Handbook of Orthopaedic Traumatology
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Transcript of Handbook of Orthopaedic Traumatology
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HANDBOOK OF
ORTHOPAEDIC
TRAUMATOLOGY
DEPARTMENT OF ORTHOPAEDICS AND
TRAUMATOLOGY
QUEEN MARY HOSPITAL
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Content
Trauma
Fracture
Principles of management of fractures----------------- 1
Comprehensive classification of long bone fractures 2
Principles of management of multiple trauma
patients
6
Acromioclavicular joint dislocation-------------------- 9
Fracture of clavicle--------------------------------------- 19
Fracture of scapula--------------------------------------- 31
Fracture of proximal humerus-------------------------- 41
Fracture of humeral shaft-------------------------------- 47
Supracondylar fracture of humerus--------------------- 49
Fracture of distal humerus------------------------------- 57
Fracture of capitellum------------------------------------ 63
Fracture of radial head----------------------------------- 67
Olecranon fracture--------------------------------------- 71
Fracture of shaft of radius and
ulna---------------------
77
Galeazzi fracture------------------------------------------ 78Monteggia fracture--------------------------------------- 79
Fracture of pelvis----------------------------------------- 81
Fracture of acetabulum---------------------------------- 101
Fracture of proximal femur------------------------------ 113
Fracture of femoral neck--------------------------------- 116
Intertrochanteric fracture of femur--------------------- 121
Subtrochanteric fracture of femur---------------------- 125
Fracture of femoral shaft--------------------------------- 129
Supracondylar fracture of femur------------------------ 131
Fracture of patella---------------------------------------- 137
Fracture of tibial plateau--------------------------------- 145
Fracture of proximal and distal
tibia--------------------
161
Fracture of tibial shaft------------------------------------ 165
Pilon fracture---------------------------------------------- 169
Malleolar fracture---------------------------------------- 173
Fracture calcaneum--------------------------------------- 181
Dislocation
Principle of management of dislocation--------------- 191
Shoulder dislocation------------------------------------- 193
Hip dislocation-------------------------------------------- 201
i ii
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Hand
Guidelines for hand
cases--------------------------------
219
Compound hand fractures------------------------------- 223
Phalangeal fractures-------------------------------------- 225
Fracture of distal radius---------------------------------- 227
Acute tendon injuries------------------------------------- 239
Others
Compartment syndrome--------------------------------- 250
Necrotizing fasciitis-------------------------------------- 253
Procedure
Principles of closed reduction--------------------------- 255
Principles of plaster technique-------------------------- 256
Intravenous regional block------------------------------ 259
Tourniquet usage----------------------------------------- 261
Halo traction---------------------------------------------- 263
Some useful classification
Gustilo and Anderson classification for open
fracture
267
Tscherne and Gotzen classification for soft tissueinjury------------------------------------------------------- 269
Injury Severity Score------------------------------------- 271
Hospital Trauma Index (Extremity Injury)------------ 272
Mangled extremity severity score (MESS) ----------- 273
Surgical site infection (SSI) ---------------------------- 275
Drugs
Recommended pre-operative antibiotic prophylaxis- 277
Use of methypredinisolone in traumatic acute spinal
cord compression----------------------------------------- 281
Drugs for CR under sedation---------------------------- 281
Telephone directory------------------------------------ 282
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PRINCIPLES OF MANAGEMENT OF
FRACTURES
• Closed vs open #
•
Assessment• site of # (e.g. humerus, radius;
intra-articular vs extra-articular)
• Type of fracture (e.g. spiral vs transverse;simple vs comminuted)
• Associated neurovascular injury
• Other concommitant injury• Treatment
1. Reduction if necessary
2. Immobilization if necessary
3.
Rehabilitation always
Principle of fracture management 1
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COMPREHENSIVE CLASSIFICATION OF
LONG BONE FRACTURE (Muller, 1990)
Metaphyseal / Diaphyseal segment
Diaphyseal Fracture Type
A: Simple
B: Wedge (2 main fragments still in direct
contact)
C: Comminuted (no direct contact between 2main fragments)
Comprehensive classification of fracture 2 3 Comprehensive classification of fracture
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Metaphyseal Fracture
A: Extra-articular
B: Partial articular (part of the articular
surface is still in continuity with the
metaphysis)
C: Complete articular (no continuity
between metaphysis and articular surface)
Comprehensive classification of fracture 4 5 Comprehensive classification of fracture
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PRINCIPLES OF MANAGEMENT OF
PATIENTS WITH SEVERE AND MULTIPLE
TRAUMA
Triage• sort patients with acute life threatening injuries
and complications from those whose life are not
in danger
1. level of consciousness2. Abnormal breathing / breathing difficulties
3. Signs of shock
Priorities
1.
Support life (eg. CPR, fluid resuscitation)
2. Locate and control bleeding
3.
Prevent brainstem compression and spinal corddamage
4. Diagnose, evaluate and treat all other injuries
and complications
Basic Management Principles
1. Emergency assessment
A--Airway obstruction (eg. noisy breathing,
respiratory distress)
B--Breathing difficulty (eg. tachypnoea, mental
confusion, cyanosis, abnormal pattern of breathing)
C--Circulatory shock (eg. cold periphery, delayed
capillary refill, low BP, rapid weak pulse)
2. Fluid resuscitation
• If necessary, 2 or 3 large 14- or 16-gaugeintravenous cannula inserted
3. Oxygen therapy
• High flow oxygen by mask ventilatory support
4. Cross-match blood
5. Analgesia
6.
Urine output monitoring•
Foley unless suspected rupture urethra(eg. blood
at urinary meatus, severe fractured pelvis)
7. Evaluation of other injuries
Evaluation of injuries
1. Head Injury
• Glascow Coma scale and Neuro-observation q1h• Inspect for presence of CSF and/or blood in ears
and nose
•
SXR (3 views) +/- CT Brain2. Facial Injury
• Exclude bleeding into airway and severeoro-pharyngeal edema (eg. from caustic burn),
which may lead to airway obstruction
•
SMV and OMV view
3. Suspected spinal injury
• Immobilize until exclusion• signs of spinal cord injury (eg. paralysis,
diaphragmatic breathing, loss of vasomotor tone,lax anal tone)
•
Cervical spine fracture or dislocation need to be
excluded in all patients with head injury (Xray
cervical spine AP and lateral; lateral Xray must
include C7 / T1 junction)
6 Principle of management of multiple trauma Principle of management of multiple trauma 7
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4. Chest
• Look for haemothorax, pneumothorax, lungcontusion, flail chest
•
Clinical signs + CXR5. Abdomen
•
Rupture viscera (eg. spleen, liver, mensenteries)
haemoperitoneum and peritoneal sign for rupture
bowel
• Retroperitoneal haemorrhage (eg,. in # pelvis)• Renal injury with retroperitoneal haemorrhage,
leading to haematuria and loin pain
•
Clinical signs + AXR (E & S)
6. Pelvis #
•
Stability of Pelvis
• Look for suspected ruptured bladder and urethral bleeding
• Clinical signs + XR pelvis (AP + inlet view +outlet view)
7. Extremities
• eg. long bone fracture, associated nerve orarterial damage
8 Principle of management of multiple trauma
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ACROMIOCLAVICULAR JONT DISLOCATION
(C. Rockwook, Fractures in Adults, 4th ed., 1342-1413, 1996)
Anatomy
• Stabilizer1.
Acromioclavicular ligament
2.
Coracoclavicular ligament–conoid part and trapezoid part
3. Dynamic stabilizer—deltoid (anterior part) and trapezius(upper portion)
•
Coracoclavicular interspace—1.1 to 1.3cm (Bearden,
1973)
• Acromioclavicular ligament—horizontal(anteroposterior) stability of ACJ
• Coracoclavicular ligament—vertical stability of ACJ
Mechanism of Injury
1.
Direct force —patient falling onto the point of shoulder
with the arm at the side in an adducted position
2.
Indirect force —fall on outstretched hand
Classification (Rockwood)
Type I
• Sprain of AC ligament•
ACJ intact
•
CC ligament intact
• Deltoid and trapezoid muscle intact
Acromioclavicular joint dislocation 9 Acromioclavicular joint dislocation 10
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Type II
• ACJ disrupted
•
ACJ wider: may be a slight vertical separation whencompared with the normal shoulder
•
Sprain of CC ligament
• CC interspace might be slightly increased• Deltoid and trapezius muscles intact
Type III
•
AC ligaments disrupted
• ACJ dislocated and the shoulder complex displacedinfreriorly
• CC ligaments disrupted• CC interspace 25% to 100% greater than the normal
shoulder
• Deltoid nad trapezius muscles usually detached from thedistal end of the clavicle
Type II Variants
1.
