Scapula

 Surgical indications (all are relative)

Glenoid rim (anterior, inferior, or posterior) fracture with
associated shoulder joint instability
• Intraarticular joint displacement of 5 mm or greater
involving more than 25% of the joint surface
• Glenopolar angle < 22°
• Medial displacement of glenoid neck fracture > 2 cm
• 100% displacement or > 45° angulation of a scapular
body fracture
• Completely displaced process fracture (acromion,
coracoid, scapular spine)
• Significant malangulation (retroversion or anteversion)
of the scapular neck
• Young polytrauma patient
• Disrupted superior shoulder suspensory complex (two
breaks in the ring)

 Surgical approaches
Superior approach- used for superior glenoid fragments ; incision runs coronally in the middle between
the clavicle clavicle and scapular spine, laterally to just past the acromioclavicular joint. The fibers of the
trapezius muscle are split. Depending upon the localization of the fragment, the supraspinatus muscle is
carefully retracted posteriorly or anteriorly. The scapular notch is always identified to avoid damaging
the suprascapular nerve.

 Fractures of the scapular neck and the ipsilateral clavicle (the so-called “floating shoulder”)
represent a double disruption of the superior shoulder suspension complex. This injury, if
displaced, may lead to deformity where the glenoid faces caudal, decreasing the glenopolar angle
and impairing function . To avoid shortening of the shoulder girdle and poor function due to
abduction weakness and stiffness, open reduction and internal fixation of the clavicle and
possibly the glenoid neck may be indicated , particularly in cases with significant medial
displacement with shortening > 2 cm.
 Aftercare :For anterior rim fractures, the arm is kept in the internally rotated position in a sling
for 2 weeks followed by gradually increasing range of motion exercises. Full external rotation is
allowed after fracture union (typically 6–8 weeks). Posterior rim fractures are held in a
“gunslinger” external rotation splint for 2–4 weeks, then allowed gradual mobilization. With
stable fixation, most glenoid neck and body fractures are placed in a sling for comfort but may be
rapidly mobilized as pain subsides with unrestricted active and passive range of motion exercises.
Strengthening is allowed after fracture union, typically at 6 weeks after surgery.
 Clavicle
 sling treatment in the acute period, followed by early range-of-motion and strengthening
exercises as the pain subsides, generally after 2–6 weeks. The use of a figure-of-eight bandage
should be discouraged, as it offers no benefits and can be complicated by axillary
pressure sores and higher rates of nonunion .
 imaging: a 20° cephalic tilt view eliminates the overlap of the thoracic cage.
 Absolute surgical indications: open fractures +those impending skin perforation.


 After surgery, the arm is supported in a sling and shoulder pendular exercises are commenced. A
follow-up visit is recommended at 2 weeks to inspect the wound and obtain x-rays. The arm sling
 can be discontinued and unrestricted range-of-motion exercises initiated but the patient is
cautioned against any lifting whatsoever. If there is evidence of bony union by 6 weeks,
strengthening exercises are commenced. Patients should be advised to avoid contact or extreme
sports for the first 3 months after surgery until the fracture has healed well.

Humerus, proximal
 Anatomy : The central column diaphyseal (CCD) angle is 135°. The humeral head is normally
retroverted on the neck, facing approximately 25° posteriorly. The greater tuberosity is the
insertion for the supraspinatus tendon superiorly, the infraspinatus tendon posterosuperiorly,
and the teres minor tendon posteriorly.
 Indications for fracture reduction and stabilization include:
1. • Displaced fractures (defined by Neer [6] as displacement
2. of the fragment > 1 cm or angulation > 45°)
3. • Head-splitting fractures
4. • Combined neurovascular injuries
5. • Open fractures
6. • Unstable fractures with disrupted medial hinge
7. • Floating shoulder
8. • Polytrauma
9. • Irreducible fracture dislocations

 Surgical aproaches : deltopectoral, transdeltoid (deltoid split).

Humerus, shaft
 Anatomy : The axillary nerve and the posterior circumflex humeral artery originate posteriorly
and wind round the surgical neck about 5–6 cm below the lateral edge of the acromion.
 Humerus, distal
Surgical indications
• Displaced intraarticular fractures
• Open fractures
• Fractures with nerve or vascular injuries
• Polytrauma

Total elbow arthroplasty is used sparingly. It is only appropriate in patients with limited functional
demands or preexisting elbow arthritis .
 Approaches :
Because adult elbows are notorious for becoming stiff after injury, the goal of operative treatment is a fi
xation that is stable enough to allow active exercises and functional use of the limb for light tasks. When
the fixation is secure, elbow exercises can start the day after surgery. If fi xation is tenuous due to fracture
complexity or poor quality bone, it is better to immobilize the elbow to help the fracture heal in a good
position. Most patients do not suffer stiffness and those that do typically respond to treatment. Loose
fracture fi xation is difficult to salvage.
The early results of total elbow arthroplasty are seductively good: It is a straightforward procedure to
perform , rapid functional restoration is the rule, and on average the range of motion is better than that
obtained with internal fixation . The enthusiasm for total elbow arthroplasty is however tempered by
the following:
• Strict life-long activity restrictions (5 kg lifting limit)
• Inevitable failure of the prosthesis
• Potentially devastating complications, such as deep infection or end-stage osteolysis (severe bone loss
after multiple revisions), for which there is currently no good treatment option.

