Mich a e l Wa gn e r, Ro b e r t Frigg

Rich a rd Bu ckle y
Em a n u e l Ga u tie r
Mich a e l Sch ü t z
AO Ma n u a l o f Fractu re Man a ge m e n t
Ch ris to p h So m m e r

In te rnal Fixators
Conce p ts and Case s u sing LCP and LISS

Vid e o s a n d a n im a t io n s o n DVD- ROM in clu d e d

AO Manual of Fracture Manage m e nt

Michae l Wagne r, Robe rt Frigg

Inte rnal Fixators

Conce pts and Case s using LCP and LISS
AO Manual of Fracture Manage m e nt

Michae l Wagne r, Robe rt Frigg

Inte rnal Fixators

Conce pts and Case s using LCP and LISS

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Ha za rd s
Gre a t ca re h a s b e e n ta ke n to m a in ta in th e a ccu racy o f th e in fo rm a tio n co n ta in e d in th is p u b lica tio n . Ho we ve r, th e p u b lish e r, a n d / o r th e d istrib u to r, a n d / o r th e e d ito rs, a n d / or the
a u th o rs ca n n o t b e h e ld re sp o n sib le fo r e rro rs o r a n y co n se q u e n ce s arisin g fro m th e u se o f th e in fo rm a tio n co n ta in e d in th is p u blica tio n. Co n trib u tio n s p u b lish e d u n d e r th e n a m e
o f ind ivid u a l a uth o rs a re sta te m e nts a n d o p in io n s so le ly o f sa id a uth o rs an d n o t o f th e p u b lish e r, a n d / o r the d istrib u to r, a n d / o r the AO Gro u p .
Th e p ro d u cts, p ro ce d u re s, a n d th e rap ie s d e scrib e d in th is wo rk a re h a zard o u s a n d a re th e re fo re o n ly to b e a p p lie d b y ce rtifie d a n d tra in e d m e d ica l p ro fe ssio n a ls in e n viro n m e n ts
sp e cially d e sign e d fo r su ch p ro ce d u re s. No su gge ste d te st o r p ro ce d u re sh o u ld b e ca rrie d o u t u n le ss, in th e u se r‘s p ro fe ssio n a l ju d gm e n t, its risk is ju stifie d . Wh o e ve r ap p lie s
p ro d u cts, p ro ce d u re s, a n d th e ra p ie s sh o wn or d e scrib e d in th is wo rk will d o th is a t th e ir o wn risk. Be ca use o f ra p id a d van ce s in th e m e d ical scie n ce s, AO re co m m e nd s th a t
ind e p e n d e n t ve rifica tion o f d ia gn o sis, th e ra p ie s, d ru gs, d o sage s, a n d o p e ra tio n m e th o d s sh ou ld b e m a d e b e fo re a n y a ctio n is ta ke n .
Alth o u gh all a d ve rtisin g m a te rial w hich m a y b e in se rte d in to th e wo rk is e xp e cte d to co n fo rm to e th ical (m e d ica l) sta n d a rds, in clu sio n in th is p u b lica tio n d o e s n o t co n stitu te a
gu a ra n te e o r e n d o rse m e n t b y th e p u b lish e r re ga rd in g q u a lity o r va lu e o f su ch p ro d u ct o r o f th e cla im s m a d e o f it b y its m a n u fa ctu re r.

Le ga l re strictio n s
Th is wo rk wa s p ro d u ce d b y AO Pu b lish in g, Da vo s, Switze rla n d . All righ ts re se rve d b y AO Pu b lish in g. Th is p u b lica tio n , in clu d in g a ll p a rts th e re o f, is le gally p ro te cte d b y co p yrigh t.
Any u se , e xp lo ita tio n or co m m e rcia liza tio n o u tsid e the n a rrow lim its se t fo rth by co p yrigh t le gisla tio n a n d the re strictio n s on u se la id o u t b e lo w, with o u t th e p u b lish e r‘s co n se n t, is
ille ga l a n d lia ble to p ro se cu tio n . Th is a p p lie s in pa rticu la r to p h o to sta t re p ro d u ctio n , co p yin g, sca n n in g o r du p lica tio n o f a ny kind , tran sla tio n , p re pa ra tio n o f m icro film s, e le ctro n ic
d a ta p ro ce ssin g, a n d stora ge su ch a s m a kin g th is pu b lica tio n a va ila b le o n In tran e t o r In te rn e t.
So m e o f th e p ro d u cts, n a m e s, in stru m e n ts, tre a tm e n ts, lo go s, d e sign s, e tc. re fe rre d to in th is p u b lica tio n a re a lso p ro te cte d b y p a te n ts a n d tra de m a rks o r b y o th e r in te lle ctu al
p ro p e rty p ro te ction la ws (e g, ”AO”, ”ASIF”, ”AO/ ASIF”, ”TRIANGLE/ GLOBE Lo go ” a re re giste re d tra d e m a rks) e ve n th o ugh sp e cific re fe re n ce to th is fa ct is n o t a lwa ys m a d e in th e
te xt. Th e re fo re , th e a p p e a ran ce o f a n a m e , in stru m e n t, e tc. with o u t d e sign a tio n as p ro p rie ta ry is n o t to b e co n stru e d a s a re p re se n ta tio n b y th e p u b lish e r th at it is in th e p u b lic
d o m a in .
Re strictio n s o n u se : Th e righ tfu l o wn e r o f a n a uth o rize d co p y o f th is wo rk m a y use it fo r e d u ca tio n a l a n d re se a rch p u rp o se s o nly. Sin gle im a ge s o r illu stra tio n s m a y b e co p ie d for
re se a rch o r e d u ca tio n a l p u rp o se s o n ly. Th e im a ge s o r illu stra tio n s m a y n o t b e a lte re d in a ny wa y a n d ne e d to ca rry th e fo llo win g sta te m e n t o f o rigin ”Co p yrigh t b y AO Pu b lish in g,
Sw itze rla n d ”.

Co p yrigh t © 2 0 0 6 b y AO Pu b lish in g, Switze rla n d , Cla vad e le rstra sse 8 , CH-7270 Da vo s Pla tz
Distrib u tio n b y Ge o rg Th ie m e Ve rla g, Rü d ige rstra sse 14 , DE-70 4 6 9 Stu ttga rt a n d
Th ie m e Ne w Yo rk, 333 Se ve n th Ave n u e , Ne w Yo rk, NY 10 0 01, USA

Re st o f Wo rld Th e Am e rica s
ISBN 978 -3 -13 -143551-4 ISBN 978 -1-5 8 8 9 0 -4 8 6 -7 234 56

iv
Table of conte nts

Co n ce p t s Ca s e s

1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s 5 Sh o u ld e r gird le

1 Os t e o s yn t h e s is 3 5 .1 Cla vicle 18 5
2 Co n ce p t s o f fra ct u re fixa t io n 10 5 .2 Sca p u la 213
3 Me ch a n ica l a s p e ct s o f p la t e a n d s cre w fixa t io n 21
4 De ve lo p m e n t o f in t e rn a l fixa t o rs 31
6 Hu m e ru s
5 Me t h o d s a n d t e ch n iq u e s in p la t e o s t e o s yn t h e s is 41
6 .1 Hu m e ru s , p ro xim a l 223
6 Min im a lly in va s ive p la t e o s t e o s yn t h e s is (MIP O) 48
6 .2 Hu m e ru s , s h a ft 283
7 Bib lio gra p h y 54
6 .3 Hu m e ru s , d is t a l 3 31
2 Su rgica l re d u ct io n t e ch n iq u e s
1 Aim o f re d u ct io n 59 7 Ra d iu s a n d u ln a
2 Diffe re n t t yp e s o f s u rgica l re d u ct io n 60 7.1 Ra d iu s a n d u ln a , p ro xim a l 365
3 In s t ru m e n t s a n d t e ch n iq u e s 69 7.2 Ra d iu s a n d u ln a , s h a ft 399
4 As s e s s m e n t o f re d u ct io n 81 7.3 Ra d iu s a n d u ln a , d is t a l 419
5 Co n clu s io n s 85
6 Bib lio gra p h y 85
8 Pe lvic rin g a n d a ce t a b u lu m
3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
8 .1 Pe lvic rin g a n d a ce t a b u lu m 453
1 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS) 87
2 Th e lo ck in g co m p re s s io n p la t e (LCP) 12 5
9 Fe m u r
3 Bib lio gra p h y 15 9
9 .1 Fe m u r, p ro xim a l 47 7
4 P it fa lls a n d co m p lica t io n s
9 .2 Fe m u r, s h a ft 515
1 Im p la n t -re la t e d p ro b le m s 16 3 9 .3 Fe m u r, d is t a l 559
2 Te ch n ica l e rro rs 16 4
3 Pit fa lls a n d co m p lica t io n s d u rin g re h a b ilit a t io n 171
10 Tib ia a n d fib u la
4 Su gge s t io n s fo r fu r t h e r re a d in g 17 9
10 .1 Tib ia a n d fib u la , p ro xim a l 622
10 .2 Tib ia a n d fib u la , s h a ft 684
10 .3 Tib ia a n d fib u la , d is t a l 779

11 Ca lca n e u s
11.1 Ca lca n e u s 843

v
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vi
Fore words
Th o m a s P Rü e d i
For alm ost 4 0 years AO com pression plate xation providin g
absolu te stability—as in trodu ced by Mau rice Mü ller—was th e
gold stan dard in operative fractu re treatm en t. In th e 1980s
th e lock in g in tram edu llary n ail open ed u p n ew perspectives
for th e stabilization of d iaph yseal fractu res. As an in tern al
splin t th is device provides relative stability, wh ich allow s
rapid fractu re h ealin g w ith abu n dan t callu s form ation . Perren
an d Tepic sh owed in th e early n in eties th at, th an ks to lockin g
h ead screw s (LHS) provid in g an gu lar stability, th e lon gitu d i-
n al stabilizer, eg, a plate cou ld be kept at a d istan ce from th e
bon e sim ilar to th e extern al xator an d w ith ou t in terferin g
w ith periosteal or cortical vascu larity. Th is in n ovative, qu ite
d ifferen t an d biologically gen tle as well as less in vasive xa-
tion prin ciple was called “in tern al xation ”. Clin ically, it was
applied as th e PC-Fix (poin t con tact xator) an d LISS (less
in vasive stabilization system).
Th e actu al breakth rou gh for th e n ew in tern al xator prin -
ciple occu rred h owever, wh en M ich ael Wagn er as clin ician ,
togeth er w ith th e en gin eer Robert Frigg, design ed an d de-
veloped th e so-called “com bin ation h ole”. Th e idea an d n ew
design of th e screw h ole—a com bin ation of th e dyn am ic com -
pression u n it for stan dard cortex screw s w ith a th readed h ole
for th e LHS—cou ld be in trodu ced in an y of th e ex istin g plates
an d requ ired on ly a few addition al in stru m en ts. Th e n ew an d
very versatile lock in g com pression plate system —LCP—w ith
its th ree d ifferen t possibilities of application s an d fu n ction s
fou n d im m ed iately w ide acceptan ce an d h as revolu tion ized
operative fractu re xation in a sim ilar way to th e origin al
com pression plate an d twen ty years later th e in terlock in g in -
tram edu llary n ail.
It seem ed th erefore logical th at M ich ael Wagn er sh ou ld also
pion eer th e collection of LCP an d LISS cases for a book th at
add resses n ot on ly th e basic prin ciples, attribu tes, an d differ-
en t application s of th e n ew im plan ts bu t also h igh ligh ts th e
pearls an d pitfalls of th e in tern al xators in th e clin ic. To-
geth er w ith th e con tribu tion s of oth er en thu siastic bu t also
critical u sers th e au th ors sh are ex perien ces w ith th ese devices
an d gives valu able, practical recom m en dation s to n ewcom ers.
Th e best stabilization system is of little u se if th e vascu lar ity
of th e soft as well as h ard tissu es are n ot carefu lly respected.
An en tire ch apter h as th erefore been ded icated to th e m ost
dif cu lt an d dem an din g ch allen ges of an y fractu re treat-
m en t—th e fractu re redu ction .
Th e ed itors, M ich ael Wagn er an d Robert Frigg, an d th e co-
au th ors h ave to be com plim en ted for a m ost com preh en sive
an d attractive book on th e clin ical application s of th e n ew
in tern al xator prin ciples w ith th e LISS an d LCP, w h ich are
in trodu cin g in terestin g possibilities a n d opportu n ities espe-
cially in articu lar fractu res as well as provid in g n ew h opes for
severely osteoporotic patien ts.
Th e team at AO Pu blish in g h as again d isplayed its ability to
produ ce, togeth er w ith Th iem e Verlag, a m ost attractive book
th at w ill n d n u m erou s readers an d th ereby h elp to im prove
patien t care.
Th om as P Rü ed i, M D, FACS
Fou n d in g Mem ber of th e AO Fou n dation
Davos, April 2006
vii
 St e p h a n M Pe rre n
Fractu re treatm en t h as u n dergon e a fascin atin g evolu tion .
Early in th e last cen tu r y th e m ain goal of treatm en t was to
reach solid u n ion . Th en stable xation an d fu n ction al post-
operative treatm en t su ccessfu lly elim in ated fractu re d isease.
Now we can take advan tage of restorin g fu n ction wh ile in -
du cin g prom pt an d safe h ealin g an d redu cin g th e r isk of bio-
logical com plication s.
In th e early days th e excessive extern al im m obilization of
th e n eigh borin g articu lation s too often resu lted in dam age to
th e ar ticu lation s an d even worse to th e soft tissu es an d blood
su pply. In m y ow n “pre AO” ex perien ce I obser ved a h igh
in ciden ce of w h at was later called fractu re d isease (Su deck’s
or re ex dystroph y). Swellin g, pain , patch y bon e loss, a n d
stiff articu lation s were accepted as th e n atu ral con sequ en ce
of fractu re. It is in terestin g to n ote th at each gen eration was
(an d is!) blin ded by th e “state-of-th e-art”.
In th e late fties th e vision ar y Mau rice E Mü ller an d h is
colleagu es effected a worldw ide ch an ge in th e gh t again st
fractu re d isease. Th ey stu d ied an d advocated precise redu c-
tion an d com pression xation so th at fractu re h ealin g cou ld
take place in a m ech an ically n eu tral en viron m en t. Dystroph y
becam e a ver y rare in ciden t an d fractu re h ealin g sh owed a
fascin atin g h istology: direct h ealin g. Th e pr ice paid for focu s-
in g on m ech an ical advan tages was th at th is approach did n ot
in du ce early h ealin g an d so im plan ts cou ld n ot be rem oved
earlier th an on e to two years postoperatively. Th is was n ot
a m ajor problem in view of th e fact th at th e im plan ts were
m ech an ically protectin g th e fractu re. Still, th e observation of
late u n ion was a stron g in d icator th at th ere was room for im -
provem en t. Con siderable dam age to th e soft tissu es an d blood
su pply to bon e in th e h an ds of th e less ex perien ced resu lted
in com plication s du e to a d isregard for biology.
viii
Th e prom oters of stable in tern al xation h ad to face h arsh
criticism , m ain ly focu sed on th e com plication s of su ch treat-
m en t like in fection s an d refractu res. A close collaboration
in clu d in g clin ical in pu t, docu m en tation , biom ech an ical re-
search , an d basic developm en t allowed th e AO to overcom e
th ese d if cu lties by de n in g th e prin ciples of treatm en t an d
offerin g th orou gh teach in g.
From th e ou tset less stable xation like th e m ore exible ver-
sion of th e in tram edu llary n ail an d also extern al xators,
both resu ltin g in in direct h ealin g, were in tegral parts of th e
AO tech n ology. Bu t it took a lon g tim e to am algam ate obser-
vation s of biological reaction s to th e m ore exible tech n iqu es
an d observation s relatin g to com pression platin g. As always,
som e ideas were n ot n ew ; we m en tion th e basic con tribu tion s
to com pression tech n ology by Lam botte an d Dan is an d th ose
of Kü n tsch er to n ailin g. Still, to brin g a n ew m eth od to bear
on a large scale n ot on ly requ ires in n ovative an d sou n d ideas
an d in gen iou s in dividu al su rgical skill, bu t also an in tegrat-
ed approach to im provem en t an d teach in g to allow oth ers to
ach ieve sim ilar resu lts.
In th e late eigh t ies w h ile stu dyin g th e poten t ia l of in ter n a l
xators t h e tea m of t h e AO Resea rch In st itu te ca m e across
a m ore ex ible plate xat ion t h at took adva n t age of locked
screw s. Th e poin t con t act xator (PC-Fix), w h ich is th e proof
of con cept of t h e in ter n a l xator, w as bor n . An im a l stu d ies
sh owed a n aston ish in g ea rly solid br idgin g of t h e fract u res
(10 weeks) a n d good loca l resist a n ce to in fect ion . Fu r t h er-
m ore, t h e oppor tu n it y to t a ke adva n t age of m on ocor t ica l
t h readed bolts w as dem on strated. Clin ica l stu d ies w it h ex-
cept ion a lly h igh follow-u p sh owed low com plication rates
in respect to in fect ion (Norber t P Haas, Alber to Fer n a n dez).
Histor y repeats itself as a r u le: aga in th ere were pion eers:
Boitzy, Weber, a n d Heitem eyer (br idge plat in g) a n d we a lso
pay tr ibu te to Gra n ow sk i (Zespol xator). It took 4 0 yea rs
from t h e rst br idge plates a n d n ea rly t wen t y yea rs from
su ccessfu l u se of th e PC-Fix for t h e adva n t ages of th e in ter-
n a l xator to be gen era lly accepted. Th e d ifferen ce bet ween
“m e too” a n d leadersh ip is rooted in basic in sigh t a n d ea rly
com m it m en t.
A n ew era star ted w ith great respect to biology: th e era of th e
in tern a l xator. In sisten ce on precise redu ction was replaced
by restr ictin g th e aim of su rger y to adequ ate a lign m en t to
restore th e or igin a l relative position s of th e two join t bear-
in g su rfaces of th e lon g bon e. Approx im ate align m en t w ith -
ou t tou ch in g th e in ter m ed iate fragm en ts beca m e acceptable.
Th e m a in in gred ien ts for su ccessfu l in ter n a l xator tech n ol-
ogy still are su f cien t stability for early fu n ction a l treatm en t
an d, n ow, su f cien t in stability for th e in du ction of prom pt
h ea lin g. Th e stra in th eor y a llowed de n ition of th e degree of
in stability w h ich is tolerated an d th e degree w h ich in du ces
h ea lin g.
Wh e n t h e bo n e is d e ad an d /o r in fe ct e d as a re su lt o f t h e
accid e n t (an d h o p e fu lly n o t o f t h e su rge ry) t h e re is a
cle ar in d icat io n fo r go o d re d u ct io n an d abso lu t e st abil-
it y an d sim ilarly p re cise re d u ct io n an d abso lu t e st abil-
it y is a re qu ire m e n t fo r in t raart icu lar fract u re s!
Livin g bon e is able to react on ce it is given th e ch an ce to do so.
Creatin g th e proper biological an d m ech an ical en viron m en t
is th e prerequ isite. Th e fu tu re w ill sh ow w h eth er add ition al
stim u lation offers an advan tage for fresh fractu res. On e m ay
qu estion wh eth er stim u lation w ill be tolerated w ith ou t cau s-
in g dam age in desperate clin ical cases su ch as ch ron ic an d
in fected n on u n ion s. Let’s n ot forget th at it took su pern atu ral
power to revive Lazaru s, in oth er words, I th in k th at stim u -
latin g n early dead cells is equ ally ch allen gin g.
With ou t perfect closu re of th e fractu re gap it is n ow possible to
follow th e repair process w ith in th e gap rad iologically. We can
n ow pin poin t th ose cases th at requ ire th e lon g-term presen ce
of th e im plan t to avoid refractu re. Som e of th e ob-servation s of
delayed h ealin g are n ot an in dication of less satisfactory h eal-
in g, bu t th ey are a con sequen ce of im proved visu alization .
Wh ile th e LISS is a fu rth er re n em en t of th e PC-Fix, th e LCP
com bin es a str ipped version of both th e LC-DCP an d PC-Fix
w ith a th readed con ical lockin g system to redu ce jam m in g
at rem oval. Th e LCP offers a con ven ien t way of m ak in g th e
tran sition from con ven tion al com pression tech n iqu es to th e
in tern al xator. As th e two prin ciples of plate screw s, n am ely,
screw s th at press th e plate to th e bon e an d th ose th at keepin g
th e plate elevated are in com patible, it is advisable to exercise
d isciplin e an d n ot to m ix th ese prin ciples in th e sam e bon e
fragm en t. Th is is also a ch allen ge for teach in g.
In view of th e basic ch an ges brou gh t abou t by th e in tern al
xator, it is of great m er it th at th e in itial ch apter of th is book
d iscu sses th e basics of th e prin ciples. M ich ael Wagn er h as u n -
dertaken w ith su ccess th e task of ex plain in g th e practical as-
pects of th e basic con cepts.
Th e book m ay be u n derstood as a tech n ical m an u al bu t, far
m ore, it is offerin g a basic u n derstan din g. Th is is an im portan t
aspect in view of th e fact th at th e im plan t re ects on ly th e m e-
ch an ical aspect of th e realization of th e in tern al xator ph i-
losoph y; balan cin g biology again st pu re m ech an ics in volves
th e im plan ts an d th e su rgeon s. Th e statem en t of Gird leston e
“rath er garden in g th an replacem en t” is u p-to-date.
ix
 Th e secon d ch apter of th e book deals w ith basic clin ical as-
pects; n am ely redu ction of th e fractu re as a prerequ isite to
su ccessfu l in tern al xation . Wh en read in g th is ch apter on e
is tem pted to add to Gird leston e w ith “rath er elegan t su rgical
tech n iqu e th an bru te force”.

Th e ch apters on LISS an d LCP are actu ally tech n ical m an u -

als, “h ow to do it”. With great care th e sequ en tial steps of th e
in tern al xation , th e special ch aracteristics of th e im plan ts
an d, for in stan ce, th e im portan ce of large span bridgin g an d
atten tion to screw leverage u sin g lon g plates are ex plain ed.

Th e last ch apter add resses th e possible errors, “wh at n ot to

do” an d special procedu res if d if cu lties arise.

I h ope th e reader en joys th is com preh en sive book—th is “ rst

sh ot” as m u ch as I h ave don e.

Steph an M Perren , Prof. Dr. m ed. D.Sc. (h .c.)

Davos, April 2006

x
Contributors

Ed it o r Au t h o rs

M ich ael Wagn er, Un iv.-Prof. Dr. m ed. Martin Altm an n An dré Fren k, Dr.
Fach arzt fü r Un fallch iru rgie u n d Syn th es Bettlach Syn th es Bettlach
Sporttrau m atlogie Gü terstrasse 5 Gü terstrasse 5
Wilh elm in en spital CH-254 4 Bettlach CH-254 4 Bettlach
Mon tleartstrasse 37
AT-1160 Wien Reto Babst, Prof. Dr. m ed. M ich ael J Gard n er, M D
Kan ton sspital Lu zern Corn ell Un iversity Med ical College
Robert Fr igg Un fallch iru rgie Hospital for Special Su rgery
Ch ief Tech n ology Of cer Spitalstrasse 535 East 70th Street
Syn th es Bettlach CH-6000 Lu zern 16 US-New York NY 10021
Gü terstrasse 5
CH-254 4 Bettlach Herm an n Bail, PD Dr. m ed. Ch ristoph W Geel, M D, FACS
Klin ik fü r Un fall- u n d Su ny Upstate Med ical Un iversity
Wiederh erstellu n gsch iru rgie Health Scien ce Cen ter
Co e d it o rs Cam pu s Virch ow - Klin iku m (CVK) Orth opaed ic Trau m a
Au gu sten bu rger platz 1 550 Harrison Cen tre, Ste 100
DE-13353 Berlin US-Syracu se NY 13202
Rich ard Bu ck ley, M D, FRCS(c)
Un iversity of Calgar y
Peter Bru n n er An dreas Gru n er, Dr. m ed.
Footh ills Med ical Cen ter
Syn th es Bettlach Un fallch iru rgisch e Klin ik
1403-29 Street N.W.
Gü terstrasse 5 Städtisch es Klin iku m Brau n sch weig
CA-Calgary AB T2N 2T9
CH-254 4 Bettlach Holwedestrasse 16
DE-38118 Brau n sch weig
Em anu el Gau tier, PD Dr. m ed.
Ulf Cu lem an n , Dr. m ed.
Hôpital Can ton al Fribou rg
Klin ik fü r Un fall-, Han d- u n d Norbert P Haas, Un iv.-Prof. Dr. m ed.
Clin iqu e de ch iru rgie orth opéd iqu e
Wiederh erstellu n gsch iru rgie Klin ik fü r Un fall- u n d
CH-1708 Fribou rg
Un iversitätsklin iku m des Saarlan des Wiederh erstellu n gsch iru rgie
Kirrberger Strasse Cam pu s Virch ow - Klin iku m (CVK)
M ich ael Sch ü tz, Prof. Dr. m ed.
DE-66 421 Hom bu rg/ Saar Au gu sten bu rger platz 1
Prin cess Alexan d ra Hospital (PAH)
DE-13353 Berlin
2 George Street
Ch ristoph er G Fin kem eier, M D
GPO Box 2434
5897 Gran ite Hills Drive David L Helfet, M D, M BCHB
AU-Brisban e 4 001
US-Gran ite Bay CA 95746 Corn ell Un iversity Med ical College
Hospital for Special Su rgery
Ch ristoph Som m er, Dr. m ed.
535 East 70th Street
Kan ton spital Chu r
US-New York NY 10021
Loëstrasse 170
CH-7000 Ch u r

xi
 Au t h o rs (co n t)
Th om as Hockertz, Dr. m ed.
Un fallch iru rgisch e Klin ik
Städtisch es Klin iku m Brau n sch weig
Holwedestrasse 16
DE-38118 Brau n sch weig
Keita Ito, Prof., M D, ScD
AO Research In stitu te
Clavadelerstrasse 8
CH-7270 Davos Platz
Rolan d P Jakob, Prof. Dr. m ed.
Hôpital Can ton al Fribou rg
Clin iqu e de ch iru rgie orth opéd iqu e
CH-1708 Fribou rg
Georges Kohu t, Dr. m ed.
Hôpital Can ton al Fribou rg
Clin iqu e de ch iru rgie orth opéd iqu e
CH-1708 Fribou rg
Ph ilip J Kregor, M D
Van derbilt Orth opaed ic In stitu te
Med ical Cen ter East
Sou th Tower, Su ite 4200
US-Nash ville TN 37232-8774
Ch ristian Krettek, Prof. Dr. m ed.
Han n over Med ical Sch ool (M HH)
Carl-Neu berg-Str. 1
DE-30625 Han n over
Fran k ie Leu n g, M D, FRCS
Qu een Mar y Hospital
Pok Fu Lam
HK-Hon g Kon g
xii
Wilson Li, M D Steph an M Perren , Prof. Dr. m ed.
Departm en t of Orth opaedics D.Sc. (h .c.)
an d Trau m atology Sen ior Scien ti c Advisor
Qu een Elizabeth Hospital Disch m astrasse 22
30, Gascoign e Road CH-7260 Davos Dorf
HK-Kow loon , Hon g Kon g
M ich ael Plecko, M D
Dean G Lorich , M D Un fallkran ken h au s Graz
Corn ell Un iversity Med ical College Göstin gersstrasse 24
Hospital for Special Su rgery AT-8021 Graz
535 East 70th Street
US-New York NY 10021 Tim Poh lem an n , Prof. Dr. m ed.
Klin ik fü r Un fall,- Han d- u n d
Marc Lotten bach , Dr. m ed. Wiederh erstellu n gsch iru rgie
Hôpital Can ton al Fribou rg Un iversitätsklin iku m des Saarlan des
Clin iqu e de ch iru rgie orth opéd iqu e Kirrberger Strasse
CH-1708 Fribou rg DE-66421 Hom bu rg
In go Melch er, Dr. m ed. Hein rich Reilm an n , Prof. Dr. m ed.
Klin ik fü r Un fall- u n d Un fallch iru rgisch e Klin ik
Wiederh erstellu n gsch iru rgie Städtisch es Klin iku m Brau n sch weig
Cam pu s Virch ow - Klin iku m (CVK) Holwedestrasse 16
Au gu sten bu rger platz 1 DE-38118 Brau n sch weig
DE-13353 Berlin
Dan iel A Rik li, Dr. m ed.
Er ika J M itch ell, M D Un fallch iru rgie
Van derbilt Orth opaed ic In stitu te Kan ton sspital Lu zern
Med ical Cen ter East Spitalstrasse
Sou th Tower, Su ite 4200 CH-6000 Lu zern 16
US-Nashville TN 37232-8774
Th om as P Rü ed i, Prof. Dr. m ed., FACS
Th om as Neu bau er, Dr. m ed. AO In tern ation al
Un fallch iru rgie Clavadelerstrasse 8
Wilh elm in en spital CH-7270 Davos Platz
Mon tleartstrasse 37
AT-1160 Wien
 Au t h o rs (co n t)
Ch ristian Ryf, M D
Clin ic for Su rger y an d Orth opaed ics
Davos Hospital
Prom en ade 4
CH-7270 Davos Platz
Klau s-D Sch aser, Dr. m ed.
Klin ik fü r Un fall- u n d
Wiederh erstellu n gsch iru rgie
Cam pu s Virch ow - Klin iku m (CVK)
Au gu sten bu rger platz 1
DE-13353 Berlin
Robert Sch avan , Dipl.-In g.
Barsch bleek 8
DE-47877 Willich
Jam es P Stan n ard, M D
Un iversity of Alabam a at
Birm in gh am
Division of Orth opaed ic Su rger y
950-B Facu lty Of ce Tower
510 20th Street Sou th
US-Birm in gh am AL 35294-34 09
M ich ael D Stover, M D
Loyola Un iversity Med ical Cen ter
Departm en t of Orth opaed ic Su rgery
2160 Sou th 1st Avenu e
US-Maywood IL 60153
Gabriele Streich er, Dr. m ed.
Un fallch iru rgisch e Klin ik
Städtisch es Klin iku m Brau n sch weig
Holwedestrasse 16
DE-38118 Brau n sch weig
Norbert Sü d kam p, Prof. Dr. m ed.
Un iversitätsklin ik Freibu rg i.Br.
Klin ik fü r Un fall- u n d
Wiederh erstellu n gsch iru rgie
Hu gstetterstrasse 55
DE-79106 Freibu rg i.Br.
Hobie D Su m m ers, M D
Loyola Un iversity Med ical Cen ter
Departm en t of Orth opaedic Su rger y
2160 Sou th 1st Avenu e
US-Maywood IL 60153
Ron ald J van Heer waarden , M D, Ph D
Sin t Maarten sklin iek
Hen gstdal 3
NL-6522 J V Nijm egen
Han s Zw ipp, Prof. Dr. m ed.
Un iversitätsklin iku m
Carl Gu stav Caru s
Klin ik fü r Un fall- u n d
Wiederh erstellu n gsch iru rgie
Fetsch erstrasse 74
DE-01307 Dresden
xiii
 Introduction
Mich a e l Wa gn e r
From th e ver y ou tset, th e goal of th e Arbeitsgem ein sch aft
fü r Osteosyn th ese (AO) h as been to im prove th e treatm en t of
fractu res an d th eir sequ elae. Th e AO proposed th is by restor-
in g in tegrity to th e broken bon e an d provid in g th e patien t
w ith early an d pain -free restoration of fu n ction . Th e em ph a-
sis h as n ever been solely on bon e u n ion , bu t h as always in -
clu ded restoration of fu n ction —as im plied in th e AO’s m otto
“Life is m ovem en t, an d m ovem en t is life.”
“Fractu re disease” was an obstacle to h ealin g an d m obility,
an d its sym ptom s often em erged after prolon ged extern al
splin tin g, im m obilization in traction —con sistin g of ch ron ic
edem a, soft-tissu e atroph y, severe osteoporosis, th in n in g of
th e articu lar cartilage, severe join t stiffn ess, an d som etim es
ch ron ic region al pain syn drom es. Fractu re disease preven ted
patien ts from startin g active exercise at an early stage an d
delayed th e retu rn of fu n ction after bon e h ealin g. Th e in n o-
vative tech n iqu es in trodu ced by th e AO to com bat th is con -
d ition h ad to m eet h igh dem an ds. Fractu re redu ction h ad to
be an atom ical, an d th e xation h ad to be stable en ou gh to
elim in ate pain an d allow fu n ction al reh abilitation of th e lim b
w ith ou t th e risks of secon dar y d isplacem en t, delayed u n ion ,
n on u n ion , or deform ity. Th e stability produ ced by th e com -
pression m eth od of fractu re osteosyn th esis m et th ese requ ire-
m en ts; it was possible to start reh abilitation im m ediately after
th e operation , an d m ost plaster im m obilization tech n iqu es
becam e ou tdated.
Th e issu es th at h ave played an im portan t role in stim u latin g
progress h ave been ,
1) differen tiatin g between th e biological requ irem en ts of ar-
ticu lar an d lon g bon e fractu res;
2) greater recogn ition of th e im portan ce of th e type an d tim -
in g of treatm en t;
3) speci c assessm en t of in ju r y to th e soft-tissu e en velope;
4) an d atten tion to th e patien t’s in dividu al fu n ction al an d
ph ysiological requ irem en ts.
xiv
It is n ow accepted th at absolu te stability is m an datory on ly
for join t fractu res an d som e related fractu res—an d th en on ly
wh en it can be ach ieved w ith ou t dam age to th e blood su pply
an d soft tissu es. Fixation of th e d iaph ysis sh ou ld always take
accou n t of len gth , align m en t, an d rotation of th e lim b, an d
th e m eth ods of ch oice are splin tin g w ith an in tram edu llary
n ail or an in tern al xator to prom ote u n ion th rou gh callu s
form ation .
If plate osteosyn th esis is requ ired, tech n iqu es of m in im al ac-
cess an d xation are able to m in im ize in su lt to th e blood su p-
ply to th e bon e fragm en ts an d adjacen t soft tissu e. Th e xa-
tion of articu lar fractu res requ ires an atom ical redu ction an d
absolu te stability to en h an ce th e h ealin g of articu lar cartilage
an d m ake early m otion possible so th at good u ltim ate fu n c-
tion w ill en su e. Th e cu rren t prin ciple of preser vin g th e blood
su pply n eeds to be applied at every stage of fractu re m an -
agem en t—from in itial plan n in g to con solidation . Th e ch oice
of strategy an d im plan t depen ds on th e biological an d fu n c-
tion al dem an ds of th e fractu re an d sh ou ld be com patible w ith
th em .
An atom y, stability, biology, an d m obilization are still th e fou r
fu n dam en tal AO prin ciples today. However, th e im plication s
of th ese prin ciples h ave ch an ged in respon se to th e n din gs
con stan tly em ergin g from scien ti c in vestigation s an d clin ical
obser vation s. Progressive ch an ges in approach es an d m eth -
ods h ave been based on con tinu in g laboratory an d clin ical
research , w ith n ew d iscoveries lead in g to th e developm en t of
m an y n ew im plan ts an d in stru m en ts. Th e strategy of fractu re
xation w ith differen t prin ciples, m eth ods an d tech n iqu es of
in tern al an d extern al xation are dyn am ic, an d fu rth er ad-
van ces w ill con tinu e to be m ade.
Th e AO p rin cip le s
AO prin ciples THEN
Fractu re redu ction an d xation to restore an atom ical rela-
tion sh ips.
Stability th rou gh xation w ith com pression or splin tin g,
as requ ired by th e fractu re pattern an d th e in ju r y.
Preser vation of th e blood su pply to th e soft tissu es an d
bon e th rou gh carefu l h an d lin g an d gen tle redu ction tech -
n iqu es.
Early an d safe m obilization of th e area bein g treated an d
of th e patien t as a wh ole.
Th ese con cise prin ciples still em body th e AO ph ilosoph y of
patien t care. In today’s approach , th e em ph asis is still ver y
mu ch on th e fact th at m ain tain in g th e blood su pply to th e
soft tissu es an d bon e is th e m ost im portan t aspect of fractu re
care—so th at th e prin ciples cou ld also be restated as follow s:
AO prin ciples NOW
Atrau m atic redu ction an d xation tech n iqu es are m an da-
tor y. Redu ction of lon g bon es n eed n ot be an atom ical, bu t
in stead sh ou ld dem on strate ax ial align m en t w ith respect
to len gth an d torsion in th e d iaph ysis an d m etaph ysis.
An atom ical redu ction is m an dator y for in traarticu lar frac-
tu res to restore join t con gru en cy.
Appropriate stability of th e con stru ct h as to be establish ed.
Join t su rfaces requ ire an atom ical redu ction w ith absolu te
stability; th e m ajority of d iaph yseal fractu res can be treat-
ed w ith m eth ods th at provide relative stability (eg, in tra-
m edu llary or extram edu llary splin tin g).
Atrau m atic soft-tissu e tech n iqu e sh ou ld be u sed w ith ap-
propriate su rgical approach es.
Early active m obilization of th e patien t is ex pected as th e
xation con stru ct is stable en ou gh to allow postoperative
fu n ction al care.
A com preh en sive classi cation of lon g bon es h as h elped m ake
treatm en t ou tcom es pred ictable. Neith er th e prin ciples n or
th e approach es h ave ch an ged, bu t de n ition s h ave becom e
m ore re n ed in relation to th e d ifferen t m eth ods an d tech -
n iqu es of fractu re xation .
Th e revolu tion is con tin u in g today—th e prin ciples rem ain th e
sam e, bu t th e m eth ods an d tech n iqu es are con tin u ally devel-
opin g an d im plan ts are bein g m od i ed an d n ewly in ven ted.
Today, th e AO develops soph isticated scien ti c an d tech n olog-
ical in stru m en t sets th at len d th em selves to application s th at
go beyon d fractu re treatm en t. Th is in clu des th e treatm en t of
com plication s related to fractu re care, an d m ore recen tly th e
treatm en t of degen erative d iseases, deform ation s, an d defects,
th e problem s th at are becom in g in creasin gly prevalen t in th e
agin g popu lation (su ch as osteoporosis).
Th ere h as been a progressive evolu tion in n ailin g an d
platin g:
Nailin g
From con ven tion al to locked in tram edu llary n ailin g, an d
from ream ed to u n ream ed n ailin g.
Platin g
From ver y stable (absolu tely stable) xation to ex ible
(relatively stable) xation , an d
from com pression plate xation to locked in tern al
xation .
xv
 Th e AO p rin cip le s
AO principles THEN
1. Anatomical, precise reduction
2. Rigid xation, absolute stability
3. Preserving blood supply
4. Early protective motion for
rehabilitation because pain was
abolished and union assured
xvi
In uences through clinical experiences and experimental investigations
Applied science concerning:
– bone healings,
– blood supply through soft tissue and bone,
– biological shortcomings of ORIF in multifragmentary shaft fractures lead
to a new way of thinking.
As a consequence, indirect reduction techniques were developed
The most notable change in the treatment of diaphyseal fractures has been
the shift from the mechanical to the biological aspects of internal xation.
The preservation of the viability and integrity of the soft-tissue envelope of
the metaphysis has been recognized as the key to success.
Today the dominant theme in the xation of fractures of the diaphysis is the
biology of bone and the preservation of the blood supply to bony fragments,
and no longer the quest for absolute stability.
Major changes have occurred in the timing of the different steps of metaphy-
seal reconstruction, as well as in the xation methods and techniques.
The comprehensive classi cation of long bones has helped predict treatment
and outcome.
The present concept still emphasizes that the blood supply through the soft
tissues and bone is the most important aspect in fracture care:
– atraumatic soft tissue technique through the appropriate surgical
approaches,
– atraumatic reduction and xation techniques are mandatory,
– implants with new bone- implant interface.
AO principles NOW
Fracture reduction and xation to restore anatomical relationships.
Reductions need not be anatomical but only axially aligned in the
diaphysis and the metaphysis. Anatomical reduction is required for
intraarticular reductions. The principles of articular fracture care:
- atraumatic anatomical reduction of the articular surfaces,
- stable xation of the articular fragments, and
- metaphyseal reconstruction with bone grafting and buttressing
apply today as they did at the beginning.
Stabilization with different grades of stability, from high (absolute
stability) to low (relative stability).
Appropriate construct stability. Stability by compression or
splinting, as the fracture pattern and the injury require.
The joint surfaces require anatomical reduction with absolute
stability. The majority of diaphyseal fractures are treated with
relative stability methods (eg, intramedullary or extramedullary
splinting).
Preservation of the blood supply to soft tissues and bone by careful
handling and gentle reduction techniques and a newly designed
bone-implant interface.
Early and safe mobilization of the part and the patient. Early active
motion can also be carried out because splint xation is stable
enough to allow postoperative functional care.
Progressive evolu tion is th e resu lt of a lon g-term collabora-
tion between th e AO Research In stitu te (ARI), th e AO De-
velopm en t In stitu te (ADI), an d th e Syn th es m an u factu rers.
Th is m an u al provides details of th e pr in ciples an d tech n iqu es
in volved in in tern al xation u sin g th e recen tly developed less
in vasive stabilization system (LISS) an d th e lock in g com pres-
sion plate (LCP). Fu tu re developm en ts w ill n eed to add ress
th e sh ortcom in gs of th e cu rren t tech n iqu es an d equ ipm en t
an d to assess th e side effects of n ew tech n iqu es, as well as
ways of prom otin g h ea lin g in cases of ch ron ically in fected,
atroph ic n onu n ion . Th e tech n iqu es of in tern al xation w ill
also n eed to be fu rth er sim pli ed to im prove both safety an d
ease of h an d lin g, ben e tin g th e treatin g su rgeon an d th e pa-
tien t.
Su gge s t io n s fo r fu r t h e r re a d in g
Mü lle r M E, A llgöw e r M , Wille n e gge r H (1965) Tech n iqu e of
in tern al xation of fractu res. Heidelberg: Sprin ger-Verlag.
Mü lle r M E, A llgöw e r M , Wille n e gge r H (1979) Manu al of in tern al
xation . Heidelberg: Sprin ger-Verlag.
Pe rre n SM (2002) Evolu tion of th e in tern al xation of lon g bon e
fractu res. Th e scien ti c basis of biological in tern al xation : ch oosin g
a n ew balan ce between stability an d biology. J Bone Joint Surg Br;
84(8):1093 –1110.
Sch at zke r J (1998) M.E. Mü ller—on h is 80th Birth day. AO Dialogue;
11(1):7–12.
Sch e n k R , Wille n e gge r H (1964) [On th e h istology of prim ary bon e
h ealin g.] Langenbecks Arch Klin Chir Ver Dtsch Z Chir; 308:4 40 –452.
xvii
 Acknowle dgm e nts
Th is book represen ts a logical step in pu blication s from th e
AO. It is som e years sin ce th e developm en t of in tern al xators
an d in itial clin ical ex perien ce h as n ow been gain ed so th at
th e tim e h as com e to m eet th e n eed for a book on th is su bject.
As we becom e m ore sen sitive to th e speci c requ irem en ts of
adu lt learn in g, an im portan t in sigh t h as been to recogn ize
th e edu cation al valu e of a case-based learn in g program . In
th e ligh t of th is, we h ave devised an approach to descr ibin g
th e m an agem en t of fractu res th at is based on a series of clin i-
cal cases su bm itted by d ifferen t au th ors worldw ide.
Martin Altm an n ( Co n ce p ts )
Reto Babst ( 6 .1.3 , 6 .3 , 6 .3 .3 , 6 .3 .4 , 9 .2 .6 , 9 .2 .7 )
Herm an n Bail (10 .3 .8 )
Peter Bru n n er ( Co n ce p ts )
Ulf Cu lem an n ( 8 .1.3 , 8 .1.4 )
Ch ristoph er G Fin kem eier ( 5 .1.1 , 5 .2 .2 )
An dré Fren k ( Co n ce p ts )
M ich ael J Gard n er ( 6 .1.4 , 6 .3 .2 , 7.2 .4 , 7.3 .3 , 9 .1.2 , 10 .1.1 ,
10 .3 .5 )
Em anu el Gau tier ( 7.2 .2 , 8 .1.1 , 8 .1.5 , 9 .1 , 9 .1.6 , 9 .2 .1 , 9 .3 .5 )
Ch ristoph er W Geel ( 7.1 , 7.1.4 , 10 .1.8 , 10 .3 .4 )
An dreas Gru n er ( 7.1.6 , 8 .1.2 , 9 .2 .4 , 9 .2 .8 , 9 .3 .2 , 9 .3 .8 , 10 .1.6 ,
10 .1.9 , 10 .2 .12 , 10 .3 .2 , 10 .3 .9 )
Norbert P Haas (10 .3 .1 , 10 .3 .8 ,
David L Helfet ( 6 .1.4 , 6 .3 .2 , 7.2 .4 , 7.3 .3 , 9 .1.2 , 10 .1.1 , 10 .3 .5 )
Th om as Hockertz ( 7.1.6 , 8 .1.2 , 9 .2 .4 , 9 .2 .8 , 9 .3 .2 , 9 .3 .8 ,
10 .1.6 ,10 .1.9 , 10 .2 .12 , 10 .3 .2 , 10 .3 .9 )
Keita Ito ( Co n ce p ts )
Rolan d P Jakob ( 9 .1.6 )
Georges Kohu t ( 7.2 .2 )
Ph ilip J Kregor ( 9 .1.3 , 9 .1.4 , 9 .3 .7, 9 .3 .9 )
Ch ristian Krettek ( Co n ce p ts )
Fran k ie Leu n g ( 6 .1.7, 10 .2 .4 )
Wilson Li ( 6 .1.2 )
Dean G Lorich ( 6 .1.4 , 6 .3 .2 , 7.2 .4 , 7.3 .3 , 9 .1.2 , 10 .1.1 , 10 .3 .5 )
Marc Lotten bach ( 9 .2 .1 )
In go Melch er (10 .3 .1)
Erika J M itch ell ( 9 .1.3 , 9 .1.4 )
xviii
Th e editors wou ld like to ack n owledge an d express th eir
th an ks to all th e colleagu es wh o con tribu ted th eir texts an d
clin ical cases. Th eir n am es are given in th e follow in g list:
We w ish to ex press ou r fu ll appreciation to ou r coed itors,
Rich ard Bu ck ley, Em an u el Gau tier, M ich ael Sch ü tz, an d
Ch ristoph Som m er, wh o played an essen tial role in th e pro-
du ction of th is m anu al on LISS an d LCP by w ritin g, review-
in g an d re n in g th e con tribu tion s. We th an k th em for tak in g
on th is great respon sibility an d givin g th eir valu able tim e to
th is project.
Th om as Neu bau er ( Co n ce p ts )
Steph an M Perren ( Fo re w o rd )
M ich ael Plecko ( 6 .1 , 6 .1.8 , 6 .3 .1 , 7.1.2 )
Tim Poh lem an n ( 8 .1 , 8 .1.3 , 8 .1.4 )
Hein rich Reilm an n ( 7.1.6 , 8 .1.2 , 9 .2 .4 , 9 .2 .8 , 9 .3 .2 , 9 .3 .8 ,
10 .1.6 , 10 .1.9 , 10 .2 .12 , 10 .3 .2 , 10 .3 .9 )
Dan iel A Rik li ( 7.3 , 7.3 .1 , 7.3 .5 , 7.3 .6 )
Th om as P Rü ed i ( Fo re w o rd , 7.2 , 10 .2 , 10 .3 )
Ch ristian Ryf ( 6 .1.9 , 7.1.2 , 7.3 .2 , 10 .1.4 , 10 .2 .11 , 10 .2 .13 ,
10 .3 .1 )
Klau s-D Sch aser (10 .3 .1)
Robert Sch avan ( Co n ce p ts )
M ich ael Sch ü tz ( 6 .3 .5 , 7.1.1 , 7.1.3 , 9 .2 .3 , 9 .3 , 9 .3 .6 , 10 .1.7 )
Ch ristoph Som m er ( 5 .1 , 5 .1.4 , 5 .1.5 , 5 .2 , 5 .2 .1 , 6 .1.1 , 6 .2 ,
6 .2 .2 , 6 .2 .3 , 6 .2 .4 , 6 .2 .5 , 6 .2 .6 , 7.1.5 , 9 .3 .3 , 9 .3 .4 , 10 .1.2 , 10 .1.3 ,
10 .1.5 , 10 .1.11 , 10 .2 .6 , 10 .2 .7, 10 .2 .8 , 10 .2 .10 , 10 .3 .3 , 10 .3 .6 )
Jam es P Stan n ard ( 6 .1.5 )
M ich ael D Stover (10 .3 .7 )
Gabr iele Streich er ( 7.1.6 , 8 .1.2 , 9 .2 .4 , 9 .2 .8 , 9 .3 .2 , 9 .3 .8 , 10 .1.6 ,
10 .1.9 , 10 .2 .12 , 10 .3 .2 , 10 .3 .9 )
Norbert Sü dkam p ( 6 .1.6 )
Hobie D Su m m ers (10 .3 .7 )
Ron ald van Heer waarden ( 9 .3 .10 )
M ich ael Wagn er ( 5 .1.2 , 5 .1.3 , 6 .2 .1 , 6 .2 .7, 7.2 .1 , 7.2 .3 , 7.3 .4 ,
9 .1.1 , 9 .1.5 , 9 .2 , 9 .2 .2 , 9 .2 .5 , 9 .2 .9 , 9 .3 .1 , 10 .1 , 10 .1.10 , 10 .2 .1 ,
10 .2 .2 , 10 .2 .3 , 10 .2 .5 , 10 .2 .8 , 10 .2 .9 , 10 .2 .14 , 10 .2 .15 , 10 .2 .16 ,
10 .3 .10 , 10 .3 .11 )
Han s Zw ipp (11 )
In add ition , we give a special ack n ow ledgm en t to Steph an M
Perren for h is review s an d h is foreword, to Th om as P Rü ed i
for su pportin g th e project an d for h is foreword, to Ch ris L
Colton for revisin g th e exten sive glossary, an d to Ch ris G Mo-
ran for en su rin g th e h igh qu ality of a wh ole ran ge of im pres-
sive illu stration s of th e su rgical approach es.

Apart from th e con tribu tors an d coed itors, a n u m ber of

people h ave con tribu ted to th e produ ction of th is pu blica-
tion . To m en tion th em by n am e is on ly a ver y sm all token
of th an ks for m u ch h ard work. Han n a Ju fer an d h er team of
illu strators reliably produ ced h igh qu ality d raw in gs on sch ed-
u le th at fu lly m eet ou r ex pectation s. Design an d layou t work
was in itiated by San d ro Isler, wh ereby we ben e ted from h is
vast experien ce.

Th e creation an d produ ction of a work of th is m agn itu de h as

requ ired th e ded ication of a n u m ber of collaborators from
AO Pu blish in g an d AO In tern ation al. Th ese in clu de M iriam
Uh lm an n , wh o was solely respon sible for coord in atin g th e
project an d all th ose involved, an d for en su rin g th e detailed
processin g of th e con tribu tion s, Roger Kistler, wh o h ad th e
task of adju stin g an d n alizin g th e overall layou t, an d Doris
Strau b Piccirillo, Urs Rü etsch i, an d An dy Weym an n for th eir
specialist in pu t an d valu able su pport.

Th e tim e an d effort in vested in th is project h as led to a m ost

reward in g resu lt.

M ich ael Wagn er, Robert Frigg

xix
 Conce pts

1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

1 Os t e o s yn t h e s is 3
2 Co n ce p t s o f fra ct u re fixa t io n 10
3 Me ch a n ica l a s p e ct s o f p la t e a n d s cre w fixa t io n 21
4 De ve lo p m e n t o f in t e rn a l fixa t o rs 31
5 Me t h o d s a n d t e ch n iq u e s in p la t e o s t e o s yn t h e s is 41
6 Min im a lly in va s ive p la t e o s t e o s yn t h e s is (MIP O) 48
7 Bib lio gra p h y 54

2 Su rgica l re d u ct io n t e ch n iq u e s
1 Aim o f re d u ct io n 59
2 Diffe re n t t yp e s o f s u rgica l re d u ct io n 60
3 In s t ru m e n t s a n d t e ch n iq u e s 69
4 As s e s s m e n t o f re d u ct io n 81
5 Co n clu s io n s 85
6 Bib lio gra p h y 85

3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
1 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS) 87
2 Th e lo ck in g co m p re s s io n p la t e (LCP) 12 5
3 Bib lio gra p h y 15 9

4 P it fa lls a n d co m p lica t io n s
1 Im p la n t -re la t e d p ro b le m s 16 3
2 Te ch n ica l e rro rs 16 4
3 P it fa lls a n d co m p lica t io n s d u rin g re h a b ilit a t io n 171
4 Su gge s t io n s fo r fu r t h e r re a d in g 17 9

xx
Conce p ts

1
 1 Background and m e thodological principle s

1 Os t e o s yn t h e s is 3
1.1 Tre a t m e n t o f d ia p h ys e a l fra ct u re s : b a ck gro u n d a n d
co n ce p t s 3
1.2 Tre a t m e n t o f a r t icu la r fra ct u re s 8
1.3 Th e p a t ie n t a n d t h e in ju r y 9

2 Co n ce p t s o f fra ct u re fixa t io n 10
2 .1 Prin cip le s : a b s o lu t e ve rs u s re la t ive s t a b ilit y 10
2 .2 Me t h o d s : co m p re s s io n ve rs u s s p lin t in g 14
2 .3 Bo n e h e a lin g 15

3 Me ch a n ica l a s p e ct s o f p la t e a n d s cre w fixa t io n 21

3 .1 Ge n e ra l co n s id e ra t io n s 21
3 .2 Pla t e s a n d s cre w s a s co m p re s s io n t o o ls 22
3 .3 Th e p la t e a s a s p lin t 26

4 De ve lo p m e n t o f in t e rn a l fixa t o rs 31
4 .1 His t o r y o f in t e rn a l fixa t o rs 31
4 .2 Lo ck in g h e a d s cre w s (LHS) 34
4 .3 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS) 38
4 .4 Th e lo ck in g co m p re s s io n p la t e (LCP) 39

5 Me t h o d s a n d t e ch n iq u e s in p la t e o s t e o s yn t h e s is 41
5 .1 Pla t e o s t e o s yn t h e s is t o d a y a n d
fu t u re d e ve lo p m e n t s 41
5 .2 Co m p re s s io n m e t h o d —
co n ve n t io n a l p la t in g t e ch n iq u e 42
5 .3 Sp lin t in g m e t h o d 45

6 Min im a lly in va s ive p la t e o s t e o s yn t h e s is (MIP O) 48

7 Bib lio gra p h y 54

2
1 Background and m e thodological principle s
1 Os t e o s yn t h e s is
Th e goals of fractu re care are to ach ieve u n ion , align m en t,
an d fu n ction .
Th e gen eral in d ication s for fractu re xation are:
To save life or lim b.
To recon stru ct d isplaced articu lar fractu res.
To preven t deform ity.
To prom ote u n ion wh en th is is delayed.
Im proved fu n ction follow in g early m otion .
Th e m ost obviou s in d ication for operative an d fu n ction al
treatm en t is an in traarticu lar fractu re wh ere displacem en t
w ill resu lt in loss of fu n ction . Certain d iaph yseal fractu res
requ ire in tern al xation : th e forearm becau se it is a “join t”
an d th e fem u r becau se im m obilization of th e in ju red th igh
mu scu latu re w ill lead to a stiff, weaken ed leg.
Fixation of an u n stable pelvic fractu re, w ith h em odyn am ic
in stability, m ay be life savin g. In add ition , stabilization of
mu ltiple lon g-bon e fractu res m ay redu ce m ortality in patien ts
w ith polytrau m a.
Lim b savin g is an oth er m ajor in d ication . With vascu lar an d
n eu rological in ju r y, th e bon e m u st be stabilized to protect th e
repaired stru ctu res. In open fractu res, stabilization w ill su p-
port th e soft-tissu es h ealin g.
To assu re u n ion an d preven t deform ity is an oth er m ajor rea-
son for in tern al xation . Th e in abilities to redu ce a fractu re,
or m ain tain redu ction , are in dication s for in tern al xation .
Fractu res at h igh risk of n ot h ealin g are also ideal for su rgery.
Fin ally, in tern al xation is also u sed in bon e recon stru ction
for n onu n ion an d m alu n ion .
1.1 Tre a t m e n t o f d ia p h ys e a l fra ct u re s : b a ck gro u n d a n d
co n ce p t s
Historically, in tern al xation h as been u sed as a last resort to
ach ieve fractu re u n ion . Un ion h as always been im portan t an d
fu n ction h as been a lesser con cern . However, th is approach to
fractu re treatm en t often sacri ced fu n ction leavin g a stiff an d
poorly fu n ction in g extrem ity. At th e begin n in g of AO h is-
tory alm ost each fractu re was stabilized w ith th e com pression
m eth od after open d irect an atom ical redu ction . However, a
problem arose: Th e blood su pply to bon e was n eglected as
th e en deavor for perfect an atom ical redu ction resu lted in in -
creased tissu e trau m a. Th e perception th at stable xation was
n ecessary led to sign i can t dam age to blood su pply, in creas-
in g th e rate of n onu n ion , in fection , an d failu re.
Th e developm en t of locked in tra m edu llar y n ailin g con rm ed
th at a m u ltifragm en tary d iaph yseal fractu re d id n ot n eces-
sitate an an atom ical redu ction . With gen eral align m en t an d
relative stability, u n ion cou ld occu r rapid ly. Th is led to th e de-
velopm en t of in d irect redu ction tech n iqu es: If th e soft tissu es
were protected an d biological, d iaph yseal xation tech n iqu es
were u sed, th e fractu re wou ld h eal w ith acceptable align m en t
an d fu n ction . Gan z, Mast, an d Jakob rein trodu ced in d irect
redu ction m eth ods an d biological fractu re xation solu tion s,
eg, bridge platin g (Boitzy, Weber).
Research con tin u ed on bon e an d its blood su pply. An u n -
derstan d in g of h ealin g in differen t m ech an ical situ ation s led
to th e strain th eor y of Perren . Mod i cation s of im plan ts to
provide m ore stability a n d early fu n ction , wh ile m ain tain in g
blood su pply to th e bon e, su ch as th e LC-DCP, LISS, an d lock-
in g com pression plates (LCP) were developed.
Cu rren t con cepts still em ph asize th e u tm ost im portan ce of
blood su pply to th e soft tissu es an d bon es in fractu re care. Th e
AO Prin ciples h ave n ot ch an ged oth er th an th at th e treatm en t
3
 of diaph yseal an d m etaph yseal fractu res h ave been re n ed
an d de n ed w ith regard to m ech an ics, biology, an d tech -
n iqu es:
1. Atrau m atic soft-tissu e tech n iqu e th rou gh appropr iate
su rgical approach es.
2. Atrau m atic redu ction an d xation tech n iqu es are
m an dator y. Redu ction n eed n ot be an atom ical bu t axial
align m en t is essen tial (in th e d iaph ysis an d th e m eta-
physis).
3. Appropriate con stru ct stability. Th e m ajority of diaph yseal
fractu res are treated w ith relative stability tech n iqu es.
4. Early active m otion can be carried ou t becau se xation is
stable en ou gh to allow fu n ction al aftercare.
Precise an atom ical redu ction of th e d iaph ysis in th e fem u r,
tibia, an d h u m eru s is n ot n ecessary. Fu n ction is n ot d im in ish ed
as lon g as len gth , rotation , an d ax ial align m en t are restored.
Th e radiu s an d th e u ln a are exception s to th is ru le. Pron ation
an d su pin ation , as well as n orm al elbow an d w rist fu n ction ,
depen d u pon th e preservation of th e n orm al an atom ical sh ape
an d relation sh ips of th e two bon es. An atom ical redu ction of
th ese two bon es is m an datory, an d stability sh ou ld be ach ieved
w ith an appropriate tech n iqu e.
In th e follow in g sequ en ces som e im portan t tech n ological
in n ovation s an d con ceptu al ch an ges of fractu re xation are
d iscu ssed.
Lo cke d in t ra m e d u lla r y n a ilin g
Th e developm en t of th is tech n iqu e sh owed th at d iaph yseal
fractu res do n ot requ ire precise an atom ical redu ction , bu t
on ly correct align m en t an d relatively stable xation (w ith
in tram edu llary splin tin g of th e fractu re zon e). Th is resu lted in
rapid u n ion th rou gh callu s form ation (in d irect bon e h ealin g).
Th is led to th e view th at in d irect redu ction tech n iqu es can be
u sed to spare th e soft tissu es an d th at exible biological xation
tech n iqu es can be u sed su ccessfu lly in diaph ysis [1, 2].
4
With th e em ph asis today on th e preser vation of th e blood
su pply to th e bon es an d soft tissu es, th e locked in tram edu llar y
n ail h as becom e th e im plan t of ch oice for th e xation of
d iaph yseal fractu res [3 ]. Locked n ailin g can be perform ed by
a m in im ally in vasive approach . Alth ou gh m u ltifragm en tary
fractu res u sed to be a con train dication to n on locked n ailin g,
th ey are cu rren tly th e prin cipal in d ication for th e u se of a
locked in tram edu llary n ail. Locked n ailin g h as also m ade it
possible to stabilize fractu res in th e proxim al an d distal th irds
of th e d iaph ysis, as well as to treat su btroch an teric fractu res
w ith in volvem en t of th e lesser troch an ter an d ipsilateral
fractu res of th e sh aft an d n eck of th e fem u r [4 , 5 ]. Th e n ew
gen eration of locked n ails exten ds th e in d ication s towards th e
proxim al an d d istal en ds of th e d iaph ysis.
Fro m d ire ct t o in d ire ct re d u ct io n
In terfragm en tary com pression requ ires predom in an tely open
d irect an atom ical redu ction . It h as been recogn ized th at d irect
m an ipu lation of bon e fragm en ts, as was u su al du rin g in tern al
xation procedu res, was a m ajor cau se of devitalization of th e
bon e fragm en ts [6 ] (see ch apter 2; Ta b 2 -1 ). In order to m in im ize
dam age to th e vascu larization of th e osseou s tissu e an d th e
su rrou n d in g soft tissu es, in d irect redu ction tech n iqu es h ave
becom e popu lar w ith open redu ction an d in tern al xation .
Th is approach was advocated by Mast an d colleagu es [7 ] wh o
in trodu ced in d irect redu ction m eth ods an d biological solu tion s
su ch as bridge platin g for d iaph yseal fractu re xation .
On e exam ple of an in d irect redu ction m eth od is th e d istraction
of fragm en ts u sin g a d istractor, an extern al xator, a plate, or
traction applied to a lim b. Th e fragm en ts are redu ced u sin g
ligam en totax is ( Tab 1-1) [8 –10 ], m in im izin g th e exten t to
w h ich th ey are m an ipu lated an d preservin g th eir blood
su pply.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Ta b 1-1 Liga m e n t o t a xis Wa ve p la t e a n d b rid ge p la t e

Im agin ative th in k in g led to th e developm en t of th e wave plate
Ligam e n to ta xis is th e p rin cip le o f m o ld in g fractu re fragm e n ts in to align -
[14] an d th e br idge plate [15 , 16 ]. Th e basic idea is to leave th e
m e n t a s a re su lt o f te n sio n ap p lie d to a fractu re b y th e su rro u n d in g in tact
fractu re zon e an d its fragm en ts u n d istu rbed, by xin g th e
so ft tissu e s.
plate to th e in tact part of th e bon e on th e prox im al an d d istal
sides of th e fractu re zon e.

Pre s e r va t io n o f t h e b lo o d s u p p ly
Th ere are two advan tages wh en a wave plate is u sed to bridge
Historically, th e m ost n otable developm en t in th e treatm en t of
a com m inu ted fractu re area. Firstly, w h en a plate is applied at
d iaph yseal fractu res h as been a sh ift away from th e m ech an ical
a d istan ce from th e bon e, it allow s better perfu sion of th e
aspects of in tern al xation toward th e biological aspects. Th e
repair tissu e—w ith th e ben e ts of better leverage an d
focu s in th e xation of d iaph yseal fractu res today is on th e
m ech an ical su pport from th e repair tissu e [17 ]. Secon d ly,
biology of th e bon e an d on preser vin g th e blood su pply to th e
wh en th e plate span s an exten ded fractu re area, th ere is m ore
bon e fragm en ts. A qu est for absolu te stability is n o lon ger th e
u n iform deform ation of th e in n er part of th e plate th at is n ot
prim ar y aim [2 , 11].
xed to th e bon e—preven tin g th e developm en t of sites of
excessive deform ation th at cou ld lead to fatigu e failu re.
Lim it s o f co m p re s s io n p la t in g: “s t re s s p ro t e ct io n ”
It was observed in earlier clin ical an d laborator y stu d ies th at
Th e tech n iqu e of bridge platin g (splin tin g m eth od w ith plates)
th e cortex u n der th e xation plate becam e excessively porou s
was developed to h elp preven t devitalization of fragm en ts in
du e to a m arked in crease in th e n u m ber of h aversian can als
m u ltifragm en tary fractu res [6 , 18 ]. Th e fractu re is rst redu ced
[12]. Th is ph en om en on was ex plain ed by Wolff’s law of bon e
by m ean s of in d irect redu ction . Th e fragm en tation zon e is
rem odelin g ( Tab 1-2 ), an d it becam e kn ow n as “stress
th en bridged w ith a plate th at is xed to th e m ain prox im al
protection .” However, on in vestigatin g th e biological effects of
an d d istal fragm en ts. Th is m ain tain s len gth , rotation , an d
con ven tion al com pression plates on th e u n derlyin g cortex,
axial align m en t. Th is type of in tern al xation is a form of
Perren an d colleagu es [13 ] m ade th e im portan t d iscovery th at
splin tin g. It is n ot absolu tely stable, an d u n ion occu rs th rou gh
plates in terfere sign i can tly w ith th e blood su pply to th e
callu s form ation . Th is platin g tech n iqu e is m ain ly in dicated
u n derlyin g cortex. Th e “stress protection ” h ypoth esis was
for th e xation of m u ltifragm en tar y fractu res. If a sim ple
th u s fou n d to be m istaken . Th is led to th e developm en t of
tran sverse or obliqu e fractu re is closely redu ced an d plated,
lim ited con tact plates later to n on con tact plates.
th en absolu te stability h as to be ach ieved u sin g in terfragm en tary
com pression ; oth er w ise failu re is likely to follow du e to
Ta b 1-2 Wo lff’s la w
excessive strain at th e fractu re site. Clin ical ex perien ce w ith
Bo ne s de ve lo p th e stru ctu re b e st su ite d to re sistin g th e fo rce s a ctin g on locked plates h as sh ow n th at close in d irect redu ction an d
th e m . An y ch an ge s in e ith e r th e fo rm o r fu n ctio n o f a b o n e are fo llo we d splin tin g of sim ple fractu re is possible an d leads to in direct
b y sp e ci c ch an ge s in its in te rnal arch ite ctu re an d se co n d ary alte ra tio n s fractu re h ealin g bu t som etim es to a delayed bon e h ealin g.
in its e xte rnal shap e —change s u sually in volving re sp o n se s to alte ra tio n s
in we igh t-b e aring stre sse s (fo rm follo w s fu nction). This applie s on ly to
long la stin g u nlo ad ing.

5
Ta b 1-3 Mile s t o n e s in p la t e d e ve lo p m e n t

Ye a r Pro d u ct In ve n t o r De s crip t io n Fixa t io n m e t h o d Te ch n iq u e

19 61 Fo rm p la te s/ T- – Can ce llo u s b o n e scre w s in th e m e tap h yse al are a Co m p re ssio n ORIF

p la te s

19 62 / 19 6 3 Ro u n d h o le p la te Mü lle r ME [19] – Co n ical h o le s, scre w s w ith co n ical h e ad s Co m p re ssio n ORIF

– Re m o va b le co m pre ssio n d e vice

19 6 3 Se m i-tu b u la r p la te Mü lle r ME [2 0 ] – Se lf-co m p re ssin g p la te (e lo n ga te d pla te h o le s) Co m p re ssio n ORIF

– Ecce n tric scre w s fo r in te rfragm e n tary
co m p re ssio n

19 6 9 Dyn a m ic Pe rre n SM [21, 2 2] – Co m p re ssio n cylin d e r a t o n e e n d o f th e Co m p re ssio n ORIF

co m p re ssio n p la te e lo n ga te d p la te h o le (DCU)
(DCP) – He ad o f th e scre w is sph e rica lly u n d e rcu t
– Scre w a n gu la tio n

19 8 0 Bru n n e r CF, We b e r BG – Tra n sve rse u n d e rcu ts Co m p re ssio n ORIF

19 81/ 19 8 2 Bru n n e r CF, – Wa ve p la te Sp lin tin g

We b e r BG [14 , 17 ]

Ma st JW, Gan z R, – Co nce p t o f “in d ire ct re d u ctio n ”

Ja ko b R [18 , 19 ]

Gan z R, Rü e d i TP – “b io -lo gical” p la tin g Sp lin tin g le ss in va sive

19 8 5 He ite m e ye r U, – Brid gin g p la te Sp lin tin g

Hie rh o lze r G [16 ]

19 9 0 LC-DCP Pe rre n SM [2 3 ] – Se lf-co m p re ssio n p la te w ith lim ite d co n tact Co m p re ssio n ORIF o r o p e n ,
– Un d e rcu ts o r sp lin tin g le ss in va sive
– Scre w a n gu la tio n s
– Sm o o th pla te b e n d in g
– Ecce n tric scre w s

19 92 PC-Fix Te p ic S, Pe rre n SM – Po in t-co n tact-p la te Sp lin tin g, open,

[24] – Angu la r stab le scre w s lo cke d sp lin tin g le ss in va sive

– Co nce p t o f su b m u scu la r p la tin g Splin tin g w ith MIPPO

co n ve n tio n al p la te s

19 9 4 LISS Frigg R, Sch a van R – LHS w ith th re ad e d co n ical scre w h e ad Lo cke d sp lin tin g MIPO
– No n co n ta ct p la te
– Angu la r stab le lo ckin g h e ad scre w s

2 0 01 LCP Wa gn e r M, Frigg R, – Co m b in a tio n h o le Co m p re ssio n a n d ORIF o r MIPO

Sch a va n R lo cke d sp lin tin g
p o ssib le

6
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Bo n e gra ft in g
Th e tech n iqu es of in d irect redu ction an d bridge platin g h ave
m ade bon e graftin g u n n ecessary in m u ltifragm en tary di-
aph yseal an d m etaph yseal fractu res [6 ]. Bon e graftin g is n ow
largely reser ved for m etaph yseal defects in articu lar fractu res
an d for open fractu res w ith bon e loss.
Pla t e s w it h lim it e d b o n e co n t a ct
Plates h avin g a sm aller su rface area in con tact w ith th e bon e,
even w h en th ey are th icker an d m ore r igid, were fou n d to
cau se less in terferen ce to th e blood su pply of bon e [2 5 ]. A
sm aller su rface con tact area w ith th e bon e also leads to less
in ten se osteoporosis th an wh ere plates w h ich are th in n er
an d m ore elastic bu t h ave a larger su rface con tact area w ith
th e bon e. Th e porosis appeared to be d irectly related to th e
am ou n t of n ecrosis occu rrin g below th e plate (Gau tier). Th is
observation led to th e developm en t of plates th at en su re lim -
ited con tact between th e bon e an d im plan t, su ch as th e lim -
ited-con tact dyn am ic com pression plate (LC-DCP).
Bio lo gica l in t e rn a l fixa t io n
Th is approach represen ts th e cu lm in ation of recen t research ,
follow in g fu n da m en tal revision of th e prin ciples of fractu re
xation an d con ceptu al an d tech n ological in n ovation s [3 , 26 ]
( Ta b 1-3 ). Th ere is n ow a better u n derstan d in g of th e way in
wh ich fractu res h eal, an d th e all-im portan t role played by th e
soft tissu es h as been recogn ized. As ou r u n derstan din g of th e
ways in w h ich bon es an d im plan ts in teract h as also im proved,
th e im portan ce of m ain tain in g th e vital balan ce between sta-
bilization an d biological fu n ction h as been grasped, an d bio-
logical in tern al xation h as been developed in order to take
th is in to accou n t. Th e prin ciple of biological in tern al xation
con sists of m in im izin g th e biological dam age cau sed by in d i-
rect redu ction , th e su rgical approach , an d by con tact between
th e im plan t an d th e bon e [2 , 27 ]. M in im izin g su ch dam age
can be ach ieved, bu t it im plies less precise redu ction an d a less
stable, m ore ex ible xation .
More th an 100 years ago, Lan e (1856 –1938) rst advocated th e
m an ipu lation of tissu es u sin g special in stru m en ts an d a “n o-
tou ch tech n iqu e,” as h e realized th at bon e h ealin g depen ded
as m u ch on th e con d ition of th e soft tissu es as on optim al
m ech an ical con d ition s. Today’s con cept of biological in tern al
xation is based on ach ievin g a balan ce between stability an d
biological in tegrity. Th e prin ciple of biological in tern al xa-
tion con sists of m in im izin g th e biological dam age cau sed by
th e su rgical approach an d redu ction tech n iqu e by an ch orin g
th e im plan t on ly in th e m ain fragm en ts. Th e m in im ization
of trau m a is ach ieved at th e expen se of less precise redu ction
an d less stable xation ( Ta b 1-4 ).
In d irect redu ction an d pu re in tern al splin tin g (based on th e
prin ciple of relative stability) h elp keep bon e fragm en ts vital.
In d irect bon e h ealin g leads to early an d reliable solid u n ion .
Th is approach can be su ccessfu l wh en ever th e acciden t h as
n ot resu lted in com plete avascu larity in th e bon e fragm en ts.
Still com plete avascu larity requ ire fractu re xation w ith ab-
solu te stability.
Bio lo gica l in t e rn a l fixa t io n w it h d iffe re n t im p la n t s ys te m s Ta b 1-4
Im p la n t Me t h o d o f fra ct u re xa t io n
Po s it io n o f s p lin t
e xte rna l xa to r e xte rna l lo cke d sp lin ting
lo cke d n ail in te rn al in tram e d u lla ry lo cke d sp lin ting
lo cke d in te rn al xa to r in te rn al e xtram e d u lla ry lo cke d splin tin g
Ta b 1-4 Bio lo gical in te rnal xa tio n w ith th e m e th o d o f lo cke d
sp lin tin g u sin g th re e d iffe re n t im pla n t syste m s acco rd in g to th e
p rinciple o f fractu re xa tio n w ith re la tive stabilit y.
7
 Th ree m ain con ven tion al tech n iqu es are available to ach ieve
biological in tern al xation : 1) splin tin g stabilization w ith ex-
tern al xators; 2) splin tin g stabilization w ith in tram edu llary
locked n ails; an d 3) th e u se of plates as pu re splin ts—ie, w ith -
ou t th e add ition al lag screw effect.
1. With extern al xators, th e tran scu tan eou s in fection rou te
offsets th e positive effects of m in im izin g im plan t–bon e
con tact an d ex ible xation .
2. Usin g an in tram edu llary n ail allow s a m in im a lly in va-
sive percu tan eou s approach , bu t th e advan tages of th is are
som ewh at offset by th e exten sive dam age cau sed to th e
in tram edu llar y circu lation , as well as local an d gen eral in -
travascu lar th rom bosis du e to tissu e dam age an d possible
fat in travasation cau sed by th e h igh in tram edu llary pres-
su re du rin g ream in g an d in sertion of th e n ail.
3. Splin tin g th e fractu re zon e w ith a plate. Th e pion eerin g
tech n iqu e today is th e locked in tern al xator (locked n on -
con tact plate) applied u sin g a m in im ally in vasive tech -
n iqu e. Research an d developm en t in th is area are on go-
in g, an d fu rth er m od i cation s an d im provem en ts w ith
th is m eth od can be ex pected in th e n ear fu tu re.
Fro m a b s o lu t e t o re la t ive s t a b ilit y
Th e m et h od of com pression fixat ion u sin g lag screw s a n d
con ven t ion a l plates (based on t h e pr in ciple of absolu te
st abilit y) h a s t h erefore been su pplem en ted by t h e m et h od
of splin t in g (ba sed on t h e pr in ciple of relat ive st abilit y),
t a k in g adva n t age of pu re splin t fixat ion w it h a plate [6 ].
Th e lat ter m et h od prov ides flex ible fixat ion t h at st im u lates
ca llu s for m at ion a n d con sequ en t ly prom otes ea rly solid
u n ion .
Th e less in vasive stabilization system (LISS) an d lock in g com -
pression plate w ith lock in g h ead screw s (LCP w ith LHS) n ow
in cor porate th e m eth odologica l prin ciples of locked in ter-
n al extra m edu llary splin tin g [2 8 ]. LISS an d LCP w ith LHS
8
resem ble plates bu t act biom ech an ically as locked splin ts or
xators—locked in tern al xators (LIF).
1.2 Tre a t m e n t o f a r t icu la r fra ct u re s
Th e prin ciples of th e treatm en t of articu lar fractu res are th e
sam e today as th ey h ave always been :
Atrau m atic an atom ical redu ction of th e articu lar su rfaces
Stable xation of th e in traarticu lar fragm en ts
Recon stru ction of th e m etaph ysis w ith bon e graftin g an d
bu ttressin g by bon e graftin g an d bu ttress plate
Fu n ction al postoperative treatm en t w ith ou t im m obiliza-
tion
Wh at h as ch an ged is th e sequ en ce of th e d ifferen t steps of
m etaph yseal recon stru ction .
In traarticu lar recon stru ction mu st be u n dertaken as early as
possible an d w ith th e least possible trau m a to th e tissu es. An y
delay leads to perm an en t deform ity, as th e articu lar fragm en ts
u n ite rapid ly an d defy later attem pts at redu ction . In traartic-
u lar cartilage does n ot rem odel [2 9 ]. An y residu al in con gru ity
becom es perm an en t an d can lead to posttrau m atic arth ritis.
In con trast, th e d iaph ysis an d m etaph ysis h ave a trem en dou s
capacity for rem odelin g an d an y residu al deform ities can be
relatively easily corrected by osteotom y.
Th e tim in g of a r ticu la r a n d m et aph ysea l recon st r u ct ion
a n d th e tech n iqu es u sed a re vit al t h erefore. It h as been
recogn ized t h at preser vin g t h e viabilit y a n d in tegr it y of
t h e soft-t issu e en velope of t h e m etaph ysis is t h e key to su c-
cess. Ex ter n a l xat ion is t h erefore often u sed as a tem po-
ra r y m easu re, to est ablish t h e len gt h a n d a lign m en t of th e
m et aph ysis, w it h de n itive recon str u ction bein g delayed for
2 –3 weeks u n t il t h e soft-t issu e en velope h as recovered [3 0 ,
31]. If t h e a r ticu la r fragm en t or a r ticu la r bon e block is sm a ll
a n d does n ot provide a n y pu rch ase for a n ex ter n a l xator,
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
th en t h e join t is br idged tem pora r ily to provide t h e n eces-
sa r y im m obilizat ion .
Wh eth er n al recon stru ction is carried ou t as a prim ar y pro-
cedu re or as a delayed procedu re, every possible step is taken
to m in im ize dam age to th e blood su pply to th e soft tissu e an d
bon e. Th e m easu res requ ired for th is in clu de in direct redu c-
tion , m in im al ex posu re, an d percu tan eou s screw xation of
th e fragm en ts. Bu ttressin g is still im portan t in preven tin g ax-
ial deform ity, bu t bu ttressin g tech n iqu es are n ow design ed to
m in im ize soft-tissu e trau m a. Bu ttressin g can n ow be ach ieved
by platin g, by u sin g an an gu lar stable plate-screw con stru ct
su ch as a blade plate.
1.3 Th e p a t ie n t a n d t h e in ju r y
Ge n e ra l a n d lo ca l fa ct o rs a ffe ct in g m a n a ge m e n t d e cis io n s
It is im portan t to iden tify th e patien t factors th at w ill effect
treatm en t, to look at th e preoperative risk factors, an d to iden -
tify oth er factors of th e in ju r y th at m ay ch an ge th e treatm en t
plan . Patien t assessm en t is best don e th rou gh th e preopera-
tive h istory an d ph ysical exam in ation as well as by variou s
in vestigation s th at are requ ired to determ in e th e h ealth of th e
patien t an d th e presen ce of blood born path ogen s. In form ed
con sen t m u st in clu de a d iscu ssion of th e ex pectation s of treat-
m en t between th e patien t an d th e su rgeon .
Th e in ju ry itself h as both system ic an d fractu re-associated
effects. Th e system ic effects in volve th e m u ltiple trau m a pa-
tien ts. Fractu re-associated con cern s are soft-tissu e in ju ry,
particu larly a cru sh syn d rom e or fractu res cau sin g fat em bo-
lism , or vascu lar an d n er ve in ju r y. Th e role of th e soft tissu e
in h ealin g, in fection , an d fu n ction is im portan t an d in u en c-
es th e tim in g an d type of xation . Th e treatm en t objectives
of th e soft-tissu e in ju r y are rst to m ain tain tissu e perfu sion ,
to preven t n ecrosis, to avoid in fection , an d to preven t fu rth er
dam age of an y soft tissu e. Th is is best don e by stabilizin g th e
soft tissu es to prom ote h ealin g an d fu n ction an d u ltim ately to
prom ote bon e u n ion . Th is is accom plish ed by skeletal stabi-
lization , wh ich decreases th e in ju r y in am m atory respon se
an d bacterial spread wh ile in creasin g perfu sion an d prom ot-
in g wou n d repair. Th e ch oice of xation tech n iqu e is based
u pon th e prin ciple th at in su lt to biology is to be m in im ized
wh ile m ech an ical stability m u st allow early fu n ction . Th u s,
a balan ce m u st be ach ieved between th e am ou n t of su rgical
biological in su lt n ecessar y to ach ieve stabilization , th e degree
of in stability an d th e m ech an ical stability n ecessary to allow
early fu n ction an d to in du ce callu s to ach ieve u n ion .
Tim in g
Fractu re su rger y is em ergen cy, u rgen t, or elective. Em ergen cy
su rgery is im m ed iate for life an d lim b-th reaten in g problem s.
Wh ere as u rgen t su rgery occu rs w ith in 12 h ou rs, elective can
u su ally be booked leisu rely after 24 h ou rs an d is a plan n ed
in terven tion w ith th e optim ized patien t an d su rgeon .
Patien t preparation w ill be determ in ed by th e particu lar n a-
tu re of th e in ju r y an d patien t con d ition . Elective su rgery w ill
allow a proper case h istory to be com pleted to determ in e
com orbid ities an d assessm en t of risks in order to optim ize
th e ou tcom e. An optim al plan for fractu re care sh ou ld ex-
ist in clu d in g plan s for appropriate postoperative care deter-
m in ed w ith th e patien t. Patien ts w h o requ ire u rgen t su rgery
can u su ally be optim ized, as m ost of th is su rgery is don e to
preven t com plication s su ch as in fection in open fractu res by
debridem en t bu t patien t u n derstan d in g of th e severity an d
con sequ en ces of th e in ju ry w ill be lim ited.
Th e n al aspect is em ergen cy su rger y, an d th is is tim e-de-
pen den t based on th e in ju ries presen t su ch as h em orrh age,
vascu lar in su f cien cy, h ead in ju ry, or oth er associated in ju -
ries requ irin g em ergen cy life-savin g in terven tion . It m ay be
to save a life or a lim b an d little can delay it, bu t m ay also be at
a poin t wh ere th e w h ole con cept of lim b salvage is im possible
9
 du e to th e fact th at th e patien t is too ill an d requ ires ex ped ien t
su rger y. Th is is a speci c exam ple wh ere orth opedic trau m a
care su persedes fractu re care thu s m od ifyin g it in relation to
th e patien t con d ition . Th is is th e m u ltiply in ju red patien t.
In ju ry assessm en t an d con d ition s w ill m od ify an y treatm en t
as eviden ced by th e m u ltiply in ju red patien t, bu t preoperative
plan an d tactic m u st in clu de th e patien t an d th e associated
in ju r y as well as th e fractu re.
Ultim ately th e tim in g of su rgery is n ot determ in ed by th e
fractu re bu t by th e patien t’s ph ysiological con d ition an d soft-
tissu e in ju ry. Th e preoperative plan allow s th e su rgeon to go
th rou gh th e proposed operative xation procedu re, an d so to
iden tify poten tial problem s before th ey occu r. It is a visu aliza-
tion of th e process an d tech n iqu es th at m ay be n ecessar y to
perform th e redu ction an d xation .
2 Co n ce p t s o f fra ct u re fixa t io n
Th e th eoretical prin ciples u n derlyin g fractu re xation are th e
establish m en t of th e con cept of stability—absolu te or rela-
tive stability m ean in g m axim al or less m ech a n ical stability
after th e osteosyn th esis. Th e two m eth ods applied in order
to ach ieve th ese goals are com pression (static or dyn am ic) or
splin tin g (locked or u n locked). A variety of tech n iqu es an d
im plan t tech n ologies are applied in th e steps requ ired to carry
ou t th ese m eth ods ( Ta b 1-5 ).
Th e presen t section describes th e prin ciples an d m eth ods of
fractu re xation , com pression an d splin tin g, an d bon e h eal-
in g, an d th e reaction of bon e to im plan ts. Ch apter 2 describes
th e gen eral tech n iqu es u sed for redu ction an d th eir relation
to differen t types of xation . Ch apter 3 describes th e speci c
tech n iqu es an d procedu res u sed for th e less in vasive stabiliza-
10
tion system (LISS) an d lock in g com pression plate (LCP) tech -
n ologies an d th e h an d lin g of th e im plan ts an d in stru m en ts
in volved.
2 .1 Prin cip le s : a b s o lu t e ve rs u s re la t ive s t a b ilit y
Th ere are two m ain prin ciples in volved in fractu re xation —
absolu te stability an d relative stability. Absolu te stability is
best ach ieved th rou gh in terfragm en tal com pression u sin g th e
lag-screw tech n iqu e. In certain situ ation s absolu te stability is
ach ieved by plate com pression . Regard less of th e tech n iqu e
selected, th e su rgeon w ill n eed to obtain an an atom ical re-
du ction wh ich restores stru ctu ral con tinu ity of th e bon e an d
provides stable xation allow in g partial weigh t bearin g an d
early m u scle reh abilitation of th e extrem ity. Relative stability
im plies a m ore ex ible atrau m atic stabilization procedu re th at
h as th e advan tage of preservin g blood su pply [2]. Th e corre-
spon din g tech n iqu es can th erefore be referred to as “biologi-
cal in tern al xation ” ( Ta b 1-4 ).
Th e two pr in ciples of fractu re xation resu lt from th e con cept
of stability ( Fig 1-1).
Th e term “stability” is u sed h ere in accordan ce w ith its m ean -
in g in clin ical practice—ie, referrin g to th e exten t to wh ich
Sp e ct ru m o f s t a b ilit y
a fte r xa tio n
Sta b ilit y is a sp e ctru m fro m
to ta l to n o n e ,
Ab s o lu t e s t a b ilit y in o th e r w o rd s In s t a b ilit y
a b so lu te to re la tive
Re la t ive s t a b ilit y
Fig 1-1 Sp e ctru m o f stab ility.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

load-depen den t d isplacem en t between th e fractu re su rfaces con trast, if th e fractu re zon e is splin ted u sin g im plan ts th at
is possible. If th e fractu red su rfaces are com pressed in ac- do n ot exert com pressive forces, relative d isplacem en t can be
cordan ce w ith th e prin ciple of absolu te stability, th en on ly proportion al to th e load applied an d in in verse proportion to
m in im al displacem en t between th e fragm en ts can occu r. By th e rigidity of th e splin tin g device wh ich bridges th e fractu re.

Diffe re n t co n ce p t s o f fra ct u re xa t io n

Prin cip le o f fra ctu re fixa tio n Me th o d Te ch n iq u e a n d im p la n ts fu n ctio n Bo n e h e a lin g

= gra d e o f s ta b iliza tio n

Ab s o lu t e s t a b ilit y Co m p re s s io n La g scre w (co n ve n tio n a l scre w) Dire ct

= h igh
Sta tic1 La g scre w a n d p ro te ctio n p la te

Co m p re ssio n p la te

Te n sio n b a n d

Dyn a m ic 2 Te n sio n b a n d p la te

Bu t tre ss p la te 6

Sp lin t in g Exte rn a l sp lin tin g Exte rn a l fixa to r

In tra m e d u lla ry sp lin tin g In tra m e d u lla ry n a il

Lo cke d 3
In te rn a l e xtra m e d u lla ry Brid gin g w ith s ta n d a rd p la te
sp lin tin g
Brid gin g w ith lo cke d in te rn a l fixa to r

Exte rn a l sp lin tin g Co n se rva tive fra ctu re tre a tm e n t

(ca s t, tra ctio n)

Un lo cke d 4 In tra m e d u lla ry sp lin tin g 5 Ela s tic n a il

Re la t ive s t a b ilit y
K-w ire In d ire ct
= lo w
1
Fra ctu re u n d e r co m p re ssio n -im p la n t u n d e r te n sio n .
2
Co m p re ssio n u n d e r fu n ctio n .
3
Lo cke d sp lin tin g w ith co n tro l o f le n gth , a lign m e n t, a n d ro ta tio n .
4
Sp lin tin g w ith lim ite d co n tro l o f le n gth , a lign m e n t, a n d ro ta tio n .
5
Ca n b e ch a n ge d to d yn a m ic co m p re ssio n in ca se o f a d yn a m ica lly lo cke d n a il o r d yn a m ic e xte rn a l xa to r.
6
Usin g a n a n gu la r s ta b le p la te —scre w co n stru ct ( ie , LISS o r LCP w ith LHS) a s b u t tre ss p la te , th e p la te a cts a s a b la d e p la te . Occa sio n a lly a b u t tre ss p la te m a y b e
co n sid e re d a s a sp lin t.

Ta b 1-5 Diffe re n t co n ce p ts o f fractu re xa tio n .

11
 De fin it io n s
Stability is de n ed as th e degree of displacem en t between
fractu re fragm en ts.
Rigid ity is de n ed as th e ph ysical properties of th e im plan t or
th e ability of th e im plan t to cou n ter deform ation . However, a
rigid im plan t m ay be applied to a fractu red bon e in a way th at
is provid in g poor stability, ie, in stability.
Stability after osteosyn th esis is a spectru m from m in im al to
absolu te. Wh ere th ere is n o m otion between th e fractu re frag-
m en ts, u n der load absolu te stability exists. Th e secon d con d i-
tion ; relative stability, is wh ere th ere is som e m otion between
th e fractu re fragm en ts. Th e am ou n t of stability between frac-
tu re fragm en ts is also determ in ed by th e degree of im paction
between th e fragm en ts. Th is w ill produ ce in tim ate con tact
an d restore stru ctu ral con tin u ity to th e bon e, thu s restorin g
th e load-bearin g capacity to th e bon e (im plan t-bon e con stru ct
sh ares th e stresses). However, th e degree of stability varies
depen d in g u pon th e bon e con tact or m eth odology. Healin g is
possible in th is variable stability situ ation as dem on strated in
th e strain th eory of Perren .
St ra in t h e o r y
Accordin g to th e strain th eor y, for a given am ou n t of displace-
m en t, th e w idth of th e gap determ in es th e resu ltin g defor-
m ation (strain) of th e repair tissu e. Wh en th e strain exceeds
th e elon gation at ru ptu re of th e tissu e con cern ed th e tissu e
is d isru pted or can n ot be produ ced. If th is situ ation occu rs
repetitively at th e fractu re site, th ese cells are con stan tly de-
stroyed an d n ever rem odel th e fractu re site bu t are u ltim ately
reabsorbed. If th ere is a larger gap wh ich m an y of th ese sim i-
lar cells n ow traverse, a sim ilar am ou n t of m otion , or even
greater, w ill allow each of th ese cells to ex pan d. Becau se
th ere are m ore cells in th e gap th ey are able to absorb m ore
d isplacem en t, rem ain w ith in th eir ow n strain levels, an d n ot
becom e d isru pted. Th e larger th e gap, th e better th e ch an ce
12
th at secon dary bon e h ealin g w ill occu r. Th ere are tissu e-spe-
ci c strain toleran ces th rou gh ou t th e process of bon e u n ion
begin n in g w ith granu lation tissu e wh ich h as a 100% strain
level, dow n to lam ellar bon e wh ich on ly h as a 2% strain level
an d can be ver y easily disru pted. Depen din g on th e ph ase
of fractu re h ealin g an d th e degree of fractu re stability pres-
en t, u n ion m ay or m ay n ot occu r. Assu m in g th at th ere is an
adequ ate blood su pply, th e given stability of th e fractu re xa-
tion w ill determ in e th e type of h ealin g an d also th e im plan t
fatigu e an d failu re th ereof if appropriate stability is n ot ch o-
sen . In versly low strain (large defect) w ill n ot in du ce bon e
form ation .
To su m m ar ize, bon e u n ion depen ds on respectin g th e ca-
pacity of th e soft tissu es to m ain tain vascu lar su pply to th e
bon e, on th e redu ction of th e fractu re, an d on applyin g th e
tech n iqu e wh ich provides th e n ecessary stability for u n ion to
occu r. Absolu te stability m ean s lack of displacem en t an d de-
m an ds an atom ical redu ction an d in terfragm en tar y com pres-
sion , wh ile relative stability perm its th e fractu re fragm en ts to
m ove w ith in th eir de n ed am ou n t of strain an d is ach ieved
w ith an ax ial align ed redu ction splin tin g.
Ela s t ic, re ve rs ib le ve rs u s p la s t ic , irre ve rs ib le d e fo rm a t io n
Absolu te stability m ean s th at th ere is n o displacem en t of, or
n o relevan t displacem en t or m ovem en t between , th e frag-
m en ts u n der a ph ysiological load.
In tern al xation tech n iqu es based on th e prin ciple of relative
stability are ach ieved u sin g elastic ex ible splin tin g. Flex ible
fractu re xation refers to a xation th at is elastic u n der load.
Elastic in dicates th at a certain am ou n t of deform ation of th e
m ech an ical con stru ct wh ich occu r u n der a speci c (perm it-
ted) load. Wh en th e load in g cycle is com pleted, th e im plan ts
w ill retu rn to th eir origin al form w h en u n loaded —reversible
deform ation .
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
An overload situ ation m ay lead to plastic irreversible defor-
m ation of th e im plan t. Plastic deform ation refers to perm a-
n en t displacem en t an d, th erefore, secon dar y d islocation of
th e fractu re = m alalign m en t.
Elastic an d stable on ly differ in th e poin t of view of th e ob-
ser ver: elastic tech n iqu es are aim ed at reversible (th at is, elas-
tic) deform ation ; stable tech n iqu es are u n derstood in term s
of th e d isplacem en t of fragm en ts—absolu tely stable m ean in g
absolu tely n o d isplacem en t; relatively stable m ean in g a cer-
tain am ou n t of d isplacem en t th at retu rn s to th e in itial state
after com pletion of th e load cycle; an d u n stable, wh ich is as-
sociated w ith perm an en t displacem en t, th at is, secon dar y dis-
location .
Ab s o lu t e s t a b ilit y
Th e prin ciple of absolu te stability m ean s th at th e com pressed
fractu re su rfaces do n ot displace u n der load. Th is requ ires an
an atom ical precise redu ction an d in terfragm en tal com pres-
sion . Com pression is ach ieved th rou gh preload an d friction on
th e fractu re su rface an d h ealin g is by direct bon e u n ion .
Th e featu res/ requ irem en ts of absolu te stability in clu de:
Precise an atom ical (m ostly open , d irect; u n frequ en t per-
cu tan eou s, d irect) redu ction .
Stable fractu re xation (com pression m eth od).
Presh apin g th e plate to m atch th e an atom y of th e bon e.
Com pression cau sed by preload in g of th e bon e an d a cer-
tain am ou n t of deform ation in th e fractu re gap.
Best ach ieved by lag screw an d/or com pression plates.
Preload in g of th e lag screw to 2500 N.
Ax ial preload in g of th e com pression screw s.
Th e redu ced bon e fragm en ts form part of th e con stru ct
an d carr y load. Th e bon e is th e com pon en t th at bears th e
m ain load.
Elim in ation of relative m otion between th e bon e
fragm en ts.
Preven tion of elon gation an d deform ation of th e repair tis-
su e, especially in th e fractu re gap.
Rem odelin g of th e h aversian system .
Direct bon e h ealin g (osteon al rem odelin g) of cortical an d
can cellou s bon e; also of stably xed n ecrotic bon e.
Absolu te stability can also be ach ieved m ore th eoretically
by u sin g an extern al xator.
High stability can be ach ieved by com pression u n der fu n c-
tion u sin g th e ten sion ban d tech n iqu e.
Th e disadvan tage of tech n iqu es in volvin g th is m eth odologica l
prin ciple is th at th ey are associated w ith bon e devitalization .
Re la t ive s t a b ilit y
Th e prin ciple of relative stability is de n ed as d isplacem en t
between fractu re fragm en ts th at is com patible w ith fractu re
h ealin g. Th is m otion is below th e cr itical strain level of repair
tissu e as determ in ed by th e strain th eory. Relative stability
requ ires in d irect h ealin g an d callu s. Relative stability is de-
pen den t u pon con n ectin g a splin t u su ally th at is less rigid
th an bon e, by a cou plin g device su ch as lock in g h ead screw s
or th readed bolts. Th ese splin ts redu ce, bu t do n ot abolish ,
fractu re m otion so pain is redu ced an d active m u scle reh abili-
tation is practical. Th e types of splin ts available are locked in -
tram edu llar y n ails, eith er ream ed or u n ream ed, bridge plates,
or extern al xation devices. Occasion ally a bu ttress plate m ay
be con sidered as a splin t. All of th ese splin ts h ave in com m on ,
th e fact th at th ey bridge a defect in th e bon e th at is n ot able
to resist a load.
Th e featu res of relative stability in clu de:
Elastic xation after in d irect closed redu ction , providin g
biologically optim al con d ition s. Elastic deform ation of th e
im plan ts occu rs. Th e effects of resor ption at th e en ds of
th e bon e fragm en t are positive (dem on stratin g good blood
su pply) an d th e fractu re gap en larges. Th e fractu re th en
con solidates w ith exu beran t callu s.
13
 In d irect h ealin g of bon e. Healin g occu rs becau se of pres-
er vation of biological fu n ction (an d rapid restoration of
blood perfu sion).
2 .2 Me t h o d s : co m p re s s io n ve rs u s s p lin t in g
Th e two basic m eth ods u sed for in tern al fractu re xation are
com pression —th e con ven tion al screw/ platin g tech n iqu e ap-
plyin g in terfragm en tar y com pression , in wh ich th e aim is ab-
solu te stability; an d splin tin g—th e biological in tern al xation
m eth od in wh ich th e locked in tram edu llar y n ail, th e exter-
n al xator, or th e in tern al xator span s th e fractu re zon e an d
th e aim is to ach ieve relative stability [2 , 6 ].
Co m p re s s io n
Com pression is a safe m eth od of ach ievin g h igh ly stable xa-
tion th at is su itable for sim ple fractu re pattern s in an y seg-
m en t of th e bon e. In practice, th e aim of th is m eth od is to
ach ieve precise an atom ic redu ction of th e fragm en ts, stable
xation , an d early reh abilitation th at protects fu n ction .
Th is leads to d irect bon e h ealin g. Static com pression can be
ach ieved u sin g th e lag screw tech n iqu e an d/or th e con ven -
tion al com pression platin g tech n iqu e. For large an d/or den se
bon es com pression plate xation ach ieves absolu te stability
bu t th e fragm en ts h ave to be in con tact rem ote to th e plate
by preben din g th e plate. It sh ou ld be n oted th at despite ap-
plyin g absolu te stability by com pression an d preben d in g, th e
com pression is m ain tain ed on ly if it is greater th an fu n ction al
d istraction applied. Th e friction produ ced w ill resist sh ear as
lon g as th e sh ear force is less th an friction . Static com pres-
sion can be also ach ieved by applyin g an extern al xator w ith
com pression .
Dyn a m ic co m p re s s io n
Dyn am ic com pression can be ach ieved u sin g th e ten sion ban d
tech n iqu e, by ten sion ban d platin g or bu ttress platin g (occa-
sion ally a bu ttress plate m ay be con sidered as a splin t). Th is
14
varian t of stability is th e application of dyn am ic com pression
or m obilizin g th e ph ysiological forces of m u scle or th e an at-
om y of eccen tr ically loaded bon es w ith a fu n ction al load. In
th is situ ation th e im plan t is applied to th e ten sion or con vex
side an d th e ten sile force is tran sform ed by th e im plan t to dy-
n am ic com pression on th e opposite side to th e im plan t. If th e
load is d irectly applied over th e fractu re, com pression occu rs.
If th at load is d isplaced eccen trically, com pression w ill occu r
on th e con cave side an d ten sion on th e con vex side. By sim ply
add in g a ten sion ban d, th is force is n eu tralized, bu t it is also
im portan t to en su re th at th ere is an in tact bu ttress opposite
th e ten sion cortex.
Sp lin t in g
Splin tin g is a m ore ex ible m eth od of xation in ten ded for
u se in treatin g m u ltifragm en tar y fractu res in th e m etadiaph -
yseal an d d iaphyseal region s of a lon g bon e. Th is prin ciple
of relatively stable fractu re xation can be im plem en ted by
applyin g extern al splin ts su ch as th e extern al xator, or in -
tern al splin ts su ch as locked n ails, bridgin g plates, or locked
in tern al xators. Relative stability depen ds on con n ectin g a
splin t u su ally less rigid th an bon e by a cou plin g device su ch
as screw s. Th ese splin ts redu ce, bu t do n ot abolish , fractu re
m otion so pain is redu ced an d active mu scle reh abilitation is
practical. All of th ese splin ts h ave in com m on th e fact th at
th ey bridge a defect in th e bon e wh ich is n ot able to carr y a
load. In order to fu n ction , splin ts m u st be cou pled to th e bon e
or lim b segm en t.
Lo cke d s p lin t in g
Extern al xators, locked n ails, an d locked in tern al xators
are locked splin ts. Factors th at affect th e stability of an y splin t
are th e size of th e im plan t givin g it stren gth , th e position of
th e im plan t to th e bon e, position of its cou plin g to th e bon e
an d th e fractu re pattern . Th e closer th e im plan t position to
th e in tram edu llary position th e stron ger it is, an d weakest
th e fu rth er away it is. Th e position of th e cou plin g devices
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
w ill also con trol stability in all splin ts; th e m ost stable be-
in g th e n ear–far position an d th e least stable bein g far–far. A
mu ltifragm en tary fractu re or a com plex fractu re are su ited
best fractu re pattern s for pu re splin tin g as th ey h ave sm all
am ou n ts of strain across th e m u ltiple an d large gap. Relative
stability leads to in d irect bon e h ealin g. Th e im plan ts span th e
fractu re zon e after in d irect closed redu ction an d preser ve th e
an atom ical axis, len gth , an d rotation of th e fractu red bon e
u n til con solidation occu rs. Th e im plan t is th e com pon en t th at
bears th e m ain load u n til early callu s sh ears th e load.
On e com plication of a n on glid in g locked splin t is seen in th e
situ ation wh ere a plate is applied to th e bon e w ith ou t ade-
qu ate stability or com pression at th e in terface between th e
two fractu re fragm en ts. Motion occu rs—th e fractu re reab-
sorbs—m otion con tin u es to occu r an d becau se th e im plan t
m ain tain s d istraction an d can n ot allow th e fractu re to col-
lapse to a stable position , it w ill loosen an d fail. With a locked
n ail th is m ay occu r bu t it can be con verted very easily to a
Ta b 1-6 Indica tions for compre ssion vs splinting me thod using pla te s
Co m p re ssio n 1 Sp lin tin g 2
Sim p le fra ctu re s:
d iap h yse a l + +/ –
m e tap h yse a l + +/ –
Mu ltifra gm e n ta ry fra ctu re s:
d ia p h yse a l – +
m e ta p h ys e a l – +
Os te o to m ie s + +
Articu la r fra ctu re s + –
Fra ctu re s in p o ro tic b o n e s +/ – + n ess.
+ = ye s; – = no; +/ – = u n d e r d iscu ssio n a n d o n ly in sp e ci c situ a tio n
1
ie , la g scre w a n d / o r co n ve n tio n a l p la tin g te ch n iq u e .
2
ie , m in im a lly in va sive p la te o ste o s yn th e sis w ith lo cke d in te rn a l xa to rs.
glidin g splin t by rem oval of on e of th e lockin g cou plin gs an d
allow in g th e fractu re to u n dergo com pression an d retu rn to
its position of stability.
In d ica t io n s
Th e in dication s for u sin g th e eith er con ven tion al platin g tech -
n iqu e (com pression m eth od) or biological in tern al xation u s-
in g a plate (th e splin tin g m eth od w ith th e plate span n in g th e
fractu re zon e) differ ( Ta b 1-6 ) accordin g to fractu re location ,
fractu re type, soft-tissu e con dition s, an d qu ality an d vascu lar-
ity of th e bon e. If th e blood su pply to th e fractu re is severely
dam aged an d th e bon e is n ecrotic, recovery m ay take m any
m on th s. Con ven tion al com pression xation th en allows for
protected in tern al rem odelin g over a lon g period. Situ ation s
of avascu larity requ ire lon g-term absolu te stability. However,
if th e blood su pply is good or can be restored, th en it m akes
sen se to take advan tage of th e addition al poten tial of bon e bi-
ology, an d splin tin g is con sidered to be th e m eth od of ch oice.
Th e two prin ciples of stabilization —absolu te an d relative sta-
bility—an d both m eth ods—in terfragm en tary com pression
an d splin tin g—are in com patible in th e sam e fractu re site.
2 .3 Bo n e h e a lin g
Pro p e r t ie s a n d re a ct io n o f b o n e t o fra ct u re a n d im p la n t s
Bon e is stron gest in com pression becau se th e apatite, or m in -
eral ph ase, resists best com pression . However, bon e w ill tear
apart becau se of th e weak n ess of collagen bers in ten sion .
Can cellou s bon e is sim ilar to cortical bon e bu t less force is
requ ired to d isru pt it. Bon e is like a stiff sprin g in th at it w ill
respon d by sh orten in g an d tak in g u p force applied to it. Im -
plan ts ch an ge th e deform ability an d th e con tribu tion to stiff-
Blo o d s u p p ly
Bon e blood ow is a two-way system . Th e n orm al blood su p-
ply to cortical d iaph yseal bon e is th rou gh a n u tr ien t m edu l-
15
 lary arter y th at su pplies th e in n er 2/ 3 of th e cortex-en dosteal
vessels wh ile th e periosteal vessels su pply th e ou ter 1/ 3 of th e
cortex. Th ese periosteal vessels reach th e bon e th rou gh fascial
an d m u scu lar attach m en ts to bon e. Th e m etaph ysis h as a rich
blood su pply from th e nu m erou s vessels in soft-tissu e attach -
m en ts. In both areas sign i can t in tern al an astom otic ch an n els
ex ist between th e per iosteal an d en dosteal vessels resu ltin g in
blood ow in eith er d irection ; in side–ou t or ou tside –in . In -
tern ally, th e en dosteal vessels bran ch off in to radial arterioles
th at en ter in to th e osteon form ed by th e osteoblast as th ey
form bon e. Thu s cortical bon e sh ow s a ver y com plex stru ctu re
wh ich allow s capillaries to develop in th e h aversian can als
an d lin ks th e en dosteal ow to th e periosteal ow. Follow in g
fractu re th is com plex vascu lar arran gem en t is d isru pted. Th e
soft tissu es m ay be dam aged by th e acciden t, tran sportation ,
an d su rgeon , lead in g to periosteal loss an d th en su rgery w ill
lead to fu rth er devascu lar ization .
Fra ct u re
Wh en bon e is m ech an ically overloaded, it fractu res. A frac-
tu re resu lts in sign i can t soft-tissu e dam age th rou gh cavita-
tion s arou n d th e bon e en ds wh ich cau ses th e fractu re en ds
to lose th eir blood su pply. Th e reaction of bon e an d adjacen t
soft tissu e to th e fractu re stim u lates bon e h ealin g to restore
th e origin al bon y in tegrity. Th is is based u pon livin g plu ripo-
ten tial cells, wh ich are locally available or tran sported by th e
blood su pply of th e soft tissu e. Th e su rgeon is respon sible for
providin g th e appropriate m ech an ical environ m en t to facili-
tate h ealin g, as well as assu rin g m ain ten an ce of align m en t by
splin tin g or fractu re xation .
Th e total am ou n t of in ju ry cau sed to th e bon e an d su rrou n d-
in g soft tissues is th e su m of th e in ju ries cau sed by th e trau -
m a, tran sport, an d su rgery. Th e su rgical in ju ry con sists of
th e dam age cau sed by th e redu ction , plu s th e approach , plu s
xation of th e fractu re plu s im plan t con tact. Th e am ou n t of
iatrogen ic dam age can be redu ced by m od ifyin g th e su rgical
16
tech n ique—eg, th e way in wh ich th e soft tissues are h an dled
an d th e tech n iqu es u sed for reduction an d xation (in sertion
an d ch oice of im plan t an d bon e–im plan t in terface).
Prim a r y b io lo gica l e ffe ct s o f im p la n t s
Fractu re xation s resu lt in varyin g degrees of stability, pri-
m arily a fu n ction of th e im plan t an d its application . A stable
bu t exibly xed fractu re m ay becom e visibly displaced in an
elastic fash ion (by as m u ch as 20% of th e gap w idth ) du r-
in g load in g. An absolu tely stable fractu re does n ot d isplace,
even m icroscopically. Th e degree of stability provided h as
an im portan t effect on th e type of bon e h ealin g th at occu rs.
Flex ible xation resu lts in m icrom otion , wh ich in du ces exu -
beran t callu s clearly visible on x-rays, wh ile stable xation
d im in ish es th is. Here lies th e relevan ce of m ech an obiology to
osteosyn th esis.
Depen din g on th e m ech an ical en viron m en t, bon e w ill h eal in
two ways. Absolu te stability leads to d irect h ealin g, an d ex-
ible xation leads to in direct bon e h ealin g [6 ].
Dire ct b o n e h e a lin g
Direct bon e h ea lin g is a biologica l process of osteon a l bon e
rem odelin g [32]. Th is bypasses ca llu s for m ation (in d irect
h ea lin g) a n d is, in essen ce, con t act h ea lin g bet ween t wo
avascu lar bon e su r faces. Rem odelin g occu rs w h ere t h ere is
con tact. Alt h ou gh t h ere is a qu a litat ive cor respon den ce be-
t ween th e basic aspects of h ea lin g in cor t ica l a n d ca n cel-
lou s bon e, th e volu m e-su r face rat io d iffers, a n d th e speed
a n d reliability of h ea lin g are t h erefore gen era lly better in
ca n cellou s bon e [3 3 ]. On ly m in or ch a n ges ca n be obser ved
rad iograph ica lly. In absolu tely stable xation , ca llu s for m a-
t ion is on ly m in im ally visible, if at a ll. Du r in g t h e rst few
days after su rger y, th ere is m in im a l act ivity in th e bon e n ear
th e fractu re. Th e h em atom a is t h en resorbed or tra n sfor m ed
in to repa ir tissu e, or bot h . Th e swellin g su bsides, a n d th e
su rgica l wou n d h ea ls. After a few weeks, th e h aversia n sys-
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
tem sta r ts rem odelin g t h e bon e in ter n a lly [3 4 ]. At th e sa m e
tim e, gaps bet ween im per fect ly t t in g fragm en t su r faces be-
gin to ll w ith la m ellar bon e t h at is or ien t ated a lon g t h e gap
pla n e. Du r in g t h e su bsequ en t weeks, cu ttin g con es reach th e
fractu re a n d cross it w h erever th ere is bon e con t act or th e
gap is m in u te [3 5 ] , produ cin g a m u lt iple m icrobr idgin g effect
th rou gh n ew ly for m ed osteon s t h at cross th e gap. Gap h ea l-
in g resu lts from th e developm en t of gra n u lat ion tissu e in
th e sm a ll gaps w h ich t h en m atu res in to la m ella a n d cor tica l
bon e. Th is process is n ot faster t h a n con tact h ea lin g a n d ca l-
lu s is n ot seen . Th e fractu re gap w ill n ot w iden u n less t h ere
is a in st ability.
In d ire ct b o n e h e a lin g
In d irect bon e h ealin g requ ires gran u lation tissu e an d callu s
precu rsors, an d is th e n orm al m ech an ism of bon e h ealin g. As
callu s form s an d m atu res th e callu s m ass stiffen s an d frac-
tu re stability w ill im prove. Th e callu s in creases th e diam eter
of th e bon e at th e fractu re site an d im proves th e m ech an ical
leverage. Th is allow s for effective bon e h ealin g wh ich can be
facilitated by splin tin g (eg, a sim ple cast).
In d irect bon e h ealin g is very sim ilar to th e process of em bry-
ological bon e developm en t an d in clu des both in tram em bra-
n ou s an d en doch on dral ossi cation . In d iaph yseal fractu res,
it is ch aracterized by th e form ation of a callu s [32], th e h eal-
in g process wh ich can be d ivided in to fou r stages: in am m a-
tion , soft callu s, h ard callu s, an d rem odelin g [3 6 , 3 7 ].
In am m ation starts soon after th e fractu re occu rs an d
lasts u n til brou s tissu e, cartilage, or bon e form ation be-
gin s (1–7 days after fractu re). In itially, a h em atom a form s,
alon g w ith in am m atory exu date from ru ptu red blood
vessels. Accom pan ied by soft-tissu e in ju r y an d platelet de-
granu lation , released cytok in es in itiate th e in am m atory
respon se. Th e h em atom a is gradu ally replaced by granu la-
tion tissu e. Osteoclasts begin to rem ove n ecrotic bon e at
th e fragm en t en ds.
Soft callu s. Even tu ally, pain an d swellin g decrease an d
soft callu s is form ed, approxim ately 2–3 weeks after th e
fractu re. Th e fragm en ts are n o lon ger able to m ove freely,
an d th ere is su f cien t stability to preven t sh orten in g, bu t
n ot an gu lation . Progen itor cells from th e periosteu m an d
en dosteu m becom e osteoblasts. In tram em bran ou s apposi-
tion al bon e grow th , away from th e fractu re gap, starts to
form a cu ff of woven bon e su bperiosteally an d en dosteally.
In grow th of blood vessels in to th e callu s follow s th e pattern
of bon e grow th . Closer to th e fractu re gap, m esen ch ym al
progen itor cells proliferate an d m igrate th rou gh th e cal-
lu s, differen tiatin g in to broblasts or ch on drocytes, each
produ cin g its ch aracteristic extracellu lar m atrix [3 8 ].
Hard callu s. Wh en th e fractu re en ds are lin ked togeth er by
soft callu s, th e h ard callu s develops u n til th e fragm en ts are
rm ly u n ited by n ew bon e (3 –4 m on th s). As in tram em -
bran ou s ossi cation con tinu es at th e periosteu m , cartilage
w ith in th e gap is con verted in to rigid calci ed tissu e by
en doch on d ral ossi cation . Bon y callu s grow th begin s in
areas rem ote from th e fractu re th at are m ech an ically idle,
an d slow ly progresses toward th e gap. Th e in itial osseou s
bridge is form ed extern ally or w ith in th e m edu llar y can al
away from th e cortex. Th en , th rou gh en doch on dral ossi -
cation , th e soft tissu e in th e gap is con verted.
Mech an ics of fractu re callu s. Fractu re callu s of m in eral-
ized cartilage occu rs between bon e en ds an d is called “gap
callu s”; alon g th e m edu llar y cavity (m edu llary callu s) an d
on th e ou ter cortex (periosteal callu s). Th e im portan ce of
callu s is to provide in itial stability th e fractu re en ds so th at
osteogen esis can occu r. Th e stiffn ess gen erated m u st resist
ben din g an d torsion al forces. Th is stiffn ess is m in im al in
th e early ph ase an d fractu re im m obilization or in tern al
xation is thu s em ployed. If absolu te stability is provided
by im plan ts, th en th ere is n o stim u lation for th e callu s
process, an d h ealin g is by “prim ary” in ten tion , ie, gap cal-
lu s h ealin g. In th is case, th e con solidation process is es-
sen tially bypassed in th e rem odelin g ph ase.
17
 a
a

b
b

Fig 1-3 a – b Callu s fo rm a tio n w ith im plan ts.

a Th e pre se n ce o f th e na il in h ibits callu s fo rm a tio n in th e e n d o s-
te u m .
b Pe rio ste al callu s is fo rm e d o n th e sid e o pp o site to th e pla te . In
ca se o f a no n co n tact p la te th e re is callu s fo rm a tio n a lso b e n e a th
c th e p la te .

of th e bon e cross-section th rou gh th e callu s m ass. With

d
Fig 1-2 a – d Callu s fo rm a tio n in fractu re d b o ne s pro vid e s re sistance
again st b e n d in g fo rce s. Ab u n d an t ca llu s fo rm a tio n in cre a se s th e
re sistan ce .
a Acu te fractu re .
b Me d u llary callu s.
c Pe rio ste a l callu s.
d Me d u llary an d p e rio ste al ca llu s.
In in direct fractu re h ealin g, th e weakest callu s is gap cal-
lu s gen erated between well-redu ced fractu re en ds. Medu l-
lar y callu s provides som e resistan ce to ben d in g m om en ts.
It is periosteal or extracortical callu s th at is m ost effective
in provid in g ben d in g forces, an d ben d in g an d torsion al re-
sistan ce w h ich is proportion al to th e 4th power of th e rad ii
in tram edu llar y devices, on e is able to see large extracorti-
cal callu s, wh ile m edu llar y callu s is m in im al ow in g to th e
presen ce of th e n ail. With plate osteosyn th esis, th ere is
abu n dan t m edu llary callu s. Periosteal callu s also form s on
th e side opposite to th e plate, especially on th e com pres-
sion side of th e bon e ( Fig 1-2 ; Fig 1-3 ).
Rem odelin g. Rem odelin g starts on ce th e fractu re h as sol-
id ly u n ited w ith woven bon e. Woven bon e is th en slow ly
replaced by lam ellar bon e th rou gh su rface erosion s an d
h aversian rem odelin g. Th is process can take from a few
m on th s u p to several years. It lasts u n til th e bon e h as com -
pletely retu rn ed to its origin al m or ph ology, in clu d in g res-
toration of th e m edu llary can al [39 ].
Fractu re h ealin g in can cellou s bon e. In con trast to in d i-
rect h ea lin g in cortical bon e, h ealin g in can cellou s bon e
occu rs w ith ou t th e form ation of a sign i can t callu s. After
th e in am m atory stage, bon e form ation is dom in ated by
in tram em bran ou s ossi cation [33 , 4 0 ] —probably du e to
th e trem en dou s an giogen ic poten tial of trabecu lar bon e,
as well as th e often m ore stable xation th at is u sed for

18
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
m etaph yseal fractu res. In u nu su al cases w ith su bstan tial
in terfragm en tary m otion , in term ed iary soft tissu e m ay
form in th e gap, bu t th is is u su ally brou s tissu e th at is
soon replaced by bon e.
Se co n d a r y b io lo gica l e ffe ct s o f im p la n t s
Foreign -body m em bran e. A foreign -body m em bran e bu ilds u p
arou n d any im plan t, depen din g on th e m aterial an d its su rface.
After capsu lectom y of th e h ip join t an d total h ip replacem en t,
for exam ple, a n ew capsu le develops [41]. Stain less-steel im -
plan ts trigger a stron ger reaction th an titan iu m . Experim en tal
eviden ce su ggests th at absen ce of th e m em bran e m ay be in -
stru m en tal in provid in g protection again st path ogen s [42].
Rem odelin g. Sim u ltan eou s resor ption an d form ation of corti-
cal bon e th rou gh h aversian rem odelin g always occu rs after
an y trau m a to bon e or in th e vicin ity of bon e. Th e trau m a
can also be iatrogen ic—eg, after in tern al xation . Th e traces
of su ch rem odelin g rem ain lon g after im plan tation , an d prob-
ably for as lon g as th e im plan t is presen t. Sequ estration of
bony islan ds m ay occasion ally resu lt from th is excessive re-
m odelin g activity [43 ].
Ro le o f t h e p e rio s t e a l b lo o d s u p p ly
Medu llary blood su pply is im portan t to th e d iaph ysis for bon e
h ealin g; an in tram edu llary n ailin g d isru pts th is sou rce. Peri-
osteal blood ow alon e can n ot reach th e en dosteu m an d en d-
osteal callu s m ay be in h ibited. An y bon e n ecrosis th at occu rs
as a con sequ en ce of th e trau m a is beyon d th e su rgeon ’s con -
trol, bu t it is u sefu l to u n derstan d its con sequ en ces. Iatrogen ic
bon e n ecrosis is th e resu lt of th e su rgical approach to bon e,
th e m an ipu lation s requ ired to redu ce th e fractu re, an d an y
procedu res preparator y to im plan t in sertion an d xation —eg,
m edu llar y ream in g, periosteal strippin g, or en dosteal perfo-
ration . Plate xation preser ves th e m edu llar y an d m etaph y-
seal vessels as well a periosteal vessels on th e opposite side of
th e “footprin t” cau sed by th e plate.
Im pairm en t of th e blood su pply to th e periosteu m at th e
plate –bon e in terface also cau ses porosity of th e u n derlyin g
bon e. For th is reason , th e LCP an d th e LC-DCP h ave a trap-
ezoidal cross-section an d lateral u n dercu ts th at redu ce th e
con tact area an d facilitate th e rem oval.
Th e in tern al xator (ie, n on con tact plates) aim s to preser ve
blood ow u n der th e plate by m in im izin g con tact w ith th e
bon e. Mu ch of th e vascu lar su pply to th e callu s area is de-
rived from th e su rrou n d in g soft tissu e. Callu s perfu sion is of
th e u tm ost im portan ce an d m ay determ in e th e ou tcom e of
h ealin g. Bon e can on ly form wh en su pported by a vascu lar
n etwork, an d cartilage w ill persist in th e absen ce of su f cien t
perfu sion . However, th is an giogen ic respon se is sen sitive to
both th e m eth od of treatm en t an d th e in du ced m ech an ical
con d ition s.
Th e vascu lar respon se appears to be greater after m ore
exible xation , possibly du e to larger am ou n ts of osseou s
callu s [2].
Large tissu e strain s cau sed by in stability redu ce th e blood
su pply, especially in th e fractu re gap [32].
Su rgica l h a n d lin g a n d b o n e vit a lit y
Vascu lar su pply. Th e m edu llary blood vessels can be in ju red
by drillin g or screw in sertion , or both . In stable con d ition s,
th e ax ial blood ow recovers rapid ly [12 , 4 4 , 4 5 ]. Mu ltiple
screw s crossin g th e m edu llar y can al can affect th e region al
vascu lar pattern an d cau se abn orm al rem odelin g of th e en d-
osteu m . In add ition , th e presen ce of a nu m ber of align ed
screw s in a sin gle cortex im pairs th e n orm al perfu sion of th e
cortical bon e. Mon ocortical screw s on ly affect on e cortex an d
possibly also th e cen tral m edu llary blood ow.
Th erm al n ecrosis. It h as been sh ow n in vitro th at dr illin g
gen erates h eat th at is locally in com patible w ith vital biologi-
cal stru ctu res [4 4]. In add ition , repeated d rillin g can in crease
19
 h eat n ecrosis in bon e. Drill bits h ave to be kept sh ar p an d
mu st be replaced if th ey becom e blu n t; th e sam e applies to
self-drillin g, self-tappin g lock in g h ead screw s. Irrigation an d
coolin g du rin g d rillin g procedu res are im portan t for m in i-
m izin g of h eat.
Lo ca l re s is t a n ce t o in fe ct io n a n d n e cro s is
An oth er con sideration is th e im plan t m aterial. Titan iu m is
m ore biologically in ert an d vessels w ill grow righ t u p to th e
plate edge. Stain less steel m ay be less effective as blood su p-
ply is redu ced n ear th e plate—a poten tially avascu lar area for
bacteria an d a dead space allow in g bacterial grow s w ith ou t
defen se.
Earlier research dem on strated th e effect of stability on su s-
ceptibility to in fection [4 6 , 47 ]. Con tact w ith th e im plan t
cau ses periosteal n ecrosis. Sin ce n ecrosis im pedes in fection
resistan ce, th e bon e–im plan t con tact sh ou ld be restricted
[2 , 12]. In fection can spread alon g an exten ded con tigu ou s
area of n ecrosis.
Local resistan ce to in fection was stu d ied ex perim en tally u s-
in g h u m an path ogen ic Staphylococcus aureus in sim u lated in -
tern al xation in th e rabbit tibia [3 5 ]. Th e stu dy in vestigated
th e effect of th e design , m aterial, an d application of th e im -
plan t in relation to th e nu m ber of colon y-form in g u n its re-
qu ired to produ ce an in fection . Th e ef cacy of dead space
(slotted versu s solid n ail), th e im plan t m aterial (steel versu s
titan iu m versu s degradable polym er), th e application (ream -
in g, approach) an d th e design of th e im plan t in m in im izin g
th e occu rren ce of n ecrosis were evalu ated. Th e overall d iffer-
en ce in in fection between th e grou ps w ith an im plan ted steel
DCP, w ith su rface con tact, an d th ose w ith a titan iu m PC-Fix,
w ith poin t con tact, represen ted a ratio of 1:450.
20
Poin t con tact alon e th erefore redu ces th e risk of large-scale
n ecrosis. It m ay well be th at th e foreign -body effect, w h ich
was th ou gh t to redu ce resistan ce to in fection , is du e less to th e
foreign m aterial an d m ore to tissu e n ecrosis an d dead space.
Re fra ct u re a n d n e cro s is -in d u ce d re m o d e lin g
Wh at h appen s to th e bon e if im plan ts create n ecrosis? Th e
n ecrosis probably stim u lates rem odelin g in th e adjacen t bon e.
Th e bon e is rem odeled as th e n ecrotic bon e is rem oved (th e
porotic stage) an d is replaced by n orm al bon e. Th is takes a
m in imu m of th ree m on th s an d is u su ally com plete by on e to
two years.
Necrosis im m ed iately u n dern eath an im plan t m ay also be re-
lated to refractu re. Alth ou gh n ecrotic bon e is rou gh ly sim i-
lar in stren gth to livin g bon e, th e biological respon se elicited
m ay weaken th e bon e [4 8 ]. Necrosis of th e bon e im m ed iately
u n dern eath an im plan t w ill resu lt in in tern al rem odelin g, re-
su ltin g in porou s an d weaken ed bon e th at is su sceptible to
repeat fractu re. Th is effect is even m ore h arm fu l wh en , in
th e con ven tion al tech n iqu e, th e plates are placed at th e side
of th e bon e, wh ere fu n ction al loadin g produ ces ten sion . After
rem oval of th e plate, th e local delay in h ealin g cau sed by th e
avascu lar n ecrotic bon e can act as a stress factor an d resu lt in
repeat fractu re du e to traction in du ced by ben d in g.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Mech an ically every plate works as a splin t. Load tran sfer

3 Me ch a n ica l a s p e ct s o f p la t e a n d s cre w fixa t io n
3 .1 Ge n e ra l co n s id e ra t io n s
On e of th e objectives of in tern al xation is to restore bon e
in tegrity. Th e plate (im plan t) serves to bear th e load from on e
fragm en t to th e oth er, h elpin g th e bon e carry ou t its m ech an i-
cal fu n ction an d tem porarily tak in g on th is fu n ction itself.
from th e bon e to th e plate occu rs by fr iction (in th e case of
plate xation w ith cortex screw s exertin g pressu re between
plate an d bon e) an d/or lock in g of th e LHS in th e th read of
th e plate h ole by load tran sfer from bon e th rou gh th e locked
screw h ead to th e plate, to restore im m ed iately th e load-bear-
in g capacity allow in g fu n ction al postoperative treatm en t (in
th e case of th e locked in tern al xator) ( Ta b 1-7 ; Fig 1-4 ).

Ta b 1-7 Bio m e ch a n ica l a s p e ct s o f p la te a n d s cre w fixa t io n

Fixa t io n m e t h o d Fra ct u re co n gu ra t io n a ft e r re d u ct io n Fixa t io n t e ch n iq u e Scre w t yp e

Co m p re s s io n Sim p le fra ctu re t yp e > fu ll co n ta ct b e t we e n th e La g scre w an d pro te ctio n pla te Co rte x scre w a s la g scre w ;
(sta tic o r d yn am ic) m ain fra gm e n ts co rte x scre w s 1 in n e u tra l p o sitio n o r LHS 2
a s p la te s cre w s

Co m p re ssio n p la te (a n d la g scre w) Co rte x scre w s in e cce n tric p o sitio n o r a xia l

co m p re ssio n w ith a te n sio n d e vice a n d
co rte x scre w s 1 in n e u tra l p o sitio n o r LHS 2
a s p la te s cre w s

Te n sio n b a n d pla te Pla te p o sitio n im p o rta n t su p p o rt

vis -à -vis su p p o rt is im p o rta n t, co rte x scre w s
in n e u tra l p o sitio n o r LHS 2

Bu ttre ss p la te co rte x scre w s 1 in n e u tra l p o sitio n o r LHS 2

a s p la te s cre w s

Sp lin t in g Mu ltifragm e n tary fractu re > p artial o r n o co n tact Brid ge p la tin g o r lo cke d in te rn al xa to r Co rte x s cre w s 1 in n e u tra l p o sitio n
b e t we e n th e m ain fra gm e n ts LHS 2

Sim p le fra ctu re t yp e ( in e xce p tio n al ca se s) > fu ll Brid ge p la tin g o r lo cke d in te rn al xa to r Co rte x s cre w s 1 in n e u tra l p o sitio n a s p la te
o r p artia l co n tact b e t we e n th e m a in fragm e n ts scre w s o r LHS 2

LHS = lo ckin g h e a d scre w(s).

Bo n e q u a lit y: 1 No rm a l, 2 Po o r, a lso fo r te ch n ica l re a so n: n o p rim ary lo ss o f re d u ctio n , a ccu ra te sh a p in g o f th e p la te is n o t n e e d e d , MIPO e a sie r.

21
 a b
Fig 1-4 a – b Lo ad tra n sfe r fro m b o ne to splin t.
a Pla te a nd co rte x scre w s (com p re ssio n).
b Pla te a n d lo ckin g h e ad scre w s.
3 .2 Pla t e s a n d s cre w s a s co m p re s s io n t o o ls
Con ven tion al screw s (com pression screw s) serve to com press
a fractu re (ie, in terfragm en tary com pression ) an d/or x th e
plate on to th e bon e to ach ieve friction between th e im plan t
an d th e bon e an d com pression alon g th e lon g axial axis of
th e bon e. Cortex screw s or can cellou s bon e screw s can be
u sed, depen d in g on th e type of bon e in th e an atom ic region
con cern ed. A screw applied as a lag screw crosses a fractu re
lin e an d is u sed to create a com pression force between th e
two bon e fragm en ts. Th e am ou n t of com pression th at can be
ach ieved depen ds on th e d iam eter of th e screw an d on th e
bon e den sity an d m ass ( Fig 1-5 ).
Th e screw s x th e plate to th e bon e. Tigh ten in g th e screw s
presses th e plate on to th e su rface of th e bon e, thu s exertin g a
com pression force. Stability of th is kin d of plate osteosyn th e-
sis depen ds on th e am ou n t of friction produ ced between th e
plate an d th e bon e ( Fig 1-4 a ). If th e forces exerted on th e bon e
(th e load applied by th e patien t du rin g m ovem en t) exceed th e
friction lim it, relative sh earin g d isplacem en t w ill occu r be-
tween th e plate an d th e bon e, cau sin g a loss of redu ction be-
tween th e bon e fragm en ts or loosen in g of th e screw, or both .
Fractu re fragm en ts can n ot be com pressed solely by attach in g
a plate w ith com pression screw s. If ax ial com pression is th e
22
aim of th e treatm en t, it is n ecessary to u se a plate equ ipped
w ith wh at are k n ow n as dyn am ic com pression h oles—a dy-
n am ic com pression plate (DCP) or a lim ited-con tact dyn am ic
com pression plate (LC-DCP). On th e lon gitu d in al ax is of th e
plate, th ese dyn am ic com pression h oles h ave an oval sh ape
an d wh at is k n ow n as a dyn am ic com pression u n it (DCU) an d
th e sph erical glid in g prin ciple. Th e DCU is in cor porated in
DCP an d LC-DCP. Wh en th e com pression screw s are in serted
eccen trically in to th e en d of th e oval h ole far from th e frac-
tu re, th e lower sph erical part of th e screw h ead m eets th e dy-
n am ic com pression in clin e of th e com pression h ole. Tigh ten -
in g th e screw d isplaces th e plate, an d con sequ en tly th e bon e
segm en t to be xed, in th e d irection of th e fractu re. Th is d is-
placem en t w ill con tin u e u n til th e screw h ead is fu lly in serted
in to th e plate h ole, th u s pressin g th e plate rm ly on to th e
bon e an d com pressin g th e fractu re site ( Fig 1-6 ). Add ition al
fractu re com pression can be applied by in sertin g a lag screw
th rou gh th e plate an d across th e fractu re lin e
An atom ical redu ction an d a su f cien t area of bon e con tact at
th e fractu re site are prerequ isites for com pression platin g; in
add ition , good qu ality of bon e is n ecessary to allow th e screw
to press th e plate toward th e bon e. If th ese prerequ isites are
m et, absolu te stability can be ach ieved in th e fractu re xa-
tion . Th e ben e t of absolu tely stable fractu re xation is th at
th e bon e form s part of th e con stru ct. Th e fu n ction of th e im -
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

An im a tio n
1-7

Fig 1-5 La g scre w e ffe ct u sin g a fu lly Fig 1-6 In te rfra gm e n ta ry co m p re ssio n Fig | An im a tio n 1-7 Th e lo ad is tran sfe rre d
th re ad e d scre w. Glid in g h o le in th e n e ar w ith p la tin g a n d e cce n tric se a tin g o f th e d ire ctly fro m o n e se gm e n t to th e a the r.
co rte x, th re ad e d h o le in th e fa r co rte x. scre w (se e also Fig 1-9; Fig 1-10).

plan t is to m ain tain th e redu ction between bon e fragm en ts
wh ile loads are tran sferred d irectly from on e bon e segm en t to
an oth er ( Fig | An im a tio n 1-7 ).
Th e d isadvan tage of com pression plate xation is th at it re-
qu ires an atom ic fractu re redu ction . Depen d in g on th e frac-
tu re pattern an d th e an atom ic region , it is often on ly possible
to ach ieve precise redu ction by exten sive soft-tissu e dissec-
tion u n der direct vision . Th is procedu re can dam age th e blood
su pply to th e fractu re fragm en ts, resu ltin g in n egative effects
on fractu re h ealin g [2 , 6 ]. In clin ical practice, an atom ical
fractu re redu ction is on ly possible for sim ple fractu res w ith
a sm all n u m ber of fragm en ts. Precise redu ction in m u ltifrag-
m en tar y fractu res is obsolete.
An oth er side effect of carr yin g ou t osteosyn th esis u sin g com -
pression plates is th e early bon e porosis observed at th e plate–
bon e in terface [2]. A redu ction in th e bon e m ass can be seen
in th e early ph ases follow in g xation of com pression plates.
Th is is an effect of th e pressu re of th e plate u pon th e bon e,
wh ich dam ages th e per iosteu m an d thu s d istu rbs vascu larity
an d perfu sion in th e bon e. Depen d in g u pon th e severity of
th e in ju r y, th e vascu larization of th e bon e m ay already be so
restricted th at add ition al exten sive su rgical trau m a m ay re-
du ce th e poten tial for biological h ealin g an d in crease th e risk
of delayed u n ion or in fection .
Diffe re n t t e ch n iq u e s fo r co m p re s s io n p la t in g
Th e aim of applyin g plates th at com press th e fractu re frag-
m en ts is to ach ieve optim al approx im ation between th e frag-
m en ts. Levels of friction are developed th at allow th e bon e to
sh are th e load. Com pression can n ot be seen an d is dif cu lt to
produ ce an d assess clin ically. Approxim ation of an d preload
between th e fragm en ts resu lt from th e in teraction between
th e plate an d rem ovable devices or plate screw s. Str ictly
speakin g, th ese sh ou ld be term ed “adaptation plates” rath er
th an “com pression plates.”

23
 Re m o va b le t e n s io n a n d co m p re s s io n d e vice s
Th ese devices are an ch ored rm ly to th e bon e above th e prox-
im al or below th e d istal m argin of th e plate an d are align ed
w ith th e plate ( Fig 1-8 ). Th e device is lin ked to th e plate so
th at ax ial d istraction an d precise fragm en t redu ction can be
ach ieved w ith th e ten sion in g device in distraction m ode. In
com pression m ode, th e fragm en ts can again be brou gh t in to
con tact w ith each oth er to ach ieve in terfragm en tar y com -
pression .
b a
Fig 1-8 a – b In o bliq ue fractu re s, th e articu la ting te n sio n d e vice ha s
to b e ap p lie d in su ch a wa y th a t th e lo o se fra gm e n ts lo ck in to th e
co rn e r fo rm e d b y th e o p p o site fractu re su rface an d th e p la te if co m -
p re ssio n is pro d uce d .
24
Application of th ese devices gen erally requ ires a m ore exten -
sive su rgical approach . On th e oth er h an d, th ey m ake it possi-
ble to close larger fractu re gaps or osteotom ies. Th ese devices
can also be u sed for carefu l an d con trolled in direct redu ction
of im pacted fractu res [7 ] or to open u p wedge osteotom ies.
Dyn a m ic co m p re s s io n p la t e s
Dyn am ic com pression plates com press bon e by u sin g th e edge
of th e plate h ole to cam th e screw sideways du rin g th e in ser-
tion an d tigh ten in g procedu re (Fig 1-9). Var iable slopes h ave
been en gin eered to optim ize th is displacem en t effect. Th e dy-
n am ic com pression u n it (DCU) is pu t to th e h ole from th e
DCP, LC-DCP, an d LCP. Th e screw is seated at th e u pper en d
of th e in clin ed su rface of th e plate h ole (an d is th erefore re-
ferred to as an “eccen tric screw ”), lead in g to variou s degrees
of preload in g of th e plate in ten sion . Th is type of screw is also
k n ow n as a “plate-ten sion in g screw,” an d th e effect is k n ow n
as “com pression by th e plate” [4 9].
b
Fig 1-9 a – b Applica tio n o f the u n ive rsal d rill gu ide .
a Ecce n tric p o sitio n .
b Ne u tral p o sitio n .
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Co m p re s s io n b a s e d o n t h e e la s t ic re co il o f t h e p la t e
For optim al ttin g, plates can be con tou red to t th e su rface
of th e bon e. Th is is a prerequ isite for con ven tion al com pres-
sion platin g tech n iqu e. To ach ieve com pression on both cor-
tices, a straigh t plate can be ben t so th at it arch es across th e
fractu re site an d h as n o con tact w ith th e bon e su rface in th at
region . Wh en ten sion is applied, th e overben t plate is straigh t-
en ed again , lead in g to com pression of th e opposite cortex an d
th ereby en h an cin g stability. Special in stru m en ts are available
for preben d in g an d con tou rin g plates. However, it sh ou ld be
n oted th at a certain lack of overall con trol lim its th e ef cacy
an d reliability of th is procedu re in clin ical practice ( Fig 1-10 ).
a
b
Fig 1-10 a – b If the pla te is sligh tly pre b e n t b e fo re b e in g
app lie d , co m pre ssio n o n b o th co rtice s can b e ach ie ve d .
Axia l co m p re s s io n b y t e n s io n in g t h e p la t e
(t e n s io n b a n d p rin cip le )
In a few location s on th e skeleton , th e lon g bon es are ex posed
to m ore or less con stan t asym m etrical fu n ction al load in g.
Plates or w ires th at work accord in g to th e ten sion ban d prin -
ciple an d carry ten sile force w ill en su re th at th e bon e can op-
tim ally resist com pressive load in g. Cortical bon e itself is able
to bear a con siderable am ou n t of static com pression loadin g
w ith ou t h arm . Th e plate does n ot n eed to be rigid an d can be
very th in ( Fig 1-11).
a b
Fig 1-11a – b Whe n app lie d to the te n sio n sid e o f th e b o n e , a pla te
acts a s a d yn a m ic te n sio n b an d .
a With ve rtical p re ssu re , th e cu rve d fe m u r cre a te s a te n sio n fo rce
la te rally and a com p re ssio n fo rce m e d ia lly.
b A p la te p o sitio n e d o n th e sid e o f th e te n sile fo rce n e u tra lize s it
a t th e fractu re site , p ro vid e d th e re is a co rtical co n tact o pp o site
to th e p la te .
25
 3 .3 Th e p la t e a s a s p lin t
Brid gin g p la t e fixa t io n (DCP, LC-DCP, LCP w it h co r t e x a n d
ca n ce llo u s b o n e s cre w s)
Treatm en t u sin g lon g plates to bridge th e fractu re zon e is
k n ow n as bridgin g-plate osteosyn th esis ( Fig 1-12 ). In con trast
to in tern al xation after precise redu ction w ith a com pression
plate, th e bon e does n ot con tribu te to th e m ech an ical stabili-
zation of th e fractu re, or on ly con tribu tes to it partially. Th e
bridgin g plate xation redu ces bu t do n ot abolish displace-
a b
c d
26
m en t between fractu re fragm en ts so pain is redu ced an d ac-
tive m u scle reh abilitation is practical. Wh en ever possible, th e
soft-tissu e en velope in th e fractu re zon e is left u n tou ch ed in -
traoperatively. As m en tion ed above, th e u n derlyin g prin ciple
h ere is th at lower stability after fractu re xation (som e m ove-
m en t at th e fractu re site, elastic xation —prin ciple of relative
stability) w ill be m ore th an adequ ately com pen sated for by
th e preservation of th e soft tissu es an d th e blood su pply. At
th e sam e tim e, m icrom otion in th e fractu re zon e prom otes
in d irect h ealin g th rou gh callu s form ation [32].
Fig 1-12 a – d Bio lo gical in te rnal xa tio n .
a Pre o p e ra tive AP x-ra y o f th e in ju ry.
b Pre o p e ra tive a xia l x-ra y o f th e in ju ry.
c AP x-ra y 6 m o n th s p o sto p e ra tive ly.
d Axia l x-ray 6 m o n th s p o sto p e ra tive ly.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Splin tin g w ith a conven tion al plate an d screw s—bridge plat-
in g: Th e spin t/ plate is xed to each m ain fragm en t of th e bon e
w ith com pression screw s, th e sh ape of th e plate h as to be
adapted to th e bon e so th at th e plate xation screw s can press
th e plate on to th e su rface of th e bon e of each m ain fragm en t.
If th e sh ape of th e plate an d bon e do n ot m atch , th e prim ar y
redu ction /align m en t of th e fractu re w ill be lost. Also th e peri-
osteal blood su pply is d istu rbed. A d isadvan tage of bridgin g
xation at th e m etaph ysis is th at screw reten tion is poor in
th e can cellou s bon e in th is area, particu larly in elderly people
w ith osteoporosis. Th is becom es apparen t in traoperatively if
screw s are over tigh ten ed even sligh tly, an d is also seen post-
operatively in th e form of screw loosen in g, w ith a resu ltin g
secon dary loss of redu ction .
to th e com pression screw, th is screw –plate con stru ct does n ot
requ ire friction between th e plate an d th e bon e to ach ieve
stable xation of th e plate to th e bon e. Th e screw h ead is de-
sign ed to lock in to th e plate h ole, an d it is th erefore n ot n eces-
sar y for th e plate to be adapted precisely to th e sh ape of th e
bon e. Th e position of th e plate relative to th e bon e rem ain s
u n ch an ged du rin g tigh ten in g of th e lock in g h ead screw s.
Wh en th is locked in tern al xator (LIF) con stru ct h as to bear
th e patien t’s weigh t, th e force is tran sferred from on e bon e
segm en t to an oth er via th e plate –screw con stru ct. Un like
com pression screw s, lock in g h ead screw s are m ore su bject to
ben d in g loads th an to ten sile on es ( Fig | An im a tio n 1-13 ). Lock-
in g h ead screw s are an gu lar an d ax ially stable an d on ly rad i-
ally preloaded [51].

Lo cke d in t e rn a l fixa t o rs (LISS, LCP) w it h lo ck in g h e a d

s cre w s
Th e im plan t con sists of a plate-like device an d lock in g h ead
screw s wh ich togeth er act as an in tern al xator ( Fig 1-4 b ;
Fig | An im a tio n 1-13 ). An in tern al xator is a con stru ct wh ere
th e screw s (bolts, pin s), wh ich are th e m ain load-tran sfer-
rin g elem en ts, are locked in th e plate (or fram e). Th e forces
are tran sferred from th e bon e to th e xator across th e screw
n ecks. No com pression of th e plate on to th e bon e is requ ired
to ach ieve stability. Th erefore th e blood su pply of th e bon e
u n der th e plate is preser ved sin ce n o (or on ly little) con tact
between th e plate an d th e bon e is n eeded (n on con tact plate).
An im a tio n
Th e lock in g h ead screw s of th e in tern al xator are actu ally 1-13

m ore like th readed bolts. Th e bolts m ain tain s th e relative

position between th e body of th e xator (ie, plate) an d th e
bon e. Lock in g h ead screw s are screw s th at are locked in to
a special plate h ole du rin g tigh ten in g. Th is gives th e screw
axial an d an gu lar stability relative to th e plate (wh ich serves
as an in tern al xator) [5 0 ]. Fractu re xation u sin g a locked
in tern al xator does n ot depen d sign i can tly on th e qu ality Fig | An im a tio n 1-13 Pla te s ( in te rnal xa to rs) w ith lo cking h e ad
of th e bon e or th e an atom ical region of an ch orage. In con trast scre w s.

27
 Op t im ize d p la t e a n ch o ra ge w it h d ive rge n t o r co n ve rge n t
lo ck in g h e a d s cre w s
Th e ben e ts of lock in g h ead screw s w ith an gu lar stability are
com parable w ith th ose of oth er im plan ts th at dem on strate
an gu lar stability, su ch as an gled-blade plates. Th ese advan -
tages preven t th e com pon en t th at is an ch ored in to th e bon e
(th e blade or screw) from togglin g relative to th e lon gitu din al
carrier (th e plate), th ereby avoid in g th e loss of fractu re redu c-
tion ( Fig 1-14 ).
Th e plate h ole is th readed to m ate w ith th e screw th read an d
en su re a lock in g con n ection , bu t th is does n ot in crease th e
pu rely axial pu ll-ou t resistan ce of th e lock in g h ead screw s.
If th e m ax im u m pu ll-ou t resistan ce is exceeded, th e screw
w ill tear ou t a bon e cylin der th e size of th e screw d iam eter
( Vid e o 1-1). Wh en lock in g h ead screw s are in serted in to a
bon e segm en t at d ivergen t an gles to on e an oth er, th eir com -
bin ed pu ll-ou t force can be in creased several tim es. Un like
d ivergin g com pression screw s, lock in g h ead screw s can n ot
align th em selves in parallel u n der traction an d th erefore cre-
ate a larger area of resistan ce. Th e design of th e LISS plate
an d th e an atom ically presh aped LCPs sh ow s screw h oles in
d ivergen t an gles.

Vid e o
1-1

a b

Fig 1-14 a – b
a Brid gin g the fractu re zo n e w ith a lo n g p la te . Th e b ridging pla te
is o n ly xe d to th e m a in fragm e n ts p roxim a lly an d d istally.
Fixa tio n w ith co n ve n tio n al scre w s p re sse s th e p la te aga in st th e
b o n e , and the shap e o f the p la te ha s to b e ad ap te d to th e Vid e o 1-1 Pu ll-o u t re sistan ce d e m o n stra te d
bone. in a n apple m o de l.
b Lo cke d in te rn al xa to r: LHS a re an gu la r an d a xial stab le . No
co m p re ssio n o f th e p la te o n to th e b o n e is re q u ire d to ach ie ve
stab ilitiy.

28
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Lo ck in g h e a d s cre w s a n d p la t e a s a s in gle , in t rin s ica lly
s t a b le co n s t ru ct
Un like con ven tion al plate an d com pression screw system s,
plates secu red w ith lock in g h ead screw s fu n ction as a xation
u n it. Th e con stru ct works as a “m on o block xation ”. Com -
pression screw s can loosen in depen den tly of on e an oth er,
often resu ltin g in sequ en tial screw loosen in g. Lock in g h ead
screw s are an ch ored in to both th e plate an d th e bon e creatin g
a sin gle xation con stru ct th at is extrem ely stable an d per-
form s well in porotic bon e ( Fig 1-15 ).

a b

90°

c d

Fig 1-15 a – e Pull-o u t o f stan da rd scre w s and lo ckin g h e ad

scre w s (LHS).
a Fixa tio n w ith co rte x scre w s.
b Pu ll-o u t o f co rte x scre w s b y a b e nd ing lo ad . Se q u e n tia l
scre w lo o se n ing.
c Fixa tio n w ith LHS, e n -b lo c xa tio n .
e d LHS p ro vid e gre a te r re sistan ce again st b e n d in g lo ad s.
e Pu ll-o u t o f LHS w ith a xial lo ad in g

29
 Re q u ire m e n t s fo r fle xib le fixa t io n an d exten sive fractu re pattern s in wh ich bone abutm en t w ill
Elastic exible xation can on ly be ach ieved w ith ou t in ter- n ot occu r u n der loadin g (ie, load con trolled deform ation)—th e
fragm en tary com pression . A splin t is a rigid stru ctu re th at m axim al elastic deform ation of th e splin t h as to be redu ced
redu ces, bu t does n ot elim in ate elastic displacem en t of frag- by adju stin g th e nu m ber an d pattern (ie, position) of screw
m en ts du rin g loadin g. Th e effect of th e size of th e im plan t on in sertion s, by applyin g a plaster cast, lim itin g weigh t bearin g,
its stru ctu ral ben d in g rigid ity is im portan t. A practical way of or other appropriate m ean s (eg, addition al tem porary extern al
ach ievin g exibility is to redu ce th e size of th e m etal im plan t. xator).
A com bin ation of a m ore com plian t m etal su ch as titan iu m
an d a th in n er im plan t is u su ally preferred. Sin ce torsion al stren gth is m ain ly restricted by th e nu m ber
of screw s, fractu res of th e hu m eru s an d radiu s wh ich are
Th e optim al con d ition s for splin tin g depen d on th e len gth of ex posed to large torsion al forces sh ou ld be stabilized w ith a
th e lever provided by th e plate on each side of th e fractu re plate th at h as a large nu m ber of screw s on eith er side of th e
site. For bon es su ch as th e fem u r an d tibia th at are ex posed fractu re zon e. Addition al screw s placed between th e two m ost
to large ben din g forces, lon g plates w ith a sm all nu m ber of periph eral screw s an d th e two screw s closest to th e fractu re
screw s sh ou ld be con sidered. Th e nu m ber of plate screw s is far w ill in crease th e an ch orage of th e plate in th e bon e, even in
less im portan t th an th eir position w ith in th e plate. Th e place- porotic bon e.
m en t of screw s at each en d of th e plate en su res th at th e fu ll
plate len gth w ill con tribu te to th e fractu re xation . Th e d is-
tan ce between th e two screw s closest to th e fractu re in each
fragm en t (th e work in g len gth ) determ in es th e elasticity of th e
fractu re xation an d, m ore im portan tly for th e im plan t, also
determ in es th e d istribu tion of th e in du ced deform ation wh en
load is applied to th e con stru ct. If th e in du ced im plan t defor-
m ation is expressed as closu re an d reopen in g of th e fractu re
gap over a d istan ce lim ited by bon e abu tm en t (ie, d istan ce
con trolled deform ation ), th en a greater d istan ce between th e
two screw s on eith er side an d closest to th e fractu re lin e w ill
offer a m ore u n iform load tran sferen ce an d w ill redu ce th e
risk of plastic deform ation in wh at wou ld oth erw ise be an
overstressed, sh ort plate segm en t.

Clin ical ex perien ce h as sh ow n th at an elastic bridge w ith

th ree u n occu pied screw h oles span n in g th e fractu re lin e h elps
d istr ibu te th e in du ced stress over an adequ ate plate len gth .

In cases in wh ich th e deform ation is not lim ited by th e size

of th e fractu re gap —for exam ple, in h igh ly mu ltifragm en tary

30
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

cally as an extern al xator, bu t is im plan ted below th e sk in

4 De ve lo p m e n t o f in t e rn a l fixa t o rs
Th e con cept of th e locked in tern al xator is a tech n ology th at
takes care of th e preservation of biology. It aim s at sim ple an d
safe h an d lin g, at optim izin g biological con d ition s for soft an d
h ard tissu es, an d at bein g u n iversally applicable. Th e device
u sed resem bles a plate bu t fu n ction s like a xator th at is fu lly
im plan ted. Th e procedu re su pports biological in tern al xa-
tion , th at is a type of in tern al xation givin g pr iority to bi-
ology over m ech an ics [52]. As ex perien ce was gain ed w ith
su bmu scu lar an d su bcu tan eou s plate xation , it becam e clear
th at th e su rgeon requ ired im proved im plan ts an d in stru m en ts
for th e procedu re.
( Fig | An im a tio n 1-16 ). Th is m eth od of in tern al extram edu llary
locked splin tin g, wh ich redu ces m obility at th e fractu re site
bu t does n ot elim in ate it, is design ed to keep th e bon e frag-
m en ts vital.
Th e clin ical su ccess of th is type of treatm en t was aston ish -
in g: in d irect h ealin g resu lted in early an d reliable solid
u n ion . At th e sam e tim e, th e sever ity of com plication s de-
clin ed, as th ere was a sh ift away from biological com plica-
tion s after com pression plate osteosyn th esis, du e to n ecro-
sis w ith sequ estration of bon e an d soft tissu es, toward rare
com plication s resu ltin g from in adequ ate m ech an ical stability
[6 , 27 ].

4 .1 His t o r y o f in t e rn a l fixa t o rs

De ve lo p m e n t a n d ra t io n a le b e h in d lo cke d in t e rn a l fixa t o rs
(LIFs)
Th e Zespol system ( Fig 1-17 ), th e rst plate w h ich fu n ction ed
as a xator for stabilizin g lon g bon es, was developed in th e
1970s in Polan d [53 ]. Toward th e en d of th e 1980s, AO started
to exam in e in tern al xator system s as a fu rth er developm en t
of th eir plates. An oth er com parable device is th e so-called
“Sch u h li” design ed by Jeffrey Mast. Here th e m ain body
lin k in g locked screw s con sists of a stan dard in tern al xation An im a tio n
plate. Its screw s are h eld in a rigid position u sin g a wash er 1-16
on th e side of th e plate facin g th e bon e. Th is h as two effects:
on e, th e screw s are locked; two, th e plate body is elevated
from th e bon e su rface. Th e key to th ese in tern al xators is th e
lock in g m ech an ism of th e screw in th e im plan t, wh ich pro-
vides an gu lar stability. Th is tech n ical detail m ean s th at th ere
is n o n eed to in du ce com pression forces at th e bon e su rface
to stabilize th e bon e–im plan t con stru ct. Th e lack of com pres-
sion im proves fractu re h ealin g an d th e lock in g h ead screw s
obtain excellen t an ch orage even in osteoporotic bon e. Th is Fig | An im a tio n 1-16 Fro m th e e xte rnal xa to r to th e in te rnal
tu rn s a plate in to an in tern al xator. It fu n ction s m ech an i- xa to r.

31

a b
d e
Th e p o in t co n t a ct fixa t o r (PC-Fix)
Th e poin t con tact xator (PC-Fix) was developed in a join t
ven tu re by th e AO Research In stitu te (ARI) an d th e AO De-
velopm en t In stitu te (ADI). Th is im plan t h as m in im al con -
tact w ith th e bon e an d is secu red by m on ocortically in serted
screw s. Th e tapered h ead of th e screw en su res th at it lodges
rm ly in th e plate h ole an d provides th e requ ired an gu lar sta-
bility. M in im al con tact between th e plate an d th e bon e is still
32
c
Fig 1-17a – f Th e Ze sp o l syste m .
a X-ra ys o f a 42-A3 tib ial sh a ft fractu re ,
open Gustilo type I, in a 23-year-old m an.
b Po sto p e ra tive x-ra ys. Op e n re d u ctio n o f
th e fractu re h a s b e e n ca rrie d o u t, fo l-
lo we d b y tran scu ta n e o u s im p lan t xa -
tio n w ith lo cke d scre w s a n d th e Ze sp o l
p la te (le ft: an te ro p o ste rio r vie w, righ t:
la te ral vie w).
c Th e clin ica l im age sh o w s th e d istan ce
b e twe e n th e skin a nd th e e xte rna l pla te
xa to r.
d Fo llo w -u p x-ra ys a fte r 4 m o n th s, sh o w -
in g b o n e he a lin g w ith ca llu s fo rm a tio n
in the fractu re .
e Fo llo w -u p x-ra ys a fte r im p la n t re m o val.
n ecessary to en su re axial stability. Like th e lim ited-con tact
dyn am ic com pression plate (LC-DCP), th e PC-Fix was sh ow n
to d isru pt th e u n derlyin g blood su pply sign i can tly less th an
th e dyn am ic com pression plate [5 4 ] ( Fig 1-18 ). Th e m on ocorti-
cal screw s appear to dam age th e en dosteal blood su pply less
th an con ven tion al bicortical screw s.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Fig 1-18 a – f Th e u n d e rsu r-
face s o f th e pla te s. Th e a re a
in co n tact w ith b o ne is sho w n
in re d .
a DCP
b LC-DCP
c PC-Fix
d LISS (n o n co n tact p la te)
e LCP w ith co rte x scre w s
f LCP w ith lo ckin g h e ad
scre w s (n on co n tact p la te)
Healin g was accelerated w ith th e PC-Fix, so th at it was possi-
ble to rem ove it after on ly 3 m on th s. Local in fection resistan ce
was im proved—750 tim es m ore Staphylococcus aureus were re-
qu ired to produ ce th e sam e in ciden ce of in fection w ith th e
PC-Fix as w ith a dyn am ic com pression plate [55 , 5 6 ]. Th ese
a advan tages were partly du e to m in im al im plan t con tact an d
partly du e to th e sw itch from stain less steel to titan iu m .
Th e PC-Fix becam e th e paren t tech n ology for th e less in vasive
stabilization system (LISS) [57 ] an d th e lock in g com pression
plate (LCP) [5 8 ], w ith th e latter im plan t provid in g both tech -
b n ologies in a m ore fam iliar plate design th an th at of th e PC-
Fix in tern al xator.
Fro m PC-Fix t o LISS a n d LCP
Th e poin t con tact xator (PC-Fix) was th e rst type of plate
xator in w h ich an gu lar stability was ach ieved by establish -
in g a con ical con n ection between th e screw h eads an d screw
c
h oles. However, th e tapered screw –plate con n ection does n ot
provide axial an ch orage of th e screw in to th e plate, so th at
poin t con tact between th e plate an d th e bon e is still requ ired
to ach ieve stability. A n ew type of th read con n ection between
th e screw h ead an d screw h ole, resu ltin g in an gu lar an d ax ial
stability, was th erefore developed so th at n o con tact at all is
d
requ ired for stability. Th e screw sim ply fu n ction s as a Sch an z
screw.
33
 4 .2 Lo ck in g h e a d s cre w s (LHS)
De ve lo p m e n t o f t h e LHS
An gu lar stable im plan ts an d especially an gu lar stable n on -
con tact plates are called locked in tern al xators (LIF). Th eir
distin gu ish in g m ech an ical featu re lies m ain ly in th e fact th at
stability is n ot ach ieved by friction between th e u n dersu rface
of th e plate an d th e bon e, w ith all th e associated disadvan -
tages, bu t rath er by con n ectin g elem en ts between th e extra-
m edu llary load carrier an d th e m ain fragm en ts of th e bon e.
Th e stable con n ection of th e pin s, blades or bolts/screw s to
th e load carrier facilitates th e m ech an ical bridgin g of th e frac-
tu re zon e w ith ou t creatin g friction between th e load carrier
an d th e bon e. Th is m ech an ical con cept is sim ilar to extern al
xator.
a b
Fig 1-19 a – b
a Fo rce d istrib u tio n o f a pla te o ste o syn th e sis w ith o u t an gu lar sta -
b ilit y: Th e scre w tigh te n ing m om e n t le ad s to su rface p re ssu re
b e twe e n th e p la te and b o n e . Th e frictio n thu s cre a te d in th e
p la te – b o n e co n tact zo ne stab ilize s th e b o n e fragm e n t in re la -
tio n to the lo ad carrie r. Th is syste m o n ly b e co m e s sta tically
se cu re a fte r b ico rtica l scre w xa tio n
b Typ ical d istribu tio n o f fo rce s fo r a LIF o ste o syn th e sis w ith an gu -
lar stab ilit y: Th is co n gu ra tio n is sta tically se cu re w ith on ly
m on o co rtical xa tio n since the lo cking he ad scre w (LHS) is
an ch o re d in a m e ch a n ically stab le m a n n e r in th e lo ad carrie r
34
Th e gu res ( Fig 1-19 ) sh ow th at a lock in g h ead screw is su b-
jected m ain ly to ben d in g forces an d sh earin g stresses th at oc-
cu r at th e n eck of th e screw. Sin ce th e ph ysiological load in g
of th e bon e ru n s perpen d icu lar to th e screw axis, th e screw
design h ad to be adapted to th e n ew m ech an ical con d ition s.
For th is reason , a sym m etrical th read w ith a coarser th read
pitch , a 0.5 m m larger ou ter diam eter an d a 1.3 m m larger
core d iam eter was ch osen . Th ese m od i cation s h ave th e fol-
low in g m ech an ical advan tages. In creasin g th e projection area
by 40% perm its th e d istribu tion of th e application forces to
a larger bon e area. Th is h as de n ite advan tages, especially
for areas of can cellou s bon e in th e vicin ity of th e join t. Du e
to th e larger core diam eter th e screw tolerates 100% m ore
sh ear stress an d 200% m ore ben d in g, wh ereby th e in ciden ce
of screw failu re is clearly redu ced ( Fig 1-2 0 a ).
a b c
Fig 1-2 0 a – c
a Sch e m a tic re p re se n ta tio n o f b o th t yp e s o f th re ad . Th e sh ad e d
are a in d ica te s th e la rge r p ro je ctio n a re a .
b Su rface p re ssu re b e t we e n th e th re ad a n ks an d th e b o n e (re d
zo n e) re su lts fro m the a xial pre lo ad arising fro m th e in se rtio n
to rq u e o f th e scre w.
c Rad ia l pre lo ad o ccu rs w h e n the pilo t ho le is sm alle r than th e
co re d iam e te r o f th e scre w. Su rfa ce p re ssu re in th is ca se o ccu rs
b e t we e n the scre w co re an d the b o n e (re d zo ne).
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
A fu rth er m od i cation relates to th e so-called preload of th e
screw. Th ere is d ifferen tiation between axial an d rad ial pre-
load ( Fig 1-2 0 b – c).
If a con ven tion al cortex or can cellou s bon e screw is in serted
in to th e bon e an d tigh ten ed, ax ial preload of th e th reads to
th e bon e w ill be ach ieved. Th is procedu re preven ts th e m i-
crom ovem en ts th at can lead to bon e resor ption an d, con se-
qu en tly, to screw loosen in g. Sin ce lock in g h ead screw s are
tigh ten ed n ot in th e bon e bu t in th e plate, n o ax ial preload
w ill occu r w ith in th e bon e. Th e lock in g h ead screw s can n ot
be overtigh ten ed even in poor bon e stru ctu res. Neverth eless,
a so-called press- t tech n iqu e, as u sed for pin -type con nec-
tion s, is applied to preven t h arm fu l m icromovements ( Fig 1-21).
Fu rth er in vestigation s h ave sh ow n , h owever, th at application
in screw-bon e con n ection s can on ly su cceed if predrillin g is
don e very precisely as th e am ou n t of m is t sh ou ld n ot exceed
2% du e to th e elon gation at yield of cortical bon e. Th e ad-
dition al requ est from th e clin ician s for a self-drillin g screw
cam e at ju st th e righ t tim e in th e developm en t sch edu le. It is
in fact possible to ach ieve rad ial preload in a on e-step tech -
a b
Fig 1-21a – b
a Micro rad io gra ph a fte r in se rtio n o f a sm o o th p in w ith o u t pre -
lo ad . Exte n sive b o ne re so rp tio n a fte r 6 we e ks.
b Micro rad io gra ph a fte r in se rtio n o f a sm o o th p in w ith 0 .1 m m
rad ia l pre lo ad . Min im a l b o ne re so rp tio n a fte r 6 we e ks.
n iqu e u sin g a self-drillin g screw. Sin ce th e su ccess of a xed-
an gle stabilization con cept depen ds very mu ch on th e con -
n ection to th e bon e, a great deal of detailed work wen t in to
th e developm en t of th e screw s. For in stan ce, th e con n ectin g
elem en t to th e bon e does n ot ju st h ave to be self-drillin g, h ave
a sym m etrical th read, an d be capable of rad ial preload, bu t
drillin g perform an ce an d tem peratu re ch an ge du rin g in ser-
tion are also of great im portan ce for th e qu ality of th e bon e –
screw in terface. As a resu lt, a special test th at cou ld m easu re
th e relevan t param eters was design ed for th e developm en t of
th e screw geom etr y ( Ta b 1-8 , Ta b 1-9 ).
Optical evalu ation of th e bon e th read also sh owed th at th e in -
ter play between drill an d th read cu ttin g geom etry is of great
im portan ce for th e qu ality of th e th read. Screw s w ith a coars-
er th read pitch an d a sh ar per drill tip perform particu larly
well in bon e region s w ith a ver y th ick cortex.
Ta b 1-8 De ve lo pm e n t stage s o f the LHS: Th e d rillin g p e rfo rm an ce
a n d p u ll-o u t fo rce ca n b e in cre a se d a n d te m p e ra tu re in cre a se co u ld
b e re d uce d b y gradu al m o d i ca tio n o f th e ge o m e try o f th e d rill a nd
th e th re ad .
35
 Vid e o
1-3
Vid e o
1-4
Ta b 1-9 Fina l co m p ara tive te stin g again st e xisting scre w s sho we d
th e cle ar su p e rio rity o f th e n e w scre w ge o m e try.
In m ech an ical testin g it was n ot on ly proven th at th e n ew ly
developed self-d rillin g, lock in g h ead screw w ith an optim ized
drill tip offered su perior perform an ce at th e bon e –screw
in terface wh en com pared w ith con ven tion al self-drillin g
screw s bu t, in biom ech an ical testin g, it was also sh ow n th at
th e sym m etrical th read perform ed optim ally in both cortical
an d can cellou s bon e. Th e resu lts of com parative testin g of a
5 m m screw w ith AO th read an d an LHS w ith sym m etrical
at th read on pairs of hu m an fem ora clearly sh owed th at th e
h igh er th read an ks for th e sam e ou ter diam eter of th e screw
d id n ot lead to h igh er ax ial pu ll-ou t valu es. However, th e su -
periority rem ain s apparen t du e to th e larger projection area
an d for situ ation s of ph ysiological load in g per pen d icu lar to
th e screw ax is.
All tests on ly refer to a sin gle screw. Th e advan tages of an gu -
lar stability becom e far clearer for a system com prisin g several
screw s in a plate. In a plate–screw con gu ration w ith n on -
36
Vid e o 1-3 , Vid e o 1-4 Stan da rd pla te pu ll-o u t, LCP pu ll-ou t.
lock in g screw s, con ven tion al screw s are stan d-alon e screw s,
sequ en tial loosen in g of th e screw s occu rs wh en force is ap-
plied. Th e lack of an gu lar stability perm its each screw to align
alon g th e ax is of force. Th is leads to gradu al loosen in g w ith
pu llou t of th e in dividu al screw s. In th e case of xed-an gle ap-
plication , en bloc xation is ach ieved. Th e LHS can n o lon ger
be regarded as a stan d-alon e screw an d th e xed-an gle con -
n ection between th e plate an d th e screw h ead preven ts screw
orien tation alon g th e axis of force. Pu ll-ou t can on ly occu r en
bloc ( Vid e o 1-4 ).
Th e effect of en -bloc xation can be rein forced by con vergen t
or divergen t position in g of th e screw s, an approach applied
ch ie y in m etaph yseal areas. Several screw s in serted in con -
vergen t or d ivergen t position s an d in xed-a n gle tech n iqu e
ach ieve su ch a h igh level of stability th at failu re can on ly be
du e to pu llou t of th e en tire system or to plate failu re.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Ma jo r a d va n t a ge s o f t h e LHS
Locked screws provide better anchorage both in elastic bridg-
ing xation and in absolutely stable xation , thu s offerin g
im portant advantages in the treatment of fractu res in os-
teoporotic bone. The im proved stability ach ieved by lock-
ing facilitates the dependable application of monocortical
screws in the region of the diaphysis. The blood su pply to
the medu llary cavity is preserved. No structu ral bone loss of
the opposite cortex. In term s of application tech n ique, mono-
cortical screws are of particu lar advantage in blind, m in im ally
invasive percutaneou s osteosynthesis (M IPO). “Bicortical” (ie,
as lon g as possible) lockin g screws offer im proved stability in the
epiphyseal and metaphyseal region s of the bone.
Ad va n t a ge s o f a n gu la r s t a b le p la t e s ys t e m s
An ch orage of th e screw in th e plate h ole m ean s th at th e bon e
th read can n o lon ger be stripped du r in g in sertion . Th e pri-
m ary an ch orage of th e screw in th e bon e is th erefore en su red
even in poor qu ality bon e.
Com pression between plate an d bon e is u n n ecessary (n on -
con tact plate). For th is reason , th e periosteal blood su pply
u n der th e plate rem ain s in tact so th at cortical bon e n ecrosis,
as described in con n ection w ith con ven tion al plates, w ill n ot
occu r. Th is m ay con tribu te to th e lower su sceptibility to in -
fection th at h as been obser ved in relation to application of an
in tern al xator.
Th e xed-an gle con n ection between th e screw an d th e plate
clearly offers im proved lon g-term stability wh en ben d in g an d
torsion al forces are applied. LHS are also axially stable. It is
scarcely possible for th e plate to pu ll ou t of th e bon e becau se
th e screw s can n ot be sequ en tially loaded or pu lled ou t du e to
tiltin g in th e plate h ole. Likew ise, th ere is little opportu n ity
for secon dary tiltin g of a sh ort join t block sin ce th is is effec-
tively preven ted by th e xed-an gle an ch orage of th e screw in
th e plate (n o secon dar y loss of redu ction ).
Sin ce th e bon e is n ot “pu lled towards” th e plate du rin g tigh t-
en in g of th e screw s, th e procedu re for m in im ally in vasive
plate osteosyn th esis (M IPO) is greatly facilitated. Th e plate
n o lon ger n eeds to be an atom ically con tou red, wh ich wou ld
h ard ly be possible in a closed procedu re (M IPO) sin ce su rgi-
cal exposu re of th e bon e su rfaces is n ot requ ired for m ost of
th e relevan t region s. If th e sh ape of th e plate does n ot exactly
m atch th e bon e su rface an d con ven tion al screw s are ch osen ,
th e fractu re fragm en ts are restored to th eir correct spatial
align m en t by th e process of screw tigh ten in g. Th is effect is
desirable if persisten t ax ial deform ity n eeds to be corrected
by redu ction to th e plate. Th e effect is u n desirable if th ere is
an y risk th at th e fragm en ts w ill d islocate du rin g tigh ten in g of
stan dard screw s becau se th e plate h as been poorly con tou red.
In th is case, loss of redu ction can be avoided by th e in sertion
of lock in g h ead, xed-an gle screw s.
In traoperative con tou rin g of th e plate is n ot n ecessar y for th e
application to speci c bon e region s of an atom ically preform ed
plate system s w ith lock in g h ead screw s. Th is in tu rn facili-
tates m in im ally in vasive application an d is also an advan tage
in all open procedu res.
Th e developm en t of th e LISS for th e d istal fem u r an d th e
proxim al tibia (1995 an d 1997, respectively) created th e rst
gen eration of preform ed xed-an gle system s. In tegrated in to
th ese system s is an attach able aim in g device th at facilitates
th e in sertion of th e screw s alon g th e en tire len gth of th e
plate, wh ereby self-drillin g, self-tappin g lock in g h ead screw s
can be in serted percu tan eou sly in a sin gle step via stab in -
cision s. Sin ce th e developm en t of th e LCP (2000) add ition al
preform ed system s for th e proxim al an d distal hu m eru s, th e
d istal rad iu s, th e proxim al an d d istal fem u r, as well as for th e
proxim al an d distal tibia h ave been developed an d are con sis-
ten tly provin g th eir valu e in clin ical application .
37
 4 .3 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS)
Th e d ifferen t steps in th e developm en t of platin g tech n iqu es
is th e less invasive stabilization system (LISS); th e tech n iqu es
an d procedu res involved are described in detail in ch apter 3.
Th e less in vasive stabilization system (LISS) for th e m an age-
m en t of d istal fem oral fractu res an d proxim al tibial fractu res
m akes it possible to u se a m in im ally in vasive su rgical tech -
n iqu e, applyin g th e pr in ciple of fractu re xation w ith relative
stability.
an d can easily be in serted percu tan eou sly an d by self-d rillin g.
Th is produ ces a better bon e–plate con stru ct as com pared to
th e u se of stan dard screw s. Th e stability of th e bon e –im plan t
con stru ct resu lts from th e an gu lar stability of th e plate–screw
in terface rath er th an from th e friction gen erated between th e
plate an d bon e, as w ith con ven tion al im plan ts. Th is h as m e-
ch an ical advan tages an d avoids problem s related to th e bon e –
im plan t in terface, su ch as th e “w in dsh ield-w iper” effect.

Th e LISS for th e d istal fem u r (LISS-DF) an d th e prox im al

lateral tibia (LISS-PLT) are im plan ts th at act as splin ts. Th e
LISS acts m ech an ically as an in tern al xator ( Fig 1-2 2 )—it
is a 100% locked in tern al xator, becau se on ly lock in g h ead
screw s (LHS) are u sed. Th e LISS is design ed for percu tan eou s
in sertion . A less in vasive approach is also possible. A closed,
in d irect redu ction an d a pu re splin tin g of th e fractu re zon e is
im portan t. In tern al fractu re xation w ith locked xators is
a n ew tech n ology in w h ich th e aim is to preserve biological
con d ition s.

Th e LISS approach is based on u sin g an atom ically sh aped bu t-

tress plates th at are an ch ored w ith self-drillin g an d self-tap-
pin g m on ocortical lock in g h ead screw s. Th e screw s are con -
n ected to th e plate by a th read on th e ou ter su rface of th e
screw h ead an d a m atin g th read on th e in n er su rface of th e
plate h ole. Th e an gu lar stability between th e screw s an d th e
plate n o lon ger requ ires an y com pression between th e plate
an d th e bon e to en su re secu re an ch orage. Th e LISS is a n on -
con tact plate. Each self-d rillin g, self-tappin g screw represen ts
a n ew, sh ar p d rill bit for drillin g, a sh ar p tap to cu t th e th read,
after wh ich th e screw follow s in to th e precisely prepared h ole.
a b
Th e m on ocortical, self-drillin g screw s lock in to th e plate an d
fasten th e proxim al an d distal m ain fragm en ts after in direct Fig 1-2 2 a – b Th e le ss in va sive stabiliza tio n syste m .
redu ction h as been carried ou t. Du e to th e lock in g design , th e a LISS-DF.
LHS u sed do n ot n eed to obtain pu rch ase in th e secon d cortex b LISS-PLT.

38
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Th e LISS is an an atom ically presh aped in tern al xator th at
can be in serted percu tan eou sly by m ean s of an adaptable
in sertion gu ide. In com bin ation w ith a trocar assem bly, th e
h an d le also ser ves as an aim in g in stru m en t for exact percu ta-
n eou s placem en t of th e self-d rillin g, self-tappin g LHS. Based
on exten sive an atom ical stu d ies, th e orien tation of th e in di-
vidu al screw s is predeterm in ed an d can n ot be ch an ged. Th e
reason for th is is th e an gu lar stable screw –plate con n ection
th at is ach ieved w ith th e ou ter th read of th e screw h ead an d
th e in n er th read of th e plate h ole; th is does n ot allow variable
or ien tation of th e screw.
Th e LISS-DF an d LISS-PLT procedu res described in th e pres-
en t m an u al h ave been in clin ical u se sin ce 1997. Several stu d-
ies an d a large n u m ber of articles h ave been pu blish ed on th e
procedu res sin ce th en , reportin g both th e biom ech an ical an d
clin ical advan tages. Th e pu blish ed data sh ow th at LISS is a
valu able treatm en t option for fractu res of th e distal femu r
[2 6 , 5 9 –74 ] an d th e prox im al tibia [6 0 –74 ].
4 .4 Th e lo ck in g co m p re s s io n p la t e (LCP)
Th e LISS was origin ally design ed as a device th at wou ld pro-
vide an gu lar stability an d wou ld on ly accom m odate lock in g
h ead screw s; all of th e plate h oles are th readed. However,
clin ician s fou n d th at th is tech n ology was too restrictive in
som e cases an d th at an all-pu r pose im plan t system wou ld of-
fer greater ex ibility. Research an d developm en t work in th is
area—w ith m u ltid isciplin ary collaboration am on g clin ician s,
research ers, developers, an d m anu factu rers—u ltim ately led
to th e con cept of a com bin ation h ole, wh ich h as been in cor-
porated in to th e m ost recen t type of plate, th e lock in g com -
pression plate—LCP.
As ex perien ce w ith in tern al xator developed, th e n eed arose
for a sin gle plate system th at wou ld allow th e su rgeon m ore
ch oices [7 5 ]. Preoperatively or in traoperatively, th e su rgeon
cou ld ch oose wh eth er or n ot to u se con ven tion al screw s,
lock in g h ead screw s, or a com bin ation of th e two screw types.
Th is led to th e developm en t of th e lock in g com pression plate
(LCP), featu rin g com bin ation h oles (described in detail in
ch apter 3).
Th e co m b in a t io n h o le
Th e LCP com bin ation h ole ( Fig 1-2 3 ) allow s in tern al xation
to be ach ieved by in sertin g eith er con ven tion al screw s (in to
th e u n th readed part of th e h ole) or lock in g h ead screw s w ith
an gu lar stability (in to th e th readed part of th e gu re-of-eigh t
h ole). Th e LHS can on ly be in serted at r igh t an gles to th e
plate. Th e LCP h ole also m akes it possible to in sert d ifferen t
screw types in to th e sam e plate, so th at th e su rgeon is able to
ch oose th e type depen d in g on in traoperative requ irem en ts.
In retrospect, com bin in g two com pletely differen t an ch orage
tech n iqu es in to a sin gle im plan t was a logical approach an d a
straigh tfor ward, practical solu tion .
Two version s of th e LCP w ith com bin ation h ole are available:
a 4.5/5.0 large-fragm en t version , a 3.5 sm all-fragm en t an d a
2.4 an d 2.0 version . Special plates are also available for m an y
an atom ical region s, . Th ese LCP is an atom ically presh aped to
t th e average sh ape of speci c bon es an d can be in serted u s-
in g open or m in im ally in vasive tech n iqu es.
Despite th e advan tages of locked in tern al xators, th ere is still
a n eed for th e an atom ical recon stru ction an d absolu te stabil-
ity th at are provided by con ven tion al plates an d screw s. Ap-
propriate in d ication s for th e latter in clu de in traarticu lar frac-
tu res, osteotom ies, com plex bon e recon stru ction procedu res,
pseu darth roses, as well as fractu res w ith trau m atic dam age to
th e blood su pply. With th e LCP, th e su rgeon h as two platin g
m eth ods to ch oose from an d is able to select th e m ore appro-
priate of th e two tech n iqu es.
39

a in vasive plate osteosyn th esis.
b c
Fig 1-2 3 a – c Lo ckin g co m pre ssio n pla te w ith co m bin a tio n h o le .
a LCP co m b in a tio n h o le co m bining two pro ve n e le m e n ts.
b On e ha lf o f th e h o le h a s th e d e sign o f th e DC/ LC-DCP (d ynam ic
co m p re ssio n u n it: DCU) fo r co n ve n tio n al scre w s.
c The o th e r ha lf is co n ica l a nd thre ad e d to acce p t the m a tching
th re ad o f the lo ckin g he ad scre w pro vid in g a ngu lar stab ility.
40
Th e option of u sin g th e LCP, eith er as a com pression plate
or as an in tern al xator, provides ideal plate an ch orage th at
can be adapted to requ irem en ts in each in dividu al case. Th is
sign i can tly exten ds th e ran ge of in d ication s in m in im ally
Usin g th e LCP, th e su rgeon is free to select th e best treatm en t
m eth od—ie, eith er th e com pression m eth od or locked splin t-
in g m eth od—to bridge th e fractu re zon e in th e in d ividu al
patien t. Plate len gth an d th e type, am ou n t, an d position of
screw s u sed d ictate th e fractu re xation m eth od an d tech -
n iqu e an d h ave to be ch osen accord in g to th e fractu re situ a-
tion ( Ta b 1-4 ). Th e LCP is in accordan ce w ith th e latest platin g
tech n iqu es (M IPO), th e aim of wh ich is to ach ieve th e sm all-
est possible su rgical in cision s, to preser ve th e blood su pply to
th e bon e an d adjacen t soft tissu es, an d to en su re a m in im al
bon e –im plan t in terface [52].
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
5 Me t h o d s a n d t e ch n iq u e s in p la t e o s t e o s yn t h e s is
5 .1 Pla t e o s t e o s yn t h e s is t o d a y a n d fu t u re
d e ve lo p m e n t s
Plates an d screw s are versatile im plan ts for d ifferen t m eth ods
an d tech n iqu es of fractu re xation . Poten tially, all types of
fractu re cou ld be xed w ith plates an d screw s. In gen eral,
fractu re xation w ith plates an d screw s produ ces satisfacto-
ry resu lts. An u n derstan din g of th e forces in volved m akes it
possible to aim for low-strain osteosyn th esis. Com plication s
are u su ally related to su rgical tech n iqu e an d th ere is a risk of
dam age to bon e an d soft tissu e. Th is is u su ally associated w ith
an in creased risk of in fection , n onu n ion , or im plan t failu re.
Th erm al n ecrosis at th e drill h oles is often u n derestim ated.
Th ere are still good in dication s for th e con ven tion al platin g
tech n iqu e: articu lar fractu res (w ith bu ttress platin g) an d
sim ple d iaph yseal an d m etaph yseal fractu res (com pression or
protection platin g). An atom ical redu ction of th e fractu re h as
always been th e goal in th e conven tion al platin g tech n iqu e,
bu t, over tim e, th e tech n iqu e of bridgin g plate osteosyn th esis
was developed for m u ltifragm en tary sh aft fractu res—a tech -
n iqu e th at, by redu cin g vascu lar dam age in th e bon e, allow s
h ealin g w ith callu s form ation , as seen after locked n ailin g.
Sin ce th e dam age to th e soft tissu es an d th e blood su pply is
less exten sive, faster fractu re h ealin g can be ach ieved.
Th e m ore recen t locked in tern al xators in volvin g LISS an d
LCP u sin g LHS con sist of plate an d screw system s in w h ich
th e screw s are locked in to th e plate. Th e lock in g process m in i-
m izes th e com pressive forces exerted on th e bon e by th e plate.
Th is m eth od of screw –plate xation m ean s th at th e plate does
n ot h ave to tou ch th e bon e at all, wh ich is particu larly advan -
tageou s for m in im ally in vasive plate osteosyn th esis (M IPO).
With th ese n ew screw s, precise an atom ical con tou rin g of a
plate is n o lon ger n ecessary an d th e plate does n ot h ave to be
pressed on to th e bon e to ach ieve stability. Th is preven ts in -
traoperatively prim ary d isplacem en t of th e fractu re cau sed by
in exact con tou rin g of a plate. Th e LISS plates are presh aped to
m atch th e average an atom ical form of th e relevan t site an d do
n ot requ ire fu rth er in traoperative alteration . Th e basic locked
in tern al xator tech n iqu e aim s to ach ieve ex ible elastic xa-
tion to stim u late spon tan eou s h ealin g, in clu d in g th e in du c-
tion of callu s form ation .
It is n ow accepted th at th e pu rsu it of absolu te stability, w h ich
was origin ally th ou gh t to be n ecessar y for alm ost all fractu res,
is m an datory on ly for join ts an d certain join t-related fractu res
(ie, fractu res of th e rad iu s an d u ln a), an d th en on ly wh en it
can be ach ieved w ith ou t dam age to th e blood su pply an d soft
tissu es. At th e d iaph ysis, len gth , align m en t, an d rotation m u st
always be respected. Wh en xation is requ ired, splin tin g by
n ail in sertion or application of an in tern al xator is u su ally
preferable an d leads to u n ion by callu s form ation . Even wh en
th e clin ical situ ation favors th e u se of a plate, proper plan n in g
an d th e cu rren t tech n iqu es for m in im al access an d xation
w ill redu ce th e degree of in su lt to th e blood su pply to th e
bon e fragm en ts an d soft tissu es.
Sim ple diaph yseal fractu res an d mu ltifragm en tary, m ore
com plex fractu res react d ifferen tly to con ven tion al com -
pression platin g an d to splin tin g by n ailin g or bridgin g w ith
a locked in tern al xator. If com pression platin g is u sed in
sim ple fractu res, absolu te stability m u st be ach ieved. In con -
trast, splin tin g can be u sed to treat all m u ltifragm en tary frac-
tu res. A d iaph yseal fractu re in th e forearm , wh ere lon g bon e
m or ph ology is com bin ed w ith qu asiarticu lar fu n ction s, re-
qu ires special con sideration . In traarticu lar fractu res requ ire
an atom ical redu ction an d absolu te stability to facilitate th e
h ealin g of articu lar cartilage an d m ake early m otion possible,
wh ich is essen tial for good u ltim ate fu n ction .
41

Fixa tio n
Re te n tio n
Re d u ctio n
Ap p ro ach
Pla n n in g
Dia gn o sis
Fig 1-24 Co rre la tio n and in te ractio n b e t we e n the ste p s o f
su rge ry.
Th e im peratives of soft-tissu e care, origin ally ex pressed in
th e pr in ciple of preservin g th e blood su pply to th e bon e, n eed
to be addressed in every ph ase of fractu re m an agem en t. A
clear u n derstan din g of th e roles of direct an d in d irect redu c-
tion , togeth er w ith in form ed assessm en t of h ow th e fractu re
pattern an d soft-tissu e in ju ries relate to each oth er, w ill lead
to adequ ate preoperative plan n in g an d correct decision s on
treatm en t strategy an d tech n iqu e ( Fig 1-24 ).
Fu t u re d e ve lo p m e n t s
To obtain th e greatest ben e ts from th e prin ciples of biologi-
cal in tern al xation an d m in im ally in vasive plate osteosyn -
th esis (M IPO), sim ple m eth ods are n eeded to allow redu ction
of th e m etaph yseal en d fragm en ts. As in locked n ailin g, bio-
logical in tern al xation on ly requ ires redu ction of th e m ain
fragm en ts in wh ich th e articu lar su rfaces are presen t. Th e re-
qu ired m eth od wou ld allow redu ction an d tem porar y m ain -
ten an ce of th e m ain fragm en ts in th e correct th ree-d im en -
sion al position in relation to ben d in g, torsion , an d len gth .
Th is wou ld m ake M IPO sim ple. Th ese aim s m ay be w ith in
th e reach of sim ple m ech an ical m eth ods on com pu ter-aided
tech n ology.
A m eth od of assessin g th e viability of th e bon e before, or at
least du r in g, su rger y wou ld also be h elpfu l for selectin g th e
m eth od of stabilization an d im provin g th e progn osis. It is d if-
cu lt to ju dge wh eth er bon e is viable. It is im portan t to k n ow
42
th is, as a com bin ation of n ecrotic bon e an d elastic xation can
He a lin g cau se problem s. In tern al xators are at a d isadvan tage h ere
sin ce in d irect bon e h ealin g is n ot possible. Fu rth er stu d ies are
n eeded on th e precise th resh old con d ition s for strain in rela-
tion to am plitu de an d tim in g.
Stabilizin g fractu res in patien ts w ith osteoporosis is a priority,
an d fractu re im plan ts th at allow load in g to be m on itored in
vivo wou ld be h elpfu l. Th e th resh old con d ition s for ex ible
xation —ie, th e lim its of strain in clin ical con dition s—n eed
to be an alyzed fu rth er.
In an im al stu d ies, th e tech n iqu e of in tern al xation w ith
poin t con tact xators h as been sh ow n to redu ce th e in ciden ce
of in fection an d to facilitate early solid u n ion [5 6 ]. Th e advan -
tages of biological in tern al xation are th e sim plicity of h an -
dlin g, th e prom pt con tribu tion to h ea lin g m ade by th e bon e,
an d resistan ce to in fection an d possibly repeat fractu re.
5 .2 Co m p re s s io n m e t h o d —co n ve n t io n a l p la t in g
t e ch n iq u e
Th e LCP is a versatile im plan t an d can be u sed for both m eth -
ods of fractu re xation —com pression an d splin tin g m eth od
an d also in d ifferen t tech n iqu es ( Ta b 1-15 ).
Th e com pression m eth od of fractu re xation , aim in g for ab-
solu te stability, in volves open redu ction an d in tern al xa-
tion (ORIF) u sin g plates an d cortex an d/or can cellou s bon e
screw s. Th is approach , th e prin ciples of wh ich are ou tlin ed
above, becam e establish ed as a stan dard an d su ccessfu l tech -
n iqu e for treatin g bon e fractu res ( Fig 1-2 5 ). Th e su ccess of th e
tech n iqu e depen ds on th e precision of th e redu ction an d th e
degree of stabilization . Wide su rgical ex posu re is n ecessary to
ach ieve redu ction , an d soft tissu es were often stripped from
fractu re fragm en ts.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Diffe re n t co n ce p t s o f fra ct u re xa t io n

Prin cip le o f fixa t io n Me t h o d Te ch n iq u e a n d im p la n t ‘s fu n ct io n Bo n e h e a lin g

= gra d e o f s ta b iliza tio n

Ab s o lu t e s t a b ilit y Co m p re s s io n La g scre w (co n ve n tio n a l scre w) Dire ct

= h igh

Sta tic1 La g scre w a n d p ro te ctio n p la te

( DCP, LC-DCP, LCP)

Co m p re ssio n p la te
( DCP, LC-DCP, LCP)

Te n sio n b a n d

Dyn a m ic 2 Te n sio n b a n d p la te
( DCP, LC-DCP, LCP)

Bu t tre ss p la te 6
( DCP, LC-DCP, LCP a n d co n ve n tio n a l scre w)

Sp lin t in g Exte rn a l sp lin tin g Exte rn a l fixa to r

In tra m e d u lla ry sp lin tin g In tra m e d u lla ry n a il

Lo cke d 3

In te rn a l e xtra m e d u lla ry Brid gin g w ith co n ve n tio n a l p la te

sp lin tin g ( DCP, LC-DCP, LCP a n d co n ve n tio n a l scre w)

Brid gin g w ith lo cke d in te rn a l fixa to r

( LISS, LCP a n d LHS)

Exte rn a l sp lin tin g Co n se rva tive fra ctu re tre a tm e n t

(ca s t, tra ctio n)

Un lo cke d 4 In tra m e d u lla ry sp lin tin g 5 Ela s tic n a il

Re la t ive s t a b ilit y
K-w ire In d ire cctt
= lo w

1
Fra ctu re u n d e r co m p re ssio n —im p la n t u n d e r te n sio n .
2
Co m p re ssio n u n d e r fu n ctio n . Po ssib le w ith LCP
3
Lo cke d sp lin tin g w ith co n tro l o f le n gth , a lign m e n t, a n d ro ta tio n .
4
Sp lin tin g w ith lim ite d co n tro l o f le n gth , a lign m e n t, a n d ro ta tio n .
5
Ca n b e ch a n ge d to d yn a m ic co m p re ssio n in ca se o f a d yn a m ica lly lo cke d n a il o r d yn a m ic e xte rn a l xa to r.
6
Usin g a n a n gu la r s ta b le p la te -scre w co n stru ct ( ie , LISS o r LCP w ith LHS) a s b u t tre ss p la te , th e p la te a cts a s a b la d e p la te . Occa sio n a lly a b u ttre ss p la te m a y b e co n sid e re d a s a
sp lin t.

Ta b 1-10 Diffe re n t co n ce p s o f fractu re xa tio n ( p o ssib ilitie s fo r u sing LCP).

43

Fig 1-25 Th e co n ve n tio n al p la tin g
te ch n iq u e u sin g th e co m p re ssio n m e th o d .
A d va n t age s
Restoration of th e precise an atom y an d early fu n ction .
Stable in tern al xation —in terfragm en tary com pression
(lag screw an d/or plates).
Lag screw —th e best tech n iqu e to ach ieve in terfragm en -
tar y com pression .
An gu lation of screw s.
Th e redu ced bon e fragm en ts sh ares th e load.
Early m obilization an d early fu n ction .
Pre re qu isit e s
Open (in th e m ost cases), d irect redu ction to ach ieve pre-
cise align em en t an d fu ll con tact of th e fragm en ts.
Exten sive open su rgical approach to th e bon e—for redu c-
tion , in sertion , an d xation of th e plate.
Stable in tern al xation , in terfragm en tar y com pression .
No m otion between th e fractu re fragm en ts—absolu te sta-
bility.
Presh apin g of th e plate to m atch th e an atom y of th e
bon e.
44
Preten sion in g (overben d in g) of th e com pression plate in
order to ach ieve stable xation -elastic recoil of th e plate.
Bicortical in sertion of th e screw s.
Com pression between th e im plan t an d th e bon e.
Stability resu lts from friction between th e plate an d th e
bon e an d/or a preloaded lag screw.
Good bon e qu ality (su f cien t screw h old in g).
Sh o rt co m in gs an d d isad van t age s
In m u ltifragm en tary sh aft fractu res, precise an atom ical
redu ction is often n ot possible w ith ou t a su bstan tial risk of
iatrogen ic soft-tissu e trau m a.
Com pression of th e periosteu m d istu rbs th e blood su pply
to th e bon e an d leads to bon e n ecrosis ben eath th e plate.
Prim ary loss of redu ction du e to im precise con tou rin g of a
plate leads to m alalign m en t (ie, d isplacem en t of th e frag-
m en ts wh ile xin g th e plate w ith com pression screw s)
Com pression screw s can be overtigh ten ed.
Com pression screw s are preloaded.
Secon dary loss of redu ction (loosen in g of screw s) leads to
m alalign m en t an d in stability.
Osteoporosis (in su f cien t screw h old in g).
Repeat fractu res ten d to occu r (du e to n ecrotic bon e u n der
th e plate an d bicortical screw h oles).
With experien ce, it becam e in creasin gly eviden t th at th ere
was a biological price to pay for precise redu ction an d abso-
lu tely stable xation . Han dlin g an d even clean in g of th e bon e
fragm en ts before an d du rin g redu ction was likely to resu lt in
dead bon e th at m igh t on ly revascu larize slow ly an d requ ire
lon g-term protection .
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
5 .3 Sp lin t in g m e t h o d
Sp lin t in g w it h s t a n d a rd p la t e s a n d co r t e x s cre w s
New m eth ods in volvin g m in im al risk were th erefore devel-
oped to accelerate bon e regen eration an d bon e h ealin g in d if-
cu lt fractu res. Wh ereas an atom ical redu ction of th e fractu re
was th e goal in th e con ven tion al platin g tech n iqu e, th e aim
in bridgin g plate osteosyn th esis for m u ltifragm en tar y sh aft
fractu res is to redu ce vascu lar dam age to th e bon e. Th e u se of
in d irect redu ction , as advocated by Mast an d colleagu es [7 ],
was in ten ded to take advan tage of th e soft-tissu e attach m en ts,
wh ich align th e bon e fragm en ts spon tan eou sly wh en traction
is applied to th e m ain fragm en ts.
A d va n t age s
In tern al xation w ith preservation of biological in tegrity.
Closed in d irect redu ction .
M in im ization of biological dam age du e to th e su rgical ap-
proach an d redu ction tech n iqu e, an d by an ch or in g th e im -
plan t on ly in th e m ain fragm en ts.
Flex ible (less stable) xation th at stim u lates callu s form a-
tion , facilitatin g early solid u n ion .
Pre re qu isit e s
In direct closed redu ction w ith ou t exposu re of th e fractu re.
Sm aller in sertion an d in cision s on ly for th e im plan t xa-
tion .
Elastic bridgin g of th e fractu re zon e w ith a con ven tion al
plate an d cortex screw s.
Th e u se of lon g plates as pu re splin ts—ie, w ith ou t th e ad-
d ition al lag screw effect.
Fixation of lon g im plan ts to th e prox im al an d d istal m ain
fragm en ts on ly.
Th e plate h as to be presh aped to th e an atom y of th e bon e.
In gen eral, bicortical cortex screw s are u sed to ach ieve
su f cien t friction between th e plate an d th e bon e in th e
proxim al an d distal m ain fragm en t.
Relative stability (elastic xation ) prom otes callu s
form ation .
Th e bon e an d soft tissu e are still alive an d/or can recover
after th e acciden t, tran sportation , an d su rgical approach .
Less experien ced su rgeon s can also u se th is tech n iqu e w ith
an open , bu t less in vasive approach . Th e fractu re zon e re-
m ain s u n tou ch ed.
Sh o rt co m in gs an d d isad van t age s
Closed redu ction an d th e in traoperative con trol of align -
m en t are n ot easy.
M in im ally in vasive plate application an d xation u sin g a
con ven tion al plate is n ot easy.
Stan dard screw s in serted bicortically are u sed to ach ieve
su f cien t friction between th e plate an d th e m ain frag-
m en ts.
Th e plate h as to be accu rately presh aped to th e an atom y of
th e bon e for th e m ain fragm en ts.
Lo cke d s p lin t in g w it h lo cke d in t e rn a l fixa t o rs
Th e n ewly developed locked in tern al xators u sed in th e LISS
an d LCP are based on th e prin ciples of biological in tern al xa-
tion an d m in im ally in vasive plate osteosyn th esis (M IPO) ( Fig
1-2 6 ). Th e M IPO approach an d bridge platin g is possible w ith
conven tion al plates, bu t th ere are add ition al advan tages if th e
M IPO tech n iqu e is com bin ed w ith th e u se of a locked in tern al
xator—th ere is n o n eed for precise con tou rin g of th e plate,
drillin g, m easu rin g, or tappin g, becau se self-drillin g, self-
tappin g m on ocortical LHS are u sed. Th ese screw s len d th em -
selves optim ally to m on ocortical xation , in wh ich case it is
n ot n ecessary to select th e len gth of th e screw precisely an d a
protru d in g screw tip is n ot able to dam age or irritate th e soft
tissu es, ten don s, or m u scles.
On ly sm all in cision s are n ecessar y to in sert th e plate w ith th e
M IPO tech n iqu e—w ith ben e ts in clu d in g n ot on ly im proved
45
 A d van t age s
Fig 1-2 6 LCP a s LIF u sin g th e splin ting m e th o d .
cosm etic resu lts, bu t above all protection of th e fractu re zon e.
“Th e skin protects th e fractu re zon e from th e su rgeon .”
[Ch ristoph Som m er].
Th e tech n ology developed for th e blin d in sertion an d applica-
tion of in tern al xators can also be u sed w ith open approach -
es. Th e open approach , u sin g an aim in g device, can h elp th e
su rgeon becom e accu stom ed to th e m ore dem an d in g tech -
n iqu e of align in g th e in tern al splin t. Th e locked m on ocortical
screw s requ ire align m en t of th e im plan t an d th e bon e ax is
w ith in com paratively n arrow lim its. Open procedu res can be
u sed for in itial train in g in th e tech n iqu es.
Also u sin g LCP w ith LHS as locked in tern al xator (locked
splin tin g m eth od) in th e M IPO tech n iqu e h as m an y tech n ical
an d biological advan tages.
46
Biological in tern al xation avoids th e n eed for precise
redu ction , especially of th e in term ed iate fragm en ts, an d
takes advan tage of in direct redu ction .
Th e aim of in d irect redu ction is to align th e prox im al an d
d istal m ain fragm en ts. Th is avoids ex posu re of th e in d i-
vidu al bon e fragm en ts.
Su bm u scu lar/su bcu tan eou s slide in sertion tech n iqu es are
possible.
M in im ization of biological dam age cau sed by th e su rgi-
cal approach , th e redu ction , an d at th e im plan t–bon e in -
terface (M IPO). Th is is ach ieved at th e ex pen se of precise
redu ction an d stable xation .
Flex ible elastic xation to stim u late spon tan eou s h ealin g,
in clu d in g th e in du ction of callu s form ation .
Locked in tern al xators are n on con tact plates; n o com -
pression of th e plate on to th e bon e is requ ired.
Th ere is n o n eed for sh apin g wh en u sin g LISS or an atom i-
cally presh aped LCP.
Optim al prede n ed screw placem en t an d screw orien ta-
tion based on an atom ical stu d ies, facilitates th e applica-
tion of an atom ically presh aped LISS an d LCP plates.
Th ere is n o n eed for exact presh apin g of th e LCP to m atch
th e bon e an atom y.
Th ere is n o n eed for d rillin g, m easu rin g, or tappin g, sin ce
self-drillin g, self-tappin g m on ocortical LHS are u sed.
Preservation of all blood su pply to th e bon e in clu d in g peri-
osteal blood su pply.
Lock in g th e screw in to th e plate en su res an gu lar, as well
as ax ial, stability an d elim in ates an y u n wan ted m ovem en t
of th e screw.
Th ere is a redu ced risk of secon dary loss of redu ction .
Th e tech n iqu e works well in osteoporotic bon e.
For treatm en t of m u ltifragm en tar y, com plex fractu res.
M IPO is easier u sin g locked n on con tact plates.
Th ere is im proved local resistan ce to in fection .
Less risk of refractu re
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Pre re qu isit e s Excessive dem an ds on th e system : th e bon e is n ot carryin g

In d irect closed redu ction w ith ou t ex posu re of th e an y load becau se it h as n ot been precisely redu ced.
fractu re. Delayed h ealin g in th e d iaph yseal region wh en th e
Sm all in cision s for in sertion of th e im plan ts. m edu llary an d/or periosteal blood su pply to th e
Im plan ts th at h ave m in im al bon e con tact (eg, LISS an d in terru pted bon e fragm en ts follow in g th e in ju ry are de-
LCP). Th e in tern al xators are sligh tly raised above th e periosted , an d th rou gh iatrogen ic add ition al distu rban ce
bon e su rface to elim in ate an y m ism atch between th e pre- of th e blood su pply to th e bon e an d soft tissu e, (w ron g
sh aped im plan t an d th e an atom y of th e bon e. redu ction an d xation).
Elastic bridgin g of th e fractu re zon e (prin ciple of relative
stability stim u lates callu s form ation ).
Plates/ xators are u sed as pu re splin ts—ie, w ith ou t th e
add ition al lag screw effect.
Self-drillin g, self-tappin g lockin g h ead screw s can be u sed
for m on ocortical in sertion ; self-tappin g lock in g h ead screw s
can be u sed for m on ocortical or bicortical in sertion .
In LISS alon e, a geom etr ical correlation h as to be ach ieved
between th e aim in g device an d th e plate for closed appli-
cation .