“Pseudodislocation” through intact periosteal sleeve
2.
Physeal injury
3.
Coracoid process fracture
Acromioclavicular joint dislocation 17 Acromioclavicular joint dislocation 18
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Type IV
• AC ligaments disrupted
•
ACJ dislocated and clavicle anatomically displaced posteriorly into or through the trapezius muscle
• CC ligaments completely disrupted
•
CC space may be displaced, but may appear same as the
normal shoulder
•
Deltoid an trapezius muscles detached from the distal
clavicle
Type V
•
AC ligaments disrupted
• CC ligaments disrupted
•
ACJ dislocated and grossly disparity between the clavicleand the scapula (i.e. 100% to 300% greater than
the normal shoulder)
•
Deltoid and trapezius muscles detached from the distal
half of the clavicle
Acromioclavicular joint dislocation 17 Acromioclavicular joint dislocation 18
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Type VI
•
AC ligaments disrupted
• CC ligaments disrupted in subcoracoid type and intact in
subacromial type •
ACJ dislocated and clavicle displaced inferior to the
acromion or coracoid process
•
CC interspace reversed in the subcoracoid type (i.e.
clavicle inferior to the coracoid), or decreased in the
subacromial type (i.e. clavicle inferior to the acromion)
•
Deltoid and trapezius muscles detached from the distal
clavicle
Radiographical Assessment
1.
Xray both ACJ (AP)
2.
Zanca view—100 to 150 cephalic tilt
Acromioclavicular joint dislocation 17 Acromioclavicular joint dislocation 18
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3.
Axillary lateral view
4.
AP stress film
•
To 15 pounds are suspended from each arm with wrist
wrap
5. Lateral stress film (Alexander view)
•
Patient is positioned as if a true
scapulolateral radiograph is taken
•
Patient is asked to thrust both
shoulder forward
6.
Stryker notch view
• demonstrate fracture base of coracoid
Treatment
1.
Non-operative treatment
• Rockwood 1 and 2 (minimally displaced)
•
Arm sling x2./52; then, early and gradual
rehabilitation
• Heavy lifting or contact sports avoided for 8 to 12
weeks
2.
Operative treatment•
Rockwood 3 to 6
• ACJ debridement
•
6MM transacromial K-wires
• repair of CC ligament + Tevedek
reinforcement
o Rehabilitation—pendulum exercise x 6/52; then, r/o
K-wires at 6/52
Acromioclavicular joint dislocation 17 Acromioclavicular joint dislocation 18
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FRACTURE CLAVICLE
Anatomy ALLAM CLASSIFICATION
GROUP 1
• middle third clavicular fracture• 80/5 of all clavicular fracture
• Proximal fragment: pulled superiorly and
posteriorly by sternocleidomastoid
• Distal fragment: drops forward as a result of gravity
and pull of pectoralis
Fracture clavicle 19 20 Fracture clavicle
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GROUUP II
• distal third clavicular fracture
• 12% to 15 % of clavicular fracture• sub classified according to the location of
coracoclavicular ligaments relative to the fracture
fragments
Neers Classification (Type I to Type III)
Type I
• most common
• Interligamentous fracture
• occurring between the conoid and trapezoid / the
coracoclavicular and acromioclavicular ligament
• minimal displacement
Type II
Coracoclavicular ligaments are detached from the
medial/proximal segment
Proximal fragment: no ligamentous attachmentDistal fragment: retained ligamentous attachment
Type IIA
• Both conoid and trapezoid remain intact on the
distal fragment
• Proximal fragment: no ligamentous attachment
Type IIB
• Conoid ligament ruptured while trapezoid ligament
remains attached to the distal fragment (i.e. Distalfragment: partial ligamentous attachment)
• Proximal fragment: no ligamentous attachment
• Thus, displacement is similar to Allam Group I
fracture
Fracture clavicle 21 22 Fracture clavicle
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• i.e. proximal fragment: pulled superiorly and
posteriorly
• distal fragment: droops forward
Type III
• Involve the articular surface of ACJ
• No ligamentous injury
• No displacement
•
Present with late degenerative arthrosis of ACJ
Type IV (Craig)
• Occur in children
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Type V (Craig)
• Comminution
• Neither the proximal nor distal fragments has
functional coracoclavicular ligament
• Coracoclavicular ligament are intact and remain
attached to a small, third comminuted intermediate
segment
• Displacement same as Group 1 # and Type II #
distal clavicle
•
More unstable than type II # distal clavicle
GROUP III
• # medial third of clavicle• 5 % to 6% of clavicular fracture
• Craig: subdivided according to the integrity of
ligamentous structures
• Type I: minimal displacement
• Type II: significant displacement (ligaments
ruptured)
• Type III: intra-articular (sterno-clavicular joint)
• Type IV: epiphyseal separation (children and
young adult)
• Type V: comminuted
Mechanism of Injury
1. Direct blow to shoulder
2. Fall on outstretched hand
Associated Injury
1. Associated skeletal injuries
• Fracture dislocations of sternoclavicular or
acromioclavicular joints• Head and neck injuries
• Fractures of first rib (ipsilateral and contralateral)
• Floating shoulder (fracture of the clavicle and
scapula)
• Rockwood
• Treatment directed primarily at stabilization of
clavicle
• For # scapula, conservative treatment unless
grossly displaced intra-articular or fracture of
glenoid fossae2. Pneumothorax
3. Brachial plexus injury
• Considerable trauma
• Force usually come from above downward or from
the front downward
• Traction injury
• Direct injury ( with lesion directly by bone
fragments)(in direct injury, ulnar nerve is usually
involved)
4.
Vascular injury• Unusual
• Major trauma required
• Potential vascular injury: laceration, occlusion,
spasm, acute compression
Most common vessels injured: subclavian artery
subclavian vein, internal jugular vein
5Fracture clavicle 25 26 Fracture clavicle
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On admission, House Officer must examine
1. significant skin impingement
2.
neurological deficit3. vascular status (e.g. radial pulse, capillary refill)
4.
whether breath sound is symmetrical bilaterally
X-ray
1. X-ray clavicle (AP)
2. X-ray clavicle: 450 cephalic view
Treatment
• Conservative vs operative• Non-union: failure to show clinical or radiographic
progression of healing at 4 –6 months
• Conservative treatment: non-union: 0.1%
• Operative treatment: non-union: 4.4%
Predisposing factors to non-union
1. Inadequate immobilization
2. Severity of trauma (with associated soft tissue
damage)
3.
Re-fracture4. Distal third fracture
5. Marked displacement
6. Primary open reduction
Principles of non-operative treatment
1. Brace the shoulder girdle to raise the outer fragment
upward, outward and backward
2.
Depress the inner fragment3. Maintain reduction
4.
Enable ipsilateral elbow and hands to be used
Treatment
Conservative Treatment
1. Figure of eight bandage
2. Arm sling (if patient cannot tolerated figure of eight
bandage)
• Immobilization should be continued until union is
complete
• Usual healing period of # of middle third of clavicle
(Rowe)Infants: 2 weeks
Children: 3 weeks
Young adults: 4 to 6 weeks
Old adults: >6 weeks
5Fracture clavicle 27 28 Fracture clavicle
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Operative Treatment (if)
1.
skin impingement2. open #
3.
neurovascular compromise
4. bilateral fracture clavicle
5. floating shoulder
6. multiple fracture
7. non-union
8.
cosmesis
Treatment – ORIF (PC Fix/3.5mm reconstruction
plate)
5Fracture clavicle 29 30 Fracture clavicle
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FRACTURE OF SCAPULA
(K.P. Butters, Fractures in Adults, 4th
ed., 1996)
Anatomy
Anterior surface of scapula
Posterior surface of scapula
Fracture scapula 31 32 Fracture scapula
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Fractures
1. Body and spine
2. Glenoid neck
3.
Intra-articular glenoid4. Coracoid
5.
Acromion
Mechanism of Injury
1. Indirect injury
• through axial loading on outstretched arm(fracture scapula neck)
2. Direct injury
• From a blow or fall (# body) (often high energy
trauma)• Direct trauma to the point of shoulder (#
acromion and coracoid)
3. Shoulder dislocation
• # glenoid4.
Traction injury
• avulsion #
Associated Injury ( occur in 35% to 98% of
patients with scapular #)
1.
Pneumothorax (11% - 38%) (Delayed in onsetfrom 1 to 3 days)
2. Ipsilateral fractured ribs (27% to 54%)
3.