When the fixation obtained is somewhat tenuous—as a result of either the complexity of the fracture,
poor bone quality or both—it may be preferable to immobilize and protect the elbow for about 4 weeks
and deal with developing stiffness rather than to lose the fixation and have to salvage with a total elbow
arthroplasty.
Active, self-assisted stretching exercises are recommended; passive manipulation should be avoided.
Proximal forearm and complex elbow injuries
Forearm, shaft
 A Galeazzi fracture is a fracture of the radial shaft withdislocation of the DRUJ. It has
been termed the “fracture of necessity” describing the requirement for open reduction
and internal fixation.
Correct reduction and fixation of the radial fracture is usually accompanied by spontaneous
reduction of the DRUJ . If the ulnar head remains subluxed or dislocated, the most common
cause is a subtle malreduction of the radial fracture. If the DRUJ remains reducible but unstable,
the joint may be cross-pinned with 1.6 mm (in children) or 2.0 mm (in adults) K-wires with the
forearm in neutral rotation or in slight supination . In these cases, additional splinting of the
forearm including elbow and wrist is mandatory to prevent rotation and wire breakage.
However, gentle flexion and extension of the elbow may be performed under the supervision of
a trained therapist.

# Surgery is indicated for the following:

• Displaced fractures of both the radial and ulnar shaft
in adults
• Displaced, rotated (> 10º) or angulated (> 10º) isolated
fracture of either bone
–– A simple, undisplaced shaft fracture may be treated
by nonoperative means (ie, with a brace or cast) [5]
• Monteggia, Galeazzi, and Essex-Lopresti type fracture
dislocations
• Open fractures
• Polytrauma, floating upper limb injury, or bilateral
upper extremity injuries

There should be six cortices or three bicortical screws in each main fragment. In simple
fractures this usually means a 7-hole or 8-hole plate; in more complex fractures even longer
plates are advisable.

# Several approaches may be used to fix shaft fractures of the

forearm:
• Ulna—entire diaphysis: A straight incision is made
along the subcutaneous border. The plate is placed on
the posterolateral (extensor) or anterior (flexor)
aspect of the bone but not on the subcutaneous
border.
• Radius—entire diaphysis: The anterior approach
according to Henry is used. The plate is placed on the
anterior (flexor) aspect of the radius [8].
• Radius—proximal and middle third of the diaphysis:
The posterolateral approach can be used with the plate
on the posterior (extensor) aspect of the radius.
  Open fractures of the forearm can be treated by immediate internal fixation with results
comparable with closed fractures.

Aftercare
Following stable fixation, postoperative treatment should be functional with early active motion
of the fingers, wrist, elbow, and shoulder to reduce the risk of stiffness or complex
regional pain syndrome (CRPS).

 Removal of the implants is not indicated in an asymptomatic patient due to the high risk
of complications, including neurovascular injury and refracture .
Distal radius and wrist
Hand
The goals in treatment of metacarpal and phalangeal
fractures are the same regardless of the method used.
These include [1–3]:
• Restoration of articular anatomy
• Correction of angular or rotational deformity
• Stabilization of fractures
• Surgical approach not compromising hand function
• Rapid mobilization
Many fractures of the hand can be treated effectively using
nonoperative means. Stable skeletal fixation, however,
should be considered in the following [4–7]:
Fractures that are:
• Multifragmentary
• Severely displaced
• Multiple metacarpal
• Short oblique or spiral metacarpal
• Accompanied by any soft-tissue injury
Fractures at particular sites:
• Neck fractures, proximal phalanx
• Palmar base middle phalanx
Displaced articular fractures:
• Bennett fracture
• Rolando fracture
• Unicondylar and bicondylar
Certain injury types:
• Complete or incomplete amputations
• Some fracture dislocations
Surgery
Principles of surgical treatment
A number of basic principles should be followed when
operating
on hand fractures:
• A thorough knowledge of anatomy.
• Careful soft-tissue handling at all times.
• Dorsal incisions in the fingers may be longitudinal.
• Palmar incisions in the fingers should not be longitudinal
unless closed with a Z-plasty.
• A skin Z-plasty must have an apex angle greater than
60° to avoid necrosis.
• Midaxial incisions in the fingers pass between the dorsal
and palmar digital nerves.
• Avoid incisions at the germinal matrix of the nail bed.
• Avoid incisions on the ulnar side of the little finger and
radial side of the index finger.
• Incisions should be planned based on the fracture pattern,
the stabilization technique to be used and the implant
selected.
• Rotation of the digit must be regularly checked during
surgery.
• Extensor tendons and lateral ligaments may be split.
• Flexor tendons must never be split or incised.
• Dorsal venous drainage must be respected.
• The hand must be immobilized in the position of safety:
–– Wrist in extension
–– Metacarpophalangeal joints flexed 90°
–– Interphalangeal joints in full extension
• Fracture fixation should allow early, controlled, active
mobilization.
• The hand must be elevated after surgery to reduce swelling.
• The patient must be aware of the importance of correct
rehabilitation.
Radiopalmar approach to the base of the thumb. The skin incision extends along the lateral,
palpable border of the thumb metacarpal and curves, at its base in a palmar direction toward
the flexor carpi radialis tendon . Branches of the superficial radial nerve must be protected
as injury can cause chronic pain. The thenar muscles are elevated from the periosteum of the
metacarpal. The joint capsule is opened on the palmar side of the abductor pollicis longus
tendon . Exposure of the fracture can be improved by supination of the metacarpal to allow
direct reduction.
Pelvic ring
The pelvis should be protected, just as the cervical spine is collared. A pelvic binder should be
applied to splint the pelvis, reducing movement and pain. If possible, it is applied
prehospital and it must be placed correctly, over the greater trochanters with internal rotation
of both knees. Clinical examination of the pelvis with bimanual compression of the iliac wings
has poor sensitivity and may disrupt the initial clot formed at the fracture site and reactivate
hemorrhage. This examination is no longer recommended.
  Pelvic fracture, urethral injury, and catheterization
If the catheter will not pass or passes and drains only blood, the balloon should not be
inflated. Instead a retrograde urethrogram should be performed by withdrawing the catheter
into the meatus and gently inflating the balloon slightly to occlude the urethra. If there is a
urethral or bladder injury, the urology service should be informed immediately.
If a urethral catheter cannot be passed, a suprapubic catheter is required.
The placement of a suprapubic catheter may alter the timing of pelvic fracture surgery and so
the pelvic fracture service should be involved at an early stage.
The indications for primary (within 48 hours) urethral repair are associated anorectal injury,
perineal degloving, bladder neck injury, massive bladder displacement, and penetrating
trauma to the anterior urethra. The recommended definitive treatment for urethral rupture in
adult males is delayed repair at 3 months after injury. There should be a clear referral
pathway to a recognized center for reconstructive urethral surgery.
The open pelvis
 The open pelvis ; Associated soft-tissue injuries require expert management and can be
differentiated into two important categories:
1) Skin wounds communicating with the pelvic fracture
hematoma
2) Perineal injuries involving or close to the rectum
Acetabulum