Less ex perien ced su rgeon s can also u se th is tech n iqu e w ith

an open , bu t less in vasive approach . Th e fractu re zon e re-
m ain s u n tou ch ed.

Sh o rt co m in gs an d d isad van t age s

Th e stability of th e fractu re xation depen ds on th e rigid-
ity of th e con stru ct.
Closed redu ction an d in traoperative con trol of align m en t
are n ot easy.
M in im ally in vasive plate application an d xation are n ot
easy.
With th e predeterm in ed screw orien tation , possible d if-
cu lties can arise wh en in sertin g a lock in g h ead screw in
n on an atom ically presh aped LCPs (pen etration of articu lar
su rface).
Redu ction toward th e plate can on ly be ach ieved w ith spe-
cial in stru m en ts or bu m ps or stan dard screw s.

47

6 Min im a lly in va s ive p la t e o s t e o s yn t h e s is (MIPO)
Th e tim in g an d tech n iqu e of in ter ven tion is cru cial to respect-
in g th e im portan t role of th e soft tissu e in bon e h ealin g. M in -
im ally in vasive su rgery h elps to redu ce th e iatrogen ic trau m a.
Dam age to tissu e in th e in ju ry zon e is th e m ajor factor for
th e occu rren ce of com plication s su ch as bon e devitalization ,
in fection , delayed u n ion , an d n on u n ion .
For m in im ally in vasive su rger y (M IS) in fractu re care, th e
term s m in im a lly in vasive osteosyn th esis (M IO) or m in im ally
in vasive plate osteosyn th esis (M IPO) are u sed.
M in im ally in vasive osteosyn th esis for join t fractu res requ ires
a soft-tissu e w in dow wh ich is large en ou gh to ach ieve a pre-
cise an atom ical redu ction . After an atom ical redu ction th e
pr in ciple of absolu te stability is applied u sin g th e com pression
m eth od.
Ta b 1-11 De fin it io n o f MIPO
Acce ss to th e b o n e th ro u gh so ft tissu e w in d o w s (n o t o n ly sm all skin in cisio n s
b u t also care fu l ge n tle ha n d lin g o f d e e p la ye rs o f th e so ft tissu e).
Min im al trau m a to th e so ft tissu e a n d th e b o n e b y in d ire ct re d uctio n .
Min im al ad d itio na l trau m a a t th e fractu re site w h e n d ire ct re d u ctio n is
n e ce ssa ry.
Re d u ctio n to o ls w h ich cau se „sm all fo o tp rin ts“.
Im p la n ts w ith ad e q u a te b o n e -im p lan t in te rfa ce:
– No n co n tact p la te s, an gu la r stab le scre w s,
– Mo n o co rtical scre w xa tio n
– Op tim ize d scre w p lace m e n t acco rd in g to th e a na to m ical re gio n
48
M IPO for sh aft fractu res in clu de in direct closed or percu ta-
n eou s d irect redu ction an d a soft-tissu e w in dow away from
th e fractu re site, large en ou gh for im plan t in sertion an d to see
an d to palpate th e plate an d th e bon e.
Re d u ct io n
An oth er prin ciple of M IPO is to redu ce th e trau m a to th e soft
tissu e an d to th e bon e by in d irect redu ction . For d iaph yseal
fractu res th e restoration of th e len gth , axis, an d rotation is
n eeded. Sm all in d ividu al fractu re fragm en ts n eed n ot to be
an atom ically redu ced. On ly th e correct position of th e adja-
cen t join ts is im portan t. For in d irect redu ction m an eu vers th e
follow in g equ ipm en t is u sed: m an u al traction , traction table,
large d istractor, extern al xator, pu sh –pu ll forceps.
Som e tim es d irect redu ction m an eu vers are n ecessary. Wh en
d irect redu ction is n ecessary u se tools w ith “sm all foot pr in ts”
percu tan eou sly, close to th e fractu re. Th e percu tan eou s u se
of a poin ted redu ction clam p, collin ear redu ction forceps or
redu ction h an d les/ joysticks h elp to m in im ize th e add ition al
trau m a at th e fractu re site.
In d ication s for d irect percu tan eou s fractu re redu ction are
sim ple articu lar fractu res, sim ple m etaph yseal an d d iaph yseal
fractu res.
Fixa t io n
Mu ltifragm en tary fractu res of th e d iaph yseal or m etaph ysical
zon e are xed by th e locked splin tin g m eth od. Th e fractu re
zon e is bridged w ith a locked in tern al xator.
Sim ple fractu re type of th e sh aft or m etaphysis can be treated
by th e com pression m eth od. Redu ction tools w ith sm all foot
prin ts an d locked n on con tact plates to protect percu tan eou s
lag screw s h elp to redu ce th e iatrogen ic trau m a.
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s
Altern atively sim ple sh aft fractu res can be xed after redu c-
tion by th e splin tin g m eth od w ith ou t lag screw.
D isad van t age s o f M IPO
Dif cu lties in in d irect closed redu ction
In creased C-arm ex posu re
Malu n ion
Pseu doarth rosis th rou gh d iastases
Delayed u n ion w ith ex ible xation in sim ple fractu res
A d va n t age s o f M IPO
Faster bon e h ealin g
Redu ced in fection rate, n o or less n eed for bon e graft
Less postoperative pain (sm all in cision s)
Faster reh abilitation (less soft-tissu e trau m a)
More aesth etic resu lt
Be n e fit s o f m in im a lly in va s ive t e ch n iq u e s w it h lo cke d
p la t e s
It was origin ally argu ed th at th e tu n n elin g requ ired to ach ieve
blin d in sertion of th e plate wou ld resu lt in th e sam e am ou n t
of dam age as w ith th e open su rgical approach . However, stu d-
ies con du cted by Krettek’s grou p on th e effect of ligatin g th e
perforatin g arteries, for exam ple, du rin g open su rgical proce-
du res for fem oral fractu res d isproved th is argu m en t [76 , 7 7 ].
Alth ou gh M IPO tech n iqu es can be u sed w ith plates an d com -
pression screw s, th e advan tages of th e tech n iqu e u sin g locked
splin ts an d m on ocortical self-drillin g screw s are greater.
In su rgical approach es in volvin g access th rou gh con tu sed ar-
eas of sk in in wh ich stability is requ ired, th e m in im ally in va-
sive approach offers con siderable advan tages.
Th e m ech an ical ben e ts of th ese system s (ie, locked n on con -
tact plates) are as follow s. Th ere is n o n eed for precise an atom -
ical presh apin g of th e plate —a procedu re wh ich is in any case
h ard ly possible w ith blin d m in im ally in vasive tech n iqu es.
LCP u sed as in tern al xator w ith LHS are n on con tact plates.
Th is featu re con siderably facilitates th e M IPO procedu re. Th e
presh aped plates su pplied by th e m anu factu rer are based on
m easu rem en ts of th e average sh ape requ ired, u sin g com pu t-
ed-tom ograph y data an d cadaver bon es. Sin ce th e plate does
n ot n eed to be pressed on to th e bon e wh en it is bein g u sed as
an in tern al xator, m in or variation s in th e bon e w ill resu lt
in areas of plate stan d-off from th e bon e. An atom ically pre-
sh aped LCP are available for certain m etaph yseal areas (th e
proxim al an d distal hu m eru s, olecran on , distal rad iu s, dis-
tal fem u r, an d prox im al an d d istal tibia), an d LISS devices
are available for th e treatm en t of fractu res of th e distal fem u r
an d th e prox im al lateral tibia. An add ition al advan tage of th e
an atom ically presh aped plates is th at th ey m ake it possible to
in sert th e screw in an appropriate d irection to su it th e an a-
tom ical con d ition s, allow in g optim al an ch orage. Th e gu id-
in g blocks h elp en su re th e correct ax ial in sertion of th e d rill
sleeves an d lock in g h ead screw s. If requ ired, stan dard screw s
can be in serted before th e gu idin g block is position ed.
An a t o m ica lly p re s h a p e d p la t e s Ta b 1-12
St ro n g d e m a n d s fo r a n a t o m ica lly p re s h a p e d p la t e s
Ad van tage s fo r a na to m ically p re sh ap e d pla te s:
– No in tra o p e ra tive sha p in g o f th e pla te re q u ire d
– Pla te h e lp s ach ie vin g th e an a to m ical re d u ctio n
– Aim in g b lo cks to in se rt th e lo cking h e ad scre w s
– Cle a r in d ica tio n s fo r a give n im p lan t
– De n e d p lace m e n t fo r a give n im p la n t
– Cle a r ru le s o f h o w to u se th e give n im p lan t
– Op tim ize d scre w place m e n t acco rd in g to th e a na to m ica l re gio n
Ta b le 1-12 Ad van tage s o f an a to m ically pre shap e d pla te s.
49
 With regard to application tech n iqu e, m on ocortical screw s
are advan tageou s in th e blin d M IPO tech n iqu e. If th e su rgeon
is fam iliar w ith th e in sertion of self-d rillin g, selft-tappin g
screw s, preparatory predrillin g an d m easu rem en t of screw
len gth m ay n ot be n ecessary. Th e self-d rillin g, self-tappin g
an d self-tappin g lockin g h ead screw s can be in serted in itially
u sin g a power tool. On ly th e n al xation n eeds to be carried
ou t w ith a torqu e screwdriver. Sh ort m on ocortical lock in g
h ead screw s are u sed in th e d iaphysis.
Th e an gu lar stability of th e screw –plate system provides sig-
n i can tly im proved lon g-term resistan ce to extern al ben d-
in g an d torsion al forces. Th e plate is u n likely to pu ll ou t of
th e bon e, as th e screw s are in capable of togglin g, slid in g, or
becom in g d islodged. Th e screw can n ot be overtigh ten ed, as
its th read m ates w ith th at of th e plate h ole. In add ition , th e
an gu lar an d axial stability of th e screw s preven ts secon dar y
tiltin g of a sh ort join t fragm en t (so th at th ere is n o secon d-
a b
Fig 1-2 7a – d Exam ple s o f ana to m ically p re shap e d pla te s.
a LCP m e ta ph yse al pla te 3 .5/ 4 .5/ 5.0 , fo r d istal tib ia .
b LCP d ista l h u m e ru s p la te (DHP).
c LCP d ista l rad iu s pla te 2 .4 .
d Lo ckin g p roxim al h u m e ru s p la te (LPHP).
50
ary loss of redu ction). Th e lock in g h ead screw w ill always
gain pu rch ase in th e bon e, even in cases of poor bon e qu ality;
d ivergen t an d convergen t in sertion of adjacen t lock in g h ead
screw s provides better xation in osteoporotic bon e [78 – 8 0 ].
Exam ples are sh ow n in Fig 1-27.
Locked in tern al xators su ch as LISS an d LCP w ith LHS also
provide im portan t biological ben e ts. Th e im proved stabil-
ity allow s reliable application of m on ocortical screw s in th e
d iaph yseal area. Mon ocortical screw s cau se less in terferen ce
w ith blood ow. Lock in g th e screw in to th e plate en su res both
an gu lar an d ax ial stability w ith ou t com pression of th e plate
on to th e bon e. Th e in tram edu llar y circu lation is con served;
an d th e far cortex an d adjacen t soft tissu es are protected from
dam age, as h as been con rm ed by biom ech an ical in vestiga-
tion s an d reports of clin ical ou tcom es. However, bicortical an -
ch orage is recom m en ded in situ ation s w ith a th in cortex or
osteoporotic bon e, an d in th e treatm en t of hu m eral sh aft frac-
c d
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

Fig 1-28 Th e pu ll-o u t re sistan ce o f th e w ho le con stru ct ca n b e

im pro ve d b y b e nd ing th e pla te in to a wa ve -like fo rm , so th a t th e
scre w s ca n b e in se rte d d ive rge n tly and co n ve rge n tly.

tu res (bon es th at are pron e to h igh torsion al forces). Bicorti-

cal an ch orage is advan tageou s wh en xation of a sh ort m ain
fragm en t allow s th e screw s to be placed close to each oth er
an d for tech n ical reason s in bon es w ith a sm all d iam eter (ie,
u ln ar an d rad ial sh aft). Th e in sertion of a bicortical LHS is a b
recom m en ded w h en ever a stan dard screw h as been in sert-
ed in traoperatively in to a com bin ation h ole for th e pu r pose Fig 1-2 9 a – b Tre a tm e n t o f a p e ripro sth e tic fractu re w ith a 4 .5/ 5.0
of tem porar y redu ction . In situ ation s w ith m alalign m en t of lo ckin g co m pre ssio n pla te (LCP) an d ce rclage w ire . Th e re is wa ve -
th e plate in th e lon gitu d in al ax is of th e bon e, a m on ocortical shap e d p re b e nd ing o f th e d istal p art o f th e pla te to acco m m o d a te
screw w ill be in su f cien t to m ain tain th e redu ction , an d a se ve re o ste o p o ro sis and pre ve n t lo o se n in g o f th e pla te . The lo ckin g
bicortical screw is th erefore su ggested. In th e m etaph ysis, th e h e ad scre w s a re in se rte d d ive rge n tly and co n ve rge n tly in to the
u se of th e lon gest possible m on ocortical or bicortical lock in g wa ve d p a rt o f the pla te to im pro ve scre w a nch o ra ge .
h ead screw s is recom m en ded.

In tern al xators w ith few m on ocortically in serted LHS also

dem on strate fewer repeat fractu res after rem oval of th e im -
plan t; th e im plan ts can be rem oved earlier du e to rapid bon e
con solidation . Earlier plate rem oval du e to rapid bon e con soli-
dation was sh owed in an im al testin g u n der con trolled situ a-
tion . In th e clin ical situ ation , tim e to bon e con solidation is
in u en ced by th e in itial an d su rgical trau m a; an d th ere are
n o ch an ges to th e bon e stru ctu re u n der th e plate.

51
 A d va n t age s
In su m m ary, th e n ew system s (ie, locked n on con tact plates)
offer clin ician s th e follow in g advan tages:
Th e locked in tern al xator is a stable system con sistin g of
a plate an d locked screw s. Th e stability of th e fractu re xa-
tion depen ds on th e stiffn ess of th e con stru ct. Th ere is n o
n eed to press th e plate on to th e bon e, an d th e blood su pply
to th e bon e is preser ved. Lock in g th e screw in to th e plate
to en su re an gu lar as well as ax ial stability elim in ates th e
possibility of in traoperative overtigh ten in g.
Th e screw is in capable of togglin g, slid in g, or becom in g
d islodged, su bstan tially redu cin g th e risk of postoperative
secon dar y loss of redu ction .
Fixation by placin g m u ltiple screw s w ith an gu lar stability
in th e epiph yseal an d m etaph yseal fragm en ts m ake it pos-
sible to treat m an y fractu res wh ere th erapy was n ot pos-
sible w ith previou s xation devices.
Th ere is im proved stability in m u ltifragm en tary, com plex
fractu res w ith loss of a m edial/ l ateral bu ttress or bon e
loss.
The locked screw –plate interface provides an gu lar stability,
wh ich avoids su bsidence in the m etaphyseal areas. It also al-
lows m edial or lateral xation , u su ally w ithout recon struct-
in g th e opposite m edial or lateral bu ttress (w ith ou t dou ble
platin g), and w ithout the u se of a prim ary bone graft.
Th ere is n o n eed to con tou r th e plate precisely to th e an at-
om y, wh ich greatly facilitates th e (M IPO) su rgical pro-
cedu re. Sin ce stability does n ot rely on com pression be-
tween th e plate an d th e bon e, th e plate does n ot h ave to
be an atom ically con tou red. Th is is especially tru e for th e
m etaph yseal areas, in w h ich th e sh ape of th e bon e can be
qu ite com plex.
Th ere is n o prim ary loss of redu ction .
Th e n ew system s offer an im proved biological en viron -
m en t th at prom otes h ealin g. Locked in tern al xators do
n ot com press th e periosteal blood su pply an d con sequ en tly
cau se less in terferen ce w ith th e fractu re h em atom a an d
52
fractu re h ealin g. Th e elastic xation of a locked in tern al
xator acts m ore like an in tram edu llary n ail or extern al
xator, allow in g bon e h ealin g w ith callu s form ation .
Im proved xation an d biology m ay lead to better clin ical
ou tcom es an d faster h ealin g.
Th e system s provide better xation in osteoporotic bon es,
especially in th e epiph yseal an d m etaph yseal areas. In os-
teoporotic bon e, LHS are m ore h igh ly resistan t to ben d in g
an d torsion al forces, w ith less pu llou t of th e screw. LHS
can n ot be overtigh ten ed in porotic bon e.
Divergen tly or con vergen tly locked screw s im prove th e
pu ll-ou t resistan ce of th e wh ole con stru ct—for exam ple,
u sin g an atom ically presh aped plates or a plate ben t in to
sligh t bu t con tinu ou s or m u ltiple u n du lation s (k n ow n as a
mu ltiple-wave plate; see Fig 1-2 8 ; Fig 1-2 9 ).
Th e plate–bon e in terface is n ot loaded alon g th e screw
axis an d th e ten den cy for th e th read to strip in th e bon e
is redu ced. Th e lock in g h ead screw s h ave a h igh er core
diam eter to resist can tilever an d ben d in g forces at th e
screw –cortex in terface. Screw s w ith an gu lar stability are
n ot su bject to th e togglin g (“w in dsh ield-w iper” effect)
seen w ith stan dard screw s.
Th ese system s do n ot, or ver y rarely, requ ire prim ary bon e
graftin g.
In d icat io n s
Th e com m on in d ication s for th e u se of LISS an d LCP/ LHS for
in tern al xation are as follow s:
Epiphyseal and m etaphyseal fractu res: short articu lar block,
m in im al bon e m ass for an ch orage, an gu lar stability.
Sit u at io n s in w h ich t h e M IPO t e ch n iqu e is in d icat e d
an d p o ssible
Sin ce accu rate con tou rin g of th e plate is n eith er possible
n or n ecessar y wh en lock in g h ead screw s are u sed, th ere is
n o loss of in itial redu ction . Th e LISS an d LCP are also rec-
om m en ded in th e d iaph yseal area if th ey can be u sed w ith
 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

th e M IPO tech n iqu e an d if in tram edu llary locked splin t-

in g (locked n ail) is n ot possible.
Fractu res w ith severe soft-tissu e in ju ries.
Fractu res in osteoporotic bon es. Sin ce th ere is better re-
sistan ce to ben d in g an d torsion al forces an d less pu llou t of
th e screw –plate con stru ct, n o strippin g of th e bon e th read
du rin g in sertion of th e screw (n o overtigh ten in g of th e
screw is possible).
Diaph yseal an d m etaph yseal fractu res in ch ild ren .

Th e clin ical application of LISS an d LCP is cu rren tly con sid-

ered advan tageou s in cases of u n avoidable su rger y for distal
rad ial fractu res close to th e join ts, d istal h u m eral fractu res,
elbow d islocation fractu res, prox im al u pper arm fractu res,
d istal fem oral fractu res, tibial plateau fractu res, an d proxim al
an d d istal tibial fractu res in clu din g pilon fractu res. Th e pro-
cedu re is also h igh ly ben e cial for stabilizin g osteotom ies an d
also in tu m or su rger y.

53

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56 . Jo h an sso n A , Lin d gre n J U, N o rd CE, e t al (1999) Material
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57. Frigg R , A p p e n ze lle r A , Ch rist e n se n R , e t al (2001) Th e
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58 . Wagn e r M , Fre n k A , Frigg R , (2004) New con cepts for bon e
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Clin Orthop Relat Res; 439:207–214.
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61. K re go r PJ, St an n ard JA , Zlow o d zk i M , e t al (2004)
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in 103 fractu res. J Orthop Trauma; 18(8):509 –520.
62 . Fan k h au se r F, Gru be r G, Sch ipp in ge r G, e t al (2004)
M in im al-invasive treatm en t of distal fem oral fractu res w ith th e
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56
63. Hah n U, P ro ko p A , Ju be l A , e t al (2002) [ LISS versu s con dylar
plate]. Kongressbd Dtsch Ges Chir Kongr; 119:498 –504.
6 4. Mark m ille r M , Ko n rad G, Sü d k am p N (2004) Fem u r-LISS
an d d istal fem oral n ail for xation of d istal fem oral fractu res: are
th ere differen ces in ou tcom e an d com plication s? Clin Orthop Relat
Res; 426:252–257.
65. R icci WM , Ru d zk i J R , Bo rre lli J Jr (2004) Treatm en t of
com plex proxim al tibia fractu res w ith th e less in vasive skeletal
stabilization system . J Orthop Trauma; 18(8):521–527.
6 6 . R icci A R , Yu e JJ, Taffe t R , e t al (2004) Less Invasive
Stabilization System for treatm en t of distal fem u r fractu res.
Am J Orthop; 33(5):250 –255.
67. Sch ü t z M , Mü lle r M , K re t t e k C, e t al (2001) M in im a lly
in vasive fractu re stabilization of d istal fem oral fractu res w ith th e
LISS: a prospective m u lticen ter stu dy. Resu lts of a clin ical stu dy
w ith special em ph asis on dif cu lt cases. Injury; 32(Su ppl3):SC48 –
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6 8 . Sch ü t z M , Haas N P (2001) [ LISS—in tern al plate xator].
Kongressbd Dtsch Ges Chir Kongr; 118:375 –379.
69. Sye d A A , A garw al M , Gian n o u d is PV, e t al (2004) Distal
fem oral fractu res: lon g-term ou tcom e follow in g stabilisation w ith
th e LISS. Injury; 35(6):599 –607.
70. We igh t M , Co llin ge C (2004) Early resu lts of th e less in vasive
stabilization system for m ech an ically u n stable fractu res of th e
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18(8):503 –508.
71. Co le PA , Zlow o d zk i M , K re go r PJ (2004) Treatm en t of
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72 . Sch ü t z M , Kääb M J, Haas N (2003) Stabilization of proxim al
tibial fractu res w ith th e LIS-System : early clin ical experien ce in
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73. St an n ard J P, Wilso n TC, Vo lgas DA , e t al (2003) Fractu re
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 1 Ba ck gro u n d a n d m e t h o d o lo gica l p rin cip le s

74. St an n ard J P, Wilso n TC, Vo lgas DA , e t al (2004) Th e less

in vasive stabilization system in th e treatm en t of com plex fractu res
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18(8):552–558.
75. Frigg R (2003) Developm en t of th e Lockin g Com pression Plate.
Injury; 34(Su ppl1):B6 –10.
76 . K re t t e k C, Sch an d e lm aie r P, M iclau T, e t al (1997) M in im ally
in vasive percu tan eou s plate osteosyn th esis (M IPPO) u sin g th e
DCS in prox im al an d d istal fem oral fractu res. Injury; 28(Su ppl1):
A20 –30.
77. Faro u k O, K re t t e k C, M iclau T, e t al (1999) M in im ally
in vasive plate osteosyn th esis: does percu tan eou s platin g d isru pt
fem oral blood su pply less th an th e trad ition al tech n iqu e? J Orthop
Trauma; 13(6):401–406.
78 . So m m e r C,Gau t ie r E (2003) [ Relevan ce an d advan tages of n ew
an gu lar stable screw-plate system s for d iaph yseal fractu res
(lockin g com pression plate versu s in tram edu llary n ail].
.Ther Umsch; 60:751–756.
79. R in g D , K lo e n P, Kad zie lsk i J, e t al (2004) Lockin g
com pression plates for osteoporotic n onu n ion s of th e diaph yseal
hu m eru s. Clin Orthop Relat Res; 425:50 –54.
8 0. Ko rn e r J, Lill H , Mü lle r LP, e t al (2003) Th e LCP-con cept in
th e operative treatm en t of distal hu m eru s fractu res--biological,
biom ech an ical an d su rgical aspects. Injury; 34(Su ppl2):B20 –30.

57
 2 Surgical re duction te chnique s

1 Aim o f re d u ct io n 59

2 Diffe re n t t yp e s o f s u rgica l re d u ct io n 60
2 .1 Fa ct o rs in flu e n cin g t h e ch o ice o f
t yp e o f re d u ct io n 62
2 .2 Dire ct o p e n re d u ct io n 63
2 .3 Dire ct p e rcu t a n e o u s re d u ct io n 64
2 .4 In d ire ct re d u ct io n , o p e n o r clo s e d 65
2 .5 Op e n in d ire ct re d u ct io n 66
2 .6 Clo s e d in d ire ct re d u ct io n 67
2 .7 Re d u ct io n a n d fixa t io n o f m e t a p h ys e a l a n d d ia p h ys e a l
fra ct u re s 68
2 .8 Re d u ct io n a n d fixa t io n o f a r t icu la r fra ct u re s 68

3 In s t ru m e n t s a n d t e ch n iq u e s 69
3 .1 Re d u ct io n in s t ru m e n t s 69
3 .2 Re d u ct io n fo rce p s 71
3 .3 Ot h e r in s t ru m e n t s , t rick s , a n d h in t s u s e fu l
fo r re d u ct io n 74
3 .4 Re d u ct io n w it h t h e h e lp o f im p la n t s
(re d u ct io n o n t o a n im p la n t) 77
3 .5 Min im a lly in va s ive re d u ct io n 80

4 As s e s s m e n t o f re d u ct io n 81
4 .1 In t ra o p e ra t ive t e ch n iq u e s fo r ch e ck in g a lign m e n t 81
4 .2 Co m p u t e r-a s s is t e d re d u ct io n 84

5 Co n clu s io n s 85

6 Bib lio gra p h y 85

58
2 Surgical re duction te chnique s
Th e rst step in th e m an agem en t of an y d isplaced fractu re is to
determ in e wh eth er reduction is to be su rgical or n on su rgical.
Reduction can be carried ou t as a closed or open procedu re.
Redu ction is th e act of restorin g th e an atom ically correct posi-
tion of th e fragm en ts, in clu d in g th e process of recon stru ctin g
can cellou s bon e by relievin g im paction . Redu ction thu s re-
verses th e process th at created th e fractu re d isplacem en t du r-
in g th e in ju ry. Logically, th is requ ires th e application of forces
an d m om en ts in direction s opposite to th ose w h ich produ ced
th e fractu re. Prelim in ary an alysis of th e d isplacem en t of frag-
m en ts an d of th e deform ation an d im paction of bon e provides
th e basis for plan n in g th e tactical steps n ecessary. Th is ap-
plies to all m eth ods, w h eth er th ey are n on su rgical, su rgical,
closed, or open [1].
Displacem en t in diaph yseal an d m etaph yseal bon es is clin i-
cally easily detected u sin g con ven tion al x-rays taken in at
least two plan es per pen d icu lar to each oth er. In th e m etaph y-
sis an d epiph ysis, obliqu e view s, often su pplem en ted by com -
pu ted tom ography w ith m u ltiplan ar recon stru ction , m ay be
n ecessar y to fu lly assess fragm en tation , fragm en t d isplace-
m en t, deform ation , an d im paction .
Carefu l an alysis of th e site an d exten t of bon e deform ation ,
as well as of th e direction an d degree of d isplacem en t, is th e
basis for selectin g th e m ost appropriate approach an d redu c-
tion tech n iqu e an d for ch oosin g a su itable im plan t or xation
device.
Wh en a fractu re occu rs, sh orten in g of th e lim b takes place,
an d th is h as to be overcom e by lon gitu d in al pu llin g (traction ).
If n ecessary, th e fractu re fragm en ts h ave to be d isen gaged,
eith er by recreatin g th e deform ity or by rotation . Th e fractu re
fragm en ts are m an ipu lated in to th e correct position by align -
in g th em alon g th e lon gitu d in al axis an d correctin g th eir
rotation . Th ese prin ciples of m an ipu lative redu ction can be
carried ou t u sin g d irect an d in d irect tech n iqu es. Th e m eth od
of redu ction ch osen h as to spare th e soft tissu es su rrou n d in g
th e fractu re as m u ch as possible. Th is is im portan t to ach ieve
bon y u n ion , preven t in fection , an d restore fu n ction . Redu c-
tion m an ipu lation is cen tral to th e art of fractu re su rgery
(m eth od an d tech n iqu e of fractu re xation).
Th e redu ction tech n iqu es u sed h ave to be gen tle an d atrau -
m atic. Th ey n eed to preser ve an y rem ain in g vascu larity, sin ce
an adequ ate tissu e respon se is a prerequ isite for h ealin g. Ad-
equ ate blood su pply to th e repair tissu es is cru cial. Bon e h eal-
in g w ill be delayed or w ill cease if on e or both of th e follow in g
factors are im paired: m ech an ical con dition s at th e fractu re
(strain ) an d th e rem ain in g capacity of th e affected tissu e for
a biological respon se.
Accu racy of th e redu ction at join t level, an d th e stability
ach ieved by th e im plan ts, are m ech an ical prerequ isites for th e
biological respon se —ie, th e type of h ealin g ach ieved. In tu rn ,
th e h ealin g process is in u en ced by an y add ition al su rgical
dam age to th e bon e an d th e su rrou n d in g soft-tissu e en velope
wh ich occu rs du rin g th e process of redu ction an d xation
(ex posu re an d im plan t position in g an d xation to th e bon e).
1 Aim o f re d u ct io n
Th e aim of redu ction in d iaph yseal an d m etaph yseal bon e is
to restore th e correct align m en t of th e epiph yses. Wh eth er
th e fractu re between th e m ain fragm en ts is sim ple, m u lti-
fragm en tar y, segm en tal, or sh ow s bon e loss, th e aim of re-
du ction is to redu ce th e epiph yses in to correct relation sh ip
to each oth er. Th is m ean s restorin g th e bon e to its origin al
len gth , ax is, an d rotation . In th e articu lar segm en t, an atom i-
cal redu ction of th e join t su rfaces, w ith elevation of im pacted
areas, is m an dator y to preven t posttrau m atic osteoarth rosis
59
 [1– 3 ]. In add ition , correct spatial orien tation of th e epiph y-
sis w ith respect to th e d iaph ysis sh ou ld be ach ieved, to avoid
lim b m alalign m en t. Ideally, n o residu al d isplacem en t sh ou ld
be tolerated. However, a w idely accepted con ven tion regards
an y form of redu ction as bein g acceptable in wh ich residu al
d isplacem en t is less th an h alf th e th ick n ess of th e articu lar
cartilage. It can be th at du rin g su rger y it is occasion ally n ot
possible to ach ieve an even better redu ction of a given join t
w ith ou t add ition al risks as are in volved in a secon d su rgical
approach , prolon gin g th e operation . Less th an perfect redu c-
tion som etim es h as to be accepted in order to preser ve th e ad-
jacen t an atom ical stru ctu res. Fractu re of th e articu lar su rface
is often accom pan ied by irreparable dam age to th e cartilage
du e to im paction at th e tim e of in ju ry [4].
2 Diffe re n t t yp e s o f s u rgica l re d u ct io n
Th ere are two fu n dam en tally d ifferen t tech n iqu es for frac-
tu re redu ction —d irect an d in d irect. Th e term “d irect redu c-
tion ” im plies th at th e redu ction of th e fractu re fragm en ts
is ach ieved by applyin g forces an d m om en ts d irectly in th e
vicin ity of th e fractu re zon e —th e fractu re fragm en ts can be
m an ipu lated d irectly. In direct redu ction m ean s th at th e forces
an d m om en ts act away from th e fractu re. Redu ction is accom -
plish ed u sin g in stru m en ts or im plan ts in trodu ced d istan t to
th e fractu re zon e, or th rou gh m in im al in cision s. Both redu c-
tion tech n iqu es—d irect an d in d irect—can be perform ed as
open , percu tan eou s, or closed procedu res. ( Ta b 2 -1 ; Ta b 2 -2 ).

Ta b 2 -1 Dire ct ve rs u s in d ire ct re d u ct io n

Dire ct re d u ct io n In d ire ct re d u ct io n
Re d u ctio n o f th e fractu re fragm e n ts is ach ie ve d b y a pp lyin g fo rce s In d ire ct re d u ctio n m e an s tha t th e fo rce s an d m o m e n ts actin g
a n d m o m e n ts d ire ctly in th e vicin it y o f th e fractu re zo n e —th e a way fro m th e fractu re are u se d to m an ip u la te an d n ally re d u ce
fractu re fragm e n ts can b e m a n ipu la te d d ire ctly. th e fractu re , b y a lim ite d o p e n e xp o su re .

De n it io n Op e n d ire ct re d uction In d ire ct close d re d uction

Th e fra ctu re lin e s a re e xp o se d su rgically, a n d th e b o n e fragm e n ts
a re re d u ce d u n d e r d ire ct visio n an d w ith in stru m e n ts d ire ctly ap -
p lie d to e ach fragm e n t, u su ally n e ar th e fra ctu re site .
Pe rcu ta ne ou s d ire ct re du ction
Th e fra ctu re lin e s a re n o t e xp o se d su rgically. Re d u ctio n in stru -
m e n ts are ap p lie d th ro u gh stab in cisio n s.
Th e fractu re lin e s are n o t d ire ctly e xp o se d an d visu a lize d , an d
th e fractu re are a re m ain s co ve re d b y th e su rro u nd in g tissu e s.
Re d u ctio n is carrie d o u t w ith in stru m e n ts o r im p la n ts th a t are
in tro d u ce d a way fro m th e fractu re zo n e .
Op e n ind ire ct re d uction
Op e n b u t o n ly lim ite d e xp o su re o f th e fra ctu re .

Co n t ro l o f re d u ct io n Ea sy, w ith d ire ct visu aliza tio n . With a n im a ge in te n si e r, o r b y clin ica l a sse ssm e n t o f th e a lign -
With a n im age in te n si e r w h e n th e p e rcu ta n e o u s d ire ct re d u ctio n m e n t.
te ch n iq u e is u se d .

In d ica t io n s Articu lar fra ctu re s, sim ple m e ta ph yse al/ d iap h yse a l fractu re s, Mu ltifragm e n ta ry m e taph yse al a n d d iap h yse a l fractu re s.
fo re a rm fra ctu re s.

Pe a rls In th e articu lar se gm e n t, a n a to m ical a n d pre cise re d uctio n o f th e

jo in t su rface , w ith e le va tio n o f th e im p acte d are a s, is m an d a to ry
in o rd e r to a vo id p o st-trau m a tic o ste o a rth ro sis.

60
 2 Su rgica l re d u ct io n t e ch n iq u e s
Ta b 2 -1 Dire ct ve rs u s in d ire ct re d u ct io n (co n t)
Dire ct re d u ct io n
Pe a rls (co n t) In sim p le d iap h yse al fractu re p a t te rn s, d ire ct re d u ctio n is te ch n ically
stra igh t fo rward an d th e re su lts a re e a sy to ch e ck. With pre cise lo cal
a p p roxim a tio n o f th e t wo m ain fragm e n ts, th e le n gth a n d a xial a n d
ro ta tio n al a lign m e n t o f th e b o n e itse lf a re re e stab lish e d . Bio lo gically,
su rgical e xp o su re in e a sy fractu re situa tio n s o f th is t yp e sh o u ld n o t
a d d su b sta n tia l va scu lar d am age to th e b o n e o r so ft tissu e s. Ho we ve r,
th is ca n o n ly b e a ch ie ve d if th e su rge ry is ca rrie d o u t care fu lly, w ith
m e ticu lo u s so ft-tissu e h an d ling an d w ith lim ite d e p ip e rio ste al e xp o -
su re o f th e b o n e .
Pit fa lls In m o re co m p le x d ia ph yse al fractu re s, th e cla ssica l ap p ro ach u se d in
d ire ct re d u ctio n te ch n iq u e s m a y le ad to m isgu id e d a tte m p ts to e xp o se
a n d x e a ch ind ivid u a l fra gm e n t. In th is p ro ce ss, th e su rge o n wo u ld
d e va scu larize e ach o f th e fragm e n ts in se q u e n ce . Th e re p e a te d u se o f
b o n e cla m p s a n d o th e r re d u ctio n to o ls o r im p la n ts m a y co m p le te ly
d e vitalize th e fra gm e n ts in th e m u ltifra gm e n tary a re a , w ith p o te n -
tially d isa stro u s co n se q u e n ce s fo r th e h e aling p ro ce ss, in clu d in g
d e la ye d u n io n , n o n u n io n , in fe ctio n , o r im p lan t fa ilu re . It is o n ly w ith
a th o ro u gh u n d e rsta n d in g o f th e b io lo gy o f b o n e an d so ft tissu e s a nd
a n a wa re n e ss o f p o o r re su lts o b ta in e d a fte r e xce ssive d e va scu lariza -
tio n th a t th e su rge o n is ab le to a vo id fa ilu re s a fte r o p e n re d uctio n a n d
in te rna l xa tio n .
Prin cip le o f Ab so lu te stab ilit y
fra ct u re xa t io n
Me t h o d o f Co m p re ssio n m e th o d —re q u irin g p re cise , accu ra te re d u ctio n . Stab ilit y
fra ct u re xa t io n o f th e xa tio n d e p e n d s o n co m p re ssio n p ro d u cin g frictio n b e t we e n
a n d pre lo ad (e la stic d e fo rm a tio n) o f th e fragm e n t e n d s.
Te ch n iq u e s La g scre w (u sua lly)
La g scre w an d p ro te ctio n pla te
Co m p re ssio n p la te
Bu ttre ss p la te
Te n sio n b a n d , te n sio n p la te
Su rgica l Op e n , fo r re d u ctio n an d im p lan t p lace m e n t a n d xa tio n . Le n gth o f
a p p ro a ch a p pro ach co rre sp o n d s to th e le n gth o f th e im p la n t u se d . In ca se o f a
sim p le fractu re t yp e a d ire ct p e rcu tan e o u s re d u ctio n w ith a m in im a lly
in va sive ap pro ach is p o ssible . Sin ce th e re is n o d ire ct visu aliza tio n o f
th e fractu re site to co n rm th e re d u ctio n d ire ctly, an im age in te n si e r
m u st b e u se d to m o n ito r th e re su lt o f th e re d u ctio n .
So m e tim e s a co m b ina tio n o f clo se d in d ire ct re d u ctio n m a n e u ve r w ith
m an u al tractio n a n d a p e rcu tan e o u s d ire ct re d u ctio n m an e u ve r w ith
p o in te d re d u ctio n fo rce p s o r co llin e a r re d u ctio n clam p is th e b e st wa y
fo r a tra u m a tic re d u ctio n .
In d ire ct re d u ct io n
In th e d iap h ysis an d m e tap h ysis, co rre ct align m e n t o f th e t wo m ain
fra gm e n ts ca rrying th e jo in t su rface s is im p o rta n t. Th e aim is to
re sto re th e o ve rall le n gth o f th e b o n e a s p re cise ly a s p o ssib le , a s we ll
a s th e a xia l an d ro ta tio n al a lign m e n t. In b io lo gical te rm s, in d ire ct
re d u ctio n te ch n iq u e s o ffe r e n o rm o u s ad van tage s, a s th e y o n ly cau se
m in im a l ad d itio n al su rgical d a m age to tissu e s th a t h a ve a lre ad y b e e n
trau m a tize d b y th e fractu re . All in stru m e n ts re q u ire d fo r re d u ctio n are
in tro d u ce d a wa y fro m th e fra ctu re zo n e , o n ly co m p ro m isin g th e tissu e
p e rfu sio n in a n a re a in w h ich trau m a h a s n o t a lre ad y d istu rb e d th e
b lo o d su p p ly.
In p ractice , co rre ct re d u ctio n u sing in d ire ct te ch n iq u e s is m u ch m o re
d if cu lt to ach ie ve . It re q u ire s accu ra te a sse ssm e n t o f th e so ft-tis-
su e le sio n , an u n d e rsta n d in g o f th e fra ctu re p a t te rn , an d m e ticu lo u s
p re o p e ra tive p la n n in g. In ad d itio n , th e actu a l p ro ce ss o f re d u ctio n
is m o re d e m a nd in g a n d re q u ire s th e u se o f an im age in te n si e r o r
in trao p e ra tive rad io gra p h y.
Re la tive stab ilit y
Sp lin tin g m e th o d —stab ilit y o f th e xa tio n d e p e n d s o n th e rigid it y o f
th e sp lin t a nd its an ch o rage to b o n e .
Min im a lly in va sive o ste o s yn th e sis (MIO), ie :
In tra m e d u llary n ailin g
Ela stic n a ilin g
Exte rn al xa to r
Sp lin tin g w ith co n ve n tio n al p la te s
Brid gin g th e fractu re zo n e w ith a lo cke d in te rn al xa to r (LISS a n d LHS,
LCP an d LHS)
Min im a lly in va sive p la te o ste o syn th e sis (MIPO) te ch n iq u e .
Le n gth o f ap p ro ach co rre sp o n d s to th e se ctio n o f th e im p la n t u se d .
On ly in cisio n s fo r im p lan t in se rtio n , o u tsid e o f th e fractu re are a
( p la te a nd scre w s; na ils a nd lo ckin g b o lts).
61
Ta b 2 -2 Diffe re n t t yp e s o f re d u ct io n

Re d u ct io n t yp e Ap p ro a ch Pla ce m e n t o f in s t ru m e n t s Re d u ct io n co n t ro l Vis u a liza t io n a n d s u rgi- Dif cu lt y o f re d u ct io n

o r fo rce s ca l d e va s cu la riza t io n co n t ro l

Dire ct Op e n Clo se to th e fractu re Dire ct vie w

Dire ct Pe rcu ta n e o u s Clo se to th e fra ctu re No d ire ct visua liza tio n , im age
in te n si e r, x-ra ys, clin ica l ch e ck

Ind ire ct Lim ite d o p e n Dista n t to th e fra ctu re Lim ite d visu aliza tio n , im age
in te n si e r

Ind ire ct Clo se d Dista n t to th e fractu re No d ire ct visu a liza tio n: x-ra ys, im -
age in te n si e r, clin ica l ch e ck

2 .1 Fa ct o rs in flu e n cin g t h e ch o ice o f t yp e o f re d u ct io n Several poin ts are to be con sidered:

Th e ch oice of th e redu ction m eth od depen ds on th e bon e, th e
pattern an d location of th e fractu re, an d th e exten t of associ-
ated soft-tissu e in ju ry. Th e goal in fractu re su rgery is always
to preser ve th e viability of bon e by m in im izin g su rgical trau -
m a to per iosseou s m u scle an d to th e fascial attach m en ts th at
provide th e bon e w ith its vascu lar su pply. As th ese tissu es are
con n ected to th e bon e fragm en ts, applyin g lon gitu d in al ten -
sion cau ses th e fragm en ts to align th em selves. Th e su rgeon
h as to decide wh eth er traction sh ou ld be applied m anu ally
by an assistan t, u sin g th e traction table or d istractor, or via a
plate, u sin g th e in d irect redu ction tech n iqu e. If th e traction
table or d istractor is u sed, th e precise position in g of th e trac-
tion or xation pin s sh ou ld be selected. If open redu ction is
plan n ed, th e su rgeon sh ou ld con sider wh ich special forceps
an d clam ps w ill be n ecessary to ach ieve an d tem porarily h old
th e redu ction . Th e su rgeon also h as to decide wh eth er an im -
age in ten si er, serial x-rays, or 3-D CT scan s w ill be n ecessar y
to gu ide an d con trol th e redu ction procedu re an d im plan t in -
sertion .
Soft tissu es
Fractu re con gu ration
Fractu re location
Con trol of redu ction (clin ical, optical, rad iograph ical)
In m oderate-en ergy fractu res, th e periosteu m is torn , bu t th e
m u scle an d in terosseou s m em bran e m ay be in tact an d can
gu ide th e redu ction in to place. In h igh -en ergy fractu res, on ly
th e sk in m ay be in tact. Norm ally th e m ain fragm en ts can eas-
ily be redu ced by traction . Bu t in tercalated fragm en ts do n ot
au tom atically redu ce becau se of th e loss of soft-tissu e con -
n ection s. Low-en ergy fractu res are often associated w ith par-
tial in tact per iosteu m creatin g a good soft-tissu e h in ge u sefu l
du rin g th e process of redu ction .
Th e fractu re con gu ration m ost su itable for in d irect redu c-
tion is a com plex m u ltifragm en tary fractu re, w h ile th e sim -
pler fractu res are u su ally m ore su itable for d irect open or d i-
rect percu tan eou s fractu re redu ction s. For a sim ple fractu re
type an d a situ ation wh ere precise redu ction is n ot requ ired,
in d irect closed redu ction is also an option .

62
 2 Su rgica l re d u ct io n t e ch n iq u e s
In th e d iaph ysis an d m etaph ysis, ax ial align m en t in th e fron -
tal an d sagittal plan es is requ ired. It is im portan t to correct
rotation in th e h orizon tal plan e as well as tran slation an d
len gth ch an ges. An atom ical redu ction of th e fragm en ts is
th erefore n ot n ecessar y, bu t an atom ical align m en t of th e lim b
segm en t is m an dator y.
Join t in volvem en t m ay som etim es requ ire an add ition al d i-
rect approach . In articu lar fractu res, th e an atom ical redu c-
tion of th e articu lar su rface is m an dator y an d th ere is n o place
for in d irect redu ction s in restorin g join t con gru ity, u n less th e
fractu res h ave som e soft-tissu e attach m en ts. Depressed join t
fragm en ts h ave n o soft-tissu e attach m en ts; n o m atter h ow
m u ch traction is applied, th e fractu re w ill n ot redu ce w ith ou t
a d irect redu ction .
Sin ce percu tan eou s d irect or closed in direct redu ction lim its
visu alization of th e fractu re site, th ere is n o m ean s of con -
rm in g th e redu ction directly. Th e best way of overcom in g
th is lim itation is to u se an im age in ten si er to m on itor th e
resu lt of th e redu ction .
Th e su rgical in cision s an d ex posu res u sed are related to th e
redu ction m eth ods. Several prin ciples m u st be obser ved.
Firstly, in cision s n eed to be both straigh t an d lon g en ou gh
to release ten sion du rin g retraction . Secon dly, n o in cision
sh ou ld be m ade over su bcu tan eou s bon es or in sk in areas
sh ow in g im portan t con tu sion an d soft-tissu e dam age. Th ird-
ly, n o su bcu tan eou s aps sh ou ld be created. After advan cin g
below th e deep fascia, th ick fascial–cu tan eou s aps can be
developed if n ecessary, to expose th e fractu re for redu ction
an d stabilization . Fin ally, work in g system atically th rou gh th e
fractu re sites is very im portan t to en su re th at n o fu rth er dam -
age occu rs.
Preoperative plan n in g w ill deter m in e th e type of redu ction ,
th e forces w h ich n eed to be overcom e, an d th e position in g
of th e redu ction device. Th e preoperative plan can be m od i-
ed depen din g on th e su rgical in cision requ ired to ach ieve
im plan t placem en t or redu ction . In d irect redu ction can be
su ccessfu lly accom plish ed u sin g a rad iolu cen t operatin g table
an d im age in ten si er as visu al aids.
2 .2 Dire ct o p e n re d u ct io n
Com plete ph arm acological relaxation is n ecessary for redu c-
tion of fem oral an d tibial sh aft fractu res.
Th e term “d irect open redu ction ” im plies th at th e fractu re
area is exposed su rgically or is already w ide open . All m a-
n eu vers are seen an d m on itored u n der direct vision ( Fig 2 -1 ).
Th is k in d of redu ction tech n iqu e is easier th an in d irect redu c-
tion an d th e redu ction can be m ore precise. Th e fragm en ts are
grasped by su rgical in stru m en ts rath er th an by h an d. Redu c-
tion of th e fractu re fragm en ts is ach ieved by applyin g forces
an d m om en ts d irectly in th e vicin ity of th e fractu re zon e.
Direct redu ction h as been de n ed as d irect reposition in g of
th e bon e fragm en ts u n der d irect vision , w ith in stru m en ts be-
in g d irectly applied to each fragm en t, u su ally n ear th e frac-
tu re site. To allow access, it m ay be n ecessary to str ip m u scles
from th e fragm en ts, particu larly th ose th at are adjacen t to th e
im plan t, an d th is m ay requ ire extraperiosteal ex posu re of th e
fractu re site. Th e fractu re is th en redu ced by traction , eith er
m anu al or u sin g a distractor, an extern al xator, or a traction
table. A tem porary xation device su ch as a clam p or K-w ire
is applied, an d xation th en follow s, u su ally w ith a plate-in -
depen den t lag screw or a lag screw in serted in to a plate to
ach ieve in terfragm en tar y com pression an d to m ain tain th e
redu ction . Th e exten t of th e d issection is lim ited by th e u se
of poin ted retractors, poin ted redu ction forceps, or tem porary
cerclage.
63
 In sim ple d iaph yseal fractu re pattern s, d irect open redu ction
is tech n ically straigh tforward, an d th e resu lt is easy to con -
trol. With precise local approxim ation of th e two m ain frag-
m en ts, th e len gth an d axial an d rotation al align m en t of th e
bon e itself are reestablish ed. Biologically, th e su rgical expo-
su re sh ou ld n ot cau se add ition al su bstan tial vascu lar dam age
to th e bon e or soft tissu es in easy fractu re situ ation s su ch as
th is. However, th is is on ly possible if th e su rger y is carried
ou t carefu lly, w ith m eticu lou s soft-tissu e h an dlin g an d lim -
ited epiperiosteal ex posu re of th e bon e [5 , 6 ]. Open redu ction
is carried ou t to redu ce a d isplaced fractu re an d to apply an
im plan t to stabilize th e redu ction . Wh en atten tion focu ses on
th e im plan t an d th e redu ction , soft tissu es are often n eglect-
ed, u n n ecessarily sacri cin g th e h ealin g poten tial of th e soft
tissu es.
Fig 2-1 Re d uctio n u nd e r d ire ct visio n (o p e n , d ire ct re d u ctio n).
64
2 .3 Dire ct p e rcu t a n e o u s re d u ct io n
In case of a sim ple fractu re type, a d irect percu tan eou s re-
du ction w ith a m in im ally in vasive approach is possible. Sin ce
th ere is n o d irect visu alization of th e fractu re site to con rm
redu ction d irectly, an im age in ten si er m u st be u sed to m on i-
tor th e resu lt of th e redu ction .
Som etim es a com bin ation of a closed in d irect redu ction m a-
n eu ver w ith m anu al traction an d a percu tan eou s d irect re-
du ction m an eu ver w ith poin ted redu ction forceps or a collin -
ear redu ction clam p is th e best way for atrau m atic redu ction .
Th is is tru e for sim ple sh aft, as well as articu lar, fractu res.
Sim ple obliqu e or spiral fractu res can be redu ced w ith th e
h elp of a poin ted redu ction forceps or pelvic redu ction forceps
work in g th rou gh sm all stab in cision s for each bran ch of th e
forceps. Th e collin ear redu ction clam p is an altern ative tool.
A sim ple split fractu re of th e join t can be redu ced by m anu al
traction an d/or d irect, percu tan eou s m an ipu lation w ith a joy
stick, later xed w ith a pelvic redu ction forceps or w ith th e
collin ear redu ction clam p ( Fig 2 -2 ).
In m ore com plex d iaph yseal fractu res, con ven tion al d irect re-
du ction tech n iqu es m ay lead to m isgu ided attem pts to ex pose
an d x each in d ividu al fragm en t—w ith each fragm en t be-
in g devascu larized in sequ en ce. Repeated u se of bon e clam ps
an d oth er redu ction tools or im plan ts m ay com pletely devi-
talize th e fragm en ts in a mu ltifragm en tary area, w ith d isas-
trou s con sequ en ces for th e h ealin g process, in clu d in g delayed
u n ion , n onu n ion , in fection , or im plan t failu re. On ly a good
u n derstan d in g of bon e an d soft-tissu e biology an d an aware-
n ess of poor resu lts observed after excessive devascu lariza-
tion can h elp th e su rgeon avoid su ch failu res follow in g open
redu ction an d in tern al xation [7 ].
 2 Su rgica l re d u ct io n t e ch n iq u e s
a b
2 .4 In d ire ct re d u ct io n , o p e n o r clo s e d
Redu ction is ach ieved by u sin g in stru m en ts or im plan ts in -
trodu ced away from th e fractu re zon e, or th rou gh m in im al
in cision s. Som e speci c im plan ts, su ch as th e in tram edu llar y
n ail or an an atom ically presh aped plate, act both as a redu c-
tion tool an d as a stabilization system .
Th ere are two d ifferen t types of in d irect redu ction —open an d
closed. Open in direct redu ction in volves an open approach ,
bu t w ith in d irect redu ction m an eu vers an d a “n o-tou ch ”
tech n iqu e. Th e term “closed in d irect redu ction ” im plies th at
th e fractu re lin es are n ot d irectly ex posed or visible an d th at
th e fractu re zon e rem ain s covered by th e su rrou n d in g soft
tissu es.
Fig 2 -2 a – b Dire ct p e rcu tan e o u s re d u ctio n w ith a
co llin e ar re d u ctio n clam p.
In practice, correct redu ction is m u ch m ore d if cu lt to ach ieve
u sin g in direct tech n iqu es. It requ ires accu rate assessm en t of
th e soft-tissu e lesion , an u n derstan d in g of th e fractu re pat-
tern , an d m eticu lou s preoperative plan n in g. In add ition , th e
actu al redu ction procedu re is m ore dem an d in g an d requ ires
th e u se of an im age in ten si er or in traoperative rad iograph y
for redu ction con trol. In biological term s, h owever, in d irect
redu ction tech n iqu es offer en orm ou s advan tages, sin ce on ly
m in im al add ition al su rgical dam age is cau sed to tissu es al-
ready trau m atized by th e fractu re. All in stru m en ts requ ired
for redu ction are in trodu ced away from th e fractu re zon e, so
th at tissu e perfu sion is on ly com prom ised in an area n ot al-
ready d istu rbed by trau m a.
Most of th e in stru m en ts an d im plan ts available can be u sed
for eith er tech n iqu e of fractu re redu ction , an d su rgical su c-
cess in preservin g th e biology of th e tissu es does n ot depen d
on th e speci c in stru m en t or im plan t u sed for th e redu ction .
65
 2 .5 Op e n in d ire ct re d u ct io n
In d irect redu ction in volves “blin d” reposition in g of th e bon e
fragm en ts u sin g som e form of d istraction , ach ieved by m an -
u al traction , an in stru m en t, or im plan t, so th at soft tissu es
arou n d th e fractu re site are m in im ally distu rbed ( Fig 2 -3 ). Th e
m ech an ics of th e redu ction procedu re are th e sam e—traction
to correct sh orten in g, an d u n lock in g th e fractu re to correct
tran slation an d rotation . Th e tech n iqu e of in direct reduction
requ ires ex posu re to apply th e redu ction devices, bu t n ot to
visu alize th e fractu re. Th e redu ction devices are u su ally re-
m ote, particu larly if it is possible to u se th e d istraction device.
Tem porary xation is u su ally part of th e redu ction tech n iqu e,
followed by de n itive xation by splin tin g u sin g in tram edu l-
lary n ails, bridgin g plates, locked in tern al xators, or extern al
xators.
a b
Fig 2 -3 a – c Op e n dire ct fractu re re d u ctio n .
a – b In d ire ct re d u ctio n o f la te ra l 41-B3 fractu re w ith large d istracto r.
Th e im p acte d articu lar su rface m u st b e e le va te d w ith a p u sh e r
th ro u gh th e fractu re .
66
Nu m erou s aids are available for in d irect redu ction —im plan ts,
d istractors, clam ps, or an y com bin ation of th ese. For exam ple,
in an in terferen ce plate redu ction on an obliqu e fractu re, th e
plate pu sh es th e fractu re u pward alon g obliqu e in clin e, thu s
redu cin g it in d irectly. On ly on e side of th e fractu re n eeds to
be exposed. Th is an tiglide or in terferen ce tech n iqu e can be
u sed for sim ple obliqu e fractu res. More com m on ly, h owever,
d istraction is applied th rou gh a series of d ifferen t devices su ch
as a d istractor, pu sh -pu ll tech n iqu es w ith plates, traction ta-
bles, or oth er types of traction device.
To ach ieve redu ction , traction is n orm ally applied alon g th e
lon g ax is of th e lim b. Th is can on ly work if th e fragm en ts are
still con n ected to som e soft tissu e. Traction can be applied
m anu ally, w ith th e aid of a traction table, or u sin g a d istrac-
tor. Th e traction table h as th e disadvan tage th at traction h as
c
c Co m p re ssio n u sin g th e p e lvic re d u ctio n fo rce p s a n d p re lim in a ry
xa tio n w ith K-w ire s.
 2 Su rgica l re d u ct io n t e ch n iq u e s

to be applied across at least on e join t. It is n ot possible for th e
su rgeon to m ove th e lim b, an d th e su rgical approach is fre-
qu en tly com prom ised. Th e d istractor, applied d irectly to th e
m ain fragm en ts, allow s th e lim b to be m an ipu lated du rin g
su rger y. An gu lar or rotation al correction s are d if cu lt to car-
ry ou t wh en th e d istractor is su bject to load in g, an d th e con -
stru ct m ay be cu m bersom e. As th ere is an in h eren t ten den cy
for n atu rally cu rved bon e to be straigh ten ed by th e d istrac-
tion procedu re, th e eccen tric force produ ced by a u n ilaterally
m ou n ted distractor m ay produ ce add ition al deform ity.
2 .6 Clo s e d in d ire ct re d u ct io n
Biological fractu re xation (see Ta b 1-1 ) is u sed u su ally after
som e form of in direct redu ction . Locked n ails, locked in ter-
n al xators, an d extern al xators are u sed for th is pu r pose.
Biological fractu re xation m ean s th e com bin ation of a closed
in d irect redu ction tech n iqu e an d th e u se of im plan t produ c-
in g low add ition al im plan t-in h eren t vascu lar dam age to bon e
an d soft tissu es.
fragm en ts in to place. Th e sam e also applies to m etaph yseal
an d epiph yseal bon e segm en ts, alth ou gh th e d istraction re-
qu ired to align th e fragm en ts is tran sferred n ot so mu ch via
m u scle attach m en ts as th rou gh capsu lar tissu es, ligam en ts,
an d (less often) ten don s. Th is ph en om en on , wh ich is regu lar-
ly observed in n on su rgical fractu re m an agem en t, is referred
to as “ligam en totax is” (see Ta b 1-1). Sim ilarly, traction applied
to an en tire lim b u sin g a traction table produ ces in d irect re-
du ction at a fractu re focu s. However, applyin g an im plan t or
large d istractor to a sin gle bon e h elps con trol redu ction m ore
effectively an d also allow s su btile adju stm en ts to be m ade. If
feasible, in d irect redu ction tech n iqu es w ith a d istractor ( Fig
2 -4 ) or extern al xator an d plate can be com bin ed. Oth er
in stru m en ts an d tools for in d irect redu ction , su ch as plates,
in con ju n ction w ith th e articu lated ten sion device an d bon e
spreaders, are described below.

Extern al xators, locked n ails, an d locked in tern al xators

are u sed for th is pu r pose —all of th em n ot relyin g on bon e-
im plan t con tact for load tran sfer. Th e xation is elastic, w ith
relative stability (see Ta b 1-5 ).

Th e goal of in d irect redu ction is to ach ieve prelim in ar y align -

m en t of a fractu red bon e, eith er before any attem pt of in tern al
xation is m ade or in con ju n ction w ith a xation device. Th e
m ech a n ical prin ciple u n derlyin g in direct redu ction is distrac-
tion , an d th is applies equ ally to d iaph yseal an d m etaph yseal
bon e. Th e m u scle envelope su rrou n d in g th e d iaphysis of m ost
lon g bon es provides a logical ration ale for in d irect redu ction ,
sin ce con trolled pu llin g on th e m u scle an d periosteal attach -
m en ts of any sin gle fragm en t w ill ten d to align it in th e de- Fig 2 -4 In d ire ct fragm e n t
sired d irection . In add ition , a m u scle en velope u n der d istrac- m an ipu la tio n w ith th e la rge
tion exerts con cen tric pressu re towards th e sh aft, easin g th e d istracto r.

67
 2 .7 Re d u ct io n a n d fixa t io n o f m e t a p h ys e a l a n d
d ia p h ys e a l fra ct u re s
Diaph yseal fractu res can be redu ced d irectly or in directly;
in depen den tly of th e tech n iqu e, an y redu ction m an eu -
ver sh ou ld be as gen tle as possible to th e soft tissu es an d
periosteu m su rrou n d in g th e fractu re in order to preser ve
th e ex istin g blood su pply. Fixation tech n iqu es m ost often
u sed in th e treatm en t of diaphyseal fractu res are in tra-
m edu llary n ailin g, platin g (w ith eith er th e com pression or
splin tin g m eth od), an d extern al xation .
A m in im ally in vasive approach after closed in d irect re-
du ction is u sed to in sert in tram edu llary n ails. Locked in -
tram edu llar y n ails allow mu ltifragm en tary fractu res to be
xed at th e correct len gth in case of at least partial con tact
between th e m ain fragm en ts. In tram edu llary n ails are in -
tern al splin ts th at are load-sh arin g an d allow early weigh t
bearin g. As th ey allow a certain degree of m ovem en t at
th e fractu re site, th eir u se is associated w ith callu s form a-
tion an d early bon e u n ion .
Plates an d screw s m ay be a good option for sh aft fractu res
th at exten d to th e m etaph yseal area or in to a join t. Th ey
can be in serted eith er by an open , less in vasive, or m in i-
m ally in vasive approach after direct or in direct redu ction
tech n iqu es.
In sim ple fractu res th at are easily reduced an atom ically, th e
conven tion al in terfragm entary lag screw, com bined w ith a
protection plate, rem ain s an excellen t m ean s of xation .
Platin g of com plex, m u ltifragm en tar y diaph yseal fractu res
sh ou ld be carried ou t w ith m in im a lly invasive tech n iqu es,
u sin g in d irect redu ction an d th e locked splin tin g m eth od,
bridgin g th e fractu re zon e w ith an in tern al xator, an d
leavin g th e fractu re focu s u n tou ch ed.
Extern al xators are still th e gold stan dard in cases of
severe soft-tissu e in ju ry, an d in parts of th e world w h ere
n ails an d plates are m ore dif cu lt to obtain an d risks are
in volved for logistical an d tech n ical reason s, su ch as th e
68
u n availability of im age in ten si cation . However, fractu re
h ealin g m ay be delayed, an d pin -track problem s (in fec-
tion , loosen in g) are com m on . Extern al xators are th ere-
fore n ot a popu lar ch oice for de n itive xation , an d a
ch an ge of m eth od is often con sidered eith er on ce th e soft-
tissu e problem is solved or in com bin ation w ith a plastic
recon stru ction of th e soft-tissu e en velope.
2 .8 Re d u ct io n a n d fixa t io n o f a r t icu la r fra ct u re s
In traar ticu lar fractu res gen erally requ ire open , d irect,
an d precise redu ction , w ith stable xation . On ly sim ple
or n on d isplaced in traar ticu lar fractu res ca n be redu ced
in a closed m a n n er w ith im age in ten si cation con trol.
All fractu re su rfaces h ave to be th orou gh ly clean ed of
h em atom a an d a n y early callu s. At th is stage, loose os-
teoch on d ral fragm en ts ca n be rem oved from th e wou n d,
bu t im pacted fragm en ts sh ou ld n ot yet be elevated from
th e u n derlyin g ca n cellou s beds. Regard less of th eir size,
a ll in traar ticu lar fragm en ts sh ou ld in itia lly be reta in ed as
keys to th e n al redu ction . If th ere is in adequ ate stabil-
ity, th e large d istractor or an ex ter n a l xator ca n be u sed
to m a in tain d istraction an d ax ia l align m en t an d to allow
a degree of in d irect redu ction of fractu re fragm en ts. Th e
in tact join t su r faces an d th e opposin g ar ticu lar su rfaces
are u sed to assess th e redu ction of d isplaced or im pacted
in traar ticu lar fragm en ts. Approach in g th e fractu re via a
w in dow created in th e m etaph ysea l cor tex, cen tra l, de-
pressed fragm en ts ca n be elevated an d redu ced. Im pact-
ed osteoch on d ral fragm en ts sh ou ld be elevated from th e
u n derlyin g m etaph yseal bon e alon g w ith an adequ ate
block of can cellou s bon e u sin g a n osteotom e or elevator.
Th is tech n iqu e m ain ta in s th e con n ection between th e
su bch on d ral cor tical bon e an d its u n derlyin g ca n cellou s
bon e, facilitatin g possible fu tu re xation .
Alth ou gh free cartilage or osteoch on dral fragm en ts w ith -
ou t can cellou s bon e su pport cou ld be h elpfu l in position -
 2 Su rgica l re d u ct io n t e ch n iq u e s
in g m ajor in traarticu lar fragm en ts, it wou ld be d if cu lt
to x an d m ain tain th eir position later if th eir lon g-term
viability is qu estion able. Th ey are th erefore d iscarded after
th ey h ave been u sed for redu ction con trol of m ajor frag-
m en ts. Bon e defects rem ain in g w ith in th e m etaphysis are
lled w ith an au togen ou s can cellou s or corticocan cellou s
graft to provide early su pport for th e articu lar su rface an d
to stim u late recon stitu tion of m etaph yseal bon e. Cortical
redu ction an d soft-tissu e attach m en ts can gu ide th e redu c-
tion of periph eral fractu re fragm en ts an d th eir associated
articu lar su rfaces. Poin ted redu ction forceps an d K-w ires
are u sed to h old th e fractu re tem porar ily in position wh ile
th e accu racy of redu ction is con rm ed.
Special circu m stan ces can n ecessitate deviation from th e
u su al recon stru ction protocol. In sim ple fractu res w ith a
sin gle large fragm en t th at h as split away from th e join t
an d wh ich is cau sin g in stability, closed redu ction can be
carried ou t in th e operatin g room . Usin g im age in ten si-
cation , th e redu ction can be con rm ed an d is followed
by stabilization of th e fractu re u sin g gu ide w ires an d can -
n u lated screw s. In th e presen ce of in traarticu lar an d m e-
taph yseal fragm en tation (C3 in ju r ies), th ere are n o parts
of th e articu lar su rface th at are in con tinu ity w ith th e
m etaph ysis. Regu larly th e rst step is recon stru ction of
th e epiph ysis (articu lar fractu re), followed by redu ction
of th e join t block to th e dia-m etaph ysis as a secon d step.
Som etim es, th e order of th e steps of redu ction h as to be
reversed an d rst th e m etaph ysis is redu ced to th e d iaph y-
sis to an atom ical lan d m arks for epiph yseal redu ction an d
recon stru ction .
Direct in spection of th e join t su rface, eith er arth roscopi-
cally or th rou gh arth rotom y, serves to evalu ate th e redu c-
tion of th e cartilagin ou s su rfaces. In traoperative im age
in ten si cation or rad iograph y provides in form ation on th e
bon e redu ction . Fixation of th e in traarticu lar portion can
be com pleted wh en redu ction is satisfactory.
Lag screw xation cau ses com pression between th e can -
cellou s su rfaces an d resu lts in stable xation of th e frag-
m en t. Care n eeds to be taken n ot to overcom press th ese
fragm en ts. If th ere are m u ltiple sm all fragm en ts, redu c-
tion of th e fractu re an d su pport for th e sm all fragm en ts
can be m ain tain ed w ith fu lly th readed position screw s to
h old th e fragm en ts in place w ith ou t com pression . In th is
case, absolu te stability m ay n ot be obtain ed du e to th e
sm all areas of con tact between th e fragm en ts.
3 In s t ru m e n t s a n d t e ch n iq u e s
Th e m ost im portan t m ech an ism for redu cin g a fractu re is
traction , wh ich is n orm ally applied alon g th e lon g ax is of th e
lim b. In th e case of a m u ltifragm en tary in traarticu lar frac-
tu re, traction across a join t m ay be able to redu ce fragm en ts
by ligam en totaxis (see Ta b 1-1). Traction can be applied m an u -
ally, by m ean s of a traction table, a d istractor, or an extern al
xator.
3 .1 Re d u ct io n in s t ru m e n t s
Tract io n t able s. Th e w idely u sed traction table h as th e
d isadvan tage th at tracttion is u su ally applied across at least
on e join t. Th e lim b can n ot be m oved by th e su rgeon , an d
th e su rgical approach is frequ en tly com prom ised ( Fig 2 -5 ).
Sm all re d u ct io n t able . Th e sm all redu ction table h as th e
advan tage th at traction an d an gu lar or rotation al correc-
tion s are applied d irectly to th e m ain fragm en ts.
D ist ract o r. Applied d irectly to th e m ain fragm en ts, th e
d istractor m akes it possible to m an eu ver th e lim b du rin g
su rger y. An gu lar or rotation al correction s are d if cu lt or
even im possible w ith th e d istractor u n der ax ial load, an d
th e con stru ct m ay be cu m bersom e. As th ere is an in h er-
69
 Fig 2 -5 Traction tab le .
en t ten den cy for cu r ved bon es to straigh ten du rin g th e
d istraction procedu re, th e eccen tric force produ ced by th e
u n ilaterally m ou n ted d istractor m ay produ ce add ition al
deform ity (see Fig 2 -4 ).
LISS d ist ract o r. Th e LISS d istractor ( Fig 2 -6 ) is th e com -
bin ation of th e large distractor w ith th e LISS-DF plate. On e
bolt of th e distractor xes th e plate th rou gh a plate h ole to
th e d istal fem u r. Th e oth er bolt is xed on to th e prox im al
fem u r. Th e LISS d istractor allow s a con trolled application
of force (distraction an d/or com pression) by th e redu ction
m an eu ver. Th is m akes redu ction possible again st th e plate
before n al xation of th e LISS plate [8 ].
70
Fig 2 -6 LISS d istracto r.
Ex t e rn al x at o r. Th e extern al xator can be u sed for
in d irect redu ction , bu t gen tle len gth en in g is m ore d if-
cu lt th an w ith th e distractor. Wh en traction is applied
across a join t ( Fig 2 -7 ), ligam en ts an d soft tissu es arou n d
th e fractu re area can h elp ach ieve redu ction th rou gh liga-
m en totaxis (see Ta b 1-1) or soft-tissu e tax is, respectively.
Th e m ain elds of application for th is device are m u lti-
fragm en tary m etaph yseal/epiph yseal fractu re, w h ere th e
con d ition of th e soft tissu e or fractu re fragm en tation does
n ot allow th e u se of open or d irect redu ction an d stabiliza-
tion tech n iqu es.
 2 Su rgica l re d u ct io n t e ch n iq u e s

Fig 2 -8 a – b Dire ct m anu al re d uctio n u sin g t wo p o in te d

re d u ctio n fo rce p s.
a Each m ain fragm e n t is h e ld w ith a p o in te d re du ctio n fo rce p s.
a b
b Le ngthe n ing is achie ve d b y m anual traction while co rre ct ro tation
Fig 2 -7a – b Jo in t-brid ging e xte rna l xa to r. and a xial alignm e n t can b e con trolle d w ith the force p s.

3 .2 Re d u ct io n fo rce p s Bo n e h o ld in g fo rce p s, se lf-ce n t e rin g (Verbru gge for-

ceps). Th e m ain fu n ction of th is forceps is to h old a plate
Po in t e d re d u ct io n fo rce p s (Weber forceps). Th e poin ted to th e d iaph yseal bon e. Du e to its speci c design , it allow s
redu ction forceps is th e rst ch oice as a redu ction tool, as it con siderable circu m feren tial ex posu re of th e bon e, as its
is gen tle to th e periosteal sleeve an d can be u sed for d irect poin ted en d h as to reach com pletely arou n d th e bon e.
an d in d irect redu ction . Good grip, n o slip of th e clam p ( Fig
2-8 ).
Re d u ct io n fo rce p s, se rrat e d jaw s. Du e to th e an gu la-
tion of th e jaw s easier in trodu ction th rou gh th e secon d
an d th ird w in dow of an ilioin gu in al approach an d pos-
sibility for its u se th rou gh th e greater sciatic n otch on to
th e qu ad rilateral su rface th rou gh th e Koch er-Lan gen beck
approach .

71
 a
b

Fig 2 -9 a – b Pu sh -pu ll te ch niq u e .

a The b o ne spre ad e r, place d b e twe e n th e e n d o f a pla te an d a n ind e p e nd e n t scre w, can b e u se d to
d istract o r pu sh ap art the fractu re fragm e n ts.
b Th e re a fte r, an d su in g th e sam e in d e p e n d e n t scre w, in te rfragm e n tary co m p re ssio n ca n b e o b tain e d b y
p u llin g th e pla te e n d to ward s th e scre w w ith a sm all Ve rbru gge clam p s.

Bo n e sp re ad e r. Th is device can be u sed for d istraction if Pe lv ic re d u ct io n fo rce p s w it h p o in t e d ball t ip s (“Kin g

it is placed between th e en d of a plate an d an in depen den t
screw 1 cm from th e en d of th e plate (“pu sh -pu ll tech -
n iqu e”) ( Fig 2 -9 ).
Co llin e ar re d u ct io n clam p . Th e collin ear redu ction
clam p allow s axial redu ction of bon e fragm en ts th rou gh a
sm all sk in in cision via th e ax ial slid in g m ech an ism on its
forceps ( Fig 2 -10 ).
Ton g” an d “Qu een Ton g” forceps), sym m etrical an d asym -
m etrical. Th ese redu ction forceps are m ain ly u sed to re-
du ce pelvic rin g lesion s or acetabu lar fractu res ( Fig 2 -11).
Pe lv ic re du ct io n fo rce p s (Farabeu f forceps). Th e Fara-
beu f forceps is design ed to grasp screw h eads in serted on
eith er side of a fractu re lin e (3.5 m m or 4.5 m m screw s)
( Fig 2 -12 ). Man ipu lation of th e forceps allows com pression
an d also perm its lim ited m an ipu lation s in two differen t
plan es. However, distraction of th e fractu re gap is n ot pos-
sible.

72
 2 Su rgica l re d u ct io n t e ch n iq u e s

Fig 2 -10 a – d
a Collin e ar re d uctio n clam p.
b – d Pe ripro sth e tic 32-A1 fractu re . Final re d u ctio n is ach ie ve d
a d ire ctly u sin g th e co lline ar re du ctio n clam p.

b c d

Fig 2 -12 Th e Farab e u f fo rce p s is m ainly u se d fo r fractu re re du ctio n

o f the p e lvic rin g in th e are a o f th e iliac cre st o r th e SI jo in t. It is
a n ch o re d o n b o th sid e s o f th e fractu re w ith e ith e r 3 .5 o r 4 .5 m m
Fig 2 -11 Ind ire ct re d uctio n u sin g fo rce p s co rte x scre w s. Th e fo rce p s is h e lp fu l o n ly to re d u ce a sid e -to -sid e
w ith b all p o in ts. d isplace m e n t o r to clo se a fractu re gap. Distractio n is n o t p o ssib le .

73
 Pe lv ic re d u ct io n fo rce p s (Ju n gblu th forceps). Th is is
xed on to both fragm en ts w ith a 4.5 m m or 3.5 m m cortex
screw, allow in g th e fragm en ts to be m oved an d redu ced
in th ree plan es (d istraction an d com pression , as well as
lateral d isplacem en t in two plan es) ( Fig 2 -13 ).

3 .3 Ot h e r in s t ru m e n t s , t rick s , a n d h in t s u s e fu l fo r
re d u ct io n

Ho h m an n re t ract o r. In cortical bon e, th e sm all-tipped

Hoh m an n retractor can be u sed as a lever or pu sh er to
ach ieve redu ction ( Fig 2 -14 ).
Ball sp ike w it h p o in t e d ball t ip , bo n e im p act o r, bo n e
h o o k . Fractu re redu ction in on e direction can be carried
ou t by in stru m en ts th at are design ed to pu sh or pu ll. Us-
in g th e ball spike, fragm en ts can be pu sh ed rm ly in to th e
righ t position . Th rou gh a can nu lated version of th e ball
spike a K-w ire for tem porar y fragm en t xation is h elpfu l.
Th e K-w ire can also be u sed to in sert a can nu lated screw.
Joyst ick re d u ct io n . In m an ipu lation of large bon y frag-
m en ts a Sch an z screw can be in serted as a joystick. Large
th readed pin s w ith h olders are also bein g devised. Th e in -
sertion of a Sch an z screw in to th e pelvic isch iu m is a tech -
n iqu e com m on ly u sed for m an ipu lation of th e posterior
colu m n of th e acetabu lu m (in case of a posterior colu m n ,
tran sverse, or T-sh aped fractu re). Th e open or percu tan e-
ou s in sertion of th readed or u n th readed K-w ires allow s
m an ipu lation of bon e fragm en ts w ith or w ith ou t direct vi-
su alization . Th e tech n iqu e is m ain ly u sed in in traarticu lar
fractu res of th e d istal radiu s an d proxim al hu m eru s [3 , 9 ]
( Fig 2 -15 ).
Re d u ct io n h an d le , t o o t h e d , to gain an d m ain tain stable
in traoperative xation of fractu re ( Fig 2 -16 ).
Fig 2-13 Th e Ju ngb lu th fo rce p s is xe d to fragm e n ts w ith 4 .5 m m
co rte x scre w s. Th is rm co n n e ctio n a llo w s tran sla tio n al re d u ctio n
m an e u ve rs in a ll th re e p la ne s.

74
 2 Su rgica l re d u ct io n t e ch n iq u e s

Fig 2 -14 a – c Diap h yse a l re d u ctio n w ith th e

sm all Ho h m a nn re tracto r. In co rtical b on e
th e tip o f th e Ho h m an n re tracto r is p lace d
b e twe e n th e two fra gm e n ts. By tu rn ing a nd
b e nd in g the re tracto r hand le the fragm e n ts
ca n b e d ise n gage d a n d re d u ce d . An o th e r
tu rn is u su ally re q u ire d to re m o ve th e Ho h -
m an n re tracto r.

a b c

Fig 2 -15 Th e jo ystick te ch n iq u e m a y also b e u se d to co n trol ro ta tio n o f the

fe m o ral d iap h ysis w h e n re d ucing a su p racon d yla r fractu re .

75
 Kap an d ji re du ct io n . With a K-w ire in serted th rough the
fractu re gap, the radiostyloid fragm en t of a distal radial
fractu re can be m an ipu lated and rotated in a fash ion sim i-
lar to th e tech n iqu e w ith th e Hom an n retractor. De n itive
stabilization is ach ieved by com pletin g the in sertion of the
K-w ire in to the opposite cortex of the bone.
Te m p o rary an d d e n it ive ce rclage . Tem porary cerclage
can be h elpfu l in redu cin g a m u ltifragm en tary fractu re
(m ain ly bu tter y fragm en ts or type B spiral fragm en ts) in
th e d iaph ysis. Th e tech n iqu e h as th e d isadvan tage th at it
a
in volves tem porar y circu m feren tial den u d in g of th e bon e
du rin g application of th e w ire [2]. Redu ction an d xation
w ith w ires h as attracted in creasin g in terest in th e treat-
m en t of per iprosth etic fractu res in elderly patien ts [10 ] be-
cau se it is a low-en ergy trau m a w ith low soft-tissu e com -
prom ise.

Fig 2 -16 a – c Re d u ctio n w ith the to o the d re d u ctio n ha nd le s.

a In se rtio n o f th e thre ad e d ro d an d a ttach m e n t o f th e re du ctio n ha nd le .
b Ap p lying large co m b in a tio n clam p s a n d a carb o n b e r ro d w ith o u t tigh te n in g th e
co n stru ct. Re d u ce th e fragm e n ts.
c
c Tigh te n th e co m b in a tio n clam p s to te m p o rarily h o ld th e re d u ctio n .

76
 2 Su rgica l re d u ct io n t e ch n iq u e s

3 .4 Re d u ct io n w it h t h e h e lp o f im p la n t s
(re d u ct io n o n t o a n im p la n t )

Ideally, an im plan t sh ou ld con tribu te both to th e redu ction

an d stabilization of a fractu re. Redu ction can be ach ieved u s-
in g an im plan t by in terfer in g w ith th e bon e.

Re d u ct io n o n t o a p lat e (see ch apter 3). Fractu res of an y

relatively straigh t portion of th e d iaph ysis can be redu ced
u sin g a plate th at acts as a splin t to restore align m en t be-
fore de n itive xation .
P u sh -p u ll t e ch n iqu e . A bon e spreader, placed between
th e en d of a plate an d an in depen den t screw can be u sed to
d istract or pu sh apart th e fractu re fragm en ts. Distractin g
th e fractu re in creases th e ten sion in th e soft tissu es, wh ich
ten ds to realign th e fragm en ts in to th eir origin al position .
Th e pu sh -pu ll tech n iqu e u sin g a bon e spreader an d th e
Verbru gge clam p (pu sh -pu ll clam p) is an elegan t an d often
u sed m eth od of distractin g an d redu cin g a fractu re—for
exam ple, in forearm bon es or in delayed su rgery for a m al-
leolar fractu re ( Fig 2 -17 ).
A n t iglid e p lat e . An oth er sim ple an d gen tle redu ction
m ech an ism u ses th e plate for an tiglide pu r poses [11]. Ap-
plyin g a properly con tou red plate to on e fragm en t of an
obliqu e m etaph yseal fractu re resu lts in au tom atically re-
du cin g th e opposite fragm en t. Th is tech n iqu e corrects
sm all displacem en ts an d an gu lation w h ile m ain tain in g
stability as th e redu ction takes place ( Fig 2 -18 ).
A n gle d blad e p lat e . Wh en an an gled blade plate is cor-
rectly in ser ted in to th e proxim al or d istal epiph yseal/ m e-
taph yseal segm en t of th e fem u r, its sh ape w ill brin g th e
d iaph yseal segm en t in to an atom ical align m en t. Th e blade
of th e plate is rst in serted in to th e proxim al or d istal en d
fragm en t. Th e sh aft is th en redu ced to th e side plate, w ith
th e Verbru gge clam p bein g u sed to h old th e two togeth er.
Fin e-tu n in g of th e redu ction can be ach ieved w ith th e
pu sh –pu ll tech n iqu e u sin g th e articu lated ten sion device Fig 2 -17 Op e n , bu t ind ire ct re d u ctio n w ith a b o n e
( Fig 2 -19 ) [1,2]. spre ad e r an d a pla te .

77

a b
Fig 2 -18 a – c In d ire ct re d uctio n w ith a pla te in bu ttre ss m o de .
a Po ste rio rly d isp lace d fractu re (typ e B) o f th e la te ra l m a llo e lu s.
b Fixa tion o f a 4 -h o le o r 5 h o le o ne -th ird tu bu la r pla te p o ste rio rly
o n to th e proxim al fra gm e n t.
c Tigh te n in g o f th e scre w fo rce s th e d istal fragm e n t to glid e
d istally an d an te rio rly a lo ng th e ob liq u e fractu re plan e in to th e
co rre ct p o sitio n , w h e re it is rm ly lo cke d b y th e p la te .
c

a b c d e

Fig 2 -19 a – e Re du ctio n w ith the h e lp o f th e co n d ylar b lad e p la te .
a Displace m e n t o f a p roxim al fe m u r fractu re w ith the p roxim al
fragm e n t in ad d u ctio n an d e xio n .
b In tro d u ctio n o f the 9 5°a ngle d b lad e pla te (= co n d ylar b lad e
p la te) an d d istractio n o f th e fractu re w ith the large d istracto r.
c Pro visio n al xa tio n w ith a re d uctio n fo rce p s d ista lly.
d Use o f th e a rticu la tin g te n sio n d e vice to d istract th e fractu re
a n d to allo w co m p le te re d u ctio n p ro xim a lly.
e By re ve rsio n o f th e sm all h o o k, th e te n sio n d e vice is u se d fo r
in te rfra gm e n tary co m pre ssio n .

78
 2 Su rgica l re d u ct io n t e ch n iq u e s
Re d u ct io n scre w . A cortex screw can be u sed to redu ce
th e bon e segm en t on to th e plate or to redu ce a severely
d isplaced bu tter y fragm en t.
Sp e cia l in st ru m e n t s fo r lo cke d i n t e rn a l x at o rs —
less in vasive stabilization system (LISS), lock in g com pres-
sion plate (LCP), a n atom ica lly presh aped LCP. Th e goa ls
of redu ction w ith th e n ew gen eration of im pla n ts are th e
sa m e as th ey were w ith th e con ven tion a l stan dard plates.
However, th ese im pla n ts appear to be m ore d if cu lt to
apply, par ticu larly if th ey are u sed as in ter n a l xators
w ith su bm u scu lar or su bcu ta n eou s in ser tion in com bin a-
tion w ith in d irect redu ction tech n iqu es. In th is t ype of
situ ation , th e d iaph ysea l fractu re h as to be redu ced rst
u sin g a d istraction device tem porar ily m a in ta in in g th e
correct a lign m en t of th e bon e. An atom ica lly presh aped
a b
Fig 2 -2 0 a – c Pu llin g d e vice (“w hirlyb ird ”).
Co rre ctio n o f varu s a nd valgu s d e fo rm itie s w ith a LISS p la te
in p o sitio n .
LISS- a n d LCP plates are th en in ser ted w ith ou t add ition a l
con tou r in g. Non a n atom ica lly presh aped plates sh ou ld be
approx im ately con tou red accord in g th e a n atom ica l loca-
tion , to avoid u n desired d istu rba n ce of cover in g soft tis-
su e. Th e im pla n t is th en in ser ted a n d xed to th e bon e
w ith lock in g h ead screw s. Th e im pla n t is th en in ser ted
w ith ou t presh apin g a n d xed to th e bon e w ith lock in g
h ead screw s. On ly a few in str u m en ts are ava ilable to h elp
th e su rgeon accom plish th is d if cu lt task. On e of th ese is
th e “w h irlybird” in str u m en t, w h ich a llow s correction of
var u s a n d va lgu s defor m ities w ith a LISS in position [12]
( Fig 2 -2 0 ; Fig | An im a tio n 2 -21). An atom ica lly presh aped
plates (LISS, specia l LCP) m a ke th e redu ction m a n eu ver
easier a n d ca n be xed on to th e m etaph ysea l fractu re
fragm en t rst.
c
79
An im a tio n
Aids for d irect redu ction :
2-21 Towel
Joystick
Hoh m an n retractor
Plate
Screw
Collin ear redu ction cla m p
Poin ted redu ction forceps
Cerclage w ire
Fig | An im a tio n 2 -21 Fin e -tu n in g w ith th e
scre w d rive r an d th e scre w ho ld ing sle e ve .
In dication :
Articu lar fractu res
Sim ple m etaph yseal fractu res
Irredu cible fractu res
Osteotom ies, n onu n ion s

Fin e -t u n in g. Usin g LHS, th e screw d river an d th e screw Goals for d irect fractu re redu ction for M IPO:
h old in g sleeve allow s correction of varu s an d valgu s defor- An atom ical recon stru ction
m ities an d redu ction on to th e plate (see case 9.2.2). Absolu te stability by rigid xation

3 .5 Min im a lly in va s ive re d u ct io n In d ire ct fra ct u re re d u ct io n fo r MIPO

Th ere are two d ifferen t prin ciples of redu ction for m in im ally
in vasive plate osteosyn th esis (M IPO). Th e rst prin ciple is in -
d irect redu ction wh ich im plies traction alon g th e axis of th e
lim b an d th e h elp of th e soft tissu es for th e redu ction m an eu -
ver (ligam en totax is). Th e secon d pr in ciple is d irect redu ction
wh ich m ean s th at th e redu ction is ach ieved close to th e frac-
tu re an d percu tan eou sly.
In d ication :
Diaph yseal fractu res
Goals for in d irect fractu re redu ction for M IPO:
Restoration of len gth , axis, an d rotation
Correct position of th e adjacen t join ts
In d ividu al fractu re fragm en ts n eed n ot be an atom ically
redu ced

Dire ct fra ct u re re d u ct io n fo r MIPO Aids for in d irect redu ction :

Hazards: Manu al traction
Ex posu re can be too w ide Large d istractor
Excessive periosteal strippin g Pu sh -pu ll forceps
Traction table
Extern al xator

80
 2 Su rgica l re d u ct io n t e ch n iq u e s
4 As s e s s m e n t o f re d u ct io n
On ce a fractu re h as been redu ced u sin g eith er d irect or in d i-
rect tech n iqu es, it h as to be ch ecked. Th ere are variou s ways
of doin g th is, in clu din g d irect visu alization , palpation (digital
or in stru m en ta l), clin ical observation , radiograph y, im age in -
ten si cation , in d irect vision u sin g an arth roscope or an en -
doscope, or w ith a com pu ter-gu ided or com pu ter-assisted sys-
tem . Som e of th ese tech n iqu es are m ore reliable th an oth ers;
h owever, m u ch depen ds on th eir availability.
The sm all inden tation s or landm arks th at are presen t in every
fractu re line h ave to be noted if the fractu re focu s is visible.
If a fractu re su rface can n ot be directly visu alized bu t can be
reach ed w ith the n gertip, palpation m ay be helpfu l—for ex-
am ple, of th e qu adrilateral su rface in th e pelvis to check th e
reduction of an acetabu lar fractu re. Th is can also be carried ou t
w ith an appropriate in stru m en t to evalu ate th e accu racy of re-
du ction of an articu lar su rface—for exam ple, in a tibial plateau
fractu re. Clin ical assessm en t of redu ction an d rotation al align -
ment m ay be dif cu lt and u n reliable, but it is often necessary,
particu larly in closed intram edu llary n ailin g or M IPO in case
of sh aft fractu re of th e leg.
Wh en ever possible, in traoperative ch eck in g of th e fractu re
redu ction an d xation sh ou ld be carried ou t u sin g im age in -
ten si cation or rad iograph y in two plan es.
4 .1 In t ra o p e ra t ive t e ch n iq u e s fo r ch e ck in g a lign m e n t
Le n gt h . Restorin g len gth in a sim ple fractu re is u su ally u n -
com plicated. Th e in d ividu a l fractu re con gu ration w ill offer
som e gu ide in assessin g len gth . Th e su rgeon can m ath th e
geom etry of fractu re fragm en ts an d m ake su re th ey are in
th e sam e level. In th e case of com plex fractu res th e risk of
obtain in g a n in correct len gth is m u ch h igh er. Preoperative
m easu rem en t of th e appropriate im plan t len gh t (in tram edu l-
lary n ail) of th e u n affected side is u sefu l an d th is read in g w ill
ser ve as a gu idelin e to th e su rgeon .
Th e su rgeon can com pare redu ction w ith th e u n affected side
du rin g su rgery. Su ch com parison can on ly be possible if th e
patien t is lyin g su pin e. Th e con tralateral fem oral len gth is
m easu red tak in g th e fem oral h ead an d th e lateral fem oral
con dyle as referen ce an d m ark in g th e len gth on th e m easu r-
in g device u sin g a clip. Th e in ju red side is m easu red iden ti-
cally an d th e len gth discrepan cy can be easily determ in ed.
Wh en a ram w ith a h an d le is u sed, th e lim b len gth can be
adju sted con tinu ou sly in both d irection s. Th e len gth of th e
tibia is m u ch easier to evalu ate th an th at of th e fem u r, an d
clin ical m eth ods are u su ally su f cien t. In som e cases th e re-
du ced sim ple bu la fractu re is h elpfu l.
Fro n t al–sagit t al p lan e . In sim ple m idsh aft fractu res of th e
fem u r an d tibia, fron tal an d sagittal plan e align m en t is u su -
ally n ot a problem . Wh ile CCD (capu t-collu m -d iaph ysis) an -
gles can be m easu red an d ch ecked by im age in ten si cation ,
th e evalu ation of th e correct weigh t-bearin g ax is is u su ally
m ore dif cu lt, especially in com plex, m u ltifragm en tary, or
m etaph yseal fractu res. Bu t th e u se of a straigh t im plan t on
a m ore or less straigh t portion of th e d iaph ysis m akes align -
m en t easier.
Th e cable t e ch n iqu e ( Fig 2 -2 2 ) con siderably facilitates in tra-
operative assessm en t of ax ial align m en t in th e fron tal plan e.
With th e patella facin g an teriorly, th e cen ters of th e fem oral
h ead an d of th e an k le join t are m arked u n der im age in ten -
si cation eith er on th e sk in or th e su rgical d rapes. Th e lon g
cable of th e electrocau ter y is th en span n ed between th ese
two poin ts, w ith th e im age in ten si er cen tered on th e k n ee
join t. Varu s/ valgu s align m en t can n ow be determ in ed u sin g
th e projection of th e cable. Sagittal align m en t is determ in ed
u sin g a lateral x-ray.
81
 a b c

e
d

Fig 2 -2 2 a – e Th e cable te chn iq u e co n side rably facilita te s in tra -
o p e ra tive a sse ssm e n t o f a xial align m e n t in th e fro n ta l plan e .
a With th e im age in te n si e r b e am strictly ve rtical, th e ce n te r o f
th e fe m o ral h e ad is ce n te re d o n th e scre e n . A p e n th e n m arks
th e ce n te r o f th e fe m o ral h e ad o n th e p a tie n t ’s skin .
b Whe n th e kn e e jo in t is vie we d th e cab le sh o u ld ru n ce n trally.
An y d e via tion o f th e proje cte d cau te ry cab le fro m th e ce n te r o f
th e jo in t in d ica te s th e a xial d e via tio n in th e fro n tal plan e .
c In a sim ilar wa y the ce n te r o f th e an kle jo in t is m arke d . An a ssis-
ta n t no w sp an s the cable o f th e e le ctro cau tio n b e t we e n the se
t wo lan d m arks.
d Vie w from la te ral.
e Cau te ry co rd sp an s fro m the ce n te r o f th e fe m o ral h e ad to th e
ce n te r o f th e a n kle jo in t.

82
 2 Su rgica l re d u ct io n t e ch n iq u e s
Ro t at io n . Th ere are several m eth ods for in traoperative as-
sessm en t of th e rotation of n ailed or bridged fractu res of th e
fem u r an d th e tibia. Clin ical assessm en t is n ot ver y precise
an d depen ds on th e position s of th e patien t an d th e leg du r-
in g su rgery. Preoperatively, th e rotation of th e in tact lim b is
establish ed, w ith th e k n ee an d th e h ip exed at 90°. In traop-
eratively, after n ailin g an d tem porar y lock in g of th e fractu red
bon e, th e rotation is ch ecked again . In th e tibia, rotation
sh ou ld be ch ecked w ith th e kn ee in exion an d th e foot dor-
si exed. However, in add ition to com parison s of th e position
of th e feet, th e ran ge an d sym m etry of foot rotation also h ave
a b
Fig 2 -2 3 a – d In trao p e ra tive rad iolo gical a sse ssm e n t o f ro ta tion ,
w ith com p a riso n o f th e sh ap e o f th e le sse r tra o ch a n te r w ith th e
co n tra la te ral sid e (le sse r tro ch an te r sh ap e sign).
a Be fo re p o sitio ning th e p a tie n t, the shap e o f the le sse r tro cha n te r
o f th e in tact o pp o site sid e ( p a te lla facin g an te rio rly) is sto re d in
th e im age in te n si e r.
to be taken in to accou n t. Rotation con trol after redu ction an d
xation : u sin g a lateral x-ray of th e k n ee join t an d an AP of
th e an k le join t.
Several sign s are available to assist rad iograph ic assessm en t of
fem oral rotation . Th ese in clu de th e lesser troch an ter sign , th e
cortical step sign , an d th e bon e d iam eter sign :
Le sse r t ro ch an t e r sign . ( Fig 2 -2 3 ) Th e radiograph ic con -
tou r of th e lesser troch an ter relative to th e proxim al fem o-
ral sh aft depen ds on th e rotation of th e bon e. Preopera-
tively, th e sh ape of th e lesser troch an ter of th e u n in ju red
c d
b Afte r d istal lo ckin g an d th e p a te lla facin g a n te rio rly, th e p roxim a l
fragm e n t is ro ta te d u n til th e sh a p e o f th e le sse r tro ch an te r
m a tch e s th e o n e o f the in tact sid e a lre ad y sto re d .
c In ca se s o f e xte rnal m a lro ta tio n the le sse r tro cha n te r is sm alle r
a n d p artia lly h id d e n b e h in d th e p ro xim a l fe m o ral sh a ft.
d In ca se s o f in te rn al m alro ta tio n th e le sse r tro cha n te r app e ars
e n large d .
83
 lim b is stored as a d igital im age. Th e h ip, w ith th e patella 4 .2 Co m p u t e r-a s s is t e d re d u ct io n
facin g in an an terior d irection , is an alyzed an d th e im age
stored in th e im age in ten si er. Before proxim al lock in g, Th e m ost recen t developm en ts in clu de th e u se of com pu ter-
w ith th e patella still facin g for ward, th e proxim al frag- gu ided system s to assist placem en t of in stru m en ts an d im -
m en t can be rotated arou n d th e n ail u sin g a Sch an z screw plan ts an d to localize bon e fragm en ts th ree-d im en sion ally.
u n til th e sh ape of th e lesser troch an ter appears to be sym - Th ese system s are based on d irect in traoperative im agin g
m etrical w ith th at on th e stored im age from th e u n in ju red w ith an im age in ten si er or preoperative com pu ted tom ogra-
side. In th e case of an extern al m alrotation , th e lesser tro- ph y. An atom ical lan d m arks on th e proxim al an d distal side of
ch an ter is sm aller becau se it is partially h idden by th e fem - th e fractu re zon e can provide a basis for calcu latin g residu al
oral sh aft. With in tern al m alrotation , h owever, th e lesser d isplacem en t (tran slation al or rotation al) u sin g speci c m ath -
troch an ter looks larger. em atical algorith m s [13 , 14 ]. In th e fu tu re, sem i-au tom atic re-
Co rt ical st e p sign . ( Fig 2 -24 ) In tran sverse or sh ort du ction of lon g-bon e fractu res at least can be en visaged.
obliqu e fractu res, th e correct rotation can be ju dged by th e
th ick n ess of th e cortices of th e prox im al an d d istal m ain
fragm en ts.
Bo n e d iam e t e r sign . ( Fig 2 -2 5 ) Th is is h elpfu l at levels
at wh ich th e bon e diam eter is oval rath er th an rou n d.
In cases of m alrotation , th e tran sverse d iam eters of th e
proxim al an d d istal fragm en ts are projected w ith differen t
d iam eters. However, all th ese sign s are n ot ver y accu rate.
Rotation al m alalign m en t of less th an 10°–15° are n ot de-
tectable w ith eith er on e of th e th ree m eth ods.

Fig 2 -2 5 Diam e te r d iffe re n ce sign . Th is

sign is p o sitive a t le ve ls w h e re the b o n e
Fig 2 -24 Co rtical ste p sign . In the pre se nce
cro ss-se ctio n is o val ra th e r th an ro u n d . With
o f a co n sid e rab le ro ta tio na l d e fo rm ity, th is
m a lro ta tion , the d iam e te rs o f p roxim al a nd
can b e d iagn o se d b y th e d iffe re n t th ickne ss
d istal m ain fragm e n ts app e ar to b e o f
o f th e co rtice s.
d iffe re n t size s.

84
 2 Su rgica l re d u ct io n t e ch n iq u e s

8. Babst R , He h li M , Re gazzo n i P (2001) [ LISS tractor.

5 Co n clu s io n s
Com bin ation of th e “less invasive stabilization system ” (LISS)
w ith th e AO distractor for distal fem u r an d proxim al tibial
Redu ction tech n iqu e is extrem ely im portan t. Redu ction n eeds fractu res.] Unfallchirurg; 104(6):530 –535.
to take in to accou n t both th e soft tissu es an d th e fractu re con - 9. He im U, Pfe iffe r K M (1988) Internal Fixation of Small Fractures.
gu ration an d sh ou ld n ot com prom ise th e h ealin g process. 3rd ed. Berlin Heidelberg New York: Sprin ger-Verlag.
Th is is th e rst step in determ in in g su rgical strategy. A sen se 10. Mo u h sin e E, Garo falo R , Bo re n s O, e t al (2004) Cable xation
of balan ce n eeds to be m ain tain ed based on th e in ju ry, loca- an d early total h ip arth roplasty in th e treatm en t of acetabu lar
tion , an d fractu re. Th e words “correct” an d “an atom ical” n ow fractu res in elderly patien ts. J Arthroplasty; 19(3):34 4 –348.
refer to redu ction tech n iqu es th at are m ech an ically adequ ate 11. We be r BG (1981) Special Techniques in Internal Fixation. Berlin
an d m in im ally h arm fu l to th e soft tissu es. Th orou gh plan - Heidelberg New York: Sprin ger Verlag.
n in g an d adaptation of th e tech n iqu e to th e given in d ividu al 12 . Co le PA , Zlow o d zk i M , K re go r PJ (2003) Less Invasive
situ ation is essen tial in all cases. Stabilization System (LISS) for fractu res of th e proxim al tibia:
in d ication s, su rgical tech n iqu e an d prelim in ar y resu lts of th e
UMC Clin ical Trial. Injury; 34(Su ppl 1):16 –29.
13. Hü fn e r T, Po h le m an n T, Tart e S, e t al (2002) Com pu ter-
6 Bib lio gra p h y
assisted fractu re redu ction of pelvic rin g fractu res: an in vitro
stu dy. Clin Orthop Relat Res; (399):231–239.
1. Mast J, Jako b R , Gan z R (1989) Planning and Reduction Technique 14. Me ssm e r P (2001) Com pu tergestü tzte dreidim en sion ale
in Fracture Surgery. 1st ed. Berlin Heidelberg New York: Sprin ger- Osteosyn th eseplanu n g u n d -simu lation au f der Gru n dlage
Verlag. zweidim en sion aler Rön tgen bilder u n d ih re Bedeu tu n g fü r die
2. Mü lle r M E, A llgöw e r M , Sch n e id e r R , e t al (1990) Manual of Au sbildu n g. Habilitation Un iversität Basel.
Internal Fixation. 3rd ed. Berlin Heidelberg New York: Sprin ger-
Verlag.
3. Sch at zke r J, Tile M (1987) The Rationale of Operative Fracture Care.
3rd ed. Berlin Heidelberg New York: Sprin ger-Verlag.
4. Marsh J L, Bu ck w alt e r J, Ge lbe rm an R , e t al (2002) Articu lar
fractu res: does an atom ical redu ction really ch an ge th e resu lt? J
Bone Joint Surg Am; 84(7):1259 –1271.
5. Le u n ig M , He rt e l R , Sie be n ro ck K A , e t al (2000) Th e
evolu tion of in direct redu ction tech n iqu es for th e treatm en t of
fractu res. Clin Orthop Relat Res; (375):7–14.
6. Ru e d i T, So m m e r C, Le u t e n e gge r A (1998) New tech n iqu es in
in d irect redu ction of lon g bon e fractu res. Clin Orthop Relat Res;
(347):27–34.
7. Gau t ie r E, Pe rre n SM , Gan z R (1992) Prin ciples of in tern al
xation . Curr Orthop; 6:220 –232.

85
 3 Te chnique s and proce dure s in LISS and LCP

1 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS) 87

1.1 Im p la n t s a n d in s t ru m e n t s 87
1.2 Le s s in va s ive s t a b iliza t io n s ys t e m fo r t h e d is t a l fe m u r
(LISS-DF) 91
1.3 Le s s in va s ive s t a b iliza t io n s ys t e m fo r t h e p ro xim a l la t e ra l
t ib ia (LISS-PLT) 10 9
1.4 Po s t o p e ra t ive t re a t m e n t 12 3
1.5 Im p la n t re m o va l 12 3
1.6 Im p la n t -s p e cific p ro b le m s a n d co m p lica t io n s 12 3
1.7 Clin ica l re s u lt s 12 4

2 Th e lo ck in g co m p re s s io n p la t e (LCP) 12 5
2 .1 Im p la n t s a n d in s t ru m e n t s 12 5
2 .2 LCP in co n ve n t io n a l co m p re s s io n p la t in g 13 6
2 .3 LCP w it h s p lin t in g 14 0
2 .4 LCP w it h a co m b in a t io n o f b o t h m e t h o d s 14 2
2 .5 Co m b in a t io n s o f d iffe re n t s cre w s 14 3
2 .6 Ca s e e xa m p le s 14 4
2 .7 Clin ica l re s u lt s 15 8

3 Bib lio gra p h y 15 8

86
3 Te chnique s and proce dure s in LISS and LCP

1 Th e le s s in va s ive s t a b iliza t io n s ys t e m (LISS)

1.1 Im p la n t s a n d in s t ru m e n t s

Alth ou gh th e less in vasive stabilization system (LISS) m ay ap-

pear to be qu ite com plex (see ch apter 1), it actu ally requ ires
very few in stru m en ts. Th ese h ave been specially design ed for
th e system an d are n ot available in th e stan dard in stru m en t
sets for plates an d screw s.

Th e system con sists of in stru m en ts requ ired to join th e xator

an d th e in sertion gu ide togeth er. Th ese in clu de th e stabiliza-
tion bolt, xation bolt, an d drill sleeve. Th e oth er in stru m en ts
h ave been design ed to facilitate th e tem porar y position in g of a
th e xator, th e adju stm en t of its position , an d redu ction be-
fore th e rst screw s are in serted to attach th e xator to th e
bon e. Th ese in clu de K-w ires th at can be in serted th rou gh th e
in sertion gu ide an d th e aim in g device for K-w ires.
b
LISS p la t e
Th e LISS plate is design ed for th e d istal lateral fem u r aspect
(LISS-DF) an d th e prox im al lateral tibia (LISS-PLT) an d acts
as an an atom ically sh aped bu ttress plate an ch ored w ith self- c
drillin g, self-tappin g, m on ocortical lock in g h ead screw s. Th e
screw s are con n ected w ith th e plate by a th read on th e ou ter
edge of th e screw h ead an d on th e in n er edge of th e plate h ole.
Th e LISS is an an atom ically presh aped in tern al xator th at
can be in serted percu tan eou sly by m ean s of an adaptable in -
d
sertion gu ide. Th e LISS is as a tru e in tern al xator sin ce lon -
ger con stru cts are applied th an in con ven tion al platin g. Th e Fig 3 -1a – d Diffe re n t t yp e s o f in te rnal xa to rs fo r th e
LISS-DF an d th e LISS-PLT are available in th ree len gth s (5, d istal fe m u r a nd th e proxim al la te ral tib ia .
9, or 13 h oles), righ t an d left version . With th e developm en t a LISS-DF p la te
of th e LCP com bin ation h ole th ere are also two an atom ically b LCP-DF p la te
presh aped LCP-DF an d LCP-PLT available ( Fig 3 -1). c LISS-PLT pla te
d LCP-PLT pla te

87
 Lo ck in g h e a d s cre w s (LHS) In s e r t io n gu id e
Th ere are on ly self-drillin g, self-tappin g LHS in th e LISS set Th e gu ide u sed to in sert an d position th e im plan t con sists
(see ch apter 1). In case of osteoporotic bon e w ith ver y th in of two parts: an alu m inu m part w ith a th ree-poin t con n ec-
cortex, bicortical self-tappin g lock in g h ead screw s from th e tion to th e xator an d a rad iopaqu e carbon -rein forced poly-
LCP 4.5/5.0 set can be u sed to x th e LISS to th e sh aft frag- eth ereth erketon e (PEEK) attach m en t ( Fig 3 -3 ).
m en t ( Fig 3 -2 a – c).
Aim in g d e vice
Se lf-t a p p in g p e rip ro s t h e t ic lo ck in g h e a d s cre w s Th e aim in g device for th e K-w ires position ed at th e prox im al
It becam e apparen t du rin g developm en t of th e LISS th at th e en d of th e xator is sh ow n in Fig 3 -4 a . Prox im al an d d istal
self-drillin g lockin g h ead screw, w ith its lon g drill tip, cou ld placem en t an d adju stm en t of th e xator position can be car-
n ot be u sed in th e area of th e prosth etic sh aft in th e treatm en t
of periprosth etic fractu res. Con sequ en tly, a self-tappin g lock-
in g h ead screw th at provides adequ ate stability even in very
th in cortical bon e above th e level of th e prosth esis was devel-
oped. As th ese screw s requ ire predrillin g, a 4.3 m m d rill an d
drill gu ide were design ed for th e pu r pose ( Fig 3 -2 d ). Th e d rill
gu ide can be screwed in to th e h oles of th e xator to en su re
precise predrillin g.

Fig 3 -3 Th e two -p art rad io p aq u e in se rtio n gu id e fo r th e LISS-DF

im plan t, w ith the xa tio n b o lt, drill sle e ve , an d stabiliza tio n b o lt.

a b c

e
b
a
Fig 3 -2 a – e Diffe re n t t yp e s o f lo ckin g h e ad scre w s.
a Se lf-d rillin g, se lf-tapp in g lo cking he ad scre w.
b Se lf-tap ping lo ckin g h e ad scre w. Fig 3 -4 a – b Aim ing d e vice fo r K-w ire s.
c Pe rip ro sth e tic lo ckin g h e ad scre w. a Th e aim in g d e vice is ce n te re d b y th e h e lp o f th e in se rtio n gu id e .
d – e Drill gu ide a nd 4 .3 m m d rill fo r p e ripro sthe tic LHS. b Te m p o rary xa tio n o f th e LISS w ith K-w ire s.

88
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
ried ou t after rem oval of th e K-w ire sleeves an d th e aim in g
device. At th e sam e tim e, th e lateral K-w ires preven t th e in -
tern al xator from m igratin g in to th e sagittal plan e. On ce
th e correct position h as been determ in ed, th e xator can be
locked tem porarily w ith a K-w ire th rou gh th e xation bolt or
th e stabilization bolt ( Fig 3 -4 b ).
Pu llin g d e vice (“w h irlyb ird ”)
Fractu re redu ction often h as to be n e-tu n ed du rin g th e LISS
procedu re. Th e pu llin g device allow s n e adju stm en t of th e
an gu lation an d tran slation of fragm en ts in th e fron tal plan e
( Fig 3 -5 ).
However, th at is n ot its on ly application .It is also recom m en d-
ed for in sertion of th e very rst screw, as th e bon e is capable
of m igratin g m ed ially du r in g th e rst screw in sertion . If th e
Fig 3 -5 Use o f th e p u llin g d e vice thro u gh th e d rill sle ve . Th e d rill
sle e ve is co n n e cte d to a syringe w ith a n in fu sio n tu b e to e n su re
co olin g o f th e se lf-d rilling pu llin g d e vice .
pu llin g device is u sed in an adjacen t h ole, th en th e xator is
attach ed to th e bon e an d m igration is preven ted.
Drill s le e ve
Th e developm en t of th e self-d rillin g Sch an z screw sh owed
th at it was possible to design self-drillin g screw s th at wou ld
gen erate n o m ore h eat du rin g in sertion th an th at gen erated
by a n ew, sh ar p drill bit. A h ot drill bit is rem oved from th e
bon e on ce th e h ole h as been drilled, wh ereas th e self-d rillin g
screw is left in th e bon e. In stan dard open procedu res, d rills
can be irr igated, bu t th is is n ot possible in m in im ally in va-
sive percu tan eou s procedu res. So a special water-cooled d rill
sleeve was developed for u se du rin g blin d percu tan eou s in ser-
tion of th e screw s, to con du ct h eat away from th e d rillin g site.
Th e drill sleeve con sists of a stan dard syrin ge an d in fu sion set
an d is u sed togeth er w ith a special power screwd river sh aft
th at d irects coolin g sterile salin e to th e screw –bon e in terface
( Fig 3 -6 ).
Fig 3 -6 Sp e cial p o we r scre wdrive r tha t d ire cts co o ling ste rile sa lin e
to th e scre w -b o n e in te rface .
89
 To preven t th e d rill sleeve from spin n in g an d en tan glin g th e
in fu sion lin e, th e drill sleeve was design ed to m ate over a
sh ort distan ce w ith a m atch in g squ are section in th e in ser-
tion gu ide. In add ition , th e en d of th e h exagon al screwdriver
sh aft h as a sm all retain in g rin g or bolt th at preven ts th e screw
from fallin g in to th e dr ill sleeve du rin g in sertion . Th is is very
im portan t, sin ce th e self-drillin g screw s can on ly be in serted
by m ach in e an d n ot m anu ally. In adequ ate lin kage between
th e h exagon al recess of th e screw an d th e screwdriver sh aft
cou ld dam age th e recess in th e screw h ead.
To rq u e -lim it in g h e xa go n a l s cre w d rive r
Th e con n ection between th e screw h ead an d th e xator is ver y
im portan t for th e lon g-term stability of th e wh ole con stru ct.
However, th is requ ires m in im u m tigh ten in g m om en t of th e
screw in th e xator wh ile at th e sam e tim e th e con n ection
h as to be protected again st over tigh ten in g. A torqu e-lim it-
in g h exagon al screwdriver was th erefore specially design ed
th at d isen gages at a de n ed m om en t of 4.0 Nm —en su rin g ad-
equ ate tigh ten in g m om en t wh ile sim u ltan eou sly protectin g
th e system again st over tigh ten in g ( Fig 3 -7 ). All of th e lock-
in g h ead screw s h ave to be tigh ten ed w ith th e torqu e-lim it-
in g screwd river. Tigh ten in g th e screw s w ith a power-d riven
device sh ou ld always be avoided.
An im a tio n
2-21
Fig 3 -7 Th e to rq u e -lim itin g he xago nal scre wd rive r e n su re s ad e -
q ua te tigh te n in g.
90
Aid s in re d u ct io n a n d LISS fixa t io n
A nu m ber of com plem en tar y con cepts are h elpfu l in closed
redu ction tech n iqu es (see ch apter 2). Th ese in clu de:
Early in t e rve n t io n . Fractu res are add ressed as soon as
possible. If sh attered, h igh -en ergy fractu res are n ot sta-
bilized w ith in th e rst 24 h ou rs, an extern al bridgin g of
th e fractu re zon e is applied to m ain tain th e len gth of th e
fractu red lim b.
Mu scle re lax at io n by ch e m ical p aralysis. Com plete
clin ical paralysis of th e patien t is n ecessary.
Su p raco n d ylar t ow e l ro lls. Su pracon dylar towel rolls
(bu m ps) are placed in th e area posterior to th e su pracon -
dylar region . Th e towel rolls are h elpfu l for redu ction of
th e h yperexten sion of th e d istal fem oral fragm en t th at is
com m on ly seen . In add ition , th e towel roll acts as a fu l-
cru m for th e vector force of m an u al traction . Relatively
sm all adju stm en ts in th e size an d/or location of th e towel
rolls can h ave a m arked effect on correction of th e fractu re
in th e sagittal plan e.
Man u al t ract io n . Forcefu l m an u al traction is h elpfu l for
establish in g len gth an d rotation an d m ay facilitate varu s/
valgu s correction . Manu al traction is applied to th e an kle
region w ith a force vector th at is directed posteriorly. With
th e towel rolls bein g u sed as a fu lcru m , m anu al traction
facilitates redu ction of th e h yperexten sion deform ity of
th e d istal fem oral con dyle.
Sch a n z scre w in se rt e d in t o t h e fe m o ral co n d y le . Par-
ticu larly wh en th ere is a ver y sh ort d istal fem oral segm en t,
correction of th e h yperexten sion deform ity m ay be d if-
cu lt. In su ch cases it is h elpfu l to u se an an terior-to-pos-
terior Sch an z screw or redu ction h an d les as a joystick to
derotate th e d istal fragm en t in to th e proper redu ction .
Pu llin g d e v ice (“wh irlybird”) (see Fig 3 -5 , an d Fig | An i-
m a tio n 2-21). Th e pu llin g device is a self-drillin g, self-tap-
pin g screw th at can be d rilled th rou gh a d rill sleve in to
th e d iaph yseal cortex, eith er in th e d istal or th e prox im al
region . Screw in g a knu rled nu t on to th e LISS pu llin g de-
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
vice w ill actu ally approx im ate th e cortex (ie, fragm en t) to
th e LISS xator. Th e device can th erefore be u sed to m ake
sm all correction s in varu s/ valgu s deform ities. More th an
on e pu llin g device can be u sed to ach ieve sm all tran sla-
tion correction s of th e prox im al segm en t. Placem en t of th e
pu llin g device can be liken ed to clam p placem en t, as it sta-
bilizes th e redu ction du rin g in sertion of th e self-d rillin g,
self-tappin g screw s.
Malle t . A m allet is occasion ally n ecessar y to pu sh m ed i-
ally on an addu cted an d/or exed prox im al fragm en t. It
can also be u sed on th e distal fragm en t to correct excess
valgu s (see case 9.3.7).
Large d ist ract o r o r e x t e rn al x at o r. Th e large d is-
tractor or extern al xator can be u sefu l in ach ievin g an d
m ain tain in g m etaph yseal an d diaph yseal redu ction . How-
ever, its u se m ay m ake n e adju stm en ts in fractu re redu c-
tion d if cu lt.
LISS d ist ract o r. Th e LISS d istractor is th e com bin ation
of th e large distractor w ith th e LISS-DF plate. On e bolt of
th e d istractor xes th e plate th rou gh a plate h ole to th e
d istal femu r. Th e oth er bolt is xed on to th e prox im al fe-
m u r. Th e LISS distractor allow s a con trolled application
of force (distraction an d/or com pression) by th e redu ction
m an eu ver. Th is m akes redu ction possible again st th e plate
before n al xation of th e LISS plate. Modi cation of th e
well-k n ow n LISS tech n iqu e by in tegratin g th e d istractor
in to th e LISS plate to sim plify redu ction an d to provide
tem porary reten tion of th e fractu re h as th e poten tial to
redu ce th e u oroscopy ex posu re, th e operation tim e, th e
rate of m alalign m en ts, an d th e learn in g cu rve for th is
M IPO tech n iqu e.
Sm all re d u ct io n t able . Th e sm all redu ction table facili-
tates n e adju stm en ts to fractu re redu ction .
Co llin e ar re d u ct io n cla m p o r large p e lv ic re d u ct io n
fo rce p s. Both clam ps an d forceps are often u sed for redu c-
tion m an eu ver in M IPO tech n iqu e.
1.2 Le s s in va s ive s t a b iliza t io n s ys t e m fo r t h e d is t a l
fe m u r (LISS-DF)
In d ica t io n s
Th e in d ication s for LISS in th e d istal fem u r in clu de all extraar-
ticu lar (su pracon dylar, d istal sh aft) an d articu lar fractu res [1]
th at can n ot be treated w ith screw s alon e—for exam ple, Mü l-
ler AO Classi cation 33-A1–A3 an d 33-C1–C3 fractu res of th e
d istal fem u r ( Ta b 3 -1) [2]. Th e LISS tech n iqu e is advan tageou s
in severe articu lar fractu res [3 ], as it allow s free placem en t
of lag screw s an d does n ot addition ally d isru pt th e con dylar
com plex after recon stru ction . It preserves th e soft tissu es in
th e m etaph yseal an d d iaph yseal region s as a resu lt of m in i-
m ally invasive in sertion an d closed redu ction [1, 4 , 5 ]. LISS
also m akes it possible to stabilize fractu res w h ere im plan ts
are already in situ —eg, total k n ee replacem en ts [6 ] —wh eth er
th ey h ave a m edu llary stem or n ot. Sin ce screw s can be in -
serted in to all seven d istal screw h oles, th e LISS offers a h igh
degree of stability an d reliability in osteoporotic bon e [7–11].
In d ica t io n s fo r LISS-DF in fe m o ra l fra ctu re s Ta b 3 -1
Su p raco n d ylar fra ctu re s (3 3 -A1– A3)
Articu lar fra ctu re s (33 -C1– C3)
Dista l sh a ft fractu re s (32-B1– B3 an d 32-C1– C3 if n ailin g is n o t p o ssib le)
Pe rip ro sth e tic fra ctu re s (d istal to h ip p ro sth e sis o r p roxim al to kn e e p ro sth e sis)
Re p e a te d fractu re w ith im p lan ts in p lace
Fractu re s in o ste o p o ro tic b o n e
Pa th o lo gica l fra ctu re s
91
 No oth er im plan t cu rren tly available h as su ch a w ide ran ge of
application s. Th ere are certain cases for w h ich LISS provides
a u n iqu e solu tion , especially wh en th e d istal articu lar block
of th e fem u r is sh ort. Th ese in clu de: m u ltiplan e, com plex dis-
tal articu lar in ju ries, especially w ith a sh ort d istal segm en t,
osteoporotic fractu res, an d fractu res above total k n ee arth o-
plasties.
Tim in g
Su rgical stabilization of d istal fem oral fractu res sh ou ld on ly
be carried ou t by a su rgeon w ith adequ ate u n derstan d in g of
th e fractu re, a su itable su rgical team , an d stable patien t con -
d ition s. If th ese con dition s are n ot available, th en particu larly
in th e case of h igh -en ergy, h igh ly d isplaced fractu res, an ex-
tern al join t bridgin g xator can provide an excellen t tem po-
rary device w ith wh ich to stabilize th e lim b, m ain tain lim b
len gth , an d m in im ize m ovem en t at th e fractu re site, w h ich
gen erally aggravates soft-tissu e swellin g. Extern al xator pin s
placed at a sign i can t d istan ce from th e k n ee join t (eg, in th e
proxim al fem u r an d distal tibia) w ill n ot com prom ise th e fu -
tu re su rgical site for th e su pracon dylar fem oral fractu re.
Ra d io gra p h y a n d co m p u t e d t o m o gra p h y
AP, lateral, an d obliqu e x-rays are m an datory before preopera-
tive plan n in g for stabilizin g th e fractu re. Poor-qu ality AP an d
lateral x-rays, especially wh en th e leg is sh orten ed are often
in su f cien t for adequ ate iden ti cation of sign i can t articu -
lar path ology. X-rays u n der traction give add ition al in form a-
tion . In cases of com plex m u ltiplan e articu lar fractu res, ax ial
com pu ted tom ograph y (CT) w ith fron tal an d sagittal plan e
recon stru ction s m ay be h elpfu l in plan n in g th e redu ction an d
su rgical stabilization .
In fractu res w ith a com plex m u ltifragm en tar y m etaph yseal
zon e, an AP x-ray of th e con tralateral u n im pacted fem u r is
very h elpfu l for preoperative plan n in g.
92
Pa t ie n t p o s it io n in g
If possible leg len gth an d rotation al pro le of th e con tralateral
extrem ity is exam in ed preoperatively, to ascertain th e cor-
rect rotation al pro le of th e distal fem u r. With th e patien t in
su pin e position , su rgical in terven tion is best carried ou t on a
com pletely rad iolu cen t table th at allow s com plete im agin g of
th e lower leg. Th e leg sh ou ld be freely m ovable. Appropr iate
padd in g is placed u n der th e u n involved lim b, w h ich is th en
secu red. Th e con tralateral leg can be placed in an obstetr ic leg
h older. Preparation an d drapin g sh ou ld allow com plete expo-
su re of th e prox im al fem u r an d h ip region , especially if th e
lon ger 13-h ole LISS plate is to be u sed. Th e k n ee join t lin e
sh ou ld be placed sligh tly d istal to th e h in ged part of th e table
to allow exion of th e kn ee du rin g su rger y. Excessive trac-
tion an d a fu lly exten ded k n ee sh ou ld be avoided; th e force
of th e gastrocn em iu s wou ld draw th e distal fragm en t in to re-
cu r vatu re. Th is n ot on ly m akes redu ction of th e fractu re d if -
cu lt, bu t also en dan gers th e popliteal arter y an d vein . In very
sh ort d istal fragm en ts, it is recom m en ded to ex th e lower leg
to approx im ately 60°. Th is also redu ces th e traction force of
th e gastrocn em iu s. In traoperative im age in ten si er con trol is
n ecessary.
Ap p ro a ch e s
Th e su rgical procedu re essen tially depen ds wh eth er or n ot
an articu lar fractu re requ ires open redu ction . In n on articu -
lar fractu res (Mü ller AO Classi cation A1–A3) an d fractu res
w ith sim ple articu lar in volvem en t (Mü ller AO Classi cation
C1 an d C2), a lateral approach to th e d istal fem u r is u sed
( Fig 3 -8 ). A lateral parapatellar approach is preferable for m u l-
tiplan e articu lar in volvem en t, m ed ial-based in tercon dylar
splits, add ition al Hoffa fractu res, an d separate in tercon dylar
n otch fragm en ts. Th e su rgeon u tilizes th e approach requ ired
to view th e articu lar su rface, an d trad ition al lag screw xa-
tion of th e articu lar su rface is perform ed ( Fig 3 -9 ).
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Th e patien t is placed in th e su pin e position . For pu rely ex-

traarticu lar fractu res of th e d istal fem u r, a lateral in cision
approx im ately 8 cm lon g is m ade from Gerdy’s tu bercle an d
exten ded in a prox im al d irection to ex pose th e lower m argin
of th e vastu s lateralis. If th ere is an y dou bt, a lateral im age
in ten si er im age m ay be h elpfu l. Th e skin in cision sh ou ld be
m ade in exact prolon gation of th e sh aft. Th e sk in an d su bcu -
tan eou s tissu e are d ivided by sh ar p d issection . Th e iliotibial
tract is split in th e d irection of its bers. No attem pt is m ade
to visu alize th e m etaph yseal com pon en t of th e fractu re. Al-
th ou gh th e join t capsu le n eed n ot be open ed in cases of n on -
articu lar fractu re, visu alization or palpation of th e an terior
aspect of th e lateral fem oral con dyle m ay be h elpfu l for correct
position in g of th e LISS xator on th e distal fem oral con dyle.
a b Th is approach is on ly appropriate for extraarticu lar an d com -
pletely u n d isplaced articu lar fractu res. It is n ot adequ ate for
Fig 3 -8 a – b Th e la te ra l app ro ach fo r in se rtio n o f the LISS-DF.
con trollin g even sm all d isplacem en ts of articu lar fractu res.

For all d isplaced articu lar fractu res of th e d istal fem u r (n ot

on ly com plex on es), a lateral parapatellar approach (in clu d in g
a m ed ial d islocation of th e patella) sh ou ld be selected th at en -
su res an optim al overview of th e articu lation . Th e join t cap-
su le can th en be d ivided in lin e w ith th e split in th e iliotibial
ligam en t. LISS xation in d isplaced articu lar fractu res begin s
w ith d irect visu alization an d stable in tern al xation of th e
articu lar su rface. Priority is always given to precise an atom i-
cal recon stru ction of th e articu lar su rface.

St ra t e g y fo r fra ct u re re d u ct io n a n d fixa t io n
Articu lar fractu re redu ction an d xation . Trad ition al redu c-
tion an d xation of th e articu lar su rface is perform ed rst.
Redu ction aids for th e articu lar su rface th at m ay be h elpfu l
in clu de:
a b
Sch an z screw s or redu ction h an d les in th e m ed ial an d lat-
Fig 3 -9 a – b Th e la te ral p arap a te llar app ro ach fo r in se rtio n o f th e eral fem oral con dyles, for u se as joysticks du rin g redu ction
LISS-DF. A m e d ial d islo ca tio n o f th e p a te lla e n su re s a n o p tim a l o ve r- of th e in tercon dylar fractu re.
vie w o f th e articu la tio n .

93
 Redu ction forceps w ith poin ts (Weber forceps), or pelvic
redu ction forceps, pelvic redu ction forceps w ith poin ted
ball tips, a collin ear redu ction clam p th at presses th e lat-
eral an d m ed ial fem oral con dylar blocks togeth er.
K-w ires for tem porar y in sertion to m ain tain th e redu ction
of th e articu lar blocks u n til de n itive lag screw xation is
ach ieved.
Den tal picks, wh ich can be h elpfu l for n e m an ipu lation
of articu lar segm en ts.
are m ou n ted in th e trocar assem blies. Clin ical experien ce h as
sh ow n th at th e u se of lon g im plan ts xed w ith speci c lock-
in g h ead screw s is advan tageou s, as it leads to good d istribu -
tion of strain across both im plan t an d bon e. It is preferable to
u se m on ocortical lockin g h ead screw s in th e sh aft area an d
lon g lock in g h ead screw s in th e m etaph yseal zon e. As a ru le,
fou r screw s sh ou ld be secu rely in serted in to th e sh aft an d ve
or six screw s in to th e con dylar block.

After redu ction of th e articu lar su rface, m u ltiple 3.5 m m cor-

tex lag screw s an d 4.0 m m or 4.5 m m can nu lated lag screw s
are in serted in a lateral to m ed ial direction for xation of an y
in tercon dylar fractu res, or in an an terior to posterior direc-
tion for xation of Hoffa fractu res. For xation of sm all os-
teoch on dral fragm en ts in th e in tercon dylar n otch , 2.7 m m
lag screw s can also be u sed. Atten tion can n ow be given to
redu ction an d xation of th e m etaph yseal an d diaph yseal
com pon en t of th e fractu res by im plan tation of th e LISS. Th is
starts w ith tem porary closed in d irect redu ction an d reten tion
of th e articu lar block on th e sh aft, w ith lim b len gth an d th e
correct ax ial an d rotation al align m en t bein g taken in to ac-
cou n t. Application of a d istractor or extern al xator m ay be
u sefu l for th is su rgical step, bu t is n ot absolu tely n ecessary.
An experien ced LISS u ser can carr y ou t im m ediate in direct
redu ction , tak in g fu ll advan tage of th e an atom ically precon -
tou red im plan ts.

Closed redu ction is carr ied ou t on th e m etaph yseal an d d i-

aph yseal com pon en t of th e fractu re, followed by su bm u scu lar
xation u sin g LISS xation . Th e LISS is in serted on th e dis-
tal fem u r u n der th e vastu s lateralis m u scle in th e epiperiostal
space an d is advan ced in a proxim al direction . Atten tion m u st
be given to correct position in g of th e LISS xator in th e con -
dylar area, an d particu larly on th e fem oral sh aft. K-w ires are
u sed to x th is position an d are in serted th rou gh th e in sertion
gu ide, an d th e self-drillin g, self-tappin g lock in g h ead screw s

94
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p -b y-s t e p s u rgica l s e q u e n ce fo r LISS-DF fixa t io n

A well-de n ed step-by-step process is u sed for LISS-DF
xation after articu lar fractu re redu ction an d xation .

Ste p 1: p re o p e ra t ive s e le ct io n o f t h e im p la n t s

Th e pre o p e ra tive x-ray plan ning te m p la te (Fig 3 -10) is u se d to de -
te rm in e th e le n gth o f th e LISS pla te an d th e p o sitio n o f th e scre w s.
It sh o u ld b e n o te d th a t all te m p la te im age s are e n large d b y 10 % to
acco u n t fo r ave rage rad io graph m agn i ca tio n . Ho we ve r, m agn i ca -
tio n m a y vary.
Pre op e ra tive scre w -le ngth se le ction u sing an AP x-ray. To se le ct the
prop e r scre w le ngth for the cond yle , take a pre o p e ra tive x-ra y w ith
calibra tor and se le ct the scre w le ngth s u sin g Ta b 3 -2 .
Take an AP x-ray o f the distal fe m u r.
Place the x-ra y calibra tor m e d ially o r la te rally a t the he igh t o f
th e co n d yle .
Me a su re th e w id th o f th e x-ray calib ra to r ( XRC) o n th e
rad io grap h .
Me a su re th e m a xim u m co n d yle w id th (MCW) o n th e rad io -
graph .
De te rm in e th e re al co n d yle w id th (RCW).
Ch e ck th e ap pro pria te co n d yle size in Ta b 3 -2 .
Re ad o ff the corre sp o nd ing scre w le ngth for scre w hole s A to
G. Po sitio n s A to G are ind ica te d o n th e p re o p e ra tive plan n in g
te m pla te and o n th e LISS-DF in se rtio n gu id e .
Alte rn a tive ly a m e a su ring d e vice w ith a 2 .0 m m K-w ire 28 0 m m
long, place d through the gu ide sle e ve can b e u se d .

For sha ft xa tion short m o no co rtical 18 m m o r 26 m m lo ng lo cking

h e ad scre w s calcu la te d o n th e x-ray are u se d .

Fe m o ra l co nd yle Ho le s
w id th (m m) A B C D E F G

60–80 65 40 40 55 65 65 55

81– 8 7 75 40 55 65 75 75 65

88–95 75 55 65 65 75 75 75

9 6 –110 85 65 75 75 75 85 85

Fig 3 -10 X-ra y pla n ning te m pla te fo r d e te rm in ing th e le n gth o f th e Ta b 3 -2 Le n gth s o f LHS fo r LISS.
LISS pla te a nd th e p o sitio n o f th e scre w s.

95
 St e p 2 : a s s e m b lin g t h e in s e rt io n in s t ru m e n t s (Fig 3 -11)

Conn e ct the two parts o f the in se rtio n gu ide .

In se rt th e xa tio n b o lt in to h o le A o f th e in se rtio n gu id e .
Place the in se rtion guide o n the LISS thre e -p o in t lo cking
m e chanism .
In se rt th e xatio n b o lt in to th e LISS an d tigh te n it sligh tly u sin g
th e p in w re n ch .
Th re ad th e n u t o f th e xa tio n b o lt in th e d ire ctio n o f th e in se r-
tio n gu id e an d tigh te n it sligh tly w ith th e p in w re n ch .
For m ore stable xa tio n o f the LISS to the in se rtion guid e dur-
ing in se rtion , in tro duce a se cond stabiliza tio n b olt w ith the
drill sle e ve in to hole B (and thre ad it in to th e LISS). a

b Fig 3 -11a – c Asse m blin g th e in se rtio n in stru m e n ts w ith

th e LISS-DF.

St e p 3: p ro vis io n a l fra ct u re re d u ct io n

Be fore the LISS xa tor is in se rte d , m anual traction is applie d , the
supraco nd ylar to we l rolls are pu t in place , and the fracture re ductio n
is visualize d o n b o th AP an d la te ral x-rays. Th e su rge o n can th e n
no te sp e ci c condition s such a s hyp e re xte n sio n o f th e d istal
fe m o ral con d yle , e xion and/ or adduction o f the proxim al fe m o ral
sha ft, and/ or valgu s o f the distal fe m oral cond yle s. Adju stm e n ts
can th e n b e m ade in th e p o sition and/ or size o f the su p racon d ylar
to we l ro lls an d th e ve cto r fo rce d ire ctio n o f m an u al tractio n , an d
d e form itie s can b e co rre cte d b y care fu l b lo w s o r p u sh in g w ith the
large m alle t. No te: practice and che ck the re ductio n -sp e ci c
m ane u ve r as part o f the pre op e ra tive pre p ara tio n . Altho ugh the
LISS in se rtio n gu id e is radiolu ce n t, b e tte r visu aliza tio n o f th e
fractu re re d u ctio n is o b tain e d b e fo re LISS in se rtio n .

96
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
St e p 4: LISS in s e rt io n (Fig 3 -12)
Th e a sse m b le d in se rtio n gu id e is u se d to in se rt th e LISS pla te b e -
twe e n the va stu s la te ralis m u scle and the p e rio ste u m (= e pip e rio s-
te al sp ace).
Th e LISS xa to r is in se rte d e ith e r th ro u gh th e an te ro la te ral in cisio n
o r throu gh the la te ral p arap a te llar appro ach . Th e xato r is pre co n -
to u re d to acco m m o d a te th e an te rio r cu rva tu re o f th e fe m u r.
Th e LISS p la te is slid p roxim ally, e n su rin g tha t its p roxim al e nd re -
m ain s in co n stan t con tact w ith the b one . The distal e nd o f the xato r
is p o sitione d again st the la te ral cond yle . To ide n tify the corre ct p o si-
tio n , th e LISS p la te is m o ve d proxim ally an d th e n b ack d istally u n til
th e p la te ts th e co n d yle . If th e p roxim al e nd o f th e in se rtio n gu id e
an d th e so ft tissu e s im p air in se rtio n o f th e p la te , it is p o ssib le to
re m o ve th e rad io lu ce n t p roxim al p art o f th e h and le fo r in se rtio n .
Fig 3 -12 LISS in se rtio n .
Th is ste p can b e carrie d o u t u nd e r b rie f lin e im age in te n si ca tio n ,
an d th e fo llo w in g te ch n iq u e s are h e lp fu l h e re:
No tin g th e tactile se n sa tio n o f th e p roxim al tip o f th e xato r o r
th e la te ral co rte x.
Alte rna tive ly, a sm all in cisio n a t th e p roxim al e n d o f th e LISS
m a y m ake it e a sie r to p o sition the LISS re la tive to the proxim al
fragm e n t. Th e p o sitio n can b e ch e cke d b o th b y p alp a tio n and
b y visio n (se e also ste p 5 and Fig 3 -13). Two Ho h m an n re trac-
to rs can ke e p th e im plan t ce n te re d o n th e m id la te ral a sp e ct o f
th e fe m u r.
Asse ssing the p o sitio n o f the in se rtion gu ide re la tive to the
la te ral a sp e ct o f the thigh .
A com m on te nde ncy is to dire ct the xa to r po ste rio rly; due to its
we igh t, the in se rtion guide te nd s to tilt do rsally. If the in se rtion
gu ide p o in ts p aralle l to th e o o r w ith th e p a tie n t in th e su p in e
p o sition , it m e an s tha t the xa tor is e xte rnally ro ta te d and is no
longe r lying a t up again st the la te ral co nd yle . The xa tio n b olt ha s
to b e o rie n te d p aralle l to th e p a te llo fe m o ral jo in t. Co n se q u e n tly,
th e in se rtio n gu id e sh o w s an in te rnal ro ta tio n o f ab o u t 10 °. Th is
o ccurre nce is also visible o n the AP vie w w ith an im age in te n si e r.
Th e xa to r ha s to lie a t u p again st th e co n d yle to e n su re o p tim al
tting o n the b o ne . Clo se p o sitio ning o f the d istal p o rtio n o f the
LISS to the la te ral a sp e ct o f the cond yle to avo id p o stop e ra tive ir-
rita tio n o f the ilio tibial fractu re .
Fig 3 -13 Ch e ckin g the p la te p o sitio n b y p alp a tio n an d b y
visio n .
97
 St e p 5: co n n e ct in g t h e p ro xim a l co n n e ct in g b o lt (Fig 3 -14)
Th ro u gh an in cisio n o ve r e ith e r h o le 5, 9, o r 13, a p roxim al co n n e ct-
ing b olt is scre we d in to the proxim al e nd o f the xa to r. This cre a te s
a xe d p aralle lo gram th a t facilita te s fu rth e r m an ip u la tio n o f th e
xa tor o n the m idla te ral a sp e ct o f the fe m ur and e n sure s pre cise
p e rcu tane ou s place m e n t o f the scre w s through the tro cars.
On ce th e LISS is p ro p e rly align e d w ith th e b o n e , th e d rill sle e ve
and stab iliza tio n b o lt are re m o ve d fro m h o le B. Th e tro car is
in se rte d through the drill sle e ve in the m o st proxim al hole o f
th e pla te . A stab incisio n is m ad e , and th e d rill sle e ve an d tro -
a b
98
car are pu sh e d do w n to th e LISS pla te . Co rre ct p o sitio n in g o f
th e p roxim al p art o f th e LISS p la te o n th e b o n e is ch e cke d , e i-
th e r u sin g a K-w ire o r d ire ct p alp a tio n . Th e p o sitio n o f th e d rill
sle e ve is se cure d w ith the la te ral scre w on the in se rtio n guide .
Th e tro car is re place d b y th e stab iliza tio n b o lt. To clo se th e
fram e , th e stab iliza tio n b o lt is th re ad e d in to th e LISS p la te .
It sh o u ld b e n o te d tha t o nce th e b olt h a s b e e n in se rte d , it w ill
b e d if cult to change the p o sitio n o f the pla te – gu ide a sse m bly,
d ue to th e so ft tissue s aro u nd th e stab iliza tio n b olt.
Fig 3 -14 a – b Co n ne cting the proxim al
co n n e ctin g b o lt.
a Incisio n
b In se rtio n o f co n n e ctin g b o lt
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 6 : e s t a b lis h in g a p p ro p ria t e p la ce m e n t o f t h e LISS fixa t o r o n t h e d is t a l fe m o ra l co n d yle (Fig 3 -15)

Th e LISS xa to r is pre co n to u re d and sh o u ld sit we ll o n th e d istal

fe m ur. Se ve ral com m e n ts are he lp fu l in e stablishing w he the r it is 1.01.0cm
cm
co rre ctly p lace d:
Th e xa to r u su ally lie s ap proxim a te ly 1.0 –1.5 cm p o ste rio r to
1.5
1.5cm cm
th e m o st an te rio r a sp e ct o f th e d istal fe m o ral co nd yle and ap -
proxim a te ly 1.0 –1.5 cm cranial to the distal fe m o ral co n d yle a
(Fig 3 -15a). Co rre ct place m e n t o f th e xato r is o fte n h e lp e d b y
pu sh in g the xa to r p roxim ally and th e n allo w ing the LISS x-
a to r to se ttle d istally o n to th e n o rm al an k o f th e fe m o ral co n -
d yle s. As the la te ral co rte x slo p e s a t approxim a te ly 10 –15°, the
in se rtion gu ide is u sually raise d approxim a te ly 10 –15° from
th e h o rizo n tal p lan e o f th e o o r (Fig 3 -15b). Co u n te rp re ssu re
is e xe rte d o n th e m e d ial asp e ct o f th e d istal fe m o ral co n d ylar
re gion , the hand d ire cting the in se rtio n guid e is raise d approx-
im a te ly 10 –15°, and the guide w ire is the n place d through drill
b
sle e ve A. This gu ide w ire should the n b e p aralle l to the jo in t
surface o f the d istal articu lar surface if a distal fe m o ral valgu s
Fig 3 -15 a – b Esta blish in g app ro pria te p lace m e n t o f th e LISS x-
m alalignm e n t o f 5° is ide n ti e d . Sm all adju stm e n ts to this re -
a to r o n th e d istal fe m o ral co nd yle .
la tion ship can b e m ad e la te r in the se q ue nce , a s no te d b e -
a Th e p o sitio n in g o f th e la g scre w h a s to re sp e ct th e p lace m e n t
lo w.
o f th e LISS. Th e LISS-DF la ys p o ste rio r to th e a n te rio r a sp e ct
o f th e la te ral co nd yle and 1.0 –1.5 cm cranial to th e jo in t su r-
face .
b Th e d istal p a rt o f th e xa to r la ys o n th e la te ral co rte x o f th e
co n d yle .

St e p 7: ch e ck in g t h e ro t a t io n a n d le n gt h o f t h e re d u ct io n
A che ck is m ade a t this p oin t u sing im age in te n si ca tion in the AP
plan e to e n su re tha t th e pro p e r le n gth h as b e e n re sto re d to th e
injure d e xtre m ity. At this tim e , the ro ta tional pro le o f the lim b is
also asse sse d , w ith asse ssm e n t o f th e AP im age , e valu a tio n o f th e
skin line s in the d istal fe m oral re gion , and aware ne ss tha t the fo o t
sh ould b e e xte rnally ro ta te d by 10 –15°.

99
 St e p 8 : p re lim in a r y LISS fixa t io n (Fig 3 -16)

If the le ngth an d ro ta tio n are corre ct, the n the p roxim al guid e w ire
can b e in se rte d a fte r it ha s b e e n ve ri e d tha t th e xa to r is o n th e
m idla te ral a sp e ct o f the fe m ur and laying a p rop e r ro ta tio nal re la -
tio n sh ip. Asse ssin g th e lo ca tio n o f th e p roxim al a sp e ct o f th e x-
a to r m ay b e facilita te d b y m akin g a large r incisio n (ap p roxim a te ly
4 – 5 cm) o ve r th e p roxim al th re e scre w h o le s (e ith e r h o le s 11, 12 ,
and 13 in a 13 -h o le xa to r o r h o le s 7, 8 , and 9 in a 9 -h o le xato r
(se e Fig 3 -13)). The incisio n is carrie d do w n in a longitudinal m an -
ne r th ro ugh the ilio tibial ligam e n t an d the va stu s la te ralis so tha t
dire ct p alp a tion o f th e xa tor and asse ssm e n t o f its re la tio n ship to
th e la te ral co rte x is p o ssib le . La te ral im age in te n si ca tio n can also
b e u se d to a sse ss place m e n t o f the xato r o n the m idla te ral asp e ct
o f the fe m u r. It is e xtre m e ly im p o rtan t to e stablish corre ct place -
m e n t, in orde r to e n sure prop e r proxim al in se rtion o f the m ono cor-
tical lo ckin g h e ad scre w s. Afte r th e p ro p e r le n gth an d ro ta tio n are
e n sure d , and appropria te p o sitio ning o f the proxim al a sp e ct o f the
xa tor on the m id la te ral fe m ur ha s b e e n e stablishe d , the proxim al
gu id e w ire can b e place d . It is still p o ssib le a t th is p o in t to co rre ct
th e sagittal p lan e align m e n t, a s n o te d b e lo w. Sm all co rre ctio n s o f
th e ad d uctio n o f th e proxim al fragm e n t o r o f th e varu s/ valgu s
align m e n t o f th e d istal fe m o ral co nd yle are p o ssib le .

For pre lim inary xa tion o f the in te rnal xa to r, 2 .0 m m K-w ire s are
in se rte d through the xa tion and stabiliza tio n b olts. The p o sitio n
Fig 3 -16 Pre lim ina ry LISS xa tion . Th e gu id e w ire th ro u gh d rill
o f the LISS pla te and le ngth o f the re d uce d injure d lim b are care -
sle e ve A sho u ld b e p aralle l to th e jo in t su rface .
fully ch e cke d . Alte rna tive ly, the aim ing de vice fo r K-w ire s can b e
u se d to in se rt the w ire s o n the an te rio r and p o ste rior side o f the
xa to r (se e Fig 3 -4 a – b).

Once th e re d u ctio n ha s b e e n su cce ssfu lly co m p le te d an d th e LISS

pla te h a s b e e n p o sitio n e d co rre ctly, th e lo cking h e ad scre w s can b e
in se rte d .

10 0
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 9 : p la ce m e n t o f s cre w s in t h e d is t a l fe m o ra l b lo ck (Fig 3 -17 )

At th is p o in t, re a sse ssm e n t is m ad e o f th e co m m o n h yp e re xte n sio n sle e ve . Using im age in te n si cation , the K-w ire is pu she d to the
and e xce ss valgu s d e fo rm itie s o f th e d istal fe m o ral co n d ylar b lo ck. d e sire d de p th , le aving at le ast 5 m m be twe e n th e tip o f the K-
Hyp e re xte n sion is co rre cte d by re p o sitio nin g th e su pracon d ylar w ire and the m e d ial corte x. Th e scre w le ngth is m e asu re d o ve r
to we l ro lls, ch an gin g th e d ire ctio n o f m an u al tractio n , an d b y m an - the K-w ire u sing the m e asuring de vice fo r K-w ire s (Fig 3 -17 ),
ual pre ssu re o r b y jo ystick co n trol o f the d istal fe m o ral blo ck. Th e le aving the guide sle e ve in place , and rounde d dow n to the
u sual e xce ssive valgu s can b e co rre cte d u sing one o f a varie ty o f ne are st scre w le ngth . This w ill e n sure that the tip o f th e lo cking
te ch n iq u e s: he ad scre w w ill no t pro trude through the m e dial co rte x.
Th e fo rce ve cto r o f th e p u ll o f m an ual tractio n can b e alte re d .
A pu llin g de vice can b e place d in the p roxim al a sp e ct o f the
distal fe m o ral cond yle . This allo w s corre ctio n o f app roxim a te ly
1– 5° o f e xce ssive valgu s.
A large re duction fo rce p s or colline ar re duction clam p, w ith
on e arm place d o n the proxim al asp e ct o f the d istal m e dial
fe m o ral cond yle and the o the r e ithe r on the xa tor or the in -
se rtion gu ide , can b e u se d to corre ct e xce ssive valgu s. It m u st
b e re co gnize d tha t this w ill re su lt in sligh t d istu rb ance o f the
p aralle l p o sition o f the xa tion in re la tion to the scre w in se r-
tio n gu id e . Ho we ve r, its u se m ay b e n e ce ssary w h e n d e alin g
w ith e xtre m e ly o ste o p o ro tic b o n e , in w h ich u se o f th e pu llin g
de vice can b e lim ite d b y scre w pullou t.

Afte r corre ct place m e n t o f the xa tor o n the d istal fe m o ral b lo ck

ha s b e e n ach ie ve d an d fo llo w in g app ro p ria te co rre ctio n o f an y d e -
form ity, se ve ral LHS can b e place d distally. All LHS are place d unde r
saline co o ling; during in se rtion —e sp e cially o f the rst LHS—the x-
a to r is “p u sh e d ” again st th e d istal fe m o ral co nd yle s, th e han d is
raise d , and co u n te rp re ssu re is ap plie d o n th e o pp o site m e d ial as-
p e ct o f the d istal fe m oral re gion .
In se rtio n o f th e se lf-d rillin g, se lf-tapp in g lo ckin g h e ad scre w s.
Scre w place m e n t de p e n d s on th e typ e o f fracture . The p o si-
tio n s o f th e LHS sh o u ld b e ch o se n in acco rd ance w ith th e e s-
tablish e d b io m e chan ical prin cip le s fo r in te rn al xatio n .
Th e le ngth o f th e co nd ylar scre w s re q u ire d can b e calculate d
from Ta b 3 -2 . It is also p o ssible to u se the m e asuring de vice Fig 3 -17 Me a su rin g o f the le ngth w ith K-w ire u sing th e
w ith a 2 .0 m m K-w ire , 28 0 m m long, place d through the guide m e a su rin g d e vice fo r K-w ire s.

101
 St e p 9 : p la ce m e n t o f s cre w s in t h e d is t a l fe m o ra l b lo ck (Fig 3 -18)
Ba tte ry-drive n o r com pre sse d -air to ols are u se d to in se rt the
se lf-drilling, se lf-tapping lo cking he ad scre w s. No te: the to rque -
lim iting scre wdrive r should b e u se d for the nal tigh te ning (Fig
3 -18).
To pro vide the b e st in te rface b e twe e n LHS and b o ne and pre -
ve n t m e d ial m igra tio n o f th e b o n e , th e p o we r to o l sh o u ld b e
u se d w ithou t high a xial force s (3 – 5 kg).
To pre ve n t he a t ne cro sis, it is im p ortan t to co ol the scre w w ith
saline so lu tion through the drill sle e ve during the drilling pro -
ce d u re (Fig 3 -18).
It sho uld b e no te d tha t once the in itial LHS ha s b e e n in se rte d
in to e ach m ain fragm e n t, le ngth and ro ta tion are de ne d .
Fig 3 -18 In se rtio n o f LHS in th e articu lar b lo ck. To pre ve n t h e a t
n e cro sis it is im p o rtan t to co ol th e scre w s w ith salin e so lu tio n
th ro u gh th e d rill sle e ve d u rin g th e d rillin g p ro ce d u re .
10 2
(co n t)
An te cu rva tu m an d re cu rva tu m d e fo rm itie s can still b e m an ip u -
la te d re la tive ly we ll, bu t the re is only lim ite d sco p e for corre ct-
ing varu s/ valgu s de fo rm itie s.
It is the re fore re co m m e nde d th a t the rst LHS sh o uld b e in -
se rte d in to the distal fragm e n t. The distal LHS sh ould b e place d
p aralle l to the kne e join t.
If a LHS ha s to b e re m o ve d and re in se rte d , it sho u ld b e d o ne
w ith th e m anu al scre wd rive r, n o t th e p o we r to o l.
Th e LHS are ad vance d in to th e b o n e u n til th e se co n d gu id e o f
th e scre wd rive r sin ks in to th e d rill sle e ve . Th e to rq u e -lim iting
scre wd rive r shou ld b e u se d for nal tigh te ning un til clicking
o ccurs a t 4 Nm . It shou ld b e che cke d tha t the scre w he ad is
co m p le te ly se a te d in th e LISS p la te .
Bo th the scre wdrive r sha ft and the to rque -lim iting scre wdrive r
are e q u ip p e d w ith a se lf-h o ld ing m e ch an ism . Sligh t p re ssu re
sho uld b e u se d to e n sure tha t the scre wdrive r sha ft p e ne tra te s
th e so cke t o f the scre w h e ad o n pick-up.
If the scre wdrive r is d if cu lt to re m o ve afte r in se rtion , it sh ould
b e disconne cte d from the po we r to ol and the drill sle e ve shou ld
b e re m ove d . Afte r the scre wdrive r h as b e e n re co nn e cte d to the
p o we r to o l, the scre wdrive r is w ithdraw n from the scre w.
A standard 4 .5 m m corte x scre w can b e u se d thro ugh the x-
a to r if re q u ire d . It sh o u ld b e n o te d , h o we ve r, tha t th e 4 .5 m m
co rte x scre w can n o t b e in se rte d th ro u gh d rill sle e ve h o le A,
w h ich se rve s to lo ck th e in se rtio n gu id e to th e im plan t. Th is
h ole can th e re fo re no t b e u se d to in se rt a scre w w hile th e xa -
tio n b o lt is a ttach e d . If a scre w is re q u ire d in h o le A, th e xa -
tio n b o lt sh o u ld b e re m o ve d —w ith th e stab iliza tio n b o lt still in
p lace —an d re xe d in an ad jace n t ho le th a t is available . Once
th e se lf-d rillin g, se lf-tapp in g LHS have b e e n p lace d , th e fre e -
h an d m e th o d can b e u se d to in se rt th e scre w in h o le A. Th e
d ire ctio n give n by the xa tio n b o lt b e fo re re m o val can b e u se d ,
o r e lse ano the r pla te and scre w can b e u se d to de te rm ine the
co rre ct d ire ctio n fo r in se rtio n .
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 10 : a p p ro p ria t e re d u ct io n o f t h e p ro xim a l fe m o ra l s h a ft w it h LHS fixa t io n (Fig 3 -19)

At th is p o in t, th e xa to r is in an ap p ro p ria te re la tio n sh ip to th e tio n d e fo rm ity o f th e proxim al fragm e n t. Th e se co rre ctio n s can

distal fe m o ral co nd yle , le ngth and ro ta tion have b e e n m ain taine d —
b o th through con tinu e d ge n tle m anual traction and through the
proxim al guide w ire —an d it has b e e n e stab lishe d tha t som e m an -
ual pre ssu re m ay have to b e place d o n the an te rior d istal a sp e ct o f
th e p roxim al fragm e n t, o r th a t th e re is a n e e d to co rre ct an ad d u c-
n o w b e m ad e , p o te n tially w ith th e h e lp o f on e o r two pu llin g d e -
vice s (“w h irlyb ird d e vice s”) (Fig 3 -19 a – b). Proxim al LHS are th e n
in se rte d . A LHS is o fte n place d in ho le s n e xt to the pu lling d e vice
in o rde r to re duce stre ss.

a b

Fig 3 -19 a – e Th e pu llin g de vice (“w h irlybird ”) ca n p ro vid e ne b Sligh t im p ro ve m e n t o f the re d u ctio n o f th e d ia ph yse al co m p o -
ad ju stm e n ts to re d u ctio n . n e n t o f th e fractu re is acco m plishe d u tilizin g a p u llin g d e vice .
a It is ultilize d to co rre ct sligh t ad d uctio n d e fo rm ity o f th e p rox-
im al fe m u r, an d to e n su re tha t th e p roxim al fe m u r d o e s no t
d isp lace d u rin g scre w in se rtio n .

103
 St e p 10 : a p p ro p ria t e re d u ct io n o f t h e p ro xim a l fe m o ra l s h a ft w it h LHS fixa t io n (Fig 3 -19) (co n t)

LHS w ith a le ngth o f 26 m m are u se d in the diaphyse al re gion . If th e pu llin g d e vice allo w s th e b o n e to b e pu lle d to ward th e LISS
th e co rte x is ve ry th ick, p re d rillin g can b e carrie d o u t u sin g th e pu ll- p la te . Sin ce th e tip o f this in stru m e n t ha s a d iam e te r o f 4 .0 m m ,
ing de vice o r sp e cial lo cking he ad scre w s 35 m m lo ng w ith a long re placing it w ith a 5.0 m m LHS still e n su re s go o d purcha se in the
drilling tip. b one .

In se rtio n o f th e in itial LHS te n d s to p u sh th e b o n e m e d ially, p ar-
ticu larly in ca se s o f d e n se b o n e and / o r u n stab le re d u ctio n s. Th e
pu llin g d e vice h e lp s so lve th is p ro b le m . Th e pu llin g d e vice , w ith o u t
th e kn u rle d n u t, is in se rte d th ro u gh th e d rill sle e ve in to th e n e igh -
b oring hole o f the rst p e rm ane n t LHS. The p o we r to o l is stopp e d
b e fo re the e n tire scre w le ngth o f the pulling de vice h as b e e n in -
se rte d . Th e p o we r to ol is re m o ve d . Scre w ing the knurle d nu t on to
While the pu lling de vice is b e ing in se rte d , it is im p o rtan t to m o nitor
th e ad vance m e n t o f th e scre w tip care fu lly. Th e p o we r to o l m u st b e
sto pp e d b e fore the pullin g de vice is se a te d o n th e pla te . Failu re to
d o so m ay re su lt in strip p ing th e thre ad in the b o n e . No te: In case
o f o ste o p oro tic b o ne w ith ve ry thin corte x bico rtical se lf-tapping
LHS can b e u se d to x the LISS to the sha ft fragm e n t.

c d
Fig 3 -19 a – e (co n t)
c Th e pu lling d e vice he lp s to p re ve n t pu sh in g th e b on e m e d ially d Th e to rq u e -lim iting scre wd rive r sh o u ld b e u se d fo r nal
d u ring in se rtio n o f th e in itial LHS. Th e pu llin g d e vice is in se rte d tigh te n in g.
th ro u gh th e d rill sle e ve in to th e n e igh b o rin g h o le o f th e rst
p e rm a n e n t LHS.

10 4
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 10 : a p p ro p ria t e re d u ct io n o f t h e p ro xim a l fe m o ra l s h a ft w it h LHS fixa t io n (Fig 3 -19) (co n t)

Fig 3 -19 a – e (co n t)

e Since th e tip o f th e pu llin g de vice ha s a d iam e te r 4 .0 m m
re placin g it w ith a 5.0 m m LHS still e n su re s go o d pu rcha se
in th e b o n e .

St e p 11: a d d it io n a l s cre w p la ce m e n t

Add itio nal LHS are su b se q u e n tly place d b o th p roxim ally an d d is-
tally. In ge n e ral, a to tal o f ve p roxim al an d ve d istal LHS are
place d . In ca se s o f se ve re o ste o p o ro sis, six proxim al an d six d istal
LHS can b e u se d . Bio cortical se lf-tapping LHS for sha ft xation in
se rve r o ste op o ro sis is re com m e nde d .
In sim p le fractu re typ e s th e scre w s clo se to th e fractu re lin e h ave
to stay away fro m th e fractu re in th e p roxim al and d istal fragm e n t
e sp e cially w he n the re is a gap a fte r re ductio n in o rd e r to le ave a
scre w -fre e zo ne ab o ve the fracture . In a m ultifragm e n tary fracture
th e scre w s sh o u ld b e place d in th e m ain fragm e n t a s clo se a s p o s-
sible to the fracture zone so tha t the working le ngth o f the in te rnal
xa tor is no t to o lo ng and the re fore no t to o e lastic. Le ave 2–3 pla te
h ole s u nu se d to avo id stre ss con ce n tra tion in th e im plan t.
In m u ltifragm e n tary fractu re s n o scre w s are u se d in th e fractu re
zon e . Thre e to four pla te h ole s a t the fractu re zone should stay
w ith o u t scre w s.
In th is ca se th e scre w s in b o th m ain fragm e n ts sh o u ld b e a s clo se
a s p o ssib le to th e fractu re zo n e . Th e d istan ce b e twe e n th e se scre w s
d e te rm ine th e e lasticity o f th e xa to r.

10 5
 St e p 12: p la ce m e n t o f t h e m o s t p ro xim a l LHS, re m o va l o f t h e in s e rt io n gu id e , a n d p la ce m e n t o f t h e “A” d is t a l fe m o ra l LHS
(Fig 3 -20)

Th e p roxim al co n n e ctio n b o lt can b e re m o ve d an d th e m o st p roxi- d isco nn e cte d fro m th e xa to r. If d e sire d , a LHS o r a scre w h o le in -
m al LHS in se rte d in to the xa to r. The in se rtio n gu ide is the n se rte r can b e in se rte d in to the A distal fe m o ral scre w p o sition .

a b

Fig 3 -2 0 a – b
a Re m o val o f th e p roxim al co n n e ctio n b o lt an d in se rtio n o f th e b Disco n ne ct th e in se rtio n gu id e from the in te rnal xa to r.
m o st p roxim al LHS. Op tio n a lly an LHS o r a scre w h o le in se rte r can b e in se rte d in to
h o le A to ke e p the h o le fre e fro m b o n e in gro w th .

10 6
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
St e p 13: in t ra o p e ra t ive a s s e s s m e n t o f fra ct u re re d u ct io n a n d s t a b ilit y a ft e r fixa t io n
Le ngth , alignm e n t, and ro ta tion should b e clinically che cke d . The
kn e e is take n th ro u gh a fu ll ran ge o f ge n tle m o tio n to e n su re ap -
prop ria te fractu re xa tion . Fractu re re d uction and fractu re xatio n
are th e n a sse sse d u sin g AP, la te ral, an d o b liq u e x-rays. Sp e ci c
qu e stio n s to b e an swe re d in this a sse ssm e n t in clud e:
1 Is the re any sagittal plane de fo rm ity? Ho w sa tisfacto ry is th e
valgu s/ varu s align m e n t? Th e cable m e th o d is re co m m e nd e d
for che cking the alignm e n t o f the lim b (se e chap te r 2—4 .1).
2 Is the re sign i can t h yp e re xte n sion o f the distal fe m o ral
co n d yle s?
3 Le ngth , alignm e n t, and ro ta tion should also b e che cke d
clin ically.
4 Ho w sa tisfacto ry is th e p lace m e n t o f th e xa to r o n th e m id la t-
e ral a sp e ct o f the fe m oral sha ft?
St e p 14: w o u n d clo s u re (Fig 3 -21).
All o f th e wo u n d s are co p io u sly irriga te d . Th e jo in t cap su le is clo se d
u sing ab so rb able su ture s, a s is the ilio tibial ligam e n t (b o th proxi-
m al and distal incision s). The skin and sub cu tane ou s tissue are
clo se d in th e ro u tin e m an n e r (Fig 3 -21).
5 Ho w sa tisfacto ry is th e place m e n t o f th e LISS xato r o n th e
la te ral a sp e ct o f the d istal fe m oral co nd yle?
6 Are all o f th e scre w s re ally place d m o n o co rtically in to th e b o n e ,
o r are som e p o sitione d to o far an te rio rly o r p o ste riorly?
7 Are an y o f th e d istal LHS in th e p a te llar gro o ve o r in te rco nd ylar
n o tch? (Alth o ugh rare , this can o ccur w ith d istal m alro ta tio n o r
e xce ssive an te rior or p o ste rio r p o sitioning o f th e xa to r.) Th is
can b e a sse sse d in trao p e ra tive ly an d b y im age in te n si ca tio n
w ith th e in te rco nd ylar n o tch vie w.
8 It sh ou ld b e ch e cke d th a t se lf-d rillin g, se lf-tapp in g lo cking
h e ad scre w s have n o t p e rfo ra te d th e m e d ial co rte x.
Fig 3 -21 Po sitio n o f the LISS a fte r
d e n itive o ste o syn th e sis a n d w o u n d
clo su re .
107
 LCP-DF
LCP-DF can be applied in th e sam e way as LISS bu t also in a
m ore in vasive approach w ith ou t in sertion gu ide. For proper
d istal screw placem en t a sm aller gu idin g block can be u sed.
To n d th e correct position of th e LCP-DF on th e lateral aspect
of th e proxim al fem u r sh aft a sm all in cision is u sed to palpate
or to see th e proxim al en d of th e plate. Con trary to th e LISS-
DF th e LCP-DF h as com bin ation h oles so th e su rgeon can u se
an gu lated cortex screw s.

Ta b 3 -3 LISS-DF a n d LCP-DF ca s e s

Ca s e Cla s s i ca t io n Im p la n t u s e d Pa ge

Spiral we dge fe m oral sha ft fractu re 32-B1 LISS-DF, 13 hole s 521

Co m p le x sp iral fe m oral sha ft fracture 32-C1 LISS-DF, 13 hole s 531

Sim ple sp iral fe m o ral sha ft fractu re , im plan t failu re 32-A1 LISS-DF, 13 h o le s 535

Sim ple sp iral fe m o ral sha ft fractu re , p e ripro sth e tic 32-A1 LISS-DF, 13 ho le s 5 47

Fe m o ral sha ft fracture , p e ripro sthe tic 32-A1 LISS-DF, 13 ho le s 551

Extraa rticu lar d istal fe m o ral fractu re 33 -A2 LCP-DF, 9 h o le s 556

Su p raco n d ylar fe m o ra l fra ctu re w ith jo in t in vo lve m e n t 33 -C2 LISS-DF, 9 h o le s 56 9

In traarticu la r d ista l fe m o ra l fractu re 33 -C2 LISS-DF, 13 h o le s 57 3

Co m p le te a rticu la r m u ltifragm e n tary d ista l fe m o ra l fractu re 33 -C3 LISS-DF, 13 h o le s 583

Op e n co m ple te articu la r m u ltifragm e n tary d istal fe m o ral fra ctu re 33 -C3 LISS-DF, 9 h o le s 587

Op e n co m ple te in traa rticu la r m u ltifragm e n tary d istal fe m o ral 33 -C3 LISS-DF, 13 h o le s 593
fractu re

Pe rip ro sth e tic d istal fe m o ra l fractu re w ith im p la n te d to tal kn e e 33 -A2 LISS-DF, 5 h o le s 6 01

e n d o p ro sth e sis

Bila te ra l o p e n su p raco nd ylar fe m o ra l fractu re s a b o ve to tal kn e e 33 -A3 LISS-DF, 13 hole s 6 05

arth ro p la st y

Double o ste o tom y fo r valgu s le g de fo rm ity due to la te ral LISS-DF, 5 h o le s 611

com partm e n t kne e o ste o arthritis

10 8
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

1.3 Le s s in va s ive s t a b iliza t io n s ys t e m fo r t h e p ro xim a l
la t e ra l t ib ia (LISS-PLT)
In d ica t io n s
Th e in d ication s for LISS in th e prox im al lateral tibia in clu de
fractu res of th e prox im al sh aft, th e m etaph ysis, an d in traar-
ticu lar fractu res in wh ich treatm en t w ith screw s alon e is n ot
possible [4 ] ( Ta b 3 -4 ). Th e prin ciple of an gu lar stable screw
xation gives th e LISS-PLT system distin ct biom ech an ical ad-
van tages over com parable devices for sim ilar in d ication s [7 ].
On ce th e system h as been applied to th e lateral aspect of th e
tibia, it preven ts varu s collapse in m etaph yseal an d d iaph yse-
al fractu res an d in fractu res of th e tibial plateau w ith m ed ial
con dyle in volvem en t. Th is m ean s th at th e LISS-PLT can also
be u sed in th e treatm en t of proxim al tibial fractu res th at in -
volve both th e lateral an d m ed ial con dyles—Mü ller AO Clas-
si cation type 41-A2, A3, C1, C2, C3, an d all prox im al type
42 fractu res [2]. In th e Sch atzker Classi cation for tibial pla-
teau fractu res, th e in d ication s in clu de Sch atzker type V an d
VI fractu res [12].
Th e LISS xator is n ot speci cally in d icated for isolated frac-
tu res of th e tibial d iaph ysis in th e m id-th ird, bu t is qu ite u se-
fu l for segm en tal sh aft fractu res in volvin g th e prox im al h alf
of th e tibia an d for ipsilateral diaph yseal an d bicon dylar tibial
plateau fractu res. Oth er less com m on con d ition s in wh ich
th e LISS-PLT h as been u sed in clu de path ological lesion s w ith
im pen d in g fractu re of th e prox im al tibia, an d periprosth etic
fractu res, an d fractu res in osteoporotic bon e.

Ta b 3 -4 In d ica t io n s fo r LISS-PLT in p ro xim a l t ib ia l fra ct u re s

Me tap h yse al fractu re s (m u ltifragm e n tary)

Proxim a l sh a ft fractu re s (m u ltifragm e n ta ry, n o t n ailab le)

Se gm e n ta l sh a ft fractu re s (n o t n a ilab le)

Articu lar fractu re s (41-A2 , A3 , C1, C2 , C3)

Fractu re s in o ste o p o ro tic b o n e

Pa th o lo gica l fractu re s

Pe rip ro sth e tic fra ctu re s

10 9
 Tim in g
Th e LISS-PLT m ay n ot always be th e procedu re of ch oice for
pr im ary treatm en t. In cases in w h ich th ere is severe soft-tis-
su e dam age in th e region of th e fractu re or fractu res, it m ay
n ot be advisable to carry ou t a sin gle-stage procedu re to in sert
an an gu lar stable in tern al xator. In th ese situ ation s, tem -
porary fractu re xation w ith an extern al xator can provide
stability for th e skeletal in ju r y an d soft tissu es u n til de n itive
m an agem en t is possible. Th is preven ts fu rth er soft-tissu e com -
prom ise an d alleviates swellin g. Th e tim in g of th e conversion
procedu re in a two-staged tech n iqu e is critical for prom otin g
h ealin g in th ese h igh -risk in ju ries.

X-ra y a n d co m p u t e d t o m o gra p h y
See ch apter 1.2.

Pa t ie n t p o s it io n in g
Th e patien t sh ou ld be placed in th e su pin e position on a rad io-
lu cen t table. Th e leg sh ou ld be freely m ovable. Th e con tralat-
eral leg can be placed in an obstetric leg h older. It is im portan t
to en su re th at both lateral an d AP im age in ten si cation of th e
proxim al tibia can be obtain ed in th is position . Bu m ps m ade
w ith towel rolls can be u sed to ex th e k n ee in to th e appro-
pr iate position (see ch apter 1.2).

110
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p -b y-s t e p s u rgica l s e q u e n ce fo r LISS-PLT fixa t io n

St e p 1: p re o p e ra t ive s e le ct io n o f t h e im p la n t s

AP an d la te ral x-rays o f th e in ju re d lim b are u se d; x-rays o f th e

o the r e xtre m ity m ay b e u se ful fo r com p arison . The pre op e ra tive
x-ray planning te m pla te (Fig 3 -2 2) is u se d to d e te rm ine th e le n gth
o f the LISS pla te and the p o sition o f the scre w s. Bo th te m pla te im -
age s are e n large d b y 10 % to acco u n t fo r ave rage rad io grap h m ag-
ni ca tio n . Ho we ve r, m agn i ca tio n m ay vary. Clinical e xp e rie nce
ha s sh o w n tha t th e u se o f lo n g im p lan ts xe d w ith lo ckin g h e ad
scre w s is ad van tage o u s, a s it re sults in go o d distribu tion o f the
strain acro ss b o th th e im plan t an d b o n e . It sh o u ld b e n o te d th a t th e
scre w s in hole s A and C p o in t to ward the articular su rface o f th e
kn e e . In h o le A, th e tip o f a 4 0 m m lo ng lo ckin g h e ad scre w w ill lie
ap p roxim a te ly a t th e sam e le ve l a s th e to p o f th e p la te . In h o le C,
th e tip o f a 75 m m lo ng lo ckin g h e ad scre w w ill lie ap p roxim a te ly
a t th e sam e le ve l a s th e to p o f th e pla te . It is p re fe rab le to u se
m o no co rtical lo cking he ad scre w s in the sha ft are a an d lon g lo ck-
ing he ad scre w s in the m e taphyse al zone .

Th e scre w s in th e tib ial sha ft w ill n o rm ally b e se lf-d rillin g, se lf-tap - Fig 3 -2 2 X-ra y plan n in g te m pla te fo r d e te rm in e th e le ngth o f th e
ping lo cking he ad scre w s 26 m m o r 18 m m lo ng. In ca se s o f o ste o - LISS-PLT pla te an d the p o sitio n o f th e scre w.
p o ro sis w ith so ft b one and th in corte x, bico rtically in se rte d se lf-
tapp in g lo ckin g h e ad scre w s (fro m th e 4 .5/ 5.0 LCP se t) are
re com m e nde d . As a rule , four lo cking he ad scre w s should b e se -
cu re ly in se rte d in to th e sha ft and ve o r six lo ckin g h e ad scre w s
in to the cond ylar blo ck. Pre op e ra tive plann ing o f the u se o f pla te
inde p e nde n t lag scre w s sh ould take place if ne ce ssary.

111
 St e p 2: in cis io n s (Fig 3 -23)

De p e n d in g o n th e n e e d , it is p o ssible to m ake e ith e r a cu rve d
(h o cke y-stick) o r a straigh t skin in cisio n fro m Ge rd y’s tu b e rcle
ab o u t 5 cm in d istal d ire ctio n . Ap proxim a te ly 0 .5 cm fro m th e tib i-
al rid ge , th e an te rio r tib ial m u scle is d e tach e d fro m th e b o n e an d
re tracte d , and the LISS is in se rte d in to the space b e twe e n th e p e ri-
o ste um and the m u scle . To allo w corre ct p o sitio ning o f the proxi-
m al part o f the LISS, it is im p ortan t to disse ct the m u scle a ttach -
m e n t site ade q ua te ly.
For co m ple x articu lar fracture s, an an te rola te ral arthro tom y tha t
p rovid e s go o d co n tro l o f th e re d u ctio n m ay b e p re fe rab le . An ad -
d itio nal m e dial, or p o ste rom e dial, or po ste rio r ap p ro ach (Fig 3 -2 3 c)
is u se d fo r so m e b ico n d ylar fractu re s. An ad d itio nal incisio n o n th e
d istal e nd is p o ssible w he n the long 13 -hole LISS-PLT pla te is b e ing
u se d .

a b c

Fig 3 -2 3 a – c Incisio n s fo r LISS-PLT.

a La te ra l a p pro ach to the tib ia l he ad . Fo r d isp lace d a rticu lar frac-
tu re s a m o re e xte n d e d ap p ro ach is n e ce ssa ry.
b – c Fo r so m e b ico n d ylar tib ial h e a d fractu re s an ad d itio n al m e d ial
o r p o ste ro m e d ial a pp ro ach is n e ce ssary.

112
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 3: re d u ct io n a n d s t a b iliza t io n o f t h e in t ra a rt icu la r fra ct u re

Th e e xact an a to m ical re co n stru ctio n o f articu lar su rface s m u st al-
ways take priority. In the ca se o f fracture s o f the tibial pla te au , a
la te ral arthro tom y sho uld b e carrie d ou t a s appropria te for the sp e -
ci c fractu re characte ristics in e ach ca se . Alte rna tive ly, an ar-
th ro sco p ically co n tro lle d re d uctio n o f th e articu lar su rface is so m e -
tim e s p o ssib le . If th e fractu re is in traarticu lar, th e w h o le jo in t
shou ld rst b e re con structe d and stabilize d . Lag scre w s are u se d to
ach ie ve in te rfragm e n tary co m p re ssio n b e twe e n th e articu lar frag-
m e n ts u sing cannula te d co rte x scre w s. Care sho uld b e take n to
e n sure tha t the se add itional scre w s do no t collide w ith the lo cking
he ad scre w s in se rte d throu gh th e in se rtio n gu ide . Figu re 3 -24
sho w s the p o ssible zone fo r pla te inde p e nde n t la te ral lag scre w s in
th e la te ral co n d yle . On ce th e jo in t su rface h a s b e e n re co n stru cte d ,
te m p o rary re d u ctio n o f th e articu lar b lo ck o n th e sha ft can b e
ach ie ve d , takin g in to acco u n t th e re sto ra tio n o f lim b le n gth an d
co rre ctio n o f th e a xial and ro ta tio nal align m e n t. It m a y b e h e lp fu l
to u se a d istracto r o r e xte rnal xa to r fo r th is su rgical ste p, bu t it is
no t ab so lu te ly n e ce ssary. An e xp e rie nce d LISS u se r can carry o u t
ind ire ct re ductio n as the prim ary pro ce du re , taking full ad van tage
o f the ana tom ically pre co n to ure d im plan ts.
Re duction o f the m e taph yse al fracture . The fracture can b e aligne d
m anually b y traction , w ith a te m p o rary kne e -bridging e xte rnal x-
a to r o r w ith a d istracto r. In trao p e ra tive x-ray o r im age in te n si e r
a sse ssm e n t is re co m m e n d e d to ch e ck re d u ctio n . In d ire ct re d u ctio n
is pre fe rable in th e m e tap h ysis an d sha ft are a . Ho we ve r, care ha s
to b e take n to e n su re tha t th e le n gth , ro ta tio n , an d a xial align m e n t
o f the m ain fragm e n ts are corre ct. The re duction the n ha s to b e
se cure ly he ld to allo w the re duce d fragm e n ts to b e bridge d w ith
th e LISS xato r.
Fig 3 -24 Po ssib le zo ne fo r
in se rtio n o f la te ral lag scre w s in
th e tib ia l co n d yle .

Som e d isplace d m e d ial pla te au fracture s in itially re qu ire m e dial

re duction and stabiliza tion w ith a sm all p o ste rom e d ial an tiglid e
pla te .

113
 St e p 4: a s s e m b ly o f t h e in s e rt io n in s t ru m e n t s (Fig 3 -2 5)
Th e two p arts o f th e in se rtio n gu id e are co n n e cte d . Th e xatio n
b olt is in se rte d through ho le A o f the in se rtion guide . The in se rtio n
gu id e is p lace d o n th e LISS th re e -p o in t lo ckin g m e chan ism . Th e
xa tion b olt is the n thre ade d in to th e LISS. The nu t o f the xatio n
b olt is thre ade d and tigh te ne d sligh tly w ith the pin w re nch .
a b
Fig 3 -2 5 a – c Asse m b ly o f th e in se rtio n in stru m e n ts.
114
For m ore stable xa tion o f the LISS to the in se rtion guide du ring
in se rtion , the stabiliza tion b olt can b e in tro duce d w ith the drill
sle e ve through hole C and thre ade d in to the LISS.
To pre ve n t tissu e ingro w th and facilita te im plan t re m oval, it is p o s-
sible to clo se the uno ccupie d scre w ho le s can b e clo se d u sing a
scre w hole in se rt b e fore the LISS pla te is in se rte d .
c
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 5: LISS in s e rt io n (Fig 3 -2 6)

Th e in te rnal xa to r is in se rte d b e twe e n th e an te rio r tib ial m u scle

and th e p e rio ste u m in th e e p ip e rio ste al sp ace . Th e LISS pla te is slid
in the d istal dire ction , w ith its distal e nd in con stan t con tact w ith
th e b o n e . Th e p roxim al e n d o f th e xa to r is p o sitio n e d again st th e
la te ral cond yle . The co rre ct p o sitio n o f the LISS o n the cond yle is
care fu lly id e n ti e d .

Fig 3 -2 6 In se rtio n o f
th e LISS-PLT.

St e p 6 : ch e ck in g t h e p o s it io n o f t h e LISS-PLT (Fig 3 -27 )

A che ck is carrie d ou t to e n su re corre ct p o sitio ning o f the LISS—dis- Corre ct p o sitioning o f the distal p art o f the pla te is che cke d e ithe r
tally o n th e an te ro la te ral sid e o f th e tib ia an d p roxim ally o n th e w ith th e im age in te n si e r o r th ro u gh d ire ct p alp a tio n .
la te ral cond yle . The in te rnal xato r m u st b e lying a t again st th e
co nd yle (Fig 3 -2 7 ). Du e to its we igh t, th e in se rtio n gu id e ha s a
te n d e ncy to tilt d o rsally. If it is d if cu lt to id e n tify th e co rre ct p o si-
tio n o f th e LISS o n th e co n d yle , th e p roxim al so ft tissu e s can b e
fu rth e r re le ase d b y e n larging th e o p e n ing.
a b

Th e LHS in h o le D is angu la te d to ward th e p o ste rio r sid e o f th e Fig 3 -2 7a – b Po sitio n o f th e LISS xa to r.

m e dial co nd yle . Exce ssive in te rnal ro ta tion o f the in se rtion guid e
ha s th e re fo re also ha s to b e p re ve n te d , as th is scre w m igh t e n dan -
ge r th e p o p lite al arte ry.
a Co rre ct p o sitio n o f th e LISS-PLT. Th e scre w in ho le D aim e s to
th e p o ste ro m e d ia l co rn e r o f th e co n d yle .
b Exce ssive in te rn a l re la tio n o f th e in se rtio n gu id e re su lts in a
w ro n g p o sitio n o f th e LISS. Th e LHS in h o le D m igh t th e n e n d an -
ge r th e p o p lite al arte ry.

115
 St e p 7: b u ild in g a fra m e (Fig 3 -2 8)
Once th e LISS is p ro p e rly align e d w ith th e b o n e , th e d rill sle e ve an d
stab iliza tio n b o lt are re m o ve d fro m h o le C. Th e tro car is in se rte d
in to the drill sle e ve through the m o st distal hole on the pla te (5, 9,
or 13). A stab incision is m ade (Fig 3 -2 8 a), an d th e d rill sle e ve an d
tro car are in se rte d d o w n to th e LISS p la te .
If a 13 -hole LISS pla te is b e in g u se d , care fu l so ft-tissu e d isse ctio n
ha s to b e carrie d o u t d o w n to th e pla te b e fo re in se rtin g th e tro car
and d rill sle e ve , in o rd e r to visualize th e su p e r cial b u lar n e rve .
a b
116
Th e p o sitio n o f th e d rill sle e ve is se cu re d w ith th e xa tio n scre w o n
th e in se rtio n gu id e . Th e tro car is re p lace d w ith th e stab iliza tio n b o lt
(Fig 3 -2 8 b). Th e stab iliza tio n b o lt is th re ad e d in to th e LISS pla te to
clo se th e fram e .
It sh o u ld b e n o te d tha t o n ce th e b o lt ha s b e e n in se rte d , it b e co m e s
dif cu lt to change the p o sitio n o f th e pla te – gu ide a sse m b ly, d u e to
th e so ft tissu e s aro u n d th e stab iliza tio n b o lt.
Fig 3 -2 8 a – b Bu ild in g a fram e .
a Ma ke a sm all incisio n o ve r th e m o st d ista l
h o le .
b Re m o ve th e d rill sle e ve a n d th e stab iliza -
tio n b o lt fro m h o le C. In se rt th e tro ca r in
th e d rill sle e ve th ro u gh th e m o st d istal h o le
o f th e pla te .
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

St e p 8 : p re lim in a r y fixa t io n o f t h e LISS-PLT (Fig 3 -2 9)

For pre lim inary xa tion o f the in te rnal xa to r, 2 .0 m m K-w ire s are
in se rte d through the m o st proxim al K-w ire hole o n the in se rtio n
gu id e (gu id e d o n ly th ro u gh th e alu m in u m fo o t p art o f th e in se rtio n
gu id e) and th ro u gh th e stab iliza tio n b o lt in th e m o st d istal h o le o f
th e LISS.

Fig 3 -2 9 Pre lim inary xa tio n o f th e LISS pla te

w ith t wo K-w ire s.

St e p 9 : ch e ck in g t h e re d u ct io n a n d p o s it io n in g o f t h e LISS-PLT

Th e p o sitio n o f th e LISS and th e re d u ctio n (le n gth , align m e n t, and

ro ta tion) o f the inju re d lim b are care fully che cke d . Whe n the re duc-
tio n ha s b e e n su cce ssfu lly co m p le te d an d th e in te rnal xa to r is in
th e co rre ct p o sitio n , th e in itial LHS can b e p lace d .

117
 St e p 10 : s cre w p la ce m e n t (Fig 3 -30 ) (se e also the no te s o n scre w place m e n t w ith the LISS-DF de vice ab ove)

Scre w place m e n t d e p e nd s on the typ e o f fractu re . The p o sitio n s o f
th e LHS sh o u ld b e ch o se n in acco rd ance w ith th e e stab lish e d b io -
m e chanical principle s for in te rnal xa tion . The LHS should b e in -
se rte d re m o te from the fracture gap in the m ain fragm e n ts. At le a st
four LHS sho uld b e u se d p e r fracture side . Thre e to four pla te hole s
a t th e fractu re zo n e sh o u ld stay w ith o u t scre w s.
It sho uld b e no te d tha t once the in itial LHS ha s b e e n in se rte d
in to e ach m ain fragm e n t, le ngth and ro ta tion are de ne d .
An te cu rva tu m an d re cu rva tu m d e fo rm itie s can still b e ad ju st-
e d w ithin narro w lim its. Fo r this re a son , it is re com m e nd e d to
start in se rtin g th e rst LHS in th e proxim al fragm e n t.
If a scre w has to b e re m ove d and re in se rte d , th e hand to rq u e -
lim iting scre wdrive r should b e u se d and no t the p o we r to ol.
The le ngth o f the co nd ylar LHS re q u ire d can b e calcu late d from
Table 3 -2 . It is also p o ssib le to u se the m e asu ring d e vice w ith
a 2 .0 m m K-w ire (Fig 3 -30 a), 28 0 m m lo ng, place d th ro ugh the
ce n te ring sle e ve in th e drill sle e ve . Using im age in te n si ca tio n ,
the K-w ire is pu sh e d to th e de sire d de p th , le aving a t le a st 5 m m
b e twe e n the tip of the K-w ire and the m e d ial co rte x. Th e scre w
le ngth is m e asure d ove r the K-w ire u sing the m e a suring de vice
for K-w ire s, le aving the guide sle e ve in place , and rounde d
do w n to th e ne are st scre w le ngth . Th is w ill e n sure tha t the tip
o f the scre w w ill no t pro trud e th rough the m e dial co rte x.
To im prove visualiza tion o f the cond yle , the drill sle e ve s for the
two m o st proxim al hole s (hole s D and E) are guide d thro ugh
th e alu m in u m fo o t p art o f th e in se rtio n gu id e o n ly. To p re ve n t
ro ta tio n o f th e d rill sle e ve , it is th e re fo re n e ce ssary to h o ld it
w ith two n ge rs d u ring in se rtio n o r re m o val o f th e K-w ire , a s
we ll a s during in se rtio n o r re m oval o f the two m o st proxim al
scre w s (Fig 3 -3 0 b).

a b

Fig 3 -3 0 a – e Scre w p lace m e n t.

a Me a su rin g o f the le ngth w ith a K-w ire u sin g th e m e a su rin g d e vice fo r K-w ire s.
b In se rtio n o f LHS in th e a rticu la r b lo ck.

118
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
St e p 10 : s cre w p la ce m e n t (Fig 3 -3 0) (co n t)
Th e im age in te n si e r sh o u ld b e o rie n te d o b liq u e ly to allo w
accu ra te visu aliza tio n o f th e p o in t a t w h ich th e K-w ire e xits
an te ro m e d ially o r p o ste ro m e d ially.
26 m m o r 18 m m LHS sh o u ld b e u se d in th e sh a ft re gio n
(Fig 3 -3 0 c).
Initially, a stab incision is m ade an d the tro car is in se rte d
th ro u gh th e d rill sle e ve .
If a 13 -hole LISS p la te is b e ing u se d , care fu l so ft-tissu e d isse c-
tio n h as to b e carrie d o u t d o w n to th e p la te fo r h o le s 10 to 13
b e fore in se rting the tro car and drill sle e ve , in orde r to visualize
th e su p e r cial bu lar n e rve . Alte rn a tive ly, b lu n t d isse ctio n
fro m ve n tral to d o rsal can also b e carrie d o u t.
Ba tte ry-drive n o r com pre sse d -air to ols are u se d to in se rt the
se lf-drilling, se lf-tapping LHS, a s only the se to ols pro vide the
re q uire d drill sp e e d . No te: For the nal tigh te ning the torque -
lim iting scre wdrive r ha s to b e u se d .
Fig 3 -3 0 a – e (co n t) Scre w p lace m e n t.
c In se rtio n o f the rst d ista l LHS a fte r che cking prop e r p o sitio n .
d Fo r n a l tigh te n in g th e to rq u e -lim itin g scre wd rive r h a s to b e u se d .
It is also im p o rtan t to co o l th e lo ckin g h e ad scre w s w ith saline
solu tion through the drill sle e ve during the drilling pro ce dure ,
to pre ve n t th e rm al n e cro sis. Th e in se rtio n sle e ve s h ave a sid e
n ipple to allo w irriga tio n . Use stan dard tu b ing an d syrin ge s
w ith salin e so lu tio n .
Bo th the scre wdrive r sha ft and the to rque -lim iting scre wdrive r
are e q u ip p e d w ith a se lf-h o ld ing m e ch an ism . Sligh t p re ssu re
sho uld b e u se d to e n sure tha t the scre wdrive r sha ft p e ne tra te s
th e so cke t o f the scre w h e ad o n pick-up.
Th e scre w s sh o u ld b e ad van ce d in to th e b o n e u n til th e b u lge
o f the scre wd rive r disapp e ars in the drill sle e ve . The to rque -
lim iting scre wdrive r is u se d fo r nal tigh te n ing un til clicking
o ccurs a t 4 Nm (Fig 3 -3 0 d ). It sh o u ld b e ch e cke d tha t th e
scre w he ad is sitting com ple te ly in the LISS pla te . So ft tissue
e n trapp e d b e twe e n the scre w he ad and the pla te can pre ve n t
th e scre w h e ad fro m b e ing u sh w ith th e p la te . In su ch case s,
a lo n g h e xago nal scre wd rive r fro m th e p e lvic in stru m e n t se t
can b e u se d to co m p le te the tigh te n in g.
d
119
 St e p 10 : s cre w p la ce m e n t (Fig 3 -3 0) (co n t)

Th e m o st d ista l LHS o n th e xa to r sh o u ld b e in se rte d la st

(Fig 3 -3 0 e), ju st b e fo re re m o va l o f th e in se rtio n gu id e , in o r-
d e r to e n su re th e sta b ilit y o f th e co n stru ct. Th e sta b iliza tio n
b o lt is th e n re m o ve d a n d th e scre w is in se rte d th ro u gh th e
d rill sle e ve .
If th e LHS is d if cult to inse rt or stop s ad van cin g b e fore lo ckin g
to th e pla te , th e n it m a y b e n e ce ssary to re m o ve th e scre w an d
cle an e n trapp e d b o n e fro m th e cu ttin g u te s u sin g a K-w ire .
Th e scre w can b e re u se d if the h e xago nal so cke t ha s no t b e e n
dam age d . If the co rte x is ve ry thick, the pu llin g d e vice can b e
u se d for pre drilling. Alte rna tive ly a sp e cial LHS w ith a longe r
drill bit can b e u se d .
If the scre wd rive r is d if cu lt to re m ove a fte r in se rtio n , it sh o u ld
b e d isco nne cte d from the p o we r to ol and the d rill sle e ve
should b e re m ove d . Afte r the scre wdrive r is re conne cte d to the
p o we r to ol, the scre wd rive r is w ithd raw n from the scre w.
A standard 4 .5 m m co rte x scre w can b e u se d through the x-
a to r if re q u ire d . Ho we ve r, it sh o u ld b e n o te d th a t th e 4 .5 m m Fig 3 -3 0 a – e (co n t) Scre w p lace m e n t.
co rte x scre w can n o t b e in se rte d th ro u gh d rill sle e ve h o le A, e Re m o val o f th e K-w ire a n d in se rtio n o f a LHS in th e m o st d istal
w hich se rve s to lo ck the in se rtion gu ide to the im plan t. This p la te ho le .
ho le can the re fo re no t b e u se d to in se rt a LHS w h ile th e xa -
tio n b o lt is a ttach e d . If a scre w is re q u ire d in h o le A, th e xa -
tio n b o lt sh o u ld b e re m o ve d —w ith th e stab iliza tio n b o lt still in
place —and re xe d in an adjace n t hole tha t is availab le . Th e d rill
sle e ve is place d in hole A and the appropria te scre w is in se rt-
e d . If all the lo cking he ad scre w s have b e e n place d , the fre e -
han d m e th o d can b e u se d to in se rt th e LHS in h o le A. Th e d i-
re ction give n b y the xa tio n b olt b e fo re re m oval can b e u se d ,
or e lse ano th e r pla te and scre w can b e u se d to de te rm in e th e
co rre ct d ire ctio n fo r in se rtio n .

120
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
St e p 11: re m o va l o f th e in s e rt io n gu id e , a n d p la ce m e n t o f t h e “A” p ro xim a l t ib ia l LHS (Fig 3 -31)
Th e in se rtio n gu id e is th e n d isco n n e cte d fro m th e xa to r. If d e -
sire d , a LHS o r a scre w ho le in se rte r can b e in se rte d in to the “A”
proxim al tibial scre w p o sition . (Fig 3 -31)
St e p 12: In t ra o p e ra t ive a s s e s s e m e n t o f fra ct u re re d u ct io n a n d s t a b ilit y a ft e r fixa t io n
Le ngth , alignm e n t, and ro ta tion should b e clinically che cke d . The
kn e e is take n th ro u gh a fu ll ge n tle range o f m o tio n to e n su re ap -
prop ria te fractu re xa tion . Fractu re re d uction and fractu re xatio n
are th e n a sse sse d u sin g AP, la te ral, an d o b liq u e x-rays. Sp e ci c
qu e stio n s to b e an swe re d in this a sse ssm e n t in clud e:
1 Is the re any sagittal plane de fo rm ity? Ho w sa tisfacto ry is th e
valgu s/ varu s align m e n t? Th e cable m e th o d is re co m m e nd e d
for che cking the alignm e n t o f the lim b (se e chap te r 2—4 .1).
2 Le ngth , alignm e n t, and ro ta tion should also b e che cke d
clin ically.
3 Ho w sa tisfacto ry is th e place m e n t o f th e xa to r o n th e m id -
la te ral asp e ct o f the tibia?
Fig 3 -31 Re m o val o f in se rtio n
gu id e .
4 Ho w sa tisfacto ry is th e place m e n t o f th e LISS xato r o n th e
la te ral a sp e ct o f the tibial co nd yle?
5 Are all o f th e scre w s re ally place d m o n o co rtically in to th e b o n e ,
o r are som e p o sitione d to o far an te rio rly o r p o ste riorly?
6 Are an y o f th e LHS in th e p o plite al fo ssa an d e n d an ge r th e
p o plite al arte ry? (Although rare , this can o ccur w ith e xce ssive
an te rio r and in te rn al ro la te d o r p o ste rio r p o sitio n ing o f th e x-
a to r.) Th is can b e a sse sse d in trao p e ra tive ly an d b y im age in -
te n si ca tio n .
7 It sh ou ld b e ch e cke d th a t se lf-d rillin g, se lf-tapp in g lo cking
h e ad scre w s have n o t p e rfo ra te d th e m e d ial co rte x.
121
 St e p 13: w o u n d clo s u re (Fig 3 -32) LCP-PLT
LCP-PLT can be u sed in th e sam e way as a LISS-PLT bu t in
Se e chap te r 1.2 .
a m ore in vasive approach w ith ou t in sertion gu ide. For prop-
er prox im al screw placem en t a sm aller gu id in g block can be
u sed. To n d th e correct position of th e LCP-PLT on th e aspect
of th e lateral distal tibia a sm all in cision is u sed to palpate or
to see th e prox im al en d of th e plate. Con trary to th e LISS-PLT
th e LCP-PLT h as com bin ation h oles so th e su rgeon can u se
an gu lated cortex screw s.

Fig 3 -32 Po sitio n o f th e LISS-PLT a fte r

d e n itive o ste o syn th e sis and w o u nd clo su re .

