forearm fascia) and lateral (LCL. forearm fascia) soft-tissue sleeves. If a triceps splitting or reflecting approach had been used. excess cement is removed. The ulnar nerve is left in a tension free position medially .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. common extensor origin. A. D. flexor pronator mass. The tourniquet that was used during surgery is released and meticulous hemostasis obtained. The ulnar nerve is left in a tension-free . transosseous nonabsorbable sutures are required to reattach the triceps tendon attachment to the olecranon through drill holes. Humeral and (B) ulnar components are placed.

9.B). Subcutaneous closure using 2-0 absorbable sutures is performed followed by skin closure with staples.9). 9.position medially (Fig.9 The wound is irrigated with saline. . and the medial and lateral soft-tissue sleeves are reapproximated and sutured together. 9. An extension splint is applied for 24 to 48 hours. We do not routinely use suction drains after a TEA.8D). FIGURE 9. The incision is closed in lay ers. Postoperative radiographs are obtained (Fig. A plaster splint is placed anteriorly to immobilize the arm in full extension for the first 24 to 48 hours postoperatively (Fig.10A.

active elbow extension exercises are restricted for 4 to 6 weeks to protect the triceps repair. 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. If a triceps-sparing approach was used. the splint is removed. but DVT prophy laxis is not used routinely for this procedure.10 Postoperative radiographs showing AP (A) and lateral (B) views of the TEA. For elbow arthroplasty done through a triceps reflecting or split approach. Postoperative antibiotics are administered for 24 hours. . unrestricted active and passive range of motion exercises of the elbow are started.FIGURE 9. In these patients. On postoperative day 3. including exercises for the shoulder and wrist.

RESULTS Outcomes following total elbow replacement for displaced intra-articular distal humerus fractures are generally good to excellent. TEA patients are allowed to return to activities of daily living with a (life-long) 5 to 10 pounds weight restriction. Mckee et al. Patients are seen for clinical follow-up in 2 weeks for inspection of incision and monitoring of adequate wound healing. 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. Patients are then followed once every few months until the 1-y ear postoperative mark. Despite extension deficits of 20 to 30 degrees. studies show that resection of the humeral condy les during TEA for distal humerus fractures does not result in substantial decreases in forearm. patients are allowed to use crutches or a walker if needed. controlled clinical trial comparing TEA to ORIF in older patients (mean age 79 y ears) found higher MEPS and DASH scores in the TEA group. followed by another 4-week follow-up when radiographs of the elbow are obtained. 5 patients (of 20) randomized to internal fixation were found to have irreparable fractures and were treated with arthroplasty. The revision rates following elbow arthroplasty for fractures are low in most series.gravity -assisted extension exercises are used during the first 4 to 6 weeks to prevent stiffness at which time active extension is permitted. Moreover. We strongly advise that patients refrain from participating strenuous activities such as tennis or golf because of the substantial forces applied to the elbow. In terms of weight bearing for patients with associated lower extremity injuries. Functional outcomes as measured by the May o Elbow Performance Score (MEPS) and Disabilities of the Arm. . Lastly. Successful outcomes after TEA for fracture have been reported in patients that have been followed up to 5 y ears after surgery. (4) in a randomized. which may lead to aseptic loosening. wrist. although they do increase over time (5 revisions in 43 index cases at a mean of 7 y ears postoperatively in one series) (14). most patients have a functional arc of elbow flexion averaging 110 degrees and good or excellent functional scores at 1 and 3-y ear follow-up (11–13). Additionally. after which annual radiographs are obtained for signs of loosening. Shoulder and Hand (DASH) scores have shown improved outcomes compared to internal fixation in clinical studies.

Early deep infection is treated with urgent operative intervention. the ulnar component is affected more frequently.e. thorough irrigation. Late loosening that is clinically sy mptomatic usually requires revision arthroplasty (20). an important factor in decreasing infection rates. Although it is unsupported by currently available evidence. The most common organisms are Staphylococcus aureus and Staphylococcus epidermidis. Additionally. although the anterior cortex of the distal humerus is an area prone to osteoly sis. 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. The goal of arthroplasty is to reproduce phy siologic kinematics as closely as possible to minimize the amount of stress that can accelerate implant loosening. and the use of antibiotic-impregnated cement. when these parameters are individually measured (15). radical débridement. and component reassembly and closure. COMPLICATIONS Deep infection is the most feared early complication of elbow arthroplasty and is seen in approximately 5% of primary arthroplasties for fracture (15. Factors that may reduce deep infection rates include the use of preoperative antibiotics. then either chronic suppressive therapy or staged revision arthroplasty is required. the availability of proper equipment.16). and surgical experience all help to minimize surgical time. Although uncommon. followed by 6 weeks of intravenous antibiotics. If the prosthesis becomes loose. This consists of disassembly of the prosthesis. meticulous attention to draping of the extremity and surgical technique. obtaining deep cultures for proper bacterial identification. a careful preoperative plan. Aseptic loosening is the most common cause of late failure following TEA (17). 2 g vancomy cin in powder form).or hand strength. If this is unsuccessful.. the authors augment this with locally implanted antibiotics (i. Proper alignment of the prosthesis with the release of any preexisting soft-tissue contractures minimizes the long-term strain on the components. the poly ethy lene and bushings can experience locking mechanism disassociation and wear. Gill and Morrey (17) described a method of identify ing 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 .

or palpable crepitus. Herscovici D Jr. and postoperative care to optimize patient outcome. Finally. REFERENCES 1. Complications related to triceps dy sfunction have been significantly decreased by the use of a triceps sparing approach and the use of a linked prosthesis. O’Driscoll and Morrey (18) classified these fractures into the May o Classification of Periprosthetic Fractures of the Elbow. are significant and require careful patient selection. Morrey B. 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 y ears) patients. patient compliance.79(6):826–832. and the literature contains little evidence in favor or against prophy laxis after TEA (10). Although rare. osteoporosis. Periprosthetic humeral fractures have been reported and may be a result of additional trauma. A comparison of . 2. Complications. If there is radiographic evidence of bushing wear and the patient has sy mptoms of pain.radiograph. 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. et al. Frankle MA. meticulous surgical technique. or aseptic loosening. Cobb T. they usually require revision with a long-stem revision implants and strut allograft augmentation. As 7 degrees of varus-valgus laxity is built into the implant.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. heterotopic ossification following elbow arthroplasty is rare. J Bone Joint Surg Am 1997. although rare. then revision of the bushings and or poly ethy lene may be indicated. stress shielding. We do not routinely use heterotopic ossification prophy laxis when performing TEA for fracture. DiPasquale TG. squeaking. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. surgical technique. implant positioning. they defined partial bushing wear as an angle between 3.

434:222–230. Singh S. My kula R. Lee KT.20:S97–S106. 4. Stern R. J Shoulder Elbow Surg 2011. 9. Dent C. Veillette CJ. Gambirasio R. An option for the elderly patient.83(7):974–978. . Kamineni S. J Trauma 2005. Lai CH. J Bone Joint Surg Am 2008. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analy sis of the results. McKee MD. 5. Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients. Total elbow replacement for complex fractures of the distal humerus. Sanchez-Stotelo J. 7. Rivstevski B.86(5):940–947.17:473–480. et al. Garcia JA. et al. Distal humeral fractures: fixation versus arthroplasty . 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. Chiu FY. Nauth A. J Bone Joint Surg Br 2008. Complex fractures of the distal humerus in the elderly. Morrey BF. randomized. Huang TL. J Orthop Trauma 2003.20:S90–S96. A multicenter. Matthews SJ. controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. Adams RA. Management of acute distal humeral fractures in patients with rheumatoid arthritis: a case series. Distal humeral fractures treated with noncustom total elbow replacement. 12. Melhoff TL. 14. J Shoulder Elbow Surg 2011.18:3–12.61(4):889–892. J Shoulder Elbow Surg 2009. et al. Approaches for elbow arthroplasty : how to handle the triceps. J Bone Joint Surg Am 2011. J Bone Joint Surg Am 2004. Riand N. J Trauma 2006. et al. Morrey BF. Prospective. 6.93:686–700. Chuang TY.58:62–69. Prasad N. Hall JA. Bennett JB. Fractures of the distal humerus in the elderly : is internal fixation the treatment of choice? Clin Orthop Relat Res 2005. McKee MD. The role of total elbow arthroplasty as a primary treatment. Agarwal M. et al. 10. J Bone Joint Surg Br 2001. Jost B. 13. 3. Stanley D.90(3):343–348. Morrey BF. Distal humeral fractures in adults. J Bone Joint Surg Br 2002. 8.90:2197–2205. 11.84(6):812–816. Srinivasan K.open reduction and internal fixation and primary total elbow arthropalsty in the treatment of intraarticular distal humerus fractures in women older than age 65.

Morrey BF.85:805–807. Ferreira JM. Effect of humeral condy lar resection on strength and functional outcome after semiconstrained total elbow arthroplasty . J Bone and Joint Surg Am 1998. Periprosthetic fractures about the elbow. Fisher D. Gill DR. 17. et al. Frankle MA.15. J Bone Joint Surg Am 2003. Pichora JE.131(2):021005. et al. Figgie MP. Defining flexion-extension axis of the ulna: implications for intra-operative elbow alignment. J Bone Joint Surg Am 1990. Pugh D. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: A ten to fifteen-y ear follow-up study . Richards R. . Virani N. et al. Brownhill JR. Orthop Clin North Am 1999.30:319–325. Wolfe SW. McKee MD. 2009. Management of infection about total elbow prostheses. 19. 20.21(4):363–373. 18. Inglis AE. Tech Orthop 2006. 16. Johnson JA and King GJ. Morrey BF.72:198–212. O’Driscoll SW.80(9):1327–1335. J Biomech Eng. Immediate total elbow arthroplasty for distal humerus fractures.

Although olecranon fractures frequently occur as isolated injuries. since this portion of the olecranon is responsible only for limited load transmission.10 Olecranon Fractures: Open Reduction and Internal Fixation James A. and ulnohumeral instability determines the method of surgery to be used to treat olecranon fractures. Evaluation of fracture displacement. Olecranon fractures occur in all age groups with a bimodal injury pattern. and repair or replacement of the radial head when these structures are injured is critical for restoration of elbow function. no single method of treatment is applicable to all fractures. There are a large number of classifications for olecranon fractures that . Careful attention to associated injuries with repair of the lateral ligament complex. repair of the anterior capsule and coronoid process. The goal of treatment in displaced fractures is to achieve stable internal fixation that allows early range of elbow motion. Peaks occur in y ounger adults following higher injury trauma and in older patients with poor bone quality following ground-level falls. They vary in complexity from relatively simple transverse fractures to highly comminuted and unstable fracture dislocations. comminution. Small areas of comminution and minor incongruities in the transverse groove are well tolerated. failure to recognize concomitant bone or soft-tissue injuries associated with ulnar fractures often preclude restoration of normal elbow function. Goulet and Kagan Ozer INTRODUCTION Fractures of the olecranon constitute approximately 10% of fractures that occur about the elbow. The critical element in treatment of a proximal ulnar fracture is restoration of the size and shape of the trochlear notch. Due to the wide spectrum of fracture patterns.

10. Both the Schatzker and May o classifications are descriptive based on the fracture pattern and a consideration of the ty pe of internal fixation required (2.have been described. The AO/OTA classification is probably the most widely used in North America (Fig.15). .4. Colton devised a simple descriptive sy stem that is still widely employ ed.1).

FIGURE 10. INDICATIONS AND CONTRAINDICATIONS FOR .1 AO/OTA classification of olecranon fractures.

. Patients who can actively extend their elbow against gravity can usually be treated nonoperatively. which is converted to a removable splint. fixation with plates (with or without locking screws). Because the olecranon and proximal ulna are subcutaneous in location.2 A displaced olecranon fracture with disruption of the extensor mechanism and articular surface. and the bone quality. and gentle active motion is initiated 2 to 3 weeks after injury . These injuries are treated in a well-molded long arm cast. 10. lowprofile implants are important to reduce the incidence of painful prominent hardware. FIGURE 10.2). Most displaced olecranon fractures require surgical treatment (Fig. and olecranon excision with triceps advancement (1–11). This is a very strong indication for surgery . Treatment alternatives include simple tension band wire fixation.SURGERY Nondisplaced and very minimally displaced fractures (<2 mm) can be treated nonoperatively if the triceps mechanism remains intact. Treatment is influenced by the size of the olecranon fragment. the degree of comminution.

Tension band wiring is contraindicated in comminuted fractures as it cannot preclude shortening with this technique. Comminuted length-unstable fractures. and olecranon fractures associated with radial head or coronoid fractures are treated with locked plates. In the past decade. In these fractures and those associated with ulnohumeral instability. precontoured periarticular proximal ulnar-locking plates have been developed and can be very helpful.Tension band wire fixation is reserved for simple transverse fractures and most noncomminuted injuries. . which constitute the majority of olecranon fractures (Fig. in patients with poor bone quality. Conventional nonlocking plates are adequate for fractures in y ounger patients with good bone quality and no fracture gaps. 10. plates and screws often provide better fixation (Fig.3).4). 10.

3 Radiographic appearance of a properly done tension band wire construct. .FIGURE 10.

10.12.4 A comminuted length unstable olecranon fracture treated with a plate and screws.FIGURE 10. . Olecranon excision with triceps advancement is used occasionally in patients with small comminuted fractures that do not affect elbow stability (5.13). Most are elderly patients with significant osteoporosis (Fig. In y oung 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.5A. Olecranon excision is contraindicated for fractures distal to the semilunar notch or for fractures associated with ligamentous instability.B).

). open wounds. etc. neurologic status. medications. patients with complex associated injuries.5 A. She was treated by excision and triceps tendon repair. The phy sical exam must evaluate and document objective findings such as swelling. etc. patients who are . ballistic injury. cardiac problems. high energy. The history should identify the mechanism of injury (low vs. and peripheral pulses. pertinent past surgical history . pertinent comorbidities (diabetes mellitus. Patients with minimally displaced olecranon fractures should be evaluated to determine if active elbow extension is present. and drug allergies. PREOPERATIVE PLANNING History and Physical Exam A careful history and phy sical exam should be performed on all patients with an elbow injury. An 87-y ear-old female with multiple medical comorbidities fell. A full trauma workup using Advanced Trauma Life Support (ATLS) protocols is necessary in patients with highenergy trauma.B. sustaining an olecranon fracture. Hand dominance should also be established. ecchy mosis.FIGURE 10.). because it is an important criterion for nonoperative treatment.

x-ray s of the entire humerus or forearm may be indicated. antibiotic administration. irrigation and débridement should be performed as soon as the patient’s condition and institutional resources permit. an anteroposterior (AP) and lateral radiographs should be obtained. high-quality orthogonal radiographs are often difficult to obtain in the conscious patient. For closed olecranon fractures. softtissue abrasions may require local skin care prior to internal fixation.obtunded. Based on the phy sical examination. Low-velocity gunshot wounds without a neurovascular injury are treated with local wound care. optimal films cannot be obtained until the patient is anesthetized in the operating room. exploration. Due to pain associated with positioning of the elbow. In some patients. radial head or coronoid fractures. In patients with highly comminuted fractures associated with grossly contaminated wounds. IMAGING STUDIES In patients with suspected elbow injuries. 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. Immediate internal fixation may be beneficial for Grade I and II open fractures. With open fractures. or fracture dislocations. and fracture stabilization if indicated. Traction films with light sedation can be helpful for evaluation of complex fractures in a cooperative patient. in patients who are hemody namically stable. repair. If a vascular injury is present. internal fixation is performed electively when the soft tissues permit. and patients who have a head injury . splinting or external fixation is preferred with sequential débridements followed by delay ed internal fixation. Because the olecranon is a subcutaneous bone. Computed tomography scans are not usually necessary for isolated olecranon fractures and are most often used for olecranon fractures associated with articular impaction. and external fixation should be performed urgently in collaboration with a vascular surgeon. SURGICAL TACTIC .

4-. and 2. However. Some surgeons prefer placing the patient either in a lateral or in a prone position. A nonsterile tourniquet is applied to the upper arm. The patient is placed in a supine position. Mansfield. the wrist may be secured with a sterile Kerlex (Kendall Healthcare Products. This determines what should be available in the operating room if surgery is required. 14 gauge angiocath to pass the wire beneath the triceps tendon. 10. Suture anchors are indispensable when ligamentous instability is suspected. limits the complexity of anesthetic . Small and medium pointed reduction clamps should also be available. a battery -powered drill.5-mm cannulated screws for intramedullary fixation. When an assistant is not available. provision should be made for “minifrag” 2. noncomminuted transverse fractures. a treatment plan is developed. A proximal radial prosthesis should also be available when a displaced radial head or neck fracture is present. For simple fractures.0-. fracture reduction often can be achieved with the elbow in 90 degrees of flexion. and a no. it is their job to support the arm. supine positioning minimizes setup time.7-mm plates and screws. MA) and attached to a weight on the patient’s contralateral side. Flexion of the elbow can be adjusted by vary ing the height of the support under the proximal forearm. Standard “small fragment” implants and instrument sets are requested for plate fixation of fractures distal to the semilunar fossa. the surgeon should plan to have 18-gauge stainless steel wire.6A).Following a careful preoperative assessment of the patient and a critical review of the injury radiographs. When an assistant is available. but most complex fractures require the freedom to freely flex and extend the elbow. Kirschner (K) wires. 2. the table is tilted obliquely toward the patient’s noninjured side. Surgery is performed with the forearm placed across the chest. To facilitate visualization and stability. and/or 4.5. SURGERY Either regional or general anesthesia can be utilized. 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. with a supportive bolster placed beneath the proximal forearm (Fig.or 6. More complex fractures require a wider array of equipment. For simple.

In case of allergy. A towel or bolster is used to support the forearm.6B). The patient is positioned supine on the table with the arm across the chest. and accommodates management of patients with multiple injuries who cannot be positioned either lateral or prone. an aminogly coside or penicillin or both are also administered. The incision starts on the subcutaneous border of the ulna and extends proximally around the tip of the olecranon.6 A. 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 . 4 to 5 cm (Fig. FIGURE 10. One gram of cefazolin is administered at the beginning of the case. vancomy cin is used. A curved incision is drawn on the skin with a sterile marking pen. The entire arm from fingertips to the tourniquet is carefully prepped and draped.monitoring. B. A C-arm intensifier is essential and must be positioned to provide high-quality intraoperative images. 10. When the fracture is open.

Another helpful tip is to drill a 2. allowing the joint to be inspected for chondral damage.or 1. 10. Debris and clot are removed from the fracture site. but is not routinely mobilized. The remaining fracture is then reduced and provisionally stabilized with one or sometimes two-pointed reduction forceps. and 2 to 3 mm of periosteum is elevated along the length of the fracture to improve visualization and subsequent reduction. The proximal fracture fragment is reflected proximally . The incision is deepened to the level of the fascia. Multiple small 1.7). In more complex cases. the reduction may be challenging (Fig. and if the resulting defect creates an unstable void. The fracture reduction is checked radiographically . The ulnar nerve is identified medially. which may be augmented with minifragment screws.25. Reduction can be facilitated by extending the elbow to reduce the pull of the triceps. .6-mm K-wires are used for provisional fixation. the fracture is reduced and held with a large pointed reduction tenaculum (Fig.incision when the soft-tissue envelope is compromised (14. and a full-thickness subcutaneous flap is elevated over the olecranon medially and laterally. The forearm muscles are minimally reflected from the ulnar diaphy sis as needed for visualization.8). and articular impaction.15). With simple two-part fracture. with the C-arm. The fracture site is identified. loose bodies. particularly those with fracture comminution and/or articular impaction. Depressed osteoarticular fragments must be elevated.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. it should be bone-grafted. 10.

7 A schematic illustration of an olecranon fracture reduced and held with a large pointed reduction forceps. .FIGURE 10.

.

This allows the Kwires to be bent. and directed into the anterior cortex of the proximal ulna (Fig. the K-wires should be backed out of the anterior cortex for a few millimeters after the anterior cortex has been penetrated. 10.or 2. advanced.8 Articular impaction in a 22-y ear-old female after a fall onto her elbow. just beneath the subchondral bone. and countersunk at the end of the procedure. The position of the wires must be confirmed with an AP and lateral image with the C-arm (Fig. Strategically placed pointed reduction forceps are used to achieve and maintain fracture reduction. Either a 1. To avoid excessively long pins through the anterior cortex.9).FIGURE 10. . 10.6.10). A tension band wire construct is used as definitive fixation in noncomminuted transverse olecranon fractures.0-mm K-wire is advanced through the tip of the olecranon on each side of the reduction tenaculum.

.9 The K-wires are placed that engage the anterior cortex of the proximal ulna.FIGURE 10.

The wires are crossed posteriorly and are then tightened by twisting the proximal wire to the distal wire both medially and laterally (Fig.FIGURE 10.10 The reduction must be confirmed radiographically using the C-arm. a single wire can be used. An 18-gauge stainless steel wire is then placed through the drill hole.11).0-mm drill bit is then used to create a transverse drill hole. Placing one wire proximally through the angiocath (which is then removed) and one wire distally is a simple and effective technique. 2 to 3 cm distal to the fracture site midway between the posterior and anterior cortex. 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. A 2.12). 10. The ulnohumeral joint should lie roughly midway between the tip of the olecranon and 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 Kwires. 10. The sty let is removed leaving the latex angiocath in place. The tension band construct can be created using either one of two wires. Alternatively.

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. .FIGURE 10. which are then tensioned and slowly tightened. The exact amount of tightening is done by “feel. After the wires are tightened. excess wire is clipped and bent to minimize wire prominence. completing fixation (Fig. Lastly. All of the slack should be “removed” from the wire(s). A variety of wire tighteners are commercially available.” Excessive tightening can easily break the wire necessitating repeating the process. or it can be done with two heavy needle drivers. the K-wires are bent 180 degrees and crimped with pliers before they are impacted over the proximal wire loop.

It is critical that the fracture is anatomically reduced prior to screw insertion (Fig. definitive fixation of a transverse noncomminuted olecranon fractures can be achieved using a 4.5 mm intramedullary screw. FIGURE 10. 10.15). which is used as a proximal anchor for the tension band wire(s). or poor fixation (Fig. Failure to follow these steps may lead to fracture translation. Equally important is to ensure that the screw is perfectly in line with the intramedullary canal.10. 10.5 or 6.14A–D).13 Completed tension band fixation. gapping. Alternatively. . The ends of the wire should be bent 180 degrees and impacted over the wire into bone.13).

. Preoperative radiographs demonstrating a displaced transverse olecranon fracture. Tension band fixation with an intramedullary screw.14 A.B. C.FIGURE 10. two loops are made to tension both sides equally .D. Before tightening the figure-of-eight wire.

.5-mm lag screw placed through the proximal end of the plate to allow for compression at the fracture site. or a 3. Securing the distal end of the plate to the proximal ulnar diaphy sis completes the fixation. it can lead to translation or gapping at the fracture site.FIGURE 10.5 mm one-third tubular plate may be modified for this purpose (Fig.15 If the intramedullary screw is not placed perfectly . Precontoured plates may be used. 10.B). a plate contoured around the proximal end of the olecranon after reduction can be an effective treatment method. the plate is applied with a 3. In some patients with a large proximal fracture. Ty pically.16A.

although pins and connecting bars from a small external fixator set are equally effective.B). Comminuted fractures and fractures with instability of the ulnohumeral joint require a more detailed approach to fracture reduction and fixation. 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. indirect reduction and plating can be helpful. 10. The fracture can then be distracted out to length (Fig.17A–C). small fracture fragments can be teased into place. with one or more plates. Sometimes. Even with improved posterior plates. 10. .18A. Commercially available “minidistractors” can be used.B. followed by definitive fixation. With indirect reduction. A second or third locking screw placed through the plate and into the proximal fragment significantly improves fixation stability. a single locking plate can replace the need for two nonlocking plates. however. I prefer to use a locking plate for simple large olecranon fractures when bone quality is poor (Fig. In these cases.16 A. a supplementary medial buttress plate may prove helpful. Small bone fragments may preclude simple piece-by -piece reassembly of the fragments and risk devascularizing of the pieces. 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. .FIGURE 10.

B.FIGURE 10.19A–D). . 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.18 A. Recognizing injuries associated with olecranon fractures is essential to obtaining consistently good functional results.” Operative management consists of radial head replacement and capsular repair in addition to reconstruction of the proximal ulnar fracture (Fig. A schematic drawing illustrating the use of indirect reduction of the proximal ulna using a minidistractor. 10.

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

Patients who do not rapidly regain their range of motion are referred to a phy sical therapist. Antibiotics are continued for 24 hours postoperatively. A drain is not usually placed if adequate hemostasis has been obtained. The fracture is examined through a full range of motion to confirm fracture stability. but may be necessary in the setting of ligamentous instability . We allow patients to use their arm for activities of daily living. At 6 weeks if the fracture is healing uneventfully. on the day following surgery. and functional capacity evaluations are administered prior to the employ ee’s return to work. The splint remains in use until adequate motor control is achieved. a single postoperative intravenous antibiotic dose is given. POSTOPERATIVE CARE Uneventful wound healing and institution of early motion are the goals following open reduction and internal fixation of an olecranon fracture. 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. the tourniquet is released. The patient is instructed to remove the splint for active assisted range-of-motion exercises three to four times each day. 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 . Hinged elbow braces are used rarely postoperatively. heat-molded splint set at 90 degrees of flexion.After fracture fixation is complete. The arm is placed in a posterior splint. Patients with simple transverse fractures are usually discharged on the day of surgery. ty pically between 3 and 4 weeks postoperatively. For most patients. work-hardening programs are utilized. RESULTS . The wound is irrigated and closed in lay ers. the elbow is placed into the precontoured. the strengthening phase of rehabilitation is initiated. and final radiographs are obtained. A progressive resistance program is employ ed to strengthen the entire upper extremity. For manual workers. In these patients. The splint is secured to the arm with Velcro straps.

If the fracture fixation is stable. If the fracture fixation is loose or unstable. Infections are more common after open fractures.9. the hardware should be removed and appropriate antibiotics utilized followed by delay ed reconstruction. A patient with a postoperative infection requires irrigation and débridement with culture-specific intravenous antibiotic therapy. with loss of terminal extension of about 10 degrees the most frequently reported complication. Some loss of motion is common.4. more than most fractures. Complications with more serious implications include soft-tissue compromise.17). Once the fracture has healed. and malunion or nonunion. The risk of infection is decreased with the use of preoperative antibiotics and careful handling of the soft tissues. Patients should be advised that motion and strength may be diminished compared to their preoperative status.16. If these measures fail and implant removal is required.6–8. ranging from 76% to 98%. removal is delay ed until at least 8 months after fracture fixation and is followed by an additional 6 weeks of protected activity . Prominent hard-ware has been reported in 20% to 80% of patients in published series. implant removal is necessary in many patients following internal fixation. with good to excellent functional results should be anticipated with surgical management of olecranon fractures (4–7.High rates of fracture union. COMPLICATIONS The most common complication following olecranon fracture fixation is discomfort associated with prominent implants. although these changes are rarely significant functionally . we recommend aggressive débridement and sy stemic antibiotic suppression. infection. . early hardware removal and external bracing are utilized until the fracture strengthens enough to withstand phy siologic loads. Infection has been reported to occur in 0% to 6% of cases. but increases in frequency with fracture complexity (19). 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. careful attention to operative technique may reduce implant prominence and reduce the need for implant removal. Nonunion is uncommon following internal fixation of simple transverse fractures. and implant removal has been reported in 34% to 66% of olecranon fractures (1.16– 18). As noted previously. elbow stiffness. Even so.

the fracture has healed.Considerable consolidation of small fracture fragments often occurs even when an olecranon fracture fails to heal. FIGURE 10. et al. Outcome of plate fixation of olecranon fractures. implant removal and repeated fixation are recommended (Fig. Patterson SC.B. Ring D. the nerve should be identified and protected during open reduction and internal fixation. so far as this can be achieved without creating articular incongruity . Compression across the fracture line is desirable. An olecranon nonunion with hardware loosening 9 months after initial fixation. Anterior interosseous nerve injury has also been noted in association with operative management of olecranon fractures (20). MacDermid J. and in most patients. 2. REFERENCES 1. often leaving a single ununited fracture line. it spontaneously resolves. Bailey CS. After infection has been ruled out as a cause of nonunion. Chin KR. Jupiter JB.15:542–548. Exploration may be considered when it does not resolve spontaneously . Following compression plating.20A.B). Double tension-band fixation of the . Ulnar neuropathy has been reported in 2% to 12% of cases following internal fixation. J Orthop Trauma 2001. Postoperative ulnar neuritis is usually transient. To limit the risk of ulnar neuritis. 10.20 A.

Scham SM. Olecranon fractures treated with AO screw and tension bands. 14. Injury 1973. 6. Dameron T Jr.28:117–122. 8. Results of open reduction and plate osteosy nthesis in comminuted fracture of the olecranon. Clin Orthop 1992.285:229– 235. J Trauma 1981.5:121–129. Kamath V. Mehia JA. AO principles of fracture management. 2000:338–339. Displaced olecranon fractures in . Shannon F. J Bone Joint Surg Br 2011. J Trauma 1969. 13. In: Ruedi TP. 5.olecranon. Sculco TP. Otis JC.9:594–602. 11. Didonna ML. Noel J. Roetker A. Schwab J. et al. Fractures of the olecranon in adults: classification and management.93(2):245–250. 9. Mullett JH. Gartsman GM. The treatment of olecranon fractures by excision of fragments and repair of extensor mechanism: historical review and report of 12 fractures. 4. 12. Injury 2000. Sever C.21:469–472. K-wire position in tension band wiring of the olecranon: a comparison of two techniques. Surgical approaches to the elbow. 7. Olecranon fractures: a clinical and radiographic comparison of tension band and plate fixation. Erturer RE. Greene W. Murphy WM.370:19–33. Wiss DA. Olecranon fractures: a review of 100 cases. Complex elbow injuries. J Shoulder Elbow Surg 2011. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. 3. 10. eds. Wilson J. Howard T. Murphy D.16:1313–1317. 16. et al.31:61–66. Bain GI. et al. Operative treatment of olecranon fractures: excision or open reduction with internal fixation. Fernandez JJ. Johnson R. Hume MC.63:718–721. New York. Tanzer T. Partial olecranon excision: the relationship between triceps insertion site and extension strength of the elbow. Colton CL. Bajwa A. Orthopedics 1993.31:427– 431. Patterson SD.9: 66–68. Sonmez MM. Tay lor TK. Orthopedics 1986. NY: Thieme Medical Publishers. J Hand Surg Am 2003. Horne J.20(3):449–454. Quintero J. 15. Inhofe P. Lim TH. Tech Shoulder elbow Surg 2000. et al. Clin Orthop 2000. J Bone Joint Surg Am 1981. Biomechanical comparison of interfragmentary compression in transverse fractures of the olecranon.

Wolfgang G. McKee MD. Bush D. Surgical treatment of displaced olecranon fractures by tension band wiring technique.224:215–223. J Bone Joint Surg Br 1994.224:192–204. Clin Orthop Relat Res 1987. Campbell DA. eds. et al.adults. 20. Anterior interosseus nerve injury following tension band wiring of the olecranon.76:627–635. Jupiter JB. 19. 1992:1455–1522. Clin Orthop Relat Res 1987. In: Browner BD. Burke F. Papagelopoulos J. Jupiter J. Parker JR. Epub March 19. Injury 2005. Skeletal trauma. Philadelphia. 17. Treatment of nonunion of olecranon fractures. Conroy J. 18. Trauma to the adult elbow and fractures of the distal humerus. 2005. PA: WB Saunders. Morrey BF.36(10):1252– 1253. . Clinical evaluation. Levine AM.

16–18). 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). perhaps due to the prevalence in these early series of isolated partial head fractures for which good results would be expected (10–15).20). INDICATIONS AND CONTRAINDICATIONS Historical Background For most of the last century. Combined with increased availability and use of more predictable metal radial head prosthesis for complex fractures of the radial head (19. Early reports of open reduction and internal fixation of fractures of the radial head were very positive. nonunion.6–8). Some subsequent reports have found that complex fractures of the radial head are prone to early failure. excision of the radial head was the only . In conjunction with the inadequacy and problems associated with the silicone rubber radial head prostheses (2. it became popular to attempt to save even the most complex fracture of the radial head by operative fixation (9). and poor forearm rotation after operative fixation (9.11 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 (2–5).

20. results of prosthetic replacement of the radial head have been quite favorable (19. 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). 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 (10–15). If excision was elected.37). the popularity of the new techniques for internal fixation of small fractures. the entire head was resected because the results of partial head excision were usually poor (24–27).commonly used treatment for fractures of the radial head (22.28) (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) (29–32). 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 good results in these series.23. .29–34). Problems have been reported related to the articulation of a metal radial head implant with native capitellar cartilage. particularly very comminuted fractures with greater than three articular fragments (9). and the increasing recognition of the importance of the radial head led many to emphasize the importance of preserving the native radial head. On the other hand. although the majority of these are related to an oversized prosthesis (36). severity.16–18). The radial head is increasingly recognized as an important stabilizer of the forearm and elbow (2–5. 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. the decision making for radial head fractures associated with instability of the forearm or elbow now focuses on fixation versus prosthetic replacement (21). In general. making it a useful alternative to open reduction and internal fixation. Some authors even suggest that ulnohumeral arthrosis after elbow fracture dislocation is accelerated in the absence of a radial head (35). The incidence.23) and decision making was simple: excise or do not excise. subsequent study have reported unpredictable results after internal fixation of more complex fractures of the radial head (9. Combined with recent improvements in radial head prostheses. Unfortunately.

Healing of the radial head with this deformity might contribute to loss of forearm motion. Particularly for unstable elbow injuries such as the terrible triad pattern of elbow fracture . This may be due to articular incongruities. many chronic EssexLopresti lesions result from failure of attempted operative fixation of the radial head. tenuous fixation of a complex radial head fracture may be inadequate and prosthetic replacement might be preferable. the initial treatment must include restoration of contact between the radial head and capitellum to prevent marked proximal migration of the radius. The primary goal of treatment is to ensure forearm rotation. Attempts to save the radial head at all costs might be unwise in this setting. compromise the stability of the forearm or elbow. Some patients with healed. For instance. although some data are at odds with this (13).41)]. 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). scarring. In this circumstance where the radial head is essential. but—based on observations of my own patients. When the interosseous ligament of the forearm has been torn [the socalled Essex-Lopresti lesion (28) and variants (40. 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. failure to restore the radial head will result in a chronic forearm instability that currently had no good solution (42). and—although relatively uncommonly — cause radiocapitellar arthrosis. Incongruity of the radial head in the proximal radioulnar joint causes loss of rotation. Loss of ulnohumeral motion is usually related to capsular contracture and only rarely related to interference from displaced fracture fragments.Goals of Treatment Fracture of the radial head can restrict forearm rotation. or heterotopic bone formation. The circumstance is similar for elbow fracture dislocations. Operative fixation can restrict forearm rotation via implant prominence. Although restoration of the radial head does not guarantee good function in this complex injury. Painful arthrosis of the proximal radioulnar joint is not usually observed. apparently well-aligned fractures of the radial head after operative fixation have substantial loss of motion that is not attributable to implant prominence (9).

it can be useful to aspirate the hemarthrosis and place a local anesthetic in the elbow joint.46). Crepitation with forearm rotation does not seem predictive of problems. 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. cause pain. secure reconstruction of the radial head is requisite.dislocation (30). Although radiographic criteria for acceptable alignment of the radial head articular surface are frequently offered (25.46. radiocapitellar arthritis is an uncommon presenting complaint about which very little has been published (48). 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. there are few data to support them. If the fracture is too complex to achieve this.45. They rarely block motion. Although displaced fractures of the radial head are extremely common. Many partial head fractures are difficult or impossible to repair securely and should also be considered for prosthetic replacement (43). Because it can be difficult to assess forearm rotation in the setting of an acute painful elbow hemarthrosis. or lead to arthrosis. Alternatively — perhaps preferably —if the patient is evaluated in the office at least 4 or 5 day s after injury. provided there is no block to motion. Since operative treatment represents an opportunity for several . there is usually sufficient pain relief to allow a reliable examination. then radial head replacement may be preferable.49. they lack scientific support. the surgeon should not take too much credit for good elbow function after operative treatment of isolated partial fractures of the radial head. 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)].32. One generally accepted indication for operative treatment of an isolated partial fracture of the radial head is a fracture that blocks forearm rotation. although this deserves further study . The part of the radial head that is fractured is the critical anterolateral buttress resisting posterior displacement of the elbow (44).50). Although radiographic criteria for operative treatment have been suggested.

Displaced. 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).54).complications. the anterolateral aspect of the radial head is fractured. 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. it is uncommon to observe a block to forearm rotation. While such fractures would seem to be obvious candidates for open reduction and internal fixation because the majority of the head remains intact. Among this small group of patients. Early failure of fixation of these fractures is potentially problematic. the small size of the fragments. they can be very challenging to treat due to fragmentation. 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. it should be undertaken with care (51). I believe that a low-energy injury in . reliable fixation can be achieved. partial head fractures are common among patients with posterior olecranon fracture dislocations—the majority of whom are older. Such fractures are usually displaced and unstable with little or no soft-tissue attachments and occasionally some fragments are lost (55). lost fragments. Therefore. particularly in the setting of an Essex-Lopresti injury or a terrible triad fracture dislocation of the elbow. but I favor retaining the stability and support of radiocapitellar contact in most cases. 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. with resultant loss of the anterior buttress of the ulnohumeral joint (44). Usually. In some cases. I have neglected or excised a small partial radial head fracture in this setting. poor bone quality. with good results. Open reduction and internal fixation is indicated when stable. Even a relatively small fracture can make an important contribution to the stability of the elbow and forearm. limited subchondral bone on the fracture fragments. Some authors believe that radial head excision is acceptable in this setting provided that the ulnohumeral joint is stable (56). and metaphy seal comminution and bone loss (43). osteoporotic women.

PREOPERATIVE PLANNING Plain radiographs are useful for determining the overall pattern of injury.an older patient is a relatively favorable setting in which to consider neglecting or resecting the radial head. Fractures Involving the Entire Head of the Radius Fractures involving the entire head of the radius [ty pe 3 according to the sy stem of Mason (22)] are almost alway s part of a more complex injury. each of sufficient size and bone quality to accept screw fixation. either with operative fixation or prosthetic replacement. reliable fixation can be achieved. When treating a fracture dislocation of the forearm or elbow with associated fracture involving the entire head of the radius. but only if the elbow and forearm are stable. particularly with forceful use. if there are more than three articular fragments. metaphy seal bone loss. impaction and deformity of fragments (39). but that retention of the radial head. In particular. and poor forearm rotation may be unacceptable (9). nonunion. active patients injured in high-energy injuries. 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 . and little or no metaphy seal bone loss. low-demand patients are best treated with resection of the radial head without prosthetic replacement. and the size and quality of the fracture fragments may make open reduction and internal fixation a less predictable choice. There is a definite risk of both early failure and later nonunion. The optimal fracture for open reduction and internal fixation will have three or fewer articular fragments without impaction or deformity. Other factors such as loss of fragments. although it can be debated whether a metal prosthetic articulating with capitellar cartilage is better than no articulation at all in the long run. both of which can contribute to recurrent instability (9). but retention of the radial head may improve the function and durability of the elbow. The rare y ounger patient with an isolated injury involving the entire radial head can also be considered for excision without prosthetic replacement. would be preferable in healthy . Some older. open reduction and internal fixation should only be considered a viable option if stable. the rates of early failure.

Intraoperative evidence of ligament injury should alway s be sought (63). complex fractures of the radial head are nearly alway s associated with a complex injury. and (e) posterior olecranon fracture dislocations (posterior Monteggia pattern injuries) (29.30.58) [the so-called terrible triad (59)] (Fig. (d) posterior dislocation of the elbow with fractures of the radial head and coronoid process (18. (b) fracture of the radial head and rupture of the medial collateral ligament complex and/or fracture of the capitellum (Fig. If there is at least one fracture fragment with no contact with the intact radial neck on radiologic studies. 11.1C).58). particularly if simple excision is being considered (23).41)] (Fig.1D). . then an associated fracture or dislocation is very likely (55).of the interosseous ligament of the forearm [Essex-Lopresti and variants (28. 11.60–62) (Fig.1B). (c) fracture of the radial head and posterior dislocation of the elbow (57. 11. (39). 11.40. As has been emphasized by Davidson et al.1A).

Fracture of the radial head and medial collateral ligament injury .FIGURE 11. An EssexLopresti lesion or variant. one should consider the possibility of one of the following complex injury patterns: A. MD. An elbow fracture dislocation. C. B. An olecranon fracture dislocation. D. (All parts Copy right David Ring.1 When evaluating a fracture of the radial head.) Plain radiographs frequently underestimate the complexity of a radial .

head fracture (Fig. 11.2). Computed tomography —particularly threedimensional 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 alway s be
prepared for prosthetic replacement of the radial head in case operative
fixation proves unfeasible or unwise (Fig. 11.2C,D).

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 Copy right 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.

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).

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 ty pically fractured, but puts the posterior interosseous
nerve at greater risk.

A more anterior interval protects the lateral collateral ligament complex,
but places the posterior interosseous nerve at greater risk (23). Some authors
recommend identify ing 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 supracondy lar ridge of the distal humerus,
if one incises the origin of the extensor carpi radialis, elevates it, and incises
the underly ing elbow capsule, it is then possible 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.
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 alway s
occurs [or nearly alway s according to some authors (68)] as an avulsion
from the lateral epicondy le. Along with a variable amount of muscle
avulsion from the lateral epicondy le (68–72), these injuries leave a
relatively bare epicondy le (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 epicondy le resulting in a relatively bare
epicondy le. This damage should be used to enhance exposure to the radial
head. (Copy right David Ring, MD.)
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
sy nostosis.

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). 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 Copy right
David Ring, MD.)
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 epicondy le. 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
epicondy le (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 11.6
In the uncommon circumstance that a complex fracture of the radial head is
not associated with injury to the lateral collateral ligament (e.g., EssexLopresti 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
epicondy le.
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 identify ing 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
ty pes include T- and L-shaped plates with standard screws, small (condy lar)
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).
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
ly ing between the radial sty loid 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.
11.7–11.20) 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 metaphy seal 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.