 An associated hip dislocation should be considered an orthopedic emergency and

requires prompt reduction followed by evaluation of stability. If there is any joint
instability, traction is indicated. The traction weight should be no more than 1/6 of the
patient’s body weight and applied skeletally if there is to be a delay before definitive
surgery. Posterior hip dislocations are more common; the hip must be kept extended
and externally rotated to assist in maintaining reduction.
 - Indications for operative intervention include displacement of the articular surface, joint
incongruity, and unacceptable roof arc measurements . These indications are based on
the principle that performing an accurate reduction of the articular surface to obtain a
congruous hip joint will restore normal joint mechanics and reduce the risk of posttraumatic
arthritis; long-term clinical outcomes closely correlate with the quality of the surgical reduction.
Malreduction or subluxation of the hip joint will lead to abnormal loading of the articular
cartilage and subsequent joint arthritis. It is generally accepted that displacement or
incongruity greater than 1–2 mm is unsatisfactory .

- Because most nondisplaced fractures will have a stable and concentric hip joint, surgery is
not required. Nonoperative management is also indicated for some displaced fractures.
These include:
• Fractures not extending into the weight-bearing dome
• Low anterior column fractures
• Small (stable) posterior wall fractures not associated
with a dislocation or not involving the posterosuperior
portion of the acetabulum
• Low transverse fractures with roof arc angles of more
than 45° on all three radiographic views
• Both-column fractures with secondary congruity in
patients with low functional demand

Timing of surgery
Acute open reduction and internal fixation is rarely indicated. Exceptions to this include
dislocations that cannot be reduced by closed means, an incarcerated intraarticular fragment
following closed reduction, and unstable posterior dislocations that cannot be held in the
reduced position because of the marked deficiency of the posterior wall. Progressive or sciatic
nerve palsy that develops after reduction of the dislocation also should be considered a surgical
emergency. Delays of over a week should be avoided if possible as anatomical reduction
becomes progressively harder to obtain.

The approach utilized is often dictated by the experience of the operating surgeon but should
provide the greatest chance of anatomical reduction and stabilization of the joint surface.

The maintenance of knee fl exion (at 90°) and hip extension throughout the procedure reduces
tension on the sciatic nerve.
Femur, proximal
Surgical indications
• Any displaced fracture of the proximal femur involving
the head, neck, or intertrochanteric region
• Polytrauma
• Nondisplaced fractures of the proximal femur (to
ensure displacement does not occur)
Femur, shaft (including subtrochanteric
fractures)
Surgical indications
Nonoperative treatment of femoral shaft fracture by traction or cast brace has unacceptable outcomes and should
only be used when surgery is not an option. Traction is used for temporary stabilization until definitive fixation can
be performed. Most femoral shaft fractures are treated using IM nails. Plates may be used when there is an
associated metaphyseal or articular fracture and for periprosthetic fractures. Temporary external fixation is used
for damage limitation surgery and sometimes in the management of infected nonunion.
There are no absolute indications for retrograde nails but relative indications are:
• Obesity (it is difficult to find the correct antegrade
entry point)
• Ipsilateral femoral neck and shaft fractures
• Ipsilateral femoral and tibial shaft fractures (one
incision for both IM nails) (Fig 6.6.2-3)
• Multiple injuries (the surgeon can prepare and drape
other extremities, abdomen, and chest with the
patient supine on the radiolucent table)
• Bilateral femoral fractures (one set up in supine
position on radiolucent table)
• Unstable spine injuries
• Pregnancy (minimization of the fetus’ exposure to
radiation)
• An uncontaminated traumatic knee arthrotomy
• Ipsilateral pelvic and/or acetabular fractures (antegrade
nail incision might interfere with subsequent incisions)
• Severe soft-tissue injuries or burns at the antegrade
nail starting site
• Preexisting proximal femoral hardware