Pulmonary contusion (11% to 54%)
4. # clavicle (23% to 39%) (associated with #
glenoid or glenoid neck)
Fracture scapula 33 34 Fracture scapula
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5. Brachial plexus injury (5% to 13%) (usually
supraclavicular type)
6. Arterial injury (11%)
7.
Skull # (24%)8. Closed head injuries (20%)
9. Fracture of thoracic spine, cervical spine, lumbar
spine
Xray Assessment
1. True AP view of shoulder
2.
Transcapular view
3. Axillary lateral view how acromial and glenoid
rim #
4.
Stryker notch view or cephalic tilt view--showcoracoid fracture
Scapular body and spine #
• examine for associated injury• conservative treatmenty with arm sling for
comfort and early mobilization exercise
Glenoid Neck # (extra-articular)
1. Stable #
• isolated glenoid neck #
•
conservative treatment
2. Unstable #
• # glenoid neck associated with # clavicle ordisruption of coracoclavicular ligament
• ORIF of # clavicle
Fracture scapula 35 36 Fracture scapula
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Intra-articular Glenoid Fracture
Ideberg Classification
(Ideberg, Acta Orthop. Scand., 58:191-192, 1987)
Type I #
• fracture of glenoid rim• > 25 % of intra-articular involvement
•
If displaced, predispose to instability ofgleno-humeral joint
1. Type IA
• anterior type• ORIF2. Type IB
• posterior type• uncommon
Type II #
•
transverse or oblique fracture through theglenoid with inferior glenoid as a free fragment
•
humeral head may subluxate inferiorly
• If humeral subluxate ORIF
Type III #
• upper third of glenoid and includes coracoid process
• often accompanied by # acromion or clavicle oracromioclavicular separation
•
(Gross, 1995) If intra-articular step > 5mm,
ORIF
Fracture scapula 37 38 Fracture scapula
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Type IV #
• horizontal glenoid # extending all the waythrough the body to the vertebral border
•
if displaced, ORIF
Type V #
•
type II + type IV
•
If humeral head is well centred
conservative treatment
Type VI #
• badly comminuted #• conservative treatment with early motion
Acromion #
• usually minimal displacement• DDx--os acromiale1. If undisplaced
• conservative treatment2.
If displaced with subacromial space andupward movement of humeral head
• investigate rotator cuff lesion
Coracoid #
• may occur with acromioclavicular dislocationwith coracoclavicular ligaments intact
• clinical evidence of third degreeacromioclavicular separation with a high-riding
clavicle
BUT
radiologically (AP shoulder) a normal and
symmetric coracoclavicular distance
suspect # coracoid (base or through an epiphyseal
line)• Stryker notch view• if # coracoid process + ACJ separation ORIF
Fracture scapula 39 40 Fracture scapula
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FRACTURE OF PROXIMAL HUMERUS
(J. Schatzker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 51-82)
Anatomy Four major fragments
1.
Humeral head superior to anatomical neck
2. Lesser tuberosity
3. Greater tuberosity
4. Shaft of humerus
Stable vs Unstable Fracture
Stable Fracture
• Impacted fracture• Shaft and head
moves as one piece
• resulted fromcompression force
Unstable Fracture
• movement betweenthe shaft and head
fragments• resulted from tension
or shear force
Fracture proximal humerus 41 42 Fracture proximal humerus
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CLASSIFICATION OF FRACTURE TYPE
1. Stable Fracture
2. Unstable Fracture
A. Minimally displaced (i. No segment displaced > 10 mm)
(ii.No segment angulated > 45)B Displaced
(C.S. Neer, JBJS , 52A: 1077-1089)
1. Two-part
a. Lesser tuberosity
b. Greater tuberosity
c. Surgical neck
d. Anatomical neck
2. Three-part--Surgical Necka. Plus Lesser tuberosity
b. Plus Greater tuberosity
3. Four-part--Anatomical Neck
Plus tuberosities
4. Fracture-dislocation
a. Two-part--with greater tuberosity
b. Three-part--Anterior, with greater
tuberosity
Posterior, with lesser
tuberosityc. Four-part—Anterior & Posterior
3. Articular
a. Head impaction—(Hill Sachs)
b. Articular fractures
1. Humeral head split
2. Glenoid rim
Fracture proximal humerus 43 44 Fracture proximal humerus
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TREATMENT
1. Stable Fracture
•
Early motion
2.
Unstable, Minimally displaced Fracture •
Collar and cuff x 3 weeks
•
then mobilization
3. 2-Part # (Displaced Unstable Fracture
Surgical Neck, Displaced Greater Tuberoisty)
& 3-Part #
•
CR + Percutaneous K-wire
•
If fail, OR + suture / wire
4. Fracture Anatomical Neck / Head Split /
4-Part #
•
Neer’s Hemiarthroplasty
Fracture proximal humerus 45 46 Fracture proximal humerus
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FRACTURE OF THE HUMERAL SHAFT
• most fractures can be treated successfully byclosed method
Acceptable alignment
1.
< 20 angulation2. > 50% bony overlap
To assess
• Neurological function (esp. radial nerve)• Vascular condition
FRACTURES WITH ACCEPTABLE
ALIGNMENT• U-slab x 3 weeks; then, functional brace• Check Xray humerus (AP + lat) after application
of U-stab
FRACTURES WITH UNACCEPTABLE
ALIGNMENT
•
Attempt CR under sedation
•
U-slab x 3 weeks
• Check for function of radial nerve after CR
•
Post-reduction Xray humerus to confirm
alignment
FRACTURES REQUIRING OPERATIVE
INTERVENTION
1. Fracture with unacceptable alignment despite
repeated CR (either due to failure to obtain asatisfactory reduction or failure to maintain
reduction)
2. Open fracture
3. Comminuted / unstable fracture
4. Multiple fractures
5. Pathological fracture
6. Nerve palsy after manipulation
7. Humeral fracture with asssociated vascular
lesion
METHOD OF FIXATION
1. Proximal and Middle 1/3
• Retrograde AO unreamed humeral nail2. Distal 1/3
• ORIF (plating)3. Open #
• AO nail / External fixator
Fracture shaft of humerus 47 48 Fracture shaft of humerus
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SUPRACONDYLAR FRACTURE OF HUMERUS
(J. Schaztker, The Rationale of Operative Fracture
Treatment , 2nd ed., 1995, 103-111)
Anatomy
1.
Articular Surface
• Capitellum •
covered by articular cartilage on its anterior
and inferior surface (not posterior)
•
articulate with radial head•
Elbow in flexion: radial head articulate with
anterior surface of capitellum
• Elbow in extension: radial head articulateswith inferior surface of capitellum
• Trochlea•
covered completely with articular cartilage
•
articulates with the trochlear notch of ulna
• Elbow in Flexion
• trochlear notch of ulna articulate with the
anterior aspect of trochlea• coronoid process of ulna rests in coronoid
fossa of humerus
•
radial head rests in radial fossa of humerus
• Elbow in Extension
• ulna articulates with inferior and posterior
aspect of trochlea
• tip of olecranon lodges within the olecranon
fossa of humerus
•
Trochlea: corresponds the physiological
valgus tendency of elbow in full extension (ie.Carrying angle, 170)
Supracondylar fracture of humerus 49 50 Supracondylar fracture of humerus
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2. At the level of olecranon fossa, the two columns of
bone on either side of the fossa
bone for fixation of implants
3. Longitudinal axis of lateral condyle makes a 60 angle
with the longitudinal axis of the shaft reconstruction plate applied to the level of lateral
condyle must be bend to angle forward
• Otherwise, extension deformity of distal fragment will
result
CLASSIFICATION
Riseborough and Radin Classification
(E.J. Riseborough and EL Radin, JBJS , 51A:130-141)
Type I Non-displaced fracture
between capitellum and
trochlea
Type II
Separation of capitellum
and trochlea without
appreciable rotation of the
fragments in frontal plane
Type III
Separation of
the fragments
with rotational
deformity
Type IV
Severe
comminution
of the articular
surface with
wide separation
of the humeral
condyles
Supracondylar fracture of humerus 51 52 Supracondylar fracture of humerus
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Comprehensive Classification Mechanism of Injury
• fall on the point of elbow
P/E
1.
Closed vs Open2. Associated vascular injury (Feel for radial pulse)
3. Associated compartment syndrome
4. Associated neurological complications
5. Associated fracture of humerus or radius and ulna
6.
Concomitant injury
Aim of treatment
1.
Accurate anatomical reduction of joint surfaces
2.
Stable internal fixation
3.
