Contributors

Authors

John Arraf, MD, FRCPC Michael Blauth, MD Hans Peter Dimai, Prof, Dr Med
Department of Anesthesia Professor Direktor der Univ. –Klinik für Unfallchirurgie Medical University of Graz
Foothills Medical Centre Director Department for Trauma Surgery Department of Internal Medicine
1403 – 29 St NW Anichstrasse 35 Division of Endocrinology and Metabolism
Calgary AB T2N 5A1 Innsbruck 6020 Auenbruggerplatz 15
Canada Austria Graz 8036
Austria
Reto Babst, Dr Med Olivier Borens, MD
Professor Vorsteher Department Chirurgie Professor Service d’Orthopédie et de Traumatologie Daren Forward, MA, FRCS, DM
Leiter Klinik Orthopädie und Unfallchirurgie Centre hospitalier universitaire vaudois (CHUV) The East Midlands Major Trauma Centre
Chefartz Unfallchirurgie Rue Bugnon, 46 Nottingham University Hospital
Luzerner Kantonsspital 1011 Lausanne Nottingham NG7 2UH
6000 Luzern 16 Switzerland UK
Switzerland
Douglas A Campell, ChM, FRCSE, FRCS (Orth) Peter Giannoudis, Dr Med
Zsolt J Balogh, MD Spire Leeds Hospital Professor Academic Department
Professor, Director of Trauma Jackson Avenue Trauma & Orthopedic Surgery
John Hunter Hospital Leeds LS8 1NT Floor D, Clarendon Wing
Locked Bag 1, Hunter Region UK Great George Street
Newcastle NSW 2310 Leeds General Infirmary
Australia John T Capo, MD Leeds LS1 3EX
377 Jersey Ave, Suite 280A UK
Paulo Barbosa, MD Jersey City, NJ 07302
Hospital Quinta D‘or USA Markus Gosch, Prof, Dr med
Rua Almirante Baltazar 435 Medical Director Department for Geriatrics
São Cristovão Keenwai Chong, MD Paracelsus Medical University Salzburg, Austria
Rio de Janeiro CEP 209401 -150 Bone Joint Institute of Singapore Nüremberg Hospital North
Brazil 08-01 Gleneagles Medical Centre Prof.-Ernst-Nathan-Str. 1
6 Napier road Nüremberg 90419
Jorge Daniel Barla, MD Singapore 258499 Germany
Hospital Italiano de Buenos Aires – Orthopedics Singapore
Potosí 4247 Les Grujic, MD
Buenos Aires C1181ACH Piet de Boer, FRCS Orthopaedic & Arthritis Specialist Centre
Argentina Oberdorfstrasse 1 Level 2, 445 Victoria Ave.
8305 Dietlikon Chatswood, NSW 2067
Friedrich Baumgaertel, MD, PhD Switzerland Australia
Associate Professor
Dept. Of Orthopedics and Traumatology Mandeep Dhillon, MD, MBBS, MS (Ortho), MNAMS Boyko Gueorguiev-Rüegg, PhD
University of Marburg – Private Practice Professor Department of Orthopaedic Surgery Professor Program Leader Biomedical Development
Neversstr. 7 Post Graduate Institute of Medical Education and AO Research Insititute Davos
Koblenz 56068 Research Clavadelerstrasse 8
Germany 92, Sector 24 7270 Davos
P.O. Box 1511 Switzerland
Brian Bernstein, MD Chandigarh 160012
P.O. Box 599 India David M Hahn, MD FRCS (Orth)
Constantia Consultant Trauma and Orthopaedic Surgeon
Cape Town 7848 Nottingham University Hospital
South Africa Queen’s Medical Centre
Nottingham NG72UH
UK