Relative indications for femoral plating include:

• Type 32B and type 32C fractures, with proximal
extension into the trochanteric area or distal extension
into the condylar area
• Children older than 8 years with open epiphyses, or
when there is no possibility of using elastic nails to
provide stability
• Fractures with a narrow or deformed IM canal
• Fractures with associated spinal or pelvic fractures
(further damage may be caused by using a fracture
table for femoral nailing)
• Fracture in association with abdominal injury that
requires a laparotomy (can proceed for plating on a
normal operating table at the same time)
• Fracture with associated vascular injury requiring
repair
• Periprosthetic or periimplant fractures
• Ipsilateral neck and shaft fractures when the neck
fracture is treated using a separate implant
• Fractures associated with severe lung contusion where
immediate IM nailing may be high risk
Femoral neck fractures are associated with femoral shaft fractures in about 2.5–6% of cases . These
neck fractures are often undisplaced and more vertical than isolated ones. They are frequently missed
injuries

If the femoral neck fracture is detected after IM nailing, additional lag screws to stabilize the neck
fracture should be inserted (“missa-nail” technique)
Femur, distal
Surgical indications
Standard treatment consists of surgical reduction and
fixation with early rehabilitation.
Nonoperative treatment is only justified in impacted, nondisplaced,
extraarticular (type A) distal femoral fractures or
in patients who are deemed nonambulatory and inoperable.
Splint care with a knee immobilizer is usually satisfactory
in these cases. Operative indications include:
• Any displaced distal femoral fracture
• Intraarticular displacement of the distal femoral joint
surface
• Malalignment of the distal femur
Modified standard lateral approach or minimally invasive
plate osteosynthesis:
The skin incision starts from Gerdy’s tubercle and extends proximally about 5–8 cm. Split the iliotibial
tract along the fibers to expose the lateral joint capsule. The joint capsule is opened which allows direct
visualization of the lateral surface of the lateral femoral condyle. A submuscular tunnel beneath the
vastus lateralis is prepared along the lateral surface of the femoral shaft to accommodate the chosen
length of plate.
 Percutaneous Schanz screws placed into the medial condylar fragment will facilitate the reduction and
clamping of simple articular fractures. With this tactic, articular exposure can be minimized. The reduced
articular fragments are provisionally held with K-wires. In most cases, 3.5 mm cortical
lag screws or 3.5 mm cannulated lag screws are then used. In multifragmentary articular fractures, a
positioning screw may be required instead of a lag screw to prevent narrowing of the articular surface of
the distal femur. Lag or positioning screws must be placed strategically so as not to hinder definitive
plate positioning and locking screw insertion. Once the articular block is reconstructed, then definitive
bridging between the articular block and the proximal shaft can be performed, with an anatomically
preshaped locking plate.
It is recommended to place locking screws bicortically to lessen the risk of pullout and increase the
screw working length. Internal rotation views with the image intensifier
at around 25° are recommended to avoid medial screw protrusion, as this causes painful irritation and
the need for implant removal. For proximal fixation, conventional screws
alone provide good fixation in young bone.
Aftercare
The aim of surgery is to provide stable fixation that allows
early functional rehabilitation of the injured knee. Active,
assisted motion of the hip, knee, and ankle can be started
as early as 48 hours, provided the soft-tissue injury allows
this and the patient has a good analgesia regimen. Continuous
passive motion may also be effective. In simple
fractures with bone contact the internal fixation is stable
enough to allow partial weight bearing (10–15 kg) immediately
after surgery. Multifragmentary fractures with bridge
plate constructs generally require more protection and should
not bear weight initially. Progressive weight bearing is allowed
after callus formation is seen during follow-up at
6–12 weeks.
Periprosthetic fractures