Early active motion
Recommended Treatment
1.
Undisplaced
Conservative
2. Displaced and intra-articular
ORIF (+ olecranon osteotomy if intra-
articular)
Supracondylar fracture of humerus 53 54 Supracondylar fracture of humerus
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Immediate management
1. Exclude need for emergency operation (eg. open #,
associated vascular injury)
2. Long arm backslab for temporary immobilization
3.
Elevation
Factors which influence success of surgical treatment
1.
Patient’s age and degree of osteoporosis
2.
Type of #
3.
Degree of displacement
4. Degree of joint comminution
5. Whether trochlea can be reconstructed
6. If trochlea can be reconstructed
ORIF
7.
If trochlea is beyond surgical reconstruction
conservative treatment (traction with early
mobilization); or
total elbow replacement (in active elderly
patients)
Rehabilitation
1. CPM
2. Indomethacin x 1/12
3. Hinged elbow brace
Supracondylar fracture of humerus 55 56 Supracondylar fracture of humerus
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FRACTURE OF DISTAL END OF HUMERUS
Anatomy
FRACTURE OF EPICONDYLE
(J. Schaztker, The Rationale of Operative Fracture
Treatment , 2nd ed., 1995, 95-97)
Fracture of Lateral Epicondyle
•
avulsion #
• Adult
• Rare
• associated with posterolateral or posteriordislocation of elbow(may be associated with #
medial epiconyle)
• Children
• lateral epicondyle is avulsed with varying
portion of capitellum
• may turn no itself by 180
•
risk of non-union and deformity• When elbow is reduced, epicondylar fragment reduces
and heals in place
• Prognosis: good
Fracture of Medial Epiconyle
• most common in children• may be seen in adult1. Direct injury
2.
AvulsionTreatment
1. Small and undisplaced
•
conservative treatment
2. Displaced
•
ORIF to prevent ulnar nerve palsy
•
ORIF {4.0mm cancellous screw
{medial approach
{ulnar nerve protected +/- anterior
transposition
•
Prognosis: good
Fracture distal humerus 57 58 Fracture distal humerus
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FRACTURE OF CONDYLES
(R.N. Hotchkiss, Fracture in Adults, 4th
ed., 1996,
953-958)
• capitellotrochlear sulcus divides the capitellar andtrochlear articular surfaces
• lateral trochlear ridge: key to analyse humeralcondyle #
Milch Classification
(H. Milch, JAMA, 160: 529-539, 1956)
1. Type I #
• lateral trochlear ridge remains with the intact condyle elbow stable (medial to lateral)
2. Type II #
• lateral trochlear ridge is involved in the fractured
condyle elbow unstable (medial to lateral)
Fracture of Lateral Condyle
1.
Type I #
•
lateral trochlear ridge remains intact
preventing dislocation of radius and ulna
2. Type II #
• lateral trochlear ridge is a part of the fractured lateralcondyle
• If + medial capsuloligamentous disruption radius and ulna may dislocate
• always extends medially and involve part of thetrochlea
Treatment
• ORIF, then early mobilization
•
Lateral approach, 2 x 3.5mm cancellous screwsPrognosis
• good
Fracture distal humerus 59 60 Fracture distal humerus
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Fracture of Medial Condyle
1. Type I #
•
Lateral trochlear ridge intact
elbow stable2. Type II #
• lateral trochlear ridge is a part of fractured medialcondyle
• If + lateral capsuloligamentous disruption radius and ulna may dislocate medially on
humerus
Treatment
• ORIF, then early mobilization
Fracture distal humerus 61 62 Fracture distal humerus
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FRACTURE OF CAPITELLUM
(J. Schatzker, The Rationale of Operative Fracture Care,
2nd ed., 1995, 97-102)
Anatomy
•
smooth, rounded, knob-like portion of lateral condyleof humerus
• covered with articular surface only on anterior and
inferior surface (but not on posterior surface)
• Elbow in Flexion
Head of radius articulated with the anterior surface of
capitellum (radial fossa, a depression on anterior
humerus just above the capitellum, accomodates the
margin of radial head when the elbow is acutely
flexed. Thus, radial fossa must be cleared of all #
fragments for the elbow to regain a FROM)• Elbow in ExtensionRadial head articulates with the inferior surface of
capitellum
1.
Isolated injury
2.
Part of comminuted supracondylar fracture
Isolated Injury
Mechanism
1. As the head of radius is forcibly driven against the
capitellum with the elbow in flexion2. Direct blow to elbow when it is fully flexed
•
Becomes a free intra-articular osteochondral body
• Always displaced antero-superiorly into the radial
fossa
limit elbow flexion
•
Occasionally, displaced posteriorly
limit elbow extension
Classification
Type I (Hahn-Steinthal) Capitellar #
Type II (Kocher-Lorenz) Capitellar #
Fracture capitellum 63 64 Fracture capitellum
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Recommended Treatment
•
closed manipulation always fail
•
attempts at internal fixation five poor results
•
If the fragment is small excision
•
If the fragment is sufficient large to allow stable
fixation
ORIF
1. Lateral approach
• posterior fixation• capitellum held in place with a small hook; then,
provisionally fixed with K-wire; then,
3.5 mm cancellous screw from back to front
2.
Fix the capitellum transarticularly
•
(head of screw must be countersunk below the level of
articular cartilage)
Fracture capitellum 65 66 Fracture capitellum
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FRACTURE OF RADIAL HEAD
(J. Schtazker, The Rationale of Operative Fracture Care,
2nd ed., 121-125)
Aim
•
preservation of elbow flexion and extension, pronation and supination of forearm
Mechanism of injury
• Fall on outstretched hand(majority)(may be associated with # capitellum)
• Valgus force to elbow(occasionally)(may be associated with fracture olecranon and torn
medial collateral ligament of elbow elbow
instability)
Permanent loss of motion
1.
Bony block(due to displaced piece of bone)
•
Treatment: removal of block
•
confirm bony block by infiltration of the joint with 2%
lignocaine and test motion
2.
Capsular and pericapsular scarring
•
Prevention: early mobilization
Conservative treatment
1. Displacement < 2mm
2.
Fragment < 1/3 of radial head3. In comminuted #, no associated elbow dislocation
4.
No bony block
Treatment
Early active mobilization as pain allow
Otherwise,
1.
OR + Bone wedge elevation + mini-screw; or2. Radial head excision and spacer (if elbow is unstable)
Type I #
• simple split wedge #• displaced vs undisplaced
Treatment
• OR + lag screw
Type II #
•
impaction #• part of the head and neck remain intact
Fracture radial head 67 68 Fracture radial head
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(usually the medial portion is intact because the injury
is usually the result of a valgus force with forearm in
supination)
• variable comminution
Treatment•
OR + Bone wedge elevation + mini-screws
Type III #
• severely comminuted #•
no portion of head and neck is in continuity
•
severe comminution
•
may be associated with torn medial collateral ligamentof elbow and fracture olecranon
1. If possible(esp. young patient)
• OR + Bone wedge elevation + mini-screws2. If irreconstructable,
• excision of radial head (except with elbowdislocation)
• excision + prosthetic replacement (if elbow isunstable)
Fracture radial head 69 70 Fracture radial head
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OLECRANON FRACTURE
(J. Schaztker, The Rationale of Operative Fracture
Treatment , 2nd ed., 1995, 113-119)
Fracture of olecranon with displacement
disruption of triceps mechanism loss of active extension of elbow
Assesment and Initial Management
1. Xray
• Simple # vs comminuted #•
Undisplaced vs displaced
2. For undisplaced fracture
• test for ability to actively extend elbow against gravity3. Long arm backslab for displaced fracture or with loss
of extensor mechanism
4.
Elevation
Recommended Treatment
1. Minimally displaced with intact extensor mechanism
Free mobilization
2.
Displaced # +/- Ipsilateral elbow dislocation
ORIF
CLASSIFICATION
• Intra-articular Fracture1. Simple Transverse Fracture
Mechanism of injury
• avulsion fracture and results from a sudden pull of both the triceps and brachialis muscle
• Direct fall on olecranonTreatment
• OR + TBW + K-wires2.