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 Copy right David Ring,
MD.)

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
Copy right David Ring, MD.)

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 Copy right David Ring, MD.)

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 Copy right 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 Copy right David Ring, MD.)

FIGURE 11.12
A. A 1.5-mm drill was used initially . B. Companion drawing to clarify
technique in (A). (Part A Copy right 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 Copy right David
Ring.)

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 Copy right 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 Copy right David Ring, MD.)

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 Copy right 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 Copy right David Ring, MD.)

FIGURE 11.18
A. In most cases, I suture this along with overly ing fascia. B. Companion
drawing to clarify technique in (A). (Part A Copy right David Ring, MD.)

FIGURE 11.19
In this patient, a subcuticular suture is used. (Copy right David Ring, MD.)

FIGURE 11.20
Steri-Strips were applied. (Copy right David Ring, MD.)
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 metaphy seal bone loss or comminution, a plate may be
preferable (Fig. 11.21).

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
epicondy le. (All parts Copy right David Ring, MD.)
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 apply ing bone graft to metaphy seal defects
—sufficient bone can often be obtained from the lateral epicondy le or
olecranon.

FIGURE 11.22
Complex fractures of the entire head are very challenging to repair. A. This

patient had a fracture dislocation play ing 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 metaphy seal comminution. D. The lateral collateral ligament was
also repaired. (All parts Copy right David Ring, MD.)

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 ty pe 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 ty pe 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 identify ing 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 sy nostosis
blocking forearm rotation—is also risk of operative treatment. Stiffness, with
or without heterotopic bone, is treated with exercises, dy namic, or staticprogressive 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.

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 Copy right David Ring, MD.)
Radial head fractures are also associated with nonunion (Fig. 11.24).
Nonunions of partial head fractures are usually asy mptomatic, 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.

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 epicondy le with
sutures through drill holes. 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 Copy right 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 metaphy seal bone
loss. (Copy right David Ring, MD.)

Delay ed 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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68A:669–674.after fracture. . J Bone Joint Surg 1986.

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. The forces generated can result in a fracture in either both bones of the forearm or an isolated fracture of the radius or ulna. or complex injuries such as Galeazzi or Monteggia fractures. Fractures in the proximal one-third of the ulna with an associated radial head dislocation are known as 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. 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. Direct trauma to the forearm can also result in extra-articular fractures of the radius or ulna. diaphy seal fractures of the forearm can be classified as a both bone fracture. In general. the interosseous membrane is not grossly disrupted allowing a small number of these patients to be managed nonoperatively. substantial fracture displacement and disruption of the soft tissues can lead to a compartment sy ndrome.1). 12.12 Forearm Fractures: Open Reduction Internal Fixation Steven J. . With this mechanism of injury. With higher energy trauma. an isolated fracture of the radius or ulna. Morgan INTRODUCTION Fractures of the diaphy seal 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 motorcy cle accidents.

and slow consolidation in diaphy seal bone requires prolonged immobilization. with permission. Internal .) The vast majority of diaphy seal fractures of the forearm require surgery because they are very difficult to reduce and maintain through healing in a cast.1 AO/OTA fracture classification.21(10 suppl). Strong deforming forces often lead to loss of reduction.FIGURE 12. (Reprinted from J Orthop Trauma 2007. and wrist joints. This often leads to loss of motion in the elbow. forearm.

occupation. nonoperative treatment can be successful. even with properly done surgery. However. Open reduction internal fixation of displaced forearm fractures in the skeletally mature patient remains the standard treatment for this injury. elbow. Preoperative Planning History and Physical Examination  A thorough history and phy sical examination and highquality radiographs of the forearm. and wrist are necessary to develop a treatment plan. injuries with angulation >10 degrees. Many patients lose some strength and forearm rotation. Loss of normal alignment results in a loss of forearm supination and pronation (3. Multiple studies have documented excellent outcomes with this method of treatment (5–10).2).fixation avoids these issues allowing restoration of length and alignment and allows early functional motion of the extremity. in a small number of patients with isolated fractures of the ulna resulting from a direct blow. alignment. previous injury. and rotation while allowing early functional range of motion of the extremity. as it is commonly referred to. The “night stick” fracture. hand dominance. is recommended in open fractures. The history should provide information as to the mechanism of injury. On the other hand. 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 . Isolated fractures involving the distal onethird 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. Internal fixation of isolated ulna fractures. and associated medical problems.4). regardless of injury mechanism. some residual deficits and functional disability may occur. Internal fixation restores length. DASH scores and general health assessments reflect these deficits (1. and in fractures with significant comminution or shortening (11). INDICATIONS AND CONTRAINDICATIONS The radius and the ulna form a complex articulation. 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.

as to assess the extent 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. Ecchy mosis, fracture blisters, and swelling
suggest significant soft-tissue injury and the index of suspicion for
compartment sy ndrome 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 xray s of the elbow or wrist joints may be necessary based on the clinical
exam or preliminary x-ray s. 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-ray s 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 xray s 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
sy ndrome, 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 sy ndrome. 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 highenergy open fractures, particularly in the multiply injured patients, irrigation
and debridement and delay ed 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, simplify ing 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 delay ed (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 delay ed internal
fixation can be helpful. In comminuted 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 in dividualized basis.
Implant Selection  The implant of choice for virtually all diaphy seal
forearm fractures in adults is a 3.5-mm dy namic compression plate and is
available in full contact and limited contact design in either titanium or
stainless steel. In theory, a limited contact dy namic compression (LCDC)
decreases devitalization of the underly ing 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 metadiaphy seal 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 employ ed. 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 TECHNIQ UE
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 vancomy cin 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.

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 .
Surgery can be performed using general or regional anesthetic
techniques. Regional anesthesia with longacting pharmacologic agents is
contraindicated in most patients with diaphy seal forearm fractures due to the
risk of masking a postoperative compartment sy ndrome (15).
In comminuted diaphy seal 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.

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 .

FIGURE 12.3
The surgical incision is based just radial to the FCR tendon.

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.

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 sty loid, 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).

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.
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).

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.

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 epicondy le 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 underly ing 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 12.11
The dorsal approach to the radius is marked along a line from the lateral
humeral epicondy le 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.

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).

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 . C. The fracture
site is exposed, y et 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 softtissue dissection and destruction, the reduction is maintained by a plate
provisionally fixed with clamps. E. Final fixation with a plate resting under
the ECU.

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 sy mptoms related to a prominent plate
that most frequently occur when the forearm is placed on a rigid surface.
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
overly ing 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.

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 .

REDUCTION AND PLATE FIXATION TECHNIQ UES
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 diaphy seal 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 12.18
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.

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 apply ing 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 bey ond the end of the plate. This “pushpull” 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).

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.

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. 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.

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.
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
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
sy ndrome following closure. The subcutaneous tissues and skin are closed in
lay ers.

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. Ty pically all restrictions are removed by 3to 4
months. Return to sedentary work is allowed 7 to 10 day s 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 sy ndrome or forearm
compartment sy ndrome. If a compartment sy ndrome 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.
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
delay ed primary closure or split-thickness skin grafting.

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 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
Sy nostosis 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
sy nostosis has fully matured, it can be resected in selected sy mptomatic
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 sy nostosis. Interposition grafts, radiation, and nonsteroidal
anti-inflammatory medications may play a role (23).

REFERENCES
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fractures of both bones of the forearm in adults. J Bone Joint Surg Am
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acute diaphy seal fractures of the radius and ulna. J Bone Joint Surg Am
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open fractures of the diaphy sis of the forearm. J Orthop Trauma
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2010 Jun 3.
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13

Distal Radius Fractures:
External Fixation

Neil J. White and 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 y oung and elderly . Many lower-energy
nonarticular fractures and most epiphy seal 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 y ounger 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 y ears. 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 y ears, there was a 50% risk for
secondary displacement, while patients over 80 y ears had a 77% increased

risk. More recently, MacKenney et al. ( 3) prospectively evaluated 4,000
distal radius fractures and identified age, metaphy seal 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 (4–6).

INDICATIONS
SURGERY

AND

CONTRAINDICATIONS

FOR

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 y ounger, 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
(7–9). After closed reduction follow-up, x-ray s are obtained in the clinic
every 7 to 10 day s 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.

TABLE 13-1 Normal and Acceptable Postreduction Radiographic
Values

aNote that the 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.
c Lunate facet of radius to ulnar head, as compared to contralateral side.
dWhile preventing point contact is important, containing the lunate is
paramount for achieving a good outcome. As such, only 1 mm of gap is
acceptable.
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 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.
In the past decade, locking plates for internal fixation of unstable distal

However. abrasions. The ability to lock the screws into the plate dramatically increases fixation stability even in patients with severe osteopenia. which are low profile and can be locked. at times. Strong Indications for External Fixation Include: Highly comminuted and. 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 ty pe or ulnar translocation of carpus Relative Indications for External Fixation Include Widely displaced fractures with significant soft-tissue swelling. radial. which supports the articular reduction in similar fashion to the subchondral screws of a volar locked plate. These include anatomically designed plates for the volar. and dorsal aspects of the radius. In our practices. Both fixed angle and variable angle screw trajectories allow the surgeon to target and stabilize displaced articular facets. 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 try ing to prevent or treat infection or significant soft-tissue injury . modern external fixation with either spanning or nonjoint spanning frames can achieve satisfactory outcomes when combined with K-wire augmentation and metaphy seal bone grafting. However. we have shifted almost completely to plating of distal radius fractures. 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. or blisters Multiply injured patients .radius fractures have become widely available.

Osteoarthritic fingers are especially vulnerable to postfracture swelling and pain. The hand should also be examined for pain or deformity. radial. comparative contralateral wrist films are helpful. 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.Complex ipsilateral limb injuries Infected wrist or forearm fractures PREOPERATIVE PLANNING History and Physical Examination A thorough history and phy sical examination is essential with particular attention focused on the soft-tissue integrity and neurocirculatory examination of the extremity. Acute tendon injuries are rare following closed distal radius fractures. or an Essex-Lopresti injury. median. Monteggia. In some cases. Any signs or sy mptoms of increasing pain or paresthesias mandate that any splints or cast be loosened or removed for a more precise evaluation and treatment. The forearm musculature should be palpated to rule out a frank or evolving compartment sy ndrome. In comminuted or complex . and expectations often guide treatment recommendations. Patient-specific information. occupational requirements. and ulnar pulses should be palpated and/or dopplered. and ulnar nerves. Once the phy sical examination has been completed. the forearm and elbow should be checked for swelling and tenderness to rule out an associated Galeazzi. Furthermore. hand dominance. Postreduction radiographs often clarify the fracture pattern and help determine fracture stability. which might indicate a combined injury such as a carpal or metacarpal fracture or dislocation. The brachial. medical comorbidities. A careful neurologic exam of the extremity should assess the motor and sensory integrity of the radial. The wrist should not be placed in a “hy per-flexed” posture that might increase pressure in the carpal canal. a closed reduction of the fracture and a sugar-tong or long-arm splint should be applied. Imaging Studies High-quality anteroposterior (AP) and lateral radiographs of the wrist and entire forearm must be obtained.

Traction films can also reveal subtle. Open fractures. In a subset of patients following closed reduction. functional requirements. displaced. and reversal of palmar tilt have been correlated with less favorable results. require urgent irrigation. on the other hand. mild or even moderate degrees of deformity do not preclude a satisfactory result. fluoroscopic traction views can also provide useful information about facet displacement and may determine or alter the surgical approach. surgery is recommended. CT scans should only be obtained after the fracture has been reduced and splinted. and stabilization. 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. Timing of Surgery Unstable closed fractures of the distal radius without neurovascular compromise require timely but thoughtful intervention. combined. there is redisplacement on follow-up radiographs. CT scans with axial. For selected unstable fractures. 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. débridement. and sagittal reconstructions can be useful to better clarify the fracture pattern and morphology. increasing the importance of individualizing treatment. carpal bone. However. Scans done with the fracture shortened. and angulated rarely provide useful information and waste health care resources. Treatment Paradigm The definitive treatment plan is based upon fracture stability. and medical comorbidities. patient expectations. These outcomes are worsened with articular incongruity and carpal subluxation (4–6). radial inclination.fracture patterns. and/or ligamentous injury . We use either an intravenous Bier block or a fracture hematoma injection. Surgery should be scheduled semielectively following reduction and splinting. Significant alterations in radial length. Patients treated nonoperatively should be followed weekly for 21 day s to monitor this potential redisplacement. coronal. All patients with compartment sy ndromes or acute carpal tunnel sy ndrome require emergent decompression. If a .

Scaphoid or lunate die-punch injuries should be treated with elevation of fragments and subchondral bone grafting stabilized with K-wire fixation. as it allows better control in restoring radial length. Outcomes are improved with adjunctive techniques such as Kapandji dorsal intrafocal pinning.11) (Fig. nonspanning external fixation may be preferable. This can be performed with arthroscopic assistance or via fluoroscopic guidance (10) (Fig. . 13. a bridging frame is used as an adjunct to an open reduction and internal fixation (Fig.4). This can be helpful with the small volar or dorsal pericapsular shear fractures associated with carpal instability. inclination.2). should be treated with a locked buttress plate.1). transradial sty loidintramedullary pinning. with sufficient distal fragment bone stock. it is important to also inject the ulnocarpal joint to improve patient comfort when there is an ulnar sty loid fracture or concomitant ligament injury.3). Unstable fractures are treated with surgery. 13. In most cases. In minimally comminuted fractures. such as Smith’s and dorsal or volar Barton’s. in highly comminuted fractures.hematoma block is used. Occasionally. 13. 13. and metaphy seal grafting with allograft or calcium phosphate bone cement (10. it is better to perform primary osteosy nthesis rather than corrective osteotomy . Unstable distal radius fractures should not be treated with joint-spanning external fixation alone (Fig. Dorsal or volar shear fractures. and palmar tilt (12).

.

.

the connecting bars obscure the image. Assessment of the lateral view of the reduction is critical. This can be . Despite initial satisfactory reduction. Thirty -three-y ear-old right-hand-dominant male sustained an intraarticular left distal radius fracture after a fall from a height. fracture fragment subsidence occurred despite the spanning frame. and in this case. to achieve and maintain reduction. Three months postinjury .1 A. the wrist is malunited (C). 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.FIGURE 13.

.prevented by placing the bars more dorsally or utilizing radiolucent material.

A closed reduction was unsatisfactory .2 Fifty -seven-y ear-old right-hand-dominant female sustained this distal radius fracture (A). Most fractures are protected for 6 weeks. and the recommended technique of augmented external fixation with K-wires was employ ed successfully (B). and pin removal can be . The frame is a neutralization device that allows the wrist to be placed in a neutral position aiding finger rehabilitation and reducing swelling.FIGURE 13.

This patient made an excellent functional recovery . .done under local anesthesia in the clinic (C).

.

.

FIGURE 13.3 Sixty -seven-y ear-old right-hand-dominant female with comminuted intra- .

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

To protect the reduction and fill the subchondral metaphy seal void. This is the ideal indication for an arthroscopic-guided reduction. Visualization through the arthroscope allows precise fragment elevation using joy stick K-wires and confirmation with the image intensifier (C). cancellous allograft was impacted through a .FIGURE 13. B.4 Fifty -three-y ear-old right-handed male fell sustaining a distal radius articular facet impaction fracture (A).

plating permitted a quicker functional recovery because of accelerated mobilization than is possible with external fixation (16). 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). to prevent late subsidence. the carpus will follow the reduction of the distal radius fracture and maintain a collinear alignment.dorsal incision at the fracture site. In most cases. Ulnar sty loid fractures occur in more than one half of all distal radius fractures. indicates a laxity of the extrinsic capsular ligaments. A first-generation cephalosporin is given . or the pattern of dorsal intercalated segment instability. the distal radioulnar joint (DRUJ) should be manipulated for signs of instability. SURGERY Positioning and Setup Surgery is performed under general or regional anesthesia. There were no differences in patient outcomes for any of the techniques (16–18). the TFCC or the ulnar sty loid should be repaired. external fixation can result in equivalent long-term outcomes and should be part of the surgeon’s armamentarium. However. Stability of the important triangular fibrocartilage complex (TFCC) attachment is more important than the size of the ulnar sty loid fragment (13–15). Regional anesthesia provides full muscle relaxation and postsurgical pain relief for 8 to 12 hours. either dorsal or palmar. 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. Following fixation of displaced distal radius fractures. The patient is placed supine on the operating room table. locked volar plating. Despite the widespread enthusiasm for volar plating of the distal radius. When not injured. We reported a randomized clinical trial comparing external fixation. If unstable. and the arm is abducted and placed on a radiolucent arm board to accommodate the C-arm image intensifier. Residual angular or rotational instability. and locked radial column plating for displaced distal radius fractures. this reduction should be protected by a spanning external fixator until early consolidation has occurred at 6 weeks.

For nonspanning frames. After arthroscopicassisted articular facet realignment and stabilization with percutaneous Kwires. External fixation 3-mm half-pins are utilized for insertion in the radius and second metacarpal. If a penicillin allergy exists. bridging or spanning external fixation frames are neutralization devices and cannot reduce displaced intra-articular fracture . which is used in virtually all cases. If these are not available. It should be released after the pins have been safely inserted. vancomy cin or clindamy cin is substituted. a spanning external fixation frame is placed. The arm is prepped and draped. we do not predrill the distal radial metaphy sis as this bone is usually less dense. The tourniquet is only used for exposure. possibly supplemented with metaphy seal void bone grafting. Adjunctive Techniques One or more percutaneously placed K-wires introduced through the radial sty loid can help prevent a translational deformity at the fracture site after application of the frame especially when using a nonspanning external fixator.intravenously prior to the inflation of the arm tourniquet. but produces about 10 times the exposure to x-ray . This neutralizes deforming forces and protects the reduction. This is particularly helpful in dorsal lunate die-punch injuries. Although the pins are self-drilling and tapping. However. When arthroscopy is used to assist fracture reduction. we prefer predrilling pilot holes to minimize the possibility of iatrogenic fracture or eccentric placement and allow drilling to be manual. the equipment is positioned near the foot of the bed. and the tourniquet is inflated to 250 mm Hg. and protection of tendon intervals and most importantly the adjacent cutaneous nerves while placing the external fixation pins. Arthroscopic assessment of the radiocarpal joint provides an exacting of the reduction and facet realignment and is more accurate than fluoroscopic images. then two connecting bars are offset volarly and dorsally to not obstruct obtaining high-quality lateral radiographs. A standard C-arm fluoroscopic unit is an acceptable alternative. identification. We routinely use the mini-C-arm for distal radius fractures. Implant Selection Radiolucent connecting bars should be used whenever possible.

5). The fracture site is opened with an elevator. Care is taken to pad and protect the . and the bone graft or cement is impacted to fill the void up to the subchondral margin. which may be injured following distal radius fractures. the K-wire is advanced from distal to proximal to engage the volar cortex to prevent redisplacement. There are no absolute indications for wrist arthroscopy of distal radius fractures. When the articular facets are impacted and cannot be reduced by traction alone. It is most useful to visualize the joint in partial articular fractures such as the radial sty loid or Chauffeur’s fracture ty pe. In addition. Additionally. 13. 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 metaphy sis. The ability to dial in the volar tilt is an advantage of the non joint spanning frame. It should be employ ed only by surgeons experienced with the technique and adds minimal additional surgical time or morbidity. which will prevent subsidence when the intrafocal pins and external fixator are removed (11).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.fragments. Once these osteoarticular fragments are reduced as assessed by the image or via arthroscope. Occasionally when treating a very distal fracture using a volar locking plate. strategically placed intrafocal (Kapandji) K-wires can be helpful to manipulate and reduce the articular facets before frame application. 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. Arthroscopically Assisted Articular Reduction Several studies have shown that wrist arthroscopy can improve the quality of reduction and placement of pins (20). wrist arthroscopy allows a thorough inspection of the articular surfaces and the intercarpal ligaments and TFCC. restoration of the normal volar tilt is impossible with a spanning frame because of the sy mmetric dorsal and palmar soft-tissue tensioning via ligamentotaxis (19). it may be helpful to ensure that the screws are not intra-articular. Grafting is done through a 3cm dorsal incision at Lister’s tubercle between the third and fourth dorsal compartments. In osteoporotic bone. Ten pounds (4.

There is adequate room for scope tower and miniimage intensifier around the injured extremity . the midcarpal portals can be used to assess the stability of the scapholunate and lunotriquetral ligaments when indicated. A 2to 3-mm incision is made with an 11 blade. The 1–2 portal is helpful in reducing radial sty loid fractures. Arthroscopy is optimally performed under tourniquet control. but any may be used. The workhorse portals are the 3–4 and 4–5 dorsal compartments. Portal placement and orientation are checked with an 18-gauge needle. curved .elbow from the adjacent tower. FIGURE 13. repair the TFCC. Finally. if necessary. The arthroscopy portals are marked on the skin and coincide with the dorsal compartment intervals. and the six radial and six ulnar portals are necessary to visualize and. The joint is distended with 3 to 5 mL of normal saline injected through the 3–4 portal.5 Operating room set up for arthroscopically guided distal radius reduction and fixation. and then a small.

In many patients. However. After the articular fragments are reduced and stabilized with provisional K-wires. It requires a distal segment of bone at least 7 mm to place the 3mm half-pins.7). However. The fracture is stabilized with subchondral K-wires and neutralized by a spanning external fixator and a metaphy seal void bone graft or filler as indicated.6). Careful inspection and palpation of the intercarpal ligaments and TFCC are performed with a probe (20). The technique can still be used even with intra-articular extension.7-mm blunt trocar and cannula. Utilizing a 2. the half-pins are placed just proximal to the articular facets. a nonspanning fixator is not employ ed. 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. Clotted blood in the joint often obscures initial visualization but is rapidly cleared with pressurized joint lavage or a sy novial shaver. APPROACH Nonspanning E xternal 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. . Extraarticular placement of joy stick reduction K-wires as well as limited open exposure at the fracture site is useful to reduce impacted articular fragments. several published series have documented the efficacy with this method of treatment (5. Half-pins are placed between the extensor compartments to avoid tendon injury (Fig. the arthroscope is inserted into radiocarpal joint. there is an articular cartilage injury on both the radial and carpal side of the joint from axial loading and impaction. 13. if the bone quality is poor or the distal segment is <7 mm.hemostat is used to penetrate the dorsal joint capsule.

FIGURE 13.7). 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 joy sticks. .6 Placement of half-pins between the extensor compartments to avoid tendon injury . 13.7A. Simply put. ligamentotaxis alone cannot realign osteoarticular fragments devoid of soft-tissue attachment. This cannot be accomplished with a joint bridging construct because of the sy mmetric tensioning of the palmar and dorsal capsule created by joint distraction. Numerous authors have shown that a nonbridging external fixation is the most effective way to reestablish radial length. which often results in a nonanatomic V-shaped articular malunion rather than the normal articular concavity (Fig. and palmar tilt (5. inclination. B).

7 A. It will not work. V-shaped malreduction of the joint surface resulting from the inability of bridging to gain volar tilt. .FIGURE 13. B. axial force applied through intact capsuloligamentous structures. and may promote finger stiffness and severe postoprative pain. Ligamentotaxis. Over distraction or flexion of the wrist joint should not be employ ed to obtain volar tilt. Note that with sy mmetrical pull of the volar and dorsal ligamentous strucutres not more than neutral volar tilt can be obtained.

Self-drilling 3-mm half-pins are placed under fluoroscopic guidance by hand so that the half-pins engage the palmar cortex. This prevents excessive palmar translation of the distal fragment when the nonbridging fixator is secured. The two distal half-pins are placed on either side of the fracture line through small longitudinal incisions. which is the reduction maneuver.If the fracture is amenable to a nonbridging external fixator. 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. The EPL tendon excursion is checked after pin placement. The extensor tendons especially the extensor policis longus (EPL) must be identified and protected prior to pin placement. Fluoroscopy is used to visualize the fracture. The scaphoid facet pin is then placed subchondral and parallel as viewed from the lateral image. they are very successful in restoring volar tilt (Fig.6 mm) should be inserted into the medullary canal of the radius. It is alway s placed first and should be oriented parallel to the subchondral surface as viewed from the sagittal image. inclination. 13. this translation K-wire is essential. Many intra-articular distal radius fractures have a split between the scaphoid and lunate facets. If the palmar cortex is fractured. The frame is assembled with pin to rod connectors and a radiolucent bar. a radial sty loid K-wire (1. For a nonbridging frame. half-pins should be placed lateral and medial to Lister’s tubercle using fluoroscopy. Either the C-arm or the wrist is elevated to obtain a lunate facet 20-degree tilted lateral view to assess the pin placement. Since they enter the bone parallel to the subchondral articular facets. the distal radial pins are placed 90 degrees to the long axis of the radius. and the half-pins are used to guide the reduction. The reduction maneuver is performed with the surgeon gently pushing the half-pins distally. and tilt and can be fine-tuned under image control. Prior to reducing the fracture using the half-pins in the distal fragment as joy sticks. The pins are then manipulated proximal to distal. .8). which distracts and corrects the length.

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 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.8 The lateral half-pin is placed.FIGURE 13. BRIDGING FIXATION . The reduction is performed with gentle distal pressure of both thumbs on the distal half-pins. This can occur when the volar distal radial column is also fractured. and the direction of reduction force may promote a malreduction. 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. This can be prevented by placing a transradialsty loid intramedullary K-wire to control this palmar translation.

the pins must engage both cortices. using either a single incision or two smaller incisions. . To avoid a pin portal fracture. 13.Bridging external fixation is utilized when the bone quality or fracture comminution precludes a nonbridging construct. The index finger should be flexed fully at all joints during pin placement to minimize tethering of the extensor mechanism. More distal pin placement may encroach on the metacarpal phalangeal joint.10). 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). The angle of insertion of the pins for a bridging external fixator is 45 degrees to the long axis of the radius and metacarpal (Fig. Metacarpal pin placement should be done through a limited open approach. the pins are placed through a limited open approach to minimize injury to the tendons and cutaneous nerves (21) (Fig. It is important to alway s place percutaneous K-wires to realign and support intra-articular fragment reduction regardless of the ty pe of spanning external fixation frame employ ed.9). 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. which can lead to finger stiffness. It also optimizes pin placement in the midaxis of the radius and metacarpals. As noted previously. the 3-mm half-pins must be placed in the center of the cy lindrical metacarpal shaft. 13. Regardless of ty pe of frame. Placing the pin proximally may allow pin fixation into the base of both the second and third metacarpals enhancing fixation stability. The distal pins are placed in the second metacarpal at 45 degrees to the long axis of the bone.

.FIGURE 13.9 Metacarpal pin-placement site using a limited open incision.

It is important to avoid excessive wrist flexion and/or ulnar deviation (Cotton-Loder). The skin closure should be adjusted around the pins to minimize skin tension leading to necrosis and pin track infection. A loose skin closure is better as it will allow some movement around the pins following final reduction and tightening of the frame.5 cm) from the skin to reduce the frame profile and improve stability.10 Pin placement at 45 degrees to the long axis of the radius and metacarpal.FIGURE 13. The small incisions should be closed after pin placement and before assembling the frame. which is a leading cause of premature pin loosening. 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. which invariably leads to finger stiffness and in some cases may be a prime factor in the initiation of complex regional pain sy ndrome (CRPS). The wrist and forearm should be in . The pin clamps and connecting radiolucent bars are placed two finger breadths (2. The other common error is futile excessive distraction of the carpus to reduce impacted fragments.

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. lateral.10). Another option is to pin the joint with a trans radioulnar K-wire with the DRUJ reduced and protected by a long-arm splint. They are inserted at the “bare” interval between the brachioradialis and the extensor carpi radialis longus muscles. If the metacarpal pins have been properly placed at 45 degrees to the long axis. fixation or immobilization of the sty loid fracture or TFCC tear is required. A single spanning bar is usually sufficient but a second may be added if the fracture is complex or very unstable.neutral rotation before tightening the frame. 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. In other words. pronation. It is important to check the stability of the DRUJ after frame application. which will not impede tendon excursion. If unstable. then the . Proximal Pin Placement Proximal pin placement is similar for both external fixation constructs. AP. We prefer self-drilling pins that are bicortical. The surgical incisions are infiltrated with a local anesthetic. and supination. Prestressing to load the pins during the assembly of the frame is unnecessary and may lead to osteoly sis around the pins and premature loosening. We do however routinely drill a pilot hole to aid with precise pin placement. 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 radial shaft pins are placed 10 cm proximal to the tip of the radial sty loid and alway s at least 5 cm proximal to any fracture lines. Note that although not absolutely necessary it is easier to assemble the frame if the proximal pin trajectory matches the distal pin trajectory. which can be performed arthroscopically or open. then the thumb will be able to fully abduct and extend. If the surgical plan is to start with a fixator frame of any ty pe. TIPS AND TRICKS 1. 13. Testing for instability should be performed in neutral.

it will promote finger stiffness and regional pain sy ndromes. Patient education before surgery including the necessity of finger motion and pin care should be performed. Over distraction can be seen on a standard AP X-ray by assessing radio-carpal spacing. The index finger motion may be limited because of pain and the proximity of the metacarpal pins. This technique will not work. apprehension. mobilization of the digits early is critical. For a nonspanning frame. Overdistraction may be used intra-operatively when using a joint spanning frame to help obtain reduction. and all drilling should be done under direct visualization and by using drill sleeves. AFTERCARE As finger stiffness is one of the most common and serious complications of wrist fractures. the surgeon should sit facing the patient’s axilla improving access to the second metacarpal and to the radial sty loid for adjunctive K-wires. Unless the ulnar sty loid or TFCC has been injured or surgically repaired and immobilized. 3. it is easiest to work left to right and avoid having to work with the right elbow awkwardly over previously placed pins. Care and time should be taken with proximal pin insertion. it is imperative to work sitting over the patient’s shoulder. This allows easy acquisition of lateral xray s while placing pins in the distal metaphy sis of the radius. 4.proximal and distal pins should be placed first. This is continued until certain milestones are met such as a full grasping fist and full supination. 2. The remainder of strengthening and mastery of activity of daily living skills (ADL) can be achieved with a home exercise . but it is certainly acceptable to use the interval between ECRL and ECRB. We generally place these pins between ECRL and brachioradialis. For a right-handed surgeon. or pain. 5. For spanning frames. institution of forearm rotation exercises should also begin within the first few day s. Hand therapy is often required to teach and guide the initial rehabilitation especially if the ability to grasp is impaired by swelling. No patient should leave the operating room with the joint over-distracted. It is imperative to protect the dorsal sensory branch of the radial nerve. It is best to rely on the lateral view and keep the pins parallel to the hand table. but more importantly.

it is important to check all frame articulations for tightness at each postoperative visit. However. The patient is seen at 2 weeks for suture removal and x-ray s and then again at 6 weeks for assessment of fracture tenderness and radiographic healing. and wrist motion and function are encouraged. SUMMARY In summary. pain management. Modern external fixation frames are mechanically sound. both cost and infection risks make external fixation a valuable tool in the treatment of unstable distal radius fractures (23). REFERENCES . Some patients present with significant swelling and stiffness postoperatively. the external fixator is removed between 6 and 8 weeks after surgery in the outpatient setting. revision surgery is often necessary . and the connecting joints usually remain snug after surgery. they must be replaced to ensure a stable frame construct and to maintain reduction.program and periodic supervision. A removable wrist splint is provided. They should be aggressively treated to avoid arthrofibrosis with loss of wrist or hand motion. Clinical and radiographic follow-up are done at 3 and 6 months. COMPLICATIONS The most common complication with external fixation is pin-track infection. 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. Generally. and even manipulation under anesthesia to maintain joint motion. a multidisciplinary team approach should be employ ed and may require regional blocks. If it occurs. Loss of reduction following pinning and external fixation of the distal radius is uncommon. If a CRPS develops. Most can be managed by local pin care with cleansing and oral antibiotics. If the pins loosen prematurely. This may be a factor in the initiation of CRPS. It is imperative to ensure that the frame itself or overdistraction is not contributing to the stiffness.

Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. 3. Hajducka C. 6. 4. Injury 1989. et al. 5. A randomised. Batra S. Lafontaine M. prospective study of bridging versus non-bridging external fixation. J Hand Surg Am 2004. Trumble TE. McQueen MM.19(2):325–340. Vedder NB. Wagner W. J Bone Joint Surg Br 1998. 10.88(9):1944–1951. Prediction of instability in distal radial fractures. 14. J Hand Surg Am 2007. Souer JS. Stability assessment of distal radius fractures.29(6):1128–1138. J Bone Joint Surg Br 1996. Nesbitt KS. Delince P. et al. J Hand Surg 1999. Factors affecting functional outcome of displaced intra-articular distal radius fractures. Distal radius fractures in older patients: is anatomic reduction necessary ? Clin Orthop Relat Res 2009. Hardy D. The effect of an associated ulnar sty loid fracture on the outcome after fixation of a fracture of the distal radius. Les C. Effect of an unrepaired fracture of the ulnar sty loid base . 7. 11. Assessment of instability factors in adult distal radius fractures. J Bone Joint Surg Br 2009. 9. J Hand Surg [Am] 2004. Mackenney PJ.24A(6):1269–1278. Debnath U. MacDermid JC. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. Anzarut A. 8. Schmitt SR.1. 13. McQueen MM. Sy nn AJ. 2. et al.32(5):685–691. et al. Rosenwasser MP.29(6):1121–1127.32(7):962–970. Hanel DP. The risk of adverse outcomes in extraarticular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. Zenke Y. J Hand Surg [Am] 1994.20(4):208–210. Chapman C. Kanvinde R. Can carpal malalignment predict early and late instability in nonoperatively managed distal radius fractures? Int Orthop 2008. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. J Hand Surg [Am] 1998. McQueen MM. Treatment of unstable distal radius fracture with cancellous allograft and external fixation. 12.91(1):102–107. Redisplaced unstable fractures of the distal radius.23(3):381–394. Grewal R. Court-Brown CM. Trumble TE.467(6):1612–1620. J Bone Joint Surg Am 2006.78(3):404–409. Failla JM. Elton R.80(4):665–669. et al.

2009. Wolfe SW. J Bone Joint Surg [Am] 1975. Ann Acad Med Singapore. J Hand Surg [Am] 1990. Poolman R. 22.91(7):1568–1577. Wei DH. et al. prospective trial. Colles’ fractures. Pratt GW. Sarmiento A. Egol K. Arthroscopy 1995. Putnam MD. 18. Limited open surgical approach for external fixation of distal radius fractures. et al.11(6):706–714. et al. Bhandari M. Dick HM. Xu GG. Unstable distal radial fractures treated with external fixation. Kim JK. Wei D. A prospective randomized trial.90(9):1214–1221.92(1):1– 6. Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. 23. Berry NC. External fixation versus internal fixation for unstable distal radius fractures: a sy stematic review and meta-analy sis of comparative clinical trials. J Orthop Trauma 2011 (forthcoming). 20.57(3):311–317. J Bone Joint Surg Am 2009.91(4):830–838. . Should an ulnar sty loid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg 2010. 15. or a volar plate. Yoo HH. et al. Functional bracing in supination. 19. Easterling KJ. Seitz WH. Prospective randomised study of intra-articular fractures of the distal radius: comparison between external fixation and plate fixation. et al.15(2):288–293. J Bone Joint Surg Am 2009.15(1):18–21. Saldana MJ. 21. et al. 17. 16.on outcome after plate-and-screw fixation of a distal radial fracture. J Bone Joint Surg Br 2008. Arthroscopic-assisted reduction of distal radius fractures. J Hand Surg [Am] 1990. Bartosh RA.38(7):600–606. Bridging external fixation and supplementary Kirschnerwire fixation versus volar locked plating for unstable fractures of the distal radius: a randomised. a radial column plate.

Koval et al. Additionally. which is heavily promoted. These commercially available volar locked plates are specifically designed for fixation of distal radius fractures (Fig. Bauer and Jesse B. Jupiter INTRODUCTION Recent epidemiological studies show that the operative treatment of distal radius fractures continues to increase. (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. .14 Distal Radius Fractures: Open Reduction Internal Fixation Andrea S. 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). 14.1). Some of this increase is related to the large number of internal fixation devices now available in the marketplace.

2). The intermediate column consists .1 A few of the many implants constructed specifically for the volar distal radius. The column theory of the distal radius. 14. This area serves to buttress the carpus radially and is the origin of important intracarpal stabilizing ligaments. While advances in technology have facilitated internal fixation of the distal radius. continues to be a useful guide in understanding and treating distal radius fractures (3) (Fig. as described by Rikli and Regazzoni in 1996. the surgeon must still be aware of the structure and biomechanics of the distal radius. The radial column consists of the radial sty loid and the scaphoid facet of the distal radius.FIGURE 14.

it is important to understand the roles of each column in restoring anatomy and biomechanics of the distal radius.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.

FIGURE 14. . The ty pe of fracture. INDICATIONS AND CONTRAINDICATIONS The decision for operative fixation of a distal radius fracture is based on a combination of fracture and patient-specific factors.2 The column theory of the distal radius.

associated soft-tissue and neurovascular injuries. associated ulna fracture. such as those involving dislocation or subluxation of the radiocarpal joint. initial fragment translation >1 cm. rotated lunate facet fragment. intra-articular disruption. Other fracture patterns. and severe osteoporosis (Table 14. initial radial shortening >5 cm. with the advent of fixedangle locking screw-plate constructs. associated fractures (of the ipsilateral limb or distant sites). some fractures with associated progressive swelling or nerve dy sfunction. There are several agreed-upon radiographic indications of fracture instability (4–6). Definite Indications for ORIF Some fracture patterns are inherently unstable. Finally.1 Definite Indications for ORIF Relative Indications Many factors specific to the fracture ty pe and the patient are relative indications for ORIF of the distal radius.2). open fractures. TABLE 14. fractures associated with ipsilateral limb trauma or in the setting of a poly trauma. .3). initial dorsal tilt >20 degrees.1). However. These include dorsal comminution >50% of the width on a lateral radiograph. cannot be reduced by closed maneuvers and require ORIF. These include bilateral displaced fractures. fractures associated with DRUJ instability. any palmar metaphy seal comminution. such as articular fractures with a displaced. fractures with unacceptable amounts of displacement that present 3 weeks or more after injury can rarely be reduced closed and require ORIF (Table 14. and the overall medical condition of the patient must all be taken into account. and require open reduction internal fixation (ORIF) to restore stability. and unstable fractures not reduced after closed reduction and cast immobilization (Ta ble 14. underly ing osteopenia is no longer a contraindication to internal fixation.

The surgeon must keep in mind that anticipated functional loading.4). low-demand elderly patients with fracture displacement but good alignment of the carpus on the forearm may not achieve functional improvement with ORIF. such as active infection or complex regional pain sy ndrome. should be used to guide treatment decisions.TABLE 14. despite radiographic improvement (7).3 Radiographic Signs of Instability Relative Contraindications Patients with medical conditions that prohibit the use of anesthesia. or with local soft-tissue problems.4 Relative Contraindications to ORIF .2 Relative Indications for ORIF TABLE 14. may not benefit from internal fixation of their fracture (Table 14. TABLE 14. rather than chronological age. with poor compliance. Additionally.

and whether fixation of the fracture will require a special exposure or additional equipment. a careful evaluation of the patient’s overall condition.PREOPERATIVE PLANNING As with any musculoskeletal injury.3). as well as that of the involved limb and hand. may further influence the decision about treatment (8). 14. . The fracture characteristics are not alway s easily appreciated before the fracture is reduced and repeat x-ray s are taken. Furthermore. a preoperative template may be useful (Fig. must be made before a decision is rendered to proceed with operative intervention. A thorough evaluation of the imaging studies preoperatively helps in determining which reduction maneuvers may be necessary. including oblique views that focus on the articular surface or computed tomography (CT) scanning. For particularly complex fractures. additional xray views.

3 Preoperative template for ORIF of a distal radius fracture.FIGURE 14. When the fracture involves impacted articular fragments and/or extensive .

4). In these cases. OPERATIVE TECHNIQ UES ORIF of the distal radius is generally performed as outpatient surgery with regional anesthesia. which will be highlighted here with emphasis on the pearls and pitfalls of each. volardisplaced Smith’s. is given at least 30 minutes prior to incision as prophy laxis against surgical site infection. or bonesubstitute grafts should be noted in the preoperative plan.metaphy seal comminution. usually cefazolin. A parenteral antibiotic. Distal radius fractures may be operatively approached through several different exposures. . Volar Approach The uncomplicated volar shearing. the patient should also be informed that bone grafting may be necessary . allogeneic. 14. pneumatic tourniquet control. A surgeon-operated mini-C-arm fluoroscopy unit is used throughout the procedure to confirm fracture reduction and hardware placement. and many dorsally displaced fractures may be approached through the modified Henry approach to the distal radius (Fig. and the involved limb extended on a hand table. as well as the extra-articular. the potential for autogenous.

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and the dorsal sheath of the FCR is incised. dorsally displaced fractures. beginning approximately 5 cm proximal to the distal wrist crease. which is almost alway s palpable. A needle placed into the radiocarpal joint can help define exactly where the shorter limb should lie. The incision is marked out directly over the FCR. . the incision is angled ulnarly to avoid crossing the crease at a 90 degrees. The skin and volar sheath of the FCR are incised. 14. Whenever possible. The modified Henry approach exploits the interval between the radial artery and the flexor carpi radialis (FCR). 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. The pronator is sharply elevated in an L fashion to expose the distal radius and the fracture site.4 A–C. 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. Volar modified Henry approach to the distal radius. with the longer limb generally from the radial aspect of the radius and the shorter limb just proximal to the radiocarpal joint. At the distal wrist crease.FIGURE 14.5). the FCR tendon is retracted. Then the muscle belly of the flexor pollicis longus is retracted to expose the pronator quadratus.