Unified Classification System

The core principles that are fundamental to the successful
assessment and management of periprosthetic fractures have
been assembled by Duncan and Haddad in the UCS. They
can be readily applied to periprosthetic fractures around the
shoulder, elbow, wrist, hip, knee, and ankle [5].
First, the anatomical location of the periprosthetic fracture
has to be coded in regard to the joint and the involved bones.
For the joint, Duncan and Haddad number the joints I-VI
starting from the shoulder (I), elbow (II), wrist (III), hip
(IV), knee (V), to the ankle (VI). For the identification of
the bones, the numbering follows that of the AO/OTA Fracture
and Dislocation Classification.
For further description of the periprosthetic fractures, they
have been divided into six types (A–F) with subtypes for
types A and B. To remember the different fracture types
more easily the following mnemonic code has been devised:
• Type A: apophyseal
• Type B: bed of the implant
• Type C: clear of the implant
• Type D: dividing the bone between two implants
• Type E: each of two bones supporting one arthroplasty
• Type F: facing and articulating with a hemiarthroplasty
Type B: bed of the implant or around the implant
The fracture involves the bone-implant interface, which is
responsible for the stability of fixation of the implant. Important
for the treatment is to further classify into one of
the three subcategories (Fig 6.6.4-3). Two questions need to
be answered:
• Is the implant well fixed or loose?
–– If well fixed: type B1
–– If loose: type B2
• In case of a loose implant, is there adequate bone
present to successfully support implant revision?
–– If yes: classification remains type B2
–– If not: type B3
Differentiation between types B1 and B2 can often be determined
with plain x-rays but sometimes needs further
radiological investigation (eg, CT or MRI) or can be only
determined during surgery.
Moreover, the distinction between types B2 and B3 is one
of individual interpretation, without a clear-cut transition.
Partially, it depends upon the reconstruction choice favored
by the surgeon. As a simple rule of thumb, the authors suggest
that the fracture is categorized as type B2 if the loose
implant can be revised with a fairly straightforward technique.
However, if more specialized techniques or a salvage procedure
is necessary, then it should be classified as type B3.
Surgery
Internal fixation
Before internal fixation can be considered, it is necessary
to assess the stability of the prosthetic implant. Besides x-
rays,
the fracture should be assessed by cross-sectional imaging
to determine if the implant is loose or well fixed. A loose
implant requires revision surgery and cannot be treated with
internal fixation. The surgeon needs to be prepared to adapt
the treatment plan in case the intraoperative situation is
different from the radiological diagnosis.
Reduction technique
There are two ways to reduce a periprosthetic fracture: direct
and indirect reduction. Direct reduction can be used for a
simple fracture (eg, spiral, short oblique, or transverse) with
two large main fragments. The fracture is exposed, reduced
anatomically and fixed with interfragmentary compression
and a protection plate. This fixation enables primary bone
healing but in osteoporotic bone interfragmentary compression
may not be possible.
Indirect reduction is the preferred technique in multifragmentary
fractures. The goal is to restore correct length,
alignment, and rotation and to bridge the fracture zone with
a long plate that extends over the whole length of the bone
but without exposure of the fracture zone. This requires a
closed reduction of the fracture. Most locking-plate systems
offer instruments that facilitate percutaneous, minimal invasive
plate and screw insertion, which maintains the softtissue
envelope.
Revision arthroplasty
In periprosthetic fractures, revision of a prosthetic component
is always an option. The most frequent indication for
revision arthroplasty in a periprosthetic fracture is loosening
of the prosthesis with associated osteolysis. Revision may
also be indicated if the cement mantle has been fractured
or the original prosthesis has been malpositioned. Preoperative
planning for both osteosynthesis and revision is important
as the final decision can only be made during surgery.
All appropriate instruments and implants have to be available
and the surgeon should be prepared to change from
the preferred procedure to a different operative plan.
For revision surgery, it is recommended to use a noncemented
implant as there is a risk that the cement could leak out
through the fracture gap, thereby delaying or even preventing
bone healing. The noncemented anchorage of the prosthesis
has better long-term stability after fracture healing
and bony integration. The advantage of a cemented implant
is that it provides immediate stability, and allows full weight
bearing postoperatively.
Patella
Preservation of active knee extension does not rule out a patellar fracture if the auxiliary
extensors of the knee (retinacula) are intact.
Surgical indications
• 2 mm of fragment displacement (gap)
• 2 mm of articular incongruity (step-off)
• Osteochondral fractures with associated intraarticular
loose bodies
• A compromised extensor mechanism at the proximal
or distal end of the patella with loss of active extension

The wire should be tightened with the knee in 90° of flexion and x-rays or image intensification
of the opposite knee will indicate the correct position of the patella.
Partial patellectomy
Whenever possible partial patellectomy is preferred to total patellectomy, as it keeps the lever
arm intact and improves strength and patient outcome. Veselko and Kastelec
reported poor outcomes with removal of more than 40% of the patella. A fragmented upper or
lower pole and even a multifragmentary zone in the middle of the patella can be
managed best by taking out all small bone fragments. If the damaged zone is in the middle of
the patella, a proximal and distal osteotomy with reduction of the main fragments,
as in a transverse fracture, can be performed . If the comminuted area is marginal, the bone
fragments are removed to prevent osteophyte formation. The extensor
mechanism is reestablished by direct suture repair of the patellar ligament to the remaining
patellar fragment. To avoid tilting the patellar fragment and increasing patellofemoral
contact forces, the patellar tendon is attached near the anterior aspect of the remaining
patellar fragment. In poor bone quality a patellotibial cerclage may be needed to
protect the transosseous suture repair .
Total patellectomy may be indicated in rare cases:
• Comminution is so extensive that partial patellectomy
cannot be performed
• Failed internal fixation
• Infection
• Tumor
• Patellofemoral arthritis

Sleeve fractures
In adolescents, a large sleeve of cartilage may be pulled off the main body of the patella along
with a small piece of bone from the distal pole. The diagnosis of this injury may
be missed because the distal bony fragment is not easily seen on x-rays. Matava observed that
avulsion fractures can involve any segment of the patellar periphery. Sleeve fractures
are accurately reduced and stabilized using modified tension band wiring around two
longitudinally placed K-wires.

Aftercare
When nonoperative management is indicated for patellar fractures, early weight bearing with a
hinged knee brace locked in extension is recommended. Isometric quadriceps
exercise and straight leg raises are started when pain has subsided. Active and active-assisted
range of motion begins at 1 to 2 weeks, and resistance exercises are added at 6 weeks.
Following operative care, early knee motion and full weight bearing is recommended and
flexion deformity must be avoided.
With injuries of the patellar tendon where a patellotibial cerclage has been used, weight
bearing may be full with a knee brace that allows 90° of motion only.