Ta b 3 -5 LISS-PLT ca s e s

Ca s e Cla s s i ca t io n Im p la n t u s e d Pa ge

Tib ia l p la te au fractu re; an d sp iral we d ge p ro xim al tib ial sha ft fractu re 41-B3; 42-B1 LISS-PLT, 13 h o le s 6 33

Pa rtial articu lar p roxim a l tib ial fractu re w ith split-d e pre ssio n 41-B3 LISS-PLT, 5 h o le s 6 45

Co m p le te a rticu la r p roxim al tib ia l fractu re w ith lo n g sp iral fra ctu re 41-C1; 42-A2 LISS-PLT, 13 h o le s 6 57
o f th e sh a ft

Sim p le articu la r fractu re p ro xim a l tib ia l w ith 41-C2 LISS-PLT, 13 h o le s 6 61

m e ta p h yse al co m m in u tio n

Articu lar m u ltifragm e n ta ry p roxim al tib ia l fractu re 41-C3 LISS-PLT, 13 h o le s 669

Op e n co m ple x irre gu lar tib ial an d b u lar sha ft fractu re 42-C3 LISS-PLT, 13 h o le s 759

122
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
Ap p ro a ch e s
A lateral approach to th e tibial h ead is recom m en ded for th e
treatm en t of extraarticu lar fractu res of th e prox im al tibia. Ac-
cess alon g th e prox im al con tou r of th e tibia sh ou ld be exten d-
ed in a m ed ial d irection to detach th e an terior tibial m u scle
close to th e bon e, w ith part of th e m u scle fascia on th e bon e
bein g left in tact to en su re easier re xation of th e m u scle. For
m ore severely displaced articu lar fractu res m ore exten ded ap-
proach es are n ecessar y (see step 2).
St ra t e g y fo r fra ct u re re d u ct io n a n d fixa t io n
A fu rth er con sideration wh en plan n in g th e su rgical proce-
du re is wh eth er or n ot th ere is an in traarticu lar fractu re th at
requ ires open redu ction . Fractu re redu ction an d xation pro-
ceed in two d istin ct steps, w ith redu ction of th e in traarticu -
lar fractu re bein g carried ou t rst. An atom ical redu ction an d
in tern al xation w ith com pression screw s are m an dator y in
articu lar fractu res. Th e secon d step is th e closed, in direct re-
du ction of th e m etaph yseal fractu re an d xation by locked
splin tin g m eth od.
1.4 Po s t o p e ra t ive t re a t m e n t
Postoperative treatm en t follow s th e sam e prin ciples as in con -
ven tion al in tern al xation procedu res an d basically con sists
of fu n ction al treatm en t w ith free m obilization of th e kn ee
join t an d partial weigh t bearin g. Mobilization of th e patien t
an d lim b is started im m ediately after th e operation . Th e op-
erated lim b m ay be rested on a con tin u ou s passive m otion
m ach in e as soon as th e patien t retu rn s to th e ward. Toe-tou ch
weigh t bear in g starts im m ed iately. Progressive weigh t bear-
in g depen ds on th e speci c fractu re situ ation (add ition al ar-
ticu lar fractu re) com m en ces wh en sign i can t callu s form a-
tion in th e su pracon dylar region becom es apparen t, or as soon
as th e h ealin g of oth er ipsilateral in ju ries allow s. Hin ged k n ee
braces are n ot u sed. Physical reh abilitation sh ou ld be started
im m ediately postoperatively, in clu d in g ran ge-of-m otion exer-
cises. Restriction s m ay be appropriate in special cases.
1.5 Im p la n t re m o va l
Th e im plan t sh ou ld on ly be rem oved after com plete con soli-
dation of th e fractu re. Th e sequ en ce of rem oval procedu res is
th e reverse of th e im plan tation process [13 ]. An in cision is in i-
tially m ade in th e path of th e old scar for th e in sertion gu ide,
an d th e in sertion gu ide is m ou n ted. To facilitate application
of th e in sertion gu ide du rin g im plan t rem oval, h ole A h as to
be closed w ith a screw h ole in serter if a screw h as n ot been
in serted in to th is h ole wh ile th e rst operation .
Stab in cision s are m ade. Th e clean in g tool h elps clean th e h ex-
agon al recess in th e screw h ead. Th e torqu e-lim itin g h exago-
n al screwdriver is u sed to rem ove th e LHS m anu ally. Rem oval
of th e LHS is com pleted w ith a power tool.
Wh en rem ovin g a 13-h ole LISS plate, carefu l soft-tissu e d is-
section h as to be carried ou t dow n to th e plate before in sert-
in g th e trocar an d d rill sleeve, in order to visu alize th e su per-
cial bu lar n er ve.
After all of th e LHS h ave been rem oved, th e LISS plate is re-
m oved. If th e plate is still stu ck after all of th e LHS h ave been
rem oved, th e in sertion gu ide sh ou ld be rem oved rst, an d
on ly th e xation bolt sh ou ld be u sed for su bsequ en t loosen -
in g of th e LISS.
1.6 Im p la n t-s p e cific p ro b le m s a n d co m p lica t io n s
(See ch apter 4) On e of th e com plication s speci c to LISS-DF is
proxim al screw pu llou t. Possible pred isposin g factors for th is
in clu de failu re to place th e LISS-DF on th e sh aft laterally, an d
possibly in correct rotation , w h ich cau ses tan gen tial place-
123
 m en t of th e screw s in th e sh aft cortex so th at th e screw s on ly
gain pu rch ase in a sm all section close to th e tip of th e screw.
Pu llou t occu rs typically after approx im ately 6 –8 weeks—ie,
as soon as th e patien t in creases weigh t bearin g.
If th e plate is lyin g too far an teriorly or posteriorly, th e screw s
w ill n ot be cen tered in th e m edu llary can al, so th at th e screw s
do n ot h ave adequ ate pu rch ase ( Fig 3 -3 3 ).
Ben din g an d tw istin g of th e LISS plate is n ot allowed, as th is
resu lts in m isalign m en t between th e h oles on th e in sertion
gu ide an d th e correspon din g plate h oles.
Fig 3 -3 3 The xa tor is o fte n m isplace d sligh tly an te rio r or p o ste rior
to th e m id sha ft o f th e proxim al fe m u r. If th is h app e n s in co n ve n tio n al
pla tin g, o n e can sim ply th e n d rill e ith e r an te rio rly o r p o ste rio rly. Th is
is no t p o ssible w ith LISS xa tion , as the scre w s e n te r p e rp e ndicular
to the su rface o f th e p late . If th e xa to r is sligh tly o ff ce n te r fro m th e
m idla te ral asp e ct o f the fe m ur or if it is sligh tly ro ta te d , the scre w s
w ill n o t o b tain ad e q ua te pu rcha se in th e co rte x.
124
1.7 Clin ica l re s u lt s
Sin ce th e in trodu ction of th e rst an atom ically con tou red
lock in g plate system s for fractu res in volvin g th e k n ee in
1997, m ost pu blication s h ave reported on th e excellen t resu lts
ach ieved even for extrem ely com plex d istal fem oral an d prox-
im a l tibia l fractu res. However, tech n ical d if cu lties du rin g its
application an d n egative effects on th e h ealin g process were
also observed.
Th e u n ion rate was 93% w ith a 3% in fection rate. Most im -
portan tly, th e problem of varu s collapse of th e distal fem o-
ral block h as been addressed. Biom ech an ically, th e LISS h as
tested su perior to th e blade plate an d th e retrograde in tra-
m edu llar y n ail for xation of su pracon dylar fem oral fractu res
in osteoporotic bon e. Th is h as also been seen clin ically, w ith
n o secon dary loosen in g of d istal xation or varu s collaps. It is
a relatively elastic im plan t so wh en ever an osteoporotic frac-
tu re xation con stru ct is loaded by th e patien t, th e im plan t
can elastically deform rath er th an cau se destru ction at th e
bon e-screw in terface.
Add ition al clin ical stu d ies fou n d in th e literatu re evalu atin g
th e LISS-DF: [14 –21].
Add ition al clin ical stu d ies fou n d in th e literatu re evalu atin g
th e LISS-PLT: [2 2 – 3 0 ].
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
2 Th e lo ck in g co m p re s s io n p la t e (LCP)
With its n ew ly design ed com bin ation h ole, th e LCP m akes it
possible to im plem en t th e pr in ciples of both com pression an d
splin tin g for fractu re stabilization in th e sam e im plan t [31]
(see ch apter 1, for a d iscu ssion of com pression versu s splin t-
in g). Th e developm en t of th e LCP is ou tlin ed in ch apter 1.
Th e follow in g con sideration s are im portan t wh en decid in g
wh eth er or n ot to u se th e LCP:
Clin ical factors:
Fractu re location an d con gu ration
Soft-tissu e con d ition
Patien t’s gen eral con d ition (m u ltiple trau m a, In ju ry Se-
verity Score, Glasgow Com a Scale)
Oth er factors:
In d ication s for oth er im plan ts: is an in tram edu llary n ail
su itable for sh aft fractu res in lon g bon es?
Borderlin e in dication s for in tram edu llar y n ails:
m etaphyseal zon e, size of th e m edu llar y can al, etc.
Presen ce of oth er im plan ts
Availability of im plan ts (eg, LCP), in stru m en ts, an d
in traoperative im agin g
Su rgeon ’s person al ex perien ce an d preferen ce
Th e biom ech an ical prin ciples an d variou s tech n iqu es for u s-
in g LCP in variou s in d ication s are su m m arized in Ta b s 1-6
a n d 1-7.
2 .1 Im p la n t s a n d in s t ru m e n t s
Se le ct in g t h e p la t e
Th e stan dard LCP h as th e sam e cross-section an d m ech an ical
properties as th e correspon d in g LC-DCP. Th e sam e type of
im plan t can th erefore be ch osen for speci c bon e segm en ts
an d fractu re con gu ration s ( Ta b 3 -6 ). Th ere are large an d
sm all fragm en t stan dard LCP available.
Special plates are available for th e epiph yseal an d m etaph y-
seal area of lon g bon es. Th ese d iffer from th e stan dard LCP in
th at th e plate segm en t close to th e join t h as a th in n er cross
section , lead in g to less in terferen ce w ith th e u su ally th in soft-
tissu e en velope an d allow in g th e in sertion of screw s on e size
sm aller close to th e join t th an in th e d iaph yseal area (LCP
m etaph yseal 3.5/4.5/5.0 an d LCP m etaph yseal 3.5). Th is type
of plate can be u sed m ore or less u n iversally close to join ts.
An atom ically presh aped plates are also available for d ifferen t
an atom ical areas: prox im al h u m eru s, d istal h u m eru s, olec-
ran on , d istal rad iu s, prox im al fem u r, d istal fem u r, prox im al
tibia, d istal tibia, pilon , an d calcan eu s. Th ese h ave th e ad-
van tage th at in traoperative sh apin g of th e plate is n o lon ger
n eeded, w ith screw in sertion bein g facilitated w ith th e u se of
gu id in g blocks ( Ta b 1-12 ). Speci c LCP for open in g an d clos-
in g wedge osteotom ies of th e distal fem u r an d th e proxim al
tibia are also available.
125
Ta b 3 -6 Se le ct th e a p p ro p ria te lo ckin g co m p re s s io n p la t e (LCP)

Im p la n t In d ica t io n Im p la n t In d ica t io n

LCP 4 .5/ 5 .0 , b ro a d
LCP 4 .5/ 5 .0 , n arro w
LCP m e tap h yse al
p la te 3 .5/ 4 .5/ 5 .0
• Me ta ph yse a l/ d iap h yse al fractu re o f th e LCP 3 .5 • Me tap h yse a l/ d ia ph yse a l fra ctu re s o f th e
fe m u r a n d h u m e ru s fo re a rm
• No n u n io n o f th e tib ia/ h u m e ru s • Ep ip h yse a l/ m e tap h yse a l fra ctu re s o f th e
p ro xim a l o r d istal h u m e ru s
• Cla vicu la r fra ctu re s
• Me ta ph yse a l/ d iap h yse al fractu re o f th e
• Tib ial p la te au fractu re s
tib ia
• Malle o lar fra ctu re s (t yp e C)
• Me ta p h yse a l/ d iap h yse al fractu re o f th e
• Sacral fractu re s
h u m e ru s in sm all wo m e n
• An te rio r an d p o ste rio r p e lvic rin g se gm e n t
• An te rio r sacro iliac jo in t pla tin g LCP m e ta p h yse al • Ep ip h yse a l/ m e tap h yse a l fra ctu re s o f th e
• Po ste rio r ilio -iliac p la tin g p la te 3 .5 d istal h u m e ru s, d ista l ra d iu s, an d o le cra n o n
• Sym p h ysis pu b is
LCP re co n stru ctio n • Ep ip h yse a l/ m e tap h yse a l fra ctu re s o f th e
• Me ta p h yse a l/ d iap h yse al fractu re s o f th e p la te 3 .5 d ista l hu m e ru s, sym p h ysis p u b is, ace tab u -
d istal tib ia w ith a sh o rt d istal fra gm e n t lar fractu re s
• Tib ial p la te a u fractu re
• Me ta p h yse a l/ d iap h yse al fractu re s o f th e
On e -th ird tu bu lar pla te • Malle o lar fra ctu re s (t yp e A, B, C)
p roxim a l an d d istal h u m e ru s

An a to m ica lly p re sh ap e d • Sp e ci c re gio n fo r w h ich th e p la te is

LCP re co n stru ctio n • No cle ar in d ica tio n
p la te s d e sign e d
p la te 4 .5/ 5 .0

LCP T- a nd L-p la te 4 .5/ 5 .0 • Ep ip h yse al/ m e ta ph yse al fractu re s o f th e

p ro xim al tib ia
• Un ico n d ylar fractu re o f th e d istal fe m u r

Se le ct in g t h e s cre w t yp e
Five d ifferen t types of screw s can be u sed w ith th e LCP. Care-
fu l an alysis of th e in ten ded fu n ction is requ ired to en su re op-
tim al u se of th e d ifferen t types ( Ta b 3 -7 ) [32 , 3 3 ].
Cortex screw, self-tappin g cortex screw, cortex sh aft
screw.
Can cellou s bon e screw, partially or fu lly th readed. Th e
partially th readed can cellou s bon e screw s are can cellou s
sh aft screw s.
Self-drillin g, self-tappin g lock in g h ead screw (for m on o-
cortical u se on ly).
Self-tappin g lock in g h ead screw (for m on o- or bicortical
u se).

126
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Ta b 3 -7 Se le ct t h e co rre ct s cre w t yp e

Typ e o f s cre w Bo n e s e gm e n t Fu n ct io n o f s cre w An ch o ra ge

Ca n ce llo u s b o n e scre w Ep ip h ysis Fre e , p la te -in d e p e n d e n t la g scre w 1 As lo n g a s p o ssib le

• partially (ie , cance llou s shaft scre w) or Me tap h ysis Pla te laggin g scre w 1
• fu lly th re ad e d Pla te xa tio n scre w

Co rte x scre w , se lf-tap p in g co rte x scre w Dia ph ysis Fre e , p la te -in d e p e n d e n t la g scre w Mo n o co rtical o r b ico rtical
Ep ip h ysis Pla te laggin g scre w
Me tap h ysis Pla te xa tio n scre w
Po sitio n scre w
Re d u ctio n scre w

Co rte x sh a ft scre w p artially th re ad e d Dia ph ysis Fre e , pla te -in d e p e n de n t lag scre w Mo n o co rtical
Pla te laggin g scre w

Se lf-ta p pin g lo ckin g h e a d scre w Diap h ysis Pla te xa tio n scre w Mo n o co rtical o r b ico rtical ( in m e tap h ysis
Ep ip h ysis Pla te d e p e n d e n t p o sitio n scre w a n d e p iph ysis a s lo n g a s p o ssib le)
Me tap h ysis

Se lf-d rillin g, se lf-tap p in g lo ckin g h e a d scre w Dia ph ysis Pla te xa tio n scre w Mo n o co rtical

1
On ly p a rtia lly th re a d e d ca n ce llo u s scre w s ca n b e u se d a s la g scre w s .

Ta b 3 -8 Diffe re n t fu n ct io n s a n d ru le s o f s cre w s

Fu n ct io n Typ e o f s cre w Effe ct Pre re q u ire m e n t s

La g scre w Co rte x scre w 1 In te rfragm e n tary co m p re ssio n Glid in g h o le , th re ad e d h o le fo r a fu lly th re ad e d

• fre e , p la te -in d e p e n d e n t co rte x sh a ft scre w 2 scre w o r a p a rtia lly th re ad e d scre w
• p la te laggin g scre w can ce llo u s sh a ft scre w 2

Ecce n tric scre w Co rte x a n d se lf-tap p in g co rte x scre w In te rfragm e n tary co m p re ssio n Dyn am ic co m pre ssio n u n it (DCU) a n d h e m i-
= co m p re ssio n scre w Can ce llo u s b o n e scre w sp h e ric scre w h e a d o f co n ve n tio n a l scre w

Pla te xa tio n Co rte x a n d se lf-tap p in g co rte x scre w s Frictio n b e t we e n b o n e a p la te Fo r co n ve n tio n a l scre w s go o d b o n e q u alit y
Can ce llo u s b o n e scre w p re b e n d in g o f th e p la te
Se lf-ta pp in g lo ckin g h e ad scre w s (LHS) Lo ckin g

Po sitio n scre w Co rte x a n d se lf-tap p in g co rte x scre w s Ho ld th e re la tive p o sitio n b e t we e n

• fre e , p la te -in d e p e n d e n t Can ce llo u s b o n e scre w s, fu lly th re ad e d t wo fragm e n ts
• th ro u gh a p la te h o le Se lf-ta pp in g LHS, o n ly pla te -d e p e n d e n t

Re d u ctio n scre w Co rte x scre w se lf-tap p in g co rte x Re d u ctio n o n to th e p la te , Re d u c- No in te rfragm e n tary co m p re ssio n
tio n o f a b u t te r y fragm e n t
LHS/ n e tu n in g LHS, scre wd rive r, scre w h o ld in g sle e ve

1
Se lf-ta p p in g scre w s a re n o t re co m m e n d e d to u se a s la g scre w s . 2 Pa rtia lly th re a d e d .

127
 Th e follow in g factors are critical for th e appropriate ch oice of
screw :
Th e m ech an ical prin ciple of xation requ ired:
Locked splin tin g m eth od to ach ieve th e prin ciple of
relative stability versu s in terfragm en tary com pression
m eth od to ach ieve th e prin ciple of absolu te stability.
Locked in tern al xator versu s stan dard platin g tech -
n iqu e
Plate xation on th e bon e w ith LHS (n on con tact plate)
or (com pression , friction) w ith stan dard screw s
Tech n iqu e of redu ction an d plate in sertion .
M in im ally in vasive plate osteosyn th esis (M IPO) tech -
n iqu e versu s open redu ction an d in tern al xation
(ORIF).
Epiph yseal/ m etaphyseal area versu s diaphyseal area.
Can cellou s bon e screw an d cortex screw. Can cellou s bon e
screw s or cortex screw s can be u sed as lag screw s, plate de-
pen den t lag screw or position screw s, eith er alon e (plate-in de-
pen den t), or th rou gh a plate h ole. In com bin ation w ith a plate
th ese screw s are also u sed as eccen tric com pression screw s
or as plate xation screw s. Th eir u se is recom m en ded wh en
th e screw h as to be in serted at an an gle in case of ax ial m a-
lalign m en t between th e bon e an d plate axis, or to avoid screw
pen etration in to a join t; wh en in terfragm en tary com pression
w ith eccen tric screw in sertion or a lag screw is requ ired; or
w ith a bridge platin g tech n iqu e w ith good bon e qu ality. Can -
cellou s bon e screw s or cortex screw s are also u sed for redu c-
tion of a fragm en t on to th e plate. Th ese screw s are u su ally an -
ch ored in both cortices; m on ocortical screw in sertion is on ly
carried ou t exception ally.
Ca n cellou s bon e screw s or cor tex screw s h ave t h e adva n -
tages th at th e screw s ca n be a n gu lated in side th e plate h ole,
m a k in g it possible to redu ce fragm en ts on to th e plate. Th eir
d isadva n t age is t h at th ey com prom ise th e blood su pply to
th e bon e cor tex, du e to th e n eed for d irect con t act bet ween
128
th e plate a n d th e bon e to a llow load tra n sm ission by a fr ic-
t ion force.
Lock in g h ead screw s. All LHS provide an gu lar an d ax ial sta-
bility in side th e plate h ole. Th ey act m ore like a bolt th an
a screw, an d th ere is a com plete absen ce of axial preload in g
in side th e screw du rin g its in sertion . Un der fu n ction al load-
in g th ey are loaded in ben d in g an d in axial load depen d in g
on th e extern al load in g con d ition . LHS can n ot be u sed as lag
screw s.
Th e advan tages of LHS in clu de im proved an ch orage in bon e
du e to th e sligh t in crease in th e ou ter screw d iam eter an d
altered load in g con d ition s. On th e biological side, th ey also
h ave th e advan tage of requ irin g n o con tact between th e plate
an d bon e, th u s protectin g th e periostal blood su pply to th e
bon e. Th e lack of an gu lation in side th e plate can be a disad-
van tage in th e epiph yseal bon e segm en t.
A d isadvan tage is th at th e su rgeon m ay com pletely lose th e feel
for th e qu ality of th e bon e du rin g screw in sertion an d tigh t-
en in g, wh en th e screw h ead en gages in th e con ical-th readed
plate h ole. Percu tan eou s in sertion of sh ort m on ocortical LHS
in th e d iaph yseal area is critical at th e en d of th e plate, wh en
th ere is som e m alalign m en t between th e lon g bon e ax is an d
th e plate. In th ese situ ation s, an ch orage is n ot obtain ed w ith
a sh ort screw, despite th e su rgical sen sation th at th ere is good
tigh ten in g ( Fig 3 -3 4 ). Tech n ically, th e problem can be solved
eith er by in sertin g a lon g self-tappin g LHS or by u sin g an an -
gu lated cortex or can cellou s bon e screw ( Fig 3 -3 5 ). Th e prob-
lem can be avoided at an early stage of th e procedu re by u sin g
th e d rill bit to cen ter th e screw an d feel th e bon e cortex before
th e m on ocortical self-d rillin g, self-tappin g LHS is in serted.
Altern atively, a sm all in cision can be m ade at th e plate en d
an d th e position of th e plate can be assessed on th e lateral side
of th e bon e by m anu al palpation an d by vision .
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

b a b
a

Fig 3 -3 4 a – b Fig 3 -3 5 a – b Scre w in se rtio n in a n e cce n tric

a Malalign m e n t b e twe e n the b o n e a xis a nd p la te le ad s to a n
e cce n tric p la te p o sitio n .
b At th e far e n d o f the p la te , a m o n o co rtical lo ckin g h e ad scre w
w ill n o t an ch o r in th e b o n e in th e se co n d itio n s.
pla te p o sitio n . To o ve rco m e th e pro b le m o f
in su f cie n t an cho rage o f a m o n o co rtical se lf-
drillin g, se lf-tap p in g scre w w h e n th e p la te is
p o sition e d e cce n trica lly, it is re co m m e nd e d
e ith e r to in se rt (a) a lo ng b ico rtical se lf-ta pping
scre w o r ( b) a co rte x scre w tha t a llo w s an gu la -
tio n in th e p la te h o le .

Two d ifferen t types of LHS are available—self-d rillin g an d

self-tappin g, or self-tappin g.

Self-drillin g, self-tappin g LHS. Self-d rillin g, self-tappin g LHS

are u sed on ly as m on ocortical screw s in th e d iaph yseal seg-
m en t of bon e wh en excellen t bon e qu ality is presen t. Th e cu t-
tin g tip of th e screw preven ts destru ction of th e bon e th read
in th e n ear cortex wh en th ere is a n arrow m edu llar y cavity,
becau se th e screw tip is able to pen etrate in to th e opposite
Fig 3 -3 6 Se lf-drillin g, se lf-tap ping lo cking
cortex ( Fig 3 -3 6 ) (see ch apter 4). Wh en a self-drillin g, self-
he ad scre w s sho u ld o n ly b e u se d in th e d iap h y-
tappin g LHS is an ch ored in both cortices, th e d rillin g u n it
se a l b o n e se gm e n t a nd o n ly a s m o n o co rtical
protru des well in to th e soft tissu es, w ith a poten tial risk of
scre w s. The cu tting tip o f the scre w p re se n ts
dam age to n eu rovascu lar stru ctu res beh in d ( Fig 3 -3 7 ).
de stru ctio n o f the b o ne th re ad in th e n e ar co r-
te x w h e n th e re is a narro w m e d u lla ry ca vity.
Settin g a self-drillin g, self-tappin g LHS percu tan eou sly, u sin g
a freeh an d tech n iqu e (w ith ou t u sin g an aim in g device) som e-
tim es resu lts in an im perfect cen terin g of th e screw tip in th e
plate h ole an d in in su f cien t an ch orage of th e h ead in side th e
plate h ole du e to an gu lation of th e LHS.

129
 Fig 3 -3 7 Pro tru sio n le n gth o f se lf-d rilling,
se lf-tap ping scre w s. Du e to the le ngth o f th e
se lf-drillin g u n it th e tip o f th e scre w p ro -
tru d e s fro m th e b o n e w h e n it is an ch o re d
w ith th e scre w th re ad in b o th co rtice s. Se lf-
d rilling, se lf-tap p in g lo cking he ad scre w s
a b
sh o u ld o nly b e u se d a s m o no co rtica l scre w s,
to p re ve n t d am age to th e so ft tissu e s o p p o -
site the p la te .

Fig 3 -3 8 In o rd e r to ga in pu rcha se in b o th
co rtice s, th e se lf-tap p in g scre w h a s to p ro -
tru d e fro m th e b o n e . Ho we ve r, d u e to th e
re la tive ly sm o o th scre w tip, n o da m age to
th e n e u ro va scu lar stru ctu re s o p p o site th e c d
p la te o ccu rs.
Fig 3 -3 9 a – d The wo rking le n gth o f m o no co rtica l scre w s de p e n d s
o n th e th ickn e ss o f th e b o ne co rte x.
a In no rm a l b o n e , th is wo rking le n gth is su f cie n t.
Self-tappin g LHS. Self-tappin g LHS are u sed in th e epiph y-
b In o ste o p o ro tic b o ne , b y co n tra st, th e co rte x is u su ally ve ry th in ,
seal, m etaph yseal, an d d iaph yseal segm en ts of th e bon e wh en
so tha t th e wo rking le n gth o f a m on o co rtical scre w is in su f -
th e in sertion of bicortical LHS or th e lon gest possible LHS is
cie n t. Th is d iffe re n ce in wo rkin g le n gth is im p o rtan t w h e n
plan n ed. Sin ce a self-tappin g LHS does n ot h ave a cu ttin g tip,
o ste o p o ro tic b o ne s such a s th e hu m e ru s ha ve to b e stabilize d .
th e tip is blu n t ( Fig 3 -3 8 ). To provide good an ch orage of th e
c In no rm al b o n e , the le n gth o f an cho rage o f the scre w th re ad is
screw th reads in both cortices, th e self-tappin g LHS sh ou ld
su f cie n t e n o ugh to w ith stan d ro ta tio nal d isplace m e n t.
protru de sligh tly beyon d th e far cortex.
d Wh e n th e re is o ste o p o ro sis, th e wo rkin g le n gth is ve ry sh o rt
d u e to th e th in co rte x, a nd u n d e r to rq u e th e b o ne th re ad w ill
Self-tappin g LHS requ ire predrillin g th rou gh th e th readed
q u ickly we ar o u t, le ad ing to se co n dary d isplace m e n t an d in sta -
drill sleeve. Used correctly, th e m on o- or bicortical self-tap-
b ility.
pin g LHS is always per pen d icu lar in th e cen ter of th e th read-
ed, con ical part of th e com bin ation h ole.

In th e presen ce of osteoporosis, th e bon e cortex is u su ally

th in . In th ese con d ition s, th e work in g len gth of a m on ocor-
tical LHS is sh ort, so th at poor an ch orage is obtain ed even
w ith lock in g h ead screw s ( Fig 3 -3 9 ). Th is problem can lead to
com plete loss of screw an ch orage, resu ltin g in in stability of

130
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
th e xation —a com m on situ ation in bon es th at are m ain ly
su bjected to torsion al load in g (eg, h u m eru s). Th e u se of bicor-
tical self-tappin g LHS is recom m en ded in all segm en ts for all
osteoporosis-associated fractu res. Th is approach im proves th e
work in g len gth an d avoids poten tial problem s at th e in terface
between th e screw th read an d th e bon e ( Fig 3 -4 0 ).
Even th e sh ortest m on ocortical self-tappin g LHS w ill destroy
th e bon e th read if th e screw tip tou ch es th e opposite cortex
before th e screw h ead h as locked in to th e plate h ole. If th is
occu rs, th e m on ocortical LHS sh ou ld be replaced w ith a bi-
cortical self-tappin g LHS, wh ich w ill en su re an ch orage in th e
opposite cortex ( Fig 3 -41). To avoid th e problem of bon e th read
destru ction th e m easu rin g of th e correct len gth of th e screw
after drillin g is im portan t.
In bon es w ith a sm all d iam eter th e problem can be avoided at
an early stage of th e procedu re by d rillin g both cortices (eg,
bon es w ith sm all d iam eter as forearm or bu la).
Mon ocortical or bicortical LHS. Mon ocortical LHS can on ly
be u sed in th e d iaph yseal segm en t of lon g bon es wh en th e
bon e qu ality is n orm al, wh en th e cortex is th ick en ou gh to
Fig 3 -4 0 Im p ro ve m e n t o f the wo rking le ngth . In o ste o p o ro tic b o n e
w ith a ve ry th in co rte x, th e stan d ard u se o f b ico rtica l scre w s is re c-
o m m e nd e d , a s th e lo nge r wo rkin g le ngth le ad s to a m uch b e tte r
to rq u e re sista n ce .
allow an ch orage of th e screw w ith a su f cien t work in g len gth
of th e th read, an d w h en th e speci c bon e h as a low load in g
level in torqu e.
Bicortical LHS are recom m en ded in th e follow in g situ ation s:
weak osteoporotic bon e; th in bon e cortex th at does n ot pro-
vide a su f cien t work in g len gth for th e screw ; h igh torqu e
load in g in th e plated bon e segm en t; a sh ort m ain fragm en t
th at on ly allow s a lim ited n u m ber of screw s; in bon es w ith
sm all d iam eter; wh en a cortex screw u sed for redu ction is
replaced by an LHS; an d destru ction of th e bon e th read in th e
n ear cortex du e to in correct in sertion of th e LHS.
a b c
Fig 3 -41a – c
a Dan ge r o f in se rtio n o f m o n o co rtica l se lf-tapp in g LHS. In b o ne s
w ith a sm a ll d iam e te r, th e tip o f th e scre w ca n co n tact th e
o pp o site b o ne co rte x b e fo re th e scre w he ad ha s e ngage d in th e
th re ad o f th e p la te h o le . Th is le ad s to th e d e stru ctio n o f th e
b o n e thre ad in th e n e ar co rte x an d co m ple te lo ss o f anch o rage
o f th e scre w.
b Th e situ a tio n ca n b e re solve d b y u sing a thre ad e d d rill sle e ve
th e o p p o site co rte x is d rille d in th e co rre ct a xis.
c In se rting a se lf-ta pp in g b ico rtica l LHS to o b tain a n ch o rage in
th e o p p o site co rte x.
131
 Po s it io n in g t h e im p la n t
Th e stan dard position s u sed for th e LC-DCP can also be u sed
for position in g th e LCP. Its fu n ction as an locked in tern al x-
ator or as protection plate xed w ith lockin g h ead screw s h as
n ot yet led to a m od i cation of th e stan dard approach es. Wh en
th e LCP is u sed as an in tern al xator, it can be placed on an y
bon e su rface th at can be con ven ien tly approach ed even w ith
a m in im ally in vasive plate osteosyn th esis tech n iqu e.
Le n g t h o f t h e im p la n t (Ta b 3 -9 ; Figs 3 - 42 , 3 -4 3)
Th e ch oice of th e appropriate len gth of th e LCP (an d of all
plates) is on e of th e m ost im portan t steps in in tern al xation .
It depen ds on th e fractu re pattern an d th e m eth od an d m e-
ch an ical prin ciple bein g u sed for xation . In in tram edu llary
n ailin g, th ere is n o qu estion regardin g th e len gth of th e n ail,
wh ich is m ore or less equ al to th e com plete len gth of th e frac-
tu red bon e from on e epiph ysis to th e oth er.

Ta b 3 -9 Gu id e lin e s fo r p la t e fixa t io n in s im p le a n d m u lt ifra gm e n t a r y fra ct u re s

Sim p le fra ct u re Sim p le fra ct u re Mu lt ifra gm e n t a r y fra ct u re

Biom e chanical p rin cip le In te rfragm e n tary co m p re ssion (splin tin g in Sp lin tin g in e xce p tio n al ca se s w ith o u t Sp lin tin g
e xce p tio n al ca se s) lag scre w

Re d u ctio n te ch n iq u e Main ly d ire ct In d ire ct o r p e rcu tan e o u s d ire ct 1

Pre fe rab ly in d ire ct

In se rtio n At le a st p artly op e n Op e n , le ss in va sive , MIPO Clo se d , m in im ally in va sive

Sh ap in g o f th e p la te Ha s to b e tte d to b o n e su rface Accu ra te sh ap in g n o t n e e d e d w ith LHS Accu ra te sh ap in g n o t re q u ire d w ith LHS

pla te le ngth 8 – 10 2–3 2–3

Pla te sp an ra tio = > > >
fractu re le ngth 1 1 1

Scre w t yp e • Co rte x scre w s in e cce n tric p o sitio n fo r • Co rte x scre w s o r LHS in go o d b o ne • Corte x scre w s or LHS in go o d b on e
co m pre ssio n • LHS in p o or b o ne and w ith MIPO • LHS in p o o r b o ne and w ith MIPO
• Corte x scre w in n e u tral p o sitio n or LHS fo r te ch niq ue te chn iqu e
pla te xatio n

Mo no co rtical/ bico rtical scre w s • Corte x scre w s: b ico rtical • Co rte x scre w s: bico rtical • Corte x scre w s: b ico rtical

LHS in th e d iap h ysis • Se lf-d rillin g/ se lf-tap p in g m o n o co rtical o r • Se lf-d rillin g/ se lf-tap ping m on o co rtical • Se lf-drilling/ se lf-tapp ing m o no co rtical
se lf-tap p in g b ico rtical o r se lf-tap p in g m o n o o r b ico rtical or se lf-tap p in g m o n o o r bico rtical

LHS in th e e p iph ysis/ m e tap h ysis • Se lf-tap pin g b ico rtical • Se lf-tapp in g bico rtical • Se lf-tap p in g b ico rtical

Pla te scre w d e n sit y (se e te xt) ≤ 0 .4 – 0 .3 ≤ 0 .5 – 0 .4 ≤ 0 .5 – 0 .4

Scre w s p e r m ain fragm e n t (n) ≥ 3; 2 e xce p tio n ally ≥ 3; 2 e xce p tionally ≥ 3; 2 e xce p tio n ally

Co rtice s p e r m ain fragm e n t (n) 3–5 ≥4 ≥4

Scre w p o sitio n Sh o rt m id d le se gm e n t w ith o u t scre w s Mid d le se gm e n t w ith o u t scre w s also Lo n g m id d le se gm e n t w ith o u t scre w s
w ith ou t lag scre w s

Em p t y p la te h o le s o ve r th e fractu re 0 –3 ≤2 ≥3

1
Sp lin tin g o f sim p le fra ctu re s sh o u ld re sp e ct th e b io m e ch a n ica l ru le s a cco rd in g to th e stra in th e o ry.

132
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
Effe ct s o f p la t e le n g t h o n s cre w lo a d in g
Th e len gth of th e plate an d th e position of th e screw s affect
th e load in g con d ition s of th e screw s. Th e “en d-of-fragm en t”
screw s are th e on es th at are critically an d m ax im ally load-
ed, an d sh ou ld be con sidered separately from th e oth er plate
screw s. Each ben d in g m om en t is th e produ ct of a force an d a
d istan ce; th e force can be redu ced u n der a given ben d in g m o-
m en t by in creasin g th e len gth or leverage. Th u s, th e lon ger th e
plate, th e sm aller th e pu ll-ou t force actin g on th e screw s—an
effect th at is pu rely du e to th e im provem en t of th e plate le-
verage actin g on th e screw s ( Fig 3 -42 a – d ). Th is applies both to
stan dard screw s an d lock in g h ead screw s.
a b
c d
Fig 3 -42 a – d Pu ll-ou t fo rce o n scre w s a nd wo rking le ve rage o f th e
p la te . Wh e n a re la tive ly sh o rt pla te is u se d , th e scre w lo ad in g is
re la tive ly high d u e to the sho rt wo rking le ve rage o f th e scre w s in
b o th d ire ctio n s o f a b e n d in g m o m e n t (a , c). Usin g a lo n ge r pla te
incre a se s th e wo rking le ve rage fo r e ach scre w. Und e r a give n b e nd -
in g m o m e n t, the p ull-o u t fo rce o f th e scre w s is th e re fo re re d u ce d
(b , d ).
Lon ger plates redu ce th e stress in th e plate as well as to th e
screw s. From th e m ech an ical poin t of view, it is th erefore
better to u se very lon g plates. Wh en th e LCP is applied as
an in tern al xator w ith lock in g h ead screw s, screw load in g
m ain ly occu rs w ith ben d in g an d n ot w ith pu llou t. All of th e
screw s are loaded sim u ltan eou sly, an d failu re at th e in terface
between th e screw th read an d th e bon e m ay be less frequ en t.
Neverth eless, th e work in g len gth of an in tern al xator sh ou ld
also be kept lon g an d well-spaced. With in d irect redu ction ,
m in im ally in vasive in sertion , an d th e LCP xation w ith LHS,
n o biological disadvan tages h ave been observed w ith lon g im -
plan ts.
FE Exte rna l fo rce cre a tin g a b e n d in g m o m e n t o n th e p la te .
LE Le ve r arm o f th e e xte rn al fo rce .
FS Pu ll-o u t fo rce o f th e scre w.
LS Le ve r arm o f th e scre w.
133
 Effe ct o f p la t e le n g t h a n d s cre w p o s it io n o n p la t e lo a d in g
Ben d in g a plate over a sh ort segm en t en h an ces th e local strain
on th e im plan t. Ben d in g it over a lon ger segm en t an d lim itin g
th e deform ation by in tercalated bon e fragm en ts redu ces th e
local strain (ie, stress distribu tion) an d provides protection
again st fatigu e failu re of th e im plan t ( Fig 3 -4 3 ).
In com pression platin g, after precise redu ction of a sim ple
fractu re, w ith th e plate an d th e bon e both sh arin g th e load,
th e two m idd le plate screw s can be in serted as closely as pos-
sible to th e fractu re site, w ith th e per iph eral screw s in serted
at each en d of th e plate. In sim ple fractu res w ith ou t precise
redu ction —leavin g a gap an d splin tin g th e fractu re, leave two
to th ree plate h oles w ith ou t screw s to avoid stress con cen tra-
tion at a sm all plate segm en t. In a m u ltifragm en tary d iaph y-
a b
c High stra in d An gu la tio n lim ite d b y
o f p la te
a n d tissu e
Fig 3 -4 3 a – d Pla te stra in in th re e -p o in t b e n d in g. De p e n d in g o n th e
d e gre e , b e n d in g m o m e n t le ad s to re ve rsib le d e fo rm a tio n ( ie , re ve rs-
ible a ngu la tio n) o f the im pla n t. Wh e n th e se gm e n t to b e b e n t is
sh o rt (a), th e re la tive d e fo rm a tio n (stra in) is h igh a n d th e im p lan t is
liable to u n d e rgo fa tigu e failu re q u ite so o n . Whe re the p la te sp a n s
a lo n ge r are a o f a m u ltifragm e n ta ry fractu re ( b , d ), th e sam e b e n d -
134
seal fractu re bridged w ith an in tern al xator as a n on glid in g
splin t, th e lon g distan ce between th e two screw s adjacen t to
th e fractu re is determ in ed by th e fractu re zon e. Th is resu lt in
less elastic deform ation of th e plate an d th e in terfragm en tary
tissu es [5 ,6 ].
For practical u se th ere are som e basic ru les:
1 Len gth of plate: rst determ in e th e fractu re len gth , th en
ch ose th e plate len gth th ree tim es th e fractu re len gth .
2 Nu m ber of screw s an d position of screw s: few screw s bu t
position precisely plan n ed, on ly 50% of plate h oles occu -
pied w ith screw s.
Th e placem en t an d position of th e screw s is m ore im portan t
th an th e n u m ber of screw s.
in te rca la te d fra gm e n ts
in g m om e n t le a d s to le ss stre ss co n ce n tra tio n o f th e p la te w h e n th e
in te rca la te d fragm e n ts are sq u e e ze d b e twe e n th e m a in fragm e n ts.
Th e d e fo rm a tio n is d istrib u te d o ve r a lo n ge r d ista n ce , le ad in g to lo w
im plan t strain and h igh e r re sistan ce again st fa tigu e fa ilu re .
FE Exte rna l fo rce cre a tin g a b e n d in g m o m e n t o n th e p la te .
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Th e extern al xator also bridges alm ost th e en tire len gth of

th e bon e. In con trast, th e len gth of th e plate h as con tin u ed to
be a m atter of con troversy for som e tim e. In th e past, a sh ort
(often too sh ort) plate was often ch osen to avoid a lon g sk in
in cision an d exten sive soft-tissu e d issection . With th e n ewer
tech n iqu es of in d irect redu ction , w ith su bcu tan eou s or su b-
mu scu lar in sertion of th e im plan t an d th e locked splin tin g
m eth od to bridge th e fractu re zon e, th e plate len gth can be in - 50%

creased w ith ou t add ition al soft-tissu e d issection . Little or n o

3
add ition al biological dam age is cau sed, an d th e plate len gth

4
.
0
h
y
can be adapted to th e m ech an ical requ irem en ts of th e speci c

t
t
h
g
i
t
s
n
g
n
e
fractu re. From th e m ech an ical poin t of view, plate loadin g

n
e
l
e
d
e
l
r
w
0%

e
an d screw load in g sh ou ld be kept as low as possible to avoid

u
t
e
t
a
c
r
l
c
a
P
s
r
fatigu e failu re of th e plate du e to cyclic load in g, or pu llou t of

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e
t
a
th e screw s du e to excessive sin gle overload in g.

Th ree segm en ts of th e plate can be d istin gu ish ed: th e m id-
d le segm en t at th e fractu re site between th e two in n erm ost
screw s, an d th e proxim al an d distal plate segm en ts an ch orin g
th e im plan t on to th e prox im al an d d istal m ain fragm en ts. Th e
len gth of th e plate an d th e position in g of th e screw s in u en ce
th e load in g con d ition s in th e plate an d screw s. Th e len gth of
th e m idd le plate segm en t an d th e m eth od of span n in g th e
fractu re are respon sible for th e biological respon se of fractu re
h ealin g (in d irect h ealin g, direct h ealin g, or failu re to h eal)
( Fig 3 -4 4 ).
Th e ideal len gth for th e in tern al xator can be determ in ed
u sin g two valu es: th e plate span ratio an d th e plate screw den -
sity [3 4 ]. Th e plate span ratio is th e ratio of plate len gth to
overall fractu re len gth . Ex perien ce h as sh ow n th at th e plate
span ratio sh ou ld be greater th an 2:1 or 3:1 in mu ltifragm en -
tary fractu res an d greater th an 8:1, 9:1, or 10:1 in sim ple frac-
tu res. Th e plate screw den sity is th e proportion of th e nu m ber
of screw s in serted to th e nu m ber of plate h oles. Valu es below
0.5 to 0.4 are recom m en ded, in d icatin g th at fewer th an h alf
of th e plate h oles are occu pied by screw s.
l
P
75%
Fig 3 -4 4 Im p o rta nce o f th e pla te -sp an ra tio a nd pla te -scre w d e n -
sity in b ridge pla tin g te chn iq u e . Th e sch e m a tic d ra w ing sh o w s a
m e cha n ically so un d xa tio n o f a m u ltifra gm e n tary d iap h yse al frac-
tu re in th e lo we r le g. Th e ra tio b e t we e n th e le n gth o f th e p la te a n d
th e le n gth o f th e fractu re is kn o w n a s th e p la te – sp a n ra tio . In th is
ca se , th e ra tio is h igh e n o u gh —ie , ap p ro xim a te ly 3 , in d ica tin g th a t
th e p la te is th re e tim e s lo n ge r th an th e o ve ra ll fractu re are a . Th e
p la te – scre w de n sit y is sh o w n fo r all th e th re e b o n e se gm e n ts. Th e
p roxim al m ain fragm e n t ha s a pla te – scre w de n sity o f 0 .5 (thre e o u t
o f six h o le s o ccu p ie d ); th e se gm e n t o ve r th e fractu re ha s a d e n sity
o f 0 (n o n e o u t o f fo u r h ole s o ccu p ie d ); an d the d istal m ain fra gm e n t
h a s a d e n sity o f 0 .75 (th re e o u t o f fo u r h o le s o ccu p ie d h o le s). Th e
h igh e r pla te – scre w d e n sit y in the d istal m ain fra gm e n t ha s to b e
acce p te d , sin ce fo r an a to m ical re a so n s th e re is n o way o f re d u cin g
it. Th e o ve rall p la te -scre w d e n sit y fo r th e co n stru ct in th is e xam p le
is 0 .43 (six scre w s in a 14 -h o le p la te).

135
 Nu m b e r o f s cre w s (Ta b s 3 -8 , 3 -9)
Earlier AO gu idelin es recom m en d in g speci c nu m bers of
screw s, an d m on ocortical or bicortical in each fragm en t sh ou ld
n o lon ger be th e on ly decisive factors wh en an ch orin g a plate
in th e m ain fragm en ts. For adequ ate stabilization , it is mu ch
m ore im portan t to in sert few screw s w ith h igh plate leverage
to redu ce th e load on th e screw s.
From a pu rely m ech an ical poin t of view, two m on ocorti-
cal lock in g h ead screw s in each m ain fragm en t in th e sh aft
area are th e m in im u m requ irem en t for keepin g th e con stru ct
stable. However, th is type of con stru ct w ill fail if on e screw
breaks du e to overloadin g or if th e in terface between th e bon e
cortex an d th e screw th read develops bon e resor ption an d
loosen in g (screw pu llou t). Th e u se of two bicortical screw s in
each fragm en t does n ot im proves th e situ ation in relation to
screw fatigu e failu re, bu t it does en h an ce th e work in g len gth
of th e screw an d thu s im prove th e an ch orage at th e in terface
between th e screw th read an d th e bon e. Even wh en th e su r-
geon en su res th at all of th e screw s are in serted correctly, th is
type of con stru ct can on ly be u sed in h ealth y bon e. For safety
reason s, a m in im u m of th ree screw s per m ain fragm en t is
recom m en ded in all oth er cases.
Wh en fractu res are bein g xed in th e epiph yseal an d m etaph -
yseal areas, n eith er th e len gth of th e plate n or th e n u m ber of
screw s sh ou ld be ch osen on th e basis of m ech an ical con sider-
ation s alon e. Th e lon gest possible LHS are recom m en ded bu t
pen etration of articu lar su rface m u st be avoided. Th e local
an atom y an d th e len gth of th e epiph yseal an d/or m etaph yseal
fragm en t are also relevan t in th e decision . In th ese cases, th e
u se of a m etaph yseal plate or an atom ically presh aped plates
is recom m en ded to ach ieve balan ced xation , w ith load bear-
in g bein g d istribu ted equ ally between th e prox im al an d d istal
plate segm en ts an ch ored in th e two m ain fragm en ts.
136
2 .2 LCP in co n ve n t io n a l co m p re s s io n p la t in g
In som e fractu re situ ation s, th e LCP w ith com bin ation h oles
can be u sed w ith a con ven tion al platin g tech n iqu e —ie, frac-
tu re xation u sin g th e com pression m eth od based on th e
prin ciple of ach ievin g absolu te stability an d direct bon e h eal-
in g. Th e su rgical tech n iqu e an d in stru m en ts h ere are sim ilar
to th ose in con ven tion al platin g w ith DCP or LC-DCP.
In d ica t io n s
Sim ple fractu res of th e diaphysis an d m etaphysis: cases in
wh ich precise an atom ical redu ction is n ecessar y for th e
fu n ction al ou tcom e; sim ple tran sverse or obliqu e fractu res
w ith little soft-tissu e com prom ise an d good bon e qu ality
(com pression platin g or protection platin g in com bin ation
w ith a lag screw or ten sion ban d xation ).
In traarticu lar fractu res (bu ttress plate).
Delayed u n ion or n onu n ion .
Closed-wedge osteotom ies.
Com plete avascu larity of th e bon e fragm en ts.
Th e follow in g con d ition s h ave to be m et for th e u se of th e
com pression m eth od:
Precise redu ction of th e fragm en ts—in m ost cases requ ir-
in g open , d irect redu ction .
Precise an atom ical presh apin g of th e plate (if th e protec-
tion plate is to be xed w ith cortex screw s).
Good bon e qu ality, to en su re adequ ate an ch orage of cor-
tex or can cellou s bon e screw s.
M in or soft-tissu e dam age.
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
Te ch n iq u e
Th e m eth od of in terfragm en tar y com pression can be ach ieved
u sin g th e follow in g approach es:
Com pression plate for axial com pression (in tran sverse
fractu res).
Lag screw an d protection plate (in obliqu e fractu res).
Ten sion ban d prin ciple u sin g a plate.
Bu ttress plate an d lag screw.
b
Fig 3 -4 5 a – b In te rfragm e n tary co m p re ssio n .
a In te rfragm e n tary co m pre ssio n is a pplie d u sing a e cce n tric co r-
te x scre w. In o rd e r to a pply co m pre ssio n fo rce s o n th e vis-à -vis
co rte x b e n d in g o f th e p la te is n e ce ssary.
b Oste o syn th e sis is th e n com p le te d w ith th e in se rtio n o f co rte x
scre w s in the n e u tral p o sitio n .
Ax ial com pression . After open an d d irect precise an atom ical
redu ction of th e fractu re an d presh apin g of th e plate, in ter-
fragm en tar y com pression is applied u sin g th e eccen tric cortex
screw option in th e dyn am ic com pression u n it (DCU) of th e
LCP com bin ation h ole ( Fig 3 -4 5 ). Fractu re com pression can
also be applied u sin g a ten sion in g device ( Fig 3 -4 6 ). Osteo-
syn th esis is th en com pleted w ith cortex screw s in serted in th e
n eu tral position .
b
Fig 3 -4 6 a – b In te rfragm e n tary com p re ssio n u sin g a
te n sio n in g d e vice .
137
 If differen t screw s are com bin ed in com pression platin g, th e
cortex screw s sh ou ld be in serted in th e m idd le part of th e
plate in th eir eccen tric position s rst, to ach ieve fractu re
com pression ( Fig 3 -47 ). As a m od i cation , th e LCP can in i-
tially be xed to on e of th e m ain fragm en ts w ith on e or two
LHS. Su bsequ en tly, com pression can be applied by in sertin g
on e eccen tric screw in to th e oth er fragm en t, or by applyin g
th e ten sion in g device ( Fig 3 -4 8 ; Fig 3 -4 9 ). Osteosyn th esis is
th en com pleted w ith lock in g h ead screw s.

Fig 3 -47 In te rfragm e n tary com pre ssion u sing d ynam ic com pre s-
sion unit. If diffe re nt scre w s are com bine d , the corte x scre w s should
be inse rte d in the m iddle part o f the plate in e cce n tric p o sition rst.
a
In a se cond ste p the LHS are inse rte d . Only in the zone whe re corte x
scre w s are use d the re is com pre ssion be twe e n the plate and the bone
with additional disturbance of the pe riostal blood supply possible .

a
Fig 3 -4 9 a – b In o ste o p o ro tic b o ne su b se q u e n tly com p re ssio n can
b e ap p lie d b y a te n sio n in g d e vice .

Fig 3 -4 8 a – b
a Afte r re d u ctio n o f th is fractu re the p la te is xe d w ith LHS to o ne
fragm e n t. Th e n an e cce n tric co rte x scre w is in se rte d in th e
d yn a m ic co m p re ssio n p art o f th e com b in a tio n ho le a t th e o the r
e n d o f th e pla te .
b Fin ally stab iliza tio n w ith an ad d itio n a l LHS. No co m p re ssio n to
th e p e rio ste u m in th e fractu re zo n e . In te rfra gm e n ta ry co m p re s-
sio n p la ting u sin g d yn am ic com p re ssio n u n it.

138
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
Lag screw an d protection plate. In terfragm en tar y com pres-
sion of a sim ple fractu re in th e m etaph yseal or d iaph yseal
segm en t, or of an in traarticu lar fractu re, can also be accom -
plish ed u sin g a lag screw in serted th rou gh th e plate. In com -
parison w ith in depen den t lag screw s position ed away from
th e plate, th is approach presen ts th e follow in g advan tages
an d dif cu lties:
Th e plate acts like a large wash er.
A w ide ran ge of in clin ation s of th e lag screw in th e plate
h ole are requ ired for optim al fu n ction .
In sertin g a lag screw in to a plate h ole: Th e position of th e
protection plate is given by correct placem en t of th e lag
screw th rou gh th e fractu re lin e.
Com pression of th e plate on to th e bon e by th e lag screw.
Add ition al cortex screw s are u sed to in crease th e friction
between plate an d bon e.
If th ere is good bon e qu ality an d an open approach is possible
so th at accu rate plate con tou r in g can be carried ou t, th en cor-
tex or can cellou s bon e screw s can be in serted. Th is protection
plate con stru ct h elps protect th e fractu red bon e from ben d in g
an d torsion al forces.
Fig 3 -5 0 Co n ve n tio nal p la tin g te ch n iq u e: Lag scre w thro ugh th e
p la te h o le re q u ire s a p re cise p o sitio n ing o f th e pla te to allo w th e
co rre ct d ire ctio n o f th e lag scre w. Fixa tio n o f th e p ro te ctio n p la te
w ith co rte x scre w s re q u ire s p re cise ad ap ta tio n o f th e im p lan t to th e
b o n e a nd go o d b o ne q uality.
Con ven tion al com pression platin g requ ires precise adaptation
of th e im plan t to th e bon e in order to m ain tain precise redu c-
tion ; th e screw s apply a com pressive preload at th e in terface
between th e plate an d th e bon e, an d th e fragm en ts are pu lled
towards th e im plan t ( Fig 3 -5 0 ). Usin g th e LCP w ith cortex or
can cellou s bon e screw s th erefore requ ires accu rate sh apin g
of th e plate in th e sam e way as w ith a con ven tion al LC-DCP.
Im perfect sh apin g of th e plate leads to a m ism atch between
plate an d bon e su rface resu ltin g in prim ary loss of redu ction
wh en tigh ten in g th e cortex or can cellou s bon e screw s. If LHS
are in serted to su pport th e redu ction an d com pression bein g
m ain tain ed by th e lag screw s, n o u n con trollable forces du e to
pressu re of th e plate on th e bon e su rface w ill be created. Th is
way th e risk of prim ar y redu ction loss is elim in ated. Lock in g
h ead screw s are preferred also in osteoporotic bon e, thu s in -
creasin g xation stability ( Fig 3 -51b ).
Fig 3 -51a – b Lag scre w an d xa tio n o f the pro te ctio n p la te w ith
LHS. No u nco n tro lle d fo rce s d ue to pre ssu re o f the pla te o n th e
b o n e su rface w ill b e cre a te d . In ca se o f o ste o p o ro sis the xa tio n o f
th e p ro te ctio n p la te w ith LHS give s a b e tte r h o ld o f th e scre w s.
a No rm a l b o ne q u ality.
b Oste o p o ro tic b o n e .
139
 Th e lag screw can also be placed in depen den tly from th e plate,
w ith a protection plate bein g xed w ith lock in g h ead screw s
( Fig 3 -52 ). To n d th e correct place an d an gu lation of a free,
plate in depen den t lag screw is easier th an u sin g a lag screw in
a plate h ole. Th e position in g of th e protection plate (w ith ou t
a plate in depen den t lag screw) is easy an d n ot d ictated by th e
lag screw an d fractu re plan e. Th e u se of a n on con tact plate,
xed w ith LHS respects th e periostal blood su pply. Th ere is
n o risk of a prim ar y loss of redu ction . Th is tech n iqu e is m u ch
easier as a lag screw th rou gh a plate h ole.
Bu tress plate. In a m etaphyseal/epiph yseal sh ear or split frac-
tu re, xation w ith lag screw s alon e m ay n ot be su f cien t. Th e
in terfragm en tary com pression w ith lag screw s sh ou ld th ere-
fore be com bin ed w ith a plate w ith bu ttress or an tiglide fu n c-
tion . To preven t an y slid in g of th e plate LHS sh ou ld be u sed.
b 45°
Fig 3 -52 a – b Pro te ctio n pla te w ith ind e p e nd e n t lag scre w.
14 0
2 .3 LCP w it h s p lin t in g
Bridge platin g can be carried ou t w ith both stan dard screw s
an d lock in g h ead screw s. Th e m eth od of bridgin g th e frac-
tu re zon e w ith con ven tion al plates an d cortex screw s, u sin g
a n o-tou ch tech n iqu e com bin ed w ith in d irect redu ction , was
a great step for ward wh en it was rst in trodu ced; on ly th e
m ain fragm en ts were xed to th e plate. With con ven tion al
screw s, it h ad been n ecessary to presh ape th e plate to t th e
m ain fragm en ts. With th e com bin ation h ole of th e LCP it is
possible to u se both cortex screw s an d LHS in h ealth y bon e.
In osteoporotic bon e on ly LHS sh ou ld be u sed for in creased
plate xation ( Fig 3 -5 3 ).
a b
Fig 3 -5 3 a – b
a Brid gin g th e fractu re zo n e w ith co n ve n tio n al p la te an d co rte x
scre w s.
b Brid gin g th e fractu re zo n e w ith LCP an d LHS in o ste o p o ro tic
b o n e . Th e lo cke d in te rnal xa to r ha s n o o r o n ly lim ite d co n tact
to th e b o n e su rface .
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
LHS are preferable for bridge platin g procedu res, as it is easier
to carry ou t th e M IPO tech n iqu e w ith LHS becau se th ere is
n o n eed to presh ape th e plate an d th ere is n o pu ll of fragm en t
on to th e plate resu ltin g in prim ar y loss of redu ction . In addi-
tion , th ere is little or n o d istu rban ce to th e periosteal blood
su pply. LHS can tran sm it m ore load to th e plate/ xator. In
splin tin g th e plate/ xator h as to w ith stan d m ore load. Tech -
n ically, th e locked splin tin g m eth od (pu re splin tin g) can be
carried ou t eith er u sin g an open approach or w ith th e M IPO
tech n iqu e an d in d irect, closed redu ction .
Splin tin g th e fractu re zon e is an elastic xation w ith rela-
tive stability; th e d isplacem en t of th e fractu re en ds u n der load
mu st be reversible. Th is elastic xation allow s pain -free m o-
bility bu t sim u ltan eou sly in du ces bon e form ation (callu s), a
precon dition of relative stability of xation is th at th e bon e
fragm en ts are vital.
In d ica t io n s
Th e LCP is u sed as a locked in tern al xator to bridge th e frac-
tu re zon e w ith a less in vasive or M IPO tech n iqu e —ie, th e
locked splin tin g m eth od w ith an in tern al xator, based on
th e prin ciple of relative stability—in th e follow in g cases:
Mu ltifragm en tary fractu res of th e diaphysis an d m etaphy-
sis.
Sim ple fractu res of th e d iaph ysis an d m etaph ysis (in cases
wh ere approx im ate redu ction is adequ ate for th e fu n ction -
al ou tcom e, alth ou gh it is im portan t to strictly observe th e
biom ech an ical prin ciples of strain toleran ce).
Fractu res in problem zon es wh ere th ere are relative con tra-
in d ication s to in tram edu llary n ailin g—eg, sh aft fractu res
w ith an om alies of th e m edu llar y m or ph ology; fractu res in
ch ildren an d adolescen ts w ith w ide-open epiph yses; sh aft
fractu res in patien ts w ith m u ltiple in ju ries.
Open -wedge osteotom ies (eg, in th e proxim al tibia).
Periprosth etic fractu res.
Oth er im plan ts in situ .
Secon dary fractu res or red islocation , in stability after in -
tram edu llary n ailin g.
Delayed conversion from an extern al xator to th e de n i-
tive in tern al xation .
Tu m or su rger y.
LCP as extern al xator in em ergen cy situ ation s.
LCP as extern al xator in problem atic fractu res su ch as
open fractu res w h ich are severely con tam in ated or in fect-
ed w ith h igh possibility of ch ron ic osteom yelitis. Th is is a
sim ple tech n iqu e an d th e acceptan ce of th e patien t is bet-
ter. Bu t th ere are som e disadvan tages: Th e fractu re h as to
be redu ced before LCP xation an d th ere is n o ch an ce for
a secon dary correction like in extern al xator. Th e tran s-
cu tan eou s xation of th e LCP h as th e risk of screw/ pin
in fection .
Exam ple cases for th is in dication are sh ow n in section 2.6 of
th is ch apter.
Te ch n iq u e
Th ere are two prerequ isites for u sin g th e LCP as a locked in -
tern al xator:
Th e locked bridgin g in tern al xator h as to be lon g—th e
lon ger th e plate, th e better.
Th e space between th e lock in g h ead screw s in each m ain
fragm en t an d in relation to th e fractu re zon e h as to be ad-
equ ate.
Lock in g a screw in to th e xator in creases stability an d avoids
th e risk of prim ar y d islocation of fragm en t towards th e plate
by tigh ten in g th e screw s an d decreases th e risk of for secon d-
ary fractu re displacem en t du e to togglin g of th e screw in side
th e plate h ole. Th e advan tages of u sin g lock in g h ead screw s
are th at in th e sh aft area th e screw len gth can be redu ced to
a m on ocortical size an d th at self-d rillin g, self-tappin g screw s
can be u sed th at rem ove th e n eed for len gth m easu rem en t.
In h ealth y bon es, m on ocortical LHS are adequ ate, bu t at least
141
 th ree screw s sh ou ld be in serted in to each m ain fragm en t on
eith er side of th e fractu re. In osteoporotic bon e, it is stron gly
recom m en ded th at at least th ree LHS sh ou ld be in serted in to
each m ain fragm en t on eith er side of th e fractu re, an d th at at
least on e or two of th ese LHS sh ou ld be in serted bicortically.
Bicortical in sertion of LHS is recom m en ded in th e follow in g
con d ition s:
Osteoporosis
Th in cortex
High torsion al forces du rin g reh abilitation an d physical
th erapy
Sh ort m ain fragm en t
Sm all m edu llary diam eter
Wh en a cortex screw was u sed for redu ction th rou gh th e
sam e plate h ole
Destru ction of th e bon e th read in th e n ear cortex du e to
in correct in sertion of th e LHS
It is im portan t to avoid stress con cen tration s at th e fractu re
site, an d th is can be ach ieved by leavin g two or th ree plate
h oles w ith ou t screw s in th e fractu re zon e ( Fig 3 -5 4 ) Distribu -
tion of stress is im portan t to th e in tern al xator tech n iqu e in
order to avoid stress con cen tration an d im plan t failu res.
Fig 3 -5 4 Pre re q u isite s fo r u sin g th e LCP a s a lo cke d in te rn a l
fixa to r: lo n g p la te / fixa to r; a d a q u a te sp a ce b e t w e e n th e LHS in
e a ch m a in fra gm e n t. Avo id stre ss co n ce n tra tio n w h ile le a vin g o u t
th re e o r fo u r p la te h o le s w ith o u t scre w s in th e fra ctu re zo n e .
142
2 .4 LCP w it h a co m b in a t io n o f t h e t w o m e t h o d s
Th e com pression m eth od an d splin tin g m eth od sh ou ld on ly be
u sed in com bin ation in situ ation s in wh ich th e bon e h as been
fractu red in two d ifferen t places. In th is con dition (two dif-
feren t fractu res), th e two biom ech an ical pr in ciples—absolu te
stability th rou gh in terfragm en tar y com pression an d relative
stability by splin tin g w ith an in tern al xator—are com bin ed
in on e sin gle bon e w ith on e LCP.
A com bin ation of th e two d ifferen t m eth ods—com pression an d
splin tin g is on ly possible in situ ation s in wh ich th e bon e is
fractu red in two differen t places.
In d ica t io n s
Segm en tal fractu res w ith two d ifferen t fractu re pattern s
(on e sim ple an d on e m u ltifragm en tar y). In th ese cases,
con ven tion al in terfragm en tar y com pression is u sed to sta-
bilize th e sim ple fractu re, wh ile splin tin g w ith an in tern al
xator stabilizes th e m u ltifragm en tar y fractu re area.
In traarticu lar fractu res w ith a m u ltifragm en ted exten sion
in to th e d iaph ysis.
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
In th ese cases, th e an atom ical redu ction an d in terfragm en tar y
lag screw com pression of th e articu lar com pon en t is com bin ed
w ith a bridgin g xation from th e recon stru cted join t block to
th e d iaph ysis.
Exam ple cases for th is in dication are sh ow n in section 2.6 of
th is ch apter.
2 .5 Co m b in a t io n s o f d iffe re n t s cre w s
It is possible to com bin e th e two platin g xation tech n iqu es—
sim u ltan eou sly applyin g com pression w ith con ven tion al
screw s an d lock in g h ead screw xation u sin g a sin gle plate—
an d th is can be valu able, depen din g on th e in d ication or situ -
ation . It is im portan t to be fam iliar w ith th e d ifferen t fea-
tu res of both tech n iqu es. Probably th e m ost frequ en t u se of a
com bin ation tech n iqu e w ill be for treatin g fractu res adjacen t
to th e join t, w ith lockin g h ead screw s bein g u sed to x th e
fragm en t close to th e join t an d stan dard screw s bein g u sed
to apply axial com pression between th e m etaph ysis an d th e
d iaph ysis in a sim ple fractu re type (in d ividu al blade plate).
Th e splin tin g m eth od can be carried ou t w ith an in tern al x-
ator an d an add ition al redu ction screw (redu cin g th e plate
on to th e bon e or redu cin g a d isplaced fragm en t) or position -
in g screw. In add ition , th e con ven tion al screw –platin g tech -
n iqu e (th e com pression m eth od) can be u sed, bu t w ith xa-
tion of th e protection plate u sin g lock in g h ead screw s.
Articu lar fractu res treated w ith lag screw s an d a bu ttress plate
xed w ith LHS.
2 .6 Ca s e e xa m p le s
Pla t e o s t e o s yn t h e s is
LCP can be u sed for plate osteosyn th esis wh en th ere is poor
bon e qu ality (osteoporosis) [3 5 – 3 7 ] , in depen den tly of th e
speci c fractu re con gu ration an d xation pr in ciple (in clu d in g
periprosth etic fractu res).
Fra ct u re s clo s e t h e jo in t
Fractu res close to th e join t or exten d in g in to th e join t, su ch as
m u ltifragm en tar y m etaph yseal fractu res, are borderlin e
in dication s for in tra m edu llary n ailin g, bu t good in dication s
for screw –plate system s w ith an gu lar stability [4 , 35 , 3 7 ]
( Fig 3 -5 8 ).
Mu lt ifra gm e n t a r y fra ct u re a n d s e ve re s o ft-t is s u e in ju r y
Th e LCP is also in d icated for fractu res associated w ith seriou s
soft-tissu e defects an d m u ltifragm en tary fractu res of th e sh aft
th at requ ire bridgin g for restoration of th e correct len gth an d
ax ial an d torsion al align m en t [4 , 3 8 ] .
143
 In th e n ext section you n d typical case exam ples h ow th e
LCP can be u sed in differen t ways. Th e rst cases are exam -
ples for th e com pression m eth od accord in g to th e prin ciple
of absolu te stability of fractu re xation . Also differen t tech -
n iqu es an d differen t plate fu n ction s are sh ow n .
Th e secon d grou p of cases deals w ith th e m eth od of locked in -
tern al extram edu llar y splin tin g to ach ieve relative stability.
Fin ally, som e few cases are presen ted w ith two fractu res in on e
bon e. In su ch situ ation s th ere is th e n ecessity to u se th e LCP
for th e com pression an d splin tin g m eth od at th e sam e tim e.
Ca s e e xa m p le s w it h t h e co m p re s s io n m e t h o d
Sim p le ra d ia l s h a ft fra ct u re —2 2-A1
• Prin cip le o f fra ctu re xa tio n: a b so lu te sta b ilit y
• Me th o d o f fra ctu re xa tio n: co m p re ssio n
• Te ch n iq u e : o p e n , d ire ct p re cise re d u ctio n
• Fixa tio n: p la te in d e p e n d e n t la g scre w a n d p ro te ctio n p la te
• Fu n ctio n o f th e LCP: p ro te ctio n p la te
• Fixa tio n o f th e LCP w ith LHS ( ie , n o n co n ta ct p la te)

e f

a b c i d g h i

Fig 3 -57a – i 25 -ye ar-o ld m a n fe ll o n th e stre e t and su staine d a sim ple fo re a rm sha ft fractu re .
a – b AP a nd la te ral vie w.
c– d Po sto p e ra tive x-ra ys, AP an d la te ral vie w. Stab le xa tio n w ith a p la te in d e p e nd e n t lag scre w an d a LCP 3 .5 a s p ro te ctio n p la te xe d
w ith LHS. Co m p re ssio n m e th o d —p rin cip le o f ab so lu te stab ility allo w s fu n ctio n al p o sto p e ra tive tre a tm e n t.
e – g In trao p e ra tive pictu re s; o p e n d ire ct re d uctio n , pla te ind e p e n de n t lag scre w, p ro te ctio n pla te xa tio n w ith LHS (n o nco n tact pla te).
h–i AP a n d a xial vie w 5 m o n th s a fte r o p e ra tio n , b o n e he aling.

14 4
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Sim p le s p lit fra ct u re o f t h e t ib ia l h e a d —41-B1

• Prin cip le o f fra ctu re xa tio n: a b so lu te s ta b ilit y
• Me th o d o f fra ctu re xa tio n: co m p re ssio n
• Te ch n iq u e : o p e n , d ire ct p re cise re d u ctio n
• Fixa tio n: p la te d e p e n d e n t la g scre w a n d b u t tre ss p la te
• Fu n ctio n o f th e LCP: b u t tre ss p la te
• Fixa tio n o f th e LCP w ith a n gu la r sta b le LHS ( ie , p a rtia lly n o n co n ta ct p la te)
• Articu la r fra ctu re a s in d ica tio n u sin g a LCP a s b u t tre ss p la te .

a b c d e

Fig 3 -5 8 a – g 6 0 -ye ar-o ld m a n fe ll o n the stre e t a nd su staine d a split fractu re

o f th e tibial he ad .
a – b AP an d la te ra l vie w.
c CT scan fro n tal pla ne .
d – e AP an d la te ra l vie w p o sto p e ra tive x-ra ys.
f– g Fo llo w -u p x-ra ys a fte r 6 we e ks.

f g

145
 Co m p le t e a r t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-C3
• Prin cip le o f fra ctu re xa tio n: a b so lu te sta b ilit y
• Me th o d o f fra ctu re xa tio n: co m p re ssio n
• Te ch n iq u e : o p e n a n d p e rcu ta n e o u s, d ire ct p re cise re d u ctio n; MIPO, p e rcu ta n e o u s la g
scre w
• Fixa tio n: p la te in d e p e n d e n t la g scre w s a n d b u t tre ss p la te
• Fu n ctio n o f th e LCP: b u t tre ss p la te
• Fixa tio n o f th e LCP w ith a n ge l s ta b le LHS ( ie , n o n co n ta ct p la te , b la d e p la te)

a b c d e f

Fig 3 -5 9 a – p A 21-ye ar-o ld fe m ale su ffe re d a fractu re o f th e tib ial

h e ad d ue to a rid ing accide n t.
a – b Pre o p e ra tive x-rays.
c– f CT scan s o f th e m u ltifragm e n tary in traarticu la r fractu re .
Using th e MIPO te ch niq u e , a tib ial LCP wa s in se rte d su b cu ta -
n e o u sly fro m th e m e d ia l a sp e ct.
g h
h An add itio nal incisio n wa s m ad e to in se rt lo cking h e ad
scre w s.
i– j Po sto p e ra tive im age s. Fractu re stab iliza tio n ha s take n place
w ith lag scre w s an d m e d ial slid e in se rtio n o f a 5 -h o le T-p la te .
The o sse o u s a vu lsio n o f th e bu lar co lla te ral ligam e n t wa s
tre a te d b y te n sio n -b an d p la tin g a n d a lag scre w.

i j

146
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

k l m n p

Fig 3 -5 9 a – p (co n t)
k– l X-ra ys a fte r 1 ye ar.
m – n X-ra ys a fte r im plan t re m o val.
o – p On co m p le tio n o f th e tre a tm e n t, th e p a tie n t h ad fre e fu n ctio n ,
n o p ain , an d o n ly m in o r scars.

147
 No n u n io n o f a s u b ca p it a l h u m e ra l fra ct u re
• Prin cip le o f n o n u n io n xa tio n: a b so lu te sta b ilit y
• Me th o d o f n o n u n io n xa tio n: co m p re ssio n
• Te ch n iq u e : o p e n , d ire ct re d u ctio n a n d w ith a re d u ctio n scre w
• Fixa tio n: co m p re ssio n p la te (e cce n tric co rte x scre w) a fte r re d u ctio n w ith a p la te
d e p e n d e n t re d u ctio n scre w (fu lly th re a d e d ca n ce llo u s b o n e scre w)
• Fu n ctio n o f th e LCP: co m p re ssio n p la te a n d te n sio n b a n d p la te
• Fixa tio n o f th e LCP in th e h u m e ra l h e a d w ith a n gu la r sta b le LHS ( ie , b la d e p la te), in th e
sh a ft w ith LHS a fte r in te rfra gm e n ta ry co m p re ssio n w ith th e e cce n tric co rte x scre w.
• De la ye d u n io n o r n o n u n io n a re o fte n a n in d ica tio n fo r co m p re ssio n p la te xa tio n
m e th o d .

a b c d e f

Fig 3 -6 0 a – f 79 -ye ar-o ld wo m a n w ith no n u n io n o f a sub ca pita l hu m e ra l fractu re .

a – b No n u nio n o f a sub cap ital hu m e ra l fractu re a fte r co n se rva tive tre a tm e n t.
c– d Stab le xa tio n w ith a LPHP, co m p re ssio n m e th o d allo w s fu n ctio n al p o sto p e ra tive
tre a tm e n t.
e–f AP a nd a xial vie w 6 we e ks a fte r o p e ra tio n , b o n e h e a lin g.

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 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Clo s e d w e d ge o s t e o t o m y
• A go o d in d ica tio n fo r p la te xa tio n w ith th e co m p re ssio n m e th o d is a clo se d w e d ge
o ste o to m y.
• Prin cip le o f clo se d w e d ge o s te o to m y xa tio n: a b so lu te s ta b ilit y
• Me th o d o f clo se d w e d ge o ste o to m y xa tio n: co m p re ssio n
• Te ch n iq u e : o p e n , d ire ct re d u ctio n b y m a n u a l clo sin g o f th e o ste o to m y ga p a fte r
re m o va l o f th e b o n y w e d ge a n d a lso w ith a te m p o ra ry re d u ctio n scre w a n d
co m p re ssio n w ith th is e cce n tric p la ce d scre w ( ie , in tra o p e ra tive w o rkin g scre w).
• Fixa tio n: co m p re ssio n p la te (co m p re ssio n w ith a n e cce n tric co rte x scre w, a fte r
in te rfra gm e n ta ry co m p re ssio n th is scre w w a s re m o ve d a n d ch a n ge d to a LHS)
• Fu n ctio n o f th e LCP: co m p re ssio n p la te
a b • Fixa tio n o f th e LCP w ith LHS ( ie , n o n co n ta ct b la d e p la te)

f g

Fig 3 -61a – g 72-ye ar-o ld m an .

a – b Va ru s a rth ritis righ t kne e .
c Lo n g a xis sh o w s th e varu s m ala lign m e n t o f th e righ t le g. On th e le ft kn e e th e sam e
o p e ra tio n alre ad y wa s so m e ye ars b e fo re .
e
d – e In trao p e ra tive x-ray. Th e o ste o to m y ga p is clo se d b y m e a n s o f a co rte x scre w (ie ,
re d u ctio n scre w) a nd th e d ista l p art o f a To m o Fix tib ial h e ad pla te , la te ra l tibia is xe d
w ith m o n o co rtica l lo ckin g h e ad scre w s.
f– g AP a n d la te ra l vie w 7 we e ks p o sto p e ra tive stab le situa tio n im m e d ia te we igh t b e arin g
c
a fte r th e op e ra tio n .

149
 Ca s e e xa m p le s w it h t h e s p lin t in g m e t h o d

Tib ia l s h a ft fra ct u re , p e rip ro s t h e t ic—42 -B1

• Prin cip le o f fra ctu re xa tio n: re la tive sta b ilit y
• Me th o d o f fra ctu re xa tio n: lo cke d in te rn a l e xtra m e d u lla ry sp lin tin g
• Te ch n iq u e : MIPO; clo se d , in d ire ct re d u ctio n
• Fixa tio n: b rid gin g th e fra ctu re zo n e w ith a lo cke d in te rn a l xa to r
• Fu n ctio n o f th e LCP: p u re sp lin t, lo cke d in te rn a l xa to r
• Fixa tio n o f th e LCP w ith LHS
• Pe rip ro s th e tic fra ctu re s a re go o d in d ica tio n fo r p la te xa tio n w ith LCP a n d LHS u sin g MIPO
te ch n iq u e .

a b c d

Fig 3 -6 2 a – d 76 -ye ar-o ld wo m a n fe ll in th e b a th ro o m a nd su sta in e d a p e rip ro sth e tic tib ial sha ft
fractu re .
a – b Pre o p e ra tive AP a nd la te ral vie w.
c– d Po sto p e ra tive AP an d la te ral vie w; clo se d re d u ctio n an d lo cke d splin tin g w ith a LCP m e taph y-
se al p la te in MIPO te ch n iq ue . Op e n re d uction and co m pre ssio n pla te xa tio n o f the b ula
fractu re .

150
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Sim p le s p ira l t ib ia l s h a ft fra ct u re in a ch ild —42 -A1

• Prin cip le o f fra ctu re xa tio n: re la tive sta b ilit y
• Me th o d o f fra ctu re xa tio n: lo cke d in te rn a l e xtra m e d u lla ry sp lin tin g
• Te ch n iq u e : MIPO; clo se d , in d ire ct re d u ctio n
• Fixa tio n: b rid gin g th e fra ctu re zo n e w ith a lo cke d in te rn a l xa to r
• Fu n ctio n o f th e LCP: p u re sp lin t, lo cke d in te rn a l xa to r
• Fixa tio n o f th e LCP w ith LHS

a b c d e f

Fig 3 -6 3 a – n 15 -ye ar-o ld b o y fe ll w h ile ice ska ting an d su stain e d a fractu re o f th e

tib ial sh a ft.
a – b AP an d la te ra l vie w.
c– d Un su cce ssfu l co n se rva tive tre a tm e n t.
e –f Op e ra tive stab iliza tio n in MIPO te ch n iq u e sp lin ting w ith a m e tap h yse a l LCP.
g– h Afte r 2 m o n th s callu s fo rm a tio n o n th e la te ral sid e .

g h

151
 i j k l m n

Fig 3 -6 3 a -n (co n t)
i– j Afte r 4 m o n th s co m ple te h e aling.
k– l Afte r 9 m o n th s th e fractu re .
m X-ray afte r im plan t re m oval shows pe riostal and e ndostal bone he aling o f the fracture
and also a pe riostal callu s form ation unde r the plate (noncon tact plate with unde rcu ts).
n De tail, p e rio stal ca llu s fo rm a tio n u n d e r th e p la te (n o n co n tact p la te w ith u n d e rcu ts).

152
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Os t e o lys is o f t h e fe m u r, im m in e n t fra ct u re , p a llia t ve s p lin t in g o f t h e o s t e o lys is zo n e

a b c d e

Fig 3 -6 4 a – e 4 6 -ye ar-old wo m a n , w ith o u t traum a .

a–c AP a n d la te ral vie w.
d – e Pa llia tive Stab ilisa tio n; MIPO, b rid gin g th e o ste lysis zo n e . Mo b iliza tio n w ith fu ll we igh t b e arin g.

Me d ia l o p e n w e d ge h igh t ib ia l o s t e o t o m y, va ru s go n a r t h ro s is , s p lin t in g o f t h e o p e n
w e d ge o s t e o t o m y

Fig 3 -6 5 a – d 50 -ye ar-o ld m an .

a – b An gu la r sta b le xa tio n a fte r b ip la n a r
osteotom y on the m edial proxim al tibia.
c– d Bo n e h e alin g w ith o u t b o n e gra ft o r
b o ne su b stitu te .

a b c d

153
 Se gm e n t a l t ib ia l s h a ft fra ct u re / LCP a s e xt e rn a l xa t o r
Ra re in d ica t io n
• Prin cip le o f fra ctu re xa tio n: re la tive sta b ilit y
• Me th o d o f fra ctu re xa tio n: lo cke d e xte rn a l sp lin tin g
• Te ch n iq u e : tra n scu ta n e o u s xa tio n o f th e LCP w ith LHS; clo se d ,
in d ire ct re d u ctio n
• Fixa tio n: b rid gin g th e fra ctu re zo n e w ith a n e xte rn a l xa to r (LCP
w ith tra n scu ta n e o u s LHS)
• Fu n ctio n o f th e LCP: p u re sp lin t, lo cke d e xte rn a l xa to r
• Fixa tio n o f th e LCP w ith tra n scu ta n e o u s LHS.

a b c d e

f g h i

Fig 3 -6 6 a – i 5 8 -ye ar-o ld fe m ale p e d e stria n wa s stru ck b y a ca r an d In trao p e ra tive p ictu re s sh o w th e xa tio n o f th e LCP w ith two
su sta in e d m ultiple s inju rie s. lo cking h e ad scre w s o n e ach m ain fragm e n t.
a In ju ry x-ra y. i Se co n d o p e ra tio n: in se rtio n o f a sm a ll LCP fro m d ista l to p rox-
b – h Tran scu tan e o u s xa tio n o f a b ro ad LCP a s e xte rn al xa to r. im a l MIPO w ith a lo cke d in te rnal xa to r.

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 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Ca s e e xa m p le s w it h t w o fra ct u re s in o n e b o n e
In su ch situ ation s th ere is th e possibility/ n ecessity to u se th e LCP for th e com pres-
sion an d th e splin tin g m eth od at th e sam e tim e.

Co m p le t e a r t icu la r s im p le (1), m e t a p h ys e a l m u lt ifra gm e n t a r y (2) p ro xim a l t ib ia l

fra ct u re —41-C2
• Prin cip le o f fra ctu re xa tio n: a b so lu te s ta b ilit y fo r th e a rticu la r fra ctu re (1) a n d re la tive
a b
sta b ilit y fo r th e m e ta p h yse a l m u ltifra gm e n ta ry fra ctu re (2)
• Me th o d o f fra ctu re xa tio n: in te rfra gm e n ta ry co m p re ssio n fo r th e a rticu la r fra ctu re (1)
a n d lo cke d in te rn a l e xtra m e d u lla ry sp lin tin g fo r th e m e ta p h yse a l m u ltifra gm e n ta ry
fra ctu re (2)
• Te ch n iq u e : MIPO a n d la g scre w s
• Re d u ctio n: Dire ct, p e rcu ta n e o u s fo r th e a rticu la r fra ctu re (1) a n d clo se d , in d ire ct
re d u ctio n fo r th e m e ta p h yse a l m u ltifra gm e n ta ry fra ctu re (2)
• Fixa tio n: la g scre w s fo r th e a rticu la r fra ctu re b rid gin g th e m e ta p h yse a l fra ctu re zo n e
w ith a lo cke d in te rn a l xa to r
• Fu n ctio n o f th e LCP: p u re sp lin t, lo cke d in te rn a l xa to r
c d
• Fixa tio n o f th e LCP w ith LHS

e f g h i j

Fig 3 -6 7a – j An 8 3 -ye ar-old fe m ale wa s kno cke d do w n b y a car an d
su sta in e d m u ltiple in ju rie s. She wa s su ffe rin g fro m se ve re o ste o p o -
ro sis.
a – b Pre o p e ra tive x-ra ys. Th e re is a m u ltifragm e n tary fractu re o f
th e p roxim al tib ia (41-C2) an d se ve re so ft-tissu e in ju ry o n th e
la te ral sid e o f the tibia .
c– d Afte r clo se d re d u ctio n o f th e articu la r fractu re , xa tio n w ith
t wo 4 .5 m m can n u la te d lag scre w s w ith m e tal wa sh e rs wa s
carrie d o u t. Th e m u ltifragm e n tary m e tap h yse al fractu re zo n e
wa s th e n b ridge d w ith a n 8 -h o le 4 .5/ 5.5 tib ia l LCP a fte r clo se d
re d u ctio n . Th e isola te d m e d ia l a n d an te rio r b o n e fragm e n ts
we re le ft u n to u ch e d .
e–f Po sto p e ra tive x-ra ys 4 we e ks la te r. Ca llu s fo rm a tio n h a s
starte d .
g– h X-rays a fte r 4 m o n th s: b o n e co n so lid a tio n can b e se e n .
i– j Find ings a t th e 1-ye ar fo llo w -u p e xam ina tio n .

155
 4 2 - C3 m u lt ifra gm e n t a r y fra ct u re o f t h e p ro xim a l t ib ia l s h a ft (1) w it h a vu ls io n fra ct u re
o f t h e t ib ia l t u b e ro s it y (2)
• Prin cip le o f fra ctu re xa tio n: re la tive sta b ilit y fo r th e m u ltifra gm e n ta ry fra ctu re (1) a n d
a b so lu te sta b ilit y fo r th e sim p le a vu lsio n fra ctu re (2)
• Me th o d o f fra ctu re xa tio n: lo cke d in te rn a l e xtra m e d u lla ry sp lin tin g (1) a n d
co m p re ssio n (2 = a vu lsio n fra ctu re)
• Te ch n iq u e : MIPO; clo se d , in d ire ct re d u ctio n (1), p e rcu ta n e o u s, d ire ct (2).
• Fixa tio n: b rid gin g th e fra ctu re zo n e w ith a lo cke d in te rn a l xa to r (1) a n d
in te rfra gm e n ta ry co m p re ssio n w ith la g scre w (2).
• Fu n ctio n o f th e LCP: p u re sp lin t, lo cke d in te rn a l xa to r
• Fixa tio n o f th e LCP w ith LHS

a b c d e f

Fig 3 -6 8 a – f 6 3 -ye ar-o ld m an fe ll o n th e stre e t.

a – b AP a nd la te ral vie w.
c– d X-ra ys a fte r 20 m o n th a fte r xa tio n w ith a m e taph yse al LCP
ad d itio na l lag scre w xa tio n o f th e avu lsio n fractu re o f th e
tib ial tu b e ro sit y. In d ire ct b o n e h e a lin g
e–f X-ra ys a fte r im p lan t re m o val.

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 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

Se gm e n t a l t ib ia l fra ct u re : p ro xim a l s im p le fra ct u re p a t t e rn (1) a n d o p e n co m p le x

a b
t ib ia l s h a ft fra ct u re (2)—42-C2
• Prin cip le o f fra ctu re xa tio n: a b so lu te sta b ilit y fo r th e sim p le , p roxim a l fra ctu re (1) a n d
re la tive s ta b ilit y fo r th e sh a ft fra ctu re (2)
• Me th o d o f fractu re xa tio n: in te rfragm e n tary co m p re ssio n fo r the proxim al, sim ple , m e -
taph yse al fractu re (1) an d lo cke d in te rn al e xtram e d ullary splin tin g fo r th e sha ft fractu re (2)
• Te ch n iq u e : MIPO a n d la g scre w s
• Re d u ctio n: Dire ct, p e rcu ta n e o u s fo r th e sim p le fra ctu re (1) a n d clo se d , in d ire ct re d u c-
tio n fo r th e sh a ft fra ctu re (2)
• Fixa tio n: la g scre w s a n d p ro te ctio n p la te fo r th e sim p le fra ctu re (1) a n d b rid gin g th e
sh a ft fra ctu re w ith a lo cke d in te rn a l xa to r (2)
• Fu n ctio n o f th e LCP: p ro te ctio n p la te a n d lo cke d in te rn a l xa to r
• Fixa tio n o f th e LCP w ith LHS

c d

f
Fig 3 -6 9 a – m 5 0 -ye ar-o ld m a n w ith ski in ju ry; se ga m e n ta l tib al
fractu re; o p e n tib al sh a ft fractu re t yp II.
a – d In ju ry x-ra ys, AP an d la te ral vie w. Se gm e n tal tib ial fractu re
proxim ally w ith sim p le fractu re p a tte rn , d istal w ith sm all
co m in u tio n a n d so ft-tissu e in ju ry.
e – g Pe rcu tan e o u s in se rte d p la te , co m p re ssio n , m e th o d w ith lag
scre w a n d p ro te ctio n pla te fo r th e p roxim a l sim p le fractu re;
e g
d ista l fractu re lo cke d splin ting.

157
 h i j k l m

Fig 3 -6 9 a – m (co n t)
h–i Fo llo w -up x-ra ys a fte r 3 m o n th s, AP an d la te ra l vie w.
j– k Fo llo w -u p x-ra ys a fte r 6 m o n th s, AP an d la te ra l vie w.
l– m AP a nd la te ral x-ra ys sh o w in g b o n e h e alin g a fte r 8 m on th s.

2 .7 Clin ica l re s u lt s

Th e follow in g are recen t clin ical stu d ies on th e u se of LCP:

[3 6 , 39 – 42]

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 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP
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30 fractu res w ith a follow u p of 20 m on th s. Acta Orthop Scand;
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15. K re go r PJ, St an n ard JA , Zlow o d zk i M , e t al (2004)
Treatm en t of d istal fem u r fractu res u sin g th e less in vasive
stabilization system : su rgical experien ce an d early clin ical resu lts
in 103 fractu res. J Orthop Trauma; 18(8):509 –520.
16 . Mark m ille r M , Ko n rad G, Sü d k am p N (2004) Fem u r-LISS
an d d istal fem oral n ail for xation of d istal fem oral fractu res: are
th ere differen ces in ou tcom e an d com plication s? Clin Orthop Relat
Res; 426:252–257.
17. R icci A R , Yu e JJ, Taffe t R , e t al (2004) Less Invasive
Stabilization System for treatm en t of distal fem u r fractu res.
Am J Orthop; 33(5):250 –255.
18 . Sch ü t z M , Haas N P (2001) [ LISS—in tern al plate xator].
Kongressbd Dtsch Ges Chir Kongr; 118:375 –379. Germ an .
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 19. Schü t z M , Mü lle r M , Kre t t e k C, e t al (2001) M in im ally
in vasive fractu re stabilization of d istal fem oral fractu res w ith
th e LISS: a prospective m u lticen ter stu dy. Resu lts of a clin ical
stu dy w ith special em ph asis on d if cu lt cases. Injury;
32Su ppl3:SC48 –54.
20 . Sye d A A , A garw al M , Gian n o u d is PV, e t al (2004) Distal
fem oral fractu res: lon g-term ou tcom e follow in g stabilisation w ith
th e LISS. Injury; 35(6):599 –607.
21. We igh t M , Co llin ge C (2004) Early resu lts of th e less invasive
stabilization system for m ech an ically u n stable fractu res of th e
d istal fem u r (AO/OTA types A2, A3, C2, an d C3). J Orthop Trauma;
18(8):503 –508.
2 2 . Go slin g T, Sch an de lm aie r P, Mü lle r M , e t al (2005) Sin gle
lateral locked screw platin g of bicon dylar tibial plateau fractu res.
Clin Orthop Relat Res; 439:207–214.
23. Lysh o lm J, Gillqu ist J (1982) Evalu ation of kn ee ligam en t
su rgery resu lts w ith special em ph asis on u se of a scorin g scale. Am
J Sports Me; 10(3): 150 –154.
24. Rasm u sse n PS (1973) Tibial con dylar fractu res. Im pairm en t of
k n ee join t stability as an in d ication for su rgical treatm en t. J Bone
Joint Surg Am; 55(7):1331–1350.
25. Hah n U, Pro ko p A , Ju be l A , e t al (2002) [ LISS versu s con dylar
plate]. Kongressbd Dtsch Ges Chir Kongr; 119:498 –504.
26 . R icci WM , Ru d zk i J R , Bo rre lli J, Jr (2004) Treatm en t of
com plex proxim al tibia fractu res w ith th e less invasive skeletal
stabilization system . J Orthop Trauma; 18(8):521–527.
27. Co le PA , Zlow o d zk i M , Kre go r PJ (2004) Treatm en t of
prox im al tibia fractu res u sin g th e less in vasive stabilization
system : su rgical ex perien ce an d early clin ical resu lts in 77
fractu res. J Orthop Trauma; 18(8):528 –535.
28 . Schü t z M , Kääb M J, Haas N (2003) Stabilization of proxim al
tibial fractu res w ith th e LIS-System : early clin ical experien ce in
Berlin . Injury; 34Su ppl1: A30 –35.
16 0
29. St an n ard J P, Wilso n TC, Vo lgas DA , e t al (2003) Fractu re
stabilization of proxim al tibial fractu res w ith th e proxim al tibial
LISS: early ex perien ce in Birm in gh am , Alabam a (USA). Injury;
34Su ppl1:A36 –42.
30 . St an n ard J P, Wilso n TC, Vo lgas DA , e t al (2004) Th e less
in vasive stabilization system in th e treatm en t of com plex fractu res
of th e tibial plateau : sh ort-term resu lts. J Orthop Trauma;
18(8):552–558.
31. Frigg R (2003) Developm en t of th e Lockin g Com pression Plate.
Injury; 34Su ppl1: B6 –10.
32 . Ellis T, Bo u rge au lt CA , Kyle R F (2001) Screw position affects
dyn am ic com pression plate strain in an in vitro fractu re m odel.
J Orthop Trauma; 15(5):333 –337.
33. Fie ld J R , To rn k v ist H , He arn TC, e t al (1999) Th e in u en ce of
screw om ission on con stru ction stiffn ess an d bon e su rface strain
in th e application of bon e plates to cadaveric bon e. Injury;
30(9):591–598.
3 4. Ro zbru ch SR , Mü lle r U, Gau t ie r E, e t al (1998) Th e evolu tion
of fem oral sh aft platin g tech n iqu e. Clin Orthop Relat Res;
354:195 –208.
35. So m m e r C, Gau t ie r E (2003) [ Relevan ce an d advan tages of n ew
an gu lar stable screw-plate system s for diaph yseal fractu res
(lockin g com pression plate versu s in tram edu llary n ail].
Ther Umsch; 60:751–756.
36 . R in g D , K lo e n P, Kad zie lsk i J, e t al (2004) Lockin g
com pression plates for osteoporotic n onu n ion s of th e diaphyseal
hu m eru s. Clin Orthop Relat Res; 425:50 –54.
37. Ko rn e r J, Lill H , Mü lle r LP, e t al (2003) Th e LCP-con cept in
th e operative treatm en t of distal hu m eru s fractu res—biological,
biom ech an ical an d su rgical aspects. Injury; 34Su ppl2:B20 –30.
38 . Wagn e r M (2003) Gen eral prin ciples for th e clin ical u se of th e
LCP. Injury; 34Su ppl2: B31–42.
 3 Te ch n iq u e s a n d p ro ce d u re s in LISS a n d LCP

39. Fan k h au se r F, Bo ld in C, Sch ipp in ge r G, e t al (2005) A n ew

lockin g plate for u n stable fractu res of th e proxim al hu m eru s.
Clin Orthop Relat Res; 430:176 –181.
4 0. Im at an i J, N o d a T, Mo rit o Y, e t al (2005) M in im ally invasive
plate osteosyn th esis for com m in u ted fractu res of th e m etaph ysis
of th e rad iu s. J Hand Surg [Br]; 30(2):220 –225.
41. Schü t z M , Ko lbe ck S, Sp ran ge r A , e t al (2003) [ Palm ar platin g
w ith th e lockin g com pression plate for dorsally displaced fractu res
of th e d istal rad iu s-- rst clin ical ex perien ces]. Zentralbl Chir;
128(12):997–1002.
42 . So m m e r C, Gau t ie r E, Mü lle r M , e t al (2003) First clin ical
resu lts of th e Lockin g Com pression Plate (LCP). Injury;
34Su ppl2:B43 –54.

161
 4 Pitfalls and com plications

1 Im p la n t-re la t e d p ro b le m s 16 3

2 Te ch n ica l e rro rs 16 4
2 .1 In co rre ct fixa t io n o f t h e LCP/ LISS 16 4
2 .2 In s u fficie n t re d u ct io n a n d d e m a n d in g MIPO 170
2 .3 In co rre ct p rin cip le a n d m e t h o d o f fra ct u re fixa t io n 171
2 .4 In co rre ct ch o ice o f p la t e 171

3 P it fa lls a n d co m p lica t io n s d u rin g re h a b ilit a t io n 171

3 .1 Se co n d a r y p la s t ic d e fo rm a t io n o f t h e LCP/ lo cke d in t e rn a l
fixa t o r 171
3 .2 Difficu lt im p la n t re m o va l: LHS a re d ifficu lt o r im p o s s ib le t o
re m o ve 17 2
3 .3 De la ye d u n io n , n o n u n io n 17 7
3 .4 Re fra ct u re a ft e r im p la n t re m o va l 17 7
3 .5 In fe ct io n 17 8

4 Su gge s t io n s fo r fu r t h e r re a d in g 17 9

162
4 Pitfalls and com plications

Jo in t p e rfo rat io n . Lock in g h ead screw s can on ly be in serted

1 Im p la n t-re la t e d p ro b le m s
Be n d in g o f t h e lo ck in g co m p re ssio n p lat e . It is possible
to ben d th e LCP 3.5 an d 4.5/5.0, straigh t an d n arrow ( Fig
4 -1). Severe ben d in g of th e plate leads to deform ation of th e
th read-bearin g part of th e com bin ation h ole, m ak in g th e h ole
in capable of h old in g a lock in g h ead screw.
So lu t io n : Leave a plate h ole of th is type w ith ou t screw or u se
on ly cortex or can cellou s bon e screw s.
in to th e plate h ole in th e th read ax is, so th e d irection is pre-
determ in ed; atten tion sh ou ld be given to avoid possible join t
perforation ( Fig 4 -2 a ).
So lu t io n : Th e correct len gth of screw sh ou ld be m easu red
an d ch ecked u sin g im age in ten si cation . Th e risk of join t per-
foration is also redu ced u sin g m etaph yseal or an atom ical pre-
sh aped plates ( Fig 4 -2 b – e ).
Scre w jam m in g a n d p ro ble m s d u rin g im p lan t re m o val.
See tech n ical errors.

Fig 4 -1 The LCP ha s a n e ve n stiffn e ss w itho u t the risk o f buckling

a t th e scre w h o le s.

990°
0°

99 5 ¡°

90¡
90° e

Fig 4 -2 a – e Jo in t p e rfo ra tio n .

a b
a To a vo id jo in t p e rfo ra tio n a co rte x o r
can ce llo u s b o n e scre w w ith fre e angu -
c la tio n is in se rte d in the m o st d ista l
co m b in a tio n h o le .
b – e In a na tom ical pre co n tou re d pla te s th e
d ire ctio n o f th e LHS is p re d e te rm in e d
to a vo id a p o ssib le jo in t p e rfo ra tio n .
To nd the p e rp e nd icu lar se a t o f th e
scre w the th re ad e d d rill sle e ve s sh ou ld
d
b e u se d .

163
 Lack o f fe e d back w h e n t igh t e n in g lo ck in g h e ad scre w s.
Tigh ten in g lock in g h ead screw s w ill always lead to a stable
in terface between screw an d plate even w ith ou t an y bon e
con tact. Th ere is also n o qu alitative feedback for th e su rgeon
regard in g th e bon e qu ality.
So lu t io n : It is ver y im portan t to ch eck th e position of th e
plate before in sertion of th e lock in g h ead screw s.
He lico p t e r e ffe ct . In order to tigh ten th e rst LHS, th e op-
posite en d of th e plate m u st be rm ly stabilized w ith h old in g
forceps, a K-w ire, a screw, or a d rill bit; oth erw ise it can tu rn
w ith th e screw du rin g th e lock in g procedu re an d cau se dam -
age of th e soft tissu es ( Fig 4 -3 ). Th e sam e applies to th e proce-
du re for extraction of th e last LHS du rin g im plan t rem oval.
2 Te ch n ica l e rro rs
2 .1 In co rre ct fixa t io n o f t h e LCP/ LISS
Pro ble m o f scre w le n gt h . Mon ocortical in serted self-tap-
pin g LHS mu st n ot be too lon g, an d th e screw tip m u st n ot
tou ch th e opposin g cortical bon e, as th is cou ld lead to pu ll-ou t
of th e bon e th read ( Fig 4 -4 a , see also Fig 3 -41 ). A self-drill-
in g, self-tappin g LHS sh ou ld n ever be u sed bicortically, as th e
sh ar p cu ttin g screw tip dam ages th e soft tissu e ( Fig 4 -4 b ). Re-
m oval of self-d rillin g, self-tappin g screw s wh ich are too lon g
can be dif cu lt, du e to bon e grow th in to th e drill u tes if th e
tip of th e screw en ds in th e opposite cortex ( Fig 4 -4 c).

a b

Fig 4 -3 a – b Te m p o rary stab iliza tio n o p p o site to the rst in se rte d

LHS pre ve n ts th e pla te from ro ta tin g a nd cau sin g d am age to th e
su rro u nd ing so ft tissue .

16 4
 4 Pit fa lls a n d co m p lica t io n s
So lu t io n : Th e proper len gth of a self-d rillin g, self-tappin g
m on ocortical screw h as to be calcu lated w ith th e h elp of x-
rays. Th e len gth of a self-tappin g screw can always be m ea-
su red by depth gau ge.
Scre w jam m in g. Each LHS m u st be tigh ten ed u sin g th e ap-
propriate torqu e-lim itin g screwdr iver. ( Fig 4 -5 )
So lu t io n : Never tigh ten a LHS u sin g a power tool.
Scre w lo o se n in g can o ccu r d u e t o in co rre ct in se rt io n
t e ch n iqu e . Screw loosen in g is m ain ly du e to in correct tigh t-
en in g of th e lock in g h ead screw s.
So lu t io n : Usin g th e th readed d rill sleeve, d rill an d m easu re
th e correct len gth an d in sert th e screw in a 90° per pen d icu lar
d irection .
a b c
Fig 4 -4 a – c Pro b le m o f scre w le n gth .
a Mo n o co rtica l se lf-ta pping LHS m u st n o t to uch th e o p p o site co r-
te x, a s th is co u ld le ad to p u llo u t.
b Se lf-d rillin g, se lf-tap p in g LHS sh o u ld n e ve r b e u se d b ico rtically,
a s th e sh ap rt tip d a m age s th e so ft tissu e .
c Whe n the tip o f th e se lf-d rillin g, se lf-tap ping scre w e nd s in th e
o pp o site co rte x, scre w re m o val ca n b e d if cu lt d u e to b o n y
in gro w th in to the d rill u te s.
In co rre ct d ire ct io n o f lo ck in g h e ad scre w s. Th is problem
can occu r w h en th e LHS are w ron gly seated in an in correct
direction .
So lu t io n : Wh en ever possible, a protective th readed d rill sleeve
sh ou ld be u sed for predrillin g to preven t th e screw from
bein g placed in th e w ron g d irection .
Fat igu e failu re o f a x at io n co n st ru ct d u e t o st re ss co n -
ce n t rat io n in sim p le d iap hy se al fract u re s. Th is problem
is u su ally seen in in correct xation s in wh ich th e plate h as
in su f cien t elasticity an d w h ere th e screw s are placed too
close to th e fractu re gap. In su f cien t redu ction an d in ade-
qu ate xation (ie, w ron g position of screw s) of a sim ple d i-
aphyseal fractu re can lead to early breakage of th e plate or to
n onu n ion ( Fig 4 -6 a -h ).
So lu t io n : To avoid stress con cen tration of th e plate, in sim ple
d iaphyseal fractu res, leave two to th ree plate h oles u nu sed
over th e fractu re zon e in order to m ake it possible for en ergy
to be absorbed over a lon ger area of th e im plan t ( Fig 4 -6 i).
Fig 4 -5 Each LHS m u st b e tigh te n e d u sing the ap pro pria te to rq u e -
lim iting scre wd rive r. The calibra tio n o f th is scre wd rive r fo r th e
4 .5/ 5.0 m m LHS is 4 .0 Nm , fo r th e 3 .5 m m LHS 1.5 Nm .
165
 e g

a b f

Fig 4 -6 a – i 75 -ye ar-o ld p a tie n t w ith a p e rip ro sth e tic fractu re o f the fe m o ra l sha ft.
a – b Inju ry x-ra ys sh o w in g a sim p le fractu re t yp e o f th e fe m o ral sha ft.
c– e Po sto p e ra tive x-ra ys sh o w in g go o d bu t no t pre cise re d uctio n o f th e fractu re and scre w s
w h ich h ave b e e n p lace d to o clo se to th e fractu re lin e .
f– g X-ra ys a fte r 7 we e ks sh o w in g a b re akage o f th e im plan t cau se d b y to o m an y scre w s
a n d scre w s in w ro n g p o sitio n .
h Scre w s w h ich we re place d to o clo se to the fractu re lin e ( ie , gap a fte r u n pre cise re d uc-
tio n) can le ad to im p lan t b re akage d u e to stre ss co n ce n tra tio n .
i To a vo id stre ss co nce n tra tio n le ave th re e o r fo u r scre w h o le s w ith o u t scre w s. Th is le ad s
c d
to a lo n ge r wo rkin g le n gth o f th e p la te fo r th e e la stic d e fo rm a tio n o f th e im p lan t.

16 6
 4 Pit fa lls a n d co m p lica t io n s
Lo ss o f x at io n co n st ru ct in a m ain bo n e se gm e n t . Th is
type of failu re is seen in cases in wh ich th e screw –bon e in ter-
face h as been su bjected to excessive stress.
So lu t io n : Th e rigidity of th e wh ole con stru ct h as to be re-
du ced in order to decrease th e stress on th e in terface ( Fig 4 -7 ).
Th is can be ach ieved by u sin g lon ger plates (ie, a lon ger bridg-
in g elem en t). Bicortical screw s u sed to an ch or a plate in a
bon e w ith a th in cortex w ill in crease th e h old in g stren gth
again st torsion al forces (eg, in an osteoporotic h u m eral sh aft)
or pu llou t (eg, fem oral sh aft).
3 0 0 kg
a b
Fig 4 -7a – b Lo ss o f xa tio n co n stru ct in a m ain b o n e se gm e n t
a The e la stic de fo rm a tio n o f the pla te u n d e r p h ysical lo ad acts
like a b o w. Th is le ad s to pu llo u t o f th e co n stru ctio n from th e
bone.
b Usin g lo n ge r p la te s an d b ico rtical scre w s re d u ce th e stre ss o n
th e scre w -b o n e in te rface a n d in cre a se s th e h o ld in g stre n gth .
If th ere are too few screw s, th e plate m ay pu ll ou t. Th ree
to fou r screw s in each m ain fragm en t are recom m en ded
depen d in g on in d ication . Avoid a sh ort plate w ith on ly
two or th ree m on ocortical LHS ( Fig 4 -8 ).
In adequ ate plate xation can occu r despite th e u se of an
adequ ate nu m ber of lock in g h ead screw s. LHS can becom e
m isplaced du e to placem en t off-cen ter of th e plate (ie, can
be locked in to th e plate even if th e bon e h as on ly been
partially pen etrated or com pletely m issed) (see Ta b 3 -9 ).
If th e w ron g screw s are selected, eg, m on ocortical LHS in
th e h u m eral sh aft or osteoporotic bon e, th e plate m ay pu ll
ou t.
Fig 4 -8 Wro n g xa tio n w ith a to o sh o rt p la te , to o fe w an d m o n o -
co rtically in se rte d scre w s in th e h u m e ra l sh a ft.
167
 If th e plate is xed to a m ain fragm en t u n der ten sion , ie,
elastic deform ation of th e plate, th e plate w ill be able to
pu ll ou t. Redu ction of th e plate to th e bon e after xation
w ith LHS to th e two m ain fragm en ts is im possible an d
leads to pu llou t of th e plate ( Fig 9 a – b ).
So lu t io n : Never redu ce a plate to th e bon e u n der h igh
ten sion . Th e plate m u st be align ed an d approx im ately pre-
sh aped to th e bon e an atom y after redu ction .
Lo o se n in g o f LHS d e sp it e t h e u se o f a t o rqu e -lim it in g
scre w d rive r. Th is type of failu re can on ly arise if th e LHS
h as been in serted off-axis relative to th e LCP h ole. Th e in ser-
tion ax is of th e lock in g h ead screw s is de n ed by th e LCP h ole
axis. In m ost straigh t LCP plates, th e lock in g h ole axis is per-
pen dicu lar to th e plate su rface. In all an atom ically presh aped
plates, th e ax is of th e h ole is prede n ed for optim al screw
placem en t in th e given an atom ical region . Th is optim ization
en su res th e best an ch orage of th e plate by m axim izin g th e
possible nu m ber of screw s an d work in g len gth of th e plate
an d by redu cin g th e risk of an atom ical m isplacem en t an d col-
lision of screw s ( Fig 4 -10 ).
So lu t io n : Use th e aim in g block/device for an atom ical pre-
sh aped LCP or th e th readed drill sleeves for stan dard LCP to
in sert th e LHS.
In se rt in g LHS in a t e n se , t h ick co rt e x . By in sertin g a self-
drillin g, self-tappin g LHS, th e torqu e-lim itin g screwdriver
m ay u n lock before th e screw h ead is locked in th e plate h ole
becau se of th e h igh resistan ce of th e th ick cortex.
So lu t io n : Ch eck th e proper position of th e LHS screw h ead in
th e plate u sin g th e im age in ten si er.
LHS p lace d in t h e co m p re ssio n u n it o f t h e co m bin at io n
h o le . M isplacem en t of a lock in g h ead screw can occu r if th e
plate h ole can n ot be visu alized (eg, in m in im ally in vasive
procedu res).
So lu t io n : Use of th e th readed d rill sleeve to iden tify th e
th readed portion of th e com bin ation h ole can redu ce th e risk
of m isplacem en t ( Fig 4 -11 ).

Fig 4 -9 a – b
a In tre a tin g a com ple x, o a tin g kn e e in ju ry, the LISS-DF wa s re d u ce d o n to th e sha ft frag-
m e n t w ith a stro ng tractio n fo rce b e cau se th e re du ction p a th way wa s to o large . If o ne
o b se rve s th e im p la n t ca re fu lly, o n e can se e th a t th is h a s actu ally le d to th e d e fo rm a tion
o f th e e xtre m e ly rigid LISS (th e p roxim al se ctio n b e nd s again st th e sha ft). In ad d itio n ,
two b ro ke n th re ad s fro m the pu lling d e vice s a re p ro o f o f a ce rtain le ve l o f fo rce u se d
d u ring th e fractu re re d uctio n a nd im plan t p o sitio n in g. Th e fra gm e n t wa s p u lle d la te rally
b y th e stro n g fo rce o f th e tractio n d e vice s an d th e n xe d w ith m o n o co rtical, se lf-d rill-
ing, se lf-tap p ing scre w s.
b In the co u rse o f th e h e a lin g pro ce ss, the im plan t ha s lo o se n e d o n th e sha ft a fte r 6
m o n th s (o ne se e s tha t th e im p la n t ha s again re su m e d its re gular fo rm . He re th e m o no -
co rtical scre w s we re p u lle d o u t o f th e b o n e a xially).

a b

16 8
 4 Pit fa lls a n d co m p lica t io n s

a b a b c

Fig 4 -10 Lo o se n in g
o f LHS d e sp ite th e
u se o f a to rq u e -
lim itin g scre wd rive r.
Fig 4 -11a – b Misplace m e n t o f th e m o st 4 -12 a – c 4 4 -ye ar-o ld wo m a n w ith sub capita l p roxim al hu m e ral
p roxim al LHS. sha ft fractu re .
a In ju ry x-ra y.
b Po sto p e ra tive x-ra y sho w s th e th ird proxim al scre w cro sse s th e
u n re du ce d fractu re lin e . Th e se co nd te ch nical e rro r is the u se o f
a re co n stru ctio n p la te fo r a h u m e ra l sh a ft fractu re .
c Im p la n t fa ilu re a fte r 3 we e ks.

LHS cro ssin g a n u n re d u ce d fract u re lin e , le ad in g t o d e -
laye d fract u re u n io n . LHS were design ed to optim ize th e
xation of a plate to th e bon e. In con trast to lag screw s, lock-
in g h ead screw s are n ot design ed to produ ce com pression . A
lock in g h ead screw crossin g an u n redu ced fractu re lin e works
as a position screw wh ile m ain tain in g th e d istan ce of th e two
fragm en ts relative to each oth er. A fractu re gap locked w ith
an LHS is th erefore u n able to produ ce callu s du e to m icrom o-
tion ( Fig 4 -12 ).
a
So lu t io n : LHS sh ou ld n ever cross a fractu re lin e.
Exception : In articu lar fractu res after precise redu ction an d
com pression w ith a redu ction tool. Th erefore th e requ ired
redu ction m u st be ach ieved before placem en t of th e lock-
in g h ead screw. Th is w ill avoid loss of redu ction an d delayed
u n ion or n onu n ion .

169
 LHS are n e ve r lag scre w s. Th ey can on ly serve as xation
screw s or position screw s. Wh en in terfragm en tar y com pres-
sion h as been obtain ed u sin g a redu ction forceps or a lag
screw, th e position in g of th e bon e fragm en ts th at h as been
ach ieved can be m ain tain ed u sin g LHS.
In co rre ct p o sit io n in g o f t h e p lat e . Th is can cau se th e plate
to im pin ge on th e soft tissu es, an d it m ay lead to th e LHS
m issin g th e bon e ( Fig 4 -13 ).
So lu t io n : Ch eck plate position w ith im age in ten si er or by
palpation if requ ired.
Pu llo u t o f t h e pu llin g de v ice fo r th e LISS (“w h irlybird ”).
In osteoporotic bon e or wh en th e redu ction path way is too
large, it is possible for th e pu llin g device (“wh irlybird”) to pu ll
ou t.
So lu t io n : Redu ce th e d istan ce between th e plate an d th e
bon e, eg, w ith a collin ear redu ction clam p.
Fig 4 -13 In ad e q u a te re d u ctio n
an d p o sitio n o f th e lo ckin g
proxim al h um e ral p la te (LPHP)
le ad s to a sub acro m ia l
im p in ge m e n t.
170
2 .2 In s u fficie n t re d u ct io n a n d d e m a n d in g MIPO
D if cu lt in d ire ct clo se d re d u ct io n . M IPO w ith locked in -
tern al xators requ ires closed in d irect redu ction . In correct
redu ction can lead to m alalign m en t.
So lu t io n : Th e procedu re h as to be learn ed an d is a d if cu lt
on e. Redu ction h as to be ch ecked du rin g th e operation both
clin ically an d rad iograph ically.
M in im ally in vasive p lat e o st e o sy n t h e sis (M IPO). With
th e sm all access rou tes th at are u sed (sm all in cision s, stab
in cision s), th e procedu re is d if cu lt an d in ju ry to vessels or
n er ves can occu r ( Fig 4 -14 ). M in im a l in vasive xation of a
13-h ole LISS-PLT: Th e su per cial peron eal n erves an d vessels
are at risk w h en seatin g th e m on ocortical LHS th rou gh stab
in cision s at th e d istal en d of th e plate.
So lu t io n : Do n ot overu se th e m in im al in vasive approach .
M IPO sh ou ld on ly be don e by su rgeon s w ith a lot of ex peri-
en ce. Oth erw ise u se a less in vasive approach .
Fig 4 -14 Th e su p e r cia l p e ro n e a l n e rve s an d ve sse ls
are a t risk se a tin g th e m o n o co rtica l LHS th ro u gh stab
in cisio n s a t th e e n d o f th e p la te o n th e d ista l tib ia .
 4 Pit fa lls a n d co m p lica t io n s

2 .3 In co rre ct p rin cip le a n d m e t h o d o f fra ct u re fixa t io n stress exam in ation . After com pletion of th e bridgin g osteo-
syn th esis for a m u ltifragm en tary fractu re u sin g an in tern al
As a resu lt of lack of plan n in g. xator, it is n ecessary to ch eck th e stability of th e xation
May also resu lt from an attem pt to com bin e two m eth ods in traoperatively u sin g an im age in ten si er. Th is allow s as-
of fractu re xation in a sin gle fractu re. sessm en t of th e degree of rem ain in g elasticity (ie, reversible
So lu t io n : see Ta b 1-10 deform ation) of th e osteosyn th esis. In lower leg fractu res, ad-
d ition al platin g of th e bu la or placem en t of an add ition al
2 .4 In co rre ct ch o ice o f p la t e tem porar y extern al xator on th e opposite side of th e locked
in tern al xator m ay be n ecessary.
Exam ples in clu de:
Wron g ch oice of plate (eg, recon stru ction plate for hu m er- Th e fractu re care follow-u p treatm en t n eeds to be adju sted to
al sh aft fractu res ( Fig 4 -12 ) th e in d ividu al fractu re situ ation an d th e cooperation of th e
Too sh ort plate ( Fig 4 -8 ) patien t. In th e case of in tern al extram edu llary splin t xation
So lu t io n : Ch oice of proper im plan ts. Please see Ta b 3 -6 an d (ie, locked in tern al xator), reh abilitation an d physical th er-
Ta b 3 -9 . apy h as to be sligh tly altered. Sin ce th is is an elastic m eth od
of xation an d th e bon e does n ot con tribu te to th e prim ary
stability, th e im plan t in itially h as to bear in itially th e en tire
load.
3 Pit fa lls a n d co m p lica t io n s d u rin g re h a b ilit a t io n

Callu s form ation mu st occu r before weigh t bear in g can be in i-

3 .1 Se co n d a r y p la s t ic d e fo rm a t io n o f t h e LCP/ lo cke d tiated an d gradu ally in creased.
in t e rn a l fixa t o r
Fig 4 -15 Sin gle ove rlo ad situa tio n w h ich
Bridge osteosyn th esis w ith locked in tern al xators (u sin g th e le ad s to a p la stic d e fo rm a tio n o f the im pla n t.
splin tin g m eth od based on th e prin ciple of relative stability On th e rst p o sto p e ra tive n igh t, th e p a tie n t
in fractu re xation ) provides ver y little prim ar y stability. As m o b ilize d w ith fu ll we igh t b e arin g.
th e fragm en ts are n ot precisely redu ced, th e bon e does n ot
con tribu te to prim ary stability. Th is type of osteosyn th esis,
w ith redu ced an d relative stability, allow s reversible elastic
deform ation of th e locked in tern al xator im plan t in th e area
of th e fractu re zon e. Th is effect is desirable an d stim u lates
in direct bon e h ea lin g.

If u n acceptable early load in g or overloadin g of th e fractu re

area occu rs, irreversible secon dar y plastic ben din g of th e
xator can occu r ( Fig 4 -15 ). Assessin g th e degree of stability
ach ieved can be carried ou t clin ically or u sin g a radiograph ic

171
 3 .2 Difficu lt im p la n t re m o va l: LHS a re d ifficu lt o r To o lo n g se lf-d rillin g, se lf-t ap p in g LHS.
im p o s s ib le t o re m o ve Wh en th e tip of a self-d rillin g, self-tappin g LHS en ds in th e
opposite cortex, screw rem oval can be d if cu lt du e to bon y
Dif cu lty in rem ovin g LHS can occu r for th e follow in g rea- in grow th in to th e drill u tes.
son s: Bo n e o n grow t h t o LHS
D am age d re ce ss o f t h e scre w h e ad . Cau ses m igh t be: As lock in g h ead screw s are locked to th e plate, m icrom ove-
A worn screwdriver tip. m en t in th e bon e, especially for slide loosen in g, n ot exists.
On ly partially in trodu ction of th e screwd river tip in to Th is m ech an ical advan tage can lead to a stron g in tegration
th e deep recess of th e screw h ead. of th e screw in to th e bon e. Th e in creased torqu e n eeded to
Tippin g or gyration of th e screwd river wh en screw in g in rem ove su ch a screw can exceed th e applicable torqu e to th e
th e screw s m anu ally. screw drive.
LHS w h ich are t o o t igh t lo cke d . Th is can occu r if th e
torqu e-lim itin g device was n ot u sed an d th e screw was in -
trodu ced u sin g a power tool d rive.
Screw he ad s jam m e d in the plate hole . Cau ses m ight be:
A w ron g d irection of LHS—n ot per pen dicu lar to th e axis
of th e th readed part of th e com bin ation h ole.
Th e position in g of th e LHS in th e w ron g part of th e LCP
com bin ation h ole.

Fig 4 -16 a – c
a AP vie w.
b Axilla ry vie w. Sh o w s a b o n y h e a lin g
8 m o n th s a fte r su rgica l tre a tm e n t o f
a p ro xim a l h u m e ra l fra ctu re —1-B1.
On e o f th e LHS in th e sh a ft ( ie , se c-
o n d scre w fro m d ista l) is in th e
w ro n g p a rt o f th e co m b in a tio n h o le
o f th e LPHP. Th is le a d s to scre w ja m -
m in g a n d p ro b le m b y im p la n t
re m o va l.
c Scre w h e a d tu rn e d o f b y th e im p la n t
re m o va l.

a b c

172
 4 Pit fa lls a n d co m p lica t io n s

Re m o va l o f LHS (w it h a d e s t ro ye d d rive )
For screw s w ith an em pty destroyed d rive recess w ith ou t For screw w ith broken in stru m en t in th e screw recess th e
broken in stru m en t th e follow in g steps are requ ired: 1, 3, follow in g steps are requ ired: 2, 3, 4, 5, 6, 7, 8.
5, 6, 7, 8. Ch eck for appropriate d rill bit.

Ste p 1

a Be fore u sing the drill bit, try to re m o ve the scre w w ith the
co n ical e xtractio n scre w. In se rt th e e xtractio n scre w u n d e r
a xial lo ad and by le ft-w ise ro ta tion (an ticlo ckw ise) (Fig 4 -17a).
Do n o t u se e xce ssive fo rce to avo id b re akin g th e e xtractio n
scre w. If this fails, a se cond appro ach m ay b e a tte m p te d .
b If the con ical e xtraction scre w d o e s no t ge t p urcha se d it is
ad visable to take th e ap p ro pria te d rill b it to pre p are th e re ce ss
(Fig 4 -17 b).

a b
Try ste p 1a again .
Fig 4 -17a – b

Ste p 2

Atte m p t to re m o ve th e b ro ke n p art o f th e in stru m e n t u sin g a sharp

ho o k an d/ o r force p s. If th is is u n succe ssful, pro ce e d to the n e xt
ste p (Fig 4 -18).

Fig 4 -18

173
 Ste p 3
Pre pare the in strum e n ts che cking Ta b 4 -1. It is re co m m e n d e d to
Scre w/ re ce ss typ e
co ve r th e are a aro u nd th e scre w re m o val site w ith ste rile ad h e sive
lm to pro te ct the surrounding so ft tissue . Pre pare the suction de - Sm all fragm ent screws
vice an d th e irriga tio n syste m . (recess: Stardrive T15
or Hex 2.5)
Large fragm ent scre ws
(recess: Stardrive T25
or Hex 3.5)
Ta b 4 -1 In stru m e n ts re q uire d fo r co m ple te scre w re m o va l.
174
In stru m e n ts
Appropriate drill bit
Irrigation system (syringe and wate r)
and suction de vice
Extraction screw, conical, for screws Ø
2.7, 3.5 and 4.0 m m
Extraction bolt for 3.5/ 4.0 m m screws
Spare ream er tube
Pliers for screw rem oval
Adhesive lm (optional)
Appropriate drill bit
Irrigation system (syringe and wate r)
and suction de vice
Extraction screw, conical, for screws Ø
4.5 and 6 .5 m m
Extraction bolt, for screws Ø 4.5 and
5.0 m m ; or extraction bolt, for screws
Ø 6 .0, 6 .5 and 7.0 m m
Spare ream er tube
Pliers for screw rem oval
Adhesive lm (optional)
 4 Pit fa lls a n d co m p lica t io n s

St e p 4

Drill b its m ad e o u t o f carb id e s are ve ry b rittle an d se n sitive to

stro ke s. To avo id d am age s o f carb id ge d rill b its, start th e d rill prio r
o f touching the scre w he ad w ith the drill bit. Ke e p the drill running
u n til the d rill bit is re m ove d from the scre w he ad . Start d rilling w ith
re vo lvin g carbide d rill bit w ith the irriga tion syste m and su ctio n
d e vice in op e ra tion . The d ire ctio n o f d rilling should b e p e rp e nd icu -
lar to the fractu re d surface o f the in strum e n t. Sm o o th the ro ugh
surface . The suction de vice should b e place d clo se to the tip o f the
d rill bit (Fig 4 -19).

Fig 4 -19

Ste p 5

Drill co n tin u o u sly w ith o u t sto p p ing. Axial fo rce is re q u ire d fo r e f - Th e 6 .0 m m carb id e d rill b it can o n ly b e u se d a fte r pre d rillin g w ith
cie n t d rilling. It is re co m m e nd e d to align th e a xis o f th e d rill b it w ith th e 4 .0 m m carbid e d rill b it.
th e a xis o f th e scre w.

No te : If a xial align m e n t canno t b e achie ve d , a large r diam e te r drill

bit m ay b e re quire d to se p ara te the pla te co m ple te ly fro m th e
scre w.

Ste p 6

Drill in to th e h e ad o f th e scre w u n til th e re is n o lo n ge r a p h ysical

co n n e ctio n b e twe e n th e scre w an d th e pla te . Th e n re m o ve th e
pla te (Fig 4 -2 0).

Fig 4 -2 0

175
 Ste p 7

Re m o ve the scre w sha ft (Fig 4 -21):

a If the scre w pro trude s from the b one , u se the plie rs for scre w
re m o val. Grip the scre w and turn cou n te r-clo ckw ise . Do no t
pu ll.
b If th e scre w d o e s n o t p ro tru d e fro m th e b o n e , u se th e sp are
re am e r tub e and the e xtraction b olt. Align the a xis o f the spare
re am e r tub e w ith the a xis o f the scre w. Re am to a de p th o f
5 mm.
Fig 4 -21a Fig 4 -21b
c Place the e xtraction b olt o ve r the scre w. While pu shing, turn
th e scre w co u n te rclo ckw ise . Th is w ill cre a te a tigh t co n n e ctio n
b e twe e n the conical shap e o f the thre ad o f the e xtraction b olt
and th e scre w sh a ft.
d Tu rn co u n te rclo ckw ise u n til th e scre w sha ft is co m ple te ly re -
m o ve d .

Fig 4 -21c Fig 4 -21d

Ste p 8

It is re co m m e n d e d to p e rfo rm a n al x-ray co n tro l e xam ina tio n to

e n sure no unde sire d m a te rial ha s b e e n le ft in the b o d y.

176
 4 Pit fa lls a n d co m p lica t io n s
Difficu lt im p la n t re m o va l b e ca u s e o f b o n y in gro w t h in t o
p la t e s a n d s cre w s
Reason s for d if cu lt rem oval of plates w ith an gu lar stability
du e to bon y in grow th m ay in clu de ( Fig 4 -2 2 ):
Th e callu s m ay grow in to th e plate h oles.
Titan iu m im pla n ts in particu lar are associated w ith
m arked bon e in grow th .
Delay in rem ovin g im plan ts in ch ild ren .
3 .3 De la ye d u n io n , n o n u n io n
In direct bon e h ealin g is ex pected in a xation by splin tin g
m eth od su ch as bridgin g th e fractu re zon e w ith a locked in -
tern al xator, resu ltin g in tim ely callu s form ation in th e frac-
tu re site an d gradu al m atu ration . If th ere is excessive elastic-
ity, bridgin g of th e callu s m ay be delayed, n ecessitatin g som e
m odi cation of th e postoperative treatm en t or a secon d op-
eration to add m ore stability (add ition al strategic screw s, ex-
tern al xator).
a b
Fractu res w ith severe soft-tissu e trau m a an d su bsequ en t d is-
tu rban ce of th e periostal blood su pply requ ire a lon ger tim e
for bon e con solidation .
Locked splin tin g of sim ple fractu res w ith in tern al xators
som etim es sh ow s delayed h ealin g.
In m ost cases treated w ith biological fractu re xation —bridg-
in g w ith LIF, prim ary bon e graftin g is n ot requ ired, bu t a sec-
on dary bon e graftin g sh ou ld be con sidered if n o clear h ealin g
sign s are given w ith in 6 m on th s (m ostly in open fractu res
w ith bon e loss.)
3 .4 Re fra ct u re a ft e r im p la n t re m o va l
Recu rrin g fractu res follow in g im plan t rem oval in fractu res
w ith in d irect bon e h ealin g an d callu s form ation are rare. Th e
in ciden ce of refractu re after rem oval of im plan ts is con sidered
lower in th e splin tin g m eth od th an in con ven tion al com pres-
sion platin g, bu t n o eviden ce h as been obtain ed to su pport
th is. Th e u se of m on ocortical screw s an d a redu ced nu m ber of
screw s appear to be ben e cial.
Fig 4 -2 2 a – b Callu s gro w th in to th e pla te
h ole s.
177
 3 .5 In fe ct io n
In fection s rarely occu r follow in g fractu re xation w ith locked
in tern al xator. Th e progression of su ch in fection s is also less
severe th an th ose seen w ith com pression plates, as th e perios-
teal blood su pply is n ot add ition ally dam aged by th e plate. If
an in fection n ear th e im plan t u sed in M IPO is su spected, its
rem oval sh ou ld be con sidered. However, th e im plan t sh ou ld
be rem oved on ly after bon e u n ion h as been obtain ed, u n less
it sh ow s sign s of loosen in g, im plyin g n o stability of fragm en ts
( Fig 4 -2 3 ).

a b c d e f g

h i j

Fig 4 -2 3 a – j In fe ctio n .
a – b Fra ctu re o f th e righ t d is ta l tib ia 4 3 -C2; n ico tin e a b u se .
c– d Po sto p e ra tive x-ra ys: MIPO w ith p e rcu ta n e o u s la g scre w s fo r th e a rticu la r fra ctu re a n d b rid gin g o f
th e m e ta p h yse a l fra ctu re w ith LCP a n d LHS. Th e a n te ro la te ra l tib ia l ke y fra gm e n t is n o t re d u ce d .
e Afte r a fe w d a ys in fe ctio n o f th e w o u n d a n d skin le sio n o ve r th e d ista l p a rt o f th e p la te . Wo u n d
th e ra p y w ith th e va cu u m m e th o d .
f– g Bo n y co n so lid a tio n a fte r 5 w e e ks a n d im p la n t re m o va l.
h Afte r im p la n t re m o va l go o d gra n u la tive so ft tissu e u n d e r th e p la te a n d go o d b lo o d su p p ly.
i– j X-ra ys a fte r im p la n t re m o va l.

178
 4 Pit fa lls a n d co m p lica t io n s
4 Su gge s t io n s fo r fu r t h e r re a d in g
Bo ld in C, Fan k h au se r F, Ho fe r H P, e t al (2006) Th ree-year Resu lts
of Prox im al Tibia Fractu res Treated w ith th e LISS. Clin Orthop Relat
Res; Pu blish Ah ead of Prin t
Co le PA , Zlow o d zk i M , K re go r PJ e t al (2003) Less Invasive
Stabilization System (LISS) for fractu res of th e proxim al tibia:
in d ication s, su rgical tech n iqu e an d prelim in ary resu lts of th e UMC
Clin ical Trial. Injury; 34 Su ppl1:A16 –29.
Gau t ie r E, So m m e r C (2003) Gu idelin es for th e clin ical application
of th e LCP. Injury; 34 Su ppl2:B63 –76.
Gau t ie r E, So m m e r Ch (2003) [ Biological in tern al xation —
gu idelin es for th e reh abilitation]. Ther Umsch; 60(12):729 –735.
Germ an .
Kääb M J, St o ck le U, Schü t z M , e t al (2005) Stabilisation of
periprosth etic fractu res w ith an gu lar stable in tern al xation :
a report of 13 cases. Arch Orthop Trauma Surg; 23:1–6.
Ko rn e r J, Lill H , Mü lle r LP, e t al (2003) Th e LCP-con cept in th e
operative treatm en t of distal hu m eru s fractu res—biological,
biom ech an ical an d su rgical aspects. Injury; 34 Su ppl2:B20 –30. Review.
Me ssm e r P, Re gazzo n i P, Gro ss T (2003) [ New stabilization
tech n iqu es for xation of prox im al tibial fractu res (LISS/ LCP)].
Ther Umsch; 60(12):762–767. Germ an .
R icci WM , Ru d zk i J R , Bo rre lli J Jr (2004) Treatm en t of com plex
prox im al tibia fractu res w ith th e less in vasive skeletal stabilization
system . J Orthop Trauma; 18(8):521–527.
R ik li DA , Babst R (2003) [ New prin ciples in th e su rgical treatm en t
of d istal radiu s fractu res—lock in g im plan ts]. Ther Umsch;
60(12):745 –750. Germ an .
Ry f C, Gö t sch U, Pe rre n T, e t al (2003) [ New su rgical treatm en t
procedu res in fractu res of th e d istal tibia (LCP, M IPO)]. Ther Umsch;
60(12):768 –775. Germ an .
Sch an d e lm aie r P, Part e n h e im e r A , Ko e n e m an n B, e t al (2001)
Distal fem oral fractu res an d LISS stabilization . Injury;
32 Su ppl3:SC55 –63. Review.
Sch ü t z M , Ko lbe ck S, Sp ran ge r A , e t al (2003) [ Palm ar platin g
w ith th e lockin g com pression plate for dorsally displaced fractu res
of th e distal radiu s— rst clin ical experien ces] Zentralbl Chir;
128(12):997–1002. Germ an .
Sch ü t z M , Mü lle r M , Kääb M , e t al (2003) Less invasive
stabilization system (LISS) in th e treatm en t of d istal fem oral fractu res.
Acta Chir Orthop Traumatol Cech; 70(2):74 –82.
Sch ü t z M , Mü lle r M , K re t t e k C, e t al (2001) M in im ally invasive
fractu re stabilization of d istal fem oral fractu res w ith th e LISS: a
prospective m u lticen ter stu dy. Resu lts of a clin ical stu dy w ith special
em ph asis on dif cu lt cases. Injury; 32 Su ppl3:SC48 –54.
Sch ü t z M , Mü lle r M , Re gazzo n i P, e t al (2005) Use of th e
less in vasive stabilization system (LISS) in patien ts w ith distal
fem oral (AO33) fractu res: a prospective mu lticen ter stu dy.
Arch Orthop Trauma Surg; 125(2):102–108.
So m m e r C, Babst R , Mü lle r M , e t al (2004) Lockin g com pression
plate loosen in g an d plate breakage: a report of fou r cases.
J Orthop Trauma; 18(8):571–577.
So m m e r C, Gau t ie r E, Mü lle r M , e t al (2003) First clin ical resu lts
of th e Lockin g Com pression Plate (LCP). Injury; 34 Su ppl2:B43 –54.
So m m e r Ch , Gau t ie r E (2003) [ Relevan ce an d advan tages
of n ew an gu lar stable screw-plate system s for diaph yseal fractu res
(lock in g com pression plate versu s in tram edu llary n ail].
Ther Umsch; 60(12):751–756. Germ an .
We igh t M , Co llin ge C (2004) Early resu lts of th e less invasive
stabilization system for m ech an ically u n stable fractu res of th e
distal femu r (AO/OTA types A2, A3, C2, an d C3).
J Orthop Trauma; 18(8):503 –508.
Wick M , Mü lle r EJ, Ku t sch a-Lissbe rg F, e t al (2004)
[ Periprosth etic su pracon dylar fem oral fractu res: LISS or retrograde
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tech n iqu e]. Unfallchirurg; 107(3):181–188. Germ an .
179
18 0
Case s

181
 Case s

5 Sh o u ld e r gird le
5 .1 Cla vicle 18 5
5 .2 Sca p u la 213

6 Hu m e ru s
6 .1 Hu m e ru s , p ro xim a l 223
6 .2 Hu m e ru s , s h a ft 283
6 .3 Hu m e ru s , d is t a l 3 31

7 Ra d iu s a n d u ln a
7.1 Ra d iu s a n d u ln a , p ro xim a l 365
7.2 Ra d iu s a n d u ln a , s h a ft 39 9
7.3 Ra d iu s a n d u ln a , d is t a l 419

8 Pe lvic rin g a n d a ce t a b u lu m
8 .1 Pe lvic rin g a n d a ce t a b u lu m 453

9 Fe m u r
9 .1 Fe m u r, p ro xim a l 47 7
9 .2 Fe m u r, s h a ft 515
9 .3 Fe m u r, d is t a l 559

10 Tib ia a n d fib u la
10 .1 Tib ia a n d fib u la , p ro xim a l 622
10 .2 Tib ia a n d fib u la , s h a ft 684
10 .3 Tib ia a n d fib u la , d is t a l 7 79

11 Ca lca n e u s
11.1 Ca lca n e u s 843

182
5 Shoulde r girdle

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

5 .1.1 Nonu nion a fte r n o n o p e ra tive tre a tm e n t o f a d isp lace d OTA 0 6 -A1 co m p re ssio n LCP 3 .5 co m p re ssio n p la te 187
tran sve rse clavicu lar m id sh a ft fractu re

5 .1.2 La te ral e xtraarticu lar m e taph yse al im p acte d clavicu lar OTA 07-A1 lo cke d sp lin tin g LCP T-p la te 3 .5 lo cke d in te rn al 191
fractu re xa to r

5 .1.3 Disp lace d clavicu lar fractu re w ith lo ss o f le n gth OTA 0 6 -C1 co m p re ssio n LCP 3 .5 lag scre w s an d 197
p ro te ctio n p la te

5 .1.4 Clavicular m id sh a ft fractu re a n d se ria l rib fractu re s OTA 0 6 -B1 lo cke d sp lin ting LCP 3 .5 lo cke d in te rn a l 203
xa to r

5 .1.5 Displace d o bliq u e clavicu lar m id sha ft fractu re an d OTA 0 6 -A1; lo cke d splin tin g LCP 3 .5 lo cke d in te rn al 207
scapu lar ne ck fractu re (flo a tin g sh ou lde r) OTA 0 9 -B3 xa to r

5 .2 .1 In traarticular m u ltifragm e n tary sca p u lar fractu re OTA 0 9 -B3 com p re ssio n LCP co m p re ssio n p la te 215
re co n stru ctio n
p la te 3 .5

5 .2 .2 In traarticu lar disp la ce d gle n o id fo ssa fractu re an d OTA 0 9 -B3 com pre ssion LCP lag scre w s an d 219
scapu lar n e ck fractu re re co n stru ctio n p ro te ctio n p la te
p la te 3 .5

183
 5 Shoulde r girdle

5 .1 Cla vicle 18 5
5 .1.1 No n u n io n a ft e r n o n o p e ra t ive t re a t m e n t o f a d is p la ce d
t ra n s ve rs e cla vicu la r m id s h a ft fra ct u re —OTA 0 6 -A1 18 7
5 .1.2 La t e ra l e xt ra a r t icu la r m e t a p h ys e a l im p a ct e d cla vicu la r
fra ct u re —OTA 0 7-A1 191
5 .1.3 Dis p la ce d cla vicu la r fra ct u re w it h lo s s o f
le n g t h —OTA 0 6 - C1 19 7
5 .1.4 Cla vicu la r m id s h a ft fra ct u re a n d s e ria l rib
fra ct u re —OTA 0 6 -B1 203
5 .1.5 Dis p la ce d o b liq u e cla vicu la r m id s h a ft
fra ct u re —0 6 -A1 a n d s ca p u la r n e ck fra ct u re —0 9 -B3
(flo a t in g s h o u ld e r) 207

5 .2 Sca p u la 213
5 .2 .1 In t ra a r t icu la r m u lt ifra gm e n t a r y s ca p u la r
fra ct u re —OTA 0 9 -B3 215
5 .2 .2 In t ra a r t icu la r d is p la ce d gle n o id fo s s a fra ct u re
a n d s ca p u la r n e ck fra ct u re —OTA 0 9 -B3 219

18 4
 Au t h o r Ch ris t o p h So m m e r
5.1 Clavicle
1 In cid e n ce o f fra ct u re s
Fractu res of th e clavicle are very com m on an d are m ostly
cau sed by a sim ple fall on th e sh ou lder w ith d irect im pact
over th e lateral part of th e clavicle. It is a typical sport in -
ju r y (bicycle, sk i, an d ball sports), an d th erefore m ost of-
ten seen in you n g an d h ealthy people. Th e clavicle is
often broken in polytrau m atized patien ts in volved in a h igh -
en ergy trau m a (road traf c acciden t), often as part of a com -
plex ch est in ju ry w ith serial r ib fractu res an d pu lm on ary con -
tu sion . In th ese h igh -en ergy in ju ries, associated n eu rovascu -
lar in ju ries are com m on an d carefu l atten tion m u st be paid
to th ese.
2 Cla s s ifica t io n
M idsh aft fractu res (OTA 06) are classi ed accordin g to th e
classi cation of th e diaphyseal parts of th e lon g bon e in A, B,
an d C types (sim ple, wedge, an d com plex). Th e fractu res of
th e m ed ial or lateral part of th e clavicle can be d ivided in to
extraarticu lar or in traarticu lar an d n on d isplaced or d isplaced
fractu res [1].
3 Tre a t m e n t m e t h o d s
a in d ication for operative treatm en t an d m an y oth er situ ation s
Most fractu res of th e clavicle are su ccessfu lly treated con ser-
vatively w ith a gu re-of-eigh t strappin g w h ich relieves pain
an d allow s early m otion [2]. Th e n on u n ion rate varies w idely
in th e literatu re an d ran ges at abou t 1–10% .
Displaced an d u n stable fractu res of th e lateral (an d ver y rarely
th e m edial) en d are in dication s for su rgery, u su ally stabilized
by open redu ction an d in tern al xation (ORIF) u sin g vari-
ou s sm all tradition al or specialized plates (eg, clavicu lar h ook
a b
c d
Fig OTA clavicle classi cation .
5 .1-1a – d
a 06-A1 Diaph ysis, sim ple spiral
b 06-C1 Diaph ysis, com plex spiral
c 07-A1 Lateral en d, extraarticu lar m etaph ysis, im pacted.
d 07-B2 Lateral en d, in traarticu lar wedge fractu re w ith d is-
location
plate for th e lateral part), ten sion ban d w irin g, or position
screw s between th e clavicle an d th e coracoid process.
Absolu te in d ication s for operative stabilization of m idsh aft
fractu res are open fractu res (or im pen din g perforation of th e
sk in by a sh ar p irredu cible fragm en t) an d fractu res w ith as-
sociated vascu lar in ju ry requ irin g su rgical repair. An oth er in -
d ication for prim ary stabilization of th e clavicle in clu des th e
d isplaced oatin g sh ou lder in ju ry. Pain fu l n on u n ion s are an
are described as relative in d ication s for a stabilization of th e
clavicle: in com bin ation w ith ipsilateral serial rib fractu res
an d ail ch est (low-stan d in g sh ou lder gird le), in cases of a
polytrau m atized patien t requ irin g cru tch es, bilateral frac-
tu res, an d fractu res w ith m ajor d isplacem en t, especially a
sh orten in g of m ore th an 2 cm [3 , 4].
Th e gold stan dard in th e stabilization of m idsh aft fractu res or
n onu n ion s of th e clavicle is th e open an atom ical redu ction
185
 5 .1 Cla vicle
an d plate xation in a tradition al com pression m eth od u s-
in g eith er a stan dard straigh t plate 3.5 (LC-DCP or LCP in an
an terior plate position) or a recon stru ction plate 3.5 (su per ior
plate position) [5 –7 ]. Th e open approach is eith er in th e sagit-
tal plan e (“cou p de sabre”) or m ore h orizon tal an d parallel to
th e bon e, recom m en ded in m ore com plex fractu re pattern s
requ irin g lon ger (bridgin g) plates.
Du e to th e qu ite h igh rate of n onu n ion s an d refractu res af-
ter im plan t rem oval (u p to 10 –20% ), wh ich m igh t be par-
tially cau sed by th e open approach w ith iatrogen ic dam age
of th e blood su pply of in term ediate fragm en ts, a less in va-
sive approach m ay redu ce th is risk. In tram edu llary stabi-
lization u sin g a titan iu m elastic n ail (TEN) is a prom isin g
m eth od for sim ple fractu res (type A) requ ir in g operative
treatm en t [8 , 9 ]. In m ore com plex fractu res (types B an d C)
or in com bin ation w ith ch est in stability or scapu lar n eck
fractu re a m ore stable im plan t is requ ired. Th e m in im al-
ly in vasive plate osteosyn th esis (M IPO) tech n iqu e u sin g a
straigh t an teriorly placed LCP 3.5 is a less in vasive bu t de-
m an d in g way to stabilize th ese fractu res, in cases wh ere a
closed redu ction is su ccessfu l [10 ].
4 Im p la n t o ve r vie w
a in tram edu llary n ailin g of m idclavicu lar fractu res w ith a titan iu m
b osteosyn th esis (M IPO) of th e clavicle treatin g th e oatin g
Fig 5 .1-2 a – b
a LCP 3.5
b LCP T-plate 3.5
18 6
5 Bib lio gra p h y
1. Ort h o p e d ic Trau m a A sso ciat io n (1996) Fractu re an d
Dislocation Com pen d iu m . J Orthop Trauma; 10 (Su ppl 1).
2 . N o rdqv ist A , Pe t e rsso n CJ, Re d lu n d -Jo h n e ll I (1998) M id-
clavicle fractu res in adu lts: en d resu lt stu dy after con servative
treatm en t. J Orthop Trauma; 12(8):572 –576.
3. Ro bin so n CM , Co u rt-Brow n CM , McQu e e n M M , e t al (2004)
Estim atin g th e risk of n onu n ion follow in g n on operative treatm en t
of a clavicu lar fractu re. J Bone Joint Surg Am; 86 –A(7):1359 –1365.
4 . Wick M , Mu lle r EJ, Ko llig E, e t al (2001) M idsh aft fractu res of
th e clavicle w ith a sh orten in g of m ore th an 2 cm predispose to
n on u n ion . Arch Orthop Trauma Surg; 121(4):207–211.
5. Ge e l CW (2000) 4.1 Scapu la an d clavicle. Rüedi TP, Murphy W M
(eds), AO Principles of Fracture Management. Stu ttgart New York:
Th iem e-Verlag, 255 –268.
6 . Sh e n WJ, Liu TJ, Sh e n YS (1999) Plate xation of fresh
displaced m idsh aft clavicle fractu res. Injury; 30(7):497–500.
7. Wu CC, Sh ih CH , Ch e n WJ, e t al (1998) Treatm en t of clavicu lar
aseptic n onu n ion : com parison of platin g an d in tram edu llary
n ailin g tech n iqu es. J Trauma; 45(3):512–516.
8 . Ju be l A , A n de rm ah r J, Fay m o nv ille C, e t al (2002)
[ Recon stru ction of sh ou lder-gird le sym m etry after m idclavicu lar
fractu res. Stable, elastic in tram edu llary pin n in g versu s ru cksack
ban dage]. Chirurg; 73(10):978 –981. Germ an .
9. Ju be l A , A n d e rm ah r J, Sch iffe r G, e t al (2003) Elastic stable
n ail. Clin Orthop Relat Res; (408):279 –285.
10. Re cko rd U, Wallise r M , So m m e r C [ Percu tan eou s LCP
sh ou lder]. Swiss Surg; 9 (Su ppl 1):34. Germ an .
 Au t h o r Ch ris t o p h e r G Fin ke m e ie r

5.1.1 Nonunion afte r nonope rative tre atm e nt of a displace d

transve rse clavicular m idshaft fracture —OTA 06 -A1
1 Ca s e d e s crip t io n In d ica t io n

41-year-old m an in ju red in No n u n io n is a go o d in d ica tio n fo r o p e ra tive tre a tm e n t.

a m otor veh icle collision Th is ca se sh o w s a m id sh a ft cla vicle fra ctu re 6 m o n th s
sh ow in g fractu re of th e left a fte r a n in ju ry p re se n tin g w ith w id e d isp la ce m e n t a n d n o
clavicle. e vid e n ce o f h e a lin g. Th e p a tie n t co m p la in s o f p a in a n d
Type of in ju r y: h igh - a sso cia te d lo ss o f p o we r in a ctive u se o f le ft sh o u ld e r. He
en ergy, m on otrau m a. a lso co m p la in s o f p a in w h e n sle e p in g o n th e le ft sid e . A
Closed fractu re. cla vicu la r fra ctu re w ith n o e vid e n ce o f b o n e h e a lin g a fte r
6 m o n th s o f n o n o p e ra tive tre a tm e n t in a p a tie n t w ith
Fig 5 .1.1-1 sign i ca n t p a in a n d re d u ce d fu n ctio n o f th e in vo lve d
Nonu n ion . AP view. e xtre m it y is a n in d ica tio n fo r o p e ra tive tre a tm e n t.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Fig 5 .1.1-2 Be a ch ch a ir p o sitio n . Pre p a re th e e n tire u p p e r

• LCP 3 .5 , 9 h o le s e xtre m it y, th e u p p e r ch e s t w a ll, a n d b e su re to in clu d e th e s te rn u m
• 4 .0 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS) a n d m a n u b riu m . If ta kin g a b o n e gra ft, p re p a re th e ip sila te ra l ilia c
• 3 .5 m m co rte x scre w cre s t a s w e ll.
• 1.6 m m K-w ire
• Bo n e gra ft
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to
a n a to m y.)

Pla ce a n x-ra y p la te u n d e r th e p a tie n t p rio r to

d ra p in g. Th is e n su re s th a t th e lm is in th e co rre ct
p o sitio n .

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 1s t ge n e ra tio n ce p h a lo sp o rin

187
 5 .1 Cla vicle

2 Su rgica l a p p ro a ch

If possible, iden tify an d tag th e su praclavicu lar n erves w ith

sm all vessel loops. Man y of th ese n erves are th in an d very
friable. On ly th e larger n erves are likely to be protected an d
preserved.

Avoid elevatin g th e periostiu m an d th e su bclaviou s m u scle at-

tach m en ts to preserve as m u ch blood su pply as possible.
Clear ou t th e brou s tissu e from w ith in th e n onu n ion site.

Open th e m edu llar y can al of each fractu re fragm en t an d

resect an y n on viable bon e at th e en ds of th e fractu re frag-
Fig 5 .1.1-3 A straigh t in cision is m ade over th e clavicle an d
m en ts. Look for pu n ctu al bleedin g as eviden ce of viability.
is cen tered over th e fractu re. Sh ar ply d ivide th e th in bers
Tr y to keep soft-tissu e attach m en ts to wedged fragm en ts as
of th e platysm a overlyin g th e clavicle bein g carefu l to avoid
th ey sh ou ld be preserved to h elp m ain tain th e len gth of th e
tran sectin g th e su praclavicu lar n erves.
clavicle.

3 Re d u ct io n

Fig 5 .1.1-4 a – b Fixation u sin g bon e

graft.
a Th e tricortical graft sh ou ld be h ar-
vested alm ost tw ice th e size n eces-
sary to ll th e gap.
b Sm all dowels are fash ion ed from
each en d of th e graft so th ey can be
in laid in to th e in tram edu llary can al
a b of each en d of th e fragm en t.

If n ecessar y, a 1.6 m m K-w ire can be

If th e bon e en ds are an gled or obliqu e, redu ction w ith a poin t-
u sed to h old th e tricortical bon e graft in
ed redu ction forceps is recom m en ded.
place.
If th e bon e en ds are straigh t (90°) th en x a plate to on e part
an d redu ce th e oth er fragm en t to th e plated fragm en t. Th is is
best don e w ith a poin ted redu ction forceps, bu t a serrated jaw
clam p can occasion ally be of u se.

If th ere is a segm en tal defect greater th an 1 cm , a tricortical

graft sh ou ld be placed to m ain tain len gth an d fu n ction . If th e
gap is less th an a cen tim eter, brin gin g th e bon e en ds togeth er
sh ou ld n ot sh orten th e clavicle too mu ch an d sh ou ld resu lt in
n orm al fu n ction .

18 8
 5 .1.1 No n u n io n a ft e r n o n o p e ra t ive t re a t m e n t o f a d is p la ce d t ra n s ve rs e cla vicu la r
m id s h a ft fra ct u re —OTA 0 6 -A1

4 Fixa t io n

a b

Fig 5 .1.1-5 a – b
a On ce th e graft is placed w ith th e
dowels in th e in tram edu llary can al
of each bon e en d it sh ou ld th en be
com pressed between th e two en ds
of th e fractu red clavicle u sin g th e
dyn am ic com pression featu re of th e
plate.
b After th e graft is com pressed an d th e
plate is in th e appropriate position at
least two add ition al 4.0 m m lock in g
h ead screw s can be placed on each
side of th e in tercalar y bon e graft.

5 Re h a b ilit a t io n

Add ition al im m obilization : a slin g is recom m en ded on ly for com fort.

Mobilization : passive an d active m obilization after on e day postoperative.
Ph ysioth erapy: started postoperatively on day on e.
Ph arm aceu tical treatm en t: m ild n arcotics su ch as h yd rocodon e or codein e are u su -
ally adequ ate for pain con trol. Non steroid an tiin am m atory agen ts sh ou ld n ot be
u sed after bon e graftin g. Local an algesics such as lidocain e or bu pivicain e in jected
im m ed iately postoperative are h elpfu l in decreasin g postoperative n arcotic u se.

Im p la n t re m o va l
After 12 m on th s.
Im plan t rem oval is recom m en ded for patien ts w ith prom in en t h ardware wh ich
cau ses pain .

18 9
 5 .1 Cla vicle

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Usin g weak im plan ts th at are likely to fail su ch as Th e LCP 3.5 provides su f cien t xation to allow im m ed i-
on e-th ird sem i-tu bu lar plates. ate weigh t bearin g on th e ipsilateral u pper extrem ity.

Ap p ro a ch Ap p ro a ch
Severin g th e su praclavicu lar n erves. On ce th e ou ter bers of th e platysm a are in cised w ith th e
Strippin g too m u ch soft tissu e off th e bon e du rin g expo- scalpel, spread th e last few bers w ith scissors to iden tify
su re. an d preser ve th e su praclavicu lar n er ves.

Re d u ct io n a n d xa t io n
Over-sh orten in g th e clavicle.
Fig 5 .1.1-6 A recon stru ction
plate can be con tou red to
better t th e clavicle if so
desired. A straigh t LCP m ay
lie sligh tly off th e bon e du e
to th e cu r ved n atu re of th e
clavicle.
Re d u ct io n a n d xa t io n
Fash ion a tricortical iliac crest in tercalary graft w ith
dowels to m ain tain len gth of th e clavicle an d allow for
com pression of th e bon e fragm en ts.
Th e m ajor ben e t of th e LCP over th e recon stru ction plate
is better resistan ce to ben din g forces.

Re h a b ilit a t io n Re h a b ilit a t io n
Im m obilizin g th e patien t. Allow im m ediate ran ge of m otion of th e sh ou lder to pre-
ven t stiffn ess an d atroph y.

19 0
 5 .1.2
Au t h o r La
Mich
t e raa le el xt
Waragn
a ret icu
r la r m e t a p h ys e a l im p a ct e d cla vicu la r fra ct u re —OTA 0 7-A1

5.1.2 Late ral e xtraarticular m e taphyse al im pacte d

clavicular fracture —OTA 07-A1
1 Ca s e d e s crip t io n

64-year-old wom an fell wh en sh e was

sk iin g an d fractu red th e left lateral clav-
icle.

Fig 5 .1.2 -1a – b

a AP view.
b Obliqu e view.

In d ica t io n

La te ra l cla vicu la r fra ctu re w ith a vu lsio n o f

th e co ra co cla vicu la r liga m e n t, clo se d fra c-
tu re , m o n o tra u m a , o p e n te ch n iq u e . In te rn a l
xa to r m e th o d , b rid gin g th e fra ctu re w ith a n
a b LCP T-p la te .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP T-p la te 3 .5 , 6 h o le s An tib io tics: n o n e
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis: n o n e
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)

Th e 4 h o le s in th e cro ssb a r o f th e T-p la te fa cilita te

sta b le xa tio n o f th e sm a ll la te ra l fra gm e n t. Th e
a lte rn a tive im p la n ts w o u ld b e th e n a rro w LCP 3 .5
a n d / o r th e re co n stru ctio n p la te . Ho w e ve r, in th is ca se
th e se p la te s w o u ld b e d isa d va n ta ge o u s b e ca u se it
w o u ld o n ly b e p o ssib le to in se rt a m a xim u m o f o n e
o r t w o scre w s in to th e sm a ll la te ra l fra gm e n t.

Fig 5 .1.2 -2 Be a ch ch a ir p o sitio n . Pre p a re th e e n tire u p p e r e xtre m it y, th e

u p p e r ch e st w a ll, a n d b e su re to in clu d e th e s te rn u m a n d m a n u b riu m . Th e
a rm is d ra p e d b u t n o t im m o b ilize d .

191
 5 .1 Cla vicle

2 Su rgica l a p p ro a ch

Fig 5 .1.2 -3 Straigh t in cision over th e lateral clavicle.

a b c

d e f

Fig 5 .1.2 -4 a – f
a – c After sterile wash in g an d free drapin g for in traoperative
m obility of th e u pper extrem ity, a straigh t in cision over
th e lateral en d of th e clavicle/acrom ioclavicu lar join t is
m ade. After division of th e su bcu tis, in ju r y to th e mu scle
attach m en ts of th e clavicu lar part of th e deltoid m u scle
is iden ti ed. Th e acrom ioclavicu lar join t is m arked w ith
a n eed le.
d–f Th e size an d sh ape of th e plate is determ in ed u sin g a
tem plate. Th e th readed drill sleeve serves as a grippin g
an d m an ipu lation h an d le for th e in sertion of th e LCP
T-plate 3.5 th at is applied to th e cran ial su rface of th e
clavicle.

19 2
 5 .1.2 La t e ra l e xt ra a r t icu la r m e t a p h ys e a l im p a ct e d cla vicu la r fra ct u re —OTA 0 7-A1

3 Re d u ct io n a n d fixa t io n

a b c

d e f

g h i

Redu ction of th e fractu re by m an ipu latin g th e

Fig 5 .1.2 -5 a – i
freely m obile draped u pper extrem ity an d tem porar y xation
of th e plate to th e fragm en ts w ith th e redu ction forceps. Th e
plate position is assessed w ith th e im age in ten si er.
For th e xation of th e plate an addition al th readed d rill sleeve
is screwed in to th e T-bar an d tigh ten ed w ith a pin w ren ch .
Th is is followed by d rillin g, len gth m easu rem en t, a n d in ser-
tion of a lock in g h ead screw (LHS). Th e n ext step is to stabi-
lize th e plate by an ch orin g th e screw s in th e cen tral clavicu lar
fragm en t. Th e drill sleeves gu aran tee a per pen dicu lar orien -
tation for drillin g an d screw in sertion .

193
 5 .1 Cla vicle

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

d e f

g h i

After len gth m easu rem en t th e LHS are in serted. Th en , add ition al LHS
Fig 5 .1.2 -6 a – i
are an ch ored in th e distal periph eral fragm en t an d thu s com plete th e bridgin g osteo-
syn th esis accord in g to th e in tern al xator m eth od —th ree LHS in th e cen tral fragm en t,
fou r LHS in th e sm all periph eral fragm en t. Su tu re xation of th e avu lsion fragm en t
of th e coracoclavicu lar ligam en t. Wou n d closu re, rein sertion of th e partially detach ed
mu scles, in sertion of th e redon drain s, layered wou n d closu re.

19 4
 5 .1.2 La t e ra l e xt ra a r t icu la r m e t a p h ys e a l im p a ct e d cla vicu la r fra ct u re —OTA 0 7-A1

4 Re h a b ilit a t io n

a b c

d e

Fig 5 .1.2 -7a – e

a Postoperative x-ray after 6 m on th s. AP view.
b – c Fu n ction al ou tcom e after 5 m on th s.
d X-ray after im plan t rem oval. AP view.
e X-ray after im plan t rem oval. Obliqu e view.

Gilch rist ban dage for 2 weeks, rem oval of th e redon drain s on th e rst postopera-
tive day.

Rem oval of th e su tu res 12 days after th e operation . Start of passive exercises for th e
sh ou lder from th ird postoperative day.

195
 5 .1 Cla vicle

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 5 .1.2 -8 a – dTh e avu lsed coracoclavicu lar ligam en t Redu ction on to th e plate w ith sm all redu ction forceps.
rem ain s d isplaced. Th e n ext step is to tr y an d redu ce th is
fragm en t w ith th e h elp of th e redu ction forceps. An y at- Th e 4 h oles in th e crossbar of th e LCP T-plate 3.5 facilitate
tem pt to stabilize th is fragm en t w ith th e aid of a lag screw stabile xation of th e sm all lateral fragm en t.
w ill fail. Th e lag screw w ill n ot n d su f cien t an ch orage
in th e sm all fragm en t. Th erefore, su tu re xation of th e Su tu re xation of th e osseou s avu lsion .
coracoclavicu lar ligam en t is preferred. Bon e h ealin g w ith
a sligh t d isplacem en t of th e avu lsion fragm en t.

a b

c d

19 6
 5 .1.3
Au t h o r Dis
Michp laa ce
e l dWa
cla
gnvicu
e r la r fra ct u re w it h lo s s o f le n gt h —OTA 0 6 -C1

5.1.3 Displace d clavicular fracture with loss of

le ngth —OTA 06 -C1
1 Ca s e d e s crip t io n

38-year-old wom an fell from a h orse

4 weeks before treatm en t, in ju rin g th e
left clavicle.
Low-en ergy trau m a; m on otrau m a.
Closed fractu re.

Fig 5 .1.3 -1 AP view.

In d ica t io n Pre o p e ra t ive p la n n in g

Fra ctu re o f th e cla vicle w ith a Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g

d isp la ce m e n t o f m o re th a n o n e
sha ft w id th . Lo ss o f a p p roxi-
m a te ly 2 cm o f le n gth , a cco m -
p a n ie d b y n e u ro lo gica l d e cit
a n d se n so ry d iso rd e r a ffe ctin g
a ll n ge rs. Th e in d ica tio n fo r
o p e ra tive tre a tm e n t is b a se d o n
th e d ia gn o sis o f sh o rte n in g o f
th e cla vicle a n d th e n e u ro lo gica l
d e cits.
• LCP 3 .5 , 8 h o le s An tib io tics: n o n e
• 3 .5 m m lo ckin g h e a d scre w s Th ro m b o sis p ro p h yla xis: n o n e
(LHS)
• 2 .7 m m co rte x scre w s
• Re d u ctio n fo rce p s
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Fig 5 .1.3 -2 Be a ch ch a ir p o sitio n . Pre p a re th e e n tire u p p e r

e xtre m it y, th e u p p e r ch e st w a ll, a n d b e su re to in clu d e th e
s te rn u m a n d m a n u b riu m o f ste rn u m . Th e a rm is d ra p e d b u t
n o t im m o b ilize d .

197
 5 .1 Cla vicle

2 Su rgica l a p p ro a ch

Fig 5 .1.3 -3 A straigh t in cision , cen tered over th e fractu re, is m ade over
th e clavicle.

3 Re d u ct io n

a b c

Fig 5 .1.3 -4 a – c
a After exposin g th e fractu re an d freein g th e m ain fragm en ts b–c As soon as th e exact len gth h as been restored, th e re-
from recen tly form ed callu s, th e two m ain fragm en ts are du ction is secu red w ith a th ird redu ction forceps.
d istracted an d th e len gth of th e clavicle is restored.
Th e two m ain fragm en ts are h eld w ith serrated redu ction
forceps.

19 8
 5 .1.3 Dis p la ce d cla vicu la r fra ct u re w it h lo s s o f le n gt h —OTA 0 6 -C1

3 Re d u c t io n (co n t )

a b c

Fig 5 .1.3 -5 a – c
a A 2.7 m m lag screw is in serted. Th e glid in g h ole for an - c Th e redu ced fractu re is xed w ith two 2.7 m m lag screw s.
oth er lag screw is drilled w ith th e 2.7 m m drill bit. Th e addition al in ter m ed iary fragm en t is stabilized w ith a
b Th e appropriate d rill bit is in serted in to th e d rill sleeve an d th ird lag screw.
th e h ole is tapped. A bon e rasp protects th e soft tissu e on
th e opposite side.

4 Fixa t io n

a b c

Fig 5 .1.3 -6 a – c
a Th e sh ape of th e bon e is determ in ed w ith th e h elp of a
tem plate in preparation for th e application of a protection
plate to th e an terior side of th e clavicle.
b An LCP 3.5, 8 h oles, is precon tou red based on th e ben d-
in g tem plate. Th e plate n eeds n ot be ben t to an absolu tely
an atom ical sh ape if lock in g h ead screw s are u sed.
c Application of th e protection plate to bridge th e in depen -
den t lag screw s. Th e screw h eads lie ben eath th e plate. In
th e m ed ial an d lateral part, th e plate is slide-in serted be-
n eath th e m u scle attach m en ts an d th e lock in g h ead screw s
are in serted via sm all in cision s th rou gh th e m u scle bers.

19 9
 5 .1 Cla vicle

4 Fixa t io n (co n t )

a b c

Fig 5 .1.3 -7a – d

a In traoperative im age sh ow in g th e m idd le section of th e protection plate th at h as
been stabilized w ith lock in g h ead screw s. In th e lateral corn er of th e in cision
on e of th e in depen den tly u sed lag screw s is seen th rou gh th e plate h ole.
b AP view, in traoperative x-ray.
c Obliqu e view. Th e fractu re is well redu ced in both plan es an d h as been stabi-
lized w ith th ree 2.7 m m lag screw s an d an add ition al LCP as a protection plate
stabilized w ith ve lock in g h ead screw s. Th ese were in serted as bicortical screw s
becau se of th e sm all d iam eter of th e clavicle.
d Sk in closu re.
d

5 Re h a b ilit a t io n

Im mediate postoperative fu nc-

tion al treatm en t w ith ou t im -
m obilization started w ith pas-
sive mobilization after 2 days.

Fig 5 .1.3 -8 a – c
a Postoperative x-ray.
b – c Fu n ction al ou tcom e
after 2 weeks.
a b c

20 0
 5 .1.3 Dis p la ce d cla vicu la r fra ct u re w it h lo s s o f le n gt h —OTA 0 6 -C1

5 Re h a b ilit a t io n (co n t )

Fig 5 .1.3 -9 a – b Postoperative x-rays after

6 weeks.
a AP view.
b Obliqu e view.

a b

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP w ith LHS n eeds n ot be con tou red absolu tely to
th e an atom ical sh ape.

Ap p ro a ch Ap p ro a ch
In ju r y to th e n eu rovascu lar stru ctu res. Better overview du rin g redu ction an d less dam age to th e
soft tissu es.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
ORIF n eeds an open tech n iqu e. An terior application of th e plate so th at an LCP 3.5 can be
u sed. Th is is far m ore stable th an th e recon stru ction plate
3.5 th at wou ld h ave to be u sed for cran ial plate applica-
tion .

Ben d in g of th e LCP 3.5 is easier to t th e an ter ior aspect

of th e clavicle. Th is plate is stron ger th an th e recon stru c-
tion plate.

In terfragm en tary com pression w ith lag screw s. Plate-

in depen den t lag screw s are n ot restricted in d irection
an d an gu lation .

201
 5 .1 Cla vicle

6 Pit fa lls – (co n t) 7 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n (co n t)
Fixation of th e protection plate w ith LHS: Th is n on con tact
plate allow s a position in g above th e screw h eads from th e
lag screw s.

Re h a b ilit a t io n Re h a b ilit a t io n
With a good an d stable osteosyn th esis, early fu n ction al
reh abilitation is possible

202
 5 .1.4
Au t h o r Cla
Ch ris
vicu
t ola
p hr m
Soidmsm
h aeft
r fra ct u re a n d s e ria l rib fra ct u re s —OTA 0 6 -B1
5.1.4 Clavicular m idshaft fracture and se rial rib
fracture s—OTA 0 6 -B1
1 Ca s e d e s crip t io n
3 cm
In d ica t io n
Th e co m b in a tio n o f se ria l rib fra ctu re s a n d
a n ip sila te ra l cla vicu la r fra ctu re is a re la tive
in d ica tio n fo r o p e ra tive in te rve n tio n . If, a s
in th is ca se , th e sh o u ld e r d ro p s se ve ra l ce n -
tim e te rs, o ste o s yn th e sis o f th e cla vicle ca n
im p ro ve th e p o sitio n o f th e sh o u ld e r co n sid -
e ra b ly.
In th is co m b in e d in ju ry, sta b le p la te o ste o -
syn th e sis is p re fe rre d . An e la stic in tra m e d u l-
la ry n a il is n o t like ly to im p ro ve th e sh o u ld e r
h e igh t. Th e e xp e cte d fo rce s o n th e cla vicle ,
d u e to th e u n sta b le th o ra x, fa vo r ve n tra l p o -
sitio n in g o f th e p la te . A m in im a lly in va sive
a p p ro a ch h e lp s su pp o rt th e b lo o d su p p ly to
th e fra gm e n ts b u t re q u ire s clo se d re d u ctio n .
50-year-old m an collided w ith an oth er sk ier an d su stain ed a
lateral th orax trau m a. He fractu red ribs 2–8 on h is righ t side,
su ffered pn eu m oth orax an d fractu re of th e righ t clavicle in
th e m idd le part. In itially, a ch est drain was applied.
Fig 5.1.4 -1 Th e x-ray in u prigh t position after th e rst few days
sh owed a displacem en t of th e clavicle an d an u n stable th orax.
Th e righ t shou lder was 3 cm lower th an th e left sh ou lder.
Pre o p e ra t ive p la n n in g
Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP 3 .5 , 10 h o le s An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
• 3 .5 m m lo ckin g h e a d Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
scre w s (LHS)
• 1.6 m m K-w ire s 1 Su rge o n
(Size o f s ys te m , in stru m e n ts, a n d
2 ORP
3
im p la n ts ca n va ry a cco rd in g to 3 1s t a ssista n t
a n a to m y.)
Fig 5 .1.4 -2 Th e im a ge in te n si e r m u s t Ste rile are a
b e p o sitio n e d to a llo w p ro je ctio n o f 2
th e e n tire cla vicu la . Fro m ve n tro ca u d a l
to p o ste ro cra n ia l a n d a lso a cro ss fro m
1
ve n tro cra n ia l to p o ste ro ca u d a l.
203
 5 .1 Cla vicle

2 Su rgica l a p p ro a ch

Fig 5 .1.4 -3 Two in cision s are m ade on e at each en d of th e

plate on th e m ed ial an d lateral sides of th e fractu re an d paral-
lel to th e clavicle exten d in g for abou t 2 –3 cm of th e clavicu la
cau dal. Sk in an d fascia of th e mu scle are cu t; d issection to th e
clavicle w ith a bon e rasp. Th e fractu re zon e is n ot ex posed.

3 Re d u ct io n a n d fixa t io n

Fig 5 .1.4 -4 a – c
Th e ch osen 10 -h ole LCP 3.5 is adapted to th e sh ape of th e
ven tral con tou r of th e left clavicle. Th e plate n eeds n ot be ben t
to an absolu tely an atom ical form if lock in g h ead screw s are
u sed.
Th e plate bed on th e ven tral side of th e clavicle is tu n n eled.
If a d rill sleeve is in serted in to th e lateral h ole an d u sed as a
a h an dle, th e plate can easily be in serted from th e lateral to th e
m ed ial side.
Th e plate position h as to be ch ecked by im age in ten si er to
en su re th at it does n ot in terfere w ith th e acrom ioclavicu lar
join t.
Tem porar y xation w ith K-w ire th rou gh th e lateral d rill sleeve
an d trocar.
A drill sleeve is n ow in serted in to th e m edial h ole an d th e
fractu re is redu ced m anu ally an d in d irectly by m an ipu lation
b of th e plate.
A secon d K-w ire is in serted in to th e m edial h ole th rou gh
a trocar. Th e plate position an d th e redu ction m u st n ow be
ch ecked w ith th e im age in ten si er.
Th e K-w ires are replaced by lock in g h ead screw s. Th e fractu re
can n ow on ly be corrected in th e fron tal plan e.
A secon d lockin g h ead screw can be in serted on both sides;
ideally on e h ole is left u n occu pied.

20 4
 5 .1.4 Cla vicu la r m id s h a ft fra ct u re a n d s e ria l rib fra ct u re s —OTA 0 6 -B1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Th e x-ray taken im m ed iately postoperatively con rm s correct

Fig 5 .1.4 -5 a – c
cen tral plate an d screw placem en t on th e clavicle.

4 Re h a b ilit a t io n

a b c

d e f

Fig 5 .1.4 -6 a – f
a – c Fu n ction al reh abilitation followed. In addition to breath in g th erapy, gu ided
m ovem en t of th e sh ou lder was perform ed. Th e clin ical an d radiological ch eck-
u p after 3 m on th s con rm ed con solidation of th e fractu re an d a pain free
patien t. Sh ou lder h eigh t on both sides was th e sam e.
d–f Clin ically, sh ou lder fu n ction on both sides was th e sam e. Th e scar h ad a sat-
isfactory appearan ce an d th e plate was cau sin g n o d istu rban ce to th e patien t
bu t rem ain s visible.

205
 5 .1 Cla vicle

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th eguLCP
An lar in
stable
stru mimen
plan
ts facilitate
ts are idealm infor
immally
in im
inally
vasiveinvasive
tech -
nprocedu
iqu es. Threse (th
plate
e plate
n eeds
n eeds
n ot be
n otcon
be tou
benred
t anabsolu
atom ically).
tely to th e
an atom ical sh ape. Th e drill sleeves are ideal for h old in g
th e plate so th at it can be tem porar ily stabilized w ith
K-w
Ap ires.
p ro a ch
A m in im ally invasive approach redu ces th e risk of dam age
to th e blood su pply, especially of th e m idd le fragm en ts. If
Ap p ro a ch an pinrodirect
Ap a ch redu ction is n ot possible, th e two sm all in ci-
Redu ction by m ean s of th is m in im ally in vasive procedu re sion
A m sincan
im ally
be con
invasive
n ectedprocedu
an d th erefractu
can be re an
canadvan
be stabilized
tage if
is d if cu lt. byere
th tradisition
soft-tissu
al ORIF.
e in ju ry.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Tan gen tial screw s in th is ven tral position cou ld provoke Re de uven
Th ct iotrocau
n a n ddalxaposition
t io n allow s in sertion of a straigh t
loosen in g of th e screw s an d plate. plate
Th e ven
whtral
ereasposition
a weakerof th
recon
e plate
struisction
idealplate
to com
is m
pen
ore
sate
ap-for
th e stron ginvertical
propriate th e cran
shial
arinposition
g forces.
.

Re h a b ilit a t io n Re h a b ilit a t io n
Early fu n ction al reh abilitation is possible w ith a good an d
stable
Re h a b osteosyn
ilit a t io n th esis. Im plan t rem oval is also possible by
aThme in
ven
imtral
allyplate
in vasive
is cau
approach
sin g n o .d istu rban ce to th e patien t.

20 6
 Au t h o r Ch ris t o p h So m m e r
5.1.5 Displace d oblique clavicular m idshaft fracture —OTA 0 6 -A1
and scapular ne ck fracture —OTA 0 9 -B3 ( oating shoulde r)
1 Ca s e d e s crip t io n
a b
23-year-old m an was stru ck on th e left sh ou lder by a fall-
in g tree. He su ffered direct trau m a w ith a resu ltin g oatin g
sh ou lder (clavicu lar m idsh aft fractu re an d d isplaced scapu lar
fractu re). Th e patien t h ad exten sive closed soft-tissu e dam -
age across th e left sh ou lder an d con com itan t paresis of th e
plexu s. In add ition , h e h ad a dislocation an d fractu re of th e
C5/6 vertebra w ith ou t n eu rological de cit. Ven ograph y of th e
m assively swollen left arm sh owed n orm al arterial circu lation
In d ica t io n
A co m b in a tio n o f a cla vicu la r fra ctu re a n d a sca p u la r fra ctu re ( o a t-
in g sh o u ld e r) m a y b e a n in d ica tio n fo r o p e ra tive sta b iliza tio n . With a
cle a r d isp la ce m e n t, a s in th is ca se , sta b le p la te o ste o syn th e sis o f th e
cla vicle is su f cie n t fo r th e sta b iliza tio n o f th e sh o u ld e r gird le . Sta n -
d a rd p ro ce d u re w o u ld b e a n o p e n a n a to m ica l re d u ctio n a n d in te rn a l
xa tio n . Un fo rtu n a te ly, th e p a tie n t ha d a skin le sio n a t th e site o f th e
c
an d drain age over th e su bclavian vein . Th e soft tissu e sh owed
great im provem en t 7 days after in itial em ergen cy treatm en t
of th e C5/6 vertebra fractu re an d local treatm en t of th e sk in
lesion .
Fig 5 .1.5 -1a – c
a M idclavicle fractu re an d displaced scapu la fractu re.
b Ven ograph y.
c Sk in lesion .
p la n n e d in cisio n . A m in im a lly in va sive a p p ro a ch in th is ca se wo u ld b e
id e a l. In tra m e d u lla ry xa tio n w ith a n e la stic n a il is ge n e ra lly n o t th e
p re fe rre d p ro ce d u re fo r th is t yp e o f co m b in a tio n fra ctu re . Sta b iliza -
tio n w ith a sm a ll e xte rn a l xa to r wo u ld b e a n o th e r a lte rn a tive .
207
 5 .1 Cla vicle

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP 3 .5 , 12 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
1 Su rge o n
ca n va ry a cco rd in g to a n a to m y.) 3 2 ORP
3 1s t a ssis ta n t
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
2
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Ste rile are a
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 5 .1.5 -2 Th e im a ge in te n si e r m u st b e p o sitio n e d to

a llo w p ro je ctio n o f th e e n tire cla vicle . Fro m ve n tro ca u d a l
to p o s te ro cra n ia l a n d a lso a cro ss fro m ve n tro cra n ia l to 1
p o s te ro ca u d a l.

2 Su rgica l a p p ro a ch

Fig 5 .1.5 -3 Th e len gth of th e LCP 3.5 is ch osen accord in g to

th e len gth of th e fractu re on th e ven trocau dal aspect. Two
in cision s are m ade h orizon tally 2 cm cau dal to th e clavicle
over th e plan n ed position s of th e plate en ds. In th is case, th e
trau m atic sk in lesion cou ld be avoided. In cision of th e su bcu -
tan eou s fascia is m ade an d th e in sertin g m u scles are sligh tly
detach ed from th e an terior border of th e clavicle m ed ial an d
lateral of th e fractu re.

20 8
 5 .1.5 Dis p la ce d o b liq u e cla vicu la r m id s h a ft fra ct u re —OTA 0 6 -A1 a n d
s ca p u la r n e ck fra ct u re —OTA 0 9 -B3 (flo a t in g s h o u ld e r)

3 Re d u ct io n a n d fixa t io n

a b

Fig 5 .1.5 -4 a – d
a A su bcu tan eou s tu n n el is m ade w ith th e h elp of a blu n t
in stru m en t (elevator, bon e rasp) ven trocau dally at th e an -
terior su rface of th e clavicle. With th e h elp of a drill sleeve
in serted in to th e lateral h ole, th e precon tou red plate can
be in serted from lateral to m edial. Aided by th e im age in -
ten si er, th e plate is position ed w ith th e m ost lateral h ole
sligh tly m edial to th e acrom ioclavicu lar join t. Th e plate is
th en xed tem porarily to th e clavicle w ith a K-w ire in sert-
ed th rou gh th e drill sleeve an d K-w ire trocar. Th e fractu re
can n ow be redu ced in d irectly.
b Next, tem porary xation of th e plate is perform ed m ed i-
ally by in sertion of a K-w ire. Im age in ten si cation sh ow s
good plate position in g at each en d, bu t still an gu lation of
th e fractu re.

c dd

c– d Th e fractu re can n ow be n ally redu ced towards th e Two LHS on each side are su f cien t in good bon e qu ality. In
plate u sin g a redu ction forceps in serted th rou gh th e osteoporotic bon e or tan gen tial screw position , th ree LHS on
sm all m ed ial an d lateral in cision s. After correct redu c- each side are recom m en ded.
tion h as been ach ieved, th e lock in g h ead screw s can
be in serted. Th e plate h as to be cen tered to th e clavicle
(AP d irection) to avoid tan gen tial in sertion of th e screw s.

20 9
 5 .1 Cla vicle

3 Re d u c t io n a n d fixa t io n (co n t )

a b

Fig 5 .1.5 -5 a – c
a – b Fixed fractu re prior to wou n d closu re.
c Th e approach es requ ired to avoid soft-tissu e dam age can
be seen h ere. A stan dard approach wou ld h ave in ter-
fered w ith th e in ju ry.

a b

Th e n al x-rays sh ow correct redu ction of th e

Fig 5 .1.5 -6 a – c
fractu re w ith clavicle len gth en in g by 2 m m .
a AP view.
b 30 º AP cran ial tilt view.
c Cran iocau dal view.

210
 5 .1.5 Dis p la ce d o b liq u e cla vicu la r m id s h a ft fra ct u re —OTA 0 6 -A1 a n d
s ca p u la r n e ck fra ct u re —OTA 0 9 -B3 (flo a t in g s h o u ld e r)

4 Re h a b ilit a t io n

c d

a b e

Fig 5 .1.5 -7a – e

a – b Fu n ction al reh abilitation follow s th e operation . Exten -
sive ph ysioth erapy an d ergoth erapy for th e preexistin g
plexu s paresis is perform ed. No m ajor load in g is recom -
m en ded for 6 weeks. Th e paresis of th e plexu s recovered
com pletely du rin g th e cou rse of treatm en t.
c– d Th e fractu re of th e clavicle an d th e scapu la sh owed good
h ealin g w ith sym m etrical sh ou lder h eigh t.
e Th e clavicle fractu re h ealed en dosteally w ith m in im al
periosteal callu s.

Fig 5 .1.5 -8 After 3 m on th s th e fractu re h ad con solidated.

a b

Fig 5 .1.5 -9 a – b
a After 18 m on th s an d ach ievin g fu ll fu n ction w ith ou t
pain , th e patien t w ish ed to h ave th e im plan t rem oved.
Th e rem oval procedu re was perform ed percu tan eou sly
th rou gh th e ex istin g in cision s.
b Th e con trol x-ray sh ow s th e con solidated fractu re.

211
 5 .1 Cla vicle

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP in stru m en ts facilitate m in im ally in vasive tech -
n iqu es. Th e plate n eeds n ot be con tou red absolu tely to th e
an atom ical sh ape. Th e drill sleeves are ideal for h old in g
th e plate so th at it can be tem porar ily stabilized w ith
K-w ires.

Ap p ro a ch Ap p ro a ch
A m in im ally in vasive approach is on ly possible if th e frac- A m in im ally invasive procedu re can be an advan tage if
tu re can be redu ced easily. In a n orm al fractu re w ith ou t th ere is soft-tissu e in ju ry.
soft-tissu e in ju ry, a stan dard approach is preferred.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Redu ction by a m in im ally in vasive approach is qu ite d if- Th e ven trocau dal position allow s in sertion of a straigh t
cu lt. Th e plate sh ou ld be ben t an atom ically (con tralateral plate wh ereas a weaker recon stru ction plate is m ore ap-
side as referen ce). Th e position of th e LCP 3.5 m u st be propriate in th e cran ial position .
strictly an terocau dal to avoid tan gen tial orien tation of th e
screw s (th e lock in g h ead screw s can on ly be in serted at a
righ t an gle).

Re h a b ilit a t io n Re h a b ilit a t io n
Early fu n ction al reh abilitation is possible w ith a good an d
stable osteosyn th esis. Im plan t rem oval is also possible by
m in im a lly invasive approach .

212
 Au t h o r Ch ris t o p h So m m e r

5.2 Scapula

1 In cid e n ce o f fra ct u re s

Fractu res of th e scapu la occu r qu ite often an d are u su ally

cau sed by a h igh -en ergy d irect im pact over th e scapu lar re-
gion . Most of th ese patien ts h ave associated in ju ries su ch as
th oracic r ib fractu res an d oth er fractu res of th e sh ou lder gir-
d le [1].

a b c

2 Cla s s ifica t io n Fig OTA classi cation .

5 .2 -1a – c
a 09-A2.3 Body fractu re
b 09-A3.2 Com plex extraarticu lar fractu re
In th e OTA classi cation th e fractu res are d ivided in to ex-
c 09-B2.3 in traarticu lar glen oid, n on im pacted
traarticu lar (type A) an d in traarticu lar (type B). A1-type
con cern s fractu res of th e processes (acrom in on an d coracoid),
A2-type stays for body fractu res an d A3-type represen ts com -
plex extraarticu lar fractu res. B type fractu res are su bgrou ped
as sim ple im pacted (B1), n ot im pacted (B2), or as com plex
(B3) glen oid fractu res [2]. Th e com bin ation of a scapu lar
n eck fractu re w ith a clavicu lar fractu re is also called oatin g
sh ou lder.

3 Tre a t m e n t m e t h o d
Most scapu lar fractu res can be treated con ser vatively w ith
sh ort im m obilization tim e an d early m otion . In dication s for
a rger y are establish ed in cases of d isplaced in traarticu lar
su
(glen oid) fractu re w ith large fragm en ts an d sh ou lder in stabil-
ity, d isplaced oatin g sh ou lder in ju ries, an d th e rare situ ation
of an open fractu re [3 ].
Glen oid fractu res are articu lar fractu res an d requ ire an an -
atom ical redu ction an d stable xation , u su ally w ith on e or
two lag screw s depen d in g on th e size of th e d isplaced
fragm en t(s). Th ese fractu res are u su ally located an terior-in -
feriorly an d occu r in com bin ation w ith a sh ou lder d islocation
in th e sam e d irection . Th ey th erefore requ ire an an terior
stan dard approach w ith open redu ction an d stable screw xa-
tion . Altern atively, if closed redu ction is su ccessfu l, a percu ta-
n eou s approach an d stabilization w ith can nu lated screw s can
be perform ed. In rare situ ation s, th e glen oid fractu re is part
of a com plex fractu re of th e scapu la, in volvin g oth er parts of
th is bon e (n eck an d body). In case of m ajor in traarticu lar d is-
placem en t, an operative treatm en t w ith open redu ction an d
stable in tern al xation u sin g screw s an d/or plates is requ ired.
Th e on ly possible approach for th ese rare fractu res is posterior
th rou gh th e in terface between in fraspin atu s an d teres m in or
m u scle. Great care m u st be taken to preser ve th e n eu rovascu -
lar stru ctu res (axillary an d su prascapu lar n erve, hu m eral cir-
cu m ex artery) [4 ]. Plate xation on th e in ferior or su perior
border of th e scapu lar body m ay be dif cu lt du e to th e th in
bon y stru ctu re. In th ese region s, th e lock in g h ead screw s of
th e LCP system offer a great advan tage an d can im prove th e
ach ieved stability (see case 5.2.1).

213
 5 .2 Sca p u la
Displaced oatin g sh ou lder in ju ries (fractu re of th e scapu lar
n eck associated w ith a fractu re of th e m idsh aft of th e ipsilat-
eral clavicle) are u su ally ver y u n stable an d sh ow a ten den cy
for cau dal rotation al d isplacem en t w ith low stan d in g sh ou l-
der gird le. Th ese in ju ries can often be treated su ccessfu lly by
stable plate xation of th e clavicle alon e [5 –7 ]. Con ser vative
treatm en t for less d isplaced fractu res m ay also be su ccessfu l
[8 ].
4 Im p la n t o ve r vie w
Fig 5 .2 -2 LCP recon stru ction plate 3.5
214
5 Bib lio gra p h y
1. Ge e l CW (2000) 4.1 Scapu la an d clavicle. Rüedi TP, Murphy W M
(eds), AO Principles of Fracture Management. Stu ttgart
New York: Th iem e-Verlag, 255 –268.
2. Ort h o p e d ic Trau m a A sso ciat io n (1986) Fractu re an d
Dislocation Com pen d iu m . J Orthop Trauma; 10(Su ppl 1).
3. Hard e gge r FH , Sim p so n LA , We be r BG (1984)
Th e operative treatm en t of scapu lar fractu res.
J Bone Joint Surg Br; 66(5):725 –731.
4. Ebrah e im N A , Me k h ail AO, Pad an ilu m TG, e t al (1997)
An atom ic con sideration s for a m odi ed posterior approach to
th e scapu la. Clin Orthop Relat Res; (334):136 –143.
5. Ego l K A , Co n n o r PM , Karu n ak ar M A , e t al (2001) Th e
oatin g sh ou lder: clin ical an d fu n ction al resu lts. J Bone Joint
Surg Am; 83-A(8):1188 –1194.
6. He rscov ici D , Fie n n e s AG, A llgow e r M , e t al (1992) Th e
oatin g sh ou lder: ipsilateral clavicle an d scapu lar n eck fractu res.
J Bone Joint Surg Br; 74(3):362–364.
7. Lable r L, Plat z A , We ish au p t D , e t al (2004) Clin ical an d
fu n ction al resu lts after oatin g sh ou lder in ju ries. J Trauma;
57(3):595 –602.
8. Ram o s L, Me n cia R , A lo n so A , e t al (1997) Con servative
treatm en t of ipsilateral fractu res of th e scapu la an d clavicle.
J Trauma; 42(2):239 –242.
 Au t h o r Ch ris t o p h So m m e r
5.2.1 Intraarticular m ultifragm e ntary scapular
fracture —OTA 0 9 -B3
1 Ca s e d e s crip t io n
a b
In d ica t io n
Th is se ve re ly d isp la ce d fra ctu re
is a cle a r in d ica tio n fo r o p e n
re d u ctio n a n d in te rn a l xa tio n .
Wh e n th e re is a fra ctu re lin e
th ro u gh th e sca p u la r b o d y a n d
n e ck, a p o ste rio r a p p ro a ch a n d
a p la te o ste o syn th e sis is id e a l. A
p la te s yste m w ith lo ckin g h e a d
scre w s is o f gre a t a d va n ta ge a t
th e sm a ll sca p u la r rim .
53-year-old m otorcyclist fell an d su ffered a d irect trau m a
to h is righ t sh ou lder gird le. He h ad serial fractu res of ribs 1–5
on h is righ t side w ith a h em atopn eu m oth orax an d was treat-
ed w ith a ch est tu be. He su ffered a mu ltifragm en tary in traar-
ticu lar scapu lar fractu re w ith a clear step in th e join t su rface,
d iagn osed as a OTA 09-B3.2 in ju ry (m u ltifragm en tary w ith
glen oid n eck an d body). Th ere were n o n eu rovascu lar in ju -
ries.
Fig 5 .2 .1-1a – b
a AP view.
b Th e CT scan sh owed a fractu re of th e glen oid w ith th ree
fragm en ts an d a large posterocau dal, severely d isplaced
glen oid part.
Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP re co n s tru ctio n p la te 3 .5 , 5 h o le s
• LCP re co n s tru ctio n p la te 3 .5 , 6 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
3
• 3 .5 m m co rte x scre w s
• K-w ire s
• We b e r re d u ctio n fo rce p s
(Size o f s yste m , in s tru m e n ts, a n d 1
im p la n ts ca n va ry a cco rd in g to a n a to m y.)
4
2
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
1 Su rge o n
Th ro m b o sis p ro p h yla xis:
2 ORP
lo w -m o le cu la r h e p a rin
3 1st a ssistan t
4 2n d a ssista n t
Fig 5 .2 .1-2 La te ra l p o sitio n . En tire righ t a rm fre e ly
m o ve a b le in clu d in g sh o u ld e r gird le .
Ste rile a re a
215
 5 .2 Sca p u la
2 Su rgica l a p p ro a ch
a b
A cu rved in cision at th e in ferior rim of th e
Fig 5 .2 .1-3 a – b
spin e of scapu la is perform ed from lateral to m edial. Th e m e-
d ial cu rve ru n s alon g th e m ed ial scapu la rim an d exten ds
to th e in ferior scapu la edge. Th e deltoid m u scle is detach ed
sh ar ply from th e spin e of scapu la an d th e basis of th e acro-
m ion leavin g a sm all residu e on th e bon e for re xation . Th e
deltoid m u scle w ith th e n eu rovascu lar bu n d le is h eld lateral-
ly. Th e approach is con tin u ed by en terin g th e gap between th e
216
in fraspin atu s an d th e teres m in or m u scles. Th e su prascapu lar
n er ve is traced on its way from lateralcau dal to th e en tran ce to
th e in fraspin atu s m u scle. Capsu lotom y sh ou ld be perform ed
in th e region of th e dorsal labru m if it h as n ot already been
torn apart. Th e sh ou lder join t is n ow freely visible an d th e
hu m eral h ead can be su blu xated in a ven tral d irection or th e
su blu xation can be su pported w ith a Hoh m an n retractor for
a better overview.
 5 .2 .1 In t ra a r t icu la r m u lt ifra gm e n t a r y s ca p u la r fra ct u re —OTA 0 9 -B3

3 Re d u ct io n a n d fixa t io n

1 Gle n o id fragm e n t
2 In fe rio r gle n o id fragm e n t
12 3 Th re ad s fo r h old in g th e la te ral
13 cap su le
4 K-w ire u se d a s a jo ystick
5 3
5 Sm all We b e r re d u ctio n fo re ce p s
1 to re d u ce th e gle n o id fragm e n ts
6 Pre sh ap e d LCP re co n stru ctio n
p la te 3 .5 , 6 h o le s
7 Co rte x lag scre w 3 .5 m m
3
4 11 7 8 Co rte x lag scre w 3 .5 m m
8 9 Se lf-ta p p ing LHS
10 Se lf-ta pp ing LHS
6 10
2 11 Pre sh ap e d LCP re co n stru ctio n
9 p la te 3 .5 , 5 h o le s
12 Co rte x scre w 3 .5 m m
13 Se lf-ta p p in g LHS
a b
Fig 5 .2 .1-4 a – b
Th e join t su rface is redu ced an atom ically u n der vision .
A K-w ire is drilled in to th e in ferior glen oid fragm en t an d u sed as a joystick. If th e K-w ire h as been in serted in a correct posi-
tion , it can be u sed to x th e cau dal fragm en t tem porarily on to th e secon d glen oid fragm en t.
Th e lateral capsu le can be h eld aside w ith th reads.
After redu ction th e glen oid fragm en ts are redu ced on to th e scapu la w ith th e h elp of th e Weber redu ction forceps.
Th e de n itive stabilization begin s cau dally w ith a ben t LCP recon stru ction plate 3.5 th at is xed w ith two cortex screw s on to
th e glen oid. Th ese cortex screw s provide in terfragm en tar y com pression an d stabilization of th e glen oid. Lock in g h ead screw s
are ideal for th e th in scapu la. Con ven tion al cortex or can cellou s bon e screw s wou ld n orm ally n ot n d su f cien t an ch orage.
A secon d LCP recon stru ction plate 3.5 is n eeded at th e cran iodorsal aspect to com plete th e de n itive stabilization of th e glen oid
an d scapu la. Lock in g h ead screw s are also u sed to en su re rm con n ection s between screw, plate, an d bon e.

Fig 5 .2 .1-5 a – c
a Th e in traoperative pictu re sh ow s
th e two dorsal recon stru ction
LCP 3.5.
b – c Th e postoperative x-rays (AP an d
tan gen tial view) con rm th e
an atom ical recon stru ction of th e
glen oid an d th e stable br idgin g to
a b c th e scapu la body.

217
 5 .2 Sca p u la

4 Re h a b ilit a t io n

a b c d e f

In a stable sh ou lder gird le w ith ou t d islocation

Fig 5 .2 .1-6 a – f after 3 m on th s sh ow com plete con solidation . A very good
ten den cy, fu n ction al treatm en t begin s on th e rst postopera- clin ical resu lt is ach ieved after 3 m on th s w ith early fu n ction -
tive day. Active assisted exercise is don e as far as tolerated. al treatm en t.
Load bear in g can be started 6 weeks after trau m a. Th e x-rays

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Locking head screws and LCP system allow good anchor-
age in the th in scapu lar body and also offer the possibility of
plate dependin g lag screws (com bin ation of different screws).

Ap p ro a ch Ap p ro a ch
Th e su prascapu lar n erve su pplyin g th e in fraspin atu s A d isplaced in traarticu lar glen oid fractu re requ ires open
m u scle is at risk. redu ction . A dorsal approach for th e scapu la n eck or
scapu la body is recom m en ded.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
A n on an atom ic recon stru ction can lead to osteoarth rosis Th e LCP w ith LHS allow s good an ch orage in th e th in
of th e glen ohu m eral join t. scapu lar body.

Re h a b ilit a t io n Re h a b ilit a t io n
Early load in g or poor com plian ce of th e patien t can lead Stable xation of th e scapu la w ith plate an d lock in g h ead
to in stability an d n on u n ion . screw s allow s early fu n ction al treatm en t an d good sh ou l-
der fu n ction is obtain ed.

218
 Au t h o r Ch ris t o p h e r G Fin ke m e ie r
5.2.2 Intraarticular displace d gle noid fossa fracture
and scapular ne ck fracture —OTA 09 -B3
1 Ca s e d e s crip t io n
a b
In d ica t io n
Th is ca se sh o w s a d isp la ce d in tra a rticu la r
gle n o id fo ssa fra ctu re a n d a sca p u la r n e ck
fra ctu re . Th e a rticu la r fra ctu re is sign i ca n tly
d isp la ce d a n d ro ta te d . Th is is n o t a cce p ta b le
fo r a n in tra a rticu la r fra ctu re a n d co u ld le a d
to n o n u n io n o r p a in fu l p o sttra u m a tic a rth ri-
tis. Th e d isp la ce d a rticu la r fra ctu re w ith th e
a d d itio n a l sca p u la r n e ck fra ctu re m a ke s th is
a n in ju ry th a t h a s a h igh p ro b a b ilit y o f d o -
in g p o o rly w ith o u t a n a to m ic re d u ctio n a n d
sta b le xa tio n .
45-year-old m ale, fractu re of left glen oid.
Type of in ju ry: low-en ergy, m on otrau m a. Closed fractu re.
Fig 5 .2 .2 -1a – b
a AP view of left sh ou lder.
b CT scan (axial cu t).
Pre o p e ra t ive p la n n in g
Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP re co n s tru ctio n p la te 3 .5 , 6 h o le s An tib io tics: sin gle d o se 2 n d
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s ge n e ra tio n ce p h a lo sp o rin
(LHS)
• 3 .5 m m co rte x scre w s
• K-w ire s
• Sm a ll a n d la rge p o in te d re d u ctio n fo rce p s
• Ta g su tu re s fo r th e in fra sp in a tu s te n d o n
a n d th e e d ge s o f th e jo in t ca p su le
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts ca n va ry a c-
co rd in g to a n a to m y.)
Fig 5 .2 .2 -2 Th e m a jo rit y o f gle n o id
fra ctu re s a re b e s t tre a te d p o ste rio rly.
Pa tie n ts ca n b e p la ce d in a la te ra l o r p ro n e
p o sitio n fo r th e b e st e xp o su re o f th e
gle n o id . Th e la te ra l p o sitio n is p re fe ra b le
a s it a llo w s th e in vo lve d u p p e r e xtre m it y
to b e m o ve d in to d iffe re n t p o sitio n s
d u rin g su rge ry, if n e e d e d .
219
 5 .2 Sca p u la
2 Su rgica l a p p ro a ch
a b
Fig 5 .2 .2 -3 a – d
a Th e in cision is m ade alon g th e in ferior border of th e scapu -
lar spin e. It can be exten ded dow n over th e lateral aspect
of th e deltoid if m ore exposu re is n eeded su ch as wh en
perform in g a glen ohu m eral arth rotom y.
b Th e posterior an d lateral h eads of th e deltoid are th en
sh ar ply detach ed from th e scapu lar spin e. Th e deltoid is
en cased by a su per cial an d deep fascial layer. Be carefu l
to iden tify both fascial layers so th at th e en tire m u scle can
be retracted to expose th e extern al rotators of th e sh ou l-
der. Avoid th e m u scle bres of th e deltoid wh ich m ake it
d if cu lt to d istin ctly iden tify th e extern al rotator m u scles
below. On ce th e su rgeon is ou t of th e correct plan e of dis-
section , it is d if cu lt to n d th e correct plan e. Oth er prob-
lem s can also occu r su ch as in creased bleed in g an d poor
visu alization as well as w ide areas of m u scle dam age.
2 20
c d
c With th e deltoid retracted in feriorly, blu n tly develop th e
in ter val between teres m in or an d in fraspin atu s m u scles
alon g th eir scapu lar body origin s u p to th e hu m eral h ead
in sertion s. Th is in terval w ill take th e su rgeon d irectly to
th e scapu lar body an d th e join t capsu le. At th is stage look
for th e su prascapu lar n erve an d accom pan yin g blood ves-
sels cou rsin g th rou gh th e spin oglen oid n otch an d en terin g
th e in fraspin atu s m u scle belly.
d In cise an d d issect off th e tedon ou s portion of th e in fra-
spin atu s in sertion on th e hu m eral h ead, keepin g th e u n -
derlyin g capsu le in tact. On ce th e ten don is elevated an d
tagged w ith a su tu re, perform a T-capsu lotom y of th e gle-
n ohu m eral capsu le to expose th e glen oid articu lar su rface.
A sh ou lder retractor is h elpfu l to retract th e h u m eral h ead
su f cien tly to see th e en tire glen oid fossa. At th is stage,
th e glen oid fossa sh ou ld be ex posed as well as th e prox i-
m al lateral border of th e scapu lar body an d th e glen oid
n eck.
 5 .2 .2 In t ra a r t icu la r d is p la ce d gle n o id fo s s a fra ct u re a n d s ca p u la r n e ck fra ct u re —OTA 0 9 -B3
3 Re d u ct io n a n d fixa t io n
a b
Fig 5 .2 .2 -4 a – c
a Redu ction begin s w ith clean in g of th e fractu re su rfaces
an d iden tifyin g th e key fragm en ts th at n eed redu ction .
As w ith all periarticu lar fractu res th e articu lar su rface is
redu ced rst. K-w ires m ay n eed to be in serted in to th e
fragm en ts to con trol th eir rotation an d an gu lation .
Redu ction screw s or d rill h oles m ay n eed to be placed in to
th e fragm en ts to provide h old in g poin ts for poin ted redu c-
tion forceps.
b On ce th e articu lar fragm en ts are redu ced, K-w ires can be
placed to provision ally m ain tain th e redu ction prior to
in terfragm en tar y lag screw s. Th e su rgeon m ay decide to
forego th e placem en t of provision al K-w ires an d proceed
d irectly to lag screw placem en t.
If th ere are m u ltiple articu lar fragm en ts, th e su rgeon
sh ou ld recon stru ct th e join t begin n in g w ith deepest frag-
m en ts an d bu ildin g ou tward. Bioabsorbable pin s are u sefu l
to x th e in terior articu lar fragm en ts in order to preven t
bu ryin g h ardware in location s th at w ill n ot be accessible
after th e ou ter portion s of th e join t are redu ced an d in -
stru m en ted. If bioabsorbable im plan ts are n ot available,
th en th e su rgeon sh ou ld u se K-w ires to h old th e in terca-
lar y pieces. Th e K-w ires n eed to be cu t u sh w ith th e bon e
su rface so th at th e n ext articu lar piece w ill t an atom i-
cally in to place.
c
Articu lar fragm en ts sh ou ld be xed w ith im plan ts appro-
pr iate for th eir size. 3.5 m m screw s are m ost com m on ly
u sed, bu t 2.7 m m an d 2.0 m m screw s can also be u sed for
sm aller pieces. As w ith m ost articu lar fractu res, th e su r-
geon sh ou ld tr y to com press th e fragm en ts, wh ich can be
accom plish ed w ith overdr illin g th e n ear cortex or u sin g
sh aft screw s.
c On ce th e glen oid fossa h as been recon stru cted, th e n ext
step is to redu ce an d x it to th e rest of th e scapu la.
Th ere are fou r m ain areas of th e scapu la w h ere adequ ate
xation can be accom plish ed: th e lateral border of th e
scapu la, th e coracoid process, th e glen oid n eck or process,
an d th e base of th e scapu lar spin e.
Th e typical xation m eth od con sists of a sm all fragm en t
recon stru ction plate th at ru n s alon g th e lateral border of
th e scapu la an d u p on to th e back of th e scapu lar n eck.
Lock in g h ead screw s are h elpfu l in th ese cases as com -
m inu tion m ay resu lt in m on ocortical xation in several
location s.
On e-th ird sem i-tu bu lar lock in g plates are adequ ate to x
fractu res of th e th in scapu la body if n eeded.
221
 5 .2 Sca p u la

4 Re h a b ilit a t io n

Addition al im mobilization : a sling or shou lder im mobilizer can be u sed to su pport

the involved shou lder for 1–2 weeks or u ntil the patient‘s pain su bsides.
Mobilization : passive m obilization after 1 day. Active m obilization after 21 to
42 days depen d in g on th e adequ acy of th e repair of th e in fraspin atu s an d th e
deltoid m u scles.
Ph ysioth erapy: begin rst postoperative day for passive an d active-assisted
exercises.
Ph arm aceu tical treatm en t: h yd rocon e an d acetam in oph en .

a b
Im p la n t re m o va l
Fig 5 .2 .2 -5 a – b Postoperative x-rays after Im plan t rem oval is n ot u su ally n ecessary an d sh ou ld be avoided du e to th e added
6 weeks. soft-tissu e trau m a an d th e risk of in ju rin g th e su prascapu lar n erve.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Work in g ou tside of th e correct tissu e plan e.

Re d u ct io n a n d xa t io n
Attem ptin g to obtain adequ ate
of th e scapu lar body.
xation in th e th in portion
Re d u ct io n a n d xa t io n
Rem em ber th e fou r areas of th e scapu la wh ere adequ ate
xation can be obtain ed: th e lateral border of th e scapu la,
th e glen oid n eck, th e coracoid process, an d th e base of th e
scapu lar spin e.

Re h a b ilit a t io n Re h a b ilit a t io n
Im m obilizin g th e sh ou lder or delayin g ph ysioth erapy Start ph ysioth erapy im m ed iately.
beyon d 2–3 weeks.

Im p la n t re m o va l Im p la n t re m o va l
Rem ovin g im plan ts for reason s oth er th an in fection or Do n ot rem ove im plan ts u n less absolu tely n ecessar y.
m ech an ical im pin gem en t.

