Review of Orthopaedic Trauma 2e 2013 PDF Unitedvrg PDF

Review
of thopaedic

Or
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https://kat.cr/user/Blink99/
SECOND EDITION

R
EVIEW
R
OF
O
THOPAEDIC
R
T
AUMA
ark R. Brinker,
M
MD
Director of Acute and Reconstructive Trauma
Texas Orthopedic Hospital and Fondren Orthopedic Group LLP
Houston, Texas
Clinical Professor of Orthopaedic Surgery
The University of Texas Health Science Center at Houston
Houston, Texas
Tulane University School of Medicine
New Orleans, Louisiana
Clinical Professor of Orthopedic Surgery
Baylor College of Medicine
Houston, Texas
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Copyright © 2013 by Lippincott Williams and Wilkins
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Library of Congress Cataloging-in-Publication Data
Review of orthopaedic trauma / [edited by] Mark R. Brinker. —- Second Edition.

p. ; cm.
Includes bibliographical references and index.
Summary: “The second edition of Review of Orthopaedic Trauma covers the entire
scope of adult and pediatric trauma care. Emphasis is placed on material likely to
appear on board and training exams. An easy-to-use outline is provided for rapid

access, exam preparation, or review of new and emerging topics. Information is

organized by anatomic region”—Provided by publisher.

ISBN 978-1-58255-783-0
I. Brinker, Mark R., editor of compilation.
[DNLM: 1. Bone and Bones—injuries. 2. Joints—injuries. WE 200]
617.4'71044—dc23
2012049621
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to
describe generally accepted practices. However, the authors, editors, and publisher

are not responsible for errors or omissions or for any consequences from application

of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication.

Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended

may not be considered absolute and universal recommendations.
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10 9 8 7 6 5 4 3 2 1

To the three most amazing women on the planet:
my mother Carole, my wife Newie, and my daughter
Sloan.You gave me life, share my life, and make
my life. In a world full of mangled extremities and
infected nonunions, you are my shining lights of
splendor.
S
CONTENT
edication v
D
ontributors xi
C
oreword to the Second dition xv
F
E
oreword to the irst dition xvii
F
F
E
oreword to the irst dition xix
F
F
E
reface to the Second dition xxi
P
E
reface to the irst dition xxiii
P
F
E
cknowledgments xxv
A
Section : verview
I
O
R 1 General Principles of Trauma 2
CHAPTE

Jo eph R. u
s
Hs
R 2 Principles of Fractures 20
CHAPTE

a k R. B inke and aniel . ’ onno
M
r
r
r
D
P
O
C
r
R 3 Principles of Deformities 37
CHAPTE

Jo eph J. Gu enheim J .
s
g
r
R 4 Biomechanics and Biomaterials 54
CHAPTE

ank .B. Gott chalk
Fr
A
s
Section : Adult r um
II
T
a
a
Par I The Lower x remi y 66
t
E
t
t

R 5 Fractures of the Femoral Neck and Intertrochanteric Region 66
CHAPTE

Ro e t icto antu and enneth J. oval
b
r
V
r
C
K
K
R 6 Fractures of the Femoral Shaft and Subtrochanteric Region 77
CHAPTE

Sean . o k
E
N
r
R 7 Fractures of the Supracondylar Femoral Region 88
CHAPTE

ilan . Sen
M
K
R 8 Knee Dislocations, Fracture-Dislocations, and Traumatic Ligamentous
CHAPTE

Injuries of the Knee 98

B yon o y, i oo e, i hna ipu aneni, u tin Richte , and Ro e t . Schenck J .
r
H
bb
Kr
s
M
r
Kr
s
Tr
r
D
s
r
b
r
C
r
R 9 Extensor Mechanism Injuries of the Knee 116
CHAPTE

uke S. hoi, ete . Ro , and a k . ille
L
C
P
r
W
ss
M
r
D
M
r
R 10 Tibial Plateau Fractures 135
CHAPTE

a k R. B inke , aniel . ’ onno , and Roman Schwa t man
M
r
r
r
D
P
O
C
r
r
s
vii
viii ontent
C
s
R 11 Tibial Shaft Fractures 143
CHAPTE

athe ine . umph ey and John . Go czyca
C
r
A
H
r
T
r
R 12 Fractures of the Tibial Plafond 162
CHAPTE

a k R. B inke and aniel . ’ onno
M
r
r
r
D
P
O
C
r
R 13 Injuries of the Ankle 175
CHAPTE

onald S. Stewa t and illiam . cGa vey
D
r
II
W
C
M
r
R 14 Injuries of the Foot 187
CHAPTE

onald S. Stewa t and illiam . cGa vey
D
r
II
W
C
M
r
Par II The Pe vis and ce abu um 210
t
l
A
t
l

R 15 Pelvic Ring Injuries 210
CHAPTE

avid J. ak
D
H
R 16 Fractures of the Acetabulum 224
CHAPTE

yle . ick on
K
F
D
s
R 17 Hip Dislocations and Fractures of the Femoral Head 244
CHAPTE

Steven . ochow and Steven . l on
C
L
A
O
s
Par III The er x remi y 262
t
Upp
E
t
t

R 18 Fractures and Dislocations of the Shoulder Girdle 262
CHAPTE

G e o y . ake and . B adley dwa d
r
g
r
N
Dr
T
r
E
r
s
R 19 Proximal Humerus Fractures and Dislocations and Traumatic Soft-Tissue
CHAPTE

Injuries of the Glenohumeral Joint 272

Je y S. She and hilip R. ozman
rr
r
P
L
R 20 Fractures of the Humeral Shaft 293
CHAPTE

Ro e t o e and an hitney
b
r
Pr
b
I
W
R 21 Fractures and Dislocations of the Elbow 300
CHAPTE

. lton Ba on and amien avi
O
A
rr
D
D
s
R 22 Forearm Injuries 314
CHAPTE

i a . annada
L
s
K
C
R 23 Fractures and Dislocations of the Wrist 323
CHAPTE

R. Jay ench
Fr
R 24 Injuries of the Hand 353
CHAPTE

homa . ehlhoff, . ai ouch, and Jame B. Bennett
T
s
L
M
C
Cr
g
Cr
s
ParT IV The ine 387
Sp

R 25 Spinal Cord and Related Injuries 387
CHAPTE

ichael ehlin , a cu imlin, and icola han
M
F
gs
M
r
s
T
N
s
P
content ix
s
R 26 General Principles of Vertebral Bony, Ligamentous, and Penetrating Injuries 406
CHAPTE

Ro e t G eenleaf, Jo y . Richman and aniel . ltman
b
r
r
r
D
D
T
A
R 27 Cervical Spine Trauma 418
CHAPTE

Jen R. s
hapman and Sohail R. i za
C
M
r
R 28 Thoracolumbar Spine Fractures and Dislocations 438
CHAPTE

ham li . a od, ichael Banffy, and itchel B. a i
C
b
ss
C
H
rr
M
M
H
rr
s
Section : Pedi tric r um
III
a
T
a
a
R 29 General Principles of Pediatric Trauma 458
CHAPTE

illiam . u ell, ichael . olfe, ed ic . a en, and owa d R. pp
W
D
M
rr
M
W
W
Fr
r
H
W
rr
H
r
E
s
R 30 Pediatric Lower Extremity Injuries 467
CHAPTE

owa d R. pp
H
r
E
s
R 31 Pediatric Upper Extremity Injuries 487
CHAPTE

B ian . G ottkau and me h S. etka
r
E
r
U
s
M
r
R 32 Pediatric Spinal and Pelvic Injuries 510
CHAPTE

Scott Ro enfeld
s
ont i uto
C
r
b
rs
Daniel T. Altman, MD Lisa K. Cannada, MD
Director of Orthopaedic Spine Trauma Associate Professor
Allegheny General Hospital Orthopaedic Traumatology
Associate Professor of Orthopaedic Surgery Department of Orthopaedic Surgery
Drexel University College of Medicine Saint Louis University School of Medicine
Pittsburgh, Pennsylvania St. Louis, Missouri
Robert Victor Cantu, MD

Michael B. Banffy, MD Assistant Professor of Orthopaedic Surgery
Orthopaedic Surgeon Dartmouth-Hitchcock Medical Center
Beach Cities Orthopedics & Sports Medicine Lebanon, New Hampshire
Manhattan Beach, California
Jens R. Chapman, MD
Professor
O. Alton Barron, MD
Department Chair
Assistant Clinical Professor of Orthopaedics
Director, Spine Service
Columbia College of Physicians and Surgeons
Hansjöerg Wyss Endowed Chair
Senior Attending
Department of Orthopaedics and Sports Medicine
St. Luke’s-Roosevelt Hospital Center
University of Washington
New York, New York
Seattle, Washington
James B. Bennett, MD Luke S. Choi, MD

Clinical Professor Director
Department of Orthopedic Surgery and Division of Center for the Athlete’s Shoulder and Elbow
Plastic Surgery Sports Medicine
Baylor College of Medicine Regeneration Orthopedics
Houston, Texas St Louis, Missouri
Chief of Staff
Texas Orthopedic Hospital and Fondren C. Craig Crouch, MD
Orthopedic Group LLP Orthopaedic Surgeon

Houston, Texas Texas Orthopedic Hospital and Fondren
Orthopedic Group LLP
Houston, Texas
Mark R. Brinker, MD
Director of Acute and Reconstructive Trauma Damien Davis, MD
Texas Orthopedic Hospital and Fondren Orthopaedic Surgery Resident
Orthopedic Group LLP St. Luke’s-Roosevelt Hospital Center
Houston, Texas New York, New York
The University of Texas Health Science Center at Kyle F. Dickson, MD, MBA
Houston Professor of Orthopedic Surgery
Houston, Texas Baylor College of Medicine
Clinical Professor of Orthopaedic Surgery Houston, Texas
Tulane University School of Medicine
New Orleans, Louisiana Gregory N. Drake, MD
Clinical Professor of Orthopedic Surgery Shoulder Fellow
Baylor College of Medicine Fondren Orthopedic Group LLP
Houston, Texas Houston, Texas
xi
xii ont i uto
C
r
b
rs
T. Bradley Edwards, MD Joseph J. Gugenheim, MD
Orthopaedic Surgeon Associate Professor of Orthopedic Surgery
Texas Orthopedic Hospital and Fondren University of Texas Medical Branch
Orthopedic Group LLP Galveston, Texas
Houston, Texas Texas Orthopedic Hospital and Fondren
Orthopedic Group LLP
Houston, Texas
Howard R. Epps, MD
Medical Director
David J. Hak, MD, MBA
Pediatric Orthopaedics & Scoliosis
Associate Professor
Texas Children’s Hospital
Denver Health
Associate Professor
University of Colorado
Department of Orthopaedic Surgery
Denver, Colorado
Baylor College of Medicine
Houston, Texas
Mitchel B. Harris, MD
Professor
Michael Fehlings, MD, PHD, FRCSC Department of Orthopaedic Surgery
Director Harvard Medical School
Neural and Sensory Sciences Program Chief
University Health Network Orthopedic Trauma Service
Toronto, Ontario Brigham and Women’s Hospital
Boston, Massachusetts
R. Jay French, MD
Orthopaedic Surgeon Christopher C. Harrod, MD
Tennessee Orthopaedic Clinics Orthopaedic Surgeon
Oak Ridge, Tennessee The Bone and Joint Clinic of Baton Rouge
Baton Rouge, Louisiana
John T. Gorczyca, MD Byron Hobby, MD

Professor Orthopaedic Trauma Fellow
Department of Orthopaedics Department of Orthopaedics
University of Rochester Medical Center UC Davis
Rochester, New York Sacramento, California
Frank A. Gottschalk, MD Joseph R. Hsu, MD

Professor of Orthopaedic Surgery Chief of Orthopaedic Trauma
UT Southwestern Medical Center Institute of Surgical Research
Dallas, Texas Assistant Program Director (Research)
Orthopaedic Surgery Residency
San Antonio Military Medical Center
Robert Greenleaf, MD
Brook Army Medical Center
Reconstructive Orthopedics
San Antonio, Texas
Moorestown, New Jersey
Catherine A. Humphrey, MD
Brian Edward Grottkau, MD Assistant Professor
Chief Department of Orthopaedics
Pediatric Orthopaedic Service University of Rochester Medical Center
Department of Orthopaedic Surgery Rochester, New York
Massachusetts General Hospital
Pediatric Orthopaedic Surgeon Kenneth J. Koval, MD
Assistant Professor of Orthopaedic Director of Orthopaedic Research
Surgery Adult Orthopaedics
Harvard Medical School Orlando Health
Boston, Massachusetts Orlando, Florida
ont i uto xiii
C
r
b
rs
Steven C. Lochow, MD William D. Murrell, MD
Orthopaedic Surgeon Consultant Orthopaedic Sports Medicine
Scott Orthopedic Center Dubai Bone & Joint Center
Huntington, West Virginia Dubai Healthcare City
Dubai, UAE
Philip R. Lozman, MD
Orthopedic Surgeon Sean E. Nork, MD
Orthopedic Specialists Associate Professor
Aventura, Florida Department of Orthopaedics and Sports Medicine
Harborview Medical Center
University of Washington
William C. McGarvey, MD
Seattle, Washington
Associate Professor
Residency Program Director
Daniel P. O’Connor, PhD
Associate Professor
The University of Texas Health Science
Department of Health and Human Performance
Center at Houston
University of Houston
Houston, Texas
Houston, Texas
Thomas L. Mehlhoff, MD Steven A. Olson, MD

Orthopaedic Surgeon Professor of Orthopaedic Surgery
Texas Orthopedic Hospital and Fondren Department of Orthopaedic Surgery
Orthopedic Group LLP Duke University School of Medicine
Team Physician Durham, North Carolina
Houston Astros
Houston, Texas Nicolas Phan, MD, CM
Division of Neurosurgery and Spinal Program
Umesh S. Metkar, MD Toronto Hospital and Univerity of Toronto Western
Consulting Spine Surgeon Hospital
Hartsville Orthopedics & Carolina Pines Regional Toronto, Ontario
Medical Center
Hartsville, South Carolina Robert A. Probe, MD
Chairman
Mark D. Miller, MD
Scott & White Memorial Hospital
S. Ward Casscells Professor of Orthopaedic Surgery
Temple, Texas
University of Virginia
Team Physician
Jory D. Richman, MD
James Madison University
Clinical Assistant Professor of Orthopaedic Surgery
JBJS Deputy Editor for Sports Medicine
University of Pittsburgh
Director
Pittsburgh, Pennsylvania
Miller Review Course
Charlottesville, Virginia
Dustin Richter, MD
Orthopaedic Surgeon
Sohail K. Mirza, MD, MPH Department of Orthopaedics & Rehabilitation
Chair University of New Mexico Medical School
Department of Orthopaedics Albuquerque, New Mexico
Dartmouth Hitchcock Medical Center
Lebanon, New Hampshire Scott B. Rosenfeld, MD
Assistant Professor of Orthopedic Surgery
Kris Moore, MD Baylor College of Medicine
Orthopedic Surgeon Pediatric Orthopedic Surgery
Providence Medical Group-Orthopedics Texas Children’s Hospital
Newberg, Oregon Houston, Texas
xiv ont i uto
C
r
b
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Peter W. Ross, MD Donald S. Stewart II, MD
Orthopaedic Surgeon Arlington Orthopedic Associates, P.A.
Kenai Peninsula Orthopaedics Mansfield, Texas
Soldotna, Alaska
Marcus Timlin, MCh, FRCS (Tr&Orth)
Consultant Orthopaedic Surgeon
Robert C. Schenck, Jr., MD Mater Private Hospital
Professor and Chair UPMC Beacon Hospital
Department of Orthopaedics Dublin, Ireland
University of New Mexico
Albuquerque, New Mexico Krishna Tripuraneni, MD
Orthopaedic Surgeon
New Mexico Orthopaedics
Roman Schwartsman, MD
Albuquerque, New Mexico
Orthopaedic Surgeon
Boise, Idaho
Fredric H. Warren, MD
Director of Pediatric Orthopaedics
Milan K. Sen, MD Ochsner Children’s Health Center
Assistant Professor New Orleans, Louisiana
The University of Texas Health Ian Whitney, MD
Science Center at Houston Resident
Houston, Texas University of Texas Health Care
San Antonio, Texas
Jerry S. Sher, MD Michael W. Wolfe, MD

Orthopedic Surgeon Assistant Professor
Orthopedic Specialists Department of Surgery
Aventura, Florida Virginia Tech Carilion School of Medicine
Roanoke, Virginia
o ewo d to the
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Second dition