Implant irritation and late hardware removal

Symptomatic hardware is among the most frequently encountered complications. Dense
cortical bone under tension requires time to heal and remodel before it can safely withstand
high tensile force without protection. Thus, removal of hardware is delayed for a minimum of
12 months after fixation.
Knee dislocations
Schenck anatomical classification:
• KD I: any knee dislocation where either the anterior cruciate ligament (ACL) or posterior
cruciate ligament (PCL) are intact
• KD II: a tear of the ACL and the PCL only
• KD III: a tear of both the ACL and PCL as well as either the posterolateral corner (PLC) or
posteromedial corner (PMC)
• KD IV: a tear of the ACL, PCL, PLC, and PMC
• KD V: an articular fracture (usually tibial plateau) associated with a knee dislocation

Patients with no vascular symptoms or signs still require close observation and should be
admitted to hospital. A detailed vascular clinical examination is recommended at
admission, after 4–6 hours and at 24 and 48 hours. This must be clearly documented in the
medical records . Late popliteal artery thrombosis, usually associated with an
asymptomatic intimal tear, is a recognized and devastating complication .

In cases of open injuries , the protocol includes exhaustive irrigation and debridement,
followed by reduction and provisional joint spanning external fixation. Pin placement should
avoid the sites of future ligament repair or reconstructions.
In cases of irreducible dislocations, the patient must be taken to the operating room where an
arthrotomy is carried out to remove interposed tissues. This is frequently the medial
collateral ligament in cases of posterolateral rotatory dislocation.
The diagnosis of a peroneal nerve palsy does not require immediate surgical exploration,
except in cases of open wounds on the lateral side of the knee or evolving, painful
nerve palsy.
 If the knee dislocation is associated with a fracture of the articular surface of the knee joint,
damage-control orthopedics with the application of an external fixator to span
the joint allows time to obtain imaging and plan complex procedures. At definitive treatment,
the fracture must be anatomically reduced and fixed with absolute stability before
any ligament repair. It is essential to examine ligament stability after fixation of the fracture. An
MRI can be “oversensitive” and fixation of the fracture often restores stability
without the need for additional ligament repair.

Indications and decision making

Most patients who sustain a knee dislocation will require surgical treatment. Functional
outcomes following nonoperative care are poor. Even poor surgical candidates will
usually benefit from at least a spanning external fixator that is left in place for approximately 2
months followed by removal of the fixator and a manipulation with the patient
under anesthesia. Patients who should be considered for nonoperative treatment are those
who have medical comorbidities or injuries that make survival of the patient following the
procedure questionable.
Postoperative treatment
The preferred protocol involves immediate range of motion starting at 0–30° on postoperative
day 1. Immediate partial weight bearing is allowed with the knee locked in extension,
and advanced to full weight bearing with the knee locked in extension over the first 2 weeks.
This is an aggressive activity protocol but has yielded good functional results. It is critical to
emphasize obtaining full knee extension from the beginning. Using an exercise bike with no
resistance can really help obtain flexion. Knee ligament rehabilitation follows standard
protocols for the ligaments being reconstructed.
Tibia, proximal
Surgical indications
Indications for surgery include:
• Open fractures
• Fractures with vascular injury or compartment syndrome
• Fracture dislocations
• Displaced intraarticular fractures
• Articular depression causing knee instability
• Malalignment, especially varus
• Polytrauma

Staged management with urgent closed reduction and

temporary, joint-spanning external fixation ahead of
definitive fi xation surgery is indicated for the following:
• Open fractures
• Acute vascular injury
• Severe, closed soft-tissue injury
• Damage control in polytrauma
Aftercare
Following surgery, isometric quadriceps exercises are initiated as soon as possible. Many
surgeons prefer 2 weeks with the knee in extension in an immobilizer to allow wound
healing and prevent knee flexion contractures. Alternatively, a continuous passive motion
device may be utilized.
Patients are generally maintained on toe-touch weight bearing for 6–8 weeks according to
fracture healing and softtissue recovery. Exceptions are fractures caused by extremely
high energy: these patients need to adhere to toe-touch weight bearing for 10–12 weeks but
have active flexion throughout the last 10 weeks of this period.
Tibia, shaft

Surgical indications
• Open fractures
• Polytrauma
• Floating knee or ankle
• Failure to obtain or maintain an acceptable reduction
with closed techniques
• Neurovascular compromise
• Compartment syndrome
 If the use of an IM nail is planned, the exchange of the external fixator for the IM nail should
be within 2 weeks of the injury to avoid increasing the risk of infection (Fig 6.8.2-9). The
surgeon must be aware of the safe zones for external fixation through which half pins,
transfixing pins, or Schanz screws can be placed without involving muscles, tendons, nerves, or
vessels . The safe zones for transfixing pins are narrower, and good knowledge of the anatomy
is essential. It is safer to use tensioned thin wires (1.8–2.0 mm) for transfixation.
 Occasionally, by reducing and plating the fibula, the tibial reduction is greatly enhanced.
Because the distractor tends to cause valgus positioning, pins for the distractor should be
placed in a slightly converging direction so that the axis is corrected with distraction. Joysticks
may also be used. Poller screws may be used to help correct axial malalignment.