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The initial screw is placed in the proximal oval hole. A locked plate is applied to the volar distal radius and held in position with K-wires. I. C. Exposure of the pronator quadratus. Planned incision. L.FIGURE 14. Exposure of the fracture site. F. Reduction of the fracture using an osteotome to elevate the distal fragment.5 An unstable fracture in a 54-y ear-old woman. Initial radiographs of the wrist demonstrate an intra-articular fracture of the distal radius. E. H. K. Fluoroscopy imaging demonstrates excellent positioning of the plate. G. D. The approach is carried out directly onto the FCR tendon. A Kwire can be inserted into the radiocarpal joint. B. Mini-Carm fluoroscopy is used to check the positioning of the plate. J. A. Final appearance of the plate and .

using 2-0 Vicry l suture. Extending this incision distally to release the transverse carpal ligament will further facilitate exposure (Fig. FIGURE 14.screws. B. 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. 14. if possible. Release of the pronator quadratus from the ulna. Extensile volar ulnar approach for complex high energy articular fractures. Postoperative radiographs. Relatively complex fractures associated with high-energy trauma or those involving a small. Approach to the transverse carpal ligament and interval between the ulnar artery and nerve and flexor tendons seen in cross-section.6 A. By . N. The pronator quadratus is repaired. M. C.6). Orbay (9) developed an extensile approach to the volar distal radius.

14.extending the Henry approach more distally.7). . which permits further displacement of the distal fragment and allows for exposure of the dorsal surface of the distal fragment (Fig. the surgeon releases the fibrous septum overly ing the FCR and step cuts the insertion of the brachioradialis tendon.

which permits wide exposure of the anterior .FIGURE 14.7 A–E. The extensile FCR exposure developed by Orbay involves distal release of the FCR septum.

2. even if it is not apparent on the lateral x-ray. 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 wound is irrigated and closed. the very distal articular rim of the radius dips anteriorly both at the radial sty loid as well as at its most ulnar aspect. which incorporates a light volar wrist splint with the fingers left free. further enhance the stability of fixation. Therefore. Anatomically. Irrespective of the approach. the volar ulnar component may be relatively small. one must suspect an element of dorsal cortical comminution. The distal screws. one implant may be unable to . Failure to support this fragment can result in postoperative volar subluxation of both the small fragment as well as the carpus (Fig. When approaching the displaced volar fracture in the older patient. In the presence of dorsal comminution. especially in osteopenic bone. In some. if placed in the subchondral position. the pronator quadratus should be reapproximated. This may cause loss of the normal volar tilt of the distal articular surface (Fig. 14. 14. Proper intraoperative fluoroscopy is essential to avoid inadvertent penetration of the articular surface during volar plate fixation of the distal radius (10. Whenever possible. This allows an unobstructed fluoroscopic view of the initial screw placement.8).11). One way to accomplish this is to alway s 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. The volar shearing radiocarpal fracture subluxation (Barton’s fracture) most often has two or more distal fracture fragments.9). an implant applied as a buttress to push up the displaced volar distal fragment has the potential to translate the fragment dorsally. Several specific fracture patterns have potential pitfalls that may lead to loss of reduction or problems with internal fixation via a volar approach: 1. which provides muscle coverage over the implant. and a bulky postoperative dressing is placed.surface as well as the ability to gain access to the dorsal surface of the distal fragment. the vast majority of fractures can be reduced intraoperatively using longitudinal traction and direct digital manipulation of the distal fracture fragment(s).

14. 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 metaphy sic (Fig. 14. When stabilizing a three. the radial sty loid (column) component may not be protected against shearing forces when a single volar implant is utilized. In addition.support the entire distal articular rim adequately (12). In these instances.or four-part articular fracture through an volar approach. 3.11) (14). .10). an additional small contoured radial implant can be applied through the same exposure by step-cutting the brachioradialis insertion (Fig. the volar lunate articular facet fragment may be found to be rotated with minimal subchondral bony support (13).

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B.FIGURE 14. Loss of volar tilt due to unstable fixation. .8 A. A complex articular fracture in an older age patient.

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FIGURE 14. Subluxation of the radiocarpal joint .9 Postoperative volar subluxation of the radiocarpal joint. B. Immediate postoperative radiographs. Shearing radiocarpal fracture subluxation with small lunate facet fragment. A. C.

FIGURE 14. D. .noted at 2 weeks caused by failure to support the lunate facet fragment. Clinical appearance.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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B. rotated. The radial sty loid and dorsal lunate facet could be reduced and held with K wires.FIGURE 14. Healed fracture at 1 y ear. C. D. Clinical wrist motion. volar. lunate-facet fragment can be done using a small gauge wire looped through the volar capsule and radius in a figure-of-eight fashion.11 Fixation of a displaced. lunate facet. ulnar. Preoperative x-ray and CT scan reveal a displaced. . but the volar lunate facet required open reduction and wire loop fixation. A. volar.

fractures with associated intercarpal ligament disruptions. the incision should be placed more dorsally. In this case. Care must be taken to avoid injury to the branches of the radial sensory nerve. The extensor retinaculum is opened between the third and fourth extensor compartments. One is between the first and second compartments. These include shear fractures of the radial sty loid with associated articular impaction. The exposure to the dorsoradial and intermediate columns can also be made through two incisions in the extensor retinaculum. Several surgical approaches can be used to access the dorsal aspect of the distal radius. This helps control the reduction when using intraoperative image intensification. For difficult reductions. This is especially useful for fractures seen late or those associated with soft-tissue swelling. A central articular impaction. and the other is between the fourth and fifth compartments. fracture reduction can be accomplished by longitudinal traction and direct manipulation of the fracture fragments. the impaction is directly elevated through the fracture site. For fractures of the radial sty loid. and some dorsally displaced fractures that present >3 weeks postinjury . and an arthrotomy of the radiocarpal joint is needed to directly visualize the articular reduction. The second extensor compartment can also be elevated subperiosteally. For the most part. there remain several indications for dorsal plating of the distal radius. a dorsal radial incision can be used to create exposure between the first and second extensor compartments. the use of either an external fixator or finger traps for traction can be considered. For a broader approach to the dorsal aspect of the distal radius. however. some complex four-part intraarticular fractures in which the dorsal lunate facet fragment cannot be reduced from a volar approach. provisional fixation with smooth Kirschner (K) wires is important with unstable articular fractures.DORSAL APPROACH Although the use of contoured locking plates has enabled many fracture patterns to be treated with volar plating. may be ineffectively reduced with traction alone. Direct visualization of the articular surface is also advisable in cases of intercarpal ligament injury . The fourth extensor compartment is elevated subperiosteally toward the ulnar fragment. There are a number of options for internal fixation via the dorsal aspect of . Additionally.

A longitudinal incision is created along the diaphy sis of the ulna. True instability of the DRUJ is rare following stable fixation of the distal radius. In those patients in whom DRUJ instability is present. strategically placed implants to support the specific fracture fragments. or allograft. and wire forms. A bone substitute such as Norian (Sy nthes. regain digital mobility. pins. leaving the extensor pollicis longus free outside of the retinacular closure. then operative repair of the triangular fibrocartilage complex may be warranted. and a bulky postoperative dressing is placed. the wound is irrigated and closed. and incorporate the hand and limb in activities of daily living. During this initial recovery period. the wrist is supported in a bulky postoperative dressing with a volar plaster splint incorporated for the first 7 to 10 postoperative day s. POSTOPERATIVE MANAGEMENT Postoperatively. which incorporates a light volar wrist splint with the fingers free. During this period.the distal radius. including elevation. but if present is best treated by operative fixation. the patient is encouraged to mobilize the upper limb. PA) works well. The concept of “fracture-specific fixation” guides fixation by using small. digital . An additional exposure is necessary to address fractures of the distal ulna. This can be done with either autogenous bone graft. Following anatomic reduction and stable fixation. West Chester. the forearm is also immobilized for 14 to 21 day s. If not. Then. Remember that the ulnar sty loid lies relatively anterior to the ulnar diaphy sis. A metaphy seal defect underly ing an articular fragment and/or concerns for the stability of the internal fixation necessitates additional support. bone substitute. FIXATION OF INSTABILITY DISTAL RADIOULNAR JOINT At the conclusion of any operation for a fracture of the distal radius. If an ulnar sty loid fracture is present. the extensor retinaculum is closed. this can be accomplished by fixation of the ulnar sty loid. stability of the DRUJ must be confirmed. as with fractures treated via a volar approach. These include anatomically shaped plates. antiedema measures are encouraged. This is done by taking the forearm through a full range of pronation and supination while palpating the ulnar sty loid for any gross movement.

Then. There have been numerous reports of flexor tendon irritation and rupture since volar plating has become more widely used. The avoidance of excessive digital swelling and early range of motion of the fingers are key to a successful initial recovery . Careful patient selection.25). Anglen JO. generally under the guidance of an occupational or phy sical therapist. Fractures of the distal part of the . Additionally. Patients often need exercises for strength and motion for at least 3 months postoperatively.27). and elastic wrapping as needed. presumably related to impingement of the volar plate on the flexor tendons (18–23). With the increasing popularity of volar plating of the distal radius. preoperative planning. et al. Similarly. REFERENCES 1. and careful postoperative management will help minimize these adverse outcomes. the inadvertent retention of angled drill guides is a complication unique to locked plating (26. nerve compression. the patient and surgeon together can decide whether and when to return to the operating room for removal. Certainly the patient must be informed of the risk of flexor tendon rupture. Koval KJ. there is increasing recognition of complications specifically associated with this approach. After 7 to 10 day s the postoperative dressing and splint are removed and the patient is encouraged to begin active wrist and forearm range of motion. infection. technical care in fixation. Resistive activities are begun once healing is assured. Harrast JJ. generally around 6 to 8 weeks.mobilization. screws that protrude out of the dorsal cortex of the distal radius may lead to irritation and rupture of extensor tendons (24. There is some debate over the proper course of action following this complication. These include loss of fixation. complex regional pain sy ndrome. with a functional end point often reached only after 12 to 18 months. and digital and/or wrist stiffness (15–17). COMPLICATIONS Complications following operative treatment of distal radius fractures are well recognized.

radius.78(4):588–592. Chin KR. 10. et al. Fractures of the distal end of the radius treated by internal fixation and early function: a preliminary report of 20 cases. Batra S. 5. Stern PJ. Distal radius fractures in older patients: is anatomic reduction necessary ? Clin Orthop Relat Res 2009. Arona S. Instr Course Lect 1993. Fractures of the distal radius. Rikli DA. Shauver MJ.86:1900–1908. Elton R. Melone CP Jr. eds. 12.5(2):103–112. 4.90(9):1855–1861.24(3):525–533. Open treatment for displaced articular fractures of the distal radius. Jupiter J. Regazzoni P. et al. J Bone Joint Surg Am 2004. 2. Makhni EC. The treatment of unstable distal radius fractures with volar fixation. 11. 15. 6. Hand Surg 2000. Operative treatment. Birkmey er JD. 7. 9. Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius. Complications of Colles’ . Fernandez DL. Got C.88(9):1944–1951. Mackenney PJ.91:1868–1873. J Bone Joint Surg Br 1996. Cooney WP III. McQueen MM. 13. et al. New York: Thieme.92(15):2523–2532. 3. Tweet ML. Calfee RP. J Hand Surg Am 2010. Linscheid RL. Epub 2010 Mar 3.35(4):619–627. J Hand Surg Am 1999. Prediction of instability in distal radial fractures. Fernandez D.33(10):1720–1723. Makhni MC. J Bone Joint Surg Am 2009.42:73–88. Soong M. Loss of fixation of the volar lunate facet after volar plating of distal radius fracture. Fluoroscopic evaluation of intraarticular screw placement during locked volar plating of the distal radius: a cadaveric study . Chung KC. J Bone Joint Surg Am 2006. 8. 2000:362. Jupiter JB. 14. Orbay JL. J Hand Surg Am 2008. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. Murphy WM. Comparative evaluation of postreduction intra-articular distal radial fractures by radiographs and multidetector computed tomography. Ruedi TP. Doby ns JH. Sy nn AJ. et al. Clin Orthop 1986.202:103–111. Katarincic J. Where’s the evidence? J Bone Joint Surg Am 2008.467(6):1612–1620. Harness N. The evolution of practice over time. Trends in the United States in the treatment of distal radial fractures in the elderly. AO principles of fracture management. J Bone Joint Surg Am 2010. Grover SB.

26. Fry kman G. Yamazaki H. Delay ed rupture of the flexor pollicis longus tendon after routine volar placement of a T-plate on the distal radius. 24. 23. Screw impingement on the extensor tendons in distal radius fractures treated by volar plating: sonographic appearance. Flexor pollicis longus tendon rupture after volar plating of a distal radius fracture. Wadgaonkar AD. Weiland AJ. Doi K. disturbance in the distal radio-ulnar joint and impairment of nerve function: a clinical and experimental study. Epub 2010 Feb 6. J Bone Joint Surg Am 1980. Report of five cases.108:5–153.83:1244–1265. 17. Baraziol R. Fernandez D. 27. Complications of distal radius fractures: instructional course lectures. Chir Main 2010. et al. Epub 2009 Mar 13.fractures.13(3):183–185.191(5):W199– W203. Schmidt CC. Glauser T. et al. Lifchez SD. 16. Hand Surg 2008. et al. Acta Orthop Scand 1967. Fusetti C. Delay ed rupture of extensor digitorum communis tendon following volar plating of distal radius fracture.4(4):406–409. 22. J Hand Surg Am 2008.13(2):123–125. Chin J Traumatol 2010. Jupiter JB. Delay ed rupture of flexor tendons caused by protrusion of a screw head of a volar plate for distal radius fracture: a case report. Adham MN. Porembski M. AJR Am J Roentgenol 2008. van Aaken J. Sakamoto S. Hand Surg 2008. 19. Am J Orthop 2007. Doi K. Bianchi S.13(1):27–29.36(12):669–670. Valbuena SE. 21. Flexor tendon injuries following locked volar plating of distal radius fractures. 25. Cross AW.29(2):109–113. 28. Wadgaonkar AD. Hattori Y. J Bone Joint Surg Am 2008. Plast Reconstr Surg 2010. Lucchina S. 20. Hattori Y.125(1):21e–23e. Bhattachary y a T. Cogswell LK. Hand 2009. Flexor tendon problems after volar plate fixation of distal radius fractures. Fracture of the distal radius including sequelae—shoulderhand-finger sy ndrome. A report of three cases. Adham C. J Bone Joint Surg 2001.33(2):164–167. Inadvertent retention of angled drill guides after volar locking plate fixation of distal radial fractures.90(2):401–403. Is early hardware removal compulsory after retention of angled drill guides in palmar locking plates? The role of pronator quadratus reconstruction. Bhattachary y a T. Inadvertent retention of angled drill . Duncan SF.62(4):613–619. Rupture of flexor tendon following volar plate of distal radius fracture. 18.

90(2):401–403. A report of three cases. J Bone Joint Surg Am 2008. .guides after volar locking plate fixation of distal radial fractures.

PART II LOWER EXTREMITY .

15.6). Femoral neck shortening . Although there is evidence documenting the superiority of parallel lag screw placement compared with other implants (13–16). with annual estimate hospital cost per hip fracture patient of $25.000 population (4. but some shortening of the femoral neck invariably follows. hip fractures are the most expensive fracture to treat (7–9). which is either accepted or overlooked. controversy remains as to the optimal treatment of choice (17). Femoral neck fractures are periarticular injuries where anatomic reduction and normal hip function are often sacrificed to maximize the potential for fracture healing. however.10. The total number of hip fractures is projected to increase from approximately 1. Lazaro.11). Lionel E. and Sreevathsa Boraiah INTRODUCTION Approximately 50% of all hip fractures involve the intracapsular femoral neck (1. Until recently. with an age-adjusted annual incidence of 725 per 100.000 and rising (7.1). a healed femoral neck fracture without implant failure or the development of avascular necrosis (AVN) was considered a success (Fig 15. The United States has the highest incidence of hip fracture rates worldwide.1). The negative impact of altered hip mechanics following fracture has been studied and reported. On a per-person basis. Lorich. Implants that allow sliding permit dy namic compression at the fracture site during axial loading. Healing.5 million in the y ear 1990 to 6 million by 2050 (3–5).15 Femoral Neck Fractures: Open Reduction Internal Fixation Dean G.2). This impacts the biomechanics of the hip joint.8. comes at the expense of a shortened femoral neck. Traditionally internal fixation has utilized with either a sliding hip screw and side plate or multiple cannulated parallel lag screws (12) (Fig.

It has also been shown to correlate with decreased quality of life (19) . 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. With an increased emphasis on preservation of hip function. This leads us to believe that anatomic reduction and internal fixation. which is maintained through fracture healing.1 AP radiographic view demonstrating two sliding constructs that healed in a shortened fashion.was shown to be associated with significantly lower phy sical function on SF36 subscores (18). understanding the pathomechanics and preservation of hip anatomy is imperative to restore in order to maximize the chance of a successful outcome. There is a large body of literature that documents high complication and . is critical for successful outcomes.

If anatomic reduction is the goal. FIGURE 15. . Anterposterior radiographic view demonstrating a valgus impacted femoral neck fracture. 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 lacks a periosteal cambium lay er that is necessary for callus formation. is bathed in sy novial fluid. the bone screw interface is strongest immediately after surgery and weakens over time.2) .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 most widely used classification for femoral neck fractures is the Garden classification. Recent studies have shown posterior roll off or angulation of the femoral head leads to increased reoperation rates (21–23) (Fig. Lateral radiographic view (B) and axial CT view (C) demonstrating posterior roll-off of the femoral head not appreciated on the AP radiographic view. However. it is important to address malalignment in all planes. and fixation of the fractures. Restoring anatomic fracture reduction often requires direct visualization prior to fixation. From a structural standpoint. The femoral neck is intracapsular. 15. this classification scheme is based on the anteroposterior (AP) radiographs alone and does not consider the lateral or sagittal plane alignment. The authors report a 56% reoperation rate if the posterior tilt is >20 degrees (21).2 A.

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

We prefer a cross-table or Clay ton-Johnson lateral.History and Physical Examination A thorough history and phy sical examination is essential. 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. Traction has not shown to be of any benefit. Unfortunately. an AP pelvis x-ray and full-length femur films of the ipsilateral side. In y ounger patients (<50 y ears) with a displaced femoral neck fracture. On phy sical exam. a traction internal rotation view can be very helpful. If any uncertainty exists as to the fracture pattern. the affected leg is usually externally rotated and shortened. where a fracture line is not visible on plain radiographs. magnetic resonance imaging (MRI) can be very beneficial. Ipsilateral femoral neck fractures are seen in 3% to 5% of patients with high-energy femoral shaft fractures. Movement of the limb is painful. In geriatric hip fracture patients. When anatomic reduction of the fracture is planned. the Garden classification does not take into account posterior displacement or angulation of the femoral head best seen on the lateral x-ray. bone scans and MRI have not . Valgus-impacted fractures. Computed tomography (CT) is helpful in determining displacement of the femoral head and the degree of femoral head comminution in some patients. a complete medical assessment and risk stratification should be performed with the assistance of an internal medicine specialist. which are ty pically amenable to in situ percutaneous pinning. the Garden classification of femoral neck fractures is based solely on the AP view of the hip. Cutaneous bruises indicate that the patient may be anticoagulated. and range of hip and knee motion is resisted by the patient secondary to pain. Unfortunately. may have posterior roll off of the femoral head. because a frog lateral position is difficult to obtain secondary to pain. A knee immobilizer may be helpful to immobilize and relieve pain. As stated earlier. A thorough neurovascular examination and assessment of the soft tissue and the skin should be made. a three-dimensional assessment of the fracture should be obtained. In patients with suspected femoral neck stress fractures. urgent reduction and fixation of the femoral neck is indicated.

The capsule is opened to visualize the femoral neck. A prophy lactic first-generation cephalosporin is given. an open reduction is performed. For the vast majority of patients. The lateral femoral cutaneous nerve is identified and retracted medially with the sartorius. Before prepping and draping. Patients are positioned supine on a fracture table against a well-padded peroneal post. It can be flexed. In y ounger patients with displaced fractures. a limited anterior SmithPetersen approach is utilized to facilitate palpation of the neck to access displacement and reduction as well as to introduce instruments to assist with reduction. In patients with minimally displaced fractures. After incising the deep fascia. we prefer spinal anesthesia. the interval between the tensor . a Watson-Jones surgical approach is used to gain complete exposure to the femoral neck. After incising the deep fascia. The unaffected limb is positioned in one of two way s. The entire hip joint and ilium can be reached using the SmithPetersen approach. the interval between sartorius and tensor fascia lata is developed. Once this interval is developed. and externally rotated and supported on a lithotomy holder or “scissored” using the opposite strut on the fracture table. For most patients.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. the surgeon should ensure that adequate AP and lateral images can be obtained. unobstructed high-quality AP and lateral images must be obtainable. SURGICAL TECHNIQ UE General or spinal anesthesia may be used. The incision is then curved distally and extended 10 cm along the anterior portion of the femur. 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 choice of anesthesia depends on the patient’s general health and consultation with the surgeon and internal medicine specialist. With either position. the tendinous portion of the rectus femoris is identified and is carefully elevated off the hip capsule. A 10-cm skin incision is made beginning just distal to the anterior inferior iliac spine. External rotation of the thigh accentuates this dissection plane. For most patients. only the inferior limb of the approach is needed. abducted.

The capsulotomy must remain anterior to the lesser trochanter at all times to avoid injury to the medial femoral circumflex artery. . 15.3). In valgus displaced femoral neck fractures. A 5-mm Schanz pin (external fixation pin) is placed laterally in the trochanter/proximal femur. (25) (Fig. 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. which extends superior and posterior to the lesser trochanter (25. 15. The anterior part of the gluteus medius and minimus is retracted posteriorly to visualize the anterior capsule.26).4).2-mm terminally threaded guide wires are placed just superior to the greater trochanter directed to the fracture line. the hematoma is evacuated. two 3.fascia lata and gluteus medius is developed. A ball spike pusher is used with posteriorly directed forces to correct the sagittal plane deformity (Fig. This is then used as a joy stick to correct the coronal plane deformity. After the femoral neck has been exposed. To avoid damage of the femoral head blood supply.

.

Then.5-mm fully threaded . a 7. 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. 15. A 7. followed by radiographic views after fracture reduction.3 A. Illustrations demonstrating the Watson Jones approach with the Zshaped caspulotomy .FIGURE 15.or 6. AP and lateral radiographic views demonstrating unreduced fracture. In femoral neck valgus fractures with posterior displacement of angulation of the head. the following sequence of fixation is used.B. These views also showed K-wires in the proximal fragment serving as a joy stick and ball spike pusher to further control alignment and reduction. attention is then turned toward creating a true length and angle stable fixation construct. After the reduction has been achieved. Sagittal plane deformity is corrected using a ball spike pusher.3. FIGURE 15.5).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.4 From left to right.

An allograft fibula is burred to a core diameter of 10 to 11 mm.to 11mm cannulated drill is used to create a track for the fibula. 15. The fibula is then gently tapped to the subchondral bone. A 10. FIGURE 15. A triangulated 3. 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. The initial partially threaded screw is then exchanged for a fully threaded screw.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.6). .5 Following reduction.screw is placed in the center of the femoral head as seen on the AP view.

” The strength of the allograft and host bone interface increases over time. unlike the bone screw interface that decreases over time. Final fluoroscopic images illustrate an acceptable reduction and placement of fibula allograft and hardware. The 7. the wounds are carefully irrigated. The rest of the sequence of screw placement is the same as before.3-m partially threaded screw is used to fix the fracture and create fracture compression. In order to stabilize the fibula allograft a 3. After the fracture has been stabilized. In varus deformities of the femoral neck.5 cortical screw inserted from the greater trochanter across the fibula allograft in the direction of the calcar. The allograft fibula acts as a “biologic screw. the fixation sequence is changed. The benefit of this configuration has been described (27). A 7.3-mm partially threaded screw is then replaced with fully threaded screw.6 The partially threaded cannulated screws and washers are replaced with fully threaded cannulated screws. .FIGURE 15.

no correlation has been found among age. (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. Haidukewy ch et al. These adverse events are considered to be secondary to mechanical failure of fixation and biological failure to heal. Contrary to the belief that nonunion occurs more frequently in y ounger patients. Patients are seen in the outpatient clinic at 2 weeks for suture removal. (31) reported a 4% rate of nonunion in patients for whom a good to excellent fracture reduction was obtained. 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. Patients are kept non–weight bearing for 8 to 12 weeks. POSTOPERATIVE MANAGEMENT Patients are mobilized from bed on the first or second postoperative day. and rate of nonunion (29). They are seen at 4. and lay ered closure of the wounds is then performed. Antibiotics are continued for 24 hours. Early range of hip motion is encouraged.34) reported a . there is an increased risk for fracture nonunion. compared to an 80% nonunion rate in patients with poor reductions. gender. (15) reported a 100% union rate in 27 patients and attributed this favorable result to emergent ORIF including anatomic reduction and compressive fixation. with an incidence that has been reported to reach 30% in older patients (28). Tian et al. Poor reduction has been demonstrated to increase nonunion rates. Swiontkowski et al.to 6-week intervals for x-ray s to assess fracture healing. In displaced femoral neck fractures. Hip muscle strengthening is emphasized beginning at 6 weeks postsurgery. The patients are gradually advanced to full–weightbearing status. The literature reports nonunion in y ounger patients with an incidence ranging from 0% to 86%.The capsule is loosely reapproximated in abduction. COMPLICATIONS Femoral neck nonunion and AVN are the two most significant long-term complications following ORIF of femoral neck fractures. Routine DVT prophy laxis is utilized. (33. Boraiah et al.

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. Swiontkowski et al. (31) reported that 29% of patients with AVN did not need additional surgical interventions. The incidence of AVN in all femoral neck fractures. and . and it receives contribution from the medial femoral circumflex artery and inferior gluteal artery (39). more recent studies in the literature fail to demonstrate an association (between time to fracture reduction and subsequent AVN). valgus osteotomy (converting shearing forces into compression forces at the fracture site). has been reported as high as 25%. In a prospective study of 92 patients. The rate of revision surgery following AVN of the femoral head is 11% to 19%. A nonunion resulting from a femoral neck fracture can be treated with arthroplasty. Nonetheless. Haidukewy ch et al. this theory fails to explain the occurrence of AVN in nondisplaced femoral neck fractures. or revision internal fixation. Patients with AVN do not alway s develop major sy mptoms. A meta-analy sis including 18 retrospective case series with patients between the ages of 15 to 50 y ears noted an overall AVN rate of 22. with arthroplasty performed for the majority of revisions (28). Jain et al. (15) showed a prevalence of AVN in 25% of patients for 27 patients aged 15 to 49 y ears. revascularization. with an average rate of 45% in y oung adults (35). the femoral head vascularity is probably not as tenuous as has been taught. an overall AVN rate of 16% was reported with no difference in patients treated before or after 48 hours at 2 y ears follow-up (38). (36) supported these findings and reported an AVN rate of 16% for 38 y oung patients treated >12 hours following the fracture and 0% when treated within 12 hours of the fracture. Also. Some authors have suggested that there is a direct association between amount of fracture displacement and disruption of femoral head vascularity . the femoral head vascularity depends on preservation of the remaining vascular supply.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). as noted in 20% of cases (35). citing emergent reduction of the fracture as the main factor associated with successful treatment. Following a femoral neck fracture. However.94% union rate with minimal shortening in 54 patients that underwent ORIF of femoral neck fracture using intraoperative compression and length-stable fixation. There is a rich intraosseous anastomosis. irrespective of patient demographics.

15. 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 (40.8).41).repair of area of necrosis prior to collapse of the subchondral bone and overly ing articular surface. . 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. stable calcar pivot.7 and 15. OUTCOMES High union rates with minimal femoral neck shortening and improved functional outcomes can be expected when length-stable fixation. and intraoperative compression are achieved during reduction of femoral neck fractures. In our experience.

no radiographic signs of AVN and bone incorporation of the fibula allograft. . AP and lateral radiographic views demonstrating a Garner IV femoral neck fracture in 60-y ear-old female.FIGURE 15. maintaining length.7 A. C. AP and lateral radiographic views 6 months after surgical intervention that demonstrate a healed femoral neck fracture. B. AP and lateral radiographic views demonstrating immediate postoperative images with the use of side plate length-stable construct.

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Gullberg B. Saeed I. Melton LJ III.45:15– 22. REFERENCES 1. C. Johnell O.16:359–371. maintaining length. J Bone Joint Surg Am 1995. AP and lateral radiographic view demonstrating failure (screw penetration) of a sliding construct. 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. Osteoporos Int 2003. Dennison EM. J Clin Densitom 2009. Crowson CS. B. Kanis JA. 2. maintaining length with development of Heterotopic Ossification (HO) over the anterior aspect of the hip.14:383–388. AP and lateral radiographic view 7 months after revision ORIF with a length-stable construct that demonstrate a healed femoral neck fracture. Osteoporos Int 1997. . and age variations. Hip fractures in the elderly : a world-wide projection. Harvey NC. Health care utilization and expenditures in the United States: a study of vosteoporosis-related fractures. Osteoporos Int 1992. Rousculp MD. sex. Indian J Orthop 2011. 3.8 A. Orsini LS. Dhanwal DK. bone incorporation of the fibula allograft.FIGURE 15. et al. Leblanc AD. Long SR. Epidemiology of hip fracture: worldwide geographic variation. Campion G. Melton LJ III. World-wide projections for hip fracture. Cooper C. 7. and no radiographic signs of AVN. Osteoporos Int 2005. Gabriel SE. 8.12(3):330– 336. Lennox DW. Austin-Moore hemiarthroplasty for failed osteosy nthesis of intracapsular proximal femoral fractures. Relative rates of fracture of the hip in the United States.33(5):423–426. Roberts C. et al. et al. Cost-equivalence of different osteoporotic fractures. 4. Carpenter RD. Ebert FR. Geographic. Hinton RY. et al. Coronal and axial CT scan view demonstrating screw penetration into the joint. 6. D.2:285–289. Parker MJ.7:407–413. Quantitative computed tomography reveals the effects of race and sex on bone size and trabecular and cortical bone density. Injury 2002. 5. et al.77:695–702.

J Orthop Trauma 2002. Swiontkowski MF. Hansen ST Jr. Choice of implant for internal fixation of femoral neck fractures. controlled trial. 21. Femoral neck fracture fixation. Direct and indirect costs of nonvertebral fracture patients with osteoporosis in the US. Clinical decision making.85:1673–1681. J Bone Joint Surg Am 1984. Devereaux PJ. Birnbaum HG. et al. et al. et al. Swiontkowski MF. et al. Tidermark J. et al.(339):20–31. Clin Orthop Relat Res 1997. A randomised. Ray NF. Tidermark J. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. Svensson O.9. Parallel or crossed garden screws? J Bone Joint Surg Br 1991. Zethraeus N. J Bone Joint Surg Br 2003. Pike C.28(5):395–409. Gurney B. J Bone Joint Surg Am 2003. et al. 14. 13.73:826–827. Schiller M. Krasheninnikoff M. Ponzer S. Melton LJ III. Blundell C. Effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. Gosvig K.16:34–38. Fractures of the femoral neck in patients between the ages of twelve and forty -nine y ears.66:837–846. 18.83:907–915. 15. J Bone Miner Res 1997. A meta-analy sis. Svensson O. Thamer M. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. 11. et al. Palm H. A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1 . Chan JK. Winquist RA. Meta-analy sis of 25 randomised trials including 4. Acta Orthop Scand 1998. et al. Eastwood DM.25:383–385. Parker MJ.85:380–388. J Bone Miner Res 2003. 12. Intracapsular fractures of the neck of femur. Adverse outcomes of osteoporotic fractures in the general population.69:138–143. Parker MJ. Porter KM. 20. Mermier C. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. Bhandari M. Pharmacoeconomics 2010. J Bone Joint Surg Am 2001. Parallel Garden screws for intracapsular femoral fractures.12:24–35.18:1139–1141. 16. 19. Bray TJ. Parker MJ. 17. 10. Injury 1994. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. Robergs R.925 patients.

Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty y ears. Lu-Yao GL. Outcomes of length-stable fixation of femoral neck fractures. Treatment of femoral neck fractures with a cancellous screw and fibular graft. et al. Mary a SK. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. Acta Orthop 2007. Gill TJ. Clin Orthop Relat Res 2004:249–254. Parker MJ. 29. et al. 22. et al. 24. J Bone Joint Surg Br 2001. Ganz R. Keller RB. et al. 26. Suk M. Outcomes after displaced fractures of the femoral neck. Surgical dislocation of the hip for fractures of the femoral head. Hammoud S. Arch Orthop Trauma Surg 2010. 28. Rothwell WS. Pearle A.78(4):498–504. Gautier E. Jacofsky DJ. Boraiah S.86:1711–1716. J Bone Joint Surg Br 1986. Johansson A. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009. Barnes B. 25. Kan S. Gardner MJ. Lapidus G.67:1675–1679. Comparison of cannulated screws fixation with different reduction methods at different time points for displaced femoral neck fractures in terms of fracture healing. A meta-analy sis of one hundred and six published reports. Outcome of undisplaced and moderately displaced femoral neck fractures. et al. Nagi ON.68:387–391. Enocson A.93(5):445–450. J Bone Joint Surg Am 2004. J Bone Joint Surg Am 2011. et al. Gardner MJ. 23. Phys Ther 1987. Bjorgul K.80(3):303–307.64:175–177. 32. Littenberg B. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-y ear follow-up of a randomized trial.130:1523– 1531. Stromqvist B. Boraiah S. Dunovan K.y ear. Tian W. Factors predicting healing complications in femoral neck fractures. Paul O. Predictable healing of femoral neck fractures treated with intraoperative compression and length-stable . Acta Orthop Scand 1993. 34. et al. Gautam VK. Reikeras O.19(5):334–342.76:15–25. Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. 138 patients followed for 2 y ears. 31.83:1119–1124.23:440–443. Haidukewy ch GJ. Cui Z. Conn KS. Nilsson LT. 33. J Bone Joint Surg Am 1994. Acta Orthop 2009. 30. Hedbeck CJ. 27. Paul O. J Orthop Trauma 2005. Functional outcomes after hip fracture.

Delay ed internal fixation of fractures of the neck of the femur in y oung adults. Chojnowski A. et al. Parker MJ. Comparison of early and delay ed fixation of subcapital hip fractures in patients sixty y ears of age or less.46:630–647. J Bone Joint Surg Am 2002. Mishra P. J Trauma 2010.36(1):131–141.69:142–147. 38. 35. 40. after internal fixation of femoral neck fractures. Stability and union in subcapital fractures of the femur.implants. Garden RS. 36. Koo M. Jain R. et al. A meta-analy sis of 18 published studies involving 564 fractures. Upadhy ay A. et al.84:1605–1612. 39. J Bone Joint Surg Br 2009:131–137. Jain P. Injury 2003:525–528. Complications after intracapsular hip fractures in y oung adults. Orthop Clin North Am 1974.5:683–712. J Bone Joint Surg Br 1964. Injury 2005. Hettrich C. Boraiah S. Papadakis SA. Reduction and fixation of subcapital fractures of the femur. Garden RS. J Bone Joint Surg Br 2004. Dy ke JP.86:1035–1040. Damany DS. Nikolopoulos KE. . A prospective. Long-term outcome of patients with avascular necrosis. 41. Kateros KT. Kreder HJ. Assessment of vascularity of the femoral head using gadolinium (Gd-DTPA)-enhanced magnetic resonance imaging: a cadaver study . randomised study comparing closed and open reduction. 37. et al.

These patients include elderly patients with compromised bone quality and fracture comminution. Over the last 10 y ears. Controversy continues regarding the optimal method of treatment (1). A long-term follow-up study of patients treated with open reduction of the displaced femoral neck fracture. evaluated 13 y ears after fracture fixation. arthroplasty allows rapid. most studies support replacement of the femoral head in older patients (2–5).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. In contrast. Numerous authors have documented high rates of osteonecrosis. .13). Economic analy ses indicate that the cost of treating such complications is immense (7–10). and nonunion when these fractures have been treated with internal fixation (6). In displaced femoral neck fractures. The indications for hemiarthroplasty versus a total hip replacement are less clear (4. safe mobilization of the patient without concern about fixation failure or fracture union (2–4. prospective randomized trials have demonstrated the superiority of arthroplasty compared with internal fixation in this group of patients over the age of 60. Replacement arthroplasty is routinely done in patients most at risk for complications after internal fixation. found that the functional outcome deteriorated even among patients with a healed fracture and no osteonecrosis (11). fixation failure.12).

.B).Despite substantial limitations. while Garden III and IV are displaced femoral neck injuries. 16. Garden I and II describe undisplaced fractures.1A. femoral neck fractures are categorized as 31-B (Fig. the Garden classification is probably the most frequently cited classification in North America. In the comprehensive AO/OTA classification scheme.

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Bipolar or Modular Hemiarthroplasty . In patients =60 y ears of age. internal fixation using cannulated screws is reserved for nondisplaced Garden I and II fractures. INDICATIONS AND CONTRAINDICATIONS Internal Fixation Internal fixation remains the treatment of choice c <60 y ears of age. The details and techniques of internal fixation are covered in Chapter 15.FIGURE 16. The AO/OTA classification of femoral neck fractures. The Garden classification of femoral neck fractures. B.1 A.

. 16.4). Strong indications for hemiarthroplasty are 1. It can be used with a fixed head (unipolar) or bipolar head and provides a relatively easy conversion to a total hip arthroplasty (THA).The bipolar or modular hemiarthroplasty is the most commonly used implants to treat displaced femoral neck fractures in the elderly. Displaced femoral neck fracture in patients over 60 to 65 y ears of age without antecedent hip arthritis (Fig. 2. Patients >60 y ears of age with minimally displaced femoral neck fractures but whose bone is too poor for internal fixation (Fig. 16. 3.2).3). if required in the future. 16. Failed internal fixation without associated acetabular damage (Fig.

FIGURE 16. .2 A displaced subcapital femoral neck fracture in an elderly female.

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.

The use of a Moore or Thompson prosthesis is of historical interest and is not recommended (Fig. 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).5). postoperative pain. Hemiarthroplasty should be modular to allow for changes in offset. length adjustment. 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.6). and recovery of ambulatory status (14–16). and tensioning of the hip girdle muscles (17.Comparisons between cemented bipolar and unipolar hemiarthroplasty have shown similar outcomes in terms of dislocation rates. Fluoroscopic evaluation after 1 y ear 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. .18). 16. 16.

FIGURE 16.5 A cemented bipolar hemiarthroplasty . .

It is a technique known to most orthopedic surgeons. The slightly higher dislocation rates combined with the difficulty in this frail patient population following the usual postoperative THA protocols has limited its use. It is not indicated for most geriatric femoral neck fractures. When used to treat hip arthritis. The initial cost is increased compared to a unipolar or bipolar arthroplasty . proponents of the technique (THA) argue that it may reduce the overall costs due to its theoretically improved long-term survival (23–32). .FIGURE 16. well-controlled studies have shown improved outcomes after THA (23.7). it has very predictable long-term results.29). Initial studies using total hip arthroplasty for fractures showed an increased rate of dislocation plus an increased amount of blood loss (20–22).6 An Austin-Moore prosthesis. It is no longer used for treatment. 16. however. in y ounger highly active patients (age 60 to 75 y ears) with little or no cognitive impairment and increased longevity of life. Total Hip Arthroplasty Total hip arthroplasty (THA) is an attractive treatment modality for selected elderly patients with displaced femoral neck fractures (Fig. However.

FIGURE 16.7 AP radiograph of an uncemented total hip replacement.31): . Strong indications for the use of THA in the management of acute femoral neck fractures in the elderly include (30.

Advanced osteoporosis with poor bone quality (Fig. 16.8). . 4. 3. 2. 5. Femoral neck fractures with associated hip joint disease. Significant sy mptomatic contralateral hip disease. Failure of internal fixation of a femoral neck fracture in patients over 60 y ears of age with acetabular damage (Fig. Failure of a hemiarthroplasty .9).1. 16.

.8 A basicervical hip fracture in a frail osteoporotic geriatric patient.FIGURE 16.

.FIGURE 16.9 Failure of a sliding hip screw to treat a femoral neck fracture.

treated with a primary total hip replacement. 16. In our center. A 62-y ear-old male fell off a ladder sustaining a displaced femoral neck fracture.Relative Indications for Total Hip Arthroplasty include 6. an elderly patient with a displaced subcapital femoral neck fracture is most commonly treated with a cemented bipolar hemiarthroplasty (4).10A. 8.B.B).10 A. Uncemented stems . Older cooperative patient with normal cognition and statistical survival rates >10 y ears. Uncemented stems are utilized in patients with excellent bone quality and canal diameters <16.5 mm. Fractures secondary to metastatic disease with acetabular involvement. FIGURE 16. 7. Healthy active patients over the age of 60 with a displaced femoral neck fracture (Fig.

it is very common to regret doing an ORIF in this particular group (Fig.11). 16. it is rare to regret doing a bipolar or modular unipolar hemiarthroplasty .12). 16. In patients that are over the 60 y ears of age with osteoporotic bone that have a displaced femoral neck fracture. however. .are also preferred in patients with significant risk factors for cardiovascular disease (32) (approximately 3% to 5% of patients) (Fig.

11 An uncemented bipolar hemiarthroplasty utilized in a healthy 71-y ear-old .FIGURE 16.

female following a displaced femoral neck fracture. .

FIGURE 16.12 Avascular necrosis of the femoral head following internal fixation of a .