2 22
6 .1 Hum e rus, proxim al

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

6 .1.1 Extraarticu la r u n stab le su b capita l hu m e ra l 11-A3 co m p re ssio n LCP m e tap h yse al lo cke d in te rna l xa to r 2 31
fractu re w ith d iaph yse al in vo lve m e n t an d lo cke d pla te 3 .5/ 4 .5/ 5 .0 an d re d u ctio n scre w
sp lin tin g

6 .1.2 Extra articu la r b ifo ca l p roxim a l hu m e ral 11-B2 co m p re ssio n LPHP p ro te ctio n p la te a n d 2 35
fractu re w ith ro ta to ry d isp lace m e n t o f th e re d u ctio n scre w 1
e piph ysis

6 .1.3 Extraarticu la r b ifo ca l p roxim a l h u m e ral 11-B2 co m p re ssio n PHILOS b la d e p la te 1 243

fractu re w ith o u t m e ta p h yse a l im p action

6 .1.4 Extraarticu lar b ifo cal p roxim al h u m e ral 11-B2 co m p re ssio n PHILOS co m p re ssio n p la te 249
fractu re w ith p roxim a l d ia p h yse a l e xte n sio n an d lag scre w 1

6 .1.5 Extra articu la r b ifo ca l p roxim a l hu m e ral 11-B3 lo cke d sp lin tin g PHILOS lo cke d in te rn a l 2 53
fra ctu re w ith gle n oh u m e ral dislo ca tio n xa to r 1

6 .1.6 In traarticu lar proxim al h u m e ral fractu re w ith 11-C1 lo cke d sp lin tin g LPHP lo cke d in te rn a l xa to r 2 59
sligh t d isp lace m e n t an d re d u ctio n scre w 1

6 .1.7 In traarticu lar p roxim a l hu m e ral fractu re w ith 11-C2 lo cke d sp lin tin g LPHP lo cke d in te rn a l xa to r 26 5
valgu s m ala lign m e n t an d re d u ctio n scre w 1

6 .1.8 In tra articu lar im p a cte d p roxim a l h um e ra l 11-C2 lo cke d sp lin tin g LPHP lo cke d in te rn a l xa to r 271
fractu re w ith d isp lace m e n t an d re d u ctio n scre w 1

6 .1.9 4 -p art proxim al h u m e ra l fractu re 11-C2 lo cke d splin tin g PHILOS lo cke d in te rn a l xa to r 279
an d re d u ctio n scre w 1

1
Ad d itio n a l te n sio n b an d w ith su tu re s fo r th e h e ad fragm e n t.

223
 6 Hu m e ru s

6 Hum e rus

6 .1 Hu m e ru s , p ro xim a l 225
6 .1.1 Ext ra a r t icu la r u n s t a b le s u b ca p it a l h u m e ra l fra ct u re w it h
d ia p h ys e a l in vo lve m e n t—11-A3 2 31
6 .1.2 Ext ra a r t icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h
ro t a t o r y d is p la ce m e n t o f t h e e p ip h ys is —11-B2 2 35
6 .1.3 Ext ra a r t icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h o u t
m e t a p h ys e a l im p a ct io n —11-B2 243
6 .1.4 Ext ra a r t icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h
p ro xim a l d ia p h ys e a l e xt e n s io n —11-B2 249
6 .1.5 Ext ra a r t icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h
gle n o h u m e ra l d is lo ca t io n —11-B3 253
6 .1.6 In t ra a r t icu la r p ro xim a l h u m e ra l fra ct u re w it h s ligh t
d is p la ce m e n t —11- C1 259
6 .1.7 In t ra a r t icu la r p ro xim a l h u m e ra l fra ct u re w it h va lgu s
m a la lign m e n t —11- C2 265
6 .1.8 In t ra a r t icu la r im p a ct e d p ro xim a l h u m e ra l fra ct u re w it h
d is p la ce m e n t —11- C2 271
6 .1.9 4 -p a r t p ro xim a l h u m e ra l fra ct u re —11- C2 27 9

2 24
 Au t h o r Mich a e l Ple cko

6 .1 Hum e rus, proxim al

1 In cid e n ce o f fra ct u re s

Fractu res of th e prox im al h u m eru s are com m on in ju ries, ac-

cou n tin g for abou t 4 –5% of all fractu res an d 45% of fractu res
of th e hu m eru s [1]. Depen d in g on th e fractu re types in clu ded,
in ciden ce rates vary from 73/100,000 [2] to 105/ 100,000 [1]. a b c
Th e in ciden ce of proxim al hu m eral fractu res is age depen den t,
Fig 11-A Extraarticu lar u n ifocal fractu re.
6 .1-1a – c
w ith a m arked in crease beyon d th e fth decade of life [3 ] an d
a 11-A1 tu berosity
a fem ale prepon deran ce of 1.5 –3:1 [1, 2]. Detailed age an d sex
b 11-A2 im pacted m etaph yseal
d istr ibu tion accordin g to th e type of fractu re is provided in
c 11-A3 n on im pacted m etaph yseal
a recen t stu dy [4 ]. Accord in g to th e Mü ller AO Classi cation
th e m ajor ity of prox im al h u m eral fractu res can be assign ed to
type A (66% ) an d B (27% ) fractu res w ith a ten den cy towards
m ore com plex fractu res w ith age [4].

Wh ile in th e you n ger patien t h igh -en ergy trau m a predom -

in ates, low-en ergy trau m a is th e m ost com m on in ju ry in th e
older patien t. Th e r ise in fractu re in ciden ce w ith age, espe-
cially w ith on ly m oderate trau m a, an d th e h igh er in ciden ce
am on g wom en are ch aracteristic epidem iologic featu res of a b c
fractu res associated w ith osteoporosis.
Fig 11-B Extraarticu lar bifocal fractu re.
6 .1-2 a – c
a 11-B1 w ith m etaph yseal im paction
In you n ger patien ts w ith h igh -en ergy trau m a, accom pany-
b 11-B2 w ith ou t m etaph yseal im paction
in g in ju ries of th e ax illar y n er ve or brach ial plexu s, as well
c 11-B3 w ith glen oh u m eral d islocation
as soft-tissu e dam age are frequ en tly obser ved. Th is is rare in
elderly patien ts w ith low-en ergy trau m a.

2 Cla s s ifica t io n

Prox im al hu m eral fractu res are classi ed accordin g to th e

Mü ller AO classi cation system an d Neer´s Classi cation [5 ,
6 ], th ou gh both classi cation system s h ave lim ited repro-
ducibility [7 ]. Classi cation is u sefu l for com parison of stu dy a b c
popu lation s an d allow s gu idelin es to be set for treatm en t an d
Fig 11-C Articu lar fractu re.
6 .1-3 a – c
reh abilitation .
a 11-C1 w ith sligh t d isplacem en t
b 11-C2 im pacted w ith m arked displacem en t
c 11-C3 d islocated

225
 6 Hu m e ru s
Th e Mü ller AO Classi cation categorizes proxim al h u m eral
fractu res accord in g to fractu re localization an d fractu re pat-
tern : type A represen ts extraarticu lar u n ifocal fractu res, type
B con cern s extraarticu lar bifocal fractu res an d type C classi-
es articu lar fractu res.
3 Tre a t m e n t m e t h o d s a n d in d ica t io n s
Non d isplaced or m in im ally d isplaced prox im al h u m eral frac-
tu res accord in g to types 11-A1.1, 11-A2.1, 11-A2.2, 11-A2.3,
11-A3.1, 11-B1.1, 11-B1.2, 11-B1.3, 11-C1.1, 11-C1.2, an d 11-
C1.3 are u su ally treated con ser vatively by early fu n ction al
treatm en t or im m obilization . More com plex an d/or u n stable
fractu re types u su ally requ ire operative treatm en t. Decision
m ak in g sh ou ld in clu de:
• fractu re type,
• patien t age,
• in d ividu al fu n ction al dem an ds, an d
• ex pected com plian ce w ith reh abilitation .
Addition al in ju ries an d biological criter ia, su ch as bon e den si-
ty, circu lation , preex istin g arth rosis of th e sh ou lder, in tegrity
of th e rotator cu ff, an d com orbid ity h ave to be con sidered.
For open fractu res as well as for fractu res w ith accom pan yin g
vascu lar or n er ve lesion s, im m ed iate operative treatm en t is
recom m en ded. In severely displaced fractu res, early redu c-
tion an d osteosyn th esis sh ou ld be ach ieved.
Operative tech n iqu es for prox im al h u m eral fractu res in clu de
m in im ally in vasive tech n iqu es like percu tan eou s pin n in g
[8 ] an d/or percu tan eou s screw xation [9 –11]. To avoid m i-
gration of th e pin s, a hu m eru s block—as described by Resch
[12] —m ay be u sed. In som e cases w ith a lim ited open ap-
proach for redu ction , screw xation w ith addition al ten sion
ban d osteosyn th esis m ay en able in creased stability [13 , 14].
M in im ally in vasive tech n iqu es h as th e advan tage of lesser
soft-tissu e dam age, bu t dem an d optim al percu tan eou s redu c-
2 26
tion of th e fractu re fragm en ts an d often add ition al slin g im -
m obilization for 3 –4 weeks.
Alth ou gh m in im a lly in vasive tech n iqu es h ave w idely been
prom oted over th e past decade, som e fractu re types seem to
be m ore su itable for th ese m in im ally in vasive tech n iqu es th an
oth ers. Good in d ication s for percu tan eou s tech n iqu es are:
type 11-A1 fractu res w ith m ore th an 3 m m d isplacem en t of
th e greater tu berosity, 11-A3.1 an d 11-A3.2 fractu res if good
closed redu ction can be ach ieved, an d 11-B1 fractu res w ith
m ore th an 3 m m displacem en t of th e greater or lesser tu ber-
osity. Valgu s im pacted 4-part fractu res type 11-C2.1 w ith m i-
n or lateral d isplacem en t between th e articu lar segm en t an d
th e sh aft can su ccessfu lly be redu ced percu tan eou sly du e to
in tact periosteu m an d soft-tissu e su pport. In con trast, 11-B2,
11-B3, som e 11-C2 an d m ost 11-C3 fractu res m ay n eed open
redu ction tech n iqu es.
In tram edu llar y xation h as prim arily been applied in h u -
m eral sh aft fractu res an d h as later on been exten ded to su b-
capital 11-A2 an d 11-A3 fractu res. Stan dard in tram edu llary
n ail design s as well as elastic in tram edu llary pin s h ave been
u sed [15 , 16 ]. In th e last few years special in tram edu llar y im -
plan ts for prox im al hu m eral fractu res h ave been developed.
Th e n ewly design ed prox im al h u m eral n ail w ith a spiral blade
(PHN) provides im proved rotation al stability com pared w ith
n ails u sin g lock in g screw s on ly [17 ] an d com bin es th e ad-
van tage of a stable im plan t w ith a lim ited open access. 11-
A3 fractu res are m ost su itable for operative treatm en t w ith
th e PHN, alth ou gh th e in evitable approach th rou gh th e rota-
tor cu ff h as to be con sidered in you n ger patien ts. In d ication s
for in tram edu llary im plan ts m ay be exten ded towards m ore
com plex fractu res like 11-B2 w ith add ition al xation of th e
tu berosities by secu re su tu res or by screw s.
Th e classic open redu ction tech n iqu e an d con ven tion al plate
xation , m ain ly u sin g th e T-plate, h as been perform ed for
m an y years. Exact preparation of th e fractu re fragm en ts led
to addition al dam age of th e blood su pply w ith a h igh rate of
avascu lar n ecrosis of th e hu m eral h ead [18 –2 0 ]. Th is problem
 6 .1 Hu m e ru s , p ro xim a l

Fig 6 .1-4 Prox im al h u m eral fractu re
w ith restored m ed ial bu ttress in th e m e-
taph yseal area.
Fig 6 .1-5 Proxim al hu m eral fractu re w ith
restored m edial bu ttress by im pactin g
th e sh aft in to th e h u m eral h ead.
Fig 6 .1-6 Prox im al h u m eral fractu re
Vid e o
w ith de cien t m ed ial bu ttress du e to 6 .1-1
m etaphyseal com m inu tion . An 8-h ole
LPHP is u sed as a locked bridgin g plate
splin tin g th e fractu re zon e.

h as been overcom e by u sin g in d irect redu ction tech n iqu es
an d carefu l soft-tissu e dissection . Usin g th e sam e im plan ts
th is m od i ed tech n iqu e redu ced th e rate of avascu lar n ecro-
sis to 0 –4% [21, 2 2]. In add ition , especially in osteoporosis,
con ven tion al screw s m ay d isen gage, leadin g to secon dary d is-
placem en t.
In th e last few years th e developm en t of an gu lar stable im -
plan ts for fractu res of th e prox im al h u m eru s, accord in g to th e
lock in g com pression plate (LCP) con cept, h as in itiated a n ew
era in th e operative treatm en t of th ese fractu res. An atom i-
cally presh aped im plan ts like th e lock in g prox im al h u m er-
al plate (LPHP), proxim al hu m eru s in tern al lockin g system
(PHILOS), or m od i ed con ven tion al im plan ts like th e clo-
verleaf plate w ith lock in g h ead screw s can be u sed for th is
n ew con cept. Som etim es xation w ith two sm all LCPs m ay
be u sefu l. Th e com bin ation of lockin g h ead screw s w ith th e
th ree d im en sion al position in g of th e screw s w ith in th e h u -
m eral h ead leads to im proved stability. Application of th ese
n ew an gu lar stable im plan ts is m ain ly con sidered wh en open
redu ction is n ecessar y. Th erefore fractu res 11-A3, 11-B2, 11-
B3, 11-C2, an d recon stru ctable 11-C3 fractu res are th e m ost
frequ en t in dication s for th ese n ew tech n iqu es.
Fixation of prox im al h u m eral fractu res w ith an gu lar stable
plate osteosyn th esis can be perform ed eith er th rou gh a del-
topectoral or a delta splittin g approach . Special atten tion to
th e ax illary n er ve an d carefu l preser vation of th e periosteal
blood su pply by in d irect redu ction m an eu vers are essen tial
(n o-tou ch tech n iqu e).
Recon stru ction of th e m ed ial bu ttress in th e m etaph yseal area
of th e hu m eru s is a key poin t in fractu re xation w ith lock-
in g prox im al h u m eral plates. If th e m ed ial bu ttress can be
restored by in d irect redu ction , th is leads to a very stable con -
stru ct an d allow s early fu n ction al reh abilitation ( Fig 6 .1-4 ).
If th ere is m ed ial com m in u tion or bon e defect, th e m ed ial
bu ttress m ay be restored by im pactin g th e sh aft in to th e h ead

227
 6 Hu m e ru s

an d xin g it in th is position w ith th e LPHP or PHILOS wh ich , Alth ou gh lon g-ter m ex per ien ce w ith a n gu la r stable prox im a l
in m ost cases, is stable en ou gh for active-assisted m obilization h u m era l im pla n ts in a la rger patien t coh or t is pen d in g, bio-
( Fig 6 .1-5 ). If th e com m in u tion is too exten sive to allow res- m ech a n ica l stu d ies as well as rst clin ica l data a re prom isin g
toration of th e m ed ial bu ttress, th e lockin g com pression plate [17, 2 3 –2 5 ].
m ay be u sed as a locked in tern al xator bridgin g th e fractu re
zon e w ith em pty plate h oles over th e fractu re ( Fig 6 .1-6 ).
4 Im p la n t o ve r w ie w
In th ese cases th e reh abilitation protocol h as to be adapted
an d on ly passive exercises sh ou ld be perform ed. Oth erw ise
stress con cen tration w ill lead to im plan t failu re.
a
Wh en dealin g w ith an gu lar stable im plan ts in th e treatm en t
of proxim al hu m eral fractu res, a few gu idelin es h ave to be
con sidered [2 5 ]. Th orou gh an alysis of th e fractu re type w ith b
respect to residu al blood su pply of th e articu lar h ead segm en t,
in order to avoid exten sive preparation of th e fractu re lin es to
preser ve th e periosteal blood su pply, an d for carefu l redu ction
c
of th e hu m eral fractu re, preferably by in direct tech n iqu e.

Adequ ate redu ction tech n iqu es are m an u al lon gitu d in al trac-
d
tion , rotation , lateralization of th e sh aft, an d gen tle m an ipu la-
tion of th e tu berosities an d th e hu m eral h ead segm en t, u sin g
Fig 6 .1-7a – d
su tu re loops th rou gh th e rotator cu ff ten don s close to th eir
a PHILOS—prox im al h u m eral plate 3.5
bony in sertion , gen tle redu ction of th e m edialized sh aft to th e
b PHILOS lon g—prox im al h u m eral plate 3.5
plate, u sin g a con ven tion al screw as redu ction screw.
c LPHP—lock in g prox im al h u m eral plate 3.5
d LCP m etaph yseal plate 3.5/4.5/5.0
Later on , correct position in g of th e im plan t to avoid su bacro-
m ial im pin gem en t, correct len gth of th e lock in g h ead screw s
w ith in th e hu m eral h ead, n on perforation of th e articu lar su r-
face, u se of self-tappin g (n ot self-drillin g, self-tappin g) screw s
w ith in th e h u m eral h ead, u se of add ition al stron g n on absorb-
able su tu res th rou gh th e rotator cu ff ten don s an d th e plate
as ten sion ban d in g are h igh ly recom m en ded as well as ap-
plication of at least two bicortical lock in g h ead screw s w ith in
th e h u m eral sh aft (in osteoporotic bon e th ree lock in g h ead
screw s are recom m en ded).

2 28
 6 .1 Hu m e ru s , p ro xim a l
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12 . Re sch H (2003) [ Fractu res of th e hu m eral h ead.] Unfallchirurg;
106(8):602 –617.
13. Rü e d i TP (1989) Th e treatm en t of displaced m etaphyseal
fractu res w ith screw s an d w irin g system s. Orthopedics;
12(1):55 –59.
14. Och sn e r PE, Ilch m an n T (1991) [ Ten sion ban d osteosyn th esis
w ith absorbable cords in proxim al com m inu ted fractu res of th e
hu m eru s.] Unfallchirurg; 94(10):508 –510.
15. Zif ko B, Po ige n fü rst J, Pe zze i C (1992) [ In tram edu llary
n ailin g of u n stable proxim al h u m eral fractu res.] Orthopäde;
21(2):115 –120.
16 . Blu m J, Ro m m e n s PM , Jan zin g H (1998) [ Retrograde n ailin g
of hu m eru s sh aft fractu res w ith th e u n ream ed hu m eru s n ail. An
in tern ation al mu lticen ter stu dy.] Unfallchirurg; 101(5):342–352.
17. He ssm an n M H , Ro m m e n s PM (2003) [The biomechanical
behavior of angular stable implants at the proximal.] 1st ed. Bern
Göttin gen Toron to Seattle: Han s Hu ber Verlag. Germ an
18 . Ku n e r EH , Sie ble r G (1987) [ Dislocation fractu res of th e
proxim al hu m eru s—resu lts follow in g su rgical treatm en t.
A follow-u p stu dy of 167 cases.] Unfallchirurg; 13(2):64 –71.
19. Sp e ck M , Lan g FJ H , Re gazzo n i P (1996) [Mu ltifragm en tary
proxim al hu m eral fractu res—Failu res after T-plate xation .]
Swiss Surg; 2:51–56. Germ an
20. Lill H , Lan ge K, Prasse –Bad d e J, e t al (1997) [ T-plate
osteosyn th esis in dislocated proxim al hu m eru s fractu res]
Unfallchirurg; 23(5):183 –190.
21. He ssm an n M , Bau m gae rt e l F, Ge h lin g H , e t al (1999) Plate
xation of proxim al hu m eral fractu res w ith in direct redu ction :
su rgical tech n iqu e an d resu lts u tilizin g th ree sh ou lder scores.
Injury; 30(7):453 –462.
2 2. Esse r R D (1994) Treatm en t of th ree-an d fou r-part fractu res
of th e proxim al hu m eru s w ith a m odi ed cloverleaf plate.
J Orthop Trauma; 8(1):15 –22.
23. Ple cko M , K rau s A (2004) In tern al xation of proxim al
hu m eru s fractu res u sin g th e lock in g proxim al hu m eral plate.
Oper Orthop Traumatol; 17:25 –50.
229
 6 Hu m e ru s

24. Lill H , He pp P, Ko rn e r J, e t al (2003) Proxim al hu m eral

fractu res: h ow stiff sh ou ld an im plan t be? A com parative
m ech an ical stu dy w ith n ew im plan ts in hu m an specim en s.
Arch Orthop Trauma Surg; 123:74 –81.
25. Lill H , He pp P, Ro se T, e t al (2004) [ Th e an gle stable lockin g-
prox im al-h u m eru s-plate (LPHP) for prox im al hu m eral fractu res
u sin g a sm all an terior-lateral-deltoid-splittin g-approach -
tech n iqu e an d rst resu lts] Zentralbl Chir; 129(1):43 –48.

230
 Au t h o r Ch ris t o p h So m m e r

6 .1.1 Extraarticular unstable subcapital hum e ral fracture

with diaphyse al involve m e nt—11-A3
1 Ca s e d e s crip t io n

63-year-old active bu sin ess wom an (self-em ployed),

sk iin g in ju r y to th e righ t dom in an t arm .

Fig 6 .1.1-1a – b
a AP view.
b Axillar y view.

In d ica t io n

Pro xim a l e xtra a rticu la r h u m e ra l fra ctu re w ith co m m in u tio n a n d d ia -

a b
p h yse a l e xte n sio n (11-A3 .3), ve ry u n sta b le a n d p a in fu l.
Op e ra tive tre a tm e n t re d u ce s p a in , in sta b ilit y is o ve rco m e , a n d p a tie n t ’s
re q u e st to u se th e righ t d o m in a n t a rm a s so o n a s p o ssib le is m e t.
No n o p e ra tive tre a tm e n t is a va lid o p tio n , sin ce th e re a re fe w d is-
p la ce m e n ts a n d n o n e u ro va scu la r in ju rie s. Ho w e ve r, xa tio n w ith a
Ve lp e a u b a n d a ge fo r 4 – 6 we e ks is re q u ire d , a n d su b se q u e n t im p a ir-
m e n t o f sh o u ld e r m o ve m e n t is to b e e xp e cte d .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP m e ta p h yse a l p la te An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
3 .5/ 4 .5/ 5 .0 , 5 + 8 h o le s Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
• 3 .5 m m lo ckin g h e a d
scre w s (LHS)
• 3 .5 m m co rte x scre w Fig 6 .1.1-2 a – b
• 2 .0 m m K-w ire s Be a ch ch a ir p o sitio n .
(Size o f s yste m , in stru m e n ts, a n d
Arm fre e ly m o ve a b le .
im p la n ts ca n va ry a cco rd in g to
a n a to m y.)

a b

231
 6 .1 Hu m e ru s , p ro xim a l

2 Su rgica l a p p ro a ch

Fig 6 .1.1-3 a – b
a A straigh t LCP m etaph yseal plate 3.5/4.5/5.0
is sligh tly con tou red to approx im ately t th e
sh ape of th e hu m eral h ead.
b A m in im ally in vasive approach (an terolateral
deltoid split) w ith two sm all in cision s (2 –3 cm
lon g) is su f cien t. Th is preserves vascu larity,
bu t does n ot allow fu ll view of th e fractu re site.
Care m u st be taken n ot to in ju re th e ax illary
n er ve. It sh ou ld be n oted th at on ly approxim ate
align m en t of ax is an d rotation is possible.

Altern atively, an open approach offers a direct view

of th e fractu re, bu t it is n ot preferable becau se of
a b addition al dam age to vascu larity.

3 Re d u ct io n a n d fixa t io n

a c d

Fig
a 6 .1.1-4 a – j
a After epiperiosteal tu n neling with an elevator, the
plate is gently in serted alon g the anterolateral as-
pect of the hu meral sh aft. The two drill sleeves,
rm ly anchored in the proxim al part of the plate
act as h andles.
b
b–d Prelim in ary xation of th e plate w ith a K-w ire placed in to th e
hu m eral h ead. Im age in ten si er sh ow s th e position of th e plate
relative to th e h u m eral h ead an d sh aft an d th e closed redu ction
obtain ed.

232
 6 .1.1 Ext ra a rt icu la r u n s t a b le s u b ca p it a l h u m e ra l fra ct u re w it h d ia p h ys e a l in vo lve m e n t—11-A3

3 Re d u c t io n a n d fixa t io n (co n t )

e f g

Fig 6 .1.1-4 a – j (co n t)

e Redu ction can be adju sted
by m ean s of th e 2.0 m m
K-w ire u sed as joystick.
f A drill sleeve is placed in
th e m ost d istal h ole of th e
plate. A 2 .0 m m K-w ire is
in serted an d position in g
of th e plate is con trolled.
g Fixation of the hu meral head w ith one 3.5 m m cortex screw
an d a 3.5 m m self-tappin g lockin g h ead screw.
Before xin g th e bridgin g plate to th e hu m eru s distally th e
fractu re redu ction an d ax ial align m en t sh ou ld be ch ecked
by im age in ten si cation on ce m ore.

h i j

h Th e m ost d istal h ole is d rilled, th e d rill bit rem ain in g in i Th e xation is com pleted j Free arm m otion an d ab-
place to secu re th e correct len gth , wh ile ax ial align m en t by in sertin g a th ird LHS duction mu st be checked
is still possible. A fu rth er ch eck w ith th e im age in ten si er distally an d two LHS prior to sk in closu re.
is advisable before th e two self-tappin g LHS are in serted proxim ally.
bicortically.

233
 6 .1 Hu m e ru s , p ro xim a l

4 Re h a b ilit a t io n

No add ition al im m obilization .

Weigh t bearin g: partial after 6 weeks; fu ll after 8 weeks.
Physiotherapy: fu nction al postoperative treatm ent w ith active-
assisted m ovem en t w ith a physioth erapist as of th e rst post-
operative day.
Ph arm aceu tical treatm en t: an algesics if requ ired.
Im plan t rem oval: on ly if patien t su ffers from th e im plan t.

Fig 6 .1.1-5 a – b Postoperative x-rays (bridgin g th e fractu re

zon e w ith th e in tern al xator m eth od).

a b

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Open approach w ith add ition al dam age to vascu larity. A m in im ally in vasive tech n iqu e does n ot requ ire ex po-
Dam age to th e an terior bran ch of th e ax illary n erve. su re of th e fractu re focu s an d preser ves vascu larity.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Note th at except for th e m ost d istal LHS, all screw s are bi-
cortical, wh ich appears m an datory in th e hu m eru s du e to
th e w ide ran ge of m otion , especially rotation of th e arm .

234
 Au t h o r Wils o n Li

6 .1.2 Extraarticular bifocal proxim al hum e ral fracture with

rotatory displace m e nt of the e piphysis—11-B2
1 Ca s e d e s crip t io n

49-year-old m an slipped an d
fell on h is sh ou lder. Type of in -
ju ry: low-en ergy, m on otrau m a.
Closed fractu re.

Fig 6 .1.2 -1a – c

a AP view.
b Ax illary view.
c Lateral view.

a b c

In d ica t io n

Bifo ca l fra ctu re o f th e su rgica l n e ck o f th e h u m e ru s is ve ry

p a in fu l a n d d isa b lin g a s th e se gm e n ts a re p u lle d b y re sp e c-
tive m u scle a ttach m e n ts in to t yp ica l d isp la ce m e n t p a tte rn s.
No n o p e ra tive tre a tm e n t o fte n re su lts in p a in fu l n o n u n io n o r
m a lu n io n w ith re stricte d ra n ge o f m o tio n . Pe rcu ta n e o u s p in -
n in g m a y re su lt in lo ss o f in itia l re d u ctio n , w h ile p la tin g w ith
tra d itio n a l im p la n ts m a y n o t b e sta b le in o ste o p o ro tic b o n e .

Fig 6 .1.2 -2 a – b
De fo rm in g fo rce s a ctin g o n th e fra gm e n ts th e su p ra sp in a tu s
p u lls th e gre a te r tu b e ro sit y in to a b d u ctio n , th e su b sca p u la ris
p u lls th e le sse r tu b e ro sit y in to m e d ia l ro ta tio n , a n d th e p e c-
to ra lis m a jo r p u lls th e sh a ft in to m e d ia liza tio n .

a b

235
 6 .1 Hu m e ru s , p ro xim a l

In d ica t io n (co n t)

c d

Fig 6 .1.2 -3 a – d Exa m p le s o f fa ile d o ste o syn th e sis.

a No n u n io n a fte r n o n o p e ra tive tre a tm e n t.
b Lo o se n in g a n d m igra tio n o f p in s w ith lo ss o f re d u ctio n .
c– d Se co n d a ry lo ss o f re d u ctio n w ith co n ve n tio n a l p la te d u e to
in a d e q u a te sta b ilit y.
a b

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• Lo ckin g p ro xim a l h u m e ra l p la te ( LPHP) An tib io tics: sin gle d o se 2 n d ge n e ra tio n
3 .5 , 5 h o le s ce p h a lo sp o rin
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d Th ro m b o sis p ro p h yla xis: n o n e
scre w s (LHS)
• 3 .5 m m co rte x scre w s Im a ge in te n si e r o n sa m e sid e a s
• 2 .0 m m K-w ire s o p e ra tin g te a m , a b le to s w in g 9 0 º
• No n a b so rb a b le su tu re s w ith o u t m o vin g th e a rm .
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Fig 6 .1.2 -4 Se m i b e a ch ch a ir p o sitio n

w ith a rm fre e ly m o ve a b le .

236
 6 .1.2 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h ro t a t o r y d is p la ce m e n t o f t h e e p ip h ys is —11-B2

2 Su rgica l a p p ro a ch

Fig 6 .1.2 -5 a – b
a Deltopectoral approach , ceph alic vein protected
m ed ially. Th e bicipital groove an d ten don are
u sefu l lan d m arks.
b No violation of th e rotator cu ff. Th ere is a sm all
risk of in ju rin g th e axillary artery a n d axillary
n er ve.

a b

3 Re d u ct io n

a b c d

Fig 6 .1.2 -6 a – d
a – b Gen tle redu ction w ith th e aid of bon e spikes to derotate
th e tu berosity segm en t an d to align th e cer vicotu bercu -
lar cortex, especially th e m edial calcar.
c– d Hold th e redu ction tem porarily w ith at least two K-
w ires in two d ifferen t plan es. Ch eck w ith th e im age
in ten si er to con rm redu ction , axial an d rotation al
align m en t.

237
 6 .1 Hu m e ru s , p ro xim a l

3 Re d u c t io n (co n t )

a b

Fig 6 .1.2 -7a – b

a Metaph yseal com m in u tion m ay be brou gh t togeth er by forceps an d in traosseou s su tu res.
b Su tu res tied to tu bercles an d brou gh t th rou gh su tu re h oles on th e plate n eu tralize m u scle
ten sion an d h elp to m ain tain redu ction . A d isplaced fractu re can be redu ced u sin g th e plate
as a redu ction tool.

4 Fixa t io n
5 mm

5 mm

a b c

Fig 6 .1.2 -8 a – c
a Apply th e lock in g prox im al h u m eral plate (LPHP) 3.5 b–c Fix th e plate on to th e cortex of th e sh aft w ith on e 3.5 m m
w ith 5 h oles to th e an terolateral cortex 5 m m cau dal to cortex screw at th e secon d m ost proxim al com bin ation
th e prox im al en d of th e greater tu bercle an d abou t 5 m m h ole. Ch eck w ith th e im age in ten si er to con rm posi-
dorsal to th e lateral edge of th e bicipital groove, w ith tion an d to exclu de overh an g on th e sides.
d rill sleeves attach ed to th e plate as h an d les th rou gh th e
gu id in g block.

238
 6 .1.2 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h ro t a t o r y d is p la ce m e n t o f t h e e p ip h ys is —11-B2

4 Fixa t io n (co n t )

c
a b

Fig 6 .1.2 -9 a – d
a Fix th e prox im al (h ead an d n eck) segm en t w ith fou r 3.5 m m self-
tappin g lock in g h ead screw s in an gu lar fash ion w ith th e aid of th e
gu id in g block.
b Depen d in g on th e degree of m etaph yseal com m in u tion an d bon e
qu ality, th e m ost prox im al com bin ation h ole can be lled w ith a cor-
tex screw or a lock in g h ead screw in a cran ial d irection as a trian gu -
lation screw, or it can be left em pty. Rem ove all K-w ires. Fill th e th ree
d istal h oles w ith cortex screw s or lock in g h ead screw s.
c Check w ith the im age inten si er for align m ent of the whole con struct.
d En su re free arm m otion before sk in closu re.

239
 6 .1 Hu m e ru s , p ro xim a l

5 Re h a b ilit a t io n

a b c d

Fig 6 .1.2 -10 a – d

a Clin ical pictu re after 6 weeks.
b – c Postoperative x-ray after 2 weeks.
d Clin ical pictu re after 18 weeks.

a b a b

Fig 6 .1.2 -11a – b Postoperative x-rays after 8 m on th s. Fig 6 .1.2 -12 a – b Postoperative x-rays after 1 year.
a AP view. a AP view.
b Axial view. b Axial view.

Add ition al im m obilization : arm slin g for com fort.

Ph ysioth erapy: pen du lu m exercises from rst postoperative
day. Gen tle passive an d active-assisted m obilization exercises
u n der su pervision of a ph ysioth erapist by th e rst week.
Ph arm aceu tical treatm en t: an algesics if requ ired.

24 0
 6 .1.2 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h ro t a t o r y d is p la ce m e n t o f t h e e p ip h ys is —11-B2

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t
In secu re tem porary xation m ay pu sh th e proxim al seg-
m en t in to varu s, especially in osteoporotic bon e.
Eq u ip m e n t
Th e plate can be u sed to redu ce th e fractu re. Plate pre-
con tou red to an atom y. Preset screw placem en t orien tation
provides an gu lar stability. LHS are good for osteoporotic
bon e.

Ap p ro a ch Ap p ro a ch
Open approach m ay add dam age to vascu larity in th is Direct assessm en t of vascu larity th rou gh an open ap-
fractu re. proach , proceed to h em iarth roplasty in elderly patien ts if
com plete disru ption .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Ax illary n er ve an d arter y m ay be in dan ger. Metaph yseal Addition al fragm en ts m ay be xed by
Fig 6 .1.2 -13 a – b
com m in u tion is d if cu lt to con trol. in traosseou s su tu res brou gh t th rou gh su tu re h oles in th e
plate.

241
 6 .1 Hu m e ru s , p ro xim a l

6 Pit fa lls (co n t ) – 7 Pe a rls (co n t ) +

Re h a b ilit a t io n Re h a b ilit a t io n
Too early overzealou s exercise in type C fractu res m ay Th e on ly im plan t th at en ables im m ed iate m obilization
resu lt in loss of redu ction . w ith th e poten tial to restore best possible m obility.

242
 Au t h o r Re t o Ba b s t

6 .1.3 Extraarticular bifocal proxim al hum e ral fracture without

m e taphyse al im paction —11-B2
1 Ca s e d e s crip t io n

69-year-old m an was cau gh t in a m ach in e an d

ex perien ced rapid torsion of th e u pper extrem ity
cau sin g an open deglovin g wou n d arou n d th e el-
bow an d a ru ptu re of th e brach ioradial n er ve.
Th e prox im al hu m eru s su stain ed a 3-part fractu re,
in itially sligh tly d isplaced an d was rst treated
con servatively.
Th e x-ray revealed a secon dar y d isplaced h ead
fragm en t w ith m in im al d isplacem en t of th e great-
er tu bercle, an im pression between th e greater tu -
bercle an d th e bicipital groove, an d an exten sion
of th e fractu re th rou gh th e lesser tu bercle, w ith an
add ition al m etaph yseal fragm en t below th e lesser
tu bercle.

Fig 6 .1.3 -1a – b

a AP view.
b Axial view.
a b

In d ica t io n

Re le va n t d islo ca tio n w ith th e d a n ge r o f va scu la r co m p ro m ise o f th e h u m e ra l h e a d

d u e to th e d isp la ce m e n t. Co n sid e r 2 -D o r 3 -D CT sca n fo r p ro p e r p re o p e ra tive
p la n n in g.

243
 6 .1 Hu m e ru s , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• PHILOS p ro xim a l h u m e ra l p la te 3 .5 , 3 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .0 m m K-w ire s
• Bo n e p u n ch
• Stro n g n o n a b so rb a b le su tu re s
• Eq u ip m e n t fo r b o n e gra ft h a rve stin g a b
• Op tio n a l: ca lciu m trip h o sp h a te b o n e su b stitu te in b lo ck fo rm
(Size o f s yste m , in stru m e n ts,
Fig 6 .1.3 -2 a – b Th e b e a ch ch a ir p o sitio n w ith a n a d d itio n a l
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.) ta b le a llo w s th e a rm to b e p o sitio n e d in a b d u ctio n . Th e d e lto id
m u scle is th e re fo re n o t u n d e r te n sio n w h ich a lso e a se s th e
Pa t ie n t p re p a ra t io n a n d p o s it io n in g a p p ro a ch to th e p o s te rio r p a rts o f th e gre a te r tu b e rcle .
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin a Be a ch ch a ir p o sitio n .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin b Be a ch ch a ir p o sitio n w ith a n a d d itio n a l ta b le .

2 Su rgica l a p p ro a ch

A sligh tly cu r ved in cision , startin g

Fig 6 .1.3 -3 a – b
below th e coracoid process, of 6 –8 cm is u su ally
su f cien t. Care sh ou ld be taken to spare th e ce-
ph alic vein , wh ich is left on th e lateral side. Th e
clavipectoral fascia is in cised lateral to th e con join t
ten don .

a b

24 4
 6 .1.3 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h o u t m e t a p h ys e a l im p a ct io n —11-B2
3 Re d u ct io n a n d fixa t io n
a b
d e
Fig 6 .1.3 -4 a – g
a – b Th e tu bercles are tted w ith 6.0 m m su tu res as ten -
sion ban ds to h elp redu ction . Th ey can be u sed at th e
en d of th e xation to ten sion ban d th e tu bercles again st
th e plate. Two K-w ires are placed as an orien tation aid
5 m m below th e top of th e greater tu bercle an d 2 –5 m m
lateral to th e bicipital groove.
c Th e fractu re is th en approxim ately redu ced th rou gh th e
fractu re gap w ith th e h elp of a bon e spreader an d/or
traction on th e arm .
d Th e PHILOS plate is n ow brou gh t on to th e sh aft by in -
sertin g th e ten sion ban d su tu res th rou gh th e prepared
h oles in th e plate. Th e plate is th en xed w ith a cortex
screw th rou gh th e glid in g h ole again st th e sh aft. Wh en
tigh ten in g th e screw, th e h ead fragm en t is h eld w ith th e
c
Vid e o
6 .1-1
f g
ten sion ban d su tu res (or w ith a poin ted redu ction for-
ceps again st th e plate). Redu ction is th en ach ieved w ith
th e plate
e Th e aim in g device (th readed d rill sleeve) is th en attach ed
to th e plate an d th e redu ction is m ain tain ed w ith blocked
2.5 m m K-w ires.
f– g Redu ction is con trolled w ith th e im age in ten si er in AP/
ax ial view.
Wh en an atom ical align m en t is ach ieved, th e lock in g h ead
screws are in serted accord in g to th e n eeds of th e fractu re pat-
tern . Th e screw s in th e sh aft can eith er be lock in g h ead screw s
or cortex screw s. If we u se th e latter in osteopen ic bon e th ey
sh ou ld be directed sligh tly obliqu ely, to get m ore th reads en -
gaged in th e th in osteopen ic cortex.
245
 6 .1 Hu m e ru s , p ro xim a l

4 Re h a b ilit a t io n

c e

a b dc

Postoperative im m obilization w ith a Gilch rist ban dage du rin g Fig 6 .1.3 -5 a – e
th e n igh t; du rin g th e day a sim ple slin g for 6 weeks is recom - a – b Postoperative x-rays 1 year after operation . Th e rst
m en ded. screw th rou gh th e glid in g h ole is too lon g sin ce it was
Ph ysioth erapy: fu n ction al reh abilitation w ith active-assisted u sed to redu ce th e fractu re w ith th e plate. No sign s of
m ovem en ts w ith a ph ysioth erapist as of th e rst postopera- osteon ecrosis.
tive day. c– e The patient h as regained an almost fu ll ran ge of motion .
Weigh t bearin g after 6 weeks an d active an d resistive
train in g.
Im p la n t re m o va l
Ph arm aceu tical treatm en t: an algesics depen d in g on th e
After 8 –12 m on th s if sym ptom atic.
postoperative pain .

5 Pit fa lls – 6 Pe a rls +

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Fig 6 .1.3 -6 For elderly patien ts

th e beach ch air position m ay be
h azardou s for cerebral perfu sion ,
th erefore a su pin e position on
a rad iolu cen t table u sin g a side
table allow s exactly th e sam e
access for ORIF of th e proxim al
h u m eru s as th e beach ch air posi-
tion .

24 6
 6 .1.3 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h o u t m e t a p h ys e a l im p a ct io n —11-B2

5 Pit fa lls – (co n t ) 6 Pe a rls + (co n t )

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Placin g th e PHILOS plate too h igh w ill cau se an im pin ge-
Fig 6 .1.3 -7Pu t K-w ires in th e
m en t.
plan n ed position of th e plate.
Th e red spots m ark th e prox im al
Redu ction of th e h ead fragm en t w ith ou t m ain tain in g its
an d an terior borderlin e of th e plate.
position again st th e plate w ill easily resu lt in a varu s posi-
tion .

If th ere is com m inu tion on th e m edial side of th e n eck,

th e h ead fragm en t ten ds to fall in to varu s. Fig 6 .1.3 -8Main tain th e h ead posi-
Vid e o
tion w ith K-w ires. Th is can also 6 .1-1
Vigorou s redu ction m an eu vers w ith redu ction forceps be ach ieved by 2.5 m m th readed
h ave th e poten tial to devascu larize th e h ead fragm en t. K-w ires locked w ith clam ps from
m in i extern al xator set.

a b
Use d irect redu ction tech n iqu es th rou gh
Fig 6 .1.3 -9 a – b
th e fractu re gap, x th e h ead fragm en ts tem porarily
an d th en u se th e plate to obtain redu ction , especially in
3- an d 4-part fractu res.
A K-w ire m ed ially d irected to su pport th e h ead fragm en t
u n til th e proxim al LHS are position ed can h elp to m ain -
tain th e correct position .
Also, ten sion ban d su tu res secu re th e fragm en ts again st
th e plate an d h elp to h old th e tu bercle an d th e h ead in
position .

247
 6 .1 Hu m e ru s , p ro xim a l

24 8
 Au t h o r Mich a e l J Ga rd n e r, De a n G Lo rich , Da vid L He lfe t

6 .1.4 Extraarticular bifocal proxim al hum e ral fracture with

proxim al diaphyse al e xte nsion —11-B2
1 Ca s e d e s crip t io n

21-year-old active fem ale fell from a h eigh t an d lan ded on h er

left side. Sh e su stain ed a spiral prox im al h u m eral fractu re
an d a greater tu berosity fractu re. Sh e also su stain ed several
lu m bar vertebral fractu res.

Fig 6 .1.4 -1a – b

a AP view.
b Axial view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

Extraarticular proxim al hum e ral Eq u ip m e n t

ne ck fracture with a displace d
proxim al diaphyse al fragm e nt and
poste rom e dial butte r y fragm e nt.
The displace m e n t, as we ll as the
fracture obliquity, m ake this frac-
ture ve ry unstable and m andate s
re duction and xation .
• PHILOS p ro xim a l h u m e ra l p la te
3 .5 , 5 h o le s
• Re co n s tru ctio n p la te 3 .5 , 5 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .0 m m K-w ire s w ith th re a d e d tip
• No n a b so rb a b le su tu re s
(Size o f s yste m , in s tru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d
p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: n o n e
a b
Fig 6 .1.4 -2 a – b Th e p a tie n t is p la ce d in th e b e a ch ch a ir
p o sitio n , w ith th e b a ck e le va te d 3 0 ° fro m th e h o rizo n ta l,
a n d w ith th e in ju re d a rm fre e fro m th e e d ge o f th e ta b le .
Th e le ft sh o u ld e r a n d a rm p re p p e d a n d fre e d ra p e d fo r
in tra o p e ra tive m o b ilit y.

249
 6 .1 Hu m e ru s , p ro xim a l

2 Su rgica l a p p ro a ch

8 cm in cision from th e an terolateral corn er of th e acrom ion .

Acro m io n Iden tify th e an terior deltoid raph e. Sh ar ply d ivide th e raph e,
begin n in g proxim ally.
Iden tify th e ax illary n erve m otor bran ch an d posterior h u -
m eral circu m ex arter y, w h ich cross th e hu m eru s approxi-
m ately 6.5 cm from th e u n dersu rface of th e acrom ion an d
3.5 cm from th e lateral prom in en ce of th e greater tu berosity.
Protect th e n eu rovascu lar bu n d le w ith a vessel loop. Exten d
Axilla ry raph e in cision d istally dow n th e hu m eral sh aft as n ecessar y.
n e rve
Fig 6 .1.4 -3 a – b Exten ded an terolateral acrom ial approach .
a Dissection in a cadaver u sin g th e exten ded an terolateral
acrom ial approach dem on strates th e appearan ce of th e an -
terior deltoid raph e.
b Splittin g the raphe in a cadaver reveals the axillary nerve,
w ith no branches other th an the m ain anterior motor branch
a b crossing at th is level.

3 Re d u ct io n a n d fixa t io n

• Use th readed 2.0 m m K-w ires as joysticks in th e h ead frag- • Use th readed K-w ires to redu ce an d stabilize th e greater tu -
m en t to redu ce th e fractu re. Pay close atten tion to len gth , berosity, an d place th e proxim al en d of th e plate to bu ttress
rotation , an d align m en t. th e fragm en t. Usin g a free n eed le, pass th e su tu res th rou gh
• Attach th e aim in g device to th e plate an d slide it d istally th e rotator cu ff ten don s to su pplem en t xation . Th ese act as
alon g th e h ead an d sh aft u n dern eath th e axillary n er ve an d ten sion ban ds to in d irectly redu ce an d stabilize th e tu ber-
vessel. osity an d h ead fragm en ts to th e sh aft.
• Loop n on absorbable su tu res th rou gh th e sm all h oles in th e
proxim al part of th e plate.
• In sert cortex screw s in to th e d istal sh aft fragm en t to stabi-
lize th e plate on th e bon e d istally.
• Use K-w ires to redu ce th e fractu re an d for tem porary xa-
tion .
• Attach th readed gu ides to th e prox im al part of th e plate,
an d in sert K-w ires in to th e hu m eral h ead provision ally.
• Rech eck redu ction w ith th e im age in ten si er. Axilla ry
• In sert lock in g h ead screw s th rou gh th e plate in to th e hu - n e rve
m eral h ead.
• In th e case of an obliqu e or spiral fractu re w ith exten sion Fig 6 .1.4 -4 In traoperatively, th e plate was slid u n dern eath
to th e proxim al d iaphysis, place a recon stru ction plate an - th e protected ax illary n er ve. Th e h oles in th e plate are u sed
ter iorly at th e apex of th e spike to bu ttress th e redu ction . for su tu res to ten sion ban d th e rotator cu ff ten don s to en -
h an ce stability.

250
 6 .1.4 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h p ro xim a l d ia p h ys e a l e xt e n s io n —11-B2

4 Re h a b ilit a t io n

Apply sterile d ressin gs an d place th e extrem ity in slin g im m obiliza-

tion .
Ad m in ister proph ylactic postoperative an tibiotics for 24 h ou rs.
Ph ysioth erapy: begin gen tle active an d passive ran ge of m otion im -
m ed iately on postoperative day on e. A con tinu ou s passive m otion
m ach in e is often h elpfu l to preven t stiffn ess.

5 m on th s postoperatively. Sign i can t h ealin g of th e

Fig 6 .1.4 -5 a – b
fractu re an d m ain ten an ce of im plan t position is seen .

Im p la n t re m o va l
If the fractu re is healed and the im plant becomes symptom atic, it m ay be
a b removed th rough a sim ilar approach at a m in imu m of 12 month s.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e m ain risk w ith th is approach is dam age to th e an te- Th is su rgical approach is a m ore direct and less-invasive
rior m otor bran ch of th e axillary n er ve at th e level of th e approach to proxim al hu m eral fractu res and is particu larly
deltoid raph e. u sefu l for greater tu berosity fractu res. It allows direct ac-
cess to the lateral m etaphysis wh ile requ irin g less soft-tis-
su e strippin g. Th e neu rovascu lar bu n dle mu st be sou gh t,
based on an atom ical lan dm arks, th rou gh carefu l dissec-
tion . Alth ou gh the posterior hu m eral circu m ex artery
con tributes to on ly a sm all portion of the hu m eral h ead
blood su pply, th is sh ou ld be protected as well.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e ax illary n er ve an d vessel m ay be in ju red du rin g h ard- Th e n eu rovascu lar bu n d le m u st be visu alized an d h an d led
ware an d fractu re m an ipu lation . carefu lly du rin g m an ipu lation .

Re h a b ilit a t io n Re h a b ilit a t io n
Prolon gin g ph ysioth erapy m ay lead to sh ou lder dysfu n c- A carefu l balan ce between early ph ysioth erapy to preven t
tion an d aggressive th erapy m ay lead to xation failu re. sh ou lder stiffn ess, an d gen tle m obilization to avoid stress-
in g th e im plan t m u st be fou n d.

251
 6 .1 Hu m e ru s , p ro xim a l

252
 Au t h o r Ja m e s P St a n n a rd

6 .1.5 Extraarticular bifocal proxim al hum e ral fracture with

gle nohum e ral dislocation —11-B3
1 Ca s e d e s crip t io n In d ica t io n

Mo st p roxim a l h u m e ra l fra ctu re s a re lo w e n e rgy in ju rie s

w ith m in im a l d isp la ce m e n t a n d a re su ita b le fo r n o n o p -
e ra tive tre a tm e n t. Th e a d va n ta ge s o f n o n o p e ra tive tre a t-
m e n t in clu d e a lo w e r co m p lica tio n ra te a n d a cce p ta b le
fu n ctio n a l o u tco m e a s lo n g a s th e fra ctu re h a s a d e q u a te
sta b ilit y to a llo w e a rly m o tio n o f th e sh o u ld e r. Disa d va n -
ta ge s o f th e n o n o p e ra tive a p p ro a ch in clu d e fre q u e n t lo ss
o f so m e m o tio n , p rim a rily fo rwa rd e xio n a n d a b d u ctio n
a b o ve sh o u ld e r h e igh t.

In d ica tio n s fo r su rgica l tre a tm e n t in clu d e :

a b
Fig 6 .1.5 -1a – c
a AP view.
b Tru e AP view.
c Axillary lateral view.
• d isp la ce d 2 -, 3 -, o r 4 -p a rt fra ctu re s th a t ca n n o t b e re -
d u ce d to a sta b le p o sitio n u sin g clo se d re d u ctio n ,
• m e d ia l co m m in u tio n a n d in sta b ilit y,
• irre d u cib le fra ctu re d islo ca tio n s,
• h e a d sp littin g fra ctu re s, a n d
• o p e n p roxim a l h u m e ra l fra ctu re s.
Re la tive in d ica tio n s in clu d e :
• m u ltip le tra u m a p a tie n ts w h o n e e d p a rtia l u se o f th e ir
u p p e r e xtre m it y fo r we igh t b e a rin g,
• b ila te ra l p roxim a l h u m e ra l fra ctu re s,
• fra ctu re d islo ca tio n s, a n d
• d o m in a n t a rm in yo u n ge r, a ctive p a tie n ts.

c Ad va n ta ge s o f su rgica l tre a tm e n t o f u n sta b le fra ctu re s in -

36-year-old wom an fell on h er righ t dom in an t sh ou lder in a m otorcycle
acciden t.
Type of in ju r y: h igh -en ergy. Mu ltiple trau m a: liver laceration .
Closed h ead in ju r y, sh ou lder d islocation , closed fractu re.
clu d e im p ro ve d re sto ra tio n o f th e a n a to m y o f th e p roxi-
m a l h u m e ru s a n d im p ro ve d sta b ilit y to a llo w e a rly m o -
tio n o f th e sh o u ld e r. Disa d va n ta ge s in clu d e a n in cre a se d
in cid e n ce o f co m p lica tio n s su ch a s: in fe ctio n , n o n u n io n ,
h a rd wa re co m p lica tio n s, h e te ro to p ic o ssi ca tio n , a n d
o ste o n e cro sis o f th e h u m e ra l h e a d .

253
 6 .1 Hu m e ru s , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• PHILOS p ro xim a l h u m e ra l p la te 3 .5 , 3 h o le s An tib io tics: ce p h a lo sp o rin
• 3 .5 m m lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
• K-w ire s
• Su tu re s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Fig 6 .1.5 -2 Th e m o st u se fu l p o sitio n fo r th e p a tie n t is to b e e ith e r

su p in e o r in th e b e a ch ch a ir p o sitio n w ith a ro ll u n d e r th e a ffe cte d
sh o u ld e r e le va tin g th a t sid e a p p ro xim a te ly 3 0 º. A ra d io lu ce n t ta b le sh o u ld
b e u se d to a llo w x-ra y vie w s to b e o b ta in e d . Th e e n tire a rm re ce ive s
a s te rile p re p a ra tio n a n d is d ra p e d fre e so th a t it is fre e ly m o b ile . Th is
p o sitio n a llo w s th e su rge o n a n d a ssista n ts to h a ve fu ll a cce ss to th e
p ro xim a l h u m e ru s w h ile sign i ca n tly im p ro vin g th e a b ilit y to o b ta in
a p p ro p ria te x-ra ys u sin g th e im a ge in te n si e r.

2 Su rgica l a p p ro a ch

Fig 6 .1.5 -3 a – b
a Deltopectoral approach . Th e in cision is m ade in a straigh t
10 –15 cm lin e from ju st above th e coracoid process in th e
lin e of th e deltopectoral groove.
b Th e in tern er vou s plan e is between th e deltoid m u scle (ax-
illar y n er ve) an d th e pectoralis m ajor mu scle (m ed ial an d
lateral pectoral n er ve).
Th e deep an atom y is frequ en tly distorted du e to th e trau -
m a. Th e sh ort h ead of th e biceps an d th e coracobrach ialis
mu scle are both retracted m ed ially, allow in g access to th e
an terior part of th e sh ou lder. Ben eath th ese m u scles are
th e tran sversely orien ted bers of th e su bscapu laris m u s-
cle, w h ich form s th e on ly rem ain in g an terior coverin g of
th e join t capsu le. If th is m u scle h as n ot already been torn
from its in sertion , it w ill h ave to be released an d tagged
w ith stay su tu res for repair at th e en d of th e case.
a b

254
 6 .1.5 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h gle n o h u m e ra l d is lo ca t io n —11-B3

2 Su rgica l a p p ro a ch (co n t )

Th e ceph alic vein is iden ti ed an d gen erally retracted later- Dan gers of th is approach in clu de th e m u scu locu tan eou s
ally alon g w ith th e deltoid m u scle. Th e pectoralis m ajor is re- n er ve, an d th e axillary n erve at th e in ferior border of th e su b-
tracted m edially. scapu laris ten don .
It is frequ en tly h elpfu l to gen tly place a blu n t retractor su peri-
orly an d posteriorly to h elp redu ce th e greater tu berosity back
to th e rem ain der of th e hu m eral h ead.

3 Re d u ct io n

a b c d

e f
Fig 6 .1.5 -4 a -f
a Gen tle redu ction of th e h u m eral h ead from su bcoracoid
dislocation u sin g lon gitu din al traction com bin ed w ith
m an ipu lation from eith er th e su rgeon ’s n ger or a blu n t
in stru m en t, su ch as a blu n t Hoh m an n retractor, arou n d
th e h ead of th e h u m eru s.
b Carefu lly place th e blu n t Hoh m an n retractor arou n d th e
greater tu berosity to assist in redu ction of th e tu berosity
an d im prove visu alization .
Redu ce th e sh aft to th e hu m eral h ead u sin g traction
w ith assistan ce from th e ball spike if n ecessary.
c– d Hold th e redu ction of th e fractu re by placin g tem porary
K-w ires to stabilize th e sh aft an d greater tu berosity to
th e h u m eral h ead.
e – f Pin plate in place w ith K-w ires after ch eck in g th e redu c-
tion an d m ak in g adju stm en ts as n ecessar y.

255
 6 .1 Hu m e ru s , p ro xim a l

4 Fixa t io n

a b c

Fig 6 .1.5 -5 a – j
a – b Th read th e 2.8 m m d rill gu ide in to th e PHILOS plate, an d drill
w ith a 2.8 m m d rill bit to th e su bch on d ral bon e. Th is step sh ou ld
be don e u sin g im age in ten si cation in both th e AP an d lateral
plan es by rotatin g th e im age in ten si er. After com pletin g th e drill-
in g, rem ove th e drill gu ide an d m easu re th e screw len gth u sin g a
stan dard sm all fragm en t depth gau ge.
c Apply a lock in g h ead screw (LHS) u sin g
power w ith th e torqu elim itin g attach -
m en t to th e screwdriver. Th e n al tigh t-
en in g m u st be don e by h an d u sin g th e
torqu e-lim itin g screwdriver.

d e f g

d–e Th e process is th en repeated placin g m u ltiple f– g Th e d iaphyseal screw s are placed th rou gh th e com bin a-
screw s at d ivergen t an gles. tion h oles th at can be eith er lock in g h ead screw s or cor-
tex screw s, depen d in g u pon th e fractu re pattern , th e bon e
qu ality, an d su rgeon ’s preferen ce.

256
 6 .1.5 Ext ra a rt icu la r b ifo ca l p ro xim a l h u m e ra l fra ct u re w it h gle n o h u m e ra l d is lo ca t io n —11-B3

4 Fixa t io n (co n t )

h i j

Fig 6 .1.5 -5 a -j (co n t)

h – j Holes h ave been m anu factu red in to th e proxim al plate to allow
placem en t of su tu res to redu ce an d stabilize large fragm en ts n ot
captu red by th e lock in g plate an d screw s. Su tu re stabilization was
very h elpfu l w ith on e large fragm en t in th is case.

Irrigate th e su rgical site an d close th e wou n d.

5 Re h a b ilit a t io n

Addition a l im m obilization : slin g or sh ou lder im m obilizer for com fort

on ly.
Mobilization : passive m obilization after on e day. Active m obilization af-
ter 4 weeks.
Ph ysioth erapy: begin n in g on rst postoperative day.

257
 6 .1 Hu m e ru s , p ro xim a l

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Redu ction can be d if cu lt to ach ieve w ith 3- an d 4-part A ball spike can aid in obtain in g th e redu ction . Also, u se
fractu res. tem porar y K-w ires an d a blu n t Hoh m an n retractor over
th e greater tu berosity to obtain an adequ ate redu ction .

Fig 6 .1.5 -6Hoh m an n

retractor over th e
tu berosity.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Be aware of m edial colu m n com m inu tion . Th e fractu re Th e rst h ole com in g dow n th e sh aft is oblon g an d allow s
w ill ten d to fall in to a varu s m al- or n onu n ion if lock in g th e plate to be m oved a sh ort d istan ce eith er prox im ally
h ead screw s th at approach th e su bch on dral bon e are n ot or distally as n eeded to im prove th e t.
u sed.
Use a su tu re th rou gh th e plate h oles an d at th e in sertion
Altern atively, attach th e aim in g device to th e prox im al of th e su praspin atu s to stabilize th e greater tu berosity or
en d of th e plate an d u se th e triple trocar system to place a oth er m ajor fragm en ts if th ey are n ot stabilized adequ ately
w ire an d m easu re th e screw len gth . It is preferred to u se by th e plate an d screw s.
th e tech n iqu e described above in th is case rath er th an th e
tech n iqu e h ere, becau se th e aim in g device is bu lky an d Fig 6 .1.5 -7 Su tu re
requ ires m ore exten sive ex posu re an d con sequ en t soft-tis- xation .
su e strippin g.

Re h a b ilit a t io n Re h a b ilit a t io n
Early m otion begin n in g on postoperative day nu m ber on e
is critical to th e n al resu lt. Adequ ate stability m u st be
ach ieved to allow early m otion .

258
 Au t h o r No rb e r t Sü d k a m p

6 .1.6 Intraarticular proxim al hum e ral fracture with slight

displace m e nt—11-C1
1 Ca s e d e s crip t io n

55-year-old m an h ad a fall du rin g sk iin g resu ltin g in low en -

ergy m on otrau m a an d closed fractu re.

Fig 6 .1.6 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n

Th is va lgu s im p a cte d 3 -p a rt fra ctu re is a n in d ica tio n fo r su rge ry in th is

a ge gro u p (e ve n in e ld e rly p a tie n ts) —if th e re is a fu n ctio n a l d e m a n d .
Re sto ra tio n o f th e a n a to m y o f th e p ro xim a l h u m e ru s is a p re re q u isite
fo r co rre ct fu n ctio n o f th e ro ta to r cu ff a n d th e sh o u ld e r jo in t.
To fu lly a n a lyze th e e xte n t o f th e in ju ry, it is u su a lly n e ce ssa ry to co n -
d u ct a CT sca n fro m th e in ju ry re gio n .
Ne ve rth e le ss, a co n se rva tive tre a tm e n t co u ld b e d iscu sse d in su ch
a ca se . Ad va n ta ge s, d isa d va n ta ge s, a n d p ro b a b le o u tco m e s o f th e
d iffe re n t tre a tm e n t o p tio n s h a ve to b e d iscu sse d w ith th e p a tie n ts to
e n a b le th e m to m a ke th is p e rso n a l ch o ice .

Fig 6 .1.6 -2 CT sca n s o f th e va lgu s im p a cte d 3 -p a rt fra ctu re .

259
 6 .1 Hu m e ru s , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• Lo ckin g p ro xim a l h u m e ra l p la te (LPHP), 5 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 1.8 m m K-w ire s
• Re d u ctio n fo rce p s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 6 .1.6 -3 Su p in e p o sitio n o f th e p a tie n t w ith se p a ra te

a rm re st.

2 Su rgica l a p p ro a ch

Fig 6 .1.6 -4 a – bDeltopectoral approach .

Th e an terior approach in th e delto-
pectoral groove is u sed. Startin g at th e
coracoid process, a sk in in cision of ap-
proxim ately 10 cm is perform ed alon g
th e deltopectoral groove.
Th e su bcu tan eou s tissu e is split. Th e
m u scle fascia is in cised an d th e ceph alic
vein is prepared. Th e vein w ill be kept
to th e lateral side w ith th e deltoid m u s-
cle sin ce it is th e drain in g vein for th e
deltoid. Th e m u scles are split an d th e
proxim al hu m eru s exposed. Th e frag-
m en ts are carefu lly treated so as n ot to
violate th e vascu lar su pply of th e at-
tach ed soft tissu es.

a b

26 0
 6 .1.6 In t ra a rt icu la r p ro xim a l h u m e ra l fra ct u re w it h s ligh t d is p la ce m e n t—11-C1

3 Re d u ct io n

Redu ction
Fig 6 .1.6 -5 a – c
w ith an elevator th rou gh th e
fractu re an d in direct redu c-
tion w ith th e h elp of th e
lockin g proxim al hu m eral
plate an d a 3.5 m m cortex
screw.

a b c

To ease redu ction , lon g-term absorbable su tu res are placed in
all th ree ten don s of th e rotator cu ff. Next to th e su tu res an
elevator can be in serted th rou gh th e fractu re, w ith w h ich th e
fragm en t is m an ipu lated in to th e correct position . In som e
cases, th e plate th at is position ed lateral to th e bicipital groove
can also be u sed for in d irect redu ction to redu ce th e h ead
fragm en t from its valgu s position in to an an atom ical on e.
Redu ction can th en be m ain tain ed tem porarily w ith K-w ires
or a poin ted redu ction forceps. Th e lockin g proxim al hu m eral
plate can be xed to th e h ead fragm en t w ith K-w ires th rou gh
th e su tu re h oles in th e prox im al plate section .
Th e im age in ten si er is u sed to verify correct redu ction in
two plan es. If th e redu ction is n ot satisfactory, th ese steps are
repeated u n til th e redu ction is acceptable.

4 Fixa t io n

Fixation is th en perform ed w ith lock in g h ead screw s in th e proxim al part of th e

fractu re, u sin g th e appropriate drill gu ide. Care m u st be taken n ot to perforate th e
h ead or rath er th e cartilage w ith th e drill bit an d to h ave th e correct len gth s of
th e screw s so as n ot to in ju re th e join t du rin g early fu n ction al treatm en t w ith too
lon g screw s. Th e sh aft portion can be xed w ith 3.5 m m cortex screw s or lock in g
h ead screw s. In elderly patien ts w ith som e osteoporosis, lock in g h ead screw s are
preferred wh ile for you n ger patien ts w ith good bon e qu ality 3.5 m m cortex screw s
are u sed.

Fig 6 .1.6 -6 Fin ish ed xation u sin g lock in g h ead screw s. Su tu re xation is n ot yet
n ish ed at th is stage.

261
 6 .1 Hu m e ru s , p ro xim a l

4 Fixa t io n (co n t )

a b c

Th e xation is con trolled w ith th e im age in ten si er an d n ally th e Fig 6 .1.6 -7a – c
preposition ed su tu res are xed to th e plate. Th is in creases th e in tr in sic a Fin al resu lt w ith LPHP an d attach ed su tu res.
stability of th e con stru ct an d en h an ces stability of th e xation for early b Postoperative x-ray con trol, AP view.
fu n ction al postoperative treatm en t. c Postoperative x-ray con trol, lateral view.

5 Re h a b ilit a t io n

Postoperatively, th e arm was pu t in an arm slin g for 2 days

an d early fu n ction al postoperative treatm en t was started on
day th ree w ith pen du lu m exercises. Active-assisted an d pas-
sive m otion exercises. Add ition ally, a con tin u ou s passive m o-
tion m ach in e is advan tageou s.
Th rom bosis proph ylax is is term in ated after 5 days.

Fig 6 .1.6 -8 a – b Follow u p x-rays after 9 weeks.

a AP view.
b Lateral view.

a b

262
 6 .1.6 In t ra a rt icu la r p ro xim a l h u m e ra l fra ct u re w it h s ligh t d is p la ce m e n t—11-C1

5 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
Im plan t rem oval is n ot m an dator y. If n ecessary or desired by
th e patien t, it is u su ally perform ed after 3 –6 m on th s.

Fig 6 .1.6 -9 a – b Follow u p x-rays after 1 year.

a AP view.
b Lateral view.

a b

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t
In adequ ate preoperative im agin g m ay resu lt in poor
u n derstan d in g of th e fractu re pattern an d position of th e
fragm en t. In traoperative denu din g of fragm en ts for bet-
ter visu alization is n ecessary an d m ay resu lt in avascu lar
n ecrosis.
Re d u ct io n
In correct redu ction an d failu re to m ain tain redu ction is
m ostly du e to in adequ ate in traoperative im agin g. Usu ally
in th e beach ch air position , th e secon d plan e can on ly be
obtain ed w ith m ovem en t of th e arm —th is m ay resu lt in
loss of redu ction .
Fixa t io n
In correct in traoperative im agin g m ay also resu lt in im -
proper screw len gth s, wh ich th en perforate th e h ead. Th is
is on ly detected at postoperative x-ray con trol.
Violation of su bch on dral bon e in th e h ead area w ith th e
d rill bit can later resu lt in secon dary screw perforation
th rou gh th e h ead.
Eq u ip m e n t
With in creasin g experien ce on ly stan dard sh ou lder in -
stru m en ts an d th e in stru m en tation for th e LPHP/ PHI-
LOS are n ecessar y to su ccessfu lly com plete th e case. For
im proved in traoperative visu alization , th e su pin e position
u su ally allow s better access w ith th e im age in ten si er. A
lateral approach w ith two in cision s (sparin g th e axillar y
n erve) can also be con sidered.
Re d u ct io n
Prior to redu cin g th e fractu re it is advisable to in sert su -
tu res in to th e th ree ten don s of th e rotator cu ff. Pu llin g on
th ese su tu res im proves redu ction m an eu vers an d h elps to
m ain tain redu ction .
Fixa t io n
Th e u se of th e aim in g block im proves th e precision of
screw direction .

263
 6 .1 Hu m e ru s , p ro xim a l

26 4
 Au t h o r Fra n k ie Le u n g

6 .1.7 Intraarticular proxim al hum e ral fracture with valgus

m alalignm e nt—11-C2
1 Ca s e d e s crip t io n

69-year-old wom an fell on level grou n d.

Type of in ju r y: low-en ergy, m on otrau m a.
Closed fractu re.

Fig 6 .1.7-1a – b
a AP view.
b Lateral view.

a b

In d ica t io n

Th e a rticu la r fra ctu re o f th e p ro xim a l h u m e ru s w ith va lgu s m a la lign -
m e n t is u n sta b le a n d p a in fu l. If le ft u n re d u ce d , th e fractu re w ill h e a l
w ith m a lu n io n ca u sin g sh o u ld e r stiffn e ss a n d p ro lo n ge d p a in .
Op e ra tive xa tio n re d u ce s th e a cu te p a in , a ch ie ve s a b e tte r re d u ctio n
o f th e fra ctu re , a n d a llo w s fo r e a rly m o b iliza tio n o f th e sh o u ld e r jo in t.
Ho we ve r, if th e fra ctu re is n o t sta b ly xe d th e re m a y b e a co m p lica -
tio n o f n o n u n io n a fte r su rgica l xa tio n , p a rticu la rly in th e a n a to m ica l
n e ck re gio n .
A lo ckin g p ro xim a l h u m e ra l p la te (LPHP) w ill b e th e im p la n t o f ch o ice
a s th e re is a n e e d fo r sta b le xa tio n o f b o th th e h u m e ra l h e a d a n d
th e d ia p h ysis.
An a lte rn a tive xa tio n m e th o d is b y w irin g in a gu re -o f-e igh t m a n -
n e r. Th e su rgica l d isse ctio n is th e sa m e b u t th e sta b ilit y a ch ie ve d w ill
b e le ss.
No n o p e ra tive tre a tm e n t is u se d o n ly in p a tie n ts u n su ita b le fo r su r-
ge ry. A co lla r a n d cu ff b a n d a ge ca n b e give n fo r 4 – 6 we e ks a n d su b -
se q u e n t sh o u ld e r stiffn e ss is e xp e cte d .

265
 6 .1 Hu m e ru s , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• Lo ckin g p ro xim a l h u m e ra l p la te (LPHP) 3 .5 , 5 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .0 m m K-w ire s
• Bo n e p u n ch
• Stro n g n o n a b so rb a b le su tu re s
• Eq u ip m e n t fo r b o n e gra ft h a rve stin g
• Op tio n a l: ca lciu m trip h o sp h a te b o n e su b stitu te in b lo ck fo rm
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: n o n e

Fig 6 .1.7-2 Be a ch ch a ir p o sitio n .

2 Su rgica l a p p ro a ch

Fig 6 .1.7-3 a – b
a Th e coracoid process is palpated an d
m arked. A stan dard deltopectoral
approach w ith a 10 –12 cm in cision
is u sed.
b Care mu st be taken to preserve the ce-
ph alic vein in order to decrease post-
operative edem a of the affected lim b.
Th e in terval between th e deltoid an d
pectoralis m ajor mu scle is developed.
Retraction of the deltoid mu scle later-
ally w ill expose the fractu re.

a b

26 6
 6 .1.7 In t ra a r t icu la r p ro xim a l h u m e ra l fra ct u re w it h va lgu s m a la lign m e n t—11-C2

3 Re d u ct io n

a b c d

Fig 6 .1.7-4 a – d
c Fix th e redu ced fractu re w ith th ree K-w ires.
a Place n on absorbable su tu res above th e greater tu berosity
d Ch eck th e redu ction w ith th e im age in ten si er. In osteopo-
in to th e ten don . Th e h u m eral h ead is redu ced w ith th e aid
rotic bon e th e K-w ire can be driven in to th e glen oid tem po-
of a bon e pu n ch .
rarily.
b Im age in ten si er sh ow s th e redu ction of th e hu m eral h ead
fragm en t. Make su re th at th e h ead fragm en t is su pported
by pu llin g dow n th e displaced greater tu berosity.

4 Fixa t io n

Fig 6 .1.7-5 a – i
a Place th e LPHP over th e an terolateral aspect of th e prox i-
m al hu m eru s an d x it tem porarily w ith a K-w ire placed
in to th e d iaph ysis. Th e su tu re h old in g th e greater tu beros-
ity is passed th rou gh on e of th e sm all h oles on th e plate.
b Th e position of th e plate is ch ecked w ith th e im age in -
ten si er. Avoid placin g th e plate too su periorly wh ich w ill
cau se sh ou lder im pin gem en t.

a b

267
 6 .1 Hu m e ru s , p ro xim a l

4 Fixa t io n (co n t )

c d e f

g h i

Fig 6 .1.7-5 a – i (co n t)

c In sert a 3.5 m m cortex screw in to th e h ole below th e an atom ical n eck fractu re. Th is w ill
greatly facilitate in sertion of th e rem ain in g screw s.
d Fix th e h u m eral h ead w ith a self-tappin g 3.5 m m LHS. Make su re th e drillin g is don e w ith
th e gu id in g block so th at proper lock in g of th e screw h ead is en su red. Th ere is n o n eed to
perforate th e articu lar su rface. Dedu ct 5 m m from th e m easu red len gth to avoid in adver-
ten t screw perforation of th e articu lar su rface.
e In sert th e rem ain in g LHS in to th e h u m eral h ead fragm en t. Ch eck th e screw len gth by im -
age in ten si cation .
f In sert LHS in to th e d iaph yseal portion . Bicortical screw s are u sed, except for th e m ost d is-
tal on e.
g Tie th e n on absorbable su tu re to secu re th e position of th e greater tu berosity.
h Ch eck th e position of th e screw s an d th e redu ction w ith th e im age in ten si er.
i Skin closu re.

26 8
 6 .1.7 In t ra a r t icu la r p ro xim a l h u m e ra l fra ct u re w it h va lgu s m a la lign m e n t—11-C2

5 Re h a b ilit a t io n

a b c d

Addition a l im m obilization : arm slin g. Fig 6 .1.7-6 a – d

Ph ysioth erapy: active-assisted exercise w ith th e ph ysioth era- a Postoperative x-ray after 6 weeks. AP view.
pist as of th e rst post operative day. b Postoperative x-ray after 6 weeks. Lateral view.
c Follow-u p x-ray after 15 m on th s. AP view.
d Follow-u p x-ray after 15 m on th s. Ax ial view.

26 9
 6 .1 Hu m e ru s , p ro xim a l

6 Pit fa lls – 7 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
It m ay be d if cu lt to pass su tu res th rou gh sm all h oles It is easier if su tu res are passed arou n d th e sm all h oles
on ce th e screw s are in serted. before an y screw xation .
Often , after th e h u m eral h ead is redu ced, th ere is a bon e Carefu l depth gau ge m easu rem en t an d con rm ation w ith
defect. th e im age in ten si er is recom m en ded.
Loss of xation of th e h u m eral h ead fragm en t can occu r if
th e screw s are too sh ort.

Fig 6 .1.7-7 Th e u se of au togen ou s corticocan cellou s bon e

graft from th e iliac crest or th e in sertion of a block of cal-
ciu m triph osph ate (wh ite arrow) w ill in crease th e stabil-
ity of th e xation an d en h an ce bon e h ealin g.

270
 Au t h o r Mich a e l Ple cko

6 .1.8 Intraarticular im pacte d proxim al hum e ral fracture

with displace m e nt—11-C2
1 Ca s e d e s crip t io n

a b c

75-year-old very active wom an , fell on th e stairs in h er h ou se. Lived alon e

before th e acciden t, d id all h ou sework an d garden in g by h erself. Un stable
pain fu l fractu re of h er left proxim al hu m eru s, n on dom in an t arm .
11–C2.1 fractu re w ith valgu s im paction of th e articu lar segm en t, poste-
rior—su perior dislocation of th e greater tu berosity, an addition al frac-
tu re of th e lesser tu berosity w ith m u ltiple fragm en ts, an d a m edial dis-
placem en t of th e h u m eral sh aft. Marked osteoporosis.

Fig 6 .1.8 -1a – e

a AP view.
b Ax ial view. d
c CT scan in fron tal plan e.
d – e CT scan in sagittal plan e sh ow in g com m inu tion an d dislocation of
th e greater tu berosity.

271
 6 .1 Hu m e ru s , p ro xim a l

In d ica t io n

Un sta b le in tra a rticu la r p roxim a l h u m e ra l fra ctu re w ith va lgu s im p a c-
tio n o f th e a rticu la r se gm e n t, p o ste rio r a n d su p e rio r d isp la ce m e n t o f
th e m u ltip le fra ctu re d gre a te r tu b e ro sit y, m e d ia l d isp la ce m e n t o f th e
sh a ft, m a rke d o ste o p o ro sis, se ve re p a in , n o a d d itio n a l n e rve le sio n
o r va scu la r d a m a ge .
Co n se rva tive tre a tm e n t is n o t a go o d o p tio n in th is ca se d u e to m arke d
d isp lace m e n t. It wo u ld o nly b e co n sid e re d if o p e ra tive tre a tm e n t
wo u ld ap p e ar to o risky d u e to co m o rb id ity in a lo w d e m an d p a tie n t.
Clo se d re d u ctio n a n d p e rcu ta n e o u s p in n in g w ith a d d itio n a l scre w
xa tio n is p o ssib le b u t, d u e to th e m u ltip ly fra ctu re d gre a te r tu b e r-
o sit y a n d a d d itio n a l o ste o p o ro sis, p e rcu ta n e o u s scre w xa tio n m a y
p ro vid e in su f cie n t sta b ilit y a n d co u ld le a d to se co n d a ry d isp la ce -
m e n t. Du e to d isp la ce m e n t o f th e sh a ft, clo se d a n d p e rcu ta n e o u s
p in n in g re d u ctio n m a y b e d if cu lt. An a d d itio n a l im m o b iliza tio n fo r
3 – 4 we e ks a s we ll a s a se co n d o p e ra tio n fo r p in re m o va l w o u ld b e
n e ce ssa ry.
Co n sid e rin g th is a n d th e p a tie n ts re q u e st fo r e a rly in d e p e n d e n ce ,
ca re fu l o p e n re d u ctio n u n d e r visu a l co n tro l a n d in te rn a l xa tio n w ith
lo ckin g p roxim a l h u m e ra l p la te a n d a d d itio n a l te n sio n b a n d in g is ch o -
se n . Th is o ffe rs th e a d va n ta ge o f o p e n re d u ctio n a n d p re se rva tio n o f
th e p e rio ste a l b rid ge s to th e fra ctu re fra gm e n ts a n d a sta b le xa tio n
w ith e a rly fu n ctio n a l re h a b ilita tio n . Qu ick p a in re lie f is a ch ie ve d .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• Lo ckin g p ro xim a l h u m e ra l p la te ( LPHP),
5 h o le s (a lte rn a tive ly: 8 h o le s)
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d
scre w s (LHS)
• 3 .5 m m co rte x scre w
• 1.8 m m K-w ire s
• No n a b so rb a b le su tu re s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Fig 6 .1.8 -2 Pa tie n t is p la ce d in

Pa t ie n t p re p a ra t io n a n d p o s it io n in g b e a ch ch a ir p o sitio n . Th e a rm is fre e -
Ge n e ra l a n e sth e sia is re co m m e n d e d , d ra p e d fo r in tra o p e ra tive m o b ilit y. An
a lte rn a tive ly a sca le n e b lo ck ca n b e u se d . im a ge in te n si e r is h e lp fu l.

272
 6 .1.8 In t ra a r t icu la r im p a ct e d p ro xim a l h u m e ra l fra ct u re w it h d is p la ce m e n t—11- C2

2 Su rgica l a p p ro a ch

a b c

Fig 6 .1.8 -3 a – c
a – b Deltopectoral approach . Perform a 12 cm in cision from
th e coracoid process to th e deltoid in sertion , split th e
deltoid an d th e pectoralis m ajor. Use th e ceph alic vein
as a lan d m ark an d leave th e ceph alic vein w ith th e del-
toid to th e lateral side. Cau tiou s blu n t preparation of th e
su bdeltoid space w ith th e n gers.
c Iden tify th e ten don of th e lon g h ead of th e biceps brach ii
mu scles an d an ch or stron g n on absorbable su tu res th rou gh
th e su praspin atu s, in fraspin atu s, an d su bscapu laris ten -
don at th e ten don -bon e in terface. Th ese su tu res allow gen -
tle m an ipu lation of th e h u m eral h ead fragm en ts. Fractu re
lin es sh ou ld be iden ti ed bu t n ot com pletely ex posed.

3 Re d u ct io n

Fig 6 .1.8 -4 Redu ce th e hu m eral h ead fragm en ts by gen tly pu llin g th e

su tu res an ch ored in th e su praspin atu s, in fraspin atu s, an d su bscapu laris
ten don . Redu ce th e articu lar segm en t by u sin g a sm all elevator. In u n -
stable situ ation s tem porar y pin n in g m ay be advisable.

273
 6 .1 Hu m e ru s , p ro xim a l

3 Re d u ct io n (co n t )

Redu ce th e sh aft
Fig 6 .1.8 -5 a – b
approx im ately by an in d irect
redu ction m an eu ver.
a Pu ll an d rotate th e d istal part
of th e hu m eru s.
b Con trol of th e redu ced frag-
m en ts.

a b

4 Fixa t io n

Fig 6 .1.8 -6 Adapt th e 5-h ole lock in g prox im al h u m eral plate

(LPHP) to th e proxim al part of th e hu m eru s an d x it tem -
porarily w ith 1.8 m m K-w ires th rou gh th e su tu re h oles. Place
th e u pper en d of th e plate 5 –7 m m below th e tip of th e greater
tu berosity an d abou t 5 m m posterior to th e bicipital groove.
Ch eck in g th e correct position of th e im plan ts w ith th e im age
in ten si er is advisable.

274
 6 .1.8 In t ra a r t icu la r im p a ct e d p ro xim a l h u m e ra l fra ct u re w it h d is p la ce m e n t—11- C2

4 Fixa t io n (co n t )

a b

In sert a 3.5 m m cortex screw th rou gh th e rst

Fig 6 .1.8 -7a – b plate, again st th e m ed ializin g m u scle forces of th e pectoralis
h ole below th e su bcapital fractu re lin e. By tigh ten in g th e m ajor m u scles.
screw th e hu m eral sh aft w ill be gen tly redu ced towards th e

a b

In sert th e th readed d rill gu ide in to th e two

Fig 6 .1.8 -8 a – b su rface. Laserm arks an d a plastic rin g on th e d rill bit facilitate
proxim al parallel lockin g h oles an d u se th e 2.8 m m drill bit direct readin g of th e drilled depth .
for th e preparation of th e h oles. Do n ot perforate th e articu lar

275
 6 .1 Hu m e ru s , p ro xim a l
4 Fixa t io n (co n t )
b c
b In sert th e th readed LCP drill gu ide in to th e h oles at th e
hu m eral sh aft. Use a 2.8 m m drill bit an d, after m easu re-
m en t of th e len gth , in sert a bicortical 3.5 m m self-tappin g
LHS in to each h ole u sin g th e torqu e-lim itin g attach m en t
on th e screwdriver. Notice th at a m in im u m of two bicorti-
cal 3.5 m m self-tappin g LHS sh ou ld be placed in th e sh aft
fragm en t. Th e h ole at th e en d of th e plate m ay be equ ipped
w ith a monocortical 3.5 m m , self-drillin g, self-tappin g LHS.
276
Fig 6 .1.8 -9 a – c
a In sert two 3.5 m m self-tappin g lock in g h ead screw s (LHS)
in to th e u pper h oles u sin g th e torqu e-lim itin g attach m en t
to th e screwdriver. Ch eck ideal len gth of th ese lock in g
h ead screw s by im age in ten si er in order n ot to pen etrate
th e articu lar su rface (leave abou t 3 m m between th e tip of
th e screw an d th e articu lar su rface).
c In sert th e th readed LCP drill gu ide in to th e rem ain in g
th ree divergen t drill h oles in th e proxim al part of th e plate
u sin g th e gu id in g block. After drillin g, in sert 3.5 m m self-
tappin g LHS u sin g th e torqu e-lim itin g attach m en t on th e
screwdr iver in each of th ese h oles. Ch eck all screw len gth s
carefu lly w ith th e im age in ten si er.
 6 .1.8 In t ra a r t icu la r im p a ct e d p ro xim a l h u m e ra l fra ct u re w it h d is p la ce m e n t—11- C2

4 Fixa t io n (co n t )

a b c

Fig 6 .1.8 -10Fix th e an ch ored su tu res Fig 6 .1.8 -11a – c

th rou gh th e su tu re h oles in th e plate an d a Ch eck sh ou lder m obility an d fractu re stability by passive m otion . Per-
tie th em tigh tly to n eu tralize th e m u scle form wou n d closu re after irrigation an d drain age.
forces of th e rotator cu ff. b – c Postoperative x-rays show good reduction and position in g of the im plant.

5 Re h a b ilit a t io n
Add ition al im m obilization : ban dage for
2–3 weeks.
Physioth erapy: passive an d active-assist-
ed m obilization as of th e secon d postop-
erative day.
Un restricted active m obilization after
3 –4 weeks.
Ph arm aceu tical treatm en t: pain killers
in th e early postoperative period, th ere-
after wh en n eeded.

Fig 6 .1.8 -12 a – cX-rays at on e year fol-

low-u p sh ow com plete h ealin g of th e
fractu re w ith ou t sign s of avascu lar n e-
crosis. On e screw seem s to pen etrate
a b c th e articu lar su rface w ith ou t cau sin g
an y clin ical sym ptom s.

277
 6 .1 Hu m e ru s , p ro xim a l

5 Re h a b ilit a t io n (co n t )

c d

Fig 6 .1.8 -13 a – d

Satisfactor y fu n ction al resu lt at on e year follow-u p. Th e patien t is free of pain
a b an d w ith ou t restriction in everyday activities.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Too exten sive ex posu re of th e fractu re fragm en ts m ay Open procedu re w ith ou t exten sive ex posu re of th e frac-
dam age vascu larity an d lead to a h igh rate of avascu lar tu re lin es m ay h elp to preserve th e blood su pply of th e
n ecrosis. segm en ts. Altern ative: sm all an terolateral splittin g of th e
deltoid m u scle.

Re d u ct io n
Brisk redu ction m an eu vers w ith redu ction forceps m ay
dam age blood su pply an d an y residu al in tact periostieu m
on th e fragm en ts.
Incorrect position in g of the plate m ay lead to su bacrom ial
im pin gement and restricted range of motion .
Re d u ct io n
In direct redu ction m an eu vers h elp to preser ve blood su p-
ply an d residu al periostieu m in th is open procedu re.
Optim al position ing of the an atom ically presh aped plate,
controlled by im age inten si cation , prevents h ardware im-
pin gement and en ables u n restricted range of motion .

Fixa t io n Fixa t io n
In correct len gth of th e LHS leads to perforation of th e Optim al len gth , especially of th e LHS, avoids perforation
articu lar su rface of th e hu m eral h ead. of th e articu lar su rface.
3.5 m m cortex screw s m ay lead to redu ced stability in LHS, in com bin ation w ith 3-D orien tation , lead to im -
osteoporotic bon e an d prem atu re loosen in g. proved stability even in osteoporotic bon e, bu t exact lock-
Lack of su f cien t m edial bu ttress w ith ou t adju stm en t of in g rem ain s essen tial.
th e reh abilitation protocol m ay lead to im plan t failu re. Recon stru ction of th e m ed ial bu ttress leads to su f cien t
stability for early fu n ction al reh abilitation .
Fig 6 .1.8 -14 In th e case of a ho-
m ogeneou s fragm en t of the lesser
tu berosity, the sutu re th rou gh the
su bscapu laris ten don m ay be re-
placed by a 3.5 m m cortex screw
from th e lesser tu berosity to th e
hu m eral sh aft.

278
 Au t h o r Ch ris t ia n Ryf

6 .1.9 4 -part proxim al hum e ral fracture —11-C2

1 Ca s e d e s crip t io n

23-year-old m an fell wh ile sk iin g an d su ffered a 4-part proxi-

m al hu m eral fractu re on th e left side. He h ad n o fu rth er in ju -
ries. A CT scan was carried ou t for fractu re stu dy.

Fig 6 .1.9 -1a – b

a AP view.
b Lateral view.

In d ica t io n

Th e d e cisio n fo r a n o ste o syn th e sis in th is ra th e r yo u n g p a tie n t w a s

ta ke n . Th e risk o f a se p tic n e cro sis in th is fra ctu re w ith su b lu xa tio n o f
a b th e h u m e ru s h e a d is co n sid e ra b le .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• PHILOS p ro xim a l h u m e ra l p la te 3 .5 , 3 h o le s
• 3 .5 m m co rte x scre w s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 2 .5 m m K-w ire
• Pa rtia lly th re a d e d K-w ire s 2 .0 m m
• Os te o su tu re s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin Fig 6 .1.9 -2 Th e p a tie n t is p la ce d in th e b e a ch ch a ir p o sitio n .
A co n ve n tio n a l x-ra y a n d a CT sca n w e re ca rrie d o u t fo r o p e ra tio n Le ft a rm fre e ly m o ve a b le .
p la n n in g. Th e va lgiza tio n , su b lu xa tio n , a n d th e fo u r m a in
fra gm e n ts a re sh o w n .

279
 6 .1 Hu m e ru s , p ro xim a l

2 Su rgica l a p p ro a ch

A deltopectoral approach is per-

Fig 6 .1.9 -3 a – b
form ed, sparin g th e ceph alic vein . Th e deltoid is
partially detach ed from th e clavicle at th e an terior
aspect.
Th ere is mu ltifragm en tar y fractu re of th e greater
an d lesser tu bercles, a lon gitu d in al split, an d cra-
n ial displacem en t as h ad been expected from th e
preoperative x-rays.
Som e sm all fragm en ts are rem oved an d reim plan t-
ed later.

a b

3 Re d u ct io n a n d fixa t io n

a b c
Fig 6 .1.9 -4 a – g
a A 2.5 m m K-w ire is dr illed in to th e b Now th e tu bercu les are pu lled in to c Th e 3-h ole PHILOS plate is applied
m assively valgizated hu m eral h ead position an d provision ally xed w ith laterally an d provision ally xed
fragm en t in th e sen se of a joystick a ber-w ire osteosu tu re. w ith a con ven tion al cortex screw
su pport. With ax ial traction an d on to th e sh aft. De n itive redu ction
rotation of th e arm an d th e joy- u n der im age in ten si cation con trol
stick, h ead redu ction can be accom - an d n e tu n in g of th e plate follow s.
plish ed.

28 0
 6 .1.9 4 -p a rt p ro xim a l h u m e ra l fra ct u re —11-XX

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 6 .1.9 -4 a – g (co n t)

d To in crease th e bon e-to-bon e con -
tact, th e sh aft is im pacted in to th e
hu m eral h ead. Now all oth er plate
h oles are occu pied w ith lock in g
h ead screw s.
e–f Osteosu tu re of th e sm aller tu ber-
cu lar fragm en ts, m ain ly from th e
greater tu bercle, w ith ber-w ire,
d e com pletin g th e stable osteosyn -
th esis.
g Th e partially rem oved deltoid
m u scle is readapted an d th e fascia
su tu red.

f g

4 Re h a b ilit a t io n

Gen tle active-assisted ph ysioth erapy begin s on th e secon d

postoperative day for at least 3 –4 weeks. A desau lt gilet is
u sed for xation .
Active m otion sh ou ld begin after 4 weeks if su pported by th e
x-ray n din gs.

Fig 6 .1.9 -5 a – b Postoperative x-rays after 4 weeks.

a AP view.
b Lateral view.

a b

281
 6 .1 Hu m e ru s , p ro xim a l

282
6 .2 Hum e rus, shaft

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

6 .2 .1 Spiral we dge hu m e ral sha ft fractu re 12-B1 lo cke d sp lin tin g LCP m e taph yse al p la te lo cke d in te rnal 289
w ith h u m e ral h e ad in vo lve m e n t 3 .5/ 4 .5/ 5.0 fixa to r

6 .2 .2 Fragm e n te d hum e ral sha ft we d ge 12-B3 lo cke d sp lin tin g LCP m e taph yse al p la te lo cke d in te rnal 2 93
fractu re 3 .5/ 4 .5/ 5.0 fixa to r

6 .2 .3 Gu n sh o t fractu re o f the hu m e ral sha ft 12-C1 lo cke d splin ting LCP 4 .5 lo cke d in te rnal 299
fixa to r

6 .2 .4 Com ple x se gm e n tal p roxim al hu m e ral 12-C2 lo cke d sp lin tin g LCP m e taph yse al pla te lo cke d in te rnal 305
sh aft fractu re 3 .5/ 4 .5/ 5.0 fixa to r an d
re d u ction scre w

6 .2 .5 Com ple x se gm e n tal hu m e ral sha ft 12-C2 lo cke d sp lin tin g LCP m e tap h yse al p la te lo cke d in te rnal 311
fractu re 3 .5/ 4 .5/ 5.0 fixa to r

6 .2 .6 Sim ple tran sve rse h u m e ral sh a ft fractu re 12-A3 lo cke d sp lin ting LCP m e tap h yse al p la te lo cke d in te rnal 317
and p artial in traarticu lar sagittal la te ral 13 -B1 3 .5/ 4 .5/ 5.0 fixa to r
h u m e ral con d yle fra cture

6 .2 .7 Pa tho lo gical hum e ral sha ft fractu re lo cke d splin ting LCP 4 .5/ 5.0 , narro w lo cke d in te rnal 321
fixa to r

6 .2 .8 In te rcalary re co n struction o f the LPHP; LCP re co n stru ctio n lo cke d in te rnal 32 5

h u m e ru s follo w in g o nco lo gical re se ction p la te 3 .5; LCP fixa to r
m e tap h yse al p la te
3 .5/ 4 .5/ 5 .0

283
 6 Hu m e ru s

6 Hum e rus

6 .2 Hu m e ru s , s h a ft 285
6 .2 .1 Sp ira l w e d ge h u m e ra l s h a ft fra ct u re w it h h u m e ra l h e a d
in vo lve m e n t—12 -B1 289
6 .2 .2 Fra gm e n t e d h u m e ra l s h a ft w e d ge fra ct u re —12 -B3 293
6 .2 .3 Gu n s h o t fra ct u re o f t h e h u m e ra l s h a ft—12 - C1 299
6 .2 .4 Co m p le x s e gm e n t a l p ro xim a l h u m e ra l s h a ft
fra ct u re —12 - C2 305
6 .2 .5 Co m p le x s e gm e n t a l h u m e ra l s h a ft fra ct u re —12 - C2 311
6 .2 .6 Sim p le t ra n s ve rs e h u m e ra l s h a ft fra ct u re —12 -A3 a n d
p a r t ia l in t ra a r t icu la r s a git t a l la t e ra l h u m e ra l co n d yle
fra ct u re —13 -B1 317
6 .2 .7 Pa t h o lo gica l h u m e ra l s h a ft fra ct u re 321
6 .2 .8 In t e rca la r y re co n s t ru ct io n o f t h e h u m e ru s fo llo w in g
o n co lo gica l re s e ct io n 32 5

28 4
 Au t h o r Ch ris t o p h So m m e r

6 .2 Hum e rus, shaft

1 In cid e n ce

Fractu res of th e h u m eral sh aft are qu ite rare in an average

popu lation an d occu r in abou t 1–2% of all fractu res. In m en ,
bim odal age distribu tion w ith a peak in th e th ird decade is th e
resu lt of m oderate to severe in ju r y. For wom en , a larger peak a b c
can be ex pected in th e seven th decade after a sim ple fall [1].
Fig 12-A Sim ple fractu re.
6 .2 -1a – c
Most fractu res occu r in th e m idth ird th ird of th e d iaph ysis
a 12-A1 spiral
w ith abou t 30% in th e prox im al an d abou t 10% in th e d istal
b 12-A2 obliqu e (≥ 30°)
th irds.
c 12-A3 tran sverse (< 30°)

2 Cla s s ifica t io n

Fractu res are categorized accord in g to th e Mü ller AO Classi -

cation as A-, B- an d C-type fractu res [2]. Low-en ergy m ech a-
n ism s (sim ple fall, arm w restlin g) u su ally lead to closed frac-
a b c
tu res w ith m ore sim ple fractu re pattern s (A1, B1), wh ereby
h igh -en ergy trau m as resu lt in a h igh rate of open fractu res Fig 12-B Wedge fractu re.
6 .2 -2 a – c
w ith eith er tran sverse (A3, B3) or com plex fractu res (C1–3), a 12-B1 spiral wedge
often associated w ith n eu rovascu lar in ju r ies. b 12-B2 ben d in g wedge
c 12-B3 fragm en ted wedge

3 Tre a t m e n t m e t h o d s

Con servative treatm en t is still th e gold stan dard for m an y hu -

m eral sh aft fractu res. Differen t m eth ods h ave been described;
th e m ost accepted is fu n ction al bracin g, resu ltin g in a h igh rate
of u n ion (94 –98% ) an d in good to excellen t fu n ction in m ost
cases [3 ]. However, th ere are clin ical situ ation s w h ere opera-
a b c
tive stabilization is m ore appropr iate. Absolu te in d ication s for
operative treatm en t are h igh er degree open fractu res II–III Fig 12-C Com plex fractu re.
6 .2 -3 a – c
(Tsch ern e classi cation ), fractu res w ith vascu lar in ju ry re- a 12-C1 spiral
qu irin g vascu lar repair, an d path ological fractu res. Th e list of b 12-C2 segm en tal
relative in d ication s is lon g an d in clu des special fractu re types c 12-C3 irregu lar
(tran sverse, lon g spiral), m u ltiple trau m a, oatin g elbow, bi-
lateral fractu res, rad ial n erve palsy, poor patien t com plian ce

285
 6 Hu m e ru s

an d obesity, wh ich m ay com plicate an altern ative con ser va-
tive treatm en t. In all th ese situ ation s, in d ividu al decision s for
con ser vative or operative treatm en t h ave to be ch osen accord-
in g to d ifferen t factors su ch as patien t’s ex pectation , su rgical
ex perien ce, available in frastru ctu re an d oth ers.
Prim ary radial n er ve palsy u su ally recovers spon tan eou sly in
cases w ith closed an d n ot largely d isplaced fractu res (low-en -
ergy m ech an ism) an d th erefore operative ex ploration seem s
to be u n n ecessary [4]. On th e oth er h an d, in h igh -en ergy trau -
m as th at often resu lt in open fractu res, prim ar y n erve palsy is
n ot in frequ en tly cau sed by a n erve tear, wh ich requ ires su r-
gical repair. In th ese cases, operative treatm en t w ith rad ial
n erve ex ploration seem s to be ju sti ed [4 , 5 ].
im portan t piece of advice is to in sert th e lock in g h ead screw s
bicortically in th e d iaph ysis in th e case of poor bon e qu ality.
Th e stan dard approach for plate xation in th e prox im al h alf
of th e sh aft is th e an terolateral an d for th e d istal h alf th e
dorsal approach . In situ ation s w ith vascu lar in ju r y, a m ed ial
approach is m an datory. Recen tly, m in im ally in vasive plat-
in g tech n iqu es even in th e h u m eru s h ave been described.
An an tero-an terolateral approach at each en d of th e in serted
plate can give safe access to th e hu m eru s, provided th e su r-
geon kn ow s th e an atom y precisely. Togeth er w ith th e applied
br idgin g tech n iqu e (u sin g a DCP) good resu lts h ave been re-
ported in a sm all grou p of patien ts.

Differen t im plan ts are available for th e operative stabilization

4 Im p la n t o ve r vie w
of hu m eral sh aft fractu res. It is still con troversial wh eth er
plate xation or in tram edu llary n ailin g is m ore appropriate.
Th ere are m an y pros an d con s for each treatm en t option . In
a
gen eral, sim ilar u n ion rates can be expected for eith er plat-
in g or n ailin g [6 – 9 ]. Sh ou lder fu n ction seem s to be m ore im -
paired after an tegrade n ailin g com pared to plate xation [6 , b
8 , 10 ] or retrograde n ailin g [11], wh ereby elbow fu n ction on
th e oth er h an d m ay be m ore im paired after plate xation .
c
Th is is especially tru e for fractu res of th e d istal th ird of th e
hu m eru s com pared to an tegrade n ailin g [6]. In su m m ary, th e
ch oice of im plan t depen ds on m any d ifferen t factors, bu t is
d
m ain ly in u en ced by th e preferen ce an d experien ce of th e
su rgeon .
Fig 6 .2 -4 a – d
a LCP m etaph yseal plate 3.5/4.5/5.0
Th e developm en t of th e an gu lar stable screw-plate system
b LCP 4.5/5.0
(LCP) offers fu rth er advan tages in th e platin g of h u m eral
c LCP recon stru ction plate 3.5
sh aft fractu res or n onu n ion s, especially in cases of osteopo-
d LPHP—Lock in g proxim al hu m eral plate 3.5
rotic bon e an d in fractu res exten d in g to th e m etaph ysis or
th e join t [12]. Th e rst clin ical ex perien ce w ith th e LCP in
th is region h owever sh owed several com plication s th at were
m ain ly cau sed by w ron g application s du e to th e u n k n ow n
n ew system . Gen eral gu idelin es for th e u se of th e LCP, espe-
cially in th e hu m eru s, h ave been provided. Possibly th e m ost

28 6
 6 .2 Hu m e ru s , s h a ft

11. Blu m J, Jan zin g H , Gah r R , e t al (2001) Clin ical

5 Bib lio gra p h y
perform an ce of a n ew m edu llary hu m eral n ail: an tegrade
versu s retrograde in sertion . J Orthop Trauma; 15(5):342 –349.
1. Ty t h e rle igh -St ro n g G, Walls N , McQu e e n M M (1998) Th e 12 . R in g D , K lo e n P, Kad zie lsk i J, e t al (2004) Lock in g
epidem iology of hu m eral sh aft fractu res. J Bone Joint Surg Br; com pression plates for osteoporotic n on u n ion s of th e
80(2):249 –253. diaph yseal hu m eru s. Clin Orthop; (425):50 –54.
2 . Mü lle r M E, N azarian S, Ko ch P, e t al (1990) Th e
com preh en sive classi cation of fractu res of lon g bon es.
Berlin Heidelberg New York: Sprin ger-Verlag.
3. Sarm ie n t o A , Zago rsk i J B, Zych GA , e t al (2000)
Fu n ction al bracin g for th e treatm en t of fractu res of th e
h u m eral diaphysis. J Bone Joint Surg Am; 82(4):478 –486.
4. A ln o t J, Osm an N , Masm e je an E, e t al (2000) [ Lesion s of
th e rad ial n erve in fractu res of th e hu m eral d iaph ysis.
Apropos of 62 cases]. Rev Chir Orthop Reparatrice Appar Mot;
86(2):143 –150.
5. R in g D , Ch in K , Ju p it e r J B (2004) Rad ial n er ve palsy
associated w ith h igh -en ergy h u m eral sh aft fractu res.
J Hand Surg [Am]; 29(1):14 4 –147.
6 . Ch ap m an J R , He n le y M B, A ge l J, e t al (2000) Ran dom ized
prospective stu dy of hu m eral sh aft fractu re xation :
in tram edu llary n ails versu s plates. J Orthop Trauma;
14(3):162 –166.
7. Lin J (1998) Treatm en t of h u m eral sh aft fractu res w ith
h u m eral locked n ail an d com parison w ith plate xation .
J Trauma; 4 4(5):859 –864.
8 . McCo rm ack RG, Brie n D , Bu ck le y R E, e t al (2000) Fixation
of fractu res of th e sh aft of th e hu m eru s by dyn am ic
com pression plate or in tram edu llary n ail. A prospective,
ran dom ised trial. J Bone Joint Surg Br; 82(3):336 –339.
9. Ro m m e n s PM , Blu m J, Ru n ke l M (1998) Retrograde
n ailin g of hu m eral sh aft fractu res. Clin Orthop; (350):26 –39.
10 . A jm al M , O‘Su llivan M , McCabe J, e t al (2001) An tegrade
locked in tram edu llary n ailin g in hu m eral sh aft fractu res.
Injury; 32(9):692 –694.

287
 6 Hu m e ru s

28 8
 Au t h o r Mich a e l Wa gn e r

6 .2.1 Spiral we dge hum e ral shaft fracture with hum e ral
he ad involve m e nt—12-B1
1 Ca s e d e s crip t io n

55-year-old wom an fell dow n th e stairs an d su ffered a

m on otrau m a to h er left arm .

Fig 6 .2 .1-1a – b
a AP view.
b Lateral view.

In d ica t io n

Pa in fu l a n d u n sta b le fra ctu re o f th e h u m e ra l sh a ft is a n in d ica tio n

fo r o p e ra tive tre a tm e n t. An te gra d e in tra m e d u lla ry n a ilin g is p o ssib le
b u t n o t a go o d o p tio n b e ca u se o f th e sm a ll p ro xim a l h e a d fra gm e n t.
Co n se rva tive tre a tm e n t is p o ssib le b u t re q u ire s a lo n g im m o b iliza -
a b tio n p e rio d .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP m e ta p h yse a l p la te An tib io tics: n o n e
3 .5/ 4 .5/ 5 .0 , 4 + 12 h o le s Th ro m b o sis p ro p h yla xis:
• 3 .5 m m lo ckin g h e a d scre w s lo w -m o le cu la r h e p a rin
(LHS)
• 4 .5 m m LHS
• 1.2 5 m m K-w ire s
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Fig 6 .2 .1-2 a – b
Be a ch ch a ir p o sitio n . a b

289
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

a b c

Fig 6 .2 .1-3 a – d
a In order to perform m in im ally in vasive plate osteosyn th esis, a deltoid split-
tin g approach prox im ally, an d an an terolateral approach to th e d istal sh aft was
ch osen .
b Splittin g of th e deltoid startin g from th e an terolateral side of th e acrom ion .
c Splittin g of th e deltoid at th e level of th e raph e. In a deltoid splittin g approach it
is n ecessar y to preser ve th e ax illar y n erve.
d An terolateral approach to th e hu m eral sh aft.
d

3 Re d u ct io n a n d fixa t io n

Fractu re redu ction w ith m an u al traction , con trol

u sin g im age in ten si er.
Tw istin g of a 3.5/4.5/5.0 m etaph yseal LCP for th e
distal tibia like a h elical plate.
Epiperiosteal tu n n elin g w ith a blu n t raspator y an d
su bm u scu lar plate in sertion in a prox im al to d istal
direction .

Fig 6 .2 .1-4 a – b
a Position in g of th e plate opposite th e bon e w ith
a b th e aid of th readed drill sleeves.
b Tem porary plate xation prox im ally an d d is-
tally w ith a 1.25 m m K-w ire.

29 0
 6 .2 .1 Sp ira l w e d ge h u m e ra l s h a ft fra ct u re w it h h u m e ra l h e a d in vo lve m e n t—12 -B1

3 Re d u c t io n a n d fixa t io n (co n t )

Fixation of th e m etaph yseal LCP proxim ally w ith

fou r 3.5 m m LHS, d istally w ith th ree 4.5 m m LHS,
two of th ese bicortical. A d rill bit broke wh ile d rill-
in g, bu t was left in place. Du e to th e torqu e of th e
plate, th e prox im al, m etaph ysis-orien ted part of
th e plate lies again st th e lateral side of th e h u m er-
al h ead. Th e d istal part is situ ated an terior to th e
sh aft.

Fig 6 .2 .1-5 a – b Postoperative x-rays.

a AP view.
b Lateral view.

a b

4 Re h a b ilit a t io n

Im m obilization in a Gilch rist ban dage

for 3 weeks. Passive exercise from day
2 postoperatively. Elbow, w rist, an d n -
ger exercises allowed from day 1 postop-
eratively. Exercises follow in g rem oval of
th e Gilch rist ban dage.

Fig 6 .2 .1-6 a – d
a – b Follow-u p x-rays after 2 m on th s.
In cipien t callu s bridgin g of th e
fractu re.
c– d X-rays after 4 m on th s. Bon e h eal-
in g of th e fractu re.

a b c d

291
 6 .2 Hu m e ru s , s h a ft

4 Re h a b ilit a t io n (co n t )

Fig 6 .2 .1-7a – b Postoperative x-rays after

7 m on th s.

Im p la n t re m o va l
Fig 6 .2 .1-7c– d Im plan t rem oval after 9 m on th s
to redu ce pain cau sed by proxim al soft-tissu e im -
pin gem en t.

a b c d

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Eq u ip m e n t
Deltoid splitting approach : danger of axillary lesion , strictly Th e m etaph yseal LCP, w h ich was preben t sim ilar to a
epiperiosteal preparation and plate in sertion is necessary. “h elical plate”, ts to th e an atom ical con dition s of th e
proxim al hu m eru s.
Anterior incision to the hu meral sh aft: preservation of the LHS allow stable xation an d early fu n ction al postopera-
brach ioradialis and radial nerve is necessary. After pu sh- tive care.
in g the belly of the biceps to the medial side, the brach ialis
mu scle is split anteriorly above the bone in the direction
of its bers. The mu scle structu re pu shed to the lateral side
protects the radialis nerve like a cu sh ion . Use of a Hoh m an n
retractor shou ld be avoided, so as not to in ict any ten sive/
com pressive forces.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Closed redu ction an d M IPO are dem an d in g. Th e splin tin g m eth od w ith an in tern al xator com bin ed
w ith M IPO tech n iqu es offers a good solu tion for m u lti-
fragm en tary fractu res in th e sh aft an d m etaph ysis region .
Im p la n t re m o va l
Du e to a sligh t protru sion of th e plate proxim ally, im -
pin gem en t occu rred w ith som e pain . Th is requ ired re-
m oval of th e im plan t.

292
 Au t h o r Ch ris t o p h So m m e r

6 .2.2 Fragm e nte d hum e ral shaft we dge fracture —12-B3

1 Ca s e d e s crip t io n

72-year-old wom an h ad a fall wh ile travelin g abroad an d

in ju red h er righ t arm . Sh e su ffered a torsion al fractu re of
th e prox im al h u m eral sh aft w ith an avu lsed in term ed iate
wedge.
Fou r days later sh e was treated by osteosyn th esis in th e form
of retrograde in sertion of a exn ail. Ju st a few days later th ere
was sligh t collapse of th e fractu re w ith pen etration of th e n ail
tip in to th e h u m eral h ead. In add ition , th e patien t was n ow
com plain in g of a sen sor y d isorder in th e region ser ved by th e
u ln ar n erve an d of loss of stren gth in th e forearm m u scles
in n ervated by th e m ed ian n er ve. Th e patien t, w h o h ad n ow
retu rn ed h om e, presen ted at ou r h ospital. Her con d ition at
th at tim e is dem on strated in Fig 6 .2 .2 -1c .

Fig 6 .2 .2 -1a – c
a Preoperative x-ray, AP view.
b Postoperative x-ray after in sertion of a exn ail.
a b c c Postoperative x-ray 1 week after in sertion of th e ex n ail.

In d ica t io n Pre o p e ra t ive p la n n in g

Th e fra ctu re wa s cle a rly in in co rre ct a lign m e n t Eq u ip m e n t 1 Su rge o n

w ith th e in su f cie n t in tra m e d u lla ry n a il in situ . • LCP m e ta p h yse a l p la te 2 Assistan t
Th is wa s co m b in e d w ith m o d e ra te sym p to m s o f 3 .5/ 4 .5/ 5 .0 , 5 + 8 h o le s 4 3 An e sth e tist
n e u ro lo gica l d e cit, p o ssib ly ca u se d b y th e p e r- • 3 .5 m m lo ckin g h e a d scre w s (LHS) 2 4 ORP
1
sistin g d islo ca tio n o f th e fra ctu re , a n d re p re se n t- • 5 .0 m m LHS
e d a cle a r in d ica tio n fo r re visio n o ste o s yn th e sis. • 3 .5 m m co rte x scre w s Ste rile are a
On e p o ssib le p ro ce d u re wo u ld b e th e a n te gra d e • K-w ire
in se rtio n o f a n in tra m e d u lla ry n a il w ith lo ckin g (Size o f s yste m , in s tru m e n ts, a n d im p la n ts ca n
o p tio n s in th e re gio n o f th e h u m e ra l h e a d , b u t va ry a cco rd in g to a n a to m y.)
th e p a tie n t ve h e m e n tly re je cte d th is p ro p o sa l.
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An a lte rn a tive p ro ce d u re w o u ld b e p la te o ste o -
An tib io tics: sin gle d o se 2 n d
syn th e sis p e rfo rm e d e ith e r in o p e n te ch n iq u e
ge n e ra tio n ce p h a lo sp o rin 3
via a n a n te ro la te ra l sta n d a rd a p p ro a ch o r in
Th ro m b o sis p ro p h yla xis: lo w -
MIPO te ch n iq u e .
m o le cu la r h e p a rin Fig 6 .2 .2 -2 Be a ch ch a ir p o sitio n .

293
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

Fig 6 .2 .2 -3 Th e prox im al location of th e fractu re requ ires xation of th e plate in th e region

of th e hu m eral h ead, w h ich can best be ach ieved by m ean s of an an terolateral deltoid split
approach . Th e in cision is m ade from th e lower m argin of th e acrom ion an d ru n s approx i-
m ately 6 cm in a distal d irection . Division of th e deltoid m u scle in th e direction of its bers,
approach an d d issection of th e su bacrom ial bu rsa. Ex posu re of th e m ost su perior bran ch of
th e ax illary n er ve th at is clearly visible at th e lower m argin of th e in cision .
Tak in g care to preserve th is n erve, th e plate bed is created by epiperiosteal tu n n elin g w ith
th e d istal plate en d w ith blu n t pen etration of th e in sertion of th e deltoid mu scle close to th e
bon e. Sin ce th e plate is on ly in serted as far as th e ju n ction of th e m id to th e distal th irds of
th e sh aft an d com es to rest in an an terolateral position , th e rad ial n erve n eed n ot be iden ti-
ed in th e distal region . Th e approach is m ade an terolaterally n ext to th e biceps mu scle an d
ru n s th rou gh th e u pper region s of th e brach ialis mu scle to th e distal hu m eral sh aft.

3 Re d u ct io n a n d fixa t io n

Fig 6 .2 .2 -4 a – b
a Th e plate is ben t sligh tly at its prox im al en d (to correspon d
to th e con tou rs of th e greater tu bercle), slide-in serted an d
in itially xed at th e u pper en d in th e h u m eral h ead w ith a
K-w ire th at is in trodu ced th rou gh a th readed d rill gu ide. A
K-w ire is also in trodu ced th rou gh th e d ista l in cision , like-
w ise th rou gh a th readed drill gu ide, in to th e d istal sh aft
on ce len gth an d rotation h ave been adju sted to be as cor-
rect as possible (in d irectly by th e weigh t an d position of
th e forearm ).
b Th e gapin g an d an gu larly d isplaced fractu re can n ow be
in d irectly redu ced to th e plate by in sertin g a 3.5 m m cor-
tex screw in to th e proxim al part as a rst step so th at th e
proxim al fragm en t is approxim ated to th e plate.

a b

294
 6 .2 .2 Fra gm e n t e d h u m e ra l s h a ft w e d ge fra ct u re —12 -B3

3 Re d u c t io n a n d fixa t io n (co n t )

a b c d

Fig 6 .2 .2 -5 a – f
a – c Sin ce th e fractu re gap is still open , an iden tical 3.5 m m cortex screw is
in serted as th e n ext step via a separate stab in cision an d tigh ten ed to act
as a redu ction screw. In th is way th e d isplaced fractu re can be pu lled
togeth er an d redu ced in a m ore or less an atom ically correct position .
Altern atively, th is procedu re cou ld be perform ed w ith collin ear redu c-
tion forceps in serted percu tan eou sly, w h ich wou ld requ ire a sligh tly
larger in cision .
d After evalu atin g axial align m en t in th e lateral view, de n itive xation
is perform ed by in sertion of ve 3.5 m m bicortical or su b-bicortical
lock in g h ead screw s prox im ally in th e h u m eral h ead section an d by
two 5.0 m m bicortical lock in g h ead screw s d istally. Th e in terfragm en -
tary lag screw in serted earlier as a redu ction screw is n ow too lon g an d
is rem oved.
e–f At com pletion , correct axial align m en t was apparen t in both plan es
as well as an alm ost an atom ically redu ced m ain fractu re zon e w ith a
sligh tly deh iscen t an terior in term ed iar y fragm en t.

e f

295
 6 .2 Hu m e ru s , s h a ft

4 Re h a b ilit a t io n

a b c d e f

Early fu n ction al reh abilitation w ith ou t im m obilization w ith active-assisted exer-

cises to stim u late sh ou lder an d elbow m obility.

Fig 6 .2 .2 -6 a – f
a – b After 6 weeks th e n eu rological de cit h ad com pletely d isappeared. Th ere
were rad iological sign s of in itial con solidation in th e m ed ial segm en ts w ith
slow form ation of callu s.
c– d In creasin g con solidation was visible even en dosteally after 3 m on th s w ith
u n ch an ged stable seatin g of th e lock in g h ead screw s.
e –f After 14 m on th s com pletely con solidated fractu re zon e in th e advan ced stag-
es of rem odelin g an d com pletely n orm al sh ou lder an d elbow fu n ction .

29 6
 6 .2 .2 Fra gm e n t e d h u m e ra l s h a ft w e d ge fra ct u re —12 -B3

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Plate system s w ith lock in g h ead screw s facilitate a m in i-
m ally in vasive procedu re. Th ere is less r isk of in fection
com pared to conven tion al plates becau se th ere is less n eed
to cau se add ition al dam age to th e vascu larity of th e peri-
osteu m an d th e fractu re zon e. An in tern al osteosyn th esis
procedu re h as advan tages over an extern al xator becau se
a very lon g tim e to h ealin g m u st be ex pected an d, th ere-
fore, th ere w ill be a correspon d in gly lon g period w ith th e
xator in situ .

Ap p ro a ch Ap p ro a ch
Deltoid splitting approach : danger of axillary lesion . Risk of The m in im ally invasive approach reduces the risk of addi-
lesion of the radial nerve due to: tion al iatrogen ic dam age to the biologically severely inju red
• an approach too lateral or too distal, or fractu re zone.
• incorrect exposu re of the nerve.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
A m in im ally in vasive approach m akes it m ore d if cu lt to A cortex screw can be u sed as a redu ction screw :
align th e fractu re in term s of axes, len gth , an d rotation . • to reduce the bone fragment onto the plate
Tan gen tial screw in sertion is to be avoided sin ce th is m ay • to reduce the fractu re gap
lead to plate pu ll-ou t. Th e in sertion of lock in g h ead screw s in creases th e prim a-
ry an d secon dar y stability of th e osteosyn th esis.

Re h a b ilit a t io n Re h a b ilit a t io n
An in tern al xation procedu re offers greatly im proved
patien t com fort com pared to stabilization w ith an exter-
n al xator.

297
 6 .2 Hu m e ru s , s h a ft

29 8
 Au t h o r Ch ris t o p h So m m e r

6 .2.3 Gunshot fracture of the hum e ral shaft—12-C1

1 Ca s e d e s crip t io n

42-year-old m an attem ptin g su icide sh ot a bu llet d iagon ally

th rou gh th e left h em ith orax an d in to th e left u pper arm . Th e
th oracic in ju ry (r igh t th rou gh th e lu n g) was treated by th orax
drain age an d h ealed. Th e sh ot th rou gh th e u pper arm cau sed
a sh aft fractu re in th e m idth ird (12-C1). Th ere were n o con -
com itan t n eu rovascu lar in ju ries.

Fig 6 .2 .3 -1a – b
a AP view.
b b Clin ical pictu re.

In d ica t io n

Gu n sh o t fra ctu re o f th e h u m e ru s is a cle a r in d ica tio n fo r o p e ra tive tre a tm e n t. So ft tissu e d e b rid e m e n t a n d sta b iliza tio n
o f th e fra ctu re is e sse n tia l. On e p o ssib ilit y w o u ld b e sta n d a rd o ste o s yn th e sis w ith a n e xte rn a l xa to r. In tra m e d u lla ry
n a ilin g o r p la te o ste o s yn th e sis p ro ce d u re s ca n a lso b e re co m m e n d e d . In a n o p e n p ro ce d u re , w h ich wo u ld b e in d ica t-
e d in a n y ca se w ith co n co m ita n t n e u ro va scu la r in ju rie s, pla te o ste o s yn th e sis w ith p rim a ry a n d se co n d a ry ca n ce llo u s
b o n e gra ftin g w o u ld b e p re fe rre d . In th e ca se p re se n te d h e re , it w a s d e cid e d to p e rfo rm m in im a lly in va sive in se rtio n
o f a n in te rn a l xa to r a fte r su rgica l d e b rid e m e n t o f th e e n try a n d e xit site s a n d irriga tio n o f th e gu n sh o t ch a n n e l.
a

Pre o p e ra t ive p la n n in g

Eq u ip m e n t 1 Su rge o n
4
• LCP 4 .5 , 13 h o le s 2 Assistan t
2
• 5 .0 m m lo ckin g h e a d scre w s (LHS) 1 3 An e sth e tist
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a c-
4 ORP
co rd in g to a n a to m y.)
Ste rile are a
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle sh o t 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
h e p a rin
a b 3

Fig 6 .2 .3 -2 a – b Be a ch ch a ir p o sitio n .

29 9
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

In cision s were m ade at th e prox im al an d d istal h u -

m eru s w ith ou t exposin g th e actu al fractu re zon e.

Fig 6 .2 .3 -3 a – bProxim ally, a sh ort stan dard in cision

is m ade in th e lin e of th e deltopectoral groove, takin g
care to avoid in ju ry of th e ceph alic vein . Th e approach
passes u n der th e deltoid m u scle wh ich is re ected lat-
erally. Distally, a stan dard an terolateral approach to
th e lateral h u m eru s is perform ed. Iden ti cation of
th e groove between th e brach ialis an d brach iorad ialis
m u scles in wh ich th e radial n er ve lies. After visu aliza-
tion an d preser vation of th e rad ial n erve, th e brach ia-
lis m u scle is d ivided at th e ju n ction of th e lateral an d
m id th irds in th e d irection of its bers, thu s facilitat-
in g d irect access to th e h u m eral sh aft.

a b

3 Re d u ct io n a n d fixa t io n

Fig 6 .2 .3 -4 A tu n n el is n ow created across th e u n exposed

fractu re zon e close to th e bon e startin g proxim ally or d istally.
Th is m an eu ver can be perform ed eith er w ith th e plate itself or
w ith a large pair of tweezers.
Blu n t pen etration of th e d istal in sertion of th e deltoid m u scle
is n ecessar y.

30 0
 6 .2 .3 Gu n s h o t fra ct u re o f t h e h u m e ra l s h a ft—12 -C1
3 Re d u c t io n a n d fixa t io n
a b
c d
(co n t )
Fig 6 .2 .3 -5 a – d
a – b Th e beach ch air position w ith th e arm dan glin g au to-
m atically leads to a fairly good in d irect redu ction in
term s of len gth an d axes. If th e forearm is h eld in th e
n eu tral position , th e rotation al align m en t w ill m ore or
less correct itself. Th e LCP, ben t sligh tly ou twards at
its prox im al an d d istal en ds, can n ow be in serted in to
th e prepared plate bed. Prim ary xation is ach ieved by
in sertion of a lon g, bicortical lock in g h ead screw in to
th e m ost prox im al h ole. After n e-tu n in g th e redu c-
tion of len gth an d rotation , a 5.0 m m bicortical lock in g
h ead screw is in serted in to th e m ost d istal plate h ole.
With th e arm h an gin g loosely an d th e patien t relaxed,
care sh ou ld be taken n ot to stabilize th e fractu re zon e
in over-d istraction . Fin e-tu n in g of ax ial align m en t can
be u n dertaken in th e lateral view by applyin g m anu al
pressu re an d cou n ter-pressu re at th e level of th e frac-
tu re zon e an d/or at th e elbow to realign an y residu al
an gu lar deform ity. Fu rth er stabilization is ach ieved by
in sertion of add ition al lock in g h ead screw s prox im ally
an d d istally. It is recom m en ded th at 4 –5 cortices sh ou ld
be xed. Bicortical screw s in crease rotation al stability,
w h ich is stron gly recom m en ded if bon e qu ality is poor.
c– d Th e postoperative x-rays con rm th at th e com m inu ted
zon e h as been bridged in correct align m en t as th e resu lt
of osteosyn th esis w ith a locked in tern al xator.
301
 6 .2 Hu m e ru s , s h a ft

4 Re h a b ilit a t io n

Open wou n d treatm en t of th e gu n sh ot

en try an d ex it sites was con tin u ed an d
led to u n even tfu l wou n d closu re w ith in
a few days. Early fu n ction al reh abilita-
tion w ith ou t im m obilization of th e left
u pper arm .

Fig 6 .2 .3 -6 a – f
e a – b After 7 weeks clear sign s of early
callu s form ation in th e com m i-
nu ted zon e w ith u n ch an ged stable
seatin g of th e plate an d screw s.
c– f At th is tim e th e patien t dem on -
c strated n orm al fu n ction of th e
sh ou lder an d elbow join ts. From
th is poin t on load in g was gradu -
ally in creased u n til fu ll load in g
was ach ieved at 3 m on th s.

a b d f

After on e year th e fractu re zon e h ad been par-

Fig 6 .2 .3 -7a – c
tially br idged. Resor ption lu cen cies arou n d th e screw s were
clearly visible on th e detailed im ages, especially arou n d th e
d istal screw s, wh ereby th ere are also sign s of reossi cation
of th ese areas as an in d ication th at com plete stability of th e
form er fractu re zon e h as been regain ed.

a b c

302
 6 .2 .3 Gu n s h o t fra ct u re o f t h e h u m e ra l s h a ft—12 -C1

4 Re h a b ilit a t io n (co n t )

A su bsequ en t exam in ation after 4 1/ 2 years

Fig 6 .2 .3 -8 a – b
sh owed predom in an tly en dosteal con solidation of th e frac-
tu re zon e w ith alm ost com plete rem odelin g. Th e resor ption
lu cen cies arou n d th e distal lock in g h ead screw s were n ow
com pletely reossi ed. Th e im plan ts w ill n ot be rem oved if th e
patien t rem ain s free of sym ptom s.

a b

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Plate system s w ith lock in g h ead screw s facilitate a m in i-
m ally in vasive procedu re. Th ere is less r isk of in fection
com pared to conven tion al plates becau se th ere is less n eed
to cau se add ition al dam age to th e vascu larity of th e peri-
osteu m an d th e fractu re zon e. An in tern al osteosyn th esis
procedu re h as advan tages over an extern al xator becau se
a very lon g tim e to h ealin g m u st be ex pected an d, th ere-
fore, th ere w ill be a correspon d in gly lon g period w ith th e
xator in situ .

303
 6 .2 Hu m e ru s , s h a ft

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Ap p ro a ch Ap p ro a ch
Lesion of the radial nerve due to incorrect exposu re of the The m in im ally invasive approach reduces the risk of addi-
nerve. tion al iatrogen ic dam age to the biologically severely inju red
fractu re zone.

Re d u ct io n a n d xa t io n
A m in im ally in vasive approach m akes it m ore d if cu lt to
align th e fractu re in term s of axes, len gth , an d rotation .
Tan gen tial screw in sertion is to be avoided sin ce th is m ay
lead to plate pu ll-ou t.
Re d u ct io n a n d xa t io n
Th e in sertion of lock in g h ead screw s in creases th e prim a-
ry an d secon dar y stability of th e osteosyn th esis.

Re h a b ilit a t io n Re h a b ilit a t io n
Du e to a sligh t protru sion of th e plate, proxim al im pin ge- An in tern al xation procedu re offers greatly im proved
m en t occu rred w ith som e pain , w h ich requ ired rem oval patien t com fort com pared to stabilization w ith an exter-
of th e im plan t. n al xator.

30 4
 Au t h o r Ch ris t o p h So m m e r

6 .2.4 Com ple x se gm e ntal proxim al hum e ral shaft

fracture —12-C2
1 Ca s e d e s crip t io n

45-year-old m an fell w h ile sk iin g an d su ffered a bifocal fractu re of

th e left prox im al h u m eru s. Th e in ju ry was a su bcapital obliqu e frac-
tu re com bin ed w ith a prox im al sh aft fractu re, wh ereby th e in term e-
d iar y fragm en t was split lon gitu d in ally (12-C2.2). No con com itan t
n eu rovascu lar in ju ries.

Fig 6 .2 .4 -1
a AP view.
b Lateral view.

In d ica t io n

Th is ve ry u n sta b le fra ctu re is n o t we ll su ite d to n o n o p e ra tive tre a tm e n t, in

a b
p a rticu la r, b e ca u se th e p roxim a l fra ctu re sh o we d e vid e n ce o f su b sta n tia l la t-
e ra l d isp la ce m e n t. Su rgica l a lte rn a tive s w o u ld in clu d e th e a n te gra d e in se rtio n
o f a n in tra m e d u lla ry n a il w ith p ro xim a l lo ckin g o p tio n in th e a re a o f th e h u -
m e ra l h e a d o r p la te o ste o syn th e sis. Min im a lly in va sive p la te o ste o s yn th e sis is
a n e le ga n t wa y to m in im ize th e su rgica l tra u m a o f a n e xte n sive a n te ro la te ra l
a p p ro a ch .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t 4 1 Su rge o n
• LCP m e ta p h yse a l p la te , 3 .5/ 4 .5/ 5 .0 , 2 2 Assistan t
1
5 + 11 h o le s 3 An e sth e tist
• 3 .5 m m lo ckin g h e a d scre w s (LHS) 4 ORP
• 3 .5 m m co rte x scre w s
Ste rile are a
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin a b 3
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
Fig 6 .2 .4 -2 a – b Be a ch ch a ir p o sitio n .
h e p a rin

305
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

Fig 6 .2 .4 -3 a – b
a Sin ce th e proxim al fractu re ru n s ben eath th e hu m eral h ead, ad-
equ ate xation in th at region is essen tial. Th erefore, an an terolat-
eral deltoid split approach is th e optim al procedu re. Th e approach
starts at th e lower m argin of th e acrom ion an d exten ds approx i-
m ately 6 cm in a distal direction as far as th e su bcapital zon e.
Division of th e deltoid in th e direction of its bers, wh ereby th e
m ost su perior bran ch of th e axillar y n er ve an d its accom pan yin g
vessels can be iden ti ed at th e lower m argin of th e in cision .
In cision of th e su bacrom ial bu rsa an d epiperiosteal tu n n elin g
in a d istal d irection w ith a blu n t in stru m en t or th e d istal plate
en d w ith re ection an d preser vation of th e bran ch of th e ax illar y
n erve. Sin ce a lon g plate is n ecessary to reach th e d istal section
of th e hu m eral sh aft, an open distal approach sh ou ld be ch osen ,
w ith iden ti cation of th e groove between th e brach ialis an d bra-
ch ioradialis m u scles an d exposu re of th e radial n er ve.
a b b An terior to th e visible rad ial n er ve, tran smu scu lar in cision th rou gh
th e brach ialis mu scle at th e ju n ction of th e lateral an d m id th irds
by m u scle division in th e direction of its bers. Direct approach
to th e distal hu m eral sh aft, wh ich can be exposed by application
of two sm all Hoh m an n retractors. Th e plate can be slid in to th e
prepared plate bed from proxim al to d istal.

3 Re d u ct io n a n d fixa t io n

Fig 6 .2 .4 -4An oth er possibility is to in sert a lon g,

stron g th read rst by m ean s of a tu n n elin g device
an d to attach th e plate to it. Th e plate can n ow be
pu lled in a d istal direction w ith th e h elp of th is
th read.

30 6
 6 .2 .4 Co m p le x s e gm e n t a l p ro xim a l h u m e ra l s h a ft fra ct u re —12-C2

3 Re d u c t io n a n d fixa t io n (co n t )

a b c d

Fig 6 .2 .4 -5 a – d
a Th e proxim al plate en d h as to be ben t sligh tly ou twards prior to in sertion to ach ieve opti-
m al adaptation to th e greater tu bercle. On ce th e plate h as been in serted, it is rst secu red
proxim ally in th e correct position w ith on e screw. In th is case, a con ven tion al 3.5 m m
cortex screw th at pressed th e plate optim ally towards th e greater tu bercle an d avoided
irritation of th e soft tissu es was ch osen . Redu ction of th e m ain fractu re zon e is ach ieved
in d irectly by th e weigh t of th e forearm as th e arm h an gs dow n , w h ereby ax ial, len gth
an d rotation al align m en t of th e prox im al fragm en t in relation to th e d istal fragm en t are
adequ ately restored in th e u su al way. After evalu ation of fractu re align m en t, a 4.3 m m
d rill bit is in serted th rou gh th e 5.0 m m th readed drill gu ide in th e m ost d istal plate h ole,
wh ereby th e d rill bit pen etrates both cortices. Before in sertin g an y fu rth er screw s, ax ial
deviation can be assessed in th e lateral view an d can be corrected in d irectly via th e plate
by m anu al pressu re an d cou n ter pressu re. After placin g addition al screw s in th e region of
th e h u m eral h ead (if possible, lock in g h ead screw s depen d in g on th e situ ation an d screw
orien tation), a bicortical screw is in trodu ced adjacen t to th e fractu re in th e distal m ain
fragm en t. On ly th en is th e drill bit in th e m ost d istal plate h ole replaced by a bicor tical
lock in g h ead screw. Sin ce th e in term ed iate fragm en t was in m arked an terom ed ial d is-
location , it was pu lled in to position by in sertion of a con ven tion al 4.5 m m cortex screw
th rou gh a stab in cision wh ich th en fu n ction ed as a redu ction screw.
b – c Th e n al x-rays con rm ed bridgin g of th e fractu re zon e in correct axial align m en t w ith
th e plate well position ed close to th e bon e.
d Wou n d closu re.

307
 6 .2 Hu m e ru s , s h a ft

4 Re h a b ilit a t io n

c d e f

Early fu n ction al reh abilitation w ith ou t im m obilization . No loadin g for th e rst 6 weeks,
wh ereby sh ou lder an d elbow m otion was stren gth en ed in gu ided active exercises.
Fig 6 .2 .4 -6 a – f
a – b After 6 weeks, in itial callu s form ation was visible at th e proxim al fractu re location ;
th e d istal location sh owed sign s of resor ption of th e fractu re m argin s, in d icatin g
th e start of con solidation .
c– f Th e patien t dem on strates very good fu n ction of th e left sh ou lder w ith active ex-
a b ion an d abdu ction to 100° as well as alm ost n orm al in n er an d ou ter rotation .

Fig 6 .2 .4 -7a – b
After 3 m on th s, in creasin g periosteal an d en dosteal con solidation of th e proxim al
fractu re site. Likew ise, in creasin g en dosteal con solidation at th e d istal fractu re site.

a b

30 8
 6 .2 .4 Co m p le x s e gm e n t a l p ro xim a l h u m e ra l s h a ft fra ct u re —12-C2

4 Re h a b ilit a t io n (co n t )

c d e

Fig 6 .2 .4 -8 a – e
a – b After 7 m on th s, com plete fractu re con solidation was docu -
m en ted, w h ereby rem odelin g was still in progress.
c– e At th is tim e, u n restricted sh ou lder an d elbow fu n ction w ith
th e affected an d con tralateral lim bs sh ow in g alm ost equ al
perform an ce.

a b

Im p la n t re m o va l
Fig 6 .2 .4 -9 a – c After 16 m on th s th e patien t requ ested im plan t
rem oval alth ou gh th ere were n ot really an y sym ptom s.
Th e fractu re com pletely rem odeled.
Im plan t rem oval was perform ed th rou gh th e sam e in ci-
sion s as th e osteosyn th esis, m ak in g su re th at th e rad ial
n erve in th e distal region was carefu lly iden ti ed, ex-
posed, an d retracted.

a b c

30 9
 6 .2 Hu m e ru s , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Plate system s w ith lock in g h ead screw s facilitate a m in i-
m ally in vasive procedu re. Th ere is less r isk of in fection
com pared to conven tion al plates becau se th ere is less n eed
to cau se add ition al dam age to th e vascu larity of th e peri-
osteu m an d th e fractu re zon e. An in tern al osteosyn th esis
procedu re h as advan tages over an extern al xator becau se
a very lon g tim e to h ealin g m u st be ex pected an d, th ere-
fore, th ere w ill be a correspon d in gly lon g period w ith th e
xator in situ .

Ap p ro a ch Ap p ro a ch
Lesion of the radial nerve due to incorrect exposu re of the The m in im ally invasive approach reduces the risk of addi-
nerve. tion al iatrogen ic dam age of the biologically severely inju red
fractu re zone.

Re d u ct io n a n d xa t io n
A m in im ally in vasive approach m akes it m ore d if cu lt to
align th e fractu re in term s of axes, len gth , an d rotation .
Tan gen tial screw in sertion is to be avoided sin ce th is m ay
lead to plate pu ll-ou t.
Re d u ct io n a n d xa t io n
Th e in sertion of lock in g h ead screw s in creases th e prim a-
ry an d secon dar y stability of th e osteosyn th esis.

Re h a b ilit a t io n Re h a b ilit a t io n
An in tern al xation procedu re offers greatly im proved
patien t com fort com pared to stabilization w ith an exter-
n al xator.

310
 Au t h o r Ch ris t o p h So m m e r

6 .2.5 Com ple x se gm e ntal hum e ral shaft fracture —12-C2

1 Ca s e d e s crip t io n

21-year-old sn ow boarder collided w ith a m arker post an d

in ju red h is righ t arm . Du rin g th e fall h e su stain ed a closed
bifocal fractu re of th e righ t h u m eral sh aft (12-C2.1). No con -
com itan t n eu rovascu lar in ju r ies.

Fig 6 .2 .5 -1 AP view.

In d ica t io n

Th is b ifo ca l fra ctu re is n o t w e ll su ite d to n o n o p e ra tive tre a tm e n t, in p a rticu la r b e ca u se th e se we re m o re

o r le ss tra n sve rse fra ctu re s situ a te d re la tive ly fa r p ro xim a lly a n d d ista lly. Th e d ista l fra ctu re co m p o n e n t is
n o t su ite d to in tra m e d u lla ry n a il xa tio n . Oth e r o p tio n s w o u ld in clu d e e xte rn a l xa to r o r p la te o ste o s yn -
th e sis. Th e o p e n p ro ce d u re fo r co n ve n tio n a l p la te o ste o syn th e sis re q u ire s a n e xte n sive a p p ro a ch a lo n g
th e e n tire le n gth o f th e h u m e ru s. Min im a lly in va sive slid e -in se rtio n te ch n iq u e re d u ce s th e le n gth o f th e
a p p ro a ch co n sid e ra b ly.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
4 1 Su rge o n
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 , 2
2 Assista n t
5 + 11 h o le s 1
3 An e sth e tist
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
4 ORP
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)
Ste rile are a

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r a b 3
h e p a rin
Fig 6 .2 .5 -2 a – b Be a ch ch a ir p o sitio n .

311
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

In cision s were m ade at th e prox i-

Fig 6 .2 .5 -3 a – b
m al an d d istal hu m eru s w ith ou t exposin g th e ac-
tu al fractu re zon e. Proxim ally, a sh ort stan dard
in cision is m ade in th e lin e of th e deltopectoral
groove, tak in g care to avoid th e ceph alic vein . Th e
approach passes u n der th e deltoid m u scle wh ich is
re ected laterally. Distally, a stan dard an terolater-
al approach for th e lateral hu m eru s is perform ed.
Iden ti cation of th e groove between th e brach ia-
lis an d brach iorad ialis m u scles in wh ich th e rad ial
n erve lies. After visu alization an d preservation of
th e rad ial n er ve, th e brach ialis m u scle is d ivided
at th e ju n ction of th e lateral part an d th e m idth ird
in th e d irection of its bers, th u s facilitatin g direct
access to th e hu m eral sh aft.

a b

3 Re d u ct io n a n d fixa t io n

Fig 6 .2 .5 -4 A tu n n el is n ow created across th e u n exposed

fractu re zon e close to th e bon e startin g proxim ally or d istally.
Th is m an eu ver can be perform ed eith er w ith th e plate itself or
w ith a large pair of tweezers. Blu n t pen etration of th e distal
in sertion of th e deltoid m u scle is n ecessar y.

312
 6 .2 .5 Co m p le x s e gm e n t a l h u m e ra l s h a ft fra ct u re —12-C2
3 Re d u c t io n a n d fixa t io n (co n t )
a b
Fig 6 .2 .5 -5 a – d
a Th e prox im al deltopectoral approach perm its tu n n elin g in
a d istal d irection an d, likew ise, th e d istal in cision perm its
tu n n elin g in a prox im al d irection u n der th e d istal portion
of th e fractu re zon e. Th e LCP m etaph yseal plate, appropri-
ately ben t at its d istal an d proxim al en ds, can be slid from
th e prox im al aspect in a d istal d irection in to th e prepared
plate bed. Fractu re redu ction is ach ieved by m ean s of th e
plate, wh ereby th is is rst an ch ored prox im ally by in ser-
tion of a bicortical lock in g h ead screw in th e su bcapital
region .
b Th e m idd le segm en t does n ot h ave to be an atom ically
adapted bu t sh ou ld be redu ced in correct axial an d len gth
align m en t, if possible. Th is can be ach ieved by m an u al
cou n ter pressu re exerted on th e m ed ial aspect of th e h u -
m eru s or by application of percu tan eou sly in serted col-
c d
lin ear redu ction forceps. Th e m idd le segm en t is secu red
w ith two screw s, w h ereby two m on ocortical screw s are
su f cien t. If bon e qu ality is poor, bicortical screw in ser-
tion sh ou ld be ch osen . To com plete th e procedu re, th e d is-
tal m ain fragm en t is redu ced by m ean s of th e plate. Th is
can be ach ieved eith er by u se of th e collin ear redu ction
forceps, th e in sertion of con ven tion al redu ction screw s or
by m ean s of th e d istraction in stru m en ts.
c Su bsequ en t d istal xation was ach ieved in th is case by in -
sertion of fou r 3.5 m m LHS, wh ereby bicortical screw s are
in serted for proxim al xation an d m on ocortical screw s for
d istal xation .
d Th e last two screw s are in serted in to on e cortex on ly to
avoid irritation of th e olecran on in th e region of th e olec-
ran on fossa.
313
 6 .2 Hu m e ru s , s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 6 .2 .5 -6 a – e
a – c In traoperative im agin g in th ree
plan es con rm s correct ax ial
bridgin g of th e bifocal fractu re,
wh ereby th e lateral view sh ow s
eviden ce of a sligh t ax ial de-
viation at th e level of th e u pper
fractu re focu s.
d–e Th e postoperative situ ation is
docu m en ted.

a b c d e

4 Re h a b ilit a t io n

Early fu n ction al reh abilitation w ith ou t an y form

of im m obilization . No load in g for th e rst 6 weeks.
Gu ided active exercises for th e sh ou lder an d elbow
u p to th e pain th resh old.

Fig 6 .2 .5 -7a – bX-rays at 6 weeks sh ow th e start of

callu s form ation at th e level of th e proxim al frac-
tu red area. Distally, th ere are on ly sign s of a certain
blu rrin g of th e fractu re m argin s as a sign of in itial
con solidation . Th e screw s are all in stable an ch orage
w ith ou t resor ption zon es.

a b

314
 6 .2 .5 Co m p le x s e gm e n t a l h u m e ra l s h a ft fra ct u re —12-C2

4 Re h a b ilit a t io n (co n t )

a b

a b c d e

Im p la n t re m o va l
Fig 6 .2 .5 -8 a – e
a – c After 6 weeks, in creased load in g w ith tran sition to u n restricted fu ll loadin g after
3 m on th s. After 16 m on th s n al exam in ation of th e sym ptom -free patien t sh ow s
eviden ce of total con solidation , wh ereby th e rem odelin g process h as been com -
pleted. Th e fractu re zon es are n o lon ger visible.
d – e Th e im plan ts were rem oved at th e requ est of th e patien t. Th is was perform ed
th rou gh th e sam e approach es, w h ereby th e d istal approach was sligh tly exten ded
to en su re a clear view an d preser vation of th e rad ial n erve.

315
 6 .2 Hu m e ru s , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Plate system s w ith lock in g h ead screw s facilitate a m in i-
m ally in vasive procedu re. Th ere is less r isk of in fection
com pared to conven tion al plates becau se th ere is less n eed
to cau se add ition al dam age to th e vascu larity of th e peri-
osteu m an d th e fractu re zon e. An in tern al osteosyn th esis
procedu re h as advan tages over an extern al xator becau se
a very lon g tim e to h ealin g m u st be ex pected an d, th ere-
fore, th ere w ill be a correspon d in gly lon g period w ith th e
xator in situ .

Ap p ro a ch Ap p ro a ch
Lesion of the radial nerve due to incorrect exposu re of the The m in im ally invasive approach reduces the risk of addi-
nerve. tion al iatrogen ic dam age of the biologically severely inju red
fractu re zone.

Re d u ct io n a n d xa t io n
A m in im ally in vasive approach m akes it m ore d if cu lt to
align th e fractu re in term s of axes, len gth , an d rotation .
Tan gen tial screw in sertion is to be avoided sin ce th is m ay
lead to plate pu ll-ou t.
Re d u ct io n a n d xa t io n
Th e in sertion of lock in g h ead screw s in creases th e prim a-
ry an d secon dar y stability of th e osteosyn th esis.

Re h a b ilit a t io n Re h a b ilit a t io n
An in tern al xation procedu re offers greatly im proved
patien t com fort com pared to stabilization w ith an exter-
n al xator.

316
 Au t h o r Ch ris t o p h So m m e r

6.2.6 Sim ple transve rse hum eral shaft fracture —12-A3 and partial
intraarticular sagittal lateral hum e ral condyle fracture —13-B1
1 Ca s e d e s crip t io n

87-year-old wom an , m en tally still reason -

ably active, fell on h er left arm an d su stain ed
a periprosth etic fractu re of th e h u m eral d i-
aph ysis (12-A3) an d a d istal, m oderately d is-
placed in traarticu lar fractu re of th e h u m eral
con dyle (13-B1.1). Statu s after im plan tation
of a hu m eral h ead prosth esis th ree years ago
w ith poor sh ou lder fu n ction an d rotator cu ff
in su f cien cy. Osteoporosis w ith a very th in
diaph yseal cortex.

Fig 6 .2 .6 -1a – d
a – b AP view.
a b c d c– d Lateral view.

In d ica t io n Pre o p e ra t ive p la n n in g

No n o p e ra tive tre a tm e n t o f th is la te ra lly d is- Eq u ip m e n t

p la ce d p e rip ro sth e tic o b liq u e fra ctu re is n o t • LCP 4 .5/ 5 .0 , n a rro w, 10 h o le s
e xp e cte d to le a d to a su cce ssfu l o u tco m e . • LCP T-p la te 3 .5 , 4 h o le s
Alte rn a tive p ro ce d u re s w o u ld b e a re p la ce - • Lo ckin g h e a d scre w s (LHS)
m e n t p ro sth e sis w ith im p la n ta tio n o f a lo n g (Size o f s yste m , in stru m e n ts, a n d im p la n ts 4
ste m p ro sth e sis a lth o u gh th e in situ ce m e n t- ca n va ry a cco rd in g to a n a to m y.) 2
1 1 Su rge o n
e d p ro sth e sis sh o u ld n o t b e re m o ve d fro m
2 Assistan t
th is ve ry th in , p o o r q u a lit y b o n e . Th e re fo re , Pa t ie n t p re p a ra t io n a n d
3 An e sth e tist
a d e cisio n wa s ta ke n to p e rfo rm p la te o s- p o s it io n in g
4 ORP
te o s yn th e sis, w h e re b y a p la te s yste m w ith An tib io tics: sin gle d o se 2 n d
lo ckin g h e a d scre w s wo u ld se e m h igh ly a p - ge n e ra tio n ce p h a lo sp o rin
Ste rile are a
p ro p ria te in vie w o f th e se ve re ly o ste o p o ro - Th ro m b o sis p ro p h yla xis:
tic b o n e . Th e d ista l in tra a rticu la r fra ctu re ca n lo w -m o le cu la r h e p a rin
b e sta b ilize d a t th e sa m e tim e to fa cilita te
e a rly fu n ctio n a l re h a b ilita tio n .
3

Fig 6 .2 .6 -2 Be a ch ch a ir p o sitio n .

317
 6 .2 Hu m e ru s , s h a ft

2 Su rgica l a p p ro a ch

In th is situ ation , a stan dard an terior open

Fig 6 .2 .6 -3 a – b
approach is preferred for th e d iaph yseal fractu re, prox im al-
ly th rou gh th e deltopectoral groove preser vin g th e ceph alic
vein . Lateral to th e biceps ten don / m u scle, th e approach is
con tinu ed d istally to th e d istal th ird of th e d iaph ysis, splittin g
th e brach ial m u scle between th e m ed ial an d m idd le th irds.
Th e rad ial n erve rem ain s m ore lateral, an d is n ot visu alized.
Th e d istal articu lar fractu re is approach ed th rou gh a strict
lateral rad ial in cision between th e triceps an d brach iorad ial
m u scles. Th e radial n er ve ru n s m ore an teriorly an d th erefore
does n ot n eed to be ex posed.

a b

3 Re d u c t io n a n d fixa t io n

In a rst step, th e prox im al periprosth etic fractu re is treated. Open approach an d

redu ction by m ean s of th e plate, wh ich is sligh tly ben t at its d istal en d, perm ittin g
d ivergen t in sertion of th e two m ost d istal lockin g h ead screw s. Th is in creases th e
stability an d redu ces th e risk of en bloc plate pu ll-ou t. Proxim al an ch orage is dif -
cu lt in view of th e ver y th in bon e. A sh ort m on ocortical, lock in g h ead screw is in -
serted in to th e m ost proxim al plate h ole. It is n ot possible to an ch or screw s in to any
of th e oth er proxim al plate h oles, n ot even cortex screw s in serted diagon ally. For
th is reason , th e plate is an ch ored in th e prox im al m ain fragm en t alm ost exclu sively
by xation w ith two cerclage w ires an d two add ition al titan iu m rin gs. Distal xa-
tion is ach ieved by in sertion of fou r bicortical lock in g h ead screw s, wh ich provide
very good stability.
Direct redu ction of th e d islocated radial con dyle is perform ed by way of th e secon d
approach as described above. An LCP T-plate 3.5 is applied as th e xation device. It
is appropr iately precon tou red an d an ch ored in th e m an n er of an in tern al xator,
ie, exclu sively w ith lock in g h ead screw s. In traoperative evalu ation con rm ed th at
stable con d ition s h ad been ach ieved at both fractu re sites.

318
 6 .2 .6 Sim p le t ra n s ve rs e h u m e ra l s h a ft fra ct u re —12-A3 a n d p a rt ia l in t ra a r t icu la r
s a git t a l la t e ra l h u m e ra l co n d yle fra ct u re —13 -B1

4 Re h a b ilit a t io n

c d

a b e f

Fig 6 .2 .6 -4 a – f
a – d Early fu n ction al reh abilitation was started cau tiou sly, wh ereby th e lim b was im m obilized
du rin g th e n igh t as a precau tion . X-ray assessm en t after 2 m on th s revealed in creasin g
con solidation of both fractu res, u n ch an ged, stable seatin g of th e im plan ts w ith ou t re-
sor ption lu cen cies arou n d th e screw s.
e – f Th e patien t was m ore or less free of sym ptom s an d dem on strated a m oderate exten sion
restriction at th e elbow w ith a de cit of approxim ately 30°. Th e ran ge of m otion at th e
sh ou lder was clearly restricted both actively an d passively (preoperative statu s).
Fu rth er clin ical an d x-ray exam in ation s w ill n ot be u n dertaken provided th e patien t rem ain s
free of sym ptom s.

319
 6 .2 Hu m e ru s , s h a ft

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Correct in tram u scu lar layers h ave to be iden ti ed to Dou ble approach (proxim al an terior; d istal lateral)
preserve th e rad ial n er ve. preser ves th e radial n erve.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Stabilization in th e proxim al part m ay fail. Th e lock in g screw-plate system is ver y h elpfu l for
periprosth etic an d osteoporotic fractu res.

Re h a b ilit a t io n Re h a b ilit a t io n
Stability is cr itical, an d th erefore too aggressive Early fu n ction al reh abilitation is essen tial to preser ve th e
reh abilitation m ay cau se a failu re of xation . already d im in ish ed preoperative sh ou lder m obility.

320
 Au t h o r Mich a e l Wa gn e r

6 .2.7 Pathological hum e ral shaft fracture

1 Ca s e d e s crip t io n

75-year-old wom an w ith path ological fractu re of th e left hu -

m eral sh aft an d m u ltiple m yelom a.

Fig 6 .2 .7-1a – b
a AP view.
b Lateral view.

a b

In d ica t io n

Pa th o lo gica l fra ctu re o f th e h u m e ra l sh a ft in th e p re se n ce o f m u ltip le

m ye lo m a . Osse o u s h e a lin g a fte r n o n o p e ra tive tre a tm e n t, n a m e ly, im -
m o b iliza tio n in a b race . Re fra ctu re im m e d ia te ly a d ja ce n t a n d d ista l to
th e p re vio u sly h e a le d fra ctu re . Th e u n sta b le , d isp la ce d fra ctu re w ith -
o u t sign s o f n e u ro lo gica l d e cit wa s a ga in tre a te d n o n o p e ra tive ly,
h o we ve r, a fte r 8 w e e ks fo llo w -u p a sse ssm e n t re ve a le d n o n u n io n .

Fig 6 .2 .7-2 a – b
a AP vie w.
b La te ra l vie w.

a b

321
 6 .2 Hu m e ru s , s h a ft

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• Me ta p h yse a l LCP 3 .5/ 4 .5/ 5 .0 , 4 + 10 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 5 .0 m m LHS
• 3 .5 m m co rte x scre w
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 6 .2 .7-3 Su p in e p o sitio n w ith h a n d ta b le .

2 Su rgica l a p p ro a ch

a b c

Fig 6 .2 .7-4 a – c
a Lateral approach to th e distal part of th e hu m eru s an d an terolateral in cision at th e proxim al sh aft.
b Carefu l preparation of th e rad ial n erve w h ich is retracted w ith th e vessel loop (wh ite).
c Su bm u scu lar tu n n elin g in preparation for su bsequ en t slide-in sertion of th e plate an d in sertion of a
gu ide th read.

32 2
 6 .2 .7 Pa t h o lo gica l h u m e ra l s h a ft fra ct u re

3 Re d u ct io n a n d fixa t io n

a b c

d e

Fig 6 .2 .7-5a – e Fractu re reduction by m anu al traction ; control u sin g im age inten si er.
a In sertion of th e n arrow 3.5/4.5/5.0 m etaph yseal LCP from th e d istal aspect in
a prox im al d irection w ith th e h elp of th e gu ide th read th at h as been passed
th rou gh th e h ole at th e prox im al en d of th e plate.
b Sin ce th e plate w ill be stabilized as a n on con tact in tern al xator w ith lockin g h ead
screws, ie, distant from the bone, the radial nerve is left beneath the xator.
c Tem porar y xation of th e d istal fragm en t is perform ed by m ean s of th e attach -
able cen terin g sleeve an d drill bit at th e distal en d of th e plate rst an d th en at a b
th e prox im al en d.
d Fixation of the metaphyseal plate w ith LHS at the distal hu meral fragment. A 3.5 Fig 6 .2 .7-6 a – b Postoperative x-rays.
m m cortex screw is in serted into the long oval hole and acts as a reduction screw a AP view. Th e gap between th e bon e
and is left in situ . The radial nerve (wh ite vessel loop) ru n s beneath the laterally an d th e plate is clearly visible. Th e
positioned plate. The radial nerve was not mobilized becau se it h ad become im mo- rad ial n er ve is situ ated in th is gap.
bilized in its su lcu s by callu s form ation related to the previou s fractu re. b Lateral view.
e To accom m odate th is, th e plate was con tou red to a wave sh ape.

Elastic xation of th e n onu n ion w ith locked in tern al xator. Th e n onu n ion was n ot
ex posed su rgically.

323
 6 .2 Hu m e ru s , s h a ft

4 Re h a b ilit a t io n

Fu ll active an d passive th era- Fu n ction al

Fig 6 .2 .7-8 a – c
py was com m en ced from th e pictu res after 2 1/2 years.
rst postoperative day. Pain free, partially restricted
a fu n ction at th e sh ou lder join t.
Fig 6 .2 .7-7a – b X-rays af- No n eu rological de cit.
ter 2 1/2 years sh ow callu s
bridgin g of th e fractu re, n o
loosen in g of th e im plan ts de-
spite osteoporosis an d partial
path ological osteolysis. b
a AP view.
b Lateral view.

a b c

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Eq u ip m e n t
Any lateral approach to the hu meru s requ ires retraction and Non con tact plates can be stabilized at a xed d istan ce
preservation of the radial nerve. from th e bon e, con sequ en tly, th e rad ial n er ve can be
perm itted to pass ben eath th e plate.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Less in vasive plate osteosyn th esis of a n on u n ion w ith
elastic xation leads to rapid, in d irect bon e h ealin g du e
to th e preservation of optim al biological con d ition s.

324
 Au t h o rs Kla u s -D Sch a s e r, No rb e r t P Ha a s , In go Me lch e r

6 .2.8 Inte rcalary re construction of the hum e rus following

oncological re se ction
1 Ca s e d e s crip t io n

32-year-old m an su stain ed a spon tan eou s, path ological frac-

tu re of th e h u m eral sh aft du e to rst m an ifestation of a Ew-
in g sarcom a of th e h u m eral d iaph ysis. Th e AP x-ray an d M RI
sh ow a d iaph yseal osteolysis w ith ou t sclerosis an d a tu m or
m atrix an d su rrou n d in g edem a.

Fig 6 .2 .8 -1a – b
a – b AP x-ray an d M RI scan sh ow in g th e d iaph yseal oste-
olysis an d in traosseou s tu m or m atrix (Ew in g Sarcom a)
w ith su rrou n d in g edem a an d path ological fractu re of
th e h u m eral d iaph ysis.

a b

In d ica t io n

Th e p a th o lo gica l fra ctu re wa s e rro n e o u sly th o u gh t to b e ca u se d b y a ju ve n ile so lid (u n ica m -

e ra l) b o n e cyst a n d su b se q u e n tly tre a te d b y clo se d re d u ctio n a n d re tro gra d e in tra m e d u lla ry
n a ilin g u sin g a so lid n a il (o th e r h o sp ita l, n o t a tu m o r ce n te r). Afte r p ro lo n ge d im m o b iliza tio n
o f th e sh o u ld e r a n d a rm th e fra ctu re sh o we d n o h e a lin g re sp o n se , h o we ve r, a p ro gre ssive ly
gro w in g p a ra o ste a l so ft-tissu e tu m o r m a ss ca u se d p a in fu l sw e llin g. Se co n d a ry in cisio n a l b i-
o p sy re ve a le d th e n a l h isto p a th o lo gica l d ia gn o sis o f Ew in g sa rco m a . Su b se q u e n tly, th e p a -
tie n t (n o m e ta sta tic d ise a se) wa s in clu d e d in e sta b lish e d o n co lo gica l tre a tm e n t p ro to co ls
(EURO-Ew in g) a n d a p re o p e ra tive n e o a d ju va n t p o lych e m o th e ra p y wa s p e rfo rm e d .

Fig 6 .2 .8 -2 a – b
Im m e d ia te p o sto p e ra tive x-ra ys a fte r clo se d re d u ctio n a n d re tro gra d e n a ilin g, p e rfo rm e d
u n d e r su sp icio n o f a u n ica m e ra l so lid ( ju ve n ile) b o n e cyst (e xte rn a l h o sp ita l, n o t a tu m o r
ce n te r).

a b

325
 6 .2 Hu m e ru s , s h a ft

In d ica t io n (co n t )

Ove ra ll o n co -su rgica l tre a tm e n t p ro to co l:

1. Ne o a d ju va n t ( p re o p e ra tive) p o lych e m o th e ra p y
2 . Su rgica l re se ctio n: w id e re se ctio n o f th e tu m o r a n d tu m o r-ce ll
d isse m in a tio n tissu e a re a s (e n tire d ia p h ysis w ith n a il)
3 . Ske le ta l re co n stru ctio n (fre e va scu la rize d a u to lo go u s b u la
tra n sfe r a n d o ste o s yn th e sis to th e re sid u a l p ro xim a l a n d d ista l
h u m e ru s u sin g LCP 3 .5)
4 . So ft-tissu e co ve ra ge a n d m u scle tra n sfe rs to re sto re fu n ctio n .
5 . Ad ju va n t ( p o sto p e ra tive) p o lych e m o th e ra p y

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• Lo ckin g p ro xim a l h u m e ru s p la te (LPHP), 8 h o le s
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 ,
13 h o le s
• LCP re co n stru ctio n p la te s 3 .5 , 6 h o le s
• LCP 3 .5 , 9 h o le s
• LCP re co n stru ctio n p la te s 3 .5 , 10 h o le s
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 ,
5 + 13 h o le s
• Lo ckin g h e a d scre w s (LHS)
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 6 .2 .8 -3 Pa tie n t in p ro n e p o sitio n w ith a rm o n a rm ta b le w ith

An tib io tics: ce p h a lo sp o rin 9 0 ° a b d u ctio n in th e sh o u ld e r jo in t a n d th e e lb o w in 9 0 ° e xio n
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin ( h a n gin g L p o sitio n).

326
 6 .2 .8 In t e rca la r y re co n s t ru ct io n o f t h e h u m e ru s fo llo w in g o n co lo gica l re s e ct io n

2 Tu m o r re s e c t io n

Fig 6 .2 .8 -4 For resection th e dorsal approach to th e hu m eru s
was u sed, leavin g th e biopsy tract u n tou ch ed an d en -bloc to
th e specim en . To perform a w ide an d safe on cological resec-
tion th e en tire extraarticu lar h u m eral d iaph ysis was resected
leavin g th e in tram edu llary n ail in situ an d w ith ou t con tact to
th e biopsy tract.
Th e rad ial n er ve (n ot in volved in th e tu m or) was preser ved.
Th e in traoperative clin ical im age sh ow s th e su rgical specim en
w ith tu m or-free resection m argin s (R0) as veri ed by in tra-
operative h istopath ological an alysis of both th e bon e m arrow
an d soft-tissu e m argin s.

3 Ske le t a l re co n s t ru c t io n

Fig 6 .2 .8 -5 a – c
a Biological recon stru ction of th e
in tercalar y defect was perform ed
by free vascu larized au tologou s
bu la tran sfer. After th e bu la, in -
clu din g th e nu trien t vessels ( bu -
lar arter y an d vein), h ad been h ar-
vested (preser ved periosteu m an d
soft-tissu e en velope) m icrovascu -
lar an astom osis was perform ed
en d-to-side to th e brach ial arter y
an d vein . Prox im a l stabilization of
th e bu lar graft after reperfu sion
a was ach ieved by u sin g a lockin g
proxim al hu m eru s plate (LPHP,
8-h ole), wh ile d istal xation was
perform ed w ith a LCP recon stru c-
tion plate 3.5 an d a LCP 3.5.
b – c AP an d lateral x-rays 10 days after
su rger y.

b c

327
 6 .2 Hu m e ru s , s h a ft

4 Mo t o r re co n s t ru ct io n a n d s o ft -t is s u e co ve ra ge

Fig 6 .2 .8 -6 To provide forward ex ion of th e sh ou lder th e

pectoralis mu scle was secu red to th e periosteu m of th e prox-
im al bu lar graft. Sh ou lder exten sion an d arm elevation
occu rs th rou gh th e tran sfer of th e deltoid, trapeziu s, latissi-
m u s dorsi to th e proxim al part of th e bu lar graft. Exten sion
of th e elbow is en su red by re xation of th e triceps m u scle to
th e d istal dorsal aspect of th e bu lar graft. Th e biceps an d
brach ioradialis were left u n tou ch ed. Th e rad ial n er ve was
tran sposition ed to th e an terior aspect of th e graft.

5 Re vis io n s u rge r y a n d fo llo w -u p

Fig 6 .2 .8 -7a – d
a – b 4 m on th s after su rgery th e proxi-
m al aspect of th e graft sh owed an
excellen t h ealin g to th e hu m eral
h ead. At th e distal part both plates
sh owed loosen in g an d pu ll-ou t of
th e screw s. Doppler u ltrasou n d
an alysis at th is tim e revealed regu-
lar ow of th e arterial an d ven ou s
m icrovessels.
c– d Con sequ en tly, im plan t rem oval
an d reosteosyn th esis was per-
form ed u sin g two lon ger LCP 3.5
th at provided stability an d exten d-
ed m ore prox im ally on th e graft.

a b c d

328
 6 .2 .8 In t e rca la r y re co n s t ru ct io n o f t h e h u m e ru s fo llo w in g o n co lo gica l re s e ct io n

5 Re vis io n s u rge r y a n d fo llo w -u p (co n t )

At 8 m on th s after su rgery a frac-

Fig 6 .2 .8 -8 a – c
tu re of th e proxim al part of th e bu lar graft
occu rred wh ile its en d sh owed bony con solidation
w ith in th e h u m eral h ead. Th e d istal aspect of th e
graft d isplayed com pleted con solidation . Again ,
re-osteosyn th esis was perform ed by rem oval of th e
lock in g prox im al h u m eru s plate (LPHP) an d bridg-
in g th e en tire bu lar graft by a lon g, preben t, an d
torqu ed 4.5 m etaph yseal LCP. In add ition , can cel-
lou s bon e graftin g of th e su bcapital fractu re region
was perform ed.

a b c

Clin ical im -
Fig 6 .2 .8 -9 a – f
ages an d x-rays at on e year
follow-u p dem on strate com -
pleted prox im al an d d istal
bon e con solidation an d ac-
ceptable m otor fu n ction . At
presen t th e patien t is free
c d from local or system ic tu m or
recu rren ce.

a b e f

329
 6 .2 Hu m e ru s , s h a ft
6 Pit fa lls –
Dia gn o s is
In correct d iagn osis an d in ter pretation of rad iograph ic
n din gs.
Failu re to perform an in cision al biopsy in qu estion able
lesion s.
Preoperative plan n in g an d su bsequ en t su rgery based on
th e in correct d iagn osis leads to seriou s con sequ en ces
wh ich com prom ise an d possibly preven t lim b sparin g
su rgery as well as im pair th e patien t’s overall progn osis.
Ap p ro a ch
Hu m eru s: rad ial n erve in ju ry du e to circu m feren tial
preparation of th e diaph ysis.
Fibu la: m orbid ity w ith th e risk of peron eal n erve in ju ry
du rin g h arvestin g of th e vascu larized graft.
Re s e ct io n
In traoperative tu m or-cell d issem in ation du e to prepara-
tion -in du ced m an ipu lation at th e tu m or site an d tu m or-
derived blood loss.
Re co n s t ru ct io n
In su f cien t perform an ce of m icrovascu lar su rger y m ay
lead to sten osis of th e an astom osis an d th rom bosis of th e
n u trien t vessels.
Bad ly ben t plates m ay in terfere w ith th e radial or u ln ar
n er ve.
In traoperative fractu re of th e bu lar graft du e to m u ltiple
perforation of th e graft (ream in g) an d in sertion of too
m any screw s.
330
7 Pe a rls +
Dia gn o s is
On su spicion of m align an t bon e tu m or refer th e patien t to
a m u scu loskeletal tu m or cen ter prior to in cision al biopsy.
Ap p ro a ch
Th e dorsal approach allow s com plete resection of
diaph yseal an d distal bon e tu m ors of th e hu m eru s
w ith ou t in terferin g w ith n eu rovascu lar stru ctu res
an d oth er com partm en ts.
Re s e ct io n
If possible an extern al xator m ay be u sed to m aintain
length and rotation after resection .
Intraoperative h istopathological an alysis is m andatory to
en su re tu mor-cell free su rgical m argin s.
Re co n s t ru ct io n
Th e LCP appears to be an ideal im plan t for prim ar y
an d revision su rgical treatm en t of segm en tal in tercalary
skeletal defects.
If on cologically ju sti able, preserve th e rotator cu ff
in sertion at th e prox im al h u m eru s for im proved m otor
fu n ction .
6 .3 Hum e rus, distal

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

6 .3 .1 Supraco nd yla r d istal h um e ral fra cture 13 -A2; co m p re ssio n LCP 3 .5; LCP d istal lag scre w, ce rclage 339
w ith e xte n sio n in to th e sh a ft an d 11-B1; m e dial h um e ru s p ro te ctio n pla te s
p roxim al u ln a r fra cture 21-B1 (DHM); LCP ole crano n
p la te

6 .3 .2 Op e n d isplace d co m p le te a rticu la r d istal 13 -C1 co m p re ssio n LCP re co n stru ctio n lag scre w s and 3 45
h u m e ra l fractu re p la te 3 .5 co m p re ssio n p la te s

6 .3 .3 Op e n co m p le te in traa rticu lar d istal 13 -C2 co m p re ssio n LCP re co n stru ctio n lag scre w s and 349
h u m e ra l fractu re p la te 3 .5 co m p re ssio n p la te s

6 .3 .4 Disp la ce d in traarticu lar d ista l h u m e ral 13 -C3 co m p re ssio n DHP d ista l h u m e ra l lag scre w s and 353
fractu re p la te 2 .7/ 3 .5 co m p re ssio n p la te s

6 .3 .5 Displa ce d in traarticu lar dista l hu m e ral 13 -C3 co m p re ssio n LCP re co n stru ctio n lag scre w s and 357
fractu re p la te 3 .5 co m p re ssio n p la te s

6 .3 .6 Pa th o lo gy o f th e e lb o w lo cke d LCP 3 .5 lo cke d in te rn al 3 61

sp lin tin g fixa to r

331
 6 Hu m e ru s

6 Hum e rus

6 .3 Hu m e ru s , d is t a l 33 3
6 .3 .1 Su p ra co n d yla r d is t a l h u m e ra l fra ct u re —13 -A2 w it h
e xt e n s io n in t o t h e s h a ft—11-B1 a n d p ro xim a l u ln a r
fra ct u re —21-B1 33 9
6 .3 .2 Op e n d is p la ce d co m p le t e a r t icu la r d is t a l h u m e ra l
fra ct u re —13 - C1 345
6 .3 .3 Op e n co m p le t e in t ra a r t icu la r d is t a l h u m e ra l
fra ct u re —13 - C2 349
6 .3 .4 Dis p la ce d in t ra a r t icu la r d is t a l h u m e ra l
fra ct u re —13 - C3 35 3
6 .3 .5 Dis p la ce d in t ra a r t icu la r d is t a l h u m e ra l
fra ct u re —13 - C3 357
6 .3 .6 Pa t h o lo g y o f t h e e lb o w 3 61

332
 Au t h o r Re t o Ba b s t

6 .3 Hum e rus, distal

1 In cid e n ce ra t e

Distal hu m eral fractu res are rare in ju ries in adu lts, com pr is-
in g 2% of all fractu res [1] bu t approxim ately 1/ 3 of all hu m er-
al fractu res [2]. A recen t epidem iologic report sh owed an in -
ciden ce for d istal h u m eral fractu res of 5.7% , [3 ] w ith an even a b c
d istr ibu tion am on g th e sexes. Distal hu m eral fractu res sh ow a
Fig 13-A Extraarticu lar fractu re.
6 .3 -1a – c
bim odal d istribu tion regardin g age an d gen der w ith th e h igh -
a 13-A1 apoph yseal avu lsion
est in ciden ce for m ales below th e age of 20 an d fem ales above
b 13-A2 m etaph yseal sim ple
th e age of 80. Detailed sex an d age d istribu tion accord in g to
c 13-A3 m etaph yseal m u ltifragm en tary
th e fractu re types is reported in th e cited stu dy. Th e m ajor-
ity of d istal h u m eral fractu res com prise extraarticu lar frac-
tu res (38.7% ). Partial articu lar fractu res h ave an in ciden ce
of 24.1% an d in traarticu lar fractu res (37.2% ) h ave a sligh tly
lower in ciden ce th an extraarticu lar fractu res [3 ].

2/ 3 of th e d istal h u m eral fractu res are cau sed by sim ple falls
(predom in an tly in fem ales), wh ereas 1/ 3 con cern s h igh -ve-
a b c
locity in ju ries (fall from a h eigh t, road traf c acciden ts, sport
acciden ts, m ain ly in m ales) [3 ]. Fig 13-B Partial articu lar fractu re.
6 .3 -2 a – c
a 13-B1 sagittal lateral con dyle
Depen d in g on th e m ech an ism of in ju ry, com plem en tary le- b 13-B2 sagittal m ed ial con dyle
sion s are n ot u n u su al su ch as add ition al fractu res arou n d th e c 13-B3 fron tal
elbow com bin ed w ith ligam en tou s in ju ries, wh ich are often
n ot eviden t du e to osseou s in stability at th e in itial assessm en t.
Vascu lar lesion s in com bin ation w ith isolated d istal h u m eral
fractu res are very rare an d m ostly associated w ith h igh -veloc-
ity m ech an ism s. Uln ar n erve palsies are m ostly seen in m e-
d ial epicon dylar fractu res (13-A1.2) in you n g adu lts, du e to
a sim ple fall or a sports in ju r y [3 ]. Open d istal hu m eral frac-
tu res are predom in an t in type C fractu res an d th eir in ciden ce
varies from 20 –50% in differen t ser ies [3 , 4].
a b c

Fig 13-C Com plete articu lar fractu re.

6 .2 -3 a – c
a 13-C1 articu lar sim ple, m etaph yseal sim ple
b 13-C2 articu lar sim ple, m etaph yseal m u ltifragm en tar y
c 13-C3 articu lar m u ltifragm en tar y

333
 6 Hu m e ru s
2 Cla s s ifica t io n
Several classi cation system s are u sed for th e description of
d istal hu m eral fractu res. Th e Mü ller AO Classi cation [5 ] an d
th e Ju piter-Meh n e classi cation [6 ] are descriptive classify-
in g system s th at in clu de m ost fractu re pattern s of th e d istal
hu m eru s. Th e latter is m ore d istin ctive con cern in g th e m ech -
an ism of extraarticu lar an d partial articu lar fractu res an d
d iffers between h igh an d low fractu re pattern s in respect of
th e olecran on fossa. Sin ce low fractu re con gu ration s are as-
sociated w ith a h igh er risk of u n ion com plication s [3 ], th is
classi cation h as a m ore detailed progn ostic valu e th an th e
Mü ller AO Classi cation .
However, th e reliability of th e Mü ller AO Classi cation is h igh
w ith a valu e of 0.94 w h en u sin g th e preoperative x-rays an d
th e su m m ar y of in traoperative n d in gs [3 ]. In con trast to th e
Ju piter-Meh n e classi cation w ith a valu e of 0.295, th e Mü ller
AO Classi cation resu lts in a su bstan tial agreem en t (0.52 an d
0.66) u sin g ju st th e preoperative x-rays [7 ]. Despite its lim ita-
tion s, today th e Mü ller AO Classi cation seem s to be th e m ost
valu able descriptive classi cation system for distal hu m eral
fractu res, especially in com bin ation w ith th e in traoperative
n din gs.
Vid e o 3 Tre a t m e n t m e t h o d s
6 .3 -1
Regardin g assessm en t an d procedu ral settin g, th e com plex
an atomy of th e distal hu m eru s presen ts a diagn ostic an d
th erapeu tic ch allen ge, in particu lar, du e to sm all osseou s frag-
m en ts, sparse su bch on dral bon e, a great am ou n t of join t carti-
lage an d th e frequ en t presen ce of relevan t osteoporosis.
Stan dard x-rays (AP/ lateral view) of th e elbow are often su f-
cien t to appreciate th e m ain fractu re pattern . An addition al
obliqu e view is recom m en ded to view oth er fractu re plan es.
Th e valu e of 2-D an d 3-D im agin g is n ot yet clear, bu t h as
334
th e poten tial to add im portan t in form ation regard in g fractu re
lin es in volvin g th e articu lar portion in th e sagittal an d coro-
n al plan es. A preoperative exten sion view u n der an esth esia
u sin g an im age in ten si er m ay add addition al in form ation
to th e preoperative assessm en t, th u s optim izin g th e su rgical
procedu re.
Th e approach is adapted to th e fractu re pattern : Partial artic-
u lar fractu res m ay be treated u sin g a d irect lateral or m ed ial
approach , wh ereas a dorsal in cision offers th e best approach
con d ition s to extraarticu lar an d in traarticu lar fractu res. Dis-
placed extraarticu lar fractu res m ay be exposed by ch oosin g
a triceps splittin g procedu re as well as follow in g th e m ed ial
or lateral m argin of th e m u scle. Wh en treatin g in traarticu lar
fractu res, d ifferen t form s of triceps re ectin g approach es like
th e olecran on osteotom y [12], th e triceps an con eu s ped icle
(TRAP) [8 ] or th e tr iceps sparin g approach [9 ] are recom -
m en ded. Th e m ajority of in traarticu lar fractu res is approach ed
u sin g an olecran on osteotom y as recom m en ded by th e AO. In
elderly patien ts w ith m u ltifragm en tar y fractu res, olecran on
preservin g approach es are preferable [9 , 8 ]. Th e latter are also
a good option for th e xation of sim ple in traarticu lar frac-
tu res. Th e sem ilu n ar n otch serves as a tem plate for th e recon -
stru ction of th e troch lea.
Alth ou gh ORIF of d istal h u m eral fractu res is ch allen gin g an d
h as com plication s [3 , 4 , 10 , 11, 15 ] su ch as im plan t failu re,
m alu n ion , n onu n ion , elbow stiffn ess, in fection , h eterotopic
bon e form ation , an d u ln ar n eu ropath y, it is gen erally accepted
to be th e better ch oice of treatm en t for d isplaced extraarticu lar,
partial articu lar, an d in traarticu lar fractu res th an a con ser va-
tive procedu re.
Con ser vative treatm en t m ay be an option for n on d isplaced
extraarticu lar (13-A) an d partial articu lar fractu res (13-B).
For in traarticu lar fractu res (13-C), it sh ou ld be restricted to
in operable patien ts [3 , 16 ]. However, 4 –6 weeks im m o-biliza-
tion is m arked by a h igh risk of secon dar y d isplacem en t, el-
bow stiffn ess, n onu n ion , an d m alu n ion leadin g to in stability
an d posttrau m atic arth ritis.
 6 .3 Hu m e ru s , d is t a l
M in im a lly in vasive approach es u sin g percu tan eou s K-w ire
xation m ay be con sidered in som e extraarticu lar an d par-
tial articu lar fractu res (13-A1, 13-B1-3) as well as in h igh -risk
patien ts w ith osteoporosis an d displaced extraarticu lar frac-
tu res of th e type 13-A2.3, 13-A3.1-2. Th ese m igh t pro t from
a percu tan eou s xation by K-w ires com bin ed w ith ten sion
ban d xation in clu d in g 4 –6 weeks im m obilization in a 90°
cylin der cast. Th e lim ited fu n ction al dem an d of th is patien t
grou p ou tweigh s th e possible draw backs of elbow stiffn ess,
n on u n ion , an d m alu n ion .
On ly ORIF w ith stable fragm en t xation by screw s an d plates
u sin g th e appropriate tech n iqu e allow s early active postop-
erative m otion . Th is con cern s all fractu res of th e d istal hu -
m eru s an d is a prerequ isite for an optim al fu n ction al resu lt;
th e su ccess rate is 75 –85% [3 , 4 , 10 , 11, 15 ]. Du e to th e com -
plex an atom y of th e distal hu m eru s, recon stru ction plates 3.5,
an d easily con tou red or presh aped plates are recom m en ded
[11, 12]. On e-th ird tu bu lar plates, alth ou gh easier to adapt,
are n ot stron g en ou gh an d w ill fail [11]. Plate xation of both ,
th e m ed ial an d th e lateral colu m n is n ecessar y to ach ieve ade-
qu ate stability of th e distal hu m eru s. Two posterior plates are
biom ech an ically less stable th an two sidew ise parallel plates
or bilateral per pen dicu lar plates as recom m en ded by th e AO
[4 , 11–15 ]. Coron al sh earin g fragm en ts are best xed eith er
by Herbert screw s or by su bcartilagin ou s cou n tersu n k 1.5 –2.0
m m m in i fragm en t screw s.
Th e problem of xation of sm all an d osteoporotic fragm en ts
u sin g conven tion al recon stru ction plates can be solved by
per pen d icu lar screw placem en t th rou gh well adapted plates
wh ich “crad le” th e m ed ial epicon dyle an d th e dorsal aspect of
th e lateral epicon dyle [16 ]. Th e n ew LCP con cept w ith an gu lar
stable lock in g h ead screw s in con vergin g d irection s w ith in
LCP recon stru ction plates 3.5 h as th e poten tial to in crease
screw an ch orage in th ose fragm en ts. First clin ical trials w ith
form plates u sin g lock in g h ead screw s w ith sm aller d iam eters
in th e articu lar area h ave sh ow n prom isin g resu lts.
Regard in g an y xation system , th e stabilizin g tech n iqu e
sh ou ld aim for an atom ical join t recon stru ction w ith prelim i-
n ar y K-w ire xation of th e articu lar block. In terfragm en tar y
com pression is ach ieved in well recon stru cted articu lar seg-
m en ts w ith a sh ort th readed can cellou s bon e screw, wh ere-
as a position in g screw m ain tain s th e correct position of th e
troch lea if fu rth er bon e fragm en ts are m issin g. Th e latter are
replaced by bon e grafts. Th e join t block is th en xed by well
adapted plates, screw in sertion startin g in th e d istal plate
h oles an d u sin g eccen tric proxim al screw s to ach ieve in ter-
fragm en tar y com pression between th e articu lar block an d
th e m eta-/d iaph yseal area. Wh en ever possible, a com pression
screw is placed between th e articu lar an d th e m etaph yseal
block to in crease stability.
A tran sposition of th e u ln ar n erve is n ot rou tin ely perform ed.
If in terferen ce or scarr in g by a plate is ex pected, a su bcu tan e-
ou s tran sposition is recom m en ded [17 ].
An olecran on osteotom y is u su ally xed by two K-w ires an d
a ten sion ban d or by a can cellou s bon e screw u sin g a wash er,
com bin ed w ith a ten sion ban d.
To ch eck th e in traarticu lar screw position , an in traopera-
tive x-ray or an im age in ten si er con trol sh ou ld be exam in ed
carefu lly. In traoperative ran ge of m otion an d stability sh ou ld
be ch ecked for im m ed iate postoperative treatm en t settin g.
Postoperative im m obilization in a splin t to deal w ith pain an d
swellin g is recom m en ded for th e rst 3 –4 days. Im m ed iate
active-assisted m obilization takes place depen d in g on swell-
in g an d pain for 6 weeks. Th e role of con tin u ou s passive m o-
tion is n ot yet de n ed [11, 16 ]. Resistive train in g starts after
rad iological con trol an d con rm ation of h ealin g progression
at 8 –12 weeks.
In elderly patien ts w ith poor bon e stock du e to age, rh eu m a-
toid arth ritis or lon g-term steroid m edication , th e treatm en t
of m u ltifragm en tar y in traarticu lar fractu re types 13-C2 an d
335
 6 Hu m e ru s

C3 by a prim ar y elbow arth roplasty m ay be con sidered. De-

6 Bib lio gra p h y
spite lack of stron g eviden ce favorin g th is approach , sm all
data series in clu din g elderly patien ts sh ow com parable resu lts
to ORIF [18 –2 0 ]. 1. Ju p it e r J B, Mo rre y BF (1993) Fractu res of th e distal hu m eru s in
th e adu lt. Morrey BF, (ed), The Ellbow and its disorders. 2n d edition
Ph iladelph ia, PA: W B Sau n ders, 328 –366.
2. Ro se SH , Me lt o n LJ, Mo rre y BF, e t al (1982) Epidem iologic
6 Im p la n t o ve r vie w
featu res of hu m eral fractu res. Clin Orthop; 168:24 –30.
3. Ro bin so n CM , H ill R M , Jaco bs N , e t al (2003) Adu lt distal
a hu m eral m etaphyseal fractu res: epidem iology an d resu lts of
treatm en t. J Orthop Trauma; 17 (1):38 –47.
b 4. Ju p it e r J B, N e ff U, Ho lzach P, e t al (1985) In tercon dylar
fractu res of th e h u m eru s. J Bone Joint Surg Am; 67(2):226 –239.
5. Mü lle r M E, N azarian S, Ko ch P, e t al (1990) Th e
c com preh en sive classi cation of fractu res of lon g bon es. Berlin
Heidelberg New York: Sprin ger.
6. Ju p it e r J B, Me h n e D K (1992) Fractu res of th e distal hu m eru s.
d Orthopedics; 15(7):825 –833.
7. Wainw righ t A M , William s J R , Carr A J (2000) In terobserver
an d in traobserver variation in classi cation system s for fractu res
e
of th e distal hu m eru s; J Bone Joint Surg Br; 82(5):636 –642.
8. O’D risco ll SW (2000)Th e triceps-re ectin g an con eu s pedicle
(TRAP) approach for d istal hu m eral fractu res an d n onu n ion s.
f
Orthop Clin North Am; 31(1):91–101.
9. Bryan RS, Mo rre y BF (1982) Exten sive posterior exposu re
of th e elbow : A triceps-sparin g approach ;
g
Clin Orthop Relat Res;166:188 –192.
10. Jo h n H , Ro sso R , N e ff U, e t al (1994) Operative treatm en t of
Fig 6 .3 -4 a – g
distal hu m eru s fractu res in th e elderly; J Bone Joint Surg Br;
a LCP 3.5
76(5):93 –96.
b LCP recon stru ction plate 3.5
11. O’ D risco ll SW, San ch e z-So t e lo J, To rch ia M E (2002)
c DHP—distal h u m eral plate dorsolateral 2.7/ 3.5
Man agem en t of th e sm ash ed distal hu m eru s;
d DHP—distal h u m eral plate dorsolateral 2.7/ 3.5 w ith
Orthop Clin North Am; 33(1):19 –33.
lateral su pport
12 . Ho ld sw o rt h BJ (2000); Hu m eru s: Distal. In AO prin ciples of
e DHP—distal h u m eral plate m ed ial 2.7/ 3.5
fractu re m an agem en t: Rü ed i TP, Mu r ph y WM, ed.
f– g LCP m etaph yseal plate 3.5, for d istal m ed ial hu m eru s
Stu ttgart New York, Th iem e.
13. Sch e m it sch EH , Te n ce r A F, He n le y M B (1994) Biom ech an ical
evalu ation of m eth ods of in tern al xation of th e d istal h u m eru s;
J Orthop Trauma; 8(6):468 –475.

336
 6 .3 Hu m e ru s , d is t a l

14 . He lfe t D L, Ho t ch k iss R N (1990) In tern al xation of th e

d istal hu m eru s: a biom ech an ical com parison of m eth ods;
J Orthop Trauma; 4(3):260 –264.
15. Wad de ll J P, Hat ch J, R ich ard s R (1988) Su pracon dylar
fractu res of th e h u m eru s: Resu lts of su rgical treatm en t;
J Trauma; 28(12):1615 –1621.
16 . Me h n e D K, Ju p it e r J B (1992) Skeletal Trau m a. Part II Fractu res
of th e d istal hu m eru s. Browner BD, Jupiter JB, Levine A M, Trafton
PG (eds), Skeletal Trauma. Ph iladelph ia Lon don Toron to Mon treal
Sydn ey Tokyo; W B Sau n ders.
17. R in g D , Ju p it e r J B (1999) Com plex fractu res of th e distal
hu m eru s an d th eir com plication s; J Shoulder Elbow Surgery;
8(1):85 –97.
18 . Fran k le M A , He rscov ici D Jr, D i Pasqu ale TG, e t al (2003)
A com parison of open redu ction an d in tern al xation an d
prim ary total elbow arth roplasty in th e treatm en t of in traarticu lar
d istal hu m eru s fractu res in wom en older th an age 65;
J Orthop Trauma; 17(7):473 –480.
19. Obre m ske y WT, Bh an d ari M , D irsch l D R , e t al (2003)
In tern al xation versu s arth roplasty of com m inu ted fractu res of
th e distal hu m eru s; J Orthop Trauma; 17(6):463 –465.
20 . Gam birasio R , R ian d N , St e rn R , e t al (2001) Total elbow
replacem en t for com plex fractu res of th e distal hu m eru s.
An option for th e elderly patien t; J Bone Joint surgery Br;
83(7):974 –978.

337
 6 Hu m e ru s

338
 Au t h o r Mich a e l Ple cko

6.3.1 Supracondylar distal hum eral fracture —13-A2 with e xtension

into the shaft—11-B1 and proxim al ulnar fracture —21-B1
1 Ca s e d e s crip t io n

41-year-old, m en tally disabled m an in -

ju red h is righ t dom in an t arm in a car ac-
ciden t. Displaced fractu re of th e hu m eral
sh aft (11-B1), extraarticu lar su pracon-
dylar fractu re of th e hu m eru s (13-A2)
an d fractu re of th e proxim al u ln a w ith
com m inu tion (21-B1). Im m ediate radial
n erve palsy after th e acciden t.

Fig 6 .3 .1-1a – e
a AP view.
b Lateral view.
c Obliqu e view.
d CT scan distal hu meru s, frontal plane.
a b c e CT scan sh aft fractu re, sagittal plan e.

Th e patien t received rst aid in a sm all h ospital. Redu ction m an eu vers were per-
form ed bu t were in effective an d th e arm was stabilized in a plaster cast for tran s-
portation pu r poses on ly.

Note: In displaced obliqu e fractu res of th e distal th ird of th e hu m eru s, th ere is a

h igh risk th at th e radial n er ve m ay be cau gh t between th e fractu re fragm en ts an d
d e becom e dam aged.

In d ica t io n

Un sta b le d isp la ce d fra ctu re a t th e m id d le to d ista l th ird . So m e m in i-
m a lly d isp la ce d fra ctu re lin e s in th e su p ra co n d yla r re gio n e xte n d in g
in to th e la te ra l co n d yle . Fra ctu re o f th e p roxim a l u ln a w ith co m m in u -
tio n zo n e . Prim a ry ra d ia l n e rve p a lsy im m e d ia te ly a fte r th e a ccid e n t.
No va scu la r d a m a ge . Clo se d so ft-tissu e tra u m a gra d e I a cco rd in g to
Tsch e rn e a n d Oe ste rn .
Nonop e ra tive m anage m e n t was no t an op tion b e cau se o f the like liho o d
that so ft tissue and the radial ne rve m igh t b e situate d in the fracture
gap. In addition , fracture o f the ole crano n w ith a com m inu tion zone is
an u n stable fracture p atte rn . Stable xation o f all fracture s se e m e d to
be the be st option be cause o f the low com pliance of the patie n t due
to his m e n tal disability. Minim ally invasive stabilization was no t con sid -
e re d be cau se of the re quire d re vision of the radial ne rve . Additionally,
the d istal hum e ral fragm e n t was to o short to o ffe r su f cie n t anchorage
for an intram e dullary de vice . The de cision was m ade to pe rform an
ope n proce dure , re vision and de com pre ssion of the radial ne rve , re duc-
tion and stable xation o f the hum e ral fractu re w ith ce rclage w ire s and
inte rfragm e ntary corte x lag scre w s (in te rfragm e ntary com pre ssion).
A double plate o ste o syn the sis w ith two LCP 3.5 se cure d w ith locking
he ad scre w s had to be pe rform e d to incre ase stability.
At th e p ro xim a l u ln a o p e n re d u ctio n a n d a n gu la r sta b le p la te o ste o -
s yn th e sis w a s p e rfo rm e d to sta b ilize th e o le cra n o n fra ctu re .

339
 6 .3 Hu m e ru s , d is t a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP 3 .5 , 12 h o le s
• LCP m e ta p h yse a l p la te 3 .5 , fo r d ista l m e d ia l h u m e ru s,
13 h o le s
• LCP o le cra n o n p la te 3 .5 (righ t), 8 h o le s (cu t to 5 h o le s)
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• Ce rcla ge w ire s
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Fig 6 .3 .1-2 Th e p a tie n t is in th e p ro n e p o sitio n . Th e a rm is
fre e ly d ra p e d a n d p o sitio n e d o n a ra d io lu ce n t a rm ta b le . No
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
to u rn iq u e t is u se d in th is fra ctu re situ a tio n a lth o u gh it w o u ld
An tib io tics: ce p h a lo sp o rin
b e h e lp fu l in a m o re d is ta l h u m e ra l fra ctu re .
Th ro m b o sis p ro p h yla xis: n o n e

2 Su rgica l a p p ro a ch

Fig 6 .3 .1-3 a – d
a A straigh t posterior in cision is m ade from th e
m idth ird of th e hu m eru s, m ed ial to th e tip of
th e olecran on , dow n to th e forearm . Altern a-
tively, th e in cision m ay be cu rved arou n d th e
tip of th e olecran on on th e rad ial side. Th e h e-
m atom a in th e olecran on bu rsa is evacu ated
an d in th is case th e bu rsa was resected.
b Th e u ln ar n erve is iden ti ed, released to th e
rst m otor bran ch an d protected. Th e triceps
m u scle is m obilized. In com plex olecran on frac-
tu re situ ation s, th e m u scle is re ected to prox i-
m al w ith on e or m ore olecran on fragm en ts in
con tinu ity w ith th e ten don .

a b

34 0
 6 .3 .1 Su p ra co n d yla r d is t a l h u m e ra l fra ct u re —13 -A2 w it h e xt e n s io n in t o t h e s h a ft—11-B1
a n d p ro xim a l u ln a r fra ct u re —21-B1
2 Su rgica l a p p ro a ch (co n t )
c d
3 Re d u ct io n a n d fixa t io n
a b
Redu ce th e fractu re fragm en ts w ith poin ted redu ction forceps
w ith ou t add ition al dam age to th e periosteal blood su pply
to th e bon e. Wh en redu ction is optim al, cerclage w ires an d
in terfragm en tary cortex lag screw s are in serted to stabilize
th e fractu re. Th is leads to in terfragm en tary com pression an d
good bon e h ealin g.
Fig 6 .3 .1-3 a – d (co n t)
c– d Th e rad ial n erve is iden ti ed an d, as ex pected, th e n er ve
h as su ffered dam age between th e two m ain hu m eral
sh aft fragm en ts. All fractu re lin es are iden ti ed, bu t are
n ot com pletely exposed in an effort to keep th e perios-
teal blood su pply in tact.
c
Fig 6 .3 .1-4 a – dTo im prove stability two protection plates are
u sed. First an LCP 3.5 is prepared for th e dorsal side of th e
sh aft an d th e rad ial colu m n . Th e plate is sligh tly precon tou red
an d xed prox im ally w ith th ree 3.5 m m lock in g h ead screw s
an d d istally w ith two. After wards, an LCP m etaph yseal plate
3.5 for d istal m ed ial h u m eru s is ch osen . Th e plate is xed w ith
lock in g h ead screw s to th e lateral side of th e m ed ial colu m n as
a protection plate. Th is n on con tact plate is n ot pressed to th e
bon e so th at th e periosteal blood su pply is preserved. Im age
in ten si cation sh ow s a gap of a few m illim eters between th e
plate an d th e m ed ial cortex. Th e u ln ar n erve is retracted w ith
a wh ite vessel loop.
341
 6 .3 Hu m e ru s , d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 6 .3 .1-4 a – d After irrigation th e n al procedu re is redu ction

(co n t)
of th e fragm en ts of th e olecran on w ith ou t an y step-off at th e articu lar
su rface. Tem porary K-w ire xation m ay be h elpfu l. For de n itive frac-
tu re stabilization of th is m u ltifragm en ted fractu re plate xation w ith an
an gu lar stable LCP olecran on plate is preferred. If th e fragm en ts at th e
tip of th e olecran on are sm all, add ition al h eavy, n on absorbable su tu res
th at x th e triceps ten don to th e plate m ay h elp to im prove stability.
Th e u ln ar n erve is eith er tran sposed to th e an terior side of th e epicon -
dyle or reposition ed in its bed in th e bicipital groove.
After irrigation an d drain age carefu l wou n d closu re h as to be perform ed
an d a soft ban dage is applied.

Postoperative x-rays sh ow a good

Fig 6 .3 .1-5 a – b
redu ction of th e fractu re of th e hu m eru s an d th e
u ln a an d good position in g of th e im plan ts.
a AP view.
b Lateral view.

a b

4 Re h a b ilit a t io n

No add ition al extern al xation is u sed. After rem oval of th e d rain s, th e patien t starts w ith active m otion .
He u ses th e arm u p to h is com fort th resh old for activities of daily livin g. A special splin t exten d in g h is
w rist an d n gers is u sed becau se of rad ial n erve palsy. No special reh abilitation protocol is prescribed
becau se of th e redu ced com plian ce of th e patien t du e to h is m en tal disability.
Ph arm aceu tical treatm en t: pain k illers in th e early postoperative period, th ereafter, as requ ired.

342
 6 .3 .1 Su p ra co n d yla r d is t a l h u m e ra l fra ct u re —13 -A2 w it h e xt e n s io n in t o t h e s h a ft—11-B1
a n d p ro xim a l u ln a r fra ct u re —21-B1

4 Re h a b ilit a t io n (co n t )

Th e fractu res rem ain ed stable an d th e x-

rays after 8 weeks sh owed n o loosen in g
of th e im plan ts an d good h ealin g. Th e
forearm splin t was still n eeded an d n o
regen eration of th e rad ial n erve cou ld be
ach ieved. Th e patien t did n ot com plain
of pain an d h ad a satisfactory ran ge of
m otion w ith exion u p to 110° an d an
exten sion de cit of 30°. Usu ally, active-
assisted an d active ph ysioth erapy is per-
form ed to im prove th e ran ge of m otion
of th e elbow join t an d passive exercises
h elp to m obilize th e w rist join t an d th e
n ger join ts. A n eu rological exam in a-
tion , n erve con du ction velocity an d an
a b c EMG (electrom yography) is plan n ed at
3 m on th s after th e in ju r y to assess re-
Fig 6 .3 .1-6 a – c 8 weeks follow-u p. cover y of n er ve fu n ction .
a AP view.
b Lateral view.
c Fu n ction al resu lt w ith ex ion u p to 110° an d an exten sion deficit of 30°.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Exten sive ex posu re of th e fractu re, lead in g to addition al
dam age to th e periosteal blood su pply to th e hu m eru s.
Uln ar an d radial n erve are in dan ger.
Th ere is a lot of scarrin g after su ch an exten sive approach ,
leadin g to som e restriction in ran ge of m otion .
Ap p ro a ch
Alth ou gh th is is an exten sile approach , carefu l preserva-
tion of th e periosteu m w ill h elp to avoid add ition al dam -
age to th e blood su pply to th e bon e. An open approach to
th is h u m eral fractu re, iden ti cation an d carefu l preser va-
tion of th e u ln ar an d radial n erve w ill h elp to avoid ag-
gravation of th e n er ve lesion .

In th e case of a d islocated, m u ltifragm en tar y fractu re of

th e olecran on , th e prox im al fragm en ts are still attach ed to
th e ten don in sertion an d can be retracted prox im ally as a
sin gle stru ctu re, th u s ex posin g th e hu m eral fractu re.

343
 6 .3 Hu m e ru s , d is t a l
5 Pit fa lls – (co n t)
Re d u ct io n
In su f cien t redu ction an d residu al d iastasis between th e
fractu re fragm en ts w ill lead to m alu n ion or n onu n ion in
a h igh percen tage of cases, especially in fractu res of th e
h u m eru s.
In obliqu e or spiral fractu res of th e d istal th ird of th e
h u m eral sh aft, closed redu ction m an eu vers m ay dam age
th e rad ial n erve becau se, in a h igh percen tage of cases,
th e n erve w ill be situ ated between th e fractu red su rfaces.
Fixa t io n
Alth ou gh th e stan dard im plan t for hu m eral sh aft frac-
tu res is a broad LCP, th e u se of th is type of plate as a
sin gle posterior im plan t w ill n ot su f cien tly stabilize
a fractu re th at exten ds in to th e con dylar region of th e
d istal h u m eru s.
K-w ire xation an d ten sion ban d osteosyn th esis w ill n ot
be su itable for a prox im al u ln ar fractu re w ith a mu ltifrag-
m en tar y zon e.
34 4
6 Pe a rls + (co n t)
Re d u ct io n
Precise redu ction of th e fractu red su rfaces is im portan t
in open osteosyn th esis of hu m eral fractu res, especially in
th e su pracon dylar region . Redu ction m an eu vers h ave to
be perform ed w ith respect to th e periosteal blood su pply
by traction , rotation , an d th e u se of poin ted redu ction
forceps to apply in terfragm en tary com pression .
Fixa t io n
Fractu res of th e d istal th ird of th e h u m eral sh aft an d th e
su pracon dylar region sh ou ld be xed by th e prin ciples of
absolu te stability. In terfragm en tary com pression is n eces-
sary an d is im plem en ted by in terfragm en tary cortex lag
screw s or cerclage w ires. To im prove stability two protec-
tion plates are advan tageou s. Th e u se of lock in g com pres-
sion plates like th e LCP m etaph yseal plate 3.5, for d istal
m edial hu m eru s, xed w ith lock in g h ead screw s, m ake
precise precon tou rin g of th e plates u n n ecessar y. Th ere is
n o risk of prim ar y loss of redu ction .
Usin g th e LCP as a n on con tact plate a sm all gap is left
between th e plate an d th e bon e for better preser vation
of th e periosteal blood su pply.
An gu lar stable platin g of th e proxim al u ln a leads to
greater stability even in m u ltifragm en tary fractu re situ a-
tion s. Th is perm its an early active reh abilitation program
to be followed.
 Au t h o rs Mich a e l J Ga rd n e r, De a n Lo rich , Da vid L He lfe t

6 .3.2 Ope n displace d com ple te articular distal hum e ral

fracture –13 -C1
1 Ca s e d e s crip t io n

Fig 6 .3 .2 -1a – b74-year-old wom an slipped an d fell on h er

righ t exed elbow an d su stain ed a Gu stilo type IIIA open d is-
tal h u m eral fractu re. Th ere were n o associated n eu rovascu lar
in ju ries or gross wou n d con tam in ation .