Complex Transverse #
Mechanism of injury
•
Direct force, such as a fall
•
comminution and depression of articular surface
Treatment
•
TBW + K-wire / Plate (in severe comminution) +/-
bone grafting
Olecranon fracture 71 72 Olecranon fracture
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c. Fracture or Dislocation of Radial head
• associated with disruption of medial collateralligament
• Treatment
• ORIF of # (TBW + K-wires)• Repair of ligament• Radial head is reduced and fixed or replaced
by a prosthesis
Olecranon fracture 75 76 Olecranon fracture
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MONTEGGIA FRACTURE
(R.R. Richards, Fracture in Adults, 4th
ed., 1996,
914-925)
•
Fracture shaft of ulna + dislocation of radial head
•
< 5% of an forearm fracture
Bado’s Classification
(J.L. Bado, Clin. Orthop., 50: 71-86, 1967)
Type I (most common)
•
anterior dislocation of radial head + anterior angulated
fracture of ulna shaft
Type II #
•
posterior dislocation of radial head + posterior
angulated fracture of ulna shaft
Type III #
•
lateral or anterolateral dislocation of radial head +
fracture of ulnar metaphysis
Type IV # (rare)
•
anterior dislocation of radial head + fracture of proximal one third of both radius and ulna
For Monteggia #,
must look for neurological injury, esp. radial nerve
(PIN), ulnar nerve injury has also been reported
Monteggia fracture 79 80 Monteggia fracture
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FRACTURE OF SHAFTS OF RADIUS AND ULNA
Aim of Treatment
1. Anatomical reduction
2. Stable fixation
Patients requiring operative treatment
1.
All displaced #
2.
Monteggia fracture and Galeazzi # with persistent
subluxed / dislocated proximal / distal radio-ulnar
joint
On admission
1. make sure Xray whole forearm(including both elbow
and wrist joint) is well taken(to rule out Monteggia
and Galeazzi #)
2.
For undisplaced # long arm pop
3. For displaced #
long arm backslab for temporary immobilization; and
work-up for OT
Operative Choice
1.
Closed #
•
ORIF (PC Fix / LCDCP)
2.
Open #
•
ORIF vs External Fixator
GALEAZZI FRACTURE
• fracture of radius (junction of middle third and distalthird) + Dislocation / Subluxation of distal radio-ulnar
joint
• Dislocation of DRUJ may occur at
1.
initial injury2.
progressively during conservative treatment
• Treatment must include reduction of DRUJ
Fracture shaft of radius and ulna 77 78 Galezzi fracture
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PELVIC FRACTURE
On admission
1.
Follow principle of management of patients with
severe trauma
2.
Assessment•
Haemodynamic condition
•
Associated potential life threatening injuries (esp. in
high enery trauma, eg. severe RTA, fell from height,
etc)
• eg. Head injuries•
Cervical spine injuries
•
Chest injuries (eg. haemothorax,
pneumothorax)
•
Abdominal injuries (eg. haemoperitoneum,
torn abdominal viscera)• Torn vessels3. Other associated injuries
• eg. ruptured bladder• ruptured urethra•
ruptured pelvic organ (eg. vagina, rectum)
•
peripheral nerve injuries
4. Fracture pelvis
•
Type and stability
•
Close vs open
5. Other associated muscoloskeletal injuries
Haemodynamic instability due to
1.
Bleeding from fracture site
•
Pelvis fracture: 1500 - 2000 ml
•
Fracture femur: 1000 ml
2.
Torn pelvic vessels (arterial or veins), withretroperitoneal haemorrhage
3. Other injuries(eg. rupture abdominal viscera,
haemothorax, etc)
For patients with haemodynamic instability / Associated
life threatening condition
1.
NPO
2.
Start Fluid resuscitation, as indicated
3.
Start oxygen therapy (high flow oxygen +/-
intubation)
4.
Insert 2 large bore iv line +/- CVP
5. Foley to BSB (uless suspect urethral injury)
6. Blood x cross-match
7. Routine blood test
8.
Must examine patient’s neurology(to r/o severe head
injury and spinal injury), chest (for pneumothorax,
haemothorax) and abdomen (for haemoperitoneum )
9. Analgesics
Fracture pelvis 81 82 Fracture pelvis
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PELVIC FRACTURE
(M. Tiles, The Rationale of Operative Fracture Care, 2nd
ed., 1995, 221-270)
Anatomy
•
Pelvic ring•
3 bones
•
Sacrum + 2 inominate bones (each consists of
ilium, ischium and pubis)
•
Stability
•
ability of pelvis to withstand physiological
force without significant displacement
•
depends mainly on surrounding soft tissues
1.
Symphysis pubis
2.
Posterior sacroiliac complex
3.
Pelvic floor
Fracture pelvis 83 84 Fracture pelvis
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SACROILIAC COMPLEX
Posterior sacroiliac complex(work like a suspension
bridge)
• transfer weight bearing forces from the spine to the
lower extremities1. Posterior sacroiliac interosseous ligaments
(strongest ligament in the whole body)
(maintain sacrum in position with pelvic ring)
2. Iliolumbar ligament
(from transverse process of L5 to iliac crest)
3. Interosseous ligament
Anterior sacroiliac ligament
• resists external rotation and shearing force
PELVIC FLOOR
• muscular layer covered by investing fascia•
contains 2 major ligaments: sacrospinous ligament
and sacrotuberous ligament
1.
Sacrospinous ligament •
resists external rotation of the pelvis
2. Sacrotuber
ous
ligament
• resistsvertical
shearing
force
Fracture pelvis 85 86 Fracture pelvis
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TYPES OF INJURIES FORCE
1. External rotation force
2.
Internal rotation force (lateral compression force)
3.
Vertical shearing force
4.
Complex force (as in high energy trauma)
External Rotation Force
1.
Direct blow to the PSIS
2. Forced external rotation through hip joints unilaterally
or bilaterally
External rotation force ( open book injury)
symphysis pubis disrupts
sacrospinous ligament and anterior sacroiliac
ligament open
impingement of the posterior ilium on sacrum
Internal Rotation Force (Lateral Compression)
1.
Direct blow to iliac crest
upward rotation of the hemipelvis (bucket handle
injury)
1. Through the femoral head, by a direct force against the
greater trochanter, often causing an ipsilateral injury
Internal rotation force / lateral compression
Fracture pelvis 89 90 Fracture pelvis
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anterior structures, usually the rami, break and then
hemipelvis rotates internally
If the posterior ligament remain intact
anterior sacrum will compress
If the posterior ligament is torn, stability is maintained by pelvic floor
Vertical Shearing Force
Vertical shearing force
marked displacement of bone gross disruption of soft
tissue structures
unstable pelvic ring with major anterior and posterior
displacement
Effects of Force on Soft Tissue
1. External rotation and Vertical Shear force
Tearing of viscera and arteries
Traction injuries to nerves
2.
Internal rotation
puncture visceracompress nerve
CLASSIFICATION
Type A
•
Stable #
•
pelvic ring not displaced
Type B
• Partially stable• retain posterior stability• cannot translate vertically ie. stable in vertical plane1.
Open book injury (external rotation force)
• (Unstable in external rotation)2. Lateral compression injury(internal rotation)
• either unstable in internal rotation; or• rigidly impactedType C
• Unstable•
complete disruption of posterior arch, pelvic floor and
usually the anterior arch
•
Type A + B : 70 %• Type C : 30 %
Fracture pelvis 89 90 Fracture pelvis
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CLASSIFICATION OF PELVIC RING
DISRUPTION
Type A: Stable pelvic ring injury
A1: Avulsion of the innominate bone
A2: Stable iliac wing fracture or stableminimally displaced ring fracture
A3: Transverse fractures of the sacrum and
coccyx
Type B: Partially stable
B1: Open book injury
B2: Lateral compression injury
B2.1: Ipsilateral type
B2.2: Contralateral type (bucket-
handle)
B3: Bilateral B injuries
Type C: Unstable (vertical shear)
C1: Unilateral
C1.1: Ilium
C1.2: Sacroiliac dislocation or fracture
dislocation
C1.3: Sacrum
C2: Bilateral, one side B, one side C
C3: Bilateral C lesions
TYPE A--STABLE FRACTURES
• pelvic ring is stable and cannot be disrupted by physiological force
Type A1
•
avulsion # of innominate bone• not involve pelvic ring• usually in adolescentType A2
• involve the iliac ring; or• anterir arch• no posterior injury•
rare
Type A3
• transverse # sacrum and coccyx
TYPE B--PARTIALLY STABLE FRACTURE
Open Book Fracture (External Rotation)
First stage
•
disruption of symphysis pubis(< 2.5cm opening of
symphysis pubis)
Fracture pelvis 91 92 Fracture pelvis
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Second stage
• continuation of external rotation force will tear thesacrospinous ligament and anterior sacroiliac
ligament
Signified by1.
Opening of pubis symphysis > 2.5cm
2.