The patient’s current list of medication must be known as many elderly patients are on anticoagulants. This includes determining important medical comorbidities such as cardiovascular disease. which have been shown to improve outcome and reduce hospital stay (33). The peripheral pulses and neurologic examination should be carefully evaluated and documented. which may impact anesthesia or the timing of surgery. medical and surgical history. Preoperative Planning Preoperative planning is important to the success of the procedure. This allows the fracture to be classified as . Confirmation. Leg length. or corticosteroids.femoral neck fracture. History and Physical A well-performed and documented history and phy sical should be performed on every patient. femoral head size. Imaging Studies Radiographs should include an anteroposterior (AP) of the pelvis. The leg is shortened and externally rotated if the fracture is displaced. The medical evaluation should proceed as quickly and safely as possible. Most elderly patients with a hip fracture benefit from internal medicine and cardiology consultation. antihy pertensive medications. and diabetes (the Charlson comorbidity index). The vast majority of hip fractures in the elderly occur as a result of a mechanical ground-level fall. hy pertension. Most patients should be ready for surgery within 24 hours of admission. and the stability of the hip have to be carefully planned prior to surgery . offset. and a lateral of the hip joint (shoot-through lateral). of the drug history. Range of motion of the hip is decreased or impossible secondary to pain. an AP of the affected hip including 50% of the femoral shaft. Phy sical examination reveals a tender and painful hip. and the presence of drug sensitivities and allergies can be very helpful in this population. Preoperative templating of the contralateral side can be used as an alternate to templating the fractured hip and is strongly recommended. with family members.

cardiac. surgery should be performed within 24 hours of admission for most patients with a displaced femoral neck fracture. a delay of 48 hours may be required to optimize the patient. pulmonary. Timing of Surgery To achieve the best outcomes. a longer neck length may be required to replace the excised neck.13). The head size is usually based on cup size but patient characteristics (age and quality of the bone) may be a factor (34). The sooner the surgery is completed the lower the immediate complications. .g. As a general rule. 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.. consideration should be given to an offset liner to replace the neck length and offset. templating is done on the uninjured hip to help reproduce the patient’s normal offset and height relative to the lesser trochanter.14). High-quality imaging is essential both to understand the fracture morphology and allow for preoperative templating. If the fracture extends to the level of the lesser trochanter. metabolic). Measure the offset of the nonfractured hip to reproduce the patient’s normal offset. 16. Cables around the lesser trochanter area may be indicated to prevent fracture extension distally (Fig. a calcar replacement component should be available. Careful pre-op planning helps ensure that the correct size hip implants are available at the time of surgery . 16. A Clay tonJohnson 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. If a low femoral neck fracture is present. Measure the acetabular diameter if a total hip is being contemplated. A larger femoral head may reduce early dislocations. Identify the planned femoral neck cut measuring from the lesser trochanter. This also has the benefit of allowing more poly ethy lene thickness and thus may permit the potential use of a larger femoral head size for stability (Fig.undisplaced Garden I or II or displaced Garden III or IV. If the patient has multiple medical comorbidities (e. When a THA is performed.

13 Stability was increased by adding a 4-mm offset liner.FIGURE 16. . a 10-degree lip. and a 36-mm head.

14 Total hip replacement utilizing a calcar component with cables for a low-​c omminuted basicervical femoral neck fracture.FIGURE 16. In some medical centers. the decision to perform a hemiarthroplasty or a .

hip. Most orthopedic surgeons are comfortable performing a hemiarthroplasty . When using the lateral position. and correct side and site of surgery before initiating the procedure. A Foley catheter is routinely used to assist with fluid management and postspinal anesthetic bladder paraly sis. pelvis. All pressure points should be well padded including the unaffected limb. 16. a total joint arthroplasty surgeon is sometimes consulted. Patient Positioning Hip arthroplasty can be done with the patient in the supine (anterolateral) or lateral position (Hardinge and posterior approach). Other invasive monitoring may be indicated in patients with labile blood pressure or significant cardiac risk factors. and the entire lower extremity are prepped and draped into the surgical field. 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. the surgical team should reverify the patient’s name. Antibiotic prophy laxis 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. if a calcar replacement is required or a total hip is indicated. SURGERY Anesthesia Unless there are specific medical contraindications such as concurrent use of anticoagulant medications.15). At this point in the case. we prefer to perform the surgery using spinal anesthesia. however. This has been shown to significantly reduce early postoperative confusion in this population. This makes it imperative that the indications for a THA are clearly understood so that the correct procedure is performed by the right surgeon. .THA may determine which surgeon or service will perform the procedure. medical record. The lower abdomen.

A hemiarthroplasty or total hip replacement can be done utilizing any of the three approaches. All have distinct advantages and disadvantages.FIGURE 16.15 Positioning and draping for a hip arthroplasty with the patient in the lateral position. Surgical Approaches Three surgical approaches will be described. The selection of approach is based .

Once the skin and subcutaneous tissue are divided.17). and the upper and lower capsular flaps are tagged with a heavy suture (Fig. greater trochanter. is created (Fig. Develop this anterior flap following the contour of the femoral neck until the anterior hip joint capsule is exposed. The anterior-superior iliac spine.primarily on surgeon preference and experience. A longitudinal incision beginning 5 cm above the tip of the greater trochanter. Most authors have recommended detaching and splitting only the anterior onethird of the gluteus medius muscle to reduce the risk of damage to the superior gluteal nerve. The rectus femoris tendon is dissected off the capsule. 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 underly ing gluteus minimus and the anterior part of the vastus lateralis (Fig. 16. . and the lesser trochanter is palpated posterior-medial. Once the anterior wall of the acetabulum is reached.5 cm above and 2 cm behind the tip of the greater trochanter. hemostasis is obtained with electrocautery. which extends down the shaft of the femur for 8 cm.18). A reported 33% functional deficit in gluteus medius muscle was noted when this modification was not utilized (27). 16. which passes 4. 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. a “T”-shaped capsulorrhaphy is created. and outline of the proximal femur should be identified and marked with a sterile pen.16). 16.

FIGURE 16.16 The skin incision for the Hardinge approach. .

.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.FIGURE 16.

18 Through a T-shaped capsulorraphy . elevator.5 cm) above the lesser trochanter. . It is important that the lesser trochanter and the tip of the greater trochanter are exposed. 16. and a T-handle corkscrew (Fig. An oscillating saw is used to make the femoral neck cut about (2 to 2.FIGURE 16.19). the fracture is exposed. This allows adequate exposure for visualization of the femoral neck fracture as well as to make the femoral neck cut. or skid. The femoral head is removed with the help of an osteotome.

a hemiarthroplasty is the procedure of choice. Once the femoral head has been removed. The fovea is identified. the acetabulum is exposed with a right angle retractor posteriorly and a narrow Hohmann retractor anteriorly.FIGURE 16. If there is no significant articular surface damage and limited arthritic changes. The cartilage of the acetabulum should be examined for defects or damage.19 The femoral neck and head are removed with a corkscrew. and the ligamentum is excised exposing the floor of the acetabulum. .

16. The head and neck trials are snapped onto the rasp using a high or low offset neck based on the preoperative plan. A blunt trochanteric reamer is utilized to further lateralize the opening. If a bipolar component is used.20). a leg bag can be created by double folding a large sheet so the inside stay s sterile even at a low height. calcar shape. 16.22). The final femoral rasp is left in place and used as a trial stem. the femoral head size is predetermined by the cup size.21).” If a premade product is not available. but the femoral neck length can be independently selected (Fig. If a monopolar component is utilized. and epicondy les of the knee.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. 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. A small curette is used to open the femoral canal. Neck length is adjusted to allow appropriate tensioning of the soft tissues but should be consistent with the template of the opposite hip preoperatively . Using the lesser and greater trochanter. Finally . the head and neck length will be chosen together. 16. A box osteotome or chisel is used to enlarge the opening in the femoral neck as well as to lateralize the entrance site (Fig. . The previously excised femoral head is measured and compared to the preoperative size. the correct hip version is established for femoral canal preparation.

FIGURE 16.20 A box osteotome is used to enlarge and lateralize the opening in the proximal femur. .

21 The femur is prepared with a rasp.FIGURE 16. .

along with the proper-sized femoral head. and the neck is shortened with a calcar reamer. To increase hip stability without adding length. as a few millimeters can greatly alter the tissue tension. the head and neck trials are removed. or the limb appears too long. If the reduction is difficult. and offset. The hip is reduced and stability as well as leg length is clinically assessed. length. tight.FIGURE 16. Once the proper components have been identified. Go up gradually. residual femoral neck length should be reassessed. and the predetermined neck offset. If the hip is either unstable or the leg is too short. the femoral rasp is advanced a few millimeters. the trials are removed and the femur and acetabulum irrigated. If shortening is the problem. increase the length of the trial neck. is attached to the femoral component. If it is too long. it is carefully placed in the canal. and the hip is ready to be reduced. . The optimal size is an implant that recreates stability.22 The bipolar components are in place. there are several treatment options. If a cementless femoral stem is to be used. add offset first by using a high offset neck.

16. this lay er may be sutured directly to the bone through separate bone drill holes (Fig. The abductor lay er is carefully reapproximated to the soft tissue on the trochanter and abductor medius. One or two bags of cement are prepared and placed into the medullary canal using contemporary cementing techniques. the medullary canal is plugged distally with an appropriate size canal plug ensuring that it is 2 cm bey ond the tip of the anticipated femoral component. and stem height. If a cemented femoral stem is chosen.The hip is reduced and checked for stability in flexion and internal rotation. the incision is closed. The capsule is closed utilizing the tagged sutures from the exposure. and cup are assembled and placed on the femoral stem. and the hip is reduced. Once the surgeon is satisfied that the hip is stable and the limb length is correct. valgus. Stability is checked as noted above. Occasionally. the head. plus extension and external rotation.23). . The canal is thoroughly irrigated and dried to minimize fat emboli during cement insertion. The femoral component is then inserted taking great care to recreate the anteversion. Once the cement has hardened. neck.

If a drain is used. Divide the fascia latae in line . The subcutaneous tissue is closed with number 2-0 absorbable suture and the skin approximated with skin staples. which is then closed with figure-of-eight no. it should be placed below the tensor fascia. any bleeders should be cauterized. and it is helpful to flex the knee 30 degrees and adduct the hip.23 Closure of the anterior flap and the anterior one-third of the gluteus medius.24). Once the skin and subcutaneous tissue are divided. 1 absorbable suture. 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. A 15-cm longitudinal lateral incision is made centered on the tip of the greater trochanter (Fig.FIGURE 16. 16.

28). With the hip externally rotated. One cable should be placed above the lesser trochanter and one below if there are linear fracture lines extending from the femoral neck. The femur is now retracted posteriorlaterally to gain access to the acetabulum. In subcapital fractures. 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. In low femoral neck fractures. a calcar replacement component can be used to maintain length and offset of the hip. the anterior one-third of the gluteus medius must be released from the greater trochanter (Fig. . heading proximally and anteriorly in the direction of the anterior superior iliac spine (Fig.5 cm above the lesser trochanter. Extend the fascial incision distal to expose the vastus lateralis. and the soft tissues to the level of the lesser trochanter are visualized (Fig.25). If posterior comminution is present. this examination leads to a decision to perform a total hip rather than a hemiarthroplasty (Fig. The superior and inferior capsule should be tagged with heavy suture for repair at the end of the case. and the gluteus minimus is detached to the mid portion of the greater trochanter.0 to 2.27). the femoral neck is cut 2. The ligamentum teres is resected to expose the floor of the acetabulum. The hip capsule must be divided up to the anterior border of the acetabulum so that excellent exposure of the hip joint is possible.29). the osteotomy can be made slightly lower to improve bone contact in which to seat the femoral component. The articular surface is inspected for damage or significant arthritis. The tendon of the rectus femoris is dissected off the capsule allowing placement of a retractor above and below the femoral neck. The femoral neck and head are removed with a corkscrew. a cerclage wire or cable may be used to prevent fracture extension during preparation of the femur. Occasionally.26). The anterolateral approach exploits the intermuscular plane between the tensor fascia latae and the gluteus medius. Alternatively. These steps significantly improve access to the femoral canal. the posterior capsule is released from the femoral neck. 16. 16. 16. 16. the anterior portion of the vastus lateralis is released. Incise the anterior capsule of the hip joint longitudinally and develop this in a “T”shaped manner.with its fibers superiorly. The fracture and the femoral head should be easily visualized at this time. Frequently. 16. With the leg externally rotated. This is where the anterior lateral approach differs from the Hardinge approach.

FIGURE 16.24 The skin incision for an anterolateral approach to the hip. .

FIGURE 16. .25 The fascia latae is opened.

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.

.28 The anterior one-third of the insertion of the gluteus medius tendon is released to improve exposure.FIGURE 16.

FIGURE 16. The lower leg is placed into a sterile leg bag and hung over the side of the bed. This can be difficult in heavy patients so a Hardinge exposure (as described above) may be preferred. offset. The . The capsule should close easily over the prosthesis. If there is any question. then an intraoperative x-ray should be done to ensure proper fit and reduction.29 Positioning the acetabular component. Once this exposure has been obtained. If the closure is tight or cannot be performed using the tagged capsule edges. The hip and knee are flexed to 90 degrees. Attention is then turned to the femur. Trial components are used to determine the correct length. In this position. exposure of the femoral medullary canal is usually possible. and the hip is externally rotated. and stability. The wounds are carefully closed in lay ers. the steps for preparation of the femoral canal are the same as described above. the head may not seated in the acetabulum correctly. The definitive femoral stem is then implemented with or without cement according to the preoperative plan.

If the torso is not stable. 16. A “T”-shaped capsulorrhaphy is done preserving the capsular attachments to the acetabular rim (Fig. Some surgeons expose the nerve and place a vesi-loop around it so it can be identified at the end of the procedure. 16. .32). It is very important to stabilize the pelvis so that it does not roll forward or backward during the procedure.to 15-cm skin incision is centered over but slightly posterior to the greater trochanter (Fig.30). errors in cup positioning may occur. 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. 16. The hip is flexed and externally rotated exposing the short external rotators (Fig.31). it should be inserted below the fascia. and the muscle fascia of the gluteus medius is opened. The remaining external rotators (superior and inferior gemellus) as well as the obturator internus are then divided. A 12. The tensor fascia latae is divided longitudinally above and below the trochanter. If a drain is to be used. 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.33).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. The subcutaneous tissue is closed with a 2-0 absorbable sutures and the skin reapproximated with staples. The sciatic nerve should be palpated to make sure that it is out of harm’s way. 16. which is closed with figure-of-eight no. 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. 1 absorbable sutures.

FIGURE 16. .30 The skin incision for the posterior approach to the hip.

FIGURE 16.32 The short external rotators are taken down from the back of the trochanter exposing the hip capsule. FIGURE 16. .31 Exposure of the short external rotators.

and a decision is made whether to utilize a hemiarthroplasty or total hip replacement. The femoral neck and head are removed using an osteotome and a T-handle corkscrew. 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.33 A T-shaped casulorraphy exposes the fracture site. Technique for a Total Hip Arthroplasty (Acetabular Preparation) Removal of the femoral head exposes the acetabulum.0 to 2. The fovea is cleared down to the inferior medial wall of the acetabulum. The femoral neck is shortened leaving 2.FIGURE 16. If a total hip is planned. The acetabular cartilage is inspected. reaming of the acetabulum .5 cm of bone above the lesser trochanter or at the highest level of intact posterior femoral neck.

posterior wall inclination.34). If the quality of the bone is good or there is concern regarding the possibility of creating a fracture. FIGURE 16. The acetabulum is reamed in 2-mm increments until the reamer meets the superior dome.34 Acetabular reamer. 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. an intraoperative radiograph should be obtained to assess cup position. When reaming is complete. and the position of the potential screw holes in the cup. If the screw holes are easily visible. The posterior wall and the dome must be carefully observed during reaming particularly in older osteoporotic bone to prevent fracture or medial penetration. a trial cup should be used to confirm fit and fill in the acetabulum (Fig. Important landmarks are the position of the pelvis. dome position.usually begins with a 44-mm reamer to obtain the proper depth. If any questions exist. 16. .

36). 16. FIGURE 16. . 16. 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.35). In this age group. Initial testing for stability is done with a 32-mm liner.reaming to within 1 mm of the planned cup size may reduce hoop stresses (Fig. One or two screws in the acetabular component are used to increase stability particularly in the elderly patient (Fig.35 A fully porous cup with screw holes.

the iliopsoas tendon or the superior attachment of the gluteus maximus is released for better exposure. A right angle retractor is used posteriorly. Once adequate visualization is achieved. A blunt T-handle reamer confirms the location of the medullary canal. and a lateralized reamer is used to ensure correct reaming. . The femur is internally rotated and adducted as well as flexed to almost 90 degrees. If the femur will not elevate out of the wound easily. 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. A small box osteotome is then used to prepare the proximal femur in the correct anteversion.36 A screw used to fix the acetabular component. a curette is utilized to locate the canal. a narrow Hohmann retractor is placed over the trochanter.FIGURE 16. Femoral Preparation and Implantation (THR or Hemiarthroplasty) Attention is then turned to the femur.

then head size can be selected depending on cup diameter.37 Seating of the femoral component.38). 16. The femoral component should be inserted with appropriate anteversion (Fig. FIGURE 16. If the length is correct . A cemented or cementless femoral component can be used in geriatric patients with a femoral neck fracture. offset.37). and length are optimal. Once the femoral component trial is in place. 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.trials. If stability. 16. a femoral neck of appropriate length and offset is inserted to allow reproduction of the original offset and length (Fig. 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 ty pe of femoral component to be implanted.

With geriatric hip fracture patients. If the hip is still unstable. To be long by happenstance is not acceptable. and leg lengths are checked one last time. UHMWP should be used if a head size >36 mm is chosen. To be slightly long in leg length by design is professionally acceptable. a final trial with the selected head and neck length can be performed before the final head and neck are implanted. Following reduction.but stability is not achieved. a small increase in neck length is another option. increasing the offset will usually help without adjusting length. however. Once the permanent components have been implanted. a regular HMWP cup can be used if a 32 or 28 mm head has been selected. the trials are removed. Offset can be altered with an offset liner or an offset neck. Excessive length (>1 cm) will cause a significant and predictable limp. . The head size is usually limited by the amount of poly ethy lene available based on cup diameter. Once component size has been determined. hip stability. The next variable to examine is head size. I favor placing in a large head with an ultrahigh molecular weight poly ethy lene (UHMWP) liner. and this age group does not compensate for leg length discrepancies as well as a y ounger population.

38 The head and neck trial used to ensure proper length. it should be inserted beneath the fascia latae. Wound closure is very important. The subcutaneous lay er is closed with number 2-0 absorbable suture and the skin approximated with skin staples. 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.FIGURE 16. The sciatic nerve should be examined or palpated to make sure it is intact and uninjured. and stability . offset. 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. Postoperative Care Patients are allowed to be weight bearing as tolerated using a walker or . The tensor fascia latae is closed with heavy interrupted figure-of-eight sutures. If a drain is used.

drainage. By 12 weeks. redness around the wound. orthopedic nurses. Gram-negative and mixed microbial infections account for the remaining 15%. Postoperative Wound Infection Streptococcus and Staphylococcus account for almost 85% of postoperative wound infections. and 12 months postoperatively. The diagnosis is confirmed with blood tests (high ESR. or pain with motion of the affected joint. atrial fibrillation. Presentation is usually with fever. DVT. Balance is a major problem in this age group. we usually perform a liner exchange as well.crutches immediately after surgery. Clinical follow-up is done at 3. For infections that occur in the first few weeks. Subacute and chronic infections invariably require removal of the prosthesis and an antibiotic spacer with staged reconstruction. most patients can progress to a single or quad cane. CRP. This is a very different group from the elective total hip population. 6. . General complications such as pneumonia. Drains. Patients are seen in the clinic at 2 weeks for wound inspection and suture removal. cardiac failure. should be removed at 24 to 48 hours. Supplemental nasal oxy gen has been shown to reduce the potential for patient confusion during the first 48 hours postoperatively. Chemical deep vein thrombosis (DVT) prophy laxis (CHEST or AAOS guidelines) is started on the first postoperative day and continued as an outpatient for 14 to 28 day s following discharge. if utilized. Hip fracture patients are more prone to confusion and delirium in the postoperative period. most patients can be permitted to ambulate without assistive devices if they were able to do so before their fracture. Complications Complications can be divided into disease-specific and general complications. and the use of walking aids is necessary until muscle rehabilitation and balance have been reestablished. occupational therapist. pulmonary embolism. Prevention of dislocation of the hip is a team responsibility and involves the surgeon. and the family . At 6 weeks. and WBC) and a positive joint aspiration. and urinary tract infections require prompt diagnosis and treatment in collaboration with medical specialists. phy siotherapist. Immediate surgical débridement of the joint combined with 6 weeks of culture-specific intravenous antibiotics has a 60% to 65% chance of success.

or head size that does not optimize the head-to-neck ratio for a given cup size. however. Nondisplaced as well as displaced femoral neck fractures in patients <60 y ears of age are usually treated by internal fixation. reduction under conscious sedation or light general anesthesia is recommended. In displaced femoral neck fractures in patients over the age of 60. The most common causes include a short neck (particularly a negative neck length). Brooker Grade I and II heterotopic ossification is not clinically significant. incorrect offset. If a closed reduction is unsuccessful. 2. incorrect anteversion. Grade III can lead to hip stiffness while grade IV is clinically fused. Hemiarthroplasty has a very low rate of dislocation (<1%). Heterotopic Bone Formation Significant heterotopic bone formation following arthroplasty for femoral neck fractures is very uncommon. CONCLUSIONS The recommendations for treatment of a femoral neck fracture include the following: 1. 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%. and prevention is the key. 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. the literature supports arthroplasty over internal fixation. however.Hip Dislocation Hip dislocation is an uncommon event following arthroplasty . more recent reports documented dislocation rates of <2%. Some studies suggest that an abduction brace may be helpful for the initial 6 weeks following closed reduction. which is similar to an elective THA. The reason for dislocation should be determined whenever possible. this may be not well tolerated in the elderly. Prophy laxis is not recommended for this population as they are not high risk. . Once diagnosed. then an open reduction with or without revision of the components is required.

Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. Bhandari M. An uncemented fully porous modular hemiarthroplasty should be considered preferentially in patients with significant cardiovascular risk factors. 5. Madsen JE. This has also permitted more predictable excellent long-term functional outcomes in this specific subgroup of displaced femoral neck fractures. 2.3. Total hip arthroplasty is a viable alternative treatment in the highly “active elderly patient.335:1251–1254. . Waaler GM. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification. Marsh JL. Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. Madsen JE. Treatment of displaced femoral neck fractures: a randomized minimum 5-y ear follow-up study of screws and bipolar hemiprostheses in 100 patients. have reduced the early dislocation rate (23.” The use of large femoral heads (>32 mm) with or without the addition of an offset neck or liner. Clin Orthop Relat Res 2008. J Orthop Trauma 2007. Acta Orthop 2010. Devereaux PJ. Roden M. Schon M. 2-y ear results involving 222 patients based on a randomized controlled trial.74:42– 44. 6. Frihagen F. et al.36). et al.21:S1–133. 5. Agel J. et al. Fredin H. Ward DM. The cost of hemiarthroplasty compared to that of internal fixation for femoral neck fractures. et al. 4. Jain NB. Frihagen F. Trends in surgical management of femoral neck fractures in the United States.81:446–452. BMJ 2007. Slongo TF. Nordsletten L. Losina E. 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. database and outcomes committee. 4. REFERENCES 1. 3. 6. Swiontkowski MF. Acta Orthop Scand 2003.466:3116–3122. Nonmodular unipolar Moore or Thompson prosthesis should no longer be used.35. plus meticulous capsular repair techniques.

10. Ravikumar KJ. Rogmark C. J Bone Joint Surg Br 2000. et al. The cost and implications of reoperation after surgery for fracture of the hip. Clin Orthop Relat . Wanner GA. 14. Opland V. Clin Orthop Relat Res 2008. Figved W.348:67–71.383:229–242. Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly .16:317–322.85-A:1673–1681. Man LX. Healy WL.74:293–298. Iorio R. et al. Park S. et al. Treatment of femoral neck fractures in elderly patients over 60 y ears of age—which is the ideal modality of primary joint replacement? Patient Saf Surg 2010.20:109–114. Barette M.414:259–265. Schey erer MJ. et al. Acta Orthop Scand 2003. 8. 7. Johnell O. et al.414:250–258. J Orthop Trauma 2002. Unipolar versus bipolar hemiarthroplasty : functional outcome after femoral neck fracture at a minimum of thirty -six months of follow-up.31:793–797. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures. 15. et al. Displaced femoral neck fractures in the elderly : outcomes and cost effectiveness. Lemos DW. hy droxy apatite coated hemiarthroplasty for displaced femoral neck fractures be recommended? Hip Int 2010. Cornell CN. Parker MJ. Aharonoff GB. Ossendorf C. 12. O’Doherty J. et al. Brix M. Clin Orthop Relat Res 2001. et al. Levine D.82:864–866. 9.4:16. Haentjens P. Autier P. Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly ? Clin Orthop Relat Res 2003. et al. Clin Orthop Relat Res 1998. Palmer SJ. 18.466:2513–2518. Ong BC. Hollingworth W. Maurer SG. et al. Clin Orthop Relat Res 2003. Raia FJ. Sy stematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Carlsson A. Can introduction of an uncemented. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur—13 y ear results of a prospective randomised study . Injury 2000. Costs of care after hospital discharge among women with a femoral neck fracture. 16. Herrera MF. Marsh G. 11. 17. Birkelund L. Chapman CB. 13. J Bone Joint Surg Am 2003. Frihagen F. Costs of internal fixation and arthroplasty for displaced femoral neck fractures: a randomized study of 68 patients. Hansen SK. Ahn J.A meta-analy sis.

Ninh CC. Hip dislocation after modular unipolar hemiarthroplasty . elderly population. 24. 6th ed. Dislocation of total hip replacement in patients with fractures of the femoral neck. Green. Tidermark J. Classification of femoral neck non-unions. Chapter 44. Choudhry R. Hunter GA. Tidermark J. et al. Skoldenberg O. Stauffer RN. Anderson GH. Fractures of the neck of the femur. J Arthroplasty 2008. Acta Orthop 2008.80:184–189.152:158–161. Enocson A. Acta Orthop 2009.467:2426–2435. pp. J Arthroplasty 2009. Malchau H. 76:891–894. et al.81:583–587. 28. et al. Chin J Traumatol Zhonghua chuang shang za zhi/Chinese Medical Association 2010. Tornkvist H. healthy . Sim FH. J Bone Joint Surg Br 1994. et al. 21. Management of hip fractures by total hip . Internal fixation or hemiarthroplasty for undisplaced fractures of the femoral neck in octogenarians. et al. Nellans KW. Salemy r M. Should we abandon primary prosthetic replacement for fresh displaced fractures of the neck of the femur? Clin Orthop Relat Res 1980. 1753– 1792.13:234–239. et al. Acta Orthop 2010. Slover J. Hedbeck CJ. Wang G. 22. Comparative study of anterolateral approach versus posterior approach for total hip replacement in the treatment of femoral neck fractures in elderly patients. Macaulay W. Leighton RL.20:291–293. Li D. Gu GS. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. 20. et al.79:211–217. 25. et al. et al.23:2–8.24:768–774. Enocson A. Dislocation of hemiarthroplasty after femoral neck fracture: better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips. 26. Garvin KL. Sethi A. 23.24:854–860. Injury 1989. In: Rockwood. A cost-effectiveness analy sis of the arthroplasty options for displaced femoral neck fractures in the active. 27. Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation. hemiarthroplasty and total hip replacement. Hatahet M. Hui AC. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach. Ellery J. Hoffman MV. 29. J Arthroplasty 2009. Skinner P.Res 2009. 30. 19. Ekman A. Riley D.

Salvati E. Available at: http://www. Fractured neck of femur— internal fixation versus arthroplasty . et al. Lee BP. Kramny P. 33. 43. British Geriatrics Society and the British Orthopaedic Association. Berlin JA. Bhandari M.nhfd.24:611–613. 35. Clin Orthop Relat Res 1980. Duff A. Orthop Clin North Am 2010. Gebhardt JS. Watson D. Vegari DN. ed. 2011. 42.co. 2007.80:70–75.uk 34. Bostrom M. et al. HSS J 2008.279:199–205. Dtsch Arztebl Int 2010. Sendtner E. A femoral head prosthesis with a built-in joint. 44. Haidukewy ch GJ. Parvizi J. Keene GS. Phillips TW. A radiological study of the movements of the two components. Berry DJ. Harmsen WS. A comparison of total hip arthroplasty and hemiarthroplasty for treatment of acute fracture of the femoral neck.282:123–131. Iorio R. et al.4:48–54. 41. J Bone Joint Surg Br 1983. Parker MJ. Hemiarthroplasty of the hip–the anterior or posterior approach? A comparison of surgical approaches. 32. Zinar DM. Total hip arthroplasty for the treatment of an acute fracture of the femoral neck: long-term results.152:191–197. Clin Orthop Relat Res 1992. Orthopedics 2008. 38. Amstutz HC. Klein GR. Verberne GH. Injury 1993. Crist BD. et al. Total hip arthroplasty for acute . JAMA 1998. Total hip arthroplasty is less painful at 12 months compared with hemiarthroplasty in treatment of displaced femoral neck fracture. Macaulay W. Nellans KW. J Bone Joint Surg Br 1987. Primary total hip arthroplasty for displaced femoral neck fracture. et al.107:401–407. The National Hip Fracture Database National Report.arthroplasty . et al. et al. Optimal treatment of femoral neck fractures according to patient’s phy siologic age: an evidence-based review. 40. J Bone Joint Surg Am 1998. A fluoroscopic study of movement over a four-y ear period. et al. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. London: British Orthopaedic Association.69:761–764. 31. Berry DJ.41:157–166. The care of patients with fragility fracture.403:118–126. Israel TA. Renkawitz T.31:990. 37. Lowe JA. Perioperative blood transfusion and postoperative mortality . The Bateman bipolar femoral head replacement. 39. Carson JL. 36.65:544–547. Clin Orthop Relat Res 2002. Currie C.

New concepts in femoral head replacement: clinical experiences [proceedings]. Lewallen DG. 52.11:132–135. J Orthop Trauma 1997. Cartlidge IJ. Thirty -day mortality following hip arthroplasty for acute fracture. Status of femoral head prelacement in treating fracture of the femoral neck. Delamarter R. II. Trask K. 46. Mehlhoff T. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop Relat Res 1987.13:249–253. Meta-analy sis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture. Clin Orthop Relat Res 1991. Orthop Rev 1973. The prosthesis and surgical procedure. Bipolar Hemiarthroplasty : To Cement or Not to Cement? Presented at the Canadian Orthopaedic Association. Moreland JR. Treatment of subcapital femoral fractures by primary total hip replacement. Su DH. J Bone Joint Surg Br 1985.21:1134–1140. J Arthroplasty 2009. Leighton RK. Liebowitz S. Primary total hip replacement for displaced subcapital fractures of the femur. Treatment of acute femoral neck fractures with total hip arthroplasty . .269:32–37. Wentzell T. ON. J Bone Joint Surg Am 2004. Parvizi J.38:57–58. 2006. 53. Landon GC. Injury 1981.femoral neck fractures using a cementless tapered femoral stem. Waddell JP. Coates RL.67:214–217. Eftekhar NS. 51. 49. Armour PC. Goh SK. Tabsh I.86-A:1983– 1988. et al. Taine WH. Total hip arthroplasty for complications of proximal femoral fractures. Samuel M. 45. 55.2:19–30. Armour P. Bull Hosp Joint Dis 1977. et al.24:400–406.218:68–74. Ereth MH. Toronto. J Arthroplasty 2006. 47. Tullos HS. 50. Primary total hip replacement for displaced subcapital femoral fractures. 48.11:166–169. Injury 1979. 54. Morton J.

The 31-A2 fracture is multifragmentary and is subdivided into progressively more unstable patterns with a loss of medial support: A2. The Orthopaedic Trauma Association (OTA) classification is useful both to determine the stability of the fracture pattern and to guide treatment (4).17 Intertrochanteric Hip Fractures: The Sliding Hip Screw Kenneth A. with a strong female preponderance throughout all age groups (2).3).1 pattern. 31-A3. Egol INTRODUCTION Hip fractures in the elderly are associated with significant morbidity and mortality and will continue to burden the health care sy stem as the population continues to age (1). This pattern can manifest as a . through the greater trochanter (A1. with 1-y ear mortality rate of 20% to 30%. progressing to several fragments (A2. Intertrochanteric hip fractures represent approximately half of the fractures that occur in the proximal femur.1).2) and fracture extension >1 cm below the lesser trochanter (A2. 31-A2.1 fractures are simple fractures with one additional fragment. the fracture enters the lateral cortex of the femur distal to the vastus ridge. Most A2 fractures are considered unstable with the exception of the 31-A2. 17. and 31-A3 fractures (Fig. The 31-A1 simple fracture is a stable fracture with a single fracture line extending along the intertrochanteric line (A1.1). In the most unstable pattern.3).2). Mortality rates for extracapsular hip fractures are comparable with those of femoral neck fractures. or below the lesser trochanter (A1. intertrochanteric fractures are best classified as stable or unstable based upon the integrity of the posteromedial cortex. Intertrochanteric fractures are classified as 31-A fractures and further subdivided into 31-A1. While several classification sy stems exist.

.1). a simple transverse fracture (A3.reverse oblique intertrochanteric fracture (A3.2).3). or a multifragmentary fracture (A3.

1 The AO/OTA classification of intertrochanteric hip fractures. .FIGURE 17.

This region is extracapsular and is less prone to many of the healing complications seen with femoral neck fractures. 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. similar to the cancellous bone 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. In a small group of patients with sy mptomatic preexisting hip arthritis or severe osteoporosis due to sy stemic medical condition such as renal failure or metastatic disease may be candidates for primary hip arthroplasty instead of fracture fixation. preinjury level of function. and short external rotators. and bone quality . 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. This area is characterized primarily by dense trabecular bone that serves to transmit and distribute stress. 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. The orientation of the trabeculae in the intertrochanteric and greater trochanteric region acts to resist highly compressive forces (5). INDICATIONS AND CONTRAINDICATIONS Virtually all patients who sustain an intertrochanteric hip fracture with any displacement should be considered for surgical repair. the iliopsoas.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. The greater and lesser trochanters are the sites of insertion of the major muscles of the gluteal region: the gluteus medius and minimus. plate) or the length or the device. Bone quality may also affect the surgeon’s choice of implant (nail vs. PREOPERATIVE PLANNING .

or metabolic event was the inciting event that led to the fall. if possible within 24 hours of admission to the . a traction radiograph with the leg internally rotated should be obtained. There is marked tenderness to palpation around the hip and proximal thigh. Any movement of the limb is painful and resisted by the patient. If there is any doubt about the fracture morphology. In a small but substantial number of patients. Patients with multiple medical problems pose a dilemma. Timing of Surgery Most patients with an intertrochanteric hip fracture should have surgery when medically optimized.. a cardiac.History and Physical Examination The vast majority of hip fractures occur in the elderly following a fall from standing height. etc. If none are identified and the patient is unable to bear weight. Many of these patients are taking anticoagulation medication that must be reversed prior to surgery. a CT scan or MRI should be obtained. pulmonary. neurological. This should be done with appropriate analgesia in the radiology suite or in the operating room prior to surgery . On phy sical examination. Bone scans are rarely used. Surgery should be performed as soon as it is safe but often requires 24 to 48 hours of medical optimization. Geriatric hip fracture management requires a treatment algorithm that takes into account the complex medical and social needs of this patient population. In patients with no obvious fracture following a mechanical fall. however. 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. important details regarding the fracture geometry may be difficult to interpret if the x-ray s were obtained with the leg shortened and externally rotated. The neurovascular status of the extremity should be carefully assessed and documented. Consultation with specialists in internal medicine. cardiology. is frequently required. the xray s should be scrutinized for a pelvic ring injury or an occult femoral neck fracture. the affected leg is usually shortened and externally rotated. This usually allows the phy sician to establish the diagnosis.

Early surgery avoids the problems of prolonged recumbency and minimizes the risk of decubiti. surgery must be delay ed bey ond 24 hours due to severe medical comorbidities. Prompt medical and anesthesia consultation also facilitate timely surgery.2). . and thrombophlebitis. 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 (6–10). which can be fatal in the frail geriatric patient. 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. On the other hand.hospital. pulmonary infections. several randomized controlled trials support the use of both an intramedullary nail and a hip screw in unstable fracture patterns. urinary tract infections. There is a large body of literature that supports the use of a sliding hip screw for stable intertrochanteric fracture patterns (Fig. atelectasis. These injuries are deemed urgent rather than emergent. Occasionally. Surgery is best done during the day time or evening and late night surgery is rarely indicated. 17. 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. This fracture pattern is more appropriately treated with a cephlomedullary implant or fixed angle implant.

A. SURGERY Positioning and Reduction Surgery can be preformed under general or spinal anesthesia.FIGURE 17.2 A stable intertrochanteric hip fracture. Traction/internal rotation view. C. B. Both anesthetic ty pes have advantages and disadvantages that should be discussed . AP radiograph. Cross-table lateral radiograph.

The affected foot and ankle is padded and placed in the boot or stirrup of the fracture table. and abducted (Fig.3). they are placed supine on a fracture table with a padded peroneal post placed between the legs. an arterial line. 17. . Most often. These images should be saved for later reference. the decreased hip motion may not allow the C-arm to be positioned between the legs. There are two way s this can be accomplished.with the anesthesiologist. in two views prior to prepping and draping. externally rotated. If there is arthritis or a contracture of the nonaffected hip. In this scenario. The fracture is reduced by longitudinal traction on the fracture table against the peroneal post with the leg in external rotation.4). with the nonaffected limb lowered and the hip extended (Fig. A cephalosporin antibiotic is administered intravenously and continued for 24 hours postoperatively. Reduction must be confirmed radiographically. For many elderly sick patients. Once the patient is stable. and an indwelling Foley catheter are necessary to improve patient care. This position is best accomplished by lowering the nonaffected limb and raising the injured limb. central venous catheter. followed by gradual internal rotation to neutral or just bey ond. the well leg is placed in a lithotomy positioner with hip flexed. another option is to “scissor” the legs. The unaffected or well leg must be positioned in a manner that allows for high-quality intraoperative imaging. 17.

.3 Positioning with the unaffected limb in the “well leg” holder in the lithotomy position.FIGURE 17.

however. this results in .5). Draping may be performed with an isolation drape (shower curtain) or using conventional split sheets.4 Positioning on the fracture table with the unaffected leg “scissored. The vastus can be split longitudinally . 17. 17.FIGURE 17. Surgical Approach A direct lateral approach to the proximal femur is utilized through an incision parallel to the femoral shaft. The ITB is incised in line with the skin incision exposing the vastus lateralis muscle belly. lower abdomen. pelvis.” The hip.6). The C-arm image intensifier is sterilely draped when appropriate. and extremity are prepped and draped. 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. The incision starts at the vastus lateralis ridge and extends distally depending upon fracture pattern (Fig.

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. FIGURE 17. one or two narrow Hohmann retractors are placed.5 The hip prepped and draped demonstrating the incision over the lateral aspect of the femur distal to the vastus ridge. It is not necessary to strip the vastus extensively off the femur (Fig. I prefer to elevate the vastus lateralis off the lateral intermuscular septum. .7).substantial bleeding and unnecessary damage to the muscle. 17.

FIGURE 17. .6 The skin incision is carried down to the ITB.

the starting point should be moved distally. Fixation The vastus lateralis ridge is palpated.FIGURE 17. A drill guide should alway s be used to accurately place the wire into the neck and head of the femur. and a drill guide (usually 130 or 135 degrees) is placed approximately 2.8). This is a crucial step. If the pin is either too anterior or too posterior on the lateral view.5 cm distal to this point. ( 11) have shown a . and the angle of the drill guide is “fine-tuned. it is repositioned accordingly. It is applied directly to the lateral cortex of the femur parallel to the floor. 17. the amount of anteversion/retroversion in the proximal femur is noted.” 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. If the pin is too superior in the head. and the surgeon should not accept poor pin position (Fig. Based on the previously saved reduction C-arm fluoroscopic views. Baumgaertner et al.7 The vastus lateralis is elevated off the intermuscular septum exposing the femur shaft.

.higher complication rate when the guide pin is malpositioned. These authors have shown that the TAD should be <25 mm (11) (Fig. FIGURE 17. He defined the tip-apex distance (TAD).8 The guidewire is advanced from the lateral cortex using a fixed angle guide. which is the summation of the distance from the tip of the pin from the center of the femoral head in the AP and lateral views.9). The wire is placed in a center-center position as see on the AP (A) and lateral (B) views. 17.

9 Demonstrates the concept of “Tip-Apex” distance. .FIGURE 17.

In patients with good quality bone. the plate barrel.10). the wire length is measured with the manufacturers’ depth gauge (Fig. 2. and bone quality ( 12).Once the position of the guide pin has been confirmed fluoroscopically to be center-center. Once tapped. 17.B). The length of side plate is determined based upon the fracture pattern. Most surgeons use side plates with two to four screw holes.12A. . fracture stability. the lag screw is inserted over the guide pin with a sleeve to the depth previously reamed (Fig. this step is not usually necessary. the lag screw core diameter.11A). 17. 17.11B). and 3. The 3 diameters of the reamer account for 1. This step should be checked with frequent fluoroscopic images to ensure that the guide pin does not inadvertently advance through the femoral head. recessing the femoral cortex to allow the plate to sit flush with the femur (Fig. 17. it is advisable to tap the screw path before inserting the compression hip screw. the side plate is inserted. Once the screw has been seated. An adjustable cannulated triple diameter reamer is “set” and used to prepare the proximal femur for the compression hip screw (Fig. In patients with poor quality bone.

.

Fully inserted (B). .11 The triple diameter reamer (A) is used to prepare the proximal femur for the lag screw. FIGURE 17. B.FIGURE 17. FIGURE 17.12 The lag screw is inserted over the guidewire (A).10 The lag screw length is indirectly measured over the guidewire. Reamer depth is monitored on image intensification.

14). 17.13A. The side plate is slid over the guidewire attachment onto the lag screw.13 The side plate is inserted over the lag screw extension in the proper “key ed” position (A).B). The plate is fixed to the femur with 4. and then impacted into the femoral neck and alongside the shaft (Fig. The guide pin is then removed. 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. .15). gently pushed.5mm bicortical screws (Fig.If a “key ed” sy stem was used. 17. Radiographs demonstrate the side plate fully seated. 17. 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. FIGURE 17. 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.