In d ica t io n

Bico lu m n a r fra ctu re o f th e d ista l h u m e ru s w ith in tra a rticu la r d is-

p la ce m e n t. Th e in tra a rticu la r n a tu re o f th is fra ctu re a n d sign i ca n t
d isp la ce m e n t o f th e fra ctu re fra gm e n ts a re th e m a in in d ica tio n s fo r
a b o p e ra tive in te rve n tio n .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP re co n stru ctio n p la te 3 .5 , 7 h o le s
• LCP re co n stru ctio n p la te 3 .5 , 8 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .7 m m co rte x scre w
• Th re a d e d 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 1st o r 2 n d ge n e ra tio n ce p h a lo sp o rin .
Th e in ju re d a rm is p la ce d o ve r a p a d d e d b o ls te r.
Th e e lb o w is e xe d 9 0 º. Th e a rm is p re p p e d a n d
d ra p e d fre e to th e a xilla . A ste rile to u rn iq u e t is
p la ce d o n th e p ro xim a l a rm .

Fig 6 .3 .2 -2 Pla ce th e p a tie n t in th e le ft la te ra l

d e cu b itu s p o sitio n w ith th e o p e ra tive sid e u p;
a b e a n b a g is u se d fo r s ta b iliza tio n o f th e b o d y.

345
 6 .3 Hu m e ru s , d is t a l

2 Su rgica l a p p ro a ch

Irrigate an d debride th e open wou n d.

Fig 6 .3 .2 -3
Make a m id lin e in cision over th e posterior arm in cor poratin g th e trau m atic wou n d, approx im ately 15 cm
proxim al to th e olecran on . Cu rve laterally arou n d th e tip of th e olecran on an d con tinu e in th e m id lin e
5 cm d istally.

Raise fu ll-th ick n ess aps m edially an d laterally.

Iden tify th e u ln ar n er ve beh in d th e m ed ial epicon dyle an d protect it w ith a vessel loop.
Dissect th e m ed ial border of th e triceps mu scle free from th e join t capsu le. Develop th is plan e d istally,
an d sh ar ply release th e triceps m u scle in sertion on th e u ln a, re ectin g th e en tire m u scle-ten don u n it
laterally, wh ile tak in g care n ot to d isru pt con tinu ity of th e exten sor m ech an ism . Altern atively, an olec-
ran on osteotom y or triceps split m ay be perform ed.

3 Re d u c t io n a n d fixa t io n

Fig 6 .3 .2 -4 Use th readed K-w ires as a joystick to redu ce th e vertical in traarticu lar split w ith th e aid of a
poin ted redu ction forceps. A poin ted redu ction forceps m ay be h elpfu l to con trol fractu re fragm en ts. As
w ith all in traarticu lar fractu res, an atom ical redu ction of articu lar fragm en ts is critical.
Place an interfragmentary 2.7 m m or 2.4 m m fu lly-th readed cortex screw to stabilize the troch lea. When
m in im al com m inution is present the fragments m ay be compressed, taking care not to overcom press. The
olecranon m ay serve as a u sefu l template for the troch lear w idth when com m inution is present.
With th e troch lea stabilized, redu ce th is d istal block to th e m edial an d lateral colu m n s. Precisely con tou r
th e recon stru ction LCP 3.5 to t appropriately. Redu ce an d stabilize th e lateral colu m n provision ally
u sin g K-w ires an d redu ction forceps. Th e m edial plate sh ou ld th en be placed on th e m edial edge of th e
h u m eru s, an d m ay h ook d istally over th e n on articu lar m edial epicon dyle.
De n itively stabilize th e lateral colu m n w ith an oth er recon stru ction LCP 3.5 applied to its poster ior su r-
face, allow in g th e plates to be placed per pen d icu lar to each oth er. Th e lateral plate sh ou ld exten d as d is-
tally as possible to en su re r igid xation . Wh en th e prox im al lim bs of th e “T” h ave an obliqu e com pon en t,
in terfragm en tary screw s m ay be placed addition ally. In sert m on ocortical or bicortical 3.5 m m lock in g
h ead screw s to com plete th e con stru ction .
Repair th e triceps ten don to th e u ln a w ith in terru pted n on absorbable su tu res th rou gh tran sverse drill
h oles in th e olecran on distally.
Th e u ln ar n erve m ay be tran sposed to th e su bcu tan eou s tissu es an teriorly to m in im ize h ardware irrita-
tion an d scar en casem en t.
Passively ex an d exten d th e elbow an d rotate th e forearm to assess ran ge of m otion an d stability prior
to wou n d closu re.

34 6
 6 .3 .2 Op e n d is p la ce d co m p le t e a r t icu la r d is t a l h u m e ra l fra ct u re –13 -C1

4 Re h a b ilit a t io n

Con tinu e an tibiotic th erapy w ith ceph alosporin for 48 –72

h ou rs an d m on itor th e wou n d closely for sign s of in fection .

Prescr ibe in dom eth acin for h eterotopic ossi cation proph y-
laxis, alon g w ith a gastroin testin al protective agen t.

From th e rst postoperative day th e splin t sh ou ld be rem oved

an d a h in ged elbow brace sh ou ld be applied.

Aggressive active an d passive ran ge of m otion exercises sh ou ld

be in itiated, as well as an elbow con tinu ou s passive m otion
m ach in e.

At 6 m on th s postoperatively, th e fractu re is
Fig 6 .3 .4 -5 a – b
well align ed w ith eviden ce of h ealin g.

a b

Im p la n t re m o va l
Fig 6 .3 .4 -6 a – b Follow in g im plan t rem oval 10 m on th s post-
operatively, th e patien t h ad good elbow fu n ction an d a h ealed
fractu re.
If th e h ardware becom es sym ptom atic an d th e fractu re is
sh ow n to h ave h ealed both in x-ray an d clin ically, th e im -
plan t m ay be rem oved, followed by protection of th e d istal
h u m eru s an d lim ited weigh t bearin g for 6 –12 weeks.

a b

347
 6 .3 Hu m e ru s , d is t a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Th e rad ial n er ve m ay be in ju red prox im ally if th e triceps
m u scle is split, or w h ile exposin g th e lateral hu m eral
sh aft.
Th e u ln ar n er ve m ay be in ju red by d irect in ju r y or trac-
tion .
Th is approach m ay lead to su blu xation of th e triceps
m ech an ism .
Ap p ro a ch
If a triceps m u scle split is u sed, th e triceps mu scle sh ou ld
n ot be split m ore th an 10 cm prox im al to its in sertion to
avoid rad ial n erve in ju r y. Th ou gh rad ial n er ve ex posu re
is n ot n ecessar y, be aware of its position du rin g lateral
d issection .
In itial d issection an d protection of th e u ln ar n erve w ith a
Pen rose d rain , an d freein g th e n erve 6 –8 cm prox im al to
th e m edial epicon dyle w ill m in im ize dam age.

It is critical to reapproxim ate th e triceps ten don an atom i-

cally an d secu rely reattach it to th e olecran on w ith n on -
absorbable su tu res.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Wh en sign i can t in traarticu lar com m in u tion is presen t Wh en sign i can t fragm en tation of th e articu lar fractu re is
recon stru ctin g th e troch lea an atom ically m ay be very presen t, u se th e dim en sion s an d con tou r of th e olecran on
d if cu lt. to recon stru ct th e troch lea an atom ically.

Ben d in g th e plates th rou gh th e screw h oles w ill n ot allow
th e u se of lock in g h ead screw s.
Hardware irritation m ay cau se u ln ar n eu ritis.
Screw s in th e olecran on or coron oid fossa m ay lim it elbow
m otion .
Wh en th e preoperative plan d ictates th e u se of a lock in g
h ead screw in a certain h ole, take care to ben d th e plate
th rou gh th e n otch an d n ot th e screw h ole.
Uln ar n eu ritis m ay be preven ted by an terior tran sposi-
tion of th e n er ve du rin g th e prim ar y procedu re. Th e u ln ar
n erve is tran sposed as su bsequ en t h ardware rem oval an d
soft tissu e release does n ot requ ire dissectin g th e n er ve
ou t of scar tissu e.

Special an atom ically form ed plates—d istal h u m eral

plate—m ake th e xation easier. No ben d in g is requ ired.

Re h a b ilit a t io n Re h a b ilit a t io n
Elbow stiffn ess an d h eterotopic ossi cation are n ot Early physical th erapy an d in dom eth acin proph ylaxis can
in frequ en t follow in g in traarticu lar d istal h u m eral m axim ize postoperative restoration of elbow m otion .
fractu res. A stable xation is n ecessary.

348
 Au t h o r Re t o Ba b s t

6 .3.3 Ope n com ple te intraarticular distal hum e ral

fracture —13 -C2
1 Ca s e d e s crip t io n

51-year-old m an su stain ed a d isplaced d istal h u m eral fractu re

of h is dom in an t arm wh en fallin g dow n stairs.

Fig 6 .3 .3 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Disp lace d in traarticu lar fractu re w ith a sim p le articu lar fractu re p a t-
te rn a n d so m e co m m in u tio n in th e e p im e tap h yse al p art. If ad d itio n al
in fo rm a tio n is ne e d e d , e ith e r a tractio n vie w in trao p e ra tive ly o r a
a b CT scan is re co m m e nd e d fo r pro p e r p re o p e ra tive plan n ing.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Fig 6 .3 .3 -2 a – b Th e p a tie n t is
• LCP re co n stru ctio n p la te 3 .5 , 6 h o le s o n th e ra d ia l in a p ro n e p o sitio n w ith h is a rm
co lu m n a n d LCP re co n stru ctio n p la te 3 .5 , 8 h o le s o n a sh o rt a rm ta b le . Arm fre e ly
o n th e u ln a r co lu m n m o va b le w ith th e p o ssib ilit y to
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS) e x m o re th a n 9 0 º
• 3 .5 m m co rte x scre w s
• 4 .0 m m ca n ce llo u s b o n e scre w a b
• 1.6 m m K-w ire s
• 1.6 m m n o n a b so rb a b le su tu re s
Fig 6 .3 .3 -3 a – b Pre o p e ra tive
(Size o f s yste m , in stru m e n ts, e xte n sio n vie w w ith th e
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
p a tie n t u n d e r a n e s th e sia
u sin g th e im a ge in te n si e r
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
is re co m m e n d e d to o b ta in
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
a d d itio n a l in fo rm a tio n if th e
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
a b p re o p e ra tive x-ra ys a re n o t
co n clu sive . Co n sid e r a lso CT
sca n s fo r p re o p e ra tive p la n n in g.

349
 6 .3 Hu m e ru s , d is t a l

2 Su rgica l a p p ro a ch

Sligh tly cu r ved in cision radial

Fig 6 .3 .3 -4 a – b
to th e olecran on tip. Isolation of th e u ln ar n er ve
an d open in g th e join t on th e u ln ar side. Oste-
otom y of th e tip of th e olecran on leavin g th e
exten sor apparatu s in tact. Th e in tact olecran on
provides a tem plate for join t recon stru ction .
Th is approach is on ly advisable wh en dealin g
w ith a sim ple articu lar fractu re.

a b

3 Re d u ct io n a n d fixa t io n

Fig 6 .3 .3 -5 a – d
a – b Th e triceps m u scle, togeth er w ith its ten -
din ou s attach m en ts are displaced rad ially
an d th e articu lation becom es visible. Note
th e olecran on join t rem ain s in tact. Th is is
a m od i cation of th e Bryan -Morrey ap-
proach wh ich is u sed for total elbow arth ro-
plasty, an d to release n ot on ly Sh ar pey’s
bers bu t th e attach ed cortical bon e of th e
olecran on as well.

a b

350
 6 .3 .3 Op e n co m p le t e in t ra a r t icu la r d is t a l h u m e ra l fra ct u re —13 -C2

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 6 .3 .3 -5 a – d (co n t)
c As a rst step th e articu lar block was re-
du ced an d xed w ith a 4.0 m m can cellou s
bon e screw. Th en th e articu lar block was
tem porarily xed w ith K-w ires an d th e ra-
dial colu m n was stabilized, rst u sin g a
LHS d istally an d th en th ree cortex screw s
proxim ally. Th e rst screw proxim al to th e
fractu re was placed in an eccen tric m ode.
Th ereafter th e u ln ar plate was adapted an d
proxim ally xed w ith cortex screw s an d dis-
tally w ith th ree LHS.
d Th e olecran on tip osteotom y is th en ipped
back an d ten sion ban ded in a gu re-of-eigh t
w ith a n on absorbable su tu re.

c d

4 Re h a b ilit a t io n

Add ition al im m obilization : splin t for 3 –4 days.

Weigh t bear in g: depen d in g on th e x-ray, startin g
after 6 –10 weeks.
Ph ysioth erapy: fu n ction al aftercare w ith active
assisted m ovem en t w ith a ph ysioth erapist as of
postoperative day 1.
Ph arm aceu tical treatm en t: pain m ed ication on
dem an d du rin g th e rst postoperative days.

Im p la n t re m o va l
On ly du e to m ech an ical irritation .

a b

Postoperative x-rays, AP- an d lateral view 12

Fig 6 .3 .3 -6 a – b
weeks postoperative. Th e ip osteotom y is clin ically h ealed, even
th ou gh th e osteotom y lin e is still visible.

351
 6 .3 Hu m e ru s , d is t a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e m od i ed Bryan -Morrey approach allow s a good visu - A sim ple extraarticu lar fractu re pattern m igh t be sta-
alization of th e distal hu m eru s wh en dealin g w ith sim ple bilized w ith a bilateral approach from each side of th e
fractu re pattern s. It is im portan t th at th e triceps m u scle triceps w ith ou t osteotom y of th e olecran on .
is released togeth er w ith th e forearm fascia an d th e u ln ar
periosteu m in con tinu ity so th at th e exten sor apparatu s
rem ain s in tact. Th is can be ach ieved eith er by d issection
of Sh ar pey’s bers (Br yan -Morrey approach) or w ith a
m in im al ip osteotom y of th e olecran on tip.

Re d u ct io n a n d xa t io n
Th e u ln ar n erve sh ou ld n ot lie d irectly on th e plate. Eith er
th e plate is covered by soft tissu e or th e n er ve sh ou ld be
tran sposed ou t of groove for u ln ar n er ve. Its position
sh ou ld be n oted in th e operative report.
Re d u ct io n a n d xa t io n
Com plex articu lar fractu res w ith a sim ple fractu re pattern
of on e colu m n are often easier to x w h en th e sim ple
colu m n fractu re is redu ced an d xed rst to th e sh aft
fragm en t. Su bsequ en tly, recon stru ction an d xation of
th e articu lar block again st th e correctly redu ced an d xed
colu m n fragm en t.

Re h a b ilit a t io n
In polytrau m atized patien ts w ith h ead in ju ries,
proph ylaxis again st periarticu lar bon e form ation h as
to be con sidered.

352
 Au t h o r Re t o Ba b s t

6 .3.4 Displace d intraarticular distal hum e ral fracture —13 -C3

1 Ca s e d e s crip t io n

23-year-old m an polytrau m atized, w ith

an open d isplaced righ t d istal h u m eral
fractu re of th e dom in an t arm , w ith
fractu re of th e righ t acetabu lu m , th e
righ t fem u r, an d rib fractu res w ith lu n g
con tu sion of th e righ t h em ith orax.

Fig 6 .3 .4 -1a – c
a AP view.
b Lateral view.
c Tem porary join t-span n in g extern al
xator.

a b c

In d ica t io n

Disp la ce d d ista l in tra a rticu la r h u m e ra l fra ctu re w ith o u t co m m in u tio n
b u t a n in te rm e d ia te fra gm e n t o f th e ra d ia l co lu m n wa s le ft o n th e
sce n e . Th e re is a lso a n u n d isp la ce d fra ctu re o f th e tip o f th e p roxim a l
u ln a . If a d d itio n a l in fo rm a tio n is n e ce ssa ry, a CT sca n w ill p ro vid e
fu rth e r in fo rm a tio n fo r a d e q u a te p re o p e ra tive p la n n in g.
Du e to ge n e ra l co n d itio n s, th e fra ctu re w a s rst im m o b ilize d w ith a
te m p o ra ry jo in t-sp a n n in g e xte rn a l xa to r (Fig 6 .3 .4 -1c) a fte r d e b rid e -
m e n t a n d p u lse irriga tio n d u rin g th e rst o p e ra tio n fo r xa tio n o f th e
fe m o ra l fra ctu re . Th e n a l xa tio n o f th e d ista l h u m e ru s to o k p la ce 7
d a ys a fte r th e a ccid e n t.

Du e to d isp la ce m e n t th e re is a d a n ge r o f co m p ro m isin g th e u ln a r
n e rve a n d th e re is a n e e d to m o b ilize th e e lb o w a s so o n a s p o ssib le
a fte r sta b le xa tio n . No n o p e ra tive tre a tm e n t is n o t a n o p tio n fo r th is
o p e n fra ctu re a s it is th e d o m in a n t a rm o f a yo u n g la b o re r.

353
 6 .3 Hu m e ru s , d is t a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• DHP—d ista l h u m e ra l p la te 2 .7/ 3 .5 , 7 h o le s o n
th e ra d ia l co lu m n , 6 h o le s o n th e u ln a r co lu m n
• 3 .5 m m a n d 2 .7 m m se lf-ta p p in g lo ckin g h e a d
scre w s (LHS)
• 3 .5 m m co rte x scre w
• 1.6 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
a b

Fig 6 .3 .4 -2 a – b
Pa t ie n t p re p a ra t io n a n d p o s it io n in g a La te ra l d e cu b itu s p o sitio n .
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin b Pro n e p o sitio n .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

2 Su rgica l a p p ro a ch

a b c

Fig 6 .3 .4 -3 Straigh t in cision alon g
th e ax is of th e hu m eral sh aft cu r vin g
on th e radial side of th e olecran on
straigh t alon g th e ax is of th e u ln a.
Preparation of th e tr iceps m u scle
an d isolation of th e u ln ar n erve.
Th e Ch evron type osteotom y is plan n ed at th e level of th e deepest
Fig 6 .3 .4 -4 a – c
con cavitiy of th e u ln ar join t. In situ ation s w ith a sim ple in traarticu lar fractu re, an
olecran on tip osteotom y m igh t also be su f cien t to ach ieve a good view for an an a-
tom ical join t recon stru ction .

354
 6 .3 .4 Dis p la ce d in t ra a r t icu la r d is t a l h u m e ra l fra ct u re —13 -C3

3 Re d u ct io n a n d fixa t io n

Fig 6 .3 .4 -5 a – f
a Th e tip of th e olecran on is th en re ected
w ith th e triceps m u scle.
b With th is sim ple troch lea fractu re pat-
tern th e join t block is redu ced rst an d
tem porarily xed w ith a K-w ire an d th en
w ith a cortex screw.
c– d Th e join t block is th en tem porarily xed
again st th e sh aft u sin g poin ted redu ction
forceps an d th en K-w ires.
a b e – f After placin g a cortex screw between th e
sh aft an d th e u ln ar fragm en t, th e d istal
h u m eral plate (6-h ole DHP) is rst xed
w ith cortex screw s on th e sh aft on th e u l-
n ar side an d th en w ith LHS d istally. Th e
defect on th e radial side is th en bridged
w ith th e rad ial d istal h u m eral plate (7-h ole
DHP). Th e plate is th en xed w ith cortex
screw s on th e sh aft an d w ith LHS in th e
d istal fragm en t. Note th e defect on th e
rad ial side du e to th e fragm en t left on th e
scen e.
c d

f
e

355
 6 .3 Hu m e ru s , d is t a l
4 Re h a b ilit a t io n
a b
Add ition al im m obilization : splin t 3 –4 days.
Ph arm aceu tical treatm en t: pain k illers on dem an d
du rin g th e first postoperative days.
Ph ysioth erapy: fu n ction al aftercare w ith active
assisted m ovem en t w ith a pyh sioth erapist as of post-
operative day 1.
Weigh t bearin g: depen d in g on th e x-ray, startin g
after 6 –10 weeks.
5 Pit fa lls –
Ap p ro a ch
Th e osteotom y of th e olecran on w ith a ch isel or a saw
sh ou ld be perform ed w ith in th e bon e an d n ot in clu de th e
cartilage.
Re d u ct io n a n d xa t io n
Th e u ln ar n erve sh ou ld n ot lie d irectly on th e plate. Eith er
th e plate is covered by soft tissu e or th e n er ve sh ou ld be
tran sposed ou t of th e groove for u ln ar n erve. Its position
sh ou ld be n oted in th e operative report.
Re h a b ilit a t io n
In polytrau m atized patien ts w ith h ead in ju ries prophylaxis
again st periarticu lar bon e form ation h as to be con sidered.
356
Fig 6 .3 .4 -7a – b
Fu n ction after 3 m on th s
was exten sion / ex ion
0/ 20/130.
a b
X-ray 12 weeks postoperative. Note th e defect on th e
Fig 6 .3 .4 -6 a – b
rad ial side. Sin ce th is was a secon d degree open fractu re an d th e
rad ial colu m n fragm en ts h ad con tact to th e posterior cortex, n o can -
cellou s bon e graft was prim arily added. Th e articu lar fractu re was
xed w ith a 3.5 m m lag screw. Th e tip of th e olecran on was stabilized
w ith two 2.7 m m cortex lag screw s. Th e osteotom y was closed w ith
K-w ires an d a ten sion ban d xation .
6 Pe a rls +
Ap p ro a ch
Sim ple articu lar fractu re pattern m igh t be stabilized w ith
a bilateral approach from each side of th e triceps m u scle
w ith ou t osteotom y of th e olecran on .
Re d u ct io n a n d xa t io n
Com plex articu lar fractu res w ith a sim ple fractu re pattern
of on e colu m n are often easier to x wh en th e colu m n
w ith its articu lar attach m en t is xed rst before th e
articu lar part of th e oth er colu m n is redu ced again st th e
n ow stabilized articu lar fragm en t.
 Au t h o r Mich a e l Sch ü t z

6 .3.5 Displace d intraarticular distal hum e ral fracture —13 -C3

1 Ca s e d e s crip t io n

A 19-year-old wom an fell ou t of a w in dow an d

was polytrau m atized. Th e in ju ries sh e su stain ed
were com plex w ith fractu re of th e pelvis, th oracic
in ju ries, an d a th ird degree open d istal h u m eral
fractu re w ith bon e defect. In th e in itial h ospital,
h er elbow was treated w ith two K-w ires an d elbow
tran s xation .
After stabilization of h er gen eral con dition , sh e re-
ceived a de n itive osteosyn thesis of the distal hu-
m eral fractu re on the fou rth day after the accident.

Fig 6 .3 .5 -1a – b
a AP view.
b Lateral view.

In d ica t io n

A d islo ca te d in tra a rticu la r d ista l h u m e ra l fra ctu re is a cle a r

a b in d ica tio n fo r o p e ra tio n in yo u n g p a tie n ts.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP re co n stru ctio n p la te 3 .5 , 8 h o le s
• Re co n stru ctio n p la te 3 .5 , 6 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w
• 1.6 m m K-w ire s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 6 .3 .5 -2 Pro n e p o sitio n , a rm o n a n a rm ta b le ,

An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin p n e u m a tic to u rn iq u e t (ste rile o r u n ste rile), x-ra y
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin a n d im a ge in te n si e r.

357
 6 .3 Hu m e ru s , d is t a l

2 Su rgica l a p p ro a ch

Posterior approach w ith in tegration

Fig 6 .3 .5 -3 a – b
of th e wou n d. Th e u ln ar n er ve is exposed an d re-
tracted.
An olecran on osteotom y m ay be requ ired in m ore
com plex in traarticu lar fractu res.

a b

3 Re d u ct io n a n d fixa t io n
Fig 6 .3 .5 -4 a – f
a Th e extern al xator is rem oved before sterile drapin g of th e patien t.
Debridem en t of th e wou n d follow s. Th e join t fragm en ts are clean ed.
Th e articu lar fractu re is redu ced w ith th e poin ted redu ction forceps.
Th e redu ction is m ain tain ed w ith two 1.6 m m K-w ires. An isolated
3.5 m m in terfragm en tary cortex screw is in serted as a lag screw to
m ain tain th e recon stru ction of th e troch lea. Redu ction of th e troch -
lea over th e rad ial su pracon dylar colu m n to th e m eta-/d iaph ysis
sh ou ld be perform ed rst becau se of bon e loss on th e u ln ar side. To
ach ieve correct axial align m en t, th e two u ln ar fragm en ts m u st be
h eld apart.
b Th e fragm en ts are in itially xed w ith two 1.6 m m K-w ires in serted
th rou gh th e join t block in to th e sh aft.
Th e LCP recon stru ction plates 3.5 are con tou red u sin g th e ben d in g
tem plate so th at th ey t th e lateral su pracon dylar colu m n (5-h ole
plate) an d th e m ed ial su pracon dylar colu m n (8-h ole plate).
a b First on e recon stru ction plate is xed to th e posterior aspect of th e
rad ial colu m n w ith on e lock in g h ead screw prox im ally an d on e d is-
tally. Th is allow s th e join t block to rotate sligh tly arou n d th e d istal
screw an d facilitates th e exact align m en t of th e m ed ial su pracon dylar
colu m n (com plication du e to th e bon e defect).

358
 6 .3 .5 Dis p la ce d in t ra a r t icu la r d is t a l h u m e ra l fra ct u re —13 -C3

3 Re d u c t io n a n d fixa t io n (co n t )

c d
Fig 6 .3 .5 -4 a – f (co n t)
c Th e u ln ar recon stru ction plate is ben t in to its
n al sh ape
an d xed to th e sh aft by in sertin g a K-w ire th rou gh th e
trocar.
d An addition al in terfragm en tary lag screw is in serted
th rou gh th e d istal h ole in th e u ln ar plate.
Wh ereas on ly m on ocortical screw s are in serted to sta-
bilize th e rad ial plate, two bicortical screw s are u sed to
e f
secu re th e oth er plate to th e u ln ar d iaph ysis in order to
n eu tralize th e prevailin g rotation al forces. Prim ar y bon e
graftin g of th e defect was n ot carried ou t.
e–f In traoperative, clin ical assessm en t of th e ran ge of m o-
tion (passive m ovem en t in all plan es) an d n al rad io-
logical con trol of plate position prior to wou n d closu re.

4 Re h a b ilit a t io n

Sterile wou n d dressin g. A dorsal splin t is applied u n til de-

n itive wou n d h ealin g. On th e secon d day active an d passive
ph ysioth erapy was com m en ced w ith th e splin t in situ . Con -
tinu ed an tibiotic treatm en t to en su re wou n d h ealin g of th e
open fractu re.

Fig 6 .3.5 -5a–b Good con solidation of th e fractu re after 9

m on th s w ith ou t th e n eed for fu rth er su rgery (eg, can cellou s
bon e graftin g).
a AP view.
b Lateral view.

a b

359
 6 .3 Hu m e ru s , d is t a l

4 Re h a b ilit a t io n (co n t )

Fig 6 .3 .5 -6 a – bAt th e en d of th e treatm en t, th e pa-

tien t h ad an u n lim ited elbow fu n ction w ith a ran ge
of m otion of 0/10/ 120 an d u n restricted rotation .

Im p la n t re m o va l
Fig 6 .3 .5 -6 c– d In the fu rther cou rse of con solida-
tion , a heterotopic ossi cation , m ain ly at the poste-
rior aspect, was excised at im plant removal.

b c d

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e u ln ar n er ve m ay be in ju red by d irect in ju r y or In itial dissection and protection of the u ln ar nerve w ith a
traction . Pen rose drain , and freein g the nerve 6 –8 cm proxim al to
Th is approach m ay lead to su blu xation of th e triceps the medial epicondyle w ill m in im ize dam age.
m ech an ism . It is critical to reapproxim ate th e triceps ten don
an atom ically an d secu rely reattach it to th e olecran on
w ith n on absorbable su tu res.

Re d u ct io n a n d xa t io n
Wh en sign i can t in traarticu lar com m in u tion is presen t,
recon stru ctin g th e troch lea an atom ically m ay be very
d if cu lt.
Ben d in g th e plates th rou gh th e screw h oles w ill n ot allow
th e u se of lock in g h ead screw s.
Hardware irritation m ay cau se u ln ar n eu ritis.
Screw s in th e olecran on or coron oid fossa m ay lim it
elbow m otion .
Re d u ct io n a n d xa t io n
Wh en sign i can t fragm en tation of th e articu lar fractu re is
presen t, u se th e dim en sion s an d con tou r of th e olecran on
to recon stru ct th e troch lea an atom ically.
Wh en th e preoperative plan d ictates th e u se of a lock in g
h ead screw in a certain h ole, take care to ben d th e plate
th rou gh th e n otch an d n ot th rou gh th e screw h ole.
Uln ar neu ritis m ay be prevented by anterior tran sposition of
the nerve du ring the prim ary procedu re.

Re h a b ilit a t io n Re h a b ilit a t io n
Elbow stiffn ess an d h eterotopic ossi cation are n ot in fre- Early ph ysioth erapy an d in dom eth acin proph ylaxis can
qu en t follow in g in traarticu lar d istal hu m eral fractu res. m axim ize postoperative restoration of elbow m otion .

36 0
 Au t h o rs Th o m a s Ho cke r t z, An d re a s Gru n e r, Ga b rie le St re ich e r, He in rich Re ilm a n n

6 .3.6 Pathology of the e lbow

1 Ca s e d e s crip t io n

16-year-old fem ale patien t w ith path ology of th e left elbow.

Fig 6 .3 .6 -1a – d Nu clear m agn etic reson an ce spectroscopy

(NM R).
a NM R of prim ary tu m or—sarcom a.
b NM R of prim ary tu m or—sarcom a.
c NM R of recu rren t sarcom a.
d NM R of recu rren t sarcom a.

a b

In d ica t io n

Yo u n g fe m a le p a tie n t w ith re cu rre n t sa rco m a o f th e le ft a rm re q u ir-

in g sta b le xa tio n a fte r co m p a rtm e n t re se ctio n a n d ilia c cre st b o n e
gra ftin g. Sin ce th e p roxim a l b o n e se gm e n t wa s ve ry sh o rt, lo ckin g
c d h e a d sta b iliza tio n .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP 3 .5 , 8 -h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 6 .3 .6 -2 Pa tie n t in su p in e
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp h o rin p o sitio n w ith th e a rm re stin g o n
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin a n a rm ta b le .

361
 6 .3 Hu m e ru s , d is t a l

2 Su rgica l a p p ro a ch

Fig 6 .3 .6 -3 Exten ded rad ial approach to th e left elbow.

3 Re d u ct io n a n d fixa t io n

Fig 6 .3 .6 -4 a – f
a Location of th e tu m or on th e d istal hu m eru s.
b – c Excision of th e tu m or in clu d in g th e u n derlyin g bon e w ith ou t d is-
tu rbin g th e con tinu ity of th e hu m eru s an d tou rn iqu et of th e radial
n er ve.
d Preben d in g an d adaptation of an LCP to t th e speci c bon e sh ape
of th e lateral d istal hu m eru s—stabilization of th e LCP in th e region
of th e distal join t by in sertion of a cortex screw an d a lock in g h ead
screw.

b c d

362
 6 .3 .6 Pa t h o lo g y o f t h e e lb o w

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 6 .3 .6 -4 a – f (co n t)
e Prox im al xation in th e area of
th e resected bon e by in sertion of
two lock in g h ead screw s—bridg-
in g of th e bon e defect to m ain tain
m obility an d weigh t bearin g capa-
bilities.
f Clin ica l view postoperatively.

f
e

4 Re h a b ilit a t io n

Add ition al im m obilization : Upper arm plaster cast u n til soft-tissu e h ealin g.

Mobilization :
• Im m obilization for 2 weeks
• Passive m obilization after 4 days
• Active m obilization after 14 days

Ph ysioth erapy: from th e 14th postoperative day.

Ph arm aceu tical treatm en t: Non steroid an tiin am m atory d ru gs.

Fig 6 .3 .6 -5 Postoperative x-ray lateral view.

Im p la n t re m o va l
Im plan t rem oval after 6 m on th s becau se
of de n itive bon e h ealin g.
Tech n ique for im plant rem oval: Sam e
approach as for in sertion of the im plant.

In traoperative situ ation

Fig 6 .3 .6 -6 a – b
at im plan t rem oval.
a b

363
 6 .3 Hu m e ru s , d is t a l

5 Pit fa lls – 6 Pe a rls +

Re h a b ilit a t io n Re h a b ilit a t io n
Early fu n ction al treatm en t m ay be possible even u n der
d if cu lt circu m stan ces.

Im p la n t re m o va l Im p la n t re m o va l
Fig 6 .3 .6 -7 Good h ealin g of th e bon e graft.

36 4
7.1 Radius and ulna, proxim al

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

7.1.1 Articu la r o le cran o n fractu re 21-B1 co m p re ssio n LCP m e ta p h yse a l lag scre w s and 371
p late 3 .5 p ro te ctio n pla te

7.1.2 Ole cra n o n fra ctu re 21-B1 co m p re ssio n LCP m e ta p h yse a l te n sio n b a n d p la te 375
pla te 3 .5

7.1.3 Op e n p roxim al u lna r fra ctu re; 21-B1; co m p re ssio n an d LCP o le cran o n lag scre w s and 3 81
sim p le u lnar sh a ft fractu re; an te rio r 2 2-A1 lo cke d splin ting pla te 3 .5 p ro te ctio n pla te a nd
d islo ca tio n o f th e rad ial h e ad lo cke d in te rnal fixa to r

7.1.4 Co m p le x rad ia l h e ad fra ctu re a n d 21-B3 co m p re ssio n LCP 3 .5 lag scre w s an d 385
e xtraarticu lar o le cran on fractu re p ro te ctio n pla te

7.1.5 3 -p art ra d ia l h e ad an d tra n sve rse 21-B3 co m p re ssio n Min i co n d ylar lag scre w s and 389
rad ial n e ck fra cture; in traa rticu la r pla te; LCP 3 .5 p ro te ctio n pla te
p roxim al u ln a r fra cture

7.1.6 Extra articu lar p roxim al u ln a r fra ctu re 21-A1 co m p re ssio n LCP 3 .5 co m p re ssio n p la te 39 5
w ith p se u d arth ro sis

365
 7 Ra d iu s a n d u ln a

7 Radius and ulna

7.1 Ra d iu a a n d u ln a , p ro xim a l 3 67
7.1.1 Ar t icu la r o le cra n o n fra ct u re —21-B1 371
7.1.2 Ole cra n o n fra ct u re —21-B1 375
7.1.3 Op e n p ro xim a l u ln a r fra ct u re —21-B1;
s im p le u ln a r s h a ft fra ct u re —2 2 -A1;
a n t e rio r d is lo ca t io n o f t h e s h a ft 3 81
7.1.4 Co m p le x ra d ia l h e a d fra ct u re a n d e xt ra a r t icu la r
o le cra n o n fra ct u re —21-B3 385
7.1.5 3 -p a r t ra d ia l h e a d a n d t ra n s ve rs e ra d ia l n e ck fra ct u re ;
in t ra a r t icu la r p ro xim a l u ln a r fra c t u re —21-B3 389
7.1.6 Ext ra a r t icu la r p ro xim a l u ln a r fra ct u re w it h
p s e u d a r t h ro s is —21-A1 395

36 6
 Au t h o r Ch ris t o p h e r W Ge e l

7.1 Radius and ulna, proxim al

1 In cid e n ce 2 Cla s s ifica t io n

Treatm en t of prox im al forearm fractu res carries u n iqu e prob- Th e prim e ch aracteristics of fractu re types are de n ed by th e
lem s, as th e in volvem en t of elbow join t stru ctu res n eeds to be Mü ller AO Classi cation :
con sidered. In stability, m alu n ion , n on u n ion , an d im pin ge-
m en t m ay resu lt in severe posttrau m atic dysfu n ct ion . Th e
an atom ical an d fu n ction al com plexity of th e elbow join t h as to
be restored w ith u tm ost care an d precision . Th erefore, fractu re
redu ction an d xation rem ain as cru cial as restoration of ad-
d ition al avu lsion s an d laceration s of ligam en tou s an d capsu lar
lesion s. a b c

Fig 7.1-1a – c21-A extraarticu lar fractu re.

Th e com plex ity of th e elbow fu n ction is based on a th ree-
a 21-A1 u ln a, rad iu s in tact
com ponent bu ildu p and structu re of the joint entity, includin g
ba 21-A2 rad iu s, u ln a in tact
th e u ln atroch lear join t, th e rad iocapitellar join t an d th e ra-
c 21-A3 both bon es
diou ln ar join t. Con servative closed treatm en t is followed by
92% u n satisfactor y resu lts [1]. Lack of early m otion leads to
fu n ction al de cien cies, par ticu larly con cern in g pron ation
an d su pin ation . On ly strict obser van ce of biological an d bio-
m ech an ical prin ciples of stability reprodu ces 90% excellen t
fu n ction al resu lts [2].
a b c
Osteoch on dral fragm en ts or loose bodies are n ot u n com m on
Fig 7.1-2 a – c21-B articu lar fractu re.
w ith radial h ead in ju ries. Capitellar abrasion s are frequ en tly
a 21-B1 u ln a, rad iu s in tact
observed. High -en ergy fractu res m ay be associated w ith d istal
b 21-B2 radiu s, u ln a in tact
in ju ries su ch as add ition a l fractu res, in terosseou s m em bran e
c 21-B3 on e bon e, oth er extraarticu lar
in ju ries an d d istal radiou ln ar join t d isru ption s [3 ].

In con sequ en ce, restoration of th e in terosseou s m em bran e as

well as of associated ligam en tou s an d capsu lar in ju ries arou n d
th e rad ial h ead an d prox im al u ln a are m an datory.

Prim ary objectives are th e restoration of th e radial bow to a b c

boost pro- an d su pin ation an d th e stable xation allow in g early
m obilization regardin g pro- an d su pin ation an d adjacen t Fig 7.1-3 a – c 21-C articu lar fractu re of both bon es.
join ts su ch as elbow an d w rist. a 21-C1 sim ple
b 21-C2 on e articu lar sim ple oth er articu lar
mu ltifragm en tar y
c 21-C3 mu ltifragm en tar y

367
 7 Ra d iu s a n d u ln a
3 Tre a t m e n t m e t h o d s
Th e rad iou ln ar join t is always to be ch ecked for su blu xation
proxim ally (Mon teggia fractu re) and distally (Galeazzi fractu re).
Prox im al u ln a fractu res resu lt in loss of ten sion m ech an ism at
th e triceps ten don in sertion . Direct h igh -en ergy forces create
a com m in u tion an d fragm en tation w ith possible in traarticu -
lar com m in u tion an d cartilage dam age. In volvem en t of th e
coron oid process or prox im al u ln a are presen tly associated
w ith h igh -en ergy trau m a an d m u ltifragm en tary fractu res.
Rad ial h ead fractu res from wedge fractu res to su bcapital frac-
tu res an d m u ltifragm en tar y fractu res can be associated w ith
or w ith ou t dislocation .
High -en ergy trau m a to th e elbow often resu lts in bru ises of
th e sk in w ith delayed su rger y as a con sequ en ce. Diagn ostic
elbow x-rays as well as w rist x-rays are m an dator y. To clarify
rad ial h ead fractu res, a 45-degree rad ial h ead obliqu e view
m agn i es th e rad ial h ead an d separates th e resu lts from th e
u ln a to ach ieve a better over view [4 ].
Restoration of dorsorad ial bow an d an atom ic len gth of ra-
d iu s an d u ln a w ith adequ ate ten sion in g of th e in terosseou s
m em bran e are of basic con sideration . Priority is to be given to
stable xation for early m obilization , in particu lar regard in g
pro- an d su pin ation . However, differen tial procedu res h ave to
be respected case w ise; an atom ical redu ction is to be lim ited
to len gth , axis an d rotation , wh ile “ch asin g all fragm en ts” is
to be con sidered u seless.
Regard in g su rgical procedu res, d ifferen t tech n iqu es m ay be
d iscu ssed:
As on ly rotation al stable in tern al xation lets await good
fu n ction al resu lts, in tram edu llar rad ial bow restoration is cu r-
ren tly n ot satisfactory. Du e to dan ger of rad ial n er ve in ju ry,
36 8
percu tan eou s platin g is su itable m ore likely for u ln a sh aft
fractu res th an for proxim al rad ial fractu res. Mu ltifragm en -
tary fractu res requ ire bridge platin g, sh ort obliqu e fractu res
w ith or w ith ou t wedge fragm en t n eed in terfragm en tar y com -
pression su pport.
Interfragm entary com pression is to be ach ieved by lag screw
tech n ique, screw extern al articu lated ten sion device and u se of
pu sh -pu ll com pression plate tech n iqu e. In radial h ead fractu res
the u se of m in i fragm ent in stru m entation is desirable [5].
Preferen ce is given to arm board su pin e position . Th e lateral
decu bitu s is especially su itable for region al an esth esia. Th e
pron e position is n ot advisable, especially in obese patien ts
an d m u ltiple trau m as (ch est wall an d ven tilation problem s).
Th e u se of a tou rn iqu et is advan tageou s.
In rad ial fractu res, a m od i ed Boyd approach w ith osteotom y
of th e lateral hu m eral con dyle to im prove visu alization of th e
rad ial h ead an d to redu ce th e risk of su per cial rad ial n erve
dam age is recom m en ded. Th e radial h ead fractu re redu ction
u ses th in w ires as a slin g for tem porary redu ction m an eu ver
as well as poin ted redu ction forceps. Th e restoration of th e
depressed rad ial h ead cen tral zon e is im portan t to regain n or-
m al an atom y an d to im prove fu n ction al ou tcom e.
In u ln ar fractu res, th e sk in in cision an d th e su bcu tan eou s ap-
proach are correspon din g w ith th e in terspace between exor
an d exten sor car pi u ln ar is m u scle. However, th e sk in in cision
sh ou ld n ot directly correlate w ith th e fu tu re im plan t position .
Moreover, a w ide sk in bridge is n eeded if an add ition al, rad ial
in cision is u sed. Com m inu ted fractu res requ ire a LC-DCP 3.5
or LCP 3.5 an d a on e-th ird tu bu lar plate on ly en gaged as ten -
sion ban d fu n ction . Fin ally, plate ben d in g is to be foreseen
ou tside th e plate h oles to preven t d istortion of th e lock in g
h oles.
 7.1 Ra d iu s a n d u ln a , p ro xim a l

4 Im p la n t o ve r vie w 5 Bib lio gra p h y

1. Hu gh st o n JC (1957) Fractu res of th e distal radial sh aft;

a m istakes in m an agem en t. J Bone Joint Surg Am; 39-A(2):249 –264.
2. Tile M , Pe t rie D (1969) Fractu res of radiu s an d u ln a.
J Bone J Joint Surg; 51-B:193 –199.
b
3. He im U (1998) [Com bin ed fractu res of th e radiu s an d th e u ln a at
th e elbow level in adu lts. An alysis of 120 cases after m ore th an
Fig 7.1-4 a – b
1 year]. Rev Chir Orthop Reparatrice Appar Mot; 84(2):142–153.
a LCP 3.5
4. Mo e d BR , Ke llam J F , Fo st e r R J, e t al (1986) Im m ediate
b LCP m etaphyseal plate 3.5
in tern al xation of open fractu res of th e d iaph ysis of th e forearm .
J Bone Joint Surg Am; 68(7):1008 –1017.
5. Ge e l CW, Palm e r A K (1992) Radial h ead fractu res an d th eir
effect on th e d istal radiou ln ar join t A ration al for treatm en t.
Clin Orthop Relat Res; 275:79 –84.

36 9
 7 Ra d iu s a n d u ln a

370
 Au t h o r Mich a e l Sch ü t z

7.1.1 Articular ole cranon fracture —21-B1

1 Ca s e d e s crip t io n

46-year-old patien t fell an d su stain ed an olecran on fractu re.

Th ere were n o oth er in ju ries.

Fig 7.1.1-1a – b
a AP view.
b Lateral view.

In d ica t io n

Acco rd in g to th e p rin cip le s o f a rticu la r fra ctu re m a n a ge m e n t, a sta b le o ste o s yn -

th e sis p e rm ittin g e a rly fu n ctio n a l tre a tm e n t w ith o r w ith o u t a sp lin t sh o u ld b e
a ch ie ve d . Du e to a n in te rm e d ia te in traa rticu la r fra gm e n t, p la te o ste o s yn th e sis
a b wa s p e rfo rm e d in ste a d o f K-w ire o r ce rcla ge xa tio n .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP m e ta p h yse a l p la te 3 .5 , 6 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 1.2 5 a n d 1.6 m m K-w ire s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Tro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 7.1.1-2 Pro n e p o sitio n , a rm o n a n a rm

ta b le , p n e u m a tic to u rn iq u e t (ste rile o r u n s te rile),
ra d io gra p h y a n d im a ge in te n si ca tio n .

371
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

Fig 7.1.1-3 Posterior in cision to th e olecran on .

3 Re d u ct io n a n d fixa t io n

a b c d

Fig 7.1.1-4 a – i
a Th e articu lar fractu re zon e is exposed. Th e prox im al m ain fragm en t is th en redu ced an atom ically
b – d Th e in term ed iate fractu re fragm en t is redu ced, u n der on to th e d istal fragm en t w ith th e h elp of th e poin ted redu c-
vision , in correct align m en t to th e d istal join t fragm en t, tion forceps. Th e com plete redu ction is stabilized w ith 1.6 m m
an d tem porar ily xed w ith two K-w ires. Th e K-w ires K-w ires.
m u st be in serted so th at th ey w ill n ot in terfere w ith th e
plan n ed position of th e plate.

372
 7.1.1 Ar t icu la r o le cra n o n fra ct u re —21-B1

3 Re d u c t io n a n d fixa t io n (co n t )

e f g

Fig 7.1.1-4 a – i (co n t)

e Th e 6-h ole m etaph yseal LCP is ben t an atom ically at its
proxim al en d to en com pass th e olecran on . To ach ieve
close bon e plate con tact, th e triceps attach m en t is split
an d th e plate is position ed. Th e plate is xed w ith two
K-w ires in serted th rou gh th e two trocars.
f Th e rst screw is a 3.5 m m cortex lag screw position ed
su bch on d ra lly as prox im a lly as possible. Th is step is
m on itored by im age in ten si cation . An oth er 3.5 m m
cortex screw is in serted in to th e sh aft. Th e in term ed iate
m etaph yseal fragm en t is xed w ith a 3.5 m m cortex lag
screw orien ted towards th e olecran on .
g Fou r lock in g h ead screw s are in serted for n al xation .
h–i Clin ical testin g of th e ran ge of m otion an d radiological
h i con trol en ds th e operation .

4 Re h a b ilit a t io n

A posterior u pper arm splin t is applied u n til wou n d h ealin g

Im p la n t re m o va l
h as occu rred.
Im plan t rem oval m ay be n ecessary du e to th e ver y th in soft-
Ph ysioth erapy begin s on postoperative day two, in itially w ith
tissu e coverage an d th e probability of irr itation .
passive m ovem en t an d later w ith active m ovem en t.

373
 7.1 Ra d iu s a n d u ln a , p ro xim a l

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n
If cortex screw s an d lock in g h ead screw s are both
bein g in serted in to th e sam e plate, th ere is a risk th at
th e xation tech n iqu es w ill in terfere w ith each oth er,
wh ich m ay lead to im plan t loosen in g.
Re d u ct io n a n d xa t io n
It is h igh ly recom m en ded to in sert all cortex (con ven tion -
al) screw s before in sertin g th e lock in g h ead screw s.

Re h a b ilit a t io n Re h a b ilit a t io n
Prolon gin g ph ysioth erapy m ay lead to elbow stiffn ess, A carefu l balan ce between early ph ysioth erapy to preven t
an d aggressive th erapy m ay lead to xation failu re elbow stiffn ess (especially pron ation an d su pin ation ), an d
(rad ial h ead). gen tle m obilization m u st be fou n d.

374
 Au t h o r Ch ris t ia n Ryf

7.1.2 Ole cranon fracture —21-B1

1 Ca s e d e s crip t io n

8 8 -yea r- old w om a n fell on t h e st reet a n d su ffered a closed

olecran on fractu re of h er left arm .

Fig 7.1.2 -1a – b

a AP view.
b Lateral view.

In d ica t io n

Te n sio n b a n d xa tio n is re q u ire d d u e to se ve re o ste o p o ro sis. Te n sio n

a b b a n d p la tin g w a s in d ica te d .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP m e ta p h yse a l p la te 3 .5 , 8 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d
scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 1.6 m m K-w ire s
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
h e p a rin
a b
Fig 7.1.2 -2 a – b Pro n e p o sitio n , a rm o n a n a rm
ta b le , p n e u m a tiq u e to u rn iq u e t.

375
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

Fig 7.1.2 -3 Sligth ly cu r ved posterorad ial approach .

3 Re d u ct io n a n d fixa t io n

Fig 7.1.2 -4 a – bOpen redu ction w ith

sm all poin ted redu ction forceps an d pre-
lim in ar y xation of th e olecran on m ain
fragm en t w ith two 1.6 m m K-w ires.

a b

a b c

Fig 7.1.2 -5 a – cSh apin g of th e plate.

Th e th in n er part of th e LCP m etaph yseal plate w ith con vertin g
screw h oles is ben t towards th e prox im al m ain fragm en ts.

376
 7.1.2 Ole cra n o n fra ct u re —21-B1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Prelim in ar y xation of th e plate w ith

Fig 7.1.2 -6 a – c
K-w ires an d correspon d in g d rill sleeves.

a b

Fig 7.1.2 -7 Ch eck redu ction an d plate Fig 7.1.2 -8 a – lDe n itive xation of th e plate.
position w ith im age in ten si er. Order of screw in sertion : First a 3.5 m m self-tappin g LHS is in serted (in a per pen -
d icu lar d irection to th e plate) in th e m ost prox im al plate h ole to h old th e prox im al
m ain fragm en t.

377
 7.1 Ra d iu s a n d u ln a , p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

A 3.5 m m cortex
Fig 7.1.2 -8 a – l (co n t)
screw is eccen trically d rilled in order to
apply th e ten sion ban d prin ciple.

c d

e f g

h i j

378
 7.1.2 Ole cra n o n fra ct u re —21-B1

3 Re d u c t io n a n d fixa t io n (co n t )

k l

Fixation is com pleted w ith two add ition al bicortical self-tap-

Fig 7.1.2 -8 a – l (co n t)
pin g 3.5 m m LHS in both m ain fragm en ts.

a b c

Fig 7.1.2 -9 a – c Ver y sm all articu lar fragm en ts attach ed to th e soft tissu e are xed w ith resorbable osteosu tu res.

Fig 7.1.2 -10 Vacu u m d rain an d wou n d closu re.

379
 7.1 Ra d iu s a n d u ln a , p ro xim a l

4 Re h a b ilit a t io n

Fu n ction al postoperative care for u n lim ited ran ge of m otion ,

pain lim ited weigh t bearin g for 6 weeks, fu ll weigh t bearin g
after x-ray exam in ation an d docu m en ted u n distu rbed bon e
h ealin g.

a b a b a b

Fig 7.1.2 -11a – b Postoperative x-rays Fig 7.1.2 -12 a – b Postoperative x-rays Fig 7.1.2 -13 a – b Postoperative x-rays
after 1 week. after 5 weeks. after 10 weeks.
a AP view a AP view a AP view
b Lateral view. b Lateral view. b Lateral view.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Severe ben d in g of th e plate m ay lead to deform ation of An atom ically presh aped plates m ay be u sefu l.
th e th readed part of th e com bin ation h ole, m ak in g th e Th e LCP is an ideal im plan t fort h e treatm en t of forearm
h ole in capable of h old in g LHS. fractu res especially in osteoporotic bon e.

Ap p ro a ch Ap p ro a ch
Dam age of th e u ln ar n erve. Adequ ate posterorad ial approach an d carefu l preparation .

38 0
 Au t h o r Mich a e l Ple cko

7.1.3 Ope n proxim al ulnar fracture —21-B1; sim ple ulnar shaft
fracture —22-A1; ante rior dislocation of the radial he ad
1 Ca s e d e s crip t io n

79-year-old m an fell from a ladder, su ffered a Gu stilo type I

open , mu ltifragm en tary fractu re of th e proxim al u ln a (21-B1)
w ith an terior dislocation of th e radial h ead an d an u n displaced
sim ple fractu re of th e u ln ar sh aft (22-A1). His righ t dom in an t
arm was affected. Addition ally, h e h ad a severe th orax trau m a
w ith mu ltiple rib fractu res an d a h em atopn eu m oth orax.

Fig 7.1.3 -1a – b

a AP view of th e righ t elbow.
b Lateral view.

After stabilizin g h is gen eral con dition , open redu ction an d

in tern al xation w ith add ition al redu ction of th e rad ial h ead
a b h ad to be perform ed w ith in th e rst 48 h ou rs.

In d ica t io n Pre o p e ra t ive p la n n in g

Se gm e n ta l fra ctu re o f th e u lna Eq u ip m e n t

21-B1, m u ltifra gm e n ta ry Gu stilo
t yp e I o p e n fra ctu re o f th e p roxi-
m a l u ln a , a n te rio r d islo ca tio n o f
th e ra d ia l h e a d , a n d a d d itio n a l
sim ple u n d ispla ce d 2 2-A1 fra c-
tu re a t th e sh a ft o f th e u ln a .
• LCP o le cra n o n p la te 3 .5 , 8 h o le s
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d
scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .4 m m co rte x scre w
(Size o f s yste m , in s tru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 7.1.3 -2 Su p in e p o sitio n w ith to w e l ro ll a t th e

An tib io tics: n o n e le ve l o f th e rib ca ge w ith th e in ju re d a rm p la ce d o n
Th ro m b o sis p ro p h yla xis: n o n e it. Ste rile to u rn iq u e t.

381
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

Fig 7.1.3-3a–c Posterior approach

to th e u ln a. Excision of blood
clot an d of th e olecran on
bu rsa. Preparation of th e u l-
n ar n er ve w ith a vessel loop.

a b c

3 Re d u ct io n a n d fixa t io n

a b

Fig 7.1.3 -4 a – c
a – b An atom ical redu ction of th e olecran on fractu re w ith a poin ted redu ction forceps an d
tem porary xation w ith a K-w ire from prox im al to d istal. Position in g of an 8-h ole LCP
olecran on plate an d tem porary xation of th e proxim al en d of th e plate by in sertion of a
K-w ire th rou gh th e th readed drill sleeve. Th e drill sleeve is correctly position ed w ith th e
h elp of th e aim in g block.
Th e rst screw to be in trodu ced th rou gh th e plate is a cortex screw to x th e coron oid
process. Th e secon d screw, a 3.5 m m LHS, is in serted in to th e sh aft fragm en t. Th e cortical
fragm en t on th e radial side is xed w ith a plate-in depen den t 2.4 m m cortex screw u sin g
th e com pression m eth od.

382
 7.1.3 Op e n p ro xim a l u ln a r fra ct u re —21-B1; s im p le u ln a r s h a ft fra ct u re —2 2 -A1; a n t e rio r d is lo ca t io n o f t h e ra d ia l h e a d

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 7.1.3 -4 a – c (co n t)

c Th e xation of th e plate is n alized w ith fou r LHS in th e
proxim al fragmen t, two in the in termediate sh aft fragment, a b
an d th ree in th e d istal sh aft fragm en t.
Fig 7.1.3 -5 a – b Th e lateral postoperative x-rays sh ow an add i-
tion al u n d isplaced sh aft fractu re of th e u ln a. Th e rad ial h ead
is redu ced.
a AP view.
b Lateral view.

4 Re h a b ilit a t io n

Fu n ction al treatm en t started on postoperative day on e w ith

active an d passive m ovem en t of th e elbow join t an d th e fore-
arm .

Fig 7.1.3 -6 a – b Ran ge of m otion 12 days after th e operation .

a b

383
 7.1 Ra d iu s a n d u ln a , p ro xim a l

4 Re h a b ilit a t io n (co n t )

a b

b
a b c d

Fig 7.1.3 -7a – b Postoperat ive x-rays a fter 6 m on t h s sh ow 6 m on th s after th e operation th e patien t was
Fig 7.1.3 -8 a – d
bon e con solidation of both fractu res w ith th e radial h ead in pain free, h ad on ly sligh tly fu n ction al restriction s, an d equ al
correct align m en t. stren gth on both sides.
a AP view. a – b Ran ge of m otion : exion /exten sion 0°/5°/ 14 0°.
b Lateral view. c– d Ran ge of m otion : pron ation /su pin ation 70°/ 0°/ 70°.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
An atom ical presh aped plates are h elpfu l in com plex
fractu re situ ation s.

Re d u ct io n a n d xa t io n
In th is case, th e u n d isplaced add ition al sh aft fractu re was
n ot clearly seen on th e preoperative x-rays.
Th e correct redu ction an d xation of th is m u lti-
fragm en tar y olecran on fractu re is th e precon dition
for th e redu ction of th e d isplaced rad ial h ead.
Re d u ct io n a n d xa t io n
Th e special, an atom ically presh aped LCP olecran on
plate 3.5 w ith th e com bin ation h ole allowed stable xa-
tion of th is segm en tal fractu re by two d ifferen t m eth ods:
th e com pression m eth od for th e olecran on fractu re an d
splin tin g m eth ode for th e u n d isplaced sh aft fractu re.
An gu lar stable platin g of th e proxim al u ln a leads to h igh -
er stability also in mu ltifragm en tary fractu re situ ation s.
Th is perm its an early active reh abilitation program .

38 4
 Au t h o r Mich a e l Sch ü t z, No rb e r t P Ha a s

7.1.4 Com ple x radial he ad fracture and e xtraarticular

ole cranon fracture —21-B3
1 Ca s e d e s crip t io n

a b c d

53-year-old m an fell wh ile rid in g h is bicycle an d su stain ed Fig 7.1.4 -1a – d

an elbow fractu re. Th ere were n o oth er in ju r ies. After a CT a Preoperative x-ray, lateral view.
scan , th e patien t was operated on th e sam e day. b – d CT scan s.

In d ica t io n Pre o p e ra t ive p la n n in g

Acco rd in g to th e p rin cip le s o f Eq u ip m e n t

in tra a rticu la r fra ctu re m a n a ge -
m e n t, a sta b le o ste o syn th e sis
a n d , d e p e n d in g o n th e liga m e n -
to u s le sio n s, e a rly fu n ctio n a l
tre a tm e n t w ith o r w ith o u t a
sp lin t sh o u ld b e a ch ie ve d .
• LCP 3 .5 , 8 h o le s
• 2 .0 m m co rte x scre w s
• 3 .5 m m co rte x scre w s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 1.2 5 m m K-w ire s
• 1.6 m m K-w ire s
(Size o f s yste m , in s tru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Fig 7.1.4 -2 Pro n e p o sitio n , a rm o n
Pa t ie n t p re p a ra t io n a n d p o s it io n in g a n a rm ta b le , p n e u m a tic to u rn iq u e t,
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin ra d io gra p h y a n d im a ge in te n si e r.
Tro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

385
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

Poster ior in cision . Th e rad ial fractu re can be

Fig 7.1.4 -3 a – b
ex posed th rou gh th e olecran on fractu re.

a b

3 Re d u ct io n a n d fixa t io n

Fig 7.1.4 -4 a – h
a – b Th e im pacted rad ial join t fragm en t is elevated an d in i-
tially xed w ith 1.25 m m K-w ires. Two 2.0 m m lag
screw s are in serted to stabilize th e m ain rad ial fractu re
fragm en ts. On e of th e screw s m u st h ave con tact w ith
th e in tact rad ial n eck zon e.

a b

38 6
 7.1.4 Co m p le x ra d ia l h e a d fra ct u re a n d e xt ra a rt icu la r o le cra n o n fra ct u re —21-B3

3 Re d u c t io n a n d fixa t io n (co n t )

c d e f

Fig 7.1.4 -4 a – h (co n t)

c– d Redu ction of th e extraar ticu lar fractu re a n d th e add ition a l m e-
taph yseal fragm en t. Two sm all poin ted redu ction forceps are u sed
to h old th e m ain fragm en ts. Th e redu ction an d th e addition al frag-
m en t are in itially xed w ith th ree K-w ires. Wh ile position in g th e
K-w ires, th e plan n ed plate position m u st be taken in to accou n t.
Th e 8-h ole LCP is ben t to en com pass th e tip of th e olecran on . To
ach ieve tigh t bon e-plate con tact, th e triceps m u scle attach m en t is
split an d th e plate position ed. At th e en d of th e operation , th e m u scle
m u st be su tu red.
e Th e plate is align ed an d drill sleeves are in serted proxim ally an d
d istally. Th e plate is n ow secu red w ith two 1.6 m m K-w ires.
f A 3.5 m m cortex screw is in serted th rou gh th e fth h ole an d d irected
toward th e coron oid process. Drillin g is perform ed u n der im age g h
in ten si cation con trol in lateral projection to en su re th e exact
placem en t of th is essen tial screw.
Th e in term ediate fragm en t is secu red w ith an add ition al isolated
lag screw in serted in a radiou ln ar direction .
Two lockin g h ead screw s proxim ally an d th ree lockin g h ead screw s
d istally stabilize th e fractu re in in tern al xator tech n iqu e.
g– h Clin ical assessm en t of th e ran ge of m otion in pron ation an d su pi-
n ation (radial h ead) an d a radiological con trol en ds th e operation .

387
 7.1 Ra d iu s a n d u ln a , p ro xim a l

4 Re h a b ilit a t io n

A posterior u pper arm splin t is applied u n til de n itive wou n d

h ealin g h as occu rred.
Ph ysioth erapy begin s on postoperative day two in itially w ith
passive m ovem en t, followed later w ith active m ovem en t.

Fig 7.1.4 -5 a – b Postoperative x-rays after 9 m on th s.

Im p la n t re m o va l
Im pla n t rem ova l m ay be n ecessar y becau se of t h e ver y t h in
soft-tissu e coverage an d th e probability of irritation .
a b

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n
If cortex screw s an d lock in g h ead screw s are both bein g
in serted in to th e sam e plate, th ere is a risk th at th e
xation tech n iqu es w ill in terfere w ith each oth er, an d
th is m ay lead to im plan t loosen in g.
Re d u ct io n a n d xa t io n
It is h igh ly recom m en ded to in sert all cortex (con ven tion -
al) screw s before in sertin g th e lock in g h ead screw s.

Re h a b ilit a t io n Re h a b ilit a t io n
Delayed ph ysioth erapy m ay lead to elbow stiffn ess, an d A carefu l balan ce between early ph ysioth erapy to preven t
aggressive th erapy m ay lead to xation failu re (rad ial elbow stiffn ess (especially pron ation an d su pin ation ), an d
h ead). gen tle m obilization m u st be fou n d.

38 8
 Au t h o r Ch ris t o p h e r W Ge e l

7.1.5 3 -part radial he ad and transve rse radial ne ck fracture;

intraarticular proxim al ulnar fracture —21-B3
1 Ca s e d e s crip t io n

56-year-old m an fell from a tree stan d du rin g h u n tin g season . Type of

in ju r y: h igh -en ergy trau m a, m u ltiple trau m a w ith ch est con tu sion w ith
pn eu m oth orax left, closed fractu re.

Fig 7.1.5 -1a – b

a AP view.
b Lateral view.

In d ica t io n

3 -p a rt ra d ia l h e a d fra ctu re a n d tra n sve rse ra d ia l n e ck fra ctu re a sso cia te d w ith
m u ltifra gm e n ta ry, in tra a rticu la r p ro xim a l u ln a r fra ctu re , w ith fra ctu re o f co ro n o id
p ro ce ss. Th is co m b in a tio n fra ctu re re n d e rs th e e lb o w jo in t u n sta b le a n d , b e ca u se
a b o f in tra a rticu la r in vo lve m e n t, is b e st tre a te d b y ORIF.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

Ra d iu s:
• Min i co n d yla r p la te 2 .0 , 7 h o le s
• 2 .0 m m a n d 2 .7 m m co rte x scre w
• 3 .5 m m scre w w ith sp ike d w a sh e r

Uln a:
• LCP 3 .5 , 9 h o le s
• Lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin Fig 7.1.5 -2 Su p in e p o sitio n o n o p e ra tin g ta b le w ith
ra d io lu ce n t a rm b o a rd .

389
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

a b

Fig 7.1.5 -3 Uln a: Radiu s:

Fig 7.1.5 -4 a – b
ORIF as rst step to secu re proper len gth of forearm Wide sk in br idge between th e two in cision s. Radial h ead approach u sed
an d to facilitate th e ORIF of th e m u ltifragm en tary m odi ed Gordon -Boyd’s approach w ith osteotom y radial collateral liga-
rad ial h ead fractu re. m en t after predrillin g of th e fu tu re an ch orin g h ole.
In cision poster iorly over su bcu t a n eou s border of
u ln a.
Iden ti cation of u ln ar border w ith ou t violatin g
periosteal coverage.
Irrigation of elbow join t an d secu rin g u ln ar n erve
w ith vessel loop.

3 Re d u ct io n

Fig 7.1.5 -5 a – bRad iu s: Tem porary cerclage arou n d

rad ial h ead after in spection of join t su rface an d
irrigation of elbow join t.
Drillin g w ith parallel soft-tissu e protector to en su re
proper placem en t of lag screw s parallel to radial
h ead join t su rface.

Uln a: in d irect redu ction of u ln ar fractu re w ith

plate in situ u sin g pu sh -pu ll tech n iqu e.

a b

39 0
 7.1.5 3 -p a r t ra d ia l h e a d a n d t ra n s ve rs e ra d ia l n e ck fra ct u re ; in t ra a r t icu la r p ro xim a l u ln a r fra ct u re —21-B3

4 Fixa t io n

First step — xation of u ln a:

An ch orin g an d xation of plate proxim ally w ith
com bin at ion of screw to preven t plate spin n in g,
followed by LHS.
Lag screw xation of corn oid process fragm en t.
In terfragm en tary add ition al com pression th rou gh
th e plate.
In sertion of d istal LHS in m on ocortical fash ion .

a b

Fig 7.1.5 -6 a – b Secon d step — xation of radiu s:

a In sertion of 2.7 m m an d 2.0 m m cortex lag screw s.
b Redu ction of th e n ow stable rad ial h ead xation to th e rad ial sh aft
w ith a m in i, con dylar plate 2.0, extraarticu lar prox im ally w ith ou t
in terferen ce w ith join t con gru en cey.

a b c

Secon d step — xation of radiu s:

Fig 7.1.5 -7a – c
Refixat ion of osteotom ized rad ia l collatera l liga m en t in ser t ion w it h spiked w ash er a n d 3.5 m m
cortex screw.

391
 7.1 Ra d iu s a n d u ln a , p ro xim a l
5 Re h a b ilit a t io n
a b
Active m obilization after 1 day.
Bon e h ealin g after 12 weeks.
a b
392
c d
Fig Postoperative x-rays.
7.1.5 -8 a – d
a AP view after 6 weeks.
b Lateral view after 6 weeks.
c AP view after 6 m on th s.
d Lateral view after 6 m on th s.
Im p la n t re m o va l
Partial im plan t rem oval after 1 m on th .
Tech n iqu e for im plan t rem oval: stab in cision u n der local
an aesth etic.
Fig 7.1.5 -9 a – b
a Reason for im plan t rem oval: screw w ith spiked wash er is
protru din g u n der skin .
b Lateral x-ray after partial im plan t rem oval.
 7.1.5 3 -p a r t ra d ia l h e a d a n d t ra n s ve rs e ra d ia l n e ck fra ct u re ; in t ra a r t icu la r p ro xim a l u ln a r fra ct u re —21-B3

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Osteotom y of th e rad ial collateral ligam en t allow s
excellen t view of articu lar su rface.

Re h a b ilit a t io n Re h a b ilit a t io n
Early active rath er th an passive m otion allow s for
a con trolled recover y.

393
 7.1 Ra d iu s a n d u ln a , p ro xim a l

39 4
 Au t h o r Ch ris t o p h So m m e r

7.1.6 Extraarticular proxim al ulnar fracture with

pse udarthrosis—21-A1
1 Ca s e d e s crip t io n

80-year-old wom an fell at h om e an d lan ded on h er

left elbow. Sh e su stain ed an extraarticu lar, closed,
sligh tly an gu lated diaphyseal fractu re of th e left
proxim al u ln a (21-A1.2). Th e patien t h as h ad an
asym ptom atic pseu darth rosis ben eath th e h ead of
th e rad iu s sin ce ch ild h ood.

Fig 7.1.6 -1a – b

a AP view.
b Lateral view.
a

In d ica t io n Pre o p e ra t ive p la n n in g

1 Su rge o n
Th is is o n ly a re la tive in d ica tio n fo r su rge ry Eq u ip m e n t
2 ORP
b e ca u se n o n o p e ra tive fra ctu re tre a tm e n t • LCP 3 .5 , 7 h o le s
3 1st a ssista n t
wo u ld a lso b e p o ssib le . Give n th e p se u d a r- • 3 .5 m m lo ckin g h e a d scre w s (LHS)
4 2nd a ssistan t
th ro sis a t th e h e a d o f th e ra d iu s, a su rgica l • 3 .5 m m co rte x scre w s
Ste rile are a
p ro ce d u re is p re fe rre d so th a t th e re ca n b e (Size o f s ys te m , in stru m e n ts,
3
e a rly fu n ctio n a l re h a b ilita tio n . Sin ce th e re is a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
o b vio u s o s te o p o ro sis , a p la te s ys te m w ith
lo ckin g h e a d scre w s su ch a s th e LCP is Pa t ie n t p re p a ra t io n a n d p o s it io n in g
4
e sp e cia lly su ita b le . Th e tre a tm e n t go a l fo r An tib io tics: 2 n d ge n e ra tio n 2
th is sim p le fra ctu re p a tte rn (o b liq u e fra ctu re) ce p h a lo sp o rin 1
is a n a to m ica l re d u ctio n a n d co m p re ssio n Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
pla te o ste o syn the sis to achie ve ab solu te sta - h e p a rin
b ilit y.

Fig 7.1.6 -2 Su p in e p o sitio n , le ft u p p e r e xtre m it y is ste rile d ra p e d a n d

in tra o p e ra tive ly m o b ile . No n ste rile to u rn iq u e t o n th e u p p e r a rm ( in su f a te d o n ly
if re q u ire d ). Th e fre e ly m o b ile a rm is p o sitio n e d o n th e p a tie n t ’s s to m a ch; th is
re q u ire s a se co n d a ssis ta n t.

395
 7.1 Ra d iu s a n d u ln a , p ro xim a l

2 Su rgica l a p p ro a ch

Fig 7.1.6 -3 Stan dard proxim al posterior approach

to th e u ln a from th e tip of th e olecran on to th e
ju n ction of th e proxim al an d m id th irds. In cision
of th e m u scle fasciae at th e posterior u ln ar aspect,
w ith carefu l ex posu re of th e u ln ar crest.

3 Re d u ct io n a n d fixa t io n

a b

c d

Fig 7.1.6 -4 a – d
a In th e presen ce of severe osteoporosis, th e so-called “wave plate” tech n iqu e is a su itable treatm en t,
whereby the plate is sligh tly bent between the individu al plate holes so th at a at, wave-sh aped plate
is created. Th is perm its th e in sertion of lock in g h ead screw s in d ifferen t, n on parallel d irection s,
th u s in creasin g th e pu ll-ou t force of th e im plan t. In a rst step, th e precon tou red plate is secu red to
th e prox im al m ain fragm en t of th e u ln a w ith th ree lock in g h ead screw s as lon g as possible.
b – c In th e n ext step, eccen tric in sertion of a 3.5 m m cortex screw in th e prox im al d iaph ysis to create
in terfragm en tary com pression .
d Th e an atom ically redu ced an d com pressed fractu re is n ow de n itively stabilized by in sertion of two
lock in g h ead screw s in to th e sh aft at th e d istal en d of th e plate. Th ese are orien ted d ivergen tly an d
th u s in crease th e prim ar y stability.

39 6
 7.1.6 Ext ra a rt icu la r p ro xim a l u ln a r fra ct u re w it h p s e u d a r t h ro s is —21-A1

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 7.1.6 -5a – b Th e postoperative x-rays con rm th e an atom ical

redu ction an d in terfragm en tar y com pression of th e fractu re.

4 Re h a b ilit a t io n

b a b

a c d

Fig 7.1.6 -6 a – bEarly fu n ction al reh abilitation w ith ou t an y
form of im m obilization . After 6 weeks th e x-rays sh ow clear
con solidation of th e fractu re w ith som e blu rrin g of th e form er
fractu re gap an d sign s of periosteal callu s form ation in d icatin g
sligh t m icrom otion related to th is bridgin g osteosyn th esis.
Fig 7.1.6 -7a – d Elbow fu n ction is alm ost n orm al at th is tim e an d
iden tical to th e level of fu n ction before th e acciden t. Fu rth er
clin ical and radiological exam in ation s w ill not be u ndertaken
provided th e patien t rem ain s free of sym ptom s. Th e im plan ts
are n ot rem oved.

397
 7.1 Ra d iu s a n d u ln a , p ro xim a l

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t
Du rin g presh apin g of th e LCP 3.5 th e h oles m ay becom e
ben t an d th e lock in g h ead screw s w ill n ot h old properly.
Th erefore, th e plate sh ou ld always be ben t an d tw isted
between th e h oles.
Eq u ip m e n t
Th e LCP is an ideal im plan t for th e treatm en t of forearm
fractu res especially in osteoporotic bon e.

Ap p ro a ch Ap p ro a ch
Th is stan dard approach to th e prox im al u ln a is n ot
u su ally problem atic.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e redu ction is easy an d can be perform ed u sin g th e Th e so-called ”wave plate“ tech n iqu e allow s th e in sertion
prin ciple of redu ction on to th e plate. In severe osteopo- of lock in g h ead screw s in differen t, n on parallel direction s,
rotic bon e, it m ay n ot be possible to ach ieve ax ial wh ich in creases th e prim ary stability of th e w h ole
com pression by eccen tric in sertion of cortex screw con stru ct. Th ere is h igh er resistan ce to ten sion in g forces.
becau se th ere is a risk of th e screw pu llin g ou t of th e
bon e. Th e proxim al lockin g h ead screw sh ou ld be as
lon g as possible bu t sh ou ld n ot pen etrate th e opposite
cortex sin ce it is u n desirable to h ave th e screw tips in
an in tra-articu lar position .

Re h a b ilit a t io n Re h a b ilit a t io n
Th e LCP applied as described in th is case provides optim al
stabilization allow in g for early fu n ction al aftertreatm en t.

39 8
7.2 Radius and ulna, shaft

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

7.2 .1 Disp la ce d rad ial sha ft fractu re 2 2-A2 co m p re ssio n LCP 3 .5 la g scre w 4 03
p ro te ctio n plate

7.2 .2 We d ge rad ial an d u ln ar sh a ft fractu re 2 2-B3 co m p re ssio n LCP 3 .5 co m p re ssio n p la te 4 07

7.2 .3 Op e n rad ia l a n d u ln ar sh a ft fra ctu re s a n d 2 2-B3; 2 3 -C com p re ssion LCP 3.5; LCP co m p re ssio n p la te 411
co m p le x articu lar d istal rad ial fractu re T-pla te 3.5

7.2 .4 Com ple x rad ial and u ln ar sha ft fractu re 2 2-C3 lo cke d splin ting LCP 3 .5 lo cke d in te rnal 415
fixa to r an d
re d u ction scre w

39 9
 7 Ra d iu s a n d u ln a

7 Radius and ulna

7.2 Ra d iu s a n d u ln a , s h a ft 4 01
7.2 .1 Dis p la ce d ra d ia l s h a ft fra ct u re —2 2 -A2 403
7.2 .2 We d ge ra d ia l a n d u ln a r s h a ft fra ct u re —2 2 -B3 407
7.2 .3 Op e n ra d ia l a n d u ln a r s h a ft fra ct u re s —2 2 -B3 a n d
co m p le x a r t icu la r d is t a l ra d ia l fra ct u re —2 3 - C 411
7.2 .4 Co m p le x ra d ia l a n d u ln a r s h a ft fra ct u re —2 2 - C3 415

400
 Au t h o r Th o m a s P Rü e d i

7.2 Radius and ulna, shaft

1 In cid e n ce 2 Cla s s ifica t io n

In th e adu lt, fractu res of th e forearm com prise abou t 10 –15% Accordin g to th e Mü ller AO Classi cation , radial an d u ln ar
of all fractu res treated su rgically. Th is is du e to th e fact th at sh aft fractu res are classi ed in A, B, an d C types.
th e an atom ical relation sh ip of th e rad iu s an d u ln a an d of th e
adjacen t join ts requ ires a precise recon stru ction an d align -
m en t an d absolu tely stable xation of both bon es in order to
allow for early m otion an d restitu tion of fu n ction . Th e in di-
cation s for n on operative treatm en t in a fu n ction al brace are
th erefore lim ited to n on d isplaced fractu res of th e m idsh aft,
preferably of on e bon e on ly. a b c

Fig 7.2 -1a – c22-A sim ple fractu res.

a 22-A1 u ln a, rad iu s in tact
3 Tre a t m e n t m e t h o d s b 22-A2 rad iu s, u ln a in tact
c 22-A3 both bon es
a
As already m en tion ed, th e forearm as su ch sh ou ld be regard-
ed as an articu lation w ith several facets th at con tribu te to
pro- an d su pin ation as well as exion an d exten sion in th e
w rist an d elbow. Th is dem an ds rigid xation wh ich is cu r-
ren tly best ach ieved w ith plates an d screw s. In tram edu llar y
devices w ith in terlock in g are u n der developm en t bu t h ave n ot
a b c
yet reach ed th e reliability of platin g.
Fig 22-B wedge fractu res.
7.2 -2 a – c
Th e well establish ed an d su ccessfu l tech n iqu es w ith th e 3.5 a 22-B1 u ln a, rad iu s in tact
DCP an d LC-DCP h ave recen tly been ch allen ged by th e in - b 22-B2 radiu s, u ln a in tact
tern al xator prin ciple. Th e PC-Fix was origin a lly in trodu ced c 22-B3 on e bon e wedge, oth er sim ple or wedge
in d ifferen t clin ical stu d ies for th e forearm bon es. It proved
its in n ovative qu alities in over 1,000 application s w ith a ver y
h igh su ccess rate. Neverth eless, th e fu rth er developm en t of
th e LCP 3.5 w ith its com bin ation h oles h as n ow replaced th e
PC-Fix, as it offers th e sam e biological advan tages as th e lat-
ter, bu t w ith h igh er versatility an d a broader spectru m of in -
d ication s.
a b c

In sim ple type A fractu res it is recom m en ded th at th e LCP Fig 22-C com plex fractu res.
7.2 -3 a – c
3.5 be applied in con ven tion al tech n iqu e w ith 3.5 m m cortex a 22-C1 u ln a com plex, rad iu s sim ple
screw s an d in terfragm en tar y com pression . For m ore com plex b 22-C2 rad iu s com plex, u ln a sim ple
Vid e o 7.2-1
type C fractu res, th e LCP can be applied pu rely as an in tern al c 22-C3 both bon es com plex

401
 7 Ra d iu s a n d u ln a

xator bridgin g th e m u ltifragm en tary fractu re zon e an d at

th e sam e tim e secu rin g th e correct ax ial align m en t an d rota-
tion . Wh ile th e rad iu s u su ally requ ires an open ex posu re, th e
u ln a can be approach ed by m in im ally in vasive tech n iqu es,
slid in g th e plate alon g th e easily palpable bon e. Th an ks to
th e lock in g h ead screw s precise con tou rin g of th e LCP is n ot
n ecessar y; h owever th e u se of bicortical self-tappin g lock in g
h ead screw s is recom m en ded.
4 Im p la n t o ve r vie w
a of diaph yseal fractu res of th e forearm . Hefte Unfallheilkd; 201:243 –258.
b Oe st e rn H J, Tsch e rn e H (1983) [ Resu lts of a collective AO follow-u p
Fig 7.2 -4 a – b
a LCP 3.5
b LCP T-plate 3.5
5 Su gge s t io n s fo r fu r t h e r re a d in g
Ch ap m an MW, Go rd o n J E, Zissim o s AG (1989) Com pression -plate
xation of acu te fractu res of th e diaphyses of th e radiu s an d u ln a.
J Bone Joint Surg Am; 71(2):159 –169.
D e Pe d ro JA , Garcia-N avarre t e F, Garcia D e Lu cas F, e t al (1992)
In tern al xation of u ln ar fractu res by lock in g n ail. Clin Orthop;
283:81–85.
D u n can R , Ge issle r W, Fre e lan d A E, e t al (1992) Im m ediate
in tern al xation of open fractu res of th e d iaph ysis of th e forearm .
J Orthop Trauma; 6(1):25 –31.
He im U, Ze h n de r R (1989) An alysis of failu res after osteosyn th esis
He rt e l R , Pisan M , Lam be rt S, e t al (1996) Plate osteosyn th esis of
diaph yseal fractu res of th e rad iu s an d u ln a. Injury; 27(8):545 –548.
of forearm sh aft fractu res]. Unfallheilkunde; 86(3):136 –142.

4 02
 Au t h o r Mich a e l Wa gn e r

7.2.1 Displace d radial shaft fracture —22-A2

1 Ca s e d e s crip t io n

25-year-old m an fell an d su ffered a m on otrau m a to h is righ t arm .

Fig 7.2 .1-1a – b

a AP view.
b Lateral view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

Th is d isp la ce d ra d ia l sh a ft fra ctu re is a n in d ica tio n fo r Eq u ip m e n t

o p e ra tive in te rve n tio n . Sh a ft fra ctu re s o f th e fo re a rm • LCP 3 .5 , n a rro w, 8 h o le s
re quire accurate re duction so ORIF is indicate d . Plate oste o - • 2 .7 m m co rte x scre w
syn th e sis o ffe rs th e o p p o rtu n it y to re sto re th e a n a to m ica l • 3 .5 m m lo ckin g h e a d scre w s (LHS)
sha p e o f th e b o n e , a ccu ra te ly w h ich is a p re re q u isite • 1.2 5 m m K-w ire s
to re ga in in g fu ll fo re a rm p ro n a tio n a n d su p in a tio n . In - • Po in te d re d u ctio n fo rce p s
tra m e d u lla ry n a ilin g w o u ld b e a n a lte rn a tive p ro ce d u re (Size o f s yste m , in s tru m e n ts, a n d
in th is fo r ra d ia l sha ft fra ctu re bu t w o u ld n o t p e rm it im - im p la n ts ca n va ry a cco rd in g to a n a to m y.)
m e d ia te fu n ctio n a l p o sto p e ra tive ca re .
Pa t ie n t p re p a ra t io n a n d
p o s it io n in g
Fig 7.2 .1-2 Su p in e p o sitio n , a rm
An tib io tics: n o n e
ta b le , b lo o d to u rn iq u e t, a rm in
Th ro m b o sis p ro p h yla xis: n o n e
a b d u ctio n .

403
 7.2 Ra d iu s a n d u ln a , s h a ft

2 Su rgica l a p p ro a ch

a b

Fig 7.2 .1-3 a – c

a Palm ar approach accord in g to Hen ry.
b An in cision for a palm ar approach is m arked on th e sk in
preoperatively.
c Split t in g of t h e fa scia a n d pr o cedu re at t h e edge of t h e
brach ioradialis m u scle.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 7.2 .1-4 a – l

a – c After exposu re of th e sh aft fractu re both th e proxim al an d distal fragm en ts are
h eld w ith a poin ted redu ction forceps an d th e redu ction is perform ed u n der
lon gitu d in al traction an d d irect vision . Th e redu ction resu lt is h eld in place
w ith a th ird pair of poin ted redu ction forceps.

404
 7.2 .1 Dis p la ce d ra d ia l s h a ft fra ct u re —2 2 -A2
3 Re d u c t io n a n d fixa t io n (co n t )
d e
g h
j k
Fig 7.2 .1-4 a – l (co n t)
d Predrillin g of th e h oles for th e 2.7 m m cortex screw w ith
variou s drill bits for th e glid in g an d th readed h oles.
e Len gth m easu rem en t.
f In sertion of th e lag screw (2.7 m m cortex screw).
g Fractu re st abilizat ion w it h a n in depen den t lag screw for
in terfragm en tary com pression .
h In sertion of th e LCP 3.5, 8 h oles an d tem porary xation
w ith K-w ires in th e prox im al an d d istal fragm en t. After
x-ray con trol of plate position , de n itive xation w ith th e
protection plate follow in g u sin g fou r LHS, two per frag-
m en t.
f
i
l
i Drillin g th rou gh a th readed drill sleeve an d lock in g of th e
LHS w ith th e torqu e-lim itin g screwdriver.
j Osteosyn th esis after com pletion .
k Redon drain age an d su tu re.
l Th is sim ple rad ial sh aft fractu re was stabilized by an open ,
precise redu ction an d com pression m eth od u sin g a 2.7 m m
lag screw. An an gu lar stable n on con tact plate xed w ith
LHS was in serted to act as a protection plate.
405
 7.2 Ra d iu s a n d u ln a , s h a ft

4 Re h a b ilit a t io n

No addition al im m obilization . Active m obilization starts on day one postoperatively,

in clu d in g active-assisted ph ysioth erapy of th e elbow an d w rist.

a b a b a b

Fig 7.2 .1-5 a – b Postoperative x-rays after Fig 7.2 .1-6 a – b Postoperative x-rays after Fig 7.2 .1-7a – b Postoperative x-rays after
1 day. 6 weeks. 5 m on th s. Direct bon e h ealin g.
a AP view. a AP view. a AP view.
b Lateral view. The gap between the non- b Lateral view. b Lateral view.
con tact plate an d th e bon e is visible.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Lesion of th e rad ial n er ve.
Circu latory dam age cau sed by open redu ction an d com -
pression osteosyn th esis in con ven tion al plate tech n iqu e.
Re d u ct io n a n d xa t io n
Fixation of a con ven tion al plate w ith cortex screw s
requ ires precise preben d in g of th e plate. Oth er w ise
th ere is a risk of prim ar y loss of redu ction .
Re d u ct io n a n d xa t io n
A plate-in depen den t lag screw is tech n ically sim pler
th an a lag screw th rou gh a plate h ole. A protection
plate secu red w ith LHS h as th e follow in g advan tages:
• Precise preben d in g of th e plate on to th e bon e su rface
is n ot n ecessar y as th e plate is secu red as a n on con tact
plate.
• No prim ar y loss of redu ction .
• M in im al periostea l circu lator y dam age.
• Redu ced risk of refractu re on poten tial im plan t rem oval.

406
 Au t h o rs Em a n u e l Ga u t ie r, Ge o rge s Ko h u t

7.2.2 We dge radial and ulnar shaft fracture —22-B3

1 Ca s e d e s crip t io n

15-year-old m an fell wh ile playin g soccer an d su ffered a m on otrau m a to

h is left arm .

Fig 7.2 .2 -1a – b

a AP view show in g tran sverse fractu res of both forearm bones. The radiu s
h as a sim ple fractu re, th e u ln a an add ition al sm all ben d in g wedge.
b Lateral view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

Th is d isp la ce d fo re a rm fra ctu re Eq u ip m e n t

(2 2-B3 .1) is in th is a ge gro u p
a n a b so lu te in d ica tio n fo r o p e n
re d u ctio n a n d in te rna l xa tio n
u sin g p la te s. In tra m e d u lla ry n a il-
in g w o u ld b e d if cu lt b e ca u se
o f th e n a rro w m e d u lla ry ca vit y.
Pla te o ste o s yn th e sis o ffe rs th e
o p p o rtu n it y to re sto re a ccu ra te -
ly th e a n a to m ica l sha p e o f b o th
fo re a rm b o n e s, w h ich is a p re -
re q u isite to re ga in in g fu ll fo re -
a rm p ro n a tio n a n d su p in a tio n .
• LCP 3 .5 , 7 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp o rin fo r 4 8 h o u rs
Th ro m b o sis p ro p h yla xis: n o n e
Fig 7.2 .2 -2 Po sitio n th e p a tie n t su p in e o n th e ta b le , w ith th e
u p p e r e xtre m it y a b d u cte d a n d su p p o rte d o n a h a n d ta b le .
A to u rn iq u e t is p la ce d o n th e u p p e r a rm .
Ap p ro a ch to th e u ln a is p e rfo rm e d w ith th e e lb o w in e xio n a n d th e fo re a rm p ro n a te d .
Ap p ro a ch to th e ra d iu s w ith e xte n sio n o f th e e lb o w a n d th e fo re a rm su p in a te d .

4 07
 7.2 Ra d iu s a n d u ln a , s h a ft

2 Su rgica l a p p ro a ch

a
b

Fig 7.2 .2 -3 a – b
a Stan dard approach to th e u ln a. b Approach to th e rad ial sh aft accord in g to Hen ry.

3 Re d u ct io n a n d fixa t io n —u ln a

After epiperiosteal exposu re of th e u ln ar sh aft th e plate is an -

chored on the distal fragm en t w ith two LHS prior to reduction .
Th e redu ction is perform ed by m anu al traction an d th e prox-
im a l fragm en t is h eld in position u sin g a sm a ll Verbr u gge
clam p. In terfragm en tar y com pression of th e fractu re is gen er-
ated u sin g a con ven tion al cortex screw in serted eccen trically
at th e proxim al en d of th e plate. Fixation is com pleted w ith a
LHS in serted close to th e fractu re.

In traoperative view of th e u ln a sh ow in g th e plate

Fig 7.2 .2 -4
in position xed to th e d istal fragm en t w ith two LHS, an d
th e proxim al fragm en t h eld in position w ith th e Verbru gge
clam p. Exten sive trau m atic periosteal strippin g m ain ly of th e
proxim al fragm en t is visible.

408
 7.2 .2 We d ge ra d ia l a n d u ln a r s h a ft fra ct u re —2 2 -B3

4 Re d u ct io n a n d fixa t io n —ra d iu s

Iden t ica l procedu re for redu ct ion a n d fixat ion of t h e rad ia l

sh aft as described for th e u ln a.

Fig 7.2.2-5 In traoperative view sh ow in g th e com pleted xation

u sin g a 7-h ole LCP 3.5.

5 Re h a b ilit a t io n

a b c d e f

Postoperatively n o add ition al im m obilization is n eeded, th e Fig 7.2 .2 -6 a – f

forearm is elevated. Active m obilization starts on th e secon d
day in clu d in g pron ation an d su pin ation of th e forearm an d
exion an d exten sion of th e elbow an d w rist join ts.
a – b Postoperative x-rays: AP view, lateral view. Note th e
weccen tric cortex screw s in th e prox im al com bin ation
h ole of each plate (arrow).
c– d X-rays after 19 weeks: AP view, lateral view.
e–f X-rays after 15 m on th s: AP view, lateral view.

409
 7.2 Ra d iu s a n d u ln a , s h a ft
5 Re h a b ilit a t io n (co n t )
a b
Fig 7.2 .2 -7a – d Fu n ction al resu lts after fou r years.
a – b Sh ow in g fu ll exten sion an d exion of th e elbow.
c– d Sh ow in g fu ll pron ation an d su pin ation of th e forearm .
6 Pit fa lls –
Re d u ct io n a n d xa t io n
Exten sile ex posu re w ith dam age to th e blood su pply of
th e cortex to ach ieve an atom ical redu ction .
A 7-h ole plate is th e m in im al len gth of plate for
stabilization of a tran sverse forearm fractu re.
Com m inu ted fractu res n eed a m u ch lon ger plate,
at least a 10 –12-h ole plate.
Two screw s per m ain fragm en t is th e absolu te m in im u m
for plate xation from th e m ech an ical poin t of view. Th is
is su f cien t on ly in good bon e qu ality. For safety reason s
at least th ree screw s (m on o- or bicortical) are recom -
m en ded.
410
c d
Im p la n t re m o va l
No im plan t rem oval becau se th e plates do n ot h in der or both -
er th e patien t.
7 Pe a rls +
Re d u ct io n a n d xa t io n
An atom ical redu ction of both bon es of th e forearm in th e
case of a relatively sim ple fractu re con gu ration to allow
com plete pron ation an d su pin ation of th e forearm to be
regain ed.
Use of in terfragm en tar y com pression as a tool for load
sh arin g between im plan t an d bon e, thu s, u n load in g th e
im plan t.
Th e com bin ation h ole perm its th e u se of eccen tric stan -
dard screw s to ach ieve in terfragm en tar y com pression an d
also stable plate xation to th e bon e w ith a m in im u m of
LHS.
Early u n restricted m obilization of all adjacen t join ts.
 Au t h o r Mich a e l Wa gn e r
7.2.3 Ope n radial and ulnar shaft fracture s—22-B3 and
com ple x articular distal radial fracture —23 -C
1 Ca s e d e s crip t io n
a b
In d ica t io n
Op e n u n sta b le sha ft fra ctu re s o f th e fo re -
a rm b o n e s (Gu stilo t yp e I), w ith a d d itio n a l
fra ctu re o f th e d ista l ra d iu s a n d jo in t in vo lve -
m e n t, p ro vid e th e in d ica tio n fo r su rge ry o n
th is m u ltip ly in ju re d fe m a le p a tie n t. Tre a t-
m e n t fo r sh o ck a n d sta b iliza tio n o f th e u n -
sta b le p e lvic rin g fra ctu re w ith tre a tm e n t o f
th e va gin a l in ju ry w ith su b se q u e n t in te n sive
ca re in th e in te n sive ca re u n it. Tre a tm e n t o f
th e o p e n d ia p h yse a l fra ctu re s o f th e fo re -
a rm b o n e s w a s ca rrie d o u t a s a n e m e rge n cy
p ro ce d u re o n th e rst d a y o n ce th e p a tie n t ’s
co n d itio n w a s sta b le .
Prim a ry tra u m a tic p a ra lysis o f th e ra d ia l
n e rve .
25 -yea r- old w om a n fell off h er
m otorcycle an d su ffered m u ltiple
in ju ries.
Fig 7.2.3-1a–c
a–b Open d iaph yseal fractu res of
th e rad iu s an d u ln a. AP view
an d lateral view.
c Open pelvic r in g fractu re
(61-C) w ith avu lsion of th e
sym ph ysis an d lesion of th e
sacroiliac join t in clu din g in -
ju ry to th e vagin a. Not de-
scribed in th is case.
c
Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP 3 .5 , n a rro w, 10 h o le s
• LCP 3 .5 , n a rro w, 9 h o le s
• LCP T-p la te 3 .5 , 5 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 1.8 m m K-w ire s
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts ca n
va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 7.2 .3 -2 Su p in e p o sitio n , a rm ta b le , b lo o d
to u rn iq u e t, a rm in a b d u ctio n .
411
 7.2 Ra d iu s a n d u ln a , s h a ft

2 Su rgica l a p p ro a ch

a
a b

c d

Fig 7.2 .3 -3 a – e
a – c Treatm en t of th e d iaph yseal fractu re of th e rad iu s. Palm ar approach accord in g to Hen ry.
d Treatm en t of th e d iaph yseal fractu re of th e u ln a. Posterior approach to th e u ln a sh aft.
e Treatm en t of th e d istal rad iu s fractu re. Palm ar approach to th e d istal rad iu s.

412
 7.2 .3 Op e n ra d ia l a n d u ln a r s h a ft fra ct u re s —2 2 -B3 a n d co m p le x a r t icu la r d is t a l ra d ia l fra ct u re —2 3 -C

3 Re d u ct io n a n d fixa t io n

Treatm en t of th e rad ial sh aft fractu re.

Open redu ction . Th e wedge fragm en t still attach ed to th e peri-
osteu m is realign ed. Th e two m ain fragm en ts were th en com -
pressed an d stabilized by application of a 10-h ole LCP 3.5 as a
com pression plate. Eccen tr ically position ed cortex screw s are
in serted in to both th e prox im al an d d istal m ain fragm en ts.
De n itive stabilization of th e plate is ach ieved by in sertion of
two m on ocortical LHS each in th e prox im al an d d istal m ain
fragm en ts.
Treatm en t of th e d iaph yseal fractu re of th e u ln a.
Open redu ction . Stabilization w ith a 9-h ole LCP. Utilization
of th e com pression m eth od by eccen tric position in g of th e
cortex screw s an d add ition al xation of th e plate w ith m on o-
cortical LHS.
Treatm en t of th e d istal rad ial fractu re.
Open redu ction of th e distal u ln ar fractu re an d stabilization
by application of a LCP 3.5. In direct redu ction an d tem porar y
xation w ith K-w ires. To com plete th e procedu re, th e plate is
precon tou red an d th en de n itively stabilized by in sertion of
LHS d istally an d th en prox im ally.
a b Wou n d closu re, redon d rain age.
Fig 7.2 .3 -4 a – b
a AP view.
b Lateral view.

4 Re h a b ilit a t io n

Im m obilization for 3 weeks followed by ph ysioth erapy. Spon -

tan eou s rem ission of th e rad ial n er ve paralysis after 6 weeks.

Fig 7.2.3 -5a–b Postoperative x-rays of the distal radial fractu re.
a AP view.
b Lateral x-ray sh ow in g avu lsion of a posterior bon e frag-
m en t th at was realign ed by posterior open redu ction in a
revision operation 1 week later an d secu red by in sertion of
a 3.0 m m can n u lated screw.

a b

413
 7.2 Ra d iu s a n d u ln a , s h a ft

4 Re h a b ilit a t io n (co n t )

Fig 7.2 .3 -6 a – d
a X-ray after 4 m on th s, AP view.
b X-ray after 4 m on th s, lateral view.
c X-ray after 18 m on th s, AP view.
d X-ray after 18 m on th s, lateral view.

a b c d

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
It is especially im portan t at th e prox im al sh aft to be
carefu l n ot to dam age th e rad ial n erve.

Re d u ct io n a n d xa t io n
Fig 7.2 .3 -7 Redu ction m an eu vers sh ou ld be as in d irect
an d tissu e-frien d ly as possible even in open redu ction
an d be perform ed exclu sively w ith th e poin ted redu ction
forceps an d n ot w ith clam ps w ith serrated jaw s.
Re d u ct io n a n d xa t io n
Th an ks to its com bin ation h oles, th e LCP can be applied
as a com pression plate by th e in sertion of eccen trically
placed cortex screw s. Th e add ition al xation of th e plate
w ith LHS provides greater stability an d en h an ces th e
follow in g tech n ical an d biological ben e ts:
• Precise preben d in g of th e plate on to th e bon e su rface
is n ot n ecessar y, as th e plate is secu red as a n on con tact
plate.
• No prim ar y loss of redu ction .
• M in im al periostea l circu lator y dam age.
• Redu ced risk of refractu re on poten tial im plan t rem oval.

414
 Au t h o rs Mich a e l J Ga rd n e r, De a n L Lo rich Da vid L He lfe t

7.2.4 Com ple x radial and ulnar shaft fracture —22-C3

1 Ca s e d e s crip t io n

58-year-old m ale pedestrian was stru ck by a car an d k n ocked in to a brick

wall. He was brou gh t to th e em ergen cy departm en t w ith eviden t left
forearm pain an d deform ity.
Th ere was n o sk in lesion or sign s of com partm en t syn drom e.

Fig 7.2 .4 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

Displace d bo th -bone s fore arm Eq u ip m e n t

fracture s are inhe re ntly un stable ,
and re duction and inte rnal xation
is ne ce ssary to re store acce ptable
function . Nonope rative tre atm e n t
has le d to unive rsally poor out-
com e s in the se fracture s.
• LCP 3 .5 , 12 h o le s
• LCP 3 .5 , 16 h o le s
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: n o n e

Fig 7.2 .4 -2 Po sitio n th e p a tie n t su p in e o n th e ta b le , w ith

th e e xtre m it y e xte n d e d a n d su p p o rte d o n a h a n d ta b le .
A to u rn iq u e t is p la ce d o n th e p ro xim a l a rm . Th e e xtre m it y
is p re p p e d a n d d ra p e d fre e . Ge n e ra l a n e sth e sia is p re fe rre d
so sign s o f co m p a rtm e n t s yn d ro m e p o sto p e ra tive ly a re
n o t a m b igu o u s .

415
 7.2 Ra d iu s a n d u ln a , s h a ft

2 Su rgica l a p p ro a ch

a b

Fig 7.2 .4 -3 a – b
a Use Hen r y’s palm ar approach for th e m idsh aft rad ial frac-
tu re. Make a lon gitudin al incision directly over the fractu re,
an d exten d prox im ally or d istally as n eeded.
Proxim ally, n d th e in terval between th e biceps an d th e
brach ioradialis mu scles ju st distal to th e elbow. Sligh tly dis-
tally, th e dissection plan e lies between th e brach ioradialis
and the pron ator teres mu scles. In th e m idsh aft, th e in ter-
n ervou s plan e is between the brach ioradialis an d the exor
carpi radialis mu scles. Th e radial artery ru n s w ith th e mu s-
cle belly of the exor carpi radialis mu scle on the m edial
side of th e wou n d. Fin d th e su per cial radial sen sory nerve
u n der the brach ioradialis mu scles laterally an d protect it.
If proxim al ex posu re is n eeded, re ect th e in sertion of th e
su pin ator m u scles su bperiosteally to protect th e posterior
in terosseou s n er ve, an d take care n ot to retract too vigorou s-
ly. For deep ex posu re in th e m idsh aft, re ect th e pron ator
an d exor digitoru m su per cialis mu scles su bperiosteally.
Distally, re ect th e exor pollicis lon gu s an d th e pron ator
qu adratu s m u scle su bperiosteally to ex pose th e volar su r-
face of th e radiu s.
b To expose th e u ln a, pron ate th e forearm an d m ake an in -
cision d irectly over th e su bcu tan eou s border of th e u ln a.
Th e in tern ervou s plan e lies between th e exor car pi u ln a-
ris an d exten sor car pi u ln aris mu scles.

3 Re d u ct io n a n d fixa t io n

Fig 7.2 .4 -4 Wh en com m in u tion is presen t an d a bridgin g tech n iqu e w ill be u sed, do n ot ex-
pose an d an atom ically redu ce each fractu re fragm en t. Rath er, attem pt to restore len gth , ro-
tation , an d align m en t of th e bon e. Add ress th e m ore d if cu lt fractu re rst, an d stabilize it
provision ally w ith a LCP 3.5 an d redu ction forceps. Wh en on e bon e is adequ ately redu ced,
provision ally stabilize th e oth er bon e. Ch oose lon g plates of at least 10 –12 h oles. Th e m ost
im portan t aspect of redu ction is to m ain tain th e an atom ical rad ial bow.
Wh en fragm en ts are overlapped an d sh orten ed, a tem porary screw can be placed 1–1.5 cm from
th e en d of th e plate, an d a lam in ar spreader is u sed to d istract th e fractu re ou t to len gth .
With both bon es provision ally redu ced, in sert 3.5 m m lock in g h ead screw s in m on ocortical or
bicortical fash ion . Space ou t th e screw s an d leave at least two h oles open over th e com m inu -
tion .
Do n ot close th e fascia of th e forearm . Close on ly th e su bcu tan eou s tissu e an d sk in over th e
su ction d rain s.

416
 7.2 .4 Co m p le x ra d ia l a n d u ln a r s h a ft fra ct u re —2 2 -C3

4 Re h a b ilit a t io n

Wh en stable xation h as been ach ieved in a reliable patien t,

plaster im m obilization is n ot n ecessary.
Apply a loose d ressin g, elevate th e extrem ity for 24 h ou rs,
an d rem ove th e d rain .
Begin early ph ysica l th erapy, in clu d in g elbow, forear m , an d
w r ist active exercises.

Fixation im m ed iately postoperatively. Becau se

Fig 7.2 .4 -5 a – b
th ese fractu res are con sidered articu lar, an atom ical restora-
tion of len gth an d align m en t is requ ired.
5 m on th s postoperatively th e patien t h ad good forearm rota-
tion an d stable in tern al xation . Sign i can t callu s h as in cor-
porated th e radial com m inu tion .
a AP view.
b Lateral view.

a b

Im p la n t re m o va l
If the h ardware becomes sym ptom atic, it m ay be removed after
th e fractu re h as h ealed. Con troversy ex ists as to th e m in i-
m u m tim e requ ired postoperatively, bu t we prefer at least 18
m on th s.
Post rem ova l, t h e ex t rem it y m u st be protected in a splin t.
Activity sh ou ld be lim ited for 3 m on th s.

417
 7.2 Ra d iu s a n d u ln a , s h a ft
5 Pit fa lls –
Ap p ro a ch
Many n eu rovascu lar stru ctu res are at risk du rin g th ese
two approach es. Du rin g th e palm ar approach to th e
rad iu s, th e rad ial arter y ru n s on th e su rface of th e su pi-
n ator an d pron ator teres m u scles. Th e su per cial rad ial
n er ve ru n s u n der th e brach iorad ialis m u scles laterally, th e
posterior in terosseou s n er ve ru n s th rou gh th e origin of
su pin ator m u scle, an d th e m edian n erve em erges from th e
brou s arch of th e exor digitoru m su per cialis m u scle.
Wh en ex posin g th e u ln a posteriosly, th e u ln ar n erve is at
risk du rin g deep m edial exposu re of th e u ln a.
Re d u ct io n a n d xa t io n
Th e rad ial bow m ay easily be u n derestim ated du rin g
redu ction , an d m ay be lost after provision al stabilization
of th e radiu s w ith clam ps an d a plate.
Fixation in th e splin tin g m eth od m ay be com prom ised
by u sin g plates th at are too sh ort.
Re h a b ilit a t io n
Th e m ost com m on setback follow in g open redu ction an d
in tern al xation is loss of su pin ation an d pron ation .
Com partm en t syn drom e m ay occu r after forearm trau m a.
418
6 Pe a rls +
Ap p ro a ch
Du rin g th e palm ar approach , carefu l dissection an d su b-
periosteal m u scle retraction w ill m in im ize n eu rovascu lar
in ju r y.
To preven t dam age to th e u ln ar n er ve th rou gh th e poste-
rior in cision , raise th e m u scle m asses su bperiosteally. Th e
n erve is on ly at risk if d issection strays in to th e m u scle
bers. Wh en proxim al exposu re is desired, th e n erve can
be iden ti ed before it passes th rou gh th e two h eads of th e
exor car pi u ln aris m u scle.
Re d u ct io n a n d xa t io n
Pay close atten tion to th e restoration of th e radial bow,
an d th at th e fractu re en ds do n ot slide m ed ially or lateral-
ly or rotate u n der th e plate du rin g forearm m an ipu lation ,
cau sin g loss of redu ction or straigh ten in g of th e bow.
Re h a b ilit a t io n
To optim ize forearm m otion , take care to restore th e ra-
d ial bow du rin g th e procedu re, an d in itiate early su per-
vised active exercises.
Postoperative com partm en t syn drom e can be avoided by
leavin g th e fascia open , u sin g deep drain s, an d elevatin g
th e extrem ity to preven t fu r th er swellin g.
7.3 Radius and ulna, distal

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

7.3 .1 Extraa rticu lar d o rsa lly d isp la ce d d ista l rad ia l 2 3 -A3 lo cke d splin ting LDRP 2 .4 bu ttre ss pla te / 42 5
fractu re (Co lle s’ fra ctu re) an gle d b lad e p la te

7.3 .2 Extraarticu lar m u ltifragm e n tary d istal radial fractu re 2 3 -A3 lo cke d splin tin g LDRP 2 .4 bu ttre ss pla te / 431
an gle d b lad e p la te

7.3 .3 Partial articu lar d istal rad ial fractu re 2 3 -B3 lo cke d sp lin tin g LDRP 2 .4; b u ttre ss p la te 437
re co n stru ctio n
p la te 2 .4
7.3 .4 Com ple x articu lar sim p le , m e tap hyse al sim p le 2 3 -C1 co m pre ssio n LDRP 2 .4; b u ttre ss pla te / 4 41
d istal rad ial fractu re an d locke d re co n stru ctio n an gle d b lad e p la te
sp lin tin g p la te 2 .4

7.3 .5 Co m p le x a rticu la r m u ltifragm e n ta ry d ista l rad ial 2 3 -C3 lo cke d splin tin g LDRP 2 .4 bu ttre ss pla te / 4 45
fractu re; do rsal d o ub le p la ting angle d blade pla te

7.3 .6 Com ple x articu lar m u ltifragm e n tary d istal rad ial 2 3 -C3 lo cke d splin tin g LDRP 2 .4 b u ttre ss pla te / 4 49
fractu re angle d blade pla te

419
 7 Ra d iu s a n d u ln a

7 Radius and ulna

7.3 Ra d iu s a n d u ln a , d is t a l 4 21
7.3 .1 Ext ra a r t icu la r d o rs a lly d is p la ce d d is t a l ra d ia l
h e a d fra ct u re (Co lle s ’ fra ct u re )—2 3 -A3 425
7.3 .2 Ext ra a r t icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l
fra ct u re —2 3 -A3 4 31
7.3 .3 Pa r t ia l a r t icu la r d is t a l ra d ia l fra ct u re —2 3 -B3 4 37
7.3 .4 Co m p le x a r t icu la r s im p le , m e t a p h ys e a l s im p le d is t a l
ra d ia l fra ct u re —2 3 - C1 4 41
7.3 .5 Co m p le x a r t icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l
fra ct u re —2 3 - C3; d o rs a l d o u b le p la t in g 445
7.3 .6 Co m p le x a r t icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l
fra ct u re —2 3 - C3 449

420
 Au t h o r Da n ie l Rik li

7.3 Radius and ulna, distal

1 In cid e n ce

Th e in d ication for in tern al xation of d istal rad ial fractu res,

th e su rgical approach (palm ar, dorsal, com bin ed palm ar an d
dorsal), an d th e ch oice of im plan ts m u st be based on a th or-
ou gh an alysis of th e in ju r y m ech an ism (patien t h istory), th e a b c
path om ech an ics of th e fractu re (eg, Fern an dez classi cation ),
Fig 23-A extraarticu lar fractu re.
7.3 -1a – c
th e fractu re pattern (con ven tion al x-ray, x-ray in traction , CT
a 23-A1 u ln a, rad iu s in tact
scan), th e qu ality of th e bon e, an d th e dem an ds of th e in di-
b 23-A2 radiu s, sim ple an d im pacted
vidu al patien t.
c 23-A3 rad iu s, mu ltifragm en tary
Special atten tion m u st be paid to th e soft-tissu e con d ition
(open fractu re, swellin g, com partm en t syn drom e, n erve in ju -
ries) an d associated lesion s at th e level of th e proxim al car pal
row (osseou s or ligam en tou s) an d th e d istal rad iou ln ar join t.
An alysis of th e fractu re u n der traction (ligam en totaxis) in th e
extern al xator u sin g con ven tion al x-ray an d CT facilitates
u n derstan d in g of th e path ology an d plan n in g of th e de n i-
tive operative strategy. Occu lt relevan t ligam en t tears at th e a b c
level of th e prox im al car pal row m ay be dem on strated u n der
Fig 23-B partial articu lar fractu re.
7.3 -2 a – c
traction (d isru ption of Gilu la’s lin es).
a 23-B1 rad iu s, sagittal
b 23-B2 radiu s, fron tal, dorsal rim
Th e th ree colu m n m odel of th e d istal rad iu s an d u ln a is of
c 23-B3 rad iu s, fron tal, volar rim
great h elp in plan n in g in tern al xation . All th ree colu m n s
sh ou ld be stable (or stabilized by in tern al xation) wh en early
fu n ction com m en ces.

2 Cla s s ifica t io n

In add ition to th e Mü ller AO Classi cation , speci c aspects a b c

regard in g an atom ical ch aracteristics an d trau m a m ech an ics
Fig 23-C com plete articu lar fractu re of rad iu s.
7.3 -3 a – c
of th e join t com plexity are con sidered u sin g th e Fern an dez
a 23-C1 articu lar sim ple, m etaph yseal sim ple
classi cation .
b 23-C2 articu lar sim ple, m etaph yseal m u ltifragm en tar y
c 23-C3 articu lar m u ltifragm en tar y
Ben din g type fractu res (Fern an dez type I) w ith or w ith ou t
articu lar in volvem en t respon d to ligam en totaxis an d are am e-
n able to variou s treatm en t option s (closed redu ction an d cast/

421
 7 Ra d iu s a n d u ln a

pin n in g, extern al xation , palm ar lock in g plate). Sh ear frac-

tu res (Fern an dez type II) n eed a palm ar bu ttress plate. Any
im pacted articu lar fragm en ts mu st be addressed speci cally.
Axial com pression fractu res (Fern an dez type III) u su ally n eed
for m a l revision a n d recon str u ct ion of t h e rad ioca r pa l join t
su rface over a dorsal arth rotom y. Th e in term ed iate colu m n a b
is th e key to th e rad iocar pal join t sin ce th e m ain path ology
is at th e level of th e lu n ate facette (dorsou ln ar/ palm aru ln ar
fragm en t). Avu lsion in ju ries (Fern an dez type IV) are frac-
tu re dislocation s. Sm all osseou s rim fragm en ts an d th e rad ial
styloid fractu re correspon d to osseou s avu lsion of th e rad io-
car pal ligam en ts. Th ese fragm en ts an d an y pu rely ligam en -
c d
tou s d isru ption m u st be addressed operatively. Early m otion
is n ot always feasible an d im m obilization of 6 –8 weeks m ay
be in d icated to allow for ligam en tou s h ealin g. Fractu res w ith
com bin ation s of th e above an d / or d iaph yseal in volvem en t
(Fern an dez type V) sh ou ld be treated accord in g to th e speci c
path ology. Relevan t associated car pal ligam en t tears (Geissler
type III an d IV) sh ou ld be addressed at th e sam e tim e wh en
treatin g th e distal radial fractu re.
e

3 Tre a t m e n t m e t h o d s Fig 7.3 -4 a – e Fern an dez classi cation .

a Type I ben d in g fractu re of th e m etaph ysis
b Type II sh arin g fractu re of th e join t su rface
In sim ple fractu res, eg, extraarticu lar, dorsally d isplaced Col-
c Type III com pression fractu re of th e join t su rface
les‘ type fractu re, t h e treat m en t sh ou ld be stra igh tfor w ard
d Type IV avu lsion fractu res, radiocar pal fractu re,
w ith a rst an d de n itive m easu re to preclu de repetitive m a-
d islocation
n ipu lation s. In m ore ”com plex” cases, eg, h igh -en ergy in ju ries,
e Type V com bin ed fractu res (I, II, III, IV);
th e application of a join t bridgin g extern al xator as a rst
h igh velocity in ju ry
m easu re in th e em ergen cy situ ation m ay be advisable. Th is
can be perform ed safely even by th e less experien ced su rgeon
in th e em ergen cy departm en t. Th e soft-tissu e in ju ry can be
treated.

Depen d in g on fractu re pattern , fractu re xation is to be per-

for m ed by u se of pa lm a r, dorsa l or com bin ed dorsopa lm a r
platin g.

42 2
 7.3 Ra d iu s a n d u ln a , d is t a l

Lock in g palm ar plates can be u sed in two ”m odes”: eith er as
a con ven tion al ”bu ttress plate” for Sm ith an d reverse Barton
type fractu res or as an ”an gled blade plate” for dorsally d is-
placed extra- an d articu lar fractu res. In th e latter m ode, th e
plate fu n ction s as an in tern al xator an d perfect adaptation of
th e plate to th e bon e is n ot m an dator y. Today, m any su rgeon s
treat dorsally d isplaced ben d in g type fractu res (Colles‘) w ith
palm ar lock in g plates. A bon e graft is n ot n ecessary.
level of the lu n ate facette. These fragm en ts are reduced u nder
Vid e o 7.3 -1
d irect con trol u sin g a lim ited dorsal arth rotom y an d th en
xed w ith a con tou red plate an d lock in g h ead screw s to su p-
port th e rad iocar pal join t su rface.
4 Im p la n t o ve r vie w

Ou r ration ale for dorsal platin g follow s th e th ree colu m n con -

a
cept. Two plates are u sed to x th e rad ial an d th e in term ed iate
colu m n separately. In d ication s for dorsal dou ble platin g are: a
c
d isplaced dorsou ln ar fragm en t, im pacted articu lar fragm en ts
b
th at n eed form al revision , su spected or apparen t associated le-
sion s of th e proxim al carpal row and early corrective osteotomy
of dorsally m alu n ited fractu res. Th e in term ediate colu m n
is approach ed th rou gh th e th ird exten sor com partm en t an d a d
lim ited dorsal arth rotom y is always perform ed. Th e radial col-
u m n is approach ed by su bcu tan eou s preparation between th e
Fig 7.3 -5 a – dLCP d istal rad iu s plates 2.4, dorsal.
sk in ap an d th e retin acu lu m , th e secon d an d fou rth com -
a LCP d istal rad iu s plate 2.4, straigh t
partm en t are left u n tou ch ed. Th e rst com partm en t is open ed
b LCP-L d istal rad iu s plate 2.4, righ t-an gled
an d th e rad ial plate is slipped u n dern eath th e ten don s to bu t-
c LCP-L d istal rad iu s plate 2.4, obliqu e-an gled
tress th e rad ial styloid.
d LCP-T d istal rad iu s plate 2.4
Com bin ed dorsal an d palm ar plates m ay be n ecessar y for m u l-
tifragm en tary articu lar fractu res. A h yperexten ded palm ar
articu lar fragm en t n eeds a palm ar plate sin ce th is fragm en t
can n ot be con trolled from th e dorsal side. Hyperexten ded
m ean s: dorsal rotation of th e fragm en t in th e sagittal plan e
w ith n o con tact to th e sh aft an d w ith com m in u tion or extru - a b
sion of th e fragm en t in to th e palm ar soft tissu e. If th is palm ar
fragm en t is large an d exten ds alon g th e en tire palm ar rim Fig 7.3 -6 a – b
in clu d in g parts of th e rad ial styloid, a palm ar T-plate can be a LCP d istal rad iu s plates 2.4, volar
u sed. If th e fragm en t is sm all, ie, a palm aru ln ar fragm en t, an b LCP d istal rad iu s plate 2.4, stan dard
L-plate is u sed to x th e fragm en t speci cally. In th ese cases
th e rad ial colu m n is bu ttressed separately w ith an S-plate
from th e palm ar approach . An add ition al lim ited dorsal ap-
proach to th e in term ediate colu m n is n eeded wh en th e above
m en tion ed situ ation is com bin ed w ith a displaced dorsou ln ar
fragm en t an d/or cen trally im pacted articu lar fragm en ts at th e

423
 7 Ra d iu s a n d u ln a

5 Su gge s t io n s fo r fu r t h e r re a d in g

A xe lro d TS, McMu rt ry RY (1990) Open redu ction an d in tern al

xation of com m inu ted, in traarticu lar fractu res of th e distal radiu s.
J Hand Surg Am; 15(1):1–11.
Fe rn an de z D L (1993) Fractu res of th e distal radiu s: operative
treatm en t. In : Heckm an n J D, editor. In stru ction al Cou rse Lectu res:
Amer Acad Orthop Surg; 42:73 –88.
Fe rn an d e z D L, Ju p it e r J B (1995) Fractu res of th e Distal Radiu s.
Berlin Heidelberg New York: Sprin ger-Verlag.
Fe rn an d e z D L, Ge issle r WB, Lam e y D M (1996) Wrist in stability
w ith or follow in g fractu res of th e distal radiu s. In : Bü ch ler U, editor.
Wrist In stability. Lon don : Martin Du n itz Ltd: 181–192.
Fe rn an d e z D L, Ge issle r WB (1991) Treatm en t of displaced articu lar
fractu res of th e rad iu s. J Hand Surg Am; 16 (3):375-384.
Ge issle r WB, Fe rn an de z D L, Lam e y D M (1996) Distal radiou ln ar
join t in ju ries associated w ith fractu res of th e distal radiu s. Clin Orthop;
(327):135 –146.
Ju p it e r J B, Fe rn an d e z D L, To h CL, e t al (1996) Operative
treatm en t of volar in tra- articu lar fractu res of th e distal en d of th e
rad iu s. J Bone Joint Surg Am; 78(12):1817–1828.
Ju p it e r J B, R in g D C (2005) AO Manu al of Fractu re Man agem en t
Han d an Wrist. Stu ttgart an d New York. Th iem e-Verlag.
R ick li DA , Re gazzo n i P (1996) Fractu res of th e distal en d of th e
rad iu s treated by in tern al xation an d early fu n ction . A prelim in ary
report of 20 cases. J Bone Joint Surg Br; 78(4):588 –592.

424
 Au t h o r Da n ie l Rik li
7.3.1 Extraarticular dorsally displace d distal radial fracture
(Colle s’ fracture)—23 -A3
1 Ca s e d e s crip t io n
a b
Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP d ista l ra d iu s p la te 2 .4 ,
3 h o le s
• Lo ckin g h e a d scre w s (LHS)
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to
a n a to m y.)
32-year-old m an . Fall from bicycle. Extraarticu lar fractu re of th e d is-
tal rad iu s w ith m arked dorsal d isplacem en t of th e d istal fragm en t.
Fractu re of th e tip of th e u ln ar styloid.
Fig 7.3 .1-1a – b In ju r y x-rays.
a AP view.
b Lateral view.
In d ica t io n
In d ica tio n fo r re d u ctio n is e vid e n t . Re s to ra tio n o f a n gle s a n d le n g th is a
p re re q u isite fo r fu n ctio n a l re co ve ry. Sta b le in te rn a l xa tio n a llo w s fo r e a rly
m o tio n a n d u se o f th e e xtre m it y fo r u n lo a d e d a ctivitie s.
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Po sitio n th e p a tie n t su p in e o n th e
ta b le , w ith th e e xtre m it y e xte n d e d
a n d su p p o rte d o n a h a n d ta b le .
No n ste rile p n e u m a tic to u rn iq u e t is
p la ce d o n th e p ro xim a l a rm .
Pro p h yla ctic a n tib io tics o p tio n a l.
Fig 7.3 .1-2 Th e p a tie n t is p o sitio n e d su p in e o n
th e ta b le , w ith th e lim b e xte n d e d a n d su p p o rte d
a n a h a n d ta b le .
425
 7.3 Ra d iu s a n d u ln a , d is t a l

2 Su rgica l a p p ro a ch

a b c

Fig 7.3 .1-3 a – cHen r y’s m od i ed palm ar approach to th e d istal rad iu s.

Straigh t in cision between th e rad ial arter y an d th e ten don of th e exor
car pi rad ialis mu scle.

a b

Fig 7.3 .1-4 a – bDissection between th e rad ial artery an d th e exor car pi rad ialis ten -
don . Th e forearm fascia is d ivided an d th e pron ator qu ad ratu s m u scle is detach ed from
th e rad ial bon y in sertion . Th e fractu re is visu alized.

426
 7.3 .1 Ext ra a rt icu la r d o rs a lly d is p la ce d d is t a l ra d ia l fra ct u re (Co lle s ’ fra ct u re )—2 3 -A3
3 Re d u ct io n
a b
Fig 7.3 .1-5 a – e
a Th e fractu re is redu ced m an u ally.
b Sin ce th e palm ar cortex is of su f cien tly good qu ality even
in very osteoporotic bon e, rad ial len gth
c– d an d axial align m en t can be restored an atom ically.
e Manu al reduction is u su ally su f cient to restore palm ar tilt.
a b
e f g acts as an an gled blade plate.
c d e
Th e d istal fragm en t is pu sh ed towards th e plate by brin gin g
th e h an d in to ex ion . Redu ction is secu red by in sertin g a
rst distal lock in g h ead screw in th is position .
c d
Fig 7.3 .1-6 a – gTo correct th e residu al dorsal d isplacem en t an d
restore palm ar tilt, th e d istal fragm en t can be redu ced in d i-
rectly. Th e lock in g plate is tted/equ ipped w ith th e th readed
drill sleeve an d placed in position , wh ere th e d rill sleeve an d
th e rad iocar pal join t lin e cover a dorsally open an gle of 10 º.
A K-w ire, an LHS, or both are u sed to x th e plate in th is po-
sition . Note th at th e plate is n ow away from th e rad ial sh aft
proxim ally. Th e sh aft of th e plate is redu ced to th e sh aft of th e
rad iu s m an u ally an d th e d istal fragm en t is th ereby brou gh t
in to th e desired position of sligh t palm ar ex ion . Th e plate
As an option , K-w ires an d Weber clam ps can be u sed to tem -
porarily h old th e redu ction .
427
 7.3 Ra d iu s a n d u ln a , d is t a l

4 Fixa t io n

a b c d e

f g h i

Fig 7.3 .1-7a – l

a – c After m anu al redu ction , th e plate is placed in th e correct position an d xed w ith a rst
cortex screw in th e elon gated plate h ole in th e rad ial sh aft. Redu ction an d plate position
are ch ecked by u oroscopy.
d–f As th e correct plate position is determ in ed an d redu ction is com pleted an d secu red u sin g
a K-w ire (option al), th e plate is de n itively xed w ith a secon d cortex or LHS in th e m ost
proxim al h ole of th e plate.
g– j In tern al xation is com pleted by in sertin g th e LHS in the distal part of the plate u sin g the
th readed drill gu ide. Care is to be taken when in sertin g the screws in order to obtain perfect
j pu rch ase of th e screw h ead in th e th reads of th e plate.

428
 7.3 .1 Ext ra a rt icu la r d o rs a lly d is p la ce d d is t a l ra d ia l fra ct u re (Co lle s ’ fra ct u re )—2 3 -A3

4 Fixa t io n (co n t )

Fig 7.3 .1-7a – l (co n t)

k– l In osteoporotic bon e in sertion of ve d istal lock in g h ead
screw s is recom m en ded. After docu m en tation of th e os-
teosyn th esis by x-ray, th e wou n d is closed an d d rain ed. A
palm ar or dorsal plaster splin t is applied u n til th e wou n d
is h ealed.

k l

5 Re h a b ilit a t io n

Reh abilitation con sists of im m ed iate

early m otion ou t of th e plaster splin t
u n der th e in stru ction of a ph ysioth era-
pist. Th e plaster splin t is later replaced
by a rem ovable velcro splin t. Th e h an d
is u sed for u n loaded daily activities su ch
as eatin g, person al h ygien e, tyin g a tie,
h old in g paper. After six weeks fractu re
h ealin g is docu m en ted by x-ray an d th e
patien t can u su ally start loaded activi-
ties.

a b c d Fig 7.3 .1-8 a – h

a Postoperative x-ray after
1 week, AP view.
b Postoperative x-ray after
1 week, lateral view.
c Postoperative x-ray after
12 weeks, AP view.
d Postoperative x-ray after
12 weeks, lateral view.
e–h Fu n ction al resu lts after
e f g h 12 weeks.

429
 7.3 Ra d iu s a n d u ln a , d is t a l

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Fig 7.3 .1-9 In som e cases th e rad ial “ear” of th e T-arm of
th e plate sh ou ld be ben t back to avoid pain fu l in terferen ce
w ith th e sk in .

Re d u ct io n a n d xa t io n
Correct position in g of th e plate m u st be ch ecked by
u oroscopy to be su re th at th e rad iocar pal join t is n ot
pen etrated by th e distal LHS.
Th e LHS m u st be d irected carefu lly in th e correct d irec-
tion in order to h ave perfect pu rch ase of th e screw s h eads
in th e plate h ole. Th e screw s m u st n ot be overtigh ten ed.
In very old people w ith osteoporotic bon e an d m en tal
alteration th e osteosyn th esis sh ou ld be protected by a
closed plaster cast.
Re d u ct io n a n d xa t io n
Fig 7.3 .1-10 a – b
Bon e graftin g is n ot n ecessary.
Th e tech n iqu e is applicable also in osteoporotic bon e.
A dorsally d isplaced Colles’ fractu re w ith sim ple, n on d is-
placed exten sion of th e fractu re in to th e rad iocar pal join t
can be treated in th e sam e way. Th ese in ju ries are u su -
ally cau sed by low en ergy ben d in g forces an d respon d to
m anu al ligam en totaxis for redu ction .

a b

430
 Au t h o r Ch ris t ia n Ryf

7.3.2 Extraarticular m ultifragm e ntary distal radial

fracture —23 -A3
1 Ca s e d e s crip t io n

a b c d

60-year-old wom an fell w h ile h ik in g an d su ffered a dorsally

d islocated d istal rad ial extraarticu lar fractu re.

Fig 7.3 .2 -1a – d

a In ju r y x-ray, AP view.
b In ju r y x-ray, lateral view.
c Fractu re treated w ith cast, AP view.
d Fractu re treated w ith cast, lateral view.

In d ica t io n

In itia lly, th e fra ctu re wa s re d u ce d clo se d a n d tre a te d w ith a ca st. In th e fu rth e r

co u rse th e fra ctu re d islo ca te d , p ro b a b ly d u e to th e m u ltifra gm e n ta ry zo n e d o r-
sa lly. Th is is a cle a r in d ica tio n fo r sta b iliza tio n a n d p la te o ste o s yn th e sis.
Th e p a lm a r a p p ro a ch w a s p re fe rre d d u e to le ss critica l a n a to m ica l stru ctu re s.
Th e a n gu la r sta b le p la te -scre w co m b in a tio n o ffe rs a ve ry go o d xa tio n , w h ich ca n
e ith e r b e u se d d o rsa l o r p a lm a r.

431
 7.3 Ra d iu s a n d u ln a , d is t a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP d ista l ra d iu s p la te 2 .4 , 4 h o le s
• Lo ckin g h e a d scre w s (LHS)
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g a b
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 7.3 .2 -2 a – d Pa tie n t in su p in e p o sitio n , h a n d o n

h a n d ta b le . To u rn iq u e t. Exte n sio n o f th e fo re a rm w ith
n ge r tra ctio n .
a Ha n d o n h a n d ta b le .
b – c Fin ge r tra ctio n .
d Po sitio n in g o f im a ge in te n si e r. c d

2 Su rgica l a p p ro a ch

a bb c

Fig 7.3 .2 -3 a – f
a – b Palm ar approach : u ln ar side of th e palm aris lon gu s ten don . Protection of th e c Retraction of th e sk in an d explorati-
m edian n er ve an d th e rad ial artery. on of th e palm aris lon gu s ten don .

432
 7.3 .2 Ext ra a rt icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l fra ct u re —2 3 -A3

2 Su rgica l a p p ro a ch (co n t )

d e f

Fig 7.3 .2 -3 a – f (co n t)

d In spection of th e m ed ian n er ve an d e In cision of th e pron ator qu adratu s f Ex posu re of th e fractu re zon e.
protection of th e palm ar bran ch es. m u scle.
Th e m ed ian n erve w ill be rad ially
retracted.

3 Re d u ct io n

Fig 7.3 .2 -4 Redu ction of th e fractu re

w ith sh ar p h ook an d per iosteal elevator.

433
 7.3 Ra d iu s a n d u ln a , d is t a l

4 Fixa t io n

a b c
Fig 7.3 .2 -5 a – p
a Position in g of th e 4-h ole LCP T-plate b–c Con tou rin g of th e T-part of th e plate.
2.4 in relation to th e articu lar lin e
an d th e fractu re zon e.

d e f

d–f Th e xation starts w ith a cortex screw th rou gh th e elon gated plate h ole.
Pred rillin g th e h ole an d m easu rin g th e len gth w ith th e depth gau ge.

g h i j

g Fixin g the plate w ith a convention al h–j Th e de n itive plate position is con trolled w ith th e im age in ten si er. In sert th e
screw to the radial sh aft by tigh ten in g drill gu ide in th e m ost proxim al h ole (th readed part of th e h ole).
the screw not too much for fu rther
adju stm en ts of th e plate position .

434
 7.3 .2 Ext ra a rt icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l fra ct u re —2 3 -A3

4 Fixa t io n (co n t )

k kl m

Fig 7.3 .2 -5 a – p (co n t)

k Mea su re t h e len gt h of t h e h ole for l– m Fixation of th e articu lar block by in sertin g th ree
t h e lock in g h ead screw w it h dept h lock in g h ead screw s.
gau ge.

n o p

n Su per cially in serted o–p Sk in closu re.

Man ovac drain age

Fig 7.3 .2 -6 a – b Postoperative x-rays after 4 weeks.

a AP view.
b Lateral view.

a b

435
 7.3 Ra d iu s a n d u ln a , d is t a l

5 Re h a b ilit a t io n

Add ition al im m obilization : n on e, n o weigh t bearin g for 4 weeks.

a b a b

Fig 7.3 .2 -7a – b Postoperative x-rays after 6 m on th s. Fig 7.3 .2 -8 a – b Postoperative x-rays after 12 m on th s.
a AP view. a AP view.
b Lateral view. b Lateral view.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch
Th e rad ial arter y an d vein are presen t at th e lateral edge
of th e wou n d an d are at risk of in ju ry.
If d issection strays m ed ially, th e m ed ian n er ve m ay be
en cou n tered.
Ap p ro a ch
Part of th e approach en tails carefu lly exposin g th e radial
n erve to visu alize its cou rse, an d gen tly retractin g it
laterally.
If dissection stays w ith in th e ten don sh eath of th e exor
car pi rad ialis mu scle, th e m ed ian n erve sh ou ld n ot be in
th e operative eld.

Re d u ct io n a n d xa t io n
Un stable, dorsally-an gu lated osteoporotic fractu res m ay
n ot be adequ ately stable follow in g palm ar platin g alon e.
Th e dorsal an gu lation m ay be d if cu lt to fu lly correct by
d irect m eth ods.
Re d u ct io n a n d xa t io n
To restore th e an atom ical 11° palm ar tilt, th e LCP m ay be
u sed to aid redu ction . Place th e d istal LHS in correct po-
sition in th e epiph ysis, leavin g th e prox im al plate several
m illim eters off th e bon e. Clam p th e prox im al plate to th e
bon e to ach ieve fu rth er palm ar tilt.

Re h a b ilit a t io n Re h a b ilit a t io n
Wrist ran ge of m otion m ay be dim in ish ed follow in g distal To m ax im ize reh abilitation poten tial, place th e patien t in
rad ial fractu res, particu larly w ith in traarticu lar fractu res. a rem ovable palm ar w r ist splin t early an d begin aggres-
sive active ran ge of m otion exercises.

436
 Au t h o rs Mich a e l S Ga rd n e r, De a n L Lo rich , Da vid L He lfe t

7.3.3 Partial articular distal radial fracture —23 -B3

1 Ca s e d e s crip t io n

67-year-old wom an (dom in an t righ t h an d) slipped in a store

an d lan ded on h er dorsi exed righ t h an d. Sh e cam e to th e
em ergen cy departm en t com plain in g of pain an d deform ity.
No n eu rological sign s or sk in com prom ise were presen t.

Fig 7.3 .3 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

Th e in tra a rticu la r d isp la ce m e n t Eq u ip m e n t

a n d im p a ctio n wa rra n ts a na -
to m ica l re d u ctio n a n d xa tio n to
m in im ize th e risk o f th e d e ve lo p -
m e n t o f o ste o a rth ro sis.
In a d d itio n , th e m e ta p h yse a l
co m m in u tio n m a ke s th is fra ctu re
h igh ly u n sta b le , a n d w a rra n ts
in te rn a l sta b iliza tio n to e n su re
a n a to m ica l a lign m e n t.
• LCP d is ta l ra d iu s p la te 2 .4 , 2 h o le s
• Re co n stru ctio n p la te 2 .4 , 7 h o le s
• 3 .5 m m co rte x scre w
• Lo ckin g h e a d scre w s (LHS)
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: n o n e

Fig 7.3 .3 -2 Th e p a tie n t is p o sitio n e d su p in e o n th e ta b le ,

w ith th e lim b e xte n d e d a n d su p p o rte d o n a h a n d ta b le .
A to u rn iq u e t is p la ce d o n th e p ro xim a l a rm . Th e e xtre m it y
is p re p p e d a n d d ra p e d fre e .

437
 7.3 Ra d iu s a n d u ln a , d is t a l

2 Su rgica l a p p ro a ch

a b c

Make a lon gitu din al in cision on th e palm ar

Fig 7.3 .3 -3 a – c
forearm , 6 –8 cm lon g, from th e w rist crease prox im ally.
Dissect th rou gh th e su bcu tan eou s layer to iden tify th e ten don
sh eath of th e exor car pi radialis m u scle. In th is position th e
rad ial artery w ill be lateral an d is often visible in th e su rgical
eld. Th e m ed ian n er ve is m ed ial.
Expose th e m u scle bers of th e exor car pi radialis m u scle
an d retract th em laterally. If proxim al exten sion is n eeded,
th e exor d igitoru m su per cialis m u scle w ill n eed to be re-
tracted laterally as well.
Retraction of th ese mu scles reveals th e pron ator qu ad ratu s
m u scle. Elevate th is m u scle su bperiosteally an d re ect it m e-
d ially, ex posin g th e volar su rface of th e d istal rad iu s.
Ex pose d istally en ou gh to visu alize th e palm ar w rist capsu le,
tak in g care n ot to violate it.
In u n stable, severely m u ltifragm en tar y fractu res, th e su rgeon
m ay w ish to apply a radial styloid plate to stren gth en xation .
If th is is n ecessary, re ect several slips of th e brach iorad ialis
ten don in sertion wh ile protectin g th e rad ial artery to allow
ex posu re of th e lateral side of th e d istal rad iu s.

3 Re d u ct io n a n d fixa t io n

Fig 7.3 .3 -4 a – b
a For th e com m on dorsally-an gu lated an d sh orten ed d istal radial fractu re, th e d istal frag-
m en t n eeds to be d isim pacted, palm arly exed an d tilted u ln arly. Th is can u su ally be ac-
com plish ed th rou gh m an u al traction , ex ion an d u ln ar deviation . Assess th e accu racy of
redu ction on AP an d lateral u oroscopy.
Place th e LCP d istal rad iu s plate 2.4 on th e palm ar su rface of th e d istal fragm en t. Attach
th e th readed gu ide w ires to u se as a h an d le an d slide th e plate d istally so it abu ts on th e
palm ar w rist capsu le.
Use u oroscopy to estim ate th e ideal plate placem en t. Place a cortex screw th rou gh th e
ovoid plate h ole in to th e proxim al fragm en t, an d tigh ten it partially, grossly correctin g th e
palm ar exion deform ity.
a Slide th e plate to n e tu n e th e len gth an d redu ction , an d tigh ten th e screw in th e ovoid
h ole to press th e plate on to th e bon e. Place a secon d cortex screw proxim ally to secu re th e
plate an d th e redu ction .

438
 7.3 .3 Pa r t ia l a r t icu la r d is t a l ra d ia l fra ct u re —2 3 -B3

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 7.3 .3 -4 a – b Wh en m etaph yseal com m inu tion exists an d th e fractu re is u n stable,
(co n t)
au gm en t xation on th e rad ial colu m n by con tou rin g a 6- or 7-h ole recon stru ction plate 2.4 to
th e rad ial styloid. Release part of th e brach iorad ialis m u scle in sertion for ex posu re.
First place a cortex screw at th e apex of th e fract u re in to th e prox im al fragm en t to correct th e
rad ia l in clin ation .
Stabilize th e plate position by placin g a secon d cortex screw proxim ally.
b With th e rad ial in clin ation corrected, n e palm ar tu n e volar ex ion by w rist m an ipu lation
u n der u oroscopic gu idan ce. Place gu ide w ires th rou gh th e th readed d rill gu ides in to th e
d istal fragm en t of th e palm ar plate.
After pred rillin g th rou gh th e gu ides, place th e LHS in to th e d istal fragm en t.
Fin ally, retu rn to th e rad ial styloid plate. In sert a 2.4 m m cortex screw d istally from rad ial
b to u ln ar in between th e previou sly placed palm ar plate LHS.
Use a bon e su bstitu te to ll th e void in th e m etaph yseal bon e an d add stability if n eces-
sar y.
Release th e tou rn iqu et an d obtain m eticu lou s h em ostasis. En su re th e rad ial vascu lar bu n -
d le h as n ot been in ju red. Reapprox im ate th e pron ator qu ad ratu s m u scle over th e plate, an d
close th e in cision over a deep su ction d rain .

4 Re h a b ilit a t io n

Place th e forearm in a plaster splin t an d ace w rap an d elevate

th e extrem ity.
In itiate ph ysioth erapy im m ed iately, in clu d in g n ger an d el-
bow active an d passive ran ge of m otion .
10 –14 days postoperatively, rem ove th e splin t an d ch eck th e
wou n d. Place th e patien t in a rem ovable w rist splin t, an d
in cor porate active w rist ex ion , exten sion , su pin ation , an d
pron ation exercises in to th e th erapy regim en .

Open redu ction th rou gh a palm ar approach

Fig 7.3 .3 -5 a – b
an d in tern al xation w ith a palm ar lock in g plate an d rad ial
styloid plate was perform ed. 4 m on th s follow in g su rgery, th e
patien t h ad excellen t w rist ran ge of m otion an d fu n ction .

a b

439
 7.3 Ra d iu s a n d u ln a , d is t a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Ap p ro a ch
Part of th e approach en tails carefu lly ex posin g th e
Th e rad ial arter y an d vein are presen t at th e lateral edge
radial n erve to visu alize its cou rse, an d gen tly retractin g
of th e wou n d an d are at risk of in ju ry.
it laterally.
If d issection strays m ed ially, th e m ed ian n er ve m ay be
If dissection stays w ith in th e ten don sh eath of th e exor
en cou n tered.
car pi rad ialis mu scle, th e m ed ian n erve sh ou ld n ot be in
th e operative eld.

Re d u ct io n a n d xa t io n
Un stable, dorsally-an gu lated osteoporotic fractu res m ay
n ot be adequ ately stable follow in g palm ar platin g alon e.
Th e dorsal an gu lation m ay be d if cu lt to fu lly correct by
d irect m eth ods.
Re d u ct io n a n d xa t io n
To restore th e an atom ical 11˚ palm ar tilt, th e lock in g plate
m ay be u sed to aid redu ction . Place th e d istal lockin g h ead
screw s in correct position in th e epiph ysis, leavin g th e
proxim al plate several m illim eters off th e bon e. Clam p th e
proxim al plate to th e bon e to ach ieve fu rth er palm ar tilt.

Re h a b ilit a t io n Re h a b ilit a t io n
Wrist ran ge of m otion m ay be dim in ish ed follow in g distal To m ax im ize reh abilitation poten tial, place th e patien t
rad ial fractu res, particu larly w ith in traarticu lar fractu res. in a rem ovable palm ar w rist splin t early an d begin
aggressive active ran ge of m otion exercises.

4 40
 Au t h o r Mich a e l Wa gn e r
7.3.4 Com ple te articular sim ple , m e taphyse al sim ple distal
radial fracture —23 -C1
1 Ca s e d e s crip t io n
a b
In d ica t io n
C1-t yp e fra ctu re o f th e d ista l ra -
d iu s w ith d o rso u ln a r fra gm e n t
a n d d o rsa l tilt. Fa ilu re o f th e
p rim a ry co n se rva tive tre a tm e n t
a tte m p t w ith re d u ctio n a n d ca st
a p p lica tio n d u e to re p e a te d d o r-
sa l tiltin g o f th e d ista l fra gm e n t.
65-year-old wom an fell an d su stain ed in ju ries to th e righ t
w r ist an d th e righ t ribs.
Fig 7.3 .4 -1a – b Fractu re treated w ith cast.
a AP view.
b Lateral view.
Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP d is ta l ra d iu s p la te 2 .4 , 3 h o le s
• 2 .4 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w
• 2 .0 m m K-w ire
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 7.3 .4 -2 Th e p a tie n t is p o sitio n e d su p in e o n th e ta b le ,
w ith th e lim b e xte n d e d a n d su p p o rte d o n a h a n d ta b le .
4 41
 7.3 Ra d iu s a n d u ln a , d is t a l

2 Su rgica l a p p ro a ch

Fig 7.3 .4 -3 a – b Palm ar approach to th e distal rad iu s.

Straigh t in cision between th e radial arter y an d th e
ten don of th e exor car pi rad ialis mu scle.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 7.3 .4 -4 a – c
a Direct percu tan eou s redu ction w ith th e aid of a 2.0 m m K-w ire in th e “Kaparan dji” tech n iqu e. On e
2.0 m m K-w ire is in serted from a dorsal d irection th rou gh th e fractu re gap in to th e in tram edu llary space
of th e proxim al sh aft fragm en t. Th is redu ction tech n iqu e corrects th e dorsal tilt of th e d istal fragm en t.
b Fixation of th e plate to th e d istal fragm en t w ith a total of ve LHS. Th en de n itive redu ction w ith th e aid
of a cortex screw.
c Com pletion of osteosyn th esis w ith LHS in th e sh aft fragm en t. Also th e cortex screw (redu ction screw)
was ch an ged to a LHS.

4 42
 7.3 .4 Co m p le t e a rt icu la r s im p le , m e t a p h ys e a l s im p le d is t a l ra d ia l fra ct u re —2 3 -C1

4 Re h a b ilit a t io n

a b a b

Fig 7.3 .4 -5 a – b Postoperative x-rays after 1 day. Fig 7.3 .4 -6 a – b Postoperative x-rays after 4 weeks.
a AP view. a AP view.
b Lateral view. b Lateral view.

Postoperative im m obilization in cast u n til su tu re rem oval.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Fig 7.3 .4 -7 In som e cases th e rad ial “ear” of th e T-arm of Th e an atom ically presh aped LCP m ay be u sed to aid
th e plate sh ou ld be ben t back to avoid pain fu l in terferen ce redu ction .
w ith th e sk in .

443
 7.3 Ra d iu s a n d u ln a , d is t a l

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Correct position in g of th e plate m u st be ch ecked w ith Most of th e u n stable, dorsally-an gu lated osteoporotic frac-
u oroscopy in order n ot to pen etrate th e radiocar pal join t tu res m ay be treated by palm ar platin g w ith an
w ith th e d istal screw s. an gu lar stable screw plate device alon e.

Th e LHS m u st be d irected carefu lly in th e correct Bon e graftin g is n ot n ecessary.

d irection in order to h ave perfect pu rch ase of th e screw s
in th e plate. Th e screw s mu st n ot be overtigh ten ed. Th e tech n iqu e is applicable also in osteoporotic bon e.

In very old people w ith osteoporotic bon e an d m en tal

alteration th e osteosyn th esis sh ou ld be protected by a
plaster cast or splin t.

4 44
 Au t h o r Da n ie l Rik li

7.3.5 Com ple x articular m ultifragm e ntary distal radial

fracture —23 -C3; dorsal double plating
1 Ca s e d e s crip t io n

40-year-old patien t fell from

a b
a ladder. Dorsally im pacted
in traarticu lar fractu re of th e
d istal rad iu s. In traarticu lar
1 fractu re of th e distal radiu s
c w ith im paction of articu lar
2
fragm en ts in to th e m etaph -
3 ysis (23-C3), dorsal dou ble
f platin g.
Fig 7.3 .5 -1a – f
d a AP view.
b Lateral view.
c– e CT scan s sh ow sligh t im paction of th e in term ediate
colu m n .
f Sch em atic represen tation of th e d istal rad ial col-
u m n s: (1) radial colu m n , (2) in term ediate colu m n ,
e (3) u ln ar colu m n .

In d ica t io n Pre o p e ra t ive p la n n in g

High e n e rgy a xia l fo rce s le a d to im p a ctio n o f a rticu la r fra gm e n ts Eq u ip m e n t

in to th e m e ta p h yse a l ca n ce llo u s b o n e . Acco rd in g to th e th re e
co lu m n m o d e l, th e in te rm e d ia te co lu m n (IC) is d ivid e d in to t wo
m a in fra gm e n ts (d o rso -u ln a r, p a lm a r-u ln a r). Th e d o rso u ln a r fra g-
m e n t is ce n tra lly im p a cte d . Th e ra d ia l st ylo id is se p a ra te d (ra d ia l
co lu m n RC). Th e se a rticu la r fra gm e n ts d o n o t re sp o n se d to liga -
m e n to ta xis. Fo rm a l o p e n re visio n is in d ica te d to re co n stru ct th e
ra d io ca rp a l jo in t su rfa ce (IC) u n d e r visio n . Ad d itio n a lly, th is t yp e
o f in ju ry ca n b e co m b in e d w ith a re le va n t liga m e n to u s in ju ry to
th e p ro xim a l ca rp a l ro w. Th e se liga m e n ts ca n b e re vise d d u rin g
th e d o rsa l a p p ro a ch b y a rth ro to m y.
• LCP d ista l ra d iu s p la te 2 .4 , 6 h o le s
• LCP d ista l ra d iu s p la te 2 .4 , 4 h o le s
• Sm a ll e xte rn a l xa to r (o p tio n a l)
(Size o f s yste m , in s tru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Fig 7.3 .5 -2 Su p in e fo re a rm o n h a n d
ta b le . No n ste rile p n e u m a tic to u rn iq u e t.
Pro p h yla ctic a n tib io tics o p tio n a l.

445
 7.3 Ra d iu s a n d u ln a , d is t a l

2 Su rgica l a p p ro a ch

a b
d e
Fig 7.3 .5 -3 a – f
a – d A straigh t dorsal in cision is perform ed
cen tered over th e d istal rad iu s. Th e
su bcu tan eou s tissu e is d ivided. To
access th e in term ediate colu m n , th e
exten sor retin acu lu m is in cised alon g
th e cou rse of th e exten sor pollicis lon -
gu s (EPL) ten don . Th e z-sh ape in ci-
sion , as depicted, spares th e d istal por-
c tion of th e ten don sh eath to preserve
th e de ected cou rse of th e ten don an d
allow s a ap draw n to be u n dern eath
th e EPL ten don du rin g closu re in
order to protect th is ten don from th e
plate. Th e EPL ten don is freed an d re-
tracted w ith an eleastic th read. Prepa-
ration of th e in term ed iate colu m n is
n ow strictly su bperiosteal. Th e 2n d
com partm en t is n ot tou ch ed.
e – f Access to th e rad ial colu m n :
preparation between skin ap
f and retin acu lu m towards radial,
take care of th e su per cial rad ial n er ve
wh ich is always visible in th e sk in ap.
Th e 1st com partm en t is in cised an d
th e abdu ctor pollicis lon gu s an d ex-
ten sor pollicis brevis ten don s are freed
en ou gh for a S-plate to be slipped u n -
dern eath in order to bu ttress th e rad ial
colu m n . Note th at th e 2n d com part-
m en t is left u n tou ch ed.

3 Re d u ct io n

A tran sverse arth rotom y ex poses th e rad iocar pal join t su rface
at th e level of th e lu n ate facette an d, partially, th e scaph oid
facette. Th e proxim al car pal row can be revised for an y liga-
m en tou s in ju ry. Th e rad iocar pal join t is n ow recon stru cted
u n der d irect vision by leverin g th e articu lar fragm en ts to-
wards th e car pal row. An y step-off or gap sh ou ld be elim in at-
ed. Th e dorsal cortical sh ells h elp to de n e len gth an d ser ve
as a bu ttress after redu ction . Sin gle fragm en ts can option ally
be xed tem porarily w ith sm all K-w ires.
Distraction of th e w rist u sin g an extern al xator is ver y h elp-
fu l du rin g recon stru ction of th e join t su rface.
Redu ction is ch ecked by im age in ten si cation .

4 46
 7.3 .5 Co m p le x a r t icu la r m u lt ifra gm e n t a r y d is t a l ra d ia l fra ct u re —2 3 -C3; d o rs a l d o u b le p la t in g

4 Fixa t io n

a b c d e

Fig 7.3 .5 -4 a – e
a After redu ction an d prelim in ar y xation of th e in term e-
d iate colu m n an LCP L-plate or T-plate is ch osen accord-
in g to th e an atom ical con gu ration an d n eed for xation
of fragm en ts. Th e plate is precon tou red, u su ally it h as to
be ben t back at th e distal en d an d tw isted in itself. Th e
plate is xed w ith a rst cortex screw in th e elon gated
plate h ole in th e rad ial sh aft.
b – e Now, th e rad ial colu m n is bu ttressed w ith a precon tou red
S-plate slipped u n dern eath th e ten don s of th e rst com -
partm en t. Th e plate is xed w ith a rst cortex screw in
th e elon gated plate h ole in th e rad ial sh aft. Redu ction
an d plate position in g is ch ecked by u oroscopy.

a b c

Fig 7.3 .5 -5 a – e
a – c After correct redu ction an d plate position in g h as been Th e d istal lock in g h ead screw s in th e tran sverse part of th e T- or
docu m en ted by u oroscopy, th e position of th e plate L-plate su pport th e radiocar pal join t su rface. An add ition al
is secu red by applyin g a secon d cortex or lock in g h ead bon e graft to ll th e m etaph yseal defect is n ot requ ired.
screw in th e m ost prox im al h ole in th e sh aft. On ly th en
is placem en t of th e d istal lock in g h ead screw s started.

4 47
 7.3 Ra d iu s a n d u ln a , d is t a l

4 Fixa t io n (co n t )

Fig 7.3 .5 -5 a – e (co n t)

d – e Th e wou n d is closed in layers. Th e EPL ten don is partially tran s-
posed su bcu tan eou sly by creatin g a retin acu lu m ap th at covers
th e plate. Su ction drain age is u sed. On ly n ow is th e extern al x-
ator, if applicable, w ith draw n . A rem ovable plaster splin t is applied
u n til th e wou n d is clean an d th e pain h as su bsided.

d e

5 Re h a b ilit a t io n

e f

a b c d g h

Early m otion w ith assistan ce of a physioth era-

Fig 7.3 .5 -6 a – h activities su ch as eatin g, person al h ygien e, tyin g a tie, h old in g
pist is started im m ed iately. Th e plaster splin t is ch an ged to a paper. After 6 weeks fractu re h ealin g is docu m en ted by x-ray
rem ovable velcro splin t. Th e h an d is u sed for u n loaded daily an d th e patien t can u su ally start loaded activities.

6 Pit fa lls – 7 Pe a rls +

Rotation al deform ities can be d if cu lt to h an d le from a
dorsal approach .
Hyperexten ded palm ar articu lar fragm en ts are d if cu lt
to con trol from an isolated dorsal approach . Th ey u su ally
n eed a palm ar plate.
Cen trally depressed fragm en ts do n ot respon se to liga-
m en totaxis.
Th is con cepts allow s for early fu n ction al reh abilitation
an d h elps to avoid dystroph y.
Bon e graft is n ot n ecessary du e to lockin g im plan ts.
In ju ries are u su ally cau sed by low en ergy ben d in g forces
an d respon d to m anu al ligam en totaxis for redu ction .

4 48
 Au t h o r Da n ie l Rik li

7.3.6 Com ple x articular distal radial fracture —23 -C3

1 Ca s e d e s crip t io n

a b c d e

50-year-old patien t fell sk i- Fig 7.3 .6 -1a – g

in g, referred th ree weeks
after th e acciden t. Com plex
in traarticu lar fractu re of th e
distal rad iu s (23-C3), com -
bin ed palm ar an d dorsal ap-
proach an d plate xation .
f g
In d ica t io n
a – b AP an d lateral view.
c– d AP an d lateral view 3 weeks after
th e acciden t.
e Sch em atic represen tation of th e
distal rad ial colu m n s: (1) radial
colu m n , (2) in term ed iate colu m n ,
(3) u ln ar colu m n .
f– g CT scan s sh ow displaced radial
colu m n an d th e in term ed iate m u l-
tifragm en tar y, d isplaced colu m n
w ith a step off in th e rad iocar pal
an d rad iou ln ar join t.

Disp la ce d ra d ia l co lu m n (RC). In te rm e d ia te co lu m n (IC), m u ltifra gm e n ta ry, d isp la ce d , ste p -

o ff in th e ra d io ca rp a l a n d ra d io u ln a r jo in t. Hyp e re xte n d e d p a lm a ru ln a r fra gm e n t. Do rso u ln a r
fra gm e n t e xtru d e d . Exte n sive m e ta -/ d ia p h yse a l co m m in u tio n . Avu lsio n o f th e tip o f th e u ln a r
st ylo id (u ln a r co lu m n , UC).
Du e to th e h yp e re xte n d e d p a lm a r-u ln a r fra gm e n t a n d th e d isp la ce d m e ta -/ d ia p h yse a l p a lm a r
fra gm e n t a p a lm a r a p p ro a ch is n e ce ssa ry. Th e ra d ia l co lu m n ca n b e co n tro lle d a n d b u ttre sse d
se p a ra te ly w ith a n S-p la te fro m th e p a lm a r a p p ro a ch . Mo st p ro b a b ly a n a d d itio n a l lim ite d
d o rsa l a p p ro a ch to re d u ce a n d b u ttre ss th e d o rso u ln a r fra gm e n t w ill b e n e e d e d .

449
 7.3 Ra d iu s a n d u ln a , d is t a l

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP d ista l ra d iu s p la te s 2 .4 Fig 7.3 .6 -2 Su p in e p o sitio n in g o f
• Lo ckin g h e a d scre w s (LHS) p a tie n t w ith fo re a rm o n h a n d ta b le .
• Sm a ll e xte rn a l xa to r (o p tio n a l) No n s te rile p n e u m a tic to u rn iq u e t.
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

2 Su rgica l a p p ro a ch

a b

Fig 7.3 .6 -3 a – b
a Th e su rgical approach to th e palm ar side of th e d istal rad i-
u s is described in case 3.7.1. It is developed rst. Th e rad ial
colu m n can be approach ed u sin g th is approach by exten d-
in g preparation arou n d th e rad iu s an d rad ial styloid. Occa-
sion ally, th e in sertion of th e brach iorad ialis ten don h as to
be partially detach ed at th e rad ial styloid in order to place
th e S-plate correctly.
b Th e su rgical approach to th e dorsal side of th e d istal rad iu s
is described in case 3.7.5. In cases wh ere a com bin ed pal-
m ar an d dorsal approach is in evitable, th e rad ial colu m n
sh ou ld be redu ced an d bu ttressed from th e palm ar approach .
Th e dorsal approach can th en be lim ited to th e in term ed i-
ate colu m n . A straigh t dorsal in cision is perform ed an d th e
retin acu lu m is in cised alon g th e cou rse of th e EPL ten don as
described. Su bperiosteal preparation develops access to th e
in term ed iate colu m n . An arth rotom y is always perform ed in
order to con trol redu ction of th e dorsou ln ar fragm en t at th e
level of th e rad iocar pal join t an d to revise th e prox im al car pal
row for any addition al ligam en tou s in ju ries. Th e 1st an d 2n d
com partm en t rem ain u n tou ch ed.

450
 7.3 .6 Co m p le x a r t icu la r d is t a l ra d ia l fra ct u re —2 3 -C3

3 Re d u ct io n a n d fixa t io n

a b c d e f g

Redu ction of th e fragm en ts is by d irect m a-

Fig 7.3 .6 -4 a – g
n ipu lation . If n ecessary, th e in dividu al redu ced fragm en ts
are xed tem porar ily w ith K-w ires. An extern al xator for
d istraction du rin g recon stru ction is of particu lar h elp an d is
always u sed in su ch com plex cases. Correct redu ction m u st be
ch ecked by u oroscopy before de n itive xation .
After redu cin g th e in d ividu al fragm en ts, th e appropriate im -
plan ts are ch osen for de n itive xation th e fractu re. Th e in -
term ed iate colu m n sh ou ld be bu ttressed at th e palm ar aspect
as well as dorsally by a separate lock in g L-plate. Th e rad ial
colu m n is bu ttressed from palm ar u sin g an S-plate. Startin g
on th e palm ar side by position in g th e L- an d th e S-plates an d
xin g th em provision ally w ith a con ven tion al screw in th e
elon gated plate h ole in t h e rad ia l sh a ft. Th is is ch ecked by
u oroscopy. Th en th e dorsal in cision is m ade to approach th e
in term ediate colu m n . After redu cin g th e dorsou ln ar frag-
m en t, th e plate is position ed an d tem porarily xed. After a
ch eck of redu ction an d plate position by u oroscopy, th e os-
teosyn th esis is com pleted as descr ibed above.

4 Re h a b ilit a t io n

Early m otion is started im m ediately. Th e plaster splin t is ch an ged to a rem ovable Fig 7.3 .6 -5 a – e
velcro splin t. Th e h an d is u sed for u n loaded daily activities su ch as eatin g, person al a AP view.
h ygien e, tyin g a tie, h oldin g paper. b Lateral view.
c– e CT scan s.

a b c d e

451
 7.3 Ra d iu s a n d u ln a , d is t a l

4 Re h a b ilit a t io n (co n t )

c d

a b e f

After 6 weeks fractu re h ealin g is docu m en ted w ith

Fig 7.3 .6 -6 a – f
x-rays an d th e patien t can start loaded activities.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t
Th e su rgeon m u st ch eck th e in tern al xation for stability
w ith im age in ten si cation in order to avoid secon dary loss
of xation du rin g early m otion . If stability is n ot su f -
cien t, extern al xation or a plaster cast m u st be added for
4 –6 weeks.
Eq u ip m e n t
Do n ot h esitate to pu t th ese fractu res in an extern al
xator as an em ergen cy m easu re. X-rays w ith th e h an d
in traction (ligam en totax is) after m ou n tin g th e extern al
xator sim pli es in ter pretation of th e fractu re pattern
dram atically.

Care mu st be taken n ot to pen etrate th e radiocar pal Th e variety of th e LCP d istal rad iu s plates 2.4 h elp to
an d radiou ln ar join ts w ith screw s. adapt th e im plan ts to th e in d ividu al situ ation .

A CT scan an d carefu l preoperative plan n in g is With th e h elp of th e CT scan , w h ich is always perform ed
m an datory. after placin g th e extern al xator, a strategy for de n itive
treatm en t accordin g to th e th ree colu m n m odel is devel-
oped.

452
8 Pe lvic ring and ace tabulum

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

8 .1.1 Un stab le p e lvic rin g fra ctu re 61-C co m p re ssio n LCP re co n struction p la te 3 .5; co m p re ssio n p la te 457
re co n stru ctio n p la te 3 .5

8 .1.2 Sym ph ysis a vu lsio n plu s 61-C com p re ssio n LCP 4 .5/ 5 .0; co m p re ssio n 4 61
tran sfo ram inal fractu re o f th e an d lo cke d LCP re co n stru ctio n p la te 3 .5 p la te ,
sacrum sp lin tin g lo cke d in te rnal
fixa to r

8 .1.3 Pe lvic rin g re co n stru ctio n 61-C co m p re ssio n LCP 3 .5; co m p re ssio n an d 465
an d lo cke d LCP re co n stru ctio n p la te s 3 .5 p ro te ctio n pla te ,
sp lin tin g lo cke d in te rnal
fixa to r

8 .1.4 Pe lvic ring an d ace tab u lar fractu re 62-B3 com pre ssio n LCP re co n stru ctio n p la te 3 .5 b u ttre ss p la te 469
an d lo cke d
sp lin tin g

8 .1.5 Ace tab ular fra ctu re 62-B1 co m p re ssio n LCP re co n stru ctio n p la te 3.5; b u ttre ss pla te 473
re co n stru ctio n p la te 3 .5

453
 8 Pe lvic

8 Pe lvic ring and ace tabulum

8 .1 Pe lvic rin g a n d a ce t a b u lu m 455

8 .1.1 Un s t a b le p e lvic rin g fra ct u re —61- C 4 57
8 .1.2 Sym p h ys is a vu ls io n p lu s t ra n s fo ra m in a l fra ct u re o f t h e
s a cru m —61- C 4 61
8 .1.3 Pe lvic rin g re co n s t ru ct io n —61- C 465
8 .1.4 Pe lvic rin g a n d a ce t a b u la r fra ct u re —6 2 -B3 469
8 .1.5 Ace t a b u la r fra ct u re —6 2 -B1 47 3

454
 Au t h o r Tim Po h le m a n n

8 .1 Pe lvic ring and ace tabulum

1 In cid e n ce 2 Cla s s ifica t io n

Even w ith m ajor advan ces in th e treatm en t of pelvic an d ace-
tabu lar fractu res, th ese in ju ries are still associated w ith several
com plication s. Su rger y is d if cu lt an d th e obser ved clin ical
an d radiological resu lts are frequ en tly less th an satisfactory
com pared to in ju ries to th e body.
Th e Mü ller AO Classi cation takes th e path om ech an ical aspects
of stability or in stability of th e posterior arch of th e pelvic
rin g in to con sideration . Acetabu lar fractu res are classi ed
separately.

By de n in g a speci c in ju ry type as “com plex pelvic frac-

tu res” (“pelvic fractu re w ith per ipelvic soft-tissu e in ju r y,
u rogen ital in ju r y, h olovisceral in ju ry, mu scle in ju r y, or n erve
in ju r y”) a grou p of patien ts u n der im m ed iate vital th reat was
iden ti ed. Th e in trodu ction of prim ar y treatm en t algorith m s
for th ese patien ts, based on th e prin ciple of im m ed iate em er- a b c
gen cy m ech an ical stabilization (extern al xator/C-clam p)
an d su bsequ en t su rgical h em ostasis in n on respon ders (pref- Fig 8 .1-1a – c Mü ller AO Classi cation of pelvic rin g fractu res.
erably by pelvic tam pon ade), led to con stan t im provem en ts. a 61-A Posterior arch in tact, stable lesion
Th e su r vival rate is n ow below 20% accord in g to th e Germ an b 61-B Posterior arch d isru ption , in com plete,
Mu lticen ter Pelvic Stu dy Grou p data (overall fatality after pel- partially stable lesion
vic fractu res: 5.9% ). c 61-C Posterior arch disru ption , com plete, u n stable lesion
a
For th e oth er 90% of patien ts su fferin g from pu re osteoliga-
m en tou s in ju r ies, a better u n derstan d in g an d u sage of u n iver-
sal classi cation system s allow s th e settin g of clear in d ication
gu idelin es an d stan dard ized conven tion al su rgical tech n iqu es
for th e variou s fractu re pattern s of pelvic rin g in ju ries an d
acetabu lar fractu res. Th e rate of lon g-term h ealin g after an a-
tom ical su rgical recon stru ction im proved to over 80% , even
after C-type fractu res in clu din g tran slation al in ju ries to th e
posterior pelvic r in g. Despite th is progress, th e rate of clin i- a b c
cally excellen t an d good resu lts for th ese in ju ries is still ob-
ser ved to be arou n d 60% . Th is leads research to focu s on th e Fig Mü ller AO Classi cation of acetabu lar fractu res.
8 .1-2 a – c
effect (on th e qu ality of ou tcom es) of soft-tissu e dam age re- a 62-A Partial articu lar, on e colu m n
lated to th e in ju r y an d su rgical in terven tion , an issu e n ot cu r- b 62-B Partial articu lar, tran sverse orien ted
ren tly bein g addressed. c 62-C Com plete articu lar, both colu m n s

455
 8 Pe lvic
3 Tre a t m e n t m e t h o d s
Th e in trodu ction of lock in g tech n ology in creased th e h ope
th at th ere wou ld be fu rth er im provem en t in th e treatm en t
m odalities available to pelvic an d acetabu lar su rgery. A close
review of th e resu lts presen ted over th e last two years h as
sh ow n th at th e LCP h as th e poten tial to im prove treatm en t
alth ou gh reprodu cible im provem en ts were fou n d to be th e re-
su lt of en h an ced preoperative visu alization . Th e latter leads
to a better u n derstan din g of th e fractu re pattern w ith su bse-
qu en t stan dardization of prim ary evalu ation , de n itive d iag-
n ostics, classi cation , an d su rgical tech n iqu es.
Presen t efforts in th e treatm en t of pelvic rin g in ju r ies are fo-
cu sed on closed an d m in im ally in vasive su rgical tech n iqu es
based on fu rth er advan ces in preoperative visu alization an d
plan n in g. Th e w idespread u se an d acceptan ce of closed su r-
gical tech n iqu es is still lim ited by th e ability to perform a n d
con trol redu ction .
From ou tcom e evalu ation of larger series, it becom es clear
th at th e stan dards of an atom ical redu ction an d stable xation
w ith early m obilization still h ave to be m et, even in cases of
poor bon e qu ality.
In th e eld of acetabu lar su rger y th e n eed for absolu te an a-
tom ical recon stru ction of th e join t su rfaces h as been u n dis-
pu ted sin ce th e basic work by Letou rn el. Dem ograph ic ch an g-
es lead to a rapid ly in creasin g n u m ber of acetabu lar fractu res
in elderly patien ts, especially fractu res of th e an terior colu m n
an d an terior colu m n com bin ed w ith posterior h em itran sverse
fractu res an d fractu res of both colu m n s. Th e valu e of prim ar y
total h ip replacem en t in th is patien t grou p is still dispu ted
w ith reports of u n acceptable rates of early loosen in g. Th ere-
fore, an in creasin g n u m ber of su rgical recon stru ction s of th e
acetabu lu m h ave to be perform ed w ith in th is age grou p. With
th e u se of special tech n iqu es of stabilization , like lock in g
com pression plates an d an adapted im plan t design , prom isin g
resu lts can be ach ieved if d isastrou s secon dar y d isplacem en t
after xation failu re can be avoided.
456
New special recon stru ction plates w ith coaxial com bin ation
h oles an d better 3-D ben d in g qu alities su pport n ewer, m in i-
m ally in vasive tech n iqu es an d w ill ease fractu re treatm en t in
situ ation s w ith poor bon e qu ality.
4 Im p la n t o ve r vie w
a
b
c
Fig 8 -3 a – c
a LCP 3.5
b LCP 4.5/5.0
c LCP recon stru ction plate 3.5
5 Su gge s t io n s fo r fu r t h e r re a d in g
Cu le m an n U, To so u n id is G, Po h le m an n T (2005)
[ Fractu res of th e accetabu lu m —treatm en t strategies an d
cu rren t diagn ostics]. Zentralbl Chir.; 130(5):W58 —71;
qu iz W72–73. Germ an .
Cu le m an n U, To so u n id is G, Re ilm an n H , e t al (2004) [ In ju ry to
th e pelvic rin g. Diagn osis an d cu rren t treatm en t option s]. Unfallchirurg;
107(12):1169 –1181; qu iz 1182 –1183. Germ an .
Gan ssle n A , Po h le m an n T, K re t t e k C (2005) [ In tern al
xation of sacroiliac join t disru ption]. Oper Orthop Traumatol;
17(3):281–95. Germ an .
Le t o u rn e l E, Ju de t R (1981) Fractures of the Acetabulum.
Berlin Heidelberg New York: Sprin ger Verlag.
Po h le m an n T, Gän ssle n A , Hart u n g S (1998) Beckenverletzungen /
Pelvic injuries: Results of the German Multicenter Study Group. Berlin
Heidelberg New York: Sprin ger Verlag.
Tile M , Bu rge ss A , He lfe t D L e t al (1995) Fractures of the Pelvis and
Acetabulum. Baltim ore: Willia m s & Wilkin s.
Tsch e rn e H , Po h le m an n T (1998) Tscherne Unfallchirurgie.
Pelvic and acetabulum. Berlin Heidelberg: Sprin ger Verlag.
 Au t h o r Em a n u e l Ga u t ie r

8 .1.1 Unstable pe lvic ring fracture —61-C1

1 Ca s e d e s crip t io n

a b c

23-year-old m an su ffered a parachu te in ju ry (5 m fall). He su s-

tain ed a pelvic rin g in ju ry w ith disru ption of th e pu bic sym -
physis, a fractu re of th e iliu m on th e righ t side, an d a stable,
2-level lu m bar spin e fractu re.

Fig 8 .1.1-1a – g
d e a AP view.
b In let view.
c Ou tlet view.
d – g CT scan s sh ow th e m u ltifragm en tar y fractu re of th e
illiu m an d an in tercalated iliac fragm en t.

f g

In d ica t io n

In d ica tio n s fo r ORIF, a n te rio r a n d p o ste rio r a re :

• In sta b ilit y o f th e a n te rio r a n d p o ste rio r p e lvic rin g se gm e n ts
• As ym m e try o f th e p e lvic rin g a n d tru e p e lvis
• In te rca la te d fra gm e n t o f th e ilia c w in g

457
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

Pre o p e ra t ive p la n n in g

Eq u ip m e n t 1 Su rge o n
• LCP re co n stru ctio n p la te 3 .5 , 6 h o le s 2 ORP
• Re co n stru ctio n p la te 3 .5 , 5 h o le s 3 1st a ssistan t
• Lo ckin g h e a d scre w s (LHS) 3
• 2 .5 m m K-w ire Ste rile are a
• Pe lvic re d u ctio n fo rce p s (Fa ra b o e u f)
• Pe lvic re d u ctio n fo rce p s (Ju n gb lu th)
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Fig 8 .1.1-2 Pa tie n t in su p in e
An tib io tics: ce p h a lo sp o rin
p o sitio n w ith le g fre e ly m o b ile
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin 1
o n th e in ju re d sid e .
2

2 Su rgica l a p p ro a ch

Fig 8 .1.1-3 Mod i ed Pfan n en stiel approach w ith preparation

of th e sym physis an d th e pu bic ram u s dorsal to th e rectu s,
w ith ou t detach m en t of th e rectu s m u scle.

Approach to th e iliac r in g th rou gh th e rst w in dow of th e

ilioin gu in al approach .

458
 8 .1.1 Un s t a b le p e lvic rin g fra ct u re —61-C1

3 Re d u ct io n

a b c

Possibilities for redu ction of th e sym ph ysis:
• Poin ted redu ction forceps in both obtu rator foram en
• Matta tech n iqu e
• Possibilities for redu ction of th e iliac rin g: Faraboeu f
forceps in th e iliac crest
Fig 8 .1.1-4 a – cRedu ction of th e sym ph ysis, accord in g to Mat-
ta. Th e Ju n gblu th forceps are xed on th e u n stable side w ith
a 3-h ole recon stru ction plate 4.5. Th is allow s a h igh pu ll on
th e pu bic ramu s w ith ou t risk of screw pu llou t. Redu ction of
th e iliu m w ith th e h elp of a Sch an z screw in serted in to th e
u n stable side an d u sed as a joystick, or w ith th e aid of a Fara-
boef forceps.

4 Fixa t io n

a b c

Th e sym ph yseal fractu re is com pressed by eccen tric placem en t Fig 8 .1.1-5 a – c
of cortex screw s in th e m iddle part of a 6-h ole LCP recon - a AP view.
stru ction plate. Add ition al xation of th e plate to th e pu bic b In let view.
ram i w ith LHS. c Ou tlet view.
Fixation of th e iliu m is perform ed w ith two 3.5 m m cortex
screw s alon g th e iliac crest an d a 5-h ole recon stru ction plate
close an d parallel to th e sacroiliac join t.

459
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

5 Re h a b ilit a t io n

a b c

Th e fractu re was n ot add ition ally im m obilized. 15 kg weigh t bearin g for 6 weeks Fig 8 .1.1-6 a – cX-rays at on e year sh ow
an d fu ll weigh t bearin g after 12 weeks. Bon e h ealin g was seen after 12 weeks. th e con solidation of th e fractu re an d
ru ptu re of th e sym ph yseal plate.
Im p la n t re m o va l a AP view.
Th e patien t was n ot keen to h ave th e im plan ts rem oved becau se h e h ad n o pain at b In let view.
all, even w ith th e plate broken at two levels. c Ou tlet view.

6 Pit fa lls – 7 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In th e posterior aspect of th e pelvic rin g a con ven tion al An terior sym ph yseal platin g w ith LCP recon stru ction
recon stru ction plate is u sed sin ce it is n ot possible to in sert plate is possible, en h an cin g th e an ch orage in th e case of
an an gu lar stable plate. osteoporotic bon e.

460
 Au t h o rs Th o m a s J Ho cke rt z, An d re a s Gru n e r, Ga b rie le St re ich e r, He in rich Re ilm a n n

8 .1.2 Sym physis avulsion plus transforam inal fracture

of the sacrum —61-C
1 Ca s e d e s crip t io n

a b c

46-year-old m an w ith pelvic in ju ry.

Type of in ju r y: h igh -en ergy trau m a.
b Mu ltiple trau m a description : pelvic
a C-type fractu re in ju ry, w rist fractu re
(C2-fractu re of th e d istal rad iu s); con -
d e f cu ssion ; m u ltiple bru isin g.

Fig 8 .1.2 -1a – f

a Preoperative
b Preoperative
c Preoperative
d – f Preoperative
In d ica t io n
overview of th e pelvis.
view of th e pelvic in let.
Unstable C-type fracture . Prote ction of the
view of th e pelvic ou tlet.
ple xu s from the local oste osynthe sis of the
CT scan s.
sacrum; e arly functional afte rcare is possible .

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP 4 .5/ 5 .0 , 9 h o le s
• LCP 4 .5/ 5 .0 , 4 h o le s
• LCP re co n stru ctio n p la te 3 .5 , 3 h o le s
• Lo ckin g h e a d scre w s (LHS)
• 4 .5 m m co rte x scre w s
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.) a b

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 8 .1.2 -2 a – b
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin a Sta b iliza tio n o f th e s ym p h ysis w ith th e p a tie n t in th e su p in e p o sitio n .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin b Tre a tm e n t o f th e d o rsa l p e lvic rin g in th e p ro n e p o sitio n .

4 61
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

Pre o p e ra t ive p la n n in g (co n t )

Fig 8 .1.2 -3 Ske tch o f p re o p e ra tive

p la n n in g. Po sitio n in g o f th e LCP (re d ), th e
co rte x scre w s ( gre e n) a n d th e LHS ( b lu e).

2 Su rgica l a p p ro a ch

Fig 8 .1.2 -4 a – b
a Approach to th e pu bic sym ph ysis by
h orizon tal Pfan n en stiel t ype in ci-
sion (7–12 cm ).
b Posterior approach to th e sacroiliac
join t. Th e sk in in cision starts 1–2
n gerbreadth s d istal an d lateral to
th e posterior su perior iliac spin e an d
ru n s in a straigh t lin e proxim ally
(abou t 10 –15 cm ).
a b

3 Re d u ct io n a n d fixa t io n

• De n itive redu ction of th e sacru m an d

local plate osteosyn th esis.
• Protection of th e osteosyn th esis by bridg-
in g LCP accord in g to in tern al
xator prin ciples.
• Approx im ate redu ction of th e pelvis
an d stabilization of th e avu lsed
sym ph ysis by plate osteosyn th esis in com -
pression tech n iqu e.

Fig 8 .1.2-5a–b
a Position of the LCP on the posterior pelvis.
a b
b Position of the LCP on the lateral pelvis.

4 62
 8 .1.2 Sym p h ys is a vu ls io n p lu s t ra n s fo ra m in a l fra ct u re o f t h e s a cru m —61- C

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 8 .1.2 -6 a – c
a Postoperative over view of th e pelvis. b Postoperative over view of th e pelvic c Postoperative overview of th e pelvic
in let. ou tlet.

4 Re h a b ilit a t io n

Weigh t bear in g: 15 kg for 6 weeks; h alf

body weigh t after 6 weeks; fu ll weigh t
bearin g after 8 weeks.
Ph ysioth erapy: from th e secon d postop-
erative day.
Ph arm aceu tical treatm en t pain th erapy
w ith n on steroid an tiin am atory dru gs.

Postoperative x-rays
Fig 8 .1.2 -7a – e
after 5 m on th s.
a AP view.
a b b In let view.
c Ou tlet view.
d – e Fu n ction al resu lt.

Im p la n t re m o va l
Du e to screw failu re, th e sym ph ysis
c d e plate was rem oved after 8 m on th s.

463
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
It is d if cu lt to determ in e th e correct len gth of th e LCP
for posterior application an d in tern al xation .

Ap p ro a ch Ap p ro a ch
M in im ally invasive approach .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Du e to th e sm all in cision s, dif cu lt h alf-open redu ction –
on ly for ex perien ced pelvic su rgeon s.

Re h a b ilit a t io n Re h a b ilit a t io n
Early m obilization is possible, th erefore better fu n ction al
ou tcom es.

No destru ction of th e sacroiliac join t sin ce it is n ot in con -

tact w ith screw s.

464
 Au t h o rs Tim Po h le m a n n , Ulf Cu le m a n n

8 .1.3 Pe lvic ring re construction – 61-C1

1 Ca s e d e s crip t io n

60-year-old wom an w ith pseu darth rosis after com -

plete pelvic rin g in ju ry in a car acciden t.
Type of in ju r y: h igh -en ergy, m on otrau m a; closed
fractu re.

Fig 8 .1.3 -1a – c

b a An x-ray taken 1 1/ 2 years after th e car acciden t
w ith th e operative treatm en t of a com plete
pelvic rin g fractu re as sh ow n .
b – c Th e CT scan s dem on strate th e n on h ealin g of
th e an terior an d posterior pelvic rin g frac-
tu res.

a c

In d ica t io n Pre o p e ra t ive p la n n in g

An u n s ta b le C-t yp e fra ctu re EqPautip

iemn te pn re
t p a ra t io n a n d p o s it io n in g
w a s m isin te rp re te d a s a B-t yp e • •LCP
An tibre io
cotics:
n s trusin
ctio
glen dpolase te s2 n3d .5
ge, n3 ehraotio
le sn ce p h a lo - 4
a n d o p e ra tive sta b iliza tio n w a s • LCP
sp ore rinco
. n s tru ctio n p la te s 3 .5 , 6 h o le s
o n ly p e rfo rm e d fo r th e a n te rio r • •LCP
Th ro3 m .5 b, 4o sis
h o le
p ro
s p h yla xis: Lo w m o le cu la r h e p a rin .
p e lvic rin g. Th e re su lt a fte r • 3 .5 m m lo ckin g h e a d scre w s (LHS)
1 1/ 2 ye a rs w a s a n o n u n io n • 3 .5 m m co rte x scre w s 1 Su rge o n
o f th e p e lvic rin g a n d p a in b e - • 7.0 m m ca n n u la te d scre w s 2 ORP 1
3
ca u se o f th e in sta b ilit y. Th e • Pe lvic re d u ctio n fo rce p s (o p tio n a l) 3 1st a ssista n t
su rgica l tre a tm e n t a im e d to (Size o f s yste m , in s tru m e n ts, a n d
4 2n d a ssista n t
e lim in a te th e d islo ca tio n o f th e im p la n ts ca n va ry a cco rd in g to a n a to m y.)
a n te rio r p e lvic rin g a n d th e in - Ste rile are a 2
sta b ilit y o f th e sa cro ilia c jo in t. Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin fo r 10 d a ys
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
h e p a rin
Fig 8 .1.3 -2 Pa tie n t in th e su p in e p o sitio n w ith
th e le g fre e ly m o b ile .

465
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

2 Su rgica l a p p ro a ch

Fig 8 .1.3 -3 a – h Ilioin gu in al approach . b Rem oval of iliac m u scle from th e c Preparation of th e m u scu lar space.
a Orien tation poin ts an d skin in cision . iliac w in g.

d Tran section of th e iliopectin eal e Mobilization of th e iliopsoas m u scle f First w in dow of th e ilioin gu in al
arch . from th e posterior pectin eal lin e. approach .

g Secon d w in dow of th e ilioin gu in al h Th ird w in dow of th e ilioin gu in al

approach . approach .

466
 8 .1.3 Pe lvic rin g re co n s t ru ct io n —61-C1

3 Re d u ct io n a n d fixa t io n

Fig 8 .1.3 -4 a – b
a Dissection of th e pseu darth rotic sacroiliacal join t, in ter posi-
tion of corticocan cellou s bon e graft from th e iliac crest an d
xation by a 7.0 m m can nu lated screw in com bin ation w ith
two LCPs.
b An terior pelvic rin g recon stru ction .

Mobilization of th e an terior part of th e pseu darth rosis. Mobili-

zation of th e posterior part of th e pseu darth rosis in open tech -
n iqu e. In ter position of corticocan cellou s bon e graft ch ip in to th e
a sacroiliac join t.

Arth rodesis of th e sacroiliac join t by a 7.0 m m can nu lated lag

screw an d two LCP recon stru ction plates 3.5, 3 h oles w ith self-
tappin g lock in g h ead screw s an d cortex screw s.

Redu ction of th e an terior pelvic r in g th rou gh th e secon d an d

th ird w in dow of th e ilioin gu in al approach an d xation w ith an
LCP 3.5, 4 h oles.

Fixation of th e su perior pu bis ram i an d th e sym physis w ith two

b LCP recon stru ction plates 3.5, 6 h oles.

4 Re h a b ilit a t io n

a b c

Weigh t bearin g: 15 kg for 8 weeks; h alf-body weigh t after 12 Fig 8 .1.3 -5 a – c Postoperative x-rays after 6 weeks.
weeks; fu ll weigh t bear in g after 16 weeks. a AP view.
Ph ysioth erapy: active an d passive. b In let view.
Ph arm aceu tical treatm en t: pain m ed ication an d c Ou tlet view.
an tiph logistics for 2 weeks.

467
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

4 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
On ly n ecessary in cases of tran s xation of th e sym ph ysis an d/
or sacroiliac join t.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Fu ll pelvic set w ith all redu ction tools is n eeded. Redu ction tools for arth rodesis.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Axis of th e lock in g h ead screw s in th e direction of th e Preben din g of th e plate to preven t th e screw ax is bein g in
load in g forces in clu des a h igh risk of pu llou t from th e th e lin e of th e load in g forces.
bon e.

Fig 8 .1.3 -6
Pitfall becau se of th e load in g forces in th e d irection of
th e ax is of th e screw s: pu llou t of th e righ t cortex screw
an d th e lockin g h ead screw from th e bon e, becau se of
in su f cien t preben d in g of th e plate.
Fig 8 .1.3 -7
B-type fractu re w ith ru ptu re of th e pu bic sym ph ysis. Post-
operative con trol after xation of th e sym ph ysis w ith LCP,
lock in g h ead screw s in th e lateral h oles, an d cortex screw s
w ith com pression in th e m idd le part of th e plate.

468
 Au t h o rs Tim Po h le m a n n , Ulf Cu le m a n n

8 .1.4 Pe lvic ring and ace tabular fracture —62-B3

1 Ca s e d e s crip t io n

79-year-old wom an w ith a fractu re of

the left pelvic rin g and acetabu lu m . Low-
energy, m on otrau m a; closed fractu re.

Fig 8 .1.4 -1a – b

a X-ray dem on strates a closed acetabu lar
b fractu re on th e left side w ith protru -
b sion of th e fem oral h ead in side th e
pelvis.
b Th e CT scan dem on strates th e com -
m inu tion of th e dom ed part of th e
acetabu lar su rface.
b
a

In d ica t io n Pre o p e ra t ive p la n n in g

Typ ica l fra ctu re p a t te rn o f a ce ta b u la r fra ctu re s in ge ria tric p a tie n ts w ith fra ctu re o f Eq u ip m e n t
th e a n te rio r co lu m n w ith p o ste rio r h e m itra n s ve rse fra ctu re . In co n gru e n cy o f th e jo in t • LCP re co n s tru ctio n p la te 3 .5 , 3 – 4 h o le s
re q u ire s re co n stru ctio n . No n o p e ra tive tre a tm e n t h a s th e risk o f e a rly o ste o a rth ro sis • Se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
a n d / o r n o n u n io n . Prim a ry to ta l h ip re p la ce m e n t ( THR) is d ifficu lt d u e to th e in sta b ilit y o f • 7.0 m m ca n n u la te d scre w
th e w e igh t su p p o rtin g fra ctu re o f th e a n te rio r co lu m n . • Ad d itio n a l p e lvic re d u ctio n fo rce p s
(Size o f s ys te m , in s tru m e n ts , a n d
Fig 8 .1.4 -2 a – c im p la n ts ca n va ry a cco rd in g to a n a to m y.)
a AP view.
b Ala view.
c Obtu rator view.

a b b c ac

Preoperat ive pla n n in g sketch es: Roof a rc m ea su rem en t s accord in g to M at t a to

facilitate decision m ak in g for n on operative/operative treatm en t.
Th e an gle between a lin e per pen d icu lar to th e acetabu lar cen ter an d th e rst vis-
ible fractu re lin e is over 45° in all th ree stan dard view s ( Fig 8 .1.4 -2 ), n on operative
treatm en t is possible.

469
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

Pre o p e ra t ive p la n n in g (co n t )

Pa t ie n t p re p a ra t io n a n d p o s it io n in g 1 Su rge o n
3
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin 2 ORP
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin 3 1st a ssistan t
4 2n d a ssistan t
Fig 8 .1.4 -3 Pa tie n t in su p in e p o sitio n w ith le g fre e ly m o b ile .
Ste rile are a

4 1 2

2 Su rgica l a p p ro a ch

Fig 8 .1.4 -4 a – h Ilioin gu in al approach . b Rem ova l of iliacu s m u scle from c Preparation of th e m u scu lar space.
a Orien tation poin ts an d sk in t h e iliac w in g.
in cision .

d Tran section of th e iliopectin eal e Mobilization of th e iliopsoas m u scle f First w in dow of th e ilioin gu in al
arch . from th e posterior pectin eal lin e. approach .

470
 8 .1.4 Pe lvic rin g a n d a ce t a b u la r fra ct u re —6 2-B3

2 Su rgica l a p p ro a ch (co n t )

Fig 8 .1.4 -4 a – h (co n t)

g Secon d w in dow of th e ilioin gu in al h Th ird w in dow of th e ilioin gu in al
approach . approach .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 8 .1.4 -5 a – c
a An atom ica l recon st r u ct ion of t h e a n ter ior colu m n . Fixat ion w it h a preben t
pelvic recon stru ction plate.
b A stepw ise redu ction can be su pported by special in stru m en ts like th e “pu sh in g-
plate“ descr ibed by Jeff Mast.
c Derotation of th e posterior colu m n an d redu ction w ith a collin ear redu ction
clam p. Fixation w ith lag screw s. In cases of poor bon e qu ality, th e u se of addi-
tion al lock in g h ead screw s en h an ces overall stability.

471
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

4 Re h a b ilit a t io n

Fig 8 .1.4 -6 a – c
Postoperative x-ray after
6 weeks.
a AP view.
b Obtu rator view.
c Ala view.

Im p la n t re m o va l
No im plan t rem oval
a b c if possible.

Weigh t bearin g: 15 kg for 8 weeks; h alf body weigh t after 10 weeks; fu ll weigh t bearin g after 12
weeks.
Ph ysioth erapy: fu n ction al postoperative treatm en t w ith active-assisted an d con tin u ou s passive
m otion w ith ph ysioth erapist as of th e secon d postoperative day.
Ph arm aceu tical treatm en t: com bin ation of pain k illers an d n on steroidal an tiph logistics.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Explore th e lateral fem oral cu tan eou s n er ve th rou gh th e
approach from 1 cm lateral to 4 cm m ed ial of th e an terior
su perior iliac spin e.

Re d u ct io n a n d xa t io n
Fig 8 .1.4 -7Con trol of all screw s in th e d irection of th e
acetabu lu m w ith th e im age in ten si er an d/or 3-D CT
scan in traoperatively.

472
 Au t h o r Em a n u e l Ga u t ie r

8 .1.5 Ace tabular fracture —62-B1

1 Ca s e d e s crip t io n

a b c

A 20-year-old m an su ffered a trau m atic

d e
f g
in ciden t wh ile d rivin g h is m otorcycle,
an d su stain ed th e follow in g mu ltiple
in ju ries/ fractu res: righ t acetabu lu m (as-
sociated tran sverse an d posterior wall
fractu re), left fem oral sh aft, righ t d istal
fem u r, r igh t patella, open righ t lower
leg, stable fractu re of th e rst lu m bar
vertebra, ribs 3 to 10 on th e righ t, an d
a ru ptu re of th e posterior cru cila liga-
m en t on th e righ t.

h i j k

Fig 8 .1.5 -1a – l In d ica t io n

a AP view.
b Obtu rator obliqu e view. To a ch ie ve co n gru it y a n d co n ta in m e n t o f
c Iliac obliqu e view. th e h ip, o p e ra tive tre a tm e n t is m a n d a to ry.
d – k Tran sverse CT scan s show the mu lti-
fragm en tary fractu re of th e poste-
rior wall w ith m argin al im paction
an d th e u n d isplaced tran sverse
fractu re com pon et.
l l 3-D recon stru ction .

473
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

Pre o p e ra t ive p la n n in g

Eq u ip m e n t 1 Su rge o n
• LCP re co n stru ctio n p la te 3 .5 , 8 h o le s 2 1st a ssistan t
2
• Re co n stru ctio n p la te 3 .5 , 5 h o le s 3 ORP
• 3 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w Ste rile a re a
• Pe lvic re d u ctio n fo rce p s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
3
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g 1
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 8 .1.5 -2 La te ra l p o sitio n o n a sta n d a rd o p e ra tin g ta b le le g fre e ly d ra p e d .

2 Su rgica l a p p ro a ch

Th e fractu re is approach ed via a Koch er-Lan gen beck approach

Fig 8 .1.5 -3
w ith a troch an teric ip osteotom y.

Th e a n gu lated in cision is cen tered over th e greater troch a n ter. Th e ten -

sor fascia lata an d glu teu s m axim u s mu scle are split. Th e posterior bor-
ders of th e glu teu s m ed iu s an d th e vastu s lateralis m u scle are ex posed
an d a ip osteotom y of th e greater troch an ter is perform ed.

Ten otom y of th e piriform an d of th e obtu rator in tern u s an d gem elli mu s-

cles w ith partial elevation of th e glu teu s m in im u s m u scle.

Capsu lotom y of th e h ip join t sh ou ld be perform ed w ith ou t fu rth er de-

vascu larization of th e fragm en ts of th e posterior wall. Wh en su rgical
dislocation of th e h ip is n eeded, th e in term ed iu s m u scle is detach ed an -
ter iorly to allow an terior capsu lotom y.

474
 8 .1.5 Ace t a b u la r fra ct u re —6 2-B1
3 Re d u ct io n a n d fixa t io n
a b
4 Re h a b ilit a t io n
a b
No ex ion of th e h ip in th e su pin e posi-
tion an d n o ex ion of th e tru n k (body)
in th e stan d in g position to avoid loadin g
of th e posterior wall.
Bon e h ealin g an d fu ll weigh t bearin g
after 12 weeks.
Fig 8 .1.5 -4 a – bSu rgical d islocation of th e h ip. Stabili-
zation of th e tran sverse fractu re com partm en t on th e
an terior part w ith a 3.5 m m cortex screw. Stabilization
of th e tran sverse fractu re posteriorly w ith a 5-h ole re-
con stru ction plate w ith two screw s. Elevation of th e
im pacted fragm en t, an d bu ttressin g w ith a can cellou s
bon e block taken from th e troch an ter. Redu ction of
th e posterior wall w ith th e ball spike w ith poin ted ball
tip, prelim in ary xation w ith K-w ires. Stabilization
of th e posterior wall w ith 8-h oles 3.5 recon stru ction
plate w ith two screw s in th e su praacetabu lar area an d
two lock in g h ead screw s in th e isch iu m . Th e greater
troch an ter is xed w ith th ree 3.5 m m cortex screw s
after su tu re of th e join t capsu le.
c
Fig Postoperative x-rays.
8 .1.5 -5 a – c
a AP view after on e week.
b Iliac obliqu e view after on e week.
c Obtu rator obliqu e view after on e
week.
475
 8 .1 Pe lvic rin g a n d a ce t a b u lu m

4 Re h a b ilit a t io n (co n t )

Fig 8 .1.5 -6 Follow-u p x-ray after 3 1/ 2 years.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Dan ger of in ju ry to th e deep bran ch of th e m ed ial
circu m ex fem oral arter y du rin g ten otom y an d su tu re
of th e extern al rotators of th e h ip w ith th e risk of
avascu lar n ecrosis of th e fem oral h ead.
Ap p ro a ch
Th e Koch er-Lan gen beck approach provides a good view
of th e posterior colu m n .
Th e en largem en t of th e stan dard Koch er-Lan gen beck
approach w ith th e troch an teric ip osteotom y allow s
su rgical d islocation of th e h ip an d a com plete view of
th e actebu lu m (from in side).

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e posterior wall fragm en t often n eeds add ition al Con trol of redu ction of th e tran sverse fractu re com pon en t
xation by m ean s of 3.5 m m , 2.7 m m , or sm all fragm en t an teriorly an d safe in traosseou s, extraarticu lar screw
screw s. placem en t in to th e an terior colu m n w ith th e fem oral h ead
d islocated laterally (in ex ion an d extern al rotation).
Im pacted posterior wall fragm en ts n eed elevation an d
bu ttressin g u sin g au tologou s bon e.

476
9.1 Fe m ur, proxim al

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

9.1.1 Avu lsion fractu re o f gre a t tro chan te r com pre ssio n LCP re co n struction pla te 3 .5 te n sio n b and pla te 483

9.1.2 Extraarticu lar tran sce rvical fe m o ral 31-B1 com pre ssio n LCP proxim al fe m u r pla te 4 .5 te n sion b and pla te 4 87
n e ck fractu re an d lag scre w

9.1.3 Extraarticu lar in te rtro chan te ric 31-A1 com pre ssion LCP p roxim al fe m u r p la te 4 .5 co m p re ssio n 491
p roxim al fe m o ral fra ctu re an d lo cke d p la te and lo cke d
sp lin tin g in te rnal fixato r

9.1.4 Fe m o ral n e ck fractu re; tran sve rse 31-B2; co m p re ssio n LCP p roxim al fe m u r p la te 4 .5 co m p re ssio n 49 9
in te rtro chan te ric fractu re; fe m o ral 31-A3; an d lo cke d p la te an d lo cke d
sh aft fractu re 32-B2 sp lin tin g in te rnal fixa to r

9.1.5 Proxim al fe m o ral o ste o lysis lo cke d splin tin g LCP 4 .5/ 5.0 , b ro ad bu ttre ss p la te 507

9.1.6 Con ge n ital coxa vara w ith re sidu al co m p re ssio n LCP 3 .5; b u ttre ss p la te 511
h ip disp la sia LCP re co n stru ctio n p la te 3 .5

477
 9 Fe m u r

9 Fe m ur

9 .1 Fe m u r, p ro xim a l 47 9
9 .1.1 Avu ls io n fra ct u re o f gre a t t ro ch a n t e r 483
9 .1.2 Ext ra a r t icu la r t ra n s ce r vica l fe m o ra l n e ck
fra ct u re —31-B1 487
9 .1.3 Ext ra a r t icu la r in t e r t ro ch a n t e ric p ro xim a l fe m o ra l
fra ct u re —31-A1 4 91
9 .1.4 Fe m o ra l n e ck fra ct u re —31-B2 ; t ra n s ve rs e in t e r t ro ch a n t e ric
fra ct u re —31-A3; fe m o ra l s h a ft fra ct u re —32 -B2 499
9 .1.5 Pro xim a l fe m o ra l o s t e o lys is 507
9 .1.6 Co n ge n it a l co xa va ra w it h re s id u a l h ip d is p la s ia 511

478
 Au t h o r Em a n u e l Ga u t ie r

9.1 Fe m ur, proxim al

1 In cid e n ce 2 Cla s s ifica t io n

Troch an teric fractu res occu r predom in an tly in geriatric patien ts; Accordin g to th e Mü ller AO Classi cation , fractu res of th e
th ey are th e m ost frequ en t fractu res of th e prox im al fem u r. proxim al fem u r are d ivided in to th ree fractu re types:
High dem an ds are m ade on th e m ech an ical stability of th e in -
tern al xation . Th e extracapsu lar fractu re localization rarely
com prom ises th e vascu larity of th e fem oral h ead an d good
postoperative resu lts can gen erally be ex pected.

Fem oral n eck fractu res are frequ en t in elderly patien ts. Th ey
m ay also occu r in you n ger in d ividu als after h igh -en ergy trau m a.
a b c
Th e in tracapsu lar fractu re localization h igh ly com prom ises
th e vascu larity of th e fem oral h ead. Un d isplaced abdu ction Fig 31-A Extraarticu lar fractu re, troch an teric area.
9 .1.1a – c
fractu res w ith valgu s im paction m ay be stable en ou gh n ot to a 31-A1 pertroch an teric sim ple
requ ire su rgical procedu re. Du e to th e dan ger of secon dar y b 31-A2 pertroch an ter ic m u ltifragm en tar y
d isplacem en t, stability sh ou ld be ch ecked regu larly. c 31-A3 in tertroch an teric

In fem oral h ead fractu res, add ition al lesion s are to be con -
sidered. Th erefore, con com itan t fem oral n eck an d acetabu lar
fractu res are frequ en t. Th e in ju ry m ostly occu rs in car ac-
ciden ts. In su ch cases, h ip d islocation h as to be ru led ou t,
oth er w ise a redu ction h as to be perform ed as soon as possible.
In gen eral, fem oral h ead fractu res requ ire u rgen t treatm en t, a b c
an atom ical redu ction bein g m an datory.
Fig 31-B Extraarticu lar fractu re, n eck.
9 .1-2 a – c
a 31-B1 su bcapital, w ith sligh t d isplacem en t
b 31-B2 tran scer vical
c 31-B3 su bcapital, d isplaced, n on im pacted

a b c

Fig 31-C Articu lar fractu re, h ead.

9 .1-3 a – c
a 31-C1 split (Pipk in )
b 31-C2 w ith depression
c 31-C3 w ith n eck fractu re

479
 9 Fe m u r

3 Tre a t m e n t m e t h o d s 4 Im p la n t o ve r vie w

Main ly to be stressed is th e con cept of dyn am ic com pression

w ith th e u se of glid in g fem oral n eck screw s attach ed to an a
in tra- or extram edu llar y im plan t alon g th e fem oral sh aft.

Differen t im plan ts w ith differen t m ech an ical ch aracteristics

are u sed to treat th e fractu res of th e troch an teric area:
Extram edu llar y im plan ts w ith glid in g fem oral n eck screw
(DHS)
b
Extram edu llar y im plan ts w ith glid in g fem oral n eck screw
an d glid in g m ech an ism alon g th e fem oral sh aft (DHS-Me-
doff)
c
In tram edu llar y im plan ts w ith glid in g fem oral n eck screw
(Gam m a n ail, PFN, Troch an teric n ail)
Extram edu llar y im plan ts w ith n on glid in g blade in th e
fem oral n eck (95° con dylar plate)
d
In elderly patien ts w ith poor bon e qu ality, xation relies
m ain ly on glid in g m ech an ism s alon g th e fem oral n eck. Som e
Fig 9 .1-4 a – d
con cepts allow for secon dary coaptation , im paction , an d sta-
a LCP prox im al fem u r plate 4.5
bilization of th e fractu re in add ition to glid in g su pport for th e
(left an d r igh t version available)
fem oral sh aft. Th u s, in th e area of th e prox im al fem u r th ere
b LCP 4.5/5.0, broad
is gen erally n o n eed for stabilization u sin g an in tern al xator,
c LCP 4.5/5.0, broad, cu r ved
w ith two exception s, n am ely path ological fractu res du e to
d LCP DHS
bon e m etastasis an d in tertroch an teric corrective osteotom ies
in ch ildren or adolescen ts.