IX
 Contributors

Yves Harder, Dr Med James F Kellam, MD, FRCS, FACS Thomas J Luger, Prof, Dr Med
Professor Vice-chief Department of Surgery McGovern Medical School Department of Anaesthesiology and General Intensive
Head Plastic, Reconstructive and Aesthetic Surgery University of Texas Care Medicine
Ente Ospedaliero Cantonale (EOC) Health Science Center at Houston Anichstrasse 35
Ospedal Regionale di Lugano; 6431 Fannin Street, Suite 6.146 Innsbruck 6020
Sede Ospedale Italiano Houston, TX 77030 Austria
Via Capelli USA
6962 Viganello – Lugano Cong-Feng Luo, MD
Switzerland Mauricio Kfuri, MD, PhD Orthopaedic Trauma Service III
Missouri Orthopedic Institute Dept. Orthopaedic Surgery
Martin H Hessmann, Dr med 1100 Virginia Ave Shanghai 6th People’s Hospital Jiaotong University
Professor Academic Teaching Hospital Fulda Columbia, MO 65201 600 Yi Shan Road
Dept. of Orthopaedic and Trauma Surgery USA Shanghai 200233
Pacelliallee 4 China
36043 Fulda Sherif A Khaled, Dr Med
Germany Professor MB, Bch, MSc orthopedics, MD orthopedics. Ching-Hou Ma, MD
32 Falaky street, Awkaf building 1, E-Da Road
Dankward Höntzsch, MD Bab El Louk square Jiau-shu Tsuen, Yan Chau Shiang
Professor BG Unfallklinik Cairo 11211 Taiwan 824
Schnarrenbergstrasse 95 Egypt Taiwan
72076 Tübingen
Germany Hans J Kreder MD, MPH, FRCS(C) Michael McKee, MD, FRCSC
Sunnybrook Health Sciences Centre Professor and Chair
James B Hunter, FRCSE (Orth) 2075 Bayview Ave. Department of Orthopaedic Surgery
Consultant Trauma and Paediatric Orthopaedic Toronto ON M4N 3M5 University of Arizona, College of Medicine
Surgeon Canada Phoenix, Arizona, USA
Nottingham University Hospital
Queen’s Medical Centre Ernest Kwek, MD Rami Mosheiff, Dr Med
Nottingham NG72UH Department of Orthopaedic Surgery Professor Director of Orthopaedic Trauma Unit
UK Tan Tock Seng Hospital Hadassah University Medical Center
11 Jalan Tan Tock Seng Ein Kerem
Chunyan Jiang, MD Singapore 308433 P.O.B 12000
Beijing Jishuitan Hospital Singapore Jerusalem 91120
31 Xinjiekoudongjie, Xicheng District Israel
Beijing 100035 Mark A Lee, MD
China Professor Director, Orthopaedic Trauma Fellowship Stefaan Nijs, MD
Vice Chair for Research Head of the dept. of Traumatology
Matej Kastelec, Dr Med UC Davis, Dept. of Orthopaedic Surgery UZ Leuven
University Medical Centre Ljubljana 4860 Y Street, Suite 3800 Herestraat 49
Zaloška cesta 7 Sacramento, CA 95817 Leuven 3000
1525 Ljubljana USA Belgium
Slovenia
Fan Liu, MD PhD Markku Nousiainen, MD, MSc, FRCSC
Stephen L Kates, MD Professor Dept. of Orthopaedic Surgery Holland Orthopaedic and Arthritic Centre
Professor and Chair of Orthopaedic Surgery The Affiliated Hospital to Nantong University Sunnybrook Health Sciences Centre
Virginia Commonwealth University 20 Xi Si Road, Nantong 621-43 Wellesley St. East
Department of Orthopaedic Surgery Jiangsu 226001 Toronto ON M4Y 1H1
1200 E. Broad St China Canada
Richmond, VA 23298
USA

X AO Principles of Fracture Management—Third Edition  Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul
Contributors