E
I, and those who studied the first edition of Dr. Mark exemplify the focus and clarity of this text in organiza-
Brinker’s Review of Orthopaedic Trauma, found it to be tion, editing, and appropriateness. The reader’s educa-
an extremely valuable textbook. Now Brinker gives us tional experience is further enhanced by the fact that
an equally comprehensive second edition with updated each chapter is framed with an eye on commonly tested
materials, new and expanded chapters, and hundreds material encountered on In-Training Examinations, Self-
of fresh and original illustrations. Assessment Examinations, and ABOS Certification and
The utility of this book is not achieved in spite of Recertification Examinations.
its purpose as a review text; rather, it is achieved be- Mark Brinker is widely known and highly respected
cause of it. While the more traditional fracture and as a gifted surgeon who routinely tackles the most
trauma textbooks certainly still have their place, the difficult reconstructive challenges of our specialty.
reader is often overburdened with subtleties, nuances, He brings the same energy and passion to Review of
and details concerning concepts and techniques that Orthopaedic Trauma, turning his talents to communicat-

fall in and out of favor or are endorsed by one faction ing the entire fund of knowledge of the specialty in one
or institution. Furthermore, it is common to encounter neat and tidy package. My advice is that residents and
lengthy discussions regarding the author’s preferred fellows read this book early on in their training; AND,
methods and specific viewpoints that are not neces- that they read it again, near the end of their training.
sarily evidenced-based. As a senior traumatologist, I found this book exception-
By contrast, in focusing on the review nature of this ally valuable in filling in the gaps in my own knowledge
work, Brinker, acting as both the editor and an author, base, and as a way to rapidly review the current think-
delivers an intellectually nourishing final product that ing on the aspects of Orthopaedic Trauma that I don’t
distills out the important core knowledge of the sub- encounter on a regular basis.
specialty. At the same time, Brinker’s work goes far It’s a real treat to be invited to write the Foreword
beyond just the basics. Review of Orthopaedic Trauma to the second edition of Review of Orthopaedic Trauma
provides an up-to-date, state-of-the-art approach to the and I am honored to have Mark as both a colleague and
essential issues of the multiply injured patient, damage friend.
control orthopedics, and long-bone and periarticular
injuries, as well as covers the current clinical thought Andy R. Burgess, MD
on specific musculoskeletal injuries in both adult and Professor and Vice-Chairman
pediatric patients. Chief, Division of Orthopaedic Trauma
Mark Brinker has both selected and edited his col- Department of Orthopaedic Surgery
leagues well, using his highly developed educational The University of Texas Health Science
skills to the fullest. The chapters on biomechanics and Center at Houston
methodologies of deformity assessment and correction
xv
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Why another text, one might ask. With the plethora into three sections. Section I is an overview; Section II,
of information now readily available, another text, an- Adult Trauma, is subdivided into the lower extremity,
other comprehensive “tome,” especially on orthopae- the pelvis and acetabulum, the upper extremity, and
dic trauma, might be thought of as redundant. However, the spine. The final section deals with pediatric ortho-
Mark Brinker and his colleagues are to be congratulated. paedic trauma.
They have identified an area, or niche, of need (i.e., a re- This is clearly a very comprehensive review text of
view text). Their target audience is obviously not those orthopaedic trauma. The style is concise, easy to read,
practicing as orthopaedic traumatologists, who want an and user friendly. Dr. Mark Brinker and his colleagues
in-depth analysis of the problem. Rather it is the general are to be congratulated for collating a prodigious
orthopaedic surgeon and/or resident looking for a con- amount of information and succeeding in achieving
cise review of the topic in an almost note-taking style their goal, a real review text for orthopaedic trauma.
and bolding of the key issues. In addition, the authors My initial skepticism of another text has changed to
have provided ample diagrams, algorithms, and tables enthusiasm after reading some of the chapters and re-
to review classification systems, treatment plans, and alizing how this text differs. It is a very easy read, full
so forth. They also have provided the most significant of information, and well organized, and I can highly rec-
references but not just as a list. Rather, they divide the ommend Mark Brinker’s Review of Orthopaedic Trauma
bibliography into classic articles, recent articles, review for anyone, be it resident or general orthopaedic sur-
articles, and textbooks, making it much easier for the geon, but especially for those reviewing for OITE, ABOS
reader to ascertain where to obtain specific further Boards, or recertification examinations. In addition, this
information. text would be applicable for nonorthopaedic surgeons
Further, in their attempt to also make this a user- (i.e., those involved in the management of trauma). As
friendly text for those taking the OITE, ABOS Boards such, it would be a useful review text for emergency
(certifying) or even recertifying examinations, the room residents and/or physicians and nurses and also
authors have listed which specific examinations and as part of the general/trauma surgery curriculum for
which specific questions are related to issues in each surgery residents for a quick and easy reference on the
chapter. This is a useful tool for those in orthopaedic diagnosis and management of orthopaedic trauma.
surgery who are in the examination review process.
Obviously, Dr. Mark Brinker did not achieve this on
his own. He has elicited an array of experts who have David L. Helfet, MD
written the many chapters. However, the style and Director, Orthopaedic Trauma
theme remains consistent throughout, giving the book Hospital for Special Surgery
a specific feel and character. The text is broken up New York, New York
xvii
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Someone recently referred to me as “The King of You may ask what are the advantages of this book
Orthopaedic Review Books.” I accept this title with a over standard multivolume trauma texts. Very simply,

sense of amusement, humility, and pride. It is now my I believe it is more user-friendly, easier to use, and
honor and privilege to introduce Review of Orthopaedic more current than any other trauma text. Dr. Brinker
Trauma, which is sure to find a prominent position in organized this book to aid practicing orthopaedists,
the Saunders royal lineage, not to mention your book- residents, and fellows, and I believe he has met his goal
shelf. Dr. Mark Brinker has done an outstanding job of with regard to both audiences.
organizing, inviting the right authors, and editing this I know I will use it in my practice. In fact, I have al-
wonderful text. I have known Dr. Brinker as an asso- ready reserved a space for the book on my nightstand
ciate and friend for 6 years. He was elected recently for those late-night calls!
to the American Orthopaedic Association, one of its
youngest inductees ever, has amassed significant clini- Mark D. Miller, MD
cal experience in the management of complex frac- Associate Professor
tures, nonunions, and malunions; and is a well-known Department of Orthopaedics
orthopaedic educator. These ample talents are evident University of Virginia
throughout this book. Charlottesville, Virginia
xix
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Second dition

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There are more than 200 bones in the adult Homosa- While the future of our specialty is undoubtedly
pien skeleton; although extraordinarily well designed bright, the world is changing at an ever-increasing
and constructed, each one is subject to cracking, splin- rate. The introduction of the 80-hour work week for
tering, and pulverization secondary to human mishap, residents-in-training mandates the creation of more ef-
aggression, and stupidity. We live in a world that is con- ficient educational tools. When I look on my bookshelf,
stantly moving faster, playing harder, and competing I see multi-volume orthopedic trauma texts with pages
more fervently. It would, therefore, seem that so long numbering 3,000 or more. While these scholarly works
as there are bones, there will likely be a need for those are rich in clinical material, they are now simply too
skilled in the art of mending them. large to function as a first source for learning. Should
In the style of the first edition, this, the second edi- we then simply throw these away? Of course not. But in
tion of Review of Orthopaedic Trauma is organized in a addition to these reference texts, our specialty needs
pleasant outline format, empowering readers to rapidly comprehensive source material with high-impact edu-
access and absorb critical information essential to their cational value that facilitates rapid assimilation of
studies and practice. Whether it is background epide- core knowledge by the reader. This is the mission of
miologic statistics, diagnostic techniques, treatment Review of Orthopaedic Trauma—to function as the first
options, or complications, the welcoming organization source for learning for medical students, residents, fel-
of the book allows facts and concepts to be quickly ac- lows, and practicing physicians interested in further-
cessed and digested. The second edition significantly ing their knowledge in the discipline of orthopedic
benefits from totally new and broadly updated chap- traumatology.
ters; the reconceived artwork heightens the educational
impact, with over 200 all-new color illustrations crafted
specifically for this textbook. Mark R. Brinker, MD
xxi
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Although orthopaedic surgery as a field continues to preparations for Orthopaedic In-Training Examinations
evolve into areas of subspecialty, musculoskeletal and the American Board of Orthopaedic Surgery board
trauma remains an important focus for clinical practice certification examination.
and postgraduate education. Orthopaedic trauma is
a vast subject matter and is somewhat unique in that
it includes most of the body. Although several quality ACKNOWLEDGMENTS
textbooks covering musculoskeletal trauma are avail- I gratefully acknowledge the generous contributions of
able, none exists that reviews the essential knowledge the chapter authors, each a gifted writer and educa-
of musculoskeletal trauma. tor. I am indebted to the staff of the Joe W. King Or-
Review of Orthopaedic Trauma is a distillation of thopedic Institute of Texas Orthopedic Hospital (Lou
the core knowledge of musculoskeletal trauma. The Fincher, Rodney Baker, and Dan [the man] O’Connor)
contributors to the text are recognized experts in their for their assistance in the preparation of the text
field and were selected based on their unique talents and figures. I would also like to acknowledge Michael
and skills as writers and educators. The text includes Cooley, a talented artist and illustrator, for the original
material gathered from Orthopaedic In-Training Ex- artwork that appears in the textbook. Special thanks to
aminations and Self-Assessment Examinations; each Michele Clowers for her dedication and perseverance
contributor reviewed 5 years’ worth of topic-specific during my perfectionist moments. The author appreci-
examination questions during the preparation of his or ates all of the individuals at Harcourt Health Sciences
her chapter. In addition, a variety of textbooks, journal who worked so hard to bring the project to completion.
articles, and board review course syllabi were reviewed I am particularly grateful to my Senior Medical Editor,

during the preparation of the textbook. Richard Lampert; my Project Specialist, Pat Joiner;
The final product is a comprehensive textbook my Project Manager, Carol Sullivan Weis; my Designer,
covering the important clinical and testable material Mark Oberkrom; and my Senior Editorial Assistant, Beth

in orthopaedic trauma. I hope that this textbook will LoGiudice. Finally, I would like to acknowledge Dr. Mark

aid practicing orthopaedic surgeons in the care of their Miller, who is a contributor to this textbook and is the
patients and in successfully passing the board recerti- originator of W.B. Saunders “Review of” series.
fication examination. Furthermore, it is my hope that
this textbooks will aid residents and fellows in their Mark R. Brinker, MD
xxiii
G S
ACKNOWLED
MENT
No project of this magnitude is possible without a ded- Ben Rivera, Manufacturing Manager. I am also most
icated team. The quality of this textbook begins and grateful to Paul Schiffmacher, who has produced more
ends with the physician contributors whose tireless than 200 original works of art for the second edition.
work on each chapter has resulted in a work of tremen- Paul’s images are not only beautiful, but they are rich
dous breadth and depth. To all contributors, I extend in educational content. And finally, there is the hero
my most sincere appreciation for their willingness to of this tale, Eileen “Wolfie” Wolfberg. Eileen stepped in
share their experience and expertise with the reader. as a freelance Developmental Editor when the process
I would also like to thank my staff Nicole Wunderlich, needed supercharging and did a magnificent job func-
MS, PA-C; Amy Shives, R.N.; and Glenda Adams for all tioning as a liaison/editor working with the contribu-
of their assistance throughout the process. I am also tors, publisher, illustrator, and yours truly. Without
extremely appreciative to the staff at my publisher, Lip- Wolfie’s energy, unwavering commitment to excellence,
pincott Williams & Wilkins, for all of their hard work and expertise, the quality (and perhaps existence) of
and attention to detail. I’d like to specifically thank this book might have been in question. Finally, I thank
Robert A. Hurley, Executive Editor; Brian Brown, Ex- my family, friends, and partners at Fondren Orthope-
ecutive Editor; David Murphy, Senior Product Manager; dic Group LLP for their continuous support. It takes a
David Orzechowski, Production Project Manager; Holly village!
McLaughlin, Design Manager; Lisa Lawrence, Marketing
Manager; Joel Jones Alexander, Project Manager; and Mark R. Brinker, MD
xxv
SECTION I
Overview
CHAPTER 1
General Principles of Trauma

Joseph R. Hsu
I. Advanced Trauma Life Support—Initial assessment pupillary size and reactivity, lateralizing signs,
of an arriving trauma patient has several stages: and spinal cord injury level (if present).
Primary Survey, Resuscitation, Adjuncts to Primary • Glasgow Coma Scale (GCS)—The GCS is a
Survey, Secondary Survey, Adjuncts to Secondary rapid method of determining the level of con-
Survey, Reevaluation, and Definitive Care. sciousness of a trauma patient and has prog-
A. Primary Survey—The ABCDEs of trauma care are nostic value (Table 1-1). The GCS categorizes
a way to systematically assess a patient’s vital the neurologic status of a trauma patient by
functions in a prioritized manner. Life-threatening assessing eye opening response, motor re-
conditions should be identified and managed sponse, and verbal response.
simultaneously. • Possible causes of decreased level of con-
1. Airway maintenance with cervical spine sciousness include hypoperfusion, direct
precautions—Airway compromise in a trauma
patient can be an imminently life-threatening
condition. It must be evaluated and managed as TA B L E 1 - 1
the first priority. A provider must assume that
there is a cervical spine injury in order to Glasgow Coma Scale
protect the spinal cord until a more detailed Assessment Area Score
assessment can be performed. This is espe- Eye Opening (E)
cially a concern in patients with an altered Spontaneous 4
level of consciousness and any blunt injury To speech 3
proximal to the clavicles. To pain 2
2. Breathing and ventilation—Adequate ventila- None 1
tion can be negatively impacted by conditions BEST Motor Response (M)
such as tension pneumothorax, flail chest with Obeys commands 6
pulmonary contusion, massive hemothorax, and Localizes pain 5
open pneumothorax. These disorders should be Normal flexion (withdrawal) 4
identified and managed during this stage. Abnormal flexion (decorticate) 3
3. Circulation with hemorrhage control— Extension (decerebrate) 2
Hemorrhage is the leading cause of prevent- None (flaccid) 1
able death after trauma. Hypotension in the Verbal Response (V)
setting of trauma must be considered hypo- Oriented 5
volemia until proven otherwise. Clinical signs Confused conversation 4
of hypovolemia include decreased level of con- Inappropriate words 3
sciousness, pale skin, and rapid, thready pulses. Incomprehensible sounds 2
External hemorrhage should be identified and None 1
directly controlled during this stage.
Adapted from American College of Surgeons. Advanced Trauma
4. Disability: Neurologic status—Rapid evalua- Life Support For Doctors: Student Course Manual. 7th ed. Chicago,
tion of potential neurologic injury should be IL: American College of Surgeons, 2004, with permission.
performed to include level of consciousness,
2
C H A P T E R 1 | G E N E R A L P R I N C I P L E S O F T R A U M A 3
cerebral injury, hypoglycemia, and alcohol/ historical information from the patient, fam-
drugs. Immediate reevaluation and correc- ily, and/or prehospital personnel.
tion of oxygenation, ventilation, and perfu- (a) Allergies
sion should be performed. Afterward, direct (b) Medications currently used
cerebral injury should be assumed until (c) Past illnesses/Pregnancy
proven otherwise. (d) Last meal
5. Exposure/environmental control: completely (e) Events/Environment related to the injury
undress the patient, but prevent hypothermia— 2. Physical examination—The head-to-toe exami-
All garments must be removed from the trauma nation should occur at this point. The clinician
patient to ensure thorough evaluation. Once must be sure to inspect the following body
the evaluation is performed, prevention of hy- regions:
pothermia is critical. Blankets, external warm- • Head
ing devices, a warm environment, and warmed • Maxillofacial
intravenous fluids should be used to prevent • Cervical spine and neck
hypothermia. • Chest
B. Resuscitation—In addition to airway and breath- • Abdomen
ing priorities, circulatory resuscitation begins with • Perineum/rectum/vagina
control of hemorrhage. Initial fluid resuscitation • Musculoskeletal
should consist of 2 to 3 L of Ringer’s lactate so- • Neurologic
lution. All intravenous fluids should be warmed E. Adjuncts to the Secondary Survey—At this point,
prior to or during infusion. If the patient is unre- specialized diagnostic tests can be performed.
sponsive to the fluid bolus, type-specific blood These tests may include radiographs of the ex-
should be administered. O-negative blood may be tremities, CT scans of the head, chest, and abdo-
used if type-specific blood is not immediately avail- men. In addition, diagnostic procedures such as
able. Insufficient fluid resuscitation may result in bronchoscopy, esophagoscopy, and angiography
residual hypotension in a trauma patient, such as can be performed if the patient’s hemodynamic
a patient with a pelvic fracture and multiple long status permits.
bone fractures. F. Reevaluation—Reevaluation is a continuous pro-
1. Elevation of the serum lactate level cess during the evaluation and management of a
(2.5 mmol/L) is indicative of residual hy- trauma patient. Injuries may evolve in a life-threat-
poperfusion. Proceeding to definitive fixation ening manner, and nonapparent injuries may be
of orthopaedic injuries in such a patient with discovered.
occult hypoperfusion may result in significant G. Definitive Care—Definitive care for each injury
perioperative morbidity such as adult respira- occurs depending on the priority of the injury and
tory distress syndrome. the physiology of the patient. This requires coordi-
C. Adjuncts to Primary Survey nated multidisciplinary care.
1. ECG
2. Urinary and gastric catheters II. Shock—Shock is an abnormality of the circulatory
3. Monitoring system that results in inadequate organ perfusion
• Ventilatory rate; arterial blood gas (ABG) and tissue oxygenation. Manifestations of shock in-
• Pulse oximetry clude tachycardia and narrow pulse pressure.
• Blood pressure A. Hemorrhagic Shock—Hemorrhage is the acute
4. X-rays and diagnostic studies loss of circulating blood volume. An element of
• CXR hypovolemia is present in nearly all polytrauma-
• AP Pelvis tized patients. Hemorrhage is the most common
• Lateral C-spine—This is a screening exam. It cause of shock.
does not exclude a cervical spine injury. 1. Classes of hemorrhage
D. Secondary Survey—The Secondary Survey is a • Class I hemorrhage is characterized by no
head-to-toe examination that begins once the measurable change in physiologic param-
Primary Survey is complete and resuscitative ef- eters (heart rate, blood pressure, urine
forts have demonstrated a stabilization of vital output, etc.) with blood loss less than 15%
functions. (750 mL).
1. History • Class II hemorrhage is characterized by
• AMPLE—AMPLE is an acronym of the fol- mild tachycardia (100 bpm), a moderate
lowing categories that assist in collecting decrease in blood pressure and low normal
4 S E C T I O N I | O V E R V I E W
urine output (20 to 30 mL per hour). It repre- possible. The resultant clinical scenario, called
sents a 15% to 30% blood loss (750 to 1,500 neurogenic shock, is one of hypotension and
mL). bradycardia. Assessment of the hemody-
• Class III hemorrhage is characterized by namic status may be aided by a Swan-Ganz
moderate tachycardia (120 bpm), a de- catheter.
crease in blood pressure, and a decrease 2. Cardiogenic—Cardiogenic shock is myocardial
in urine output (5 to 15 mL per hour). The dysfunction that can result from blunt injury,
patient is typically confused. It represents a tamponade, air embolism, or cardiac ischemia.
30% to 40% blood loss (1,500 to 2,000 mL). Adjuncts such as ECG, ultrasound, and CVP
• Class IV hemorrhage is characterized by a monitoring may be useful in this setting.
severe tachycardia (140 bpm), decreased 3. Tension pneumothorax—Tension pneumotho-
blood pressure, and negligible urine output. rax is the result of increasing pressure within
The patient is lethargic. It represents blood the pleural space from a pneumothorax with
loss of over 40% (2,000 mL). a flap-valve phenomenon. As air enters the
2. Blood loss due to major fractures—Major frac- pleural space without the ability to escape, it
tures may result in blood loss into the site of causes a mediastinal shift with impairment
the injury to such an extent that it may compro- of venous return and cardiac output. The clini-
mise the hemodynamic status of the patient. cal scenario involves decreased/absent breath
• Tibia/humerus—As much as 750 mL (1.5 sounds, subcutaneous emphysema, and tra-
units) blood loss cheal deviation. Emergent decompression is
• Femur—As much as 1,500 mL (3 units) blood warranted without the need for a diagnos-
loss tic X-ray.
• Pelvic fracture—Several liters of blood may 4. Septic shock—Septic shock may occur as the
accumulate in the retroperitoneal space in as- result of an infection. In trauma, this would be
sociation with a pelvic fracture. The greatest more likely in a patient presenting late with
average transfusion requirement occurs penetrating abdominal injuries.
with anteroposterior compression pelvic
fractures. III. Associated Injuries
B. Nonhemorrhagic Shock A. Head Injury—One of the guiding principles in
1. Neurogenic—Neurogenic shock can occur managing a patient with a traumatic brain injury
as a result of loss of sympathetic tone to the (TBI) is to prevent secondary brain injury from
heart and peripheral vascular system in cases conditions such as hypoxemia and hypovolemia.
of cervical spinal cord injury. Loss of sympa- Patients with head injury are at increased risk of
thetic tone to the extremities results in vaso- developing heterotopic ossification (HO).
dilation, poor venous return, and hypotension. 1. Glasgow Coma Scale (GCS)—The GCS
Because of unopposed vagal tone on the heart, (Table 1-1) is employed to stratify injury sever-
tachycardia in response to hypotension is not ity in patients with head injuries (TBI).
TA B L E 1 - 2
Recommendations for Return to Play after Concussion
Grade First Concussion Second Concussion Third Concussion
1 RTP if asymptomatic RTP after 2 wk if asymptomatic Terminate season. RTP next
for 1 wk for 1 wk season if asymptomatic
2 RTP if asymptomatic No RTP for 1 mo. May RTP after that Terminate season. RTP next
for 1 wk if asymptomatic for 1 wk. Consider season if asymptomatic
termination of the season
3 No RTP for 1 mo. May RTP Terminate season. RTP next season
after that if asymptomatic if asymptomatic
for 1 wk. Consider termi-
nation of the season
RTP, return to play; “asymptomatic,” no postconcussion syndrome (including retrograde or anterograde amnesia at rest or with
exertion.
Adapted from Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and
safe return to play. J Athl Train. 2001;36(3):244–248, with permission.
• Mild brain injury (GCS, 14 to 15)—Patients