The proximal dynamic lock option (only one locking screw located in the proximal region of the
dynamic locking) should only be used when there is a gap of up to 2 mm at the focus
of simple transverse fracture .
“Back-tapping” can be performed to close the fracture gap in a tibial fracture that stays
distracted after nailing. This simple technique is performed by placing the distal screws first and
the distal segment is “pulled” back toward the proximal segment by tapping on the insertion
device which is still in place.

Generally, Poller screws are placed in the smaller fragment and into the concave side of the
deformity. However, the surgeon should perform an individual assessment of the patient to
determine the best position of the Poller screw.
Aftercare
When a static locked tibial nail has been used, progressive weight bearing with crutches is
permitted immediately.
When a plate has been used, the patient is allowed to get up with partial-weight bearing (10–
15 kg). At 4–6 weeks, weight bearing is increased. Depending upon the original fracture
pattern and clinical follow-up, full-weight bearing should be possible 12 weeks postoperatively.
If definitive treatment is with a unilateral external fixator and the frame is stable, the patient
may start with partial weight (10–15 kg). With clinical and radiographic progression
of consolidation, weight bearing is increased gradually until the patient is full-weight bearing.
Circular frames allow immediate full-weight bearing. After removal of the external fixator, a
brace is a useful measure to prevent new fractures.
Tibia, distal intraarticular (pilon)
Three basic bony fragments are constantly present: the anterolateral (Tillaux-Chaput)
fragment, the medial malleolar fragment, and the posterolateral (Volkmann) fragment.
“Angiosomes” are 3-D vascular territories formed by skin and deep tissue vessels . Vascular
connections between adjacent angiosomes allow bidirectional perfusion. Compensation is
possible in cases where one branch is injured or occluded due to fracture displacement, closed
degloving or open wounds. The surgeon must be aware of the anatomical territory of each
angiosome around the ankle . If early open surgery is performed, incisions must be
planned according to the angiosomes. Full thickness, longitudinal incisions are safe to use once
tissue swelling has subsided.
Treatment options
• Nonoperative:
–– Undisplaced stable closed fracture (43A, B1 or C1)
–– Significant comorbidities (excessive risk with
surgery)
• Operative:
–– Articular step more than 2 mm
–– Valgus angulation more than 5°
–– Any varus angulation
–– Open fractures
–– Compartment syndrome
–– Vascular injury
–– Polytrauma

• Staged approach (initial reduction with external

fixation followed by delayed ORIF):
–– Unfavorable soft-tissue condition: blisters and
open fractures
–– Patients presenting late or delayed transfers
–– Polytrauma patients requiring damage control
–– Associated vascular injury
–– Lack of experience, facilities, or implants
Aftercare
Leg elevation is recommended for 2–5 days postoperatively with the foot supported in a
neutral position to prevent equinus deformity. Active-assisted exercises are started
within a few days. Immobilization is not necessary (unless the soft tissues need protection) and
mobilization starts with toe-touch weight bearing (10–15 kg). Depending upon fracture
consolidation, weight bearing can be increased after 6–8 weeks with full weight bearing usually
after 3 months. If the fracture is delayed in healing, early bone grafting is
recommended at 6–8 weeks with autograft being used to enhance healing. Smoking should be
discouraged as delayed healing is common in this population. Implant removal may
be necessary in cases of soft-tissue irritation by the implant. The best time for removal is after
complete remodeling, at least 12 months after surgery.
Hindfoot—calcaneus and talus
Surgical indications
• Surgical indications—absolute [1]:
–– Open fractures
–– Skin compromise (posterior skin [tongue-type
fracture])
–– Poor foot shape and heel position
–– Fracture dislocation of hindfoot
• Surgical indications—relative:
–– Severe comminution of joint (best served by
primary fusion of subtalar joint and calcaneal
shape reconstruction)
–– Displacement of articular surface greater than 2 mm
–– Bilateral calcaneal fractures (each foot treated on
respective CT characteristics)
–– Nonsmoker
• Surgical contraindications:
–– Swollen, blistered foot
–– Peripheral vascular disease
–– Neuropathy
–– Medically unwell patient
–– Noncompliant, permanent head injury or psychiatric
patient
–– Alcohol and/or drug abuse
• Other key factors to consider:
–– Soft tissue condition: wrinkle sign on skin on
lateral hindfoot
–– Patient older than 60 years but medically optimized

The return of skin wrinkles to the lateral foot at the surgical incision site should be used as a
guide for timing of surgery, which is usually possible 7–14 days after injury.
 One strategy is to perform the reduction in the following
sequence:
• Reduction of the anterior process (and, hence, the
calcaneocuboid joint)
• Reduction of the anterior process to the medial
sustentacular fragment
• Reduction of the tuberosity fragment to the medial
sustentacular fragment
• Reduction of the lateral articular fragment of the
posterior articular surface
• Replacement of the lateral wall
 Impaction results in a large bone defect below the posterior articular surface of the calcaneus
after reconstruction. Some surgeons do not fill the defect, while others use autograft,
allograft, or bone substitutes to fill the defect. However, this may not be necessary with the
locking calcaneal plate.
The surgical incision should be closed in layers. The deep closure consists of multiple,
interrupted sutures that incorporate the periosteum and are usually tied from peripheral to
central. Care should be taken to ensure that this portion of the closure adequately re-
approximates the deep tissues. The skin can then be closed without tension
using interrupted, modified Allgöwer-Donati sutures.