480
 9 .1 Fe m u r, p ro xim a l

5 Su gge s t io n s fo r fu r t h e r re a d in g

D av is TR , Sh e r J L, Ho rsm an A , e t al (1990) In tertroch an teric

fem oral fractu res. Mech an ical failu re after in tern al xation .
J Bone Joint Surg Br; 72(1):26 –31.
Larsso n S, Fribe rg S, Han sso n LI (1990) Troch an teric fractu res.
In u en ce of redu ction an d im plan t position on im paction an d
com plication s. Clin Orthop Relat Res; (259):130 –139.
Sch ip p e r IB, St e ye rbe rg EW, Cast e le in R M , e t al (2004)
Treatm en t of u n stable troch an teric fractu res. Ran dom ised
com parison of th e gam m a n ail an d th e proxim al fem oral n ail.
J Bone Joint Surg Br; 86(1):86 –94.
A d am s CI, Ro bin so n CM , Co u rt-Brow n CM , e t al (2001)
Prospective ran dom ized con trolled trial of an in tram edu llary n ail
versu s dyn am ic screw an d plate for in tertroch an teric fractu res of
th e femu r. J Orthop Trauma; 15(6):394 –400.
D av id A , Hü fn e r T, Le w an d row sk i KU, e t al (1996) [ Th e dyn am ic
h ip screw w ith su pport plate—a reliable osteosyn th esis for h igh ly
u n stable “reverse” troch an teric fractu res?] Chirurg; 67(11):1166 –1173.
D av iso n J N , Calde r SJ, A n d e rso n GH , e t al (2001) Treatm en t for
displaced in tracapsu lar fractu res of th e proxim al fem u r.
A prospective, ran dom ised trial in patien ts aged 65 to 79 years.
J Bone Joint Surg Br; 83(2):206 –212.
Parke r M J, K h an R J, Craw fo rd J, e t al (2002) Hem iarth roplasty
versu s in tern al xation for d isplaced in tracapsu lar h ip fractu res in
th e elderly. A ran dom ised trial of 455 patien ts. J Bone Joint Surg Br;
84(8):1150 –1155.
D re in h o fe r K E, Schw arzko p f SR , Haas N P, e t al (1996) [ Femu r
h ead d islocation fractu res. Lon g-term ou tcom e of con servative an d
su rgical th erapy.] Unfallchirurg; 99(6):400 –409.
A sgh ar FA , Karu n ak ar M A (2004) Fem oral h ead fractu res:
diagn osis, m an agem en t, an d com plication s. Orthop Clin North Am;
35(4):463 –472.
Sie be n ro ck K A , Gau t ie r E, Wo o A K H , e t al (2002) Su rgical
dislocation of th e fem oral h ead for join t debridem en t an d accu rate
redu ction of fractu res of th e acetabu lu m . J Orthop Trauma;
16(8):543 –552.

481
 9 Fe m u r

4 82
 Au t h o r Mich a e l Wa gn e r

9.1.1 Avulsion fracture of the gre at trochante r

1 Ca s e d e s crip t io n

46-year-old m an fell over on th e street an d lan ded on h is left

h ip. Mon otrau m a. Closed fractu re.

Fig 9 .1.1-1 Avu lsion fractu re of th e left greater troch an ter.

AP view.

In d ica t io n Pre o p e ra t ive p la n n in g

Pa in a n d m u scu la r in su f cie n cy Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
o f th e p e lvitro ch a n te ric m u scle s • LCP re co n s tru ctio n p la te 3 .5 , An tib io tics: n o n e
d u e to a d isp la ce d a vu lsio n fra c- 9 h o le s Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
tu re o f th e gre a te r tro ch a n te r. • 3 .5 m m lo ckin g h e a d scre w s
(LHS)
1 Su rge o n
• 2 .0 m m K-w ire s
2 ORP
• Ce rcla ge w ire
3 1st a ssistan t
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts
3
4 2n d a ssista n t
ca n va ry a cco rd in g to a n a to m y.)

Ste rile a re a

4
1
2

Fig 9 .1.1-2 Su p in e p o sitio n o n ra d io lu ce n t o p e ra tin g ta b le .

483
 9 .1 Fe m u r, p ro xim a l

2 Su rgica l a p p ro a ch

Fig 9 .1.1-3 Straigh t lateral in cision to th e great troch an ter.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .1.1-4 a – c
a After division of th e iliotibial tract, exposu re of th e dis- c Presh apin g of a 9-h ole recon stru ction LCP 3.5 to form a
placed fractu re. A stron g th read is w rapped arou nd the tip h ook plate, wh ereby th e h ooked part w ill be placed arou n d
of th e troch an teric fragm en t at th e ten don in sertion site an d th e tip of th e troch an ter (piriform fossa).
reduction is perform ed w ith pointed reduction forceps.
b In sert two 2.0 m m K-w ires from th e tip of th e troch an ter
in to th e m edu llar y cavity. Th ey w ill be u sed later for ten -
sion ban d xation .

484
 9 .1.1 Avu ls io n fra ct u re o f t h e gre a t t ro ch a n t e r

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

d e

Fig 9 .1.1-5 a – e
a After preten sion in g th e plate in a distal d irection w ith th e aid of th e poin ted
redu ction forceps, th e recon stru ction LCP is stabilized w ith a total of 4 m on o-
cortical LHS.
b To ach ieve an add ition al ten sion ban d effect, th e w ire is w rapped arou n d a d istal
lock in g h ead screw.
c Ten sion in g of th e cerclage w ire.
d Th e n al con stru ct.
e Troch an teric ten sion ban d xation an d h ook plate: in traoperative x-ray.

485
 9 .1 Fe m u r, p ro xim a l

4 Re h a b ilit a t io n

Fu ll weigh t bearin g after 2 weeks. Resu lt of th e follow-u p

in vestigation after 2 years: n o pain , free fu n ction .

Fig 9 .1.1-6 a – b
Postoperative x-rays after 2 years.
a AP view.
b Lateral view.

a b

486
 Au t h o rs Mich a e l J Ga rd n e r, De a n G Lo rich , Da vid L He lfe t

9.1.2 Extraarticular transce rvical fe m oral ne ck fracture —31-B1

1 Ca s e d e s crip t io n

a b c

80-year-old active h ealthy m an fell wh ile walkin g, lan ded on h is righ t side, su stain ed Fig 9 .1.2 -1a – c
a fem oral n eck fractu re w ith a sligh t varu s an d posterior an gu lation . Th ere were n o a AP view.
associated bon y, soft-tissu e, or n eu rovascu lar in ju ries. He h ad a h istory of a prox i- b AP view detail.
m al fem oral sh aft fractu re on th e righ t side over 50 years previou sly, wh ich h ad c Lateral view.
been treated w ith a plate. He also h ad a h istory of a fem oral n eck fractu re of th e
left h ip 3 years previou sly, w h ich h ad been treated w ith can n u lated screw xation ,
wh ich su bsequ en tly failed. He wen t on to salvage total h ip arth roplasty, an d devel-
oped m atu re h eterotroph ic ossi cation .

In d ica t io n Pre o p e ra t ive p la n n in g

Th is sligh tly d isp la ce d fe m o ra l n e ck fra ctu re in a n a ctive Eq u ip m e n t

p a tie n t re q u ire s re d u ctio n a n d xa tio n to a tte m p t to re -
ta in th e n a tive fe m o ra l h e a d a n d m in im ize th e risk o f
o ste o n e cro sis o f th e fe m o ra l h e a d .
• LCP p ro xim a l fe m u r p la te 4 .5 , 9 h o le s
• 5 .0 m m a n d 7.3 m m lo ckin g h e a d scre w s (LHS)
• 4 .5 m m co rte x scre w s
• 7.3 m m p a rtia lly th re a d e d ca n n u la te d scre w
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Afte r in tra o p e ra tive cu ltu re s h a ve b e e n ta ke n ,
give a n tib io tics 2n d ge n e ra tio n ce p h a lo sp o rin s

487
 9 .1 Fe m u r, p ro xim a l

Pre o p e ra t ive p la n n in g (co n t )

Fig 9 .1.2 -2 Su p in e p o sitio n o n ra d io lu ce n t ta b le o r 1 Su rge o n

tra ctio n ta b le . 2 ORP
4
3 1st a ssista n t
4 2 n d a ssistan t

Ste rile are a

3 1
2

2 Su rgica l a p p ro a ch

b
a

Fig 9 .1.2 -3 a – bPrior to preppin g an d drapin g, th e fractu re sh ou ld be m eticu lou sly redu ced u sin g
closed m an ipu lation w ith th e aid of th e traction table. Make a 10 cm in cision alon g th e proxim al
lateral th igh , startin g at th e greater troch an ter distally. Dissect th rou gh th e su bcu tan eou s tissu e
an d troch an teric bu rsa to expose th e iliotibial ban d. Make an L-sh aped in cision in th e iliotibial
ban d to iden tify th e vastu s lateralis. Re ect th e vastu s lateralis from th e vastu s ridge to expose
th e prox im al fem u r.

488
 9 .1.2 Ext ra a rt icu la r t ra n s ce r vica l fe m o ra l n e ck fra ct u re —31-B1
3 Re d u ct io n a n d fixa t io n
a b
In itially, u se th e traction table to place ax ial
Fig 9 .1.2 -4 a – c
traction on th e in ju red leg. Use AP an d lateral x-rays to vi-
su alize fractu re redu ction . Intern ally rotate the foot approxi-
m ately 45–90º as necessary. Abdu ct th e leg to correct varu s
align m en t.
A ball-spike pu sh er m ay be placed th rou gh a stab in cision an d
blu n t d issection alon g th e an ter ior fem oral n eck to correct
posterior align m en t. Wh en appropr iate position is obtain ed,
slowly release axial traction to allow fu ll con tact of th e fem o-
ral n eck fragm en ts.
Expose th e proxim al fem u r an d place th readed gu ides in th e
plate to aid position in g an d m an ipu lation . In sert a gu ide w ire
in th e 95° h ole so th at it ru n s approx im ately 1 cm below th e
piriform fossa. En su re th e w ire is cen tered in th e fem oral n eck
an d h ead on th e lateral view. Place a cortex screw th rou gh a
com bin ation h ole distally to secu re th e plate to th e fem oral
c
sh aft. Con rm th at th e 95º gu ide w ire h as rem ain ed in ad-
equ ate position w ith in th e fem oral h ead, an d rem ove an d re-
position it if n ecessary. If in d icated, place a 7.3 m m partially
th readed can n u lated screw ou tside th e plate for add ition al
xation an d to ach ieve in itial com pression .
In sert th e gu ide w ires th rou gh th readed gu ides in to th e 120 º
an d 135º h oles. Measu re an d in sert th e th ree correspon d in g
lock in g h ead screw s in to th e fem oral h ead —7.3 m m (95º), 7.3
m m (120 º), an d 5.0 m m (135º). Secu re th e plate to th e proxi-
m al fem u r th rou gh th e d istal screw h oles u sin g lockin g or
n on lock in g screw s.
Reapprox im ate th e vastu s lateralis fascia laterally, su tu r in g it
to th e plate if n ecessary. In sert a deep su ction drain an d close
th e wou n d in layers, repairin g th e iliotibial ban d in cision .
48 9
 9 .1 Fe m u r, p ro xim a l

4 Re h a b ilit a t io n

Con tinu e prophylactic an tibiotics for 24 h ou rs.

In itiate deep ven ou s t h rom bosis (DVT) proph yla x is w ith
low-m olecu lar h eparin an d pn eu m atic foot pu m ps.
Mobilize the patient on the rst postoperative day w ith physical
therapy, u sing a regimen of 10 kg touchdow n weight bearin g
c for 6 weeks, increasin g progressively to fu ll weight bearin g at 3
month s.
Fig 9 .1.2 -5 a – c
a – b 4 m on th s follow in g locked platin g of th e righ t fem oral n eck, th e im plan t an d fractu re
are still well position ed.
c Th e patien t n ow am bu lates w ith ou t d if cu lty or pain , an d h as good active h ip ran ge
a b of m otion at th e h ip.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Cu rren tly, th e 5.0 m m lock in g h ead screw system is In particu larly large patien ts, or in patien ts w ith lon g
available in m axim u m len gth s of 95 m m , w h ich m ay fem oral n ecks, th e screw s m ay be too sh ort. In th is case,
be too sh ort for som e patien ts. n on lock in g screw s or an oth er device sh ou ld be u sed.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Often prim arily th e redu ction m an eu ver is visu alized on It is critical to pay close atten tion to th e redu ction on th e
th e AP x-ray, wh ich m ay lead to in adequ ate redu ction . lateral view. In th e vast m ajority of cases, th e proxim al
fragm en t is an gled posteriorly, resu ltin g an an ter ior apex
position . Be su re to correct th is position of m alalign m en t.
Th e m ajor advan tage of th is device is th at it m ain tain s
fem oral n eck len gth an d h ip an atom y.

Re h a b ilit a t io n Re h a b ilit a t io n
If weigh t bearin g is advan ced too qu ick ly, xation failu re The LCP proxim al femu r plate is optim ally u sed in you nger,
m ay occu r. mentally alert and t patients who can reliably rem ain
partially weight bearin g for weeks. For elderly or demented
It is often d if cu lt to determ in e h ealin g of th e fem oral patients, an altern ative device th at allows early fu ll weight
n eck. bearing m ay be preferable.

Closely mon itor serial x-rays to assess ch an ge in screw

position in the femoral head and evidence of healing of the
femoral neck.

49 0
 Au t h o rs Ph ilip J Kre go r, Erika J Mit ch e ll
9.1.3 Extraarticular inte rtrochante ric proxim al fe m oral
fracture —31-A3
1 Ca s e d e s crip t io n
b ten sion was seen w ith in volvem en t of th e lesser
In d ica t io n
Th is fra ctu re re p re se n ts a h igh ly-d isp la ce d , p roxim a l fe m o ra l fra c-
tu re w ith d e fo rm it y in a n e ld e rly, o ste o p o ro tic fe m a le . No n o p e ra tive
m a n a ge m e n t wo u ld le a d to sign i ca n t d e fo rm it y, in a b ilit y to m o b i-
lize th e p a tie n t, a n d a h igh e r risk o f n o n u n io n . Su rgica l o p tio n s fo r
sta b iliza tio n b y in te rn a l xa tio n in clu d e a n a n gle d b la d e p la te 9 5°,
d yn a m ic co n d yla r scre w 9 5°, ca n n u la te d tro ch a n te ric xa tio n n a il o r
70-year-old wom an fell dow n th e stairs an d su s-
tain ed a fractu re of h er r igh t prox im al fem u r. Low-
en ergy trau m a, closed fractu re.
Fig 9 .1.3 -1a – b
a AP x-ray of th e righ t prox im al fem oral region .
Th e x-ray depicted sign i can t varu s deform ity
an d extern al rotation of th e prox im al fem oral
region . In add ition , sign i can t d iaphyseal ex-
troch an ter (m ild osteoarth r itis of th e h ip was
also n oted).
b Cross-table lateral of th e prox im al fem u r is u su -
ally d if cu lt to obtain in th is settin g. Non eth e-
less, it gives h elpfu l in form ation . On th is x-ray,
on e n otes th e sign i can t ex ion of th e prox im al
fragm en t. In addition , n o exten sion of fractu re
lin es in to th e greater troch an ter or piriform
fossa region is n oted.
LCP p roxim a l fe m u r p la te . Th e a d va n ta ge s o f a 9 5° a n gle d b la d e p la te
in clu d e a vo id a n ce o f su rgica l in su lt to th e a b d u cto rs, b u t it d o e s re -
q u ire a la rge su rgica l e xp o su re . Th e ca n n u la te d tro ch a n te ric xa tio n
n a il a vo id s la rge r su rgica l e xp o su re s, b u t re m o ve s a re la tive ly la rge
a m o u n t o f b o n e in th e p roxim a l fe m u r a n d is a lso a sso cia te d w ith
su rgica l in su lt to th e h ip a b d u cto rs.
491
 9 .1 Fe m u r, p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP p ro xim a l fe m u r p la te 4 .5 , 14 h o le s
• 5 .0 m m lo ckin g h e a d scre w (LHS)
• 7.3 m m LHS
• Exte rn a l xa to r Sch a n z scre w s (5 .0 a n d 6 .0 m m )
to h e lp fa cilita te re d u ctio n
• Po in te d re d u ctio n fo rce p s ( We b e r fo rce p s)
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 9 .1.3 -2 Th e p a tie n t is p la ce d o n a tra ctio n

a b
Fig 9 .1.3 -3 a – b
a An AP x-ra y o f th e p ro xim a l fe m u r is n o te d u n d e r tra ctio n .
b Sh o w s a cro ss-ta b le la te ra l vie w o f th e p ro xim a l fe m u r. Th e re is s till
p o s te rio r d isp la ce m e n t o f th e d is ta l se gm e n t re la tive to th e p ro xim a l
se gm e n t, a n d a e xio n d e fo rm it y o f th e p ro xim a l se gm e n t. Th e p irifo rm
fo ssa re gio n sh o u ld a lso b e e xa m in e d a t th is p o in t to se e if th e re is a n y
e xte n sio n in to th is re gio n . No n e w a s n o te d in th is ca se .
ta b le . Th e fo o t is p u t in a w e ll-p a d d e d b o o t, a n d th e
righ t lo w e r e xtre m it y is in b o o t tra ctio n . Fo r a h igh -
e n e rgy fra ctu re , righ t d ista l fe m o ra l tra ctio n m a y
b e a p p lie d , a s a gre a te r fo rce fo r re d u ctio n m a y b e
n e e d e d . Th e le ft lo w e r e xtre m it y lie s in a w e ll-le g
h o ld e r, a n d th e righ t a rm is p la ce d o ve r p a d d in g o f
th e ch e s t.
Th e im a ge in te n si e r is b ro u gh t b e t w e e n th e t w o
le gs a n d b e fo re p re p a ra tio n a n d d ra p e in g, it is
e n su re d th a t a go o d AP a n d la te ra l x-ra y o f th e h ip
ca n b e o b ta in e d . A sm a ll a m o u n t o f tra ctio n w a s
e xe rte d .

492
 9 .1.3 Ext ra a rt icu la r in t e r t ro ch a n t e ric p ro xim a l fe m o ra l fra ct u re —31-A3

2 Su rgica l a p p ro a ch

Fig 9 .1.3 -4 a – b
a An 8 –10 cm m id lin e in cision over th e prox im al aspect of
th e lateral fem u r is m ade, begin n in g approx im ately 1 cm
cran ial to th e tip of th e greater troch an ter an d con tin u in g
dow n th e m id lateral aspect of th e fem u r. Sh ar p d issection
is carried dow n th rou gh th e sk in an d su bcu tan eou s tissu e
a to th e level of th e iliotibial ban d, wh ich is in cised.
A distal m id lin e in cision is m ade over th e distal aspect of
th e plate, over approx im ately th e d istal 3 h oles. Th is in ci-
sion is an alogou s to th e proxim al in cision over th e prox i-
m al en d of a 13-h ole LISS xator. It allow s th e su rgeon to
palpate th e plate on th e m id lateral aspect of th e fem oral
sh aft. In add ition th e rotation al relation sh ip between th e
plate an d th e con vex su rface of th e d iaph yseal fem u r can
b be assessed an d m odi ed.
b An L-sh aped in cision in th e vastu s lateralis mu scle is th en
m ade to detach th e posterior 50% of th e vastu s lateralis
from its origin .

493
 9 .1 Fe m u r, p ro xim a l
3 Re d u ct io n a n d fixa t io n
a b
Fig 9 .1.3 -5 a – e
a Th e LCP prox im al fem u r plate is th en in serted in a su b-
m u scu lar m an n er an d an appropriate relation sh ip to th e
proxim al fem u r is establish ed. Note th e th ree sleeves for
placem en t of 2.5 m m gu ide w ires in th e prox im al fem u r.
In preoperative plan n in g, a 95° tem plate of th e plate on
th e opposite in tact femu r can pred ict wh ere th e rst screw
(7.3 m m ) sh ou ld be in serted in to th e proxim al fem u r. Th e
rst screw of th e plate is at a 95° an gle to th e lon g axis of
th e plate. Th e secon d screw (7.3 m m ) is at an an gle of 120°,
an d th e th ird screw is at an an gle of 135°. At th is poin t th e
proxim al fem u r was still in extern al rotation an d in sligh t
varu s position .
49 4
c d
b A Sch an z screw is placed from th e su perior aspect of th e
greater troch an ter from an terior to poster ior. Th is Sch an z
screw is u sed to con trol extern al rotation an d varu s defor-
m ity. Care m u st be taken to en su re th at th e Sch an z screw
is n ot in th e way of th e even tu al plate placem en t.
c Th e Sch an z screw is u sed to correct a sm all am ou n t of
varu s deform ity.
d An add it ion a l gu ide w ire is placed in t h e prox im a l fem u r
(first d r ill gu ide) on ce t h e va r u s defor m it y h as been
corrected.
e Appropriate placem en t of th e proxim al gu ide w ires (an d
h en ce even tu al screw s) mu st be con rm ed via lateral im -
age in ten si cation view.
 9 .1.3 Ext ra a rt icu la r in t e r t ro ch a n t e ric p ro xim a l fe m o ra l fra ct u re —31-A3

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 9 .1.3 -6 a – c
a Med ial tran slation of th e d istal segm en t is n oted. How-
ever, appropriate len gth h as been ach ieved.
b A bicortical cortex screw is u sed as a redu ction device,
brin gin g th e fem oral sh aft to th e plate. It sh ou ld be n oted
th at prior to doin g th is, an in cision was m ade over th e d is-
tal en d of th e plate to en su re th at it is on th e m id lateral as-
pect of th e fem u r. If th is is th e case, a gu ide w ire is placed
in th e m ost d istal h ole to h old th e plate on th e m id lateral
aspect of th e fem u r.
c Redu ction of th e fem oral sh aft to th e plate.

Fig 9 .1.3 -7 In traoperative view of th e proxim al en d of th e xator

on th e prox im al femu r. Note th at n o visu alization of th e fractu re
is seen , an d n o devitalization of th e abdu ctors occu rs. Note th at
two 7.3 m m LHS, fu lly th readed, can th en be placed over th e two
gu ide w ires. Prior to th is, th e Sch an z screw h as been rem oved
from th e proxim al fem u r. An addition al th ird screw (5.0 m m) is
th en placed in th e th ird h ole. Th is sh ou ld abu t th e rst screw an d
act as a “kickstan d” to preven t varu s collapse of th e rst screw.

495
 9 .1 Fe m u r, p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 9 .1.3 -8 a – b
a In th is x-ray, th e th ird screw is n ot of optim al len gth , an d
sh ou ld be 5 m m lon ger.
b A lateral x-ray con rm s appropriate placem en t of th e th ree
proxim al screw s in th e fem oral n eck an d h ead. It can also
be u tilized to determ in e th e redu ction in th e lateral plan e.
Note th at n o attem pt was m ade to redu ce or x th e poste-
b rior bu tter y fragm en t.

Fig 9 .1.3 -9 a – b
a AP x-ray of postoperative redu ction of th e prox im al fem u r.
Th is x-ray was obtain ed postoperatively in th e operatin g
room w ith both legs in in tern al rotation . Th e su rgeon
sh ou ld ju dge th e redu ction qu ality by look in g at restora-
tion of Sh en ton ’s lin e, com parison of th e n eck – sh aft an gle
w ith th e opposite site, an d com parison of th e m or ph ology
of th e lesser troch an ter to ascertain rotation al pro le (if
th e lesser troch an ter is n ot in volved).
b Postoperative lateral x-ray of th e proxim al fem u r, wh ich
dem on strates appropr iate align m en t of th e proxim al seg-
m en t to th e d istal segm en t. Several lock in g h ead screw s
are placed in th e d istal segm en t du e to th e osteoporosis in
a b th is 70-year-old fem ale.

49 6
 9 .1.3 Ext ra a rt icu la r in t e r t ro ch a n t e ric p ro xim a l fe m o ra l fra ct u re —31-A3

4 Re h a b ilit a t io n

Add ition al im m obilization : No; braces are u tilized.

Weigh t bearin g: Half body weigh t after su rgery. Fu ll weigh t bearin g after 6 –8
weeks. It m u st be recogn ized in th e geriatric osteoporotic in d ividu al th at is it n ot
possible for th e patien t to con trol weigh t bearin g well. Th e patien t h as im m ed i-
ate ran ge of m otion of th e h ip an d k n ee. Qu adriceps fem ori an d abdu ctor m u scles
stren gth en in g is em ph asized.
Bon e h ealin g after 12 weeks.

b c

Fig Follow-u p x-rays at 4 1/ 2 m on th s.

9 .1.3 -10 a – c
a AP view of th e righ t prox im al fem u r.
b AP view of th e pelvis.
c Lateral view of th e righ t proxim al fem u r.

497
 9 .1 Fe m u r, p ro xim a l
5 Pit fa lls –
Eq u ip m e n t
In ability to obtain good AP an d lateral view s of th e h ip
in traoperatively can m ake it d if cu lt to assess appropr iate
gu ide-w ire an d screw placem en t.
Ap p ro a ch
Soft-tissu e d issection to visu alize th e fractu re is u su ally
u n n ecessar y an d can lead to devitalization of th e fractu re.
Re d u ct io n a n d xa t io n
Failu re to recogn ize or correct th e extern al rotation an d
varu s deform ity of th e proxim al fragm en t w ill m ake it
d if cu lt to place th e proxim al screw s appropriately an d
w ill also lead to m alredu ction .
It can be d if cu lt to place an d m ain tain a lon g plate on
th e m id lateral aspect of th e fem u r wh en placed u sin g a
su bm u scu lar approach . Th is can lead to m alredu ction if
proxim al xation is perform ed before distal align m en t of
th e plate is en su red.
49 8
6 Pe a rls +
Eq u ip m e n t
Th e im age in ten si er sh ou ld be brou gh t in prior to
preparation an d drapin g to en su re th at good AP an d
lateral view s can be obtain ed.
Ap p ro a ch
Th e vastu s lateralis is elevated on ly en ou gh to allow
placem en t of th e th ree prox im al lock in g sleeves.
Re d u ct io n a n d xa t io n
Sch an z screws in the greater troch anter or a Hoh m an n
retractor placed posterior to the greater troch anter can be
u sed to correct the deform ity prior to placement of the
proxim al screws.
The proxim al femu r h as been derotated and kicked out of
varu s by u se of traction and w ith the aid of the Sch an z pin
placed in the proxim al femu r. It is then locked into position
w ith two proxim al gu ide w ires. One bicortical screw h as
been placed ju st distal to the fractu re. Th is screw can be u sed
to bring the sh aft to the plate for appropriate align ment.
A sm all incision is m ade over the distal aspect of the plate
prior to de n itive proxim al xation to en su re align ment on
the m idlateral femoral sh aft. The plate is then held in place
w ith a gu ide w ire.
 Au t h o rs Ph ilip J Kre go r, Erika J Mit ch e ll
9.1.4 Fe m oral ne ck fracture —31-B2; transve rse inte rtrochante ric
fracture —31-A3; fe m oral shaft fracture —32-B2
1 Ca s e d e s crip t io n
a b
In d ica t io n
Th is m u ltile ve l p ro xim a l fe m o ra l/ fe m o ra l sh a ft in ju ry in a p o lytra u -
m a tize d e ld e rly p a tie n t p ro vid e s a cle a r in d ica tio n fo r o p e ra tive sta b i-
liza tio n . It is re co gn ize d tha t a h igh ly d isp la ce d Pa u we ls’ cla ssi ca tio n
t yp e III fe m o ra l n e ck fra ctu re in a n e ld e rly w o m a n wo u ld o rd in a rily
b e a n in d ica tio n fo r a n a rth ro p la st y. Ho w e ve r, th e co m p le x p ro xim a l
fe m o ra l fra ctu re , th e a sso cia te d d ista l fe m o ra l sh a ft fra ctu re , a s we ll
a s o p e n wo u n d s in th e se t tin g o f a p o lytra u m a tize d p a tie n t m a ke th e
d e cisio n m a kin g fo r o p e n re d u ctio n in te rn a l xa tio n ve rsu s a rth ro -
p la st y n o t cle a r cu t.
71-year-old wom an wh o was in volved in a m otor veh icle colli-
sion an d su stain ed m u ltiple in ju ries: mu ltiple facial fractu res,
left rib fractu res, basilar sku ll fractu re, left mu ltifragm en tary
8 cm open d istal h u m eral fractu re, left m u ltifragm en tary
proxim al u ln ar fractu re, left both -bon e forearm fractu re, an d
th is com plex prox im al fem oral fractu re w ith associated fem o-
ral sh aft fractu re. Th e left lower extrem ity fractu re con sists
of a vertical sh ear (Pau wels’ classi cation grade III) fem oral
n eck fractu re, a tran sverse in tertroch an ter ic fractu re, an d a
d iaphyseal fem oral sh aft fractu re w ith separate wedge bu t-
ter y fragm en t laterally.
Fig 9 .1.4 -1a – b
a AP view of th e d iaph yseal fem oral sh aft fractu re w ith sep-
arate wedge bu tter y fragm en t laterally.
b X-ray of th e vertical sh ear fem oral n eck fractu re an d th e
tran sverse in tertroch an teric fractu re.
Po ssib le o p tio n s in clu d e :
1. Tro ch a n te ric n a il p la ce m e n t a fte r o p e n re d u ctio n o f th e fe m o ra l
n e ck fra ctu re .
2 . Hip a rth ro p la st y o r h e m ia rth ro p la st y w ith p la te xa tio n o f th e d ista l
fe m o ra l sh a ft fra ctu re .
3 . Op e n re d u ctio n in te rn a l xa tio n o f th e fe m o ra l n e ck fra ctu re w ith
xa tio n o f th e p roxim a l fe m o ra l fra ctu re a n d fe m o ra l sha ft fra c-
tu re s w ith p la te xa tio n .
49 9
 9 .1 Fe m u r, p ro xim a l

In d ica t io n

Fig 9 .1.4 -2
Th e ch a lle n ge in th is ca se is to p ro vid e a d e q u a te xa tio n o f th e fe m o -
ra l n e ck fra ctu re a fte r a p p ro p ria te re d u ctio n w ith o u t d istu rb in g th e
re d u ctio n b y p la cin g th e im p la n t u tilize d fo r xa tio n . Th e re w o u ld b e
co n ce rn re ga rd in g d ispla ce m e n t o f th e fe m o ra l n e ck fra ctu re if th e
95°
su rge o n p la ce d e ith e r a n a n gle d b la d e p la te 9 5° o r a tro ch a n te ric n a il.
Fo r th is re a so n , th e LCP p ro xim a l fe m u r p la te 4 .5 is id e a l.

Th e thre e proxim al scre w h o le s are a t th e follo w ing angle s: rst p roxi- 120 °
m al ho le (7.3 m m can nu la te d scre w s) 95°, the se co nd p roxim al ho le
(7.3 m m cann u la te d scre w s) 120 °, and the th ird p roxim al h o le (5.0 m m
cann ula te d scre w s) 135°. The th re e proxim al scre w s have con ical and
135°
lo cking he ad op tions. Distally, LCP com bina tion hole s are pre se n t.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP p ro xim a l fe m u r p la te 4 .5 , 14 h o le s
• 4 .5 m m lo ckin g h e a d scre w s (LHS)
• 3 .5 m m scre w s (fo r xa tio n o f co rtica l
fra gm e n ts in th e fe m o ra l n e ck).
• 4 .0 m m a n d 5 .0 m m Sch a n z scre w s
• K-w ire s
• Po in te d re d u ctio n fo rce p s
( We b e r cla m p s)
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: rst ge n e ra tio n ce p h a lo sp o rin a n d a m in o glyco sid e
(se co n d a ry to o p e n in ju ry o f th e le ft d is ta l h u m e ru s)
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin fo r th re e
w e e ks
Fig 9 .1.4 -3 Th e p a tie n t is p la ce d su p in e
o n a co m p le te ly ra d io lu ce n t ta b le w ith a
sm a ll b u m p u n d e rn e a th th e le ft b u t to ck.
Th e e n tire le ft b u t to ck a re a a n d le ft lo w e r
e xtre m it y is th e n p re p p e d a n d d ra p e d
fre e .

500
 9 .1.4 Fe m o ra l n e ck fra ct u re —31-B2; t ra n s ve rs e in t e r t ro ch a n t e ric fra ct u re —31-A3;
fe m o ra l s h a ft fra ct u re —32 -B2

2 Su rgica l a p p ro a ch

Th e su rgical approach for th is case is a Watson -Jon es approach
for redu ction an d xation of th e prox im al fem oral fractu re,
followed by a closed redu ction an d su bm u scu lar platin g of
th e fem oral sh aft fractu re. A sm all in cision is m ade over th e
fractu re to m an ipu late th e bu tter y fragm en t in to position .
A sm all d istal sk in in cision is m ade over th e distal fem oral
sh aft. Th is is don e to allow for palpation of th e plate on th e
d istal aspect of th e fem u r. Th is also allow s for placem en t of
screw s in th e d istal aspect of th e fem u r.

3
3
4
1

a b

1 Gre a te r tro chan te r

2 An te ro sup e rio r iliac sp in e
3 Te n so r o f fa scia la ta
4 Glu te u s m e d iu s
5 Va stu s la te ra lis

5
4

c d

Fig 9 .1.4 -4 a – d
a Th e Watson -Jon es approach em ploys a cu rvilin ear in cision , c Th e vastu s lateralis m u scle is th en re ected in feriorly, an d
wh ich is cen tered over th e an terior aspect of th e greater th e h ip capsu le is ex posed. Th e fatty tissu e on th e an terior
troch an ter. Th is in cision begin s approx im ately 4 cm d istal aspect of th e h ip capsu le is rem oved.
to th e iliac crest at approx im ately 3 –4 cm posterior to th e d Th e dotted lin es represen t th e T capsu lotom y w ith th e base
an terosu perior iliac spin e. at th e in tertroch an teric lin e.
b A fatty w h ite stripe delin eates th e in ter val between th e
ten sor of fasciae latae an d th e glu teu s m ed iu s m u scle. Th e
in terval is th en split u p to approx im ately 5 cm from th e
iliac crest.

501
 9 .1 Fe m u r, p ro xim a l

3 Re d u ct io n a n d fixa t io n

Sch an z scre w fo r ro ta tio n a l co n tro l

1
Fractu re

a b

c d e

Fig 9 .1.4 -5 a – e
a Th e Watson -Jon es in terval gives d irect ex posu re of th e vertical fem oral n eck fractu re (1)
an d th e in tertroch an ter ic fractu re (2). Th e key is to re-establish th e m ed ial cortex of th e
fem oral n eck an d to obtain com pression across th e fem oral n eck.
b – e Redu ction aids for th e fem oral n eck fractu re in clu de: m anu al traction , a 4.0 m m Sch an z
screw in th e fem oral n eck/ h ead fragm en t for rotation al con trol of th is fragm en t, a 5.0 m m
Sch an z screw in th e prox im al fem oral sh aft, an d large poin ted redu ction forceps. Th e poin t-
ed redu ction forceps (Weber forceps) are extrem ely im portan t in provid in g com pression
across th e fem oral n eck fractu re an d for re-establish in g th e n orm al n eck sh aft an gle. Often ,
a m od i ed (straigh ten ed) ton g of th e Weber forceps is placed in th e su perior aspect of th e
fem oral n eck th rou gh a pilot h ole an d th e oth er ton g of th e Weber forceps is placed on th e
lateral cortex of th e proxim al fem u r.
In th is particu lar case, th e an terior cortical piece in th e in ferom ed ial aspect of th e fem oral
n eck area is keyed back in to position an d a lag screw is placed from an terior to poster ior.
Provision al xation of th e proxim al fem u r is th en em ployed an d th e LCP proxim al fem u r
plate is th en slid dow n in a su bm u scu lar m an n er alon g th e fem oral sh aft fractu re.
Note: x-rays sh ow n in th is gu re dem on stratin g redu ction of th e fem oral n eck are u sed for
illu strative pu r poses an d are n ot associated w ith th e speci c case u n der d iscu ssion .

5 02
 9 .1.4 Fe m o ra l n e ck fra ct u re —31-B2; t ra n s ve rs e in t e r t ro ch a n t e ric fra ct u re —31-A3;
fe m o ra l s h a ft fra ct u re —32 -B2

3 Re d u c t io n a n d fixa t io n (co n t )

a b c d

Fig 9 .1.4 -6 a – e Dem on strates th e postoperative AP an d lat-

eral x-rays of th e prox im al an d d istal fem u r after redu ction
an d xation of th is fractu re. Note th at th e n orm ally straigh t
proxim al fem oral plate h as been con tou red, an d, on th e im -
m ediate postoperative x-ray, th is con tou rin g appears to create
excess valgu s (h owever fu tu re x-rays dem on strate th at th e
valgu s is acceptable).
In th e im m ediate postoperative x-ray excess valgu s is in deed
apparen t. However, x-rays dem on strate clin ically acceptable
align m en t. Th e su rgeon mu st also rem em ber to torqu e th e
d istal en d of th e plate to t th e lateral slope of th e d istal fem o- e
ral cortex.

4 Re h a b ilit a t io n

Th e patien t h as im m ed iate ran ge of m otion of h er left h ip an d

k n ee w ith qu adriceps stren gth en in g an d abdu ctor stren gth -
en in g. Becau se of h er com plex left u pper extrem ity in ju r y,
sh e was on ly able to go from bed to wh eelch air for th e rst
14 weeks. After th at tim e, progressive weigh t bearin g was al-
lowed. Sh e was fu ll weigh t-bearin g by week 16.

503
 9 .1 Fe m u r, p ro xim a l

4 Re h a b ilit a t io n (co n t )

a b

Fig 9 .1.4 -7a – ePostoperative x-rays after 1 year. Sh e h as a com pletely

n orm al h ip, n o sign s of left lower extrem ity sh orten in g, sligh t clin ical
valgu s (approxim ately 3°).
a AP view pelvis.
b AP view left prox im al fem u r.
c Lateral view left d istal fem u r.
d AP view left d istal fem u r.
e Lateral view left d istal fem u r.

d e

504
 9 .1.4 Fe m o ra l n e ck fra ct u re —31-B2; t ra n s ve rs e in t e r t ro ch a n t e ric fra ct u re —31-A3;
fe m o ra l s h a ft fra ct u re —32 -B2
5 Pit fa lls –
Eq u ip m e n t
Th e placem en t of th e LCP prox im al fem u r plate 4.5 on th e
proxim al fem u r is critical to th e placem en t of th e screw s
an d m u st be ch ecked both on th e AP an d lateral x-rays.
Wh en u tilizin g a lon g LCP prox im al fem u r plate 4.5 or
an y plate placed in a su bm u scu lar m an n er, th e appropri-
ate valgu s an d sligh t in tern al rotation al tw ist on th e d istal
aspect of th e plate sh ou ld be effected.
Ap p ro a ch
Th e com m on m istake is to en ter in to th e m u scle belly of
eith er th e ten sor fasciae latae or th e glu teu s m ed iu s.
If th e T-com pon en t of th e capsu lotom y in th e h ip join t is
n ot cen tered over th e m idportion of th e fem oral n eck, th is
can m ake exposu re su boptim al.
Re d u ct io n a n d xa t io n
Th e m ajor pitfall w ith open redu ction an d in tern al xa-
tion of th e fem oral n eck fractu re is lack of com plete visu -
alization of th e m edial aspect of th e fem oral n eck. Th is is
im portan t becau se th is m u st be com pletely restored. In
add ition , it is im perative th at th e fem oral n eck fractu re be
com pressed for u ltim ate stability. Fin ally, a pitfall wou ld
be for displacem en t of th e fem oral n eck fractu re w ith th e
im plan t u tilized for xation .
6 Pe a rls +
Eq u ip m e n t
Carefu l placem en t of th e LCP proxim al fem u r plate 4.5 in
term s of distal cran ial placem en t an d in term s of an tever-
sion can m ake relatively large ch an ges in th e placem en t of
th e screw s. As lon g as th is is con trolled rad iograph ically,
screw placem en t can be ideal.
Utilization of in traoperative saw-bon e m odels for th e
d istal fem u r m ay be h elpfu l in ju dgin g th e con tou r in g of
th e d istal aspect of th e xator. In add ition , u tilization of
im age in ten si cation view s of th e d istal femu r com pared
w ith th e con tou rin g of th e xator m ay be h elpfu l.
Ap p ro a ch
Carefu l delin eation of th e fatty w h ite strip between
th e ten sor fascia lata an d th e glu teu s m ed iu s mu scle w ill
en su re proper developm en t of th e in ter val.
With a sm all am ou n t of traction on th e leg, eith er by
m anu al traction or w ith a traction table, im age in ten si ca-
tion of th e cen ter of th e fem oral n eck is h elpfu l.
Re d u ct io n a n d xa t io n
If th e Watson -Jon es approach is appropr iately m ade, good
visu alization of th e en tire fem oral n eck is possible. Th e
su rgeon can key in separate cortical fragm en ts, an d th en
com press th e fractu re as n oted in th is case via Weber
forceps. Rotation al con trol of th e two fragm en ts is m ade
possible via Sch an z screw s in eith er th e proxim al segm en t
or th e distal segm en t. Utilization of th e LCP proxim al
fem u r plate 4.5 w ill allow for n on aggressive placem en t of
th e im plan t in th e proxim al fem u r. In add ition , n on lock-
in g screw s m ay be placed w h ich are partially th readed.
Th ey allow com pression . In th is case on e su ch partially
th readed can cellou s bon e lag screw is u sed.
505
 9 .1 Fe m u r, p ro xim a l

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

A com m on pitfall in th e su bm u scu lar xation of th e
fem oral sh aft fractu re is failu re to recreate th e an terior
cu r vatu re of th e fem oral sh aft.
Bu m ps of 8, 10, an d 12 towels rolled u p in elastic ban dage
m ay be u tilized on th e posterior aspect of th e leg to h elp
recreate th e n orm al an terior cu r vatu re of th e fem oral
sh aft. Sligh t ch an ges in th e placem en t or size of th e bu m p
can m ake large ch an ges in th e sagittal plan e redu ction .

Re h a b ilit a t io n Re h a b ilit a t io n
Stiffn ess of th e kn ee or h ip can be problem atic in th is Aggressive ran ge of m otion of th e h ip an d kn ee is possible
com plex fractu re. postoperatively secon dary to th e good stability afforded by
th e LCP prox im al fem u r plate 4.5.

506
 Au t h o r Mich a e l Wa gn e r
9.1.5 Proxim al fe m oral oste olysis
1 Ca s e d e s crip t io n
a b
In d ica t io n
Th re a te n e d fra ctu re o f th e
p ro xim a l fe m u r w ith p a th o lo gica l
o ste o lysis. Pa llia tive sta b iliza tio n
in o rd e r to a llo w th e p a tie n t to
b e m o b ilize d w ith a s little p a in
a s p o ssib le .
62-year-old wom an path ological os-
teolysis of th e left prox im al fem u r
w ith m am m a tu m or, th reaten ed
fractu re, an d pain . Gen eralized bon e
m etastases in th e lu m bar spin e an d
pelvis, addition al h epatal an d pu l-
m on ar y secon dary m etastases.
Fig 9 .1.5 -1a – c
a AP view.
b AP view detail.
c Lateral view.
c
Pre o p e ra t ive p la n n in g
Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP 4 .5/ 5 .0 , b ro a d , 17 h o le s An tib io tics: 4 th ge n e ra tio n ce p h a lo sp o rin
• Lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
• 2 .0 m m K-w ire s
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts 1 Su rge o n
ca n va ry a cco rd in g to a n a to m y.)
2 ORP
3 1st a ssistan t
3
4 2n d a ssista n t
Ste rile a re a
2 4
1
Fig 9 .1.5 -2 Su p in e p o sitio n o n ra d io lu ce n t o p e ra tin g ta b le .
507
 9 .1 Fe m u r, p ro xim a l

2 Su rgica l a p p ro a ch

a b

c d e

Fig 9 .1.5 -3 a – e
a Lateral approach to th e proxim al fem u r an d add ition al lateral approach to th e
m idsh aft.
b Preoperative m ark in g of lan d m arks an d osteolysis zon e.
c Lateral in cision to th e proxim al fem u r an d prede n ed distal en d of th e plate in
th e m idsh aft of th e fem u r.
d Follow in g splittin g of th e fascia an d m obilization of th e rectu s vastu s lateralis,
th e m etastasis is revealed.
e Su bm u scu lar tu n n elin g for preparation of th e epiperiosteal space pr ior to plate
in sertion in a prox im al to d istal d irection .

508
 9 .1.5 Pro xim a l fe m o ra l o s t e o lys is

3 Re d u ct io n a n d fixa t io n

a b c

d e

Fig 9 .1.5 -4 a – e
a Preben d in g of th e broad LCP 4.5/5.0 to t to th e an atom y of th e prox im al fem u r.
A th readed drill sleeve is u sed as a h an d le.
b Th e plate is in serted su bm u scu larly, w ith th e aid of th e th readed drill sleeve,
in to th e epiperiosteal space in a prox im al to d istal d irection .
c After screw in g in a secon d d rill sleeve at th e distal en d of th e plate an d applyin g
two gu id in g sleeves for 2.0 m m K-w ires, tem porary xation of th e plate w ith th e
aid of two K-w ires an d con trol u sin g th e im age in ten si er.
d Su bsequ en t proxim al xation w ith th ree self-tappin g LHS. Preben d in g of th e
plate allow s th em to ru n in a con vergin g d irection .
e Th e poin ts of th e tweezers are poin tin g to th e tu m or tissu e in th e area of th e
proxim al fem u r.

Fixation of th e broad LCP prox im ally w ith fou r self-drillin g an d d istally w ith fou r
self-d rillin g, self-tappin g LHS.

509
 9 .1 Fe m u r, p ro xim a l

4 Re h a b ilit a t io n

Mobilization w ith fu ll weigh t bearin g

from day 1 postoperatively.

Fig 9 .1.5 -5 a – d Postoperative x-rays

a AP view.
b Distal en d of th e plate in AP view.
c Lateral view.
d Distal en d of th e plate in lateral view.

a b c d

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP prox im al fem u r 4.5 is an altern ative im plan t.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
M IPO provides a good option for th e palliative
stabilization of th e prox im al fem u r, in order to preven t
a th reaten ed fractu re an d to allow th e patien t to be
m obilized despite th e osteolysis. Du e to th e add ition al
m etastases it was decided to refrain from resection of
th e bon e m etastases.

510
 Au t h o rs Em a n u e l Ga u t ie r, Ro la n d P Ja ko b

9.1.6 Conge nital coxa vara with re sidual hip d ysplasia

1 Ca s e d e s crip t io n

c d

a b e

Th is patien t was operated at th e age of Fig 9 .1.6 -1a – e

7 for a fatigu e fractu re of th e fem oral a AP view sh ow s coxa vara w ith n on u n ion of th e fem oral n eck.
n eck on th e righ t side. Sh e presen ted b Du n n view sh ow s a h igh retrotorsion of th e righ t fem u r.
w ith con gen ital coxa vara w ith pseu d- c– e CT scan s con rm th e n onu n ion .
arth rosis of th e fem oral n eck, retrotor-
sion of th e prox im al fem u r, an d residu al
h ip dysplasia.

In d ica t io n Pre o p e ra t ive p la n n in g

Th e in d ica tio n fo r a trip le p e lvic o ste o to m y

is give n d u e to th e re sid u a l h ip d ysp la sia to Ace ta b u la r 15°
15°

re sto re n o rm a l a ce ta b u la r in d e x a n d fe m o ra l In d e x ~ 3 0 °
h e a d co ve ra ge .
In te rte a r d ro p lin e
An in te rtro ch a n te ric o ste o to m y is in d ica te d
fo r t wo re a so n s: a b c
1) Re sto re th e a n a to m y o f th e p ro xim a l
fe m u r ( b y va lgiza tio n a n d d e ro ta tio n)
2) De cre a se th e b e n d in g lo a d o n th e n e ck
n o n u n io n b y va lgiza tio n o ste o to m y.
Fig 9 .1.6 -2 a – e
a – c Pla n n in g o f th e trip le o ste o to m y
30 °
45° o f th e h ip .
d – e Pla n n in g o f th e in te rtro ch a n te ric
d e o ste o to m y o f th e fe m o ra l n e ck.

511
 9 .1 Fe m u r, p ro xim a l

Pre o p e ra t ive p la n n in g (co n t )

1 Su rge o n
Eq u ip m e n t
2 ORP
• LCP 3 .5 , 7 h o le s
4 3 1st a ssista n t
• LCP re co n stru ctio n p la te 3 .5 , 5 h o le s
4 2n d a ssista n t
• Lo ckin g h e a d scre w s (LHS)
• 2 .5 m m K-w ire s
Ste rile are a
• In s tru m e n ts to p e rfo rm th e
trip le p e lvic o s te o to m y
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g 3
1
An tib io tics: ce p h a lo sp o rin
2
Th ro m b o sis p ro p h yla xis: n o
Fig 9 .1.6 -3 Su p in e p o sitio n o n ra d io lu ce n t o p e ra tin g ta b le , le g d ra p e d fre e ly.

2 Su rgica l a p p ro a ch

a b

Fig 9 .1.6 -4 a – b
a Th e triple pelvic osteotom y is perform ed u sin g th ree ap- b An terolateral approach to th e h ip to perform th e in tertro-
proach es: (1 ) Lu dloff approach for th e osteotom y of th e ch an teric correction osteotom y.
isch iu m , ( 2 ) a partial ilioin gu in al approach to perform th e
osteotom ies of th e su perior pu bic ram u s, an d ( 3 ) th e ap-
proach to th e illiu m .

512
 9 .1.6 Co n ge n it a l co xa va ra w it h p s e u d a r t h ro s is o f t h e fe m o ra l n e ck a n d re s id u a l h ip d ys p la s ia

3 Re d u ct io n a n d fixa t io n

Fig 9 .1.6 -5 a – c
a Prelim in ar y xation of th e triple pelvic osteotom y w ith
two 2.5 m m K-w ires. After correction , de n itive stabiliza-
tion w ith K-w ires.
b Lateral xation w ith a 5-h ole 3.5 LCP w ith two proxim al
lock in g h ead screw s passin g th rou gh th e pseu darth rosis
of th e fem oral n eck. Add ition al an terior xation w ith a
7-h ole LCP u sin g lock in g h ead screw s.
c Postoperative x-ray.

a b

513
 9 .1 Fe m u r, p ro xim a l

4 Re h a b ilit a t io n

Add ition al im m obilization w ith pel-

vis an d leg splin t for th ree m on th s.
K-w ires were rem oved after 4 m on th s.
Weigh t bearin g: 15 kg for 4 weeks, fu ll
weigh t bearin g after 4 m on th s.

Postoperative x-ray
Fig 9 .1.6 -6 a – b
after 18 weeks sh ow in g h ealin g of th e
in tertroch an teric osteotom y an d th e
pelvic osteotomy.
a AP view.
b Ax ial view.

a b

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP 3.5 in titan iu m is d if cu lt to rem ove. On e sh ou ld con sider th e u se of steel im plan ts.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Ver y stable xation of th e fem oral osteotom y w ith two
plates, on e laterally, on e an teriorly.

514
9.2 Fe m ur, shaft

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

9.2 .1 Spiral we dge fe m o ral sha ft fracture 32-B1 lo cke d splin ting LISS-DF lo cke d in te rnal 521
fixa to r

9.2 .2 Spiral we dge fe m o ral sha ft fractu re 32-B1 lo cke d splin ting LCP 4 .5/ 5.0 , lo cke d in te rnal 525
b ro ad fixa to r

9.2 .3 Com ple x sp iral fe m o ral sha ft fractu re 32-C1 lo cke d splin ting LISS-DF lo cke d in te rnal 531
fixa to r

9.2 .4 Sim ple sp iral fe m o ral sha ft fractu re , im p lan t failu re 32-A1 lo cke d sp lin tin g LISS-DF lo cke d in te rnal 535
fixa to r

9.2 .5 Sub tro chan te ric fracture o f the p roxim al fe m o ral 32-A1 lo cke d sp lin ting LCP 4 .5/ 5 .0 , lo cke d in te rnal 539
sh a ft a fte r o ste o m ye litis b ro a d fixa to r

9.2 .6 Sim ple sp iral fe m o ral sha ft fractu re , p e rip ro sth e tic 32-A1 lo cke d splin tin g LCP 4 .5/ 5 .0 , lo cke d in te rnal 5 43
b ro a d fixa to r

9.2 .7 Sim ple sp iral fe m o ral sha ft fractu re , p e ripro sthe tic 32-A1 lo cke d splin ting LISS-DF lo cke d in te rnal 5 47
fixa to r

9.2 .8 Fe m o ral sha ft fracture , p e ripro sthe tic 32-A1 lo cke d splin ting LISS-DF lo cke d in te rnal 551
fixa to r

9.2 .9 Sp iral fe m o ral sha ft fracture , p e ripro sthe tic 32-A1 lo cke d splin ting LCP 4 .5/ 5.0 , lo cke d in te rnal 555
b ro a d fixa to r

515
 9 Fe m u r

9 Fe m ur

9 .2 Fe m u r, s h a ft 517
9 .2 .1 Sp ira l w e d ge fe m o ra l s h a ft fra ct u re —32 -B1 5 21
9 .2 .2 Sp ira l w e d ge fe m o ra l s h a ft fra ct u re —32 -B1 525
9 .2 .3 Co m p le x s p ira l fe m o ra l s h a ft fra ct u re —32 - C1 5 31
9 .2 .4 Sim p le s p ira l fe m o ra l s h a ft fra ct u re , im p la n t
fa ilu re —32 -A1 535
9 .2 .5 Su b t ro ch a n t e ric fra ct u re o f t h e p ro xim a l fe m o ra l s h a ft
a ft e r o s t e o m ye lit is —32 -A1 539
9 .2 .6 Sim p le s p ira l fe m o ra l s h a ft fra ct u re ,
p e rip ro s t h e t ic—32 -A1 543
9 .2 .7 Sim p le s p ira l fe m o ra l s h a ft fra ct u re ,
p e rip ro s t h e t ic—32 -A1 5 47
9 .2 .8 Fe m o ra l s h a ft fra ct u re , p e rip ro s t h e t ic—32 -A1 5 51
9 .2 .9 Sp ira l fe m o ra l s h a ft fra ct u re ,
p e rip ro s t h e t ic—32 -A1 555

516
 Au t h o r Mich a e l Wa gn e r

9.2 Fe m ur, shaft

1 In cid e n ce

Som e ch aracteristic sign s su ch as axial deviation , sh orten in g,

abn orm al fu n ction an d pain , clin ical diagn osis of fem oral sh aft
fractu res, in clu din g su btroch an teric fractu res, are obviou s.
30°
a b c
Clin ical exam in ation h as to in tegrate soft-tissu e in volvem en t.
Du e to den se soft-tissu e w rappin g, open fractu res are less Fig 32-A sim ple fractu re.
9 .2 -1a – c
com m on . Neu rovascu lar de cien cies are to be detected im - a 32-A1 spiral
m ediately. Stan dard x-ray exam in ation s con sist of view s in b 32-A2 obliqu e (> 30°)
two plan es, in clu d in g join ts to ru le ou t add ition al ipsilateral c 32-A3 tran sverse (< 30°)
fractu res of th e fem oral n eck or tibial h ead.

2 Cla s s ifica t io n

Th e sh aft area in clu des th e su btroch an teric region . Th e Mü ller

AO Classi cation con siders sim ple, wedge an d com plex frac-
a b c
tu res. Add ition ally, soft-tissu e dam age h as to be taken in to
accou n t. Fig 32-B wedge fractu re.
9 .2 -2 a – c
a 32-B1 spiral wedge
b 32-B2 ben din g wedge
c 32-B3 fragm en ted wedge
3 Tre a t m e n t m e t h o d s

Differen t m eth ods of closed redu ction are practicable su ch

as m an u al traction or d istraction u sin g a traction table or a
Sch an z screw-assisted d istractor. To facilitate th e in tram ed-
u llary n ailin g procedu re, a sh ort n ail m ay be u sed as a “joy-
stick” to h an d le th e prox im al fragm en t. Ligam en totax is m ay
be effective in th e redu ction of com plex fractu res.
a b c

Ju st a sm all lon gitu din al in cision of abou t 3 –5 cm is recom m en ded Fig 32-C com plex fractu re.
9 .2 -3 a – c
for an tegrade fem oral n ailin g an d placed approx im ately 12 –15 a 32-C1 spiral
cm prox im al to th e tip of th e greater troch an ter. b 32-C2 segm en tal
c 32-C3 irregu lar

517
 9 Fe m u r
In con ven tion al platin g a large skin in cision is m ade on th e
lateral side of th e th igh exten d in g from th e greater troch an ter
to th e lateral fem oral con dyle. Fractu re exposu re follow s th e
fascia lata splittin g an d retractin g of th e vastu s lateralis m u s-
cle alon g th e in term u scu lar septu m dow n to th e lin ea aspera.
Preferably, th e perforatin g vessels sh ou ld be preser ved. In
com par ison , less in vasive platin g procedu res requ ire an in ser-
tion poin t restricted to a 3 –5 cm sk in in cision , u su ally placed
an terolaterally at th e level of th e lateral fem oral con dyle. Fol-
low in g in d irect fractu re redu ction , th e su bm u scu lar d issection
for plate in sertion alon g th e sh aft of th e fem u r is prepared
u sin g an elevator. Screw s are in serted percu tan eou sly u sin g
sm all separate in cision s.
Redu ction h as to con sider len gth an d align m en t (an te- recu r-
vatu m deform ity, varu s, valgu s an d rotation). Approxim ate re-
duction is the key to ach ievin g correct len gth in sim ple fractu res.
Drapin g of th e u n in ju red side facilitates in traoperative con trol
an d com parison of len gth , align m en t an d rotation .
Th e ch oice of im plan ts depen ds on a n u m ber of factors su ch
as th e con d ition of th e patien t, fractu re pattern an d location ,
Vid e o
9 .2-1
size of th e m edu llary can al an d soft-tissu e con d ition s. Fu rth er
aspects m ay be presen ce of oth er im plan ts, person al ex peri-
en ce an d preferen ce an d availability of im plan ts, in stru m en ts
an d in traoperative im agin g.
Depen d in g on differen t con dition s, in tra m edu llary n ailin g
rem ain s overall th e treatm en t of ch oice in fem oral sh aft frac-
tu res. Plate osteosyn th esis is applicable for special in dication s,
for exam ple, in com bin ed fem oral sh aft an d fem oral n eck
fractu res, polytrau m a an d correction osteotom y.
Th e open platin g tech n iqu e w ith broad access to th e fractu re
is as adequ ate as sem i- closed procedu res w ith in d irect redu c-
tion an d less in vasive operative tech n iqu es.
In open platin g tech n iqu e, possible devitalization of fractu re
fragm en ts by attem pts at an atom ical redu ction h as to be tak-
518
en in to con sideration . Th erefore, precise redu ction an d rigid
xation by in terfragm en tary com pression sh ou ld on ly be per-
form ed to treat sim ple fractu res. Oth er w ise, a blood-su pply
savin g procedu re, leavin g th e fractu re area u n tou ch ed an d
br idged by a lon g plate, is to be favored.
In su btroch an teric fractu res, especially in th ose w ith ou t a
m ed ial bon e bu ttress, plate fatigu e is likely. Bon e graftin g
m ay becom e n ecessary to optim ize static con d ition s.
In gen eral, d ifferen t im plan ts are su itable for su btroch an teric
fractu re treatm en t su ch as con dylar plates, dyn am ic con dylar
screw s (DCS), proxim al fem oral n ails (PFNA) an d solid fem o-
ral n ails (UFN) u sin g th e spiral blade device. Moreover, in tra-
m edu llary n ailin g is recom m en ded in diaph yseal fractu res. In
type A an d type B m idsh aft fractu res th e u n iversal or th e n ew
can nu lated n ail in serted after ream in g of th e m edu llary cavity
an d u sin g th e in terlockin g tech n iqu e is advisable. In com pari-
son , com plex type C m idsh aft fractu res an d fractu res of th e
proxim al an d distal th ird m ay be stabilized u sin g th e solid or
can nu lated in tram edu llary n ail. In exception al cases, platin g
m ay be in dicated u sin g th e broad LC-DCP 4.5, th e lon g con dy-
lar plates, th e dyn am ic con dylar screw, th e broad 4.5/5.0 LCP,
th e LCP prox im al femu r plate, th e LCP-DF or th e LISS-DF.
Today, in plate osteosyn th esis for su btroch an teric fractu res,
in d irect redu ction procedu res an d less in vasive operative tech -
n iqu es are preferred to avoid u n n ecessary lim itation of th e
blood su pply to th e fragm en t. Bon e graftin g m ay occasion ally
be u sefu l, even in com plex m u ltifragm en ted fractu res.
As a ru le, sim ple fractu res can be an atom ically reduced an d
stably xed by the prin ciples of absolu te stability w ith in ter-
fragm en tary com pression wh ile mu ltifragm en tary cases are
preferably treated by indirect reduction an d bridge platin g.
Bridge platin g w ith m in im al access can be perform ed u sin g
th e plates m en tion ed above, th e LISS-DF (less in vasive stabi-
lization system ), or th e LCP-DF.
.
 9 .2 Fe m u r, s h a ft

In u n stable fractu re pattern s or in cases of poor bon e stock,

4 Im p la n t o ve r vie w
su btroch an teric fractu res can be treated w ith th e prox im al
fem oral n ail (PFN).
a
In cases of severe soft-tissue in ju ry, tem porary extern al xation
is recom m en ded as well as u n ream ed or m in im ally ream ed
in tram edu llary n ailin g. Th e extern a l xator m in im izes local b
an d system ic in terferen ce an d is th erefore recom m en ded in
severely polytrau m atized patien ts. To avoid th e obviou s risk of
pin -track in fection , secon dar y stable in tern al xation sh ou ld
be perform ed w ith in 1–2 weeks.

Im m ed iate start of ph ysioth erapeu tic postoperative care is es-

c
sen tial. Am bu lation m ay be delayed du e to th e patien t’s over-
all con dition , con com itan t in ju ries an d patien t com plian ce.
Prim ary partial weigh t bearin g (10 –15 kg) sh ou ld be possible
w ith ou t exception . Depen d in g on fractu re pattern an d type of
xation , su bsequ en t m an agem en t an d in creasin g load h ave to
be ju dged on an in d ividu al basis.

Fig 9 .2 -4 a – e
a LCP 4.5/5.0, broad
b LCP 4.5/5.0 broad, cu rved
c LISS-DF 5.0 (left an d righ t version available)
d LCP-DF 4.5/5.0 (left an d righ t version available)
e LCP con dylar plate 4.5/5.0
(left an d r igh t version available)

519
 9 Fe m u r

5 Su gge s t io n s fo r fu r t h e r re a d in g

Bo n e LB, Jo h n so n K D , We ige lt J, e t al (2004) Early versu s delayed

stabilization of fem oral fractu res: a prospective ran dom ized stu dy.
Clin Orthop Relat Res; (422):11–16.
Ro be rt s CS, Pap e HC, Jo n e s A L, e t al (2005) Dam age con trol
orth opaed ics: evolvin g con cepts in th e treatm en t of patien ts wh o h ave
su stain ed orth opaedic trau m a. Instr Course Lect; 54:4 47–462. Review.
Pap e HC, H ild e bran d F, Pe rt schy S, e t al (2002) Ch an ges in th e
m an agem en t of fem oral sh aft fractu res in polytrau m a patien ts: from
early total care to dam age con trol orth oped ic su rgery. J Trauma;
53(3):452–461; discu ssion 461–462.
Pap e HC, Grim m e K , Van Grie n sve n M , e t al (2003) EPOFF Stu dy
Grou p. Im pact of in tram edu llary in stru m en tation versu s dam age
con trol for fem oral fractu res on im mu n oin am m atory param eters:
prospective ran dom ized an alysis by th e EPOFF Stu dy Grou p. J Trauma;
55(1):7–13.
St e p h e n D J, K re de r H J, Sch e m it sch EH , e t al (2002) Fem oral
in tram edu llary n ailin g: com parison of fractu re-table an d m an u al
traction . a prospective, ran dom ized stu dy. J Bone Joint Surg Am;
84-A(9):1514 –1521.
Faro u k O, Kre t t e k C, M iclau T, e t al (1999) M in im ally in vasive
plate osteosyn th esis: does percu tan eou s platin g d isru pt fem oral blood
su pply less th an th e trad ition al tech n iqu e? J Orthop Trauma;
13(6):401–406.
A gu s H , Kale n d e re r O, Eryan ilm az G, e t al (2003) Biological
in tern al xation of com m in u ted fem u r sh aft fractu res by bridge
platin g in ch ildren . J Pediatr Orthop; 23(2):184 –189.
Kin ast C, Bo lh o fn e r BR , Mast J W, e t al (1989) Su btroch an teric
fractu res of th e femu r. Resu lts of treatm en t w ith th e 95 degrees
con dylar blade-plate. Clin Orthop Relat Res; (238):122–130.

520
 Au t h o rs Em a n u e l Ga u t ie r, Ma rc Lo t t e n b a ch

9.2.1 Spiral we dge fe m oral shaft fracture —32-B1

1 Ca s e d e s crip t io n

56-year-old fem ale was in volved in a sk i acciden t an d fractu red h er left

fem u r.

Th e x-rays sh ow a spiral fractu re of th e distal fem oral

Fig 9 .2 .1-1a – b
sh aft w ith a posterior wedge.
a AP view.
b Lateral view.

In d ica t io n

Th is u n sta b le fe m o ra l sh a ft fra ctu re is a n a b so lu te in d ica tio n fo r o ste o syn th e sis.

In th is d ista l fe m o ra l sh a ft fra ctu re , th e LISS o ste o syn th e sis w ith lo ckin g h e a d
scre w s a llo w s go o d a n ch o ra ge o f th e p la te in th e co n d yla r fra gm e n t, e ve n in
a b ca se s o f o ste o p o ro sis.

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
1 Su rge o n
• LISS-DF, 13 h o le s
2 Assistan t
• 5 .0 m m lo ckin g h e a d scre w s (LHS)
3 ORP
• 1.6 m m K-w ire s
Ste rile are a
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n
va ry a cco rd in g to a n a to m y.)

1
Pa t ie n t p re p a ra t io n a n d p o s it io n in g a
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
fo r 4 8 h o u rs. Fig 9 .2 .1-2 a – b
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin . a Su p in e p o sitio n o n a 2
In a d d itio n , th e p a tie n t is tre a te d w ith sta n d a rd o p e ra tin g ta b le .
a n tio ste o p o ro tic m e d ica tio n . b Th e im a ge in te n si e r is p la ce d 3
o n th e co n tra la te ra l sid e . b

521
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

Fig 9 .2 .1-3 Sh ort lateral sk in in cision cu rved toward

th e tibial tu berosity w ith a lateral arth rotom y.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .2 .1-4 a – c
a Th e fractu re is redu ced by m an u al traction . Th e plate is
in serted w ith th e h elp of th e aim in g device in M IPO tech -
n iqu e. First th e plate is xed d istally w ith a lockin g h ead
screw. Care is given to align th e plate properly w ith respect
to th e ax is of th e fem u r in th e lateral view.
b Plate position is assessed by im age in ten si cation , followed
by xation w ith a secon d screw distally, an d in sertion of
th e prox im al an d d istal screw s.
c Wou n d closu re an d de n itive osteosyn th esis.

522
 9 .2 .1 Sp ira l w e d ge fe m o ra l s h a ft fra ct u re —32 -B1

4 Re h a b ilit a t io n

a b a b a b

Postoperative x-rays af-

Fig 9 .2 .1-5 a – b Postoperative x-rays af-
Fig 9 .2 .1-6 a – b Postoperative x-rays
Fig 9 .2 .1-7a – b
ter 8 weeks sh ow in g correct align m en t ter 12 weeks sh ow in g in tegration of th e after 15 m on th s.
in both plan es. wedge fragm en t in to th e callu s. a AP view.
a AP view. a AP view. b Lateral view.
b Lateral view. b Lateral view.

Im p la n t re m o va l
If th e fractu re h as h ealed an d th e h ard-
ware becom es sym ptom atic, h ardware
m ay be r e m ove d t h r ou gh a sim ila r
approach at a m in im u m of 18 m on th s.
a b

Postoperative x-rays
Fig 9 .2 .1-8 a – b
after 18 m on th s.
a AP view.
b Lateral view.

523
 9 .2 Fe m u r, s h a ft

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Redu ction an d plate position h ave to be ch ecked by th e No-tou ch redu ction tech n iqu e w ith preservation of th e
im age in ten si er. bon e vascu larity is possible.

Con trol of redu ction is d if cu lt an d on ly clin ically In d irect redu ction tech n iqu e w ith ou t ex posu re of th e
possible (in tern al-extern al rotation of th e exed h ip) fragm en ts.

Dan ger of creatin g an exten sion al m alalign m en t Su bm u scu lar in sertion of th e plate.
(recu r vation ).
Rapid in tegration of th e wedge fragm en t in to th e callu s.

524
 Au t h o r Mich a e l Wa gn e r

9.2.2 Spiral we dge fe m oral shaft fracture —32-B1

1 Ca s e d e s crip t io n

68-year-old wom an h ad a dom estic fall an d su stain ed a

fem oral sh aft in ju r y.

Fig 9 .2 .2 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Un sta b le sp ira l fra ctu re o f th e fe m o ra l sh a ft w ith fra ctu re ssu re s

e xte n d in g in to th e co n d yla r b lo ck. Give n th is fra ctu re p a tte rn , n a il
xa tio n w ith tra n s ve rse lo ckin g w o u ld b e e xtre m e ly d if cu lt a n d su f-
a b cie n t a n ch o ra ge u n ce rta in in o ste o p o ro sis.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP 4 .5/ 5 .0 , b ro a d , 17 h o le s
• Se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 2 .0 m m K-w ire
• Sch a n z scre w a n d T-h a n d le to b e u se d a s a jo ys tick
• So ft-tissu e re tra cto r
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

a bb
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 9 .2 .2 -2 a – d
a Su p in e p o sitio n w ith e xe d kn e e (4 5°) w ith su p p o rt.
b Th e p o ssib ilit y o f clo se d in d ire ct re d u ctio n b y m a n u a l
tra ctio n a n d e xte rn a l su p p o rt is e va lu a te d b y im a ge
in te n si e r b e fo re s ta rtin g th e in cisio n .
c– d To re d u ce th e d isp la ce m e n t in th e sa git ta l p la n e u se a c d
jo ystick in th e p ro xim a l fra gm e n t (n e a r th e fra ctu re zo n e).

525
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

a b c d

Fig 9 .2 .2 -3 a – d
M in im ally invasive approach : c Divide th e iliotibial tract in th e d irection of its bers an d
a Fin d th e lan d m arks on th e d istal lateral fem oral con dyle. open th e epiperiosteal space ben eath th e vastu s lateralis of
b Mark an d m ake a sh ort in cision on th e lateral fem u r con - th e qu ad riceps fem oris.
dyle. d Plan n ed prox im al in cision .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .2 .2 -4 a – c
Redu ction w ith m an u al lon gitu d in al traction (u n der im age
in ten si er con trol).
An terior in sertion of th e Stein m an n pin w ith T-h an d le in to
th e prox im al fragm en t ( joystick).
a Measu re for plate len gth .
b Ben d th e LCP w ith th e h elp of th e ben d in g press an d ben d in g
iron s.
c Su bm u scu lar slide-in sertion of th e plate from d istal to
proxim al–wh ereby a drill sleeve acts as a h an d le.

526
 9 .2 .2 Sp ira l w e d ge fe m o ra l s h a ft fra ct u re —32 -B1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

d e

Fig 9 .2 .2 -5 a – e
a Iden tify an d ach ieve visibility of th e proxim al en d of th e plate th rou gh th e m ost
proxim al in cision .
b Prelim in ar y xation of th e plate proxim ally an d d istal in sertion of a 2.0 m m
K-w ire. Use th e im age in ten si er to ch eck th e position of th e plate.
c Distal xation of th e plate w ith th ree self-tappin g lockin g h ead screw s. Th ese
screw s w ill be position ed convergen tly becau se of th e ben ds in th e con tou red
plate. Th e lon gest screw s possible are in serted in th e m etaph yseal region .
d A total of fou r lock in g h ead screw s are requ ired for th e prox im al xation . Th e
screw s are in serted th rou gh an add ition al in cision .
e Th e soft-tissu e retractor is h elpfu l. Th e fou rth screw is in serted prox im ally
th rou gh an add ition al in cision . A specu lu m is u sed to obtain a better view of
th e plate h ole w ith ou t d issection .

527
 9 .2 Fe m u r, s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 9 .2 .2 -6 a – f
a Sin ce th e plate was in itially n ot properly seated on th e bon e in th e proxim al
region , th e m eth od of n e-tu n in g was applied wh ereby all th e screw s are
d isen gaged from th e plate, th e proxim al fragm en t is d raw n towards th e plate
u sin g th e screw h oldin g sleeve, an d th e screw s are th en screwed back in to th e
plate h oles.
b Th e two m ost proxim al screw s w ill be position ed d ivergen tly du e to th e ben d
at th e prox im al en d of th e plate.
c In cision s after com pletion of plate xation .
d Redon d rain s w ith su bsequ en t sk in closu re.
d e –f Postoperative x-rays, AP an d lateral view. Th ree screw s are in serted bicorti-
cally becau se of th e osteoporotic con d ition of th e bon e (in creased rotation al
stability).

e f

528
 9 .2 .2 Sp ira l w e d ge fe m o ra l s h a ft fra ct u re —32 -B1

4 Re h a b ilit a t io n

a b c d

Fig 9 .2 .2 -7a – f Mobilization w ith walker, rollator, or u n derarm

cru tch es an d h alf body weigh t (elderly patien t).
a – b 8 weeks—callu s form ation , fractu re gap on ly indistinctly
visible, start of fu ll weigh t bearin g.
c– d 4 month s—clearly apparent increase in callu s form ation .
e – f 18 m on th s—bon e con solidation .

e f

529
 9 .2 Fe m u r, s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Correct position in g of a lon g straigh t plate is n ot easy. Fig 9 .2 .2 -9Th e lon g broad 4.5/5.0 LCP is also available as
A cu r ved lon g plate ts th e an tecu r vatu re of th e fem u r a cu rved version . Th is plate ts th e an atom ical sh ape of
better. th e fem u r better.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e plate h as n o con tact w ith th e bon e in th e
Fig 9 .2 .2 -8 Th e soft-tissu e retractor is a ver y h elpfu l in stru m en t to
proxim al region . Use th e m eth od of n e-tu n in g to correct protect th e soft tissu es.
im proper position of th e plate.

530
 Au t h o rs Mich a e l Sch ü t z, No rb e r t P Ha a s

9.2.3 Com ple x spiral fe m oral shaft fracture —32-C1

1 Ca s e d e s crip t io n

67-year-old wom an su ffered a distal femoral monotrau m a when

sh e fell off h er m otorbike (32-C1). Th e patien t was operated
im m ed iately after d iagn osis.

Fig 9 .2 .3 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Th is is a cle a r in d ica tio n fo r re d u ctio n o f th e fra ctu re in a xis, le n gth ,

a n d ro ta tio n to a llo w e a rly fu n ctio n a l tre a tm e n t. In th is ca se , a
LISS-DF, 13 h o le s, to b e in se rte d in m in im a lly in va sive te ch n iq u e ,
a b w a s ch o se n fo r fra ctu re sta b iliza tio n .

Pre o p e ra t ive p la n n in g

Sta n d a rd x-ra ys o f th e kn e e a n d fe m u r w e re su f cie n t in th is ca se fo r p re o p e ra tive p la n n in g.

A ske tch is m a d e ta kin g in to a cco u n t th e so ft-tissu e in ju ry a n d th e ra d io lo gica l a n a lysis. Th is
ske tch sh o u ld co n ta in th e s ta b iliza tio n p ro ce d u re w ith im p la n t le n gth a n d scre w p o sitio n in g
(a t le a s t fo u r in th e p ro xim a l fra gm e n t). Fre e scre w h o le s sh o u ld a lso b e p la n n e d to a llo w
b io m e ch a n ica l m o tio n o f th e im p la n t.

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Eq u ip m e n t
• LISS-DF, 13 h o le s
• 5 .0 m m lo ckin g h e a d scre w s (LHS)
• 2 .0 m m p a rtia lly th re a d e d K-w ire s
(Size o f s ys te m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Th e p a tie n t is p o sitio n e d o n th e ra d io lu ce n t ta b le , a llo w in g im a ge in te n si ca tio n o f th e

w h o le fe m u r. Th is h a s to b e ch e cke d b e fo re th e o p e ra tio n . Th e u n in ju re d le g m u st b e Fig 9 .2 .3 -2 Su p in e p o sitio n , kn e e jo in t
e xte n d e d a n d lo w e re d (a b o u t 3 0 ° h ip e xte n sio n) to a llo w la te ra l im a ge in te n si e r p ro je ctio n . e xe d to a p p ro xim a te ly 3 0 °.

531
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

Fig 9 .2 .3 -3Lateral approach to th e distal fem u r an d addition -

al sm all in cision s in th e region of th e fem oral sh aft.

3 Re d u ct io n a n d fixa t io n

Fig 9 .2 .3 -4 a – b
a An atom ical reduction of the fractu re by lon gitudin al traction
payin g atten tion to leg len gth , ax is, an d rotation . Th e frac-
tu re is tem porarily xed w ith two percu tan eou sly in serted
K-w ires. Th ey m u st n ot in terfere w ith im plan t position in g.
Th e redu ction can be su pported w ith towel rolls. Altern a-
tively, an extern al xator or d istractor can m ain tain th e
redu ction . Th e m etaph yseal fractu re fragm en ts are n ot
tou ch ed du r in g th is m in im ally invasive procedu re. A fu r-
th er m in im al adju stm en t of th e redu ction can be ach ieved
u sin g th e im plan t itself.
Th e 13 h ole LISS-DF is in serted w ith th e aid of th e in ser-
a tion gu ide an d is in trodu ced u n der th e vastu s lateralis.
Estim ated placem en t of th e LISS on th e lateral con dyles.
Th e LISS h as to be position ed parallel to th e con dyles
to preven t irritation of th e iliotibial tract. Th e proxim al
trocar is applied. Fixation of th e im plan t w ith proxim al
an d distal K-w ires. Th e d istal K-w ire sh ou ld be parallel to
th e join t su rface. Th e an atom ically preben t im plan t n ow
m ain tain s th e redu ction .

532
 9 .2 .3 Co m p le x s p ira l fe m o ra l s h a ft fra ct u re —32-C1

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 9 .2 .3 -4 a – b (co n t)
b It is recom m en ded th at a 3 cm lon g in cision be m ade prox-
im ally to ver ify th e position of th e plate. In th is case, th e
an terior aspect of th e fem u r was palpated an d th e im plan t
was advan ced towards th e n ger.

If th e fractu re is n ow redu ced correctly in ax is, rotation , an d

len gth , th e rst lock in g h ead screw can be in serted d istally
an d sh ou ld be parallel to th e articu lar su rface.
Th e d istractor is applied prox im ally an d a correction of abou t
ve degrees can be ach ieved. A m on ocortical lock in g h ead
screw is in serted percu tan eou sly in to th e adjacen t h ole.
Th e redu ction an d th e position of th e plate are assessed clin i-
cally an d by im age in ten si cation (ax is, len gth , rotation). Th e
rem ain in g lock in g h ead screw s are in serted in accordan ce
w ith th e preoperative plan .
b Th e in sertion gu ide is rem oved an d th e wou n d is closed.

4 Re h a b ilit a t io n

Apply sterile dressin gs.

Gen tle active an d passive m otion exercises begin im m ed iately
on day 1 postoperatively.
Th e u se of th e con tin u ou s passive m otion m ach in e is h igh ly
recom m en ded.
Mobilization w ith partial weigh t bearin g as soon as th e gen er-
al an d local con d ition of th e patien t allow s it. In creased weigh t
bearin g after 4 weeks, fu ll weigh t bearin g after 6 weeks.

Fig 9 .2 .3 -5 a – b Follow-u p x-rays after 5 m on th s.

a AP view.
b Lateral view.
a b

533
 9 .2 Fe m u r, s h a ft

4 Re h a b ilit a t io n (co n t )

Fig 9 .2 .3 -6 a – d
Postoperative x-rays after
12 m on th s.
c a AP view.
b Lateral view.
c– d Fu n ction al resu lt.

d a

Im p la n t re m o va l
After de n itive con solidation (2 years after su r-
gery) an d on th e requ est of th e patien t, th e im plan t
a b was rem oved.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
A too exten sive exposu re of th e m etaph yseal fractu re zon e In d irect redu ction tech n iqu e for extraarticu lar fractu res.
m ay dam age th e blood su pply to th e bon e fragm en ts.

Re d u ct io n a n d xa t io n
In correct position in g of th e im plan t in relation to th e sh aft
m ay lead to early im plan t loosen in g.
In correct position in g of th e im plan t in relation to th e
d istal fragm en t m ay lead to soft-tissu e irr itation s.
A too sh ort im plan t in creases th e risk of im plan t
loosen in g.
A too stable im plan t xation in creases th e r isk of im plan t
failu re.
Re d u ct io n a n d xa t io n
Carefu l con trol of im plan t position u sin g d irect an d
in d irect con trol m ech an ism s (visu alization , palpation ,
an d im age in ten si cation).
Th e u se of lon g im plan ts an d few screw s is n ecessar y to
allow im plan t m otion an d better stress distribu tion .

Re h a b ilit a t io n Re h a b ilit a t io n
Prolon gin g physioth erapy m ay lead to a decreased ran ge of Carefu l early active an d passive ph ysioth erapy is essen tial
k n ee m otion . for good join t fu n ction .

534
 Au t h o rs Th o m a s J Ho cke rt z, Ga b rie le St re ich e r, An d re a s Gru n e r, He in rich Re ilm a n n

9.2.4 Sim ple spiral fe m oral shaft fracture , im plant failure —32-A1

1 Ca s e d e s crip t io n

75-year-old m an w ith fractu re of th e d istal th ird of th e fem oral sh aft. Cau se

of in ju ry u n k n ow n .
Ty pe of in ju r y: low-en ergy t rau m a, m on ot rau m a, closed fractu re, severe
osteoporosis.

Fig 9 .2 .4 -1a – b
a AP view after prim ar y treatm en t.
b Lateral view after prim ary treatm en t.

a b

In d ica t io n

In sta b ilit y, p ain , a n d b lo o d lo ss a fte r p la te b re akth ro u gh

a t th e fe m u r (e m e rge n cy situ a tio n). Tre a tm e n t to p ro -
vid e s ta b ilit y.

Fig 9 .2 .4 -2 a – c
a Pro tru sio n o f LISS in AP vie w.
b Pro tru sio n o f LISS la te ra lly.
c Pro tru sio n o f LISS; clo se u p.

a b c

535
 9 .2 Fe m u r, s h a ft

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie Fig
n t p9re.2p.4a -3
ra t ioSu
n pa in
n de ppoossitio
it io n in g
• LISS-DF, 13 h o le s • An tibw ith
io tics:
e le va
sintio
glen od of se
th e2in
nd
ju
gerende ra
letio
g, n ce p h a lo -
• 5 .0 m m lo ckin g h e a d scre w s (LHS) sp osu rinp. p o rt th e kn e e w ith a to w e l
• “Se lva ge rin g” • Th roromll.b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d
ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis:
lo w -m o le cu la r h e p a rin

2 Su rgica l a p p ro a ch

Fig 9 .2 .4 -4 Lateral in cision over th e lateral fem oral con dyle

an d lon gitu din al d ivision of th e iliotibial tract.
Preparation of th e plate bed w ith an elevator startin g d istally
an d work in g in a prox im al d irection alon g th e lateral fem oral
sh aft.
In cision over th e prox im al en d of th e plate after slide-in ser-
tion of th e im plan t.

536
 9 .2 .4 Sim p le s p ira l fe m o ra l s h a ft fra ct u re , im p la n t fa ilu re —32-A1

3 Re d u ct io n a n d fixa t io n

b c d e

Approx im ate redu ct ion u n der lon git u d in a l

Fig 9 .2 .4 -5 a – e After de n itive redu ction an d plate position in g h as been
tract ion a n d align m en t of th e axis of th e in ju red leg. ach ieved, in sert th e screw s altern ately in th e d istal an d prox i-
Position in g of th e plate to th e bon e an d tem porary xation m al h oles. In th e sh aft bicortical self-tappin g LHS are u sed.
w ith K-w ires. To secu re th e prox im al fragm en t an d plate position , m ou n t
Precise redu ction prior to de n itive xation of th e plate w ith a “selvage rin g” after precon tou rin g an d adaptin g it to th e
th e in sertion gu ide. fem oral d iam eter. Fixation of th e rin g w ith two lock in g h ead
screw s.

4 Re h a b ilit a t io n

No add ition al im m obilization . Im p la n t re m o va l

Weigh t bearin g: 15 kg for 8 weeks; fu ll weigh t bearin g after Im plan t rem oval after 24 m on th s. If th e im plan t is cau sin g
8 weeks. sym ptom s, it can be rem oved. Th e im plan t can be left in place
Ph ysioth erapy: from th e th ird postoperative day. in elderly patien ts.
Ph arm aceutical treatment: non steroid antiin am m atory drugs.

537
 9 .2 Fe m u r, s h a ft

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 9 .2 .4 -6 Special featu re of th is case: fractu re lin e Fig 9 .2 .4 -7a – bTh is “selvage rin g” developed by Hockertz
ru n n in g lon gitu d in ally th at join ed u p th e in d ividu al h elps to ga in con t rol over d ifficu lt sit u at ion s at a rev i-
h oles—cau se u n certain . sion operation . A short n arrow LCP 4.5/5.0 is u sed to create
th is in dividu al device. Altern atively cerclage w ire w ith
w ire mou nts can be u sed (see case 9.2.9). Also bicortical
LHS (self tappin g) are recom m en ded in osteoporotic bon e.

Monocortical xation in osteoporotic bone and a too short

intern al xator can lead to im plant failu re. a b

538
 Au t h o r Mich a e l Wa gn e r
9.2.5 Subtrochante ric fracture of the proxim al fe m oral shaft
afte r oste om ye litis—32-A1
1 Ca s e d e s crip t io n
a b
In d ica t io n
Un sta b le su b tro ch a n te ric sh a ft fra ctu re in
th e o ste o m ye litic zo n e is a cle a r in d ica tio n
fo r o p e ra tive sta b iliza tio n th a t w ill fa cilita te
m o b iliza tio n o f th e p a tie n t. Sta b iliza tio n w ith
a n e xte rn a l xa to r is p o ssib le b u t u n co m fo rt-
a b le fo r th e p a tie n t. Th e re is th e a d d itio na l
risk o f p in -tra ck in fe ctio n b e ca u se th e re -
q u ire d p e rio d o f xa tio n is lo n g. In tra m e d -
u lla ry n a ilin g is n o o p tio n b e ca u se o f th e
o ste o m ye litis. Sta b iliza tio n w ith a lo cke d
in te rn a l xa to r p ro vid e s a d e q u a te sta b ilit y
a n d ca n b e a p p lie d e ve n in th e p re se n ce o f
in fe ctio n .
33-year-old m an w ith su btroch an teric fractu re of th e righ t
proxim al fem oral sh aft after fen estration of th e fem oral sh aft
du e to h em atogen ic osteom yelitis. Postoperative fractu re in
th e in fected region of th e femu r occu rred du e to th e degrada-
tion an d fen estration of th e cortex.
Fig 9 .2 .5 -1a – b
a AP view.
b Detail of AP view.
Pre o p e ra t ive p la n n in g
Eq u ip m e n t
• LCP 4 .5/ 5 .0 , b ro a d , cu rve d , 16 h o le s
• 5 .0 m m lo ckin g h e a d scre w s (LHS)
• 2 .0 m m K-w ire s
• Scre w h o le in se rt
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts ca n va ry
a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
Fig 9 .2 .5 -2
h e p a rin
Su p in e p o sitio n o n tra ctio n ta b le .
539
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

a b c

Th e su rgical approach was d ictated by th e in cision s of th e rst operation .

Fig 9 .2 .5 -3 a – d
a Lateral approach to th e proxim al fem oral sh aft.
b – c In a rst step, th e su tu res from th e previou s operation were rem oved (fen estra-
tion of th e bon e du e to osteom yelitis).
d Debridem en t an d irrigation of th e su rgical wou n d an d th e in fected fractu re.

3 Re d u ct io n a n d fixa t io n

a b c

Redu ction by m ean s of traction table an d assessm en t by im age in ten si cation .

Fig 9 .2 .5 -4 a – h
a – b Preben din g of th e proxim al en d of a broad cu rved 16-h ole LCP 4.5/5.0 in order
to adapt it to th e lateral an atom y of th e troch an ter.
In sertion of th e screw h ole in serter in th e 5th h ole from th e proxim al en d an d
in th e 4th h ole from th e d istal en d to preven t com pression of th e periosteu m
after plate xation .
c– d In sertion of th e plate from prox im al to d istal in to th e epiperiosteal space u n der
th e lateral fem oral vastu s lateralis. A th readed LCP d rill gu ide can be u sed as a
d h an dle.

5 40
 9 .2 .5 Su b t ro ch a n t e ric fra ct u re o f t h e p ro xim a l fe m o ra l s h a ft a ft e r o s t e o m ye lit is —32-A1

3 Re d u c t io n a n d fixa t io n (co n t )

e f g

Fig 9 .2 .5 -4 a – h (co n t)
e Ch eck plate position on th e im age in ten si er.
f Tem porar y prox im al an d d istal xation by in sertion of K-w ires in to th e m ost
proxim al an d m ost d istal plate h oles an d redu ction of th e fractu re w ith th e h elp
of th e collin ear redu ction forceps.
g Fixation of th e plate w ith bicortical lock in g h ead screw s proxim ally an d d istally.
h Fixation of th e proxim al fragm en t w ith a total of fou r lockin g h ead screw s wh ere-
h by th e screw s w ill be an gled in d ifferen t direction s du e to th e an atom y of th e
proxim al fem u r.

Postoperative x-rays sh ow th e re-

Fig 9 .2 .5 -5 a – c
du ction of th e fragm en ts an d th e xation of th e
proxim al part of th e plate w ith fou r LHS, wh ere-
by th e secon d screw h as been in serted so th at it
lies close to th e th ick m ed ial cortex of th e fem oral
n eck. Th e distal fragm en ts are xed by m ean s of
th ree bicortical LHS at th e d istal en d of th e plate
an d by on e self-drillin g, self-tappin g LHS adjacen t
to th e fractu re.

a b c

541
 9 .2 Fe m u r, s h a ft

3 Re h a b ilit a t io n

Mobilizat ion on u n der-a r m cr u tch es a n d

w eigh t bea r in g u p to 15 kg. St a r t of fu ll
weigh t bearin g from th e 8th week.

Postoperative im ages after

Fig 9 .2 .5 -6 a – c
4 month s. Uneventfu l healin g and fu ll weight
bearin g was ach ieved.
a X-ray AP view.
b X-ray lateral view.
c Con d ition of th e soft-tissu es, n o sign of
a b in fection .

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e in tern al xator is a n on con tact plate an d cau ses on ly
m in im al dam age to th e periosteal blood su pply. For th is
reason , it can be applied at low risk in situ ation s of bon e
in fection , especially if th e in d ication for an extern al
xator is poor. Lon g LHS offer adequ ate an ch orage in th e
m etaphyseal region an d act as an “in d ividu al” blade plate.

5 42
 Au t h o r Re t o Ba b s t

9.2.6 Sim ple spiral fe m oral shaft fracture , pe riprosthe tic—32-A1

1 Ca s e d e s crip t io n

91-year-old wom an . Low im pact fall at h om e. Displaced spiral fractu re d istal to a

clin ically stable cem en ted h em iarth roplasty w ith severe osteopen ia. Th e patien t h as
lim ited walkin g capacity an d lives in a nu rsin g h om e.

Fig 9 .2 .6 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Re le va n t d isp la ce m e n t o f th is sp ira l fe m o ra l fra ctu re . Eve n th o u gh th e h e m ia rth ro p la st y h a s

ra d io lo gica l sign s o f in sta b ilit y, th e p a tie n t, w h o ha d lim ite d wa lkin g ca p acit y, ha d n o p a in b e -
fo re th e fa ll. Op e ra tive tre a tm e n t in th is fra il o ld la d y a im e d a t a m in im a lly in va sive p ro ce d u re ,
w h ich w o u ld a llo w fo r ra p id m o b iliza tio n a t le a st in a w h e e lch a ir. No n o p e ra tive tre a tm e n t
w ith tra ctio n is a sso cia te d w ith p ro lo n ge d b e d re st a n d n o t a n o p tio n in e ld e rly p a tie n ts.
a b

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP 4 .5/ 5 .0 , b ro a d , 2 2 h o le s
• 5 .0 m m lo ckin g h e a d scre w s (LHS)
• La rge d istra cto r, p u sh -p u ll d is tra cto r
• Ho h m a n n re tra cto r
• Co llin e a r re d u ctio n cla m p
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 9 .2 .6 -2 Th e fra ctu re d le g is p la ce d w ith th e kn e e e xe d a t 2 0 – 3 0 °,
w h e re a s th e u n in ju re d le g is p la ce d o n a le g h o ld e r.
Ma rk th e ce n te r o f th e fe m o ra l h e a d a n d th e ce n te r o f th e a n kle jo in t fo r
in tra o p e ra tive a lign m e n t co n tro l w ith th e ca b le m e th o d .
Alte rn a tive ly b o th le gs a re d ra p e d fre e o n a ra d io lu ce n t ta b le fo r
in tra o p e ra tive co m p a riso n o f th e fe m o ra l a xis in re sp e ct to th e u n in ju re d le g.

543
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

Fig 9 .2 .6 -3 a – d
a – b Two in cision s are m ade, on e in th e
m idd le aspect of th e lateral con -
dyle, th e oth er on e in th e region of
th e fu tu re en d of th e plate. Preop-
erative plan n in g for plate len gth
is m an dator y an d plate len gth is
m arked on th e sk in . After distal
an d prox im al in cision s (tran smu s-
a b cu lar approach prox im ally) an d
position in g th e proxim al sh aft of
th e fem u r between two Hoh m an n
retractors, th e fem oral en d of th e
plate can be seen an d palpated.
An epiperiosteal rasp prepares th e
tu n n el for th e LCP.
c– d The plate is then in serted w ith
a plate holder alon g th e fem oral
sh aft an d directed between th e two
proxim al Hoh m an n retractors.
c d

3 Re d u ct io n a n d fixa t io n

a b c

Th e plate is xed d istally w ith a Sch an z screw

Fig 9 .2 .6 -4 a – c
an d pressed again st the sh aft u sin g a sleeve of the large distractor.
A pu sh -pu ll clam p is m ou n ted on a Sch an z screw, w h ich h as
been in serted in to th e last h ole at th e proxim al plate en d.

5 44
 9 .2 .6 Sim p le s p ira l fe m o ra l s h a ft fra ct u re , p e rip ro s t h e t ic—32 -A1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 9 .2 .6 -5 a – c
a – c With th e pu sh -pu ll distractor u sed in th is case, th e fractu re is in directly redu ced
aga in st t h e plate. Fin a l redu ction is ach ieved d irectly u sin g th e collin ea r
redu ction forceps.

a b

Fig 9 .2 .6 -6 a – c
a – b Before de n itive xation of th e plate, reduction is con -
trolled by the cable m ethod.
c After percu tan eou s xation w ith screw s, wou n d closu re
w ith su ction d rain s com pletes th e procedu re.

545
 9 .2 Fe m u r, s h a ft
4 Re h a b ilit a t io n
a b c d
5 Pit fa lls –
Re d u ct io n a n d xa t io n
Malu n ion is easily ach ieved u sin g M IPO, th erefore all
precau tion s sh ou ld be taken to redu ce th is risk, eg, cable
m eth od, con tralateral u n in ju red leg, in traoperative x-ray.
Th e d istal position of th e plate is critical, it sh ou ld n ot be
closer th an on e cen tim eter from th e articu lar join t lin e
an teriorly an d d istally oth er w ise irritation of th e iliotibial
tract m ay becom e a problem . Th e correct position of th e
plate in th e prox im al part is of th e sam e im portan ce oth -
er w ise th e screw s do n ot gain adequ ate pu rch ase an d w ill
tear off.
5 46
Physiotherapy: continuou s passive m o-
tion begin n in g th e rst postoperative
day w ith ou t lim itation except pain .
Mobilization w ith partial weigh t bear-
in g for 8 –10 weeks depen d in g on th e x-
ray 6 weeks postoperatively.
Ph arm aceutical treatm ent: m edication
depen d in g on th e postoperative pain .
Im plan t rem oval after 18 –24 m on th s if
sym ptom atic.
Fig Postoperative x-rays
9 .2 .6 -7a – d
1 year after su rgery. Th e fractu re sh ow s
secon dar y bon e h ealin g w ith callu s for-
m ation du e to th e bridge platin g prin -
ciple in th is sim ple fractu re pattern . Un -
even tfu l h ealin g an d fu ll weigh t bearin g
was ach ieved.
6 Pe a rls +
Re d u ct io n a n d xa t io n
In d irect redu ction of th e bon e w ith an extern al xator or
a large d istractor or th e pu sh -pu ll clam p to th e su bm u scu -
lar slide-in sertion plate after applyin g traction m anu ally,
h elps to redu ce th e risk of m alu n ion .
Position in g of two K-w ires to con trol correct plate posi-
tion d istally an d visu al an d d igital con trol th rou gh th e
sm all prox im al in cision can h elp to preven t in correct plate
placem en t.
Redu ction con trol w ith th e cable m eth od an d/or both legs
draped free for in traoperative com parison of th e fem oral
axis an d rotation .
 Au t h o r Re t o Ba b s t

9.2.7 Sim ple spiral fe m oral shaft fracture , pe riprosthe tic—32-A1

1 Ca s e d e s crip t io n

89-year-old wom an . Low im pact fall at h om e. Displaced spiral

fractu re between a stable n on cem en ted total h ip an d a n on -
con strain ed total k n ee arth roplasty in a severe osteopath ic
patien t.

Fig 9 .2 .7-1a – b
a AP view.
b Lateral view.

In d ica t io n

Re le va n t d isp lace m e n t w ith im p o ssib ilit y to m o b ilize th e p a tie n t.

Co n se rva tive tre a tm e n t w ith tractio n o r sp lin ts is a sso cia te d w ith p ro -
a b lo nge d b e d re st w h ich is de le te rio u s fo r o ld e r age p a tie n ts.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LISS-DF, 13 h o le s
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• LISS p e rip ro s th e tic scre w s
• La rge d istra cto r
• Co llin e a r re d u ctio n cla m p
• Ho h m a n n re tra cto rs
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Fig 9 .2 .7-2 Th e fra ctu re d le g is p la ce d w ith th e kn e e e xe d a t
2 0 – 3 0 °, w h e re a s th e u n in ju re d le g is o n a le g h o ld e r o r stra igh t o n th e
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
ta b le . Ma rk th e ce n te r o f th e fe m o ra l h e a d a n d th e ce n te r o f th e a n kle
An tib io tics: sin gle d o se 2n d ge n e ra tio n ce p h a lo sp o rin
jo in t fo r in tra o p e ra tive a lign m e n t co n tro l w ith th e ca b le m e th o d .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Alte rn a tive ly b o th le gs a re d ra p e d fre e o n a ra d io lu ce n t ta b le fo r
in tra o p e ra tive co m p a riso n o f th e fe m o ra l a xis in re sp e ct to th e
u n in ju re d le g.

547
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

a b

Fig 9 .2 .7-3 a – b
a Two in cision s are m ade, on e in th e m iddle aspect of th e
lateral con dyle, th e oth er on e in th e region of th e fu tu re
en d of th e plate. Preoperative plan n in g of th e plate len gth
an d m ark in g on th e sk in are recom m en ded.
b Th e prox im al in cision is tran sm u scu lar an d th e fem oral
sh aft becom es visible between two Hoh m an n retractors,
wh ich are h eld by a m ou n ted “Hoh m an n h older”.

3 Re d u ct io n a n d fixa t io n

a b

Fig 9 .2 .7-4 a – c
a The LISS w ith the in sertion gu ide is in serted distally.
b It glides a lon g t h e fem ora l sh a ft a n d is t h en d irected
between th e two Hoh m an n retractors proxim ally.
c With m an u al traction or a large d istractor th e in sertion
gu ide h as to be rem oved an d th e large distractor h as to be
m ou n ted w ith on e Sch an z screw th rough th e distal m iddle
h ole an d th e oth er proxim al on e, proxim al to th e en d of
th e plate.

5 48
 9 .2 .7 Sim p le s p ira l fe m o ra l s h a ft fra ct u re , p e rip ro s t h e t ic—32 -A1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 9 .2 .7-5 a – c
a After in d irect redu ction of th e fractu re again st th e plate by traction
w ith th e large d istractor, direct percu tan eou s redu ction is ach ieved
w ith th e collin ear redu ction clam p.
b X-ray con trol for axis an d rotation . Th e plate is xed w ith two LHS in
th e prox im al an d d istal fragm en t. Th e d istractor is th en rem oved an d
th e in sertion gu ide is xed again to allow for easy percu tan eou s plate
xation .
c Th e screw s are th en placed th rou gh th e in ser-
tion gu ide. Screw s in th is case are all applied
in a m on ocortical fash ion . Of th e ve prox im al
screw s, th e two m ost prox im al screw s are peri-
prosth etic screw s.

4 Re h a b ilit a t io n

Ph ysioth erapy: con tin u ou s passive m otion begin -

n in g th e rst postoperative day w ith ou t lim itation
except pain .
Mobilizat ion w it h pa r t ia l weigh t bea r in g for
8 –10 weeks depen d in g on th e x-ray 6 weeks post-
operatively.
Ph a r m aceu t ica l treat m en t: pa in m ed icat ion de-
pen din g on th e postoperative pain .
Im plan t rem oval 18 –24 m on th s if sym ptom atic.

Fig 9 .2 .7-6 a – dPostoperative x-ray 1 year after

th e operation . Th e fractu re sh ow s secon dar y bon e
h ealin g w ith callu s form ation du e to th e splin tin g
m eth od in th is sim ple fractu re pattern . Un even t-
fu l fractu re h ealin g an d fu ll weigh t bearin g was
ach ieved.

a b c d

549
 9 .2 Fe m u r, s h a ft
5 Pit fa lls –
Re d u ct io n a n d xa t io n
Fig 9 .2 .7-7Malu n ion is easily ach ieved in M IPO,
th erefore all precau tion s sh ou ld be taken to redu ce th is
risk (eg, cable m eth od, con tralateral u n in ju red leg,
in traoperative x-ray).
Th e d istal position of th e plate is critical, it sh ou ld n ot be
closer th an on e cen tim eter from th e articu lar join t lin e
an teriorly an d d istally oth er w ise irritation of th e iliotibial
tract m ay becom e a problem . Th e correct position of th e
plate in th e prox im al part is of th e sam e im portan ce
oth erw ise th e screw s do n ot gain adequ ate pu rch ase an d
w ill tear off.
550
6 Pe a rls +
Re d u ct io n a n d xa t io n
Fig 9 .2 .7-8 In d irect redu ction w ith an extern al xator or
w ith a large distractor th rou gh th e d istal plate h ole to th e
su bm u scu lar slide-in sertion plate after applyin g traction
m anu ally, h elps to redu ce th e r isk of m alu n ion .
Position in g of two K-w ires to con trol correct plate posi-
tion d istally an d visu al an d d igital con trol th rou gh th e
sm all prox im al in cision can h elp to preven t in correct plate
placem en t.
Fig 9 .2 .7-9 a – bDirect percu tan eou s redu ction is ach ieved
w ith th e collin ear redu ction cla m p.
a b
 Au t h o rs An d re a s Gru n e r, Th o m a s J Ho cke r t z, Ga b rie le St re ich e r, He in rich Re ilm a n n

9.2.8 Fe m oral shaft fracture , pe riprosthe tic—32-A1

1 Ca s e d e s crip t io n

89-year-old m an fell on th e way to th e bath room at th e old

people’s h om e an d in ju red h is left femu r.
Type of in ju ry: low-en ergy trau m a, m on otrau m a, closed frac-
tu re.

Fig 9 .2 .8 -1a – b
a AP view.
b Detail AP view.

In d ica t io n

Pe rip ro sth e tic fra ctu re o f th e le ft fe m u r w ith im p la n te d ce m e n te d

se m i-h ip a rth ro p la st y. No clin ica l o r ra d io lo gica l sign s o f lo o se n in g.
Be fo re th e a ccid e n t th e p a tie n t w a s m o b ile w ith o u t cru tch e s a n d
a b w ith o u t s ym p to m s .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 9 .2 .8 -2 Su p in e p o sitio n ,
• LISS-DF, 13 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n th e le g is fre e d ra p e d fo r
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g lo ckin
ce pg h a lo sp o rin . in tra o p e ra tive m o b ilit y,
h e a d scre w s (LHS) • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin . e le va tio n o f th e in ju re d lim b,
• LISS p e rip ro s th e tic scre w s a n d e xio n o f th e kn e e jo in t
• 2 .0 m m K-w ire s a t a p p ro xim a te ly 3 0 °, lo w e r
(Size o f s yste m , in stru m e n ts, a n d
th e co n tra la te ra l le g fo r b e t te r
im p la n ts ca n va ry a cco rd in g to a n a to m y.) in tra o p e ra tive x-ra y a sse ssm e n t,
cu sh io n th e d is ta l fe m u r o f th e
Pa t ie n t p re p a ra t io n a n d p o s it io n in g in ju re d le g, e g, w ith a to w e l ro ll.
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

551
 9 .2 Fe m u r, s h a ft
2 Su rgica l a p p ro a ch
3 Re d u c t io n a n d fixa t io n
a b
552
Fig 9 .2 .8 -3Sk in in cision from Gerdy’s tu bercle in a proxim al d irection .
Divide th e iliotibial tract in th e d irection of its bers an d dissect to th e
per iosteu m wh ile retractin g th e vastu s lateralis. Addition al sm all in ci-
sion s for prox im al xation .
Fig 9 .2 .8 -4 a – c Approx im ate redu ction of th e fractu re an d
th e lon gitu d in al ax is by applyin g ax ial ten sion w ith th e k n ee
exed to approx-im ately 30° to relax th e gastrocn em iu s.
Prepare th e plate bed from d istal to prox im al by epiperiosteal
tu n n elin g w ith a lon g bon e rasp u n der th e vastu s lateralis
m u scle.
Select th e appropriate plate len gth u n der im age in ten si -cat-
ion an d in sert th e im plan t in to th e plate bed; m ake an in ci-
sion at th e proxim al en d of th e plate to com plete th e correct
position in g of th e LISS.
Stabilize th e im plan t by in sertin g K-w ires proxim ally an d
d istally th rou gh th e im plan t an d ch eck plate position in two
plan es.
Precise redu ction of th e sh aft fragm en ts w ith th e pu llin g de-
vice.
In sert th e screw s altern ately in th e d istal an d prox im al h oles
startin g d istally, determ in e screw len gth accord in g to Ta b 3 -
2 , ch a p te r 3 , wh ereby th e special prosth esis d r ill w ith lim ited
drill depth an d th e special periprosth etic screw s sh ou ld be
u sed proxim ally on ce th e stem of th e prosth esis is in position .
Th is avoids collision w ith prosth etic com pon en ts an d an y as-
sociated th read strippin g in th e cortex.
c
 9 .2 .8 Fe m o ra l s h a ft fra ct u re , p e rip ro s t h e t ic—32-A1

4 Re h a b ilit a t io n

Weigh t bea r in g: 15 kg for 2 w eek s; h a lf body w eigh t a fter

4 weeks; fu ll weigh t bearin g after 6 weeks.
Ph ysioth erapy: from 2n d postoperative day an d con tin u ou s
passive m otion .
Ph arm aceu tical treatm en t: pain th erapy an d n on steroid an ti-
in am ator y d ru gs.

Fig 9 .2 .8 -5 a – d
a – c Postoperative x-rays after 1 week.
a b c d Clin ical pictu re after 1 week.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In correct plate len gth : wh en in sertin g sh ort m on ocortical Mon ocortical an ch orage in th e LISS sh aft in th e region of
periprosth etic screw s it is especially im portan t to en su re th e prosth esis bed.
th at th ere is adequ ate an ch orage in th e cortex. Fig 9 .3 .X-3 a – c
Th e prosth esis m u st be rm ly seated. Weight bearin g:
- 15 kg for 4 weeks
- Half body weight after 2 weeks
Ap p ro a ch Ap p ro a ch - Fu ll weight bearing after 6 weeks
In adequ ate preparation of th e d istal fem u r an d, con se- Physiotherapy: from second postoperative
qu en tly, plate position in g too far an teriorly or posteriorly day and CPM
an d risk of trappin g th e iliotibial tract. Ph arm aceutical treatment: Pain therapy
and NSAID.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Displacem en t of th e m anu al redu ction an d ax is, in correct Anchorage is possible in the presence of endoprostheses w ith
screw len gth an d abu tm en t of th e LISS screw s before h ead sh aft com ponents or correction endoprostheses.
lock in g is ach ieved. Con sequ en t th read strippin g. Use of periprosthetic screws.

Re h a b ilit a t io n Re h a b ilit a t io n
Im m obilization for too lon g tim e. Partial weigh t bearin g can n ot always be ach ieved w ith
elderly patien ts.

553
 9 .2 Fe m u r, s h a ft

554
 Au t h o r Mich a e l Wa gn e r

9.2.9 Spiral fe m oral shaft fracture , pe riprosthe tic—32-A1

1 Ca s e d e s crip t io n

93-year-old wom an fell at h om e. Displaced spiral

fractu re d istal to a clin ically stable u n cem en ted
h ip arth roplasty w ith severe osteopen ia.

Fig 9 .2 .9 -1a – b
a AP view.
b Lateral view.

a b

In d ica t io n

Re le va n t d isp la ce m e n t o f th e sp ira l fe m o ra l sh a ft fra ctu re . Eve n o th e r o p e ra tive o p tio n is to ch a n ge th e u n s ta b le fe m o ra l ste m o f

th o u gh th e a rth ro p la st y h a s ra d io lo gica l sign s o f in s ta b ilit y, o p e ra - th e p ro sth e sis to a lo n ge r re visio n ste m w ith a d d itio n a l ce rcla ge
tive tre a tm e n t w ith a m in im a lly in va sive p ro ce d u re , w h ich a llo w s w ire . No n o p e ra tive tre a tm e n t w ith tra ctio n is a sso cia te d w ith p ro -
fo r ra p id m o b iliza tio n , w a s in d ica te d in th is fra il o ld w o m a n . An - lo n ge d b e d re st a n d is n o t a n o p tio n in e ld e rly p a tie n ts .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 9 .2 .9 -2 Th e fra ctu re d le g is

• LCP 4 .5/ 5 .0 , b ro a d , 16 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo - p la ce d w ith kn e e e xe d a t 2 0 –
• Lo ckin g h e a d scre w s (LHS) sp o rin . 3 0 °, w h e re a s th e u n in ju re d le g is
• Ce rcla ge w ire s • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin . p la ce d stra igh t o n th e ta b le .
• Wire m o u n ts
• Pe lvic re d u ctio n fo rce p s
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

555
 9 .2 Fe m u r, s h a ft

2 Su rgica l a p p ro a ch

b c

Fig 9 .2 .9 -3 a – c
a Two in cision s are ch osen , on e on th e lateral side of th e prox im al femu r, th e
oth er on e in th e region of th e fu tu re d istal en d of th e plate.
b – c Preoperative plan n in g for plate len gth is m an datory. Th e plate is ch osen in th e
appropriate len gth an d preben t to th e lateral aspect on th e fem oral sh aft. After
m ak in g distal an d proxim al in cision s (tran sm u scu lar approach proxim ally)
an d position in g of two cerclage w ires arou n d th e sh aft of th e fem u r, a th ird
cerclage w ire is in serted at th e level of th e fractu re d istal to th e prosth etic
a stem .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .2 .9 -4 a – k b Th e en d of th e plate can be seen an d palpated th rou gh th e

a The plate is in serted alon g the fem oral sh aft from distal to proxim al in cision . Th is allow s correct position in g of th e
proxim al. plate on th e lateral aspect of th e femu r.
A th readed d rill sleeve is xed in th e d istal part of th e c Prelim in ar y m u ltiple cerclage w ires were led arou n d th e
plate an d u sed as a h an d le. fem u r an d th e plate.

556
 9 .2 Fe m u r, s h a ft

4 Re h a b ilit a t io n

Ph ysioth erapy: con tin u ou s passive m otion begin n in g on th e

rst postoperative day w ith ou t lim itation except pain .
Mobilization w ith partial weigh t bearin g for 8 –10 weeks de-
pen din g on th e x-rays 6 weeks postoperatively.
Ph a r m aceu t ica l t reatm en t: pa in m ed icat ion depen d in g on
postoperative pain .

Fig 9 .2 .9 -5 a – b
Postoperative x-rays 3 m on th s after th e operation . Th e frac-
tu re sh ow s good bon e h ealin g w ith callu s form ation du e to
th e bridgin g plate prin ciple in th is sim ple fractu re pattern .
Th e cerclage w ires are n ecessary for redu ction an d proxim al
plate xation an d do n ot d istu rb in d irect bon e h ealin g.
a AP view.
b Lateral view.

a b

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n
Malu n ion is easily ach ieved u sin g M IPO, th erefore every
precau tion sh ou ld be taken to redu ce th is risk (eg, cable
m eth od, con tralateral u n in ju red leg, in traoperative x-ray).
Th e prox im al xation of th e plate in a periprosth etic
fem oral fractu re is critical. In th e case of a bu lky stem ,
on ly sh ort m on ocortical LHS can be u sed.
Re d u ct io n a n d xa t io n
Direct redu ction w ith cerclage w ires an d redu ction clam ps
is a sim ple tech n iqu e to th e su bm u scu lar slide-in sertion
plate after applyin g traction m anu ally, an d h elps to redu ce
th e risk of m alu n ion .
Sin gu lar cerclage w ires do n ot preven t in direct bon e
h ealin g
Wire m ou n ts preven t cerclage w ires from m ovin g
proxim ally or distally an d h elps to x th e LCP.

Cerclage w ires th rou gh w ire m ou n ts are h elpfu l for

redu ction an d xation

558
9.3 Fe m ur, distal

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

9.3 .1 Extraarticu lar distal fe m o ral fractu re 33 -A2 lo cke d splin ting LCP-DF lo cke d in te rnal 565
fixa to r

9.3 .2 Supracond ylar fe m oral fractu re w ith jo in t 33 -C2 co m p re ssio n LISS-DF lag scre w s an d 569
in vo lve m e n t an d locke d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .3 In traarticu lar d istal fe m o ral fractu re 33 -C2 com pre ssion LISS-DF lag scre w s an d 57 3
an d locke d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .4 In traarticu lar d istal fe m o ral fractu re w ith 33 -C2 co m p re ssio n LCP 4 .5/ 5 .0 , lag scre w s and 57 7
m u ltifragm e n tary fractu re o f th e p ate lla an d locke d b ro a d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .5 Com ple te articu lar m u ltifragm e n tary distal 33 -C3 co m p re ssio n LISS-DF lag scre w s an d 583
fe m o ral fractu re an d locke d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .6 Op e n co m ple te articular m u ltifragm e n tary d istal 33 -C3 co m p re ssio n LISS-DF la g scre w s a n d 5 87
fe m o ral fractu re an d locke d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .7 Op e n co m ple te in traarticu lar m ultifragm e n tary 33 -C3 co m p re ssio n LISS-DF la g scre w s a n d 593
d istal fe m o ral fractu re an d locke d lo cke d in te rnal
sp lin tin g fixa to r

9.3 .8 Pe ripro sthe tic d istal fe m o ral fractu re w ith 33 -A2 lo cke d sp lin tin g LISS-DF lo cke d in te rn al 6 01
im plan te d to tal kne e e n do pro sthe sis fixa to r

9.3 .9 Bila te ral o p e n su praco nd ylar fe m o ral fractu re s 33 -A3 lo cke d sp lin tin g LISS-DF lo cke d in te rn al 605
ab o ve to tal kn e e arth ro p la sty fixa to r

9 .3.10 Do uble o ste o to m y fo r valgu s le g d e fo rm ity d u e LISS-DF; To m o fix 611

to la te ra l co m p a rtm e n t kn e e o ste o arth ritis tib ial h e ad pla te

559
 9 Fe m u r

9 Fe m ur

9 .3 Fe m u r, d is t a l 5 61
9 .3 .1 Ext ra a r t icu la r d is t a l fe m o ra l fra ct u re —3 3 -A2 565
9 .3 .2 Su p ra co n d yla r fe m o ra l fra ct u re w it h jo in t
in vo lve m e n t—3 3 - C2 569
9 .3 .3 In t ra a r t icu la r d is t a l fe m o ra l fra ct u re —33 - C2 57 3
9 .3 .4 In t ra a r t icu la r d is t a l fe m o ra l fra ct u re w it h m u lt ifra gm e n -
t a r y fra ct u re o f t h e p a t e lla —3 3 - C2 57 7
9 .3 .5 Co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l
fra ct u re —33 - C3 583
9 .3 .6 Op e n co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l
fra ct u re —33 - C3 587
9 .3 .7 Op e n co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l
fra ct u re —33 - C3 593
9 .3 .8 Pe rip ro s t h e t ic d is t a l fe m o ra l fra ct u re w it h im p la n t e d t o t a l
k n e e e n d o p ro s t h e s is —33 -A2 6 01
9 .3 .9 Bila t e ra l o p e n s u p ra co n d yla r fe m o ra l fra ct u re a b o ve t o t a l
k n e e a r t h ro p la s t y—33 -A3 605
9 .3 .10 Do u b le o s t e o t o m y fo r va lgu s le g d e fo rm it y d u e t o la t e ra l
co m p a r t m e n t k n e e o s t e o a r t h rit is 611

56 0
 Au t h o r Mich a e l Sch ü t z

9.3 Fe m ur, distal

1 In cid e n ce

Th e in ciden ce of d istal fem oral fractu res is 12 per 100,000

popu lation an d accou n ts for 6 –7% of all fem oral fractu res.
Th ese fractu res occu r predom in an tly in two age grou ps:
you n ger patien ts between 20 an d 35 years of age an d elderly a b c
patien ts.
Fig 33-A Extraarticu lar fractu re.
9 .3 -1a – c
a 33-A1 sim ple
Th e you n ger patien ts are m ostly m ale an d su stain a d istal
b 33-A2 m etaphyseal wedge an d/or fragm en ted wedge
fem oral fractu re as a resu lt of h igh -velocity trau m as, gen eral-
c 33-A3 m etaph yseal com plex
ly car or m otorbike acciden ts, w h ereby th e fractu re occu rs as
a con sequ en ce of d irect application of force to th e exed k n ee
join t. Road traf c acciden ts are in volved in over 50% of th e
fractu re cases. Over 30% of th ese patien ts are polytrau m a-
tized. Add ition al in ju ries to th e affected lim b are frequ en t.

A well k n ow n path om ech an ism in road-traf c acciden ts is th e

socalled “dash board in ju ry”, wh ereby an im pact on th e exed
a b c
k n ee join t forces th e patella back in between th e fem oral con -
dyles like a wedge. Th is ex plain s th e com bin ed in ju ries of Fig 33-B Partial articu lar fractu re.
9 .3 -2 a – c
patellar fractu res an d in traarticu lar d istal fem oral fractu res. a 33-B1 lateral con dyle, sagittal
Wh en forces act on th e lon gitu d in al axis of th e leg w ith th e b 33-B2 m edial con dyle, sagittal
k n ee join t in exten sion , th e tibial plateau is pressed again st c 33-B3 fron tal
th e con dyles. Th is leads to a su pracon dylar fem oral fractu re
an d possibly splits th e con dylar block an d th e fem oral sh aft.

The second age peak occu rs in patients, mostly fem ale, between
the ages of 60 and 75 years. The inciden ce of distal fem oral
fractu res even rises to 170 per 100,000 popu lation for patients
older th an 85 years. Th e type of acciden t in th is patien t grou p is
predom in an tly a low-en ergy trau m a. Th ere is often a ten den cy
a b c
for fractu res to be du e to an osteoporotic bone structu re.
Fig 33-C Com plete articu lar fractu re.
9 .3 -3 a – c
Accord in g to th e literatu re an d ou r ow n obser vation s, patien ts a 33-C1 articu lar sim ple, m etaph yseal sim ple
wh o h ave su stain ed a d istal fem oral fractu re w ill h ave a con - b 33-C2 articu lar sim ple, m etaphyseal m u ltifragm en tary
com itan t fractu re of th e patella in 10 –15% of cases, a patellar c 33-C3 articu lar m u ltifragm en tary
ligam en t in stability requ irin g treatm en t in 20 –30% an d fu r-
th er bon e lesion s of th e ipsilateral leg in 20 –25% of cases. Th e
“ oatin g k n ee“ is a ver y speci c in ju ry pattern . Th is com bin a-

561
 9 Fe m u r

tion of a d istal fem oral fractu re w ith a prox im al tibial fractu re
is d iagn osed in approxim ately 5% of all patien ts w ith d istal
fem oral fractu res. In con trast, con com itan t vessel an d n erve
in ju ries are relatively rare (<5% ) bu t m u st n everth eless al-
ways be assessed an d exclu ded. Con com itan t in ju ries ten d to
be rare in elderly patien ts affected by a low-en ergy trau m a.
of in ju ry as well. Th e 5-d igit alph anu m eric code in cor porates
fractu re site an d type based on a com preh en sive evalu ation .
With its su bdivision s regardin g type A, B an d C th is classi -
cation takes in to accou n t essen tial con sideration s con cern in g
th erapeu tic procedu re an d progn osis. Th e degree of fractu re
severity in creases from type A to C an d from su bgrou p 1 to 3
as th e progn osis worsen s in term s of u n su ccessfu l h ealin g.

In ju r y In cid e n ce

3 Tre a t m e n t m e t h o d s
Po lytra u m a 44%

Clo se d so ft-tissu e in ju rie s 20%

Distal fem oral fractu res today are treated operatively alm ost
Op e n fra ctu re s 24 – 4 0 % w ith ou t exception , wh ereby a broad spectru m of d ifferen t
operative tech n iqu es an d im plan ts is available. Regard less
Ne rve a n d ve sse l in ju rie s 3%
of th ese differen ces, th e aim of treatm en t rem ain s th e sam e.
Liga m e n to u s in ju rie s 10 –19 % Treatm en t sh ou ld lead to an optim al restoration of th e join t
su rfaces an d correct ax ial align m en t of th e d istal fragm en t
Da m a ge to th e m e n iscu s 4%
in relation to th e sh aft perm ittin g early fu n ction al, cast- free
Ca rtila gin o u s in ju rie s ( a ke fra ctu re s) 7% reh abilitation .
Pa te lla r fra ctu re s 4 –19 %
Alth ou gh th e operative treatm en t of d istal fem oral fractu res
Ch a in in ju rie s to th e ip sila te ra l lim b 17–27 % was n ot well recom m en ded u p to th e 1960s, a rst case series
of 112 patien ts was pu blish ed by th e AO in 1970 docu m en tin g
In ju rie s to th e co n tra la te ra l lim b 10 –13%
clearly im proved ou tcom es obtain ed by operative treatm en t.
Ta b 9 .3 -1In ju ry pattern s an d con com itan t in ju ries in d istal In alm ost 75% of th e cases th e ou tcom e was fou n d to be good
fem oral fractu res. or ver y good. Th is was a sign i can t progress com pared to th e
data pu blish ed in th e 1960s by Stewart an d Neer w h o h ad
ach ieved a satisfactor y resu lt in on ly 50% of patien ts treated
su rgically. Fu rth er pu blication s reportin g on im proved ou t-
2 Cla s s ifica t io n
com es after operative treatm en t were pu blish ed in qu ick su c-
cession .
A n u m ber of d ifferen t classi cation s are available for d istal
fem oral fractu res, eg, Stewart, Neer, Sein sh eim er or Sch atz- For a lon g tim e, th e a im of treatm en t was th e a n atom ical
ker an d Lam bert. Th e Mü ller AO Classi cation ( Fig 9 .3 -1 , Fig recon stru ction of all fragm en ts, in clu d in g th e m etaph y-
9 .3 -2 , Fig 9 .3 -3 ) h as proven its worth an d h as becom e well seal region , a n d h igh pr im ar y stability. Th is was ach ieved
establish ed. by ex ten sive ex posu re of th e fractu re site an d by in ser tion
of n u m erou s in depen den t lag a n d plate screw s. A poten tial
Th e advan tage of th e Mü ller AO Classi cation is th at it perm its com plication of su ch excessive procedu res, n a m ely d istu rbed
precise fractu re categorization an d a progn osis for each type fractu re h ea lin g, was h an d led by u se of exten sive pr im ar y

562
 9 .3 Fe m u r, d is t a l

bon e graft, a procedu re th at was per form ed in u p to 86% of u sin g extra- or in tram edu llary tech n iqu es. Su f cien t an ch or-
th e pu blish ed cases. age in th e d istal fragm en t is a decisive factor for th e ch oice of
th e im plan t. Today, th e locked in tern al xator is th e stan dard
Today, “biological“ osteosynthesis and in direct reduction tech- im plan t in cases of severe com m in u tion , open fractu re w ith
n iques w ithout an atom ical reduction of every individu al fragment excessive bon e loss or in a very sm all d istal fragm en t.
perm it better con ser vation of th e bon e-to-soft- tissu e
con n ection s in n on articu latin g region s an d en su re h igh er
fragm en t vascu larization . Th e “red iscovered“ relevan ce of iat-
4 Im p la n t o ve r vie w
rogen ic soft-tissu e trau m a an d th e in u en ce of blood su pply
to th e fragm en ts led to n ew con cepts in term s of su rgical tech -
n iqu es: M IPO —m in im ally invasive percu tan eou s plate os-
a
teosyn th esis, TARPO tran sarticu lar join t recon stru ction an d
in d irect plate osteosyn th esis an d n ally n ew extram edu llar y
im plan ts. It was proven experim en tally th at m in im ally in - b
vasive approach es cau sed less iatrogen ic dam age to th e blood
su pply an d led to in creased restitu tion . Very good resu lts were
also obtain ed u n der clin ical con d ition s.

Th e su rgeon h as to con sider a m u ltiplicity of factors wh en

c
ch oosin g th e m ost appropriate operative procedu re: fractu re
type, con com itan t in ju ries, bon e qu ality, gen eral con d ition
of th e patien t, h is ow n exper ien ce an d th at of th e operat-
in g team , logistic prerequ isites, an d region al preferen ces. A
preoperative draw in g is in dispen sable to detail th e fractu re
pattern , to plan th e redu ction , an d to ch oose type an d size
of th e im plan t. It is also im portan t to an ticipate u n foreseen d
local circu m stan ces an d to con sider altern ative su rgical pro-
cedu res. e

Extraarticu lar d istal fem oral fractu res can be treated by ex-
Fig 9 .3 -4 a – e
tra- or in tram edu llary tech n iqu es. In gen eral, it is preferable
a LCP 4.5/5.0, broad
to perform in direct redu ction an d m in im ally in vasive sta-
b LCP 4.5/5.0 broad, cu rved
bilization . Th erefore, extram edu llary treatm en t m akes u se
c LISS-DF 5.0 (left an d righ t version available)
of an gu lar stable im plan ts (con dylar plate, DCS, or in tern al
d LCP-DF 4.5/5.0 (left an d righ t version available)
xator). For in tram edu llar y procedu res, an tegrade an d retro-
e LCP con dylar plate 4.5/5.0 (left an d righ t version available)
grade n ailin g tech n iqu es are available. Partially in traarticu lar
fractu res (type B fractu res) are stabilized by screw xation .
In cases of exception ally poor bon e qu ality, a protective plate
osteosyn th esis or an in tern al xator m ay becom e n ecessar y.
Even com pletely in traarticu lar fractu res can be stabilized by

563
 9 Fe m u r

Ian n aco n e WM , Be n n e t t FS, D e Lo n g WG Jr, e t al (1994) In itial

5 Su gge s t io n s fo r fu r t h e r re a d in g
experien ce w ith th e treatm en t of su pracon dylar fem oral fractu res
u sin g th e su pracon dylar in tram edu llary n ail: a prelim in ary report.
Babst R , He h li M , Re gazzo n i P (2001) [ LISS tractor. Com bin ation J Orthop Trauma; 8(4):322–327.
of th e “less in vasive stabilization system ” (LISS) w ith th e AO d istractor Mo e d BR , Wat so n J T (1995) Retrograde in tram edu llary n ailin g,
for d istal fem u r an d proxim al tibial fractu res.] Unfallchirurg; w ith ou t ream in g, of fractu res of th e fem oral sh aft in m u ltiply in ju red
104(6):530 –535. patien ts. J Bone Joint Surg Am; 77(10):1520 –1527.
Kre t t e k C, Sch an d e lm aie r P, Tsch e rn e H (1996) [ Distal fem oral He rscov ici D Jr, Wh it e m an K W (1996) Retrograde n ailin g of th e
fractu res. Tran sarticu lar recon stru ction , percu tan eou s plate femu r u sin g an in tercon dylar approach . Clin Orthop Relat Res;
osteosyn th esis an d retrograde n ailin g]. Unfallchirurg; 99(1):2–10. (332):98 –104.
St o cke r R , He in z T, Ve cse i V (1995) [ Resu lts of su rgical D av id SM , Harrow M E, Pe in d l R D , e t al (1997) Com parative
m an agem en t of d istal fem u r fractu res w ith join t in volvem en t]. biom ech an ical an alysis of su pracon dylar femu r fractu re xation :
Unfallchirurg; 98(7):392–397. locked in tram edu llary n ail versu s 95-degree an gled plate.
Bau m gae rt e l F, Go t ze n L (1994) [ Th e “biological” plate J Orthop Trauma; 11(5):34 4 –350.
osteosyn th esis in mu lti-fragm en t fractu res of th e para-articu lar Firo o zbak h sh K, Be h zad i K , D e Co st e r TA , e t al (1995) Mech an ics
fem u r. A prospective stu dy.] Unfallchirurg; 97(2):78 –84. of retrograde n ail versu s plate xation for su pracon dylar fem u r
Bo lh o fn e r BR , Carm e n B, Cliffo rd P (1996) Th e resu lts of open fractu res. J Orthop Trauma; 9(2):152–157.
redu ction an d in tern al xation of distal femu r fractu res u sin g a Maie r D G, Re isig R , Ke pp le r P, e t al (2005) [ Post-trau m atic
biologic (in d irect) redu ction tech n iqu e. J Orthop Trauma; torsion al d ifferen ces an d fu n ction al tests follow in g an tegrade or
10(6):372–377. retrograde in tram edu llary n ailin g of th e distal fem oral diaphysis.]
Ost ru m R F, Ge e l C (1995) In direct redu ction an d in tern al xation Unfallchirurg; 108(2):109 –117.
of su pracon dylar femu r fractu res w ith ou t bon e graft. J Orthop Trauma;
9(4):278 –284.
Fan k h au se r F, Gru be r G, Sch ip p in ge r G, e t al (2004) M in im al-
in vasive treatm en t of d istal fem oral fractu res w ith th e LISS (Less
Invasive Stabilization System): a prospective stu dy of 30 fractu res w ith
a follow u p of 20 m on th s. Acta Orthop Scand; 75(1):56 –60.
Sch u e t z M , Mu e lle r M , K re t t e k C, e t al (2001) M in im ally invasive
fractu re stabilization of d istal fem oral fractu res w ith th e LISS: a
prospective mu lticen ter stu dy. Resu lts of a clin ical stu dy w ith special
em ph asis on dif cu lt cases. Injury; 32(Su ppl 3):SC48 –54.
Sye d A A , A garw al M , Gian n o u d is PV, e t al (2004) Distal fem oral
fractu res: lon g-term ou tcom e follow in g stabilisation w ith th e LISS.
Injury; 35(6):599 –607.
Kre t t e k C, M iclau T, Grü n O, e t al (1998) In traoperative con trol of
axis, rotation an d len gth in fem oral an d tibial fractu res—tech n ical
n ote. Injury; 29(Su ppl3):29 –39.
D an zige r M B, Cau cci D , Ze ch e r SB, e t al (1995) Treatm en t of
in tercon dylar an d su pracon dylar d istal fem u r fractu res u sin g th e GSH
su pracon dylar n ail. Am J Orthop; 24(9):684 –690.

56 4
 Au t h o r Mich a e l Wa gn e r

9.3.1 Extraarticular distal fe m oral fracture —33 -A2

1 Ca s e d e s crip t io n

48-year-old m an stu m bled an d fell in th e street su stain in g a

closed fractu re of h is left d istal fem u r.

Fig 9 .3 .1-1a – b
a AP view.
b Lateral view.

In d ica t io n

Un sta b le d isp la ce d fra ctu re o f th e le ft d ista l fe m u r w ith m u ltip le fra g-

m e n ta tio n o f th e b e n d in g we d ge . Th e in d ica tio n to o p e ra te a n d th e
ch o ice o f im p la n t a rise fro m th e ve ry sm a ll d ista l fra gm e n t a s th is
a b sm a ll jo in t fra gm e n t m u st b e se cu re ly sta b ilize d .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP-DF, 9 h o le s
• 5 .0 m m lo ckin g h e a d scre w s (LHS)
• 2 .0 m m K-w ire s
• Sm a ll re d u ctio n ta b le
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 9 .3 .1-2 Su p in e p o sitio n a n d re d u ctio n o n th e sm a ll

re d u ctio n ta b le .

565
 9 .2 .9 Sp ira l fe m o ra l s h a ft fra ct u re , p e rip ro s t h e t ic—32-A1

3 Re d u c t io n a n d fixa t io n (co n t )

d e f

g h

Fig 9 .2 .9 -4 a – k (co n t)
d A clam p or a screwd river w ith screw h older sleeve is u sed
to h old th e w ire m ou n t.
e Th e w ire m ou n ts were in serted in th e con ical, th readed
part of th e com bin ation h ole an d th e cerclage w ires were
pu sh ed th rou gh th e h oles.
f Redu ction starts by sim u ltan eou s m an u al traction , d irect
redu ction w ith redu ction forceps, an d tigh ten in g th e cer-
clage w ires w ith th e cerclage tigh ten in g forceps.
i j g Fixation of th e prox im al fragm en t w ith a self-tappin g LHS
in th e m ost prox im al h ole. In th e secon d prox im al h ole th e
cerclage w ire th rou gh th e w ire m ou n t is seen .
h Fu rth er prox im al xation of th e plate w ith on e add ition al
LHS an d on e w ire m ou n t in th e th ird an d fou rth prox im al
plate h oles.
i In t raop erat ive im age in ten sifier con t rol of t h e fract u re
redu ction an d th e prox im al fractu re xation .
j In traoperative im age in ten si er con trol of th e d istal plate
xation .
k Distal plate xation w ith fou r LHS, th ree of th em m on o-
k cortically.

557
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

Fig 9.3 .1-3a – b Lateral extraarticu lar ap-

proach to t h e d ista l fem u r. A stra igh t
in cision is m ade over th e lateral fem oral
con dyle. After d ivision of th e iliotibial
tract, th e epiperiosteal space ben eath
th e vastu s lateralis is prepared.

a b

3 Re d u ct io n a n d fixa t io n

a b c d

Fig 9 .3 .1-4 a – o
a – b In a rst step two 5.0 m m Sch an z screw s are in serted c– d Two m ore Sch an z screw s are in serted in to th e sm all
in to th e prox im al fem u r from th e lateral aspect th rou gh distal fragm en t from th e m ed ial aspect.
two stab in cision s.

e f g

e Th ese Sch an z screw s are con n ect- f Closed redu ction follow s u sin g th e g After m ou n tin g th e in sertion gu ide
ed to t h e sm a ll redu ct ion t able by sm all redu ction table. on th e LCP-DF, th e plate is in serted
m ean s of u n iversal clam ps. in to t h e epiper iostea l space from
d istal to prox im al.

56 6
 9 .3 .1 Ext ra a rt icu la r d is t a l fe m o ra l fra ct u re —33 -A2

3 Re d u c t io n a n d fixa t io n (co n t )

h i j

Fig 9 .3 .1-4 a – o (co n t)

h Assessm en t of plate position w ith i– j Tem porary xation of th e plate to th e bon e w ith K-w ires an d in sertion of self-
th e im age in ten si er. drillin g, self-tappin g LHS th rou gh th e drill gu ide of th e in sertion gu ide.

k l m

k– m In traoperative x-ray im agin g after in sertion of th e LHS. Th e plate is xed to th e sh aft w ith fou r m on ocortical self-d rillin g,
self-tappin g LHS, an d to th e d istal segm en t w ith six LHS.

n Postoperative x-ray, AP view.

o Postoperative x-ray, lateral view.

n o

567
 9 .3 Fe m u r, d is t a l

4 Re h a b ilit a t io n

Partial weigh t bearin g for 4 weeks u p to 20 kg; fu ll weigh t bearin g after 6 weeks.

Fig 9 .3 .1-5 a – b Postoperative x-ray im agin g after 6 weeks.

a AP view.
b Lateral view.

a b

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n Re d u ct io n
In d irect redu ction of th is ver y d istal fem oral fractu re is Th e sm all redu ction table is a u sefu l device for in d irect
d if cu lt an d requ ires addition al in stru m en ts su ch as th e redu ction of fem oral fractu res.
large d istractor or sm all redu ction table an d possibly u se
of th e joystick tech n iqu e.

Fixa t io n
Particu lar atten tion n eeds to be paid to exact position in g
of th e im plan t on th e lateral side of th e fem u r.
Fixa t io n
An gu lar stable, an atom ically precon tou red plates en able
th e stable xation of fractu res, especially of ver y sm all
d istal fragm en ts an d perm it im plan t in sertion in a m in i-
m ally in vasive tech n iqu e.

56 8
 Au t h o rs Ga b rie le St re ich e r, Th o m a s J Ho cke rt z, An d re a s Gru n e r, He in rich Re ilm a n n

9.3.2 Supracond ylar fe m oral fracture with joint

involve m e nt—33 -C2
1 Ca s e d e s crip t io n

85-year-old wom an wh o fell ou t of bed

at th e old people’s h om e an d su stain ed
a su pracon dylar d istal fem oral fractu re
w ith join t in volvem en t. Prox im al fem -
oral n ail in place, in serted to treat an
earlier fem oral fractu re adjacen t to th e
h ip. Type of in ju ry: low-en ergy, m on o-
trau m a, closed fractu re.

Fig 9 .3 .2 -1a – c
a AP view.
b Detailed AP view.
c Lateral view.

In d ica t io n

Fra ctu re o f th e righ t fe m u r w ith im p la n te d

p ro xim a l fe m o ra l n a il. Pre vio u s fe m o ra l
fra ctu re a d ja ce n t to th e h ip jo in t clin ica lly
a n d ra d io lo gica lly h e a le d . Th e p a tie n t w a s
m o b ile b e fo re th e a ccid e n t w ith o u t cru tch -
a b c e s a n d w ith o u t a n y s ym p to m s .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 9 .3 .2 -2 Su p in e p o sitio n ,
• LISS-DF, 9 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo - th e le g is fre e -d ra p e d fo r
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g lo ckin
sp og rin . in tra o p e ra tive m o b ilit y, e le va tio n
h e a d scre w s (LHS) • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin . o f th e in ju re d lim b a n d e xio n o f
• 6 .5 m m ca n ce llo u s b o n e scre w w ith w a sh e r th e kn e e jo in t a t a p p roxim a te ly
• LISS p e rip ro s th e tic scre w s 3 0 °, lo w e r th e co n tra la te ra l le g
• 2 .0 m m K-w ire s fo r b e t te r in tra o p e ra tive x-ra y
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
a sse ssm e n t, cu sh io n th e d ista l
fe m u r o f th e in ju re d le g, e g, w ith
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
a to w e l ro ll, a n d p o sitio n th e
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
im a ge in te n si e r o n th e o p p o site
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
sid e .

56 9
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

An terolateral parapatellar sk in in cision exten d in g in

Fig 9 .3 .2 -3
a prox im al d irection for better con trol of th e redu ction of join t
fragm en ts an d restoration of th e fem oral con dyles.
Divide th e iliotibial tract in th e d irection of its bers an d d issect
to th e periosteu m .

3 Re d u ct io n a n d fixa t io n

Fig 9 .3 .2 -4 a – b
a Approx im ate redu ction of th e fractu re an d th e
lon gitu d in al ax is by applyin g axial ten sion w ith
th e k n ee exed to approx im ately 30° to relax
th e gastrocn em iu s m u scle.
b Redu ction of th e con dylar an d join t com pon en ts
of th e d istal fem u r by tran sverse com pression
an d tem porary K-w ire xation . Th e an terolat- b
eral approach perm its adequ ate assessm en t of
th e join t su rfaces.

570
 9 .3 .2 Su p ra co n d yla r fe m o ra l fra ct u re w it h jo in t in vo lve m e n t—33 - C2
3 Re d u c t io n a n d fixa t io n (co n t )
a b
Osteosyn th esis of th e distal fem u r to stabilize
Fig 9 .3 .2 -5 a – e
th e su pracon dylar an d join t fractu res. Make a stab in cision
m edially an d, after predrillin g, in sert a 6.5 m m can cellou s
bon e screw w ith wash er. Rem ove th e tem porary K-w ires.
Prepare th e plate bed by epiper iosteal tu n n elin g from d istal to
proxim al u n der th e vastu s lateralis w ith a lon g bon e rasp.
Iden tify th e appropriate len gth of plate u n der im age in ten -
si cation an d slide th e im plan t in to th e plate position . Make
an in cision at th e proxim al en d of th e plate to com plete th e
osteosyn th esis. Elevate th e d istal fragm en t ou t of its recu rva-
tu re position from th e dorsal side u sin g th e elevator.
4 Re h a b ilit a t io n
a b c
c d e
Stabilize th e im plan t on th e proxim al an d distal sides by
in sertin g K-w ires an d ch eck plate position in two plan es.
Precise redu ction of th e sh aft fragm en ts w ith th e pu llin g
device.
In sert th e screw s altern ately in th e d istal an d prox im al h oles
startin g d istally, determ in e screw len gth accord in g to Ta b 3 -2 .
Th e special prosth esis d rill w ith lim ited d rill depth an d th e
special LISS periprosth etic screw s are u sed in th is case be-
cau se of th e in tram edu llary load carrier, an d to avoid str ippin g
of th e screw th read in th e cortex.
Weigh t bearin g: 15 kg for 4 weeks; h alf-body weigh t after 4 weeks,
fu ll weigh t bearin g after 8 weeks.
Ph ysioth erapy: from th e secon d postoperative day an d con tin u ou s
passive m otion .
Ph a r m aceu t ica l treat m en t: pa in t h erapy a n d n on steroid a n t iin -
am m atory dru gs.
Fig 9 .3 .2 -6 a – c Postoperative x-rays after 6 m on th s.
571
 9 .3 Fe m u r, d is t a l

4 Re h a b ilit a t io n (co n t )

Fig 9 .3 .2 -7a – e
a – c Postoperative x-ray after
6 m on th s.
d d–e Clin ical pictu res after 10 m on th s.

a b c e

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In correct plate len gth : Wh en in sertin g sh ort m on ocortical Mon ocortical an ch orage of th e LISS sh aft in th e region of
periprosth etic screw s it is especially im portan t to en su re th e im plan t bed.
th at th ere is adequ ate an ch orage in th e cortex. Use of periprosth etic LHS.

Ap p ro a ch Ap p ro a ch
In adequ ate preparation of th e d istal fem u r an d, Perm its im plan t position in g an d sim u ltan eou s redu ction
con sequ en tly, plate position in g too far an teriorly or an d con trol of th e join t fractu re.
posteriorly an d risk of trappin g th e iliotibial tract.

Re d u ct io n a n d xa t io n
Loss of m an u al redu ction an d ax ial align m en t, in correct
screw len gth especially in th e region of th e n ail w ith
abu tm en t of th e LISS screw s before h ead lock in g was
ach ieved. Con sequ en t th read strippin g.
Re d u ct io n a n d xa t io n
In m u ltifragm en tar y C-type fractu res th e LISS-DF is th e
m ost u sefu l im plan t for fractu re treatm en t. Th e locked
in tern al xator is especially h elpfu l in osteoporotic bon e.

Re h a b ilit a t io n Re h a b ilit a t io n
Im m obilization for too lon g. Partial weigh t bearin g can n ot always be ach ieved w ith
elderly patien ts. Fu ll weigh t bearin g was ju st possible in
th is case.

572
 Au t h o r Ch ris t o p h So m m e r

9.3.3 Intraarticular distal fe m oral fracture —33 -C2

1 Ca s e d e s crip t io n

53-year-old m an su ffered a m otorcycle in ju r y. He h ad an open ,

in traarticu lar fractu re of th e left d istal femu r (Gu stilo type II,
33-C2.3). Th e con dyles were fractu red sligh tly on th e lateral
side of th e m id lin e w ith a sm all in term ed iate fragm en t. Th e
patien t also su ffered a d isplaced distal radial fractu re.

Fig 9 .3 .3 -1a – b
a AP view.
b Lateral view.

a b
In d ica t io n
Th is in ju ry is a n a b so lu te in d ica tio n fo r im m e d ia te o p e ra tive sta -
b iliza tio n o f th e fra ctu re a s w e ll a s d e b rid e m e n t a n d je t la va ge
o f th e so ft tissu e . Th e LISS-DF is a n id e a l im p la n t w ith w h ich
to sta b ilize th e fra ctu re . Alte rn a tive ly, a DCS, a co n d yla r p la te ,
o r a co n ve n tio n a l p la te s yste m co u ld b e u se d . Th e in te rm e d ia te
fra gm e n t, p la ce d in th e in te rco n d yla r n o tch , w o u ld te n d to b e
re ga rd e d a s a co n tra in d ica tio n fo r re tro gra d e n a ilin g.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t 1p re pSu rget io
a ra o nn a n d p o s it io n in g Fig 9 .3 .3 -2 Po sitio n o f
• LISS-DF, 13 h o le s • An tib io 2 tics:ORP
sin gle d o se 2 n d ge n e ra tio n ce p h a lo - th e OR te a m . Pa tie n t in
• 5 .0 m m lo ckin g h e a d scre w s (LHS) sp o rin3. 1st a ssista n t su p in e p o sitio n , e le va tio n
• 3 .5 m m co rte x scre w s • Th ro m4b o sis 2npdroa pssistan t Lo w m o le cu la r h e p a rin .
h yla xis: o f th e in ju re d le g, a n d
• La rge d istra cto r e xio n o f th e kn e e jo in t to
Ste rile are a
a p p roxim a te ly 3 0 °.
(Size o f s yste m , in stru m e n ts, a n d 1
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin 2
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
4
h e p a rin
3

573
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

a b c
Fig 9 .3 .3 -3 a – c
a – b Th e wou n d at th e an terolateral c Th e join t is open ed by a parapatellar arth rotom y ju st lateral to th e vastu s lateralis.
apsect is in tergrated in th e parapa- Th e cen tral part of th e qu adriceps ten don h ad been cu t by th e sh ar p edge of on e
tellar approach . of th e m etaph yseal fractu re fragm en ts. A clear view of th e fractu re zon e an d th e
soft tissu e is possible after jet lavage.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .3 .3 -4 a – c Th e m ost d istal screw m u st be in serted str ictly parallel

a – b Th e join t block is redu ced an d h eld w ith th e h elp of
pelvic redu ction forceps in serted laterally th rou gh th e
in cision an d m ed ially percu tan eou sly tech n iqu e. Th e
in term ed iate fragm en t is m an eu vered in to position . Pre-
lim in ary xation w ith K-w ires follow s an d two 3.5 m m
cortex screw s are in serted ven trally an d su bch on d rally.
Th e LISS-DF, 13-h ole plate is th en in serted u n der th e
vastu s lateralis in a proxim al direction . Th e plate is h eld
distally in th e correct position w ith th e cen ter of th e
plate between th e an terior an d m idd le th ird of th e lat-
eral con dyle.
After tem porar y xation w ith K-w ires at its distal en d,
the position is then con trolled w ith im age in ten si cation .
to th e join t su rface. To determ in e th e screw d irection ,
a K-w ire is in serted th rou gh a d rill sleeve u n der im age
in ten si cation . If th e K-w ire is parallel to th e join t su r-
face, on e lockin g h ead screw is in serted. Th e m eta- an d
diaph yseal zon es are redu ced an d h eld in correct len gth
an d rotation by m anu al traction or w ith th e h elp of a
large d istractor or extern al xator.
c A sm all in cision is m ade over th e m ost proxim al h ole.
A drill sleeve is in serted an d th e plate is brou gh t in to
proper position over th e bon e. Th e plate m u st be in a
cen tral position over th e bon e before d rillin g. A h ole is
drilled bicortically w ith a 4.3 m m drill bit. Th e d rill bit is
th en left in th e bon e to m ain tain tem porary redu ction .

574
 9 .3 .3 In t ra a r t icu la r d is t a l fe m o ra l fra ct u re —33 -C2

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

d e f g h

Fig 9 .3 .3 -5 a – h
a In a lateral view, sligh t retrocu r vatu re is apparen t in th e exten ded k n ee position .
b Th is can be corrected by placin g a towel roll u n der th e fractu re an d by applyin g cou n ter pressu re.
c On ce th e correct position h as been con rm ed, at least fou r to ve LHS are in serted in to th e join t block
an d th ere sh ou ld be an ch orage in at least fou r cortices on th e proxim al side. Th is m ean s in sertion of at
least fou r m on ocortical self-tappin g, self-drillin g LHS (w ith in sertion gu ide) or bicortical self-tappin g
LHS (w ith ou t in sertion gu ide). If th e bon e is osteoporotic, at least six to eigh t cortices sh ou ld be u sed.
Th e cen tral cu t in th e qu ad riceps ten don is th en sew n togeth er.
d – e Th e in traoperative x-rays sh ow correct axial align m en t in both plan es. Six cortices are u sed proxim ally
(two m on ocortical an d two bicortical LHS).
f– h Th e join t is redu ced w ith ou t an y step-off; in terfragm en tary com pression is m ain tain ed by lag screw s. Th e
in term ed iate m etadiaph yseal fractu re zon e is n ot tou ch ed; th is zon e is bridged w ith a locked in tern al
xator in splin tin g m eth od.

575
 9 .3 Fe m u r, d is t a l

4 Re h a b ilit a t io n

Fig 9 .3 .3 -6 a – e
a – c Th e patien t is in stru cted to practise early
fu n ction al train in g w ith partial weigh t
bear in g (10 kg) for 6 weeks, th en h alf body
weigh t bearin g u n til 3 m on th s after th e op-
eration . Th e con trol x-rays sh ow early cal-
lu s form ation in th e m eta- an d diaph yseal
zon es. Th e in traarticu lar fractu re is rad io-
logically con solidated. Th e patien t can start
fu ll weigh t bearin g at th is poin t. Th e fu r-
th er cou rse of h ealin g was u n even tfu l.
a b c d e d–e After 1 year th e fractu re sh owed a com plete
callu s bridge an d th e start of rem odelin g.
Im p la n t re m o va l
The plate was removed after 14 month s becau se of a slight irritation
of the iliotibial tract over the distal end of the LISS plate.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LISS-DF or LCP-DF is th e ideal im plan t for m in im ally
invasive su rger y of C-type fractu res of th e d istal fem u r.
Th e plate n eed n ot be ben t.

Ap p ro a ch
Th e m in im ally in vasive approach to bridgin g th e m etad i-
aph yseal fractu re zon es is associated w ith a h igh risk of
postoperative m alalign m en t (if n ot don e properly).
Ap p ro a ch
Th e m in im ally in vasive procedu re con serves th e blood
su pply of th e su pracon dylar an d d iaph yseal zon es by
preser vin g m ore of th e perforator vessels (com pared to
an open approach).

Re d u ct io n a n d xa t io n
To avoid postoperative ax ial or rotation al m alalign m en t,
in traoperative x-ray con trol m u st be perform ed. Th e frac-
tu red leg h as to be com pared w ith th e h ealth y leg (pre-
or in traoperatively).
Re d u ct io n a n d xa t io n
The reduction can be performed over the an atom ically
precontu red plate (w ith or w ithout in sertion gu ide) u sing an
appropriate tech n ique. LHS provide h igh stability m ain ly in
osteoporotic bone in cases w ithout medial bone contact.

Re h a b ilit a t io n Re h a b ilit a t io n
Irritation of th e iliotibial ban d over th e d istal en d of th e Early fu n ction al treatm en t can be perform ed even in
LISS plate. osteoporotic bon es. Fu ll weigh t bearin g is possible before
com plete con solidation of th e fractu re.

576
 Au t h o r Ch ris t o p h So m m e r

9.3.4 Intraarticular distal fe m oral fracture with m ultifragm e ntary

fracture of the pate lla —33 -C2
1 Ca s e d e s crip t io n

40-year-old m an fell asleep wh ile drivin g a car an d collided

w ith a tree. He su ffered several fractu res of h is lower lim bs.
On h is left side, h e h ad a Gu stilo type I open patellar fractu re
an d a fractu re of th e tibial h ead. Th ese in ju r ies are n ot de-
scribed h ere.
He also su ffered a Gu stilo type II open in traarticu lar fem oral
fractu re (33-C2.3) w ith mu ltifragm entary fractu re of the patella
on th e righ t leg. No n eu rovascu lar dam age.

Fig 9 .3 .4 -1a – b
a AP view.
b Lateral view.

a b

In d ica t io n Pre o p e ra t ive p la n n in g

In th is o p e n fra ctu re situ a tio n , EqPautip

iemn te pn re
t p a ra t io n a n d p o s it io n in g 1 Su rge o n
th e in d ica tio n fo r e m e rge n cy • •LCP
An tib
4 .5/
io tics:
5 .0 , sin
b rogle
a d ,d15 o seh o2le
nd
sge n e ra tio n ce p h a lo - 2 ORP
sta b iliza tio n a n d d e b rid e m e n t • Lospckin
o ring. h e a d scre w s (LHS) 3 1st a ssistan t
w ith la va ge is cle a r. Be ca u se • •6Th
.5 ro
mm mbca o sis
n cepllo
ro pu hs yla
b oxis:
n e scre
Lo wwm o le cu la r h e p a rin . 4 2n d a ssista n t
th e fra ctu re is ve ry d ista l, a n • La rge d is tra cto r 1
o ste o s yn th e sis s ys te m w ith (Size o f s yste m , in s tru m e n ts, a n d
Ste rile are a
lo ckin g h e a d scre w s, fo r e xa m - im p la n ts ca n va ry a cco rd in g to a n a to m y.)
2
p le , a LISS-DF o r LCP, w o u ld b e
id e a l. In a h igh ly co n ta m in a te d Pa t ie n t p re p a ra t io n a n d
situ a tio n , a te m p o ra ry jo in t- p o s it io n in g 4
b rid gin g e xte rn a l fixa to r w ith An tib io tics: sin gle d o se 2n d 3 ?
d e fin itive re co n s tru ctio n in a ge n e ra tio n ce p h a lo sp o rin
se co n d o r th ird s ta ge w o u ld Th ro m b o sis p ro p h yla xis:
h a ve b e e n p re fe rre d . lo w - m o le cu la r h e p a rin Fig 9 .3 .4 -2 Su p in e p o sitio n , th e le g is fre e d ra p e d fo r
in tra o p e ra tive m o b ilit y, e le va tio n o f th e in ju re d lim b a n d
e xio n o f th e kn e e jo in t a t a p p roxim a te ly 3 0 °.

577
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

Fig 9 .3 .4 -3 A parapatellar, lateral, vertical approach is plan n ed. Bu t, becau se th e soft tissu e
is trau m atized m edially, th e wou n d is excised an d th e m ed ial in cision is en larged cran ially
an d cau dally in a lateral direction . Th is speci c approach is perform ed th rou gh th e patellar
fractu re an d involves in cision of th e lateral retin acu lu m h orizon tally. Th e su perior parts of
th e patella are h eld cran ially an d th e in ferior parts cau dally. Th e articu lar part of th e fem oral
fractu re can n ow be addressed u n der m axim al exion of th e k n ee join t. At th e level of th e
proxim al en d of th e plate, a sm all lateral approach alon g th e an terior border of th e lateral
in tram u scu lar septu m is perform ed for precise lateral placem en t of th e plate. Th is secon d ap-
proach is far distan t from th e m etad iaphyseal fractu re zon e w h ich is n ot open ed.

3 Re d u ct io n a n d fixa t io n

c d

Fig 9 .3 .4 -4 a – d
a – b First th e con dylar block is redu ced an d h eld w ith a Weber forceps.
c– d Th e block is xed w ith a posteriorly placed 6.5 m m can cellou s bon e screw (lag screw),
b keepin g th e redu ction forceps in position .

578
 9 .3 .4 In t ra a r t icu la r d is t a l fe m o ra l fra ct u re w it h m u lt ifra gm e n t a r y fra ct u re o f t h e p a t e lla —33 -C2

3 Re d u c t io n a n d fixa t io n (co n t )

Th e align m en t of th e con dylar block to th e diaph ysis is perform ed w ith th e aid

Fig 9 .3 .4 -5 a – b
of th e large distractor. Th e rst Sch an z screw is in serted in to th e con dylar block in a lateral
3 to m ed ial d irection (1 ), th e secon d on e in to th e proxim al fem oral sh aft ( 2 ). With th e h elp of
a T-h an d le con n ected to th e d istal Sch an z screw over th e loosely attach ed d istractor clam p,
1 th e fractu re is redu ced in to correct varu s-valgu s position . With a th ird Sch an z screw in serted
in to th e con dylar block from an terior to posterior, th e fractu re can be redu ced in correct
an terior-posterior position ( 3 ). After correct align m en t, th e d istractor clam ps are tigh ten ed
on to th e Sch an z screw s. Fin ally, th e len gth is adju sted u sin g th e d istractor. Com parison w ith
th e h ealthy leg an d/or observation of th e fractu re fragm en ts u n der im age in ten si cation h elp
a iden tify th e correct len gth . It is im portan t to exam in e both an te- an d retrocu r vatu re of th e leg
by im age in ten si cation in th e lateral view.

On ce correct align em en t h as been ach ieved, a

Fig 9 .3 .4 -6 a – b
ben t, broad LCP 4.5/5.0 is in serted u n der th e vastu s lateralis.
The plate is xed w ith at least th ree to fou r LHS in the con dylar
block. Th e proxim al position of th e plate is exam in ed via th e
proxim al in cision (a LISS-DF, LCP-DF, lock in g con dylar plate,
or cu r ved, broad LCP 4.5/5.0 m igh t be a better altern ative).

a b

579
 9 .3 Fe m u r, d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

b c d e

Fig 9 .3 .4 -7a – e
a – c With th e plate cen trally position ed, on e to two bicortical LHS are in serted. Fu rth er LHS,
possibly m on ocortical screw s, are in serted via sm all in cision s, as requ ired. Th reads are
xed to th e h eads of th e screw s an d h eld u n der ten sion to avoid losin g th e screw s in th e
soft tissu e.
d–e Now the mu ltifragmented patella is recon structed by ten sion band w irin g. The postoperative
x-rays sh ow correct bridgin g of th e fractu re zon e an d correct axial align m en t of th e leg
as well as an atom ical join t su rface recon stru ction .

580
 9 .3 .4 In t ra a r t icu la r d is t a l fe m o ra l fra ct u re w it h m u lt ifra gm e n t a r y fra ct u re o f t h e p a t e lla —33 -C2

4 Re h a b ilit a t io n

a b c d e

f h i j k

Fig 9 .3 .4 -8 a – m c– e After 3 m on th s, th e con solidation of th e fractu re was ad-

a – b Early fu nction al treatment of the fractu re is done w ith the
help of a continuou s passive motion m ach ine. The soft tis-
sue shows no irritation 6 days after the operation . For the
rst month , the patient was mobilized in a wheelch air,
then w ith fou r-point mobilization and h alf body weight
bearing on both sides.
vanced an d fu ll weigh t-bearin g was allowed.
f– i After 6 m on th s th e callu s was circu lar.
j– m After 1 year an d im plan t rem oval at th e patella, th e fem oral
fractu re was fu lly con solidated an d partial rem odelin g of
the distal fractu re on the righ t side cou ld be seen . Clin i-
cally, th e fu n ction of th e kn ee join t was qu ite good w ith
good exten sion an d con siderable exion .

581
 9 .3 Fe m u r, d is t a l

4 Re h a b ilit a t io n (co n t )

b a b

Im p la n t re m o va l 3 years after th e operation th ere is practically fu ll ex-

Fig 9 .3 .4 -10 a – b
Fig 9 .3 .4 -9 a – b Du e to irritation of th e iliotibial ion w ith correct ax ial align m en t of both legs. Th e patien t in ten tion ally
tract, th e plate was rem oved 13 m on th s after th e lost 20 kg by pu rsu in g regu lar sportin g activities (walk in g, bik in g).
operation .

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP 4.5 can on ly be u sed if th e con dylar block is big Th e LCP system allow s th e com bin ation of lock in g h ead
en ou gh to h old th ree to fou r screw s. If th e fractu re is screw s an d cortex screw s (com pression or lag screw s), as
m ore d istally, a LISS-DF, LCP-DF, lock in g con dylar plate requ ired.
wou ld be a better altern ative.

Ap p ro a ch Ap p ro a ch
Th e plate cou ld en d u p in an eccen tric position on th e A m in im ally in vasive approach con ser ves th e blood su p-
fem oral sh aft if th e prox im al approach is in su f cien t. ply to th e m etaph yseal an d d iaph yseal fractu re zon es.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
If th e con dylar block is very sh ort, d istal xation of th e Th e large d istractor is a good aid for th e redu ction of com -
plate wou ld be in su f cien t. Also, th e prox im al screw s plex fractu res of th e d istal fem u r, m ain ly in very m u scu -
m igh t pu ll ou t if th e plate was eccen trically position ed or lar patien ts.
if m on ocortical screw s were u sed in osteoporotic bon e.

Re h a b ilit a t io n Re h a b ilit a t io n
Too early fu ll weigh t bearin g cou ld ben d th e plate (m ain ly Early fu n ction al treatm en t is essen tial for th e h ealin g of
in bilateral fractu res). com plex k n ee join t fractu res.

5 82
 Au t h o r Em a n u e l Ga u t ie r

9.3.5 Com ple te articular m ultifragm e ntary distal

fe m oral fracture —33 -C3
1 Ca s e d e s crip t io n

62-year-old m an was in volved in a h igh -en ergy fron tal car
collision . He su stain ed m u ltiple in ju ries in clu d in g splen ic
ru ptu re, ru ptu re of th e liver in segm en t III, bilateral in traar-
ticu lar d istal fem oral fractu res, lower leg fractu re, talu s frac-
tu re an d cu n eiform fractu re on h is left side, open olecran on
fractu re an d open u ln a fractu re, an d a m alleolar fractu re on
h is righ t side. Th e pu bic bon e was fractu red on both sides. Th e
patien t h ad an add ition al trau m atic peron eal n erve lesion on
h is righ t side.

Fig 9 .3 .5 -1a – b
a AP view sh ow in g a d istal in traarticu lar fem oral fractu re.
Th e articu lar fragm en ts seem to be on ly sligh tly d isplaced.
Th ere is eviden ce of preex istin g fem orotibial osteoarth ritis
m ain ly in th e lateral com partm en t.
b Lateral view sh ow in g th e m etaph yseal com m inu tion , th e
sh ort con dylar fragm en t m ed ially an d laterally, an d th e
obliqu e fractu re lin e of th e lateral con dyle in th e fron tal
a b plan e (33-B3 Hoffa type con gu ration).

In d ica t io n Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d
• LISS-DF, 13 h o le s p o s it io n in g
• 5 .0 m m lo ckin g h e a d scre w s An tib io tics: sin gle d o se 2 n d
(LHS) ge n e ra tio n ce p h a lo sp o rin
• 2 .7 m m co rte x scre w s
• La rge d is tra cto r
• 1.6 , 2 .0 , 2 .5 m m K-w ire s
a b • Pe lvic re d u ctio n fo rce p s

(Size o f s ys te m , in stru m e n ts, a n d

In itia lly th e d ista l fe m o ra l fra ctu re w a s stab ilize d in th is e m e rge n cy im p la n ts ca n va ry a cco rd in g to a n a to m y.)
situ a tio n w ith a kn e e -b rid gin g e xte rn a l fixa to r. Th e d e fin itive tre a t-
m e n t o f th e fra ctu re w a s p e rfo rm e d 3 1/ 2 w e e ks a fte r in ju ry a fte r
th e ca rd io -p u lm o n a ry situ a tio n h a d b e co m e s ta b le .

Fig 9 .3 .5 -2 a – b
Fig 9 .3 .5 -3 Su p in e p o sitio n w ith o u t p n e u m a tic to u rn iq u e t.
a AP vie w.
b La te ra l vie w.

583
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

Fig 9 .3 .5 -4Arth rotom y was perform ed

via a lateral approach .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 9 .3 .5 -5 a – g
a Th e join t fragm en ts are redu ced d irectly w ith th e poin t-
ed redu ction forceps. On th e lateral border of th e fem oral
con dyle som e osteoph ytes are visible.
b Th e fragm en ts are in itially xed w ith K-w ires: from later-
ally an d percu tan eou sly from m ed ially. Th e im age in ten si-
er sh ow s correct redu ction of th e lateral fem oral con dyle,
bu t a gap between th e m ed ial an d th e lateral con dyles at
th e in tercon dylar groove is still presen t. Th is gap is closed
later on u sin g pelvic redu ction forceps.
c The reduction is com pleted w ith the help of the pelvic reduc-
tion forceps. Th e forceps are in serted percu tan eou sly at th e
m edial aspect. De n itive xation of th e fem oral con dyles
is perform ed u sin g 2.7 m m lag screw s.

5 84
 9 .3 .5 Co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3

3 Re d u c t io n a n d fixa t io n (co n t )

d e f

Fig 9 .3 .5 -5 a – g (co n t)
4 d Du e to th e pu ll of th e gastrocn em iu s, th e distal fragm en t
h as a ten den cy to be displaced in to exten sion at th e m e-
1
taph yseal fractu re area.
To avoid th is, th e k n ee is brou gh t in to fu ll exten sion , an d
th e d istal fem oral fragm en t is stabilized in th is position
to th e tibia u sin g eith er an extern al xator or tem porary
cerclage w ire arou n d a Sch an z screw in serted in th e d istal
3
fem u r an d th e prox im al tibia.
e Sh ow in g th e in traoperative situ ation w ith all redu ction
tools in position : Th e Sch an z screw w ith th e T-h an dle
(1 ) an d th e cerclage w ire arou n d it ( 2 ) a secon d Sch an z
screw in serted in to th e proxim al tibia is u tilized to h old
2 th e d istal fem oral fragm en t in fu ll exten sion w ith respect
to th e k n ee join t. Th e large fem oral distractor ( 3 ) align s
g th e fem oral sh aft to th e tibial sh aft an d th e pelvic redu c-
tion forceps (4 ).
f Th e redu ction is n ow assessed by im age in ten si er.
g Th e LISS plate can be in serted on ce th e in sertion gu ide
h as been m ou n ted. On e screw is in serted distally in to th e
articu lar block an d th e im plan t is adju sted w ith respect
to exion an d exten sion . Two screw s are th en in serted
proxim ally. Fu rth er m on ocortical screw s are u sed on th e
proxim al fragm en t an d lock in g h ead screw s are in serted
in to th e articu lar block.

585
 9 .3 Fe m u r, d is t a l
4 Re h a b ilit a t io n
a b c d
Th e fractu re was n ot add ition ally im m obilized. Weigh t bear-
in g was n ot possible for th is polytrau m atized patien t. For
th e rst 4 m on th s, th e patien t was on ly tran sferred from th e
bed to th e wh eelch air. Today, th e patien t works fu lltim e as a
craftsm an .
Fig 9.3.5 -6 a – f
a – b AP an d lateral view sh ow in g correct an atom ical redu c-
tion of th e articu lation as well as correct align m en t of th e
fem oral sh aft an d th e articu lar block in both plan es.
5 Pit fa lls –
Re d u ct io n a n d xa t io n
Im proper align m en t of th e fem oral sh aft an d th e articu lar
block. Th e m ost frequ en t deform ity is a exion deform ity
at th e fractu re site leadin g to an exten sion de cit at th e
k n ee join t.
Dif cu lty of proper plate position in g in th e prox im al part.
5 86
e f
c– d At 5 m on th s postoperatively, th e m u ltifragm en tary m e-
taph yseal area h as h ealed. Th e x-rays sh ow in tegration
of th e fragm en ts in to th e br idgin g callu s on th e m edial
an d th e posterior aspect of th e fem u r.
e–f Clin ical resu lt at 6 years. Th e ax is of th e leg is correct.
Th e m obility of th e righ t k n ee join t for ex ion -exten -
sion is 100°–5°–0° (120°–0°–0° on th e left). Th e lim ited
m obility of th e righ t kn ee is at least partially du e to th e
preexistin g osteoarth ritis.
6 Pe a rls +
Re d u ct io n a n d xa t io n
Direct reduction tech n ique for the fractu res of the femoral
condyles.
Indirect (no-touch) reduction tech n ique to properly align
the femoral sh aft w ith respect to the distal femoral fragment.
Rapid integration of mu ltifragmentary metaphyseal frag-
ments into the bridgin g callu s.
 Au t h o rs Mich a e l Sch ü t z, No rb e r t P Ha a s

9.3.6 Ope n com ple te articular m ultifragm e ntary distal fe m oral

fracture —33 -C3
1 Ca s e d e s crip t io n

Fig 9 .3 .6 -1a – c
a AP view.
b Lateral view.
c CT scan s.

a b c

23-year-old wom an su stain ed a bilateral fem oral fractu re, a

In d ica t io n
foot in ju r y, an d a blu n t th orax trau m a in a m otorbike acciden t.
Th e fem oral fractu re on th e righ t side was a closed d istal fem -
In d u b ita b ly, th e re is a cle a r n e e d fo r o ste o s yn th e sis o f a th ird
oral fractu re w ith soft-tissu e in ju ry. Th e fractu re on th e left
d e gre e o p e n d is ta l fe m o ra l fra ctu re . Th e tim in g o f th e o ste o s yn th e sis
side was a Gu stilo type IIIA fractu re w ith m etaph yseal bon e
d e p e n d s o n th e p a t te rn o f in ju rie s th a t th e p a tie n t h a s su s ta in e d .
loss (33-C3). To treat th is in ju ry pattern , debridem en t of th e
Wo u n d d e b rid e m e n t a n d a p p lica tio n o f a n e xte rn a l fixa to r sh o u ld
open fractu re an d closu re w ith syn th etic wou n d coverin g an d
b e ca rrie d o u t. In th is ca se , th e co rre ct p o sitio n in g o f th e e xte rn a l
stabilization of th e fractu res w ith an extern al xator was per-
fixa to r is e sse n tia l fo r se co n d a ry re d u ctio n a n d im p la n t p la ce m e n t.
form ed im m ed iately th e sam e n igh t. After fu rth er d iagn osis
In th is sp e cific ca se , th e e xte rn a l fixa to r w a s a p p lie d to th e a n te -
of th e distal fem u r w ith CT scan , th e patien t was operated
rio r a sp e ct. Th e d e fin itive tre a tm e n t o f th e fra ctu re d e p e n d s o n
on again on th e follow in g day. After in tram edu llary n ailin g
se ve ra l fa cto rs re la tin g to th e in ju ry p a t te rn a n d a lso th e a va ila b le
of th e fem oral fractu re on th e righ t (n ot illu strated), th e left
in fra stru ctu re . To a ch ie ve th e b e st re su lt, th e co rre ct re d u ctio n o f
fem u r was operated.
th e a rticu la r su rfa ce s is e sse n tia l.

587
 9 .3 Fe m u r, d is t a l

Pre o p e ra t ive p la n n in g

A co n ve n tio n a l x-ra y o f th e w h o le fe mPau rt iea n dt pa reCTp asca

ra tnioanrea n de ce
p ossa
s itry
io ntoinpgla n th e o p e ra tio n .
Ta kin g in to a cco u n t th e so ft-tissu e in •juAn rie tib
s aion dtics:
th esinra gle
d io lo
d ogica
se 2l nadna
gelyse
n e ras,tio
a nske
cetchp h aislom- a d e to
d e te rm in e im p la n t le n gth , p o sitio n o f th
speo scre
rin . w s, a n d a p p ro a ch . Th e im p la n t le n gth o f th e
e xte rn a l xa to r m u st a llo w th e p la ce m • eThn troom f ab to le
sisa sptrofopuhryla
scre
xis:
w Lo
s inw thmeo lep roxim
cu la r ahlefra
p a gm
rin .e n t.
Fo r b io m e ch a n ica l re a so n s, so m e h o le s m u st b e le ft u n o ccu p ie d to a llo w fo r m icro m o tio n o f
th e p la te . In th is ca se , a LISS-DF, 9 h o le s w a s ch o se n .

Eq u ip m e n t
• LISS-DF, 9 h o le s
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w s
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 9 .3 .6 -2 Su p in e p o sitio n , kn e e jo in t
Th e p a tie n t is p o sitio n e d o n th e x-ra y ta b le . X-ra y o f th e e n tire fe m u r m u s t b e p o ssib le . Th e e xe d to a p p ro xim a te ly 3 0 °.
u n in ju re d le g sh o u ld b e e xte n d e d a n d lo w e re d (a b o u t 3 0 ° h ip e xte n sio n) to a llo w la te ra l
x-ra y p ro je ctio n . Th e in ju re d le g is e xe d to 3 0 ° a t th e kn e e jo in t, b u t m u s t a lso a llo w e xio n
u p to 6 0 ° to re lie ve th e ga stro cn e m iu s m u scle s . Th is ca n a lso b e a ch ie ve d b y u sin g s te rile
d ra p e s. Th e s te rile co ve rin g m u st a llo w fu ll m o tio n o f th e le g. It m a y b e h e lp fu l to u n co ve r
b o th le gs w h e n tre a tin g ve ry co m p le x fra ctu re s in o rd e r to a ch ie ve co rre ct a d ju stm e n t a n d
co m p a riso n o f le n gth a n d ro ta tio n .

2 Su rgica l a p p ro a ch

In th e case presen ted h ere, a lateral parapatellar

Fig 9 .3 .6 -3 a – b
approach w ith in clu sion of th e soft-tissu e in ju ry was ch osen .

a b

588
 9 .3 .6 Op e n co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3

3 Re d u ct io n a n d fixa t io n

b c

Fig 9 .3 .6 -4 a – g
a An atom ica l redu ct ion of t h e in t raa r t icu la r fract u re w it h t h e h elp of t h e
poin ted redu ction forceps. Th e redu ction is tem porarily xed w ith 2.0 m m
K-w ires.
b Th e join t block is xed w ith an isolated 3.5 m m lag screw. Th e fractu re alon e
determ in es th e position s of th e screw s. Now th e join t block is redu ced tak in g
in to accou n t len gth , ax is, an d rotation an d u sin g th e extern al xator on th e
an terior aspect to m an ipu late th e fragm en ts. Sligh t adju stm en ts are m ade by
in sertin g a K-w ire in to th e join t block an d u sin g it as a joystick. Th e redu ction
is m ain tain ed in a lign m en t w ith an elevator (an tecu r vatu re, retrocu r vatu re).
Th e m etaph yseal fractu re zon e sh ou ld n ot be tou ch ed an d an atom ical redu c-
tion is n ot n ecessary. Th e redu ction is tem porarily xed w ith two K-w ires
in serted th rou gh th e join t block in to th e d iaph ysis. Th e K-w ires sh ou ld n ot
in terfere w ith th e im plan t placem en t. If an in su f cien t redu ction persists, th e d
im plan t can be adju sted to m ake sligh t correction s.
c– d Th e LISS-DF, 9 h oles is in serted u n der th e vastu s lateralis u sin g th e in sertion
gu ide. Th e LISS plate m u st be parallel to th e con dyles to preven t an irritation
of th e iliotibial tract. Th e m ost proxim al h ole is con n ected to th e plate w ith a
trocar. Th e im plan t is tem porarily xed w ith 2.0 m m K-w ires in serted prox i-
m ally an d d istally. Th e distal K-w ire m u st be parallel to th e con dyles in th e
an teroposterior projection . In th is position , th e an atom ically preben t im plan t
sh ou ld m atch th e bon e.

58 9
 9 .3 Fe m u r, d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 9 .3 .6 -4 a – g (co n t)
e It is recom m en ded th at a 3 cm lon g in cision be m ade prox-
im ally to verify th e position of th e plate. In th e described
procedu re, th e an terior aspect of th e fem u r was palpated
an d th e im plan t was advan ced toward th e n ger. As soon
as th e redu ction is an atom ically correct, lock in g h ead
screw s are in serted in to th e distal fragm en t. Th e in sertion
of a K-w ire is recom m en ded to determ in e screw len gth
an d to avoid collision w ith a previou sly in serted lag screw.
Th e screw can th en be in serted th rou gh th e trocar. Th is
screw sh ou ld also be parallel to th e con dyles in th e AP
projection .
A rst prox im al m on ocortical lock in g h ead screw is in -
serted. Th e redu ction an d th e position of th e plate are
con trolled clin ically an d by im age in ten si cation (ax is,
len gth , rotation ). Th e rem ain in g lock in g h ead screw s are
e in serted in accordan ce w ith th e preoperative plan .
Th e in sertion gu ide is rem oved an d th e wou n d is closed.
f In traoperative x-ray, AP view.
g In traoperative x-ray, lateral view.

f g

59 0
 9 .3 .6 Op e n co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3

4 Re h a b ilit a t io n

a b c d

Gen tle active an d passive m otion begin s im m ediately on day 1 postoperatively.

Th e u se of th e con tin u ou s passive m otion m ach in e is h igh ly recom m en ded.
Mobilization w ith partial weigh t bearin g as soon as th e gen eral an d local con dition
of th e patien t allow s it.

Fig 9 .3 .6 -5 a – f
a – b Postoperative x-rays after 9 weeks.
c– d 6 m on th s after th e in itial operation , a bon e defect on th e m ed ial side still
persisted. Secon dar y cortico-can cellou s bon e graftin g an d screw xation was
n ecessar y.
e–f Fu n ction al pictu res 18 m on th s postoperatively.

591
 9 .3 Fe m u r, d is t a l

4 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
Fig 9 .3 .6 -6 a – b 3 years after th e acciden t th ere was
de n itive bon e h ea lin g in th is you n g patien t, bu t
th e im plan t h ad to be rem oved becau se of irritation
of th e iliotibial tract.

a b

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Too exten sive ex posu re of th e m etaph yseal fractu re zon e Open redu ction of th e in traarticu lar fractu re com pon en t
m ay dam age th e blood su pply of th e bon e fragm en ts. com bin ed w ith an in d irect redu ction tech n iqu e for th e
com plex m etaph yseal com pon en t.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In correct position in g of th e im plan t in relation to th e sh aft Carefu l con trol of im plan t position u sin g d irect an d
m ay lead to early im plan t loosen in g. in d irect con trol m ech an ism s (visu alization , palpation ,
an d im age in ten si cation).
In correct position in g of th e im plan t in relation to th e
d istal fragm en t m ay lead to soft-tissu e irr itation s.

A too sh ort im plan t in creases th e risk of im plan t Th e u se of lon g im plan ts an d few screw s is n ecessar y
loosen in g. to allow im plan t elasticity an d better stress distribu tion
(splin tin g m eth od is an elastic fractu re xation ).
A too stiff im plan t xation in creases th e risk of im plan t
failu re.

Re h a b ilit a t io n Re h a b ilit a t io n
Late physioth erapy m ay lead to in traarticu lar adh esion s Carefu l early active an d passive ph ysioth erapy is essen tial
an d join t stiffn ess. for good join t fu n ction .

592
 Au t h o r Ph ilip J Kre go r
9.3.7 Ope n com ple te intraarticular m ultifragm e ntary distal
fe m oral fracture —33 -C3
1 Ca s e d e s crip t io n
a b
Fig 9 .3 .7-1a – b
a AP x-ray of th e d istal fem u r after th e span n in g extern al
xator was placed abou t th e femu r. It dem on strates a su -
pracon dylar/ in tercon dylar fem oral fractu re w ith probable
com plex articu lar in ju r y (Mü ller AO Classi cation 33-C3).
Th e fem u r len gth h as been restored w ith th e u se of th e
extern al xator.
b Lateral x-ray sh ow in g typical h yperexten sion deform ity of
th e d istal fem u r an d sign i can t posterior d isplacem en t of
cortical fragm en ts. Becau se of th e posterior d isplacem en t
of th e fragm en ts, a possible vascu lar in ju ry sh ou ld be su s-
pected. An an k le-an k le in dex (AAI) was perform ed an d
was fou n d to be 0.98, w h ich is n ot su ggestive of an arterial
in ju ry.
22-year-old m an , polytrau m a w ith bilateral pn eu m oth orax
requ irin g bilateral ch est tu bes, grade III righ t h epatic lobe lac-
eration , righ t acetabu lar fractu re an d open righ t d istal femu r
fractu re, Gu stilo type II (5 cm open an terolateral wou n d over
m etaph yseal region , w ith mu scle exposed).
In itially th e patien t was h em odyn am ically u n stable an d n ot
able to proceed to th e operatin g room . Th erefore, in th e in -
ten sive care u n it u n der sterile preparation an d d rapin g, th e
5 cm open in cision abou t th e righ t d istal an terolateral th igh
was debr ided. Th e bon e en ds were cu retted an d debr ided an d
th e wou n d lavaged. A span n in g extern al xator was placed.
A sterile dressin g an d splin t were applied.
a b
Fig 9 .3 .7-2 a – b
a An terior fron tal plan e recon stru ction CT scan of th e righ t
d istal fem u r. Th is dem on strates th at th e m ed ial aspect of
th e fem oral con dyle h as n o sign i can t articu lar in ju r y bu t
th at th ere is a sign i can t d isplacem en t of th e lateral fem oral
con dyle.
b More posteriorly placed fron tal plan e recon stru ction of
th e righ t d istal fem u r. Th is dem on strates an in traarticu lar
split of th e lateral fem oral con dyle (arrow).
593
 9 .3 Fe m u r, d is t a l

In d ica t io n

In d ica tio n s fo r o p e ra tive sta b iliza tio n o f th is d is ta l fe m o ra l fra ctu re in clu d e :

• p o lytra u m a tize d p a tie n t,
• o p e n fra ctu re ,
• se ve re a rticu la r in ju ry w ith sign ifica n t d isp la ce m e n t,
• u n s ta b le su p ra co n d yla r/ in te rco n d yla r fe m o ra l fra ctu re .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LISS-DF, 13 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n
• 5 .0 m m lo ckin g h e a d scre w s (LHS) ce p h a lo sp o rin .
• 2 .0 m m co rte x scre w s • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• 2 .7 m m co rte x scre w s
• 5 .0 a n d 6 .0 m m e xte rn a l xa to r Sch a n z scre w s
• Po in te d re d u ctio n fo rce p s (w ith We b e r cla m p)
• La rge p e lvic re d u ctio n fo rce p s a
(Size o f s yste m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin , a m in o clyco sid e 1 Su rge o n
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin 2 1st a ssistan t
3 ORP

Ste rile a re a

Fig 9 .3 .7-3 a – b
a Th e p a tie n t is p la ce d su p in e o n a co m p le te ly 1
ra d io lu ce n t ta b le . Th e b ila te ra l u p p e r e xtre m itie s
a n d le ft lo w e r e xtre m it y a re se cu re d a n d
a p p ro p ria te ly p a d d e d . A b u m p is p la ce d b
u n d e rn e a th th e le ft sid e o f th e p e lvis in o rd e r to
tilt th e p e lvis a p p ro xim a te ly 2 0 ° (a s a re su lt, a t
2
th e e n d o f th e ca se , th e fo o t sh o u ld b e e xte rn a lly 3
ro ta te d 5 –10 °).
In th e p re o p e ra tive p e rio d , th e h ip ro ta tio n a l b Th e im a ge in te n si e r is b ro u gh t in fro m th e
p ro le o f th e righ t sid e w a s d e te rm in e d so th a t o p p o site sid e o f th e ta b le . Th e 1s t a ssis ta n t
th is co u ld b e ch e cke d a n d co m p a re d w ith th e sta n d s a t th e e n d o f th e ra d io lu ce n t ta b le to
o p e ra tive sid e p o sto p e ra tive ly. p ro vid e m a n u a l tra ctio n .

59 4
 9 .3 .7 Op e n co m p le t e in t ra a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3
2 Su rgica l a p p ro a ch
Th e patien t h ad a d istal fem oral fractu re (33-C3) w ith a com -
plex articu lar in volvem en t of th e lateral fem oral con dyle. No
Hoffa fractu re (fron tal plan e split) in th e d istal fem oral con -
dyles was n oted. In add ition , th e patien t h ad a 5 cm an terolat-
eral wou n d over th e d istal fem u r w h ich h ad previou sly u n der-
a b
c
gon e irrigation an d debridem en t. Th is wou n d is n ow exten ded
in both a prox im al an d d istal d irection an d tran sform ed in to
a m od i ed lateral parapatellar approach for appropriate visu -
alization of th e articu lar su rface of th is C3 in ju ry.
Fig 9 .3 .7-4 a – c
a Sch em atic d raw in g of th e wou n d over th e d istal aspect of
th e righ t d istal fem u r.
b Sch em atic draw in g of th e n orm al lateral parapatellar ap-
proach to th e distal fem u r. In gen eral th e qu adriceps ten don
is d ivided in its m id su bstan ce (or sligh tly lateral to its m id
su bstan ce) an d a cu ff of tissu e approx im ately 8 m m is left
on th e lateral aspect of th e patella.
c In th is particu lar case secon dar y to th e in ju r y to th e lateral
aspect of th e qu ad riceps, th e su rgical approach is m od i ed
so as n ot to pen etrate th e m id su bstan ce of th e qu ad riceps
ten don bu t rath er rem ain lateral to th e qu ad riceps fem ori.
Fig 9 .3 .7-5 In traoperative im age of th e su rgical approach to
th e d istal femu r. A su pracon dylar bu m p of 10 towels h as been
placed posteriorly to th e su pracon dylar region an d a 6.0 m m
Sch an z screw h as been placed in th e m edial fem oral con dyle
for pu r poses of articu lar su rface redu ction .
Note th at th e ex posu re is lateral to th e qu ad riceps fem ori an d
th at th e qu adr iceps ten don is n ot d isru pted.
595
 9 .3 Fe m u r, d is t a l
3 Re d u ct io n a n d fixa t io n
Fig 9 .3 .7-6 Visu alization of th e articu -
lar su rface of th e d istal femu r is pos-
sible th rou gh th e lateral parapatellar
approach . Th e articu lar su rface of th e
d istal fem u r is redu ced w ith th e aid of:
1. Com plete relaxation of th e patien t.
2. A 6 m m Schan z screw in the medial
femoral condyle to act as a reduction aid.
3. Poin ted redu ction forceps from th e
m edial fem oral con dyle to th e lateral
fem oral con dyle.
4. Provision al K-w ire xation of th e
lateral fem oral con dyle to th e m edial
fem oral con dyle.
59 6
a b
Fig 9 .3 .7-7 Here, th ree 3.5 m m lag Fig 9 .3 .7-8 a – bDirect visu alization of
screw s from lateral to m ed ial h ave been th e articu lar su rface is u tilized to ju dge
placed. Th e screw s are at th e periph ery th e redu ction . Im age in ten si cation
of th e distal fem oral con dyle. is gen erally n ot relied u pon . However,
in traoperative x-rays do dem on strate
appropriate redu ction of th e articu lar
su rface (AP an d lateral).
Fig 9 .3 .7-9 Th e n ext step after appropriate articu lar su rface recon stru ction is to
“learn th e fractu re.” Th at is, th e closed redu ction of th e m etaph yseal/d iaph yseal
com pon en t of th e fractu re is viewed u n der im age in ten si cation , an d ju dged in th e
AP an d lateral plan es. Th e im age in ten si er u n it is brou gh t in from th e opposite side
of th e table an d th e closed redu ction of th e m etaphyseal/diaphyseal com pon en t of
th e fractu re is ach ieved th rou gh a com bin ation of:
• com plete relaxation of th e patien t,
• towel bu m ps placed posteriorly in th e su pracon dylar region ,
• m anu al traction ,
• m an ipu lation of the distal femoral fragment u sing Sch an z screws. A screw placed
from m edial to lateral can be u sed to control varu s/ valgu s an gu lation . A Sch an z
screw placed from an terior to posterior can correct the hyperexten sion deform ity.
• A m allet can be u sed to exert force on th e an terom ed ial aspect of th e distal aspect
of th e fem oral sh aft fragm en t, as lon g as th is proxim al fragm en t is addu cted an d
exed.
 9 .3 .7 Op e n co m p le t e in t ra a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3

3 Re d u c t io n a n d fixa t io n (co n t )

15 °

a b

AP an d lateral x-rays of th e d istal fem u r are

Fig 9 .3 .7-10 a – b Fig 9 .3 .7-12 Often , th e xator is passed sligh tly m ore cran i-
obtain ed an d th e im age in ten si er is u sed to scan th e d istal ally th an n eeded. Th e xator is th en pu sh ed sligh tly d istally,
fem u r in both AP an d lateral projection s to learn of an y defor- an d allowed to settle back on th e fem oral con dyles. Th e in ser-
m ity an d to ch eck redu ction . tion gu ide for th e LISS is th en raised approx im ately 10 –15°
an d cou n ter pressu re by th e su rgeon ’s left h an d is exerted on
th e m ed ial aspect of th e fem oral con dyle.
At th is poin t, w ith th e fem oral LISS/d istal fem oral con dylar
1.0 cm block relation sh ip establish ed, a gu ide w ire is placed th rou gh
h ole A. If th e appropriate varu s/ valgu s h as been establish ed,
an d if th e gu ide w ire is n ot ben t, th e gu ide w ire sh ou ld be
1.5 cm parallel to th e join t su rface.

Next, appropriate len gth an d rotation are establish ed th rou gh

m anu al traction an d/or u se of th e Sch an z screw s in th e d istal
fem oral con dyle. After th is h as been accom plish ed, a gu ide
Fig 9 .3 .7-11 After th e ar ticu lar redu ction an d xation h as w ire is placed in th e m ost prox im al h ole th rou gh th e previou s
been com pleted, th e fractu re is “learn ed” u n der im age in ten - con n ectin g bolt.
si cation gu idan ce, an d appropr iate redu ction of th e m eta-
ph yseal/d iaph yseal com pon en t of th e fractu re is obtain ed an d Next, several lockin g h ead screw s m ay be placed in th e d istal
m ain tain ed via m anu al traction , th e LISS xator is in serted. fem oral block. Especially w ith placem en t of th e rst LHS,
Th e LISS xator is slid in a su bm u scu lar m an n er ben eath th e care m u st be taken to en su re th at th e LISS xator is pressed
vastu s lateralis. Tactile sen sation of th e tip of th e xator is again st th e fem oral con dyles, as th e LHS w ill ten d to pu sh
u tilized as th e xator is bein g passed in a cran ial d irection . away th e bon e.
Th e appropr iate relation sh ip of th e xator to th e d istal en d of
th e fem u r is th en establish ed. In gen eral, th e an ter ior aspect
of th e xator is approxim ately 1 cm poster ior to th e an te-
rior aspect of th e fem oral con dyles an d th e distal en d of th e
xator is approxim ately 1.5 cm from th e d istal aspect of th e
fem oral con dyle.

597
 9 .3 Fe m u r, d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

a b

Fig 9 .3 .7-13 a – bTh en , a pu llin g device (“wh irlybird”) is u tilized to brin g Fig 9 .3 .7-14Note th at a prox im al in -
th e d iaph ysis to th e fem oral LISS. cision h as been m ade to palpate th e
Mu ltiple LHS are th en placed th rou gh th e in sertion gu ide prox im ally xator on th e m id lateral aspect of th e
an d distally. fem u r.

a b c d

In traoperative x-rays con rm th at

Fig 9 .3 .7-15 a – e
th e xator is in th e appropriate position d istally
an d prox im ally.

59 8
 9 .3 .7 Op e n co m p le t e in t ra a r t icu la r m u lt ifra gm e n t a r y d is t a l fe m o ra l fra ct u re —33 -C3

4 Re h a b ilit a t io n

Th e patien t is allowed 10 kg weigh t

bearin g for 10 weeks. Aggressive im -
m ediate ran ge of m otion is begu n w ith
physioth erapy. Qu adriceps stren gth en -
in g exercises are also em ph asized. At 10
weeks, progressive weigh t bearin g is al-
lowed, w ith th e goal of am bu lation w ith
can e by weeks 12 –14 postoperatively.
No braces are u tilized.

a b a b

Fig 9 .3 .7-16 a – b 3 weeks postoperative Fig 9 .3 .7-17a – b Callu s form ation at 10

x-rays. weeks.

a b c

Fig 9 .3 .7-18 a – c Follow-u p x-rays after 7 m on th s.

59 9
 9 .3 Fe m u r, d is t a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Im proper d ivision of th e qu adriceps ten don prox im ally: Th e su rgeon sh ou ld visu alize th e m ed ial an d lateral aspect
th is leads to poor qu ality of wou n d closu re. of th e qu adriceps ten don well an d th en d ivide th e ten don
in its m id lin e (or sligh tly lateral to it).

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In self-d rillin g, self-tappin g LHS, th e u tes of th e screw
can becom e lled w ith bon e. Th e su rgeon “feels” th is
wh en th e screw does n ot advan ce easily. Th e screw sh ou ld
be w ith draw n , an d th e u tes clean ed. Th e screw w ill th en
advan ce easily. Special self-d rillin g, self-tappin g LHS w ith
a lon g d rillin g tip are available.
Fig 9 .3 .7-19 Screw plu ggin g w ith bon e in case of a ver y
th ick cortex. Lon g-leg x-rays of th e fem u r w ill alert th e su rgeon to th e
deform ity. Th is can be corrected by a ch an ge in th e vector
Postoperative deform ity of valgu s. of m anu al traction or u tilization of a Sch an z screw from
m edial to lateral in th e d istal fem oral block.
Postoperative deform ity of extern al rotation of th e d istal
fem u r. If th e pelvis is tilted 20°, th e foot sh ou ld be rotated 5 –10°
du rin g redu ction an d extern ally xation . A carefu l as-
Screw s are too lon g on th e m ed ial aspect of th e femu r. sessm en t of th e postoperative rotation al pro le sh ou ld be
com pared w ith th e opposite side.
LISS xator in correctly position ed on th e prox im al fem u r.
It sh ou ld be rem em bered th at th e m edial aspect of th e
d istal fem u r slopes approx im ately 25°. Th erefore an terior
screw s sh ou ld appear “sh ort” on th e AP x-ray.

Especially w ith a 13-h ole LISS, an in cision is m ade proxi-

m ally (over h oles 12 an d 13) to palpate th e proxim al en d
of th e plate. Th is en su res th at th e xator is on th e m id-
lateral aspect of th e fem u r an d th at proper rotation of th e
xator is carried ou t.

Re h a b ilit a t io n Re h a b ilit a t io n
Kn ee stiffn ess. Im m ed iate, aggressive ran ge of m otion is m an dator y in all
cases. No braces are u tilized.

600
 Au t h o rs Th o m a s J Ho cke rt z, An d re a s Gru n e r, Ga b rie le St re ich e r, He in rich Re ilm a n n

9.3.8 Pe riprosthe tic distal fe m oral fracture with im plante d total

kne e e ndoprosthe sis—33 -A2
1 Ca s e d e s crip t io n

81-year-old wom an wh o tripped on th e cu rb w h en walkin g

dow n th e street, fell an d broke h er left fem u r.
Ty p e of in ju r y: low - en er gy t r au m a , m on ot r au m a , clo se d
fractu re.

Fig 9 .3 .8 -1a – b
a AP view.
b Detail AP view.

In d ica t io n

Pe rip ro sth e tic fra ctu re o f th e le ft fe m u r w ith im p la n te d ce m e n te d

kn e e a rth ro p la st y. No clin ica l o r ra d io lo gica l sign s o f lo o se n in g.
Be fo re th e a ccid e n t th e p a tie n t w a s m o b ile w ith o u t cru tch e s a n d
a b w ith o u t s ym p to m s .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 9 .3 .8 -2 Su p in e p o sitio n ,
• LISS-DF, 5 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo - th e le g is fre e d ra p e d fo r
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g sp o rin . in tra o p e ra tive m o b ilit y, e le va tio n
lo ckin g h e a d scre w s (LHS) • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin . o f th e in ju re d lim b a n d e xio n o f
• 2 .0 m m K-w ire s th e kn e e jo in t a t a p p ro xim a te ly
(Size o f s yste m , in stru m e n ts, a n d
3 0 °. Lo w e r th e co n tra la te ra l le g
im p la n ts ca n va ry a cco rd in g to a n a to m y.) fo r b e t te r in tra o p e ra tive x-ra y
a sse ssm e n t, cu sh io n th e d ista l
Pa t ie n t p re p a ra t io n a n d p o s it io n in g fe m u r o f th e in ju re d le g, e g, w ith
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin a to w e l ro ll.
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

6 01
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

Fig 9 .3 .8 -3 Sk in in cision from Gerdy’s tu bercle in a proxim al direction . Divide

th e iliotibial tract in th e d irection of its bers an d d issect to th e per iosteu m wh ile
retractin g th e vastu s lateralis.

3 Re d u ct io n a n d fixa t io n

Fig 9 .3 .8 -4 a – b
a Approx im ate redu ction of th e frac-
tu re an d th e lon gitu din al axis by ap-
plyin g ax ial ten sion w ith th e k n ee
exed to approxim ately 30° to relax
th e gastrocn em iu s.
b From th e posterior aspect, elevate
th e d istal fragm en t from its tilted
position in recu r vatu re w ith th e
a elevator or by em ployin g a Sch an z
screw in serted an terolaterally as a
joystick.

602
 9 .3 .8 Pe rip ro s t h e t ic d is t a l fe m o ra l fra ct u re w it h im p la n t e d t o t a l k n e e e n d o p ro s t h e s is —33 -A2

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 9 .3 .8 -5 a – bPrepare th e plate bed from d istal to prox im al by epiperiosteal

tu n n elin g u n der th e vastu s lateralis m u scle w ith a lon g bon e rasp.
Select th e appropriate plate len gth u n der im age in ten si cation an d in sert th e
im plan t in to th e plate bed. Make an in cision at th e prox im al en d of th e plate to
com plete th e procedu re.
Stabilize th e im plan t on th e proxim al an d distal sides by in sertin g K-w ires an d
ch eck plate position in two plan es.
Precise redu ction of th e fragm en ts w ith th e pu llin g device, wh ich pu lls th e
fragm en t to th e LISS plate.
In sert th e screw s altern ately in th e d istal an d prox im al h oles startin g d istally,
determ in e screw len gth accord in g to Ta b le 3 -2 , wh ereby screw len gth is m ea-
su red d istally u sin g K-w ires in th e presen ce of an im plan ted prosth esis. Th is
avoids in terferen ce w ith prosth esis com pon en ts an d any associated strippin g of
th e screw th read.
a b

4 Re h a b ilit a t io n

a b c d e f

Weigh t bearin g: 15 kg for 2 weeks, h alf body weigh t after 4 weeks,

fu ll weigh t bearin g after 6 weeks.
Physiotherapy: from the second postoperative day and continuou s passive m otion .
h Ph arm aceutical treatm en t: pain therapy and non steroid antiin am m atory drugs.
Fig 9 .3 .8 -6 a – i
a – b Postoperative x-rays after 6 weeks.
c– d Postoperative x-rays after 12 weeks.
e – f Postoperative x-rays after 18 weeks.
g i g– i Clin ical pictu res after 18 weeks.

6 03
 9 .3 Fe m u r, d is t a l

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In correct plate len gth so th at n ot en ou gh lock in g h ead Good con trol over im plan t position in g du e to a closed
screw s can be in serted in to th e sh aft. Th e LISS-DF m u st system an d predeterm in ed screw position in g via stab
be properly seated. in cision s.

Ap p ro a ch Ap p ro a ch
In adequ ate preparation of th e d istal fem u r an d, con se- M in im ally in vasive approach , fragm en ts retain th eir
qu en tly, plate position in g too far an terior or posterior soft-tissu e attach m en ts.
an d risk of trappin g th e iliotibial tract.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Loss of m an u al redu ction an d ax ial align m en t, in correct Anchorage possible in the presence of endoprostheses w ith
screw len gth an d abu tm en t of th e screw s before h ead sh aft components or correction endoprostheses.
lock in g is ach ieved. Con sequ en t th read strippin g.

Re h a b ilit a t io n Re h a b ilit a t io n
Im m obilization for too lon g. Partial weigh t bearin g can n ot always be ach ieved w ith
elderly patien ts. In th is case, im m ed iate fu ll weigh t
bearin g was perm itted.

604
 Au t h o r Ph ilip J Kre go r

9.3.9 Bilate ral ope n supracond ylar fe m oral fracture s above total
kne e arthroplastie s—33 -A3
1 Ca s e d e s crip t io n

67-year-old wom an was in volved in a m otor veh icle collision an d su stain ed

a left in tertroch an ter ic h ip fractu re an d bilateral open su pracon dylar fem -
oral fractu res above total k n ee arth roplasties. Sh e was in itially h em ody-
n am ically u n stable. After appropriate resu scitation , sh e was taken to th e
operatin g room an d h ad xation of h er in tertroch an teric h ip fractu re u tiliz-
in g a dyn am ic h ip screw. Sh e h ad irrigation an d debridem en t of h er open
6 cm wou n ds on both th e r igh t an d left lower extrem ities. Sh e su bsequ en tly
h ad span n in g extern al xators placed across h er k n ee join t.