with a mild brain injury often have a brief
loss of consciousness (LOC) and may have
amnesia of the event. Most have an unevent-
ful recovery, but approximately 3% will de-
teriorate unexpectedly. A CT of the head
should be considered if the individual has
lost consciousness for more than 5 minutes,
has amnesia, severe headaches, GCS of less
than 15, and/or a focal neurologic deficit.
(a) Concussion—The term “concussion” is
often used to describe a mild TBI.
(b) Sports-related concussion—Return to ath-
letic play after a concussion is guided by
recommendations based on grading the
concussion and the number of concus-
sions that the individual has sustained
(Table 1-2).
• Grade 1 (mild): No LOC. Amnesia or
symptoms for less than 30 minutes
• Grade 2 (moderate): LOC for less than
1 minute. Amnesia or symptoms for
30 minutes to 24 hours.
• Grade 3 (severe): LOC for more than
1 minute; amnesia for more than 24
hours; postconcussion symptoms for
more than 7 days.
• Moderate brain injury (GCS, 9 to 13)—All
of these patients require a CT of the head,
baseline blood work, and admission to a fa-
cility with neurosurgical capability.
• Severe brain injury (GCS, 3 to 8)—Patients
with severe TBI require a multidisciplinary
approach to ensure adequate management
and resuscitation of other life-threatening
injuries and urgent neurosurgical care.
2. Anatomical types of brain injury (Figure 1-1)
• Diffuse brain injury—Diffuse brain injury
can be a wide spectrum from mild TBI to a
profound ischemic insult to the brain.
• Epidural hematoma—Epidural hematomas
are located between the dura and the skull.
They usually result from a tear of the mid-
dle meningeal artery secondary to a skull
fracture.
• Subdural hematoma—Subdural hematomas FIGURE 1-1 Computed tomography scans showing
are located beneath the dura as a result of (top) epidural hematoma, (center) subdural hematoma
injury to small surface vessels on the brain. (right arrow; this patient also has an intraparenchymal
They frequently result in a greater brain in- contusion at the curved arrow and a subarachnoid
jury compared with epidural hematomas. hemorrhage at the center arrow), and (bottom)
intracerebral hemorrhage. (From Pascual JL, Gracias VH,
• Contusion and intracerebral hematoma—
LeRoux PD. Injury to the brain. In: Flint L, Meredith JW,
Contusion or hematoma within the brain Schwab CW, et al., eds. Trauma: Contemporary Principles
can occur at any location, but they most and Therapy. Philadelphia, PA: Lippincott Williams &
frequently occur in the frontal or temporal Wilkins, 2008, with permission.)
lobes. Contusions can evolve into intrace- simultaneous restoration of blood volume
rebral hematomas over time, which require and drainage of the chest are indicated. Tho-
emergent surgical evacuation. racotomy may be required in cases of ongo-
3. Management of head injuries ing blood loss.
• Primary Survey—Includes an evaluation of 5. Cardiac tamponade—Cardiac tamponade is
airway, breathing, and circulation. due to fluid accumulation within the peri-
• Neurologic examination. cardial sac. Diagnosis has been described by
• Diagnostic procedures—Cervical spine ra- Beck’s triad: elevated venous pressure (dis-
diograph series, computed tomography tended neck veins), decreased arterial pres-
(CT) scan for intracranial conditions. sure, and muffled heart sounds. A focused
• Intravenous fluids—Maintenance of normo- assessment sonogram in trauma (FAST) or
volemia is important following head injury. pericardiocentesis may be necessary to es-
Hypotonic fluids and glucose are no longer tablish the diagnosis. The pericardiocentesis
recommended, and hyponatremia can be a may be diagnostic and therapeutic.
concern. 6. Simple pneumothorax—Simple pneumotho-
• Hyperventilation—Hyperventilation may be rax may be associated with thoracic spine
used in select patients under close moni- fractures and scapular fractures. Decreased
toring to decrease intracranial pressure by breath sounds and hyperresonance upon
decreasing the partial pressure of carbon percussion are present, and an upright expi-
dioxide and increasing vasoconstriction. ratory chest radiograph may aid diagnosis.
• Medications—A variety of adjunctive medi- Treatment is with placement of a chest tube.
cations may be used, but should be adminis- 7. Pulmonary contusion—Pulmonary contusion
tered under consultation with a neurologist. can lead to respiratory failure. Treatment in-
B. Thoracic Trauma cludes intubation and assisted ventilation if
1. Tension pneumothorax—See description un- the patient is hypoxemic.
der nonhemorrhagic shock 8. Blunt cardiac injury—Blunt injury to the
2. Open pneumothorax—Open pneumothorax heart can result in cardiac arrest (“commo-
is also called a “sucking chest wound.” It oc- tio cordis”), cardiac contusion, valvular dis-
curs when there is a large chest wall defect. ruption, or rupture of a cardiac chamber.
This external opening to the environment 9. Aortic disruption—Aortic disruption usually
precludes the chest wall’s ability to gener- occurs after a high-speed deceleration in-
ate the negative pressure within the pleural jury. Radiographic signs include a widened
space required to inflate the lung. Treatment mediastinum, obliteration of the aortic knob,
is to close the defect with an occlusive dress- deviation of the trachea to the right, oblit-
ing that is taped on three sides. This creates a eration of the space between the pulmonary
valve that allows air to escape but not to enter artery and aorta, depression of the left main
the defect in the chest wall. stem bronchus, deviation of the esophagus
3. Flail chest—Flail chest is a severe impairment to the right, widened paratracheal stripe,
of chest wall movement as a result of two or widened paraspinal interfaces, presence of a
more rib fractures in two or more places, pleural or apical cap, hemothorax on the left
so that the segment has paradoxical move- side, and fractures of the first or second rib
ment during respiration. The underlying or scapula.
pulmonary contusion is the true challenge 10. Diaphragmatic injuries—Diaphragmatic inju-
in this clinical scenario. The pulmonary ries commonly occur on the left side and can
contusion may cause severe impairment of be seen on chest radiographs.
oxygenation. Management involves ensuring C. Abdominal Trauma—Abdominal trauma can
adequate ventilation and appropriate fluid occur with varying degrees of frequency depend-
management to prevent fluid overload of the ing on whether the mechanism of injury was pen-
injured lung. Mechanical ventilation may be etrating or blunt. Blunt injury to the abdomen
necessary. may result in damage to the viscera by a crush
4. Massive hemothorax—Massive hemotho- or compression mechanism; the spleen is the
rax occurs when large amounts of blood most commonly injured organ, followed by the
(1,500 mL) accumulate within the pleu- liver. Penetrating injuries such as stab wounds
ral space. This results in lung compres- and gunshot wounds impart direct trauma to the
sion and impairment of ventilation. Urgent, viscera by laceration or perforation.
1. Blunt abdominal injuries (b) Ultrasound

• Diaphragm—Diaphragmatic rupture may be (c) CT scan
detected on the chest X-ray by elevation or D. Gastrointestinal—Range from ileus (treat with
blurring of the hemidiaphragm, an abnor- nasogastric tube and antacids) to upper GI
mal gas shadow, or nasogastric tube travel- bleeding. Postoperative ileus is more common
ing into the chest. in diabetics with neuropathy. Upper GI bleed-
• Duodenum—Duodenal rupture may occur ing is more common in patients with a history
from a direct blow to the abdomen. Retro- of ulcers, use of NSAIDs, trauma, and smoking.
peritoneal air on CT may signal this injury. Treatment of GI bleeding includes lavage, antac-
• Pancreas—A pancreatic injury should be ids, and H2-blockers. Vasopression (left gastric
suspected if a patient has a persistently el- artery) may be required for more serious cases.
evated serum amylase level. E. Genitourinary
• Genitourinary (GU)—A GU injury should 1. Urinary tract infections (UTI)—The most com-
be suspected with any hematuria. Associ- mon nosocomial infection, established UTIs
ated injuries and the mechanism of injury should be treated before surgery. Perioperative
may help in localization of the injury. Renal catheter removed 24 hours after surgery may
injuries tend to be associated with direct reduce the rate of postoperative UTI; prolonged
trauma to the flanks, while lower GU injuries catheterization increases incidence of UTI.
such as urethral and bladder injuries are as- UTI can increase risk of postoperative wound
sociated with anterior pelvic ring fractures. infection.
• Small bowel—Small bowel injury should be 2. Genitourinary injury—A retrograde urethro-
suspected in a patient with a “seat belt sign” gram best evaluates lower genitourinary inju-
across the abdomen or a flexion-distraction ries in patients with displaced anterior pelvic
fracture or dislocation of the lumbar spine. fractures. The differential diagnoses after a
• Solid organ—Traumatic lacerations to the direct blow to the scrotum are contusion, tes-
liver, spleen, or kidney can be life threaten- ticular rupture, epididymal rupture, and testic-
ing due to hemorrhage. Lesser injuries in ular torsion. Emergent urologic evaluation and
stable patients may be observed. Urgent consultation are required.
celiotomy is necessary in patients with a 3. Prostatic hypertrophy—Causes urinary re-
solid organ injury and evidence of ongoing tention; if the history, physical examination
hemorrhage. (prostate), and urine flow studies (17 mL per
2. Penetrating abdominal injuries—Emergent second peak flow rate) are suggestive, urologic
celiotomy is indicated in any patient with consultation should be obtained.
a penetrating abdominal injury with as- 4. Acute tubular necrosis—Can cause renal fail-
sociated hypotension, peritonitis, and/or ure in trauma patients. Alkalinization of the
evisceration. urine is important during the early treatment
3. Assessment of this disorder.
• History—Determining the type of accident F. Skin and Soft Tissue Injuries
is important. In automobile accidents, deter- 1. Thermal injuries
mine whether seat belts or other restraints • Burns
were being used. In a penetrating injury, iden- (a) Assessment—Ruling out inhalation in-
tifying the type of weapon used can be useful. jury is imperative; signs of inhalation in-
• Signs—Involuntary muscle guarding, re- jury include facial burns, singeing of face
bound tenderness, and free air under the and hair, carbon in the pharynx, and car-
diaphragm on chest radiograph suggest ab- bon in the sputum. Removing all clothing
dominal injury. to stop the burning process is important.
• Tests (b) Definitions
(a) Diagnostic peritoneal lavage (DPL)—DPL • First-degree burn—Involves the epi-
is deemed positive if there are at least dermis
100,000 red blood cells per cubic millili- • Second-degree burn—Involves the
ter, at least 500 white blood cells per cu- dermis
bic milliliter, or a positive Gram’s stain. • Third-degree burn—Involves the sub-
Pelvic fractures can lead to false positive cutaneous tissues
DPL, so DPL should be performed from a • Fourth-degree burn—Involves the
supraumbilical portal in these patients. deep tissues
FIGURE 1-2 “Rule of nines” for (A) infant,
(B) adult, and (C) child. (From Blinman TA,
Nance ML. Special considerations in trauma in
children. In: Flint L, Meredith JW, Schwab CW,
et al., eds. Trauma: Contemporary Principles and
Therapy. Philadelphia, PA: Lippincott Williams
& Wilkins; 2008, with permission.)
A B C
c
(c) Calculation of burned body area—In-