14 Screws are drilled and placed to secure the plate to the bone.15 . FIGURE 17.FIGURE 17.

The wound is thoroughly irrigated and closed over a suction drain. The subcutaneous tissues are closed with an absorbable suture.17). the wound is closed in lay ers beginning with the ITB.16 Following irrigation.Final radiographs demonstrate implant placement for a stable intertrochanteric hip fracture. The drain is attached to suction. FIGURE 17. absorbable sutures (Fig. 17. The vastus is allowed to fall back into its anatomic position over the implant. and the skin is closed with ny lon (Fig. The ITB is closed with interrupted heavy. AP radiograph and (B) lateral radiograph.16). 17. A. .

dressing. we obtain a rehabilitation consult on the first . and adaptive skills including toileting. psy chological. beginning with mobilization from bed to chair. Most elderly patients who sustain an intertrochanteric fracture benefit from 7 to 10 day s of inpatient rehabilitation. we use a mechanical compression device and a pharmacologic anticoagulation medication that is continued for 6 weeks. bathing. they are assisted into a dangling position in their bed. This includes helping the patient regain perceptual. and social situation. If the patient is unable to tolerate this transfer.FIGURE 17. motor. Occupational therapy should focus on assisting patients to regain independence in activities of daily living. 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 phy sical. Phy sical and occupational therapy are initiated on the first postoperative day.17 Final skin closure prior to dressing placement. For this reason. Postoperative Care Deep venous thrombosis (DVT) prophy laxis is started on the first postoperative day. and cooking. Unless there is a specific contraindication.

Coordination between a social worker. A leg-length discrepancy >2 cm can lead to hip pain and a limp. arrangements are made for continued outpatient phy sical and occupational therapy. usually within 3 to 4 months. 3. Johnston AT. Patients are seen in the clinic at monthly intervals for clinical and radiographic follow-up until the fracture has healed. J Bone Joint Surg Br 2010. J Bone Joint Surg Am 2002. Zuckerman JD. Nonunion following internal fixation using a sliding hip screw is rare. J Trauma 2010. Barnsdale L. If sy mptomatic. Following discharge. et al. All require thorough evaluation and treatment in conjunction with the medical specialists. Kesmezacar H.84(4):670–674. The most common medical complications include pneumonia. they often require revision fixation with or without bone grafting or complex revisions to joint arthroplasty . Wound drainage that persists for more than a few day s is aggressively treated with irrigation and débridement. Orthopaedic Trauma Association . Smith R. urinary tract infection. National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. case manager. Most orthopedic complications are preventable. Fracture and dislocation compendium. Change in long-term mortality associated with fractures of the hip: evidence from the Scottish hip fracture audit. DVT.postoperative day for disposition planning. Malunion is most commonly the result of excessive limb shortening following controlled collapse in unstable fracture patterns. REFERENCES 1. 2. Ay han E.68(1):153–158. phy siatrist. Unlu MC. et al. and constipation. and intravenous antibiotics. Morris AH. 4. deep wound cultures. Complications Complications following internal fixation of an intertrochanteric hip fracture can be divided into medical and orthopedic.92(7):989–993. and the patient’s family is invaluable to determine the optimal setting for each patient.

7. Park SR. Kim HS. Cells Tissues Organs 2009. 12. Int Orthop 1998. et al. The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases. Carmen B. J Bone Joint Surg Am 2008. Pry or GA. 8. Parker MJ. 5.60(2):325–328. Baumgaertner MR. et al. . J Orthop Trauma 1999. Baur-Melny k A.22(3):157–160. Crawford CH. 9. Function-orientated structural analy sis of the proximal human femur. Cordray S. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw—a randomised prospective trial. Skuban TP. et al.77(7):1058–1064. et al. Kang JS.466(11):2827–2832. J Orthop Trauma 1996. 10. Tosteson AN. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate.20(3):163–168. Aros B. Malkani AL. Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res 2008. 6. Meta-analy sis of ten randomised trials. J Trauma 2006. J Bone Joint Surg Am 1995. Gottlieb DJ. The value of the tipapex distance in predicting failure of fixation of peritrochanteric fractures of the hip. 11..10(Suppl 1):36–40. A review of the American Board of Orthopaedic Surgery Database. Vogel T. Bolhofner BR. Gamma versus DHS nailing for extracapsular femoral fractures. discussion 8–9. Lindskog DM.90(4):700–707.13(1):5–8. Anglen JO. Curtin SL.Committee for Coding and Classification. Int Orthop 1996. Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. et al.190(5):247–255. Russo PR.

and nearly 50% of these patients do not regain preinjury levels of activity. 18.1) to least (31A3. The cost burden exceeds 20 billion dollars annually. The 1-y ear mortality following surgery for a hip fracture remains around 20%. These fractures ty pically occur in elderly osteoporotic females. Approximately one in four hip fracture patients requires long-term placement in an assisted care environment. There are numerous classifications for hip fractures. which does not include care bey ond 1 y ear from injury. or reverse obliquity in the main fracture line.18 Intertrochanteric Hip Fractures: Intramedullary Hip Screws Michael R. All attempt to distinguish between stable and unstable fracture patterns. with 90% of fractures occurring in patients older than 65 y ears of age (1). Baumgaertner and Thomas Fishler INTRODUCTION The number of hip fractures in the United States is estimated to be approximately 400. classify ing intertrochanteric fractures along a spectrum from most (31A1. Unstable fracture patterns are marked by significant disruption of the posteromedial cortex.3) stable (Fig. subtrochanteric extension.1). The AO/OTA classification of these fractures incorporates each of these features.000 per y ear and will increase 50% by the y ear 2025. .

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Implant insertion can be performed in a closed. Contraindications to the use of a cephalomedullary nail include fractures of the femoral neck. and this is only partially prevented by a sliding hip screw. . 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. minimizing surgical trauma at the fracture site. A relative contraindication is the y oung trauma patient because of concerns regarding removing substantial bone from the trochanteric block in order to accommodate these large implants. will resist medial and compressive loads and can be treated with either a compression hip screw and side plate or an intramedullary nail. percutaneous manner. particularly those with subtrochanteric extension and reverse oblique fracture patterns (AO/OTA 31A3). A sliding hip screw and side plate remains the implant of first choice for stable two-part fractures. On the other hand. maintaining length and alignment while restoring the mechanical support of the posteromedial cortex. unstable three and four-part intertrochanteric fractures invariably collapse into varus and shorten. Even when healing is successfully achieved. and hip anky losis.1 The AO/OTA classification of intertrochanteric hip fractures. Cephalomedullary nailing is indicated in unstable intertrochanteric hip fractures. and multiple studies have shown no advantage with the use of an intramedullary device in this subgroup (2–5). preventing shaft medialization. and reducing intraoperative blood loss. The device functions as an intramedullary buttress. limb shortening >2 cm and medialization of the shaft can lead to poor outcomes.FIGURE 18. deformities within the femoral shaft including preexisting implants. once reduced. Stable two-part and some three-part fractures. An additional indication for nailing is an impending or pathologic fracture of the proximal femur. Cephalomedullary nails direct a screw(s) or a triflanged blade into the femoral neck and head through a variable length intramedullary nail.

should be obtained because deformities in the shaft may preclude the use of an intramedullary device. It is important to obtain a thorough medical and social history. Consultation with an internal medicine specialist is recommended to optimize the patient for surgery. 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. . On phy sical examination. Prophy laxis against venous thromboembolism should take into account the relative risks of pulmonary embolism and bleeding complications. the affected extremity is usually shortened and externally rotated.PREOPERATIVE PLANNING History and Physical Examination Elderly patients ty pically present after a mechanical ground level fall and are unable to stand or walk. There is exquisite tenderness to palpation around the hip and proximal thigh. Internal rotation and traction radiographs are invaluable for understanding the fracture anatomy as well as the success of the anticipated closed reduction. Antiplatelet agents are usually stopped preoperatively but restarted shortly after surgery (6). Computed tomography is not usually necessary but is obtained in complex fractures on a case-by case basis. but mechanical prophy laxis is indicated for all patients. 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-ray s. The choice of pharmacologic agent remains contoversial. Occasionally. which includes associated medical history and the patient’s ambulatory status. including an AP pelvis. Patients on anticoagulation therapy require temporary normalization of their clotting parameters prior to surgery. centered over the pubic sy mphy sis and full-length radiographs of the entire femur. Dehy dration and associated metabolic abnormalities are common and should be corrected preoperatively. Diabetic patients must have good perioperative glucose control. x-ray s of the unaffected hip and femur are useful for preoperative planning.

and screw length. anesthesiologist. A decision on the method of anesthesia should be made in collaboration with the surgeon.Timing of Surgery In all cases. it carries a higher risk of perioperative morbidity and mortality. Other authors advocate the use a full-length implant to protect the entire femur for all cases. The preoperative prophy lactic antibiotic of choice is a first-generation . Surgical Technique Surgery is performed under a general or spinal anesthetic. It is important to note that the nail is not designed to fill the canal. On the other hand. 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. as mortality is increased when surgery is delay ed bey ond 48 to 72 hours from admission (7). we most commonly perform the procedure on the day following hospital admission. this timetable is altered by the need to correct coagulopathy or perform more involved preoperative medical studies. optimization efforts can and should be performed through the nighttime hours. Surgical Tactic Careful examination of the preoperative radiographs as well as x-ray s of the unaffected hip are important parts of the preoperative plan and help guide implant selection with respect to the neck-shaft angle. While general anesthesia allows for complete muscle relaxation. Occasionally. Although first-generation short-stem implants were associated with an unacceptably high rate of subsequent femoral fracture. a recent meta-analy sis showed no increased relative risk for this complication when intramedullary devices were compared to side plates (8). and consulting internal medicine specialist. Surgery is ideally performed during day light hours with a rested team. diameter. medical optimization should be expeditious. 7 day s a week. particularly in the elderly hip fracture patient with multiple medical comorbidities. 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. as a result.

Both lower extremities are secured to the table. but a fracture table may be used as well. “Scissoring” the extremities in such a way prevents the pelvis from rotating on the perineal post as traction is applied to the fractured limb. In cases of penicillin allergy. a suitable alternative. which can lead to a varus reduction (Fig.cephalosporin.C). and traction is applied. is given.2 A. FIGURE 18. 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. B.3).2B. the patient is supine on the orthopedic table with the torso windswept and the lower extremities in balanced traction. A well-padded post is placed in the perineum. ty pically vancomy cin or clindamy cin. 18. In the ty pical position. 18. The Carm . We prefer to use an orthopedic table that allows for balanced traction to be applied to both lower extremities.

is positioned on the contralateral side of the patient. C. “Scissoring” of the lower extremities allows for unimpeded lateral fluoroscopic imaging. .

Prior to prepping and draping the field. Once the patient has been securely positioned on the table. . the pelvis rotates around the perineal post. the fracture is reduced. as this deformity is not reducible by manipulative means. The hip abducts.FIGURE 18. A particularly troublesome deformity is subsidence of the proximal fragment into the intramedullary canal of the distal fragment. Most stable fracture patterns will reduce with longitudinal traction and internal rotation of the limb. hampering access to the starting point. There are two goals.3 With the application of unopposed traction. must be recognized. However. here. such as slight external rotation. a percutaneous intrafocal reduction aid as described by Carr is helpful (Fig. The hallmark radiographic sign of a triangular double density. the first of which is to gain access to the starting point in the proximal femur. we confirm that we can see the following areas with fluoroscopy : the anterior cortex of the proximal femur. the fracture zone. unstable intertrochanteric fractures may require different maneuvers. 18.4A–E) (9). representing the overlap between the fragments. the second being anatomic reduction of the fracture.

the anterior neck. . the entire circumference of the femoral head. the posterior neck. and the greater trochanter.

Traction will not correct the apparent apex posterior deformity .B. Increased valgus is permissible because it reduces the bending forces on the implant and may offset limb shortening that occurs . On the AP view. E. we determine an acceptable neck-shaft angle to be 130 to 145 degrees. the medial cortex is restored. seen on the lateral x-ray . C. A double density of the medial cortex corresponds to an intussusception of the neck into the shaft.FIGURE 18. D. but an intrafocal pin will. A levering action disengages the fragments and allows for a line-to-line anterior cortical reduction.4 A. In considering the reduction.

a number of percutaneous maneuvers may be attempted. collinear clamp. as seen on the lateral view. If the closed reduction is inadequate. 18.with fragment impaction.5A–C). and cerclage wire to improve the reduction (Fig. utilizing such tools as the ball spike pusher. We use a sterile shower-curtain-ty pe drape but add an extra sterile lay er proximally to protect against puncture hole contamination from the instruments. is unacceptable. Loss or gain of femoral anteversion >15 degrees. . 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. Once a provisional reduction has been achieved.

and adjunctive definitive fixation in fracture patterns with a long subtrochanteric spike. provisional fixation. Colinear clamp with Hohmann-sty le arm attachment. inserted percuta-neously and used to correct varus in a reverse-oblique fracture.5 Percutaneous reduction aids include the (A) ball-spike pusher to correct flexion deformity of the proximal fragment. B. passed atraumatically . A small cerclage wire. can be a powerful reduction aid. C. The tip of the trochanter and the femoral shaft axis is marked in both .FIGURE 18.

it helps reduce fluoroscopy time. ty pically just medial to the tip of the greater trochanter. the guide pin should be centered in line with the medullary canal. Using a freehand technique. 18. This location will counteract the tendency toward varus and increased neck-shaft offset as well as minimize any damage to the gluteus medius insertion.planes with a sterile skin marker under fluoroscopy (Fig. and on the AP. the reduction should be verified with biplanar imaging. engaging the bone at a point in line with the intramedullary canal. Prior to instrumenting the proximal femur. FIGURE 18. a 3. In addition.6). .7A–B). This provides a visual aid for the correct insertion of the guide pin and the nail. 18. On the lateral fluoroscopic view. it should be aimed slightly medial (Fig.6 Marking of the femoral shaft axis and the tip of the trochanter.2-mm guide pin is inserted percutaneously approximately 5 cm proximal to the greater trochanter.

In these cases. 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. 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).FIGURE 18.7 A. The skin is infiltrated with local anesthetic containing epinephrine. We ream until the widest part of the drill has reached the lesser trochanter (Fig. 18.8). Placing firm medial-directed pressure on the trochanteric mass as well as pushing the reamer medially as it is advanced will ensure appropriate canal preparation (Fig. . the proximal femur is opened with a large cannulated drill. Appropriate guide pin location: centered on the lateral view. 18. through fascia. and directly onto the greater trochanter (Fig. 18. B. we employ flexible medullary reamers.9A).9B). and a 2cm incision is made along the guide pin. Once the guide pin is properly placed. It is unnecessary to ream to the isthmus unless the medullary canal is exceptionally narrow. Appropriate guide pin location on the AP view. An incorrect entry site is more problematic than generous reaming in this patient population.

a perfectly placed. . minimally invasive path is cut for atraumatic passage of the reamer and implant.FIGURE 18.8 By keeping the bevel of the blade in contact with the guide pin.

Also. 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. 18. . soft-tissue release.9 A. B. A combination of expanding the entry portal. If the nail does not fully advance but does not appear “tight” on the AP image. isthmic (flexible) reaming. or implant downsizing usually solves the problem. Only hand force should be required.10). Insertion of the proximal reamer so that the widest part is at the level of the lesser trochanter. because many nail sy stems do not incorporate a sagittal bow. the soft tissues should be checked to ensure that they are not restricting the entrance site. The nail is assembled on the driving/targeting device and pushed into the intramedullary canal. forcing the nail with a hammer risks iatrogenic fracture (Fig. The nail can be inserted with or without a guide pin. Firm medial pressure is placed to prevent lateral fracture displacement and to assure that a channel for the implant is created. the surgeon should check the lateral image to see if the tip of the nail is impinging on the anterior cortex.FIGURE 18.

The correct position for the lag screw is estimated on the intraoperative fluoroscopic views.10 The nail is fully seated in the canal.FIGURE 18. 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. Manipulation of the insertion handle connected to the nail can improve the . we confirm and. when necessary. the surgeon should advance the appropriate guide pin through the jig and nail into the femoral neck and head. Taking into account the anteversion of the femoral neck. “fine tune” the reduction. At this point. and a 2-cm skin incision is made in the proximal lateral thigh.

11A. a 3. The reduction can often be improved (after removing the guide pin) with increased traction as well as abduction of the extremity.11C).“sag” or translation on the lateral view. If it is parallel to the neck but too superior or inferior in the head. However. 18. With the nail seated to the appropriate depth. 18. the nail is advanced or backed out slightly.B). defined as the point where the subchondral bone is intersected by a line parallel to and in the center of the femoral neck. the guide pin acts as an excellent reference because it is 135 degrees to the shaft. 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. The guide pin is removed. This necessitates both central and deep placement. Significant valgus can be achieved by simply abducting the extremity at this point. The aim is to minimize the tip-apex distance (TAD). if guide pin is not parallel with the femoral neck. and the pin is reinserted. The pin should be directed toward the apex of the femoral head. The known length of the guide pin’s threaded tip can serve as a reference when estimating TAD that effectively controls for magnification (Fig. the fracture is usually in varus. On the AP view. the adduction necessary to access the entry site is no longer needed. It is very helpful to remember that once the nail is seated in the femur. the neck-shaft angle is acceptable. .2mm guide pin is inserted centrally and deep into subchondral bone using both the AP and lateral fluoro images for guidance (Fig. A partially radiolucent aiming jig can make placement of the pin along the axis of the neck on the lateral view considerably easier.

Once satisfied with the reduction and the position of the guide pin.FIGURE 18.11 A. The technique to measure TAD. . 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. an auxiliary stabilizing pin for all unstable fractures is placed (Fig. C. Appropriate guide pin placement on the AP x-ray . 18.B). B. Appropriate guide pin placement on the lateral x-ray .12A. 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.

FIGURE 18. An obturator should be used during removal of the reamer to prevent inadvertent removal of the guide pin. the centering sleeve should be advanced though the lateral cortex and into the nail using the sleeve pusher (Fig.13B). 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. 18. 18. 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. With the guide pin seated deep into the subchondral bone of the femoral head. exactly as one would do when using a sliding hip screw and side plate. B. It is placed out of the path of the lag screw. The lag screw is then inserted over the guide pin with the centering sleeve.12 A. Once the lag screw has reached the appropriate depth (Fig. For a 135-degree nail. We seldom use a tap because of the bone quality ty pically seen in this patient population. we ream 3 to 5 mm short of the subchondral bone. An auxiliary stabilizing pin is added to help control rotation.13A) and the reduction is verified. Certain implant sy stems provide a targeting attachment to place the auxiliary stabilizing pin. . a 95mm screw is the most common size.

In right hips. 18. This locks the rotational reduction but allows unimpeded sliding of the screw within the sleeve. The reduced position is then maintained while an AP image is obtained to confirm the reduction.FIGURE 18. Image was taken prior to centering of sleeve insertion. the clockwise seating of the screw flexes the hip and worsens such a deformity. However. 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. The lag screw is seated to the appropriate depth. which often helps correct the common mild extension deformities at the fracture. for left-side fractures. screw tightening tends to extend the proximal fragment. The sleeve is locked to the nail when it is tightened with the set screw. The centering sleeve is advanced through the lateral cortex and into the nail using the sleeve pusher. .13 A.14). The head-neck fragment is ty pically torqued somewhat as the screw is seated into the dense subchondral bone. B.

For most cases. Rotation of the screw results in fracture reduction. with full-length nails.15). or. 18. If the fracture fragments move as a unit. a single screw is placed in the dy namic slot using the alignment jig.FIGURE 18. . traction should be released from the extremity prior to considering a distal interlocking screw. we insert a compressing screw to initiate sliding and increase the immediate stability of the fracture (Fig. by a freehand technique. two distal interlocking screws are placed through the insertion jig. Lag screw insertion in a left hip showing worsening of extension deformity . For length-stable fractures. This also prevents the rare but catastrophic complication of proximal disengagement of the screw from the nail. If there is any question of motion.B). 18.16A. B. We then assess rotational stability by securing the distal extremity and gently rotating the insertion jig.14 A. we consider distal interlocking optional (Fig. For length-unstable fractures.

Note how the fracture reduces with the applied compression.15 A–C.FIGURE 18. A demonstration of compression screw insertion. .

16 A.B. AP and lateral postoperative radiographs. .17). 18. The subcutaneous tissue and skin are closed in lay ers.FIGURE 18. A dry sterile dressing is applied with care in consideration of the elderly patient’s fragile skin. The proximal wound is at risk of contamination from a disoriented elderly patient’s wandering fingers (Fig. The abductor fascia proximal to the trochanter at the nail insertion site is closed with a heavy absorbable suture.

17 The two small skin incisions with staple closure. POSTOPERATIVE MANAGEMENT Patients receive antibiotic prophy laxis for 24 hours. Patients are ty pically discharged to a short-term rehabilitation facility on postoperative day 3 or 4. All patients who sustain a low-energy fracture of the hip should be evaluated and treated for osteoporosis. Prophy laxis against deep venous thrombosis is carefully considered with a combination of sequential compression devices and pharmacologic medication. Patients are seen in the outpatient clinic at 10 to 14 day s for suture removal and at 6 and 12 weeks to confirm clinical and radiographic union. . Patients are mobilized from bed to chair and are gait trained with a phy sical therapist on the first or second postoperative day. generally with a firstgeneration cephalosporin. weight bearing to tolerance.FIGURE 18.

A number of techniques. A varus neck-shaft angle universally leads to an increased TAD and an increased offset when an intramedullary device is used. It may be avoided entirely by appropriate reduction and implant placement. and extracapsular anatomic region. REFERENCES 1. particularly in unstable fracture patterns (11). does lead to limb length discrepancy and reduced femoral offset. as well as the low-energy mechanisms that most often cause these fractures. such as conversion to a hip replacement. Nonunion is rare in this highly vascularized. Dawson-Hughes B. provide a superior maintenance of anatomy. It is here where intramedullary nails. however. . Additional complications include femoral shaft fracture. and painful hardware. and forgiving. soft-tissue necrosis. Solomon DH. which collapse less than a sliding hip screws. both of which contribute to an asy mmetric gait with a limp. revision osteosy nthesis with a long-stem implant.COMPLICATIONS The soft-tissue envelope surrounding the proximal femur is redundant. and surgical site infection are rare following internal fixation. Fortunately. like screw cut-out. depending on the extent of process. When it occurs. or open reduction and internal fixation. The absolute importance of TAD in predicting screw cut-out with intramedullary devices has been recently confirmed (10). wound dehiscence. Screw cutout has historically been the primary mode of failure for both compression hip screws and cephalomedullary nails. metaphy seal. When it occurs. it can be attributed. Excessive collapse of the sliding hip screw. Incidence and economic burden of osteoporosis-related fractures in the United States. Burge R. For these reasons. Stiffness of the hip following fixation is commonly encountered but rarely limits function. 2005–2025. can be used to address these problems. these complications are uncommon with proper surgical technique and new generation devices (12). to malreduction or poor implant placement. well vascularized. fractures below the implant. treatment ranges from oral or intravenous antibiotics to surgical débridement. et al.

279 fractures. et al. Intramedullary nails for extracapsular hip fractures in adults. Handoll HH. Geller JA. 8. A prospective. 9. Int Orthop 2010. Chest 2008. et al. Krallis P. Bhandari M. Utrilla AL. 3. Saifi C.133(6 Suppl):299S–339S. The perioperative management of antithrombotic therapy : American College of Chest Phy sicians Evidence-Based Clinical Practice Guidelines (8th ed). Are short femoral nails superior to the sliding hip screw? A meta-analy sis of 24 studies involving 3. prospective. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 2005.(3):CD000093.3:CD004961. Handoll HH. Munoz FM. 7.22(3):465–475. Gamma and other cephalocondy lic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. J Orthop Trauma 2002. 10. et al. 12. Parker MJ. Descamps PY. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized.21(7):485–489. Berger PB. et al. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Parker MJ. 11. Morrison TA. Dunn AS. Cochrane Database Syst Rev 2006. Cochrane Database Syst Rev 2008. randomized study of one hundred patients.34(5):719–722. 6. comparative study in 210 elderly patients with a new design . Jönsson A. Jones HW.23(6):460–464. Moran CG. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized. Saudan M. prospective study of 206 patients comparing the dy namic hip screw and proximal femoral nail.J Bone Miner Res 2007. J Orthop Trauma 2007. et al. J Bone Joint Surg Am 1998. et al. J Orthop Trauma 2009. Johnston P.80(5):618–630. Wenn RT.16(6):386–393. Douketis JD. 2. Parker M. et al. 5. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analy sis. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction.30(2):69–78. Sadowski C. Sikand M. Int Orthop 2006. Lübbeke A. 4. Schemitsch E.87:483– 489. Reig JS. Hardy DC. Carr JB. Use of an intramedullary hipscrew compared with a compression hip-screw with a plate for intertrochanteric femoral fractures.

.of the gamma nail.19(4):229–233. J Orthop Trauma 2005.

The vast majority of intertrochanteric hip fractures treated with modern internal fixation devices heal. This has led some surgeons to consider the use of a prosthesis in the management of selected. However. surgical techniques. and specific technical details needed to achieve a successful outcome. poses its own unique challenges including the need for so-called calcar replacing prostheses. The use of arthroplasty in this setting. Also addressed are the potential complications of hip arthroplasty for fractures of the intertrochanteric region of the femur. Randomized prospective studies of displaced femoral neck fractures in elderly osteoporotic patients treated with internal fixation have shown high complication rates. Haidukewych and Benjamin Service INTRODUCTION The number of patients treated for intertrochanteric hip fractures continues to increase and represents a significant financial and societal impact.19 Intertrochanteric Hip Fractures: Arthroplasty George J. certain unfavorable fractures patterns. In theory. and it raises questions regarding the need for acetabular resurfacing and the management of the often-fractured greater trochanteric fragment. or patients with poor hardware placement can lead to fixation failure with malunion or nonunion. fractures in patients with severely osteopenic bone. this may allow earlier mobilization and minimize the chance of internal fixation failure and need for reoperation. osteoporotic. For this reason. intertrochanteric hip fractures. . however. unstable. The purpose of this chapter is to review the indications. most surgeons favor arthroplasty. which has fewer complications and offers the advantage of early weight bearing.

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. If a pathologic fracture due to metastasis is diagnosed. it is scheduled as an elective procedure similar to a total hip. whether stable or unstable. however. sy mptomatic osteoarthritis of the hip with an unstable fracture pattern. and anemia is important. and in patients with severe preexisting. In North America. PATIENT EVALUATION PLANNING AND PREOPERATIVE Because these patients are ty pically elderly and frail with multiple medical comorbidities. using modern internal fixation devices. Recent studies have documented that hip arthroplasty for salvage of failed internal fixation provides predictable pain relief and functional improvement. pathologic fractures due to neoplasm (primarily metastatic disease). will heal uneventfully when the procedure is performed correctly. and pelvis are important for preoperative planning. surgery is performed within 48 hours of injury to avoid prolonged recumbency following medical consultation. internal fixation failures or established nonunions where the patient’s age or proximal-bone stock precludes revision internal fixation. computed tomography (CT) or magnetic resonance imaging (MRI) scanning can be helpful. there is a higher perioperative mortality rate among these patients compared to those who undergo internal fixation. Preoperative correction of dehy dration. If the surgeon has any concern regarding the possibility of a pathologic fracture. femur. electroly te imbalances. full-length femur radiographs are critical to rule out distal femoral lesions that would .INDICATIONS The overwhelming majority of intertrochanteric hip fractures. When done as a reconstruction procedure. Plain anteroposterior (AP) and lateral radiographs of the hip. a thorough medical evaluation is recommended. In acute cases. 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.

and a C-reactive protein should be obtained preoperatively. implant-specific extraction equipment and a broken screw removal set. If previous hardware from internal fixation is present. a sedimentation rate.impact treatment. many of the surgical principles are similar regardless of the preoperative diagnosis. Templating cup size and femoral component length and diameter is an important part of the preoperative plan. 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. Obtaining the original operative report can assist the surgeon in determining the implant manufacturer if it is not recognized from the radiographs. SURGICAL TECHNIQ UE The exact surgical technique will vary. Careful scrutiny of the hip joint is necessary to determine whether a total hip arthroplasty is needed rather than hemiarthroplasty. and whether a cemented or uncemented femoral component fixation is necessary. are invaluable. It is often difficult to determine preoperatively whether hemiarthroplasty or total hip arthroplasty is appropriate. or a nonunion with failed hardware. I prefer to have a variety of acetabular resurfacing and femoral-component fixation options available intraoperatively. a complete blood count with differential. with or without the use of fluoroscopy. However. of course. based on whether the reason for performing the arthroplasty is an acute fracture. 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. The patient is placed in lateral decubitus position using a commercially available positioner on the operating . To evaluate infection as a possible contributing factor in a patient with failed internal fixation. a neglected fracture. a pathologic fracture. it is wise to be prepared for unexpected situations that arise during these challenging reconstructions. General or regional anesthesia is utilized. A final decision is often made intraoperatively after visual inspection of the quality of the remaining acetabular cartilage. Although having such a large inventory of implants available for a single case is cumbersome.

and the status of the greater trochanter is evaluated. which facilitates proper acetabular-component implantation when necessary. to leave the abductor– greater trochanter–vastus lateralis complex intact in a long sleeve during the reconstruction. Several commercially available hip positioners are available that provide accurate and stable pelvic positioning. In the acute fracture situation. insert an axillary roll. The fascia is incised in line with the skin incision. . either an anterolateral or posterolateral approach can be used effectively based on surgeon preference. and ankle to minimize the chance of neurological or skin pressure problems due to positioning. protect the peroneal nerve area. and lower abdomen are prepped and draped in the usual fashion. Antibiotics are continued for 48 hours postoperatively until the intraoperative culture results are available and then stopped or continued if the culture is positive. If possible. it is alway s preferable. A stable vertical and horizontal position allows the surgeon to improve pelvic positioning.1). the so-called trochanteric slide technique may be useful (Fig. the trochanter may be malunited and preclude access to the intramedullary canal. is given. pelvis. The technique of preserving the vastus-trochanter-abductor sleeve may minimize the chance of so-called trochanteric escape and should be used whenever possible. ty pically a first-generation cephalosporin. We carefully pad the down side. if possible. In nonunions or neglected fractures. hip. The leg. In this situation. If no previous incision is present. If the greater trochanter is not fractured. An intravenous antibiotic. the previous surgical incisions are used. then a simple curvilinear incision centered over the greater trochanter is recommended. as these surgeries can be long with significant blood loss.room table. Consideration should be given to the use of intraoperative blood salvage (cell saver). 19.

1 A. Note continuity of the musculotendinous sleeve with mobilization of the greater trochanter. Trochanteric slide technique. If hardware is present in the proximal femur. B. Trochanteric slide technique. initial exposure: the sleeve of abductors and vastus lateralis are in continuity . The torsional stresses on the .FIGURE 19. deep exposure. I have found it helpful to dislocate the hip prior to hardware removal.

a total hip replacement is strongly recommended. With the hip dislocated either anteriorly or posteriorly. If previous surgery has been performed. then a hemiarthroplasty is most commonly utilized. It should be emphasized that the femoral side of the reconstruction is ty pically more challenging than the acetabular side in this setting. and iatrogenic femur fracture can occur with attempted hip dislocation. Appropriate attention to head size with hemiarthroplasty is important as an undersized component can lead to medial loading. all nonviable tissues are débrided. having implant-specific extraction tools is extremely helpful. The quality of the remaining acetabular cartilage is evaluated. and the proximal femoral-head fragment is resected with placement of an antibiotic-impregnated poly methacry late spacer. If there is evidence of acute inflammation or other gross clinical evidence of infection. and pain. especially in these ty pically stiff hips. the proximal fragment is excised. an acetabular component may provide more predictable pain relief. instability. If preexisting degenerative change is seen on radiographs or the acetabular cartilage is damaged from prior hardware cutout. Whether removing an intramedullary nail or sliding compression hip screw and side plate. Attention is then turned to the femur. The general principles of femoral reconstruction are summarized diagrammatically in Figure 19. The acetabulum is reamed circumferentially until a bleeding bed is obtained. . and head size options. while an oversized component can lead to peripheral loading. The principles of reconstruction are similar regardless of whether a nail or plate was used. the hardware is removed. and the acetabulum is circumferentially exposed. Reconstruction is delay ed 6 to 12 weeks or longer while the patient receives organism-specific intravenous antibiotics based on the intraoperative cultures. and pain as well. It is important to carefully evaluate the level of bony deficiency medially. bearing surface.2. and this decision should be made at the time of surgery. I prefer uncemented acetabular fixation due to the versatility it allows with the liner. even in the setting of normal-appearing acetabular cartilage. If the cartilage is well preserved. sclerotic subchondral bone commonly found in patients with osteoarthritic hips. intraoperative cultures and frozen section pathology are obtained from the deep soft tissues and bone.femur during surgical dislocation can be substantial. Of course. I also ty pically augment the cup fixation with several screws. instability. The acetabulum is carefully reamed because these hips do not have the thick.

reduction by wire or cable can potentially result in bony healing. which helps in determining femoral component height. a large posteromedial fragment may be reduced and stabilized with cerclage wires or cables. a calcar prosthesis is almost alway s necessary to restore leg length and hip stability. 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.Ty pically. In the acute fracture situation. Occasionally. . Therefore. Femoral components with modular calcar augmentations are available and allow intraoperative flexibility in restoring the hip mechanics. thereby restoring medial bone stock.

.

Cemented fixation may be advantageous for elderly patients with capacious. Regardless of whether cemented or uncemented fixation is used. I use an extensively coated design that can achieve distal diaphy seal fixation. If a compression screw and side plate are present. osteopenic femoral canals. standard reamers and broaches can be used to prepare the canal more safely . Once these sclerotic areas have been opened. Note the restoration of appropriate femoral-component height using a calcarreplacing stem. Note the stem length chosen to by pass all cortical stress risers by a minimum of two diaphy seal diameters. Illustration summarizing the general principles of femoral reconstruction for intertrochanteric fracture or salvage of failed internal fixation. Note the acetabular erosion superiorly from the lag screw. can alter the morphology of the proximal femur increasing the technical difficulty . Secure fixation of the greater trochanter has been obtained as is ty pical: with a cable through and a cable below the lesser trochanter.. Postoperative reconstruction with a total hip arthroplasty with particulate bone grafting of the superior acetabular cavitary defect. etc. callus. If an uncemented femoral component is chosen. Referencing the tip of the greater trochanter as a guide to restoring the center of rotation. This strategy allows the surgeon to by pass stress risers effectively y et not rely on proximal bony support for implant stability. These alterations can deflect reamers and broaches. Preoperative nonunion and hardware cutout after ORIF of an intertrochanteric fracture. I have found it useful to use a large diameter burr to provisionally shape the funnel of the proximal femur. intraoperative radiographs are recommended to assure appropriate alignment and length as well as to rule out iatrogenic fracture or .FIGURE 19. Because most adult femoral shafts are approximately 30 mm in diameter. I recommend that the femoral stem by passes the most distal screw hole in the shaft by at least two cortical (diaphy seal) diameters. Sclerotic hardware tracks.2 A. Either cemented or uncemented femoralcomponent fixation can be effective in this ty pe of reconstruction and is based on the preoperative as well as the intraoperative assessment of bone quality. leading to intraoperative fracture or femoral perforation. B. templating for 6 cm of by pass is a good general guideline for stem length. C. fracture translation.

intraoperative radiographs should be obtained. the greater trochanteric fragments are still somewhat attached and can be used as a gross guide for evaluating the appropriate level of calcar buildup. and the greater trochanteric fragment fixation.5. if necessary. 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.extravasation of cement. Regardless of the method chosen. screw-hole extravasations can usually be ignored as long as they are by passed sufficiently by the femoral component. Liberal autogenous bone graft from reamings is applied around the interface of the greater trochanter and the femoral shaft. The author ty pically obtains an intraoperative radiograph after the permanent acetabular component and the trial femoral component are in place. subcutaneum. 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. medial. but their lateral bulk can be problematic in thin patients. Countless methods of greater trochanteric fixation have been described. and it if it occurs. it should be carefully removed. Again.2 to 19. Although this may be difficult to assess in the presence of a trochanteric fracture. Regardless of the method of femoral fixation. Representative cases emphasizing these principles are shown in Figures 19. Intraoperative fluoroscopy can be very useful and is used routinely . and leg lengths and hip stability are assessed. Commercially available “claw plates” may be advantageous. usually. the greater trochanteric fixation should be stable through a full range of motion of the hip. after the definitive femoral components are implanted. and then once again. . A trial reduction is performed. Extravasated cement can be a cause of late periprosthetic fracture. and the skin are in lay ers. Small. The fascia. if necessary. most surgeons now use multiple wires or a cable claw technique. is complete. however.

FIGURE 19. .3 A. thereby restoring leg length and hip stability . Preoperative failed ORIF with proximal fragment translation and screw cutout. Postoperative reconstruction with a total hip arthroplasty with calcar augmentation to restore appropriate femoral-component height. B.

.FIGURE 19. Preoperative failed ORIF of a reverse obliquity fracture. B. Note the difficulty in managing the greater trochanter in this situation.4 A. Postoperative reconstruction with calcar-replacing bipolar hemiarthroplasty through a trochanteric slide technique.

the selective use of an abduction orthosis. B. and 5 y ears postoperatively. 2. and. and periodic radiographs are obtained to evaluate component fixation and trochanteric healing. Clinical and radiographic follow-up is performed at 6 weeks. If trochanteric fixation is required. 3 months. Postoperative radiograph demonstrating a cemented calcar-replacing bipolar hemiarthroplasty . 12 weeks. The acetabular joint space is well preserved. and avoidance of abductor strengthening until trochanteric union has occurred is recommended. the status of the greater trochanter. quality of intraoperative component fixation achieved. Preoperative failed ORIF with screw cutout.FIGURE 19. 1 y ear. weight bearing can progress as tolerated after surgery . partial weight bearing for 6 weeks. the follow-up periods are modified to 6 weeks. and 1. For asy mptomatic elderly patients with transportation difficulties. and then . Sutures are ty pically removed at 2 weeks. REHABILITATION In general. the surgeon should individualize the rehabilitation regimen based on patient compliance. however. most importantly. then every 2 y ears thereafter.5 A.

however. Dislocation was not a problem. complications still remain concerning. and early mobilization are recommended. Both bipolar and total hip arthroplasties performed well. and nonunion.every 5 y ears thereafter. It is important to lavage and dry the canal thoroughly prior to cementing longer stems in these frail patients. frail patients undergoing complex. If a long-stem cemented implant is used. Patients should be counseled preoperatively that such chronic complaints are very common. Bony union will occur in many but not all trochanteric fragments. and little. intraoperative embolization and cardiopulmonary complications can occur. and the 7-y ear survivorship free of revision was 100%. are the most common complications after reconstruction. They generally document the efficacy of arthroplasty as an alternative treatment for the acute fracture. persistent trochanteric complaints and problems obtaining bony trochanteric union were common. COMPLICATIONS Medical complications are common due to elderly. pressurization should be used. perioperative antibiotics. prolonged surgery. The principles of treatment of an infected arthroplasty are bey ond the scope of this chapter. Overall. if any. Most reports using arthroplasty for intertrochanteric fractures are for salvage of failed internal fixation. Calcar-replacing designs and long stem prostheses were necessary in the majority of cases. however. Pain relief was predictable. Trochanteric complaints. Infection and dislocation are surprisingly rare after such reconstructions in which modern techniques and implants are used. RESULTS There are several reports of arthroplasty for intertrochanteric fracture in the literature. Stable . hardware pain. including bursitis. Problematic recurrent dislocations due to trochanteric (abductor) insufficiency in patients with well-positioned components can be effectively managed with constrained acetabular liners. Thromboembolic prophy laxis. Dislocations are managed with closed reduction and bracing as long as the trochanteric fragment fixation remains secure. Haidukewy ch and Berry reported on 60 patients undergoing hip arthroplasty for salvage of failed ORIF. functional status improved in all patients.

371:206–215. Cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients. with extremely secure initial trochanteric fixation. Displaced trochanteric escape.33:721. Trochanteric complications are common. Carcangiu A. is ty pically treated with a repeat internal fixation attempt with some form of bone grafting. Attention to specific technical details is important to avoid complications and provide a durable reconstruction. salvage of internal fixation failure and nonunion. Ahn JH. Cemented hemiarthroplasty for elderly patients with intertrochanteric fractures. Hip arthroplasty for failed treatment of proximal femoral fractures. liberal use of autograft bone at the trochanter-femur interface. it is reserved for neglected fractures.34:939–942. Kim SY. preexisting degenerative change. the use of the trochanteric slide technique if mobilization of the trochanter is required. SUMMARY Hip arthroplasty is a valuable addition to the armamentarium of the surgeon treating intertrochanteric hip fractures. pathologic fractures due to neoplasm. Problematic high Brooker grade heterotopic ossification is rare after these reconstructions.trochanteric fibrous unions in good position will often be asy mptomatic and not require treatment. Clin Orthop 1988. sy mptomatic. Orthopedics 2010. Eschenroeder HC Jr. Cho CH. Ko JH. Krackow KA. et al.236:210–213. Yoon SH. et al. and careful postoperative rehabilitation and bracing. .2:221–226. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Clin Orthop 2003. D’Arrigo C. if sy mptomatic. Clin Orthop Surg 2010. and the senior author does not use routine prophy laxis. but functional improvement and pain relief are predictable. In general. RECOMMENDED READING Chan KC. Late onset femoral stress fracture associated with extruded cement following hip arthroplasty. and (rarely ) for fracture in patients with severe. The best treatment is prevention. Choy WS. Perugia D. Gill GS. Int Orthop 2010.