Avulsion fracture fo ischial spine
• strong posterior sacroiliac ligament remain intact( stable in vertical force)
Third stage
• external rotation force go beyond the yield point of
posterior ligament
posterior complex ruptures
unstable Type C # now (avulsion fracture of L 5
transverse process)
Lateral Compression Fracture (Internal Rotation)
Ipsilateral Injury
• anterior and posterior lesion on the same side
•
direct blow to greater trochanter• superior and inferior pubic rami break + crush at
anterior part of SIJ
• posterior ligamentous structures are intact• possible rupture of bladder +/- blood vessels• elastic recoil
Fracture pelvis 93 94 Fracture pelvis
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Contralateral Injury (Bucket-handle injury)
• anterior fracture on the opposite side of posteriorlesion
• (or all four rami may fracture anteriorly but the
anterior displacement is on the side opposite the posterior lesion)
• usually has major leg length discrepency (shorteningof the side of posterior lesion because of marked
internal rotation of hemipelvis)
• posterior structures are firmly impacted
• reduction require derotation of hemipelvis rather than pure vertical traction
TYPE C--UNSTABLE FRACTURE
• complete disruption of posterior sacroiliac arch +rupture of pelvic floor(including the sacrospinous and
sacrotuberous ligaments)
Radiographic signs of Instability1. Avulsion fracture of the transverse process of L5
vertebrae
• (indicating rupture of ilio-lumbar ligament)
2.
Avulsion fracture of ischial spine or avulsion of sacral
attachment of sacrospinous ligament (indicating
rupture of ischiospinous ligament)
3. > 1cm posterior or vertical translation
MANAGEMENT FO PELVIC #
Depends on
1.
“Personality” of injury2. Associated injuries
Management
• Assessment
• Resuscitation• Provisional stabilization• Definite stabilization
Fracture pelvis 95 96 Fracture pelvis
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ASSESSMENT
General assessment
•
general assessment and management of a
polytraumatised patient
Specific Musculoskeletal assessment•
Aim: Determine the stability of pelvic ring
Clinical Assessment
1.
History
•
High-energy injury(eg.RTA, fell from height) vs
low-energy injury
2. P/E
• Major bruising or bleeding from urethral meatus,vagina, rectum (may signify an open fracture)
• Rotatory deformity or limb shortening (may implyunstable pelvic injury)
•
Test pelvic stability
• apply both hands to ASIS and move the affectedhemi-pelvis (external rotation vs internal rotation)
• apply one hand to the pelvic iliac crest and usingthe other to apply traction to the leg (displacement
in vertical plane)
Radiological Assessment
• Plain Xray
• Xray pelvis (AP)• Xray Pelvis (inlet view)
•
direct Xray beam 60 from head to midpelvis• demonstrate posterior displacement
• Xray pelvis (outlet view)
• Xray beam from the foot of patient to thesymphysis at an angle of 45
• demonstrate superior or inferior migration• CT scan
Diagnosis of Pelvic Stability
1. Type C (Completely unstable)
• Clinically, lack of a firm end-point in rotation ortraction
• Radiologically,• displacement / gap (vertical displacement or
antero-posterior displacement)on Xray or CT >
1cm
• Avulsion # of ischial spine or sacrum
2.
Type B (Partially stable)• Clinically, firm end-point on palpation
Fracture pelvis 97 98 Fracture pelvis
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RESUSCITATION
• Pelvic # hamorrhage (arterial, venous, bony)•
Risk in unstable # > stable #
1. Massive fluid replacement, as indicated
2.
Pneumatic antishock garment3. Application of anterior external frame / Pelvic C
Clamp
• in hypotensive patients / unstable #• pelvic volume tamponade effect• help to stop venous and bony bleeding4. Embolization of pelvic vessels
• usually only help to control bleeding from asmall-bore artery
• Small-bore artery bleeding may be asssumed if,although the patient can be well controlled using the
above methods of fluid replacement, PASG, an
fracture stabilization, he or she goes into a shocked
state each time the fluid is slow down
5. Direct surgical control
•
rarely indicated and usually unsuccessful
PROVISIONAL STABILIZATION
Provisional stabilization by Anterior External Fixator
/ Pelvic C Clamp
Indications
• those fractures with potential increase in pelvic
volume and patients with unstable haemodynamecondition
• Wide open book injury (B1, B3)
• Unstable pelvic fracture C
• rarely required for lateral compression injuries (B2)
Anterior External Fixator
• 2 pins percutaneously place in each ilium, atapproximately 45 to each other
• one pin in ASIS
•
one in iliac tubercle• joined by an anterior rectangular configurationPelvic C Clamp
• point of entry• 4 finger breadth from PSIS on a line joining ASIS and
PSIS
Provisional stabilization with Skeletal traction
•
for patient with no haemodynamic instability
•
temporary skeletal traction pin in distal femur
•
5 - 20 kg of traction to prevent hemipelvis from
shortening
Fracture pelvis 99 100 Fracture pelvis
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ACETABULAR FRACTURE
(M. Tile, The Rationale of Operative Fracture
Treatment , 2nd ed., 1995, 271-324)
Aim of Treatment
•
anatomical reduction of hip joint without
operative complication
Major factors affecting prognosis
1. Degree of initial displacement
2. Damage to superior weight bearing surface of
acetabulum or femoral head
3. Degree of joint instability caused by posterior
wall fracture
4. Adequacy of reduction, either open or closed
5.
Late complications
• AVN of femoral head• Heterotropic ossification• Chondrolysis• Sciatic or femoral nerve injury
Anatomy
Mechanism of injury
• pathological anatomy of the fracture depends onthe position of the femoral head at the moment of
impact
1.
External rotation
of hip
• anterior column #2. Internal rotation
of hip
• posterior column#
3. Abduction of hip
• Low transverse #
4.
Adduction of hip• high transverse #
1. Direct blow on the acetabulum / upon the greater
trochanter
usually a transverse acetabular #
2. Dashboard injury (Flexed knee joint strikes the
dashboard of a motor vehicle, driving the femur
posteriorly on the acetabulum)
posterior wall or posterior column fracture or
fracture dislocation of hip joint
Fracture acetabulum 101 102 Fracture acetabulum
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ASSESSMENT
•
Follow principles of assessment of polytrauma
patient
• Specific assessment of # acetabulumXray pelvis (AP)
Important landmarks
1. iliopectineal line
• denoting limit of anterior column2. ilioischial line
• denoting limit of posterior column3. Anterior lip of acetabulum
4. Posterior lip of acetabulum
5.
Tear drop
6.
Superior dome
Iliac oblique view
• 45 external rotation of the affected pelvis• by elevating the uninjuried side on a wedge foam• Landmarks1.
best depicits the extent of posterior column
2.
anterior lip of acetabulum
3. entire iliac crest
Fracture acetabulum 103 104 Fracture acetabulum
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Obturator Oblique View
• 45 internal rotation of the affected hemipelvis• by placing a foam wedge under the affected hip• Landmarks1.
best shows the anterior column
2.
posterior lip of acetabulum
3. best show displacement of iliac wing in the
coronal plane (because iliac crest is seen
perpendicular to its normal plane)
Classification
• acetabulum consistsof 4 basic
anatomical areas
1.
Anterior column
2. Posterior column
3. Anterior wall of lip
4. Posterior wall of lip
Fracture Types
1. Isolated Anterior
Column fractures
2. Isolated Posterior
Column fractures
3. Combined anterior
column and anterior
lip fracture
4. Combined posterior
column and
posterior lip
fracture
5.
Transverse fracture
• both anterior and posterior columns are broken
Fracture acetabulum 105 106 Fracture acetabulum
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6. T Fracture
• both columns are broken and
separated from
each other
• both transverse orT fracture may be
associated with an
anterior or
posterior lip #
•
Transverse / T
fracture, a portion
of acetabular
dome is always
attached to the intact ilium
7. Both Column Fractures
• both anterior and posterior columns
are fractured and
separated from
each other
• but the fracture inthe columns is
proximal to theacetabulum in the
ilium
• true floatingacetabulum
• no portion of theweight-bearing
surface of the acetabulum remain attached to the
acetabulum
Management (Depends on)
1.
Fracture factor
2.