volves the “rule of nines” (Fig. 1-2). This TA B L E 1 - 3
calculation is important for assessing
Abbreviated Injury Scale
fluid-replacement requirements.
AIS Injury Description
(d) Fluid replacement—A total of 2 to 4 mL
1 Minor
of lactated Ringer’s solution per kg of
2 Moderate
body weight per percent of burned body
area is administered in the first 24 hours 3 Serious
for second- and third-degree burns. Half 4 Severe
is given in the first 8 hours, and the re- 5 Critical
mainder is given over the next 16 hours. 6 Unsurvivable
• Cold injuries Adapted from Baker SP, O’Neill B, Haddon W Jr, et al. The
(a) General—Injured tissues should be rap- injury severity score: a method for describing patients with
multiple injuries and evaluating emergency care. J Trauma.
idly warmed in a water bath at 40° C 1974;14(3):187–196, with permission.
(104° F). Local wound care and tetanus
immunization should be administered.
Cold injuries are the most common 2. Injection injuries—Typically result from ac-
cause of bilateral upper and lower ex- cidental high-pressure injection by paint or
tremity amputations. grease guns. These injuries may appear rela-
(b) Frostbite—Results from tissue freezing tively benign but are surgical emergencies
caused by intracellular formation of because these substances rapidly destroy soft
ice crystals and the occlusion of the tissues.
microcirculation. Treatment is via rapid 3. Wound healing—Adequate soft-tissue heal-
warming in a 40° C water bath. ing after injury or surgery is promoted by a
• Electrical injuries transcutaneous oxygen tension level higher
(a) Ignition—Involves a burn at the site of than 30 mm Hg, an ischemic index (such as
direct contact. the ankle/brachial systolic index) of at least
(b) Conductant—Involves injury propaga- 0.45, an albumin level of at least 0.30 g/dL,
tion along neurovascular structures. and a total lymphocyte count higher than
(c) Arc—Involves high-voltage currents 1,500 cells/mm3. These values may be im-
propagating along flexor surfaces of proved by nutritional support, including oral
joints and leads to contractures. hyperalimentation. Oxygenated blood is a
• Chemical burns—Severity of chemical burns prerequisite for wound healing. The ischemic
depends on the amount and concentration index is the ratio of the Doppler pressure at
of the agent, duration of contact, tissue pen- the level being tested to the brachial systolic
etrability of the agent, and the agent’s mech- pressure; an index of 0.45 at the surgical level
anism of action. The most important aspect is generally accepted as the level to support
of treatment is copious irrigation. wound healing. Values may be falsely elevated
and thereby misleading in patients with periph- aminoglycoside; penicillin is added for grossly
eral vascular disease due to noncompressibil- contaminated (type IIIB) open fractures.
ity and noncompliance of calcified arteries. C. Overall, Staphylococcus aureus remains the lead-
G. Pelvic Ring Injuries—Hypotensive patients with ing cause of osteomyelitis and nongonococcal
evidence of a pelvic ring injury should have septic arthritis. In general, the virulence of S. epi-
urgent placement of a pelvic binder or cir- dermidis infections is closely related to orthopae-
cumferential sheet. dic hardware. Clindamycin achieves the highest
H. Injury Severity Score (ISS)—Injury Severity Score antibiotic concentrations in bone (nearly
is a score utilized to stratify the severity of injury equals serum concentrations after intravenous
sustained by a polytrauma patient. In order to cal- administration) and is bacteriostatic. To pre-
culate the ISS, an Abbreviated Injury Score (AIS) vent the development of vancomycin-resistant
must be assigned for each of the six body regions strains, vancomycin should not be used in pa-
injured (head and neck, face, chest, abdomen, ex- tients with a blood culture of coagulase-negative
tremity, external). The AIS is scored from least se- S. aureus that is not methicillin resistant.
vere to unsurvivable (Table 1-3). The highest AIS D. Antibiotic-Resistant Bacteria—Two types of anti-
in each body region is used. The AIS scores from biotic resistance exist.
the three most severely injured body regions are 1. Intrinsic resistance—Inherent features of a cell
squared and then summed together. This creates that prevent antibiotics from acting on the cell
a score between 0 and 75. If any injury has an AIS (such as the absence of a metabolic pathway or
score of 6 (unsurvivable), the ISS is automatically enzyme). MRSA has a gene (mecA) that pro-
75. Recent studies have demonstrated greater duces penicillin-binding protein 2a (PBP2a),
predictive value for the New Injury Severity Score an enzyme that prevents the normal enzy-
(NISS) when compared with the ISS for outcomes matic acylation of antibiotics.
such as sepsis, multiple organ failure, ICU days, 2. Acquired resistance—A newly resistant strain
and mortality. emerges from a population that was previously
sensitive (acquired resistance is mediated
IV. Other Trauma-Related Topics by plasmids [extrachromosomal genetic ele-
A. Nutrition—Several indicators exist (e.g., anergy ments] and transposons).
panels, albumin level, transferrin level); mea- 3. Antibiotic indications and side effects
surement of arm muscle circumference is the (Table 1-4)
best indicator of nutritional status. Wound 4. Mechanism of action of antibiotics (Table 1-5)
dehiscence and infection, pneumonia, and sepsis 5. Alternate forms of antibiotic delivery
can result from poor nutrition. Lack of enteral • Antibiotic beads or spacers—polymethyl
feeding can lead to atrophy of the intestinal methacrylate (PMMA) impregnated with an-
mucosae, leading in turn to bacterial trans- tibiotics (usually an aminoglycoside) can be
location. Full enteral or parenteral nutrition (ni- useful when treating osteomyelitis with bony
trogen 200 mg/kg per day) should be provided defects. Antibiotic powder is mixed with ce-
for patients who cannot tolerate normal intake. ment powder; the microorganism guides the
Early elemental feeding through a jejunostomy antibiotic used, and the selected antibiotic
tube can decrease complications in the multiple- and type of PMMA guide the dosage. Tobra-
trauma patient. Enteral protein supplements mycin, gentamicin, cefazolin (Ancef) and
have proved effective in patients at risk of de- other cephalosporins, oxacillin, cloxacillin,
veloping multiple organ system failure. methicillin, lincomycin, clindamycin, colistin,
B. Antibiotics—Antibiotics in orthopaedics may fucidin, neomycin, kanamycin, and ampicil-
be used in prophylactic treatment to prevent lin have been used with PMMA for infection.
postoperative sepsis (for clean surgical cases, Chloramphenicol and tetracycline appear to
administer 1 hour preoperatively and continue be inactivated during polymerization. Anti-
for 24 hours postoperatively), initial care after biotics elute from PMMA beads, with an ex-
an open traumatic wound, and treatment of es- ponential decline over a 2-week period, and
tablished infections. Types I and II open fractures cease to be present locally at significant lev-
require a first-generation cephalosporin (some els by 6 to 8 weeks. Much higher local tissue
authors have recently suggested the addition of concentrations of antibiotic can be achieved
an aminoglycoside or the use of a second-gen- than those obtained by systemic administra-
eration cephalosporin); type IIIA open fractures tion. Increased surface area of PMMA (e.g.,
require a first-generation cephalosporin plus an with oval beads) enhances antibiotic elution.
TA B L E 1 - 4
Antibiotic Indications and Side Effects
Antibiotics Organisms Complications/Other
Aminoglycosides G–, PM Auditory (most common) and vestibu-
lar toxicity is caused by destruction
of the cochlear and vestibular sen-
sory cells from drug accumulation in
the perilymph and endolymph; renal
toxicity; neuromuscular blockade
Amphotericin Fungi Nephrotoxic
Aztreonam G, no anaerobes
Carbenicillin/ticarcillin/piperacillin Better against G Bleeding diathesis (carbenicillin)
Cephalosporins
First generation Prophylaxis (surgical) Cephazolin is the drug of choice
Second generation Some G/G
Third generation G, fewer G Hemolytic anemia (bleeding diathesis
[moxalactam])
Chloramphenicol Haemophilus influenzae, Bone marrow aplasia
anaerobes
Ciprofloxacin G, methicillin-resistant Tendon ruptures; cartilage erosion in
S. aureus children; antacids reduce absorp-
tion of ciprofloxacin; theophylline
increases serum concentrations of
ciprofloxacin
Clindamycin G, anaerobes Pseudomembranous enterocolitis
Erythromycin G (PCN allergy) Ototoxic
Imipenem G, some G Resistance, seizure
Methicillin/oxacillin/nafcillin Penicillinase resistant Same as penicillin; nephritis (methi-
cillin); subcutaneous skin slough
(nafcillin)
Penicillin Strep, G Hypersensitivity/resistance; hemolytic
Polymyxin/nystatin GU Nephrotoxic
Sulfonamides GU Hemolytic anemia
Tetracycline G (PCN allergy) Stains teeth/bone (up to age 8)
Vancomycin Methicillin-resistant Ototoxic; erythema with rapid IV
S. aureus, C. difficile delivery
G, gram positive; G, gram negative; GU, genitourinary; IV, intravenous; PM, polymicrobial; PCN, penicillin; Strep,
streptococcus.
Beads are inserted only after thorough de- antibiotics, facilitated by a Hickman or Bro-
bridement, and the beads should always be viac indwelling catheter.
eventually removed. Antibiotic powder in • Immersion solution—Contaminated bone
doses of 2 g/40 g of powdered PMMA (simplex from an open fracture may be sterilized (100%
P) does not appreciably affect the compres- effective) by immersion in a chlorhexidine
sive strength of PMMA, but higher concentra- gluconate scrub and an antibiotic solution.
tions (4 to 5 g antibiotic powder/40 g PMMA) E. Transfusion
significantly reduce the compressive strength. 1. Transfusion reactions
• Osmotic pump—Delivers high concentra- • Allergic reaction—Most common; occurs
tions of antibiotics locally. Used mainly for toward the end of transfusion and usually
osteomyelitis. subsides spontaneously. Symptoms include
• Home intravenous therapy—Cost-effec- chills, pruritus, erythema, and urticaria. Pre-
tive alternative for long-term intravenous treatment with diphenhydramine (Benadryl)
TA B L E 1 - 5
Mechanism of Action of Antibiotics
Class of Antibiotics Examples Mechanism of Action
β-lactam antibiotics Penicillin Inhibit bacterial peptidoglycan synthesis (the
Cephalosporins mechanism is via binding to the penicillin-
binding proteins on the surface of the bacterial
cell membrane)
Aminoglycosides Gentamicin Inhibit protein synthesis (the mechanism is via bind-
Tobramycin ing to cytoplasmic ribosomal RNA)
Clindamycin and macrolides Clindamycin Inhibit the dissociation of peptidyl-transfer RNA from
Erythromycin ribosomes during translocation (the mechanism
Clarithromycin is via binding to 50S ribosomal subunits)
Azithromycin
Tetracyclines Inhibit protein synthesis (on 70S and 80S ribosomes)
Glycopeptides Vancomycin Interfere with the insertion of glycan subunits into
Teicoplanin the cell wall
Rifampin Inhibits RNA synthesis in bacteria
Quinolones Ciprofloxacin Inhibit DNA gyrase
Levofloxacin
Ofloxacin
Oxazolidinones Linezolid Inhibit protein synthesis (blocks formation of the 70S
ribosomal translation complex)
and hydrocortisone may be appropriate in tetani. Prophylaxis requires classifying the patient’s
patients with a history of allergic reactions. wound (tetanus-prone or nontetanus-prone) and
• Febrile reaction—Also common; occurs after a complete immunization history. Tetanus-prone
the initial 100 to 300 mL of packed RBCs have wounds are more than 6 hours old; are irregularly
been transfused. Chills and fever are caused configured; are deeper than 1 cm or the result of
by antibodies to foreign WBCs. Treatment a projectile injury, crush injury, burn, or frostbite;
consists of stopping the transfusion and giv- have devitalized tissue; and are grossly contami-
ing antipyretics, as for an allergic reaction. nated. Patients with tetanus-prone wounds who
• Hemolytic reaction—Less common, but most have an unknown tetanus status or have received
serious. Occurs early in the transfusion, with fewer than three immunizations require tetanus
symptoms that include chills, fever, tachy- and diphtheria toxoids and tetanus immune globu-
cardia, chest tightness, and flank pain. Treat- lin (human). Fully immunized patients with tetanus-
ment consists of stopping the transfusion, prone wounds do not require immune globulin, but
administering intravenous fluids, performing tetanus toxoid should be administered if the wound
appropriate laboratory studies, and monitor- is severe or over 24 hours old or if the patient has
ing the patient in an intensive care setting. not received a booster within the past 5 years. A
2. Transfusion risks—Include transmission of patient with a nontetanus-prone wound with an un-
hepatitis (C [1 in 1,935,000 per unit transfused], known immunization history or a history of fewer
B [1 in 205,000 per unit transfused]), cytomega- than three doses of tetanus immunization requires
lovirus (highest incidence, because over 70% tetanus toxoid. Established tetanus is treated with
of donors are positive, but not clinically impor- diazepam to control the patient’s muscle spasms.
tant), human T-cell lymphotropic virus (HTLV- Initial antibiotic therapy includes penicillin G or
1) (1 in 2,993,000 per unit transfused), and HIV (1 doxycycline; alternative antibiotic therapy includes
in 1,125,000 per unit transfused). metronidazole.
F. Tetanus—A potentially lethal neuroparalytic G. Rabies—An acute infection characterized by
disease caused by an exotoxin of Clostridium irritation of the CNS that may be followed by
paralysis and death. The organism involved in care workers. Immune globulin is administered
rabies is a neurotropic virus that may be pres- after exposure in nonvaccinated persons.
ent in the saliva of rabid animals. In dog or 3. Hepatitis C—Recent advances in screening
cat bites, healthy animals should be observed for methods have decreased the risk of hepatitis C
10 days; there is no need to start antirabies treat- as a cause of transfusion-associated hepatitis
ment. If the animal begins to experience symp- (1 in 1,935,000 per unit transfused). Hepatitis
toms, human rabies immune globulin with human C is also related to intravenous drug abuse.
diploid cell vaccine or rabies vaccine absorbed PCR is the most sensitive method for early
(inactivated) should be started. For bites from detection of infection.
known rabid dogs and cats, vaccination of the J. Hypothermia—Treatment of hypothermia (core
patient should occur immediately. Skunks, rac- body temperature 35° C [95° F]) includes pas-
coons, bats, foxes, and most carnivores should sive external warming with blankets, clothing,
be considered rabid, and bitten patients immu- and warmed IV fluids, and active core rewarm-
nized immediately. Mouse, rat, chipmunk, gerbil, ing with peritoneal lavage, and pleural lavage for
guinea pig, hamster, squirrel, rabbit, and rodent severe cases. Hypothermia is life threatening and
bites rarely require antirabies treatment. made worse by surgery and anesthesia; therefore,
H. HIV Infection surgery should be delayed until the hypothermic
1. HIV primarily affects the lymphocyte and mac- state is corrected.
rophage cell lines and decreases the number
of T-helper cells (formerly known as T4 lym- V. Orthopaedic Management in the Polytraumatized
phocytes but now known as CD4 cells). Patient
2. Diagnosis—The diagnosis of AIDS requires A. Timing Definitive Procedures
an HIV-positive test plus one of the follow- 1. Stable patients—Patients who are hemodynam-
ing two scenarios: (a) one of the opportu- ically stable can be treated for their injuries in a
nistic infections (such as pneumocystis) or manner that is timely for those specific injuries.
(b) a CD4 count of less than 200 (normal Since the stable patient does not have physi-
CD4 count 700 to1,200). ologic derangement, he or she may be able to
3. Transmission—The risk of seroconversion undergo definitive reconstruction (e.g., intra-
from a contaminated needle stick is 0.3% medullary nailing of a femur fracture) at the
(increases if the exposure involves a larger discretion of the specialist.
amount of blood); the risk of seroconversion 2. In extremis—A patient “in extremis” has a pro-
from mucous membrane exposure is 0.09%. found physiologic derangement. He/she can be
The risk of HIV transmission via a large, frozen hypotensive, coagulopathic, and hypothermic.
bone allograft is 1 in 1 million; donor screen- These are life-threatening conditions. Such a
ing is the most important factor in prevent- patient requires urgent cessation and/or re-
ing viral transmission. versal of the cause of the derangement (e.g.,
4. Associated risks—Even if asymptomatic, HIV- hemorrhage) and adequate resuscitation. Res-
positive patients with traumatic orthopaedic toration and stabilization of the patient’s physi-
injuries (especially open fractures) or under- ology takes priority over reconstruction of his/
going certain orthopaedic surgical procedures her non–life-threatening injuries.
appear to be at increased risk for wound infec- 3. Borderline patients—In patients with contin-
tions and non–wound-related complications ued physiologic derangements after resus-
(e.g., UTI, pneumonia). Patients with HIV can citation, performance of “damage control
develop secondary rheumatologic conditions orthopaedics” is prudent. External fixation
such as Reiter syndrome. of long bone fractures rather than definitive
I. Hepatitis fixation of these injuries is recommended in the
1. Hepatitis A—Common in areas with poor sani- borderline patient.
tation and public health concerns, but not a 4. Associated head injury—Orthopaedic interven-
major problem regarding surgical transmission. tions should be timed appropriately to minimize
2. Hepatitis B—Approximately 200,000 people are risk of detrimental neurologic effects. Intra-
infected with the hepatitis B virus each year, operative hypotension adversely affects the
and there are currently more than 12 million long-term outcome of trauma patients with
carriers in the United States and 350 million associated head injuries.
carriers worldwide. Screening and vaccination B. Inflammatory Mediators—Inflammatory mediators
have reduced the risk of transmission for health or cytokines are released into the bloodstream in
measurable levels as a response to trauma and tissue may occur in the setting of trauma due to immo-
injury. Elevation of several of these mediators has bilization and endothelial injury. Approximately
been linked to the systemic inflammatory response 700,000 people in the United States have an as-
to trauma. IL-6 has been most closely associated ymptomatic PE each year, of which 200,000 are
with the magnitude of this systemic inflamma- fatal.
tory response to trauma and with the develop- 1. Deep venous thrombosis
ment of multiple organ dysfunction syndrome. • Diagnosis—Clinical suspicion is often more
C. Open Fracture Management helpful than physical examination (pain,
1. Pre- and postdebridement cultures—The avail- swelling, Homans sign) for DVT. Useful stud-
able evidence demonstrates a lack of utility for ies include venography (the “gold stan-
pre- and/or postdebridement wound cultures in dard”), which is 97% accurate (70% for iliac
open fractures. Ninety-two percent of infections veins); 125I-labeled fibrinogen (operative-site
are nosocomial. The wound cultures rarely artifact causes false positives); impedance
identify the infecting organism and are often plethysmography (poor sensitivity); duplex
negative in fractures that become infected. ultrasonography (B-mode), which is 90% ac-
2. Antibiotics—Antibiotic use with open frac- curate for DVT proximal to the trifurcation
tures decreases the risk of infection by 59%. vessels; and Doppler imaging (immediate
Unfortunately, choice and duration of antibiotic bedside tool, often best first study). Vir-
are based largely on expert opinion. A recent chow’s triad of factors involved in venous
evidence-based review by the Surgical Infection thrombosis is venous stasis, hypercoagula-
Society found sufficient evidence to support bility, and intimal injury.
the short duration use of a first generation • Prophylaxis—DVT prophylaxis with mechan-
cephalosporin (e.g., cefazolin) in open frac- ical, pharmacological, or both mechanisms
tures. This short duration can be as little as 24 is recommended. Immediate mechanical pro-
hours. Although there is conflicting evidence phylaxis with delayed pharmacological pro-
on the effectiveness of extended coverage with phylaxis in a study by Stannard et al. (2006)
an aminoglycoside, it is still the general recom- showed similar efficacy in DVT prevention.
mendation to add an aminoglycoside to the first Retrievable inferior vena cava filters may
generation cephalosporin for type III open frac- also be considered in a patient with a con-
tures. It is also recommended to add penicillin traindication to anticoagulation, although
in farm or vascular injuries for activity against limited clinical data on efficacy and com-
anaerobes. plication rate exists. The anticoagulation
3. Irrigation—High-volume irrigation (3 to 9 L) effects of warfarin (Coumadin) result
with sterile normal saline is recommended from the inhibition of hepatic enzymes,
for open fractures. Additives to irrigation so- vitamin K epoxide, and perhaps vitamin
lutions include antiseptics, antibiotics, and K reductase. This inhibition results in de-
soaps. Antiseptic additives are toxic to tissues. carboxylation of the vitamin K–dependent
Antibiotics are of questionable value and have protein factors II (prothrombin), VII (the
even shown higher wound complication rates first to be affected), IX, and X. Warfarin
than soap solutions. There are conflicting data inhibits posttranslational modification of
on the use of soap solutions. vitamin K–dependent clotting factors. Ri-
4. Timing of debridement—Several recent pub- fampin and phenobarbital are antagonists
lications have challenged the traditional to warfarin.
“emergent” nature of debridement of open • Treatment—Treatment is recommended for
fractures within the first 6 hours. Timely de- all thigh DVTs; however, treatment of DVTs
bridement (within 24 hours) remains the rec- occurring below the popliteal fossa is con-
ommendation as long as other factors such as troversial. Preoperative identification of a
vascular injury and compartment syndrome are DVT in a patient with lower extremity or
absent. Other orthopaedic emergencies such as pelvic trauma is an indication for place-
a hip dislocation may now be prioritized ahead ment of a vena cava filter.
of open fracture debridement. 2. Pulmonary embolism
• Diagnosis—PE should be suspected in pa-
VI. Complications Associated with Trauma tients with an acute onset of pleuritic pain,
A. Venous Thromboembolic Disease—Deep venous tachypnea (90%), and tachycardia (60%).
thrombosis (DVT) and pulmonary embolus (PE) Initial workup includes an ECG (right bundle
branch block, right axis deviation in 25%; well-demarcated, red, raised, painful plaque,
may also show ST depression or T-wave in- similar to cellulitis but more superficial. In dia-
version in lead III), a chest radiograph (hy- betics, the most common organisms are group
perlucency rare), and ABGs (normal pO2 A Streptococcus, Staphylococcus aureus, En-
does not exclude PE). A nuclear medicine terobacteriaceae, and Clostridia. Treatment of
ventilation–perfusion scan may be helpful, early or mild cases includes second- or third-
but pulmonary angiography is considered generation cephalosporin or amoxicillin. Se-
the “gold standard” to make the diagnosis if vere cases may require imipenem (Primaxin),
there is any question. meropenem, or trovafloxacin. Diabetics may
• Treatment—The most important factor require surgical debridement to rule out nec-
for survival is early diagnosis and prompt rotizing fasciitis and obtain definitive cultures.
therapy initiation. Treatment may include 4. Necrotizing fasciitis—Infection of the muscle
heparin therapy (continuous intravenous in- fascia that is aggressive and life threatening. It
fusion) and monitored by the partial throm- may be associated with an underlying vascular
boplastin time, thrombolytic agents, vena disease (particularly diabetes), and commonly
cava filter, or other surgical measures. occurs after surgery, trauma, or streptococ-
B. Compartment Syndrome—Compartment syn- cal skin infection. Many acute cases involve
drome is increase in pressure within an osteo- several organisms; groups A, C, and G strep-
fascial space to a level that compromises the tococcus are the most commonly isolated.
perfusion within that space. When performing a Clostridia or polymicrobial infections (aerobic
four-compartment fasciotomy of the leg, injury plus anaerobic) are also seen, as well as meth-
to the superficial peroneal nerve can occur dur- icillin-resistant S. aureus (MRSA). Treatment
ing release of the anterior and lateral compart- requires emergent, extensive surgical debride-
ments as it exits the fascia. Continuous traction ment involving the entire length of the over-
during intramedullary nailing of tibia fractures lying cellulitis and initial treatments with IV
has been found to contribute to the development antibiotics: penicillin G for strep or clostridia;
of compartment syndrome. imipenem, cilastatin, or meropenem for poly-
C. Infection—Infection after orthopaedic trauma microbial infections; and vancomycin if MRSA
can occur most commonly in the setting of an is suspected.
open fracture. If an appropriate debridement of 5. Gas gangrene—Injuries contaminated with soil
devitalized tissue and bone is not performed, a may result in anaerobic, Gram-positive, spore-
patient may develop a chronic infection. Treat- forming rods producing exotoxins (classically
ment of chronic posttraumatic osteomyelitis Clostridium species) infections resulting in
requires excision of the sequestrum (necrotic gas gangrene. Patients presenting with clinical
bone) as well as an extensive debridement that sepsis and a limb infection with subcutaneous
may include removal of hardware. crepitus and visible gas on radiographs re-
1. Infection with flaps—Infection rates and flap quire an urgent surgical debridement, leaving
failure rates with open fractures requiring the wound open, and intravenous antibiotics.
coverage are lowest if the flap is performed 6. Toxic shock syndrome—TSS is a form of tox-
within 72 hours of the injury. emia, not a septicemia. In orthopaedics, TSS is
2. Cellulitis—Infection of the subcutaneous tissues, secondary to colonization of surgical or trau-
generally deeper and with less distinct margins matic wounds (even after minor trauma).
than erysipelas. Clinical signs include erythema, • Staphylococcal—Presents with fever, hypo-
tenderness, warmth, lymphangitis, and lymph- tension, and erythematous macular rash with
adenopathy. Group A streptococcus is the most a serous exudate (Gram-positive cocci are
common organism, and S. aureus much less present). The infected wound may look be-
common. Initial antibiotic treatment is peni- nign and may be misleading with regard to
cillinase-resistant synthetic penicillins (PRSPs the seriousness of the underlying condition.
[nafcillin or oxacillin]). Alternative therapies Treatment is with irrigation and debridement
include erythromycin, first-generation cephalo- and IV antibiotics with IV immune globulin.
sporins, amoxicillin/clavulanate (Augmentin), Initial antibiotic treatment is a PRSP (nafcillin
azithromycin, clarithromycin, dithromycin, and or oxacillin), vancomycin if MRSA. Alternative
tigecycline. therapies include first-generation cephalospo-
3. Erysipelas—Infection of the superficial tis- rins. Patients may also require emergent fluid
sues characterized by progressively enlarging, resuscitation.
TA B L E 1 - 6
Bite Injuries
Source of Bite Organism(s) Primary Antimicrobial (or Drug) Regimen
Human Bacteroides Early treatment (not yet infected): amoxicil-
Staphylococcus epidermidis lin/clavulanate (Augmentin)
Streptococcus viridans (100%) With signs of infection: ampicillin/sulbactam
Corynebacterium (Unasyn), cefoxitin, ticarcillin/clavulanate
S. aureus (Timentin), or piperacillin-tazobactam
Peptostreptococcus Patients with penicillin allergy: clindamy-
Eikenella cin plus either ciprofloxacin or
trimethoprim/sulfamethoxazole
Eikenella is resistant to clindamycin, nafcil-
lin/oxacillin, metronidazole, and possibly
to first-generation cephalosporins and
erythromycin; susceptible to fluoroqui-
nolones and trimethoprim/sulfamethoxa-
zole; treat with cefoxitin or ampicillin
Dog S. aureus Amoxicillin/clavulanate (Augmentin),
Pasteurella multocida clindamycin (adults), or clindamycin
Bacteroides plus trimethoprim/sulfamethoxazole
Fusobacterium (children)
Capnocytophaga Consider antirabies treatment
Only 5% become infected
Cat P. multocida Amoxicillin/clavulanate, cefuroxime axetil,
S. aureus or doxycycline
Possibly tularemia
Rat S. moniliformis Amoxicillin/clavulanate or doxycycline
Spirillum minus Antirabies treatment not indicated
Pig Polymicrobial (aerobes and anaer- Amoxicillin/clavulanate, third-generation
obes) cephalosporin, ticarcillin/clavulanate
(Timentin), ampicillin/sulbactam, or
imipenem–cilastatin
Skunk, raccoon, bat Varies Amoxicillin/clavulanate or doxycycline
Antirabies treatment is indicated
Pit viper (snake) Pseudomonas Antivenom therapy
Enterobacteriaceae Ceftriaxone
S. epidermidis Tetanus prophylaxis
Clostridium
Brown recluse spider — Dapsone
Catfish sting Toxins (may become secondarily Amoxicillin/clavulanate
infected)
Adapted from Gilbert DN, Moellering RC, Eliopoulos GM, et al. The Sanford Guide to Antimicrobial Therapy. Hyde Park, VT:
Antimicrobial Therapy, Inc.; 2006, p. 38, with permission.
• Streptococcal—Involves toxins from Group 7. Surgical wound infections—Most commonly