113:222–227. Acta Orthop Belg 2008.71(8):1214–1225. Arch Orthop Trauma Surg 1994. J Bone Joint Surg Am 2003. J Bone Joint Surg Am 1989.13:1131–1136.85:899–905. Nonunion of intertrochanteric fractures of the hip: a . J Arthroplasty 2005. Israel TA. Reverse obliquity of fractures of the intertrochanteric region of the femur. Said HG.20:337–343. Clin Orthop 2003. Berry DJ. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients: primary bipolar arthroplasty compared with ORIF. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. Green S. et al.60:124–128. DeBoerk H. Orthopedics 1990. Richman J. Kulich RG. Grimsrud C. Total hip arthroplasty following failure of dy namic hip screw fixation of fractures of the proximal femur. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Kim Y-H. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. Abdel-Aal A. Clin Orthop 1992. Salvage of neglected unstable intertrochanteric fractures with cementless porous-coated hemiarthroplasty.224:169–170.74:788–792. Casteley n PP.83:643– 650. Monzon RJ. Acta Orthop Belg 1994.277:182–187. Haidukewy ch GJ. Casteley n PP.Geiger F. J Bone Joint Surg Am 2001. Heisel C. Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly . Stern RE. Hammad A. et al. Knight WM.127:959–966. Haentjens P.412:184–188. Moore T. Acta Orthop Trauma Surg 2007. Revision internal fixation and bone grafting for intertrochanteric nonunion. Haentjens P. Haidukewy ch GJ. Koh Y-G. Opdecam P. Opdecan P. Harwin SF. DeLee JC. Haidukewy ch GJ. Berry DJ. Primary bipolar arthroplasty or total hip arthroplasty for the treatment of unstable intertrochanteric or subtrochanteric fractures in elderly patients. Oh J-H. Zimmermann-Stenzel M. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Casteley n PP. Haentjens P. et al. et al. Trochanteric fractures in the elderly : the influence of primary hip arthroplasty on 1-y ear mortality . Berry DJ. Proano F. Clin Orthop 1987.

Primary bipolar hemiarthroplasty for unstable intertrochanteric fractures.4:287–292.case study and review. Singh AP. Parvizi J. et al. Arch Orthop Trauma Surg 1998. Clin Orthop 1991. Chen WJ. Ky le RF.117:193–196. Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation: results of second attempts to gain union. Lifeso R. Patterson BM. Int Orthop 2010. Kaplan H.73:729– 736. Ereth MH. Waddell JP.75:340–345. Cabanela ME. Huo MH. Sarathy MP. Landon GC. et al. Fractures of the proximal part of the femur. Laffosse JM. Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients. Tabsh I. Stoffelen D. Sharvill RJ. Acta Orthop Belg 1994.26:233–237. Salvati EA.34:789–792. Sidhu AS.44:227–253. Long-stem revision prosthesis for salvage of failed fixation of extracapsular proximal femoral fractures. The neglected hip fracture.60:135–139. Tricoire JL. . Madhavan P. Nonunion of intertrochanteric fractures of the femur.72:776–777. Russell TA. Acta Orthop Belg 2009.269:32–37. Mehlhoff T. Haentjens P. Wu CC. Total hip arthroplasty for complications of proximal femoral fractures. Shih CH. Lewallen DG. Total hip arthroplasty following failed internal fixation of hip fractures. Younge D. Treatment of cutout of a lag screw of a dy namic hip screw in an intertrochanteric fracture.11:166–169. Acta Orthop Belg 2007. Total hip replacement as primary treatment of unstable intertrochanteric fractures in elderly patients. Singh AP.16:438. Morton J. J Bone Joint Surg Am 2004. Orthop Trans 1982. J Orthop Trauma 1990. et al. et al. J Orthop Trauma 1997. Kiral A. Mariani EM.86:1983–1986. Ferran NA. Total hip arthroplasty for complications of intertrochanteric fracture: a technical note.77:90–92. Clin Orthop 1987. et al. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Molinier F. J Bone Joint Surg Br 1994. Tullos HS. Jones HG. Rodop O. et al. Rand JA. et al. Ravichandran KM. Rey nders P. Int Orthop 2002. Thirty day mortality following hip arthroplasty for acute fracture. Instr Course Lect 1995. J Bone Joint Surg Am 1990.218:81–89.

Collinge INTRODUCTION Subtrochanteric femur fractures are challenging injuries to manage. and poor bone quality increase the difficulty in treatment and require careful preoperative planning. and the surgeon’s experience and resources (1–8). 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. Subtrochanteric fractures are usually treated with an intramedullary nail or a fixed angle plate. fracture comminution. the choice of implant depends on the fracture pattern. powerful hip muscle forces often lead to complex but predictable deformities (Fig. Beltran and Cory A. Following a fracture.1). . Several classification schemes have been proposed to categorize subtrochanteric fractures. The goal of surgery is to restore length. Intertrochanteric extension.20 Subtrochanteric Femur Fractures: Plate Fixation Michael J. and no single method of treatment is applicable to all fracture patterns. host factors. however. and rotation using an implant that provides stable internal fixation and allows early mobilization and protected weight bearing. alignment. stable internal fixation. The comprehensive classification of the AO/OTA is predominately descriptive while the Russell-Tay lor classification attempts to guide treatment with either a nail or plate. 20.

INDICATIONS AND CONTRAINDICATIONS .1 Muscle attachments around the proximal femur lead to predictable deformity pattern after displaced subtrochanteric fracture.FIGURE 20.

For any surgery in the proximal femur.4. There is a large body of literature documenting successful outcomes following nailing of these difficult injuries (1. a working knowledge of fracture fixation principles.. compared with nailing. minimizing the incidence of heterotopic ossification. especially in patients with head injuries. an intramedullary nail is the treatment of choice.2.8). PREOPERATIVE PLANNING History and Physical Examination . 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. Given the substantial and serious risks associated with nonoperative care. For internal fixation after corrective osteotomies for malunion or nonunion of the proximal femur. stemmed total knee prosthesis). pressure decubiti. including deep vein thrombosis. is that it reduces the risk of injury to the hip abductors and short external rotators. 3. Proximal femoral plating is contraindicated in any circumstance where the surgeon is unfamiliar with these techniques. is necessary. The advantage of plating. urinary tract infections. A preexisting implant that must be removed through an open approach. traction and casting should only be considered in patients with extremely serious medical comorbidities that preclude surgical intervention. 2. Furthermore. For most subtrochanteric fractures. both mechanical and biologic. There is widespread agreement that the benefits of correctly done surgery far exceed the risks. 4. Open reduction and plate fixation of a subtrochanteric femur fractures is indicated in the following situations: 1.Virtually all subtrochanteric femur fractures in adolescents and adults require surgery.e. 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. The use of an intramedullary implant is precluded by distal implants (i. the surgeon must be familiar with the anatomy around the hip to achieve consistently good outcomes. and pneumonia.

particularly in the poly traumatized patient with a head or chest injury. All open fractures require early and thorough surgical débridement with fracture stabilization. an AP pelvis.90 require a vascular consultation and workup (11). motorcy cle or motor vehicle collisions and falls from a height). The phy sical examination should clearly document the neurovascular status. Imaging Studies Initial radiographs should include an AP and lateral of the femur and hip. The first group is elderly osteoporotic patients with fractures that occur following low energy falls or bisphosphonate-related stress fractures. as shortening and external rotation are ty pically present and often obscure the true fracture geometry . Advanced Trauma Life Support protocols are used in all seriously injured patients. However. Abnormal or asy mmetric distal pulses warrant further studies (i. as the subtrochanteric region of the femur is a common site for bony metastasis.While subtrochanteric femur fractures are seen in all age groups. the secondary and later tertiary survey s should identify all other musculoskeletal injuries. as well as knee films to rule out associated injuries. a history of malignancy should also be sought.g. Recent studies have shown a correlation between prolonged bisphosphonate use and aty pical fractures of the femur (9. Computed tomography (CT) is not ty pically required for subtrochanteric fractures below the level of the lesser trochanter. they most commonly occur in two age clusters. In older patients. Virtually all patients present with a painful swollen thigh and are unable to stand or walk. Traction views with intravenous sedation of the femur are very helpful.e. Motion in the leg is reduced and very painful.. ABIs <0. Concomitant injuries often impact the timing of surgery and patient positioning and may alter the surgical approach or ty pe of implant to be used. ankle-brachial indices) to rule out a vascular injury . A thorough history and phy sical examination is mandatory prior to treatment. The second group of patients is y ounger individuals whose fracture occurs after high-energy trauma (e. The leg is externally rotated and shortened. Once life and limb-threatening injuries have been appropriately addressed. While uncommon.. open fractures of the proximal femur often involve small anterior or anterolateral wounds secondary to an inside-out mechanism.10). a CT scan may be useful if plain radiographs suggest or show involvement .

2). damage control surgery using a spanning external fixator may be indicated. Imaging studies must be critically reviewed to determine the integrity of the proximal fragment. preferably within 24 hours. The latter ty pically involve a simple transverse or short oblique fracture associated with cortical beaking and thickening (9. . Open fractures require emergent débridement and irrigation. or piriformis fossa. but when present the addition of penicillin is advisable. a surgical tactic should be developed to enhance efficient surgery and minimize surgical errors (Fig. whether a traditional fixed angle device or a proximal locking plate is necessary. since extensive comminution here may preclude the use of an intramedullary nail. especially longer plates.of the femoral neck. Surgical Tactic When surgery is planned. and whether a percutaneous technique can be employ ed. internal fixation with a plate or nail should be done as soon as possible. With the use of a 95-degree blade plate. 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. which may require special order. a preoperative plan also ensures that all necessary implants are available. Tracing out the fracture on paper may help the less-experienced surgeon understand the fracture geometry and the reduction steps better. We prefer to treat Gustilo and Anderson ty pe I and II fractures with a firstgeneration cephalosporin and ty pe III open fractures with the addition of an aminogly coside. In the poly traumatized patient in extremis and borderline patients with head and/or chest trauma. the length of the blade should be determined preoperatively. In a patient who is stable and cleared for surgery. greater trochanter. In circumstances where hospital inventory is limited. Subtrochanteric fractures secondary to low energy falls should also be assessed to rule out a pathologic lesion or an aty pical fracture secondary to prolonged bisphosphonate use. 20.10). The surgical tactic outlines whether a direct or indirect reduction is required. because intraoperative removal of a wrong-sized implant is difficult and fraught with problems. Grossly contaminated wounds are uncommon in the proximal femur.

The preoperative plan should also take into consideration how intraoperative imaging will be obtained. Prior to draping. and potentially make any errors on paper instead of in surgery . abducted. the C-arm should be positioned to confirm that correct views can be consistently obtained. Two methods of plate fixation for subtrochanteric femur fractures are presented with clinical and radiographic images to demonstrate specific points. because the flexed. High-quality intraoperative imaging is absolutely critical for fracture reduction and screw placement into the femoral head. mobilize necessary resources.FIGURE 20. and externally rotated position of the proximal fragment makes obtaining standard orthogonal AP and lateral projections difficult.2 A preoperative plan allows the surgeon to review the important concepts for repair of these complex fractures. unhindered by overlap of the contralateral thigh. First is the “classic” example of a 95-degree angled blade plate (see .

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. persistence of pain. IMPLANT SELECTION Compared to plates. recent studies of subtrochanteric femur fractures fixed with intramedullary nails have demonstrated high union rates and a low incidence of complications (1.11). This requires reaming with removal of substantial amounts of bone from the proximal femur (Fig. Patient positioning and reduction and fixation strategies are similar for both implants. and prevents shaft medialization. Furthermore. .10). As a result of these advances. 20. varus angulation.3). nails have a biomechanical advantage given their intramedullary location that decreases bending stresses.Fig. intramedullary nailing of subtrochanteric fractures can be technically difficult and fraught with problems. fracture extension from the entry portal may occur during reaming or insertion of the nail and may cause fracture displacement or varus malalignment. and the second uses a “modular” fixed angled implant (see Fig. Despite their mechanical advantages. injury to the abductor mechanism has been reported leading to gait disturbances. 20. or difficulties if revision surgery is required.4). 20. Occasionally. Virtually all nails have an enlarged upper portion to accommodate the proximal interlocking screws designed for femoral head placement.

20.3 Intraoperative fluoroscopy during revision surgery shows significant amount of bone removed during cephalomedullary nailing (arrowheads). Ty pe 2B fractures. due to fracture extension into the piriformis fossa. Ty pe 2A fractures. Ty pe IA and IB fractures are easily managed with nails placed through either a piriformis or trochanteric starting point at the discretion of the surgeon. preclude use of a piriformis starting point but are often still well treated with trochanteric nails. The Russell-Tay lor classification sy stem was devised to help guide implant selection (Fig.FIGURE 20.4). particularly .

Classically . these fractures were treated with a 95-degree blade plate or a dy namic condy lar screw (DCS) and side plate and recently with periarticular locking plates. Fixed angle plates have been successfully used to treat selected subtrochanteric fractures and avoid many of the problems encountered during nailing. are perhaps the best indication for plating of the proximal femur. .those complicated by lateral wall comminution.

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The 95-degree DCS (Fig.6) was developed to address some of these technical issues. Bridge plating of unstable fractures creates a load bearing rather than load-sharing implant and is mechanically inferior to a nail. it is not commonly utilized due to technical complexity and surgeon inexperience. PA).4 Russell-Tay lor classification of subtrochanteric factors attempts to predict which subtrochanteric fractures may be well treated with nailing. plating of the proximal femur is most commonly performed with either a 95-degree angled blade plate. increasing mechanical stability and reducing implant fatigue. and length must be restored if optimal healing and return of function are to be achieved. but requires removal of significant .FIGURE 20. However. Plate tensioning and fracture compression allow the bone to share load with the plate. and can be used as a reduction aid. The risk of failure increases in patients with poor bone quality treated with conventional plates and screws. fracture reduction in terms of axial alignment. and there is a large body of literature supporting its use (6.5) was the most commonly used implant for the internal fixation of proximal femur fractures. which may be particularly important in y ounger patients. 20. Historically. All of these implants are fixed angle devices that improve stability in the proximal femur. 20.12–14). In this setting. when applied properly. Currently. a 95-degree DCS (Sy nthes. Paoli. More complex and comminuted fracture patterns are better treated with indirect reduction and bridge plating (relative stability ). or newer proximal femur locking plates. In either case. the 95-degree blade plate (Fig. Ty pes A versus B addresses involvement of lesser trochanter and posteromedial buttress. rotation. outside academic medical centers. Ty pe I versus II addressed involvement of piriformis fossa/greater trochanter where a nail may propagate or deform fractures.7. the substantial forces across the subtrochanteric region may lead to implant failure. Simple two. The use of these implants allows either direct anatomic reduction with internal fixation or indirect reduction and bridge plating techniques. Fixed angle plates minimize injury to the abductor mechanism.or three-part fractures can be reduced anatomically and fixed leading to absolute stability and primary bone healing. plating the proximal femur carries its own set of disadvantages. However.

amounts of proximal bone and has never gained widespread acceptance. .

.5 Case example x-ray s of a subtrochanteric fracture in a 35-y ear-old man above a preexisting plate (healed fracture) repaired using a 95-degree angled blade plate.FIGURE 20.

may be more “user friendly ” compared to a traditional 95-degree blade plate. These plates improve mechanical stability using multiple screws that are locked into the plate creating a construct with multiple “fixed angle” screws. Newer locking plates anatomically contoured to fit the proximal femur have recently been developed (Fig.FIGURE 20.7).6 Case example radiographs of a 26-y ear-old man with multisegmental femur fractures repaired with shaft nailing and use of a 95-degree DCS device for the proximal fractures. Finally. while still technically challenging. a locking proximal femur plate. Additionally. these locking plates were manufactured to facilitate submuscularly insertion using smaller and potentially more biologically sparing approaches. 20. Thoughtful and technically proficient . locking plates for the proximal femur are not a panacea for this difficult injury. Despite these apparent benefits.

subsequently repaired using a proximal femur locking plate. central lines should be . We prefer general anesthesia as it allows complete muscle paraly sis that helps overcome the powerful deforming muscle forces in the proximal femur necessary to obtain a reduction.7 Case example x-ray s of a 45-y ear-old man with a subtrochanteric femur fracture 2 y ears after acetabular reconstruction with osteotomy .surgical techniques are important because implant failures are not uncommon (15). FIGURE 20. SURGERY Positioning and Setup General or spinal anesthesia is utilized in consultation with the anesthesiologist. For poly traumatized patients and those with serious medical comorbidities.

The supine position also allows other injuries to be addressed without the need to reposition the patient. An additional benefit of the supine position is in the poly traumatized patient with pulmonary injury because it avoids a “dependent” lung.17). which may be important in nonteaching hospitals where qualified assistants are not available. We prefer the lateral decubitus position on a radiolucent table. Minneapolis. The injured leg is elevated while the unaffected leg is lowered.considered and blood products made readily available because blood loss 500 mL or more is common.and chlorhexidine-based solution) is applied to the skin. For patients with a penicillin allergy and previous methicillin-resistant Staphylococcus aureus infection and for high-risk patients.g. we recommend 1 to 2 g of cefazolin (Ancef) administered within an hour of skin incision and continued for 24 hours postoperatively. alternatives such as clindamy cin or vancomy cin may be indicated. A thorough aseptic prep (e. MN) to isolate the surrounding skin and perineum . The use of a well leg lithotomy holder is less attractive because the pelvis cannot be fully stabilized against the peroneal post. alcohol. The patient can be positioned supine or lateral. Strong and sustained traction can also lead to pudendal nerve palsies. When using a fracture table with the patient in the supine position. Adducting the limb against the perineal post often increases the varus deformity particularly in large or obese patients. supine positioning on the fracture table does not consistently eliminate reduction problems such as posterior sag or varus malalignment. reduction and imaging are improved by “scissoring” the legs up and down. most of these surgeries have been done with the patient positioned supine on a fracture table. We routinely use an iodine impregnated adhesive (Ioban. based on surgeon preference and experience.. 3M. Traditionally. For closed fractures. comparison views of the opposite hip are not possible. The pelvis. 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. Most surgeons are comfortable with this position. hip. However. and entire lower limb are prepped and draped free to allow for traction and manipulation of the extremity as well as aiding intraoperative fluoroscopy . and it allows for strong sustained longitudinal traction. either on a radiolucent flattop or fracture table. and compartment sy ndromes have been described (16.

Imaging Whether using a fracture table or a flat-top radiolucent table. leg length and limb rotation should to compared to the opposite side. The imaging sequence should be rehearsed prior to prepping and draping to ensure optimal AP.from the operative field and to secure draping.8 Clinical photographs of patient with a subtrochanteric femur fracture (A) in lateral position on a radiolucent flat top table. FIGURE 20. If the patient is positioned laterally.8). 20. The limb is draped free (B) to . A true lateral of the femoral neck is obtained with a dual roll over view. AP views are easily obtained. optimal anteroposterior (AP) and lateral imaging of the proximal femur including the head and neck are mandatory and must be confirmed preoperatively. but obtaining a good lateral view generally requires that the C-arm be rotated “off axis” to account for the ty pical external rotation deformity seen as well as to can be obtained clear the well leg. “AP” views of the hip and femur are easily obtained with a “shoot-thru” posteroanterior view (Fig. and lateral visualization of the proximal femur can be obtained during the procedure. Accurate AP imaging requires the C-arm to be rolled bey ond neutral to accommodate rotational deformities. Whenever possible. With the patient positioned supine. and a slight cranial tilt often improves visualization of the flexed proximal fragment. 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 vastus ridge on the lateral wall of the trochanter. .9). If this area is fractured. 20. Surgical Approach A direct lateral approach to the proximal femur is used for open reduction and plate osteosy nthesis of subtrochanteric fractures (Fig. is easily identified and represents an important landmark for orienting a blade plate or proximal locking plate.allow manipulation and a direct lateral approach to the proximal femur is planned. direct reduction and lag screw fixation is usually required to restore the lateral wall. After incising the skin and subcutaneous tissue. 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. the iliotibial band is incised in line with the skin incision. if not fractured. especially if a blade plate is to be utilized.

FIGURE 20. A. C. The tensor fascia lata is divided longitudinally in line with the skin incision. .9 Lateral approach to the proximal femur is diagrammed. Perforating vessels are identified and ligated. The vastus lateralis is elevated anteriorly and the lateral aspect of the proximal femur is exposed without extensive soft-tissue stripping. B. The greater trochanter and lateral femur can usually be palpated and the skin incision follows this longitudinal line.

exposing the lateral aspect of the femoral shaft. These are technical procedures that require thoughtful and vigilant usage of fluoroscopy to restore alignment. Using these methods. which should be identified and cauterized or ligated to avoid significant bleeding. The origin of the vastus lateralis muscle contains dense Sharpey ’s fibers. Minimally Invasive Techniques In addition to traditional open approaches. the surgeon must adhere to the mechanical principles of modern fracture management (i. which must be released for optimal plate application. and plates are placed submuscularly in an effort to minimize the “surgical footprint. when using minimally invasive techniques. plates may also be applied using minimally invasive. The approach exposes multiple perforating femoral vessels. For minimally invasive plating of subtrochanteric fractures. planning for absolute or relative stability and long plates. with minimal or no dissection medially to limit further devitalization.” The ultimate goal of these approaches is to maintain the fracture biology by minimizing the amount of additional softtissue trauma and maintaining the fracture environment. which is already prone to slow healing and subject to significant mechanical forces that may limit the longevity of implants. and/or cannulated drill and screw guides. Some fixation sy stems dedicated to repair of proximal femur fractures have features to aid in minimally invasive insertion of plates and screws.. The dissection usually begins proximally and is carried distally.e. Finally. submuscular techniques. Soft-tissue elevation should be confined to the lateral femur. calibrated. the “working” incision is proximally based: a longitudinal skin incision is centered laterally over or just inferior to the vastus ridge. including radiolucent targeting devices. as direct visualization of the fracture is precluded using these approaches. surgeons make smaller incisions. according to preoperative plan) and executing the plan that carries out these principles. The tensor fascia lata is incised in line with the skin incision.The muscle belly of the vastus lateralis is carefully elevated from the lateral intermuscular septum and retracted anteriorly. The plate is inserted through the incision using the attached handle/targeting . Care must be taken to avoid periosteal stripping in this area. Comminuted fracture fragments should be left in situ.

20. When correctly applied.device. and the short external rotators of the hip. or temporary external fixation.. Reduction Subtrochanteric femur fractures are associated with characteristic deformities.1). abducted. a universal distractor (Sy nthes. For simpler fracture patterns where reduction is relatively straightforward. (either the 95-degree blade plate or proximal femur locking plate) proximally. With the plate properly secured to the lateral aspect of the proximal fragment. For fractures that are comminuted and displaced. gluteus medius. PA). Weber clamps) or a carefully applied serrated clamp can help reposition and reduce the proximal fragment to the femoral shaft. the construct can be reduced to the distal fragment and confirmed fluoroscopically . The femoral shaft is usually medialized by the pull of the adductors and sags posteriorly and collapses into varus. where the construct capturing the proximal segment is modular and can be applied without forceful manipulation. apply ing a well-contoured plate.e. we often reduce the fracture first and then apply the plate and screws. The proximal fragment is usually flexed. We recommend direct reduction with minimal soft-tissue stripping for . anatomically contoured proximal femoral plates can improve the reduction by reducing the fracture to the plate. When simple correction of abduction or flexion is necessary. The plate is slid along the shaft of the femur between muscle and periosteum keeping the distal tip of the plate against bone. This may be done most easily with a proximal femoral locking plate. Plate position is confirmed fluoroscopically in the AP and lateral projections. the use of a fracture table. Deformity correction involves longitudinal traction to restore length and can be accomplished by manual traction. Paoli. Finally. and using it as a reduction aid can be very helpful. 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. but must be considered carefully if it will significantly affect the local biology at the fracture site or impede definitive fixation. Large pointed reduction clamps (i. respectively (Fig. and externally rotated by the pull of the iliopsoas. a well-placed small or minifragment “tacking” plate can aid in maintaining an unstable reduction.

otherwise. because stress concentration occurs at the level of the fracture.19). noncomminuted fracture patterns and those fractures with one or two large butterfly fragments amenable to lag screw fixation. the use of a universal distractor is necessary to regain length and indirectly reduce some of the cortical fragments via ligamentotaxis. distal screws are inserted using multiple small incisions or a short open lateral approach distally. By tensioning the plate and creating a load-sharing environment with the bone.simple. spacing rather than clustering screws in the shaft may be an effective means of modulating implant stiffness. If medial cortical contact has been restored. After length has been restored. compression of the fracture can be performed using an articulated tensioning device attached to the end of the plate. no attempt is made to expose the fracture fragments distal to the head-neck segment after proximal plate application. With submuscular plate application. If proximal plate application is correct.10)  The use of a blade plate is technically demanding but provides excellent stability in the proximal femur and has a strong clinical record. mechanical alignment of the limb should be restored once the plate is fixed distally. In this situation. a longer plate is desirable to increase mechanical stability and minimize dissection in the zone of injury. as this process must be . Fixation 95-Degree Angled Blade Plate: (Fig. It is important to have at least six to eight screw holes available below the fracture site. an indirect reduction should be performed. especially when locking screws are used. The use of shorter plates in comminuted fracture patterns is not advised. increasing the chance of implant failure or nonunion (18. With longer working lengths. fracture healing with a low incidence of nonunion and hardware failure has been reported (14). 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. In this setting. Most of the technical challenge lies in positioning the cutting chisel for blade placement. 20. indirect fracture reduction using a bridge plate technique should be performed. Longer plates with well-spaced screws are thought to be advantageous during bridge plating. When comminution precludes the use of direct reduction techniques or when a submuscular plate application is planned.

In y ounger patients with dense cortical bone. A channel is created in the lateral cortex by predrilling with a linear triple drill guide before chisel insertion. alignment wires and the 95-degree alignment guide can be used before cutting the blade’s path with the seating chisel. will minimize technical errors and ensure proper preparation for the blade. 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. the chisel should be backed out frequently to minimize the risk of incarceration. The next guide wire is inserted to control coronal plane alignment.precise simultaneously in three planes or a malreduction will occur. the chisel can be inserted using the 95-degree alignment guide. The slotted hammer is used to guide the chisel and make minor corrections as it is inserted. Constant attention to the appropriate positioning of the chisel. To facilitate accurate placement. With both guide wires in place. The blade should pass about 10 mm below the superior face of the basicervical femoral neck. and a common mistake is to place a wire centrally within the trochanter. Using a preset alignment guide. the femoral neck originates from the anterior one-half of the greater trochanter. Anatomically. 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. When inserted properly. . this wire is placed through the superior portion of the trochanter at an angle of 95 degrees relative to the femoral shaft. just proximal to the vastus ridge. in concert with frequent AP and lateral fluoroscopic imaging. Proper blade placement requires that the seating chisel enters in the anterior half of the greater trochanter. which may lead to external rotation deformity.

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B. the appropriate length blade as templated from preoperative . A. The 95-degree blade plate is inserted and fixed with an additional point of screw fixation proximally (F) before the fracture reduction is finalized.FIGURE 20. D.10 Case example of a 72-y ear-old woman with a subtrochanteric femur fracture after a fall. C. and shaft fixation applied. Intraoperative positioning is on the fracture table and incision is marked. After chisel placement into the inferomedial femoral head is confirmed fluroscopically. Postoperative and 6-month follow-up (G) radiographs are shown. E. Intraoperative fluoroscopy images show use of summation pins to aid in correct insertion of chisel and 95-degree blade plate. Injury radiographs. compression achieved. The chisel is placed along the axis of the femoral neck.

and intraoperative radiographs is inserted. Furthermore. Proper reduction of the fracture and alignment of the plate relies on placing guide wires within the femoral head. sagittal. it allows for incremental adjustment in the plate position prior to definitive screw placement. Because virtually no bone is removed during guide wire insertion. 20. so slight adjustments in blade positioning are possible but technically difficult.11) Locked plating has advanced the treatment of unstable periarticular fractures. correct application of locked plates using biologically friendly techniques has been shown to improve results in other areas. While clinical data regarding outcomes following locked plating of the proximal femur is limited. Careful attention to detail is necessary to minimize the tendency for varus malalignment. including subtrochanteric and peritrochanteric femur fractures. and axial plane alignment when the plate is fixed proximally and then distally. and continued diligence in blade placement is necessary. Locking Proximal Femur Plate (Demonstrated in Fig. Chisel placement does not remove bone from the femoral head and neck. additional screw fixation into the proximal fragment and calcar femorale should be done. because final plate position is dependent on guide wire position in the femoral head and the lateral wall. After successful blade placement. The blade cannot be assumed to follow the natural path cut by the chisel. an intact vastus ridge is not critical for proper implant placement. . An anatomically contoured plate applied to the proximal fragment may help restore coronal.

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The plate is centered along the lateral femur to gain an “optimal” fit and the guide pin is placed through the Alpha hole.11 Case example of a 43-y ear-old woman with a subtrochanteric femur fracture (A) with peritrochanteric extension treated with a proximal femoral locking plate. D. B. along the calcar and centrally to ensure that fixation will be suitable. . In this case the patient was positioned lateral and the leg draped free for ease of reduction and visualization.FIGURE 20. C. Additional fixation is applied according to the preoperative plan. Postoperative (E) and 6-month follow-up (F) x-ray s show an aligned and ultimately healed proximal femur. Reduction was achieved with a small buttress plate and a pointed reduction clamp before plate application.

when confirmed to be correctly placed fluoroscopically. but should not penetrate the subchondral bone. We describe the use of the Peri-Loc Proximal Femur Locking Plate (PFP. the nonlocking cortical screws must be inserted first before any locking screws are inserted (lag before y ou lock). . Kwires or a narrow clamp may be useful to stabilize the plate. which is a 316-L stainless steel plate reinforced in the subtrochanteric area to resist fatigue failure. or the fixation of those screws can be compromised.Proximal femoral periarticular locking plates are now available from a variety of orthopedic implant manufacturers. We recommend that a nonlocking screw be inserted into the “Alpha” hole first. and the pin reinserted. If the guide wire is not in the correct position in the femoral head. Combining standard nonlocked screws to lag the bone to the plate followed by locked screws to improve construct stability is very helpful. AP and lateral C-arm radiographs must be obtained to ensure that guide wire placement is properly placed. Remember that if a combination of nonlocking and locking screws is used. A 3. Screw lengths are determined by measuring the guide pin with a calibrated depth gauge. The plate is positioned against the lateral aspect of the proximal femur and adjusted under C-arm control until an “optimal fit” is confirmed. TN). Subsequent screws can be either nonlocking or locking depending on the bone quality or fracture pattern. allows cannulated screws to be precisely inserted. 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). Prior to fixation. The authors recommend that at least two guide pins be inserted into the proximal femur and alignment confirmed on AP and lateral x-ray s before proceeding with screw insertion. Memphis. which serves as the designated reference point for correct plate and pin position within the proximal fragment. Smith and Nephew. The modularity of modern locking plates allows for more flexibility in when and how reduction is achieved. The drill guides can also be used as handles to aid in positioning the plate. The PFP allows up to six screws to be directed into the femoral head. plate position should be centered distally on the shaft as well.2-mm guide pin is placed into the “Alpha” hole of the plate. The guide pin should be inserted deep within the femoral head. the plate repositioned slightly. it should be removed. It is very important to avoid stripping the screws when using a powered drill. It uses guide wires strategically directed into the femoral neck and. and final tightening should alway s be done by hand.

and externally rotated. Preoperative drawings are a useful exercise. The proximal fragment is ty pically flexed. The preoperative plan allows for a more efficient and less-stressful surgical experience and can decrease the risk for surgical failure. These are not every day cases for ANY surgeon. 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. while the distal segment sags posteriorly and may be deformed by the pull of the adductor complex. and the Verbrugge clamp is useful for aligning the plate to bone (or vice versa) or apply ing compression with a push-pull screw.Tips and Tricks 1. Large AO bone forceps should be available when open reduction is planned. The fracture hematoma is biologically valuable. it should be preserved whenever possible. 6. particularly for surgeons unfamiliar with the techniques or those in training. 7. 3. In order to obtain high-quality fracture reductions. Minifragment or small fragment plates can be applied to effectively counteract deforming forces and functionally simplify a fracture pattern (Case 2). and while it may be entered to facilitate reduction in cases where open reduction and internal fixation with absolute stability is used. including a comprehensive method of achieving this critical component for “successful” surgery. POSTOPERATIVE MANAGEMENT . abducted. An organized. The articulated tensioner is also useful for apply ing compression in a similar manner. Intraoperative assessment of alignment is discussed in several parts of this chapter. step-by -step assessment should be a part of the preoperative plan. the surgeon must have a clear understanding of the deformity affecting both the proximal and distal fragments. 5. The large serrated reduction clamps are useful for holding the major bone fragments. This practice helps ensure that the proper equipment and implants are available as determined before surgery . 4. These plates should be placed with caution. 2. so as not to impede the path of future screws or further devitalize bone. The femoral neck and head are anterior to the shaft.

Thromboembolic chemoprophy laxis is routinely employ ed and is strongly recommended.21). patients are allowed to increase weight bearing. We ty pically follow these patients with AP and lateral radiographs at 6-week intervals after the initial postoperative visit until the fracture is healed. Quadriceps and abductor stretching and strengthening are initiated during the first week. As healing progresses. Because most plate constructs are load bearing. The use of longer plates with fewer but well-spaced cortical screws may limit implant stiffness and encourage callus formation. screw penetration into the hip joint.A cephalosporin antibiotic is used for 24 hours after fixation of closed fractures. gapping at the fracture site should be avoided because it increases the likelihood of implant failures and nonunion (22). With locked plating. In cases where anatomic reduction has been achieved and compression has created a load-sharing construct. Eight cortices of fixation distally are recommended to provide the necessary implant strength to prevent early torsional and axial failure. fracture shortening. 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. Newer techniques to . Technical errors include angular and rotational malalignment. When direct reduction of the fracture is utilized. until wound closure is achieved. touchdown weight bearing is employ ed until there is radiographic evidence of callus formation. because weakness in these muscles has been documented at 1y ear postinjury and may influence long-term functional outcomes (20. Patients are mobilized on the first or second postoperative day depending on associated injuries. A common technical error encountered during indirect reduction and bridge plating is an overly stiff implant. and improper or inappropriate implant selection and application. The most common technical error is residual varus malalignment. an implant of sufficient length is necessary to allow for spacing the screws to prevent stress concentration and premature implant breakage. earlier weight bearing may be allowed. and an aminogly coside is added for open fractures and continued for 48 to 72 hours. Hip joint violation is avoidable with careful analy sis of the intraoperative fluoroscopy views.

implants should be removed. and. Smokers and immunocompromised patients are particularly prone to these complications. a more aggressive approach is mandated. If deep infection is obvious or highly suspected. although this complication is theoretically reduced with use of locking screws. the use of an intramedullary device may be advisable to decrease stress across the fracture and implant. 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. The wound bed may be well addressed with antibiotic beads or a negative pressure dressing. wide surgical débridement and treatment with intravenous antibiotics are obligatory. Implant failure is more likely to occur in elderly patients with osteoporotic bone (especially varus cutout). 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. A recent study suggests that a successful outcome is possible with retained implants for acute deep infections (26). if fixation is lost. The hardware should be carefully assessed for loosening. and nonunion is more common. slotting of near cortical holes. but when it occurs is potentially devastating. A wound hematoma is much more common than infection and generally much easier to treat. Once the infection is controlled. the area is under high mechanical stress. In osteoporotic bone where varus cutout is a concern. some subtrochanteric femur fractures fail to unite. Persistent wound drainage after surgery should be monitored carefully. Delayed Union/Nonunion The subtrochanteric area has correctly been labeled as a problem area in terms of healing. If a true infection is present. and threaded screw head inserts are all new methods designed to give surgeons control of implant stiffness with some modulation of the healing environment (23–25). Despite well-performed surgery using modern operative techniques. . Postoperative Infection Postoperative infection is relatively uncommon. Under normal circumstances.modulate locking plate stiffness have recently been reported. revision internal fixation may be appropriate. Far cortical locking.

Many of these problems are successfully avoided through the process of preoperative planning. autogenous bone grafting should be considered.This may be especially true if there is residual malalignment or the stability is compromised. diabetes. which remains the gold standard. flexion. If unsuitable alignment is recognized at any step during surgery. Alternatives to autogenous iliac crest bone graft are considered in high risk patients such as obesity. Malalignment Unfortunately. we favor hardware removal and cephalomedullary nailing. In some comminuted fractures that have failed to unite. the subtrochanteric area is presumed to be a vascular watershed. malalignment is common after plating (or nailing) of subtrochanteric femur fractures. and any or all of these may need to be addressed. If there is no progression toward healing 12 or 14 weeks postoperatively. or a combination of these. These commonly involve varus. If the nonunion is very proximal. and vigilance during this part of surgery is mandatory if these problems are to be avoided. Biologically. including minimally invasive approaches have become more popular. external rotation. the appropriate steps should be taken to correct the problem(s). We still favor iliac crest autograft. As more biologic approaches. then revision plating may be preferable. Bone grafting of a well-stabilized fracture may be a lesser surgical burden than hardware removal and intramedullary nailing. OUTCOMES Outcomes after traditional blade plate fixation of subtrochanteric femur . Virtually all of the assessment must be done radiographically. and steroids. the rates of malunion appear to have increased as direct visualization is avoided. For a sy mptomatic subtrochanteric nonunion requiring revision fixation. and infectious factors may play a role in nonunion. much of the fracture will have healed. where additional insult after a high-energy injury or aggressive surgical dissection may not allow adequate local biology for healing. Suffice it to say that mechanical. biologic. leaving a simpler “pattern” of nonunion to address. although reamer irrigator aspirator grafting from the contralateral femur or bone morphogenic proteins are alternatives in some cases.

Subtrochanteric fractures of the femur: results of treatment by interlocking nailing. while theoretically attractive. randomized study .238:122–130. Kinast C. with no nonunions reported in their series. Yoo MC. Khan LA. (6) demonstrated superior outcomes after indirect reduction of subtrochanteric femur fractures compared to direct reduction. Mast JW. Like other technically challenging orthopedic procedures. J Orthop Trauma . et al. Houshian S. Kang S. 7. Subtrochanteric fractures of the femur: results of treatment with the 95 degree condy lar blade plate. Indirect reduction and submuscular plating. Kinast et al. especially given recent reports of early plate breakage (15. as this has been associated with unfavorable results. 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). Treatment of unstable peritrochanteric femoral fractures using a 95 degree angled blade plate. et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degree screw-plate: a prospective. et al. Johnson KD. and improved outcomes can be expected with experience.283:231– 236. Bolhofer BR. Saudan M. Wiss DA. Lundy DW. Robinson CM. Kim KI. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by lowenergy trauma. Brien WW.87:2217–2226.84:372–381. especially when biologic principles are followed (6). 5. Lubbeke A. must be tempered by a lack of clinical evidence. J Am Acad Orthop Surg 2007. 6. McAndrew MP. Sadowski C.15:663–671. REFERENCES 1. Cho YJ.9:453– 463. 3. Clin Orthop Relat Res 1992. J Orthop Trauma 1995. J Bone Joint Surg Am 2002.fractures are generally good. The reconstruction locked nail for complex fractures of the proximal femur.27). stripping of individual fragments is ill-advised. 2. a learning curve exists. Subtrochanteric femoral fractures. J Bone Joint Surg Am 2005. 4. Clin Orthop Relat Res 1989. If direct reduction of a comminuted fracture is performed.

Can M. Haidukewy ch GJ. Clin Orthop Relat Res 1994.15:580–583. Jando VT. et al. Capeci CM. Dunbar RP. Archdeacon M. et al. Perry JJ. Compartment sy ndrome of the well leg as a result of the hemilithotomy position: a report of two cases and review of the literature. Koh JS. Planning and reduction technique in fracture surgery. 11. et al. Schatzker J. et al. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. 17. J Orthop Trauma 2008. Israel TA. Indirect reduction and biological internal fixation of comminuted subtrochanteric fractures of the femur. Barei DP.11:509–520. Wy rich J. Banovetz J. Locking compression plate loosening and plate breakage: a report of four cases. 9. 20. Subtrochanteric fractures of the femur. Muratli HH. 10. Injury 2006. Lu T. Tejwani NC. Subtrochanteric insufficiency fractures in patients on alendronate therapy : a caution. Ganz R.19:687–692. Ford KR.22:10–15. Compartment sy ndrome in the well leg resulting from fracture-table positioning. J Trauma 2004. Orthop Clin North Am 1980. Babst R. Germany : Springer-Verlag.18:571–577. 18. 14.25:76–83.301:239–242. Yang KY.89:349–353. Glassner PJ. 19. J Bone Joint Surg Br 2007. Sommer C. Muller M.2005. et al. 13. Murray PC. McNair P. Reverse obliquity fractures of the intertrochanteric region of the femur. Goh SK. 12. 16.56:1261–1265. Anglen J.91:2556–2661. Berry DJ. Evans JM. Mathews PV. J Am Acad Orthop Surg 2009. Helmy N.37:740–750. 8. Berling. 21. Tejwani NC. Failure of fracture plate fixation. Wadell JP. Mills WJ. Failure of proximal femoral locking compression plate: a case series. A prospective functional outcome and motion analy sis evaluation of the hip abductors after femur . J Bone Joint Surg Am 2001. J Orthop Trauma 2001.83:643–650. Jakob R. 1989. J Orthop Trauma 2004. J Orthop Trauma 2011. J Bone Joint Surg Am 2009.17:647–657. Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures. 15. Mast J. Gardner MJ. Celebi L. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.

Stall A. Annual Meeting of the Orthopedic Trauma Association. Pallotta NA. 2006. et al. Far cortical locking can reduce the stiffness of locked plating constructs while retaining construct strength. Kobbe P. Berkes M. Maintenance of hardware after early postoperative infection following fracture internal fixation. 27. J Orthop Trauma 2011. Fitzpatrick DC.91:1985–1994. O’Toole RV. J Bone Joint Surg Am 2010. Effects of near cortical slotted holes in locking plate constructs. Scannell B.25:65–71. Threaded screw head inserts improve locking plate biomechanical properties. 28. Phy sical and biological aspects of fracture healing with special reference to internal fixation. et al. Phoenix.92:823–828. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. 25. J Orthop Trauma 2011.23:628–633. . Mitchell E. et al. Doornink J. J Orthop Trauma 2008.fracture and antegrade nailing. Dow K. Sellei RM. Floy d JC. 24. Submuscular locked plating for pertrochanteric femoral fractures: early experience in a consecutive one-surgeon series. Bottlang M. Arizona. et al. et al. 23. Kregor P.25:S35–S40. J Orthop Trauma 2009. Perren SM. Garrison RL. 22. Clin Orthop Relat Res 1979. J Bone Joint Surg Am 2009.138:175–196. 26.22:3–9. Bellapianta J. Obremskey WT.