Patient’s factor (age and bone quality, general
medical status, associated injuries)
Fracture factor
Non-operative management if
Hip stable and Congrous
Undisplaced fractures (all types)
require no skeletal traction
Minimally displaced # (displacement < 2mm)
Low anterior column # (# not involve major weight
bearing area)
Low transverse #
• through theacetabular
fossa area
(infratectal)
• skeletaltraction
•
Low transverse# (infratectal)
• main portion ofthe weight
bearing dome is intact
Fracture acetabulum 107 108 Fracture acetabulum
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• medial portion of the dome act as a buttress to the
femoral head, preventing redisplacement
c.f. High transverse
# (Supratectal,
tanstectal)
divides the
mid-portion of the
superior
weight-bearing
dome
medial fragment
remains displaced
and the femoral
head is congrous with that portion rather than the
dome portion
Both column fractures without major posterior
column displacement
• true floating acetabulum• no portion of the weight bearing dome attached
to the axial skeleton
• exhibit secondary congruence (Letournel, 1980)• skeletal traction
Operative management
• indicated for unstable and/or incongruous hip joint
Instability
• hip dislocation associated with1. Posterior wall or column displacement (posterior
instability)
2.
Anterior wall or column displacement (anterior
instability)
Incongruity
1. Fractures through the roof of the dome
• displaced dome fragement•
High transverse or T types # (transtectal)
• Both-column types with incongruity (displaced posterior column)
2. Retained bone fragments
3. Displaced fractures of femoral head
4. Soft tissue interposition (usually posterior
capsule)
Other operative indications
1.
development of a sciatic or femoral nerve palsyafter reduction of the acetabular # (possible
entrapment of the nerve)
2. Presence of a femoral artery injury associated
with an anterior column fracture of the
acetabulum
Fracture acetabulum 109 110 Fracture acetabulum
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3. Fracture of the ipsilateral femur / disruption of
ipsilateral knee, which makes closed treatment of
acetabulum virtually impossible
Fracture acetabulum 111 112 Fracture acetabulum
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FRACTURE OF PROXIMAL FEMUR
*For patients < 60 years old presenting with acute
intracapsular fracture neck of femur (both displaced
and undisplaced), need EOT x CR + IF (AO screw)
(J. Schaztker, The Rationale of Operative FractureCare, 2nd ed., 1995, 323-340)
Anatomy
• Neck shaft angle: 125 - 135
Blood Supply of Femoral Head
1. Via retinacular vessels in the posterior capsule of
hip joint
• Common femoral artery
medial circumflex femoral artery
posterior superior retinacular vessels and
posterior inferior retinacular vessels posterior superior retinacular artery gives rise
to lateral superior epiphyseal vessels
Femoral artery
(Lateral femoral circumflex artery
anterior retinacular vessels
not contribute to blood supply of head
Fracture proximal part of femur 113 114 Fracture proximal part of femur
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2. Via ligamentous teres (supply a small portion of
head close to their site of entry)3.
Intraosseous blood supply
Attachment of capsule of hip joint
1. Front
• along the intertrochanteric line2. Back
• attach to the neck only halfway to theintertrochanteric crest
Fracture Proximal Part of Femur
1. Intracapsular
• Subcapital # neck of femur• Transcervical # neck of femur
•
In these fractures, capsule may be torn
blood supply of femoral head is at risk
2.
Extracapsular
•
Fracture basal neck of femur
•
Intertrochanteric fracture of femur
• Subtrochanteric fracture of femur• In these fractures, capsule is intact Femoral head is not at risk of AVN
Intracapsular Fracture Neck of FemurGarden Classification (1964)
• use the relationship of medial trabeculae(compression trabeculae) in the head and pelvis
as an index of displacement
• undisplaced # (Garden I and II) vs displaced #(Garden III and IV)
1. Undisplaced Fracture
• capsule is less likely to be injuried lower incidence of AVN
2.
Displaced Fracture• capsule is likely to be torn higher incidence of AVN and higher
incidence of failure of fixation and nonunion
Fracture proximal part of femur 115 116 Fracture neck of femur
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Garden I
• head impacted invalgus
Garden II
•
undisplaced #
Garden III
• partially displaced#
Garden IV
• completelydisplaced #
History
• simple fall with pain over groin +/- inability towalk
P/E
• R/O concomittant injury (eg. head injury, # distalradius)
• Affected leg shortened and externally rotated• Pain on manipulation of the affected leg
Treatment
1. For all young patients (< 60 years) with
intracapsular fracture neck of femur (both
displaced and undisplaced #) need EOT x CR + IF
2.
For patients > 60 years
• for elective OT uless medically unfit• Undisplaced intracapsular Fracture (Garden I
and II)
AO screws +/- AMA
Fracture neck of femur 117 118 Fracture neck of femur
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• Displaced intracapsular fracture (Garden III
and IV)
AMA / Cemented Thompson
CR of intracapsular fracture neck of femur
• Femoral head usually displaces into varus andretroversion
• femoral shaft externally rotates
Methods of CR (under Image Intensifier)
1. Longitudinal traction (bring the head out of varus
position)
2. Gentle internal rotation of the limb (correct
retroversion)
Acceptable alignment(Schatzker)
1. Anatomical reduction or one with the head in
slight valgus position
2. Head in neutral version or minimally anteverted
• repeated attempts of CR increase risk of AVN
Fracture neck of femur 119 120 Fracture neck of femur
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Kyle’s III
•
unstable and has a large postero-medial
comminuted area
Kyle’s IV
• fracture with subtrochanteric extension• highly unstable
Treatment
• all #TOF require elective OT for internal fixationwith DHS (dynamic hip screw)
• look for assicated injuries (eg. head injury,fracture distal radius)
•
work-up for OT
Intertrochanteric fracture of femur 123 124 Intertrochanteric fracture of femur
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SUBTROCHANTERIC FRACTURE
(J. Schaztker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 349-366)
•
Subtrochanteric segment--extends from lesser
trochanter to the junction of proximal and middlethird of the diaphysis
Biomechanical
consideration
• subtrochantericregion is
subjected to:
1. axial load
2. bending force
because of
eccentric load
application to
the femoral head
• medialcortex--loaded
in compression
• lateralcortex--loaded
in tension
Factors important for stability (in order of
importance)
1. Degree of comminution
2.
Level of fracture3. Pattern of fracture
Degree of comminution
1. irreconstructable medial cortex comminution
(shattered medial cortex)
2. irreconstructable segmental comminution
Level of fracture
1.
Closer the fracture to the lesser trochanter
shorter the lever arm and the lower the bending moment
2. Involvement of greater trochanter
• difficult to keep the intramedullary nail withinthe proximal fragment
• better to fix the fracture with an angled device(eg. angled blade plate)
3. Involvement of lesser trochanter
• lock proximally within the femoral neck andhead (eg. AO unreamed femoral nail + spiral
blade locking)
Pattern of fracture
• determine the mode of internal fixation
Subtrochanteric fracture of femur 125 126 Subtrochanteric fracture of femur
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Comprehensive Classification of Fractures
(Muller, 1990)
Type A #
•
simple
•
transverse / oblique / spiral
Type B #
• wedge #• can still be reconstructed to yield a stable
structure
lateral wedge medial wedge
Type C #
•
comminution to a degree that a stable unit cannot
be achieved
Indications for surgery
• all subtrochanteric fracture of femur needsoperative treatment
On admission
1. r/o associated injury
2. skeletal traction
3.
work-up for OT
Surgery
• AO unreamed intramedullary nail with spiral blade locking
Subtrochanteric fracture of femur 127 128 Subtrochanteric fracture of femur
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FRACTURE SHAFT OF FEMUR
• result of high energy trauma• rule out associated injury• follow management of polytrauma patient
Comprehensive Classification of Fracture
(Muller, 1990)
Type A
• simple #• A1--long oblique• A2--short oblique• A3--transverse
Type B
•
wedge fracture
Type C
• complex #• C1--spiral• C2--segmental•
C3--irregular
Treatment
• All adult femoral fracture• Closed #O unreamed femoral nail• Open #xternal fixator
On admission
•
Follow management of polytrauma patient (if
applicable)
• Skeletal traction•
work-up for operation
Fracture shaft of femur 129 130 Fracture shaft of femur
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SUPRACONDYLAR FRACTURE OF FEMUR
(J. Schaztker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 387-413)
1. Younger patient
•
high energy trauma• severe fracture with greater intra-articular
disruption or segmental comminution
• possible association with open wound, multiplefractures, ligamentous injury
2. Older patients
• low energy trauma (eg. slip an fell)• associated with severe osteoporosis
Aim of treatment
1.
accurate anatomical reduction of Joint surface
2. Stable internal fixation of the articular surface
3.