A, B, C, or G Streptococcus pyogenes. The clin- attributable to S. aureus, but Groups A, B,
ical presentation is similar to staphylococcal C, and G strep and Enterobacteriaceae are
TSS. Initial antibiotic treatment is clindamy- not uncommon. Methicillin-resistant S. au-
cin plus penicillin G and IV immune globulin. reus (MRSA) species infections are increas-
Alternative therapies include erythromycin, ing, and vancomycin-methicillin–resistant S.
or ceftriaxone and clindamycin. aureus (VMRSA) has been reported. MRSA
species are best treated with vancomycin (al- complication after open reduction of a femo-
ternatives to vancomycin for MRSA include ral neck fracture. Nonunion following intra-
teicoplanin, trimethoprim [Bactrim] plus medullary nail stabilization of femoral shaft
sulfamethoxazole, quinupristin/dalfopristin, fractures is associated with the use of nonste-
linezolid, daptomycin, dalbavancin, fusidic roidal anti-inflammatory drugs.
acid, fosfomycin, rifampin, and novobiocin). F. Occult Orthopaedic Injuries—Understanding pat-
8. VMRSA is treated with quinupristin/dalfopris- terns of injury and associated injuries may de-
tin, linezolid, or daptomycin. crease the risk of missing an occult orthopaedic
9. Bite injuries—See Table 1-6. injury. The most common reason for missed frac-
10. Puncture wounds of the foot—The most tures in a polytrauma patient is that the extremity
characteristic organism resulting from was not properly imaged. The most commonly
a puncture wound from a nail through missed component of a distal femur fracture
the sole of an athletic shoe is P. aerugi- is a coronal fracture of the lateral femoral
nosa (unless the host is immunocompro- condyle, which is best diagnosed by CT. The
mised or diabetic). Pseudomonas infections most common associated injury in a patient
(Gram-negative rod) require aggressive with a hip dislocation is an ipsilateral knee
debridement and appropriate antibiotics injury. Occult femoral neck fractures can be
(often a two-antibiotic regimen). The ini- associated with femoral shaft fractures. Diag-
tial antibiotic regimen for an established nostic workup includes radiographs of the femo-
infection should include ceftazidime or ce- ral neck.
fepime; an alternative initial antibiotic regi- G. Posttraumatic Stress Disorder (PTSD)—Post-
men might include ciprofloxacin (except in traumatic stress disorder is common (51%)
children), imipenem, cilastatin, or a third- in orthopaedic trauma patients. The patient’s
generation cephalosporin. The prophylac- feeling that their emotional problems caused
tic antibiotic treatment for a recent (hours) by the injury have been more difficult to deal
puncture through the sole of an athletic with than the physical problems is suggestive
shoe (without infection) remains controver- of PTSD.
sial. Osteomyelitis develops in 1% to 2% of
children who sustain a puncture wound VII. Miscellaneous Musculoskeletal Traumatic Injuries
through the sole of an athletic shoe. A. Limb-Threatening Injuries—Recent publications
11. Brackish water/shellfish exposure—A mus- have demonstrated similar outcomes with limb
culoskeletal injury involving brackish water salvage and amputation in high-energy lower-
(areas of mixing of fresh and sea water) or extremity trauma (HELET) (Bosse et al., 2002;
shellfish should include a third generation MacKenzie et al., 2005).
cephalosporin (e.g., ceftazadime). This will 1. Limb Injury Severity Scores —Limb Iinjury
provide antibiotic coverage against Vibrio vul- Severity Scores such as the Mangled Extrem-
nificus, which, if untreated, can result in a life- ity Severity Score (MESS); Limb Salvage Index
threatening systemic infection. (LSI); Predictive Salvage Index (PSI); the Nerve
D. Heterotopic Ossification—HO can result from Injury, Ischemia, Soft-Tissue Injury, Skeletal In-
traumatic injuries about the hip, knee, and el- jury, Shock, and Age of Patient Score (NISSSA);
bow. In the case of a traumatic amputation, and the Hannover Fracture Scale-97 (HFS-97)
performing the amputation through the zone were not shown to have clinical utility in a
of injury and blast mechanism are predictive prospective evaluation of more than 500 pa-
of development of HO. Significant HO can tients with HELET (Bosse et al., 2001).
even develop in the quadriceps from the use 2. Salvage versus amputation—Orthopaedic sur-
of distal femoral skeletal traction. HO can also geons surveyed in the LEAP study identified
develop in the setting of a quadriceps contusion limb injury characteristics as the most impor-
from trauma or athletics. The treatment for a tant factors in the decision to salvage or ampu-
quadriceps contusion with early evidence of tate the limb (MacKenzie et al., 2002). Severity
HO is rest and range-of-motion exercises. It is of soft tissue injury and plantar sensation had
also possible to develop HO in and around the the greatest impact on their decision. The pa-
knee as a result of a knee dislocation or retro- tient’s overall ISS did not have an impact
grade nailing of the femur. on their decision to attempt limb salvage.
E. Nonunion—Nonunion is a common complication 3. Plantar sensation—A lack of plantar sensation
of orthopaedic trauma. It is the most common in a patient with a mangled lower extremity
has been a traditional indication for immedi- 2. High velocity—High velocity is defined as
ate amputation. A cohort of patients identified greater than 2,000 ft per second. Formal de-
in the LEAP study had an “insensate foot” in bridement and intravenous antibiotics are
association with their HELET. Of the 55 limbs recommended.
that were insensate at presentation, 26 under- 3. Spine involvement—Gunshot injuries to the
went amputation and 29 underwent salvage. spine are generally mechanically stable. There
At two years, there were no significant differ- is still some controversy over the necessity for
ences in the SIP scores or rates of return-to- surgical debridement of low-velocity gunshot
work. In the insensate salvage group, 55% injuries to the spine with involvement of an
had return of normal sensation by 2 years. abdominal viscus. Current recommendations
The others had some impairment of sensation with a viscus injury are no debridement and
with the exception of 1 limb that remained in- 7 to 14 days of broad-spectrum intravenous
sensate. In other words, the insensate foot antibiotics even when there is involvement
in association with HELET likely repre- of the spinal canal. Gunshot injuries to the
sents a neuropraxia. It can be expected to cervical spine can be a life-threatening situa-
recover to some degree at 2 years. tion due to critical local anatomy such as the
4. Ischemic limbs—Muscle necrosis and second- trachea and great vessels of the neck. With
ary myoglobinemia and acidosis can result a gunshot injury to the cervical spine, ATLS
during the reperfusion phase after vascular principles are the priority: airway, breathing,
reconstruction or replantation of an ischemic and circulation.
limb or traumatic amputation. High-volume
VIII. Summary—General principles of orthopaedic
diuresis with alkalanization of the urine
trauma include prioritization of immediately life-
will mitigate the impact of myoglobinemia
threatening conditions through the employment
due to ischemia-reperfusion injury.
of ATLS guidelines. Treatment of shock and asso-
B. Nerve Injuries—There are three types of trau-
ciated injuries precedes orthopaedic intervention.
matic nerve injury: neuropraxia, axonotmesis,
The orthopaedic surgeon’s role in the polytrau-
and neurotmesis. Neuropraxia represents a
matized patient demands an understanding of
temporary nerve injury from stretch or con-
the appropriate timing of intervention, damage
tusion that recovers in days to months. Axo-
control orthopaedics, and open fracture manage-
notmesis is disruption of the axon itself with
ment. Throughout evaluation and management of
maintenance of the integrity of the nerve sheath
a trauma patient, careful surveillance and preven-
(epineurium and perineurium). Recovery takes
tion of complications are critical.
several weeks to several months, because the
nerve must regenerate from proximal to distal.
Neurotmesis is complete loss of the continuity
of the nerve and its surrounding connective
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CHAPTER 2
Principles of Fractures
Mark R. Brinker and Daniel P. O’Connor
I. Fracture Description caused by a farm injury are special catego-

A. Soft Tissues ries of Type III open fractures.
1. Closed fractures—The fracture is not exposed (d) Type IIIa injuries have extensive con-
to the external environment. The soft-tissue in- tamination and/or injury to the underly-
jury ranges from minor to massive (e.g., crush ing soft tissues, but adequate viable soft
injury). Closed soft-tissue injuries are com- tissue is present to cover the bone and
monly graded by the method of Tscherne. neurovascular structures without a mus-
• Grade 0 injuries have negligible soft-tissue cle transfer.
injury. (e) Type IIIb injuries have such an extensive
• Grade 1 injuries have superficial abrasions injury to the soft tissues that a rotational
or contusions of the soft tissues overlying the or free muscle transfer is necessary to
fracture. achieve coverage of the bone and neuro-
• Grade 2 injuries have significant contusion vascular structures. These injuries usu-
to the muscle, contaminated skin abrasions, ally have massive contamination.
or both types of injury. The bony injury is (f) Type IIIc injuries are any open fractures
usually severe in these injuries. with an associated vascular injury that
• Grade 3 injuries have a severe injury to the requires an arterial repair.
soft tissues, with significant degloving, crush- Often, what appears to be a Type I or II open
ing, compartment syndrome, or vascular fracture on initial examination in the emer-
injury. gency room is noted to have significant peri-
2. Open fractures—The fracture is exposed to osteal stripping and muscle injury at the time
the external environment. The amount of soft- of operative debridement, and may require
tissue destruction is related to the level of en- muscle transfer for coverage after serial de-
ergy imparted to the limb during the traumatic bridements. Thus, there is a tendency for the
episode. Gustilo classification type to increase with
• Classification—Open fractures are com- time.
monly described using the Gustilo grading • Antibiotic prophylaxis for open fractures—
system. Prophylactic antibiotics following an open
(a) Type I open fractures have small (1 cm), fracture are given for 48 to 72 hours (as com-
clean wounds; minimal injury to the mus- pared with only 24 hours in clean surgical
culature; and no significant stripping of cases). In patients returning to the operating
periosteum from bone. room for serial debridement, most ortho-
(b) Type II open fractures have larger (1 cm) pedic surgeons continue the antibiotics for
wounds, but do not have significant soft- 48 hours following the final debridement. The
tissue damage, flaps, or avulsions. regimen for prophylactic antibiotic coverage
(c) Type III open fractures have larger wounds is dependent on the severity (Gustilo type) of
and are associated with extensive injury to the open fracture.
the integument, muscle, periosteum, and (a) Gustilo Type I—First or second generation
bone. Gunshot injuries and open fractures cephalosporin (most commonly, Ancef)
20
C H A P T E R 2 | P R I N C I P L E S O F F R A C T U R E S 21
(b) Gustilo Type II—First or second generation (c) Ligaments—The ultrastructure of liga-
cephalosporin (most commonly, Ancef) ment is similar to that of tendons, but
(c) Gustilo Type IIIa—First or second genera- the fibers are more variable and have a
tion cephalosporin plus an Aminoglycoside higher elastin content. Unlike tendons,
(d) Gustilo Type IIIb and IIIc—First- or ligaments have a “uniform microvascu-
second-generation cephalosporin plus an larity,” which receives its supply at the
Aminoglycoside plus Penicillin (addi- insertion site. Ligament healing benefits
tional antibiotic coverage with a third- from normal stress and strain across
generation cephalosporin should be the joint. Early ligament healing is with
considered for patients with open marine Type III collagen that is later converted
[such as swamp] injuries). to Type I collagen. Immobilization ad-
• Tetanus prophylaxis—See Chapter 1, General versely affects the strength (elastic mod-
Principles of Trauma. ulus decreases) of an intact ligament and
• Traumatic amputation—The recommended of a ligament repair. The most common
sequence of structural repair during replanta- mechanism of ligament failure is rup-
tion is skeletal stabilization, arterial repair, ve- ture of sequential series of collagen
nous repair, nerve repair, and muscle suture. fiber bundles distributed throughout
3. Soft-tissue injuries the body of the ligament and not local-
• Overview—The requirements for wound ized to one specific area. Ligaments do
healing are oxygenation, functioning cellular not plastically deform (“they break not
mechanisms, and a clean wound without con- bend”). Midsubstance ligament tears
tamination or necrotic tissue. There are four are common in adults; avulsion in-
phases of wound healing: juries are more common in children.
(a) Coagulation phase (minutes) Avulsion of ligaments typically occurs be-
(b) Inflammatory phase (hours) tween the unmineralized and mineralized
(c) Granulation phase (days) fibrocartilage layers.
(d) Scar formation phase (weeks) • Management of soft-tissue injuries associated
• Specific issues with fractures
(a) Skeletal muscle—Muscle injuries typi- (a) Overview—The care of patients with
cally heal with dense scarring. Surgical soft-tissue injuries proceeds in an or-
repair of clean lacerations of skeletal derly fashion through three phases. The
muscle usually result in minimal regen- acute phase includes wound irrigation,
eration of muscle fibers distally, scar for- wound debridement, skeletal stabiliza-
mation at the laceration, and recovery of tion, reconstruction of the soft tissues,
approximately 50% of muscle strength. and resumption of joint range of motion.
(b) Tendons—Tendons are composed of fi- The reconstructive phase deals with
broblasts arranged in parallel rows in sequelae of the traumatic injury (de-
fascicles. Two types of tendons exist: layed unions, nonunions, deformities,
• Paratenon—Covered tendons (vascu- infections). The rehabilitative phase
lar tendons)—many vessels supply a addresses the patients’ psychological,
rich capillary system. social, and vocational recovery.
• Sheathed tendons—A mesotenon (vin- (b) General principles of the acute phase
cula) carries a vessel that supplies only treatment
one segment of the tendon; avascular • Assess for the zone of soft-tissue
areas receive nutrition via diffusion injury—The soft-tissue zone of injury
from vascularized segments. Because is generally much larger than the area
of these differences in vascular supply, of the fracture itself (Fig. 2-1).
paratenon-covered tendons heal better • Assess for associated vascular injuries
than sheathed tendons. (limb viability).
Tendinous healing in response to injury is • Assess for nerve injuries.
initiated by fibroblasts that originate in the • Pulsating irrigation in the operating
epitenon and macrophages that initiate heal- room should be performed with copi-
ing and remodeling. Tendon repairs are weak- ous isotonic solution, removing ne-
est at 7 to 10 days; they regain most of their crotic and foreign material.
original strength at 21 to 28 days and achieve • Debridement (meticulous) of all foreign
maximum strength at 6 months. and necrotic material from the wound.
This should be performed every 24 to

48 hours until the wound is felt to be
ready for closure or coverage.
• Open wounds should be extended
using a scalpel to allow access to un-
derlining tissues for assessment and
debridement.
• Free bony ends should be delivered
into the open wound; small devitalized
pieces of cortical bone are removed.
The intramedullary cavity is examined
and cleaned.
Zone of soft- Fracture (c) Types of wound closure or coverage
site
tissue injury • Primary closure
• Delayed primary closure
• Healing by secondary intention
• Split-thickness skin grafts
• Random flaps—Such as a cross finger
flap
• Vascularized pedicle flaps—Such as
gastrocnemius flap
• Free flaps (Fig. 2-2)—These may be fas-
ciocutaneous flaps or myocutaneous
flaps.
(d) Timing of wound closure or coverage—
Early wound closure or coverage (3 to
FIGURE 2-1 Diagrammatic representation of the zone of
soft-tissue injury. Note that the area of soft-tissue injury is 5 days) is associated with improved
much greater than the area of the fracture site. outcomes.
Medial FIGURE 2-2 Topical atlas of the most commonly

Temporoparietal
arm used donor sites for free tissue transfer.
Radial
Latissimus dorsi arm
Rectus
abdominus
Iliac crest
Groin
Gastrocnemius
Gracilis
Fibular
B. Bone Comminuted fractures generally result from