21 Subtrochanteric Femur Fractures: Intramedullary Nailing Clifford B. Intramedullary nailing of the proximal femur has become the standard method of treatment for most subtrochanteric femur fractures. nails are labeled as piriformis or trochanteric entry nails. Successful treatment methods require neutralization of these forces while maintaining the blood supply to enhance healing. Their proximal screw insertion pattern is either transverse or oblique and directed from the greater to the lesser trochanter. interlocking screw insertion can be performed transversely from lateral to medial or are multidirectional. 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. Either combination can be utilized for reconstruction nailing of subtrochanteric fractures. Currently. 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. Contemporary femoral nails are categorized by their screw orientation and nail design. Jones INTRODUCTION Subtrochanteric femur fractures are much less common than hip or shaft fractures. Distally. a full-length statically . They are usually associated with high-energy trauma in y oung adults or with lower-energy falls in the elderly. With these options. Standard antegrade femoral nails have a radius of curvature or anterior bow to facilitate its insertion into the femoral canal.

21. which can be confusing because of conflicting terminology and regional differences. For this reason.locked reconstruction nail of sufficient diameter can be utilized to treat fractures extending from the greater trochanter to the distal femoral metaphy sis. INDICATIONS AND CONTRAINDICATIONS The OTA/AO fracture classification describes subtrochanteric fractures as 31-A (1) (Fig. Not surprisingly. pertrochanteric. fracture extension into the greater trochanter and piriformis fossa creates problems with nailing and increases the risk of comminution and instability.1).2). This subgroup of fractures includes intertrochanteric. 21. . Fracture extension into the lesser trochanter and medial buttress creates problems with sagittal alignment and varus angulation. Russell and Tay lor based their classification on the integrity or compromise of the greater trochanter/piriformis fossa region and the lesser trochanter/medial calcar region (2) (Fig. and subtrochanteric.

1 OTA/AO proximal femoral fracture classification. .FIGURE 21.

It is also useful in treating aty pical (bisphosphonate) femoral fractures (3–5). This implant can also be utilized for some ipsilateral femoral neck and shaft fractures. it is an excellent implant to treat a wide variety of fracture ty pes. Since the reconstruction nail protects the entire femur. The implant can be inserted through a trochanteric entry site for selected proximal femoral fractures in adolescents. 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.2 Components of the Russell-Tay lor IB subtrochanteric pattern with greater trochanter intact and lesser trochanteric fracture. A reconstruction nail can be utilized for virtually all acute subtrochanteric femur fractures. It can be also used for prophy lactic nailing of impending and pathologic femur fractures. Reconstruction nails are useful in the treatment of malunions. With screw(s) directed into the femoral head. .FIGURE 21.

oblique radiographs have been . PREOPERATIVE PLANNING Subtrochanteric fractures occur with a bimodal frequency (6). and pain. In the past. Whenever possible. femoral implant. Subtrochanteric fractures usually present with a limb shortening. 21. The first and foremost contraindication is surgeon skill. Traction radiographs are obtained with gentle and gradual traction of the limb in a neutral rotation. Significant comminution and displacement of the greater trochanter or fracture extension into the femoral neck are relative contraindications to nailing. These are complex injuries and there is long learning curve that must be mastered for successful nailing. We often obtain contralateral femoral radiographs to serve as a template for neck-shaft angulation. and limb length. anterior femoral bow. There are several contraindications to nailing of subtrochanteric fractures. Fortunately. The proximal femur is exquisitely tender. the goals of fracture reduction with proper alignment and healing are more important than nailing technique. nerve and vascular injuries are uncommon.nonunions. or a distal prosthesis that could impede intramedullary nailing. A patient with a femur fracture following highenergy trauma mandates a thorough trauma evaluation for other life. Older elderly patients sustain lower-energy fractures with falls through osteoporotic bone. medullary diameter. Preoperative imaging consists of a low anterior-posterior (AP) radiograph of the pelvis and AP and lateral radiographs of the hip (Fig.or limb-threatening injuries. and any motion in the limb is painful. The entire femur must be imaged to evaluate for preexisting deformities. nail insertion may be impossible secondary to a relatively short neckshaft transition. retained hardware. or stemmed total knee arthroplasty are also contraindications to nailing. and failed plate fixation of selected proximal femur fractures. Furthermore. These radiographs are helpful to evaluate the fracture morphology.3). short neck width. external rotation. However. pattern. neck-shaft transition. and extent. in some small stature people and races. A preexisting femoral diaphy seal deformity. Young adults usually sustain high-energy fractures with associated injuries and fracture patterns. closed nailing is preferred over an open procedure to decrease the risk of infection and improve healing. and small medullary diameter. This is especially important when there is comminution or bone loss.

the stability of the nailing construct may be impaired. . CT scans with axial. Alternatively. It is best performed with some traction and the leg in neutral rotation. piriformis fossa. coronal. an open or semiopen nailing technique may be required for reduction and subsequent nailing.4). and greater trochanteric anatomy (Fig. a periarticular proximal femoral-locking plate may be indicated. sagittal reconstruction are the best modality to evaluate the femoral neck. 21. Fracture extension into the piriformis fossa and/or greater trochanter with a coronal split complicates femoral nailing. Therefore. If the integrity of the proximal femoral canal is compromised.used to evaluate the femoral neck but have been replaced by computed tomography (CT) imaging.

FIGURE 21. and AP femur (D) of subtrochanteric femoral fracture in 63-y ear-old female after a lowenergy fall. Lat hip (C). AP hip (B). .3 Injury radiographs of AP pelvis (A).

risk of deep vein thrombosis. fixation within 24 hours of admission is necessary because of pain. and be ty ped and cross-matched for surgery. For most patients. Patients should be aggressively resuscitated. and thy roid . have routine blood chemistries. parathy roid. and pressure sores. vitamin D.4 Coronal CT cut through the proximal femur demonstrating comminution and displacement of the greater trochanter in a 47-y ear-old female after a MVA. A metabolic panel including calcium.FIGURE 21. continued blood loss.

The transition from the thickened proximal portion to the diaphy seal portion is variable depending on the manufacturers.5). 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. making reconstruction nailing very difficult or impossible.0 mm and spread is 1. Proximal screw size varies from 5. 21. measurements. associated injuries. contralateral femoral radiographs may help with preoperative planning.5 to 2 cm. Inexperience.0 to 8. screw insertion can be suboptimal or impossible. short neck-shaft transition. Reconstruction nails are available in many lengths and diameters (Fig. proximal femoral geometry. Depending on the fracture pattern.stimulating hormone should be obtained in elderly patients with lowerenergy fractures. and femoral diaphy seal anatomy. and small medullary canals. fracture pattern. PERIOPERATIVE EVALUATION Nail selection is dependent on surgeon experience. Most reconstruction ty pe nails are expanded or thickened in the upper end to accommodate the proximal screws and high mechanical forces in the proximal femur. With varus reductions or aty pical anatomy. Some ethnicities and races of small stature have relatively narrow femoral necks. traction should be started to maintain length and reduce blood loss and reduce pain. The proximal screws are either partially or fully . If the fracture anatomy is not clear. Trochanteric entry nails ty pically 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. and templating. 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. failure to understand the deforming forces. and inadequate imaging studies greatly increase the chance of fracture malreduction. Despite the nail anteversion. Deep vein thrombosis prophy laxis with sequential compression devices and/or chemical methods should be initiated postoperatively. Depending on the manufacture. 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. and surgeon preference.

. all reconstruction nails should be locked distally with either one or two screws. 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 these situations. For older more osteoporotic fractures. In y ounger patients with more comminuted fracture patterns. Because of inherent fracture instability . nail diameter has to be tailored to the patient’s anatomy to avoid distal cortical penetration.threaded. 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. larger diameter nails are recommended.

.

7). 21.62 mm) anteriorly or posteriorly to the entry portal proximally can aid in reconstruction of complex. and derotate fracture fragments.6). 21. Kirschner wire insertion (0. 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. translate. trochanteric.7) can translate and reduce large fracture fragments (Fig.FIGURE 21.0 mm) inserted percutaneously or openly can help realign.5 and/or 5. .10). reduce. or universal start site) and standard reconstruction IMN (straight. Secondary to the proximal deforming forces.8).9). devices that realign the proximal femur in both the sagittal and coronal planes are beneficial (Fig. 21. and solidify a tubular construct proximally for reaming and nailing without displacing the fracture (Fig. Schantz pins (2. Large and small tenaculum clamps (Weber Clamp. 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. Ball-tipped spike pushers (3.5 The two ty pes of reconstruction IMN are trochanteric reconstruction IMN (curved. anterior piriformis start site). 21. 21. multiplanar fracture patterns. Anterior to posteriorly directed Schantz pins can act as pollarblocking pins to narrow the metaphy sis and correctly direct reaming and subsequent nail insertion.

5.0-mm Schantz pins. 2. and Ball-Tip Spike Pusher. .FIGURE 21. Universal Chuck.6 Assistive reduction devices for proximal femoral fracture reduction: small and large Weber clamp. Shoulder Hook.and 5.

FIGURE 21.7 .

and maintains reduction during reaming and nail insertion. .Large and small Weber clamps. FIGURE 21. improves proximal start site accuracy .8 Unstable subtrochanteric fracture with flexion and abduction deformity (A) corrected with percutaneously inserted ball-tip spike pusher (B) that corrects deformity .

9 Imaging demonstrate injury pattern (A) and then two percutaneously inserted 5. . derotate.0-mm Schantz pins that translate. the Schantz pins were backed-up to the lateral cortex to allow for reaming and nail insertion. While holding the reduction. and realign (B) an oblique proximal femoral fracture in an 85-y ear-old male.FIGURE 21.

. Furthermore.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. 21. and patient positioning is faster and the fracture reduction may be improved (Fig.FIGURE 21. It also requires different equipment to accommodate the patient and extremities while on the fracture table. However. 21. Some of these difficulties can be overcome by lateral nailing on a fracture table. the lateral position is less familiar to y ounger surgeons and OR staff. PATIENT POSITIONING The patient can be positioned either supine or lateral on a fracture table. The disadvantage of the supine position is longitudinal traction on the extended limb often exacerbates multiplane proximal femoral fracture deformity .12). The supine position is more common since it is familiar to surgeons and staff.11). which is critical for successful fracture reduction and nailing (Fig. the supine positioning facilitates intraoperative visualization of the proximal femur with the C-arm.

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. Intraoperative traction can be accomplished with a boot or skeletal pin traction. If this is required. Boot traction can be performed in the majority of patients if surgery is performed within the first 48 hours. in a patient with a painful swollen knee. 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. particularly those with a “dashboard” mechanism of injury. the traction should be periodically reduced or released during the case to minimize the risk of a pudendal or sciatic nerve injury. In a small percentage of patients with high-energy trauma. skeletal traction through a distal femoral pin may be a safer alternative until the knee injury . an occult knee ligament injury may be present. If surgery is further delay ed. skeletal traction may be necessary to restore leg length. The use of paraly zing agents during surgery also facilitates fracture reduction. Therefore.

First. FRACTURE REDUCTION . Once the above steps are performed. Fourth. the x-ray beam has to be angled about 10 to 25 degrees from the floor to obtain a true lateral view. 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. the fracture should be reduced as well as possible before beginning the procedure. Usually . With either method. Third. with the patient on the fracture table. The contralateral leg can be positioned in a scissored or hemilithotomy position. flex the foot traction device about 15 to 20 degrees. apply traction through the peroneal post and foot piece. In the supine position. AP visualization may require a slight rollover and cephalad tilt of the beam to accommodate the neck flexion and abduction. Following irrigation and débridement of open fractures. High-quality AP and lateral radiographs of the hip. Scissoring can accommodate longer procedures but can interfere with lateral visualization. externally rotate (not internally rotate as with intertrochanteric fractures) the secured limb through the boot holder. A cephalosporin antibiotic is administered intravenously within 1 hour of skin incision and continued for 24 to 48 hours postoperatively. The monitor should be placed at the end of the fracture table so that both surgeon and fluoroscopy technician can easily see the screen. length. If the patient is lateral on the fracture table. Second. and alignment preoperatively. are essential to determine the fracture reduction and femoral neck anteversion angle. The prep and drape must extend from the ipsilateral lower chest wall to the midcalf.is better clarified. Hemilithotomy positioning facilitates lateral visualization but may be of concern with extended length cases (increased compartmental pressures) and patients with limited hip motion. begin fluoroscopic assessment of the reduction and provide small incremental changes in the above parameters to “fine-tune” the reduction. I routinely reprep and drape. provide about 10 to 15 degrees of adduction to improve nail insertion trajectory. persistent intraoperative monitoring of the uninvolved leg for pressure areas and compartments is necessary . The opposite uninjured leg is a good template to assess limb rotation.

Usually. and alignment in both coronal and sagittal planes (Fig.13 Intraoperative imaging of incorrect (A) and correct (B) rotation of a spiral fracture. FIGURE 21. 21. With the fracture aligned.Whenever possible. reduction of the flexion redirects the skin incision anteriorly and aids in proper entry site selection. lateral. rotation. AP. fracture reduction should be performed and confirmed fluoroscopically before the surgical incisions are made. Remember that correct fracture reduction requires restoration of length. When the fracture is persistently flexed and in varus. this will be performed through a small anterolateral incision that counters the flexion and abduction y et is out of the plane of image intensifier. and oblique (roll over or roll under) images will assist in the assessment of fracture reduction. the proximal segment should be reduced with either a ball-tipped spike pusher or Schantz pin placed through a small skin incision. Since the fracture may be in relative flexion initially.13). 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. Again. which is best seen on the lateral view (Fig.16).14). If the fracture does not reduce. 21..e. it is usually malrotated or flexed. Loosening the footplate prior to tightly clamping the fracture often helps to improve rotational alignment before final tightening. the clamp is opened enough to slide it over the cortex and then closed to reduce the fracture (Fig. perpendicular to the diaphy sis in both planes). For spiral fracture patterns. 21.to 4-cm anterolateral incision. . 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.15). a combination of both a ball spike pusher and Weber tenaculum clamps can efficiently reduce and maintain the fracture reduction (8). Once the location of the fracture is confirmed on fluoroscopy. 21. through a 3. spread the vastus in line with its fibers and insert the Weber clamp (i.

slided alongside the bone.FIGURE 21. a 4-cm incision is created. Once against the bone and parallel to the fracture plane. and a large Weber clamp is inserted parallel to the muscle fibers done to the bone (A). . and compresses the fracture utilizing the tines only (C). the clamp is rotated 90 degrees (B).14 For a spiral fracture pattern.

15 This is a lateral view of the Weber clamp compression but with flexion deformity still present. .FIGURE 21.

With gentle loosening of the clamp. anterior to posteriorly directed force through the pusher translates the fragment until perfect.B).16 Through the same anterolateral incision. 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 . key ed-in reduction for stability and reaming (C.FIGURE 21. For segmental fractures. a ball-tip spike pusher is inserted along the proximal segment (A.D). The clamp is then retightened allowing for anatomic.

21. and nail insertion (B).17 An injury AP radiograph of a displaced unstable segmental subtrochanteric fracture with diaphy seal extension (A). realign. 21.distal shoulder hook to correct translation (Fig. and distal segment translation with a shoulder hook.18). . FIGURE 21. patterns of apex posterior sag or angulation can be corrected with an inferiorly applied mallet and manual downward pressure applied anteriorly .17). segmental 5. and translate the proximal segment (Fig. the unstable pattern is realigned to create a conduit for guide pin.0-mm Schantz pin translation and derotation. With proximal spike-pusher control. Another less common method for reduction is application of a bicortical Schantz pin along the anteromedial calcar femorale area to derotate. reamer. Furthermore.

.

5-mm Schantz pins.18 A translated and malrotated fracture imaged with AP (A) and LAT (B) fluoroscopy has a combination utilization of percutaneous inserted 2.G). and nail insertion (F.D).FIGURE 21. .0-mm Schantz pins. 5. and Weber Clamp stabilize deforming forces for entry site terminally threaded guide pin (C. reaming (E).

very proximal incisions for nail entry are crucial to avoid varus reductions (9–11).19). skin marks are applied to the skin (A). With obese and muscular patients. continue to palpate the trochanter to triangulate the direction of the pin and confirm this with fluoroscopy .NAIL ENTRY SITE The skin incision should be placed in line with the femoral diaphy sis (7). Once the guide pin is placed percutaneously through the skin.20). FIGURE 21. 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. The percutaneous start site is . 21. Make an incision just distal to the iliac crest and direct it toward the greater trochanter (Fig. Avoid short incisions placed over the greater trochanter or using an awl to gain entry as this potentiates varus deformities. 21.19 With the aid of an externally referenced guide pin with AP and LAT images.

and the guide pin is inserted percutaneously (right) utilizing cerebral tactile triangulation. it will make screw insertion into the femoral neck and head difficult or mechanically suboptimal. For reconstruction nailing in the supine position. the guide pin should parallel or be just posterior to the femoral neck.created at the confluence of the skin marks (B. it will create an excessive anterior-to-posterior screw insertion angle and increase proximal hoop stresses for nail insertion.21). the guide pin “appears” to be about 10 to 15 mm distal to the femoral neck on the AP radiograph.C). On the lateral view. FIGURE 21. my preferred starting point is 10 to 15 mm anterior to the standard piriformis starting point (Fig. 21. If the start site is too posterior. If the start site is too anterior.20 The central aspect of the greater trochanter is palpated with the off-hand (left) as a reference. which increases the risk of . 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.

proximal femoral blow out. 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. Once the entry site is confirmed on both the AP and lateral images. .22). insert the terminally threaded guide pin to the level of the lesser trochanter in line with the femoral diaphy sis in both planes. Once the guide pin is advanced and the entry site is confirmed. 21.

The correct start point is the “universal start site.21 The incorrect start point is at the tip or lateral to the tip of the greater trochanter (A).FIGURE 21. .” which corresponds to a direct line down the diaphy sis on the AP (B) and LAT (C) images.

to 16-mm) drills found in most sets to avoid splintering. widening. Advance the guide wire down the medullary canal to the distal femoral phy seal scar under fluoroscopic control maintaining the wire in the middle of the medullary cavity (Fig. .25). and/or displacing the proximal fragment (Fig. 21. Advance the ball tip into the dense subchondral bone without penetrating the chondral surface to decrease the chance the guide wire will be withdrawn during reamer insertion and removal. 21. I prefer to open the proximal femoral cortex with a cannulated (usually 8to 9-mm) drill instead of the larger (12.to 3-cm incision is created around the guide pin allowing for mobility and cannulated instrument insertion.23). The pin should not be entrapped by skin or fascia superficially . insert a ball-tipped guide wire with or without a bend at the tip (Fig. Once opened.24). 21.FIGURE 21.22 A 2.

.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.

REAMING .FIGURE 21.25 The ball-tipped guide rod is inserted deep into the cancellous bone of the central femoral condy lar area.

1. If utilizing a straight nail in osteoporotic bone. Attention to detail is necessary to avoid reaming away the posterior cortex or lateral wall. Eccentric reaming most commonly occurs during reamer insertion and extraction and is exacerbated by varus start sites. It is important to ream the canal. obesity. bone quality.5 to 2. .5 mm greater than the measured nail size is adequate.0 to 1.0 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 (12.26). Usually. ream proximally across the fracture site and distally in 0.With the fracture reduced. Final reaming size is dependent upon canal diameter. soft-tissue pressure from medial to lateral. and muscularity. surgeon experience.5 mm increments (Fig. reaming 1.13). Eccentric reaming is minimized when the fracture is well reduced and the entry portal is correct. Reaming proximally is dependent upon specific proximal nail dimensions. 21. utilize a nail size of 10 to 11 mm to allow for adequate stability at the fracture site and y et avoid anterior distal cortical penetration. and nail availability.

FIGURE 21. NAIL LENGTH .26 The fracture is held reduced with clamp assistance while sequential reaming is performed.

The residual length nonoverlapped will be equal to the length of the nail. The most accurate method is the subtraction method. 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. In situations of marked comminution or bone loss. FIGURE 21. premeasuring the contralateral uninjured limb may be helpful. . 21. Some sy stems utilize an external “premagnified” ruler applied parallel to the femur and touching the skin. Many sy stems allow for a cannulated ruler to be inserted over the guide wire to the level of the greater trochanter or femoral neck (Fig.27). This ruler compensates for the known guide pin length and is manufacturer dependent.27 The subtraction method of nail length is determined. This method is dependent on guessing the correct magnification and is usually less accurate than the guide wire or subtraction method.Nail length can be determined by several different methods.

Place a drill through both drill sleeves and confirm central position within the holes of the nail (Fig. impact the guide wire into the dense subchondral bone distally to avoid inadvertent guide wire migration. confirm the correct nail rotation and orientation is paired with the correct proximal targeting device including drill sleeves. If the ball tip is bigger than the inner nail diameter. Check to ensure that the diameter of the ball-tip guide wire is smaller than the inner diameter of the nail to avoid incarceration. Nail insertion is performed over the guide wire.NAIL INSERTION Before inserting the nail. Also. 21. exchange the ball-tip guide wire for a smaller nonbeaded guide wire through a radiolucent exchange tube after reaming.28). Again. . confirm that the bow is anterior not posterior.

FIGURE 21.28 .

and confirm it with AP and lateral images (Fig. it may be caused by.2-mm “anteversion pin” from lateral to medial.The guide arm and sleeve position is confirmed to correlate with proper nail orientation and drill/screw insertion angle. incorrect entry portal (increasing hoop stresses) or an incarcerated fracture fragment. When this occurs.29). which parallels the anterior femoral neck. place a 3. Rereaming another 0. Nail insertion should be smooth with minimal resistance. If there is significant resistance to nail advancement.30 and 21. Reconfirm fracture reduction quality and central position of the nail within the femoral condy les before proceeding further. remove the nail and reassess the situation. The nail is gradually externally rotated as the nail is advanced down the shaft. the femoral nail is internally rotated 90 degrees and inserted in that position for the fi rst 5 or 6 cm. 21. Prior to insertion. Following nail insertion. 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.5 to 1. 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. Some nail sy stems deploy external guides to overlay the femoral neck to confirm nail depth but are dependent upon a true perpendicular beam to the femoral neck. .0 cm larger may be helpful.31). 21. Insert the nail distally to the level of the distal epiphy seal scar. too large of a nail (in comparison to the final reaming diameter). Percutaneously . Also check to ensure there are no comminuted fracture fragments trapped in the medullary canal.

.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.

The final screw position is centrally located within the femoral neck and head.FIGURE 21. guide arm. and drills are parallel and therefore centrally inserted into the femoral neck and head.30 A. The external reference guide pin. The external reference guide pin and guide arm parallel reference confirms correct nail insertion rotation. . C. B.

33).31 The trochanteric nail (4-degree bend) is inserted 90 degrees (A) to facilitate nail insertion and proximal femoral anatomy confirmed with imaging (B). If the targeting guide is blocked by soft tissues. . 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.FIGURE 21. 21.32). extend and deepen the skin incision through the adipose tissue to allow for the guide to be inserted with less deforming forces (Fig. 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. .

This guide arm width–thigh width mismatch is accommodated with skin incision to appropriate depth (B) to allow for guide arm insertion (C). First. In order to avoid misguided proximal screws. Within the proximal nail guide. insert the obliquely oriented drill sleeves through small skin incisions down to the lateral cortex. proximal screw insertion can be performed. several steps must be accomplished in order. remove the central guide wire inside the nail.33 Obese girth of patient’s thigh impedes guide arm insertion without deformation (A). Confirm that the targeting guide is firmly attached to the nail.FIGURE 21. It is important to avoid hammering the drill sleeve against the femoral cortex to prevent changes in . PROXIMAL INTERLOCKING SCREW INSERTION Once the nail is seated to the desired depth.

determine the screw length. Once the initial caudad drill is inserted. the drill may be above or below the nail holes or hitting the anterior or posterior cortex of the femoral neck. and advance it slowly through the lateral cortex and then the interlocking holes in the nail. confirm the drill position by looking “above” and “behind” the proximal nail guide (Fig. If resistance is encountered. Then retract the drill bit about 1 to 2 cm. Also. Because the proximal nail guide obscures true lateral imaging. gently insert the drill sleeves with the inner trochar and carefully advance it to bone.drill angulation. Insert a drill bit through the caudad (lower) sleeve until it reaches the lateral cortex. Both views should confirm placement within the femoral neck and head. Once drilled.34). start the drill. 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. With a depth gauge or calibrated drill. the “above” view should parallel the preexisting anterior femoral neck guide pin (anteversion pin). the second cephalad drill should be safe and accurate. . oblique views are required during this step. again confirm the depth (5 mm within subchondral bone) and position (central) within the femoral neck and head. 21. To diminish this risk.

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.FIGURE 21. Once satisfied with the drill position. Tapping the screw holes is . keep one drill in position to stabilize the targeting device and the nail construct.

35 Confirmation of correct nail rotation and cephalomedullary screw insertion with above (A) and below (B)LAT images.35). DISTAL INTERLOCKING SCREW INSERTION In length-stable fractures. Again. For successful distal interlocking. confirm correct nail and screw position proximally. the beam of the fluoroscopy machine must . Place the screw deep into the subchondral bone to ensure optimal stability and then insert the second screw to the desired depth. If the screw stops advancing within the nail. 21. I prefer partially threaded cancellous screws rather than fully threaded cortical screws. The proximal nail guide and anteversion pin can now be removed. the partial screw threads cannot capture the cortical bone and the screw will just spin without advancing. release some or all of the traction to minimize distraction at the fracture site and allow some impaction at the fracture site. Gently tapping or pushing the screw while slowly advancing the screwdriver can be helpful. Confirm screw position “above” and “below” the attached guide (Fig. FIGURE 21. Some surgeons favor retaining the proximal guide locked to the nail until distal screws have been inserted.dependent on bone quality.

apply magnification on the machine (one. The freehand drilling technique can be performed in several different way s. Move the machine base to accommodate the position of the leg. The drill can then be drilled through the nail or gently tapped with a mallet through the nail. confirm drill bit orientation. 21. and then fine-tune position of the C-arm under fluoroscopic control. “Perfect circles” must be obtained for consistent and reproducible distal screw insertion with a freehand technique. Confirm proper screw insertion within the nail with a perfect lateral position again (Fig. 21. Do not rotate the leg to accommodate fluoroscopic visualization. Avoid long screws projecting medially as they can be a source of pain postoperatively . 21. Drill through the far cortex. Make a 2-cm skin incision through the skin and deep fascia and spread the deeper tissues with a hemostat.be perfectly perpendicular to the nail. . Once advanced.or twofold). Place a knife blade parallel to the skin until centered within the perfect circle (Fig. The nail is usually slightly externally rotated because of the anteversion required for proximal screw insertion.38). I prefer to bring the fluoroscopy head close to the distal femur. I prefer to place the tip of the drill bit within the center position of the perfect circle (Fig. Advance the drill bit parallel to the projected line of the C-arm beam.36). Measure screw length with a calibrated drill guide or depth gauge and insert the screw.37).

36 Confirmation of perfect circle distal screw hole reference to imaging and skin insertion site with scalpel reference.FIGURE 21. .

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.

POSTOPERATIVE MANAGEMENT
The wounds are closed in lay ers. 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
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 prophy laxis 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 y ounger
individuals should be initiated in the first several day s. 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 weightbearing status to tolerance over the next several weeks. Gentle range of
motion of the hip and knee are started during the first week postoperatively.
Inelderly patients, calcium citrate and vitamin D3 supplementation should be
considered.

FIGURE 21.39
Final postoperative AP and LAT images of complex multifragmentary
subtrochanteric femur fracture successfully treated with reconstruction nail
(A–D).

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 y ear 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 (14–18). Painfree 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 alway s correlate with fracture healing. If varus
and shortening are avoided, full-unrestricted function should be expected. In
elderly patients with subtrochanteric fractures, 1-y ear 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 (9–13). Very proximal start sites in line
with the femoral diaphy sis 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).

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. Inout-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).

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.

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

condy les is very important 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 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 21.42
Anterior cortical distal femoral penetration caused by femoral osteoporosis,
increased anterior femoral bowing, and a relatively stiff and straight
femoral nail.

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 delay ed 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.

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 highenergy forces (especially open fractures) and delay ed healing and require
an infection workup. If infection is ruled out, treatment consists of exchange
nailing with or without autogenous bone grafts.

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.

FIGURE 21.44
An oligotrophic nonunion (A) is successfully treated to union (B) with a
larger reamed exchange nail and partially threaded screws.

Atypical Femoral Fractures Associated with Prolonged
Bisphosphonate Administration
Recently, a number of studies have been published regarding patients with
aty pical subtrochanteric or proximal femoral fractures following prolonged
bisphosphonate use (4,20). The fracture pattern is ty pically transverse or
short oblique and is often associated with thickened cortices, which should
alert health care providers to inquire 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 delay s in healing. Since there is a high incidence of bilaterality,
radiographs of the contralateral femur should be obtained.

FIGURE 21.45
An aty pical femoral fracture with shortening and displacement (A) is
treated with a reconstruction nail (B).

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 .
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 sy mptoms 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).

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 dy sfunction. This problem was successfully treated with open
reduction internal fixation of the greater trochanter with a hook plate placed
outside the retained nail (B).

REFERENCES
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compendium—2007: Orthopaedic Trauma Association classification,
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Skeletal trauma. 1993.
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standard proximal locking screws for nailing femoral shaft fractures. J
Orthop Trauma 24;12:717–722.
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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
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6. Waddell JP. Subtrochanteric fractures of the femur: a review of 130
patients. J Trauma 1979;19(8):582–592.
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peritrochanteric fractures using the Gamma nail. Clin Orthop Relat Res
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subtrochanteric fractures of the femur. J Bone Joint Surg Am
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lipomatous
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entry portal for the treatment of femoral shaft fractures. J Orthop
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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.
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fracture of the femur associated with removal of the Zickel nail. J Bone
Joint Surg Am 1988;70(2):239–243.
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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
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cephalomedullary nailing of subtrochanteric fractures caused by lowenergy trauma. J Bone Joint Surg Am 2005;87(10):2217–2226.
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subtrochanteric femoral fractures fixed using cephalo-medullary nails.
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Trauma 2011;25(4):202–207.

22

Femur Fractures: Antegrade
Intramedullary Nailing

Christopher G. Finkemeier, Rafael Neiman, and Frederick
Tonnos

INTRODUCTION
Diaphy seal femur fractures are classified according to the AO/OTA
classification (Fig. 22.1). The diaphy sis is defined as the area remaining
when subtracting the areas formed by a box around the proximal and distal
metaphy seal areas of the femur (1). Intramedullary nailing is the most
common form of diaphy seal 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).

FIGURE 22.1
OTA classification of femur fractures.
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 phy siologic effects, which include acute respiratory
distress sy ndrome and sy stemic inflammatory response sy ndrome (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 sy stem to cool and clear the products of reaming. Most
North American surgeons use reaming when nailing diaphy seal femur
fractures, because the risk/reward ratio is still very favorable.

INDICATIONS AND CONTRAINDICATIONS
Most diaphy seal fractures can be nailed, regardless of the degree or amount
of comminution, angulation, or shortening. Metaphy seal 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 ly tic lesions from metastasis.
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 epiphy sis may be better treated with flexible nails that avoid the
growth plates. Severe sy stemic 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
phy siologic 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.

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 highenergy 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 ty pe, 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-ray s 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 (11–13). 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 delay ed 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 phy siologic state may deteriorate rapidly.
If surgery is delay ed >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 poly trauma 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 day s)
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 phy sical 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
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.
Prophy lactic antibiotics should be given based on the patients’ drug
allergies and soft-tissue status. An antibiotic with staphy lococcus and
streptococcus coverage such as a first-generation cephalosporin is
recommended for closed fractures. An alternative antibiotic such as
clindamy cin should be given if the patients have a significant penicillin
allergy. Routine antibiotic prophy laxis is ty pically given for 24 hours postop. 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 (gentamy cin) 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 day s after the
last washout is reasonable based on initial wound contamination.

Patient Positioning

There are several way s 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 alway s 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 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.
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.

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 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 delay ed 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 on
the injured side is secured across the chest and held on bolsters, a May o
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 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 sy mmetric 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
dy sfunction. 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 my ofascia,
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.

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).
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 employ ed simultaneously to allow
successful guide wire passage.

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.

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 diaphy seal fractures are encountered,
this instrument can be used to control the flexed, externally rotated, and
abducted proximal fragment during reduction.

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.

12). If closed or percutaneous reduction methods are unsuccessful after a reasonable period of time (20 to 30 minutes). The pins should be placed unicortically or above or below the passage of the proposed path of the guide rod.FIGURE 22. the surgeon prepares to ream the intramedullary canal. 22. An open reduction should not be considered a treatment failure.11 The surgeon must be cognizant not to block passage of the guide rod with the pins. 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. an open reduction with direct passage of the ball-tipped guide wire should be done. Reaming After C-arm confirmation of satisfactory placement of the ball-tipped guide wire in the femur (central and advanced to the epiphy seal scar. pudendal nerve palsy. Fig. and heterotopic ossification. To avoid inadvertent .

and deep cutting flutes are utilized. When using a trochanteric entry portal.5 to 1. At this time. the work area above the insertion site and adjacent to the patient’s abdomen and chest should be inspected.contamination. we often add an additional sterile sheet near the head of the table. an overhead light or IV pole at the head of the table can create potential obstructions and need to be moved. Whenever possible. 22.0 mm increments until the cortical chatter is encountered.13). a skin protector is utilized to avoid damage to the skin and soft tissues at the entry site (Fig. The femur should be “overreamed” 1. Based on the estimated canal width determined preoperatively. Reamer size is increased in 0. an end-cutting reamer at least 1 mm smaller than the medullary canal diameter is introduced. 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. sharp reamers with narrow drive shafts. Not uncommonly. small heads. Ideally.5 mm increments to avoid nail incarceration and thermal necrosis. it is advisable to increase size by 0. .0 to 1. Thereafter. 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.5 mm greater than the planned nail diameter.

.12 Fluoroscopic AP image showing the ball-tipped guide wire centered in the distal femur at the level of the epiphy seal scar.FIGURE 22.

. a second guide wire of the same length can be placed adjacent to it down to the entry site.FIGURE 22. Keeping the original ball-tipped guide wire in place. The surgeon should ensure that the fracture is reduced radiographically. A lap-pad strap is tied to the protector to prevent it from falling on the floor.13 A skin protection instrument will protect the skin edges from burning or abrasion during reaming. Length can be fine-tuned and adjusted using the fracture table as needed. 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 length of the wire above the tip of the original guide wire is the correct length of the nail to be inserted. then the “two-wire” technique can be used. If the surgeon is using a nailing sy stem without a length measurement tool.

The nail with its attached insertion handle nail is then manually pushed down the intramedullary canal until it stops. blocking screws may be necessary. When inserting a trochanteric or a piriformis entry nail. the C-arm images should be scrutinized to ensure that the nail is not stuck on a bone fragment or fracture edge (Fig. but cannot predictably realign metadiaphy seal injuries due to nail size and medullary canal mismatch. If back slapping is needed to compress or shorten the fracture. 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 will be at the proper level.14). 22. with comminuted infraisthmal fractures. the nail does not advance smoothly with each tap of the mallet. The nail is advanced taking periodic spot views with the C-arm. the nail should be inserted slightly deeper into the femur so that after the fracture is compressed. During passage of the nail across the fracture. and frontal and sagittal plane alignment reassessed.Nail Insertion The nail should alway s be inserted over a ball-tipped guide wire. the surgeon should utilize any reduction “techniques” previously used to reduce the fracture. It is then advanced with light blows using a mallet or hammer. then the surgeon proceeds with cross-locking. the distal cross-locks need to be placed first. Once the nail tip is past the lesser trochanter. it may be helpful to rotate the nail 90 degrees toward the patient to facilitate nail passage through the proximal femur. rotation. the implant should be removed and length. If back slapping is needed to overcome distraction at the fracture site. Once the nail is placed into the correct position. the guide wire is removed. If at any time. Occasionally. just below the tip of the greater trochanter. If the fracture is at its proper length. the surgeon slowly rotates the nail back to its normal position while the nail is being tapped into place. It is important to remember that an intramedullary nail can only realign fractures in the middle third of the femur. If the fracture is malreduced after nailing.

.

If closed reduction maneuvers fail to overcome malalignment. In some cases. then blocking screws can be helpful. In general. In most cases. muscle forces. or a mismatch of the canal diameter and the nail. . the blocking screw should be left in place after nail placement (Fig. the guide wire is reinserted into the new path and then reamed to assist with nail passage. Blocking screws are designed to narrow the canal within metaphy seal bone and direct the nail in a preferential direction by “blocking” its passage down a less optimal path.14 The surgeon should not hesitate to image the nail if smooth passage of the nail is interrupted. 22. Blocking Screws Not uncommonly. Care must be taken when reaming near the blocking screw to prevent jamming or reamer head damage. 22.FIGURE 22. the nail may get hung up on a bone fragment or the edge of a fracture fragment. Once the blocking screw is placed.16). The nail can now be reinserted and statically locked. 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. it is difficult to obtain or maintain coronal or sagittal plane alignment in fractures proximal or distal to the isthmus due to comminution. 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.15). The blocking screw is most effective if placed closer to the fracture site than farther away from it.

15 If proper coronal or sagittal plane alignment is difficult to achieve by indirect methods. .FIGURE 22. blocking screws placed on the concave side of the deformity in the proximal fragment can help align the fragments into a satisfactory position.

FIGURE 22. The surgeon should verify with the C-arm that the proposed cross-locking screws will not enter the fracture site. A common pitfall with proximal locking is making the . most modern proximal cross-locking jigs work very well. If the handle is tight. Proximal Locking The most important aspect to successful proximal cross-locking is verify ing that the insertion jig handle is still fully tightened onto the nail.16 Example of a blocking screw placed to prevent varus malalignment of a distal femoral fracture.

Other attempts at simplify ing distal locking have included radiolucent drill attachments. 22. After placing the proximal cross-locking screw(s). and the modern trend is to fix both fractures with separate implants (i.incisions for the drill sleeves too small. Having both of the patient’s lower extremities in extension and scissored as described above facilitates . Distal Locking Whereas proximal locking is done with a jig. some surgeons currently advocate routine placement of cephalomedullary screws into the femoral neck for all patients with a femoral shaft fractures. muscle. they are expensive and not widely available. The surgeon should consider placing cross-locking screw into the femoral 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. which could affect drilling and subsequent screw placement. The vast majority of distal cross-locking is still done freehand. Because most current nail sy stems use the drill sleeves to measure the screw length. cannulated screws for the neck fracture and a retrograde nail or plate for the shaft fracture. their position should be confirmed fluoroscopically . Distal locking jigs have been developed. handheld radiolucent drill guides.) Despite this controversy. and an intramedullary radiofrequency probes. 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). navigation. distal locking is most commonly accomplished using a freehand technique.17).. it is critical that the sleeves are placed firmly against bone. Some nail designs allow proximal cross-locking screws to be placed into the femoral head (historically referred to as reconstruction nails). and fascia. Freehand distal locking is predicated on obtaining “perfect circles” of the distal locking holes with the C-arm (Fig.e. The drill sleeves need adequate room to slide smoothly down to the bone to avoid entrapment by the skin. but for the most part have been abandoned as unreliable. While these devices can be helpful.

what adjustments should be made to the angle of insertion.18).5cm skin incision is made through the skin and iliotibial band and spread down to bone. For length stable fractures in the middle one-third of the femur. Virtually all femur fractures should be statically locked to prevent loss of reduction. After the screws have been tightened into place. A 1. 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. (2) has shown that statically locked femur fractures do not have higher rates of nonunion. The position of the drill bit should be clearly visualized on several projections. the C-arm is used to confirm that the locking screws are through the nail. length can be measured with a standard depth gauge. the surgeon localizes the spot on the skin overly ing the center of the intended cross-locking hole with a drill bit or tip of a knife blade. However. for comminuted fractures and infraisthmal injuries. 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. a spot image with the C-arm should be obtained. 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. If at any time. the length of the screw can be determined from the calibrations on the drill bit. the surgeon loses his direction or encounters unexpected resistance. Pressure should be kept on the drill bit so that it does not “walk” or slip off the rounded cortex. the drill is adjusted to be “in line” with the x-ray beam. 22. and flush with the lateral cortex.freehand distal locking. If more than one cross-locking screw is planned. Brumback et al. one cross-locking screw is sufficient (20). at least two distal cross-locking screws are necessary to avoid rotation or toggling of the distal fragment (Fig. the steps listed above should be repeated until the drill bit has successfully traversed the nail. which has been reported to occur in up to 10% of femur fractures (21). are of appropriate length. Once the drill bit penetrates the far cortex. If the drill bit has deviated from its intended course. The lateral cortex is opened with the drill. Of course. Once the tip is confirmed to be in the center of the cross-locking hole. Once the C-arm has been positioned to project perfect circles. 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. .

The goal is to pass the beam exactly in line with the axis of the screw .FIGURE 22.17 The C-arm should be positioned to obtain an optimal lateral view of the distal femur.

FIGURE 22. Malalignment in the sagittal plane makes holes appear as horizontal ellipses. The C-arm can be rotated 180 degrees around the femoral neck taking spot images. the patient is moved off the fracture table and limb length. Malalignment of the beam in the coronal plane makes the holes appear as vertical ellipses. With the patient still under anesthesia. the surgeon should reassess the hip region to rule out a missed femoral neck fracture. the holes appear as perfect circles. An elliptical appearance of the holes suggests malalignment of the beam. When the C-arm is properly aligned.holes. and rotation is compared to the opposite side. Ligamentous .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. Final Details At the completion of the nailing.