Mahmoud M Odat, MD, FACS David Ring, MD PhD Susan Snape

Senior Consultant Orthopedic & Trauma Surgeon Associate Dean for Comprehensive Care Microbiology department
Arab Medical Center Professor of Surgery and Psychiatry Nottingham University Hospital
P.O. Box 128 University of Texas at Austin Queen’s Medical Centre
Amman 11831 Department of Surgery and Perioperative Care Nottingham NG72UH
Jordan Dell Medical School UK
1912 Speedway
Chang-Wug Oh, MD Austin, TX 78712 Christoph Sommer, Dr med
Professor & Director USA Kantonsspital Graubünden
Department of Orthopedic Surgery Department Chirurgie
Kyungpook National University Hospital Michael Schütz, Dr Med, FRACS Loëstrasse 170
130 Dongdeok-ro, Jung-gu Professor Geschäftsführender Direktor 7000 Chur
Daegu 700-721 Klinik für Unfall- und Wiederherstellungschirurgie Switzerland
South Korea Klinik für Orthopaedie
Universitaetsklinikum Charité (CVK,CCM) James Stannard, MD
Jong-Keon Oh, MD Augustenburger Platz 1 Hansjorg Wyss Distinguished Chair in Orthopedic
Department of Orthopaedic Surgery Berlin 13353 Surgery
Guro Hospital Germany 1100 Virginia Ave,
Korea University College of Medicine Columbia, MO 65212
80 Guro 2-dong, Guro-gu Rogier KJ Simmermacher, MD, Dr med USA
Seoul 152-703 Dept. of Surgery
South Korea University Medical Center Utrecht Martin Stoddart, PhD, FRSB
PO Box 85500 Professor
Rodrigo Pesántez, MD GA Utrecht 3508 AO Research Institute Davos
Professor The Netherlands Clavadelerstrasse 8
Avenida 9# 116-20 7270 Davos
Consultorio 820 Michael S Sirkin, MD Switzerland
Bogotá 140 Bergen St
Colombia Suite d1610 Wa’el Taha, MD
Newark NJ 07103 Department of Surgery
Chanakarn Phornphutkul, MD USA Prince Mohammed bin Abdulaziz National Guard
Department of Orthopaedics Health Affairs
Faculty of Medicine Theddy Slongo, MD Madina 41466
Chiang Mai University Senior Consultant for Paediatric Trauma and Saudi Arabia
Chiang Mai, 50200 Orthopedics
Thailand University Children’s Hospital John R Williams, DM FRCS (Orth)
Freiburgstrasse 7 Upper Limb Trauma Unit
Matthew Porteous, Dr Med 3010 Bern Royal Victoria Infirmary
West Suffolk Hospital Switzerland Queen Victoria Road
Hardwick Lane Newcastle upon Tyne NE1 4LP
Bury St Edmunds R Malcolm Smith, MD FRCS UK
Suffolk IP33 2QZ Chief Orthopaedic Trauma Service
UK Department of Orthopaedic Surgery
Massachussets General Hospital
R. Geoff Richards, FBSE, FIOR 55 Fruit Street YAW 3600
Professor Director Boston MA 02114
AO Research Insititute Davos USA
Clavadelerstrasse 8
7270 Davos
Switzerland