1. Anatomic location—Name of bone(s) involved high-energy injuries.
2. Regional location • Pathologic fracture—A fracture through an
• Diaphysis area of pre-existing disease with weakened
• Metaphysis bone (primary bone tumors, metastases to
• Epiphysis bone, bone infections, osteoporosis, meta-
(a) Extra-articular bolic bone disease, and others).
(b) Intra-articular • Incomplete fracture—One in which the bone
• Physis (in skeletally immature individuals) is not broken into separate fragments.
3. Direction of fracture lines • Segmental fracture—One in which there is a
• Transverse—The loading mode resulting in middle fragment of bone surrounded by a proxi-
fracture is tension mal and a distal segment. The middle fragment
• Oblique—The loading mode resulting in frac- usually has an impaired blood supply. These
ture is compression injuries are typically high-energy injuries with
• Spiral—The loading mode resulting in frac- soft-tissue stripping (muscle and periosteum)
ture is torsion from bone, and are therefore prone to poor
4. Condition of bone (Fig. 2-3) healing (delayed union or nonunion).
• Comminution—A comminuted fracture is • Fracture with bone loss—This may be caused
one with three or more bony fragments. by an open fracture where bone is left at
FIGURE 2-3 Condition of the bone in fractures.
Comminuted Pathologic Incomplete Segmental Fracture with

bone loss
Butterfly Stress Avulsion Impacted

fragment
the scene of the injury (a high-energy open • Angulation—Describes the direction (frontal,

injury) or is devitalized by the injury and sagittal, oblique) in which the apex of the an-
requires debridement, or a closed fracture gulation points
where a segment is comminuted so severely • Rotation—Describes the turning of fracture
that from a practical standpoint there is a fragments (or healed bony segments) along
“missing” segment of bone. the long axis of a bone
• Fracture with a butterfly fragment—This is • Translation—Describes anteroposterior and
similar to a segmental fracture except that medial-lateral displacement of fracture
the butterfly segment does not span the fragments such that the fragments remain
entire cross-section of the bone. The loading parallel to their initial position or each
mode resulting in fracture is bending. other
• Stress fracture—A fracture caused by re-
peated loading such as in military recruits II. Fracture Management
(who march all day) or ballet dancers. Amen- A. Nonoperative Treatment—It is best used in pa-
orrheic female runners are also prone to tients with lower-energy injuries or with patients
stress fractures. Common sites of stress frac- who are not candidates for operative treatment
tures include the metatarsals, calcaneus, and because of systemic or local factors.
tibia (other sites are possible). 1. Reduction via manipulation
• Avulsion fracture—Caused by the pull of a • Three steps
tendon or ligament at its site of bony inser- (a) Longitudinal traction
tion. Acute avulsion fractures display irregu- (b) Disengagement of the fracture fragments
lar borders on radiography. These should not (accentuating the deformity)
be confused with sesamoid bones (hands, (c) Reapposition of the fracture ends
foot, others) or an unfused center of ossifi- 2. Casting techniques
cation (bipartite patella, accessory navicular, • Three-point fixation (Fig. 2-4)
os trigonum). • Cylinder hydraulics
• Impacted fracture—The fracture fragments 3. Traction techniques
are compressed together (generally the re- • Skin traction
sult of an axial load). • Skeletal traction
5. Type of bone involved (Table 2-1) B. Operative Treatment
6. Deformities—See Chapter 3, Principles of 1. External fixation—Indicated for open fractures,
Deformities closed fractures with a severe soft-tissue in-
• Length—Describes shortening or jury, and fractures (or nonunions) associated
overlengthening with infection.
TA B L E 2 - 1
Types of Bone
Microscopic Appearance Subtypes Characteristics Examples
Lamellar Cortical Structure is oriented Femoral shaft
along lines of stress
Strong
Cancellous More elastic than cortical Distal femoral metaphy-
bone sis
Woven Immature Not stress oriented Embryonic skeleton
Fracture callus
Pathologic Random organization Osteogenic sarcoma
Increased turnover Fibrous dysplasia
Weak
Flexible
2. Internal fixation
• Arbeitsgemeinschaft für Osteosynthesefra-
gen (AO) Principles of Fracture Care
(Table 2-2)
• Interfragmentary compression
(a) Static—Such as with a lag screw
(b) Dynamic—Such as an intramedullary
nail that is not locked, a sliding hip
screw, or a tension band.
• Splintage—A construct which allows slid-
ing between the implant and the bone,
such as occurs with intramedullary nail
fixation
• Bridging—Implants bridge an area of
comminution
3. Indirect reduction is a technique in which dis-
traction is performed across an area of com-
minution so that the fracture fragments are
reduced by the tension generated in their soft-
tissue attachments. The distraction force may
FIGURE 2-4 Three-point fixation casting technique.
be generated using a femoral distractor, an
A three-point cast or splint can hold a fracture reduced
by keeping the soft tissues hinge under tension. (From external fixator, an AO articulating tension de-
Court-Brown CM. Principles of nonoperative fracture vice, or a lamina spreader. Ligamentotaxis is
treatment. In: Bucholz RW, Court-Brown CM, Heckman a method by which intra-articular fracture frag-
JD, et al., eds. Rockwood and Green’s Fractures in Adults. ments may be reduced by applying traction to
7th ed. Philadelphia, PA: Lippincott William & Wilkins, the ligamentous and capsular structures sur-
2010, with permission.) rounding the joint.
TA B L E 2 - 2
The Evolution of the AO Principles of Fracture Care
AO Principle Original Concept Current Concept
The first AO principle: anatomic Perfect anatomic reduction of all Epiphysis—perfect anatomic
reduction of the fracture fracture fragments of the epiphysis, reduction of articular fragments
fragments metaphysis, and diaphysis Diaphysis—restoration of length,
alignment, and rotation
Metaphysis—restoration of length,
alignment, and rotation with
bone grafting of bony defects
The second AO principle: stable Absolute rigid fixation of all fracture Epiphysis—rigid internal fixation
internal fixation fragments of the epiphysis, Diaphysis and Metaphysis—relative
metaphysis, and diaphysis stability (enough to allow bony
union)
The third AO principle: preserva- Atraumatic surgical techniques Closed and indirect reduction
tion of blood supply techniques; implant constructs
that are biologically sparing of
the blood supply to bone and the
soft tissues
The fourth AO principle: early Early joint range of motion Early joint range of motion
active pain-free mobilization exercises exercises
TA B L E 2 - 3
Types of Bone Formation
Type of Ossification Mechanism Examples of Normal Mechanisms
Enchondral Bone replaces a cartilage model Embryonic long bone formation
Longitudinal growth (physis)
Fracture callus
The type of bone formed with the use of
demineralized bone matrix
Intramembranous Aggregates of undifferentiated Embryonic flat bone formation
mesenchymal cells differenti- Bone formation during distraction
ate into osteoblasts which osteogenesis
form bone Blastema bone
Appositional Osteoblasts lay down new bone Periosteal bone enlargement (width)
on existing bone The bone formation phase of bone remodeling
III. The Biology of Bone Formation and Fracture Healing later replaced, via the process of enchondral

A. Overview—Fracture healing involves a series of ossification, by woven bone (hard callus).
cellular events including inflammation, fibrous Another type of callus, medullary callus,
tissue and cartilage formation, and enchondral supplements the bridging callus, although
bone formation. The cellular events of frac- it forms more slowly and occurs later. The
ture healing are influenced by undifferentiated amount of callus formation is related to
cells in the area of the fracture and osteoinduc-
tive growth factors released into the fracture
environment.
TA B L E 2 - 4
B. Types of Bone Formation (Table 2-3)
C. Fracture Repair—The response of bone to Biological and Mechanical Factors Influencing
injury can be thought of as a continuum of Fracture Healing
histological processes, beginning with inflam- Biological Factors Mechanical Factors
mation, proceeding through repair (soft callus Patient age Soft-tissue attachments to
followed by hard callus), and finally ending in Metabolic bone disease bone
remodeling. Fracture repair is unique in that Comorbid medical Stability (extent of
healing is completed without the formation conditions immobilization)
of a scar. Fracture healing may be influenced Functional level Anatomic location
by a variety of biological and mechanical factors Nutritional status (1,500 Level of energy imparted
mg of elemental Extent of bone loss
(Table 2-4).
calcium/day recom-
1. Stages of fracture repair mended in patients
• Inflammation—Bleeding from the fracture with fractures)
site and surrounding soft tissues creates Nerve function
a hematoma (fibrin clot), which provides Vascular injury
a source of hematopoietic cells capable of Hormones
secreting growth factors. Subsequently, fi- Growth factors
broblasts, mesenchymal cells, and osteo- Health of the soft-tissue
progenitor cells are present at the fracture envelope
site, and fibrovascular tissue forms around Sterility (in open
fractures)
the fracture ends. Osteoblasts, from sur-
Cigarette smoke
rounding osteogenic precursor cells and/or
Medications
fibroblasts proliferate. Local pathologic
• Repair—Primary callus response occurs conditions
within 2 weeks. If the bone ends are not in Level of energy imparted
continuity, bridging (soft) callus occurs Type of bone affected
(fibrocartilage develops and stabilizes the Extent of bone loss
bone ends). The soft callus (fibrocartilage) is
TA B L E 2 - 5
Type of Fracture Healing Based on Type of Stabilization
Type of Immobilization Predominant Type of Healing Comments
Cast (closed treatment) Periosteal bridging callus Enchondral ossification
Compression plate Primary cortical healing (Remodeling) Cutting cone type remodeling
Intramedullary nail Early-periosteal bridging callus Enchondral ossification and
Late-medullary callus intramembranous ossification
External fixator Dependent of extent of rigidity
Less rigid—periosteal bridging callus
More rigid—primary cortical healing
Inadequate Hypertrophic nonunion Failed enchondral ossification. Type II
collage predominates
the amount of immobilization of the frac- by noggin and chordin; balance between these
ture. Primary cortical healing, which re- agonists and antagonists appears to be impor-
sembles normal remodeling, occurs with tant in fracture healing. Activation of a trans-
rigid immobilization and anatomic (or membrane serine/threonine kinase receptor
near-anatomic) reduction (bone ends are leads to activation of intracellular proteins
in continuity). Fracture healing varies with called SMADs, the signaling mediator for
the method of treatment (Table 2-5). With BMPs. BMP 2, 6, and 9 appear most important
closed treatment, “enchondral healing” for osteoblast differentiation of mesenchymal
with periosteal bridging callus occurs. With stem cells, whereas most BMPs appear to in-
rigidly fixed fractures (such as with a com- duce osteogenesis in mature osteoblasts.
pression plate), direct osteonal or primary 2. Transforming growth factor–beta (TGF-)—
bone healing occurs without visible callus. Induces mesenchymal cells to produce Type
Intramedullary nailing results in repair II collagen and proteoglycans. Also induces
through both intramembranous ossifica- osteoblasts to synthesize collagen. TGF- is
tion and enchondral ossification. found in fracture hematomas and is believed
• Remodeling—This process begins during to regulate cartilage and bone formation
the middle of the repair phase and contin- in fracture callus. Chondrocytes and osteo-
ues long after the fracture has clinically blasts synthesize TGF-. The largest source of
healed (up to 7 years). Remodeling allows TGF- is the extracellular matrix of bone.
the bone to assume its normal configura- 3. Insulin-like growth factor II (IGF-II)—Stimulate
tion and shape based on the stresses to Type I collagen, cellular proliferation, and car-
which it is exposed (Wolff’s law). Through- tilage matrix synthesis, and bone formation.
out the process, woven bone formed dur- 4. Platelet-derived growth factor (PDGF)—
ing the repair phase is replaced with Released from platelets following fracture; it at-
lamellar bone. Fracture healing is com- tracts inflammatory cells and osteoprogenitor
plete when there is repopulation of the cells to the fracture site (chemotactic).
marrow space.
2. Biochemistry of fracture healing—Four bio-
chemical steps of fracture healing have been
described (Table 2-6). TA B L E 2 - 6
D. Growth Factors of Bone
1. Bone morphogeneticic proteins (BMPs)— Biochemical Steps of Fracture Healing
Osteoinductive; induces metaplasia of plueuri- Step Predominate Collagen Type(s)
potential stem cells into osteoblasts; up to 20 Mesenchymal I, II, (III, V)
different BMPs have been described. The tar- Chondroid II, IX
get cell for BMPs is the undifferentiated peri- Chondroid-osteoid I, II, X
vascular mesenchymal cell. BMPs stimulate Osteogenic I
bone formation and their actions are inhibited
5. Growth hormone–insulin-like growth factor I- • Pulsed electromagnetic fields (PEMF)—

Produces proliferation without maturation Initiate calcification of fibrocartilage (can-
of the growth plate, resulting in linear bone not induce calcification of fibrous tissue),
growth. upregulate BMPs and TGF-.
E. Effects of Hormones on Fracture Healing (Table 2-7) H. Effect of Radiation on Bone
F. Ultrasound and Fracture Healing 1. Long-term changes of bone injury following
1. Clinical studies show that low-intensity pulsed high dose irradiation are the result of changes
ultrasound accelerates fracture healing and in the Haversian system and a decrease in
increases the mechanical strength of callus in- overall cellularity.
cluding torque and stiffness. 2. High dose irradiation (90 kGy, the dose needed
2. The postulated mechanism of action is that the for viral inactivation) of allograft bone signifi-
cells responsible for fracture healing respond cantly reduces its structural integrity.
in a favorable manner to the mechanical en-
IV. Bone Grafts
ergy transmitted by the ultrasound signal.
A. Overview—Bone grafts are an important adjunct
G. Electricity and Fracture Healing
in the treatment of fractures, delayed unions,
1. Definitions and nonunions. Bone grafts have four important
• Stress-generated potentials—Serve as sig- properties.
nals that modulate cellular activity. Piezo- B. Graft Properties (Table 2-8)
electric effect and streaming potentials are
1. Osteoconductive matrix—Acts as a scaffold or
examples of stress-generated potentials.
framework into which bone growth occurs.
• Piezoelectric effect—Charges in tissues are
2. Osteoinductive factors—Growth factors such
displaced secondary to mechanical forces.
as BMP and TGF- promote bone formation.
• Streaming potentials—Occur when electri-
3. Osteogenic cells—Include primitive mesenchy-
cally charged fluid is forced over a tissue
mal cells, osteoblasts, and osteocytes.
(cell membrane) with a fixed charge.
• Transmembrane potentials—Generated by 4. Structural integrity
cellular metabolism. C. Specific Bone Graft Types
2. Fracture healing—Electrical properties of carti- 1. Type of graft
lage and bone are dependent on their charged • Cortical grafts—Incorporate through slow
molecules. Devices intended to stimulate frac- remodeling of existing Haversian systems via
ture repair by altering a variety of cellular ac- a process of resorption (which weakens the
tivities have been introduced. graft) followed by deposition of the new bone
(restoring its strength). Resorption is con-
3. Types of electrical stimulation
fined to the osteon borders, and interstitial la-
• Direct current (DC)—Stimulates an inflam-
mellae are preserved. Cortical bone is slower
matory-like response.
to turn over compared with cancellous bone,
• Alternating current (AC)—“capacity cou-
and it is used for structural defects.
pled generators.” Affects cyclic AMP, colla-
• Cancellous grafts—Cancellous bone is com-
gen synthesis, and calcification during the
monly used for grafting nonunions or cavi-
repair stage.
tary defects because it is quickly remodeled
and incorporated (via creeping substitu-
tion). Cancellous bone is rapidly revascu-
larized; osteoblasts lay down new bone on
TA B L E 2 - 7
old trabeculae, which are later remodeled
Effects of Hormones on Fracture Healing (“creeping substitution”).
Hormone Effect Mechanism • Vascularized bone grafts—Although techni-
Growth hormone Positive Increased callus cally difficult, they allow more rapid union
volume with preservation of most cells. Vascular-
Thyroid hormone Positive Bone remodeling ized grafts are best employed for irradiated
Parathyroid Positive Bone remodeling tissues or when large tissue defects exist.
hormone (However, there may be donor site morbid-
Calcitonin Positive? Unknown ity with vascularized grafts [i.e., fibula]).
Cortisone Negative Decreased callus • Osteoarticular (osteochondral) allografts—
proliferation These are being used with increasing fre-
quency for tumor surgery. These grafts are
TA B L E 2 - 8
Bone Graft Properties
Osteogenic Structural
Graft Osteoconduction Osteoinduction Cells Integrity Other Properties
Cancellous autograft Excellent Good Excellent Poor Rapid incorporation
Cortical autograft Fair Fair Fair Excellent Slow incorporation
Allograft Fair Fair None Good Fresh has the high-
est immunogenicity.
Freeze dried is the
least immunogenic
but has the least
structural integrity
(weakest). Fresh
frozen preserves bone
morphogenic proteins
(BMP)
Ceramics Fair None None Fair
Demineralized bone Fair Good None Poor
matrix (DBM)
Bone marrow Poor Poor Good Poor
Source: Modified from Brinker MR, Miller MD. Fundamentals of Orthopaedics. Philadelphia, PA: WB Saunders; 1999:7, with permission.
immunogenic (cartilage is vulnerable to in- and osseointegration. These materi-

flammatory mediators of immune response als biodegrade at a very slow rate.
[cytotoxic injury from antibodies and lympho- Many are prepared as ceramics (apatite
cytes]); the articular cartilage is preserved crystals are heated to fuse the crystals
with glycerol or dimethyl sulfoxide treatment; [sintered]).
cryogenically preserved grafts leave few • Tricalcium phosphate
viable chondrocytes. Tissue-matched fresh • Hydroxyapatite (e.g., Collagraft Bone
osteochondral grafts produce minimal immu- Graft Matrix [Zimmer, Inc., Warsaw, IN,
nogenic effect and incorporate well. USA]; purified bovine dermal fibrillar
• Demineralized bone matrix (Graf- collagen plus ceramic hydroxyapatite
ton)—It is both osteoconductive and granules and -tricalcium phosphate
osteoinductive. granules).
• Bone marrow cells (c) Calcium sulfate—Osteoconductive (e.g.,
2. Source of Graft OsteoSet [Wright Medical Technology
• Autograft—Bone is harvested from the Inc., Arlington, TN, USA]).
same person. (d) Calcium carbonate (chemically unal-
• Allograft—Bone is harvested from a cadav- tered marine coral)—It is resorbed and
eric donor. All allografts must be harvested replaced by bone (osteoconductive)
with sterile technique, and donors must (e.g., Biocora; Inoteb, France).
be screened for potential transmissible (e) Corralline hydroxyapatite—Calcium
diseases. carbonate skeleton is converted to cal-
• Synthetic grafts—Composed of calcium, sili- cium phosphate via a thermoexchange
con, or aluminum. process (e.g., Interpore 200 and 500; In-
(a) Silicate-based grafts—These incorpo- terpore Orthopaedics, Irvine, CA, USA).
rate the element silicon (Si) in the form (f) Other materials
of silicate (silicon dioxide). • Aluminum oxide—Alumina ceramic
• Bioactive glasses bonds to bone in response to stress
• Glass-ionomer cement and strain between implant and bone.
(b) Calcium phosphate-based grafts—These • Hard tissue—A replacement polymer
grafts are capable of osseoconduction is used.
D. Graft Preparation—Allograft bone can be pre- C. Biology