Restoration of normal axial alignment and
length
4. Buttressing of metaphysis
5. Early mobilization
6. thus, operaive treatment for all patients
On admission
•
Follow management of polytrauma patient (ifapplicable)
•
Skeletal traction
•
work-up for OT
Comprehensive Classification of Fractures
(Muller, 1990)
Type A
•
extra-articular• A1--extra-articular, simple• A2--extra-articular, metaphyseal wedge• A3--extra-articular, metaphyseal complex
Type B
• partial articular• part of the articular surface intact and in contact
with the diaphysis
• B1--partial articular, lateral condyle, sagittal
•
B2--partial articular, medial condyle, sagittal• B3--partial articualr, frontal
Supracondylar fracture of femur 131 132 Supracondylar fracture of femur
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Type C
• complete articular• articular surfaces are fractured and have lost
continuity with the diaphysis• C1--cmplete articular #, articular simple,
metaphyseal simple
• C2--complete articular #, articular simple,metaphyseal multifragmentary
• C3--complete articular #, multifragmentary
Treatment
• ORIF (May plate +/- Bone grafting +/- Cementaugmentation)
Surgical Anatomy
1.
Anatomical axis:• in valgus• with sagittal plane• (79 to 82) with the
knee joint axis
(parallel to ground)
2. Mechanical axis:
• line projectedthrough the centre
of femoral head,
knee joint an ankle
joint
•
with sagittal plane
• with anatomical axisof femur
Supracondylar fracture of femur 133 134 Supracondylar fracture of femur
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Lateral view
• when posterior cortex of the shaft is projecteddistally, it divides the epiphysis into an anterior
and posterior half
•
Anterior position of condyles appear as acontinuation of shaft
• thus, blade of a condylar plate / screw of a DCSshould be placed into the anterior part of
condyle; or the plate will not fit the femur
Cross Section
• distal femur appear as a trapezoid• anterior and posterior surfaces are not parallel• medial and lateral walls are inclined (medial wall
inclined at 25 to the vertical)• important in selecting the length of compression
screw
Supracondylar fracture of femur 135 136 Supracondylar fracture of femur
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FRACTURE PATELLA
(J. Schaztker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 415-418)
Anatomy
•
seasmoid bone within the tendon of quadricepsmuscle
• displacement with disruption of quadricepsmechanism
loss of active extension of knee and loss of ability
to lock the knee in extension
• Patella is bound1.
proximally to quadriceps tendon
2. distally to infrapatellar tendon
3. on either side to retinacular expansion which are
adherent to the capsule
Classification
Transverse fracture
• result from sudden, violent contraction of thequadriceps (eg. when a person tries to stop a fall)
• may disrupt quadriceps mechanism• may result in avulsion of quadriceps tendon, or
infrapatellar tendon, or transverse fracture of patella
• associated with a tear into retinacular expansion•
If undisplaced # with intact extensor mechanism
long leg cylinder x 6 weeks and FWB walking
• For all displaced fracture open reduction + TBW / Cerclage wiring
Fracture patella 137 138 Fracture patella
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Partial patellectomy
Fracture patella 143 144 Fracture patella
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TIBIAL PLATEAU FRACTURE
(J. Schaztker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 419-438)
History• Mechanism of injury(S/F, RTA, Fell from
height)
• High velocity injury vs Low velocity injury• Direction of force• Patient’s expectation and level of function
required
P/E
• Soft tissue condition (open wound, swelling, bruising, etc)
• Site of Local tenderness (may indicate possibledisruption of collateral ligament)
• Neurological deficit• Vascular deficit• Compartment syndrome
Management
1.
Rule out concomitant injury
2.
Rule out patients requiring EOT (eg. openfracture, vascular injury, acute compartment
syndrome)
3. Long leg backslab for temporary immobilization
Tibial Plateau Fracture
• about 50 % patients get satisfactory results (bothclosed and open treatment)
Causes of failure of treatment
1. Residual pain
2. Stiffness
3. Instability of knee joint
4. Deformity
5. Recurrent effusions
6. Giving way
Mechanism of Injury
•
usually a combination of vertical thrust and bending
Aims of Treatment
1. Stable Joint
2. Congruent articular surface
3. Correct axial alignment
4. Satisfactory range of movement
Fracture tibial plateau 145 146 Fracture tibial plateau
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Schatzker Classification of Tibial Plateau
Fracture
TREATMENT
1. Undisplaced Fracture (< 5mm depression, no
splaying of condyles)
hinged knee brace x 6 weeks
+ protected weight bearing(NWB walking x 6/52
PWB walking x 6/52
FWB walking)
2. All others / Open Fracture / Fracture
associated with acute compartment syndrome
/ Fracture associated with vascular or
neurological injury (vascular injury is most
often associated with type IV tibial plateau
injury)
i. OR + Buttress Plate + Bone Graftii. CR + Ilizarov +/- Mini-open technique + bone
graft
Rehabilitation
• early mobilization
Fracture tibial plateau 147 148 Fracture tibial plateau
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Type I Fracture
• wedge fracture of lateral tibial plateau1. Undisplaced
2. Displaced with lateral wedge fragment
• spread apart from the metaphysis broadening of joint surface
• Depressed• Both spread and depressed
• (For fracture with significant displacement,
lateral meniscus may be trapped in the #)Mechanism
• result of bending and shearing forceAge
• usually young people < 30 years (because ofdense cancellous bone of lateral tibial plateau)
Treatment
1. Undisplaced
• Hinged knee brace x 6/52; protected weight bearing
2. Displaced
•
ORIF +/- bone graft(Young people: lag screw
Old people : lag screw + buttress plate)
3. Minor displacement
• may need arthroscopy to make sure that themeniscus is not trapped in the fracture
Prognosis
• excellent if the joint is carefully reconstructed
Fracture tibial plateau 149 150 Fracture tibial plateau
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Type II Fracture
• wedge fracture + depression adjacent weight bearing portion of lateral tibial plateau
• Depressed fragment may be anterior, central, posterior, or a combination of all three
Mechanism
• result of bending and shearing force
Age
•
> 50 years
Treatment
1. Undisplaced and Depression < 5mm
• Hinged knee brace x 6/52• Protected weight bearing2. Displaced fracture
•
ORIF (buttress plate) + Bone graft3.
Displaced Fracture with contraindication to
surgery
• CR + Hinged knee brace x 6/52 + Protectedweight bearing
Prognosis
1. Poor results if residual joint depression,
incongruity, joint instability
2.
Significant knee stiffness if prolonged
immobilization
Fracture tibial plateau 151 152 Fracture tibial plateau
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Type III Fracture
•
most common but least serious tibial plateaufracture
• Depression of articular surface of the lateraltibial plateau without an associated lateral wedge
fracture
Mechanism
• result of smaller force exerting its effect onweaker bone
Age
• > 55 years
Treatment
1. Depression < 5mm and No knee instability
• Hinged knee brace x 6/52 + Protected weight bearing
2.
Depression > 5mm• ORIF (Buttress plate + Lag screw below the
elevated portion of tibial plateau + Bone graft)
Prognosis
• excellent
Fracture tibial plateau 153 154 Fracture tibial plateau
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Type IV Fracture
• fracture medial tibial plateau• carry worst prognosis
1.
High velocity injury
•
Younger individual
• medial plateau splits as a simple wedge with anassociated fracture of the intercondylar eminence
and adjacent bone with the attached cruciate
ligament
•
may be associated with a posterior split wedge ofmedial plateau
femoral condyle subluxate posteroirly on
flexion
• frequently a concomitant disruption of the lateralcollateral ligament complex (tear through the
substance of ligament or avulsion of bone, such
as the proximal fibula)
• possible stretching or rupture of the peronealnerve (as a result of traction)
•
occasionally, damage to popliteal vessels•
represents a subluxation or a dislocation of knee
which has been reduced
• Poor prognosis--because of associated soft tissueinjury and other complications, such as
compartment syndrome, Volkmans’ contracture,
footdrop
2. Trivial Low Velocity Injury
• elderly with marked osteoporotic bone•
medial tibial plateau crumbles into an
irreconstructable mass of fragments
• Poor prognosis--because of joint incongruity andinstability
Fracture tibial plateau 155 156 Fracture tibial plateau
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Treatment
1. Undisplaced with No significant soft tissue
injury
• Hinged knee brace x 6/52 + Protected weight
bearing2. Displaced and/or associated ligamentous or
neurovascular lesion
• Open repair of ligamentous injury• ORIF--buttress plate to medial plateau + BG
Avulsed intercondylar #:
Fixed with lag screw or wire loop
Posterior split wedge fracture
2nd buttress plate posterio-meduially
• CR + Ilizarov External Fixator +/- Mini-opentechnique + bone grafting
Type V Fracture
•
bicondylar fracture, which consists of a wedge
fracture of the medial and lateral tibial plateau
•