Th e patien t was brou gh t back to th e operatin g room on postin ju ry day two for
de n itive treatm en t of h er d istal fem oral fractu res.

Fig 9 .3 .9 -1a – d
a – b AP x-rays of both th e righ t an d left su pracon dylar fem u r fractu res above
th e total k n ees. Both are ch aracterized by sh ort d istal segm en ts an d
com m in u tion in th e m etaph yseal region .
c Th e lateral x-ray of th e righ t d istal fem u r. Note th at th e d istal fem oral
block is qu ite sh ort, bu t th at it is well xed to th e fem oral com pon en t.
d Th e lateral x-ray of th e left d istal fem u r. Th e d istal fem oral block is well
xed to th e fem oral com pon en t of th e total kn ee arth roplasty.
a b

In d ica t io n

In d ica tio n s fo r o p e ra tive sta b iliza tio n o f th is d ista l fe m o ra l fra ctu re in clu d e :
• Po lytra u m a tize d p a tie n t,
• Op e n fra ctu re ,
• Disp la ce d su p ra co n d yla r fe m o ra l fra ctu re s a b o ve to ta l kn e e a rth ro p la stie s.

Wh ile n o n o p e ra tive tre a tm e n t o f n o n d isp la ce d o r m in im a lly d isp la ce d fractu re s a b o ve

to ta l kn e e a rth ro p la stie s ca n b e co n sid e re d , b o th o f th e se fra ctu re s d e m o n stra te d
c d sign i ca n t in sta b ilit y.

6 05
 9 .3 Fe m u r, d is t a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LISS-DF, 13 h o le s, le ft
• LISS-DF, 13 h o le s, righ t
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin a n d a m in o glyco sid e a
(se co n d a ry to th e o p e n n a tu re o f th e fra ctu re)
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 9 .3 .9 -2 a – b Th e p a tie n t is p la ce d su p in e o n a
co m p le te ly ra d io lu ce n t ta b le .
a A b u m p w a s p la ce d u n d e rn e a th th e le ft sid e o f th e p e lvis 1 Su rge o n
in o rd e r to tilt th e p e lvis a p p roxim a te ly 2 0 ° (a s a re su lt, a t 2 ORP
th e e n d o f th e ca se , th e fo o t sh o u ld b e e xte rn a lly ro ta te d 3 1st a ssistan t
a p p roxim a te ly 5 –10 °).
b Th e im a ge in te n si e r is b ro u gh t in fro m th e o p p o site Ste rile a re a
sid e o f th e ta b le . Th e su rge o n is s ta n d in g. Firs t a ssista n t
is a t th e e n d o f th e ra d io lu ce n t ta b le to p ro vid e m a n u a l
tra ctio n . 1

Th e le ft lo w e r e xtre m it y w ill b e a d d re sse d rst. In o rd e r

n o t to co n fu se th e ro ta tio n a l p ro le o f th e b ila te ra l lo w e r
e xtre m itie s, th e y a re o p e ra te d o n o n e a t a tim e . Re ve rse d b
p o sitio n s fo r th e righ t lo w e r e xtre m it y. 3 2

606
 9 .3 .9 Bila t e ra l o p e n s u p ra co n d yla r fe m o ra l fra ct u re s a b o ve t o t a l kn e e a r t h ro p la s t ie s —33 -A3

2 Su rgica l a p p ro a ch

Th e patien t in itially h ad a repeat irrigation an d debridem en t

of th e distal fem oral fractu re. Th is con sisted of aggressive de-
br idem en t of th e su bcu tan eou s tissu e an d qu adriceps mu s-
cu latu re th at h ad been devitalized du e to th e fractu re. In ad-
d ition , cu rettage of th e bon e fragm en ts was also perform ed.
Fin ally, copiou s irrigation w ith 6 liters of pu lsatile lavage
was th en carried ou t. After th is, th e left lower extrem ity was
prepped again an d was on ce again draped ou t.

Fig 9 .3 .9 -3Th e open d istal fem oral wou n d was exten ded
both proxim ally an d distally. It was in itially on th e lateral
aspect of th e d istal fem u r.

3 Re d u ct io n a n d fixa t io n

Th e LISS xator is th en slid in a su bm u scu lar m an n er th rou gh

th e d istal fem oral wou n d.

Fig 9 .3 .9 -4 a – c
a Th is x-ray sh ow s th e LISS xator slid u p alon g th e m id lat-
eral aspect of th e fem u r w ith th e d istal gu ide w ire bein g
placed th rou gh a drill sleeve in th e in sertion gu ide for th e
LISS xator. Note th at th e gu ide w ire sh ou ld be parallel
w ith fem oral com pon en t. Note also th at th e d istal aspect
of th e proxim al segm en t is addu cted. It was also n oted to
be sligh tly exed.
b A m allet placed on th e an ter ior aspect of th e d istal com -
pon en t of th e fem oral sh aft was th en u sed to redu ce th e
a b an terior tran slation of th e distal segm en t of th e d istal sh aft
an d a “wh irlybird” device (pu llin g device) was th en u sed
to brin g th e fem oral sh aft to th e LISS xator.
c In traoperative im age of th e su pracon dylar bu m p poste-
rior to th e distal aspect of th e fem u r. Note th e su rgical
approach .

6 07
 9 .3 Fe m u r, d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

As is detailed in case 9.3.7, several add ition al steps of LISS
xation of th is d istal fem u r fractu re are carried ou t:
Before th e “wh irlybird” is u tilized, an in cision over h oles 12
an d 13 is th en m ade to palpate th e LISS xator on th e fem u r.
Th is is don e to en su re th at th e LISS is on th e m id lateral aspect
of th e fem u r an d th at appropriate rotation of th e LISS xator
is m ade.
As w ith an y LISS xation , th e fractu re h ad been learn ed be-
fore th e LISS xator was slid in . It is especially im portan t to
learn th e sagittal plan e redu ction .
Several d istal lock in g h ead screw s are th en placed th rou gh
th e in sertion gu ide in to th e d istal fem oral com pon en t an d
m u ltiple m on ocortical lockin g h ead screw s are placed in th e
proxim al aspect of th e fem u r.
Usu ally in osteoporotic cases, su ch as th is, ve to six d istal
lock in g h ead screw s an d ve to six prox im al lock in g h ead
screw s are u tilized.

a b

Fig 9 .3 .9 -5 a – b
a Th e LISS xator after th e in sertion gu ide h as been rem oved.
Note th at in th is case th e xator is brou gh t qu ite d istal to
en su re adequ ate xation of th e d istal fem oral block.
b In traoperative im age sh ow in g th e distal fem oral in cision ,
th e prox im al fem oral in cision , an d m u ltiple percu tan eou s
in cision s for placem en t of th e m on ocortical sh aft screw s.

608
 9 .3 .9 Bila t e ra l o p e n s u p ra co n d yla r fe m o ra l fra ct u re s a b o ve t o t a l kn e e a r t h ro p la s t ie s —33 -A3

4 Re h a b ilit a t io n

Th e patien t was bed to wh eelch air for 12 weeks. Sh e h ad m or-

bid obesity wh ich m ade am bu lation d if cu lt. At 12 weeks,
sh e began am bu lation w ith a walker. Sh e converted to a can e
at 20 weeks postoperatively. Im m ediate ran ge of m otion ex-
ercises were begu n postoperatively. Her n al ran ge of m otion
was 0 –90° bilaterally. Th is was th e sam e as before th e in ju r y.
Fu ll weigh t bearin g after 14 weeks.

a b a b c

Postoperative AP x-rays of
Fig 9 .3 .9 -6 a – b Fig 9 .3 .9 -7a – c
both th e righ t an d left lower extrem ities. a – b Follow-u p x-rays after 5 m on th s. Sign i can t callu s form ation is
seen .
c Lateral x-ray of th e left d istal fem u r dem on strates con solidation .

609
 9 .3 Fe m u r, d is t a l

5 Pit fa lls – 6 Pe a rls +

Su rgica l a p p ro a ch Su rgica l a p p ro a ch
Devitalization of th e m etaph yseal/d iaph yseal com pon en t Th e su rgeon m u st strive to leave soft-tissu e attach m en ts
of th e fractu re m ay lead to delayed u n ion or n onu n ion . in tact in th e m etaph yseal/d iaph yseal area. No attem pt is
m ade to redu ce or visu alize com m inu tion .

Re d u ct io n a n d xa t io n
Gain in g d istal xation in a sh ort segm en t w ith osteo-
porotic bon e can be dif cu lt. In addition , th e fem oral
com pon en t of th e total k n ee arth roplasty m ay m ake th e
placem en t of certain screw s im possible.
Re d u ct io n a n d xa t io n
Th e LISS xator sh ou ld be brou gh t relatively d istal on
th e fem oral con dyle. It is sligh tly m ore d istal th an in a
n on arth roplasty case. A good cross table lateral of th e d is-
tal fem oral block w ill also allow th e su rgeon to plan th e
placem en t of th e LISS xator in th e appropriate position
to optim ize th e nu m ber of screw s in th e d istal fem oral
block. Th is m ay requ ire placin g th e LISS xator sligh tly
m ore an terior or posterior th an th e u su al placem en t.
Visu alization of th e fem oral com pon en t of th e total k n ee
arth roplasty.

Th e com m on deform ity seen w ith placem en t of th e d istal Th e extern al rotation deform ity can be carefu lly con -
fem oral LISS is th at of extern al rotation an d valgu s defor- trolled for by placin g th e pelvis at approxim ately a 20°
m ity. tilt. In doin g so, th e foot sh ou ld be approx im ately 10°
extern ally rotated at th e en d of th e case.

Utilizin g th e im age in ten si er to scan u p an d dow n th is

femu r can be very advan tageou s to discern an y sligh t
valgu s deform ity.

If a valgu s deform ity is n oted, it can be corrected by:

• Man u al traction in a sligh t varu s d irection ,
• placin g a “wh irlybird” (pu llin g device) in to th e
proxim al aspect of th e distal fem oral block,
• u tilizin g a 6.0 m m Sch an z screw th rou gh a sm all stab
in cision on th e m ed ial aspect of th e d istal fem oral block
an d u tilizin g th is Sch an z pin as a redu ction device.

Re h a b ilit a t io n Re h a b ilit a t io n
Stiffn ess of th e k n ee. Im m ediate ran ge of m otion of th e kn ees is begu n .
No braces are u tilized.

610
 Au t h o r Ro n a ld va n He e r w a a rd e n

9.3.10 Double oste otom y for valgus le g de form ity due to late ral
com partm e nt kne e oste oarthritis
1 Ca s e d e s crip t io n

37-year-old wom an , d irect k n ee trau m a 20 years ago. Previou s su rgery: arth rotom y
20 years ago (u n kn ow n), total lateral m en iscectom y 6 years ago, partial m ed ial
m en iscectom y, recen tly. Progressive valgu s leg deform ity after in itial trau m a in -
creased after lateral m en iscectom y. Kn ee pain du r in g weigh t bearin g an d at rest,
in stability du e to valgu s an d loss of m otion .
Exam in ation : valgu s leg align m en t, an talgic gait pattern , k n ee ran ge of m otion :
90/15/ 0, k n ee swellin g, con tracted valgu s deform ity.

42 3 m m 42 5 m m Deform ity: valgu s leg align m en t of 16° in stan din g position . Exten sion de cit 15°.
No associated tran sverse plan e deform ities.

X-rays: Grade 4 OA lateral com partm en t (Ah lback gradin g), grade 1 OA m edial com -
partm en t.

94° 91°

97 ° 90°

35 5 m m
16 °
0°

Fig 9 .3 .10 -1 Stan d in g x-rays both legs.

45º ex ion weigh t bearin g
Fig 9 .3 .10 -2
AP view (Rosen berg-view).

611
 9 .3 Fe m u r, d is t a l

De fo rm it y a n a lys is

1. Fu ll leg weigh t-bearin g x-ray: weigh t-bearin g lin e th rou gh Co n clu s io n

lateral com partm en t. Tibiofem oral an gle: 16° valgu s, n o as- Lateral com partm en t osteoarth r itis, sin gle plan e 16°
sociated sagittal plan e bon e deform ities of fem u r an d tibia. valgu s deform ity, bon e deform ity localized in th e fem u r 5°
(LPFA + m LFDA) an d proxim al m edial tibia 10° (M PTA). As-
2. Deform ity an alysis (accord in g to Paley): sociated m ed ial join t lin e open in g 2° (J LCA).

An gle Pa tie n t No rm a l

La te ra l p ro xim a l fe m o ra l a n gle ( LPFA) 86° 90°

Me ch a n ica l la te ra l d ista l fe m o ra l a n gle (m LDFA) 86° 88°

Me d ia l p ro xim a l tib ia l a n gle (MPTA) 97 ° 87°

La te ra l d is ta l tib ia l a n gle (LDTA) 89° 89°

JLCA 4° 2°

In d ica t io n fo r o s t e o t o m y

Pro gre ssive s ym p to m a tic la te ra l co m p a rtm e n t o ste o a rth ritis w ith

p ro gre ssive va lgu s d e fo rm it y ca u sin g ga it a b n o rm a litie s a n d sym p -
to m s a t o th e r jo in ts. Ra n ge o f m o tio n im p a ire d b y co n tra cte d va lgu s
d e fo rm it y a n d jo in t co m p a rtm e n t o b lite ra tio n .
No n o p e ra tive tre a tm e n t (m e d ica tio n , in ltra tio n , sh o e in la ys, b race
tre a tm e n t) h a d fa ile d .

Pre o p e ra t ive p la n n in g

Pla n n in g o f d e fo rm it y co rre ctio n Me t h o d s

Go a ls
1. Le g a lign m e n t co rre ctio n to n e u tra l o r sligh t va ru s a lign m e n t
to u n lo a d th e la te ra l co m p a rtm e n t fo r p a in im p ro ve m e n t a n d
n o rm a liza tio n o f ga it.
2 . Ra n ge o f m o tio n im p ro ve m e n t w ith re sto ra tio n o f fu ll
e xte n sio n .
1. Do u b le o s te o to m y: 10 ° m e d ia l clo sin g w e d ge o s te o to m y o f
th e p ro xim a l tib ia to n o rm a l MPTA a n d 5 ° la te ra l o p e n in g
w e d ge o ste o to m y o f th e d is ta l fe m u r w ith in se rtio n o f b o n e
w e d ge m a te ria l ta ke n fro m th e p ro xim a l tib ia . As 2 ° o f va lgu s
d e fo rm it y is d u e to m e d ia l jo in t lin e o p e n in g (JLCA: 4 °) n o
o ve rco rre ctio n is n e ce ssa ry to cre a te sligh t va ru s a lign m e n t.
2 . In tra a rticu la r re se ctio n o f o ste o p h yte s in th e in te rco n d yla r
n o tch a n d re le a se o f co n tra cte d la te ra l ca p su le .

612
 9 .3 .10 Do u b le o s t e o t o m y fo r va lgu s le g d e fo rm it y d u e t o la t e ra l co m p a r t m e n t k n e e o s t e o a r t h rit is
Pre o p e ra t ive p la n n in g (co n t )
Fig 9 .3 .10 -3 Pla n n in g o f d o u b le o ste o to m y.
Do u b le o s te o to m y o f 15 ° w ill cre a te sligh t
va ru s a lign m e n t w ith n o rm a l kn e e jo in t lin e
o rie n ta tio n . In tra a rticu la r re le a se a im e d a t
im p ro ve m e n t o f ra n ge o f m o tio n .
Eq u ip m e n t
• LISS-DF, 5 h o le s
• Lo ckin g h e a d scre w s (LHS)
• To m o x tib ia l h e a d p la te , m e d ia l, p ro xim a l, 4 h o le s
• Sa w gu id e
• Rigid w h o le le g a lign m e n t b a r
• Sim p le ru le r (fo r m e a su re m e n t o f o s te o to m y ga p)
(Size o f s ys te m , in stru m e n ts, a n d
im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Pro p h yla ctic a n tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 9 .3 .10 -4 Su p in e p o sitio n . Wh o le le g fre e ly
m o ve a b le a n d a cce ssib le w ith th e im a ge in te n si e r.
Fu ll le g d ra p e d fre e . Ste rile o r n o n s te rile p n e u m a tic
to u rn iq u e t h igh o n th e fe m u r.
613
 9 .3 Fe m u r, d is t a l

2 Su rgica l a p p ro a ch

Ex istin g scar of previou s arth rotom y exten ded d istally to ex pose th e prox im al,
m ed ial part of th e tibia. Sm all arth rotom y to rem ove osteoph ytes in th e n otch of th e
lateral com partm en t. Closu re of arth rotom y.

Tibial approach : blu n t Hoh m an n retractor position ed posteriorly (su bperiosteally)

on th e tibia, cran ial of th e pes an serin u s ten don s, an d retractor ex posin g th e an te-
rior part of th e tibia.

Fem u r approach : blu n t Hoh m an n retractor position ed posteriorly (su bperiosteally)

on th e fem u r an d sh ar p Hoh m an n retractor position ed an teriorly on th e fem u r.

Fig 9 .3 .10 -5Stan dard lon gitu d in al approach w ith m edial parapatellar capsu lar
in cision (Payer) u sed becau se of th e scar from th e previou s arth rotom y, an d an tici-
pated total join t replacem en t in case of progressive OA in th e fu tu re.

Med ial approach to th e m ed ial proxim al tibia

Fig 9 .3 .10 -6 Fig 9 .3 .10 -7 Lateral approach to th e fem u r th rou gh a
an d retractor. lon gitu d in al in cision .

614
 9 .3 .10 Do u b le o s t e o t o m y fo r va lgu s le g d e fo rm it y d u e t o la t e ra l co m p a r t m e n t k n e e o s t e o a r t h rit is
3 Clo s in g w e d ge t ib ia l o s t e o t o m y
Fig 9 .3 .10 -8Osteotom y direction . Distally tu berosity osteot-
om y in th e area of plan n ed wedge rem oval. Tibial osteotom y:
obliqu e startin g m ed ially an d en d in g in th e lateral prox im al
tibia approxim ately 1 cm in side th e lateral cortex.
Fig 9 .3 .10 -9Th e d istal tu berosity osteotom y is m ade an d a
sm all saw blade is position ed in th e osteotom y to protect th e
tu berosity du r in g th e tibial osteotom y.
For precise wedge plan n in g K-w ire position in g at th e plan n ed
correction an gle an d an aim in g device, or a com bin ed aim in g
an d sawgu ide, is h elpfu l. Th e sawgu ide is position ed over th e
plan n ed osteotom y area an d xed to th e bon e w ith K-w ires
u n der im age in ten si er con trol.
Fig 9 .3 .10 -10 Both saw cu ts are m ade w ith a n ew saw blade
u n der in ten se rin sin g w ith retractors protectin g an terior an d
posterior soft tissu es. Wedge rem oval an d closu re of th e tibial
osteotom y.
Plate xation . Su bcu tan eou s plate position in g over th e soft
tissu es w ith prox im al bicortical xation w ith th ree LHS an d
distal xation w ith on e bicortical LHS an d th ree m on ocorti-
cal LHS. A lag screw is u sed to x th e tu berosity osteotom y.
615
 9 .3 Fe m u r, d is t a l

4 Op e n w e d ge fe m u r o s t e o t o m y

Fig 9 .3 .10 -11Osteotom y d irection . Position in g of blu n t Hoh m -
an n retractor su bper iosteally posteriorly on th e d istal fem u r
an d an teriorly on th e d istal fem u r. Fem u r osteotom y: obliqu e
startin g lateral an d en d in g in th e m ed ial fem u r con dyle ju st
in side th e m ed ial cortex. Saw d irection an d saw depth is veri-
ed w ith a K-w ire u n der im age in ten si er con trol.
Fig 9 .3 .10 -13Open in g of th e wedge w ith a calibrated wedge
spreader an d correction to n eu tral leg align m en t is ch ecked
w ith a r igid align m en t bar. Th e size of th e open ed wedge is
m easu red w ith a ru ler.

Fig 9 .3 .10 -12A saw cu t is m ade u n der in ten se rin s-

in g w ith retractors protectin g an terior an d posterior
soft tissu es.

616
 9 .3 .10 Do u b le o s t e o t o m y fo r va lgu s le g d e fo rm it y d u e t o la t e ra l co m p a r t m e n t k n e e o s t e o a r t h rit is

4 Op e n w e d ge fe m u r o s t e o t o m y (co n t )

Rem oval of wedge spreader, position in g of a bon e spreader an d

open in g of th e wedge to th e size previou sly m easu red w ith th e
ru ler. Part of th e bon e wedge rem oved from th e proxim al tibia
is n ow in serted in to th e gap prepared.

a b

Fig 9 .3 .10 -14 a – bFixation of th e LISS-DF plate prox im ally

w ith th ree bicortical lock in g h ead screw s an d d istally w ith
fou r lock in g h ead screw s.

617
 9 .3 Fe m u r, d is t a l

5 Re h a b ilit a t io n

No add ition al im m obilization .

Weigh t bearin g: 15 kg w ith two elbow cru tch es u n til 6 –8 weeks

postoperatively. After th at, fu ll weigh t bearin g depen din g on
bon e h ealin g.

Ph ysioth erapy: from 1st postoperative day fu n ction al postop-

erative treatm en t w ith active assisted m ovem en t w ith a ph ys-
ioth erapist, active exten sion an d ex ion to 90° allowed. After
42 0 m m wou n d h ealin g, active ex ion an d exten sion as tolerated.
421 m m

Ph arm aceu tical treatm en t: pain m ed ication if n eeded, an ti-

th rom botic m ed ication

X-rays to evaluate bone healing after 6 weeks, 12 weeks, 24 weeks,

an d 1 year.

89° 92°

89°
88°

-2 ° 35 8 m m
35 0 m m

Fig 9 .3 .10 -15 Leg align m en t postoperatively. Fig 9 .3 .10 -16Leg align m en t postoperatively at 3 m on th s.
Neu tral leg align m en t. Kn ee ran ge of m otion 115-0-0.

618
 9 .3 .10 Do u b le o s t e o t o m y fo r va lgu s le g d e fo rm it y d u e t o la t e ra l co m p a r t m e n t k n e e o s t e o a r t h rit is

5 Re h a b ilit a t io n (co n t )

Im plan t rem oval on e year postoperatively th rou gh th e ex ist-

in g scars if th e im plan ts are d istu rbin g th e patien t (after fu ll
con solidation ).

a b a b

Fig 9 .3 .10 -17a – b X-rays after fu ll con solidation . Fig 9 .3 .10 -18 a – b X-rays after im plan t rem oval.
a AP view. a AP view.
b Lateral view. b Lateral view.

619
 9 .3 Fe m u r, d is t a l
6 Pit fa lls –
Pla n n in g
Deform ities of th e proxim al fem u r an d d istal tibia m ay
exaggerate th e bon e deform ity m easu red at th e d istal
fem u r an d prox im al tibia. Ligam en t lax ity at th e k n ee
join t m ay add to th e w h ole leg deform ity.
Plan n in g of osteotom ies w ith ou t tak in g in to accou n t th e
join t lin e obliqu ity m ay produ ce sh ear forces at th e k n ee
join t.
Ra n ge o f m o t io n a n d a n gu la r co rre ct io n co n s t ra in t s
In tra- an d extraarticu lar con strain ts to ran ge of m otion
m ay preven t join t m otion an d deform ity correction
speci cally in con tracted deform ities. Osteophytes in th e
n otch an d at th e in tercon dylar em in en ce m ay m ech an i-
cally con strain an an gu lar correction .
Os t e o t o m y a n d xa t io n
Osteotom y m u st be preferably in com plete (in tact lateral
cortex on th e tibia an d m ed ial cortex on th e fem u r) for
m axim u m con stru ct stability of th e osteotom y an d plate
xation .
620
7 Pe a rls +
Pla n n in g
Deform ity an alysis of th e wh ole leg w ill reveal bon e
deform ities at prox im al an d d istal parts of th e bon es as
well as ligam en t lax ities du e to abn orm ality of th e join t
lin e con gru en ce an gle. Osteotom y correction s th at aim
to restore th e n orm al valu es of th e tibia an d fem u r w ill
reveal th e n eed to perform a dou ble osteotom y an d w ill
preven t excessive join t lin e obliqu ity.
Ra n ge o f m o t io n a n d a n gu la r co rre ct io n co n s t ra in t s
In tra- an d extraarticu lar capsu lar release w ill en large
ran ge of m otion an d en h an ce deform ity correction in
con tracted deform ities. Rem oval of osteoph ytes in an
arth roscopic or open procedu re w ill rem ove th ese
restrain ts to an gu lar correction .
Os t e o t o m y a n d xa t io n
In case of fractu re of th e con tralateral cortex, com pression
can be exerted on th is cortex by a lag screw position ed in
th e com bih ole n ext to th e osteotom y an d by add ition al
bicortical screw xation .
621
 10 Tib ia a n d fib u la

10.1 Tibia and bula, proxim al

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

10 .1.1 Po sto p e rative n o n un io n a fte r e xtra articu la r 41-A3 co m p re ssio n LCP p roxim al tib ial co m p re ssio n p la te 62 9
m e taph yse al m u ltifragm e n tary p roxim al tib ial p la te 4 .5/ 5 .0;
fractu re LCP re co n stru ctio n
p la te

10 .1.2 Tibial p la te au fractu re; a nd sp iral we d ge 41-B3; 42-B1 co m p re ssio n LISS-PLT lag scre w s an d 6 33
p roxim a l tib ial sh a ft fractu re an d locke d lo cke d in te rnal
sp lin tin g fixa to r

10 .1.3 La te ral tib ial p la te au fractu re w ith two 41-B3 co m p re ssio n LCP T-p la te lag scre w s 6 39
ad d itio n al d isp lace d o ste o ch o n d ral p la te au 4 .5/ 5 .0 b u ttre ss pla te
fragm e n ts

10 .1.4 Partial articu lar p roxim al tib ial fractu re w ith 41-B3 co m p re ssio n LISS-PLT lag scre w s a n d 6 45
sp lit-d e p re ssio n p ro te ctio n p la te

10 .1.5 Partial a rticu la r, d islo ca te d tib ia l h e a d fra cture 41-B3 co m p re ssio n LCP T-p la te b u ttre ss pla te 6 49
w ith sp lit-d e p re ssio n 4 .5/ 5 .0

10 .1.6 Com ple te articu lar p roxim al tib ial fractu re w ith 41-C1; 42-A1 co m p re ssio n LISS-PLT lag scre w s an d 6 57
lo ng spiral fractu re o f the sha ft an d locke d lo cke d in te rnal
sp lin tin g fixa to r

10 .1.7 Sim ple a rticu la r proxim al tib ia l fra ctu re w ith 41-C2 co m p re ssio n LISS-PLT lag scre w s an d 6 61
m e tap hyse al co m m in u tion an d locke d lo cke d in te rnal
sp lin tin g fixa to r

10 .1.8 Articula r m u ltifra gm e n tary p roxim al tibial 41-C3 co m p re ssio n LCP p roxim al tib ial lag scre w s an d 665
fractu re an d locke d p la te 4 .5/ 5 .0 lo cke d in te rnal
sp lin tin g fixa to r an d
p ro te ctio n p la te

10 .1.9 Articu la r m u ltifra gm e n tary p roxim al tibia l 41-C3 co m p re ssio n LISS-PLT lag scre w s an d 669
fractu re an d lo cke d lo cke d in te rnal
sp lin tin g fixa to r

622
 10 .1 Tib ia a n d fib u la , p ro xim a l

Ca s e s (co n t)

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

10 .1.10 Com p le te a rticu lar m u ltifragm e n ta ry p roxim a l 41-C3 co m p re ssio n LCP T-p la te lag scre w s and 6 73
tibial fractu re and avu lsio n fractu re o f th e an d locke d 4 .5/ 5 .0 lo cke d in te rnal
fib u la r h e ad sp lin tin g fixa to r a nd
p ro te ctio n pla te

10 .1.11 In ve rse d Y-fractu re o f th e tib ial h e ad w ith 41-C3 co m p re ssio n LCP L-p la te lag scre w s and 677
im pre ssio n o f th e an te rola te ral jo in t surface an d locke d 4 .5/ 5 .0 lo cke d in te rnal
sp lin tin g fixa to r a nd
p ro te ctio n pla te

623
 10 Tib ia a n d fib u la

10 Tibia and bula

10 .1 Tib ia a n d fib u la , p ro xim a l 625

10 .1.1 Po s t o p e ra t ive n o n u n io n a ft e r e xt ra a r t icu la r m e t a p h ys e a l
m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-A3 629
10 .1.2 Tib ia l p la t e a u fra ct u re —41-B3 a n d s p ira l w e d ge
p ro xim a l t ib ia l s h a ft fra ct u re —4 2 -B1 633
10 .1.3 La t e ra l t ib ia l p la t e a u fra ct u re w it h t w o
a d d it io n a l d is p la ce d o s t e o ch o n d ra l p la t e a u
fra gm e n t s —41-B3 639
10 .1.4 Pa r t ia l a r t icu la r p ro xim a l t ib ia l fra ct u re w it h
s p lit-d e p re s s io n —41-B3 645
10 .1.5 Pa r t ia l a r t icu la r, d is lo ca t e d t ib ia l h e a d fra ct u re w it h
s p lit-d e p re s s io n —41-B3 649
10 .1.6 Co m p le t e a r t icu la r p ro xim a l t ib ia l fra ct u re —41- C1 w it h
lo n g s p ira l fra ct u re o f t h e s h a ft 4 2 -A1 6 57
10 .1.7 Sim p le a r t icu la r p ro xim a l t ib ia l fra ct u re w it h m e t a p h y-
s e a l co m m in u t io n —41- C2 6 61
10 .1.8 Ar t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —
41- C3 665
10 .1.9 Ar t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —
41- C3 669
10 .1.10 Co m p le t e a r t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l
fra ct u re —41- C3 a n d a vu ls io n fra ct u re o f t h e fib u la r
head 67 3
10 .1.11 In ve rs e d Y-fra ct u re o f t h e t ib ia l h e a d w it h im p re s s io n o f
t h e a n t e ro la t e ra l jo in t s u r fa ce —41- C3 677

624
 Au t h o r Mich a e l Wa gn e r

10.1 Tibia and bula, proxim al

1 In cid e n ce 2 Cla s s ifica t io n

Fractu res of th e tibial plateau are in creasin g in in ciden ce

becau se of th eir relation sh ip to sports an d traf c acciden ts
(4.83% of th e total).

Tibial plateau fractu res are fractu res occu rrin g above th e tibi-
al tu berosity an d in volvin g th e tibial con dyles. Th ey represen t
a b c
1% of all fractu res overall bu t are m ore com m on in th e el-
derly, com prisin g 8% of all fractu res in th at popu lation . Tibial Fig 43-A Extraarticu lar fractu res.
10 .1-1a – c
plateau fractu res are articu lar fractu res m ost com m on ly in - a 41-A1 Avu lsion
volvin g th e lateral plateau . b 41-A2 Metaphyseal sim ple
c 41-A3 Metaph yseal m u ltifragm en tar y
Th e frequ en cy of tibial plateau fractu res is h igh er in older
wom en th an in older m en , becau se of th e greater in ciden ce of
osteoporosis in wom en .

Wh en th ey occu r in you n ger patien ts, m ost of th ese fractu res

are du e to h igh -en ergy trau m a. Th e m ost com m on m ech a-
n ism is a stron g valgu s force cou pled w ith axial load in g,
wh ich su bsequ en tly d rives th e fem oral con dyles in to th e tibial
a b c
plateau , produ cin g th e fractu re. Th ese in ju ries are som etim es
referred to as “car bu m per in ju ries,” becau se th e m ost com - Fig 43-B Partial articu lar fractu res.
10 .1-2 a – c
m on settin g in w h ich th ey occu r is wh en th e bu m per of a car a 41-B1 Pu re split
strikes th e lower leg. b 41-B2 Pu re depression
c 41-B3 Split-depression
Wh ile h igh -en ergy trau m a is th e ru le in tibial plateau fractu res
in th e you n g, th e elderly m ay su stain fatigu e an d stress frac-
tu res of th e tibial plateau w ith m in im al or even n o iden ti ed
trau m a. Th ese fractu res are u su ally th e resu lt of com pressive
forces actin g on osteoporotic bon e. In fact, an y h em arth rosis
of th e kn ee occu rrin g in an elderly person sh ou ld be assu m ed
to be a tibial plateau fractu re u n til proven oth erw ise.
a b c
Fractu res of th e tibial plateau are com m on ly accom pan ied by
dam age to th e collateral ligam en ts, a fact easily explain ed by Fig 43-C Com plete articu lar fractu res.
10 .1-3 a – c
exam in in g th e m ajor m ech an ism s of in ju r y. Avu lsion frac- a 41-C1 Articu lar sim ple, m etaph yseal sim ple
tu res of th e lateral tibial plateau are accom pan ied by a con cu r- b 41-C2 Articu lar sim ple, m etaph yseal m u ltifragm en tary
ren t ACL ru ptu re in 75% to 100% of cases. Th is special type c 41-C3 Articu lar m u ltifragm en tary

625
 10 Tib ia a n d fib u la
of tibial plateau fractu re u su ally occu rs in sportin g even ts an d
is du e to m ech an ism s of in ju r y th at produ ce k n ee exion ,
excessive in tern al rotation , an d varu s stress.
3 Tre a t m e n t m e t h o d s
Th e aim s of su rgery are:
• to restore articu lar con gru ity, join t stability, an d th e origi-
n al k n ee axis;
• to provide fractu re stability allow in g for early pain free
m ovem en t of th e k n ee an d m obilization of th e patien t;
• to obtain fu ll fu n ction al recovery as th e lon g term goal;
• to avoid posttrau m atic arth ritis.
An atom ical redu ction an d com plete restoration of th e h eigh t
of both tibial plateau s sh ou ld be attem pted in all in stan ces.
Th is m ay be d if cu lt w ith bon e loss, in severely d isplaced AO
type C fractu res, or wh en delayed recon stru ction is n eces-
sary.
Non operative treatm en t. In u n d isplaced fractu res, n on opera-
tive treatm en t m ay be a safe altern ative. Th is prin ciple m ay
also be of valu e for aged an d bedridden patien ts. Varu s/ valgu s
stability on ph ysica l exam in ation in dicates th at lim b align -
m en t w ill be assu red u pon fractu re h ealin g. Patien ts wh o
presen t w ith a low risk of developin g arth ritis m ay also be
good can didates for n on operative treatm en t.
Ext ra a r t icu la r fra ct u re s (41-A)
Most of th ese fractu res ben e t from operative stabilization
even if n ot greatly d isplaced or u n stable. Differen t m eth ods
h ave been described, bu t du e to th e sh ort proxim al segm en t
an d th e biom ech an ical problem s described above, plates pro-
vidin g an gu lar stability are preferred; th ey can u su ally be ap-
plied w ith m in im al or n o exposu re of th e fractu re focu s. Early
reports abou t th e clin ical u se of th e LISS plate an d LCP h ave
sh ow n prom isin g resu lts regard in g fractu re u n ion , in fection
626
rate an d secon dar y loss of redu ction . Th e fractu re m u st be
redu ced before xation . Th is is ach ieved w ith th e h elp of th e
large distractor an d redu ction clam ps placed on th e m ain
fractu re fragm en ts th rou gh sm all in cision s. Som etim es, ad-
d ition al lag screw s or a m ed ial plate are n eeded to stabilize
isolated fragm en ts.
Tim in g in fractu res w ith severe soft-tissu e dam age is critical
becau se th ere is a h igh risk of wou n d h ealin g problem s. To
avoid th is, extern al xation as a prim ar y tem porar y stabili-
zation is perform ed. Th e xation fram e m ay bridge th e k n ee
join t or is placed on th e tibial plateau allow in g k n ee m otion .
After soft tissu e con dition in g, th e extern al fram e is replaced
by in tern al xation . As an altern ative, th e h ybr id extern al
xator m ay be applied.
In t ra m e d u lla r y n a ilin g
Con ven tion al in tram edu llar y n ails are n ot really su ited to th e
stabilization of prox im al tibial fractu res. Som e n ew n ail de-
sign s, eg, th e expert tibia n ail h ave u p to ve in terlock in g
option s prox im ally. Fu rth erm ore, th e prox im al lock in g screw
can be xed in position by th e block in g en d cap, thu s provid-
in g an gu lar stability. Th e prox im al fractu re m u st be redu ced
before n ail in sertion .
Ar t icu la r fra ct u re s
La t e ra l p la t e a u —s p lit fra ct u re s (41-B1)
Pu re split fractu res (41-B1) m ay be treated by im m ediate lag
screw xation . In order to ascertain th at n o fu rth er d isplace-
m en t h as occu red, arth roscopic con trol m ay be u sefu l. Two
large can cellou s screw s w ith wash ers are u sed for xation .
A th ird screw w ith a wash er is recom m en ded in an an tiglide
position .
La t e ra l p la t e a u —p u re im p a ct io n fra ct u re (41-B2)
If available, in traoperative CT scan n in g is to be preferred to as-
certain com plete redu ction an d secu re xation w ith screw s.
 10 .1 Tib ia a n d fib u la , p ro xim a l

La t e ra l p la t e a u —s p lit-d e p re s s io n fra ct u re s (41-B3)

4 Im p la n t o ve r vie w
Fixation is best ach ieved by a plate. Lag screw s m ay be in sert-
ed in depen den tly an d/or th rou gh th e plate. Th ese fractu res
are also good in dication s for th e LISS, or special plates th at al-
low “raftin g” of screw s to su pport th e im pacted join t su rface.
a e

Me d ia l p la t e a u fra ct u re s (41-B2 .2 / B3 .2)

Redu ction m ay be obtain ed w ith th e large “Kin g Kon g” for-
ceps percu tan eou sly an d even th e in sertion of screw s an d /or
a bu ttress plate m ay be don e th rou gh sm all in cision s postero-
f
m edially. b

Bico n d yla r fra ct u re s (41- C)

Man y of th ese fractu res w ill requ ire an in itial join t-span n in g
g
extern al xator wh ile th e soft tissu es settle.
c

Percu tan eou s redu ction w ith a large forceps m ay be attem pted
in pu re split fractu res. ORIF sh ou ld be perform ed to ach ieve
an atom ical redu ction an d stable xation . Plates providin g
an gu lar stability (Tibia LISS plate or LCP) appear to be es- d h
pecially su ited for th ese m ore com plex type C2 an d C3 frac-
tu res. Th e an atom ic proxim al tibial lock in g plate can be u sed Fig 10 .1-4 a – h
as a bu ttress, u su ally does n ot requ ire con tou rin g an d can a LISS-PLT 5.0 (left an d righ t version available)
provide an gu lar stability. In itial lag-screw xation of th e ar- b LCP-PLT 4.5/5.0 (left an d righ t version available)
ticu lar block prior to plate application is essen tial, wh ile an y c LCP proxim al tibial plate 4.5/5.0 (lateral left an d
m etaph yseal or d iaph yseal com m inu tion m ay be bridged w ith lateral righ t version available)
a lon g lock in g plate. d LCP T-plate 4.5/5.0
e LCP T-bu ttress plate 4.5/5.0
f LCP L-bu ttress plate 4.5/5.0 (left an d righ t
version available)
g LCP 4.5/5.0, n arrow
h LCP recon stru ction plate 4.5/5.0

627
 10 Tib ia a n d fib u la
5 Su gge s t io n s fo r fu r t h e r re a d in g
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associated soft tissu e in ju ries. J Orthop Trauma; 8:1838. 8(3):183 –188.
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after su bmu scu lar xation of prox im al tibia fractu res. Injury;
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Clin Orthop; 292:87–100.
Sh e p ard L, A bd o llah i K, Le e J, e t al (2002) Th e prevalen ce of soft
tissu e in ju ries in n on operative tibial plateau fractu res as determ in ed
by m agn etic reson an ce im agin g. J Orthop Trauma; 16:628 –631.
Ch an P, K lim k ie w icz J, Lu cke t t i W, e t al (1997) Im pact of CT scan
on treatm en t plan an d fractu re classi cation of tibial plateau fractu res.
J Orthop Trauma; (11):484 –489.
Bro ph y D , O’Malle y M , Lu i D , e t al (1996) M R im agin g of tibial
plateau fractu res. Clin Radiol; 51(12):873 –878.
Yaco u bian SV, N e v in s RT, Sallis JG, e t al (2002) Im pact of M RI on
treatm en t plan an d fractu re classi cation of tibial plateau fractu res.
J Orthop Trauma; 16:632–637.
We be r WN , N e u m an n CH , Barako s JA , e t al (1991) Lateral tibia
rim (Segon d) fractu res: M R im agin g ch aracteristics. Radiology;
180-3:731–734.
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an d m en iscectom y on join t align m en t an d con tact pressu res for
fractu res of th e lateral tibial plateau . J Orthop Trauma; 15:101–106.
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prox im al tibia treated w ith a fu n ction brace. Clin Orthop; 417:293 –302.
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com plex tibial plateau fractu res. J Bone Joint Surg [Br]; 76(2):285 –289.
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of tibial fractu res by lim ited in tern al xation . Clin Orthop; 339:47–57.
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tibial plateau fractu res? A m u lticen tre ran dom ized stu dy of bon e graft
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Clin Orthop Relat Res; 439:207–214.
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 Au t h o rs Mich a e l J Ga rd n e r, De a n G Lo rich , Da vid L He lfe t

10.1.1 Postope rative nonunion afte r e xtraarticular m e taphyse al

m ultifragm e ntary proxim al tibial fracture —41-A3
1 Ca s e d e s crip t io n

a b c d f

50-year-old con stru ction worker, w ith a sign i can t sm ok in g h istor y, fell Fig 10 .1.1-1a – f
5 m eters from scaffold in g. Su stain ed a mu ltifragm en tary fractu re of th e a – b Extraa r ticu la r prox im a l tibia l a n d bu lar
proxim al tibia an d bu la. Oth er in ju ries in clu ded con tralateral 2n d an d fractu re.
3rd m etatarsal an d cu n eiform fractu res an d an L3 bu rst fractu re w ith ou t c– d Follow in g treatm en t w ith a LISS plate, t h e
retropu lsion of th e fragm en ts in to th e spin al can al or n eu rologic sym p- im plan t was rem oved 9 m on th s later an d re-
tom s. vealed a n onu n ion .
Th e soft-tissu e en velope h ad sign i can t swellin g. Moderate ecch ym osis e–f To fu rth er ch aracter ize th e n on u n ion pattern ,
was presen t. Th ere were n o sign s of com partm en t syn d rom e or eviden ce a CT scan was obtain ed an d con rm ed lack of
of n eu rological or vascu lar in ju r y. He was treated in itially w ith a LISS bony bridgin g.
plate, an d 9 m on th s postoperatively h e com plain ed of persisten t pain
alon g th e d istal exten t of th e plate.
A CT scan was obtain ed an d h e was d iagn osed w ith a n on u n ion .

In d ica t io n

Ab se n ce o f co m p le te h e a lin g 9 m o n th s p o sto p e ra tive ly re q u ire s ta ke d o w n o f

th e n o n u n io n a n d re visio n o p e n re d u ctio n , in te rn a l xa tio n , a n d b o n e gra ftin g to
stim u la te fra ctu re h e a lin g.

629
 10 .1 Tib ia a n d fib u la , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LCP p ro xim a l tib ia l p la te 4 .5/ 5 .0 , 11 h o le s
• LCP re co n stru ctio n p la te 3 .5 , 6 h o le s
• Lo ckin g h e a d scre w s (LHS)
• Th re a d e d 2 .0 m m K-w ire s
• Pe lvic re d u ctio n fo rce p s
• Syn th e tic b o n e su b s titu te
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Afte r in tra o p e ra tive cu ltu re s h a ve b e e n ta ke n , give
a n tib io tics; 2 n d ge n e ra tio n ce p h a lo sp o rin s

Fig 10 .1.1-2 Po sitio n th e p a tie n t su p in e o n th e o p e ra tin g ro o m ta b le . Pla ce a to u rn iq u e t o n th e

u p p e r th igh . Pre p a re a n d d ra p e th e le g fre e a n d p la ce a to w e l ro ll u n d e r th e kn e e . Po sitio n th e
im a ge in te n si e r to e n su re a d e q u a te AP a n d la te ra l vie w s.

2 Su rgica l a p p ro a ch

Fig 10 .1.1-3 Use th e sam e in cision as was u sed previou sly—m ake a straigh t in cision
over th e lateral prox im al tibia exten d in g d istally approx im ately 10 cm .
Raise fu ll-th ick n ess aps dow n to th e fascia.
Follow th e in vestin g fascia of th e an terior com partm en t m ed ially to th e tibial crest,
an d sh ar ply elevate th e en tire com partm en t from th e an terolateral tibial su rface w ith -
ou t violatin g th e com partm en t.
Rem ove th e previou s im plan t an d debride th e brou s n onu n ion back to bleed in g bon e
su rfaces.

6 30
 10 .1.1 Po s t o p e ra t ive n o n u n io n a ft e r e xt ra a r t icu la r m e t a p h ys e a l m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-A3
3 Re d u ct io n a n d fixa t io n
a b
Fig 10 .1.1-4 a – cAttem pt to m anu ally redu ce th e fractu re u n -
der im age in ten si cation gu idan ce.
Often , th e bu la w ill be h ealed an d w ill im pede redu ction of
th e tibia. In th is case, m ake a separate lateral in cision over
th e previou s bu la fractu re site. Con n ect drill h oles w ith an
osteotom e to m ake an obliqu e osteotom y.
En su re th e tibia can be redu ced an d com pressed u n der d irect
visu alization .
Place a lon g LCP prox im al tibial plate over th e lateral su rface
of th e tibia. Use a cortex screw for com pression rst an d se-
cu re it prox im ally to th e bon e, th en u se lock in g h ead screw s
in th e prox im al lim b of th e plate. Use a redu ction clam p to
redu ce th e d istal fragm en t to th e lateral plate to restore proper
axis an d align m en t in th e coron al plan e.
Nex t, place a stra igh t 3.5 lock in g recon str u ction plate on
th e an terior su rface of th e tibia, an d secu re it d istally w ith a
3.5 m m cortex screw to in d irectly redu ce th e fractu re in th e
sagittal plan e.
c
Use a large poin ted redu ction forceps from th e d istally xed
an terior plate to th e lateral plate wh ich h as been xed prox i-
m ally to com press across th e fractu re site.
With th e fractu re redu ced, u se lag screw s th rou gh th e an te-
rior plate an d eccen tr ic cortex screw s th rou gh th e lateral plate
to apply add ition al com pression . Place an oth er cortex screw
in th e an terior plate d istal to th e fractu re site, an d space ou t
lock in g h ead screw s at th e en ds of th e plate.
Fin ally, place on e or two lock in g h ead screw s percu tan eou sly
in th e d istal en d of th e lateral plate for de n itive xation .
Pack th e n onu n ion site w ith dem in eralized bon e m atr ix
m ixed w ith bon e graft.
Close wou n ds over su ction d rain s, an d apply a soft bu lky
dressin g w ith a locked h in ged k n ee brace.
Place th e patien t in a plaster sh ort leg splin t an d k n ee im -
m obilizer.
631
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n

Postoperatively, in itiate low-m olecu lar weigh t h eparin for deep ven ou s th rom bosis
prophylaxis.
Con tinu e an tibiotic th erapy for 24 –48 h ou rs u n til cu ltu res are n egative.
Apply a h in ged k n ee brace locked in exten sion in itially for patien t com fort, w h ich
m ay be u n locked w h ile th e patien t is in bed.
On day 1 or 2 postoperatively, begin passive an d active assisted ran ge of m otion an d
qu ad riceps stren gth en in g exercises su pervised by a ph ysical th erapist.
Th e patien t sh ou ld be kept tou ch -dow n weigh t bear in g for at least 6 weeks, an d
progressed slowly to fu ll weigh t bearin g over th e n ext 8 –12 weeks.
Wh en qu adriceps con trol retu rn s, th e brace m ay be d iscon tin u ed.

4 m on th s follow in g open redu ction , n on u n ion takedow n , revision

Fig 10 .1.1-5 a – b
platin g, an d bon e graftin g, th e fractu re sh ow s sign s of h ealin g.

Im p la n t re m o va l
If th e im plan t is prom in en t, con sider rem ovin g th e xation at least 18 –24 m on th s
after th e procedu re. Protected weigh t bearin g an d bracin g sh ou ld be in stitu ted for
a b 6 –8 weeks follow in g rem oval.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e lock in g h ead screw h eads m ay becom e jam m ed in th e In sert th e rst 2/ 3 of th e screw u n der power an d seat th e
screw h oles du rin g in sertion . screw u sin g a torqu e-lim ited screwd river.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Wh en in sertin g a screw in to h ole 10 or h igh er (m ore d is- Wh en u sin g a plate lon ger th an 10 h oles, always protect
tal from th e plateau), th e su per cial peron eal n erve m ay th e su per cial peron eal n er ve or visu alize th e bon e prior
be in ju red. to screw in sertion . Make su re th e distal tip of th e plate is
Th e an terior tibial vessels m ay be ten ted by th e d istal tip u sh on th e bon e to preven t dam age to th e an terior tibial
of th e plate. artery an d vein .

Re h a b ilit a t io n
Fractu res abou t th e k n ee, particu larly n on u n ion s in
wh ich k n ee m otion m ay h ave been lim ited for prolon ged
periods, are often associated w ith som e degree of arth ro-
brosis.
Re h a b ilit a t io n
In itiate passive and active motion as soon as possible, and
in struct the patient on the im portance of their active role.

6 32
 Au t h o r Ch ris t o p h So m m e r
10.1.2 Tibial plate au fracture —41-B3 and spiral we dge
proxim al tibial shaft fracture —42-B1
1 Ca s e d e s crip t io n
a b
31-year-old wom an skier w ith a torsion valgization trau m a of
h er righ t lower leg. A com bin ation in ju ry w ith tibial plateau
fractu re (41-B3.1) an d fractu re of th e prox im al tibial sh aft can
be seen on th e x-ray (wedge fractu re, spiral wedge m iddle sec-
tion). No soft-tissu e in ju ry.
In d ica t io n
Th e in d ica tio n fo r a n o p e ra tive p ro ce d u re is cle a r. Th e im p a cte d jo in t
fra ctu re is tre a te d b y o p e n re d u ctio n , ca n ce llo u s b o n e gra ftin g, a n d
scre w o ste o syn th e sis. Th e sha ft fra ctu re o n its o w n wo u ld b e id e a l
fo r a n a il o ste o s yn th e sis, b u t sin ce th is is a co m b in a tio n fra ctu re , sta -
c d f
Fig 10 .1.2 -1a – f
a AP view of th e tibial plateau fractu re.
b Lateral view of th e tibial plateau fractu re.
c AP view of th e proxim al tibial sh aft fractu re.
d Lateral view of th e proxim al tibial sh aft fractu re.
e – f A CT scan was obtain ed for m ore precise d iagn osis
an d sh owed a 1–1.5 cm im paction of th e an terolateral
articu lar su rface.
b iliza tio n w ith a LISS-PLT is id e a l. Th e sa m e a p p ro a ch ca n b e u se d fo r
b o th fra ctu re s. A n a il o ste o syn th e sis w o u ld n o t b e id e a l b e ca u se th e
a rticu la r la g scre w s co u ld in te rfe re w ith th e n a il a n d a se co n d in cisio n
w o u ld b e n e ce ssa ry.
633
 10 .1 Tib ia a n d fib u la , p ro xim a l

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g 1 Su rge o n
• •LISS-PLT,
An tib io tics:
13 hsin
o le
gle
s d o se 2 n d ge n e ra tio n ce p h a lo - 2 ORP
• 5sp
.0 omrin
m. se lf-ta p p in g lo ckin g h e a d scre w s (LHS) 3 1s t a ssis ta n t
• •3Th
.5 ro
mmm bco o sis
rtepxro
scre
p h yla
w s xis: Lo w m o le cu la r h e p a rin . 4 2 n d a ssis ta n t
4
• K-w ire s
3
Ste rile are a
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin 1
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .1.2 -2 Th e e n tire le g is p re p a re d a n d d ra p e d u n d e r ste rile co n d itio n s, in clu d in g th e ilia c cre st

so th a t ca n ce llo u s b o n e ca n b e h a rve ste d . Th e in ju re d le g is e xte n d e d b u t is su p p o rte d b e lo w th e kn e e
w ith a m e ta l tria n gu la r b lo ck o r la rge to w e l ro ll, w h ich ca n b e re m o ve d a s th e situ a tio n re q u ire s.

2 Su rgica l a p p ro a ch

Fig 10 .1.2 -3 At th e level of th e tibial h ead a 6 –7 cm lon g in cision arch in g in an

an terior d irection is m ade. Th e iliotibial tract is d ivided an d detach ed at Gerdy’s
tu bercle. A su bm en iscal arth rotom y in th e rst 2/ 3 is perform ed. A good overview
of th e fractu re can be obtain ed by liftin g th e m en iscu s. Th e m en iscal tear is sew n
togeth er an d lifted cran ially w ith th reads.

6 34
 10 .1.2 Tib ia l p la t e a u fra ct u re —41-B3 a n d s p ira l w e d ge p ro xim a l t ib ia l s h a ft fra ct u re —42 -B1
3 Re d u ct io n a n d fixa t io n
a b
First th e sagittal fractu re split of th e lateral
Fig 10 .1.2 -4 a – f
plateau is open ed by u se of a blu n t in stru m en t.
After th is, th e im pacted join t fragm en t can be lifted to th e
level of th e m edial join t su rface. In th e case of a large defect,
it sh ou ld be lled w ith can cellou s bon e graft or bon e su bsti-
tu te.
Th e sagittal fractu re split is n ow closed w ith a m ed ial per-
cu tan eou sly in serted redu ction forceps (large Weber forceps
or pelvic redu ction forceps) an d tem porarily retain ed w ith a
K-w ire.
After im age in ten si cation con trol, th e plateau fractu re can
be xed w ith two 3.5 m m lag screw s, in serted close to th e
articu lar su rface an d com pressin g th e lateral wall to th e re-
du ced cen tral fragm en t an d m edial plateau . An oth er screw
can be in serted from an terior to posterior to provide add i-
tion al su pport.
A 13-h ole LISS-PLT stabilizes th e diaph yseal fractu re. Th e
plate is in serted u n der th e an terior tibial m u scle eith er w ith
th e in sertion gu ide or by h an d.
Th e redu ction of th e fractu re in th is case is easily ach ieved by
m anu al traction an d sligh t rotation al m ovem en t on th e lower
leg. Altern atively, percu tan eou sly in serted redu ction forceps
can be u sed (large Weber forceps, redu ction forceps). Th ese
forceps are best applied after th e plate h as been in serted an d
ch ecked u n der im age in ten si cation . Oth er w ise th e redu c-
tion forceps can obstru ct th e in sertion of th e plate.
Th e LISS plate is xed cran ially w ith a lock in g h ead screw in
on e of th e two m ost prox im al screw h oles. Th is screw h as to
be parallel to th e articu lar su rface (in AP view).
635
 10 .1 Tib ia a n d fib u la , p ro xim a l
3 Re d u c t io n a n d fixa t io n
a b
c d
4 Re h a b ilit a t io n
a b
6 36
(co n t )
Fig 10 .1.2 -4 a – f Wh en correct rotation al
(co n t)
an d lon gitu d in al align m en t h as been ach ieved,
th e m ost d istal plate h ole is occu pied w ith an
LHS to stabilize th is position . If th e in sertion
gu ide is u sed, self drillin g, self-tappin g LHS are
in serted in th e sh aft area. If th e in sertion gu ide
is n ot bein g u sed, bicortical self-tappin g LHS
are preferred.
At th is poin t an an te- or retrocu rvatu re can
still be corrected an d th erefore exam in ation by
im age in ten si er (lateral view) is carried ou t.
Depen din g on th e bon e qu ality, th e plate is
xed in th e tibial h ead area w ith fou r to ve
LHS. Fou r to six cortices are u sed for sh aft xa-
tion (fou r to six m on ocortical screw s or two to
th ree bicortical screw s).
e f
Mobilization started on th e th ird postoperative day w ith fu n ction al treat-
m en t. In itial weigh t bearin g was 10 –15 kg for 6 weeks, th en 30 kg for an -
oth er 6 weeks. Fu ll weigh t bearin g started after th e th ird m on th . After 16
m on th s th e con trol x-rays sh owed good con solidation of th e fractu re an d
iden tical position of th e im plan t. Th e plate was rem oved after on e year be-
cau se th e patien t com plain ed of a sligh t irritation of th e iliotibial tract at th e
u pper part of th e plate.
Fig 10 .1.2 -5 a – b X-rays after 16 m on th s sh ow in g good con solidation of th e
fractu re.
a AP view.
b Lateral view.
 10 .1.2 Tib ia l p la t e a u fra ct u re —41-B3 a n d s p ira l w e d ge p ro xim a l t ib ia l s h a ft fra ct u re —42 -B1

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
LISS (or altern ativly th e LCP-PLT) is an ideal im plan t for
th e stabilization of com bin ed in ju ries of th e tibial h ead
an d th e proxim al or m id tibial sh aft.

Ap p ro a ch Ap p ro a ch
Th e an terior tibial arter y an d th e deep peron eal n erve are Both fractu re com pon en ts (partly open tibial plateau ,
en dan gered by d rill in sertion of th e distal percu tan eou s partly percu tan eou s tibial sh aft) can be treated via th is
screw s. sm all in cision .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
If a sim ple sh aft fractu re is n ot precisely redu ced,
a delayed or n on u n ion can occu r.

Re h a b ilit a t io n Re h a b ilit a t io n
Non com plian ce w ith early fu ll weigh t bearin g can resu lt Fu n ction al treatm en t is possible w ith ou t restriction .
in a red islocation of th e tibial plateau w ith collapse of th e
elevated fragm en t.

637
 10 .1 Tib ia a n d fib u la , p ro xim a l

6 38
 Au t h o r Ch ris t o p h So m m e r
10.1.3 Late ral tibial plate au fracture with two additional
displace d oste ochondral plate au fragm e nts—41-B3
1 Ca s e d e s crip t io n
a b
Fig 10 .1.3 -1a – c
a AP view.
b Lateral view.
c Draw in g of th e in ju red stru ctu res.
39-year-old wom an su ffered a valgization an d extern al rota-
tion trau m a w h ile sk iin g. Th e x-ray sh owed a lateral tibial
plateau fractu re w ith two add ition al d isplaced osteoch on d ral
plateau fragm en ts, on e situ ated between th e con dyles .
Th e fractu re is a 41-B3.1 (partial articu lar fractu re, split de-
pression laterally). Becau se of th e h igh velocity, an add ition al
ligam en t com pon en t h as to be con sidered. In traoperative in -
spection an d stability testin g after osteosyn th esis sh ow th e
In d ica t io n
Th is in ju ry is a cle a r in d ica tio n fo r o p e n re d u ctio n o f th e fra ctu re
a n d tre a tm e n t o f kn e e d a m a ge . A p re o p e ra tive MRI w o u ld sh o w th e
w h o le e xte n t o f th e in ju ry. Th e p re fe rre d a p p ro a ch is th e sta n d a rd
1 Fe m o ra l ru p tu re o f th e MCL
2 Co m p le te ru p tu re o f th e la te ra l
m e n iscu s
3 Co m p le te ru p tu re o f th e ACL
4 3 1 4 Sm a ll o ste o ch o n d ra l fra gm e n t
2 5 Sm a ll o ste o ch o n d ra l fra gm e n t
c
fu ll exten t of th e dam age. Com plete ru ptu re of th e lateral
m en iscu s an d in ter position in to th e fractu re zon e as well as
ru ptu re of th e m en iscotibial ligam en ts. Th e m ed ial collateral
ligam en ts (MCL) an d th e posterior obliqu e ligam en ts (POL)
h ave been com pletely torn ou t of th e fem oral com partm en t.
Th ere is in traligam en tou s tear of th e an terior cru ciate liga-
m en t (ACL).
a n te ro la te ra l a p p ro a ch a n d su b m e n isca l a rth ro to m y w ith o p e n
re d u ctio n u n d e r visu a l co n tro l a n d a la te ra l su p p o rtin g o ste o syn th e sis.
A m e d ia l a p p ro a ch m a y b e re q u ire d to tre a t th e o th e r kn e e in ju rie s.
639
 10 .1 Tib ia a n d fib u la , p ro xim a l

Pre o p e ra t ive p la n n in g

Eq u ip m e n t 1 Su rge o n
• LCP T-p la te 4 .5/ 5 .0 , 3 h o le s 2 ORP
• 5 .0 m m se lf-ta p p in g 3 1st a ssistan t
lo ckin g h e a d scre w s (LHS) 4 2n d a ssista n t
• 6 .5 m m ca n ce llo u s b o n e scre w s
1
• 4 .5 m m co rte x scre w s 3 Ste rile a re a
• K-w ire s
• In stru m e n ts fo r ca p su le -liga m e n t
4
xa tio n
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts 2
ca n va ry a cco rd in g to a n a to m y.)
Fig 10 .1.3 -2 Th e e n tire le g is p re p a re d a n d d ra p e d u n d e r s te rile co n d itio n s,
Pa t ie n t p re p a ra t io n a n d p o s it io n in g in clu d in g th e ilia c cre st so th a t ca n ce llo u s b o n e ca n b e h a rve s te d . Th e in ju re d
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin le g is e xte n d e d b u t is su p p o rte d b e lo w th e kn e e w ith a m e ta l tria n gu la r b lo ck
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin o r la rge to w e l ro ll, w h ich ca n b e re m o ve d a s th e situ a tio n re q u ire s.

2 Su rgica l a p p ro a ch

Fig 10 .1.3 -3 An an terolateral stan dard approach is

perform ed an d th e iliotibial tract is d ivided at th e
level of th e join t. Th e tract is detach ed from th e lat-
eral tibial h ead. Add ition al sm all m ed ial approach
for MCL repair.

640
 10 .1.3 La t e ra l t ib ia l p la t e a u fra ct u re w it h t w o a d d it io n a l d is p la ce d o s t e o ch o n d ra l p la t e a u fra gm e n t s —41-B3
3 Re d u ct io n a n d fixa t io n
1 Th e m e n iscu s is h e ld
cran ially b y so m e th re ad s
2 Th e o ste o ch o n d ral
fragm e n ts a re re m o ve d
3 6 .5 m m can ce llo u s b o n e
scre w fo r co m pre ssio n
1 4 Co rte x scre w 4 .5 m m
5 Co rte x scre w 4 .5 m m
6 Se lf-tap p in g LHS 5 .0 m m
2 7 Se lf-tap p in g LHS 5 .0 m m
7
3
6
a b
Fig 10 .1.3 -4 a – b
a Th e an terior tibial com partm en t is open ed approx im ately
4 cm . At th is poin t, th e ru ptu re of th e m en iscotibial liga-
m en t is already visible. After th e lateral plateau fragm en t
h as been lifted to th e side, th e m en iscu s can be seen deep
in th e fractu re zon e. Th e m en iscu s is redu ced an d h eld
cran ially by som e th reads for better visibility of th e tibial
plateau . Th e join t is rin sed th rou gh th e fractu re zon e u n -
der valgu s stress. Th e two sm all osteoch on d ral fragm en ts
from th e lateral tibial plateau are too sm all to be xed an d
are rem oved. Th e m ain bon e fragm en t is redu ced w ith
th e pelvic redu ction forceps, wh ich are in serted m ed ially
th rou gh a sm all in cision . Th e fractu re is tem porarily sta-
bilized w ith K-w ires an d th e redu ction is ch ecked u n der
im age in ten si cation . A 3-h ole LCP T-plate 4.5/5.0 is ben t
an d placed on th e an terolateral aspect. Th e rst screw to
be in serted is a 6.5 m m can cellou s bon e lag screw w ith
lon g th read to com press th e fractu re zon e. Fu rth er xa-
tion of th e plate d istally follow s w ith th e in sertion of two
4.5 m m cortex screw s (su f cien t in good bon e qu ality).
1 Kn o t
2 Re xa tio n o f th e
m e nisco tib ial ligam e n t
w ith a sta p le
3 Re visio n an d re xa tio n o f
th e MCL w ith t wo stap le s
3 4 ACL n o t re co n stru cte d
4
1
2
For th e de n itive xation of th e com pressed fractu re zon e,
two 5.0 m m self-tappin g LHS are in serted prox im ally.
Th ese screw s sh ou ld be as lon g as possible w ith ou t pen -
etratin g th e opposite cortex to preven t an irritation of th e
pes an serinu s.
b In spection of th e in tercon dylar region sh ow s th e in tra-
ligam en tou s ru ptu re of th e ACL. Th e stability of th e k n ee
join t is ch ecked after osteosyn th esis an d a m edial in sta-
bility is d iscovered. Th e MCL h as to be re xed. A m ed ial
approach an d sm all in cision at th e level of th e k n ee join t
is perform ed. Th e approach is an terior to th e pes an seri-
nu s. Th e MCL is treated by open redu ction an d xed w ith
two staples to th e fem oral part. With th is in ter ven tion , th e
stability is clearly im proved. Th e ACL can n ot be su tu red
an d an ACL replacem en t sh ou ld n ot be perform ed in th is
acu te situ ation . It can be con sidered at a later stage after
con solidation of th e fractu re if th ere is sym ptom atic k n ee
in stability.
6 41
 10 .1 Tib ia a n d fib u la , p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

Th e postoperative x-rays con rm ed th e an a-

Fig 10 .1.3 -5 a – b
tom ical recon stru ction of th e lateral tibial plateau w ith a sm all
cen trolateral defect (du e to th e two m issin g osteoch on d ral
fragm en ts). Th e m ed ial ligam en t staple xation an d th e lat-
eral capsu le xation can be seen .

a b

4 Re h a b ilit a t io n

Fig 10 .1.3 -6 a – i
a – b Th e k n ee was im m obilized w ith a rem ovable splin t for
4 weeks. Mobilization began on th e th ird day w ith
10 –15 kg weigh t bearin g. Active m ovem en t an d stren gth -
en in g of th e qu adriceps an d h am strin g m u scles were
practised. After 6 weeks th e fractu re sh owed en dosteal
con solidation .

a b
a b

6 42
 10 .1.3 La t e ra l t ib ia l p la t e a u fra ct u re w it h t w o a d d it io n a l d is p la ce d o s t e o ch o n d ra l p la t e a u fra gm e n t s —41-B3

4 Re h a b ilit a t io n (co n t )

Fig 10 .1.3 -6 a – i (co n t)

c– d Th e fractu re was fu rth er con solidated after 3 m on th s
an d fu ll weigh t bearin g began .
e–i After 7 m on th s th e fractu re was com pletely con solidated
w ith a n orm al k n ee join t space. At th is tim e, th e patien t
sh owed n orm al k n ee join t m ovem en t an d n o sign of
in stability. An ACL replacem en t was n ot n ecessar y, th e
prepatellar scar origin ates from an earlier patellar frac-
tu re an d osteosyn th esis.

c d

e f g i

6 43
 10 .1 Tib ia a n d fib u la , p ro xim a l

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
LCP is an ideal im plan t for th is in dication , an gu lar stabil-
ity wou ld n ot be requ ired in good bon e qu ality.

Ap p ro a ch
An an terolateral stan dard approach bears few risks. A
dou ble approach an terolaterally an d m ed ially can be as-
sociated w ith th e r isk of sk in n ecrosis. Carefu l h an d lin g of
th e soft tissu e is essen tial.
Ap p ro a ch
Even d if cu lt d isplaced fractu res can be treated w ith th e
h elp of th ese two sm all in cision s.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
With persistin g in stability after correct osteosyn th esis, th e
recon stru ction of th e capsu le an d ligam en ts is requ ired.

Re h a b ilit a t io n Re h a b ilit a t io n
Failu re to im m obilize th e k n ee join t en dan gers th e xa-
tion of th e ligam en ts, particu larly th e m ed ial ligam en ts.
Speci c, gu ided, active m ovem en t ou t of th e splin t is n ec-
essary to preven t k n ee stiffn ess.

644
 Au t h o r Ch ris t ia n Ryf

10.1.4 Partial articular proxim al tibial fracture with

split-de pre ssion —41-B3
1 Ca s e d e s crip t io n

34-year-old wom an fell wh ile sk iin g an d su stain ed

a prox im al articu lar lateral tibial fractu re.

Fig 10 .1.4 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n

Afte r in itia l ra d io lo gica l a n d CT sca n a n a lyse s, re gre ssio n

o f sw e llin g a n d n o in d ica tio n fo r a co m p a rtm e n t s yn -
d ro m e , th e fra ctu re wa s o p e ra te d o n . With th is a rticu la r
fra ctu re a n d d islo ca tio n o f th e la te ra l tib ia l jo in t su rfa ce ,
th e in d ica tio n fo r o p e ra tive tre a tm e n t wa s cle a r.

Fig 10 .1.4 -2 a – b CT sca n s.

a b

6 45
 10 .1 Tib ia a n d fib u la , p ro xim a l

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
Pa t ie n t p reFig 10t io
p a ra .1.4
n -3a nad– b
p o sSuit iop ninin
e gp o sitio n w ith e le va tio n
• LISS-PLT, 5 h o le s
• An tib io tics:
o f th
sineglein jud re
o se
d lim
2 n d bgea n edra tio
e xio
n nceopfhth
a lo
e -kn e e jo in t to
• 5 .0 m m se lf-ta p p in g
sp o rin . a p p ro xim a te ly 3 0 °. To u rn iq u e t o n th e fe m u r.
lo ckin g h e a d scre w s (LHS)
• Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• 6 .5 m m ca n ce llo u s b o n e scre w s
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 4 th ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin a b

2 Su rgica l a p p ro a ch

a b c

Fig 10 .1.4 -4 a – c
a All th e palpable stru ctu res are m arked. In cision lateral to th e patellar edge.
b Th e iliotibial tract is split an d partially detach ed from th e lateral tibial h ead.
Th e join t is n ow open ed.
c Th e lateral m en iscu s is presen ted an d d islocated cran ially.

646
 10 .1.4 Pa r t ia l a r t icu la r p ro xim a l t ib ia l fra ct u re w it h s p lit-d e p re s s io n —41-B3

3 Re d u ct io n a n d fixa t io n

a b c

d e f

g h i

Fig 10 .1.4 -5 a – i
a Redu ction of th e lateral fragm en t w ith a ch isel.
b Prelim in ary xation of th e redu ced fragm en t w ith
K-w ires.
c– d Th e redu ced lateral fragm en t is de n itively xed w ith
two can cellou s bon e screw s w ith wash ers in serted from
lateral to m ed ial. Th ese two su bch on dral screw s m u st be
parallel to th e join t su rface.
e–f To ach ieve a stable osteosyn th esis, a LISS plate is in -
serted su bm u scu larly an d prelim in arly xed w ith two
K-w ires proxim ally an d d istally.
g– h Th e prox im al xation follow s. Fou r LHS are in serted
for th is pu r pose. Fou r m on ocortical LHS are in serted
distally.
i Rem ova l of t h e in ser t ion gu ide a n d refix at ion of t h e
m en iscu s.

6 47
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n

Add ition al im m obilization : n on e, partial weigh t bearin g an d th erapy w ith th e con tin u os passive m otion m ach in e.
Weigh t bearin g: 15 kg for 6 weeks; h alf body weigh t after 8 weeks; fu ll weigh t bearin g after 10 to 12 weeks.

a b a b a b

Fig 10 .1.4 -6 a – b Postoperative x-rays Fig 10 .1.4 -7a – b Postoperative x-rays Fig 10 .1.4 -8 a – b Postoperative x-rays
after 6 weeks. after 3 m on th s. after 8 m on th s.
a AP view. a AP view. a AP view.
b Lateral view. b Lateral view. b Lateral view.

Im p la n t re m o va l
a b Im plan t rem oval after 18 m on th s.

Fig 10 .1.4 -9 a – b X-rays after im plan t

rem oval.
a AP view.
b Lateral view.

648
 Au t h o r Ch ris t o p h So m m e r
10.1.5 Partial articular, dislocate d tibial he ad fracture with
split-de pre ssion —41-B3
1 Ca s e d e s crip t io n
a b
29-year-old sk ier w ith m assive valgization trau m a of h er left
kn ee. Severe soft-tissu e swellin g a n d th e begin n in g of com -
partm en t syn d rom e. Rad iologically, a tibial h ead d islocation
fractu re was iden ti ed as a 41-B3.3 (partial articu lar fractu re
split-depression , in volvin g th e tibial tu bercles an d on e of th e
su rfaces). Closed redu ction an d xation w ith an extern al x-
ator bridgin g th e join t h ad been perform ed in a sm aller h ospital.
A con ven tion al rad iological exam in ation w ith th e redu ced
join t an d a CT scan was perform ed at ou r h ospital. Two join t
fragm en ts were pu sh ed in to th e m etaph ysis. Th e tu bercles of
th e in tercon dylar em in en ce h ad su stain ed m u ltifragm en tar y
fractu re. An terior cru cial ligam en t (ACL) dam age an d in ju r y
to th e lateral m en iscu s du e to th e dislocation of th e lateral
join t h ad to be assu m ed.
2
1
3
c d
Fig 10 .1.5 -1a – d
a AP view in itial x-ray.
b Lateral view in itial x-ray.
c AP view after prelim in ary xation w ith extern al xator.
d Th e dam age as veri ed in traoperatively. Distal avu lsion of
th e an terior cru ciate ligam en t (ACL) (1 ). Backed h an d le
ru ptu re of th e lateral m en iscu s ( 2 ). Im pacted cen trolateral
join t fragm en t (im pedim en t to redu ction , if n ot redu ced as
a rst step) ( 3 ).
Fig 10 .1.5 -2 7 days after in itial treatm en t, n orm al soft-tissu e
con dition an d redu ced dan ger of com partm en t syn d rom e; th e
m om en t is ideal for de n itive in tern al xation .
6 49
 10 .1 Tib ia a n d fib u la , p ro xim a l

In d ica t io n

Th is ca se p re se n ts a cle a r in d ica tio n fo r a n o ste o s yn th e sis. Th e sp e - b u t th is a p p ro a ch d o e s n o t a llo w xa tio n o f th e m e n iscu s n o r re d u c-

ci c p a rtia l jo in t fra ctu re , w ith th e co m b ina tio n o f in ta ct la te ra l co n -
d yle a n d im p a cte d p o ste ro la te ra l a rticu la r fra gm e n ts, is o n e o f th e
m o st d if cu lt fra ctu re s to tre a t. A m in im a lly in va sive te ch n iq u e is
u n like ly to b e su cce ssfu l. In a d d itio n , in ju ry to th e la te ra l kn e e liga -
m e n ts a n d la te ra l m e n iscu s is p ro b a b le . Th e p o ste ro m e d ia l a p p ro a ch
is id e a l fo r b u ttre ssin g th e d isp la ce d m e d ia l co n d yle w ith a p la te ,
tio n o f th e im p a cte d jo in t fra gm e n ts. Th e re fo re , a s a rst ste p, a n
a n te ro la te ra l a p p ro a ch m u st b e p re fe rre d . Th is a llo w s th e re xa tio n
o f th e m e n isco -liga m e n to u s stru ctu re a s we ll a s th e re d u ctio n o f th e
im p acte d jo in t fra gm e n t. Th is is fo llo w e d b y a lim ite d p o ste ro m e d ia l,
e xtraa rticu la r a p p ro a ch fo r re d u ctio n a n d p la te xa tio n o f th e m a in
m e d ia l co n d yle .

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• •LCP
An tib
T-piolatics:
te 4sin
.5/ gle
5 .0 ,d5o se
h o2len ds ge n e ra tio n ce p h a lo - An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
• 5sp
.0 omrin
m. se lf-ta p p in g lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis: n o n e
• •4Th
.5 ro
mmm bco o sis
rtepxro
scre
p h yla
w xis: Lo w m o le cu la r h e p a rin .
• K-w ire s
• Pe lvic re d u ctio n fo rce p s
• La rge d istra cto r
• Aim in g d e vice fo r tra n so sse o u s ACL xa tio n
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

1 Su rge o n
2 ORP
3 1st a ssistan t
3 4 4 2n d a ssista n t

1 Ste rile a re a
4

3
1

2 2
a b

Fig 10 .1.5 -3 a – b Po sitio n in g fo llo w s t w o p h a se s:

a La te ra l a p p ro a ch , th e su rge o n s ta n d s o n th e la te ra l sid e , th e w h o le le g a n d ilia c cre s t a re a cce ssib le ,
im a ge in te n si e r o n th e o p p o site sid e .
b Me d ia l a p p ro a ch , th e su rge o n a n d th e se co n d a ssista n t ch a n ge to th e o p p o site sid e , th e re st sta ys in p la ce .

6 50
 10 .1.5 Pa r t ia l a r t icu la r, d is lo ca t e d t ib ia l h e a d fra ct u re w it h s p lit-d e p re s s io n —41-B3

2 Su rgica l a p p ro a ch

a b c

Fig 10 .1.5 -4 a – c
a Su rgical eld.
b Th e an terolateral in cision begin s above th e k n ee join t an d exten ds for approx im ately 5 –6 cm in a d istal d irection .
c Th e posterom ed ial in cision begin s at th e join t space an d ru n s d istally (extraarticu lar approach ).

3 Re d u ct io n a n d fixa t io n

Fig 10 .1.5 -5 First th e an terior extern al xator is

partially rem oved an d th e large d istractor is xed
on to two Sch an z screw s th at were left in situ . A
towel is placed u n der th e k n ee wh ich is position ed at
20 –30° exion . Anterolateral approach and division
of th e iliotibial tract follow s.

651
 10 .1 Tib ia a n d fib u la , p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

a b

Fig 10 .1.5 -6 a – c
a After th e su bm en iscal tran sverse arth rotom y, th e ru ptu red
m en isco-tibial ligam en ts are visible.
b An addition al an terolateral capsu lotom y for a better over-
view of t h e fractu re a n d th e in tercon dyla r em in en ce is
perform ed.
1
c Th e lateral m en iscu s sh ow s a backed h an d le ru ptu re from
fron t to back w ith in ter position of th e ru ptu red m ed ial
part in to th e fractu re gap. It h as to be redu ced an d xed
w ith prepared th reads (1 ). Th rou gh th e an terolateral cap-
3
su lotom y, th e m ain fractu re gap is open ed w ith a bon e
spreader ( 2 ). Th e two im pacted osteoch on dral fragm en ts
are iden ti ed. Th e sm aller fragm en t is too sm all for re x-
ation an d th erefore rem oved. Th e large fragm en t is h eld
an d correctly position ed w ith th e aid of a K-w ire (u sed
as a joystick) an d tem porarily xed w ith an oth er 1.6 m m
K-w ire in serted from lateral th rou gh th e in tact con dyle
( 3 ). Th is secon d K-w ire sh ou ld n ot pen etrate th e fragm en t
en tirely, n or tou ch or in terfer w ith th e m ain m ed ial con -
dylar fragm en t, wh ich w ill be redu ced later.
2

6 52
 10 .1.5 Pa r t ia l a r t icu la r, d is lo ca t e d t ib ia l h e a d fra ct u re w it h s p lit-d e p re s s io n —41-B3
3 Re d u c t io n a n d fixa t io n (co n t )
a b
Fig 10 .1.5 -7a – d
a As a n ext step, th e large an terior em in en tial fragm en t, to
wh ich th e ACL ad h eres, is en circled by a th ick n on resorb-
able th read. With th e h elp of th e drill gu ide, two 2.0 m m
h oles are drilled parallel from th e an terior aspect in to th e
fractu re zon e. Th e th reads can n ow be pu lled th rou gh th e
h oles in an an terior direction allow in g th e redu ction of
th e tu bercle. Th e th read is n ot yet k n otted.
b Th e team of su rgeon s ch an ges sides. Now th e postero-
m ed ial approach is m ade 10 cm d istal to th e join t wh ile
con ser vin g th e great saph en ou s vein an d th e saph en ou s
n er ve. Th e fractu re zon e is en tered from beh in d th e pes
an serin u s an d th e MCL towards th e posterom ed ial tibial
border. On ly a sm all am ou n t of periosteu m is detach ed to
sh ow th e referen ce lin es for visu al con trol. Th e redu ction
is m an aged w ith th e pelvic redu ction forceps placed on th e
posterom edial an d an terolateral aspects n ear th e join t (1 ).
1
Fin e redu ction can be ach ieved eith er u sin g large K-w ires
as joysticks or w ith th e LCP T-plate 4.5/5.0. Th e plate is
sligh tly tw isted an d adapted to th e poster ior edge. Th e rst
screw is a 4.5 m m cortex screw in serted im m ed iately dis-
tal to th e fractu re lin e ( 2 ). A persistin g d isplacem en t can
be redu ced d irectly over th e plate. After exam in in g th e
redu ction u n der im age in ten si cation , th e th reads from
th e em in en ce can be k n otted tigh tly pu llin g th e em in en ce
in to th e fractu re gap. An add ition al K-w ire can su pport
th e redu ction ( 3 ). De n itive com pression is obtain ed w ith
a lag screw from posterom ed ial to an terolateral. Th is screw
h as to be placed close to th e articu lar su rface, preven tin g
a m alrotation of th e m ain m ed ial con dylar fragm en t. De-
pen din g on th e position of th e plate, th is lag screw can be
placed th rou gh a plate h ole or in depen den tly (as in th is
case) (4 ).
6 53
 10 .1 Tib ia a n d fib u la , p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .1.5 -7a – d (co n t)

c– d After rem oval of th e pelvic redu ction forceps an oth er
lag screw can be in serted su bch on drally. Th e n al xa-
tion is ach ieved by in sertin g an an gu lar stable 5.0 m m
self-tappin g lock in g h ead screw in to th e join t block
an d two cortex screw s (on ly in good bon e qu ality) or
lock in g h ead screw s (osteo porotic bon e) in to th e sh aft.
At th e en d of th e operation , x-ray assessm en t sh ow s cor-
rect redu ction of th e tibial h ead w ith ideal position in g
of th e posterom ed ial plate an d th e 4.5 m m lag screw ju st
u n der th e fractu re lin e. Th e em in en ce is sligh tly raised
(2–3 m m ) on th e lateral view.

c d

4 Re h a b ilit a t io n

Mobilization began on th e th ird postoperative day w ith a re-

m ovable k n ee brace to protect th e dam aged ligam en ts of th e
k n ee. In itially 10 –15 kg weigh t bearin g an d after 6 weeks h alf
body weigh t.

Th e fractu re was n early com pletely con soli-

Fig 10 .1.5 -8 a – b
dated after 3 m on th s. At th at tim e fu ll weigh t bearin g was
started an d tolerated w ith ou t com plain ts.

a b

6 54
 10 .1.5 Pa r t ia l a r t icu la r, d is lo ca t e d t ib ia l h e a d fra ct u re w it h s p lit-d e p re s s io n —41-B3

4 Re h a b ilit a t io n (co n t )

a b d

Fig 10 .1.5 -9 a – d
a – b After 9 m on th s th e fractu re is n o lon ger visible, even
th e in itially sligh tly elevated tibial spin e sh ow s a sm ooth
in grow th w ith good rem odelin g.
c– d At th is tim e, th ere was good k n ee fu n ction w ith a sligh t
active exten sion de cit of 10° bu t passive fu ll exten -
sion .

After 16 m on th s th e rem odelin g process was

Fig 10 .1.5 -10 a – b
com pleted leavin g a sm all defect in th e m etaph yseal part. Th e
join t space was n orm al an d iden tical in both k n ees w ith ou t
an y sign of secon dary arth rosis. Th e patien t h ad n o com -
plain ts an d sh owed good activity. Th e k n ee was stable in all
a b direction s.

655
 10 .1 Tib ia a n d fib u la , p ro xim a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Th e dou ble approach , ie, an terolateral an d posterom ed ial,
can en dan ger th e soft tissu e. A broad an terior soft-tissu e
bridge is n ecessary.
Ap p ro a ch
Th e an terolateral an d posterom ed ial dou ble approach is
ideal to treat th is com plex fractu re. Th e soft-tissu e bridge
is n ot en dan gered if it is broad en ou gh . Th is approach
provides a good over view over th e fractu re an d offers
ideal position in g of th e posterom ed ial plate.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
A posterom ed ial approach wou ld be in su f cien t for
adequ ate treatm en t of th is in ju r y, wh ich is ver y d if cu lt
to h an d le. Th e im pacted lateral fragm en ts, wh ich wou ld
jeopard ize correct redu ction , cou ld n ot be redu ced an d
xed w ith th is approach on ly. Also th e in ju red m en iscu s
cou ld n ot be treated. An an terolateral approach for redu c-
tion of th e articu lar an d m en iscal fragm en ts is absolu tely
m an dator y before th e m edial con dyle can be redu ced.

Re h a b ilit a t io n Re h a b ilit a t io n
Early fu ll weigh t bearin g cou ld lead to secon dar y A stable osteosyn th esis an d stable xation of th e an terior
d isplacem en t an d ch ron ic in stability of th e join t em in en ce allow s early fu n ction al treatm en t.
(th e em in en ce cou ld pu ll ou t).

6 56
 Au t h o rs An d re a s Gru n e r, Th o m a s J Ho cke r t z, Ga b rie le St re ich e r, He in rich Re ilm a n n

10.1.6 Com ple te articular proxim al tibial fracture —41-C1

with long spiral fracture of the shaft—42-A1
1 Ca s e d e s crip t io n

60-year-old wom an w ith in ju r y to th e r igh t tibia.

Type of in ju r y: m on otrau m a, closed fractu re.

Fig 10 .1.6 -1a – b

a AP view.
b Lateral view.

In d ica t io n

a b
Mu ltifo ca l fra ctu re o f th e righ t tib ia; n o im p o rta n t a xia l m a la lign m e n t d u e to th e a ccid e n t, th e
fra ctu re in clu d e d fra ctu re o f th e tib ia l h e a d p lu s to rsio n fra ctu re o f th e tib ia l sh a ft e xte n d in g
to th e tra n sitio n a re a fro m th e m id to th e d ista l th ird . Th e p a tie n t wa s 6 0 ye a rs o ld a t th e
tim e o f th e a ccid e n t a n d a d ip o se . Op e ra tive tre a tm e n t wa s re q u ire d to re co n stru ct th e jo in t
su rfa ce s a n d to p re se rve kn e e jo in t fu n ctio n a n d a xis o f th e tib ia .

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
Pa t ie n t p reFig 10t io
p a ra .1.6
n -2
a n d Su
p opsinit eio pn oinsitio
g n
• LISS-PLT, 13 h o le s
• An tib io tics:
w ith
sinegle
le vad tio
o sen 2onfd th
geenine ra jutio
re dn lim
ce pbh a lo -
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g
sp o rin . a n d e xio n o f th e kn e e jo in t to
lo ckin g h e a d scre w s (LHS)
• Th ro m b o sis
a p pproxim
ro p h yla
a texis:
ly 3Lo0 °,wlomwoelerin cuglaorf h e p a rin .
• 2 .0 m m K-w ire s
th e co n tra la te ra l le g fo r b e t te r
• 6 .5 m m ca n ce llo u s b o n e scre w s
in tra o p e ra tive x-ra y a sse ssm e n t,
(Size o f s yste m , in stru m e n ts, a n d im p la n ts cu sh io n in g o f th e d is ta l fe m u r o f
ca n va ry a cco rd in g to a n a to m y.)
th e in ju re d lim b , e g, w ith a to w e l
ro ll.
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

657
 10 .1 Tib ia a n d fib u la , p ro xim a l

2 Su rgica l a p p ro a ch 3 Re d u c t io n a n d fixa t io n

Fig 10 .1.6 -4
Approx im ate redu ction of th e join t su rfaces by ten sion ad
ax im an d tap ou t th e collapsed join t su rface com pon en ts from
th e d istal side to restore join t con gru en cy, tem porary xation
by su bch on dral in sertion of K-w ires.
Secu re redu ction by in sertin g can cellou s bon e screw s from
th e m ed ial side an d parallel to th e join t su rface th rou gh a stab
in cision after pred rillin g.
Prepare th e plate bed from prox im al to d istal epiperiosteally
in th e com partm en t of th e an terior tibialis m u scle w ith a lon g
bon e rasp, takin g special care w h en crossin g th e d istal frac-
tu re zon e.
Determ in e correct plate len gth u n der im age in ten si cation
an d slide th e im plan t in to th e plate bed.
Fig 10 .1.6 -3Hockey-stick in cision ap-
proxim ately 5 cm lon g from Gerdy’s
tu bercle exten din g in a d istal d irection ,
an d dissection to th e periosteu m .

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .1.6 -5 a – c
St abilize t h e im pla n t tem pora r ily w ith
K-w ires an d ch eck plate position in two
plan es.
Precise redu ction of t h e fragm en ts w ith
th e pu llin g device.
In ser t th e screw s a lter n ately in th e d is-
tal an d prox im al h oles startin g prox i-
m ally, determ in e screw len gth accord-
in g to Tab 3 -2 ; ch apter 3).

a b c

6 58
 10 .1.6 Co m p le t e a rt icu la r p ro xim a l t ib ia l fra ct u re —41-C1 w it h lo n g s p ira l fra ct u re o f t h e s h a ft—42-A1

4 Re h a b ilit a t io n

a b c d e f

Weigh t bearin g: h alf body weigh t u n til

6 weeks, fu ll weight bearing after 6 weeks.
Ph ysiot h erapy: from t h e secon d post-
operative day an d con tin u ou s passive
m otion .
Ph arm aceu tical treatm en t: pain th erapy
and non steroid antiin am m atory drugs.

Fig 10 .1.6 -6 a – j Postoperative x-rays.

a – b After 1 week.
c– d After 2 weeks.
e – f After 1 m on th .
g– h After 3 m on th s.
i– j After 1 year.

g h i j

659
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
After 16 m on th s. Reason for im plan t rem oval: m ech an ical
irritation of th e im plan t bed proxim ally. Tech n iqu e for im -
plan t rem oval: rem oval of screw s th rou gh stab in cision an d
b rem oval of th e LISS via th e origin al prox im al approach .

Fig 10 .1.6 -7a – f

a After im plan t rem oval.
c b – d Fu n ction al pictu res after im plan t rem oval.
e – f X-rays 6 m on th s after im plan t rem oval.

a d e f

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Len gth of plate too sh ort an d, con sequ en tly, too few Facility to bridge a m u ltifocal fractu re w ith on e im plan t
screw s in th e d istal fragm en t. an d good position in g du e to th e in sertion gu ide.

Ap p ro a ch Ap p ro a ch
In adequ ate preparation of th e tibial h ead leads to in cor-
rect plate position in g (too far poster ior or too far an ter ior).

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Pu ll-ou t of th e pu llin g device du e to osteoporosis or a Prim ary restoration of th e join t block an d recon stru ction
redu ction d istan ce th at was too lon g, in correct len gth of of th e join t su rface, su bsequ en t con n ection to th e sh aft
th e can cellou s bon e screw s for th e tibial h ead—irritation fragm en t
of th e LISS bed/or in adequ ate an ch orage.

Re h a b ilit a t io n Re h a b ilit a t io n
Prem atu re fu ll weigh t bearin g w ith join t in volvem en t. Early m obilization w ith partial/ fu ll weigh t bearin g.

660
 Au t h o rs Mich a e l Sch ü t z, No rb e r t P Ha a s

10.1.7 Sim ple articular proxim al tibial fracture with m e taphyse al

com m inu tion —41-C2
1 Ca s e d e s crip t io n

56-year-old m an su ffered m u ltiple in ju ries as th e resu lt of a road traf c acciden t,

in clu d in g a type 41-C2 fractu re of th e prox im al tibia rad iatin g in to th e d iaph ysis.
Th e fractu re was in itially stabilized w ith an extern al xator becau se th e patien t’s
gen eral con d ition was critical an d relievin g in cision was perform ed to avert im m i-
n en t com partm en t syn drom e.

Fig 10 .1.7-1a – b
a AP view.
b Lateral view.

In d ica t io n

No n d islo ca te d , sim p le a rticu la r fra ctu re w ith a co m p le x m e ta p h yse a l m u ltifra gm e n ta ry fra c-

tu re . It is e sse n tia l to a ch ie ve sta b le xa tio n o f th e a rticu la r fra ctu re w ith b rid gin g o f th e m e ta -
a b d ia p h yse a l zo n e a n d e a rly fu n ctio n a l re h a b ilita tio n b e in g ca re fu l to a vo id jo in t co n tra ctu re s.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LISS-PLT, 13 h o le s
• 5 .0 0 m m se lf-d rillin g, se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 7.0 m m ca n n u la te d ca n ce llo u s b o n e scre w s
• 2 .0 m m K-w ire s
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 10 .1.7-2 Su p in e p o sitio n .

6 61
 10 .1 Tib ia a n d fib u la , p ro xim a l

2 Su rgica l a p p ro a ch

Th e prox im al part of th e su rgical approach is u sed in th is operation to

access th e com partm en ts.

Fig 10 .1.7-3 Th e proxim al in sertion of th e an terior tibial m u scle is de-

tach ed sparin gly. It is recom m en ded th at part of th e m u scle fasciae be
left on th e bon e to facilitate rein sertion later. Th e mu scle is carefu lly
retracted w ith th e bon e rasp.

3 Re d u ct io n a n d fixa t io n

Fig 10 .1.7-4 a – d
a Screw xation of th e tibial h ead in closed tech n iqu e w ith two 7.0 m m
can nu lated can cellou s bon e screw s w ith a 32 m m th read is perform ed
rst. Wash ers are u sed to preven t th e screw h eads from sin k in g in to
th e bon e. Ax ial, rotation al, an d len gth align m en t is ch ecked w ith th e
aid of th e extern al xator th at was applied in th is rst operation .
b Su bmu scu lar in sertion of th e 13-h ole LISS-PLT alon g th e lateral tibia
w ith th e h elp of th e in sertion gu ide. Align m en t w ith th e tibial h ead.
a Stab in cision over th e m ost distal plate h ole, in sertion of th e con n ectin g
trocar between th e in sertion gu ide an d th e im plan t.
Palpation of correct im plan t position on th e sh aft. Th is is possible on
th e tibial ridge w ith ou t exten d in g th e in cision becau se of th e m in im al
soft-tissu e coverage. Tem porar y xation of th e prox im al an d d istal
con n ectin g bolts w ith partially th readed 2.0 m m K-w ires.

6 62
 10 .1.7 Sim p le a r t icu la r p ro xim a l t ib ia l fra ct u re w it h m e t a p h ys e a l co m m in u t io n —41- C2

3 Re d u c t io n a n d fixa t io n (co n t )

In sertion of th e rst LHS close to th e join t so th at it is situ ated ben eath th e can cellou s
bon e screw s an d parallel to th e join t su rface.
Th e align m en t of th e d iaph ysis is n ely adju sted in th e an teroposterior plan e w ith
th e aid of th e extern al xator an d stabilized. Ax ial, rotation al, an d len gth align -
m en ts are reassessed clin ically an d radiologically.
Th e rem ain in g lock in g h ead screw s are th en in serted.
Th e m eth od of locked splin tin g xation over a lon ger diaph yseal d istan ce is recom -
m en ded in order to ben e t from th e advan tages of a biom ech an ically elastic fractu re
xation .
Th e in sertion gu ide is d ism an tled an d th e extern al xator is rem oved. Rein sertion of
th e fasciae ju st beyon d th e proxim al en d of th e im plan t. Wou n d closu re by layers.

Fig 10 .1.7-4 a – d (co n t)

c Postoperative x-ray, AP view.
d Postoperative x-ray, lateral view.

c d

4 Re h a b ilit a t io n

Apply sterile d ressin gs.

Ph ysioth erapy: gen tle active an d passive ran ge of m otion im m ed iately on day on e
postoperatively.
Th e u se of th e con tin u ou s passive m otion m ach in e is h igh ly recom m en ded.
Mobilization w ith partial weigh t bearin g as soon as th e gen eral an d local con dition
of th e patien t allow s it.

Fig 10 .1.7-5 a – d
Postoperative x-rays after
12 m on th s.
a AP view.
b Lateral view.
c AP detail view.
d Lateral detail view.

a b c d

6 63
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
It m ay be n ecessar y to rem ove th e im plan t if th e proxim al
part of th e plate is cau sin g irritation .

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Too exten sive ex posu re of th e m etaph yseal fractu re zon e Open , d irect redu ction of th e articu lar fractu re com po-
m ay dam age th e vascu larity of th e bon e fragm en ts. n en t, bu t in d irect redu ction tech n iqu es for a com plex
m etaph yseal com pon en t.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In correct position in g of th e im plan t on th e sh aft m ay lead Precise, an atom ical redu ction an d in terfragm en tary
to early im plan t loosen in g. In correct position in g com pression , of th e articu lar fractu re w ith lag screw s.
of th e im plan t on th e lateral tibial h ead m ay lead to
soft-tissu e irritation s. Align m en t an d splin tin g of th e m u ltifragm en tary
m etaphyseal fractu re.
A too sh ort im plan t in creases th e risk of im plan t
loosen in g. Carefu l con trol of im plan t position u sin g direct an d
in d irect con trol m ech an ism s (palpation , an d im age
A too rigid im plan t xation in creases th e risk of im plan t in ten si er).
failu re.
Use of lon ger im plan ts for th e locked splin tin g m eth od.
Som e plate h oles in th e region of th e d iaph ysis sh ou ld
be left u n occu pied so th at th e xation h as a better stress
d istr ibu tion .

Re h a b ilit a t io n Re h a b ilit a t io n
Prolon gin g ph ysioth erapy m ay lead to in traarticu lar ad h e- Carefu l early active an d passive ph ysioth erapy.
sion s an d join t stiffn ess.

664
 Au t h o r Ch ris t o p h e r W Ge e l

10.1.8 Articular m ultifragm e ntary proxim al tibial fracture —41-C3

1 Ca s e d e s crip t io n

59-year-old wom an fell an d broke h er

righ t proxim al tibia.

Fig 10 .1.8 -1a – d

a AP view.
b Lateral view.
c– d 3D CT scan .

c d

In d ica t io n

Tw o -sta ge d tra u m a ca re : In itia l tre a tm e n t w ith sp a n n in g e xte rn a l fixa to r u n til so ft-tissu e

re co ve ry. Th e n o p e n re d u ctio n a n d in te rn a l fixa tio n (ORIF) o f m u ltifra gm e n ta ry, a rticu la r
a b tib ia l p la te a u a n d sh a ft fra ctu re s .

Pre o p e ra t ive p la n n in g
Eq u ip m e n t
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP p ro xim a l tib ia l p la te 4 .5/ 5 .0 , 12 h o le s
• An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo -
• Lo ckin g h e a d scre w s (LHS)
sp o rin .
• 6 .5 m m ca n ce llo u s b o n e scre w s
• Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• K-w ire s
• Po in te d re d u ctio n fo rce p s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Fig 10 .1.8 -2 Pa tie n t su p in e w ith b u m p
An tib io tics: ce p h a lo sp o rin
u n d e r h ip a n d u n d e r kn e e o n ra d io lu ce n t
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
ta b le .

6 65
 10 .1 Tib ia a n d fib u la , p ro xim a l

2 Su rgica l a p p ro a ch

Cu rvylin ear an terior parapateller

Fig 10 .1.8 -3 a – b
lateral in cision . Parapatellar lateral arth rotom y.
Elevation of lateral m en iscu s. In cision of peron eal
mu scle com partm en t in an L-sh ape fash ion .

a b

3 Re d u ct io n a n d fixa t io n

Fig 10 .1.8 -4 a – d
a – b Prelim in ar y xation of th e re-
du ced join t su rface w ith K-w ires
an d two poin ted redu ction forceps
u sin g th e extern al xator as an in -
direct redu ction tool.
Ver ify redu ction w ith im age in -
ten si er.
c 12-h ole LCP prox im a l t ibia plate
4 .5/ 5.0 is ad ju st e d t o t h e lat e r a l
a b plateau an d is u sed as a redu ction
tool for th e m etaphyseal-diaph y-
seal ju n ction : pu sh -pu ll prin ciple.
d Fixation prox im ally rst to restore
t h e jo in t su r face a n d t h e t ibia l
con dyles.

c d

666
 10 .1.8 Ar t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-C3

3 Re d u c t io n a n d fixa t io n (co n t )

Fixation of th e diaph ysis to th e plate after

Fig 10 .1.8 -5 a – b
verifyin g th e correct position of th e plate in AP an d lateral
im age in ten si er view s.

a b

4 Re h a b ilit a t io n

Weigh t bea r in g: 15 kg for 4 w eek s; h a lf bo dy w eigh t a fter

9 weeks; fu ll weigh t bearin g after 14 weeks.
Ph ysioth erapy: Ra n ge of m ot ion exercise of t h e a n k le a n d
k n ee join ts to be started on day on e postoperatively.

Fig 10 .1.8 -6 a – b Postoperative x-rays after 6 weeks.

a AP view.
b Lateral view.

a b

6 67
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n (co n t )

Fig 10 .1.8 -7a – b Postoperative x-rays after 12 m on th s.

a AP view.
b Lateral view.

Bon e h ealin g after 12 weeks.

a b

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Fig 10 .1.8 -8 a – b Im age in ten si er as preoperative plan -
n in g is h elpfu l w ith so-called traction view s becau se it
allow s assessm en t an d ef cacy of in direct redu ction u sin g
an extern al xator or a large distractor.

a b

Re h a b ilit a t io n Re h a b ilit a t io n
Cartilage is cru m bled an d cru sh ed bu t m ore th an 50% of
th is in ju red su rface is covered by m en iscu s.

668
 Au t h o rs Ga b rie le St re ich e r, Th o m a s J Ho cke rt z, An d re a s Gru n e r, He in rich Re ilm a n n

10.1.9 Articular m ultifragm e ntary proxim al tibial fracture —41-C3

1 Ca s e d e s crip t io n

52-year-old m an w ith in ju r y to th e tibial h ead. Type of in ju -

r y: h igh -en ergy trau m a, m on otrau m a, open fractu re Gu stilo
type II.

Fig 10 .1.9 -1a – b

a AP view.
b Lateral view.

In d ica t io n

Pro xim a l a rticu la r m u ltifra gm e n ta ry fra ctu re o f th e tib ia l h e a d w ith

o b vio u s d islo ca tio n (41-C3), u n sta b le jo in t fra ctu re w ith in vo lve m e n t
o f th e p ro xim a l th ird o f th e tib ia . Op e ra tive tre a tm e n t is in d ica te d to
a b re co n stru ct th e jo in t su rfa ce s a n d p re se rve kn e e jo in t fu n ctio n .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LISS-PLT, 9 h o le s
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g
• 2 .0 m m K-w ire s
• 6 .5 m m ca n ce llo u s b o n e scre w s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo -
lo ckin
sp ogrin
h e. a d scre w s (LHS)
• Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .1.9 -2 Su p in e p o sitio n w ith e le va tio n o f th e in ju re d

le g a n d e xio n o f th e kn e e jo in t a t a p p roxim a te ly 3 0 °,
lo w e rin g o f th e co n tra la te ra l le g fo r b e t te r in tra o p e ra tive x-ra y
a sse ssm e n t, cu sh io n in g o f th e d is ta l fe m u r o f th e le g to b e
o p e ra te d o n , e g, w ith a to w e l ro ll.

6 69
 10 .1 Tib ia a n d fib u la , p ro xim a l

2 Su rgica l a p p ro a ch 3 Re d u ct io n a n d fixa t io n

Fig 10 .1.9 -3 Hockey-stick Fig 10 .1.9 -4 Approxim ate

incision approxim ately 5 cm redu ction of th e join t su rfac-
lon g from Gerdy’s tu bercle es by ax ial ten sion an d tap
exten d in g in a d istal d i- ou t th e collapsed join t su r-
rection , an d d issection to face com pon en ts from th e
th e periosteu m . d istal side w ith th e h elp of
pelvic redu ction forceps.

3 Re d u c t io n a n d fixa t io n (co n t )

b c d e

Fig 10 .1.9 -5 a – e Secu re redu ction by in sertin g can cellou s bon e screw s from th e m ed ial side an d parallel
to th e join t su rface th rou gh a stab in cision .
Prepare th e plate bed from prox im al to d istal epiperiosteally in th e com partm en t of th e an terior tibialis
mu scle w ith a lon g bon e rasp.
Determ in e correct plate len gth u n der im age in ten si cation an d slide th e im plan t in to th e plate bed.
Stabilize th e im plan t tem porar ily w ith K-w ires an d ch eck plate position in two plan es.
Precise redu ction of th e fragm en ts w ith th e pu llin g device.
In sert th e screw s altern ately in to th e d istal an d prox im al h oles startin g prox im ally, determ in e screw
len gth accord in g to Ta b 3 -2 .

670
 10 .1.9 Ar t icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-C3

4 Re h a b ilit a t io n

Weigh t bearin g: h alf body weigh t after 2 weeks, fu ll weigh t bearin g after
10 weeks.
Ph ysioth erapy: from th e secon d postoperative day.
Ph arm aceu tical treatm en t: pain treatm en t an d n on steroid an tiin am m atory
dru gs.

Fig 10 .1.9 -6 a – b Bon e h ealin g after 12 weeks.

a AP view.
b Lateral view.

a b
Im p la n t re m o va l
After approxim ately 12–18 m on th s.
Reason for im plan t rem oval: m ech an ical irritation at th e lateral tibial h ead
cau sed by th e im plan t.
Tech n iqu e for im plan t rem oval: rem oval of screw s th rou gh stab in cision an d
rem oval of th e LISS via th e origin al prox im al approach .

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Len gth of plate too sh ort.

Ap p ro a ch Ap p ro a ch
In adequ ate preparation of th e tibial h ead leads to in cor- Preservation of blood vessels du e to a m in im ally in vasive
rect plate position in g (too far poster ior or too far an ter ior). approach .
Be aware of th e peron eal n er ve.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Pu ll-ou t of th e pu llin g device du e to osteoporosis or too In traoperative x-ray con trols to en su re th at th e plate is
lon g a redu ction d istan ce. correctly position ed in th e lateral plan e.

Re h a b ilit a t io n Re h a b ilit a t io n
Prem atu re fu ll weigh t bearin g w ith join t in volvem en t. Early m obilization w ith partial/ fu ll weigh t bearin g.

671
 10 .1 Tib ia a n d fib u la , p ro xim a l

672
 Au t h o r Mich a e l Wa gn e r
10.1.10 Com ple te articular m ultifragm e ntary proxim al tibial
fracture —41-C3 and avulsion fracture of the bular he ad
1 Ca s e d e s crip t io n
a b
In d ica t io n
Disp la ce d a rticu la r fra ctu re w ith
liga m e n ta ry in sta b ilit y is a cle a r
in d ica tio n fo r a n a to m ica l re d u c-
tio n a n d sta b le xa tio n in o rd e r
to re sto re go o d fu n ctio n . Th e
o p e ra tio n wa s p e rfo rm e d o n th e
th ird d a y a fte r th e a ccid e n t a fte r
CT e xa m in a tio n h a d b e e n co m -
p le te d .
19-year-old wom an fell from a h orse.
Mu ltifragm en tar y ar ticu lar fractu re of
th e left tibial h ead w ith bon e avu lsion of
th e lateral ligam en t of th e bu lar h ead
an d con tu sion of th e soft tissu es.
Fig 10 .1.10 -1a – d
c a AP view.
b Lateral view.
c CT scan in th e fron tal plan e sh ow s
th e m u ltifragm en tar y articu lar frac-
tu re w ith sm all fragm en ts.
d CT scan in th e sagittal plan e.
d
Pre o p e ra t ive p la n n in g
Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP T-p la te 4 .5/ 5 .0 , 5 h o le s • An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h alo -
• 4 .5 m m a n d 5 .0 m m lo ckin g h e a d scre spwosrin .
(LHS)
• 4 .0 m m ca n n u la te d ca n ce llo u s b o n e• scre
Th row ms,b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
p a rtia lly th re a d e d
• 2 .0 m m K-w ire s
(Size o f s yste m , in s tru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
h e p a rin
Fig 10 .1.10 -2 Su p in e p o sitio n o n ra d io lu ce n t o p e ra tin g ta b le w ith th e le g fre e ly m o ve a b le .
673
 10 .1 Tib ia a n d fib u la , p ro xim a l
2 Su rgica l a p p ro a ch
3 Re d u ct io n a n d fixa t io n
a b
Fig 10 .1.10 -4 a – h
a Redu ction of th e join t fragm en ts an d
tem porar y xation w ith pelvic re-
du ction forceps an d a ball spike.
674
Fig 10 .1.10 -3 Medial approach for su bm en iscal
m ed ial arth rotom y, an addition al m edial distal ap-
proach for plate xation in M IPO tech n iqu e, an d
a th ird sm all lateral approach for redu ction an d
xation of th e avu lsion fractu re of th e bu lar
h ead.
c
b Sh ow s th e screw h ead of th e 4.0 m m c Th e partial ru ptu re of th e m edial
lag screw situ ated as far proxim ally as collateral ligam en t an d th e pes an se-
possible u n der th e articu lar su rface r inu s ten don can be seen .
an d th e su bm en iscal arth rotom y
th rou gh wh ich th e redu ction was
assessed.
d Th e join t block th at h as been stabilized w ith two lag screw s in serted
from m edial to lateral is th en redu ced in relation to th e d iaph yseal
fragm en t by m anu al ten sion an d ball spike. Th e redu ction is stabi-
lized by in sertion of a gu ide w ire in an an teroposterior orien tation .
Th e th ird lag screw is th en in serted.
 10 .1.10 Co m p le t e a rt icu la r m u lt ifra gm e n t a r y p ro xim a l t ib ia l fra ct u re —41-C3
a n d a vu ls io n fra ct u re o f t h e fib u la r h e a d

3 Re d u c t io n a n d fixa t io n (co n t )

e f g h

Fig 10 .1.10 -4 a – h (co n t)

e – f After secu rin g th e drill gu ides, in sertion of th e plate g– h Addition al in cision s are m ade at th e d istal plate en d.
from proxim al to distal. Th e plate com es to rest above Tem porar y xation w ith K-w ires an d assessm en t of im -
th e pes an serin u s ligam en t an d th e in sertion of th e d istal plan t position by im age in ten si cation ; xation w ith
ligam en t. lock in g h ead screw s.

Th e last step is th e xation of th e bu lar h ead fractu re w ith a

can nu lated 4.0 m m can cellou s bon e screw th rou gh an add i-
tion al sm all lateral in cision . Th e screw th read is an ch ored in
th e n arrow in tram edu llary cavity of th e bu lar sh aft.

Fig 10 .1.10 -5 a – b Postoperative x-rays.

a AP view.
b Lateral view.

a b

4 Re h a b ilit a t io n

Mobilization began after rem oval of th e drain s in a rem ov-

able k n ee brace to relieve th e dam aged ligam en ts of th e k n ee.
In itially 10 –15 kg weigh t bearin g an d after 6 weeks h alf body
weigh t.

Postoperative x-rays after 2 m on th s sh ow

Fig 10 .1.10 -6 a – b
bon e con solidation of all fractu res an d all im plan ts in situ .
a AP view.
b Lateral view.

a b

675
 10 .1 Tib ia a n d fib u la , p ro xim a l

4 Re h a b ilit a t io n (co n t )

Fig 10 .1.10 -7a – b Postoperative x-rays after 1 year. All fractu res h ave h ealed,
fu n ction is u n restricted an d th e k n ee is stable an d pain free.
a AP view sh ow s th e gap between th e an gu lar stable n on con tact plate an d
th e bon e. Th e ten don s of th e pes an serin u s an d th e d istal in sertion of th e
m ed ial collateral ligam en t are placed in th is space.
b Lateral view.

a c

a b

Im p la n t re m o va l
Fig 10 .1.10 -8 a – d
a – b Fu n ction al resu lt, fu ll ran ge of
m otion before im plan t rem oval.
c– d Th e im plan t was rem oved becau se
a b it cou ld be felt u n der th e sk in at
th e m ed ial aspect.

c d

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Eq u ip m e n t
Th e peron eal n er ve m ay be dam aged in a m ed ial ap- Th e su bm u scu lar arth rotom y perm itted d irect visu aliza-
proach . tion of th e redu ced articu lar su rface.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Dif cu lt to redu ce an articu lar fractu re in a less in vasive Pelvic redu ction forceps an d th e large poin ted redu ction
tech n iqu e. forceps perm it d irect, percu tan eou s redu ction of articu -
lar fragm en ts. Th e xation of can nu lated screw s in serted
over a gu ide w ire perm its th e optim al placem en t of th e lag
screw s.

Th e LCP T-plate w ith LHS allow s th e stable xation of

very sm all join t blocks to th e sh aft an d does n ot exert
pressu re on th e ten don s an d ligam en ts ben eath it. Th is
stable xation perm its early fu n ction al reh abilitation .

676
 Au t h o r Ch ris t o p h So m m e r

10.1.11 Inve rse d Y-fracture of the tibial he ad with im pre ssion of

the ante rolate ral joint surface —41-C3
1 Ca s e d e s crip t io n

c d e

Fig 10 .1.11-1a – e
a AP view.
b Lateral view.
c– e A preoperative CT scan was perform ed for m ore speci c
d iagn osis. An a n terolatera l im pression of 5 –10 m m of
a b th e join t cou ld be iden ti ed w ith on ly a sligh t d isplace-
m en t of th e m ed ial con dyle.
30-year-old m an su stain ed a valgization trau m a w h ile sk iin g.
No soft-tissu e dam age. Statu s after operation of osteoch on d ro-
sis d issecan s of th e lateral fem oral con dyle. An in versed Y-frac-
tu re of th e tibial h ead can be seen on th e x-ray w ith im pression
of th e an terolateral join t su rface (41-C3.1, com plete articu lar
fractu re, lateral articu lar mu ltifragm en tar y fractu re). Th e m e-
d ial tibial con dyle is on ly m in im ally d isplaced.

In d ica t io n Pre o p e ra t ive p la n n in g

Th is fra ctu re is a cle a r in d ica tio n fo r re d u ctio n a n d sta b iliza tio n . Sin ce Eq u ip m e n t
th e in ju ry to th e la te ra l tib ia l p la te a u is a m u ltifra gm e n ta ry fra ctu re , • LCP L-p la te 4 .5/ 5 .0 , 6 h o le s
th e re is th e in d ica tio n fo r a su b m e n isca l a rth ro to m y a n d re d u ctio n • 5 .0 m m lo ckin g h e a d scre w s (LHS)
u n d e r visio n . Th e m e d ia l p la te a u is n o t d isp la ce d so a sin gle a n te ro - • 4 .5 m m co rte x scre w s
la te ra l a p p ro a ch w ith a n a n gu la r sta b le T-p la te sh o u ld b e su f cie n t. • K-w ire s
Alte rn a tive ly, a LISS-PLT co u ld b e u se d . If th e m e d ia l p la te a u wa s d is- • Pe lvic re d u ctio n fo rce p s
p la ce d , a se co n d p o ste ro m e d ia l a p p ro a ch a n d a sm a ll p o ste ro m e d ia l (Size o f s ys te m , in stru m e n ts, a n d im p la n ts ca n
p la te wo u ld b e a p p lie d in a rst ste p. va ry a cco rd in g to a n a to m y.)

677
 10 .1 Tib ia a n d fib u la , p ro xim a l

Pre o p e ra t ive p la n n in g (co n t )

Pa t ie n t p re p a ra t io n a n d p o s it io n in g 1 Su rge o n
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin 2 ORP
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin 3 1st a ssistan t
4 2n d a ssistan t

Ste rile are a

4
1

Fig 10 .1.11-2 Th e e n tire le g is p re p p e d a n d d ra p e d

u n d e r s te rile co n d itio n s, in clu d in g th e ilia c cre s t so
th a t ca n ce llo u s b o n e ca n b e h a rve ste d . Th e in ju re d le g 3
is e xte n d e d b u t is su p p o rte d b e lo w th e kn e e w ith a
m e ta l tria n gu la r b lo ck o r la rge to w e l ro ll, w h ich ca n b e
re m o ve d a s th e situ a tio n re q u ire s . 2

2 Su rgica l a p p ro a ch

Fig 10 .1.11-3 a – bAn terolateral stan dard approach

w ith two add ition al in cision s for th e percu tan eou s
in sertion of th e pelvic redu ction forceps.

a b

678
 10 .1.11 In ve rs e d Y-fra ct u re o f t h e t ib ia l h e a d w it h im p re s s io n o f t h e a n t e ro la t e ra l jo in t s u r fa ce —41-C3
3 Re d u ct io n a n d fixa t io n
4
3
1 1
3
5
4
2
2 2
a b
Fig 10 .1.11-4 a – c
a With th e h elp of an an terolateral stan dard approach an d
release of th e iliotibial tract from th e lateral tibial h ead,
a h orizon tal arth rotom y is perform ed an d th e fractu re
is stabilized in open redu ction tech n iqu e. Th e sagit-
tal fractu re lin e is presen ted an d th e lateral fragm en t
is folded ou twards w ith th e h elp of a bon e spreader (1 ).
After rem ovin g th e h em atom a, th e two join t fragm en ts
can be lifted in to th e correct position u n der vision ( 2 ). Th e
redu ced join t fragm en t can be h eld in place w ith a tem po-
rary K-w ire in serted in an an teroposterior d irection ( 3 ). If
th e bon e fragm en t were n arrow or th e defect very large,
th e defect cou ld be lled w ith can cellou s bon e an d bicorti-
cal iliac bon e graft (4 ).
b Replace th e m an u ally extracted join t fragm en t an d apply
th e presh aped LCP 4.5 to th e an terolateral aspect of th e
tibia (1, 2 ). With th e h elp of th e pelvic redu ction forceps,
(in serted m ed ially an d laterally via sm all in cision s) an d
w ith th e lateral fragm en t correctly position ed, th e fractu re
1
3
4
c
can n ow be com pressed. Th e forceps can be applied cran i-
ally or ideally th rou gh th e poster ior plate h ole ( 3 ). Th e
rst screw to be u sed is a 4.5 m m cortex screw in serted
in to th e m etaph yseal com bin ation h ole (4 ). After verifyin g
th e redu ction an d th e correct placem en t of th e plate u n der
im age in ten si cation , th e fractu re zon e can be com pressed
w ith a 6.5 m m can cellou s bon e screw th rou gh th e u pper
an terior h ole ( 5 ).
c After rem oval of th e pelvic redu ction forceps an d th e
K-w ire, th e oth er screw s can be in serted (1 ). 5.0 m m LHS
in th e tibial h ead are ideal. Pay atten tion to th e correct
an gle of th e screw s in relation to th e plate. In th e case
described h ere, an LHS was in serted in to th e m etaph yseal
aspect of th e plate to h old th e m ed ial con dyle ( 3 ). Th e xa-
tion of th e plate on to th e sh aft can be accom plish ed w ith
bicortical 4.5 m m cortex screw s or in poor bon e qu ality
w ith bicortical LHS ( 2 ). In th is case, th e rst 4.5 m m cor-
tex screw was replaced w ith a LHS for a better h old ( 4 ).
679
 10 .1 Tib ia a n d fib u la , p ro xim a l

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .1.11-5 a – b Th e x-rays at th e en d of th e operation sh owed

an an atom ical recon stru ction of all fractu re com pon en ts. Th e
sligh t varu s position on th e AP projection (a) is sym m etr ical
to th e u n in ju red leg (b).

a b

4 Re h a b ilit a t io n

Given good stability of th e k n ee join t (tested at th e en d

of th e operation), th e join t cou ld be treated fu n ction -
ally w ith a ran ge of m otion u p to th e rst in d ication
of pain . Mobilization started on th e th ird day w ith
10 –15 kg weigh t bearin g for 6 weeks.

Fig 10 .1.11-6 a – h
a – b Th e rst x-ray ch eck-u p after 7 weeks sh owed a good
an atom ical ax is an d a level join t su rface w ith a stable t
for th e plate.

a b
a b

680
 10 .1.11 In ve rs e d Y-fra ct u re o f t h e t ib ia l h e a d w it h im p re s s io n o f t h e a n t e ro la t e ra l jo in t s u r fa ce —41-C3

4 Re h a b ilit a t io n (co n t )

Fig 10 .1.11-6 a – h (co n t)

c– d Wh en th e fractu re lin e h ad n early d isappeared, weigh t
bearin g was in creased to fu ll weigh t after 3 m on th s. Th e
fractu re was con solidated after th is tim e.
e–f Th e ran ge of m otion was practically iden tical for both
k n ees an d th e patien t was able to go on a 7 h ou r cyclin g
tou r w ith 2700 m ascen t.
g– h After 8 m on th s th e patien t w ish ed to h ave th e plate re-
m oved becau se of a sligh t irritation of th e iliotibial tract
cau sed by th e proxim al plate en d. At th is tim e, th ere
was com plete radiological con solidation an d rem odelin g
of th e fractu re.

c d

e f

g h

6 81
 10 .1 Tib ia a n d fib u la , p ro xim a l
5 Pit fa lls –
Eq u ip m e n t
Du rin g presh apin g of th e LCP 4.5/5.0 th e h oles m ay
becom e ben t an d th e lock in g h ead screw s w ill n ot h old
properly. Th erefore, th e plate sh ou ld always be ben t
an d tw isted between th e h oles.
Ap p ro a ch
Th e stan dard approach h as few risks. Bu t th e saph en ou s
n er ve an d vein an d th e in fragen icu lar n erve m ay be
en dan gered by a m ed ial approach (n ot perform ed in th is
case).
Re d u ct io n a n d xa t io n
Un der early fu ll weigh t bearin g, th e LCP 4.5/5.0 m ay
tw ist, resu ltin g in a varu s m alalign m en t.
Re h a b ilit a t io n
Good com plian ce is requ ired. Early fu ll weigh t bearin g
can cau se d islocation w ith ch an ge of join t su rface level
an d/or varu s m alalign m en t.
6 82
6 Pe a rls +
Eq u ip m e n t
Ideal im plan t for treatm en t of a fractu re in com bin ation
tech n iqu e (com pression of th e join t su rface w ith cortex
screw s an d can cellou s bon e screw s an d bu ttressin g of th e
m etaphyseal zon e w ith lock in g h ead screw s).
Ap p ro a ch
An an terolateral approach allow s th e stabilization of a
C-type fractu re (in con trast to th e dou ble plate tech n iqu e
w ith m ed ial an d lateral approach ).
Re d u ct io n a n d xa t io n
LCP 4.5 plates are ideal for m ed ial an d lateral partial join t
fractu res (41-B-type fractu res). With a sim ple m ed ial
fragm en t an d good bon e qu ality, th e LCP 4.5/5.0 w ith
LHS can also be u sed for 41-C-type fractu res (in con trast
to th e dou ble plate tech n iqu e). Th e less exible LISS-PLT
sh ou ld be preferred in m ore com plex fractu res.
Re h a b ilit a t io n
6 83
 10 Tib ia a n d fib u la

10.2 Tibia and bula, shaft

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

10 .2 .1 Sim ple sp ira l tib ial sha ft fractu re 42-A1 lo cke d splin ting LCP 4 .5/ 5.0 , lo cke d in te rnal fixa tor 6 91
n a rro w

10 .2 .2 Sim ple o b liq u e tib ia l a nd fibu lar sha ft fractu re 42-A2 lo cke d splin ting LCP m e tap h yse al lo cke d in te rnal fixa tor 6 97
p la te 3 .5/ 4 .5/ 5 .0 ,
for d istal tibia

10 .2 .3 Spira l we d ge tib ial sha ft fractu re 42-B1 lo cke d splin ting LCP 4 .5/ 5.0 , lo cke d in te rnal fixa tor 701
n a rro w

10 .2 .4 Spira l we d ge tib ial sha ft fractu re 42-B1 lo cke d splin ting LCP m e tap h yse a l lo cke d in te rnal fixa tor 70 5
p la te 3 .5/ 4 .5/ 5 .0

10 .2 .5 Spira l we d ge tib ial sha ft fractu re w ith e xte n sio n 42-B1 lo cke d sp lin tin g LCP 4 .5/ 5 .0 , lo cke d in te rnal fixa tor 711
in to the jo in t n a rro w

10 .2 .6 Spiral we d ge tib ial an d fibular sh a ft fractu re 42-B1 lo cke d sp lin tin g LCP m e tap h yse al lo cke d in te rnal fixa tor 717
p la te 3 .5/ 4 .5/ 5 .0

10 .2 .7 Fragm e n te d we d ge tibia l a n d fibu la r sha ft 42-B3 lo cke d sp lin tin g LCP 3 .5 lo cke d in te rna l fixa to r 72 3
fractu re

10 .2 .8 Fragm e n te d we d ge tibia l sh a ft a nd 42-B3 co m p re ssio n LCP 4 .5/ 5 .0; lag scre w an d 7 29

m u ltifragm e n tary su p ra synd e sm o tic fibu lar 4 4 -C2 an d lo cke d LCP 3 .5 p ro te ctio n pla te;
sh aft fractu re sp lin tin g lo cke d in te rnal fixa to r

10 .2 .9 Com p le x sp iral tib ia l sh a ft fractu re 42-C1 lo cke d sp lin tin g LCP m e tap h yse a l lo cke d in te rnal fixa to r 737
p la te 3 .5/ 4 .5/ 5 .0 ,
for d istal tibia

10 .2 .10 Op e n co m p le x se gm e n tal tib ia l sh a ft fractu re 42-C1 lo cke d sp lin tin g LCP m e tap h yse al lo cke d in te rnal fixa to r 745
p la te 3 .5/ 4 .5/ 5 .0 ,
for d istal tibia

10 .2 .11 Com p le x se gm e n ta l tib ia l sh a ft fra cture w ith 42-C2 lo cke d sp lin tin g LCP m e taph yse al lo cke d in te rnal fixa to r 749
o n e in te rm e d ia te se gm e n t an d ad d itio n al p la te 3 .5/ 4 .5/ 5 .0
we d ge fragm e n t

684
 10 .2 Tib ia a n d fib u la , s h a ft

Ca s e s (co n t)

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

10 .2 .12 Op e n co m ple x se gm e n tal tib ia l sha ft fractu re 42-C2 co m p re ssio n LCP 4 .5/ 5 .0 lag scre w s an d 755
an d lo cke d p ro te ctio n plate and
sp lin tin g lo cke d in te rnal fixa tor

10 .2 .13 Op e n co m ple x irre gu lar tib ial a n d fibu lar sh a ft 42-C3 lo cke d sp lin tin g LISS-PLT la g scre w s an d lo cke d 759
fractu re in te rnal fixato r

10 .2 .14 Op e n co m p le x irre gu lar tib ia l sh a ft fractu re 42-C3 com pre ssio n LCP 4 .5/ 5 .0 lag scre w s an d lo cke d 76 3
an d lo cke d in te rnal fixato r
sp lin tin g

10 .2 .15 Spira l tibial sha ft fractu re in a ch ild 42-A1 lo cke d sp lin tin g LCP m e tap h yse al lo cke d in te rnal fixa to r 767
p la te 3 .5/ 4 .5/ 5 .0

10 .2 .16 Pe ripro sth e tic fractu re o f th e tib ia l sha ft 42-B1 co m p re ssio n LCP m e tap h yse al lo cke d in te rnal fixa to r 7 71
an d lo cke d p la te 3 .5/ 4 .5/ 5 .0; an d co m p re ssio n
sp lin tin g LCP 3 .5 p la te

10 .2 .17 Pse uda rthro sis o f th e tib ia 42-B1 lo cke d splin ting LCP 4 .5/ 5 .0 , lo cke d in te rnal fixa to r 7 75
n a rro w

6 85
 10 Tib ia a n d fib u la

10 Tibia and bula

10 .2 Tib ia a n d fib u la , s h a ft 687

10 .2 .1 Sim p le s p ira l t ib ia l s h a ft fra ct u re —42 -A1 6 91
10 .2 .2 Sim p le o b liq u e t ib ia l a n d fib u la r s h a ft
fra ct u re —4 2 -A2 697
10 .2 .3 Sp ira l w e d ge t ib ia l s h a ft fra ct u re —4 2 -B1 701
10 .2 .4 Sp ira l w e d ge t ib ia l s h a ft fra ct u re —4 2 -B1 70 5
10 .2 .5 Sp ira l w e d ge t ib ia l s h a ft fra ct u re w it h
e xt e n s io n in t o t h e jo in t—4 2 -B1 711
10 .2 .6 Sp ira l w e d ge t ib ia l a n d fib u la r
s h a ft fra ct u re —4 2 -B1 717
10 .2 .7 Fra gm e n t e d w e d ge t ib ia l a n d fib u la r s h a ft
fra ct u re —4 2 -B3 723
10 .2 .8 Fra gm e n t e d w e d ge t ib ia l s h a ft—4 2 -B3 a n d
m u lt ifra gm e n t a r y s u p ra s yn d e s m o t ic fib u la r
s h a ft fra ct u re —4 4 - C2 729
10 .2 .9 Co m p le x s p ira l t ib ia l s h a ft fra ct u re —4 2 - C1 7 37
10 .2 .10 Op e n co m p le x s e gm e n t a l t ib ia l s h a ft
fra ct u re —4 2 - C1 74 5
10 .2 .11 Co m p le x s e gm e n t a l t ib ia l s h a ft fra ct u re w it h
o n e in t e rm e d ia t e s e gm e n t a n d a d d it io n a l w e d ge
fra gm e n t —42 - C2 74 9
10 .2 .12 Op e n co m p le x s e gm e n t a l t ib ia l s h a ft
fra ct u re —4 2 - C2 75 5
10 .2 .13 Op e n co m p le x irre gu la r t ib ia l a n d fib u la r s h a ft
fra ct u re —4 2 - C3 75 9
10 .2 .14 Op e n co m p le x irre gu la r t ib ia l s h a ft
fra ct u re —4 2 - C3 76 3
10 .2 .15 Sp ira l t ib ia l s h a ft fra ct u re in a ch ild —4 2 -A1 767
10 .2 .16 Pe rip ro s t h e t ic fra ct u re o f t h e t ib ia l s h a ft—4 2 -B1 7 71
10 .2 .17 P s e u d a r t h ro s is o f t h e t ib ia —4 2 -B1 775

686
 Au t h o r Mich a e l Wa gn e r

10.2 Tibia and bula, shaft

1 In cid e n ce

Tibial sh aft fractu res are frequ en t in sports in ju ries an d in

road traf c acciden ts. Pedestrian s are en dan gered wh en h it
or jam m ed by bu m per bars. For speci c an atom ical reason s
th e soft-tissu e in volvem en t is of path -break in g im portan ce re-
a b c
gard in g fractu re evalu ation an d treatm en t plan n in g.
Fig 42-A sim ple fractu re.
10 .2 -1a – c
An y h in t or eviden t sign of decreased local vascu larization a 42-A1 spiral
h as to be taken in to con sideration as well as exten sive soft- b 42-A2 obliqu e (>
_ 30°)
tissu e de cien cy an d h as to rem ain a warn in g com pon en t for c 42-A3 tran sverse (> 30°)
a safe su rgical sch edu le. In som e cases, it m ay be advisable to
await decreased soft tissu e swellin g before carryin g ou t tem -
porary bridgin g extern al xation .

In tibial fractu res, arterial in ju ries are m ore com m on th an

n erve in volvem en ts. Later on , th e dan ger of a com partm en t
syn d rom e is obviou s, favorin g th e an terior com partm en t.
a b c

Fig 42-B wedge fractu re.

10 .2 -2 a – c
2 Cla s s ifica t io n
a 42-B1 spiral wedge
b 42-B2 ben d in g wedge
In th e d iaph ysis, th e Mü ller AO Classi cation d istin gu ish es c 42-B3 fragm en ted wedge
between sim ple (A), wedge (B), an d com plex (C) fractu res.

3 Tre a t m e n t m e t h o d s

Non operative treatm en t m ay be plan n ed in exception al cases if

th ere are stable an d m in im ally d isplaced fractu re con d ition s.
a b c
Good fu n ction al resu lts are to be expected by in itial im m obili-
zation in an appropriate cast followed by early weigh t bearin g. Fig 42-C com plete articu lar fractu res.
10 .2 -3 a – c
In m ost cases, h owever, fractu res of th e tibial sh aft reveal in - a 43-C1 spiral
stability an d d isplacem en t an d n eed operative xation . b 43-C2 segm en tal
c 43-C3 irregu lar

6 87
 10 Tib ia a n d fib u la
For th e m ajority of closed m idsh aft fractu res as well as for
open fractu res w ith a su f cien t soft-tissu e cover in tram ed-
u IIary n ailin g is th e key to su ccess. In m etaph yseal fractu res
th e sh ort fragm en t m ay be d if cu lt to h an dle so th at platin g
possibly seem s m ore appropriate. In closed fractu res ream ed
in tram edu llar y n ails are advan tageou s allow in g th e u se of
stron ger im plan ts an d th u s en h an cin g h ealin g con dition s. In
m ost open tibial fractu res, th e solid “u n ream ed” n ail is th e
im plan t of ch oice.
As a ru le an d to en su re in d ispen sable stability, lock in g is
recom m en ded in all situ ation s u n less th e n ail h as ach ieved
excellen t en dosteal con tact above an d below a stable m id-d i-
aph yseal fractu re.
Lock in g resu lts in a static bon e –im plan t u n it th at im pedes
ben e cial fractu re loadin g. Con sequ en tly, an d depen din g on
th e fractu re type, on ly dyn am ic lock in g is recom m en ded. Dy-
n am ization is requ ired in delayed u n ion s of th e h ypertroph ic
type at 4 –6 m on th s. In com bin ed distal fractu res it is advisable
to x th e bu lar com pon en t w ith a on e-th ird tu bu lar plate,
th u s assu rin g redu ction an d en h an cin g stability.
In appropriate in cision , n ail en try poin t an d n ail position in g
m ay cau se con siderable irritation of th e patellar ligam en t.
Th erefore, an y in cision abou t th e an terior aspect of th e k n ee
is to be avoided.
A fu rth er com plication m ay be th e breakage of lock in g screw s
du e to th e u se of sm aller n ails or to prolon ged bon e h ealin g
tim e. On th e oth er h an d, a h igh rate of u n ion an d a low in ci-
den ce of in fection are to be stressed.
Displaced, u n stable fractu res of th e proxim al an d distal th irds
of th e tibia sh aft—w ith or w ith ou t articu lar involvem en t—are
best xed w ith plates (becau se it is dif cu lt to obtain an an a-
tom ical redu ction an d m ain tain it w ith an IM n ail). In th ese
areas th e n ail does n ot redu ce th e fractu re n or does it m ain -
tain th e redu ction adequ ately. Plate xation is also in d icated
in cases th at requ ire an atom ically accu rate redu ction (m ore
688
accu rate th an n ailin g w ill n orm ally allow), for exam ple, in
h igh perform an ce ath letes.
Platin g is con train d icated in u n reliable patien ts or wh en th e
soft tissu es are dam aged or de cien t. If th e possibility of early
weigh t bearin g is m ore im portan t th an perfect align m en t, in -
tram edu llary n ailin g is preferred.
Th e lock in g plates, ie, th e LCP 4.5 an d th e Tibia LISS len d
th em selves to m in im ally in vasive in sertion an d extraperios-
teal position in g, especially in com plex type C fractu res.
Selection of th e correct redu ction tech n iqu e is probably th e
m ost im portan t part of in tern al xation . Wh en u sin g d irect
or in direct m eth ods, th e goal is to restore th e correct len gth ,
ax ial align m en t, an d rotation . Len gth is th e key to th e cor-
rect redu ction an d sh ou ld be restored as th e rst step in m ost
redu ction s. Man ipu lation s to obtain redu ction m u st be gen tle
an d atrau m atic in order n ot to com prom ise th e essen tial blood
su pply to th e fractu re fragm en ts.
With a sim ple type A or type B fractu re patter n or ben d in g
an d spiral wedges w ith a sin gle fragm en t, d irect a n atom i-
cal redu ction sh ou ld be m ain ta in ed by in ter fragm en tar y
lag screw xation an d a protection or com pression plate to
provide absolu te stability. Br idge platin g, even w ith lock in g
plates, sh ou ld n ot be u sed for th ese fractu re patter n s. In com -
plex type C fractu res, exact redu ction is n ot requ ired a n d th e
plate sh ou ld on ly h ave br idgin g fu n ction . M in im a lly in vasive
tech n iqu es w ith in d irect redu ction an d extra lon g im pla n ts,
preferably w ith lock in g h ead screw s, provide relative stability
w ith a low strain en viron m en t a n d allow h ea lin g by callu s
form ation .
Th e LCP 4.5 can be u sed for d iaph yseal fractu res of th e tibia.
Con ven tion al platin g requ ires screw xation in at least six
cortices on eith er side of th e fractu re. Broad plates sh ou ld n ot
be u sed in th e tibia; th ey are too stiff an d too bu lky. Sm aller
plates (eg, LCP 3.5) are occasion ally in d icated in th e d istal
tibia in ver y sm all patien ts. In th e LCP fam ily th ere are m e-
 10 .2 Tib ia a n d fib u la , s h a ft
taph yseal plates w ith on e en d sligh tly precon tou red an d ta-
pered as well as special form plates for both th e proxim al an d
th e d istal en d of th e tibia. For th e prox im al lateral tibia, a
low pro le L-sh aped plate as well as th e som ewh at h eavier
LISS-PLT w ith com bin ation h oles are available an d su itable
for com plex plateau fractu res exten d in g in to th e d iaph ysis.
For th e d istal en d of th e bon e th ere is th e d istal tibia LCP.
Th e cu rren t tren d for both bridge platin g an d th e con ven tion al
tech n iqu es is to u se lon ger plates (8-h ole to 10-h ole) an d n ot
to ll ever y h ole. Two or th ree bicortical screw s above an d two
or th ree below th e fractu re focu s are con sidered su f cien t,
provided th ey are spaced apart an d an ch ored in good qu ality
bon e. More screw s are probably u n n ecessar y. In com plex type
C fractu res a bridgin g plate sh ou ld be abou t 3 tim es th e len gth
of th e fractu re zon e.
M in im ally in vasive percu tan eou s plate application is a tech -
n iqu e w h ich can be u sed as an altern ative to classical ORIF.
It requ ires ex perien ce in in d irect redu ction tech n iqu es (w ith
eith er a large distractor or extern al xator), as correct len gth
an d axial align m en t are m an datory before th e plate is ap-
plied. In distal tibial fractu res, in direct partial redu ction an d
fu rth er stability m ay be ach ieved by platin g th e bu la. Th e
len gth an d rotation of th e bu la m u st be exact or th e tibia
w ill be m alalign ed. On ce th e fractu re is redu ced an d th e plate
con tou red, th e sk in in cision to in trodu ce th e plate is placed
eith er prox im ally or d istally to th e fractu re. With an eleva-
tor, an extraperiosteal tu n n el is prepared to in sert th e plate.
Th e LCP h as a tapered en d to facilitate th e su bcu tan eou s pas-
sage. Th e correct position is ch ecked u n der u oroscopy an d
su bsequ en tly th e screw s are in serted th rou gh stab in cision s.
As percu tan eou s plate application does n ot allow precise con -
tou rin g of th e im plan t, th e LCP—u sed as an in tern al xator—
is th e ideal im plan t for th is tech n iqu e. Th an ks to th e lock in g
h ead screw s th e plate is n ot pressed again st th e bon e, th ereby
preven tin g secon dary m alalign m en t.
In d ication s for extern al xation m ay be in a way far-reach in g.
With rare exception s h owever, extern al xation w ill be in -
ten ded to provide tem porary xation an d to be su pplem en ted
by secon dar y in tern al xation .
Th erefore, its relevan ce is to be carefu lly con sidered in com -
prom ised soft tissu e vascu larization , in severe open fractu res,
in open fractu res in volvin g bon e loss an d/or soft tissu e de -
cien cy, in life-th reaten in g polytrau m a a n d in prim ar y com bi-
n ation w ith an in tern al xation .
Th e fram e design sh ou ld be as sim ple as possible, easy to h an -
d le an d sh ou ld allow access to th e wou n d for secon dar y soft-
tissu e procedu res an d de n itive in tern al xation . In d iaph y-
seal fractu res th e u n ilateral h alf pin fram e m igh t be favored
in m ost situ ation s wh ereas in prox im al an d d istal fractu res
th e u se of a circu lar fram e h elps to avoid join t im pairm en t.
Fin ally, th e u se of a pin less xator is advisable in view of sec-
on dary in tram edu llary n ailin g. To preven t pla n tar ex ion
con tractu re it m ay be h elpfu l to add a pin in th e rst m etatar-
sal to h old th e foot in a n eu tral 90 º position .
Su m m arizin g, d ifferen t an d well-establish ed treatm en t m o-
dalities are option al in th e treatm en t of d iaph yseal fractu res
of th e tibia. Th e n ew an gu lar stable plate w ith m ore “biologi-
cal” approach es, especially in th e proxim al an d d istal th ird of
th e tibia, is open in g u p n ew d im en sion s in savin g su f cien t
vascu larization . However, th e state of th e soft-tissu e cover is
decisive for th e ch oice of xation device.
6 89
 10 Tib ia a n d fib u la

4 Im p la n t o ve r vie w 5 Su gge s t io n s fo r fu r t h e r re a d in g

a Be h re n s F, Se arls K (1986) Extern al xation of th e tibia. Basic

con cepts an d prospective evalu ation . J Bone Joint Surg [Br];
68 (2):246 –254.
b
Bh an d ari M , A u d ige L, Ellis T, e t al (2003) Operative Treatm en t
of Extra-articu lar Proxim al Tibial Fractu res. J. Orthop Trauma;
17:591–595.
c
Bo n e LB, Su cat o D , St e ge m an n PM , e t al (1997) Displaced isolated
fractu res of th e tibial sh aft treated w ith eith er a cast or in tram edu llary
n ailin g. An ou tcom e an alysis of m atch ed pairs of patien ts. J Bone Joint
d Surg [Am]; 79 (9):1336 –1341.
Gau t ie r E, So m m e r C (2003) Gu idelin es for th e clin ical application
of th e LCP. Injury; 34 (5-B63 – 5-B76).
e Karlad o n i A , Gran h ad H , Ed sh age B, e t al (2000) Displaced tibial
sh aft fractu res. Acta Orthop Scand; 71:160 –167.
Lan g GJ, Co h e n BE, Bo sse M J, e t al (1995) Proxim al th ird tibial
sh aft fractu res. Sh ou ld th ey be n ailed? Clin Orthop; (315):64 –74.
f Wh it e R R , Babik ian GM (2001) Tibia: sh aft. In : Rü edi TP, Mu rphy
WM, ed itors. AO Prin ciples of Fractu re Man agem en t. Stu ttgart,
New York: Th iem e.
g

Fig 10 .2 -4 a – g
a LCP 4.5/5.0, broad
b LCP m etaph yseal plate 3.5
c LCP m etaphyseal plate 3.5/4.5/5.0
d LISS-PLT 5.0 (left an d righ t version )
e LCP-PLT 4.5/5.0 (left an d righ t version)
f LCP prox im al tibia plate 4.5/5.0,
(lateral left an d lateral r igh t version)
g LCP d istal tibial plate 2.7/ 3.5, m ed ial
(left an d righ t version )

690
 Au t h o r Mich a e l Wa gn e r

10.2.1 Sim ple spiral tibial shaft fracture —42-A1

1 Ca s e d e s crip t io n

41-year-old patien t slipped on th e ice an d su stain ed a spi-

ral fractu re of th e righ t d istal tibia. Mon otrau m a, closed
fractu re.

Fig 10 .2 .1-1a – b
a AP view.
b Lateral view.

In d ica t io n

Fig 10 .2 .1-2 In tra m e d u lla ry na ilin g is im -

p o ssib le b e ca u se th e re is a n im p la n t in situ
a fte r a co rre ctio n o p e ra tio n in th e re gio n o f
th e la te ra l tib ia l h e a d a n d , in a d d itio n , th e re
is lim ite d ra n ge o f m o tio n a t th e kn e e jo in t;
e xio n is o n ly p o ssib le to 9 0 °.
a b

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
4 .5/
io tics:
5 .0 , sin
n a rro
glew,d o14
se h2on dlege
s n e ra tio n ce p h a -
• Selolf-ta
sp o prin
p in
. g lo ckin g h e a d scre w s (LHS)
• •2Th
.0 ro
mmm bK-wo sisire
p ro
s p h yla xis: Lo w m o le cu la r h e p a rin .
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e
Fig 10 .2 .1-3 Su p in e p o sitio n w ith
Th ro m b o sis p ro p h yla xis:
e le va tio n o f th e in ju re d le g a n d e xio n
lo w -m o le cu la r h e p a rin
o f th e kn e e jo in t a t a p p ro xim a te ly 3 0 °,
lo w e rin g o f th e co n tra la te ra l le g fo r
b e t te r in tra o p e ra tive x-ra y a sse ssm e n t.

6 91
 10 .2 Tib ia a n d fib u la , s h a ft
2 Su rgica l a p p ro a ch
a b
d e
g h
Fig 10 .2 .1-4 a – i
a Short incision over the medial m alleolu s takin g care not to
dam age the great saphenou s vein . Incision at the plan ned
site for the proxim al end of the plate and screw in sertion .
b Mark th e plan n ed in cision s arou n d th e fu ll exten t of th e
fractu re zon e.
c Measu re for plate len gth u sin g a tem plate.
Obtain th e approxim ate su rface con tou rs of th e distal
tibia by applyin g th e ben d in g tem plate.
d Ch eck th e ch osen plate len gth .
e–f Presh ape th e plate w ith th e ben d in g press an d ben d-
in g iron s. Preben d th e plate to m atch th e su rface of th e
d istal tibia.
6 92
c
f
i
g In cision of th e prox im al side of th e m ed ial m alleolu s an d
preparation of the epiperiosteal space w ith su rgical scissors.
h In cision at th e plan n ed site for th e prox im al en d of th e
plate. Preparation of th e epiperiosteal space w ith su rgical
scissors.
i After preparation of th e epiperiosteal space, slip in th e
plate. A drill sleeve rm ly an ch ored in th e d istal part of
th e plate acts as a h an d le. Slide-in sertion of th e plate from
d istal to proxim al.
 10 .2 .1 Sim p le s p ira l t ib ia l s h a ft fra ct u re —42-A1
3 Re d u ct io n a n d fixa t io n
ba b cb
e f
Fig 10 .2 .1-5 a – j
a – b Ch eck th e n ecessar y closed redu ction m an eu ver u n der
th e im age in ten si er. Ten sion is applied at th e h eel to
ach ieve closed redu ction of th e d istal fragm en t. Assess-
m en t of plate position an d fractu re redu ction by x-ray;
align th e plate on th e lon gitu d in al ax is of th e tibial
sh aft.
c On e d istal sk in in cision for plate in sertion an d two stab
in cision s for th e prox im al xation .
d
g
d–e In sert a cen terin g sleeve an d a 2.0 m m K-w ire in to th e
m ost distal plate h ole an d u se th e K-w ire to m easu re th e
requ ired len gth of distal screw (protect th e join t cavity!).
Th e d istal fragm en t is approx im ated to th e plate w ith
th e aid of a cortex screw (redu ction screw) an d th en
n ely adju sted.
f– g Prelim in ar y proxim al xation of th e plate w ith a drill
bit. Rad iological assessm en t of plate position .
693
 10 .2 Tib ia a n d fib u la , s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

h i j

Fig 10 .2 .1-5 a – j (co n t)

h In sertion of self-tappin g lock in g h ead screw s in to th e th ree j Proxim al plate xation w ith fou r m on ocortical LHS (good
m ost distal plate h oles (th e cortex screw th at was u sed for bon e qu ality). Atten tion is paid to leavin g th e lon gest distan ce
redu ction pu r poses is replaced by an LHS). possible between screw s on e an d fou r.
i In order to locate th e plate h oles correctly, ie, in m in im ally
in vasive tech n iqu e, a secon d plate w ith th e sam e pattern
of h oles is u sed as an aid.

a b

Fig 10 .2 .1-6 a – d
a Sk in in cision s before wou n d closu re.
b Sk in su tu re, closin g th e in cision s.
c– d Postoperative x-rays, AP an d lateral. Th e postoperative x-rays con rm correct
ax ial align m en t. It is deliberate th at n o attem pt was m ade to ach ieve an atom i-
cal redu ction of th is sim ple spiral fractu re. c d

6 94
 10 .2 .1 Sim p le s p ira l t ib ia l s h a ft fra ct u re —42-A1

4 Re h a b ilit a t io n

After 4 weeks, pain less fu ll weigh t bear in g.

Th e 12 m on th follow-u p con rm ed com plete rad io-
logical con solidation of th e fractu re w ith a ver y
good clin ical ou tcom e.

Fig 10 .2 .1-7a – c
a – b AP a n d latera l at t h e on e yea r follow-u p.
Bon e con solidation of th is h ealed fractu re.
c X-ray view of th e lon gitu din al leg axes.

a b c

695
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n
Varu s/ valgu s tiltin g of th e d istal fragm en t.
In correct align m en t of th e plate on th e lon gitu d in al ax is
of th e bon e m ay lead to in correct position in g of th e LHS,
a tan gen tial screw position an d, th erefore, redu ced
an ch orage in th e bon e. Th is w ill n ot be n oticed wh en
in sertin g an d lock in g th e screw becau se th e screw h ead
locks in th e plate in an y case.
Re d u ct io n a n d xa t io n
In traoperative correction is possible w ith th e aid of a
cortex screw (redu ction screw) th at pu lls th e fragm en t
towards th e plate.
Th e LCP m etaph yseal plates 3.5/4.5/5.0, for d istal tibia
an d th e LCP distal m edial tibial plate are an atom ically
presh aped an d t th e distal en d of th e tibia.

In traoperative evalu ation of plate orien tation in relation

to th e lon gitu din al axis.

Th e correct len gth of th e d istal LHS is im portan t to avoid

pen etration of th e articu lar su rface

Th e th ick n ess of th e n arrow LCP 4.5/5.0 m ay cau se

soft-tissu e problem s in th e m alleolar region . Altern atively
a th in n er m etaph yseal plate can be u sed.

696
 Au t h o r Mich a e l Wa gn e r

10.2.2 Sim ple oblique tibial and bular shaft fracture —42-A2

1 Ca s e d e s crip t io n

55-year-old m an slipped in a eld an d fell on h is left leg. Th ere were n o in ju ries

oth er th an th e sim ple obliqu e tibial fractu re.

Fig 10 .2 .2 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Th e d ia gn o sis o f a n u n sta b le fra ctu re o f th e tib ia a t th is a ge is a n in d ica tio n to o p e r-

a te . In se rtio n o f a n in tra m e d u lla ry n a il w o u ld b e p o ssib le . An a lte rn a tive w o u ld b e a
a b slid e -in se rtio n p la te in MIPO te ch n iq u e .

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
m eiotatics:
p h yse
sinagle
l p la
d otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio
fonr dceista
p h la lo
tib- ia ,
4sp+ o12
rinh. o le s
• •3Th
.5 ro
mm m bloo sis
ckinpgrohpehayla
d scre
xis: wLosw(LHS)m o le cu la r h e p a rin .
• 5 .0 m m LHS
• 2 .0 m m K-w ire s
• Sm a ll re d u ctio n ta b le
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin Fig 10 .2 .2 -2 Su p in e p o sitio n .

697
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .2 -3Medial in cision s for plate in sertion an d xation ,

an d add ition al stab in cision s are requ ired for in sertion of th e
Sch an z screw s.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .2 .2 -4 a – i
a In d irect closed redu ction by m ean s b Th e m ost appropriate plate len gth is c Preparation of th e epiper iosteal
of a sm all redu ction table. determ in ed. space from d istal to prox im al.

d e f g

d–e Ben d in g an d tw istin g of th e plate at th e f The drill sleeves are screwed g In sertion of th e plate from d istal to
ju n ction of th e d iaph ysis an d m etaph ysis. in to th e distal en d of th e proxim al.
plate w ith th e h elp of th e
gu iding block.

6 98
 10 .2 .2 Sim p le o b liq u e t ib ia l a n d fib u la r s h a ft fra ct u re —42 -A2

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .2 -5 a – b
Postoperative x-rays.
a AP view.
b Lateral view.

h i

Fig 10 .2 .2 -4 a – i (co n t)
h Temporary xation with K-w ires
after assessm en t of plate posi-
tion .
i Fixation of th e plate w ith
locking head screws th rough
a total of fou r sm all in ci-
sion s. Wou n d closu re.
a b

4 Re h a b ilit a t io n

Partial weigh t bearin g for 8 weeks.

Postoperative x-rays after 6 weeks. On ly

Fig 10 .2 .2 -6 a – b
m in im al callu s form ation was visible at th is tim e, bu t
weigh t bearin g was in creased becau se th e patien t did n ot
feel an y pain .
a AP view.
b Lateral view.

a b

699
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n (co n t )

a b c a b a b

Fig 10 .2 .2 -7a – cPostoperative x-rays after 3 Fig 10 .2 .2 -8 a – b Postoperat ive Im p la n t re m o va l

m on th s sh ow in g good callu s h ealin g. x-rays after 6 m on th s sh ow in g Th e im plan t was rem oved on
a AP view. en dosteal an d callu s h ealin g of th e requ est of th e patien t.
b Lateral view. th e fractu re. Dif cu lties relatin g to th e
c Lateral rotation . a AP view. im plan t d id n ot occu r.
b Lateral view.
Fig 10 .2 .2 -9 a – b
a AP view.
b Lateral view.

5 Pit fa lls – 6 Pe a rls +

Fixa t io n
Th e stan dard LCP m ay be too th ick. Th e preferred im plan t
is th e LCP m etaph yseal plate 3.5/4.5/5.0, for d istal tibia.
Fixa t io n
An gu lar stable screw-plate system s perm it both stable
xation an d a m in im ally in vasive su rgical tech n iqu e.
Th e operative tim e can be sh orten ed an d in sertion of th e
plate eased if th e fractu re is redu ced in advan ce. A large
d istractor, th e extern al xator, or a sm all redu ction table
can be u sed for th ese procedu res.

70 0
 Au t h o r Mich a e l Wa gn e r

10.2.3 Spiral we dge tibial shaft fracture —42-B1

1 Ca s e d e s crip t io n

58-year-old wom an fell on th e street cau sin g an isolated fractu re of th e tibial

sh aft of h er righ t leg.

Fig 10 .2 .3 -1a – b
a AP view.
b Lateral view.

In d ica t io n

An u n s ta b le fra ctu re o f th e tib ia is a go o d in d ica tio n fo r o p e ra tive s ta b iliza tio n .

Na ilin g o f th is t yp e o f fra ctu re is p o ssib le b u t w o u ld o n ly b e fe a sib le w ith n e w
ge n e ra tio n n a ils th a t h a ve a ve ry d ista l lo ckin g o p tio n . No n o p e ra tive tre a tm e n t
w ith e xte n sio n a n d p la ste r ca s t re q u ire s a lo n g h o sp ita l sta y a n d a lo n g p e rio d o f
a b im m o b ilit y. MIPO u sin g a n LCP a s a lo cke d in te rn a l fixa to r is a go o d o p tio n .

Pre o p e ra t ive p la n n in g

EqPautip
iemn te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
4 .5/
io tics:
5 .0 , sin
n a rro
glew,d o11
se h2on le
d
ge
s n e ra tio n ce p h a lo -
• 5sp.0 omrin
m. se lf-d rillin g, se lf-ta p p in g
•loTh
ckin
ro m g bhoe sis
a d pscre
ro pwh yla
s (LHS)
xis: Lo w m o le cu la r h e p a rin .
• 5 .0 m m se lf-ta p p in g LHS
• 3 .5 m m co rte x scre w
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e Fig 10 .2 .3 -2 Su p in e p o sitio n o n
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin ra d io lu ce n t o p e ra tin g ta b le .

701
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .3 -3 Preoperative m ark in g of lan d m arks for th e sh ort m ed ial

in cision s of th e M IPO tech n iqu e.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .2 .3 -4 a – i Closed in d irect redu ction w ith m an u al

traction .
a – b Th e n ext step is to select th e proper len gth of th e plate c Preparation of th e epiperiosteal space w ith th e
an d to ben d an d tw ist th e d istal part of th e plate so th at scissors from d istal to proxim al.
it approx im ates to th e an atom ical sh ape of th e tibia.

d A cortex screw is in serted in th e th ird h ole from th e d istal

en d as part of th e de n itive redu ction . It fu n ction s as a
redu ction screw an d pu lls th e fragm en t towards th e plate.
Th e d istal fragm en t is th en stabilized by in sertion of two
lock in g h ead screw s in th e d istal fragm en t.

70 2
 10 .2 .3 Sp ira l w e d ge t ib ia l s h a ft fra ct u re —42-B1

3 Re d u c t io n a n d fixa t io n (co n t )

e f g

Fig 10 .2 .3 -4 a – i (co n t)
e – g De n itive xation of th e prox im al fragm en t by in sertion
of a total of fou r m on ocortical lockin g h ead screw s, on e
of wh ich is a self-drillin g, self-tappin g screw. It w ill be
n ecessar y to predrill w ith th e h elp of th e u n iversal drill
sleeve before in sertin g th e self-drillin g LHS if th e diaphyseal
cortex is th ick an d h ard. Th is en su res optim al cen ter in g of
th e screw in th e th readed part of th e com bin ation h ole.

h All fou r in cision s at com pletion of th e osteosyn -

th esis.
i In traoperative x-ray evalu ation .

703
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

a b c d e f

Mobilization w ith partial weigh t bearin g an d u n derarm cru tch es; in -

creased weigh t bearin g from th e 4th week; fu ll weigh t bearin g after
8 weeks.
Fig 10 .2 .3 -5 a – f
a – b Postoperative x-rays after 1 week.
c– d Th e postoperative x-rays after 5 m on th s sh ow th at en dosteal
an d periosteal h ealin g is n ot yet com pleted.
e–f Th e postoperative x-rays after 10 m on th s sh ow com plete bon e
con solidation .

a b c
Im p la n t re m o va l
Fig 10 .2 .3 -6 a – c
Th e stan dard n arrow LCP 4.5/5.0 was palpable an d cau sed visible
a AP view.
th icken in g at th e m ed ial m alleolu s. Th is was u n com fortable for th e
b Lateral view.
patien t an d th e im plan t was th erefore rem oved.
c Im plan t after im plan t rem oval.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e saph en ou s vein an d n er ve m ay be in ju red du rin g th e
cou rse of d istal m ed ial in cision . Th e su per cial peron eal
n er ve is en dan gered by lateral in cision .

Fixa t io n Fixa t io n
Th e stan dard plate m ay be too th ick. Th e preferred im - Th e LCP m etaph yseal plate 3.5/4.5/5.0, for d istal tibia is
plan t is th e LCP m etaph yseal plate 3.5/4.0/5.0, for d istal an atom ically presh aped an d ts th e distal en d of th e tibia.
tibia.

70 4
 Au t h o r Fra n k ie Le u n g

10.2.4 Spiral we dge tibial shaft fracture —42-B1

1 Ca s e d e s crip t io n

39-year-old m an fell dow n th e stairs. Low-en ergy, m on otrau m a, closed fractu re.

Fig 10 .2 .4 -1a – b Preoperative x-rays.

a AP view.
b Lateral view.

a b

In d ica t io n

Th is is a d ista l d ia p h yse a l e xtra a rticu la r fra ctu re o f th e tib ia w ith
d isp la ce m e n t (42-B1.2). Th e re is a lso a fra ctu re o f th e fib u la ju s t b e -
lo w th e fib u la r n e ck. No n o p e ra tive tre a tm e n t, ie , clo se d re d u ctio n
a n d ca s tin g, is n o t re co m m e n d e d a s th e fra ctu re is ve ry u n sta b le
a n d w ill te n d to h e a l w ith sh o rte n in g a n d va ru s m a la lign m e n t.
Mo re o ve r, a lo n g le g ca st is n e e d e d fo r 6 – 8 w e e ks, w h ich m a y
ca u se jo in t stiffn e ss a n d d e la y w e igh t b e a rin g.
Op e ra tive fixa tio n o f th e tib ia re d u ce s th e a cu te p a in , a ch ie ve s a
b e t te r re d u ctio n o f th e fra ctu re , a n d a llo w s e a rly m o b iliza tio n o f
th e a d ja ce n t jo in ts .
Th e tib ia l fra ctu re ca n b e fixe d w ith a b rid gin g LCP in se rte d in
m in im a lly in va sive te ch n iq u e . Th e re is lit tle d is tu rb a n ce o f th e
va scu la rit y o f th e fra ctu re fra gm e n ts a n d b o n e h e a lin g w ill b e in d i-
re ct w ith ca llu s fo rm a tio n . Th e le n gth a n d a xis o f th e le g ca n a lso
b e m a in ta in e d . An a lte rn a tive fixa tio n m e th o d is in tra m e d u lla ry
n a ilin g. Ho w e ve r, it is d ifficu lt to o b ta in a d e q u a te s ta b iliza tio n o f
th e sh o rt d ista l tib ia l fra gm e n t a n d th e risk o f m a lu n io n is h igh e r.
An o th e r a lte rn a tive fixa tio n m e th o d is a h yb rid e xte rn a l fixa to r.
An kle jo in t m o tio n ca n b e p re se rve d a s co m p a re d w ith b rid gin g
e xte rn a l fixa tio n a cro ss th e a n kle jo in t. Th e re is a ce rta in risk o f
p in tra ck in fe ctio n a n d th e d u ra tio n o f e xte rn a l fixa tio n is u su a lly
u p to 10 –12 w e e ks.

70 5
 10 .2 Tib ia a n d fib u la , s h a ft

Pre o p e ra t ive p la n n in g

EqPautip
iemn te pn re
t p a ra t io n a n d p o s it io n in g Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• •LCP
An tibm eiotatics:
p h yse
sinagle
l p lad otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio
5 n+ ce
11p h aolo
le -s An tib io tics: ce p h a lo sp o rin
• 3sp.5 omrin
m. se lf-ta p p in g lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis: n o n e
• •3Th
.5 ro
mm m bca o sis
n cepllo
ro pu hs yla
b oxis:
n e scre
Lo wwm s o le cu la r h e p a rin .
• 2 .0 m m K-w ire s
• 3 .0 m m Ste in m a n p in fo r d istra ctio n a t th e h e e l
Fig 10 .2 .4 -2 Su p in e p o sitio n o n ra d io -
• (Op tio n a l) la rge d istra cto r
lu ce n t o p e ra tin g ta b le .
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

2 Su rgica l a p p ro a ch

a b c

d e

Fig 10 .2 .4 -3 a – e
a Iden tify th e fractu re site an d m ark th e an k le join t an d th e
m ed ial m alleolu s. A m in im ally in vasive approach w ith
th ree sm all in cision s is su f cien t. Th ere is n o n eed to ex-
pose th e fractu re site. Restore th e len gth an d axial align -
m en t. Rem em ber th at rotation is im portan t bu t th ere is n o
n eed for an atom ical redu ction of th e fractu re itself.
b–c A straigh t 5 + 11 h ole LCP m etaph yseal plate 3.5/4.5/5.0
is con tou red approx im ately to t th e m ed ial aspect of
th e d istal tibia.
d In sertion of a Stein m an pin th rou gh th e calcan eu s for
distraction , an d redu ction of th e fractu re by th e su rgical
assistan t. Altern atively, in sert a large d istractor for th e
sam e pu r pose.
e Make a sm all in cision (3 –4 cm lon g) ju st proxim al to
th e m ed ial m alleolu s for th e in sertion of th e LCP.

70 6
 10 .2 .4 Sp ira l w e d ge t ib ia l s h a ft fra ct u re —42-B1

3 Re d u ct io n

a b c d

Fig 10 .2 .4 -4 a – d
a In sert th e plate gen tly alon g th e m ed ial aspect of th e c– d Fix th e plate on to th e tibia w ith K-w ires after redu ction
tibia. Attach a lock in g d rill sleeve to th e plate an d u se it of th e fractu re. Perform an d ch eck th e redu ction on th e
as a h an d le. im age in ten si er.
b Palpate th e plate alon g th e m ed ial su bcu tan eou s plan e
of th e calf. Make sm all stab in cision s (2–3 cm lon g) an d
ex pose th e prox im al en d of th e plate. Attach an oth er
lock in g dr ill sleeve to th e prox im al en d of th e plate.

4 Fixa t io n

Fig 10 .2 .4 -5 a – c
a – b In sert a fu lly th readed 3.5 m m can cellou s bon e screw
in to th e d istal tibial fragm en t. Th is w ill h elp to x th e
plate on to th e bon e an d w ill greatly facilitate su bsequ en t
xation .
c In sert a 3.5 m m self-tappin g lock in g h ead screw in to th e
distal fragm en t. Ch eck th e fractu re redu ction an d axial
a b align m en t again .

707
 10 .2 Tib ia a n d fib u la , s h a ft

4 Fixa t io n (co n t )

a b c

Fig 10 .2 .4 -6 a – c
a In sert a bicortical self-tappin g 5.0 m m lock in g h ead screw in to th e proxim al
segm en t th rou gh on e of th e stab in cision s.
b Com plete th e xation by in sertin g two m ore 3.5 m m LHS distally, an d on e
m ore bicortical 5.0 m m LHS proxim ally.
c Su tu re th e skin in cision s.

5 Re h a b ilit a t io n

Weigh t bearin g: 15 kg for 2 weeks, h alf body weigh t after 4 weeks; fu ll weigh t bear-
in g after 6 weeks.
Ph ysioth erapy: Ran ge of m otion exercise of th e an kle an d k n ee join ts to be started
on day on e postoperatively.

Fig 10 .2 .4 -7a – b Postoperative x-rays after 6 weeks.

a AP view.
b Lateral view.

a b

70 8
 10 .2 .4 Sp ira l w e d ge t ib ia l s h a ft fra ct u re —42-B1

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
A poorly con tou red plate w ill lead to sk in im pin gem en t Precon tou rin g th e plate on a plastic bon e w ill facilitate
an d affect patien t acceptan ce. th e application .

Ap p ro a ch Ap p ro a ch
Open redu ction of a d isplaced fractu re w ith add ition al A m in im ally in vasive approach w ill preserve vascu larity.
strippin g of th e periosteu m . Th e em ph asis is on restoration of len gth , ax is, an d rota-
tion in stead of fractu re redu ction .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Overzealou s effort to com press th e plate on to th e bon e Wh en th e rst con ven tion al screw is in serted, ch eck
w ith a cortex screw w ill d isplace a redu ced fractu re. th e redu ction on th e im age in ten si er.
Poor xation of th e d istal fragm en t du e to an in adequ ate Carefu l preoperative plan n in g of th e nu m ber an d sites of
n u m ber of screw s. th e screw s to be in serted.

Re h a b ilit a t io n Re h a b ilit a t io n
In m u ltifragm en tary fractu res, prem atu re weigh t bear in g If possible, perform bu lar platin g in order to in crease th e
m ay lead to valgu s m alalign m en t of th e fractu re. stability of th e xation . Moreover, weigh t bearin g in m u l-
tifragm en tary fractu res sh ou ld be delayed to 4 –6 weeks.

70 9
 10 .2 Tib ia a n d fib u la , s h a ft

710
 Au t h o r Mich a e l Wa gn e r

10.2.5 Spiral we dge tibial shaft fracture with e xte nsion into
the joint—42-B1
1 Ca s e d e s crip t io n

61-year-old m an fell w h ile sk iin g an d su stain ed an u n stable fractu re of th e

left tibia.

Fig 10 .2 -5 -1a – b
a AP view.
b Lateral view.

In d ica t io n

Un sta b le fra ctu re w ith fissu re s e xte n d in g in to th e jo in t. Go o d in d ica tio n fo r

a b MIPO.

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
4 .5/
io tics:
5 .0 , sin
n a rroglew, d o14se h2on dlege
s n e ra tio n
• LCP
ce p4h.5/
a lo5sp.0o, rin
n a .rro w, 2 0 h o le s
• •5Th
.0 rom m bse o sis
lf-tap proppinh gylaloxis:
ckinLo gwh em
a do le cu la r h e p a rin .
scre w s (LHS)
• 6 .5 m m ca n ce llo u s b o n e scre w
• 2 .0 m m K-w ire s
• Po in te d re d u ctio n fo rce p s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Fig 10 .2 .5 -2 Su p in e p o sitio n o n
An tib io tics: n o n e
ra d io lu ce n t o p e ra tin g ta b le .
Th ro m b o sis p ro p h yla xis:
lo w -m o le cu la r h e p a rin

711
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .5 -3 Med ial in cision proxim al of th e m alleolu s an d two addi-

tion al in cision s in th e region of th e plan n ed position of th e prox im al
h alf of th e plate.

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .2 .5 -4 a – e
a Closed in d irect redu ction w ith m an u al traction an d rotation of th e foot, an d
d irect redu ction w ith percu tan eou sly in serted, poin ted redu ction forceps. Th e
forceps n ot on ly works as a redu ction tool, bu t also m akes tem porary xation
possible.
b – c Preben d in g of a 14-h ole n arrow LCP, 4.5/5.0 wh ereby a ben d in g tem -
plate is rst applied to th e sk in on th e m ed ial aspect an d con tou red to
determ in e th e cu rvatu re an d rotation of th e d istal tibia; also determ in ation
of th e len gth of th e plate. Th e plate is ben t an d tw isted in to sh ape w ith th e
ben d in g press an d ben din g iron s.
d – e In sertion of th e plate from d istal to prox im al an d d istal xation w ith a
6.5 m m can cellou s bon e screw parallel to th e u pper an k le join t an d two ad-
d ition al lock in g h ead screw s prox im ally. A total of ve m on ocortical LHS are
in serted to attach th e plate to th e tibial sh aft.

d e

712
 10 .2 .5 Sp ira l w e d ge t ib ia l s h a ft fra ct u re w it h e xt e n s io n in t o t h e jo in t—42-B1

4 Re h a b ilit a t io n

Mobilization w ith par- Fig 10 .2 .5 -6 a – b

tial weigh t bearin g an d The postoperative x-rays
act ive e xe r cise of t h e after 9 weeks sh ow th e
knee an d an k le join t. begin n in gs of callu s for-
Fu l l w e igh t b e a r i n g m ation .
after 6 weeks. a AP view.
b Lateral view.
Fig 10 .2 .5 -5 a – b
Postoperative x-rays af-
ter 6 weeks. Callu s for-
m ation was n ot visible
at th is tim e.
a AP view.
b Lateral view.

a b a b

5 Re fra ct u re —Ca s e d e s crip t io n

Fig 10 .2 .5 -7a – b Fig 10 .2 .5 -8 a – b

11 weeks after th e rst CT scan s sh ow th e m ost
operation , th e patien t recen t fractu re at th e
fell off h is m otorbike proxim al en d of th e
an d su stain ed an ad- plate, th e rst fractu re
d ition al fractu re at th e w ith callu s bridgin g
proxim al en d of th e an d th e LCP secu red
plate. by th e lock in g h ead
a AP view. screw s, wh ich h ad n ot
b Lateral view. loosen ed.
a 3D CT scan fron tal
plan e.
b 3D CT scan sagittal
plan e.

a b a b

713
 10 .2 Tib ia a n d fib u la , s h a ft

6 Re fra c t u re —In d ica t io n 7 Re fra c t u re —Su rgica l a p p ro a ch

A revision osteosyn th esis was requ ired Sam e in cision s as for th e rst operation .
to treat th e u n stable spiral fractu re w ith Add ition al proxim al in cision s were n ec-
th e plate in situ . essary becau se a lon ger plate was selected
for th e revision procedu re.

Fig 10 .2 .5 -9 Illu strates th e requ isite

in cision s for th e revision operation an d
for im plan t rem oval.

8 Re fra ct u re —Re d u ct io n a n d fixa t io n

a b c

d e f

Fig 10 .2 .5 -10 a – f
a Rem oval of th e 14-h ole LCP.
b Th e ex plan ted plate served as a tem plate for th e lon ger 20-h ole LCP.
c Tu n n elin g th rou gh th e epiperiosteal space from d istal to prox im al th rou gh th e
proxim al in cision .
d In sertion of th e lon ger plate from d istal to proxim al w ith th e h elp of a th readed
LCP drill sleeve u sed as a h an dle.
e–f Tem porary xation d istally an d prox im ally w ith a K-w ire.

714
 10 .2 .5 Sp ira l w e d ge t ib ia l s h a ft fra ct u re w it h e xt e n s io n in t o t h e jo in t—42-B1

8 Re fra ct u re —Re d u ct io n a n d fixa t io n (co n t )

De n itive xation of th e 20 h ole LCP dis-

Fig 10 .2 .5 -11a – c
tally w ith a fu lly th readed can cellou s bon e screw an d two
lock in g h ead screw s, w h ereby care was taken to u tilize th e
ex istin g screw h oles in th e bon e. Add ition al d istal xation at
th e level of th e rst an d n ow con solidated fractu re by in ser-
tion of two m on ocortical LHS, prox im al plate xation w ith
th ree LHS, of wh ich on e sh ou ld h ave bicortical an ch orage.
a To en su re on ly lim ited plate-to-bon e con tact, a spacer was
in serted in th e secon d prox im al h ole.
Th e im age of 20 º ou ter rotation sh ow s th e gap between th e
plate an d th e bon e. Fixation of th e prox im al fractu re in 8º
valgu s.
a AP view.
b 20 º ou ter rotation .
c Lateral view.

a b c

9 Re fra ct u re —Re h a b ilit a t io n

Partial weigh t bearin g for 6 weeks; fu ll weigh t bearin g

after 8 weeks.

Postoperative x-rays after 14 m on th s.

Fig 10 .2 .5 -12 a – b
Both fractu res sh ow solid h ealin g.
a AP view.
b Lateral view.
a

a b

715
 10 .2 Tib ia a n d fib u la , s h a ft

9 Re fra ct u re —Re h a b ilit a t io n (co n t )

a b c d e

Im p la n t re m o va l
Im plan t rem oval after 15 m on th s th rou gh stab in cision s becau se of dysesth esia in th e region of th e
saph en ou s n er ve. f

Fig 10 .2 .5 -13 a – f
a Rem oval of th e LHS at th e d istal en d of th e plate.
b Th e n erve is seen h ere in direct con tact w ith th e screw.
c– e 3D CT scan s in th e an terior, posterior an d lateral view s reveal callu s bridgin g of both fractu res.
Th ere is in correct axial align m en t in th e region of th e proxim al fractu re.
f X-ray after im plan t rem oval, AP view.

10 Pit fa lls – 11 Pe a rls +

Re d u ct io n a n d xa t io n
Problem of closed redu ction an d in traoperative ax ial
assessm en t for th e M IPO procedu re.
Postoperative ax ial m alalign m en t (8º valgu s at
reoperation).
Nerve lesion s du e to sm all in cision s or M IPO tech n iqu e.
Re d u ct io n a n d xa t io n
In tern al xator system s w ith lock in g h ead screw s are
com plem en tar y to M IPO tech n iqu e an d perm it th e stable
xation of com plex fractu res an d situ ation s th at cou ld n ot
be treated by in tram edu llary n ail xation .

716
 Au t h o r Ch ris t o p h So m m e r

10.2.6 Spiral we dge tibial and bular shaft fracture —42-B1

1 Ca s e d e s crip t io n

a b c d e

Fig 10 .2 .6 -1a – e41-year-old m an u n der th e in u en ce of alcoh ol fell on an icy su rface.

42-B1.3 extra-articu lar lower leg spiral fractu re.
a – b Preoperative x-rays.
c Th e fractu re was stabilized w ith a m etaph yseal LCP (M IPO tech n iqu e) im m e-
d iately after trau m a. Th e lon g fractu re zon e was br idged w ith a locked in tern al
xator.
d On th e rst postoperative n igh t, th e patien t m obilized h im self w ith fu ll
weigh t bearin g wh ile in an alcoh olic deliriu m . Th e plate becam e ben t by 10°
resu ltin g in valgu s m alalign m en t of th e fractu re.
e Even w ith all precau tion s taken , th e patien t m obilized h im self again th e n ext
n igh t an d th e plate ben t even m ore, n ow w ith a valgu s m alalign m en t of 25°.

717
 10 .2 Tib ia a n d fib u la , s h a ft

In d ica t io n

Fig 10 .2 .6 -2 Th is m a la lign m e n t ca n n o t b e to le ra te d a n d m u s t b e co rre cte d .

Th e re a re t wo p o ssib ilitie s:
• le a ve th e p la te in situ a n d b e n d it b a ck a s sh o w n h e re .
• re d o th e o ste o s yn th e sis o f th e tib ia , ie , re m o ve th e o ld p la te a n d sta b ilize th e
tib ia w ith a n e w p la te .
If th e p la te b e n d s sh o rtly a fte r th e o p e ra tio n a n d a ll scre w s a re s till a n ch o re d
tigh tly in th e b o n e , th e rst p o ssib ilit y ca n b e trie d .
Sta b iliza tio n o f th e b u la to su p p o rt th e lo n g tib ia b rid gin g p la te sh o u ld a lso b e
co n sid e re d . Th is a d d itio n a l sta b iliza tio n o f th e b u la is re co m m e n d e d in p a tie n ts
w ith p o o r co m p lia n ce . Th e clin ica l p ictu re sh o w s th e va lgu s m a la lign m e n t b e fo re
th e se co n d o p e ra tio n .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
1 Su rge o n
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 ,
2 ORP
4 + 12 h o le s
3 1st a ssista n t
• LCP 3 .5 , 10 h o le s
• Se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
Ste rile are a
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
1
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis:
lo w -m o le cu la r h e p a rin 2

Fig 10 .2 .6 -3 Po sitio n in g o f OR te a m .

718
 10 .2 .6 Sp ira l w e d ge t ib ia l a n d fib u la r s h a ft fra ct u re —42-B1

2 Su rgica l a p p ro a ch

Fig 10 .2 .6 -4 Two sh ort in cision s at th e proxim al

a n d d ist a l en ds of t h e plate across t h e fibu la a re
n eeded.

3 Re d u ct io n a n d fixa t io n

Fig 10 .2 .6 -5 a – d
a–b A sh ort in cision is m ade at th e level
of th e ben t tibia plate directly over
a palpable plate h ole. A ball spike
w ith poin ted ball tip is in serted
in to th is h ole an d h eld by th e as-
sistant. Th e su rgeon can ben d th e
plate into th e correct position by
applyin g stron g cou n terpressu re
a on th e foot and lower leg.
c– d In traoperative x-ray sh ow s su c-
cessfu l ben d in g of th e tibial plate
in con trast to th e pre-operative
im ages. Th e localization of th e
spike is m arked on th e im age.
Th e m alalign m en t of th e bu la is
also corrected in d irectly du rin g
th is procedu re.

b c d

719
 10 .2 Tib ia a n d fib u la , s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .6 -6 a – c
a – b Th e sim ple bu lar fractu re can n ow be
xed in a rou tin e way. Becau se of th e
m arked soft-tissu e swellin g, a m in i-
m ally in vasive procedu re is preferred.
Th e straigh t 10-h ole LCP 3.5 in dicates
th e sk in in cision s prox im ally an d d is-
tally. Th e plate bed is form ed d irectly
a w ith th e rou n ded an d atten ed en d of
th e plate. A d rill sleeve h elps to h old
an d in sert th e plate in a d istal to prox i-
m al direction .
c Th e plate is h eld in position proxim ally
an d d istally w ith two bicortical self-
tappin g lock in g h ead screw s to form a
bridgin g plate on th e bu la.

b c

Th e postoperative im ages
Fig 10 .2 .6 -7a – c
con rm th e correct ax is of th e lower leg as
well as a correct an d con gru en t an k le join t.

a b c

7 20
 10 .2 .6 Sp ira l w e d ge t ib ia l a n d fib u la r s h a ft fra ct u re —42-B1

4 Re h a b ilit a t io n

Fig 10 .2 .6 -8 a – g
a – c Fu n ction al reh abilitation began w ith 10 –
15 kg weigh t bearin g for 6 weeks. Th e actu al
weigh t bearin g was greater th an stipu lated
in th is patien t w ith poor com plian ce. Th e
patien t bore fu ll weigh t after th e secon d op-
eration alm ost all th e tim e. Callu s form ation
is seen 6 weeks after th e operation at both
th e tibia an d bu la w ith ou t loosen in g of th e
screw s.
d – g After 3 m on th s clearly advan ced callu s an d
en dosteal con solidation of both fractu res is
seen . Begin n in gs of syn ostosis between th e
d ist a l bu la a n d t ibia. Th e pat ien t h ad n o
com plain ts at th is tim e an d was m obile w ith
fu ll weigh t bearin g.

a b c

d e f g

721
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e u se of lock in g h ead screw s sim pli es m in im a lly
in vasive procedu res becau se th e plate does n ot h ave to be
an atom ically ben t. 3.5/4.5/5.0 m etaphyseal LCPs are ideal
for osteosyn th esis of th e d istal tibia, particu larly if th e
join t block is sm all.

Ap p ro a ch Ap p ro a ch
Th e cran ial in cision on th e lateral aspect of th e bu la m ay M in im ally in vasive plate osteosyn th esis (M IPO) spares
en dan ger th e su per cial peron eal n erve. th e soft tissu e an d redu ces th e risk of iatrogen ic vascu lar
dam age at th e fractu re level.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Lock in g h ead screw s en able good xation of th e plate,
particu larly in th e m etaph yseal part.

Re h a b ilit a t io n
A lon g bridgin g LCP 4.5/5.0 on th e tibia alon e can ben d
in a patien t w ith poor com plian ce w h o exercises fu ll
weigh t bear in g. In th ese cases, xation of th e bu la is
recom m en ded, particu larly in d istal bu lar fractu res.
Re h a b ilit a t io n
Th e add ition al xation of th e bu lar fractu re in creases
th e stability of a lower leg fractu re. Fu ll weigh t bearin g
du e to poor com plian ce often h as n o con sequ en ces.

7 22
 Au t h o r Ch ris t o p h So m m e r
10.2.7 Fragm e nte d we dge tibial and bular shaft fracture —42-B3
1 Ca s e d e s crip t io n
a b
e f
58-year-old m an h it a post w ith h is righ t lower leg
wh ile lan d in g w ith h is parach u te; n o relevan t soft-
tissu e in ju ry bu t a 42-B3.3 wedge fractu re of h is
lower leg. Th e fractu re was stabilized im m ed iately
after trau m a w it h a 15-h ole LCP 4.5/ 5.0 in M IPO
tech n iqu e an d a percu tan eou s in terfragm en tary
lag screw.
Fig 10.2.7-1a–g
a–b AP and lateral view of preoperative x-rays.
c–d The postoperative x-rays showed a valgu s m a-
lalign ment in a not perfectly reduced fractu re.
e –gAn orthoradiogram and x-rays centered on the
lower leg were obtained for precise docu menta-
tion . The valgu s m alalign ment measu red about
15–20º compared w ith the u n inju red leg. Ma-
lalign ment represents one of the m ain problem s
of m in im ally invasive plate procedu res becau se
the position of the fragments can on ly be as-
sessed by im age inten si cation (>10º is u n ac-
c d ceptable and mu st be corrected).
In d ica t io n
Fig 10.2.7-2a–b Functional
testing under a second anes-
thetic showed the valgus (a)
and varus (b) position by
m anual pushing-pulling. Be -
cause of the high exibility of
the LCP, it is possible to bend
the plate into the correct po -
sition. In this situation, given
that the syndesmosis is in-
tact, plate stabilization of
the bula can result in a very
stable xation of this lower
g leg fracture. a b
723
 10 .2 Tib ia a n d fib u la , s h a ft

Pre o p e ra t ive p la n n in g 2 Su rgica l a p p ro a ch

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Eq u ip m e n t
• An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo -
• LCP 3 .5 , 10 h o le s
sp o rin .
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• Sm a ll o r la rge d istra cto r
(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

1 Su rge o n
2 ORP
3 1st a ssista n t

Ste rile are a

1
Fig 10 .2 .7-4 A 10-h ole LCP 3.5 is ch osen to bridge th e m u l-
tifragm en tary fractu re of th e bu la. Th e ideal len gth of th e
plate is determ in ed by im age in ten si cation an d at both en ds
of th e plate abou t 4 cm lon g in cision s are m ade laterally over
2 th e bu la. Th e fractu re zon e is n ot ex posed. At th e cran ial ap-
3
proach , th e possible cou rse of th e su per cial peron eal n er ve
Fig 10 .2 .7-3 Lo w e r le g e le va te d o n a p a d .
across th e bu la h as to be taken in to con sideration .

3 Re d u ct io n a n d fixa t io n

Redu ction of th e valgu s m alalign m en t is perform ed m an u ally by th e rst assistan t (or by

3 2
th e u se of a d istractor attach ed from prox im al to d istal tibia or to talu s). Th e preben t
LCP 3.5 is in serted epiperiosteally in a distal to proxim al direction . A drill sleeve can be
u sed as a h an dle. Th e plate is position ed u n der im age in ten si cation an d is xed d istally
at th e cen ter of th e bu la w ith a 3.5 m m self-tappin g, lock in g h ead screw. Th e plate h as
to t tigh tly to th e bon e to avoid soft-tissu e irritation . Th e plate is th en xed tem porarily
th rou gh th e cran ial in cision w ith redu ction forceps after correction of th e ax is an d len gth .

Fig 10 .2 .7-5 a – b
a M in im ally in vasive plate osteosyn th esis of a d istal bu lar fractu re. Fixation of th e plate
by in sertion of a self-tappin g lockin g h ead screw in to th e m ost distal plate h ole (1 ).
1 Th e valgu s m alalign m en t is corrected bim anu ally or w ith th e h elp of a d istractor ( 2 ).
Redu ction of th e bu la an d tem porary plate xation w ith th e redu ction forceps ( 3 ).
2
a

7 24
 10 .2 .7 Fra gm e n t e d w e d ge t ib ia l a n d fib u la r s h a ft fra ct u re —42-B3

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .7-5 a – b (co n t)

b Altern atively, th e redu ction can be m an aged by in sertion
of a 2.8 m m drill bit in to th e cran ial plate h ole th rou gh a
d r ill sleeve or by th e u se of th e com pression device.

a b c d e f g

Fig 10 .2 .7-6 a – gTh e xed bu lar len gth is de n itively h eld
by in sertion of fu rth er self-tappin g lock in g h ead screw s. It is
recom m en ded th at bicortical screw s are u sed in th e sh aft area
(two to th ree, depen d in g on th e bon e qu ality). Self-tappin g
lock in g h ead screw s are also u sed in th e d istal part. Th e screw s
sh ou ld pen etrate th e m etaphysis, bu t sh ou ld n ot pen etrate
th e far cortex as protru sion cou ld irr itate th e syn desm osis.
In th is case, th ree screw s were u sed prox im ally an d d istally.
Th e bu lar fractu re is redu ced an d bridged correctly. Th e in -
terfragm en tary lag screw from th e rst operation is rem oved.
Th e screw is n ot n eeded w ith th is bridgin g tech n iqu e an d can
delay bon e h ealin g. Th e postoperative x-rays after th e secon d
operation sh ow correct align m en t of th e tibia an d bu la.

725
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

c f

a b d e g h

Fig 10 .2 .7-7a – h
a – d Mobilization began on th e secon d postoperative day w ith 10 –15 kg weigh t
bearin g for 6 weeks. After 6 weeks th e bu la sh owed n orm al h ealin g an d
callu s. In con trast, th e tibia sh owed n o sign s of h ealin g at th is tim e. Th e soft-
tissu e situ ation was n orm al.
e – h Fu ll weigh t bear in g was com m en ced after 9 –10 weeks. Th ere was still n o sign
of con solidation of th e tibia after 10 weeks bu t th ere was n orm al h ealin g of
th e bu la. Non e of th e screw s sh owed an y sign s of loosen in g. At th is tim e, th e
patien t was walk in g n orm ally w ith ou t a can e.

7 26
 10 .2 .7 Fra gm e n t e d w e d ge t ib ia l a n d fib u la r s h a ft fra ct u re —42-B3

4 Re h a b ilit a t io n (co n t )

Fig 10 .2 .7-8 a – fAfter 4 m on th s callu s

form ation h ad started at th e tibia on th e
lateral side. Clin ically, th e fractu re zon e
was sligh tly warm an d sligh tly swollen
bu t th e patien t h ad n o com plain ts w ith
regard to n orm al walk in g.

c d

a b e f

Both fractu res h ad con solidated after 8

Fig 10 .2 .7-9 a – d
m on th s an d sh owed con siderable en dosteal rem odelin g.

a b d

727
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP is ideal for th e M IPO tech n iqu e (th e plate m u st
be con tou red absolu tely correctly).

Ap p ro a ch Ap p ro a ch
Lesion of th e su per cial peron eal n er ve in th e approach to Percu tan eou s approach to th e bu la preven ts iatrogen ic
th e bu la. dam age to th e vascu larity of th e n u m erou s fragm en ts of
th e bu lar fractu re.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Axial deform ity du e to M IPO tech n iqu e. Th e drill in serted in to th e th readed drill sleeve is ideal for
Bridgin g th e fractu re zon e w ith a LIF in th e splin tin g prelim in ar y reten tion of corrected len gth .
m eth od is an elastic fractu re xation . Som etim es it is
better to redu ce th e am ou n t of elastic deform ation by
add ition al stabilization of th e bu lar fractu re.

Re h a b ilit a t io n Re h a b ilit a t io n
Fu ll weigh t bearin g can be perm itted early if both th e
tibia an d bu la are stabilized.

7 28
 Au t h o r Ch ris t o p h So m m e r
10.2.8 Fragm e nte d we dge tibial shaft—42-B3 and m ultifragm e n -
tary suprasynde sm otic bular shaft fracture —4 4 -C2
1 Ca s e d e s crip t io n
a b
In d ica t io n
Th is fra ctu re is a cle a r in d ica tio n fo r o p e ra tive tre a tm e n t. Be ca u se
th e fissu re lin e e xte n d s clo se to th e a n kle jo in t, a n in tra m e d u lla ry
n a il m igh t n o t b e su ita b le . In te rn a l fixa tio n w ith p la te s se e m s to
b e th e o p tim a l tre a tm e n t in th is ca se w ith o n ly m in o r so ft-tissu e
p ro b le m s.
Th e re a re t w o re a so n s fo r a d d itio n a l fixa tio n o f th e fib u la:
1. Co m b in a tio n t yp e in ju ry
2 . Th e re la tive ly sh o rt d ista l tib ia b lo ck w ith critica l fixa tio n to
th e p la te
48-year-old m an fell 1.5 m from a ladder an d su stain ed a tor-
sion al in ju ry of h is lower leg an d an k le. No obviou s soft-tissu e
in ju ries.
Fig 10 .2 .8 -1a – b Preoperat ive x-rays. Diaph ysea l fractu re of
th e d istal th ird of th e tibia w ith fractu re lin e dow n to th e m e-
taph ysis. Th e bu la fractu re sh ow s a lon g spiral wedge above
th e syn desm osis wh ich does n ot appear to be disru pted. Tak-
in g th e Volk m an n trian gle in to accou n t, th is in ju ry cou ld be
regarded as a com bin ation type fractu re of d istal tibial an d
m alleolar fractu re.
a AP view.
b Lateral view. Th ere are two in term ediate fractu re
fragm en ts an d an addition al isolated fractu re of the
Volkm an n trian gle.
If b o th b o n e s a re sta b ilize d a s in th is ca se th e sim p le r fra ctu re
sh o u ld b e tre a te d rst. In o u r ca se th e b u la r fra ctu re is sim p le r
a n d ca n b e re d u ce d a n a to m ica lly a n d sta b ilize d a b so lu te ly u sin g
a n o p e n a p p ro a ch , a n a to m ica l re d u ctio n , a n d co m p re ssio n m e th o d
a n d th e co n ve n tio n a l la g scre w a n d p ro te ctio n p la te te ch n iq u e .
Th e tib ia l fra ctu re is n o t id e a lly su ite d to a n a to m ica l re d u ctio n
o f th e d iffe re n t fra ctu re fra gm e n ts a n d th e re fo re a m in im a lly in -
va sive p la te o ste o s yn th e sis in a sp lin tin g m e th o d ( b rid ge p la te ,
in te rn a l fixa to r) is p re fe rre d .
729
 10 .2 Tib ia a n d fib u la , s h a ft

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
4 .5/
io tics:
5 .0 , sin
12 gle
h o ledso se 2 n d ge n e ra tio n ce p h a lo -
• 5sp
.0 omrin
m. lo ckin g h e a d scre w s (LHS)
• •4Th
.5 ro
mmm bco o sis
rtepxro
scre
p h yla
w s xis: Lo w m o le cu la r h e p a rin .
• LCP 3 .5 , 10 h o le s
• 3 .5 m m LHS
• 2 .7 m m co rte x scre w s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n ce p h a lo sp o rin Fig 10 .2 .8 -2 Su p in e p o sitio n w ith
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r e le va tio n o f th e le g to b e o p e ra te d o n
h e p a rin a n d sligh t b e n d in g o f th e kn e e jo in t.

2 Su rgica l a p p ro a ch

Fig 10 .2 .8 -3 a – b
a Fibu la: lateral in cision of 12 cm len gth for th e bu la. Th e level
of fractu re access to th e bon e is in fron t of th e peron eal m u s-
cles/ ten don s. On ly m in im al periosteal strippin g of th e bu t-
ter y fragm en t.
b Tibia: 3 cm sligh tly cu r ved in cision above th e m ed ial m alleo-
lu s, preservin g th e saph en ou s vein an d n er ve, th e approach
goes straigh t dow n to th e periosteu m . On ly stab in cision s are
u sed for in sertion of th e proxim al screw s.

a b

7 30
 10 .2 .8 Fra gm e n t e d w e d ge t ib ia l s h a ft—42-B3 a n d m u lt ifra gm e n t a r y s u p ra s yn d e s m o t ic fib u la r s h a ft fra ct u re —4 4 -C2

3 Re d u ct io n a n d fixa t io n

a b

Redu ction of th e bu la. Th e bu la was re-

Fig 10 .2 .8 -4 a – c
du ced in a conven tion al open tech n iqu e w ith d irect redu ction
m an eu vers u sin g two sm all poin ted redu ction forceps. After
absolu tely precise, an atom ical redu ction , two 2.7 m m cortex
screw s were applied for in terfragm en tary com pression . Th ese
two screw s were protected in th is case by a LCP 3.5 in an
in tern al xator m eth od u sin g two bicortical LHS on each side
of th e fractu re. Th e advan tage of th is m eth od is th at th e pro-
tection plate does n ot h ave to be ben t an d tw isted precisely.
a AP view.
b Lateral view.
c Clin ical view of th e lateral in cision for th e bu la an d th e
in tern al xator (LCP 3.5).

731
 10 .2 Tib ia a n d fib u la , s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

a b c d

Fig 10 .2 .8 -5 a – i
a Redu ction of th e tibia. Th e presh aped an d sligh tly tw isted c Wh ile pu sh in g th e d rill sleeve (an d th e plate) prox im ally
LCP 4.5/5.0 is, prior to in sertion , ch ecked u n der im age (arrow), th e fractu re wen t in to varu s position .
in ten si cation . Care h as to be taken n ot to overben d th e Th is is on ly possible if th e screw a lready in ser ted is n ot a
plate, w h ich wou ld lead to a soft-tissu e irritation at th e LHS an d n ot fu lly tigh ten ed.
d istal en d of th e plate. d After correct align m en t h ad been ach ieved, in clu din g cor-
b Th e plate is th en in serted th rou gh th e sm all su pram alleolar rect rotation , wh ich h as to be ch ecked clin ically, a bicortical
in cision an d pu sh ed cran ially feelin g an d bypassin g th e LHS was in serted th rou gh a stab in cision in th e m ost proxi-
fractu re zon e. In th is case th e m ost distal h ole is rst oc- m al hole of the plate and the distal screw was tigh tened.
cu pied u sin g a 4.5 m m cortex screw wh ich is n ot yet fu lly
tigh ten ed. Th rou gh a sm all stab in cision above th e fractu re,
a drill sleeve is in serted in the th readed part of the com bin a-
tion h ole. Usin g th is d rill sleeve as a h an d le, th e a lign m en t
of th e fractu re in th e coron al plan e cou ld be in d irectly
ach ieved: pu sh in g th e drill sleeve distally (arrow), th e dis-
tal fragm en t an gu lated towards a valgu s position .

7 32
 10 .2 .8 Fra gm e n t e d w e d ge t ib ia l s h a ft—42-B3 a n d m u lt ifra gm e n t a r y s u p ra s yn d e s m o t ic fib u la r s h a ft fra ct u re —4 4 -C2

3 Re d u c t io n a n d fixa t io n (co n t )

e f

Fig 10 .2 .8 -5 a – i (co n t)
e – f At th is stage, th e axis in th e lateral view h as to be con trolled u n der
im age in ten si cation . Residu al axial deviation can th en be n ally
adju sted u sin g m an ipu lation by h an d. Both m ain fragm en ts were
able to rotate sligh tly arou n d th e sin gle screw s in serted in th e m ost
proxim al an d m ost d istal plate h oles.
g– h After th is n al align m en t, fu rth er LHS are in serted. Th e secon d
screw in each fragm en t is placed close to th e fractu re zon e in a
m u lt ifragm en t a r y fract u re sit u at ion . In good bon e qu a lit y, t w o
bicortical LHS (fou r cortices) are su f cien t in th e diaph ysis. At least
th ree screw s sh ou ld be u sed in th e m etaph ysis.
i Fin al view after M IPO of th e tibia.

g h

733
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

Early m ovem en t is practised im m ediately follow in g su rgery.

Mobilization is allowed 2–3 days after th e operation , depen d in g
on t h e soft-t issu e situ at ion u n der toe-tou ch w eigh t bea r in g
(10 –15 kg).

a b a b

Fig 10 .2 .8 -6 a – b Follow-u p x-rays after 6 weeks sh owed a Fig 10 .2 .8 -7a – bFollow -u p x-rays a fter 6 m on t h s. Com plete
stable situ ation an d correct align m en t an d th e begin n in gs of d irect bon e h ealin g of th e bu la an d on goin g in d irect h ealin g
d irect bon e h ealin g on th e bu la (sligh t bon e resor ption at th e of th e tibia, m ain ly by en dosteal callu s form ation .
fractu re lin e). Load in g was gradu ally in creased depen d in g on
th e clin ical situ ation (swellin g an d pain at th e fractu re zon e).
Fu ll weigh t bearin g was allowed after 3 m on th s.
a AP view.
b Lateral view.

7 34
 10 .2 .8 Fra gm e n t e d w e d ge t ib ia l s h a ft—42-B3 a n d m u lt ifra gm e n t a r y s u p ra s yn d e s m o t ic fib u la r s h a ft fra ct u re —4 4 -C2

4 Re h a b ilit a t io n (co n t )

a b

After 14 m on th s th e fractu re was com pletely h ealed

Fig 10 .2 .8 -8 a – b
wh ereby th e rem odelin g process on th e tibia was still goin g.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e percu tan eou s approach to th e tibia is safe an d can
be perform ed on th e day of th e in ju r y. A dou ble open
approach to th e bu la an d th e tibia can be dan gerou s
an d can lead to wou n d n ecrosis.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Om ittin g an atom ical redu ction of th e bu la w ill lead to LCP w ith d ifferen t screw types allow s for in d irect
in correct align m en t of th e tibia. redu ction in a m in im ally in vasive approach u sin g th e
In com plex bu lar fractu res, th e tibia mu st be addressed drill sleeves as redu ction tools (h an dles).
rst.

735
 10 .2 Tib ia a n d fib u la , s h a ft

7 36
 Au t h o r Mich a e l Wa gn e r

10.2.9 Com ple x spiral tibial shaft fracture —42-C1

1 Ca s e d e s crip t io n

28-year-old m an fell on ice.

Fig 10 .2 .9 -1a – b Em ergen cy care in an oth er h ospital w ith

lon g-leg cast.
a AP view.
b Lateral view.

In d ica t io n

a b Un sta b le tib ia l sh a ft fra ctu re .

Pre o p e ra t ive p la n n in g

EqPautip
iem n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
m eiotatics:
p h yse
sinagle l p la
d otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio n
foce
r pd hista
a lol sp
tiboia
rin, 4. + 12 h o le s
• •3Th
.5 ro
mm m blo o sis
ckinpgrohpehayla d scre
xis: wLosw(LHS)m o le cu la r h e p a rin .
• 5 .0 m m LHS
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e
Fig 10 .2 .9 -2 Su p in e p o sitio n o n
Th ro m b o sis p ro p h yla xis:
ra d io lu ce n t o p e ra tin g ta b le .
lo w -m o le cu la r h e p a rin

737
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

a b

Fig 10 .2 .9 -3 a – b M IPO; th ree in cision s on th e m ed ial side of th e tibia.

a Sh ort in cision over th e m ed ial m alleolu s tak in g care n ot to dam age th e great saph en ou s vein .
In cision at th e plan n ed site for th e prox im al en d of th e plate.
b Preoperative m ark in g of lan d m arks.

3 Re d u ct io n a n d fixa t io n

Fig 10 .2 .9 -4 a – m
a LCP m etaphyseal plate 3.5/4.5/5.0,
for d istal tibia is ch osen accord in g
to len gth .
b With th e aid of th e gu id in g block
th e th readed d r ill sleeves are in -
serted in th e prede n ed d irection .
a b c– d After preparin g th e epiperiosteal
space w ith a lon g bon e rasp th e
plate is in serted from a d istal to
proxim al direction ; con trol u sin g
im age in ten si er.

c d

7 38
 10 .2 .9 Co m p le x s p ira l t ib ia l s h a ft fra ct u re —42-C1
3 Re d u c t io n a n d fixa t io n (co n t )
e f
h i
k l
Fig 10 .2 .9 -4 a – m (co n t)
e Closed reduction by m anu al traction ; control u sin g im age
in ten si er.
f Control of plate position w ith regard to the lateral aspect of
the bone. Then tem porary xation w ith a K-w ire distally.
g– h At th e prox im al en d of th e plate an in cision is m ade an d
th e plate is secu red w ith a K-w ire.
g
j
m
i– j In order to preven t th e plate from protru d in g beyon d
th e bon e, th e plate is pu lled close to th e bon e w ith th e
aid of a cortex screw. In th is case th e cortex screw was
on ly placed m on ocortically th rou gh th e oval lon g h ole.
k– m Add ition al in cision an d xation of th e proxim al m ain
fragm en t close to th e fractu re site, tem porarily w ith th e
drill bit in serted th rou gh th e drill sleeve in order to in -
crease stability for de n itive redu ction .
739
 10 .2 Tib ia a n d fib u la , s h a ft

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

d e f

g h i

Fig 10 .2 .9 -5 a – i
a Place LHS in th e d istal m ain fragm en t.
b In order to avoid tiltin g of th e d istal fragm en t an d to re-
tain th e redu ction wh ile in sertin g th e d istal LHS, a cor-
tex screw is placed as a redu ction screw. Th en th e d rill
bit is u sed th rou gh th e dr ill sleeve to pred rill parallel
to th e u pper a n k le join t. Su bsequ en tly, a 3.5 m m LHS
is in serted.
c– d After a total of fou r 3.5 m m LHS h ave been in serted in to
th e d istal fragm en t, th e redu ction screw (cortex screw)
is replaced by a bicortical 5.0 m m LHS.
e–i Th e cor rect ion of t h e a x is is ch ecked u sin g t h e cable
m eth od.