pared using a variety of methods. 1. Under optimal stable conditions, bone is
1. Fresh (increased antigenicity due to cell sur- formed via intramembranous ossification.
face glycoproteins) 2. In an unstable environment, bone forms via
2. Fresh frozen—Less immunogenic than fresh. enchondral ossification or, in an extremely
Fresh frozen allograft bone preserves bone unstable environment, a pseudoarthrosis may
morphogenetic proteins (BMPs). The marrow occur.
cells of a bone allograft incite the greatest im- D. Histological Phases
munogenic response as compared with other 1. Latency phase (5–7 days)
constituents. 2. Distraction phase (typically 1 mm per day, ap-
3. Freeze-dried (lyophilized)—Loses structural proximately 1 inch per month)
integrity and depletes BMPs. Freeze-dried al- 3. Consolidation phase (typically twice as long as
lograft bone is least immunogenic and purely the distraction phase)
osteoconductive and lowest likelihood of E. Conditions That Promote Optimal Bone Forma-
viral transmission, commonly known as tion During Distraction Osteogenis
“croutons.” 1. Low energy corticotomy or osteotomy
4. Bone matrix gelatin is the digested source of 2. Minimal soft-tissue stripping at the corticot-
BMPs. omy site (preserving the blood supply)
3. Stable external fixation to eliminate torsion,
V. Distraction Osteogenesis (Fig. 2-5)
shear, and bending moments
A. Definition—The use of distraction to stimulate
4. Latency period (no lengthening) of 5 to 7 days
the formation of bone.
5. Distraction at 0.25 mm three to four times per
B. Clinical Applications
day (0.75 to 1.0 mm per day)
1. Limb lengthening
6. Neutral fixation interval (no distraction) dur-
2. Hypertrophic nonunions
ing consolidation
3. Deformity correction (via differential
7. Normal physiologic use of the extremity, in-
lengthening)
cluding weight bearing
4. Segmental bone loss (via bone transport)
VI. Imaging
A. Nuclear Medicine
1. Bone scan—Technetium 99m-phosphate
complexes reflect increased blood flow
and metabolism and are absorbed onto
the hydroxyapatite crystals of bone in
areas of infection, trauma, neoplasia,
and so forth. Whole-body views and more
detailed (pin-hole) views can be obtained.
It is particularly useful for the diagnosis of
subtle fracture, avascular necrosis (hypo-
perfused [diminished blood flow] early, in-
creased uptake during the reparative phase),
and osteomyelitis (especially when a triple-
phase study is performed in conjunction
with a gallium or indium scan). Three-phase
(or even four-phase) studies may be helpful
for evaluating diseases such as complex re-
gional pain syndrome and osteomyelitis. The
three phases of a triple phase bone scan are
as follows:
• First phase (blood flow, immediate)—
FIGURE 2-5 Radiograph of a patient who has undergone This phase displays blood flow through the
bone transport for a large distal tibial segmental defect. arterial system.
This AP radiograph of the proximal tibia shows the • Second phase (blood pool, 30 minutes)—
regenerate of distraction osteogenesis; bone formation is This phase displays equilibrium of tracer
via intramembranous ossification. throughout the intravascular volume.
• Third phase (delayed, 4 hours)—This C. Computed Tomography (CT)—It continues to

phase displays the sites at which the tracer be important for evaluating many orthopae-
accumulates. dic areas. CT demonstrates bony anatomy
2. Gallium scan—Gallium 67 citrate localizes better than any other study. CT best dem-
in sites of inflammation and neoplasia onstrates joint incongruity following closed
probably because of exudation of labeled reduction of a dislocated hip. More recent
serum proteins. Delayed imaging (usually Multidetector CT (MDCT) uses more of the
24–48 hours or more) is required. Gallium x-ray beams to produce a much higher reso-
scan is frequently used in conjunction with a lution image.
bone scan—A “double tracer” technique. Gal- D. Measurement of Bone Density (Noninvasive
lium is less dependent on vascular flow than Methods)—Several methods are available for
technetium and may identify foci that would measuring bone density and assessing the risk
otherwise be missed. It is difficult to differen- of fracture. These methods may be particularly
tiate cellulitis from osteomyelitis on a gallium useful in geriatric patients with fractures related
scan. to decreased bone density.
3. Indium scan—Indium 111-labeled WBC’s 1. Single photon absorptiometry—The basic
(leukocytes) accumulate in areas of inflam- principle of this technique is that the density
mation and do not collect in areas of neo- of the cortical bone being tested is inversely
plasia. Indium scan is useful for evaluation of proportional to the quantity of photons pass-
acute infections (such as osteomyelitis). ing through it. The best use of single photon
4. Technetium-Labeled WBC Scan—Similar to in- absorptiometry is the appendicular skeleton
dium scan. (radius-diaphysis or distal metaphysis); the
B. Magnetic Resonance Imaging test cannot be reliably used for the axial skel-
1. Overview—Magnetic resonance imaging eton (due to alterations caused by the depth
(MRI) is an excellent study to evaluate the soft of the soft tissues).
tissues and bone marrow. It is used frequently 2. Dual photon absorptiometry—Similar to
to evaluate osteonecrosis, neoplasms, infec- single photon absorptiometry, dual photon
tion, and trauma. MRI allows both axial and absorptiometry is an isotope-based means of
sagittal representations. It is contraindicated measuring bone density. Dual photon absorp-
in patients with pacemakers, cerebral aneu- tiometry, however, allows for measurement
rysm clips, or shrapnel or hardware in certain of the axial skeleton and the femoral neck
locations. (the method accounts for the attenuation of
2. Specific applications of MRI the signal which is caused by the soft tissues
• Osteonecrosis—MRI is the most sensitive overlying the spine and the hip).
method for early detection of osteone- 3. Quantitative computed tomography—
crosis (detects early marrow necrosis and Allows preferential measurement of trabecu-
ingrowth of vascularized mesenchymal tis- lar bone density (the bone which is at the
sue) (tomography is the best method for greatest risk of early metabolic changes).
staging ON [of the hip]). MRI is highly spe- The technique involves the simultaneous
cific (98%) and reliable for estimating age scanning of phantoms of known density in
and extent of disease. T1 images demon- order to create a standard calibration curve.
strate diseased marrow as dark. MRI allows Precision is excellent; accuracy is within 5%
direct assessment of overlying cartilage. to 10%.
• Infection and trauma—MRI has excellent 4. Dual-Energy X-ray absorptiometry (DEXA)—
sensitivity to the increases in free wa- DEXA measures bone mineral content and
ter and demonstrates areas of infection soft-tissue composition by emitting X-ray
and fresh hemorrhage (dark on T1, and beams at two different energy levels, which
bright on T2 studies; postgadolinium T1- are differentially absorbed by different tis-
weighted image with fat suppression sues. By evaluating the difference in the abor-
showing a bright bone marrow signal bances of the two beams, the presence and
relative to the surrounding fat suggests density of target tissues, such as bone, can be
osteomyelitis). MRI is an excellent (accu- quantified. DEXA is the most reliable and
rate and sensitive) method for evaluat- accurate method of predicting fracture
ing occult fractures (particularly in the risk, and has a lower radiation dose than
elderly hip). quantitative CT.
VII. Complications of Fractures reflect the organisms present deep within

A. Delayed Union—Represents a fracture that has the wound and within bone).
failed to unite in the anticipated time frame but 2. Acute hematogenous osteomyelitis—Bone
continues to show some biologic activity. and bone marrow infection caused by blood
B. Nonunion (Fig. 2-6)—Represents a fracture with- borne organisms. Children are commonly af-
out clinical or radiographic evidence of healing fected (boys are more commonly affected
(and without evidence of the ability for progres- than girls). In children, the infection is most
sion to healing). common in the metaphysis or epiphysis of
1. Atrophic nonunion—These nonunions are the long bones and is more common in the
avascular and lack the biological capac- lower extremity than in the upper extremity.
ity to heal. The ends of the bone are typi- Radiographic changes of acute hematogenous
cally narrowed (such as a pencil point) and osteomyelitis include soft-tissue swelling
are avascular. The treatment of an atrophic (early), bone demineralization (10–14 days),
nonunion is stimulation of the local biologi- and sequestra (dead bone with surround
cal activity (such as with a bone graft or a granulation tissue) and involucrum (perios-
corticotomy for bone transport). teal new bone) later.
2. Hypertrophic nonunions—These nonunions • Adults, 21 years of age or older—The most
are hypervascular and possess the biologi- common organism is Staphylococcus au-
cal capacity to heal but lack mechanical reus, but a wide variety of other organisms
stability. The ends of the bone are typically have been isolated. Initial empiric therapy
hypertrophied, and they give the appearance includes nafcillin, oxacillin, or cefazolin;
that the fracture has “attempted to heal.” vancomycin can be used as an alternative
The treatment of a hypertrophic nonunion initial therapy.
is to add further mechanical stability (such • Sickle cell anemia—Salmonella is a charac-
as with plate and screw fixation); bone graft- teristic organism. The primary treatment
ing is not needed. The initial biological is with one of the fluoroquinolones (only
response of a hypertrophic nonunion to in adults); alternative treatment is with a
plate stabilization is mineralization of third generation Cephalosporin.
fibrocartilage. • Hemodialysis patients and intravenous
3. Oligotrophic nonunions—Have an adequate drug abusers—S. aureus, S. epidermidis,
blood supply but little or no callus forma- and Pseudomonas aeruginosa are common
tion. Oligotrophic nonunions arise from in- organisms. The treatment of choice is one
adequate reduction with displacement at the of the penicillinase-resistant semisynthetic
fracture site. The treatment of an oligotro- penicillins (PRSPs) plus Ciprofloxacin; an
phic nonunion is reduction to obtain contact alternative treatment is vancomycin with
between bone ends and mechanical stability. Ciprofloxacin.
4. Infected nonunions—Nonunions associated 3. Acute osteomyelitis (following open fracture
with a chronic infection of bone. The treat- or following open reduction with internal fixa-
ment of an infected nonunion focuses first on tion)—Clinical findings may be similar to that
eliminating the infection and then on healing of acute hematogenous osteomyelitis. Treat-
the bone. ment includes radical irrigation and debride-
C. Malunion (see Chapter 3, Principles of Deformities) ment with removal of orthopaedic hardware
D. Bone Infections as necessary. Open wounds may require
1. Introduction—Osteomyelitis is an infection of rotational or free flaps. The most common
bone and bone marrow which may be caused offending organisms are S. aureus, P. aerugi-
by direct inoculation of an open traumatic nosa, and coliforms. Empiric therapy prior to
wound or by blood borne organisms (hema- definitive cultures is Nafcillin with Ciproflox-
togenous). It is not possible to predict the acin; alternative therapy is Vancomycin with
microscopic organism that is causing os- a third generation Cephalosporin. Patients
teomyelitis based on the clinical picture with acute osteomyelitis and vascular insuf-
and the age of the patient; therefore, a spe- ficiency and those who are immunocompro-
cific microbiologic diagnosis via deep cul- mised generally show a polymicrobic picture.
tures with sampling from multiple foci is 4. Chronic osteomyelitis—May arise as a result
essential (organisms isolated from sinus of an inappropriately treated acute osteomy-
tract drainage typically do not accurately elitis, trauma, or soft-tissue spread, especially
C
A B
E F
FIGURE 2-6 A. AP radiograph and (B) clinical photograph of a 59-year-old man with a grossly infected nonunion of the
right distal tibia. C. Intraoperative radiograph following segmental bony resection of infected and necrotic bone.
D. Sequence of radiographs during proximal-to-distal bone transport. E. Final radiograph showing solid bony union.
F. Clinical photographs showing full weightbearing and excellent range of knee and ankle motion.
33
in the Cierney Type C elderly host, the immu- osteomyelitis or may occasionally develop in
nosuppressed, diabetics, and IV drug abus- a fracture hematoma. Unlike acute osteomy-
ers. Chronic osteomyelitis may be classified elitis, WBC count and blood cultures are fre-
anatomically (Fig. 2-7). Skin and soft tissues quently normal. Erythrocyte sedimentation
are often involved and the sinus tract may rate (ESR), bone cultures, and radiographs
occasionally develop into squamous cell are often useful. Subacute osteomyelitis most
carcinoma. Periods of quiescence (of the in- commonly affects the femur and tibia; and
fection) are often followed by acute exacer- unlike acute osteomyelitis, it can cross the
bations. Nuclear medicine studies are often physis even in older children.
helpful for determining the activity of the 6. Chronic sclerosing osteomyelitis—An un-
disease. Operative sampling of deep speci- usual infection that involves primarily di-
mens from multiple foci is the most accu- aphyseal bones of adolescents. Typified by
rate means of identifying the pathologic intense proliferation of the periosteum lead-
organisms. A combination of IV antibiotics ing to bony deposition, it may be caused
(based on deep cultures), surgical debride- by anaerobic organisms. Insidious onset,
ment, bone grafting, and soft-tissue coverage dense progressive sclerosis on radiographs,
is often required. Unfortunately, amputations and localized pain and tenderness are com-
are still required in certain cases. S. aureus, mon. Malignancy must be ruled out. Surgi-
Enterobacteriaceae, and P. aeruginosa are the cal and antibiotic therapies are usually not
most frequent offending organisms. Treat- curative.
ment is based on cultures and sensitivity 7. Chronic multifocal osteomyelitis—Caused
testing and empiric therapy is not indi- by an infectious agent, it appears in children
cated in chronic osteomyelitis. without systemic symptoms. Normal labora-
5. Subacute osteomyelitis—Usually discovered tory values, except for an elevated ESR, are
radiologically in a patient with a painful limp common. Radiographs demonstrate mul-
and no systemic (and often no local) signs tiple metaphyseal lytic lesions, especially in
or symptoms. Subacute osteomyelitis may the medial clavicle, distal tibia, and distal
arise secondary to a partially treated acute femur. Symptomatic treatment only is rec-
ommended because this condition usually
resolves spontaneously.
8. Osteomyelitis with unusual organisms—
Several unusual organisms occur in certain
clinical settings. Radiographs show charac-
teristic features in syphilis (Treponema pal-
lidum) (radiolucency in the metaphysis from
granulation tissue) and tuberculosis (joint
destruction on both sides of a joint). Histol-
ogy can also be helpful (e.g., tuberculosis
with granulomas).
Medullary Superficial
E. Complex Regional Pain Syndrome—A disorder
characterized by pain, hyperesthesia, tender-
ness of the extremity, as well as local irregu-
larities in blood flow, sweating, and edema. The
disorder involves an abnormality of the auto-
nomic nervous system, commonly following
trauma or surgery. Early clinical findings include
burning pain, and sensitivity, which is out of the
proportion to the traumatic or surgical insult.
Later changes include dystrophic changes to
the skin and soft tissues, which are progressive
and ultimately irreversible. Radiographic exami-
nation of the involved extremity shows diffuse
Localized Diffuse osteopenia. Treatment is with early recognition,
FIGURE 2-7 Cierny’s anatomic classification of adult aggressive physical therapy, and consideration
chronic osteomyelitis. of sympathetic blockade.
F. Heterotopic Ossification (HO)—Ectopic bone Lane JM, Suda M, von der Mark K, et al. Immunofluorescent
forms in the soft tissues, most commonly in re- localization of structural collagen types in endochondral
fracture repair. J Orthop Res. 1986;4:318–329.
sponse to an injury or a surgical dissection. Myo-
Neale HW, Stern PJ, Kreilein JG, et al. Complications of muscle-
sitis ossificans (MO) is a form of HO that occurs flap transposition for traumatic defects of the leg. Plast Re-
specifically when the ossification is in muscle. constr Surg. 1983;72:512–517.
Patients with traumatic brain injuries are par- Nelson CL, Green TG, Porter RA, et al. One day versus seven
ticularly prone to developing HO and recurrence days of preventive antibiotic therapy in orthopaedic sur-
gery. Clin Orthop. 1983;176:258–263.
following operative resection is likely if the neu-
Panjabi MM, Walter SD, Karuda M, et al. Correlation of radio-
rologic compromise is severe. Common sites of graphic analysis of healing fractures with strength: a sta-
posttraumatic HO include the elbow, hip, and tistical analysis of experimental osteotomies. J Orthop Res.
thigh; Injury Severity Score is correlated with 1985;3:212–218.
formation of HO following knee dislocation. Patzakis MJ, Wilkins J. Factors influencing infection rate in
open fracture wounds. Clin Orthop. 1989;343:36–40.
Irradiation (usually in doses of 700 rad) prevents
Seale KS. Reflex sympathetic dystrophy of the lower extremity.
proliferation and differentiation of primordial Clin Orthop Relat Res. 1989;243:80–85.
mesenchymal cells into osteoprogenitor cells Urist MR. Bone: formation by autoinduction. Science.
that can form osteoblastic tissue. Oral diphos- 1965;150:893–899.
phonates inhibit mineralization of osteoid, but Van de Putte KA, Urist MR. Osteogenesis in the interior of in-
tramuscular implants of decalcified bone matrix. Clin Orthop
do not prevent the formation of osteoid matrix;
Relat Res. 1965;43:257–240.
when the oral diphosphonate therapy is discon- Wahlig H, Dingeldein E, Bergmann R, et al. The release of genta-
tinued, mineralization with formation of HO may mycin from polymethylmethacrylate beads: an experimental
occur. and pharmacokinetic study. J Bone Joint Surg. 1978;60B:270.
G. Compartment Syndrome (see Chapter 1, Gen- Waters RL, Campbell JM, Perry J. Energy cost of three-point
crutch ambulation in fracture patients. J Orthop Trauma.
eral Principles of Trauma)
1987;1:170–173.
H. Neurovascular Injuries—Vary based on ana- Wood MB, Cooney WP III. Above elbow limp replantation: func-
tomic location (See specific chapters). Neuro- tional results. J Hand Surg. 1986;11A:682–687.
vascular injuries may arise as a result of the Wood MB, Cooney WP, Irons GB. Lower extremity salvage and
traumatic injury itself, or the surgical procedure reconstruction by free-tissue transfer: analysis of results.
Clin Orthop. 1985;201:151–161.
involved in treating the injury.
I. Avascular Necrosis—Incidence varies by in- Recent Articles
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chapters). docrine abnormalities in patients with nonunions. J Orthop
Trauma. 2007;21:557–570.
Cheng H, Jiang W, Phillips FM, et al. Osteogenic activity of
the fourteen types of human bone morphogenetic proteins
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Burchardt H. The biology of bone graft repair. Clin Orthop. tomography (QCT) of the forearm using general purpose
1983;174:28–42. spiral whole-body CT scanners: accuracy, precision and
Christian EP, Bosse MJ, Robb G. Reconstruction of large di- comparison with dual-energy X-ray absorptiometry (DXA).
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CHAPTER 3
Principles of Deformities
Joseph J. Gugenheim Jr.
I. Consequences of Lower Extremity Deformity • A deformity may consist of a component in
A. Although degenerative arthritis has multiple etiol- one, two, or three planes.
ogies, limb deformity may be one etiology due to: (a) A deformity with a component in more
1. Eccentric stress on joint than one plane is not a biplanar or triplanar
2. Shear stress on joint deformity; it is an oblique plane deformity.
B. Limb length inequality may cause: (b) The magnitude of the oblique plane de-
1. Increased energy consumption with gait formity is greater than the component of
2. Possible detrimental effect on hip and spine greatest magnitude in any of the three or-
(controversial) thogonal planes.
2. Direction (or orientation)
II. Skeletal Deformity Is a Vector
3. Location
A. Like all vectors, a deformity has three components:
B. Standardized radiographic techniques are neces-
1. Magnitude—The magnitude of a skeletal defor-
sary to measure the magnitude, direction, and lo-
mity has six components.
cation of the deformity.
• Three angulations—In a xyz three-dimensional
C. These three components can be used to accu-
coordinate system:
rately describe a deformity due to:
(a) Angulation in the xy (anteroposterior
1. Malunion
[AP]) plane is:
2. Acute fracture
• Varus
3. Developmental and congenital disorders
• Valgus
(b) Angulation in the yz (lateral) plane is: III. For accurate deformity correction, it is both neces-
• Apex anterior sary and sufficient to correct:
• Apex posterior A. AP Mechanical Axis of the Extremity
(c) Angulation in the xz plane is: B. Joint Orientation Angles in all Three Orthogonal
• Internal rotation Planes
• External rotation C. Limb length inequality
• Three translations—By convention in ortho-
pedics, the direction of translation of the IV. Mechanical Axis of the Lower Extremity
distal segment of the extremity with respect A. The mechanical axis of the lower extremity is a
to the proximal segment determines the straight line from the center of the hip to the cen-
direction. ter of the ankle on the AP radiograph (Fig. 3-1).
(a) Translation on the x-axis (AP plane) B. In a normal lower extremity, the mechanical axis
• Medial translation line intersects the knee at the center of the tibial
• Lateral translation spines or a maximum of 10 mm medial to the cen-
(b) Translation on the y-axis ter of the spines.
• Lengthening C. The distance in millimeters from the center of the
• Shortening tibial spines to the mechanical axis is mechanical
(c) Translation on the z-axis (lateral plane) axis deviation (MAD) (Fig. 3-2).
• Anterior translation 1. Medial MAD is varus.
• Posterior translation 2. Lateral MAD is valgus.
37
D. Standardized radiographic imaging technique to