XI
 Abbreviations

Abbreviations
ABI ankle-brachial index DHS dynamic hip screw
ACL anterior cruciate ligament DICOM digital imaging and communications in medicine
ACT autogenous chondrocyte transplantation DMB demineralized bone matrix
AFN antegrade femoral nail DRUJ distal radioulnar joint
AIS abbreviated injury score DVT deep vein thrombosis
ALARA as low as reasonably achievable (ALARA is a principle in radiation protection) DXA dual x-ray absorptiometry
AO Arbeitsgemeinschaft für Osteosynthesefragen EAC early appropriate care
AP anteroposterior EGF epithelial growth factor
APC anodic plasma-chemical treatment EHN expert humeral nail
APC anterior-posterior compression EMG electromyogram
APL abductor pollicis longus EPB extensor pollicis brevis
APTT activated partial thromboplastin time EPL extensor pollicis longus
ARDS adult respiratory distress syndrome ESIN elastic stable intramedullary nailing
ARR absolute risk reduction (or increase) ESR erythrocyte sedimentation rate
ASA acetylsalicylic acid ETC early total care
ASIA American Spinal Injury Association ETNS expert tibial nail system
ATLS advanced trauma life support FCR flexor carpi radialis
AVN avascular necrosis FCU flexor carpi ulnaris
BCP biphasic calcium phosphate FDA Food and Drug Administration
BMC bone mineral content FES fat embolism syndrome
BMD bone mineral density FGF fibroblast growth factor
BMP bone morphogenic protein FPL flexor pollicis longus
CAS computer-assisted surgery FWB full weight bearing
CAOS computer-assisted orthopedic surgery GCS Glasgow Coma Scale
CaP calcium phosphate GDF growth and differentiation factor
CARS compensatory antiinflamatory syndrome GOS Glasgow Outcome Score
C-clamp compression clamp (for pelvis) HA hydroxyapatite
CDMP cartilage derived morphogenic protein HFS Hanover fracture scale
CE Conformité Européenne hGH human growth hormone
CFN cannulated femoral nail HMSC human mesenchymal stem cells
CNS central nervous system HRT hormone replacement therapy
CPM continuous passive motion HTO heterotopic (ectopic) ossification
cpTi commercially pure titanium IASP International Association for the Study of Pain
CRE carbapenem-resistant Enterobacteriacaea ICP intracranial pressure
CRP C-reactive protein ICU intensive care unit
CRPS I complex regional pain syndrome type I IGF insulin-like growth factor
CRPS II complex regional pain syndrome type II IGF-BP IGF-binding proteins
CTA computed tomography angiography IGS image-guided surgery
CTN cannulated tibial nail IMP intramuscular pressure
CTPA computed tomography pulmonary angiogram INR international normalized ratio
DAD distal aiming device (for tibial nail) ISS injury severity score
dBP diastolic blood pressure IVC inferior vena cava
DCO damage-control orthopedics K-wire Kirschner wire
DCS damage-control surgery LC-DCP limited-contact dynamic compression plate
DCS dynamic condylar screw LCL lateral collateral ligament
DEXA dual energy x-ray absorptiometry LCP locking compression plate
DFN distal femoral nail LDUH low-dose unfractionated heparin

XII AO Principles of Fracture Management—Third Edition  Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