Return to preinjury function can be prolonged after a femoral shaft fracture. knee extensor weakness. Once fracture callus is evident on radiographs. Hip. With union rates ranging from 97% to 99% in most series. Follow-up 10 to 14 day s postoperatively is recommended for suture/staple removal and wound evaluation. there is a significant discrepancy between fracture healing and functional recovery. knee. deep vein thrombosis (DVT) prophy laxis. Phy sical therapy is continued to assist with early functional recovery. POSTOPERATIVE MANAGEMENT The early postoperative phase. or anticoagulation therapy.evaluation of the knee should also be performed. and the patient weaned from external supports. and hip pain are all common postoperative . antibiotics. pain control. patients are continued on DVT prophy laxis for 2 weeks and pain medications as needed. This occasionally warrants surgical evacuation. hip abductor weakness. Prolonged drainage usually may be due to an underly ing seroma. should focus on patient monitoring. 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 day s although blood transfusions are uncommon. hematoma. In patients with other injuries. or hospital phase. If the deformity is small or the patient is too sick. Radiographs are obtained at follow up and at 4 to 6-week intervals to assess fracture healing. and ankle motion is stressed along with isometric strengthening exercises. surgical site care. After hospital discharge. and early phy sical therapy. variations from the routine management are often necessary. the problem should be corrected before leaving the operating room. The incision is kept covered with clean. If gross malalignment is detected. 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. as this may be painful once awake. Phy sical therapy focuses on early mobilization. Abnormal gait. knee pain. weight bearing is advanced. dry dressings until oozing stops. a post-op CT scan should be obtained. Up to 20% of people fail to return to full-time preinjury employ ment after 3 y ears (22). We strongly recommend mechanical and chemical prophy laxis for DVT prevention. which is initiated within 24 hours in the absence of any contraindications.

Malunion/Delayed Union/Nonunion Ty pically. If the infection is delay ed more than several weeks and involves the intramedullary canal. Early infections can be effectively treated with irrigation and débridement of the infected wound and hematoma. This antibiotic nail is not stable so the femur should be temporarily stabilized with an external fixator or KAFO for a few day s to allow maximal antibiotic elution. Hip abductor and knee extensor weaknesses ty pically occur and contribute to a limp that may persist for several months. focused rehabilitation. Deep cultures should be obtained to direct antibiotic choice. COMPLICATIONS With careful technique. Paoli. Surgeons treating these fractures must have a sy stem in place to be able to assess the length.issues. angulation. Malunion is more common than nonunion. After a few day s to a few weeks. All these factors support the need for early. Patients commonly experience mild hip and knee pain as well as loss of motion. For intramedullary infections. The Reamer Irrigator Aspirator (Sy nthes. PA) is a useful device to ream the canal and irrigate and aspirate the intramedullary contents at the same time. antibiotics will usually be given for several weeks based on the organism. its sensitivities to various antibiotics. complications are uncommon. and host factors. and rotational components intraoperatively. and a long-term exercise programs (23). Angular malunion is seen most commonly with fractures that are near the proximal or distal shaft region . An intramedullary nail made of poly methy lmethacry late and antibiotic (tobramy cin and/or vancomy cin) is a simple way to deliver highdose local antibiotics to the intramedullary canal. Post-Op Wound Infection Postoperative wound infection occurs in fewer than 1% of patients. Soft-tissue damage from the trauma can be a significant cause of disability as well. malunions result from improper alignment at the time of fixation. the existing nail should be removed and the intramedullary canal reamed to remove infected tissue. the antibiotic nail can be exchanged for a standard interlocking nail. Antibiotics will usually be administered for several weeks due to the presence of hardware.

Because the canal width in proximal and distal ends of the femur are wider than in the middle third. AO/OTA ty pes 32-B and 32-C) (21).” even after appropriate guide pin placement. failure to obtain adequate reduction prior to reaming. Functional limitations were greater in patients that were externally rotated (24). If exchange nailing is not successful. as well as cases of bone loss. exchanged nailing is successful in 70% to 100% of cases (27). this will prevent secondary malalignment from the smaller segment rotating or angulating around the nail. As the proximal femur is opened. which is eccentric and lateral to that which is intended. the technique of removing the proximal or distal interlocking screws to allow fracture compression with during weight bearing. Another series reported an average of 16 degrees of malrotation (25).5% with nonreamed nails (21). reamed. For aseptic nonunion within the diaphy sis and without bone loss. If the nail has a “dy namic slot. Dy namization. Ty pical pitfalls contributing to malunion include improper starting point. With newer generation nails. Whether BMP (bone morphogenic protein) can be used to substitute for autologous bone in this setting is not settled. should be considered for length stable fractures that have not healed within 3 to 4 months. In these cases. Malrotation is the most common ty pe of malunion and > 15 degrees of malrotation has been reported to occur in 28% of cases in one study. and not critically assessing length and rotation prior to cross-locking. The overall nonunion rate with the use of reamed. the trochanteric starting point may be inadvertently “lateralized. dy namization may be successful in only 50% of cases (26).” this should be used to help prevent loss of rotational and angular alignment. Exchange nailing may not be as successful in nonunions associated with high-energy comminuted fractures (28).and also with unstable. The authors recommend following the FDA . Delay ed unions in the proximal or distal thirds for the femoral shaft should have the crosslocking screws removed farthest from the fracture site. the reamer will follow the path of least resistance and be pushed laterally by the tension of the soft tissues. a second attempt is warranted as many nonunions will go on to heal after the second procedure.e. bone grafting should be considered in addition to exchange nailing. comminuted fracture patterns (i. statically locked nails is 2% to 3% as compared to 7. The ideal fracture would have a gap <1 cm and showing some callus. even if recognized intraoperatively . reaming a path. This results in a varus malalignment and can be challenging to correct.. However.

and the surgeon may not wish to go back through the knee to exchange or remove the nail. and the surgeon is concerned about torsional stability. If the neck fracture is identified intraoperatively. Displaced fractures will most likely require an open reduction. In select cases. Surgeons treating femoral shaft fractures should remain vigilant before. Stabilization of a reduced femoral neck fracture ipsilateral to a diaphy seal fracture can be accomplished in several way s: reconstructionty pe nail. the treatment depends on whether the fracture is displaced and whether the nail has been inserted prior to diagnosis. Because many of these femoral neck fractures are nondisplaced and difficult to see on radiographs in the acute trauma setting. partially threaded screws can be placed either anterior or posterior to the nail to secure the fracture. The FDA has approved the use of BMP-7 for nonunions when autologous bone graft is not feasible. and after treatment of the femoral shaft fracture for a femoral neck fracture. partially threaded screws and a plate or partially threaded screws and a retrograde nail. plating is an excellent treatment option for nonunion. up to 25% of ipsilateral femoral neck fractures are missed (13). Plating has a limited role in femoral diaphy seal nonunion. the surgeon can consider adding a plate to a femoral shaft nonunion with an existing nail in place (29). Missed Femoral Neck Fracture A femoral neck fracture ipsilateral to a femoral shaft fracture is rare. Open reduction can be difficult if the nail is not removed. One scenario where this may make sense is when a retrograde nail was used to treat the initial injury.2% of cases (13). moving the patient off the fracture table to a radiolucent table is not practical so one of the other methods should be used. A plate may also be added to a nail when simple exchange nailing has not worked. Plating is also a good option for nonunions with deformity or in refractory nonunions that require open bone grafting. If the . during. partially threaded screws placed around the nail after reinsertion of the nail. For proximal or distal femoral shaft fractures within or near the metaphy sis. Combined plating and nailing may provide the advantage of direct nonunion compression with the plate and early weight bearing afforded by the nail. If the patient is on a fracture table. occurring in 3.recommendation for use of BMP in nonunions. If the femoral neck fracture is nondisplaced and identified after the nail has been inserted.

Richmond JH. 3. 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. James P. et al. Kuntscher G. Watson JT. 2. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion —a cause of posttraumatic ARDS? J Trauma 1993.70:1453–1462. Database. Ricci WM. (Original work published 1947). J Orthop Trauma 2007. J Orthop Trauma 1998. J Bone Joint Surg Am 2011. 2006:2. Third generation nailing. et al. Unreamed retrograde intramedullary nailing of fractures of the femoral shaft. et al. J Bone Joint Surg Am 1988. J Orthop Trauma 2008. Cramer KE. Schwappach J. The surgeon can then place partially threaded screws around the nail or choose a reconstruction-ty pe nail with screws directed into the femoral head. Intramedullary nailing of femoral shaft fractures. 8. Switzerland: Stry ker Trauma GmBH. Part II: Fracture-healing with static interlocking fixation. 7. 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. Controversies in intramedullary nailing of femoral shaft fractures. Stannard MD.12:334–342. Tejwani N. Tucker M. REFERENCES 1. et al. Larry Bankston MD. 5. 4. Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals.21:S31–S42. Paffrath T.22:S1.20(10):663–667. Brumback RJ. J Orthop Trauma 2006. Russel T. Fracture Classification Compendium2007: Orthopedic Trauma Association Classification. Pape H-C. Auf’m’Kolk M.neck fracture is nondisplaced and identified prior to nail insertion. Regardless of the method chosen to stabilize the femoral neck fracture. Uwagie-Ero S.93(15):1385–1391. Moed BR. The Marrow Nailing Method. and Outcomes Committee. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. Lakatos RP. et al. AO/OTA classification—Marsh JL. et al. Wolinsky P. 6. 9. J Bone Joint Surg Am .34(4):540–548.

Marcantonio A. Viehe T. Ostrum RF. Marburger R. J Orthop Trauma 2010.23:254–260. et al. Jensen EJ.68:633–640. 20. J Bone Joint Surg Br 1998. Achor T. et al. Collinge C. Intramedullary nailing of open fractures of the femoral shaft. J Orthop Trauma 2008.71:1324–1331.75:519–525. J Orthop Trauma 2010. J Bone Joint Surg Am 1993.89:39–43. 12. Park HW. Reilly JP.24:224–229. 11. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. . et al. Tornetta P III. et al. Liparace F. 14.90:218–222. Prasarn ML. 16. J Trauma 2010. J Bone Joint Surg Am 2000. J Orthop Trauma 2009. Scannell BP. et al. Waldrop NE. et al. Southeastern Fracture Consortium. Yang KH. Cephalomedullary screws as the standard proximal locking screws for nailing femoral shaft fractures. J Bone Joint Surg Am 1989. 15. 19.83:1404–1415. et al. Turen CH.2001. Nowotarski PJ. Creevy WR. Cattaneo MD. Surgical technique. 13. Manka MA. 21. Poka A. Brumback RJ. Brumback RJ. Sasser HC.70:1441–1452. Cates CA.80:673–678. Koval K. The effect of entry point on malalignment and iatrogenic fracture with the Sy nthes Lateral Entry Femoral Nail. The use of one compared to two distal screws in the treatment of femoral shaft fractures with interlocking intramedullary nailing: a clinical and biomechanical analy sis. A critical analy sis of the eccentric starting point for trochanteric intramedullary femoral nailing. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. Han DY. Cannada LK. et al. Ellison PS Jr.82:78. J Bone Joint Surg Am 1988.24:717–722. A retrospective review of high-energy femoral neck-shaft fractures. Improvement with a standard protocol. 18. J Bone Joint Surg Am 2007. et al. Fracture of the ipsilateral neck of the femur in shaft nailing. Mutty C. Brumback RJ. Intramedullary nailing of femoral shaft fractures. Poka A. part I: decision making errors with interlocking fixation. Hajek PD. Bronson WE.22:S25–S30. 10. Kain MS. Femoral nerve block for diaphy seal and distal femoral fractures in the emergency department. et al. The role of CT in diagnosis. 17. J Bone Joint Surg Am 2008. Bicknell HR.

et al. Injury 2003. Ricci WM.45:747– 752. Bednar DA.36:464–466. Archdeacon MT. 29.23:S39–S46. Femoral exchange nailing for aseptic non-union: not the end to all problems. Paterno MV. et al. Taitsman LA. Shih CH. J Orthop Trauma 2001.16:88–97. Jaarsma RL.34:349–356. 25. 28. Bellabarba C. . Augmentative plate fixation for the management of femoral nonunion with broken inter-locking nail. et al. O’Connor DP.15:90–95. Angular malalignment after intramedullary nailing of femoral shaft fractures. Verdonschot N. J Trauma 1998. Pervez A. Ueng SW. Barei DP. J Orthop Trauma 2004. Rotational malalignment after intramedullary nailing of femoral fractures. Current concepts review exchange nailing of ununited fractures. Intramedullary nailing of femoral shaft fracture: reoperation and return to work.18:403–409. Ly nch JR. Femoral nonunion: risk factors and treatment options. Brinker MR. J Bone Joint Surg Am 2007. 23.89:177–188. Sabboubeh A. Pakvis DFM. Lewis R. Banaszkiewicz PA. Can J Surg 1993.22. 26. 24. et al. 27. McLeod I. J Am Acad Orthop Surg 2008. Is there a standard rehabilitation protocol after femoral intramedullary nailing? J Orthop Trauma 2009.

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.23 Femoral Shaft Fractures: Retrograde Nailing Robert F. Closed reamed intramedullary nailing remains the gold standard of treatment for the vast majority of patients following fracture. particularly those with complex articular injuries (Fig. B.1). intramedullary nailing can be accomplished with either an antegrade or retrograde nail. . In this location. the techniques for intramedullary nailing have been refined to include newer nail designs. and C depending on the degree of comminution. and interlocking options. Femoral shaft fractures are classified by the AO/OTA as 32 A. insertion sites. metallurgy. What has remained unchanged is that intramedullary nailing of the femur is still a highly technical procedure regardless of the implant employ ed. distal or supracondy lar 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. On the other hand. Ostrum INTRODUCTION Femoral shaft fractures are one of the most common injuries following blunt or penetrating trauma to the lower extremity . Over the last 60 y ears. 23.

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Fourth. Furthermore. in patients with ipsilateral hip. most authors recommend independent fixation of each injury. First. a retrograde nail done acutely or following initial treatment with an external fixator may be an excellent treatment option. There are several strong indications for retrograde nailing. a locked plate is a better and more suitable option. If the femoral component has an “open box” configuration. the so-called floating knee. Contraindications to retrograde nailing include adolescents with open growth plates. bilateral femoral shaft fractures are optimally treated with a retrograde nailing on a radiolucent flat-top table. poly traumatized patients with multisy stem 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. There are several relative indications for retrograde nailing. acetabular. This approach allows for the best possible treatment of each fracture without compromising the surgical approach or fixation of either one.5 cm above the knee joint. nailing is a viable treatment alternative if the prosthesis is not loose. ipsilateral fractures of the femur and tibia. in multiply injured patients with ipsilateral or contralateral lower extremity fractures. If the femoral component is “closed” and will not accept a nail.FIGURE 23.1 OTA classification of distal femur fractures. can often be managed through a single. INDICATIONS AND CONTRAINDICATIONS Retrograde nailing is indicated for selected diaphy seal femur fractures located 5 cm distal to the lesser trochanter extending down to the supracondy lar region 7. In patients with an associated vascular injury. Second. small knee incision with placement of a retrograde femoral nail and an antegrade tibial nail. Another relative indication for a retrograde nail is a femur fracture above a total knee replacement. patients with a previous anterior cruciate ligament . These include femoral shaft fractures in the obese or very muscular patients or in individuals with trochanter lipody strophy where antegrade nailing may be difficult. saving valuable operating time. supine retrograde nailing on a radiolucent table allows either simultaneous or sequential fixation of other fractures. or pelvic fractures. Third.

PREOPERATIVE PLANNING History and Physical Examination A detailed history and phy sical examination should be performed. a skeletal traction pin through the distal femur or proximal tibia is indicated to relieve pain and restore limb length. 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. The limb is usually shortened and externally rotated. bridging external fixation and delay ed nailing may be a safer approach. If orthopedic surgery is delay ed >12 hours. Motion of the affected hip and knee is resisted secondary to pain.reconstruction. In many patients. 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. Isolated femoral shaft fractures should be treated within 12 to 24 hours whenever possible. Many patients with femur fractures have serious associated limb or life-threatening injuries. A multidisciplinary approach is required in the multiply injured patient to optimize patient care. 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 diaphy seal nail fit and fill with meticulous preoperative planning. Computerized tomography (CT) of the knee is recommended in patients with supracondy lar femur fractures to rule out . Virtually all patients with an acute femur fracture have a very painful leg that is swollen. and those with preexisting femoral hardware that would prohibit retrograde nailing. Dedicated x-ray s of the hip and knee are often required to rule out intercondy lar extension or an ipsilateral femoral-neck fracture based on the clinical exam and initial x-ray s. The condition of the soft tissues and limb compartments as well as the neurovascular status should be evaluated and clearly documented. Imaging Studies Full-length AP and lateral radiographs of the entire femur are mandatory. Open fractures require emergent irrigation and débridement with fracture stabilization with a nail or temporary external fixator.

Most trauma patients undergo CT scanning of their abdomen and pelvis as part of the ATLS protocol. In a patient with an ipsilateral femoral-neck fracture. a more extensile approach is usually necessary. traction views or fluoroscopic radiographs in the operating room. Cannulated screws of similar metallurgy to the retrograde nail should be used as well as any hardware if an associated hip fracture is present. and those with developmental problems often have very narrow canals. Surgical Tactic Full-length films are necessary to allow measurement of the length and diameter of the femur. preoperative planning is necessary for positioning and draping to optimize resources. In comminuted and displaced fractures. persons of Asian descent. The decision to use a percutaneous or limited open approach for nail insertion is dictated by the status of the distal femoral fragment. a nondisplaced split between the femoral condy les can be treated with independent cannulated screws inserted through small stab incisions laterally. may be helpful in clarify ing the fracture geometry or to identify subtle injuries to the hip or knee joint. . The presence of an intraarticular split in the femoral condy les should be a major priority when planning the approach.an unrecognized intercondy lar split or coronal plane fracture of the femoral condy le (Hoffa fracture). If the distal fragment is displaced with fracture extension into the knee joint. Patients of small stature. When it is intact. Many studies have shown that the best results following retrograde femoral nailing are achieved when a full-length canal fill nail is utilized. Most manufacturers do not make retrograde nails smaller than 9 or 10 mm in diameter. In patients with other extremity fractures. It is important to ensure that there is a full complement of nails available at the time of surgery. Occasionally. Visualization and fixation of the articular surface may be compromised by an incorrectly placed incision. This must be recognized prior to surgery so that either a nail of appropriate diameter is available or other surgical options are considered. with the patient anesthetized. a percutaneous approach is preferred. These scans should be carefully reviewed to assess the integrity of the hip and rule out an occult femoral neck fracture. important decisions must be made prior to surgery about the ty pe of table and patient position for this combined injury.

SURGERY Patient Positioning and Setup Intramedullary nailing is usually performed under general anesthesia. usually a first-generation cephalosporin. The limb is sterilely prepped and draped from the toes to the iliac crest. 23. are administered and continued for 24 hours postsurgery. but in isolated injuries particularly in the elderly with medical comorbidities. central venous catheters. but care must be taken to avoid excessive pelvic obliquity that can lead to rotational errors. Preoperative antibiotics. Arterial lines. The optimal position for nailing is with the patient supine and the patella pointing straight upward. a spinal may be preferable. Vancomy cin or clindamy cin is used in patients with penicillin allergies. We prefer general anesthesia because it allows predictable muscle paraly sis for fracture reduction and fixation. and the need for a Foley catheter are inserted on a caseby -case basis. Some surgeons prefer a bolster beneath the torso. Retrograde femoral nailing is performed with the patient supine on a radiolucent table. . 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.2).

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Furthermore.3 . If this is not available. 23. FIGURE 23.FIGURE 23. Too little knee flexion does not allow correct position of the guide pin or passage of the reamers and nail. a sterile bolster can be used. Protection sleeves should alway s 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. which can lead to articular damage.3). Too much knee flexion makes radiographic visualization of the distalfemoral entry site difficult and puts the patella in the way of the insertion. inadequate knee flexion risks damage to the tibial plateau from contact with the instruments (Fig. The ability to flex the knee between 40 and 50 degrees is very important.2 Preoperative radiograph showing a middiaphy seal femoral shaft fracture.

Right knee flexed over triangle at 40 to 50 degrees.B). 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. a 2. Surgery For the percutaneous approach. On the lateral view. A 3-cm incision through the skin and patellar tendon is made. The guide pin is then advanced 4 to 5 cm into the distal femoral metaphy sis under fluoroscopic control to ensure that the pin is centered in both projections. FIGURE 23.5).4 . 23. the guide pin is centered just anterior to the tip of the inverted V formed by Blumensaat’s line and the femoral groove (Fig. a patellar tendon-splitting approach can be used.4A. The guide pin is then removed. A retractor is used to protect the patellar tendon. Alternatively.to 3-cm incision is made just medial to 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 . With the C-arm in the anterior-posterior and tilted 20 degrees cephalad. and the fat pad and sy novium are bluntly dissected in the intercondy lar region with a scissors or long hemostat. a trochartipped guide pin is positioned in the center of the intercondy lar notch. 23. The joint capsule is opened.

The cartilage and the patellar tendon are protected by a reaming sleeve. A 3. alignment can be improved by positioning sterile bolsters under the thigh or using external devices to apply force.6A.5 Reaming with the opening reamer to make the entry hole in the distal femur. AP fluoroscopic view of centered guide pin. FIGURE 23. The fracture is reduced by strong longitudinal traction with muscle paraly sis. Once the length is restored.B). 23.2-mm ball-tipped guide wire with a slight bend at the tip is inserted into the opening in the distal femur. 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. Lateral fluoroscopic view showing proper insertion site just anterior to the V formed by Blumensaat’s line and the femoral groove. When traction alone does not reduce the fracture.A. B. .

. Another technique for reduction is to place an intramedullary reduction device over the guide rod in the distal fragment.7). Schanz pin inserted in the distal fragment with mallet as external reduction aid to pass ball tip guide rod. FIGURE 23.Alternatively. Once the guide rod is passed across the fracture site. A 5-mm Schanz pin has been inserted into the distal fragment percutaneously to assist with the reduction.6 A. The femoral distractor should be placed with the distraction rod anterolateral to allow for distal interlocking with the distractor in place. the Schanz pin is removed B. manipulate the fracture. When a distractor is used. Passage of the ball tip guide rod into the intramedullary canal. the most distal pin is placed distal and anterior in the distal fragment at the level of the epiphy seal scar to allow unimpeded passage of the reamers and the nail. and pass the guide rod retrograde to the intertrochanteric region of the femur. 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. 23. usually just proximal to the lesser trochanter. The proximal pin is placed as proximal as possible. to allow unimpeded reamer and nail passage (Fig.

the retrograde nail tip .7 Placement of ball tip guide rod into proximal femur.FIGURE 23.

Determination of nail length in comminuted fractures can be difficult. FIGURE 23.B). This decreases the potential for a stress riser at the tip of the nail and minimizes the windshield-wiper effect in the distal femoral metaphy sis. An AP and lateral fluoroscopic view should be used to ensure that the measuring device is 2 to 3 mm inside the intercondy lar notch (Fig. The nail should span from 5 mm deep to the articular surface of the knee joint to a level just above the lesser trochanter. There are several methods to determine femoral length. 23.8 A. One way is with a radiopaque ruler placed on the anterior surface of the leg with the fracture out to length.8A. Measuring from the insertion hole in the distal femur to determine the appropriate length for the retrograde IM nail B. Another method to determine nail size is to use a calibrated ruler that can directly measure length from the guide pin. Full-length canal fit nails inserted to the level of the lesser trochanter should be employ ed regardless of the location of the femur fracture.should be above the lesser trochanter. End of measuring guide against the intercondy lar notch insertion site. Full-length nails provide a longer working length and better fit in the isthmus and prevent nail toggle within the intramedullary canal. In .

FIGURE 23.these cases. In patients who are brought to the operating room urgently. which may lead to iatrogenic comminution or malalignment following nail placement (Fig. The nail is inserted by hand until resistance is encountered and then advanced with light blows with a hammer (Fig. Reaming is routinely performed using modern. sharp.5 mm greater than cortical chatter and a nail 1 mm less in size than the final reamer is inserted (Fig. and limb length can be assessed intraoperatively using a radiopaque ruler placed on the anterior surface of the uninjured limb if not fractured. Nail diameter is determined based on the preoperative plan.9A).0 to 1.9B). Reaming should continue up to 1 .9 A. 23. It is very important that the femur is reduced during reaming to avoid eccentric reaming. 23. both limbs can be prepped and draped. Reaming is usually performed to 1. 23. The insertion and targeting guide is attached to the nail on the back table with the outrigger for the distal screws aligned laterally. flexible medullary reamers.10A). Reaming of the intramedullary canal. careful preoperative planning using the intact femur is the best method to avoid leg length discrepancies.

. Intraoperative fluoroscopy view showing reaming being performed with the femur fracture reduced.mm greater than when “chatter” is encountered B.

Retrograde IM nail inserted. Insertion of the retrograde IM nail over the ball tip guide rod. B. note slight gapping of the lateral cortex. Notice difficulty in determining the location of the end of the nail on the AP view C. The IM nail should be inserted with the aiming arm parallel to the floor to prevent rotation of the nail. This can be corrected after distal interlocking. Lateral view may be easier to determine where the end of the retrograde nail is with relation to the cartilage D.10 A.FIGURE 23. Careful attention to rotation of the limb is necessary as the patella should be straight anterior. .

However. and rotation is a critical step prior to final nail seating and locking (Fig. Rings on the insertion jig that delineate the nail/targeting junction are visualized fluoroscopically. For minimally comminuted femoral shaft fractures with at least 50% cortical contact.11 and 23. With most retrograde nails. 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. 23. .12A. Comminuted and spiral fractures that do not have axial stability require at least two distal locking screws (Figs. 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 epiphy seal scar. In elderly patients with compromised bone stock or in any patient where distal screw fixation is questionable should have a second screw inserted. the most distal screw hole is 15 mm from the tip of the nail.10B. it is important to obtain a true lateral of the distal femur by superimposing the femoral condy les for a more accurate assessment of the contour and anatomy of the distal femur.B).C). the best way to ascertain the depth of the nail in relation to the articular cartilage is on the lateral C-arm view.Recognition of nail insertion depth. one distal locking screw is usually sufficient. 23. femoral length. For many nailing sy stems.

distal interlocking is performed by using the insertion jig and measuring the screw length off the sleeve and drill bit.FIGURE 23.11 Once the nail has been determined to be at the appropriate depth. .

Distal interlocking screw inserted through the sleeve on the insertion handle. New generation retrograde nails now have sites for multiple distal interlocking screws at oblique angles to give multiplanar distal fixation improving stability. Similar to distal locking. Prior to proximal locking. and some are locked to prevent the screw from backing out. if there is excessive rotation of the nail. Insertion of the distal interlocking screw through the sleeve on the insertion jig handle. Errors. Other screw designs allow for better purchase in cancellous bone. it is imperative that the starting point is in the .12 A. two screws should be employ ed. one screw is sufficient in minimally comminuted and length stable fractures.FIGURE 23. and Complications When nailing distal fractures. the oblique screws may enter the patellofemoral joint. One screw distally can be used for axially stable fractures while two screws can be used for unstable fractures and distal fractures B. 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. However. For all other injuries. Pitfalls. final determination of length must be determined. Screws are directed from anterior to posterior. Proximal locking is most commonly done using a free-hand technique.

23. .center-center position to prevent varus-valgus deformities. Light blows in a reverse direction with the slap hammer will not usually result in over distraction due to the intact iliotibial band. For the occasional fracture that was distracted during nailing.14A. A “blocking screw” is placed percutaneously immediately adjacent to the guide wire on the concave side of the deformity from anterior to posterior. More commonly. 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. Fluoroscopy should be used to confirm that the tip of the nail is 3 to 5 mm deep to the articular surface (Fig. To help restore femoral length. the nail is “back slapped” after insertion of the distal interlocking screws to restore length. comminuted fractures tend to shorten during the nailing process. The locking screws from the nail set can be used for this purpose or another small fragment screw. If malalignment does occur after nail insertion. correction can be obtained by placing the distal interlocking screws and then tapping on the insertion handle to close the gap (Figs. 23. The nail should not be prominent by even 1 mm at the notch because this may adversely affect the patellofemoral joint.B).13). the implant should be removed leaving the guide wire in place.10D and 23.

the IM nail would be slapped backward to lengthen the femur.FIGURE 23. . If the fracture was shortened. since there was distraction of the fracture.13 After distal interlocking of the retrograde IM nail. the IM nail is hammered in to compress the fracture.

to 2-cm anterior incision is made over the screw hole as determined by fluoroscopy. and a hemostat is used to spread down to the bone. Proper seating of retrograde IM nail a few millimeters deep to the articular cartilage. A 1.15A. For unstable fractures. For axially stable fractures. .14 A. tipped. After IM nail insertion handle removal.B). The perfect circle technique of rotating the C-arm until round holes are obtained is essential to successful interlocking (Fig. insertion of the proximal screw can be done in the upper or lower portion of the hole depending on the fracture morphology. a dy namic screw can be placed at the top of the hole to allow for compression with weight bearing.FIGURE 23. the proximal interlocking screws are inserted. For nails with a dy namic oblong hole. the screw can be placed in the bottom portion of the hole to prevent further shortening. 23. 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. The drill is inserted through the proximal cortex perpendicular. short. 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. A trochar. Proximal Interlocking With the limb in neutral rotation and the knee bolster removed. The quadriceps fascia is opened sharply with a knife.

The posterior cortex is then drilled taking care not to plunge too deeply with the drill bit to avoid injury to the sciatic nerve. Final screw seating should be checked with a crosstable lateral of the leg to assure that the screw is fully seated. and those with extensive comminution. If a locking screwdriver is not available. A depth gauge is used to determine screw length.and the image intensifier is used to evaluate the position of the drill bit in relation to the hole. and a trocar tip drill bit . Often the screw tightens significantly when it enters the dense far cortex giving the false impression that the screw is seated. and a bicortical screw is inserted. With some sy stems. Using a perfect circle technique after removal of the triangle. 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. FIGURE 23. 23.15 A. 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. but with very proximal fractures. the addition of a second screw is recommended.16A–C).to 2cm incision is made. a 1. One screw is sufficient for most fractures. it is tapped through the nail with a mallet. and once it is centered in the hole and drilled through the proximal cortex. the quadriceps fascia is opened. Minor adjustments to the drill bit can then be made.

and this site will allow for some compression of the fracture site in a stable fracture.is inserted. and the posterior cortex is drilled B. the drill handle is removed. Drill point inserted in the middle of the dy namic hole after obtaining perfect circles. the drill bit is tapped through the hole in the IM nail. The drill is centered on the visible nail hole. drilled through the anterior cortex. the drill handle is reassembled on the drill bit. .

After depth gauging the hole.16 A. Screw for .FIGURE 23. 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. the screw is inserted.

17A. Sterile dressings are applied. 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. length. 23. POSTOPERATIVE MANAGEMENT Active range of motion is encouraged in the early postoperative period. The small wounds are irrigated with saline and carefully closed in lay ers. Final A-P fluoroscopy view with C-arm demonstrating fracture alignment after retrograde intramedullary nailing B. angulation.proximal interlocking inserted in the middle of the dy namic slot C. and a compression bandage is applied from toes to groin.B). AP radiograph showing fracture reduction and proper placement of retrograde intramedullary nail. With the drapes removed but the patient still under general anesthesia. The ipsilateral knee is also examined for ligamentous instability (Fig.17 A. FIGURE 23. Continuous passive motion machines are reserved for multiply injured . and rotation of both limbs are compared.

Once there is firm bridging callus. Most fractures heal between 3 and 6 months. Weight bearing can be initiated early in axially stable fractures but is usually delay ed 6 to 10 weeks until callus forms in unstable fractures. Several studies comparing antegrade and retrograde nailing of femoral shaft fractures have not shown a difference in knee motion. Full extension and flexion >90 degrees should be obtained between 6 and 8 weeks postoperatively. full weight bearing can be initiated without restrictions. Suppressive antibiotics can be continued until union. or knee scores. Full extension and flexion to 120 degrees should be expected with a well- . In patients with limited knee motion. COMPLICATIONS Soft Tissue/Infection Fortunately.patients or in those with head injuries. Most of these patients benefit from late removal of the nail with reaming of the intramedullary canal. Stiffness and Knee Motion Most patients regain their knee motion by 8 to 12 weeks. Early knee motion is encouraged to prevent arthrofibrosis. Low molecular weight heparin and mechanical prophy laxis with sequential compression hose are routinely used. Continuous passive motion machines may be considered for obtunded patients or those with multiple injuries that require prolonged bed rest. 10. Leaving the nail prominent at the intercondy lar notch can lead to patellar impingement and should be revised as soon as it is recognized. Follow-up visits are scheduled at 6. 16. Quadriceps adhesion to the suprapatellar pouch is common in supracondy lar fractures. we recommend an aggressive phy sical therapy program for limb rehabilitation. infections following retrograde nailing are uncommon and rarely lead to a septic knee joint. strength of the quadriceps. Active assisted knee motion should be encouraged and supervised in the early postoperative period. Weight bearing is increased based on clinical and radiographic healing. Localized infection can be treated with an incision and drainage with maintenance of hardware if the infection is in the early postoperative period. Patients are seen in the clinic at 2 weeks postoperatively to remove sutures and assess knee motion. and 20 weeks or longer until union occurs.

Nonunion/Malunion Nonunion is more frequent when small diameter. If by 4 months. Long-term knee pain is uncommon with proper operative technique. and screws that appear with their tips just outside the medial femoral cortex are usually too long.placed. Reamed canal-sized implants have been shown to achieve union rates >90%. For this reason. a patient has not achieved 90 degrees of knee flexion. Most malunions that have been reported with the use of retrograde nails for fractures occur in the proximal and distal ends of the femur. The most distal locking screw is inserted into the trapezoidal distal femur. including those in the supracondy lar region. full-length nails are recommended for all fractures. Knee Pain/Symptomatic Hardware Pain caused by prominent distal screws is common and is usually caused by screws that are too long. In patients with delay s in union. RECOMMENDED READING . manipulation under anesthesia should be considered. dy namization can be performed if the fracture is axially stable. With bilateral fractures. retrograde. 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. or a painful screw may be removed once abundant callus is visible on radiographs. femoral nail. Almost alway s. Residual anterior knee pain is occasionally seen and is most common secondary to original injury or with residual weakness in the quadriceps muscle. This is beneficial in fractures that have some callus but have a gap at the fracture site with a well-fitting nail. noncanal filling nails are employ ed. Sy mptomatic distal screws can be removed as an outpatient procedure once union has occurred. Fractures at the tip of the implant have been reported in osteoporotic bone with the use of short nails. which compare favorably to antegrade nailing. Sometimes the screw heads are prominent or click or snap under the iliotibial band in thin patients. 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.

23(9):640–644. Lakatos R.375:43–50.77:1520–1527. Antegrade or retrograde reamed femoral nailing: a prospective. J Orthop Trauma 2009. et al. Watson JT. Litsky AS. et al. DiCicco J. J Orthop Trauma 2009. Retrograde intramedullary nailing.10(5):309–316. Ricci WM. Maurer JP. Clin Orthop Relat Res 1996. Ostrum RF. et al. Whiteman KW. randomised trial. without reaming. et al. J Bone Joint Surg Br 2000. J Orthop Trauma 1998. Riche K.15:161–169. Retrograde intramedullary nailing of femoral diaphy seal fractures. Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing.24(11):677–682. O’Toole RV.14:496–501. Karpik K. Retrograde nailing of the femur using an intercondy lar notch approach. Analy sis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures. J Bone Joint Surg Am 1995. Ostrum RF. Tornetta P III. Ostrum RF. Clin Orthop 2000. Distal third femur fractures treated with retrograde femoral nailing and blocking screws. Ostrum RF.Daglar B. of fractures of the femoral shaft in multiply injured patients. Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphy seal femoral fractures: results of isokinetic evaluation. Lakatos R. Ostrum RF. Gregory P. et al. Delialioglu OM. Bellabarba C.12:464–468. Tiburzi D. Herscovici D. J Orthop Trauma 2000. J Orthop Trauma 2001. DiCicco J. . et al. Treatment of floating knee injuries through a single percutaneous approach.18:354–360.332:98–104. J Orthop Trauma 1996. A mechanical study of gap motion in cadaveric femurs using short and long supracondy lar nails. Gungor E. J Orthop Trauma 2004. Retrograde versus antegrade nailing of femoral shaft fractures.82:652–654. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. Sears BR. Moed BR. Agarwal A.23(9):681– 684. J Orthop Trauma 2010. Cannada LK. Evanoff B.

INDICATIONS SURGERY AND CONTRAINDICATIONS FOR While the vast majority of distal femur fractures in adults are managed surgically. prolonged external fixation. Highenergy fractures ty pically occur in y ounger patients and are associated with open fractures. These include truly nondisplaced fractures that can be managed for a short period . For all of these reasons. For the most of these fractures. Lee INTRODUCTION The treatment of distal femur fractures is challenging due to disruption of the joint surface. there are a few indications for nonoperative treatment.24 Distal Femur Fractures: Open Reduction and Internal Fixation Brett D. and intra-articular comminution. Most distal femur fractures in adults are managed operatively due to poor outcomes with nonoperative management even in elderly patients. diaphy seal extension. Lower-energy fractures usually occur in elderly females secondary to ground-level falls and may be extra-articular or intra-articular. plate osteosy nthesis is the implant of first choice. and limited space for fixation in fractures with small articular segments. 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. Periprosthetic femur fractures above a total knee or below a total hip arthroplasty create unique problems in treatment. bone loss in open fractures. metaphy seal comminution. Crist and Mark A. or medial plating.

If surgery is delay ed. Similarly . a preexisting surgical history (particularly arthroplasty ). Critical factors include mechanism of injury and associated medical comorbidities that might increase the risk of intra.or postoperative complications. and preinjury ambulatory and functional status. nonoperative management of displaced fractures is associated with poor outcomes because of an increased risk of pneumonia. a complete history and phy sical should be performed. If there is diminished or absent pulses. diabetes mellitus. frequent skin and neurovascular checks should be . and spine to avoid missed injuries. Ecchy mosis and swelling develop rapidly and should be noted. PREOPERATIVE PLANNING History and Physical Examination As with all patients that sustain trauma. deep vein thrombosis. Occasionally. an impacted stable supracondy lar fracture in an elderly patient can be managed without surgery . tobacco use. pelvis. their extremity. gentle longitudinal traction should be applied to the lower extremity. and reexamination should be performed to see if the vascular status improves. displaced distal femur fractures that occur in adults are primarily managed surgically to restore stability and allow early range of knee motion and rehabilitation.of time in a cast or hinged knee brace. These include underly ing cardiovascular disease. pressure ulcers. osteoporosis. and knee stiffness (1). Even in elderly patients. Lastly. This often distinguishes whether the difference in the pulse is secondary to fracture displacement or due to an arterial injury that requires vascular consultation. nonoperative management should be considered. On the other hand. in extremely frail patients with multiple medical comorbidities who do not walk. Ty pically the affected lower extremity is shortened and externally rotated. adolescents with open epiphy sis and minimally displaced fractures are often well managed in a cast. Careful skin inspection and neurovascular exam should be done to avoid missing an open fracture wound posteriorly or neurovascular compromise including compartment sy ndrome. Once the phy sical examination is complete. A complete phy sical should include evaluation of the patient. either a well-padded long-leg splint or knee immobilizer is applied to relieve pain and provide support to the injured limb.

24.B). traction. Additionally. radiographs can be obtained following appropriate sedation. Since the fracture is ty pically shortened and rotated. When the fracture is significantly shortened or the patient is not comfortable in a splint or brace. This information helps guide the choice of implants particularly in the elderly. bone quality can be assessed on plain films on the basis of the cortical diaphy seal thickness and intramedullary diameter. proximal tibial skeletal traction should be considered. Computed tomographic (CT) scans with 2D and increasingly 3D reconstructions are obtained for many fractures and virtually all injuries with intra-articular extension. .performed. Full-length femur films are required to avoid missing a more proximal fracture or hip injury.1A. 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.

frequently dictated by surgeon preference. The distal femur region is designated as 33 in the comprehensive classification of fractures. 24. 33B fractures are partial articular injuries and may involve either the medial or lateral femoral condy le. It is best seen on the sagittal reconstruction of the CT scan. .2). This fracture can occur in up to 38% of fractures and if missed leads to poor outcomes (2). Ty pe 33C fractures involve both the articular surface and metadiaphy sis and range from fairly simple splits to highly comminuted fracture patterns.B. Initial injury AP and lateral knee radiographs.FIGURE 24.1 A. It is mandatory to rule out a coronal plane fracture (B3 component or Hoffa fracture) with even simple supracondy lar/intercondy lar patterns. Ty pe 33A fractures are extra-articular distal femur injuries and can be fixed with a variety of implants. The AO/OTA classification is useful to guide treatment including the surgical approach and fracture implants (Fig.

FIGURE 24.2 .

Digital imaging software can be used for preoperative planning and to ensure that adequate distal fixation can be achieved with the implant. locked implants are not indicated for these fractures. We use both plain radiographs and CT scans for preoperative planning. 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. .3. 33A fractures are extra-articular and can be treated with plates or medullary implants. It is critical to have a plate of proper length.The AO/OTA classification of distal femoral fractures. Almost all contemporary implants include a 95-degree reference screw or wire to assist in frontal plane reduction and restoration of the LDFA. The AP and lateral radiographs of the distal femur are helpful to determine plate length. as short plates are a common cause of fixation failure. selection. First. Finally . 33C fractures require restoration of the articular surface as well as the relationship of the distal articular segment to the shaft of the femur. Current implant designs have increased our ability to gain fixation in increasingly distal fracture patterns. 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. 33B fractures are articular injuries that are best treated with open reduction and compression across the fracture. 24. This radiograph also determines the normal lateral distal femoral angle (LDFA). Hoffa fracture) that usually require independent interfragmentary screw fixation and may affect implant fixation. Once this is known. 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. Second. the CT may reveal unrecognized coronal plane fractures (Fig. detailed information is gained regarding the distal extent of the fracture to determine whether or not internal fixation is technically feasible. and primary distal femoral replacement arthroplasty is rarely performed today . CT scans are very important in preoperative planning for two reasons. and location.

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most supracondy lar fractures should be surgically repaired as soon as the patient’s overall condition permits. The external fixator can also be used intraoperatively as a reduction device. In patients with open fractures. Temporary Spanning External Fixation The indications for temporary spanning external fixation have increased over the past 10 y ears to manage complex extremity fractures in the seriously injured patient. . we do not utilize temporary spanning external fixation for distal femur fractures. usually within the first 48 hours. The benefits of temporary external fixation include decreased pain. improved mobilization of the patient. implant availability. even for higher energy articular patterns.B). and a detailed preoperative plan remains important especially with intraarticular fracture patterns as this can influence implant selection. and preoperative planning. Ur