74 0
 10 .2 .9 Co m p le x s p ira l t ib ia l s h a ft fra ct u re —42-C1

3 Re d u c t io n a n d fixa t io n (co n t )

a b c

Fig 10 .2 .9 -6 a – e
a – c Operative in cision s before closin g. Wh en closin g th e d istal in cision , care
m u st be taken to preserve th e great saph en ou s vein .
d Postoperative x-ray, AP view.
e Postoperative x-ray, lateral view.

Splin tin g of th e fractu re w ith a lon g, locked in tern al xator. Th e LCP m etaph yseal
plate 3.5/4.5/5.0, for d istal tibia is xed prox im ally w ith two m on ocortical an d on e
bicor tica l 5.0 m m LHS; t h e d ist a l fragm en t is fixed w it h on e bicor t ica l screw a n d
fou r add ition al 3.5 m m LHS.

d e

741
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

a b a b a b

Partial weigh t bearin g

Fig 10 .2 .9 -7a – b Radiological procedu re.
Fig 10 .2 .9 -8 a – b Callu s form ation visible
Fig 10 .2 .9 -9 a – b
for 8 weeks. Postoperative x-rays after No rad iological sign s of callu s form ation on x-ray after 4 m on th s.
2 m on th s. after 3 m on th s. Th e patien t was pain free a AP view.
a AP view. wh en totally m obilized w ith fu ll weigh t b Lateral view.
b Lateral view. bearin g.
a AP view.
b Lateral view.

742
 10 .2 .9 Co m p le x s p ira l t ib ia l s h a ft fra ct u re —42-C1

4 Re h a b ilit a t io n (co n t )

a b c

d e f

Im p la n t re m o va l
Du e to sligh t pain at th e d istal en d of th e plate th e
patien t requ ested im plan t rem oval after 14 m on th s.

a b Fig 10 .2 .9 -11a – i
a – b Use of the existin g scars. After clean in g th e socket
of th e screw h ead w ith th e n e den tist’s h ook
Fig 10 .2 .9 -10 a – b Fractu re con solidation
an d th e sm all bon e rasp, rst th e d istal, th en th e
after 7 m on th s.
proxim al LHS are rem oved.
a AP view.
c– d Su bsequ en tly, u sin g th e soft-tissu e retractor in a
b Lateral view.
proxim al d irection , th e plate is freed of soft-tissu e
ad h esiolysis.
e –f With th e aid of th e plate h older xed to th e d istal
en d of th e plate, tiltin g m ovem en ts can be per-
form ed w ith th e plate so th at th e last soft-tissu e
rem n an ts are released. Th en th e plate is pu lled
ou t in a d istal d irection .
g Closu re of t h e in cision s a fter im pla n t rem ova l,
wh ich was performed via the scars from the in itial
operation .
h X-ray after im plan t rem oval, AP view.
h i i X-ray after im plan t rem oval, lateral view.

743
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP m etaph yseal plate 3.5/4.5/5.0, for d istal tibia is
an atom ically presh aped an d ts th e distal en d of th e tibia.

Th e u se of lock in g h ead screw s sim pli es m in im a lly

in vasive procedu res becau se th e plate does n ot h ave to be
an atom ically ben t. Th e d istal m etaph yseal LCPs are ideal
for osteosyn th esis of th e d istal tibia, particu larly
if th e join t block is sm all.

Ap p ro a ch Ap p ro a ch
M in im ally in vasive plate osteosyn th esis (M IPO) preserves
soft tissu es an d redu ces th e risk of iatrogen ic vascu lar
dam age at fractu re level.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Varu s/ valgu s tiltin g of th e d istal fragm en t In traoperative correction is possible w ith th e aid of
a cortex screw = ”redu ction screw ” th at pu lls th e
fragm en t towards th e plate.

Lock in g h ead screw s en able good xation of th e plate,

particu larly in th e m etaph yseal part.

Re h a b ilit a t io n Re h a b ilit a t io n
If m obilized too early w ith too m u ch weigh t bearin g or in Early fu n ction al postoperative treatm en t is possible even
a n on com plian t patien t, th e plate m ay ben d. in com plex fractu res if th e fractu re is well stabilized.

74 4
 Au t h o rs Mich a e l Wa gn e r, Th o m a s Ne u b a u e r

10.2.10 Ope n com ple x se gm e ntal tibial shaft fracture —42-C1

1 Ca s e d e s crip t io n

36-year-old m an fell off h is m otorbike

an d th e m otorbike fell on h is left leg.
Th is cau sed a Gu stilo type III open tibial
fractu re w ith a sem icircu lar wou n d on
c th e posterior aspect of th e lower leg an d
trau m atic severage of th e posterior tibial
artery.
Fig 10 .2 .10 -1a – e
a AP view.
b Lateral view.
d c– e Sem icircu lar wou n d.

a b e

In d ica t io n Pre o p e ra t ive p la n n in g

Gu stilo t yp e III o p e n se gm e n ta l EqPautip

iem n te pn re
t p a ra t io n a n d p o s it io n in g
fra ctu re o f th e lo w e r le g w ith • •LCP
An tib
m eiotatics:
p h yse
sinagle
l p la
d otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio n ce p h a lo -
tra u m a tic se ve ra n ce o f th e fosp
r od rin
ista. l tib ia , 4 + 16 h o le s
p o s te rio r tib ia l a rte ry is a n a b - • •3Th
.5 ro
mm m blo o sis
ckinpgrohpehayla
d scre
xis: wLosw(LHS)m o le cu la r h e p a rin .
so lu te in d ica tio n fo r su rgica l • 5 .0 m m LHS
tre a tm e n t. Wo u n d d e co n ta m i- • 2 .0 m m K-w ire s
n a tio n , ve sse l su tu re , a n d s ta - • 2 .0 m m tita n iu m e la s tic n a il
b iliza tio n o f th e fra ctu re m u st (Size o f s yste m , in s tru m e n ts, a n d im p la n ts
b e p e rfo rm e d im m e d ia te ly. ca n va ry a cco rd in g to a n a to m y.)
Re visio n o p e ra tio n s a n d p la stic
su rge ry m u st b e in co rp o ra te d Pa t ie n t p re p a ra t io n a n d p o s it io n in g
in to p la n s fo r su b se q u e n t tre a t- An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
m e n t. Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin Fig 10 .2 .10 -2 Su p in e p o sitio n .

745
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Th e approach is partly given becau se th e in ju r y is an open fractu re.

Addition ally, d istal m ed ial an d proxim al m ed ial in cision s are m ade.

3 Re d u ct io n a n d fixa t io n

a b c d

Fig 10 .2 .10 -3 a – f After wou n d debridem en t an d m an u al traction , th e plate is in serted

from distal to proxim al th rou gh th e distal m ed ial su rgical in cision . It is position ed
over th e d istal an d prox im al m ain fragm en ts an d stabilized. Fou r 3.5 m m lock in g
h ead screw s are in serted d istally an d fou r 5.0 m m LHS prox im ally. Th e in term ed i-
ar y segm en t is stabilized w ith a m on ocortical LHS. In tram edu llar y osteo-syn th esis
of th e segm en tal fractu re of th e bu la is ach ieved w ith a 2.0 m m titan iu m elastic
n ail. Th e wou n d is closed w ith arti cial sk in .

e f

74 6
 10 .2 .10 Op e n co m p le x s e gm e n t a l t ib ia l s h a ft fra ct u re —42-C1

4 Re h a b ilit a t io n

a b c

Fu rth er cou rse of treatm en t: several sec- Fig 10 .2 .10 -4 a – h

on d look operation s plan n ed to treat th e a – c Clin ical pictu re of th e soft-tissu e Severe sk in con t u sion s a n d sk in
severe soft-tissu e dam age. situ ation at th e secon d look operation defects are visible.
on the 4th day after the operation .

d e f

d Exten t of sk in n ecrosis an d defects. e Extent of skin defects after excision of f De n itive size of th e skin defect after
t h e n ecrot ic sk in . Th e in ter n a l fix- several n ecrosectom ies.
ator is partially ex posed.

g Th e soft-t issu e defects a re covered

w ith gastrocn em iu s aps prox im ally
an d latissim u s aps distally.
h Soft-tissu e situ ation after con solida-
tion .

g h

747
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n (co n t )

a b

a b a b

Fig 10 .2 .10 -5 a – b Fig 10 .2 .10 -7a – b

Postoperative x-rays after 6 m on th s Postoperat ive x-rays a fter 20 m on t h s
sh ow th e start of fractu re con solidation . sh ow th at th e fractu re h as been bridged
a AP view. c at th e posterior an d lateral aspects. Th e
b Lateral view. bu lar fractu res h ave h ealed.
Clin ical situ ation
Fig 10 .2 .10 -6 a – c a AP view.
6 m on th s after soft-tissu e con solida- b Lateral view.
tion . Fu ll weigh t bearin g.

5 Pit fa lls – 6 Pe a rls +

Fixa t io n Fixa t io n
Locked in tern al xators are a good altern ative to th e
extern al xator in th e treatm en t of fractu res w ith severe
soft-tissu e in volvem en t. Th ey are less d istressin g for th e
patien t.

74 8
 Au t h o r Ch ris t o p h So m m e r

10.2.11 Com ple x se gm e ntal tibial shaft fracture with one inte r-
m e diate se gm e nt and additional we dge fragm e nt—42-C2
1 Ca s e d e s crip t io n

31-year-old wom an fell w h ile sk iin g at

h igh velocity an d fractu red h er left low-
er leg at two levels (closed fractu re).
Fig 10 .2 .11-1a – d
a AP view.
b Detail AP view of th e ssu re
in to th e u pper an k le join t.
c Lateral view.
d Obliqu e view.

In d ica t io n

Com ple x fracture , se gm e ntal with one interm e -

a b
d ia te se gm e n t a n d a d d itio n a l w e d ge fra g-
m e n t. Fissu re in the dire ction o f the upp e r
ankle join t. Be cau se the tibial fracture had a
ssure into the uppe r ankle joint, a nail oste o -
synthe sis was no t suitable . This fracture is a
go o d ind ication for stabiliza tio n w ith a m e ta -
physe al LCP 3.5/ 4.5/ 5.0. In addition, an intra -
m e dullary xation o f the long bular fracture
c d was p e rform e d (e lastic nail).

Pre o p e ra t ive p la n n in g

Pa ut ie
Eq ipnmt epnret p a ra t io n a n d p o s it io n in g 1 Su rge o n
• LCP
An tibmioetics:
ta p hsin
yseglea l pdlao te
se 32.5/
nd
ge
4 .5/
n e5ra.0tio
, n ce p h a lo - 2 ORP
5sp+o rin
11 . h o le s 3 1st a ssistan t
4
• 3Th.5rommmb ose sislf-ta
p roppphinyla
g loxis:
ckin
Logwhm e aodlescre
cu law
r hs e(LHS)
p a rin . 4 2n d a ssista n t
• 5 .0 m m se lf-ta p p in g LHS 1
• Tita n iu m e la s tic n a il Ste rile are a

(Size o f s yste m , in stru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to

a n a to m y.)
3
2
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin Fig 10 .2 .11-2 Lo w e r le g e le va te d o n a p a d .

749
 10 .2 Tib ia a n d fib u la , s h a ft
2 Su rgica l a p p ro a ch
Fig 10 .2 .11-3 Sh ort 4 cm approach on th e an tero-
m edial aspect of th e distal an d proxim al tibia. Ad-
d ition al in cision s on th e lateral tibial sh aft an d
over th e tip of th e lateral m alleolu s.
750
3 Re d u ct io n a n d fixa t io n
Fig 10.2.11-4a–b Epiperiosteal and
su bfascial tu n nelin g w ith th e
ben t 5 + 11-h ole metaphyseal LCP
to prepare th e in ten ded plate
bed. Th e plate position is close
to th e an kle joint sin ce th e join t
a block is qu ite sh ort. A 3.5 m m
self-tappin g LHS is in serted u n -
der im age in ten si cation in to
th e m ost distal h ole. Th e screw
sh ou ld pen etrate th e wh ole m e-
taph ysis bu t shou ld n ot go be-
yon d th e far cortex so as n ot to
irritate th e syn desm osis.
b
a b
a b c
Fig 10 .2 .11-5 a – c Th e fractu re is redu ced m anu ally w ith sligh t traction
on th e foot a n d is su pported by a plate. A drill sleeve is in serted in to th e
proxim a l h ole. With th e h elp of th is drill sleeve, th e fractu re can be in di-
rectly redu ced (len gth , rotation). Sim ple fractu re com pon en ts sh ou ld be
accu rately redu ced, eith er w ith a percu tan eou sly applied Weber forceps
or collin ear reduction clam p.
 10 .2 .11 Co m p le x s e gm e n t a l t ib ia l s h a ft fra ct u re w it h o n e in t e rm e d ia t e s e gm e n t a n d a d d it io n a l w e d ge fra gm e n t—42-C2

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .11-6 a – i
a – b After carefu l redu ction an d im age in ten -
si er con trol, fu rth er LHS are in serted.
3.5 m m self-tappin g LHS are u sed in th e
d istal m etaph yseal part. Two 5.0 m m
self-tappin g bicortical LHS in th e prox i-
m al part are su f cien t (fou r cortices
in th e sh aft area are su f cien t). In ad-
d ition , th e in term ed iate fragm en t was
st abilized w it h a 5.0 m m bicor t ica l self-
tappin g LHS. Un der in traoperative valgu s
an d varu s stress, th e lower leg sh owed
a b c d m alalign m en t du e to th e h igh exibility
of th e in tern al xator.
c– e Becau se of th is circu m stan ce, th e bu la
w a s add it io n a lly st a bilize d w it h a n
in tram edu llary titan iu m elastic n ail.
Postoperative x-rays are sh ow n an d th e
soft-tissu e situ ation before wou n d clo-
su re.
f– i Th e postoperative x-rays in two plan es
reveal good redu ction of th e fractu re.

f g h i

751
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

a b c d e f

Mobilization began on th e rst postoperative day w ith 10 –15 kg weight bearing.

Fu nction al treatment of the u pper an kle joint was added.

Fig 10 .2 .11-7a – f
a – c Th e begin n in g of callu s form ation was seen 6 weeks after th e operation on th e
proxim al tibia an d bu la.
d–f Weigh t bearin g was in creased to 20 –30 kg for an oth er 6 weeks. Callu s form a-
tion in creased on th e u pper tibia an d bu la. Th e d istal fractu re segm en t h ad
h ealed en dosteally from th e m ed ial to th e lateral side.

752
 10 .2 .11 Co m p le x s e gm e n t a l t ib ia l s h a ft fra ct u re w it h o n e in t e rm e d ia t e s e gm e n t a n d a d d it io n a l w e d ge fra gm e n t—42-C2

4 Re h a b ilit a t io n (co n t )

a b c a b

After on e year th e fractu re was en tirely con -

Fig 10 .2 .11-8 a – c Im p la n t re m o va l
solidated an d th e callu s rem odeled. Th e im plan t position was Fig 10 .2 .11-9 a – b Im plan t rem oval after 14 m on th s.
u n ch an ged.

753
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP m etaph yseal plates 3.5/4.5/5.0 are ideal
for prox im al or d istal fractu res close to a join t (th e
d istan ces between th e h oles are sh orter in th e 3.5 plate
part com pared w ith th e 4.5/ 0.5 plate part).

Ap p ro a ch Ap p ro a ch
Th e great saph en ou s vein an d th e saph en ou s n er ve can be
en dan gered by th e d istal approach .

Re d u ct io n a n d xa t io n
Malalign m en t becau se of th e m in im ally in vasive
approach . Assessm en t x-rays mu st be obtain ed.
Re d u ct io n a n d xa t io n
Lock in g h ead screw s also stabilize sm all join t fragm en ts.
Splin tin g a lon g fractu re zon e w ith a locked in tern al
xator resu lts in an elastic stabilization . In th is ciru m -
stan ce, an add ition al osteosyn th esis of th e bu lar fractu re
is recom m en ded.

Re h a b ilit a t io n Re h a b ilit a t io n
If m obilized too early w ith too m u ch weigh t or in a Early fu n ction al postoperative treatm en t is possible even
n on com plian t patien t, th e plate m ay ben d. in com plex fractu res if th e fractu re is well stabilized an d
if th e soft tissu e allow s.

754
 Au t h o r Ch ris t ia n Ryf

10.2.12 Ope n com ple x se gm e ntal tibial shaft fracture —42-C2

1 Ca s e d e s crip t io n

50-year-old m an w ith sk i in ju r y; open tibial sh aft fractu re

Gu stilo type II.

Fig 10 .2 .12 -1a – d

a AP view, prox im al fractu re.
b Lateral view, prox im al fractu re.
c AP view, sh aft fractu re.
d Lateral view, sh aft fractu re.

In d ica t io n

Th e p a tie n t su ffe re d a n o p e n s e gm e n t fra ctu re w h ile skiin g. Th e

a b co m p a rtm e n t p re ssu re s a n d n e u ro lo gy w e re n o rm a l.

Pre o p e ra t ive p la n n in g

EqPautip
iemn te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib io tics:
4 .5/ 5 .0 , sin glew,
n a rro d o2se
0 h2on dlege
s n e ra tio n ce p h a -
1 Su rge o n
• 5lo.0spmomrinlo. ckin g h e a d
2 ORP
•scre
Th rowm b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
s (LHS)
3 1st a ssistan t
• 4 .5 m m co rte x scre w s
(Size o f s ys te m , in stru m e n ts, Ste rile are a
a n d im p la n ts ca n va ry a cco rd in g
to a n a to m y.) 3

c d
Pa t ie n t p re p a ra t io n a n d
p o s it io n in g 2
1
An tib io tics: 2 n d ge n e ra tio n
ce p h a lo sp o rin fo r 4 8 h o u rs
Th ro m b o sis p ro p h yla xis: lo w - Fig 10.2 .12-2 Pa tie nt in supine
m o le cu la r h e p a rin p osition . Tournique t on the fe m ur.

755
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .12 -3Th e wou n d is debrided an d jet-lavaged.

Th e preex istin g wou n d is exten ded som e 2 cm .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .2 .12 -4 a – d
a Open redu ction of th e prox im al fractu re w ith th e poin ted redu ction forceps an d in d irect
redu ction of th e d istal fractu re.
b Th e prox im al fractu re is xed w ith two 4.5 m m cortex lag screw s.
c An LCP 4.5, 20 h oles is ben t to t th e tibia. Two d rill sleeves are m ou n ted on to th e plate
on th e prox im al aspect an d u sed to h old it in place. Prox im al in cision an d in sertion of th e
plate in to th e epiperiosteal space.
d Th e rst screw is in serted at th e distal en d of th e plate. Th en th e proxim al screws are in serted, d
followed by th ose for th e m idsh aft.

756
 10 .2 .12 Op e n co m p le x s e gm e n t a l t ib ia l s h a ft fra ct u re —42-C2

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .12 -5 a – c Postoperative x-rays.

a AP view.
b Lateral view, proxim al part.
c Lateral view, d istal part.

After open , direct precise redu ction of th is proxim al sim ple

fractu re, the fractu re was com pressed by a lag screw. Th e LCP
acts h ere as a n on con tact plate w ith th e fu n ction of a protection
plate. In direct, closed redu ction of th e mu ltifragm en tary, open
sh aft fractu re an d xation by the locked splin tin g m eth od.

a b c
c c

4 Re h a b ilit a t io n

Weigh t bearin g: 15 kg for 6 weeks; h alf body weigh t after 12 weeks; fu ll weigh t bearin g after 16 weeks.

a b a b a b

Fig 10 .2 .12 -6 a – b Postoperative x-ray Fig 10 .2 .12 -7a – b Postoperative x-ray Fig 10 .2 .12 -8 a – b Postoperative x-ray
after 6 weeks after 6 m on th s after 8 m on th s
a AP view. a AP view. a AP view.
b Lateral view. b Lateral view. b Lateral view.

757
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP su pports th e M IPO tech n iqu e.
Th e percu tan eou s approach to th e tibia is safe.

Th e LCP w ith com bin ation h oles allow s a fractu re speci c

xation m eth od—com pression for sim ple fractu res an d
locked splin tin g for m u lifragm en tary fractu res.

758
 Au t h o rs Ga b rie le St re ich e r, An d re a s Gru n e r, Th o m a s Ho cke r t z, He in rich Re ilm a n n

10.2.13 Ope n com ple x irre gular tibial and bular shaft
fracture —42-C3
1 Ca s e d e s crip t io n

17-year-old patien t wh o was ru n in to by a car an d su ffered an in ju r y to th e left

leg.

Fig 10 .2 .13 -1a – b

a Preoperative clin ical pictu re.
b Preoperative x-ray AP view.

In d ica t io n

As th e re su lt o f a h igh -e n e rgy in cid e n t th e p a tie n t su sta in e d a n o p e n fra ctu re w ith so ft-tissu e

a b in vo lve m e n t (Gu stilo t yp e IIIB). Th is o p e n fra ctu re is a n a b so lu te in d ica tio n to o p e ra te .

Pre o p e ra t ive p la n n in g

Eq u ip m e n t
• LISS-PLT, 13 h o le s
• 5 .0 m m se lf-d rillin g, se lf-ta p p in g
lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin .
Fig 10 .2 .13 -2 Su p in e p o sitio n w ith e le va tio n o f th e le g to b e o p e ra te d o n
a n d e xio n o f th e kn e e jo in t to a p p roxim a te ly 3 0 °, lo w e rin g o f th e o th e r le g
to im p ro ve in tra o p e ra tive ra d io gra p h ic d ia gn o sis, cu sh io n in g o f th e d ista l
fe m u r o f th e in ju re d le g, e g, w ith a to w e l ro ll.

759
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .13 -3 An terolateral approach to th e tibial h ead th rou gh a 5 cm

in cision in to th e prox im al region of th e com partm en t of th e tibialis an -
terior m u scle.

Preparation to th e periosteu m an d th e im plan t bed w ith th e lon g bon e

rasp.

3 Re d u ct io n a n d fixa t io n

a b c d e

After determ in in g plate len gth u n der im age in ten si cation , Fig 10 .2 .13 -4 a – j
in sertion of th e im plan t in to th e plate bed from th e prox im al a Postoperative x-ray, AP view.
aspect an d bridgin g of th e approx im ately redu ced fractu re b Postoperative x-ray, lateral view.
zon e. c Postoperative x-ray, lateral view k n ee.
Secon d in cision at th e d istal en d of th e plate, com pletion of d Postoperative x-ray, AP view detail.
th e LISS fram e an d tem porar y xation of th e prox im al an d e Postoperative x-ray, AP view fragm en t xation .
d istal en ds of th e plate w ith K-w ires.
Proxim al an d d istal xation of LISS to th e bon e by in ser tion
of lock in g h ead screw s.
In ter polation of th e m u ltiple in term ed iar y fragm en ts an d xa-
tion of th e two large fragm en ts w ith LHS an d cortex screw s.

76 0
 10 .2 .13 Op e n co m p le x irre gu la r t ib ia l a n d fib u la r s h a ft fra ct u re —42-C3

3 Re d u c t io n a n d fixa t io n (co n t )

f g h

i j

Fig 10 .2 .13 -4 a – j (co n t)

f Postoperative pictu re of th e lateral approach .
g Postoperative pictu re of th e vacu u m dressin g.
h Vacu u m d ressin g.
i Clin ical statu s after vacu u m d ressin g.
j Gran u lation after vacu u m d ressin g.

4 Re h a b ilit a t io n

Weigh t bearin g: 15 kg for 6 weeks; h alf body weigh t after 6 weeks;

fu ll weigh t bearin g after 12 weeks.
Ph ysioth erapy: from th e 2n d postoperative day
Ph arm aceu tical treatm en t: Non -steroidal an tiin am m atory d ru gs

Fig 10 .2 .13 -5 a – e
a Postoperative x-ray after 2 weeks, AP view.
b Postoperative x-ray after 2 weeks, lateral view.

a b

761
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n (co n t )

Fig 10 .2 .13 -5 a – e (co n t)

c Postoperative x-ray after 5 weeks,
AP view
d Postoperative x-ray after 5 weeks,
lateral view
e Clin ical pictu re.
e

c d
Im p la n t re m o va l
Reason for im pla n t rem ova l: m ech a n ica l ir r it ation of t h e latera l t ibia l h ead by t h e
im plan t.
Tech n iqu e for im plan t rem oval: Rem oval of th e screw s th rou gh stab in cision s an d
rem oval of th e LISS th rou gh th e previou s prox im al in cision .

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
An im plan t th at is alm ost too sh ort so th at adequ ate distal
xation is on ly ju st possible.

Ap p ro a ch Ap p ro a ch
In adequ ate preparation of th e tibial h ead leads to
in correct plate position in g (too far on th e an terior
or posterior side).

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Rotation al errors if th e fractu re zon e is too len gth y.

Re h a b ilit a t io n Re h a b ilit a t io n
In open fractu res, a procedu re on ly for specialists. Prim ary de n itive fractu re treatm en t is possible despite
ex posed bon e an d m assive soft-tissu e in ju ry.

762
 Au t h o r Ch ris t ia n Ryf

10.2.14 Ope n com ple x irre gular tibial shaft fracture —42-C3

1 Ca s e d e s crip t io n

52-year-old m an fell from a ladder an d fractu red

h is righ t lower leg. Open fractu re Gu stilo type II.

Fig 10 .2 .14 -1a – d

a AP view.
b Lateral view.
c– d CT scan s.
c

a b d

In d ica t io n Pre o p e ra t ive p la n n in g

Th e p a tie n t su ffe re d a m a ssive so ft-tissu e EqPautip

iemn te pn re
t p a ra t io n a n d p o s it io n in g
s w e llin g o f th e w h o le lo w e r le g. Th e fra ctu re d • •LCP
An tib4 .5/
io tics:
5 .0 , sin
n a rro
glew, d o16
se h2on dlege
s n e ra tio n ce p h a lo - 1 Su rge o n
d is ta l fib u la p e rfo ra te d th e skin . Eve n w ith • Lospckin
o ring. h e a d scre w s (LHS) 2 ORP
th is e xte n d e d s w e llin g, n o co m p a rtm e n t • •4Th
.5 ro
mm mbco o sis
rtepxroscre
p h yla
w s xis: Lo w m o le cu la r h e p a rin . 3 1st a ssistan t
s yn d ro m e w a s o b se rve d . Th e d is ta l b lo o d • 2 .4 m m ca n ce llo u s b o n e scre w s
su p p ly a n d n e rve s we re n o t d a m a ge d . So a n • Exte rn a l xa to r u se d a s a re d u ctio n 3 Ste rile are a
o p e ra tive tre a tm e n t se e m e d p o ssib le . A to o l
p e rcu ta n e o u s scre w o ste o s yn th e sis a n d a (Size o f s ys te m , in stru m e n ts, a n d im p la n ts ca n va ry
b rid gin g p la te fo r th e sh a ft fra ctu re (MIPO), a cco rd in g to a n a to m y.)
ie , a lo n g LCP 4 .5/ 5 .0 , w e re p la n n e d .
2 1
Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 2 n d ge n e ra tio n Fig 10 .2 .14 -2 Su p in e p o sitio n o f th e
ce p h a lo sp o rin fo r 4 8 h o u rs p a tie n t w ith a to u rn iq u e t o n th e th igh .
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r Th e lo w e r le g is p o sitio n e d o n a p illo w
h e p a rin o n a ra d io lu ce n t o p e ra tin g ta b le .

763
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .14 -3 Debridem en t of th e lateral wou n d. Jet lavage of

th e lateral wou n d w ith polih exan id. Plate position an d len gth
are m arked. Stab in cision s for th e two articu lar screw s u n der
im age in ten si er an d len gth in cision d istal m ed ial an d an te-
rior to th e m edial m alleolu s. Th e great saph en ou s vein an d
th e saph en ou s n erve m u st be iden ti ed an d spared to preven t
irritation . Th e proxim al in cision is perform ed proxim ally over
th e tibial edge at th e previou sly m arked position .

3 Re d u ct io n a n d fixa t io n

Fig 10 .2 .14 -4 a – c
a Th e a r t icu la r fract u re is redu ced by ex ter n a l pressu re
u n der im age in ten sifier con t rol a n d m a n ipu lated w it h
K-w ires. Th e join t fractu re is tem porarily xed w ith per-
cu tan eou s K-w ires.
b Defin it ive st abilizat ion of t h e a r t icu la r fragm en t s w it h
2.4 m m ca n cellou s bon e screw s as lag screw s. Th e t wo
Sch an z screw s are in serted. Th e prox im al screw is placed
d irectly d istal to th e tibial tu berosity in an an teroposterior
d irection an d th e d istal screw tran sverses th e calcan eu s.
c Th e extern al xator is m ou n ted an terolaterally so as n ot to
d istu rb th e plate position .
Th e fractu re can n ow be redu ced u n der im age in ten si er
con trol an d h eld in th is position w ith th e extern al xator.

a b c

76 4
 10 .2 .14 Op e n co m p le x irre gu la r t ib ia l s h a ft fra ct u re —42-C3

4 Fixa t io n

Fig 10 .2 .14 -5 a – c
a Two drill sleeves are u sed as h an d les to in sert th e plate
in to th e preform ed su bfascial space. Th e plate is in serted
u n der im age in ten si er con trol to preven t m isplacem en t
of th e fragm en ts. Atten tion h as to be paid to n ot h arm in g
th e saph en ou s vein or n er ve an d to preven tin g posterior
m isplacem en t.
b A rst d istal lock in g h ead screw is in serted. Lock th e screw
after in sertion of a proxim al screw. In th is m an n er, cor-
rection is still possible.
After correct redu ction was con rm ed, a total of th ree
proxim al m on ocortical lock in g h ead screw s an d two distal
bicortical lock in g h ead screw s were in serted.
c Th e d islocated in term ed iate fragm en t is approach ed w ith
a 4.5 m m cortex screw (redu ction screw). Care m u st be
taken n ot to pu sh th e fragm en t wh ile d rillin g. A form a l
in terfragm en tar y com pression is n ot possible becau se of
a lack of an atom ical redu ction . An elastic bridgin g osteo-
syn th esis is ach ieved. b c

5 Re h a b ilit a t io n

Weight bearing: 15 kg for 12 weeks; h alf body

weigh t after 12 weeks; fu ll weigh t bearin g
after 18 weeks.
Physiotherapy: active therapy of the neigh-
bor in g join ts postoperatively. Lym ph atic
d rain age an d com pression th erapy is applied
because of a tendency towards swelling.

a b

Fig 10 .2 .14 -6 a – b Fu n ction al resu lts after 6 weeks.

765
 10 .2 Tib ia a n d fib u la , s h a ft

5 Re h a b ilit a t io n (co n t )

a b a b

Fig 10 .2 .14 -7a – b Postoperative x-rays Fig 10 .2 .14 -8 a – b Postoperative x-rays

after 18 weeks. after 36 m on th s.
a AP view. a AP view.
b Lateral view. b Lateral view.

76 6
 Au t h o r Mich a e l Wa gn e r

10.2.15 Spiral tibial shaft fracture in a child —42-A1

1 Ca s e d e s crip t io n

15-year-old boy fell off h is bicycle an d su stain ed an isolated tibial sh aft fractu re.

Fig 10 .2 .15 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n

Prim a ry u n d isp la ce d fra ctu re o f th e tib ia a t

th is a ge is a go o d in d ica tio n fo r n o n -o p e ra tive
tre a tm e n t. If th is is p e rfo rm e d in co n se -
q u e n tia lly, va ru s m a la lign m e n t w ill o ccu r
in th e p la ste r ca st a n d th is th e n p ro vid e s
th e in d ica tio n fo r su rgica l tre a tm e n t . An
a lte rn a tive to MIPO w o u ld b e th e a p p lica tio n
o f in d e p e n d e n t scre w s, a n e xte rn a l fixa tio n ,
o r e la s tic n a ilin g in p a tie n ts in th is a ge
gro u p.

Fig 10 .2 .15 -2 a – d
a – b Fra ctu re tre a te d w ith p la ste r ca st.
c– d Va ru s m a la lign m e n t.

a b c d

767
 10 .2 Tib ia a n d fib u la , s h a ft

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5 ./ 5 .0 , 5 + 14 h o le s An tib io tics: n o n e
• 3 .5 m m lo ckin g h e a d scre w s (LHS) Th ro m b o sis p ro p h yla xis:
• 5 .0 m m LHS lo w -m o le cu la r h e p a rin
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.) Fig 10 .2 .15 -3 Su p in e p o sitio n .

2 Su rgica l a p p ro a ch

Fig 10 .2 .15 -4 Th ree m ed ial in cision s.

3 Re d u ct io n a n d fixa t io n

Fig 10 .2 .15 -5 a – c
a AP view.
b Lateral view.
c Sk in closu re.

a b
Closed redu ction w ith m anu al traction ; con trol u sin g th e im age in ten si er.
Preparation of th e epiperiosteal space w ith th e scissors from d istal to proxim al
an d proxim al to d istal.
Plate in sertion from d istal to prox im a l an d tem porar y xation w ith K-w ires at
th e d istal an d prox im al fragm en ts.
Distal xation w ith fou r 3.5 m m LHS an d proxim al xation w ith fou r
4.5/5.0 m m m on ocortical LHS.

76 8
 10 .2 .15 Sp ira l t ib ia l s h a ft fra ct u re in a ch ild —42-A1

4 Re h a b ilit a t io n

Fu ll weigh t bearin g after 2 weeks.

a b a b

Postoperative x-rays
Fig 10 .2 .15 -6 a – b Fig 10 .2 .15 -7a – b Postoperative x-rays after
after 2 m on th s sh ow callu s br idgin g of 8 m on th s sh ow en dosteal an d callu s
th e fractu re. bridgin g of th e fractu re.
a AP view. a AP view.
b Lateral view. b Lateral view.

Im p la n t re m o va l
Im plan ts sh ou ld be rem oved
from ch ildren . Fu rth er-
m ore, th e plate was situ ated
d irectly u n der th e sk in .
a b

Fig 10 .2 .15 -8 a – c
a Th e con tou r of th e plate is seen ben eath th e sk in at th e m ed ial tibia.
Good cosm etic resu lt.
b X-ray exam in ation after im plan t rem oval. Periosteal callu s is form ed
on th e side opposite to th e plate; in th e case of a n on con tact plate
th ere is also callu s form ation ben eath th e plate an d in th e region of
th e plate u n dercu ts.
c AP view after im plant rem oval. Osseou s h ealin g of th e fractu re. Correct
axial align m en t. c

76 9
 10 .2 Tib ia a n d fib u la , s h a ft

5 Pit fa lls – 6 Pe a rls +

Fixa t io n Fixa t io n
Isolated tibial fractu res in ch ild ren ten d to con solidate in M IPO u sin g a LIF is a good altern ative in fractu res in
varu s m alalign m en t if treated in a plaster cast an d n eed to ch ildren of th is age an d allow s fu ll weigh t bearin g after
be corrected su rgically later. 2 weeks.

Bridgin g a fractu re w ith a locked in tern al xator in du ce

in direct bon e h ea lin g.

In th e case of a n on con tact plate, th ere is also callu s

form ation ben eath th e plate.

770
 Au t h o r Mich a e l Wa gn e r

10.2.16 Pe riprosthe tic fracture of the tibial shaft—42-B1

1 Ca s e d e s crip t io n

76-year-old wom an fell wh ile ou t walk in g.

Fig 10 .2 .16 -1a – b

a AP view.
b Lateral view.

In d ica t io n

In tra m e d u llary tre a tm e n t wa s n o t p o ssib le b e cau se th e re wa s a to ta l e n d o -

p ro sth e sis o f th e kn e e in situ . Th e b e st so lu tio n in te rm s o f su rgica l tre a tm e n t
is b rid gin g th e fractu re w ith a lo cke d in te rn a l xa to r in MIPO te ch n iq u e .
Em e rge n cy tre a tm e n t: Tractio n b y in se rtio n o f a K-w ire th ro u gh th e ca lca -
a b n e u s a n d p o sitio n in g o n a tractio n b e d .

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g Fig 10 .2 .16 -2 Su p in e
• •LCP m io
An tib e tatics:
p h yse
sinagle
l p la
d otese3 2.5/
nd
4ge
.5n./e5ra
.0tio
, 4n+ce16
p hhaolole- s p o sitio n w ith th e in ta ct
• LCP
sp o3rin
.5., 7 h o le s lim b lo w e re d to fa cilita te
• •3Th
.5 ro
mmmblo ckinpgrohpehayla
o sis d scre
xis: wLosw(LHS)
m o le cu la r h e p a rin . x-ra y a sse ssm e n t in th e
• 5 .0 m m LHS la te ra l p la n e w ith th e
• 2 .0 m m K-w ire s im a ge in te n si e r.
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

771
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

a b c

Fig 10 .2 .16 -3 a – c M IPO ve in cision s on th e m ed ial side of th e tibia.

a Sh ort in cision over th e m ed ial m alleolu s tak in g care n ot to dam age th e great saph en ou s vein .
In cision at th e plan n ed site for th e prox im al en d of th e plate an d add ition al stab in cision s for th e LHS.
b Preoperative m ark in g of lan d m arks.
c Care sh ou ld be taken n ot to dam age th e saph en ou s n erve an d vein du rin g d istal in cision .

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .2 .16 -4 a – l
a Closed redu ction w ith m an u al traction ; con trol
u sin g th e im age in ten si er.
b – e Preparation of th e epiperiosteal space w ith
th e scissors an d lon g bon e rasp from d istal to
proxim al an d proxim al to distal.

d e

772
 10 .2 .16 Pe rip ro s t h e t ic fra ct u re o f t h e t ib ia l s h a ft—42-B1

3 Re d u c t io n a n d fixa t io n (co n t )

f g h

i l

j k

Fig 10 .2 .16 -4 a – l (co n t)

f– g Th e an atom ical sh ape of th e tibia is determ in ed w ith th e h elp of a ben d in g tem plate.
h Presh apin g of th e plate.
i Plate in sertion from d istal to prox im al an d tem porar y xation w ith K-w ires at th e d istal an d prox im al fragm en ts.
j– k Th is is followed by xation of th e two m ain fragm en ts w ith ve lock in g h ead screw s in th e d istal fragm en t an d
ve LHS in th e prox im al fragm en t. Sh ort m on ocortical screw s are in serted in th e prox im ity of th e k n ee prosth esis.
Th e lateral m alleolar fractu re is stabilized by application of a 7-h ole LCP 3.5 w ith lock in g h ead screw s.
l In cision s after com pletion of th e osteosyn th esis.

773
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n

Partial weigh t bearin g for

Fig 10 .2 .16 -5 a – b
8 weeks. Postoperative x-rays after 8 weeks.
a AP view.
b Lateral view.

a b

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
Th e saph en ou s vein an d n er ve m ay be in ju red du rin g th e
cou rse of d istal, m ed ial in cision . Th e su per cial peron eal
n er ve is en dan gered by lateral in cision .
Eq u ip m e n t
Th e LCP m etaph yseal plate 3.5/4.5/5.0, for d istal tibia is
an atom ically presh aped an d ts th e distal en d of th e tibia.
Th e u se of lock in g h ead screw s sim pli es m in im a lly
in vasive procedu res becau se th e plate does n ot h ave to
be precisely con tou red to an atom ical sh ape. 3.5/4.5/5.0
m etaphyseal LCPs are ideal for osteosyn th esis of th e distal
tibia, particu larly if th e join t block is sm all.
In th is case, th e prox im al en d of th e plate h ad to be
adapted to th e bon e con tou rs becau se th e plate was
extrem ely lon g.
Th e m etaph yseal plate h as 3.5 m m h oles in th e area of
th e join t so th at it is possible to in sert several lock in g
h ead screw s w ith in a sm all space. Th ese can be in serted
d ivergen tly to each oth er an d are an gled away from th e
articu lar su rface.

774
 Au t h o r Mich a e l Wa gn e r

10.2.17 Pse udarthrosis of the tibia —42-B1

1 Ca s e d e s crip t io n

81-year-old wom an su ffered a spon tan eou s fractu re of th e tibial

sh aft at th e en d of th e cem en ted stem of a revised kn ee pros-
th esis. Th e spon tan eou s fractu re was treated n on operatively
an d en ded in a pseudarth rosis w ith varu s m alalign m en t.

Fig 10 .2 -17-1a – c
a AP view.
b Lateral view.
c Varu s m alalign m en t.

In d ica t io n

Sta b iliza tio n o f th e n o n u n io n a n d co rre ctio n o f th e a xia l m a la lign -

a b c m e n t.

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
4 .5/
io tics:
5 .0 , sin
n a rro
glew, d o15
se h2on dlege
s n e ra tio n ce p h a lo -
• 5sp
.0 omrin
m. lo ckin g h e a d scre w s (LHS)
• •3Th
.5 ro
mmm bco o sis
rtepxroscre
p h yla
w s xis: Lo w m o le cu la r h e p a rin .
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: 3 rd ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin
Fig 10 .2 .17-2 Su p in e p o sitio n .

775
 10 .2 Tib ia a n d fib u la , s h a ft

2 Su rgica l a p p ro a ch

Fig 10 .2 .17-3 Med ia l in cision s over th e d ista l tibia an d t wo add ition al

stab in cision s for th e in trodu ction of th e screw s.

3 Re d u ct io n a n d fixa t io n

a b

Fig 10 .2 .17-4 a – c
a – b First, th e bon e cem en t in th e region of th e pseu darth rosis was re-
m oved. Decortication of th e pseu darth rosis.
c After in sertion of th e presh aped plate from distal to proxim al, th e
plate is tem porarily stabilized by in sertin g a drill bit in to th e proxim al
h ole. Axial correction is ach ieved by applyin g th e pu sh -pu ll forceps
th at are xed in th e m ost d istal plate h ole.

776
 10 .2 .17 Ps e u d a rt h ro s is o f t h e t ib ia —42-B1

3 Re d u c t io n a n d fixa t io n (co n t )

Fig 10 .2 .17-5 a – c
a – b Th ree lockin g h ead screw s are in serted in to
th e d istal fragm en t. On e lock in g h ead screw
an d th ree cortex screw s are in serted in to th e
proxim al fragm en t.
c Sk in closu re.

a b

4 Re h a b ilit a t io n

Im m ed iate fu ll weigh t Fig 10 .2 .17-7a – b

bearin g. Postoperative x-rays after
1 yea r sh ow solid bon e
Fig 10 .2 .17-6 a – b con solidation an d good
Postoperative x-rays axial align m en t.
after 8 weeks. a AP view.
a AP view. b Lateral view.
b Lateral view.

a b a b

777
 10 .2 Tib ia a n d fib u la , s h a ft

4 Re h a b ilit a t io n (co n t )

Im p la n t re m o va l
Th e d istal en d of th e im plan t was th e
cau se of sligh t pain an d so th e im plan t
was rem oved 18 m on th s after th e op-
eration .

Postoperative x-rays
Fig 10 .2 .17-8 a – d
after im plan t rem oval. Bon e h ealin g
in correct align m en t. Note th e callu s
form ation (w ith ou t bon e graftin g) also
on th e m ed ial side ben eath th e n on -
con tact plate.
a – b AP view.
c– d Lateral view.

a b c d

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e com bin ation h ole of th e LCP perm its th e in sertion
of LHS an d cortex screw s. Th is facilitates application of
th e LCP in th e treatm en t of periprosth etic fractu res. Th e
pu sh -pu ll forceps provide a less invasive tech n iqu e for
th e correction of ax ial m alalign m en t by m ean s of platin g.

778
10.3 Tibia and bula, distal

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ctio n Pa g e

10 .3.1 Extraarticu lar sim p le d ista l tibial an d 43 -A1 co m p re ssio n LCP m e tap h yse al p la te lag scre w an d 78 5
fibular fractu re an d lo cke d 3 .5/ 4 .5/ 5.0; o n e -th ird p ro te ctio n pla te
sp lin tin g tu bular pla te lo cke d in te rnal fixa to r

10 .3.2 Extraarticu lar we d ge d istal tibia l a nd 43 -A2 lo cke d sp lin tin g LCP m e tap h yse al p la te lo cke d in te rnal fixa tor 789
fibu lar fractu re 3 .5/ 4 .5/ 5 .0

10 .3.3 Partial articu la r m u ltifragm e n ta ry 43 -B3 lo cke d sp lin tin g LCP p ilo n p la te 3 .5 lag scre w an d 793
d istal tib ial fractu re (p ilo n) p ro te ctio n pla te
10 .3.4 Co m ple te articu lar sim p le distal 43 -C1 co m p re ssio n LCP d istal tib ial p la te lag scre w s and lo cke d 79 9
tib ial and fibular fractu re an d lo cke d 2 .7/ 3 .5, m e d ial in te rn al fixa to r
sp lin tin g

10 .3.5 Articular m u ltifragm e n ta ry d istal 43 -C3 co m p re ssio n LCP 3 .5; LCP lag scre w s and lo cke d 8 03
tib ial and fibular fractu re an d lo cke d re co n stru ctio n p la te 3 .5; in te rn al fixa to r
sp lin tin g LCP b u ttre s p la te

10 .3.6 Com ple te articu lar m u ltifragm e n tary 43 -C3 co m p re ssio n On e -th ird tu b u lar p la te; co m p re ssio n p la te 809
d istal tib ia l fractu re (p ilo n) an d lo cke d LCP T-p la te 3 .5; LCP 3 .5 an d b u ttre ss p la te
sp lin tin g (tibia) and lo cke d
in te rn al fixa to r

10 .3.7 Op e n co m ple te a rticu la r 43 -C2 co m p re ssio n LCP d istal tib ial p la te lag scre w s and lo cke d 817
m u ltifragm e n tary d istal tibial and an d locke d 2 .7/ 3 .5, m e dial in te rn al fixa to r
fibu lar fractu re sp lin tin g

10 .3.8 Bila te ral co m p le te articu la r 43 -C3 co m p re ssio n LCP d istal tib ial p la te lag scre w s and lo cke d 82 3
m u ltifragm e n tary d istal tibial an d locke d 2 .7/ 3 .5, m e dial; LCP in te rnal fixa to r
fractu re sp lin tin g m e taph yse al p late
3 .5/ 4 .5/ 5 .0

10 .3.9 Ado le sce n t b o n e cyst—w ith lo cke d splin ting LCP m e taph yse al p la te b u ttre ss p la te 8 31
im m ine n t fractu re o f the d istal tibia 3 .5/ 4 .5/ 5 .0

10 .3.10 Fibu lar fractu re w ith m e dia l 4 4 -B2 co m p re ssio n LCP o n e -th ird tu b u la r lag scre w and bu ttre ss 8 35
ligam e n tou s le sion p la te 3 .5 p la te

10 .3.11 Bim alle olar fractu re w ith m e d ial 4 4 -B2 co m p re ssio n LCP o n e -th ird tu b ula r lag scre w and 8 39
le sio n p la te 3 .5 p ro te ction p la te

779
 10 Tib ia a n d fib u la

10 Tibia and bula

10 .3 Tib ia a n d fib u la , d is t a l 7 81
10 .3 .1 Ext ra a r t icu la r s im p le d is t a l t ib ia l a n d
fib u la r fra ct u re —4 3 -A1 78 5
10 .3 .2 Ext ra a r t icu la r w e d ge d is t a l t ib ia l a n d
fib u la r fra ct u re —4 3 -A2 78 9
10 .3 .3 Pa r t ia l a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l
fra ct u re (p ilo n )—4 3 -B3 793
10 .3 .4 Co m p le t e a r t icu la r s im p le d is t a l t ib ia l a n d
fib u la r fra ct u re —4 3 - C1 799
10 .3 .5 Ar t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l a n d
fib u la r fra ct u re —4 3 - C3 803
10 .3 .6 Co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l
fra ct u re (p ilo n )—4 3 - C3 809
10 .3 .7 Op e n co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l
a n d fib u la r fra ct u re —4 3 - C2 817
10 .3 .8 Bila t e ra l co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l
t ib ia l fra ct u re —4 3 - C3 823
10 .3 .9 Ad o le s ce n t b o n e c ys t—w it h im m in e n t fra ct u re o f t h e
d is t a l t ib ia 8 31
10 .3 .10 Fib u la r fra ct u re w it h m e d ia l liga m e n t o u s
le s io n —4 4 -B2 835
10 .3 .11 Bim a lle o la r fra ct u re w it h m e d ia l le s io n —4 4 -B2 839

78 0
 Au t h o r Th o m a s P Rü e d i

10.3 Tibia and bula, distal

1 In cid e n ce

Fractu res of th e d istal en d of th e tibia AO type 43-A–C—

so-called pilon fractu res—h ave for a lon g tim e been con sid-
ered n ot am en able to operative treatm en t. With th e in tro-
du ction of AO tech n iqu es an d equ ipm en t, it becam e eviden t
a b c
th at on ly an atom ical recon stru ction of th e articu lar su rface
an d correct align m en t of th e axis, togeth er w ith rigid xa- Fig 43-A Extraarticu lar fractu res.
10 .3 -1a – c
tion , wou ld perm it satisfactory resu lts to be obtain ed in th e a 43-A1 sim ple
lon g-term . Today, n on operative treatm en t m ay be con sidered b 43-A2 wedge
in m in im ally d isplaced fractu res on ly. c 43-A3 com plex

Alth ou gh th e m ajority of low-en ergy in ju r ies from sports

acciden ts were origin ally treated by em ergen cy ORIF, a sim i-
lar approach to h igh -en ergy road traf c in ju r ies associated
w ith severe soft-tissu e lesion s often resu lted in ser iou s com -
plication s an d d isability. Today th e m ajority of com plex pilon
fractu res are th erefore treated in two or m ore steps or stages,
wh ich perm its n ot on ly th e appropriate tim in g accord in g to a b c
th e soft-tissu e recover y bu t also carefu l preoperative evalu a-
Fig 43-B Partial articu lar fractu res.
10 .2 -2 a – c
tion (in clu d in g CT scan) an d detailed plan n in g.
a 43-B1 pu re split
b 43-B2 split-depression
c 43-B3 m u ltifragm en tar y depression
2 Cla s s ifica t io n

Th e Mü ller AO Classi cation gives detailed con sideration to

th e degree of in volvem en t of th e an k le join t.

3 Tre a t m e n t m e t h o d s
a b c

Th e m ost w idely u sed tech n iqu es for th e recon stru ction of
pilon fractu res in volve plates an d screw s, wh ich are applied
accord in g to th e fou r well establish ed AO prin ciples. Altern a-
tively, extern al xators as well as rin g or h ybrid xators h ave
been proposed an d m ore recen tly even special in tram edu llary
n ails w ith very distal in terlockin g possibilities. Th e origin al
Fig 43-C Com plete articu lar fractu res.
10 .2 -3 a – c
a 43-C1 articu lar sim ple, m etaph yseal sim ple
b 43-C2 articu lar sim ple, m etaph yseal m u ltifragm en tar y
c 43-C3 articu lar m u ltifragm en tar y

781
 10 Tib ia a n d fib u la

w ide ex posu re of th e en tire fractu re zon e h as been replaced by

4 Im p la n t o ve r vie w
a m ore lim ited approach to th e recon stru ction of th e articu lar
com pon en ts, com bin ed w ith a slid in g in of th e im plan t for th e
bridgin g of th e m etaph ysis accord in g to th e M IPO tech n iqu e.
Vid e o s a
10 .3 -1, 10 .3 -2 Th e in trodu ction of specially design ed plates w ith com bin a-
tion h oles (LCP) an d lock in g h ead screw s (LHS) th at provide
b
an gu lar stability h as con siderably exten ded th e possibilities
of platin g. Fu rth erm ore, th e risk of secon dary displacem en t
h as been m in im ized, wh ile th e n eed for can cellou s au tograft c
cou ld be redu ced. Th e actu al ch oice of im plan t depen ds ver y
mu ch on th e fractu re pattern , th e size of th e distal fragm en ts
d
an d th e location of th e m ajor im paction . Neverth eless th e cor-
rect tim in g of su rgery an d carefu l soft-tissu e h an d lin g are th e
e
m ost im portan t an d decisive factors for su ccess or failu re of
an y su rgical procedu re in th e d istal tibia. Preoperative plan -
n in g an d sk illfu l su rgery are n ext in im portan ce.

Fig 10 .3 -4 a – i
a LCP 3.5
b LCP recon stru ction plate 3.5
c LCP T-plate 3.5
d – e LCP m etaph yseal plate 3.5/4.5/5.0 for d istal tibia
f LCP pilon plate 2.7/ 3.5
g LCP on e-th ird tu bu lar plate 3.5
h LCP d istal m ed ial tibial plate 3.5
i LCP an terolateral d istal tibial plate 3.5

782
 10 .3 Tib ia a n d fib u la , d is t a l

5 Su gge s t io n s fo r fu r t h e r re a d in g

Bast ian L, Blau t h M , Th e rm an n H e t al (1995) [ Variou s th erapy

con cepts in severe fractu res of th e tibial pilon (type C in ju ries).
A com parative stu dy]. Unfallchirurg; 98 (11):551-558
Be ck E (1993) Resu lts of operative treatm en t of pilon fractu res.
In :Tsch ern e H, Sch atzker J, editors. Major Fractu res of th e Pilon ,
th e Talu s an d th e Calcan eu s. Berlin Heidelberg New York: Sprin ger-
Verlag, 49-51.
Blau t h M , Bast ian L, K re t t e k C, e t al (2001) Su rgical option s for
th e treatm en t of severe tibial pilon fractu res: a stu dy of th ree
tech n iqu es. J Orthop Trauma; 15(3):153 –160.
Cru t ch e ld EH , Se ligso n D , He n ry SL e t al (1995) Tibial pilon
fractu res: a com parative clin ical stu dy of m an agem en t tech n iqu es an d
resu lts. Orthopedics; 18 (7):613-617
Tre n t z O, Frie d l H P (1993) Critical soft- tissu e con dition s in pilon
fractu res. In : Tsch ern e H, Sch atzker J, ed itors. Major Fractu res of th e
Pilon , th e Talu s an d th e Calcan eu s. Berlin Heidelberg New York:
Sprin ger- Verlag, 59-64.

783
 10 Tib ia a n d fib u la

78 4
 Au t h o r Ch ris t ia n Ryf

10.3.1 Extraarticular sim ple distal tibial and bular

fracture —43 -A1
1 Ca s e d e s crip t io n In d ica t io n

60-year-old m an fell wh ile sk iin g an d Th e p a tie n t su ffe re d a co m p le te lo w e r le g

su stain ed a d istal tibial an d bu lar sh aft fra ctu re . Afte r d e cre a se d so ft-tissu e sw e llin g,
fractu re. th e fra ctu re wa s o p e ra te d o n .

Fig 10 .3 .1-1a – b
a AP view.
b Lateral view.

a b

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
1 Su rge o n
• •LCP
An tib
m eiotatics:
p h yse
sinagle
l p la
d otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio n
2 ORP
5ce
+ p13
h a lo
h ospleos rin .
3 1st a ssistan t
• •On
Thero-th
mirdb o sis
tu bpuro
la pr hpyla
la texis:
, 5 Lo
h owle ms o le cu la r h e p a rin .
• Lo ckin g h e a d scre w s (LHS)
Ste rile a re a
• 3 .5 m m co rte x scre w s
• 4 .0 m m ca n ce llo u s b o n e scre w s
1
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.) a b

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 10 .3 .1-2 a – b Pa tie n t in su p in e

An tib io tics: sin gle d o se 2 n d ge n e ra tio n p o sitio n . To u rn iq u e t o n th e fe m u r. Ma rk b
2
ce p h a lo sp h o rin th e p la n n e d in cisio n s . 3
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r
h e p a rin

785
 10 .3 Tib ia a n d fib u la , d is t a l

2 Su rgica l a p p ro a ch

a b c

Fig 10 .3 .1-3 a – c
a In a rst step, th e bu la is redu ced
an d xed to determ in e th e correct
lower leg len gth . Th e in cision is m ade
d irectly over th e fractu re zon e.
b Th e d istal in cision is m ade over th e c Th e proxim a l in cision is localized
m edial m alleolu s to allow redu ction d irectly over th e prox im al part of
an d th e in sertion of th e m etaph yseal th e plate for xation .
plate.

3 Re d u c t io n —fib u la

Th e d istal fragm en t of
Fig 10 .3 .1-4 a – b
th e bu lar fractu re is lifted sligh tly. Th e
fractu re is th en redu ced an atom ically
an d h eld in position w ith th e poin ted
redu ction forceps.

a b

4 Re d u ct io n —t ib ia

After com plete redu c-

Fig 10 .3 .1-5 a – b
tion an d plate xation of th e bu la, th e
tibia is redu ced u n der im age in ten si er
con trol w ith th e poin ted redu ction for-
ceps.

a b

78 6
 10 .3 .1 Ext ra a r t icu la r s im p le d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -A1

5 Fixa t io n —fib u la

a b c

Fig 10 .3 .1-6 a – c
a A rst an teroposterior screw secu res b–c For th e de n itive xation a on e-th ird tu bu lar plate is an atom ically preben t
th e redu ced bu lar fractu re. an d screwed on to th e bon e, h old in g th e fractu re stable for th e fu rth er tibial
osteosyn th esis.

6 Fixa t io n —t ib ia

a b c

Fig 10 .3 .1-7a – c
a A 5 + 13-h ole m etaph yseal LCP is b Distal xation of th e plate w ith c Proxim al lock in g h ead screw s are
in serted from d istal to prox im al. Th e lock in g h ead screw s an d cortex u sed to x th e plate on to th e bon e.
rm ly attach ed drill sleeve in th e screw s.
m ost distal h ole is u sed as a h an dle
to gu ide th e plate.

787
 10 .3 Tib ia a n d fib u la , d is t a l

7 Re h a b ilit a t io n

Addition al im m obilization : n on e.
Weigh t bearin g: 15 kg for 6 weeks; h alf body weigh t after
8 weeks.

Im p la n t re m o va l
Im plan t rem oval n ot before 12 –18 m on th s.

8 Pit fa lls – 9 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e LCP m etaph yseal plate 3.5/4.5/5.0, for d istal tibia is
an atom ically presh aped an d ts th e distal en d of th e tibia.
Th e u se of lock in g h ead screw s sim pli es th e m in im ally
in vasive procedu res becau se th e plate does n ot h ave to be
an atom ically con tou red. Th e d istal m etaphyseal LCPs are
ideal for osteosyn th esis of th e d istal tibia, particu larly if
th e join t block is sm all.

Ap p ro a ch Ap p ro a ch
M in im ally in vasive plate osteosyn th esis (M IPO) preserves
th e soft tissu es an d redu ces th e risk of iatrogen ic vascu lar
dam age at fractu re level.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Precise an atom ical redu ction an d stable xation (of th e
bu lar fractu re) w ith a lag screw an d protection plate facil-
itates th e d irect percu tan eou s redu ction of th e tibia an d
its tem porar y reten tion w ith poin ted redu ction forceps.
After redu ction , locked splin tin g u sin g th e M IPO tech -
n iqu e is easy.

Lock in g h ead screw s en able good xation of th e plate,

particu larly in th e m etaph yseal area.

A lon g in tern al xator is m an datory for locked splin tin g.

78 8
 Au t h o rs Ga b rie le St re ich e r, An d re a s Gru n e r, Th o m a s J Ho cke r t z, He in rich Re ilm a n n

10.3.2 Extraarticular we dge distal tibial and bular

fracture —43 -A2
1 Ca s e d e s crip t io n

67-year-old wom an w ith in ju ry to th e d istal tibia.

Type of in ju ry: low-en ergy trau m a, m on otrau m a, closed
fractu re.

Fig 10 .3 .2 -1a – b
a AP view.
b Lateral view.

In d ica t io n
Gro ss a xia l m a la lign m e n t a n d in sta b ilit y o f th e fra ctu re o f th e d ista l
a b tib ia , im m in e n t risk o f in co rre ct lo a d in g o f th e a n kle jo in t.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP m e ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 ,•5An
+ tib
4 hiootics:
le s sin gle d o se 2 n d ge n e ra tio n
• 5 .0 m m lo ckin g h e a d scre w s (LHS) ce p h a lo sp o rin .
• 3 .5 m m LHS • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• 4 .5 m m co rte x scre w (re d u ctio n to o l)
• 2 .0 m m K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n
ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .3 .2 -2 Su p in e p o sitio n w ith e le va tio n o f th e

le g to b e o p e ra te d o n a n d sligh t b e n d in g o f th e kn e e
jo in t.

78 9
 10 .3 Tib ia a n d fib u la , d is t a l

2 Su rgica l a p p ro a ch

Fig 10 .3 .2 -3 M ake an in cision approx im ately 4 –5 cm lon g an terom ed ially

at th e in n er m alleolu s an d dissect to th e periosteu m . Prepare th e plate
bed alon g th e m ed ial tibial crest from d istal to proxim al w ith th e bon e
rasp. Make a cou n ter-in cision over th e prox im al en d of th e plate th rou gh
wh ich to in sert th e screw s.

3 Re d u ct io n

a b c d

Fig 10 .3 .2 -4 a – d
a Preben d th e plate an d in sert it from d istal to prox im al in to th e plate bed.
b – c After approxim ate redu ction an d tem porar y xation of th e plate w ith a K-w ire, th e fragm en t an d
plate can be align ed w ith a cortex screw (redu ction screw).
d Situ ation after redu ction : th e bon e is in correct axial align m en t adjacen t to th e plate. Fixation can
n ow start.

79 0
 10 .3 .2 Ext ra a rt icu la r w e d ge d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -A2

4 Fixa t io n

a b c d

Fig 10 .3 .2 -5 a – d
a – c Th e LHS are in serted altern ately in to th e distal an d proxim al plate h oles.
d In th is way, bridgin g of th e fractu re zon e is ach ieved; th e screw h oles in th e im m ed iate
vicin ity of th e fractu re are left em pty. Th e cortex redu ction screw is rem oved.

a b c d e f

Fig Postoperative x-rays.

10 .3 .2 -6 a – f
a AP ax is view. d Lateral axis view.
b AP view. e Lateral view.
c An k le join t cen tered, AP view. f An kle join t cen tered, lateral view.

791
 10 .3 Tib ia a n d fib u la , d is t a l

5 Re h a b ilit a t io n

Addition al im m obilization : lower lim b plaster cast u n til

Im p la n t re m o va l
de n itive h ealin g.
Rem ove th e plate th rou gh a sm all in cision in th e region of th e
Weigh t bearin g: h alf body weigh t after 4 weeks, fu ll weigh t
previou s approach es.
bearin g after 6 weeks.
Reason for im plan t rem oval: th e im plan t was cau sin g m ech an -
Ph ysioth erapy: from th e secon d postoperative day.
ical irritation of th e in n er m alleolu s.
Ph arm aceu tical treatm en t: n on steroid an tiin am m atory
dru gs.

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In correct preben d in g of th e plate. Application of an LCP m etaph yseal plate for th e d istal
tibia (an atom ically precon tou red plate) or a m etaph yseal
LCP (easier to presh ape th an an LCP 4.5/5.0) facilitates
better adaptation to th e sh ape of th e bon e.

Ap p ro a ch Ap p ro a ch
In ju r y to th e saph en ou s vein an d n erve if th e approach is Preser vation of soft tissu e in th e region of th e fractu re
too far on th e ven tral side of th e in n er m alleolu s. du e to a m in im ally in vasive approach .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In correct position in g of th e plate, especially in th e lateral In traoperative x-ray con trols to en su re th at th e plate
plan e. is correctly position ed in th e lateral plan e.
Fin al redu ction in th e fron tal plan e w ith a cortex
screw —pu lls th e bon e on to th e plate (redu ction screw).

Re h a b ilit a t io n Re h a b ilit a t io n
Early m obilization w ith partial load in g is possible.

792
 Au t h o r Ch ris t o p h So m m e r

10.3.3 Partial articular m ultifragm e ntary distal tibial

fracture (pilon)—43 -B3
1 Ca s e d e s crip t io n

c d e

a b f g h

Fig 10 .3 .3 -1a – k
a AP view.
b Lateral view.
c– h 2D-CT recon stru ction .
i– k 3D-CT recon stru ction
sh ow s th e fractu re
of th e an ter ior sem i-
circu m feren ce in
a better way.

i j k

29-year-old wom an slipped wh ile icefall clim bin g. Sh e fell approx im ately 5 m an d su ffered a
h yperexten sion in ju ry to th e u pper an k le join t. Th e x-ray sh owed an articu lar tibial fractu re
w ith ou t a fractu re of th e bu la (43-B3.2). Th e an terior tibial join t su rface was im pacted an d
h ad fractu red in to m u ltiple fragm en ts, an d both th e an terolateral an d th e an terior parts of th e
m edial m alleolu s were fractu red.

793
 10 .3 Tib ia a n d fib u la , d is t a l

In d ica t io n Pre o p e ra t ive p la n n in g

Be ca u se o f th e in co n gru e n t jo in t, th is fra c- Eq u ip m e n t
tu re is a n a b so lu te in d ica tio n fo r a n o p e ra - • LCP p ilo n p la te 2 .7/ 3 .5 , 6 h o le s
tive p ro ce d u re . With o n ly sligh t m a la lign m e n t • Lo ckin g h e a d scre w s (LHS)
a n d n o su b lu xa tio n o r d islo ca tio n , a o n e - • 3 .5 m m co rte x scre w
sta ge p ro ce d u re ca n b e p e rfo rm e d . Th is • 1.2 m m K-w ire s 1 Su rge o n
o p e ra tio n is b e st d o n e 5 –10 d a ys a fte r in ju ry. • La rge d is tra cto r 2 ORP
Th is m u ltifra gm e n ta ry fra ctu re ca n n o t b e (Size o f s yste m , in stru m e n ts, a n d im p la n ts
3 1st a ssista n t
re d u ce d clo se d ( in su f cie n t liga m e n to ta xis ca n va ry a cco rd in g to a n a to m y.)
fo r im p a cte d a rticu la r fra gm e n ts), a n d 1 Ste rile are a
re q u ire s a n o p e n p ro ce d u re . Give n th is fra c- Pa t ie n t p re p a ra t io n a n d p o s it io n in g
tu re p a tte rn , a n a n te rio r im p la n t is id e a l An tib io tics: sin gle d o se 2 n d
to h o ld th e a n te rio r jo in t rim . Th e n e w ge n e ra tio n ce p h a lo sp o rin
p ilo n LCP 3 .5 is id e a l o r, a lte rn a tive ly, a Th ro m b o sis p ro p h yla xis: lo w -
d o u b le p la te o ste o s yn th e sis w ith co n ve n - m o le cu la r h e p a rin
tio n a l p la te s co u ld b e u se d (t wo o n e -th ird
2 3
tu b u la r p la te s 3 .5). Ca n ce llo u s b o n e gra ftin g
m a y b e n e ce ssa ry d e p e n d in g o n th e size o f
Fig 10 .3 .3 -2 Po sitio n in g o f OR te a m .
th e m e ta p h yse a l d e fe ct a n d th e im p a cte d
fra gm e n ts.

2 Su rgica l a p p ro a ch 3 Re d u ct io n a n d fixa t io n

Fig 10 .3 .3 -4Th e optim al tim e for th is

operation was after seven days (sk in
w rin k les were visible). First th e large
distractor is position ed on th e tibial
Fig 10 .3 .3 -3On ly on e an terom ed ial approach is n ecessar y ( bu la in tact). Th is sh aft an d th e talu s n eck. Th e talu s is
approach h as to be lon g en ou gh for adequ ate open join t redu ction , bu t does n ot pu lled in a cau dal an d posterior direc-
h ave to be exten ded to th e fu ll len gth of th e plate, wh ich can be in serted retrograde tion u n der d istraction to allow a good
to th e d iaphysis. view in to th e an k le join t.

79 4
 10 .3 .3 Pa r t ia l a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re (p ilo n )—4 3 -B3
3 Re d u c t io n a n d fixa t io n (co n t )
a 1 b c
6 7
d e
Fig 10 .3 .3 -5 a – o
a Th e approach ( 2 ) is straigh t an d ru n s from th e an terior
tibial m argin to th e base of th e n avicu lar bon e. Th e large
d istractor is still in place (1 ).
b – c Th e an terom edial fragm en t is h eld m ed ially ( 3 ) an d th e
an terolateral fragm en t (4 ) is h eld laterally. Now th e large
im pacted m ain fragm en t can be seen . Th is fragm en t is
rem oved an d tem porarily set aside ( 5 ).
d – e The sm all im pacted central fragment is reduced an at-
om ically u nder vision onto the posterior joint rim . Now
the large im pacted fragment, th at h ad previou sly been
removed, is reduced an atom ically onto the central, poste-
rior fragment and held by a K-w ire in serted in an anterior
3
4
8
f g
to posterior direction ( 6 ). In the next step, the anterome-
dial and the anterolateral fragments are rotated back to
their an atom ical position s ( 7, 8 ). To do th is, distraction
w ith the large distractor mu st be interru pted becau se these
two fragments are attached at the joint capsu le. These two
fragments are held in their an atom ically correct position s
w ith the help of the Weber forceps.
f– g K-w ires are in serted for fu rth er stabilization . Im age
in ten si cation im ages sh ow th e correct redu ction of th e
join t su rfaces. With th is good qu ality of bon e an d th e
sm all m etaph yseal defect zon e, can cellou s bon e graftin g
is n ot n ecessary.
795
 10 .3 Tib ia a n d fib u la , d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

11

12 18
10
14
13 17
9
15
16

h i j k

l m n o

Fig 10 .3 .3 -5 a – o (co n t)
h – i A 6-h ole LCP pilon plate 2.7/ 3.0 is cu t d istally to t th e
bon e. Th e lateral sides of th e plate w ill h old th e an tero-
lateral fragm en t an d th e m ed ial m alleolu s. Th e plate
is ben t so th at th e m idd le part of th e plate is n ot tou ch in g
th e bon e ( 9 , 10 , 11 ). A 3.5 m m cortex screw is in serted
prox im al to th e fractu re, thu s com pressin g th e frag-
m en ts w ith th e in ferior en d of th e plate (12 , 13 , 14 ).
j– k Lock in g h ead screw s are n ow in serted in to th e join t
block to h old th e an atom ical redu ction in place (15 ). A
screw is in serted in to th e m ost prox im al h ole (16 ) an d
th e rst screw is exch an ged for a lock in g h ead screw to
redu ce th e pressu re on th e periosteu m (17, 18 ).
l– o Th e x-ray con trol at th e en d of th e operation con rm s
th e an atom ical redu ction an d th e correct position of th e
screw s an d plate. Two cen tral lock in g h ead screw s are
ver y n ear to th e join t su rface. To exclu de pen etration of
th e join t su rface, an x-ray in th e d irection of th e screw s
can be obtain ed. Th is view w ill sh ow screw position in
relation to th e join t.

79 6
 10 .3 .3 Pa r t ia l a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re (p ilo n )—4 3 -B3
3 Re d u c t io n a n d fixa t io n (co n t )
a b
Th e postoperative x-rays sh ow good an at o-
Fig 10 .3 .3 -6 a – d
m ical redu ction an d stabilization of th e pilon fractu re.
4 Re h a b ilit a t io n
a b
c d
Mobilization begin s after wou n d h eal-
in g on th e 1–5 postoperative day w ith
toe-tou ch weigh t bearin g (10 –15 kg).
Early fu n ction al an d active m ovem en t
m u st be started.
Fig 10.3.3 -7a– d
a– b 6 weeks after su rger y, th e fractu re
is practically con solidated an d th e
im plan t is in th e correct position ;
weigh t bearin g can be in creased to
30 kg.
c– d After 11 weeks, th e fractu re is
com pletely con solidated. Osteope-
n ia du e to partial weigh t bearin g
w ill dim in ish rapidly. Th ere were
n o fu rth er problem s an d th e plate
cou ld be rem oved after 11 m on th s
c d w ith good ran ge of m otion .
797
 10 .3 Tib ia a n d fib u la , d is t a l

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
If th e plate is bad ly ben t, irritation of th e exten sor ten don s Th e LCP pilon plate is an ideal plate for th e treatm en t of
can occu r. an terior sem icircu lar m u ltifragm en tary fractu res.

Ap p ro a ch Ap p ro a ch
An approach too far m edially cou ld com plicate th e An an terior or an terom ed ial approach is ideal for th e
redu ction of th e an terolateral fragm en t an d th e in sertion treatm en t of th ese fractu res.
of th e plate.

Re d u ct io n a n d xa t io n
In su f cien t redu ction an d xation of th e an terolateral
fragm en t provokes in stability of th e an k le join t w ith post-
trau m atic osteoarth ritis. Th e sam e can h appen du e to
a bad ly redu ced cen tral fragm en t.
Re d u ct io n a n d xa t io n
Th e large distractor is a h elpfu l in stru m en t for th e
prelim in ar y d istraction of fractu res an d allow s a good
view of th e tibial join t su rface. Th e 2.7 m m lock in g
h ead screw s are ideal for m u ltifragm en tar y an d ver y
d istal pilon fractu res.

Re h a b ilit a t io n Re h a b ilit a t io n
Fu ll weigh t bearin g too early can red isplace th e Early fu n ction al m ovem en t is u su ally possible in all
fragm en ts an d/or lead to an im plan t failu re. Th e screw s stabilized fractu res wh ere su f cien t prim ary stability h as
m ay cu t th rou gh th e join t in osteoporotic bon e. been ach ieved.

79 8
 Au t h o r Ch ris t o p h e r W Ge e l

10.3.4 Com ple te articular sim ple distal tibial and

bular fracture —43 -C1
1 Ca s e d e s crip t io n

68-year-old-m an h as a left pilon fractu re du e to fallin g off a

ladder. Type of in ju ry: low-en ergy, m on otrau m a, closed frac-
tu re.

Fig 10 .3 .4 -1a – b
a AP view.
b Lateral view.

In d ica t io n

In su lin d e p e n d e n t d ia b e tic w ith a rticu la r fra ctu re w ith p roxim a l

e xte n sio n . Mo d e ra te o ste o p o ro tic b o n e . Ve ry a ctive life st yle w ith
a b d a ily wa lkin g.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• LCP d ista l tib ia l p la te 2 .7/ 3 .5 , m e d ia
• l,An8tib
h oioletics:
s sin gle d o se 2 n d ge n e ra tio n ce p h a lo -
• Lo ckin g h e a d scre w s (LHS) sp o rin .
• 3 .5 m m co rte x scre w • Th ro m b o sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .3 .4 -2 Su p in e o n a ra d io lu ce n t o p e ra tin g ta b le .
Im a ge in te n si ca tio n , co n tra la te ra l, p e rp e n d icu la r to ta b le
a xis .

79 9
 10 .3 Tib ia a n d fib u la , d is t a l

2 Su rgica l a p p ro a ch

Fig 10 .3 .4 -3 a – b
a Cu r vylin ear a n terom ed ia l m alleolu s in cision
w ith preser vation of th e greater saph en ou s
vein .
b Preparation of th e fu tu re plate position u sin g a
w ide Cobb elevator to tu n n el su bcu tan eou sly;
preser vation of th e periosteu m .
a b

3 Re d u ct io n

Closed redu ction w ith traction u n der im age in ten si cation .

Fig 10 .3 .4 -4 Place plate an d verify its proper position by m ak in g on add ition al 2.5
cm lon g in cision prox im a lly.
First, xation of th e plate distally to h ave an an ch or to aid redu ction .
Fin ish in g th e redu ction w ith th e plate an d pu sh -pu ll screw proxim ally in th e last
lock in g screw h ole.
Verify th e redu ction an d th e plate position u n der im age in ten si er in AP an d lateral
view.

4 Fixa t io n

a b c

To en su re an atom ical join t recon stru ction , rst x th e LCP Fig 10 .3 .4 -5 a – c

d istal tibial plate 2.7/ 3.5 m ed ial, 8 h oles d istally.
Use a secon d plate as a tem plate th at is placed on th e sk in so
th at th e in sertion sites for both th e lock in g an d con ven tion al
screw s can be m arked w ith a m arker pen .
Stab in cision at desired lock in g or stan dard h ole.
a In sert d rill gu ide an d ch eck its proper align m en t in th e
lock in g h ole.
b – c After drillin g m easu re len gth u sin g th e depth gau ge an d
in sert th e lock in g h ead screw w ith torqu e lim iter.

800
 10 .3 .4 Co m p le t e a r t icu la r s im p le d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -C1

4 Fixa t io n (co n t )

Fig 10 .3 .4 -6 a – d
a – b Fin al xation an d evalu ation w ith im age in ten si er in
AP an d lateral view s, in clu d in g th e m ortise view. To
im prove stability, place screw s as far an d as n ear to th e
fractu re site as possible.
c– d Percu tan eou sly drill an d in sert an 3.5 m m cortex screw
(len gth 85 m m ) u n der im age in ten si er gu idan ce to sta-
bilize th e tran sverse d istal bu lar fractu re.

a b

c d

5 Re h a b ilit a t io n

Addition al im m obilization : u -splin t.

Weigh t bearin g: 15 kg for 4 weeks; h alf body weigh t after
8 weeks; fu ll weigh t bearin g after 12 weeks.
Ph ysioth erapy: startin g on e day postoperatively.
Ph arm aceu tical treatm en t: codein e.

Fig 10 .3 .4 -7a – c Postoperative x-rays after 8 weeks.

a AP view.
b Lateral view.
c Overview.

a b c

8 01
 10 .3 Tib ia a n d fib u la , d is t a l

5 Re h a b ilit a t io n (co n t )

Fig 10 .3 .4 -8 a – b Postoperative x-rays after 12 m on th s.

a AP view.
b Lateral view.

a b

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Fig 10 .3 .4 -9Osteoporotic an d osteo-
pen ic bon e requ ires lon g plates
an d bicortical lock in g h ead screw s.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Placem en t of screw s: as close an d as far away
from th e fractu re site provides adequ ate stability.

Re h a b ilit a t io n Re h a b ilit a t io n
Fig 10 .3 .4 -10Percu tan eou s xation
requ ires n o com prom ise in th e
redu ction of articu lar fractu res.

802
 Au t h o rs Mich a e l J Ga rd n e r, De a n G Lo rich , Da vid L He lfe t

10.3.5 Articular m ultifragm e ntary distal tibial and bular

fracture —43 -C3
1 Ca s e d e s crip t io n

c d e

Fig 10 .3 .5 -1a – e
ac AP view.
b Lateral view.
c– e Axial, coron al, an d sagittal CT scan s detail th e articu lar
a b fragm en ts an d m etaph yseal com m inu tion .

55-year-old m an ridin g a slow movin g m otorcycle, when it
slipped out from u nderneath h im and landed on h is right an kle.
He cam e to the emergency departm ent com plain in g of sign i -
cant pain and deform ity. X-rays revealed a right articu lar pilon
fractu re, and an an kle-bridgin g extern al xator was placed
im mediately. There were no associated in ju ries.
Moderate soft-tissu e swellin g was presen t w ith fractu re blis-
ters an teriorly an d m ed ially w h ich persisted for 15 days before
th e soft tissu es were su itable for su rgery. Th ere was n o evi-
den ce of n eu rovascu lar com prom ise.

In d ica t io n Pre o p e ra t ive p la n n in g

Th e in traa rticu la r d isp la ce m e n t a n d im p a ctio n wa rra n ts a n a to m ica l EqPautip

iem
n te pn re
t p a ra t io n a n d p o s it io n in g
re d u ctio n a n d xa tio n to m in im ize th e risk o f th e d e ve lo p m e n t o f • •LCP
An tib
3 .5io, tics:
9 h osin
le sgle d o se 2 n d ge n e ra tio n ce p h alo -
o ste o a rth ro sis. • LCP
sp ore
rinco . n s tru ctio n p la te 3 .5 , 6 h o le s
In a d d itio n , th e m e ta p h yse a l co m m in u tio n m a ke s th is fra ctu re h igh ly • •LCP
Th rob m
u tbtreo sis
ss p la
rotep h3yla
.5 ,xis:
8 hLo
o lews m o le cu la r h e p a rin .
u n sta b le , a n d wa rra n ts in te rn a l sta b iliza tio n to e n su re a n a to m ica l • Lo ckin g h e a d scre w s (LHS)
a lign m e n t. • 2 .0 m m K-w ire s
• La rge p e lvic re d u ctio n fo rce p s
• La rge d is tra cto r
• Syn th e tic b o n e su b s titu te
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

8 03
 10 .3 Tib ia a n d fib u la , d is t a l

Pre o p e ra t ive p la n n in g (co n t )

Im
Pamt ie
e dniat pt eret preaarat m
t ioe n ta n d p o s it io n in g
An
• tib
Aniotibtics:
io tics:
sin sin
glegle d o se
d o se
2 n d2 nge
d
ge
n enra
e ratiotio
n ncece p hp ahlo
a lo
sp- o rin
Pla sp
ce oarin
n e. xte rn a l xa to r im m e d ia te ly u sin g a tra n s ve rse Sch a n z
scre
• Th wrothmrob uo ghsis th p roe pphroxim
yla xis:a l Lo
tibwia ma no dle cu
th ela ca
r hlca
e p na erin
u s.
. Th is a llo w s
gro ss a lign m e n t o f th e fra ctu re fra gm e n ts b y liga m e n to ta xis.
Ele va te th e p a tie n t ’s le g fo r 10 –14 d a ys u n til th e so ft tissu e s
p e rm it a su rgica l in cisio n , a s ju d ge d b y w rin klin g o f th e skin u p o n
p a lp a tio n .

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
Fig 10 .3 .5 -2 Po sitio n th e p a tie n t su p in e o n th e o p e ra tin g ta b le ,
p la ce a to u rn iq u e t o n th e u p p e r th igh , p re p a re a n d d ra p e th e le g
fre e , a n d p o sitio n th e im a ge in te n si e r to e n su re a d e q u a te AP
a n d la te ra l vie w s .

2 Su rgica l a p p ro a ch

Fig 10 .3 .5 -3 Make an in cision directly over th e bu la laterally, from th e lateral

m alleolu s an d exten d in g approxim ately 20 cm proxim ally.
Dissect to th e level of th e fascia of th e peron eal m u scles. Iden tify an d protect th e
su per cial peron eal n erve as th e in cision exten ds prox im ally.
Con tinu e an terior to th e peron eal m u scles to expose th e bu la, an d th en follow th e
in terosseou s m em bran e an d an terior in ferior tibio bu lar ligam en t (AITFL) m ed i-
ally to th e lateral border of th e tibia. Take care to preserve th e soft-tissu e attach -
m en ts, to th e Ch apu t fragm en t, in clu d in g th e AITFL.
Elevate th e an terior com partm en t m u scles su bperiosteally. Take care n ot to stray
in to th e an terior com partm en t to avoid dam age to th e an terior tibial n eu rovascu lar
bu n dle. Th e bu la an d an terior an d lateral tibia are n ow exposed.
For percu tan eou s application of th e LCP bu ttress plate, m ake a 3 cm in cision over
th e m ed ial m alleolu s exten d in g d istally past th e tip. Make a secon d 3 cm in cision
proxim ally, cen tered on th e tibia in th e lateral view, over wh ere th e plan n ed site for
th e prox im al en d of th e plate. Place th e plate over th e sk in as a rou gh gu ide for
placem en t. Gen tly slide ton sil clam ps from each in cision towards th e oth er to
blu n tly develop th e epiperiosteal space. Attach a th readed drill gu ide to th e d istal
en d of th e plate for u se as an in sertion h an d le, an d slide th e plate su bcu tan eou sly
u p th e m ed ial tibia.

804
 10 .3 .5 Ar t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -C3

3 Re d u ct io n a n d fixa t io n

a b c

Fig 10 .3 .5 -4 a – f
a Rem ove th e extern al xator an d place th e large
d istractor on th e sam e Sch an z screw s, both
m ed ially an d laterally. Position th e th readed
bars poster iorly to elevate th e leg off th e table.
b First, redu ce an d stabilize th e bu la u sin g a
straigh t LCP. If com m in u tion ex ists an d th e
bu la is sh orten ed, a pu sh -pu ll tech n iqu e m ay
be u sed w ith a lam in ar spreader an d a screw
ou tside th e plate to aid redu ction . Extrem e care
m u st be taken to ach ieve an atom ical redu ction
of th e bu la, as th is w ill u ltim ately affect redu c-
tion of th e tibia.
Next, iden tify th e an terolateral key tibial frag-
m en t. Th is Ch apu t tu bercle fragm en t is fre-
qu en tly large an d attach ed to an in tact an terior tibio bu lar ligam en t.
Follow in g redu ction of th e bu la, th is m ay be rou gh ly redu ced to th e
tibia.
Hin ge th e Ch apu t fragm en t an teriorly to iden tify th e posterior Volk-
m an n fragm en ts. Th ese m ay be visu alized directly an d redu ced an d
stabilized. Th is step is critical in ach ievin g an atom ical articu lar
redu ction .
c Next, in sert th readed K-w ires in to th e Ch apu t tu bercle to u se as joy-
sticks. Redu ce th e tu bercle d irectly u sin g th e talu s as a m old, an d
stabilize it provision ally w ith K-w ires. Assess redu ction u n der im age
in ten si cation .
Disim pact an y add ition al articu lar fragm en ts from th e m etaph yseal
defect.

8 05
 10 .3 Tib ia a n d fib u la , d is t a l
3 Re d u c t io n a n d fixa t io n (co n t )
d e
Fig 10 .3 .5 -4 a – f (co n t)
d Con tou r a lockin g recon stru ction plate 3.5, an d secu re it to
th e an terolateral su rface of th e tibia.
Most h igh -en ergy pilon fractu res w ill h ave som e elem en t
of m etaph yseal im paction . Con rm u n der im age in ten si-
cation th at th e len gth of th e articu lar block h as been
restored. Adju stin g th e fem oral d istractors can im prove
len gth . Place a lock in g h ead screw prox im ally to secu re
th e an terior plate.
e Next, place a LCP bu ttress plate su bcu tan eou sly th rou gh
a sm all d istal in cision . A lag screw m ay be placed if an
obliqu e or spiral fractu re lin e ex ists. Com pression screw s
m ay be directed th rou gh th e plate an teriorly or posteriorly
to captu re th e Ch apu t or Volk m an n fragm en ts, respec-
tively.
806
f Use th e im age in ten si er to determ in e th e location of th e
plate h oles, an d place proxim al lock in g h ead screw s percu -
tan eou sly th rou gh stab in cision s.
Havin g ach ieved overall stability of th e m etaph yseal an d
articu lar fragm en ts w ith th e previou sly placed an terolat-
eral an d m ed ial plates, n e tu n e th e articu lar redu ction
u n der d irect an d im age in ten si er visu alization , an d pro-
vision ally secu re w ith K-w ires. Strategically d irect su b-
ch on dral lag screw s across th e articu lar fragm en ts to
ach ieve u ltim ate xation .
Fill th e m etaph yseal defect w ith iliac crest bon e graft or
syn th etic bon e su bstitu te.
Close th e wou n d over m ediu m su ction drain s. Apply a
sh ort leg plaster splin t in th e operatin g room .
 10 .3 .5 Ar t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -C3

4 Re h a b ilit a t io n

c d

Con tinu e prophylactic an tibiotics for 24 h ou rs.

In itiate deep ven ou s th rom bosis proph ylaxis w ith low-
m olecu lar h eparin .
On postoperative day 2, rem ove th e splin t, ch eck th e
wou n d, an d apply a rigid walk in g boot.

Fig 10 .3 .5 -5 a – d Postoperative x-rays.

a AP view.
b Lateral view.
c– d Ph ysioth erapy sh ou ld com m en ce early, an d in clu de
cru tch or walker train in g, 9 kg tou ch dow n weigh t
bearin g, an d aggressive active an d passive an k le ran ge
of m otion exercises.

a b

8 07
 10 .3 Tib ia a n d fib u la , d is t a l
5 Pit fa lls –
Eq u ip m e n t
If a lock in g plate is ben t th rou gh a h ole, th e lockin g
h ole th reads becom e distorted an d w ill n o lon ger t a
th readed gu ide or lock in g h ead screw.
Ap p ro a ch
Th e su per cial peron eal n er ve is at risk du rin g th e bu lar
approach .
Th e an terior tibial n eu rovascu lar bu n d le m ay be dam aged
wh ile d issectin g across th e in terosseou s m em bran e. Th e
fascial envelope is often d isru pted by th e fractu re an d th e
an atom y is distorted.
Several large vein s are located su bcu tan eou sly alon g th e
m edial side of th e leg an d are at risk wh en m ak in g stab
in cision s.
Re d u ct io n a n d xa t io n
Visu alizin g an d redu cin g th e articu lar fragm en ts m ay
be d if cu lt.
Sign i can t m etaph yseal im paction often exists.
Re h a b ilit a t io n
Som e degree of an k le stiffn ess frequ en tly occu rs follow in g
m u ltifragm en tar y in traarticu lar pilon fractu res.
808
6 Pe a rls +
Eq u ip m e n t
Use stan dard plate ben ders to con tou r th e plate. Plan
wh ich h oles w ill be u sed for lock in g h ead screw s, an d be
certain n ot to ben d th e plate th rou gh th ese h oles. On ly
ben d lock in g recon stru ction plates th rou gh th e n otch es.
Ap p ro a ch
Th e su per cial peron eal n erve pierces th e fascia in
th e lin e of th e lateral in cision as it exten ds prox im ally.
Be aware of its position an d protect it.
As d issection progresses m ed ially, raise th e an terior
com partm en t m u scu latu re su bperiosteally from th e bu la
an d tibia, an d directly from th e in terosseou s m em bran e.
Do n ot stray an teriorly in to th e m u scle bellies to avoid th e
an terior tibial vessels an d n er ve.
Be aware of th ese large vein s, th ey can often be visu al-
ized or palpated th rou gh th e sk in . Make in cision s th rou gh
th e su bcu tan eou s layer, an d spread it gen tly to avoid
in cisin g th e vein s.
Re d u ct io n a n d xa t io n
In order to adequ ately redu ce th e articu lar su rface,
begin posteriorly w ith th e Volk m an n fragm en t. Visu alize
th is by retractin g th e Ch apu t tu bercle. Progress sequ en -
tially in an an terior direction . Stabilize provision ally w ith
K-w ires.
Redu cin g th e bu la an atom ically at rst w ill h elp
estim ate th e appropriate len gth of th e d istal tibia. Use th e
large distractor, an d assess join t lin e obliqu ity to n alize
len gth determ in ation .
Re h a b ilit a t io n
Prior to disch arge, replace th e plaster splin t w ith a
rem ovable r igid cast boot. In itiate early ph ysioth erapy to
assist in aggressive active an d passive ran ge of m otion .
 Au t h o r Ch ris t o p h So m m e r

10.3.6 Com ple te articular m ultifragm e ntary distal tibial fracture

(pilon)—43 -C3
1 Ca s e d e s crip t io n

a b c d

Fig 10.3.6 -1a – g

a AP view in itial x-ray.
b Lateral view in itial
x-ray.
c AP view after prelim i-
n ary xation w ith
tran sarticu lar extern al
xator.
d Lateral view after
prelim in ary xation
w ith tran sarticu lar
extern al xator.
e f g e–g CT scan s.

62-year-old wom an slipped on a ladder an d fell approx im ately
1 m to th e grou n d. Sh e su ffered a d istal articu lar lower leg
fractu re. Th ere was a severe d isplacem en t in th e m etaph yseal
zon e w ith m ajor soft-tissu e in ju ry above th e m edial m alleolu s
(Tsch ern e grade II). Th e articu lar su rface of th e tibia as well
as th e su pram alleolar bu la h ad fractu red in to several frag-
m en ts. Th e valgu s m alalign m en t was redu ced w ith an exter-
n al xator br idgin g th e an kle join t. CT im agin g sh owed a
m u ltifragm en tar y join t fractu re of th e tibia (43-C3) w ith at
least on e large im pacted cen tral fragm en t. Th e an terolateral
fragm en t appeared to be still attach ed to th e d istal bu la by
th e in tact an terior syn desm otic ligam en t.

809
 10 .3 Tib ia a n d fib u la , d is t a l

In d ica t io n

Fig 10 .3 .6 -2 a – b Th is d isp la ce d p ilo n fra ctu re is a n a b so lu te in d ica -

tio n fo r re d u ctio n a n d xa tio n o f th e tib ia a n d th e b u la . Du e to th e
so ft-tissu e in ju ry a n d th e co m p le xit y o f th e fra ctu re , a sta ge d p ro ce -
d u re is a d vise d . First th e fra ctu re is b rid ge d w ith a tra n sa rticu la r
e xte rn a l xa to r u n til th e s we llin g h a s d im in ish e d .

Co n ve n tio n a l d e n itive re co n stru ctio n a cco rd in g to th e AO Prin cip le s

o f Fra ctu re Ma n a ge m e n t co n sists o f fo u r ste p s:
a 1. th e re co n stru ctio n o f th e b u la ,
2 . th e re co n stru ctio n o f th e tib ia l jo in t su rfa ce ,
3 . ca n ce llo u s b o n e gra ftin g a t th e m e ta p h yse a l d e fe ct, a n d
4 . a n te ro m e d ia l p la te o ste o s yn th e sis o f th e tib ia .

Alte rn a tive ly, a p e rcu ta n e o u s scre w o ste o s yn th e sis a n d a h yb rid

xa to r co u ld b e u se d . Ne ve rth e le ss, a m in im a l o p e n jo in t a p p ro a ch is
re q u ire d to re d u ce th e ce n tra l im p a cte d fra gm e n t.
In th is ca se , p rio r xa tio n o f th e tib ia a n d su b se q u e n t xa tio n o f th e
bu la is p re fe ra b le b e ca u se , give n th e m u ltifra gm e n ta ry fra ctu re o f
th e b u la , co rre ct re d u ctio n in le n gth a n d ro ta tio n o f th e b u la w o u ld
b
b e ve ry d if cu lt.

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •On
Anetib
-thioird
tics:
tu bsin
u lagle
r pdlaotese, 42 nhd oge
lens e ra tio n ce p h a lo -
1 Su rge o n
• LCP
sp oT-p
rin .la te 3 .5 , 6 h o le
2 ORP
• •LCP
Th ro3 m
.5 b, 10
o sish op le
rosp h yla xis: Lo w m o le cu la r h e p a rin .
3 1st a ssista n t
• 3 .5 m m se lf-ta p p in g lo ckin g h e a d scre w s (LHS)
• 3 .5 m m co rte x scre w
Ste rile are a
• 1.2 m m a n d 1.6 m m K-w ire s
• La rge We b e r fo rce p s
• La rge d istra cto r
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.) 1

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .3 .6 -3 Po sitio n in g o f OR te a m .
2 3

810
 10 .3 .6 Co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re (p ilo n )—4 3 -C3

2 Su rgica l a p p ro a ch

A sm all an terom ed ial straigh t approach of

Fig 10 .3 .6 -4 a – b
lim ited len gth is m ade in th e d irection of th e an k le join t. Th e
in cision begin s abou t 5 cm cran ial to th e an k le join t over th e
an terior tibial edge in th e d irection of th e talon avicu lar join t.
Th e bridgin g (M IPO) of th e bu la is carr ied ou t in m in im ally
in vasive tech n iqu e. Th e approach is lim ited to th e prox im al
an d d istal en ds of th e plate at th e posterolateral m argin of th e
bu la.

a b

3 Re d u ct io n a n d fixa t io n

a b

Fig 10 .3 .6 -5 a – b
a Th e de n itive stabilization of th e pilon fractu re is perform ed on th e seven th day
after in ju ry. Th e extern al xator is rem oved except for th e Sch an z screw s in th e
calcan eu s an d in th e prox im al tibial sh aft. Th e large d istractor is n ow m ou n ted
on th ese two screw s. Th e an k le join t is redu ced an d d istracted. Th e d istraction
perm its excellen t d irect vision of th e tibial join t su rface.
b Th e an terom ed ial approach is m ade on to th e periosteu m . A lim ited h orizon tal
capsu lotom y is perform ed in a cau dal d irection . Th e an terolateral fragm en t is
h eld aside. Th e periosteu m is h an d led carefu lly an d detach ed m in im ally at th e
fractu re lin es (1–2 m m).

811
 10 .3 Tib ia a n d fib u la , d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

1
4

3
5

a b c

Fig 10 .3 .6 -6 a – n
a Th e im pacted cen tral fragm en t is n ow visible. A 1.2 m m K-w ire is in serted as a joystick
in to th e cen tral fragm en t ( 1 ). With th e h elp of th is joystick, th e fragm en t can be rotated
an d redu ced to its an atom ical position . After correct redu ction , th e K-w ire is drilled in to
th e posterior articu lar fragm en t ( 2 ).
b – c As th is K-w ire preven ts th e redu ction of th e an terolateral fragm en t, it w ill be replaced by
a secon d K-w ire in serted percu tan eou sly over th e m ed ial m alleolu s ( 3 ). Th e recon -
stru cted join t block is n ow n ally redu ced to th e m etaph ysis by a large Weber forceps ( 4 ).
To ach ieve th is, th e distraction over th e large distractor h as to be released.
d Prelim in ar y xation is ach ieved by two 1.6 m m K-w ires in serted from th e m edial m al-
leolu s. Th e an terolateral fragm en t can be redu ced an d tem porarily xed w ith an oth er
K-w ire ( 5 ).

812
 10 .3 .6 Co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re (p ilo n )—4 3 -C3

3 Re d u c t io n a n d fixa t io n (co n t )

11
6

8
7
10

g
e f

Fig 10 .3 .6 -6 a – n (co n t)
e A ben t 4-h ole on e-th ird tu bu lar plate ( 6 ) is placed over th e an terolateral K-w ire ( 7 )
an d on to th e an terolateral tibia. Th e plate is xed rst by in sertion of a 3.5 m m cortex
screw in to th e secon d prox im al h ole. Th e plate pu sh es th e fragm en t again st th e bon e
(an tiglide plate). Now th e an terolateral K-w ire can be rem oved ( 8 ). A 3.5 m m cortex
lag screw is in serted th rou gh th e d istal h ole, com pressin g th e an terolateral syn des-
m otic fragm en t to th e cen tral an d posterior join t fragm en ts ( 9 ).
f Th e K-w ire h old in g th e cen tral fragm en t is n ow rem oved (10 ). An LCP T-plate 3.5 is
ben t an d in serted m ed ially close to th e level of th e join t space (11 ). Th is plate is rst
xed w ith a 3.5 m m cortex screw proxim al to th e fractu re. 3.5 m m self-tappin g LHS
are ch osen for th e m ost distal h oles; th e screw s sh ou ld be as lon g as possible w ith ou t
pen etratin g th e opposite cortex (syn desm osis). Th e h oles are drilled over th e dr ill
sleeves allow in g correct m easu rem en t of ideal screw len gth . Fin ally, th e plate is xed
proxim ally by two fu rth er screw s.
g– h In traoperative x-rays con rm th e an atom ical redu ction an d stable xation of th e h
tibia. Th ey also sh ow th e epiperiosteal position of th e two plates.

813
 10 .3 Tib ia a n d fib u la , d is t a l

3 Re d u c t io n a n d fixa t io n (co n t )

i j k

Fig 10 .3 .6 -6 a – n (co n t)
i– j Th e sm all periosteal “w in dow ” can be seen between th e
two plates. Also, th e lim ited h orizon tal arth rotom y at
th e join t rim level is visible.
k M in im ally in vasive osteosyn th esis (M IPO) of th e bu la
is th e n al step. A sligh tly con tou red 10 -h ole LCP 3.5 is
in serted from d istal to prox im al th rou gh th e sm all in ci-
sion s m en tion ed earlier. First th e plate is xed w ith an
LHS in th e d istal fragm en t. Th e correct len gth of th e
bu la is assessed u n der im age in ten si cation . Su bse-
qu en tly, a 3.5 m m cortex screw xes th e plate tigh tly to
th e prox im al sh aft fragm en t.
l After correct axial align m en t h as been ach ieved an d
con rm ed in th e lateral view, de n itive xation w ith
LHS prox im ally an d d istally is perform ed. Th e clin ical
appearan ce before sk in closu re is sh ow n .
m – n Th e postoperative x-rays two days after su rgery sh ow
an atom ical redu ction an d stable xation of th e tibia
w ith a con gru en t an k le an d correct ax ial align m en t.
Th e bu la is also correct in len gth .
m n

814
 10 .3 .6 Co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re (p ilo n )—4 3 -C3

4 Re h a b ilit a t io n

Th e sk in lesion above th e m ed ial m alleolu s developed in to a d ry n ecrosis

of abou t 2 cm an d h ad to be treated w ith a fasciocu tan eou s ap. For
th is reason , th e an k le was stabilized w ith a rem ovable h in ged splin t
for 6 weeks. Mobilization started two weeks after th e operation w ith
0 –15 kg weigh t bearin g, ch an ged to fu ll loadin g after 3 m on th s. Th e tibia
was fu lly con solidated after 4 m on th s w ith still on goin g bon e h ealin g of
th e bu la.

Fig 10 .3 .6 -7a – b Postoperative x-rays after 4 m on th s.

a AP view.
b Lateral view.

a b

a b d

Th e m ed ial plate was rem oved 1 year after su rger y on th e requ est of th e
Fig 10 .3 .6 -8 a – d
patien t. Scar correction was perform ed at th e sam e tim e. Th e x-rays at th is poin t sh ow a fu lly
con solidated tibia an d bu la an d n o sign s of posttrau m atic osteoarth ritis. Fu ll ran ge of m otion
was presen t at th at tim e an d th e sk in lesion h ad h ealed.

815
 10 .3 Tib ia a n d fib u la , d is t a l
5 Pit fa lls –
Eq u ip m e n t
Ap p ro a ch
A too sm all in cision for th e tibia cou ld com plicate or
even preven t an an atom ical join t redu ction . A too w ide
ex posu re cou ld provoke sk in n ecrosis.
Re d u ct io n a n d xa t io n
Dou ble plate osteosyn th esis is on ly recom m en ded
w ith low pro le plates. In th e presen ce of join t in con gru -
en ce, posttrau m atic arth rosis m ay occu r. Th e xation
of th e articu lar part h as to be absolu tely stable—u sin g th e
com pression m eth od w ith lag screw s an d bu ttress platin g.
If n ot, osteon ecrosis, m ain ly of th e cen tral fragm en t,
m ay becom e m an ifest.
Tim in g is cru cial: if th e ORIF is perform ed too early,
wou n d h ealin g problem s m ay occu r.
Re h a b ilit a t io n
If m obilized too early or w ith too m u ch weigh t, secon dar y
collapse an d/or im plan t failu re can occu r.
816
6 Pe a rls +
Eq u ip m e n t
An gu lar stable screw-plate system s su ch as th e LCP
are ideal for com plex pilon fractu res. M IPO tech n iqu e is
facilitated by th ese im plan ts.
Ap p ro a ch
A lim ited open approach to th e tibia offers th e possibility
of correct an atom ical redu ction w ith a lim ited risk of
wou n d h ealin g problem s. A m in im ally in vasive approach
decreases th e risk of perfu sion dam age to an already
en dan gered m u ltifragm en tary zon e ( bu la).
Re d u ct io n a n d xa t io n
Lock in g h ead screw s also stabilize th e sm all join t block.
Re h a b ilit a t io n
Early fu n ction al postoperative treatm en t is possible even
in com plex fractu res provided th at th e fractu re is well
stabilized.
 Au t h o rs Mich a e l D St o ve r, Ho b ie D Su m m e rs

10.3.7 Ope n com ple te articular m ultifragm e ntary distal tibial and
bular fracture —43 -C2
1 Ca s e d e s crip t io n

27-year-old m an su ffered a h igh veloc-

ity ballistic in ju r y on th e righ t d ista l
tibia; h igh en ergy trau m a w ith open
fractu re (Gu stilo type IIIB).

Fig 10 .3 .7-1a – f
a – b Clin ical pictu res of extrem ity:
Plan n ed in cision in coporates an te-
rior en tran ce wou n d, th e lateral
ex it wou n d is also sh ow n .
b c– d In itial AP an d lateral x-rays.
e–f Traction view s can be h elpfu l in
iden tifyin g fractu re fragm en ts.

c d e f

817
 10 .3 Tib ia a n d fib u la , d is t a l

In d ica t io n

Co m p le te a rticu la r fra ctu re o f th e d ista l tib ia w ith m e ta ph yse a l fra g-
m e n ta tio n a n d a sso cia te d fra ctu re o f th e b u la . Op e ra tive in d ica tio n s
in clu d e a rticu la r d isp la ce m e n t gre a te r th a n 2 m m , a n kle jo in t in sta -
b ilit y, a n d u n a cce p ta b le a xia l a lign m e n t o f th e lim b. Op e ra tive tre a t-
m e n t w ill re sto re jo in t co n gru it y, ske le ta l sta b ilit y, o ve ra ll lim b a lign -
m e n t, a n d a llo w s fo r e a rly fu n ctio n a l re h a b ilita tio n a n d jo in t m o tio n
to im p ro ve ca rtila ge n u tritio n a n d h e a lin g. Th e p rim a ry risk o f su rgica l
in te rve n tio n co n ce rn e s th e so ft-tissu e e n ve lo p e . Ca re fu l h a n d lin g
o f th e skin a n d su rro u n d in g so ft tissu e s is cru cia l fo r a su cce ssfu l
o u tco m e . In th is ca se , n o n o p e ra tive tre a tm e n t is like ly to le a d to a
p o o r re su lt w ith p o ssib le m a lu n io n , n o n u n io n , stiffn e ss fro m im m o -
b iliza tio n , a n d a rth ro sis o f th e a n kle jo in t. Op e ra tive tre a tm e n t a lso
p ro vid e s ske le ta l sta b ilit y fo r a p p ro p ria te ca re o f th e so ft-tissu e in ju ry
a sso cia te d w ith o p e n fra ctu re s.

Pre o p e ra t ive p la n n in g

EqPautipie m
n te pnre
t p a ra t io n a n d p o s it io n in g La te ra l co lu m n ( b u la r) xa tio n m a y n o t b e n e ce ssa ry w ith th e u se o f a n a n gu la r
• • LCP
An tibd ista
io tics:
l tibsin
ia lgle
p la dteo se
2 .7/2 n3d.0ge
,mn eera
d ia
tiol,n12
cehpohle
a lo
s- sta b le d e vice . Th is m a y b e u se d a s a to o l fo r in d ire ct re d u ctio n o f th e tib ia o r in
• 3sp .5 omrinm. lo ckin g h e a d scre w s (LHS) th e ca se o f a n o p e n fra ctu re w ith re sid u a l d isp la ce m e n t (a s in th is ca se).
• • 3Th
.5 ro
mm mbcoo sis
rtepxroscre
p h yla
w sxis: Lo w m o le cu la r h e p a rin .
• 2 .0 m m K-w ire s
• La rge d istra cto r
• Pu lsa tile irriga to r (o p e n fra ctu re)
• In tra m e d u lla ry d e vice , sm a ll fra gm e n t fo r b u la r
s ta b iliza tio n
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: ce p h a lo sp o rin
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .3 .7-2 Su p in e o n ra d io lu ce n t ta b le . No n ste rile p n e u m a tic to u rn iq u e t

a ro u n d th igh . Bu m p u n d e r a ffe cte d h ip to in te rn a lly ro ta te th e lim b.

818
 10 .3 .7 Op e n co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -C2

2 Su rgica l a p p ro a ch

Fig 10 .3 .7-3 a – b Make a 3 –5 cm cu rvilin ear sk in in cision

over th e an terior portion of th e m edial m alleolu s an d an terior
m ed ial join t to allow for adequ ate join t visu alization in th e
presen ce of articu lar involvem en t. Altern atively for extraar-
ticu lar (A-type) fractu res, a 2–3 cm lon gitu d in al in cision can
be m ade over th e m edial m alleolu s to expose th e d istal tip
w ith ou t en terin g th e an k le join t, preservin g th e periosteu m
wh en possible.

Preserve th e saph en ou s vein an d n erve as th ey pass an terior

to th e m ed ial m alleolu s. An terior h orizon tal arth rotom y can
be perform ed to evalu ate join t redu ction or an terolateral frag-
m en ts can be h in ged open on th eir d istal lateral ligam en ts.
Talar access for placem en t of a Sch an z screw an d m ediu m dis-
tractor for in d irect redu ction is an terior to th e deep deltoid
ligam en t in th e n on articu lar an ter ior talar body.
b
a

3 Re d u ct io n

Articu lar recon stru ction sh ou ld precede placem en t of th e

plate. Redu ce th e articu lar fragm en ts u n der d irect visu aliza-
tion an d/or w ith th e assistan ce of an im age in ten si er u sin g
periarticu lar clam ps or K-w ires as joysticks. Th e fragm en ts
m ay be provision ally xed w ith 2.0 m m K-w ires.

Obtain in direct redu ction of axial an d rotation al align m en t.

Th is can be perform ed w ith a m ed iu m d istractor. Man u al
in d irect redu ction th rou gh th e foot can be facilitated w ith th e
u se of sm all towel bu m ps, sligh tly larger ju st below th e kn ee
th an at th e m etaph yseal fractu re site to allow for posterior
proxim al tibial slope.

Fig 10 .3 .7-4In d irect redu ction of ax ial an d rotation al align -

m en t can be perform ed w ith a m ediu m d istractor.

819
 10 .3 Tib ia a n d fib u la , d is t a l
4 Fixa t io n
Obtain in terfragm en tary xation of th e articu lar fragm en ts
w ith sm all or m in i fragm en t screw s. Fixation im m ed iately
ceph alad to th e join t su rface, if possible, w ill allow for su bse-
qu en t placem en t of an gu lar stable lock in g h ead screw s w ith -
ou t in terferen ce. Fixation of articu lar fragm en ts m u st precede
xation of th e articu lar block to th e m etaphyseal/diaph yseal
segm en t.
Assem ble th e LCP d istal tibial plate w ith 2 –3 screw gu ides
th readed in to th e plate alon g w ith a th readed plate h older to
assist w ith in sertion an d su bsequ en t d istal screw placem en t.
In sert th e LCP d istal m ed ial tibial plate in th e in cision an d
slide it su bcu tan eou sly an d extraperiosteally alon g th e pos-
terom edial border of th e bon e. Du e to th e su bcu tan eou s
n atu re of th e m ed ial su rface of th e tibia, direct palpation
an d gu idan ce of th e plate placem en t is possible. Verify plate
position on AP an d lateral x-rays. Wh en th e plate is correctly
position ed over th e d istal block, tem porar y xation m ay be
accom plish ed w ith a 2.0 m m K-w ire th rou gh th e h ole pro-
vided in th e plate.
On ce len gth , rotation , an d ax ial align m en t h ave been cor-
rected, secu re th e plate to th e prox im al fragm en t. A sm all
a b
8 20
in cision (5 m m ) is m ade over a plate h ole prox im ally. Drill
2.5 m m m on ocortical h oles th rou gh th e plate prox im ally an d
d istally, placin g 3.5 m m cortex screw s in to each fragm en t to
secu re th e plate to th e bon e.
Fu ll len gth biplan ar x-rays m ay be in d icated prior to n al x-
ation to con rm align m en t. Begin lock in g h ead screw in ser-
tion d istally u sin g th e 2.8 m m th readed drill gu ide an d d rill
bit for 3.5 m m lock in g h ead screw s. It is im portan t to n ote
th at all lag/com pression screw s m u st be placed prior to th e
placem en t of lock in g h ead screw s. Th e d istal screw h oles are
design ed to be parallel to th e join t su rface. Mon ocortical xa-
tion is gen erally adequ ate bu t bicortical xation m ay be con -
sidered in osteoporotic bon e. Th e n u m ber of xation poin ts
w ill be determ in ed based on bon e qu ality an d fractu re redu c-
tion .
Place proxim al screw s by m akin g sm all in cision s over plate
h oles an d secu rin g 2.8 m m gu ide in to plate. Th e screw len gth
can be determ in ed by d irect m easu rem en t. Work in g screw s
can be rem oved on ce locked xation is obtain ed in each frag-
m en t, sin ce th ese were placed in a m on ocortical fash ion an d
h ave n ow been replaced w ith a bicortical lock in g h ead screw.
In sertion an d
Fig 10 .3 .7-5 a – c xation
c of th e LCP d istal tibial plate.
 10 .3 .7 Op e n co m p le t e a rt icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l a n d fib u la r fra ct u re —4 3 -C2

4 Fixa t io n (co n t )

Fig 10 .3 .7-7a – bPostoperative im ages of

th e extrem ity sh ow in g th e closed in cision
an teriorly w ith th e sm all stab in cision s
m edially for screw placem en t.

a b a

Fig 10 .3 .7-6 a – bObtain plain x-rays

pr ior to th e en d of th e operation . a

5 Re h a b ilit a t io n

Add ition al im m obilization : A sh ort leg splin t is u sed for 3 –7 days to allow soft-
tissu e swellin g to su bside an d th e wou n d edges to seal.
Weigh t bearin g: 15 kg for 6 weeks; h alf body weigh t after 6 weeks; fu ll weigh t
bearin g after 10 weeks.
Mobilization : active m obilization after 7 days
Ph ysioth erapy: Active an d active-assisted ran ge of m otion is started as soon as th e
patien t is com fortable. Passive dorsi exion stretch in g is allowed w ith foot at. No
stren gth en in g is perm itted u n til th e fractu re h as h ealed.
Ph arm aceu tical treatm en t: Pain m an agem en t as n eeded.

Fig 10 .3 .7-8 a – b Postoperative x-ray after 12 weeks. Bon e graft was perform ed.
a AP view.
b Lateral view.

a b

821
 10 .3 Tib ia a n d fib u la , d is t a l

5 Re h a b ilit a t io n (co n t )

Fig 10 .3 .7-9 a – b Postoperative x-rays after u n ion .

a AP view.
b Lateral view.

a b

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Redu ction can be d ifficu lt w ith m an u al d istraction alon e. Th e u se of an extern al fixator or a large d istractor is key
to m ain tain in g len gth an d align m en t.
In sert two to th ree 2.8 m m th readed d rill gu ides in to
d istal plate to ease in itial lockin g h ead screw in sertion .

Ap p ro a ch Ap p ro a ch
Be aware of soft-tissu e com plication s. Avoid raisin g flaps an d perform extraperiosteal dissection
to m ain tain vascu larity of fractu re fragm en ts.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Relyin g on im age in ten si cation to determ in e axial Fu ll len gth x-rays follow in g provision al redu ction .
align m en t. Poor atten tion to rotation al redu ction .

8 22
 Au t h o rs He rm a n n Jo s e f Ba il, Kla u s -Die t e r Sch a s e r, No rb e r t P Ha a s

10.3.8 Bilate ral com ple te articular m ultifragm e ntary distal tibial
fracture —43 -C3
1 Ca s e d e s crip t io n

28-year-old wom an , ju m ped off a

bu ild in g (6 –8 m h eigh t) in su icidal
in ten t, wh ich resu lted in polytrau m a
w ith pelvic rin g in ju r y (type B-frac-
tu re), m oderate ch est trau m a, d istal
rad ial (type A-fractu re) an d bilateral
closed pilon fractu res (type C3).

a b
c d
Lateral an d AP x-rays
Fig 10 .3 .8 -1a – d
sh ow th e m u ltifragm en tar y pilon frac-
tu res on both d istal tibiae. On th e left
side severe m etaph yseal com m in u tion
is presen t.
a AP view of left pilon fractu re.
b Lateral view of left pilon fractu re.
c AP view of righ t pilon fractu re.
d Lateral view of righ t pilon fractu re.

In d ica t io n

The se im pacte d , in traarticu lar, and also m e taph yse al m ulti-fragm e n tary
fracture s w ith m ultifragm e n tary jo in t incongrue nce are an ab solu te
indica tion for surgical in te rve ntion , ie , anatom ical re construction . Due
to the se ve re clo se d so ft-tissue dam age on b o th side s and in the face o f
the patie n t’s ove rall cond itio n (p olytraum a) a pre lim inary clo se d re duc-
tion and e xte rnal xation was p e rform e d (orthop e dic dam age con trol
su rge ry).
In a se cond ste p and a fte r soft-tissue consolidation , se que ntial ope n
re duction and in te rnal xation was p e rform e d on b o th side s via an
an te rom e dial appro ach u sing se ve ral lag scre w s and a LCP m e taphyse al
pla te 3.5/ 4.5/ 5.0 on the right, and an LCP distal tibial pla te 2 .7/ 3.5 on
the le ft. The righ t bu lar fracture was stabilize d b y an LCP 3.5. Prim ary
cance llous bone grafting was ne ce ssary be cau se of the se ve re ly
im pacte d fragm e n ts and the e xte nsive m e taphyse al de fe ct situa tion .

823
 10 .3 Tib ia a n d fib u la , d is t a l

In d ica t io n (co n t)

a b c

d e f

Fig 10 .3 .8 -2 a – f Afte r p rim a ry e xte rn a l xa tio n , p re o p e ra tive CT sca n s o f b o th sid e s sh o w a d isp la ce d a n te ro la te ra l

fra gm e n t, a ce n tra lly im p a cte d fra gm e n t, a m e d ia l m a lle o la r fra gm e n t, a n d a Vo lkm a n n fra gm e n t. Th e sa gitta l re co n -
stru ctio n s re ve a l tha t o n th e righ t sid e th e clo se d re d u ctio n p ro d u ce d a b e t te r a lign m e n t co m p a re d w ith th e le ft
sid e .
a – c Le ft sid e .
d – f Righ t sid e .

824
 10 .3 .8 Bila t e ra l co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re —4 3 -C3

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
d ista
io tics:
l tibsin
ia l gle
p la te
d o 2se.7/23n d.5ge
,mn eera
d ia
tiol,n5 ce
h ople
h as lo -
• LCP
sp omrine.ta p h yse a l p la te 3 .5/ 4 .5/ 5 .0 , 10 h o le s
• •3Th
.5 ro
mmm bco o sis
rtepxroscre
p h yla
w s xis: Lo w m o le cu la r h e p a rin .
• 3 .5 m m lo ckin g h e a d scre w (LHS)
• 5 .0 m m LHS
• 1.6/ 2 .0 m m K-w ire s
• Pe lvic re d u ctio n fo rce p s
• La rge e xte rn a l xa to r
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g Fig 10 .3 .8 -3 Su p in e p o sitio n w ith e le va tio n o f th e in ju re d lim b o r

An tib io tics: ce p h a lo sp o rin co n tra la te ra l le g lo w e re d b e lo w th e ta b le le ve l (a llo w in g la te ra l in tra o p e ra tive
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin x-ra y).

2 Su rgica l a p p ro a ch

Fig 10 .3 .8 -4 a – bAn an terom edial approach (exten din g sig-

m oidally from th e m edial m alleolu s to th e an terior rim of
th e tibial sh aft) was ch osen for su f cien t visu alization an d
recon stru ction of th e join t su rface at th e join t level. Fixation
of th e plate at th e dia/-m etaphysis m ay be perform ed percu ta-
n eou sly.
a An terom ed ial approach to th e righ t d istal tibia.
b An terom ed ial approach to th e left d istal tibia. Add ition al
lateral approach to th e left bu la is n ot sh ow n .

a b

825
 10 .3 Tib ia a n d fib u la , d is t a l

3 Re d u ct io n —le ft d is t a l t ib ia

Th e extern al xator was left in place, th ereby m ain tain in g
len gth an d ax is as well as sligh t d istraction of th e an k le join t.
Th e operation started w ith a lateral approach to th e d istal
bu lar fractu re. Th e bu la was redu ced an d xed w ith an
LCP 3.5. Du rin g th e com plete su rgical procedu re, th e calca-
n eal Sch an z’ screw was u sed for d istraction of th e an k le join t
an d m ain ten an ce of th e ligam en totaxis. Wh ile th e lateral
approach to th e bu la was left open , th e an terom ed ial
approach was perform ed. After gen tly retractin g th e an tero-
m edial fragm en t, th e im pacted cen tral pilon fragm en t becam e
visible. Before th is key fragm en t was redu ced, th e posterolat-
eral fragm en t, wh ich was add ition ally im pacted an d d islo-
cated, was redu ced to th e poster ior aspect of th e talu s an d
tem porarily xed w ith a K-w ire. Su bsequ en tly, th e cen tral,
im pacted pilon fragm en t was an atom ically redu ced an d pin -
n ed w ith a K-w ire to th e posterolateral already redu ced an d
xed fragm en t. Fin ally, th e an terom edial an d an terolateral
fragm en ts were redu ced an d h eld in position by redu ction
forceps an d K-w ires in th e sagittal plan e. Su bsequ en tly, two
cortex lag screw s were in serted per pen d icu lar to th e cen tral
fragm en t an d fractu re lin es an d parallel to th e join t lin e
for in terfragm en tar y com pression . An atom ical redu ction an d
absolu te stability was ach ieved for th e join t block. Th e defect
at th e m etaph yseal level was lled by can cellou s bon e graft
h ar vested from th e ipsilateral iliac crest. Th e fragm en t in -
volvin g th e m ed ial m alleolu s was relatively large in th e h ori-
zon tal plan e bu t on ly th in in a vertical d irection m ak in g xa-
tion to th e oth er join t fragm en ts in secu re. Th erefore, a lon g
cortex screw was placed from th e m ed ial m alleolu s to th e
adjacen t in tact lateral cortex of th e prox im al m eta-/d iaph ysis.
Fin ally a LCP distal tibial plate 2.7/ 3.5, m ed ial was in trodu ced
an d a cortex screw was in serted th rou gh th e plate an d xed
to th e d iaph ysis followed by th ree lock in g h ead screw s to th e
sh aft. Thu s, th e m etaphyseal defect zon e was bridged by u sin g
th e LCP as a pu re in tern al xator. Th e lon g lag screw on ly
en gages th e m ed ial m alleolu s an d h as n o m ech an ical effect in
th e m etaph yseal area.

b c

AP an d lateral x-rays im m ed iately postoperatively, left side:

Fig 10 .3 .8 -5 a – c
An LCP distal tibial plate 2.7/ 3.5 was u sed. It offers m u ltiple screw option s.
Th e m etaphyseal area is bridged by th e plate wh ich offers relative, bu t an gu -
lar stability via lock in g h ead screw s in th e proxim al an d distal (articu lar)
fragm en t.
a

8 26
 10 .3 .8 Bila t e ra l co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re —4 3 -C3

4 Re d u ct io n —righ t d is t a l t ib ia

Neith er a lateral approach n or can cellou s bon e graftin g were
n ecessar y in th e m etaph yseal area as th ere were fewer frag-
m en ts an d th e bu la was n ot fractu red.
Th e redu ction tech n iqu e was sim ilar to th at for th e left side
w ith tem porar y redu ction forceps an d K-w ire xation . On e
lag screw was in serted percu tan eou sly for xation of th e
previou sly redu ced an terolateral fragm en t. An oth er lag screw
com pressed th e join t block for absolu te stability. Two m ore lag
screw s were placed in th e sagittal plan e for xation / in terfrag-
m en tar y com pression of m etaph yseal split fragm en ts. How-
ever, as a con sequ en ce of th e large split fragm en t exten din g to
th e m ed ial aspect of th e m eta-/d iaph ysis, a d istal tibial LCP
was n ot con sidered to provide en ou gh xation in th e d iaph y-
sis. Th u s, a LCP m etaph yseal plate 3.5/4.5/5.0 was u sed an d
in serted su bcu tan eou sly at th e d iaph ysis w h ere th e 5.0 m m
lock in g h ead screw s were in serted percu tan eou sly. All an gu -
lar stable option s adjacen t to th e join t level were u sed w ith
3.5 m m lock in g h ead screw s. Th e an gu lar stable LCP n eu -
tralizes in com in g sh ear forces. Prin cipally, on e can d iscu ss
wh eth er th e fth 5.0 m m screw from prox im al is n eeded. Th is
LHS crosses th e fractu re gap in th e m eta-/d iaph yseal tran si-
tion zon e an d resu lts in a m ixtu re of prin ciples. If th e LCP is
u sed as a protection plate, an oth er lag screw wou ld follow th e
prin ciple of absolu te stability, wh ich can be applied in th e
treatm en t of sim ple m etaph yseal fractu res. If th e LCP were
bein g u sed as a bridgin g in tern al xator, th e fth an d th e
fou rth LHS (cou n ted from prox im al) sh ou ld be om itted. An
an gu lar stable screw w h ich crosses th e fractu re zon e m ay
both er sligh t in terfragm en tary m ovem en t wh ich is h elpfu l for
h ealin g.

AP an d lateral x-rays d irectly postoperatively, righ t side:

Fig 10 .3 .8 -6 a – b
An LCP m etaphyseal plate 3.5/4.5/5.0 is u sed as a n eu tralization plate to
protect th e absolu te stability ach ieved w ith th e lag screw s in th e distal
m etaph yseal fractu re area. For protection of th e soft tissu es on both
sides, th e extern al xator was m ain tain ed u n til th e ten th postoperative
a day.

827
 10 .3 Tib ia a n d fib u la , d is t a l

5 Re h a b ilit a t io n

After 12 weeks of partial weigh t bearin g on both sides th e

patien t started fu ll weigh t bearin g rst on th e righ t side fol-
lowed by th e left side at 15 weeks.
5 m on th s after su rgery th e patien t was able to walk w ith ou t
cru tch es an d stan d on tiptoe.

6 weeks postoperative:
Fig 10 .3 .8 -7a – d
On th e left side, good callu s form ation
in th e m etaph yseal defect area is visible.
On th e righ t side, n o loss of redu ction
cou ld be iden ti ed. As d iscu ssed in th e
text, in th e m eta-/d iaph yseal tran sition
area, n o lag screw was in serted bu t a
lock in g h ead screw crosses th e fractu re
gap.

a b c d

Fig 10.3.8 -8 a – d 12 weeks postoperative:

No im plan t loosen in g or breakage is
visible. Th e m etaphyseal zon e and join t
area is h ealed on both sides. At th is tim e,
fu ll weigh t bearin g was allowed startin g
w ith the righ t side.

a b c d

8 28
 10 .3 .8 Bila t e ra l co m p le t e a r t icu la r m u lt ifra gm e n t a r y d is t a l t ib ia l fra ct u re —4 3 -C3

5 Re h a b ilit a t io n (co n t )

a b c

Th e clin ical im ages sh ow u n even tfu l soft-

Fig 10 .3 .8 -9 a – c
tissu e h ealin g an d good m otor fu n ction on both sides.

6 Pit fa lls – 7 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
Th e d istal tibial LCP m ay be too sh ort for fractu res wh ich Th e d istal tibial LCP is an ideal plate for mu ltifragm en tary
exten d in to th e d iaph yseal area. com plete articu lar fractu res.

Th e m etaph yseal LCP m ay offer too few xation option s Th e LCP m etaph yseal plate 3.5/4.5/5.0 is an ideal im plan t
in th e d istal part to x com plete m u ltifragm en tary for fractu res wh ich exten d in to th e d iaph yseal area.
articu lar fractu res.

Ap p ro a ch Ap p ro a ch
With th e an terom ed ial approach th e con trol of th e Th e an terom ed ial approach allow s optim al con trol
Volk m an n fragm en t m ay be d if cu lt. of th e an terior an d th e m edial fragm en ts. For con trol
of th e an terolateral fragm en t, th e approach can be
exten ded prox im ally an d d istally as n eeded.

829
 10 .3 Tib ia a n d fib u la , d is t a l
6 Pit fa lls – (co n t)
Re d u ct io n a n d xa t io n
In com plete m u ltifragm en tary pilon fractu res, referen ce
con tou rs for redu ction of key fragm en ts are gen erally h ard
to n d.
In com plete articu lar d istal tibial fractu res w ith a
m u ltifragm en tar y m etaph yseal zon e, n o proxim al refer-
en ce fragm en ts for recon stru ction of th e join t segm en t
are available.
Ex posu re of th e mu ltifragm en tar y m etaph yseal area
in order to n d a referen ce fragm en t leads to periosteal
strippin g an d soft-tissu e stress.
Re h a b ilit a t io n
Too early fu ll weigh t bearin g in cases w ith m etaph yseal
defect areas m ay lead to im plan t failu re.
M ixtu re of prin ciples (h ere a lock in g h ead screw crossin g
th e fractu re lin e) m ay lead to prolon ged fractu re con soli-
dation .
8 30
7 Pe a rls + (co n t)
Re d u ct io n a n d xa t io n
If th e posterolateral fragm en t (Volk m an n fragm en t) can
be redu ced to th e m etaph yseal fragm en t, th e join t can be
recon stru cted based on th e correct position of th at
fragm en t.
If n o d irect redu ction of an articu lar fragm en t to a
m etaphyseal fragm en t is possible, th e recon stru cted bu la
provides th e referen ce for th e orien tation of th e join t
segm en t.
For recon stru ction of th e articu lar su rface, th e su rface of
th e join t partn er (h ere: talu s) can serve as a referen ce.
Re h a b ilit a t io n
In m u ltifragm en tary m etaph yseal fractu res an gu lar
stability allow s early fu n ction al postoperative treatm en t
w ith con tin u ou s passive m otion of th e join t.
In m u ltifragm en tar y articu lar fractu res (w ith absolu te
stability), an gu lar stable xation of th e recon stru cted join t
segm en t in m an y cases allow s partial weigh t bear in g.
 Au t h o rs An d re a s Gru n e r, Th o m a s J Ho cke r t z, Ga b rie le St re ich e r, He in rich Re ilm a n n

10.3.9 Adole sce nt bone cyst—with im m ine nt fracture

of the distal tibia
1 Ca s e d e s crip t io n

14 -year-old fem ale patien t w ith an abn orm al con d ition .

Type of d isorder: tu m or of th e d istal tibia—adolescen t bon e
cyst—w ith im m in en t fractu re of th e d istal tibia

Fig 10 .3 .9 -1a – d
a AP view.
b b AP view detail.
c Lateral view detail.
d Lateral view.

a c d

In d ica t io n

a b c d e

Bo n e cyst o f th e d ista l tib ia , le ft, in a 14 -ye a r-o ld girl. Th e p o sitio n o f Fig 10 .3 .9 -2 a – e CT sca n s o f th e a d o le sce n t b o n e cyst.
th e cyst a t th e d ista l tib ia l m e ta p h ysis im m e d ia te ly a d ja ce n t to th e
e p ip h ysis is a sso cia te d w ith th e risk o f fra ctu re . Th e cyst wa s lle d
w ith se ro u s u id , u n ica m e ra l, co n ta in e d p se u d o se p ta , a n d a ffe cte d
th e e n tire d ista l tib ia (se e CT sca n).

831
 10 .3 Tib ia a n d fib u la , d is t a l

Pre o p e ra t ive p la n n in g

EqPautip
iem
n te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tib
m io
e tatics:
p h yse
sinagle
l p la
d otese3 2.5/
nd
4ge
.5/n 5e .0
ra ,tio
5 n+ 9 h o le s
• 5ce
.0 pmh m
a lolospckin
o ring. h e a d scre w s (LHS)
• •3Th
.5 ro
mmm bLHSo sis p ro p h yla xis: Lo w m o le cu la r h e p a rin .
• K-w ire s
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.)

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: sin gle d o se 2 n d ge n e ra tio n Fig 10 .3 .9 -3 Su p in e p o sitio n , th e le ft le g is fre e -d ra p e d fo r in tra o p e ra tive
ce p h a lo sp o rin m o b ilit y, th igh to u rn iq u e t, righ t le g lo w e re d b y a p p ro xim a te ly 2 0 º, im a ge
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin in te n si e r fro m th e righ t.

2 Su rgica l a p p ro a ch

a b c

An terior in cision over th e d istal tibia, dissec-

Fig 10 .3 .9 -4 a – c Preben d in g of th e m etaph yseal LCP w ith th e plate ben d in g
tion to th e periosteu m , create a bon e apertu re, m obilize th e press an d adaptation u n der im age in ten si cation .
cystic con ten t dow n to th e cyst-sh aft in terface. Skin in cision parallel to th e tibial axis at th e proxim al en d of
Approx im ately 5 cm lon g, cen tral sk in in cision lon gitu d in ally th e im plan t bed.
over th e in n er m alleolu s, d issect to th e periosteu m , prepare
th e plate bed by epiperiosteal tu n n elin g from d istal to prox i-
m al w ith a lon g bon e rasp.

8 32
 10 .3 .9 Ad o le s ce n t b o n e cys t—w it h im m in e n t fra ct u re o f t h e d is t a l t ib ia

3 Re d u ct io n a n d fixa t io n

a b c d f

Fig 10 .3 .9 -5 a – f
a No redu ction is requ ired sin ce th is is n ot a case of fractu re. Plate in sertion , tem porary xation u sin g
K-w ires proxim ally, im age in ten si cation in two plan es, possibly adaptation of th e LCP to th e tibial
sh aft w ith th e pu llin g device.
b–f Fixation w ith th ree 5.0 m m lock in g h ead screw s proxim ally an d ve 3.5 m m m on ocortical lockin g
h ead screw s d istally. En su re th at th e screw s h ave secu re an ch orage in th e d istal epim etaph ysis an d
protru de in to th e cystic stru ctu re, sk in in cision is always a stab in cision over th e plate bed.

833
 10 .3 Tib ia a n d fib u la , d is t a l

4 Re h a b ilit a t io n

Fig 10 .3 .9 -6 a – b Postoperative x-rays after 18 m on th s.

a AP view.
b Lateral view.

Addition al im m obilization : fu n ction al postoperative treatm en t.

Weigh t bearin g: fu ll weigh t bearin g after 4 weeks.
Passive m obilization after 1 day.
Active m obilization after 2 days.
Ph ysioth erapy: from th e rst postoperative day.
Ph arm aceu tical treatm en t: perioperative pain m edication .

Im p la n t re m o va l
a b Im plan t rem oval after de n itive h ealin g of th e bon e cyst.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In correct preben d in g of th e LCP. LCP m etaph yeal plate does n ot rest on th e in n er m alleolu s
in th e d istal region .

Ap p ro a ch Ap p ro a ch
In ju r y to th e saph en ou s vein an d n erve if th e approach is
too far on th e an terior side of th e in n er m alleolu s.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Correct position in g of th e im plan t, w h ereby th e
cu r vatu re of th e plate sh ou ld be sligh tly less th an
th e cu rvatu re of th e bon e.
In correct position in g of th e plate, especially in th e lateral
plan e.

Re h a b ilit a t io n Re h a b ilit a t io n
Early m obilization w ith partial load in g is possible.

8 34
 Au t h o r Mich a e l Wa gn e r

10.3.10 Fibular fracture with m e dial ligam e ntous le sion —4 4 -B2

1 Ca s e d e s crip t io n

50-year-old wom an fell w h ile ou t walk in g an d su stain ed an

isolated fractu re of th e righ t an k le join t.

Fig 10 .3 .10 -1a – b

a AP view.
b Lateral view.

a b

In d ica t io n

Disp la ce d m a lle o la r fra ctu re w ith liga m e n t o n th e m e d ia l sid e .

Pre o p e ra t ive p la n n in g

EqPau tip
iemn te np tre p a ra t io n a n d p o s it io n in g
• •LCP
An tib
o nioe -th
tics:irdsin
tugle
b u la
d or se
p la2ten d 3ge
.5n, e6rahtio
o lens 1 Su rge o n
• 3 ce
.5 pmhm a loco sprte
o rin
x scre
. w 2 ORP
• •3 Th
.5 rom m blo o sis
ckinpgrohpehayla
d scre
xis: w Losw(LHS)
m o le cu la r h e p a rin . 3 1st a ssistan t
(Size o f s ys te m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.) Ste rile are a

Pa t ie n t p re p a ra t io n a n d p o s it io n in g
An tib io tics: n o n e 1
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

2 3
Fig 10 .3 .10 -2 Po sitio n in g o f OR te a m .

835
 10 .3 Tib ia a n d fib u la , d is t a l

2 Su rgica l a p p ro a ch

Fig 10 .3 .10 -3 a – b Lateral approach to th e lateral m alleolar

fractu re.

a b

3 Re d u ct io n a n d fixa t io n

a b c d

Fig 10 .3 .10 -4 a – d
a Open redu ction of th e lateral m alleolu s fractu re w ith redu ction forceps w ith serrated
jaw s.
b After an atom ical redu ction , xation w ith a lag screw (3.5 m m cortex screw). A glidin g
h ole an d a th readed h ole are d rilled.
c Th e th read is tapped.
d Th e lag screw (cortex sh aft screw) is in serted.

8 36
 10 .3 .10 Fib u la r fra ct u re w it h m e d ia l liga m e n t o u s le s io n —4 4 -B2

3 Re d u c t io n a n d fixa t io n (co n t )

a b c d

Fig 10 .3 .10 -5 a – e
a – b A straigh t LCP on e-th ird tu bu lar plate is xed by in sertion of a cortex screw to th e sligh tly
cu r ved lateral aspect of th e bu lar m alleolu s an d takes on th e add ition al fu n ction of a
bu ttress plate to cou n teract lateral fragm en t displacem en t.
c– d Add ition al stabilization w ith a 6-h ole LCP on e-th ird tu bu lar plate stabilized by LHS —
two in th e prox im al an d two in th e d istal fragm en t.
e Th e plate in situ after com pletion of th e operation sh ow s th e d ifferen t types of screw s
in th e LCP coax ial com bin ation h oles of th e on e-th ird tu bu lar plate.

4 Re h a b ilit a t io n

Addition al im m obilization postoperatively in a split plaster

cast. As soon as th e redon drain s h ave been taken ou t, th e
cast can be rem oved to perm it im m ediate early fu n ction al
treatm en t. After rem oval of stitch es 12 days postoperatively,
m obilization of th e patien t w ith fu ll weigh t bearin g in a sh ort-
leg walk in g cast for 6 weeks follow in g su rgery.

a b

Fig 10 .3 .10 -6 a – b Postoperative x-rays after 6 m on th s. No

pain , fu ll fu n ction , n o n eed for im plan t rem oval.
a AP view.
b Lateral view.

837
 10 .3 Tib ia a n d fib u la , d is t a l

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
A lateral in cision can place th e su per cial peron eal
n er ve at risk. Du rin g th e operation care sh ou ld be taken
to trau m atize th e soft tissu e as little as possible by
carefu l d ivision of stru ctu res.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Stan dard screw s m ay becom e loose if th e bon e is An atom ical redu ction of a m alleolar fractu re is im per-
osteoporotic. ative. Revision an d treatm en t of th e m edial ligam en -
tou s in ju ry m ay n ot be n ecessary if precise an atom ical
redu ction an d position in g of th e troch lear of th e talu s in
th e m ortise can be ach ieved. Th e in sertion of LHS in to
th e d istal fragm en t perm its stable fragm en t xation .

Th e LCP redu ces th e risk of screw loosen in g in osteo-

porotic bon e.

8 38
 Au t h o r Mich a e l Wa gn e r

10.3.11 Bim alle olar fracture with m e dial le sion —4 4 -B2

1 Ca s e d e s crip t io n

a b c d

61-year-old wom an fell wh ile ou t walk in g, d islocated fractu re of th e left an k le join t.

Fig 10 .3 .11-1a – d
a AP view. In d ica t io n
b Lateral view.
c– d AP view an d lateral view after closed redu ction Disp la ce d b im a lle o la r fra ctu re . As th is is a n u n sta b le fra ctu re o f
an d xation in split plaster cast. th e a n kle jo in t, th is is a cle a r in d ica tio n fo r sta b le fixa tio n .

Pre o p e ra t ive p la n n in g

EqPautip
iemn te pn re
t p a ra t io n a n d p o s it io n in g
• •LCP
An tibo nioe tics:
-th irdsin
tugle
b u la
d or se
p la2ten d 3ge
.5n, e6rahtio
o lens La t e ra l m a lle o lu s Me d ia l m a lle o lu s
• 4ce.0 pmh m
a locaspnonrin
u la. te d scre w s w ith m e ta l w a sh e rs 1 Su rge o n 1 1st a ssista n t
• •3Th
.5 ro
mm m bco o sis
rtepxroscre
p h yla
w xis: Lo w m o le cu la r h e p a rin . 2 ORP 2 ORP
• 3 .5 m m lo ckin g h e a d scre w s (LHS) 3 1st a ssista n t 3 Su rge o n
(Size o f s yste m , in stru m e n ts, a n d im p la n ts
ca n va ry a cco rd in g to a n a to m y.) Ste rile are a Ste rile are a

Pa t ie n t p re p a ra t io n a n d p o s it io n in g 1
An tib io tics: n o n e
Th ro m b o sis p ro p h yla xis: lo w -m o le cu la r h e p a rin

Fig 10 .3 .11-2 2
Po sitio n in g o f OR te a m . 3

839
 10 .3 Tib ia a n d fib u la , d is t a l

2 Su rgica l a p p ro a ch

a b c d

Fig 10 .3 .11-3 a – d
a – b Medial approach . Th e articu lar su rface of th e talu s dom e is seen
th rou gh th e fractu re of th e in n er m alleolu s.
c– d Lateral approach . Th e fractu re of th e lateral m alleolu s is visible.

3 Re d u ct io n a n d fixa t io n

a b c

Open redu ction of th e lateral m alleolu s fractu re an d xation w ith a lag screw (3.5 m m cortex
screw). Add ition al stabilization w ith a 6-h ole LCP on e-th ird tu bu lar plate, xed w ith 5 LHS.
Despite osteoporosis, th e distal LHS n d pu rch ase in th e sm all distal m alleolar fragm en t an d
th e plate acts as an “in d ividu al” blade plate.
After exact redu ction th e m ed ial m alleolu s is stabilized w ith two 4.0 m m can nu lated screw s
w ith wash ers. Th e screw s are on ly partially th readed an d act as lag screw s.

Fig 10 .3 .11-4 a – c
a Th e LCP on e-th ird tu bu lar plate stabilizes th e lateral m alleolar fractu re.
b AP view.
c Lateral view.

840
 10 .3 .11 Bim a lle o la r fra ct u re w it h m e d ia le s io n —4 4 -B2

4 Re h a b ilit a t io n

a b c d

Addition a l im m obilization postoperatively in a split plaster Fig 10 .3 .11-5 a – d

cast. After rem oval of th e redon d rain s th e cast is rem oved a Postoperative x-ray after 6 weeks, AP view.
for in term ed iate early fu n ction al treatm en t. After rem oval of b Postoperative x-ray after 6 weeks, lateral view.
stitch es 12 days postoperatively, m obilization of th e patien t c Postoperative x-ray after 5 m on th s, AP view.
w ith fu ll weigh t bearin g a in sh ort-leg walkin g cast for 6 d Postoperative x-ray after 5 m on th s, lateral view.
weeks follow in g su rger y.

5 Pit fa lls – 6 Pe a rls +

Eq u ip m e n t Eq u ip m e n t
In th e even t of severe osteoporosis loosen in g of th e LCP redu ces th e risk of screw loosen in g in osteoporotic
im plan ts m ay som etim es occu r (con ven tion al bon e.
screw s an d on e-th ird tu bu lar plate w ith secon dary
fractu re displacem en t).

Re d u ct io n a n d xa t io n
Operative in ju r y to th e su per cial peron eal n er ve as
a resu lt of in cision or in traoperative trau m a.
Also in adequ ate tech n iqu e can lead to sk in n ecrosis.
Re d u ct io n a n d xa t io n
After an atom ical open d irect redu ction , xation w ith a
plate-in depen den t lag screw to ach ieve in terfragm en tary
com pression . Th e plate acts as protection plate. Two
m on ocortical LHS secu re th e sm all d istal fragm en t, even
in osteoporotic bon e.

8 41
 10 .3 Tib ia a n d fib u la , d is t a l

8 42
11 Calcane us

Ca s e s

Ca s e Cla s s i ca tio n Me tho d Im p la n t u s e d Im p la n t fu n ct io n Pa g e

11.1 In traarticu lar calcan e al fractu re Calcan e al lo ckin g p la te 3 .5 8 47

11.2 Se rve re fractu re d islo ca tio n o f th e Calcane al lo cking pla te 3.5 8 53

ca lcan e u s

8 43
 11 Ca lca n e u s

11 Calcane us

11 Ca lca n e u s 845
11.1 In t ra a r t icu la r ca lca n e a l fra ct u re 8 47
11.2 Se ve re fra ct u re d is lo ca t io n o f t h e ca lca n e u s 853

844
 Au t h o r Ha n s Zw ip p

11 Calcane us

1 In cid e n ce

Calcan eal fractu res occu r in 1–2% of all fractu res of th e

hu m an skeleton bu t represen t 60 –75% of all foot fractu res.
Th e m ean age is 42 years. Th e m ale:fem ale-ratio is recorded
as 5:1. A h igh -velocity trau m a is th e basic cau se in falls from
a b
a h eigh t (43 –82% ), in traf c acciden ts (13 –53% ), in sports
(5% ) an d in polytrau m a (35% ). Th e fractu res are open in
Fig 11-1a – b A-type fractu re.
3 –12% , w ith com partm en t syn drom e in 4 –5% , an d bilateral
in 10 –20% .

2 Cla s s ifica t io n

A-type fractu res are n ot often seen (13% ).

B-type frctu res are m ost com m on (82% ).
C-type fractu res are rare (5% ).

a b
3 Tre a t m e n t m e t h o d s

Fig 11-2 a – b B-type fractu re.

Extraarticu lar fractu res of 1–3 segm en ts are treated con ser va-
tively if th ey h ave on ly sligh tly d isplacem en t. In cases of
severe d isplacem en t an d varu s/ valgu s m alalign m en t th ey are
m ost often treated w ith ORIF or in m in im a lly invasive tech -
n iqu e w ith screw s.
a
a b
In traarticu lar fractu res of 1–3 join ts are treated by ORIF if th e
join t d isplacem en t is m ore th an 1–2 m m as visu alized on th e
CT scan s an d if con train dication s for su rger y are n ot given .

Fractu re d islocation s of 1–3 join ts greatly n eed ORIF becau se

late recon stru ction s are th e m ost d if cu lt on es. In cases of c
con train d ication s for ORIF, m in im ally in vasive tech n iqu es
w ith percu tan eou s screw xation sh ou ld be perform ed to d
restore th e statics of th e h in dfoot.
Fig 11-3 a – d C-type fractu re.

8 45
 11 Ca lca n e u s

4 Im p la n t o ve r vie w 5 Su gge s t io n s fo r fu r t h e r re a d in g

Zw ip p H (1994) Surgery on the foot. Berlin : Sprin ger Verlag.

Zw ip p H , Ram m e lt S, Bart h e l S (2005) Fractu re of th e calcan eu s.
Unfallchirurg; 108(9):737–747.

Fig 11-4 Calcan eal lock in g plate 3.5.

8 46
 Au t h o r Ha n s Zw ip p

11.1 Intraarticular calcane al fracture

1 Ca s e d e s crip t io n

49-year-old m an ju m ped du rin g a psych otic attack

from th e secon d oor an d fractu red th e righ t cal-
can eu s.

Fig 11.1-1a – d
a – b Lateral view an d Broden ’s view (20 º) sh ow
<
1
4 1
th e deep im paction of th e posterior facet (1 ),
th e in volvem en t of th e cu boidal facet ( 2 ), th e
2
3 lateral tran slation of th e tu berosity fragm en t
( 3 ), th e tiltin g of th e lateral part of th e poste-
r ior facet ( 4 ), an d a su spiciou s in term ediate
a b fragm en t of th e posterior facet.
c– d Coron al CT scan an d axial cu t sh ow precisely
th e sh iftin g of th e m ed ial part of th e poste-
r ior facet ( 5 ) w ith adjacen t su sten tacu lu m
tali m ed ially, th e tilted an d im pacted in ter-
m ediate fragm en t of th e posterior facet ( 6 ),
an d th e severely d islocated m ed ial part of th e
5 cu boidal facet ( 7 ) m edially.
6
7

c d

In d ica t io n

Se ve re d isp la ce m e n t o f th e su b ta la r a n d ca lca n e o cu b o id jo in t. Th e re a re n o
ge n e ra l o r lo ca l co n tra in d ica tio n s fo r ORIF.

8 47
 11 Ca lca n e u s

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• Ca lca n e a l lo ckin g p la te 3 .5 So ft-tissu e re co ve ry a fte r 8 d a ys w ith e le va tio n , ice o r lym p h d ra in a ge .
• 3 .5 m m lo ckin g h e a d scre w s To u rn iq u e t (2 0 0 – 3 0 0 m m m e rcu ry) fo r 3 0 – 4 5 m in u te s.
• 3 .5 m m co rte x scre w s
• 2 .0 m m co rte x scre w s
• 2 .0 m m K-w ire s
• Arth ro sco p y se t
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)
Fig 11.1-2 La te ra l
p o sitio n in g o f th e p a tie n t
o n th e o p e ra tin g ta b le .

2 Su rgica l a p p ro a ch

Exten ded lateral approach (Seattle approach).

Fig 11.1-3 Th e L-sh aped in cision is perform ed as a fu ll th ick-

n ess ap in clu d in g th e su ral n er ve. Th e peron eal ten don s
sh ou ld n ot be seen , except in th e area of th e peron eal tu bercle
wh ere a m ed ial sh eath is m issin g. Distally th e peron eal ten -
don s h ave to be m obilized w ith in th eir sh eath s for ex posu re
of th e calcan eocu boid join t. Th e bu lo-calcan eal ligam en t is
detach ed from th e bon e an d all preparation is don e epiper ios-
teally. Gen erally n o sh ar p h ooks are u sed. As soon as th e su b-
talar join t is visu alized, th ree 2.0 m m K-w ires are in trodu ced
close to th e join t in to th e talar body an d n eck, a fou rth in to
th e cu boid if ex posu re of th e calcan eocu boid join t is n eeded.

8 48
 11.1 In t ra a r t icu la r ca lca n e a l fra ct u re
3 Re d u ct io n a n d fixa t io n
a b c
Fig 11.1-4 a – c If th e m edial part of th e poster ior facet is n ot
con gru en t to th e talu s on e h as to rst redu ce th is su sten tacu -
lar fragm en t con gru en t to th e talu s, keepin g it tem porarily
redu ced w ith a 2.0 m m K-w ire com in g from th e plan tar side
an d xin g it an atom ically to th e talu s. After th is th e in term e-
d iate posterior facet fragm en t sh ou ld be redu ced an d xed
tem porarily w ith 1–2 K-w ires w h ich ru n from lateral th rou gh
th e sk in m ed ially. Th ey are retracted so far m ed ially th at on e
can n ow redu ce th e larger lateral part of th e posterior facet
con gru en t to th e in term ed iate an d m ed ial part of th e poste-
rior facet as well as to th e talu s by advan cin g th e K-w ires from
m edial to lateral to h ave th e com plete su btalar join t tem po-
rarily xed in an an atom ical position .
After th is m an eu ver th e tu berosity fragm en t an d th e an terior
process fragm en ts are redu ced, keepin g th em in th e correct
position w ith K-w ires. After th is an atom ical redu ction th e
plate is rou gh ly m odeled an d applied to th e calcan eal wall.
1
6
4
2
Fig 11.1-5 Th e tab in th e critical an gle of Gissan e (CAG) is
precisely ben t in to place w ith special forceps to keep th e
an terior process fragm en t in position . Usu ally 6 –7 screw s are
in serted in to th e calcan eal bon e: 2 –3 from th e su bth alam ic
area in to th e su sten tacu lu m , 2 in to th e tu berosity fragm en t
far dorsally, an d 2 screw s in to th e an terior process fragm en t
close to th e calcan eocu boid join t. Fin e-tu n in g adaptation of
th e plate before in sertin g th e lock in g h ead screw s is ach ieved
by u sin g th e th readed tab ben ders especially in th e su bth a-
lam ic an d calcan eocu boid join t area. Be aware th at th e ver y
rst su bth alam ic screw sh ou ld n ot be a lock in g h ead screw
bu t a 3.5 m m cortex screw (com pression screw) so as n ot to
leave a gap in th e posterior facet.
Th e in traoperative pictu re ( Fig 11.1-5 ) sh ow s th e situ ation
after an atom ical redu ction an d xation w ith th e lock in g
plate. 1 ) On e of th e fou r 2.0 m m K-w ires wh ich are in serted
in th e talu s an d cu boid is keepin g th e fu ll th ick n ess ap u p for
optim al ex posu re. 2 ) Tab ben t close to th e bon e in th e calca-
n eal n eck area to keep th e an terior process fragm en t in an at-
om ical position . 3 ) Tab ben t towards th e bon e, wh ich option -
ally m igh t keep a plan tar trian gu lar fragm en t in position . 4 )
2.0 m m cortex screw x in g th e lateral part of th e posterior
facet wh ich was addition ally broken in itself. 5 ) On e of th e
lock in g h ead screw s, h ere close to th e calcan eocu boid join t.
6 ) 3.5 m m cortex screw w h ich h as to be in serted as a com -
pression screw at th e ver y begin n in g so as n ot to leave a gap
in th e su btalar join t.
8 49
 11 Ca lca n e u s

4 Re h a b ilit a t io n

c d

With split lower leg cast (8 days), con tinu ou s passive m otion
(startin g 2n d day), active m otion , partial weigh t bearin g
(20 kg) for 6 weeks in patien t’s ow n sh oes, fu ll weigh t bear in g
after 8 –9 weeks.

Fig 11.1-6 a – d
a – b An atom ical redu ction an d xation w ith th e lock in g
calcan eal plate is ach ieved w ith ou t th e n eed for bon e
graftin g.
c– d Exten sion , ex ion , as well as pron ation , su pin ation of
a b
th e foot after 3 m on th s.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch
If th e h orizon tal part of th e exten ded lateral approach is
position ed too far in th e plan tar d irection , th e over view of
th e su btalar m igh t be lim ited; if th e vertical part of th e
in cision is n ot position ed dorsally en ou gh , th e su ral n er ve
m igh t be in ju red.
Ap p ro a ch
Fig 11.1-7a – b Th e lim ited su sten tacu lar approach
in add ition to th e exten ded lateral approach (patien t in
th e su pin e position ) is ver y h elpfu l in cases wh ere
th e m ed ial facet is broken in itself (see Fig 11.1-9 b – d ).
Recon stru ction of th e m u ltifragm en ted su btalar join t
(m ed ial an d posterior facet) always h as to be started from
m ed ial to lateral. Th is approach is recom m en ded also
for isolated fractu res of th e su sten tacu lu m tali.
1
1
2
3 3 4

2
a b

1 Po ste rio r tib ialis te n d o n .

2 Fle xo r d igito ru m lo n gu s te n d o n .
3 Fle xo r h a llu cis lo n gu s te n d o n h e ld a wa y w ith ru tte r b an d s.
4 Su ste n tacu lu m tali.

8 50
 11.1 In t ra a r t icu la r ca lca n e a l fra ct u re
5 Pit fa lls – (co n t)
Re d u ct io n
Fig 11.1-8 a – b Be aware of th e tilted part of th e m edial
portion of th e posterior facet wh ich m u st rst be redu ced
con gru en t to th e talu s an d tem porarily xed w ith a
K-w ire as sh ow n in Fig 11.1-4 a – c .
a b
6 Pe a rls + (co n t)
Re d u ct io n
Fig 11.1-9 a – b After redu cin g th e fou r parts of th e su b-
th alam ic zon e, u sin g th e exten ded lateral an d th e lim ited
su sten tacu lar approach sim u ltan eou sly, on e can screw
an d x th e su bth alam ic block w ith 4.0 m m can cellou s lag
screw s.
851
 11 Ca lca n e u s

8 52
 Au t h o r Ha n s Zw ip p

11.2 Se ve re fracture dislocation of the calcane us

1 Ca s e d e s crip t io n

a b c d

28-year-old m an fell dow n stairs an d su stain ed a severe fractu re d isloca-

tion of th e calcan eu s.

Fig 11.2 -1a – g

a – b AP an k le view an d lateral x-ray sh ow severe d islocation of th e
tu berosity an d bu rstin g of th e lateral m alleolu s. Severe com m inu -
tion of th e an terior part of th e calcan eu s also affectin g th e calca-
n eocu boid join t.
c– g Th e dorso-plan tar x-ray an d th e CT scan s im pressively sh ow th e
e f dislocated tu berosity, in clu din g th e m ain part of th e posterior facet.
Com m inu tion of th e distal bu la an d th e an terior h alf of th e calca-
n eu s in volvin g th e m edial an d cu boidal facets.

In d ica t io n

Se ve re st fra ctu re d islo ca tio n o f th e le ft ca lca n e u s w ith co m p le te d islo ca tio n a t

th e su b ta la r le ve l, in traa rticu la r fra ctu re o f th e p o ste rio r fa ce t, m e d ia l/ a n te rio r
fa ce t a n d cu b o id a l fa ce t, la tte r co m m in u te d . Ad d itio n a l m u ltifra gm e n ta ry fra ctu re
o f th e d ista l b u la . De sp ite d ia b e te s th e in d ica tio n fo r ORIF is give n b e ca u se o f
g th e se ve rit y o f th e d islo ca te d h in d fo o t a n d yo u th o f th e p a tie n t.

8 53
 11 Ca lca n e u s

Pre o p e ra t ive p la n n in g

Eq u ip m e n t Pa t ie n t p re p a ra t io n a n d p o s it io n in g
• Ca lca n e a l lo ckin g p la te 3 .5 Pre o p e ra tive a n tib io tics .
• 3 .5 m m lo ckin g h e a d scre w s Liftin g th e le ft p e lvis w ith a 4 5 ° w e d ge .
• 4 .0 m m ca n ce llo u s b o n e scre w Fixin g th e p e lvis la te ra lly o n b o th sid e s to a llo w ta b le tiltin g.
• 2 .0 m m co rte x scre w s
• Ca n ce llo u s 6 .5 m m Sch a n z scre w w ith h a n d le
to re d u ce th e tu b e ro sit y fra gm e n t
• La rge p e lvic re d u ctio n fo rce p s
• Arth ro sco p y se t
(Size o f s yste m , in stru m e n ts,
a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.)

Fig 11.2 -2 Su p in e p o sitio n o f th e

p a tie n t o n th e o p e ra tin g ta b le .

2 Su rgica l a p p ro a ch

2
1

a b

Mod i ed palm ar approach ru n s from th e dorsal aspect of th e bu la to th e an terior aspect

Fig 11.2 -3 a – b
of th e base of th e fth m etatarsal, tak in g care of th e peron eal ten don s w h ich , in th ese cases, u n n on -
an atom ically becau se of th eir avu lsion from th e proxim al retin acu lu m an d con secu tive dislocation .
Severe cartilage dam age (1 ) to th e posterior facet wh ich is d islocated far lateral ju st below th e m u ltifrag-
m en ted d istal bu la ( 2 ).

8 54
 11.2 Se ve re fra ct u re d is lo ca t io n o f t h e ca lca n e u s

2 Su rgica l a p p ro a ch (co n t )

3
b
a

Fig. 11.2 -4 a – bModi ed McReyn olds approach . Th e in cision is m ade h orizon tally or as a 1 Su ste n tacu la r fragm e n t
lazy S, abou t 8 –10 cm , exactly h alfway between th e tip of th e m ed ial m alleolu s an d th e sole. 2 An te rio r p ro ce ss fragm e n t
Th e n eu rovascu lar bu n d le is iden ti ed an d carefu lly h eld away w ith a pen rose d rain . Th e 3 Tu b e ro sity fragm e n t
abdu ctor h allu cis m u scle is retracted dow n wards, w h ereas th e exor h allu cis lon gu s ten don is
on ly iden ti ed an d left in place.

3 Re d u ct io n a n d fixa t io n

After approach in g from laterally an d m edially an d h avin g
clean ed th e fractu re sites in th e rst step , a 6.5 m m can cel-
lou s Sch an z screw w ith h an dle is position ed in to th e large
tu berosity fragm en t after stab in cision an d predrillin g
(3.2 m m).
By pu llin g th e tu berosity fragm en t dow n a n d sh iftin g it m edi-
ally, th e posterior facet can be redu ced below th e talu s.
Con trollin g th e position of th e tu berosity fragm en t w ith th e
adjacen t posterior facet from lateral, th e redu ction towards
th e su sten tacu lar fragm en t is con trolled from m ed ial.
As soon as an an atom ical redu ction h as been ach ieved, th e
large pelvic redu ction forceps w ith ball an d spike is brou gh t
in to place, ie towards th e m ed ial su sten tacu lar wall an d
th e lateral su bth alam ic area, in th is way com pletin g m ed ial
sh iftin g an d safe an atom ical redu ction .
Wh ile com pressin g th e tu berosity fragm en t towards th e
su sten tacu lar fragm en t w ith th e large pelvic redu ction for-
ceps, a 4.0 m m can cellou s bon e lag screw is in serted from th e
lateral su bth alam ic zon e in to th e su sten tacu lar fragm en t.
A two-h ole part of th e lock in g calcan eal plate is cu t off w ith
th e special sm ooth -cu ttin g forceps to x th e su sten tacu lar
an d th e large tu berosity fragm en t from th e m edial side u sin g
screw s for lock in g, an d rebu ild in g in th is way a stable m ed ial
wall.
a b
Fig 11.2 -5 a – d
a – b After an atom ical redu ction of th e m u ltifragm en ted
an terior h alf of th e calcan eu s by rem odelin g th e cu boi-
dal facet towards th e cu boid an d xin g th e fragm en ts
tem porar ily w ith K-w ires, a 6-h ole part of th e lock in g
calcan eal plate is cu t off.

855
 11 Ca lca n e u s

3 Re d u c t io n a n d fixa t io n (co n t )

c d

Fig 11.2 -5 a – d (co n t)

c Th e plate is an atom ically ben t w ith th e th readed tab ben d- d Fou r lock in g h ead screw s are in serted u sin g th e torqu e
ers an d brou gh t dow n to th e calcan eal wall. lim iter.

After com pletely restorin g th e calcan eu s, th e m u ltifragm en ted lateral d istal m alleolu s is rebu ilt w ith fou r 2.0 m m cortex
screw s. At th e least, th e d islocated peron eal ten don s are redu ced beh in d th e lateral m alleolu s an d th e proxim al retin acu lu m is
su tu red back to its origin in tran sosseu s su tu re tech n iqu e.

4 Re h a b ilit a t io n

a b c d

With split lower leg cast (8 days), con tinu ou s passive m otion (startin g secon d day), active m otion , partial weigh t bearin g
(20 kg) for 6 –8 weeks in patien t’s ow n sh oes, fu ll weigh t bearin g is ach ieved after 8 weeks.

An atom ical redu ction an d xation w ith th e lock in g calcan eal plate is perform ed w ith ou t u se of an y bon e graft.
Fig 11.2 -6 a – k
Exten sion , exion , as well as pron ation /su pin ation of th e foot are close to n orm al. Fu lly active as a beer brewer.

8 56
 11.2 Se ve re fra ct u re d is lo ca t io n o f t h e ca lca n e u s

4 Re h a b ilit a t io n (co n t )

e f

g h i k

Fig 11.2 -6 a – k (co n t) Th e fractu re h as h ealed an atom ically w ith ou t sign s of posttrau m atic arth ritis at 15 m on th s follow-u p.

857
 11 Ca lca n e u s
5 Pit fa lls –
Exp o s u re
Ch oosin g th e in correct approach , like th e exten ded lateral
approach in th ese cases, m ean s th at th e lateral
m alleolu s an d th e dislocated peron eal ten don s can n ot be
con trolled an d repaired.
Re d u ct io n
Not u sin g a bilateral approach or th e 6.5 m m can cellou s
Sch an z screw w ith h an d le to m an ipu late th e tu beros-
ity fragm en t, or failin g to u se th e big rou n d pelvis clam p,
on e w ill probably n ot be able to ach ieve an atom ical
redu ction of th ese severely d islocated fractu res as dem on -
strated by th e follow in g m alu n ited case.
Fig 11.2 -7a – d By u sin g a bilateral approach , m obilizin g
th e m alu n ited fragm en ts, sh iftin g th e tu berosity fragm en t
w ith th e in serted Sch an z screw (6.5 m m ) w ith h an d le
an d u sin g th e large pelvic redu ction forceps (a ) th e large
laterally d islocated tu berosity fragm en t in clu din g
th e poster ior facet can be redu ced an d xed an atom ically
freein g u p th e lateral m alleolu s (com pare to b an d d ).
a b
c d
8 58
6 Pe a rls +
Exp o s u re
In th e case of a com pletely destroyed cu boidal facet, th e
sk in in cision sh ou ld ru n beyon d th e cu boidal join t to
ach ieve en ou gh ex posu re of its calcan eal facet u sin g th e
cu boid as a m old.
Re d u ct io n
Fig 11.2 -8 a – d By u sin g a m in i distractor after h avin g
placed on e pin in to th e cu boid an d on e pin in to th e
u n broken part of th e calcan eu s, redu ction of th e com m i-
nu ted cu boidal facet becom es possible. Fixation w ith a
lock in g plate offers stability, even in com plex foot frac-
tu res like th is on e.
a b
c d
 Glo s s a r y

Glossary

An y dru g or n atu rally occu rrin g su bstan ce, w h ich

a n tib io tic
With a ckn o w le d ge m e n ts to Ch ris to p h e r L Co lto n ,
can in h ibit th e grow th of, or destroy, m icroorgan ism s.
Ch ris to p h e r G Mo ra n , a n d Ste p h a n M Pe rre n

Preven ts sh ear displacem en t of an obliqu e

a n tiglid e p la te
Th e glossar y provides th e work in g de n ition s for term s th at
fractu re fragm en t wh ereby th e an tiglide plate fu n ction s as a
h ave been u sed by au th ors th rou gh ou t th e book. We h ope th e
bu ttress.
glossar y w ill h elp readers u n derstan d th e text.

An in am m ator y con d ition of a syn ovial join t. It

a rth ritis
a b d u ctio n Movem en t of a part away from th e m id lin e.
m ay be septic or aseptic.

a b so lu te s ta b ilit y See stability, absolu te.

Fu sion of a join t by bon e as a plan n ed ou tcom e
a rth ro d e sis
of a su rgical procedu re.
a d d u ctio n Movem en t of a part towards th e m idlin e.

a rticu la r fra ctu re —p a rtia l On ly part of th e join t is in volved

Altern atively kn ow n as Re ex Sym path etic
a lgo d ystro p h y
wh ile th e rem ain der rem ain s attach ed to th e d iaph ysis. Th ere
Dystroph y, Su dek’s atroph y, or type II com plex region al pain
are several varieties:
syn d rom e (CRPS)—see also fra ctu re d ise a se .
• p u re d e p re ssio n An articu lar fractu re in wh ich th ere is de-
pression alon e of th e articu lar su rface w ith ou t split. Th e
a llo gra ft Bon e or tissu e tran splan ted from on e in d ividu al to
depression m ay be cen tral or periph eral—see im p a cte d fra c-
an oth er.
tu re .
• p u re sp lit An articu lar fractu re in wh ich th ere is a lon gi-
Th e referen ce position of th e body—
a n a to m ica l p o sitio n
tu d in al m etaph yseal an d articu lar split, w ith ou t an y add i-
stan d in g facin g th e obser ver, w ith th e palm s of th e h an ds
tion al osteoch on d ral lesion .
facin g for ward.
• sp lit-d e p re ssio n A com bin ation of a split an d a depression ,
in wh ich th e join t fragm en ts are u su ally separated.
a n a to m ica l re d u ctio n Rein statem en t of th e exact pre-fractu re
• m u ltifra gm e n ta ry-d e p re ssio n A fractu re in wh ich part of
sh ape of th e bon e.
th e join t is depressed an d th e fragm en ts are com pletely
separated.
Th e property of an im plan t con stru ct, wh ich
a n gu la r sta b ilit y
is design ed so th at th e d iscreet parts of th e im plan t, wh en as-
Th e en tire articu lar su rface is
a rticu la r fra ctu re —co m p le te
sem bled, are xed in th eir an gu lar relation sh ip to each oth er,
separated from th e d iaph ysis.
to stabilize th e fractu re. Usu ally applied to plates an d screw s,
wh en th e screw h eads, on ce driven h om e in th e plate h ole,
Graft of tissu e from on e site to an oth er w ith in th e
a u to gra ft
are in tercon n ected w ith th e plate—th is is ach ieved by an ex-
sam e in dividu al (h om ograft).
tern al th read on th e screw h ead wh ich en gages w ith an in ter-
n al th read in th e plate h ole.

859
 Bon e wh ich h as
a va scu la r n e cro sis (o fte n a b b re via te d a s AVN)
been depr ived of its blood su pply d ies. In th e absen ce of sepsis,
th is is called avascu lar n ecrosis. Th e dead bon e retain s its n or-
m a l st ren gt h u n t il t h e n at u ra l process of reva scu la r izat ion ,
by cre e p in g su b stitu tio n , starts to rem ove th e dead bon e, in
preparation for th e layin g dow n of n ew bon e.
a vu lsio nPu llin g off, eg, a bon e fragm en t pu lled off by a liga-
m en t or m u scle attach m en t is an avu lsion fractu re.
b a cte ricid a l Capable of k illin g bacteria.
b ico rtica l scre w A screw th at en gages in both th e n ear an d th e
far cortex.
Th e ability to ex ist in h arm on y w ith , an d
b io co m p a tib ilit y
n ot to in ju re, associated biological tissu es or processes.
A tech n iqu e of su rgical ex posu re,
b io lo gica l in te rn a l fixa tio n
fractu re redu ction an d xation in clu d in g th e bon e-im plan t
in terface wh ich favors th e preservation of th e blood su pply
an d th ereby optim izes th e h ealin g poten tial of th e bon e an d
soft tissu es.
b o n e gra ftBon e rem oved from on e skeletal site an d placed
at an oth er. Bon e grafts are u sed to stim u late bon e u n ion an d
also to restore skeletal con tinu ity wh ere th ere h as been bon e
loss—see a llo gra ft , a u to gra ft , an d xe n o gra ft .
b o n e h e a lin g See h e a lin g .
Wh ere th ere is a fractu re com plex w ith a
b u t te rfly fra gm e n t
th ird fragm en t wh ich does n ot com prise a fu ll cross section
of th e bon e (ie, after redu ction th ere is som e con tact between
th e two m ain fragm en ts), th e sm all wedge-sh aped fragm en t,
wh ich m ay be spiral, is occasion ally referred to as a bu tter y
fragm en t—see w e d ge fra ctu re .
860
Con stru ct th at resists axial load by applyin g force at
b u t tre ss
90° to th e ax is of poten tial deform ity.
ca llu s A com plex tissu e of im m atu re bon e an d cartilage th at
is form ed at th e site of bon e repair.
Trabecu lar bon e of spon gy stru ctu re, fou n d
ca n ce llo u s b o n e
m ostly at th e proxim al an d distal bon e en ds.
Th e active cells of cartilage w h ich produ ce
ch o n d ro cyte s
type II collagen an d proteoglycan s th at m ake u p th e ch on d ral
m atrix.
Ra ised pressu re in a closed fascia l
co m p a rt m e n t s yn d ro m e
com pa r t m en t t h at resu lt s in lo ca l t issu e isch aem ia —see
m u scle co m p a rtm e n t .
Fractu re w ith on e or m ore in term ed iate
co m p le x fra ctu re
fragm en ts in wh ich th ere is n o con tact between th e m ain
fragm en ts after redu ction .
co m p re ssio n scre w See la g scre w .
co m p re ssio n plate A plate applied u n der ax ial ten sion to
com press fractu re su rfaces an d orien ted m ore or less per pen -
d icu larly to th e lon g ax is of th e bon e.
Th e act of pressin g togeth er to in crease
co m p re ssio n m e th o d
or ach ieve stability. Com pression stabilizes by preloadin g an d/
or produ cin g friction .
Occu rs between two fragm en ts of bon e m ain -
co n ta ct h e a lin g
tain ed in m otion less con tact. Th e fractu re is th en repaired by
direct in tern al rem odelin g.
All plates w ith ou t th readed screw h oles.
co n ve n tio n a l p la te
Com pare: an gu lar stable plate.
 Glo s s a r y
Cortex screw s or can cellou s bon e screw s,
co n ve n tio n a l scre w
ie, n ot lock in g h ead screw.
co ro n a lTh is is a vertical plan e of th e body passin g from side
to side, so th at a coron al bisection of th e body wou ld cu t it in to
a fron t h alf an d a back h alf. Also called th e fron tal plan e.
co rtica l b o n eTh e den se bon e form in g th e tu bu lar elem en t of
th e sh aft, or d iaph ysis (m idd le part) of a lon g bon e. Th e term
is also applied to th e den se, th in sh ell coverin g th e can cellou s
bon e of th e m etaphysis.
co rtico to m y A special osteotom y wh ere th e cortex is su rgi-
cally d ivided bu t th e m edu llar y con ten t an d th e periosteu m
are n ot in ju red.
co n tin u o u s p a ssive m o tio n —CPM The u se of apparatu s to provide
periods of passive m ovem en t of a join t th rou gh a con trolled
ran ge of m otion .
cre e p in g su b s titu tio n Th e slow replacem en t of dead bon e w ith
livin g, vascu lar bon e.
Th e su rgical excision from a wou n d or path o-
d e b rid e m e n t
logical area, of foreign m aterial an d all avascu lar, con tam i-
n ated an d in fected tissu e.
A m aterial (bon e, im plan t, etc.) placed u n der
d e fo rm a b ilit y
load is deform ed. Th e larger th e deform ability, th e larger th e
deform ation u n der a given load. Deform ability is in verse to
stiffn ess. Th e im plan ts are gen erally m ore deform able th an
bon e. As an exam ple: u n der an applied ben d in g m om en t th e
n ail m ay deform abou t 10 tim es m ore an d a plate abou t 50
tim es m ore th an th e correspon d in g bon e.
d e fo rm a tio n Deform ation m ay be elastic (reversible) or plastic
(irreversible).
For a given load th e deform ation
d e fo rm a tio n -tissu e
of differen t repair tissu es m ay differ by a factor of abou t
1 : 1,000,000 (granu lation tissu e : cortical bon e).
d e fo rm it y An y abn orm ality of th e form of a body part.
Un ion is n ot tak in g place at wh at is accepted
d e la ye d u n io n
as th e ex pected tim e cou rse for a particu lar fractu re (an d th e
patien t’s age).
Th e cylin drical or tu bu lar part between th e en ds of
d ia p h ysis
a lon g bon e, often referred to as th e sh aft.
d islo ca tio nA displacem en t of a join t su ch th at n o part of on e
articu lar su rface rem ain s in con tact w ith th e oth er. Som e-
tim es u sed in correctly to den ote fractu re d isplacem en t.
Th e con d ition of bein g or m ovin g ou t of place.
d isp la ce m e n t
A fractu re is d isplaced if th e fragm en ts are n ot perfectly an a-
tom ically align ed. Th e fragm en ts of a fractu re d isplace in re-
lation to each oth er. Th e d isplacem en t m ay be reversible or
irreversible.
d ista l Away from th e cen ter of th e body, m ore periph eral.
d uctility Th e ability of a m ater ial to develop sign i can t, per-
m an en t deform ation before it breaks—see plastic d e fo rm a tio n .
In creasin g m ech an ical load across a fractu re to
d yn a m iza tio n
en h an ce bon e form ation .
e la stic d e fo rm a tio n See p la stic d e fo rm a tio n .
A sin gle layered m em bran e th at lin es th e in terior
e n d o ste u m
su rface of th e bon e, ie, th e wall of th e m edu llary cavity. Its
cells h ave osteogen ic poten tial.
8 61
 Wh en tissu es are in ju red, th e dam age is du e to
e n e rgy tra n sfe r
en ergy th at is tran sferred to th e tissu es. Th is is m ost com m on -
ly du e to th e tran sfer of kin e tic e n e rgy from a m ovin g object
(car, m issile, fallin g object, etc).
Th e en d of a lon g bon e wh ich lies u pon th e grow th
e p ip h ysis
plate in a ch ild’s skeleton —see m e ta p h ysis .
Skelet a l st abilizat ion u sin g pin s, w ires, or
e xte rn a l fixa tio n
screw s th at protru de th rou gh th e sk in an d are lin ked exter-
n ally by bars or oth er devices.
Does n ot in volve th e articu lar su rface
e xtra a rticu la r fra ctu re
bu t m ay be w ith in th e capsu le of th e join t.
fa r co rte x Th e cortex m ore d istan t from th e operator.
Soft-tissu e aps, based u pon a perforatin g
fa scio cu ta n e o u s
artery, wh ich in clu de th e sk in , th e su bcu tan eou s tissu es an d
th e deep fascia.
fascio tom y Th e su rgical division of th e wall of a mu scle com -
partm en t, u su ally to release h igh in tracom partm en tal pres-
su re—see com partm e n t syndrom e and m u scle com partm e n t .
Tissu e con sistin g of elem en ts of cartilage an d
fib ro ca rtila ge
of brou s tissu e. It is th e n orm al con stitu en t of th e m en isci
an d th e trian gu lar brocartilage at th e w rist. It form s as th e
repair tissu e after in ju r y to articu lar cartilage.
A con dition ch aracterized by disproportion -
fra ctu re d ise a se
ate pain , soft-tissu e swellin g, patch y bon e loss, an d join t stiff-
n es. Lin ked term s are algodystroph y, re ex sym path etic dys-
troph y (RSD), Su deck’s atrophy an d type II com plex region al
pain syn d rom e.
8 62
Application of a m ech an ical device to a bro-
fra ctu re fixa tio n
ken bon e to allow h ealin g in a con trolled position an d (u su -
ally) early fu n ction al reh abilitation . Th e su rgeon determ in es
th e degree of redu ction requ ired an d th e m ech an ical en vi-
ron m en t th at in u en ces th e m ode of h ealin g.
fra ctu re zo n e Th e area adjacen t to th e fractu re
glid in g h o leTh e cortex u n der th e screw h ead is drilled to th e
size of th e ou ter th read d iam eter so th at th e th read gets n o
pu rch ase. It is u sed for lag screw tech n iqu es.
A splin t (su ch as a n on locked in tram edu llar y
glid in g sp lin t
n ail) wh ich allow s som e d isplacem en t of th e fractu re frag-
m en ts, eg, axial sh orten in g.
Ha ve rsia n s yste m Th e cortical bon e is com posed of a system
of sm all ch an n els (osteon s) abou t 0.1 m m in d iam eter. Th ese
ch an n els con tain th e blood vessels an d are rem odeled after
a d istu rban ce of th e blood su pply to bon e. Th ere is a n atu ral
tu rn over of th e Haversian system s by con tinu ou s osteon al re-
m odelin g; th is process is part of th e dyn am ic an d m etabolic
n atu re of bon e. It is also in volved in th e adaptation of bon e to
an altered m ech an ical en viron m en t. Direct fractu re h ealin g
m ay by a side effect of osteon al rem odelin g of n ecrotic bon e.
h e a lin gRecovery of origin al in tegrity; clin ical bon e h ea lin g;
regarded as com plete wh en bon e h as regain ed adequ ate stiff-
n ess an d stren gth to w ith stan d fu n ction al loadin g.
Observed follow in g in tern al xation w ith ab-
h e a lin g—d ire ct
solu te stability. It is ch aracterized by th e absen ce of callu s;
th ere is n o resor ption at th e fractu re site. Bon e form s by in -
tern al rem odelin g w ith ou t in term ed iate repair tissu e. Direct
fractu re h ealin g was form erly called “prim ary” h ealin g. Di-
rect h ealin g takes on e to two years u n til safe fu n ction al load-
in g after im plan t rem oval is possible.
 Glo s s a r y
Direct bon e h ealin g du e to in tern al rem od-
h e a lin g—co n ta ct
elin g w h en th ere is absolu te stability an d th e bon e en ds are
in con tact.
h e a lin g—ga pDirect bon e h ealin g w h en th ere is absolu te sta-
bility bu t a sm all gap between th e fractu re fragm en ts. Lam el-
lar bon e form s in th e gap an d is th en rem odeled by pen etrat-
in g osteon s.
Bon e h ea lin g by callu s form ation in frac-
h e a lin g—in d ire ct
tu res treated eith er w ith relative stability, or left u n treated.
In d irect h ealin g takes on ly a few m on th s to regain adequ ate
stiffn es an d stren gth for fu n ction al load in g—see ca llu s .
A fractu re in w h ich th e opposin g bon y
im p a cte d fra ctu re
su rfaces are dr iven on e in to th e oth er.
Bon e fragm en ts are pressed to-
in te rfra gm e n ta ry co m p re ssio n
geth er, eith er w ith a lag screw or plate, to produ ce preload in g
an d friction between th e fragm en ts accord in g to th e prin ciple
of absolu te stability.
fixa to r A device attach ed to th e fragm en ts of a fractu re u sin g
a splin t an d pin s. Th e xator bridges th e fractu re site an d re-
du ces load-depen den t in stability.
e xte rnal xator A xator placed ou tside the body an d con n ect-
ed to th e bon e u sin g tran scu tan eou s pin s an d clam ps.
A xator placed in side th e body. Th e in tern al
in te rn a l fixa to r
xator replaces th e clam ps by lockin g th readed pin s (screw s)
w ith in th e plate h ole. Th e fu lly im plan ted in tern al xator re-
sem bles a plate bu t fu n ction s like a xator, ie, its stiffn ess re-
du ces load depen den t deform ation or d isplacem en t. Like th e
extern al xator, wh en elevated from th e bon e su rface, it does
n ot requ ire exact sh apin g to t th e bon e su rface. It can , th ere-
fore, be u sed w ith ou t broad su rgical ex posu re (M IPO).
isch e m iaRedu ction in blood ow resu ltin g in tissu e h ypox ia
an d m etabolic stan dstill.
kin e tic e n e rgy Th e en ergy stored by a body by virtu e of th e
fact th at it is in m otion . Kin etic en ergy is calcu lated accord in g
to th e form u la E = m v2 / 2, wh ere m is th e m ass of th e m ovin g
object an d v its velocity.
la g scre w A screw th at passes th rou gh a glid in g h ole to grip
th e opposite fragm en t in a th readed h ole, produ cin g in ter-
fragm en tary com pression wh en it is tigh ten ed.
lo ckin g p la te A plate w ith screw h oles th at allow tigh t m e-
ch an ical cou plin g to a lock in g h ead screw. Th e less in vasive
stabilization system (LISS) w ill accept on ly th is type of screw,
wh ile lock in g com pression plates (LCP) h ave a com bin ation
h ole th at w ill accept conven tion al (n on lock in g) screw h eads
or lock in g screw h eads.
lo ckin g h e a d scre w ( LHS)Screw s w ith , for in stan ce, th reads
cu t in to th e h ead wh ich provide a m ech an ical cou plin g to a
th readed screw h ole in a plate, th ereby creatin g an an gu lar
an d ax ial stable device, ie, after application th e screw can n ot
tilt or m ove alon g its lon g ax is. Th e lock in g h ead screw s of
th e in tern al xator resem ble an d act m ore like th readed bolts
th an con ven tion al screw s. Th e LHS m ain tain s th e relative po-
sition s of th e body of th e xator an d th e bon e.
m a lu n io n Th e fractu re h as h ealed in a position of d e fo rm it y.
m e taphysis In the adu lt, th is is the segm ent of a lon g bone lo-
cated between the articu lar su rface an d the sh aft (diaphysis). It
con sists mostly of cancellou s bone w ith in a th in cortical shell.
m e tho d o f fractu re xatio n Th e two basic m eth ods are com -
pression an d splin tin g.
8 63
 Any su rgical procedu re u n dertak-
m in im a lly in va sive su rge ry
en u sin g sm all sk in in cision s. Exam ples in clu de laparoscopic
abdom in al su rger y, arth roscopy, an d closed in tram edu llar y
n ailin g.
Redu ction an d
m in im a lly in va sive p la te o s te o s yn th e sis (MIPO)
plate xation w ith ou t direct su rgical ex posu re of th e fractu re
site, u sin g sm all sk in in cision s an d su bcu tan eou s, or su bm u s-
cu lar, in sertion of th e plate. Preferably locked an d sligh tly el-
evated im plan ts are u sed. In stru m en ts w ith sm all footprin t
are m an datory.
m o n o co rtica l s cre w A screw t h at en gages on ly in on e (t h e
n ear) cortex.
A fractu re w ith m ore th an on e
m u ltifra gm e n ta ry fra ctu re
fractu re lin e so th at th ere are th ree pieces or m ore —see also
co m p le x fra ctu re .
An an atom ical space, bou n ded on all
m u scle co m p a rtm e n t
sides eith er by bon e or deep fascia wh ich con tain s on e or
m ore m u scle bellies.
Th e cortex n ear th e operator an d on th e side of
n e a r co rte x
in sertion of an im plan t.
A plate, or oth er im plan t, wh ich redu ces th e
n e u tra liza tio n
load placed u pon a lag screw xation , th u s protectin g it from
overload. Th is term h as been replaced by protection ( p ro te c-
tio n p la te ).
n o n co n ta ct p la tePlates elevated from th e bon e su rface in or-
der to avoid d istu rban ce of blood su pply to soft tissu es an d
bon e. Th e lock in g h ead screw (th readed bolt) of th e locked
in tern al xator does n ot press th e plate (body of th e xator)
toward th e bon e—see also in te rn a l fixa to r, lo ckin g p la te , lo ckin g
h e a d scre w ( LHS) .
864
n o n u n io nTh e fractu re is still presen t an d h ealin g h as com e
to a stan dstill. Un der n o circu m stan ces w ill th e fractu re u n ite
w ith ou t su rgical in ter ven tion . It is u su ally du e to im proper
m ech an ical or biological con d ition s—see u n ion , pseu dar-
th rosis, an d delayed u n ion .
ORIF A w idely u sed abbreviation for open redu ction an d in -
tern al xation ( o ste o s yn th e sis ).
A con d ition of syn ovial join ts wh ich is ch arac-
o s te o a rth ritis
terized by loss of articu lar cartilage, su bch ondral bone sclerosis,
bon e cysts, an d th e form ation of osteoph ytes.
o s te o lysis Soften in g an d absor ption of bon e tissu e.
An acu te or ch ron ic in am m atory con dition
o s te o m ye litis
affectin g bon e an d its m edu llary cavity, u su ally th e resu lt of
in fection .
o s te o nTh e n am e given to th e sm all ch an n els wh ich com -
bin e to m ake u p th e Haversian system in cortical bon e.
A redu ction in bon e m ass between 1 an d 2.5
o ste o p e n ia
stan dard deviation s below th e m ean for a you n g adu lt (ie, a T
score of -1 to -2.5)—see o s te o p o ro sis .
A redu ction in bon e m ass m ore th an 2.5 stan -
o s te o p o ro sis
da rd deviat ion s below t h e m ea n for a you n g adu lt (ie, a T
score of < -2.5)—see o ste o p e n ia an d p a th o lo gica l fra ctu re .
A term coin ed by Albin Lam botte to describe
o s te o s yn th e sis
th e “syn th esis” (derived from th e Greek for pu ttin g togeth er,
or u n ion) of a fractu red bon e by a su rgical in ter ven tion u sin g
im plan ted m aterial. It d iffers from “in tern al xation ” in th at
it also in clu des extern al xation .
o s te o to m y Con trolled su rgical d ivision of a bon e.
 Glo s s a r y
An exactly con tou red plate is sligh tly
o ve rb e n d in g (o f p la te)
arch ed at th e level of a tran sverse fractu re, so th at its cen tral
portion stan ds sligh tly off th e u n derlyin g cortex. As com pres-
sion is applied, th e far cortex is com pressed rst, th en th e
n ear cortex (w ith ou t th e arch , th e plate w ill on ly com press
th e n ear cortex—th is is n ot a stable situ ation ).
p a th o lo gica l fra ctu re A fractu re th rou gh abn orm al bon e wh ich
occu rs at n orm al physiological load or stress.
p e rio s te u m Th e
brovascu lar m em bran e coverin g th e exterior
su rface of a bone. The deep cell layer h as osteogen ic potential.
p ilo t h o leA drill h ole wh ich h as th e sam e diam eter as th e
core of th e screw. Th is can th en be u sed to gu ide th e in sertion
ch an n el for screw s th at cu t th eir ow n th read (self-tappin g) or
a tap th at w ill cu t th e th reads an d produ ce a th readed h ole.
Bon e resor ption at a xator pin -bon e in terface
p in lo o se n in g
u su ally th e resu lt of in terface m icrom otion .
A perm an en t ch an ge in a m aterial’s
p la stic d e fo rm a tio n
len gth or an gle, ie, it w ill n ot be reversed wh en th e deform in g
force is released.
Mu ltiple in ju ry to on e or m ore body system s or
p o lytra u m a
cavities w ith sequ en tial system ic reaction s. An In ju r y Sever-
ity Score (ISS) of m ore th an 15 is u su ally taken to in d icate
polytrau m a.
p re b e n d in g o f p la te ( p re co n to u rin g, p re sh a p in g) Preoperative
or in traoperative ben din g of a plate to t th e sh ape of th e
plated bon e exactly.
p re cise re d u ctio n See a n a to m ica l re d u ctio n .
A plate, or oth er im plan t, w h ich sh ares load
p ro te ctio n p la te
w ith bon e an d th u s redu ces th e load placed u pon a lag screw
xation , thu s protectin g it from destru ctive overload. Th is
term h as replaced n eu tralization .
p se u d a rth ro sis literally m ean s “false join t”. Wh en a n on u n ion
is m obile an d allowed to persist for a lon g period, th e bon e
en ds becom e sclerotic an d th e in ter ven in g soft tissu es d iffer-
en tiate to form a type of syn ovial articu lation —see d e la ye d
u n io n , n o n u n io n , u n io n .
re d u ctio n Th e realign m en t of a d isplaced fractu re.
re d u ctio n —d ire ctRedu ction ach ieved by direct m an ipu lation
u sin g h an ds or in stru m en ts.
Fragm en ts are m an ipu lated in d irectly by
re d u ctio n —in d ire ct
applyin g corrective force at a d istan ce from th e fractu re, or by
d istraction or oth er m ean s.
A screw th at pu lls a bon e, or bon e fragm en t
re d u ctio n scre w
towards th e screw h ead or plate.
On e of th e n am es given to
re fle x s ym p a th e tic d ys tro p h y ( RSD)
algodystroph y—see fra ctu re d ise a se .
re fra ctu re A fu rth er fractu re occu rr in g after a fractu re h as
been solidly bridged by bon e, at a load level oth er w ise toler-
ated by n orm al bon e. Th e resu ltin g fractu re lin e m ay coin cide
w ith th e or igin al fractu re lin e, or be w ith in th e area of bon e
th at h as u n dergon e ch an ges as a resu lt of th e fractu re an d its
treatm en t.
re la tive sta b ilit y See sta b ilit y, re la tive .
8 65
 Th e process of tran sform ation of ex-
re m o d e lin g (o f b o n e)
tern al bon e sh ape (extern al rem odelin g), or of in tern al bon e
stru ctu re (in tern al rem odelin g, or rem odelin g of th e Haver-
sian system ).
rigid it y Th e ability to resist deform ation u n der an applied
load.
Rigid xation : Th is term is som etim es u sed to de n e a
xation u sin g a r igid im plan t. Th e term is in correct becau se
m ost im plan ts h ave a stru ctu ral rigidity, wh ich is less th an
th at of bon e. Th e im plan t m aterials rigid ity is less im portan t
th at th e geom etry or dim en sion s of th e im plan t—see sta b ilit y,
a b so lu te .
sa git ta lTh is is a vertical plan e of th e body passin g from fron t
to back, so th at a sagittal bisection of th e body wou ld cu t it
in to a righ t h alf an d a left h alf.
Su rgical in spection of a wou n d or in ju ry zon e,
se co n d lo o k
24 to 72 h ou rs after th e in itial m an agem en t of a fractu re or
wou n d.
se gm e n ta lIf th e sh aft of a bon e is broken at two levels, leav-
in g a separate sh aft segm en t between th e two fractu re sites, it
is called a “segm en tal” fractu re com plex.
A piece of dead bon e lyin g alon gside, bu t sepa-
se q u e s tru m
rated from , th e bon y bed from wh ich it cam e. In fected se-
qu estra are form ed in ch ron ic osteom yelitis.In ten si cation of
n ecrosis-in du ced porosity m ay lead to con u en ce of th e pores
wh ereby th e dead bon e becom es separated an d a sequ estru m
is form ed —see o ste o m ye litis .
sh e a rA sh earin g force is on e wh ich ten ds to cau se on e seg-
m en t of a body to slide u pon an oth er, as opposed to ten sile
forces, w h ich ten d to elon gate a body.
866
Th ere is a sin gle fractu re lin e produ cin g two
sim p le fra ctu re
fractu re fragm en ts.
Splin tin g is a m eth od of fractu re xation .
sp lin tin g m e th o d
Movem en t at th e fractu re site is redu ced by attach in g a rigid
su pport to th e m ain bon e fragm en ts. Th e splin t m ay be ex-
tern al (plaster, extern al xators) or in tern al (plate, in tern al
xator, in tram edu llary n ail).
sp lin t—lo cke d Th ere are xed con n ection s between th e bon e
an d splin tin g device, above an d below th e fractu re zon e, so
th at th e w o rkin g le n gth between th e m ain fragm en ts can n ot
ch an ge (eg, static, locked n ail).
sp lin t—glid in gTh e con n ection between th e bon e an d th e
splin tin g device allow s (con trolled) axial m ovem en t, so th at
th e d istan ce between th e m ain fragm en ts can ch an ge (eg, dy-
n am ic, locked n ail).
No ax ial con n ection s between th e bon e
sp lin t-n o n lo ckin g
an d th e splin t (eg, n on lock in g n ail, TEN).
An articu lar in ju ry w ith a fractu re lin e ru n -
sp lit d e p re ssio n
n in g in to th e m etaph ysis (split) an d im paction of separate os-
teoch on d ral join t fragm en ts (depression).
spontane ous fracture A fractu re th at occu rs at physiological load
or stress, u su ally in abnorm al bon e—see pathological fracture .
Th is is ch aracter ized by th e degree of re-
sta b ilit y o f fixa tio n
sidu al m otion at th e fractu re site after xation .
 Glo s s a r y
On e of th e prin ciples of fractu re xation .
sta b ilit y, a b so lu te
Fixation of fractu re fragm en ts so th at th ere is virtu ally n o d is-
placem en t of th e fractu re su rfaces u n der ph ysiological load.
Th is allow s d irect bon e h ealin g. Th e fractu re is m ore or less
repaired as a resu lt of n orm al tissu e ren ewal. Th e process of
h ealin g is m ain ly effected by th e rem oval of n ecrotic bon e
du rin g in tern al rem odelin g.
An oth er prin ciple of fractu re xation . A x-
sta b ilit y, re la tive
ation con stru ct th at allow s sm all am ou n ts of m otion in pro-
portion to th e load applied. Th is resu lts in in d irect h ealin g by
callu s form ation . Th e sm all degree of fractu re in stability al-
low s th e repair tissu e to recogn ize th e presen ce of th e fractu re
wh ereby an early repair process is in itiated.
stiffn e ss Th e resistan ce of a stru ctu re to deform ation . Th e
stiffn ess of a stru ctu re is ex pressed for in stan ce as its You n g’s
m odu lu s of elasticity, wh ich is th e ratio of stress to strain .
ben d in g stiffn ess of an im plan t is in versely
stiffn e ss, b e n d in g
proportion al to th e squ are of its w o rkin g le n gth .
Torsion a l stiffn ess of a n im pla n t is in -
s tiffn e ss , to rsio n a l
versely proportion al to its w o rkin g le n gth .
Th e th ick n ess of a stru c-
stiffn e ss a n d ge o m e trica l p ro p e rtie s
tu re affects deform ability by its th ird power. Ch an ges in ge-
om etry are, th erefore, m u ch m ore cr itical th an ch an ges in
m aterial properties.
stra in Ch an ge in th e len gth of a m aterial wh en a given force
is applied. Norm al strain is th e ratio of deform ation (len gth -
en in g or sh orten in g) to origin al len gth . It h as n o d im en sion s
bu t is often expressed as a percen tage.
Tissu e deform ation —am on g oth er th in gs—
stra in in d u ctio n
m ay resu lt in in du ction of callu s. Th is is an exam ple of a m e-
ch an ically in du ced biological reaction .
stra in to le ra n ce Th is determ in es th e toleran ce of tissu es to
deform ation . No tissu e can rem ain in tact an d fu n ction prop-
erly wh en an in crease in len gth (ie, strain ) cau ses th e tissu e
to d isru pt. Th is is th e critical strain level.
strain the ory—Pe rre n With a sm all fractu re gap, an y m ove-
m en t w ill resu lt in a relatively large ch an ge in len gth (ie, h igh
strain). If th is exceeds th e strain to le rance of th e tissu e, h ealin g
w ill n ot take place. If a larger fractu re gap is su bject to th e
sam e m ovem en t, th e relative ch an ge in len gth w ill be sm aller
(ie, less strain) an d, if th e critical strain level is n ot exceeded,
th ere w ill be n orm al tissu e fu n ction an d in d irect h ealin g by
callu s. If th e d istan ce between th e fractu red su rfaces is exces-
sive, h ealin g w ill n ot occu r.
stre n gth Th e ability to w ith stan d load w ith ou t stru ctu ral fail-
u re. Th e stren gth of a m aterial can be ex pressed as u ltim ate
ten sile stren gth , ben d in g stren gth , or torsion al stren gth .
In th e vicin ity of a sm all n otch in th e
stre ss co n ce n tra tio n
bon e excessive stress m ay occu r w ith in th e m aterial u n der
load. Refractu re m ay resu lt wh en a fractu re gap is n ot ade-
qu ately bridged du e to an im paired blood su pply at th e bon e-
im plan t in terface.
stre ss d istrib u tio n Th e pattern of stress w ith in a m aterial—
see stre ss co n ce n tra tio n .
stre ss p ro te ctio nUsin g an im plan t to redu ce peak loads ap-
plied to a screw xation , for exam ple. Th e th eor y of “stress
protection ”, th at is th e explan ation th at early tem porary poro-
sis of bon e in th e vicin ity of th e im plan t con tact is th e resu lt of
u n loadin g accord in g to Wolff’s law, is n o lon ger acceptable.
8 67
 stre ss rise rA sm all su rface defect (n otch) th at brin gs abou t a
con cen tration of stress. A screw h ole m ay to som e degree act
as a weak spot.
stre ss sh ie ld in gBon e deprived of fu n ction al stim u lation by
h avin g its fu n ction al load redu ced m ay react in th e lon g-term
by becom in g less den se or stron g.
A displacem en t of a join t bu t w ith partial con tact
su b lu xa tio n
between th e two articu lar su rfaces.
Th e prin ciple by wh ich an im plan t, attach ed to
te n sio n b a n d
th e ten sion side of a fractu re, con verts th e ten sile force in to
a com pressive force at th e cortex opposite th e im plan t. Wh ile
w ires, cables, an d su tu res are often u sed for ten sion ban d x-
ation , plates an d extern al xators, wh en appropriately placed,
can also fu n ction as ten sion ban ds.
th re a d h o le Discu ssed in con ju n ction w ith p ilo t h o le .
to gglin g Sligh t m ovem en t at th e cou ple between a screw an d
a plate or n ail. Im plan ts m ay be design ed to allow toggle, eg,
in tram edu llar y n ails wh ere th e toleran ces of th e assem bly do
n ot perm it exact t. Toggle between plates an d screw s m ay
occu r du rin g plate failu re w ith loosen in g of th e im plan t.
to rq u eTh e m om en t produ ced by a tu rn in g or tw istin g force.
As an exam ple: torqu e is applied to d rive h om e an d tigh ten a
screw. Th e m om en t is equ al to th e produ ct of th e lever arm (in
m eters) an d force (in New ton s), produ cin g torsion an d rota-
tion abou t an ax is (th e u n it of torqu e in Nm ).
tra n sla tio n Displacem en t of on e bon e fragm en t in relation to
an oth er, u su ally at r igh t an gles to th e lon g axis of th e bon e —
see d isp la ce m e n t .
868
u n io n Th e bon e h as u n ited an d regain ed its n orm al stiffn ess
an d stren gth . In clin ical term s, th is m ean s th ere is n o m ove-
m en t or ten dern ess at th e fractu re site an d n o pain on stress-
in g th e fractu re site. Rad iologically, th ere sh ou ld be eviden ce
of bon e trabecu lae bridgin g th e fractu re site.
va lgu s Deviation away from th e m id lin e in th e an atom ical
position .
varu s Deviation toward the m idline in the an atom ical position .
w a ve p la te Th e cen tral section of a plate is con tou red to stan d
off th e n ear cortex over a distan ce of several h oles. Th is leaves
a gap between th e plate an d th e bon e, wh ich (a) preserves
th e biology of th e u n derlyin g bon e, (b) provides a space for
th e in sertion of a bon e graft, an d (c) in creases th e stability
becau se of th e d istan ce of th e “waved” portion of th e im plan t
from th e n eu tral axis of th e sh aft. Su ch platin g is u sefu l in
n onu n ion treatm en t.
Fractu re com plex w ith a th ird fragm en t in
w e d ge fra ctu re
wh ich , after redu ction , th ere is som e d irect con tact between
th e two m ain fragm en ts—see b u t te rfly fra gm e n t .
w o rkin g le n gth Th e d istan ce between th e two poin ts of im -
plan t xation (on e on eith er side of th e fractu re) between an
im plan t, u su ally an in tram edu llary n ail, an d th e bon e.
xe n o gra ft Bon e or tissu e tra n spla n ted from on e species to
an oth er.
Th e en tire volu m e of bon e an d soft tissu e dam -
zo n e o f in ju ry
aged by en ergy tran sfer du rin g trau m a.