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Abbreviations

LHS locking head screw PLLA polylactides

LISS less invasive stabilization system PMMA polymethylmethacrylate
LMWH low-molecular-weight heparin PMN polymorphonuclear neutrophils
MCL medial collateral ligament PQ pronator quadratus
MEFiSTO monolateral external fixation system for traumatology and orthopedics PTH parathyroid hormone
MESS mangled extremity severity score PTSD posttraumatic stress disorder
MFA musculoskeletal function assessment PWB partial-weight bearing
MIO minimally invasive osteosynthesis QCT quantitative computed tomography
MIPO minimally invasive plate osteosynthesis QMRI quantitative magnetic resonance imaging
MIS minimally invasive surgery QST quantitative sensory testing
MMA methyl methacrylate QUS quantitative ultrasound
MOdDAD modular distal aiming device R/AFN expert retrograde/antegrade femoral nail
MODS multiple organ dysfunction syndrome RCT randomized control trial
MOF multiple organ failure RES reticuloendothelial system
MPP mean muscle perfusion pressure RIA reamer irrigator aspirator
MRC medical research council ROM range of motion
MRI magnetic resonance imaging RRR relative risk reduction
MRSA methicillin-resistant Staphylococcus aureus RSD reflex sympathetic dystrophy, also called complex regional pain syndrome (CRPS)
MSC mesenchymal stem cells RTW return to work
MSSA methicillin-sensitive Staphylococus aureus SBP systolic blood pressure
MVA motor vehicle accident SIGN Surgical Implant Generation Network
NNT number needed to treat/number needed to harm SIRS systemic inflammatory response syndrome
NPWT negative-pressure wound therapy, also called vacuum-assisted wound closure (VAC) SMP sympathetically maintained pain
NSAIDs nonsteroidal antiinflammatory drugs SPION superparamagnetic iron oxide nanoparticles
OA osteoarthritis SSSC superior shoulder suspension complex
OC oral contraceptives SUN simplified universal nail
OR operating room SXA single x-ray absorptiometry
ORIF open reduction and internal fixation TAN titanium aluminium niobium
ORP operating room personnel TBI traumatic brain injury
OTA Orthopaedic Trauma Association ß-TCP ß-tricalcium phosphate
OTD Orthopedic Trauma Directions TEN titanium elastic nail
PACS picture archiving and communication systems TGF transforming growth factor
PCA patient-controlled analgesia TFCC triangular fibrocartilaginous complex
PCL posterior cruciate ligament TFN trochanteric femoral nail
PDGF platelet-derived growth factor Ti-15Mo titanium molybdenum
PDLLA poly-D, L-lactide TLSO thoracolumbosacral orthosis
PDS polydioxanone TNF- α tumor necrosis factor α
PE pulmonary embolism TRAP triceps-reflecting anconeus pedicle
PEEK polyetheretherketone TTWB touch toe weight bearing
PEG polyethylene glycol TXA tranexamic acid
PEKK polyetherketoneketone UHMWPE ultra-high molecular weight polyethylene
PEP pulmonary embolism prevention UHN unreamed (solid) humeral nail
PET positron emission tomography USP United States Pharmacopocia
PET-CT positron emission tomography combined with computerized tomography USS universal spine system
PFN proximal femoral nail UTN unreamed tibial nail
PFNA proximal femoral nail antirotation VAC vacuum-assisted wound closure, also called negative-pressure wound therapy (NPWT)
PGA polyglycolic acid VAS Visual Analog Scale
PHILOS proximal humerus internal locked system VEGF vascular endothelial growth factor
PHN proximal humeral nail VTE venous thromboembolism
PLA polylactic acid WBAT weight bearing as tolerated
PLGA polyglycolides WBCT whole-body computed tomography (for trauma)

XIII

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 Online AO Educational Content

Online AO Educational Content

Abundant online educational offerings from across AO are

accessible through the QR codes printed on each chapter title
page. Using a QR code scanner on a mobile device, readers
will be taken to specific chapter microsites that contain not
only the Videos and Fig/Animations for each chapter, but also
supplemental AO educational content curated by the book
editors specifically for that chapter topic.

Links to supplemental AO educational content include:

• AO Surgery Reference
• AO Skills Lab
• AOSTaRT
• Webinars and webcasts
• Lectures
• Teaching videos
• eLearning modules
• Mobile apps
• ICUC cases

As the array of online AO educational resources evolves and

develops, the offerings in the chapter microsites will be
­regularly reviewed and updated by the book editors. This will
ensure that readers are linked to the latest in AO education.

XIV AO Principles of Fracture Management—Third Edition  Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

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 XV

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 Table of contents

Front matter Reduction, approaches, and fixation techniques

Reduction and approaches

Foreword V

Introduction VI 3.1.1 Surgical reduction 117

Rodrigo Pesantez
Acknowledgments VII
3.1.2 Approaches and intraoperative handling 137
Contributors VIII
of soft tissues
Abbreviations XII Ching-Hou Ma

Online AO Educational Content XIV 3.1.3 Minimally invasive osteosynthesis 149

Reto Babst

Techniques of absolute stability

Volume 1–Principles
3.2.1 Screws 173
Wa’el Taha

3.2.2 Plates 185

AO philosophy and basic principles
Mark A Lee

1.1 AO philosophy and evolution 3 3.2.3 Tension band principle 209
Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul Markku Nousiainen