Aftercare
Initially, the patient’s leg is kept in a well-padded posterior splint that maintains the foot in a
neutral position.
Surgical drains are removed at the latest 2 days after surgery.
Because of concerns regarding wound healing, the leg should be slightly elevated above heart
level for several days.
The ankle and subtalar joint are put through range of motion exercises that can begin as soon
as the incision allows, usually at 2–5 days. Weight bearing is delayed for 8–12 weeks,
depending on the degree of comminution and the adequacy of the fixation. Activity can
progress depending on symptoms but impact activities should be avoided for 6 months
from the time of injury.
Fractures of the talus

Surgical indications—absolute
• Any displacement of neck or body anatomy indicated
on CT scan
• Debris which is a result of injury left in any of the
joint spaces of the hindfoot
• Noncongruent reduction
• Skin compromise, or open fractures
• Neurovascular compromise

Osteotomy of the medial malleolus or the fi bula is often

necessary for inspection and fi xation of talar body fractures.
On the medial side, great care must be taken to protect the
artery that runs along the deltoid ligament.
Aftercare
A well-padded posterior splint with the foot in a neutral position is applied after surgery. Early and
unrestricted active ankle and subtalar joint range of motion exercises can be initiated as soon as wound
healing allows. Weight bearing on the affected extremity should be restricted for at least
6–12 weeks to allow for fracture healing. X-rays at 6 and 12 weeks are evaluated for healing and
radiographic evidence of revascularization.

Subchondral lucency of the talar dome demonstrated on the mortise x-ray indicates that the bone is
vascular and suggests aseptic necrosis to be less likely. This is termed Hawkins sign and is a good
prognostic sign.
Midfoot and forefoot

Navicular body fractures are usually associated with other midtarsal injuries, which must be diagnosed
and treated. Undisplaced fractures are treated using a well-molded short leg cast for
6 weeks. Displaced fractures of the navicular are treated operatively
with screws, a plate, or a small temporary external fixator.
Fractures of the cuboid
If there is minimal impaction, nonoperative management
with a below-knee cast for 6 weeks is appropriate. However,
if there is significant loss of length or abduction deformity
of the lateral column of the foot, it is likely that the
long-term outcome will be pain and dysfunction in the calcaneocuboid
joint and/or the peroneus longus tendon. Management
should include early anatomical reconstruction of
the joint surfaces as well as restoration of the
length of the lateral column by open reduction and internal
fixation. Plates that bridge across the joints of the lateral
column or external fixators can be used to offload the construct
and maintain length of the column.
Tarsometatarsal joint injuries
The inherent stability of the tarsometatarsal joint is due
to the bone anatomy of the keystone-like base of the
second metatarsal and to the strong ligaments between
each tarsometatarsal joint.
Generally, the plantar ligaments are stronger and the Lisfranc
ligament is the largest and strongest of all. It originates from
the plantar aspect of the medial cuneiform and inserts on
the plantar aspect of the base of the second metatarsal and
is the only link between the first and second metatarsal. The
Lisfranc ligament “locks” the base of the second metatarsal
in place, further limiting motion and providing stability to
this keystone structure.
 Any tarsometatarsal joint with a displacement of > 2 mm
compared with normal joint position on plain, stress, or
weight-bearing x-rays is considered unstable and
operative treatment is indicated.

The double-incision, dorsal approach is preferred because it allows excellent exposure

and direct reduction. The incisions are centered over
the first and fourth metatarsal and the tarsometatarsal joints
and dissection continues straight down, without undermining.
This protects the neurovascular bundle and soft tissues
between the two incisions. Once at the periosteum, medial
and lateral dissection raises full-thickness flaps. The first
tarsometatarsal joint and the medial half of the second tarsometatarsal
joint are approached through the medial incision.
The lateral half of the second tarsometatarsal joint and
the third tarsometatarsal joint are approached through the
lateral incision. The fourth and fifth tarsometatarsal joints
usually reduce with the medial metatarsals.
Metatarsal fractures

Fractures of the proximal fifth metatarsal

The proximal fifth metatarsal can be divided into three zones:
• Zone 1: the tuberosity
• Zone 2: metaphyseal-diaphyseal junction
• Zone 3: the proximal diaphysis
Fractures through zone 2 are known as the Jones fracture.
Healing potential varies according to the zones and hence
the treatment strategies are different.
Intraarticular and extraarticular fractures with no displacement
can be treated functionally in a below-knee cast or
boot with early full weight bearing; the possibility of delayed
union/nonunion should be kept in mind. Athletes may be
offered initial operative management . The operative
method of choice is placement of an adequately sized screw
across the fracture site into the medullary cavity of the fifth
metatarsal entering from the tuberosity of the bone. The
starting point should be high and inside, and image intensifier-
aided guide wire placement is followed by reaming
with gradually increasing drill sizes. The screw should be
placed such that the threads cross the fracture site and there
is adequate purchase of the screw threads into the bony
endosteal surface. Weight bearing as tolerated is allowed
after 4 weeks with the foot supported in a molded orthosis.