1.2 Biology and biomechanics in bone healing 9

Techniques of relative stability
Boyko Gueorguiev-Rüegg, Martin Stoddart

1.3 Implants and biotechnology 27 3.3.1 Intramedullary nailing 217

Geoff Richards Martin H Hessmann

1.4 Fracture classification 39 3.3.2 Bridge plating 241

James F Kellam Friedrich Baumgaertel

1.5 Soft-tissue injury: pathophysiology, evaluation,  51 3.3.3 External fixator 253
and classification  Dankward Höntzsch
Brian Bernstein
3.3.4 Locking plates 269
Christoph Sommer

Decision making and planning

2.1 The patient and the injury: decision making 73

in trauma surgery
Christopher G Moran

2.2 Diaphyseal fractures: principles 83

Piet de Boer

2.3 Articular fractures: principles 93

Chang-Wug Oh

2.4 Preoperative planning 105

Matthew Porteous

XVI AO Principles of Fracture Management—Third Edition  Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

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Table of contents

General topics Complications

4.1 Polytrauma: pathophysiology, priorities, 311 5.1 Malunion 493

and management Mauricio Kfuri
Peter V Giannoudis
5.2 Aseptic nonunion  513
4.2 Open fractures 331 R Malcolm Smith
Rami Mosheiff
5.3 Acute infection  529
4.3 Soft-tissue loss: principles of management 357 Olivier Borens, Michael S Sirkin
Yves Harder
5.4 Chronic infection and infected nonunion  547
4.4 Pediatric fractures 379 Stephen L Kates, Olivier Borens
Theddy Slongo, James Hunter

4.5 Antibiotic prophylaxis 421

Susan Snape

4.6 Thromboembolic prophylaxis 429

Hans J Kreder

4.7 Postoperative management: general  437

considerations
Liu Fan, John Arraf

4.8 Fragility fractures and orthogeriatric care 451

Michael Blauth, Markus Gosch, Thomas J Luger,
Hans Peter Dimai, Stephen L Kates

4.9 Imaging and radiation hazards 481

Chanakarn Phornphutkul

XVII

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 Table of contents

Volume 2–Specific fractures

Scapula and clavicle Femur and periprosthetic fractures

6.1.1 Scapula  565 6.6.1 Femur, proximal 773

Michael McKee Rogier KJ Simmermacher

6.1.2 Clavicle 573 6.6.2 Femur, shaft (including subtrochanteric fractures) 789
Ernest Kwek Zsolt J Balogh

6.6.3 Femur, distal 815

Humerus
Jong-Keon Oh

6.2.1 Humerus, proximal 587 6.6.4 Periprosthetic fractures 837

Chunyan Jiang Michael Schütz

6.2.2 Humerus, shaft 607

Knee
John Williams

6.2.3 Humerus, distal 623 6.7.1 Patella 853

David Ring Mahmoud M Odat

6.7.2 Knee dislocations 865

Forearm and hand
James Stannard

6.3.1 Proximal forearm and complex elbow injuries 637

Tibia
Stefaan Nijs

6.3.2 Forearm, shaft 657 6.8.1 Tibia, proximal 877

John T Capo Luo Cong-Feng

6.3.3 Distal radius and wrist 673 6.8.2 Tibia, shaft 899
Matej Kastelec Paulo Roberto Barbosa de Toledo Lourenço

6.3.4 Hand 699 6.8.3 Tibia, distal intraarticular (pilon) 913

Douglas A Campbell Sherif A Khaled

Pelvis and acetabelum Malleoli and foot

6.4 Pelvic ring 717 6.9 Malleoli 933

Daren Forward David M Hahn, Keenwai Chong

6.5 Acetabulum 745 6.10.1 Hindfoot—calcaneus and talus 961

Jorge Barla Richard E Buckley

6.10.2 Midfoot and forefoot 983

Mandeep S Dhillon

Appendix

Glossary A1
Christopher L Colton, Christopher G Moran

Index A15

XVIII AO Principles of Fracture Management—Third Edition  Richard E Buckley, Christopher G Moran, Theerachai Apivatthakakul

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