insure accuracy and reproducibility requires:
1. A 51- 14-in cassette with a variable grid to
visualize the hip, knee, and ankle joints
2. A distance of 10 ft from the beam source to the
film to minimize magnification and distortion,
with the beam centered at the knee
3. Patient weight bearing, with weight equally dis-
tributed on both feet (Fig. 3-3)
• Patellas straightforward.
• Knees fully extended.
• If there is a limb length discrepancy, a block
should be placed under the shorter extrem-
ity to level the pelvis and to keep the knees
extended with weight evenly distributed.
4. Magnification can be calculated precisely by
affixing a 30-mm ball bearing at the level of
FIGURE 3-1 Mechanical axis of the lower extremity,

which normally lies 0 to 10 mm medial to the knee joint
center. (Adapted with permission from Brinker MR,
O’Connor DP. Principles of malunions. In: Bucholz, RW,
Court-Brown CM, Heckman JD, et al., eds. Rockwood
and Green’s Fractures in Adults. 7th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2010.)
30 mm
FIGURE 3-3 Bilateral weight-bearing 51-in AP alignment

FIGURE 3-2 Medial mechanical axis deviation. (Reprinted radiograph. (Reprinted with permission from Brinker
with permission from Brinker MR, O’Connor DP. Principles of MR, O’Connor DP. Principles of malunions. In: Bucholz,
malunions. In: Bucholz, RW, Court-Brown CM, Heckman JD, RW, Court-Brown CM, Heckman JD, et al., eds. Rockwood
et al., eds. Rockwood and Green’s Fractures in Adults. 7th ed. and Green’s Fractures in Adults. 7th ed. Philadelphia, PA:
Philadelphia, PA: Lippincott Williams & Wilkins, 2010.) Lippincott Williams & Wilkins, 2010.)
C H A P T E R 3 | P R I N C I P L E S O F D E F O R M I T I E S 39
the bone and measuring the image of the ball 3. The pelvis is rotated slightly to avoid superim-
bearing with calipers. Placing the ball bear- posing both lower extremities.
ing or a ruler with radiopaque graduations on 4. The imaged knee is in maximum extension.
the cassette will not facilitate measurement of
V. Axes of the Femur and Tibia
magnification because they are closer to the
A. AP Mechanical Axes of the Femur and Tibia—In
film than the bone.
addition to the mechanical axis of the lower ex-
E. There is no similarly defined mechanical axis of
tremity, there are mechanical axes of the femur
the lower extremity in the sagittal plane (lateral
and the tibia. In the normal lower extremity, the
view) because the knee flexes and extends during
mechanical axis of the femur and the mechanical
the gait cycle. However, the following technique
axis of the tibia coincide with the mechanical axis
is used to obtain an image orthogonal to the AP
of the lower extremity. Just as normal mechanical
view (Fig. 3-4).
axis of the lower extremity (colinearity of the hip,
1. The patella is directed lateral, 90° to the posi-
knee, and ankle) is necessary but not sufficient for
tion on the AP view.
accurate deformity correction, superimposable
2. Only one extremity can be imaged on a 51-
mechanical axes of the femur and tibia with the
14-in film.
mechanical axis of the lower extremity are nec-
essary but not sufficient for accurate deformity
correction.
1. The AP mechanical axis of the femur is a straight
line from the center of the hip to the center of
the knee (Fig. 3-5).
FIGURE 3-5 The mechanical axis of a long bone is

defined as the line that passes through the joint centers
FIGURE 3-4 51-in lateral alignment radiograph. of the proximal and distal joints. The mechanical axis
(Reprinted with permission from Brinker MR, O’Connor of the femur is shown here. (Reprinted with permission
DP. Principles of malunions. In: Bucholz, RW, Court-Brown from Brinker MR, O’Connor DP. Principles of malunions.
CM, Heckman JD, et al., eds. Rockwood and Green’s In: Bucholz, RW, Court-Brown CM, Heckman JD, et al.,
Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott eds. Rockwood and Green’s Fractures in Adults. 7th ed.
Williams & Wilkins, 2010.) Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
2. The AP mechanical axis of the tibia is a straight

line from the center of the knee to the center of
the ankle (Fig. 3-6).
B. Anatomic Axes of the Femur and Tibia—The ana-
tomic axis of any long bone is a line formed by a
series of mid-diaphyseal points. It is the site of a
straight intramedullary nail.
1. AP femoral anatomic axis—The AP femoral ana-
tomic axis is a straight line from the piriformis
fossa, extending distally in the diaphysis to a
point approximately 10 mm medial to the center
of the knee in an average adult (approximately,
the intersection of the concave intercondylar
notch with the convex medial femoral condyle)
(Fig. 3-7).
2. AP tibial anatomic axis—The AP tibial anatomic
axis is a straight line formed by a series of mid-
diaphyseal points. It is parallel to the lateral
tibial cortex, approximately, 2 to 5 mm medial
to the mechanical axis. Because the AP tibial
mechanical and AP tibial anatomic axes are so
close, they can be considered identical (Fig. 3-8).
3. Lateral femoral anatomic axis—Because of the
normal bow of the femur in the lateral plane,
FIGURE 3-7 AP Anatomic axis of the femur. (Reprinted

with permission from Brinker MR, O’Connor DP.
Principles of malunions. In: Bucholz, RW, Court-Brown
CM, Heckman JD, et al., eds. Rockwood and Green’s
Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2010.)
a series of mid-diaphyseal points will not define

a straight line. For deformity analysis, a best-fit
straight line can be drawn for the proximal or
distal segment of the femur. The intersection of
the proximal and distal segments forms a 10°
angle, apex anterior.
4. Lateral tibial anatomic axis—The lateral tibial
anatomic axis is a series of mid-diaphyseal
points parallel to the anterior cortex of the
tibia. The lateral tibial mechanical and ana-
tomic axes can be considered identical.
C. It is only necessary to differentiate between the
AP anatomic femoral axis and the AP mechanical
femoral axis. For deformity analysis, the lateral
femoral axis, AP tibial axis, and lateral tibial axis
can be considered to be a straight line formed by a
FIGURE 3-6 The mechanical axis of the tibia. (Reprinted series of mid-diaphyseal points, without differenti-
with permission from Brinker MR, O’Connor DP. ating between anatomic and mechanical methods.
CM, Heckman JD, et al., eds. Rockwood and Green’s VI. Joint Orientation—Normal joint orientation, as mea-
Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott sured by the joint orientation angle, is also neces-
Williams & Wilkins, 2010.) sary but not sufficient for correction of deformity.
mLPFA
aMPFA
B
FIGURE 3-8 AP Anatomic axis of the tibia. (Reprinted
with permission from Brinker MR, O’Connor DP.
CM, Heckman JD, et al., eds. Rockwood and Green’s FIGURE 3-9 A. The joint orientation line from the tip
Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott of the greater trochanter to the center of the femoral
Williams & Wilkins, 2010.) head and the mechanical axis of the femur describe the
mechanical Lateral Proximal Femoral Angle. B. The joint
orientation line from the tip of the greater trochanter
The joint orientation angle is the angle formed
to the center of the femoral head and the anatomic axis
by the intersection of the joint orientation line with of the femur describe the anatomic Medial Proximal
the axis (either anatomical or mechanical) of the Femoral Angle. (Reprinted with permission from Brinker
respective bone. MR, O’Connor DP. Principles of malunions. In: Bucholz,
A. Joint Orientation Lines RW, Court-Brown CM, Heckman JD, et al., eds. Rockwood
1. AP plane and Green’s Fractures in Adults. 7th ed. Philadelphia, PA:
• Proximal femur Lippincott Williams & Wilkins, 2010.)
(a) Tip of the greater trochanter to the cen-
ter of the femoral head (Fig. 3-9), or • Proximal tibia—A line across the subchon-
(b) Longitudinal axis of the femoral neck dral bone of the tibial plateau (Fig. 3-15)
(Fig. 3-10) • Distal tibia—A line between the anterior
• Distal femur—A straight line tangential to and posterior corners of the distal tibia
the femoral condyles (Fig. 3-11) (Fig. 3-16)
• Proximal tibia—A straight line from the me- B. Joint Orientation Angles
dial corner to the lateral corner of the tibial 1. The angles are abbreviated by five letters:
plateau (Fig. 3-12) • The first letter is a lower case a or m, which
• Distal tibia—A line across the subchondral designates anatomic or mechanical.
bone of the ankle mortise (Fig. 3-13) • The second letter is M (medial), L (lateral),
2. Lateral plane A (anterior), or P (posterior), which desig-
• Proximal femur—Neck–shaft angle is rarely nates the location of the angle with respect
used in the lateral plane. to the axis of the bone so that the normal
• Distal femur—A line connecting the anterior value of the joint orientation angle is 90°
and posterior extent of the distal femoral phy- or less. This nomenclature is not used for
sis or the site of the closed physis (Fig. 3-14) the femoral neck–shaft angle because of the
NSA
mLDFA aLDFA
A B
FIGURE 3-10 The longitudinal axis of the femoral

neck and the anatomic axis of the femur describe the
medial neck–shaft angle. (Reprinted with permission FIGURE 3-11 A. The distal femoral joint orientation
from Brinker MR, O’Connor DP. Principles of malunions. line and the mechanical axis of the femur describe the
In: Bucholz, RW, Court-Brown CM, Heckman JD, et al., mechanical Lateral Distal Femoral Angle. B. The distal
eds. Rockwood and Green’s Fractures in Adults. 7th ed. femoral joint orientation line and the anatomic axis of the
Philadelphia, PA: Lippincott Williams & Wilkins, 2010.) femur describe the anatomic Lateral Distal Femoral Angle.
(Reprinted with permission from Brinker MR, O’Connor
DP. Principles of malunions. In: Bucholz, RW, Court-Brown
longstanding traditional method of measur- CM, Heckman JD, et al., eds. Rockwood and Green’s
ing the relationship between the femoral Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott
neck and shaft as the larger of the two sup- Williams & Wilkins, 2010.)
plementary angles at this site.
• The third letter is P (proximal) or D (distal).
• The fourth letter is F (femur) or T (tibia). (d) Lateral distal tibial angle (LDTA) 89°
• The final letter is A, the abbreviation for (range, 86° to 92°) (Fig. 3-13)
angle. • AP plane (anatomic)
• Usually a (anatomic) or m (mechanical) is (a) Medial neck–shaft angle (NSA) 130°
only used at the distal femur in which the (range, 124° to 136°) (Fig. 3-10)
aLDFA and mLDFA differ by 7°. (b) Medial proximal femoral angle (aMPFA)
2. The normal values and ranges of normal are: 84° (range, 80° to 89°) (Fig. 3-9)
• AP plane (mechanical) (c) Anatomic lateral distal femoral angle
(a) Lateral proximal femoral angle (aLDFA) 81° (range, 79° to 83°) (Fig. 3-11)
(mLPFA) 90° (range, 85° to 95°) (Fig. 3-9) (d) In the tibia, the anatomic and mechani-
(b) Mechanical lateral distal femoral an- cal joint orientation angles can be con-
gle (mLDFA) 88° (range, 85° to 90°) sidered identical.
(Fig. 3-11) • Sagittal plane
(c) Medial proximal tibial angle (MPTA) (a) The proximal femoral joint orientation
87° (range, 85° to 90°) (Fig. 3-12) angle is rarely used.
MPTA
LDTA
FIGURE 3-13 The distal tibial joint orientation line and

the mechanical axis of the tibia describe the Lateral
FIGURE 3-12 The proximal tibial joint orientation line Distal Tibial Angle. (Reprinted with permission from
and the mechanical axis of the tibia describe the Medial Brinker MR, O’Connor DP. Principles of malunions.
Proximal Tibial Angle. (Reprinted with permission from In: Bucholz, RW, Court-Brown CM, Heckman JD, et al.,
Brinker MR, O’Connor DP. Principles of malunions. eds. Rockwood and Green’s Fractures in Adults. 7th ed.
In: Bucholz, RW, Court-Brown CM, Heckman JD, et al., Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
eds. Rockwood and Green’s Fractures in Adults. 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
cortices at the proximal tibial joint orienta-

(b) Posterior distal femoral angle (PDFA)
tion line (Fig. 3-15).
83° (range, 79° to 87°) (Fig. 3-14)
• Anterior distal tibial angle (ADTA) 80°
• Although this angle is formed by the
(range, 78° to 82°) Fig. 3-16)
intersection of the anatomic axis of
Normally, the anatomic axis intersects the
the femur with the distal femoral joint
distal tibial joint orientation angle at a line
orientation line, it is not preceded by
midway between the anterior and posterior
a (anatomic) because the mechanical
cortices at the distal tibial joint orientation
posterior distal femoral angle is never
line (Fig. 3-16).
used.
C. Other Considerations
• Normally, the anatomic axis inter-
1. AP plane—The femoral and tibial joint orien-
sects the distal femoral joint orienta-
tation lines should be parallel or intersect lat-
tion line at a point posterior to the
erally (valgus) at an angle of 2° or less (joint
anterior cortex by one third the dis-
convergence angle [JCA]) (Fig. 3-17).
tance between the anterior and pos-
2. Lateral plane—With the knee in maximum
terior cortices at the distal femoral
extension, the axis of the femur (or distal ex-
joint orientation line (Fig. 3-14).
tension of the anterior cortex) and the axis of
• Posterior proximal tibial angle (PPTA) 81°
the tibia (or proximal extension of the ante-
(range, 77° to 84°) (Fig. 3-15).
rior cortex) should form an angle of 0° (lateral
Normally, the anatomic axis intersects the
femoral–tibial angle [LFTA]).
proximal tibial joint orientation line poste-
rior to the anterior cortex by one-fifth the VII. Identification of the Presence of Lower Extrem-
distance between the anterior and posterior ity Skeletal Deformity—The following sequence is
PPTA
PDFA
FIGURE 3-14 The lateral view distal femoral joint

orientation line and the anatomic axis of the femur
describe the Posterior Distal Femoral Angle. (Reprinted FIGURE 3-15 The lateral view proximal tibial joint
with permission from Brinker MR, O’Connor DP. orientation line and the anatomic axis of the femur
Principles of malunions. In: Bucholz, RW, Court-Brown describe the Posterior Proximal Tibial Angle. (Reprinted
CM, Heckman JD, et al., eds. Rockwood and Green’s with permission from Brinker MR, O’Connor DP.
Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Principles of malunions. In: Bucholz, RW, Court-Brown
Williams & Wilkins, 2010.) CM, Heckman JD, et al., eds. Rockwood and Green’s
recommended to identify the presence of skeletal
deformity:
A. On the 51- 14-in AP radiograph, draw the me- 1. Proximal femur
chanical axis of the lower extremity from the • Tip of greater trochanter to center of femo-
center of the femoral head to the center of the ral head
ankle mortise. • Axis of femoral neck
B. Measure the MAD, the distance between the 2. Distal femur
center of the knee and the mechanical axis at 3. Proximal tibia
the level of the knee. 4. Distal tibia
1. MAD indicates presence of deformity. E. Measure the AP joint orientation angles and the
2. Absence of MAD does not indicate absence of AP joint convergence angles.
deformity. The mechanical axis may be nor- 1. NSA, mLPFA, aMPFA
mal in the presence of: 2. aLDFA and mLDFA
• Joint malorientation (abnormal joint orien- 3. MPTA
tation angles) at the hip, knee, or ankle 4. LDTA
• Compensatory angular deformities 5. JCA
C. On the AP radiograph, draw the mechanical axis F. Measure the effective total length discrepancy
of the femur, the anatomic axis of the femur, and by measuring the vertical distance between the
the axis of the tibia. horizontal lines drawn perpendicular to the film
D. Draw the joint orientation lines. edge to an easily visualized landmark on both
mLDFA = 87°
JLCA = 10°
MPTA = 80°
ADTA
FIGURE 3-16 The lateral view distal tibial joint

orientation line and the anatomic axis of the tibia
describe the Anterior Distal Tibial Angle. (Reprinted FIGURE 3-17 In this pathologic case, the joint line
with permission from Brinker MR, O’Connor DP. convergence angle is 10° medial (normal ≤2° lateral).
CM, Heckman JD, et al., eds. Rockwood and Green’s M. Deformity is present if there is any of the
following:
1. MAD lateral to or more than 10 mm medial to
the center of the knee
2. Abnormal joint orientation angle(s)
3. Abnormal JCA
extremities (femoral head, sacroiliac joint, or
4. Abnormal LFTA
iliac crest).
G. Measure the length of the femur from the su- VIII. Measurement of Angular Deformity: Magnitude,
perior aspect of the femoral head to the distal Location, and the Concept of CORA
femoral joint orientation line. A. The deformity resolution point for an angular
H. Measure the length of the tibia from the center deformity is called the center of rotation of an-
of the tibial spines to the center of the ankle gulation (CORA).
mortise. 1. The CORA and apex of the deformity may
I. On the lateral radiograph, draw the axes of the not be identical (Fig. 3-18).
femur and tibia. 2. The CORA differs from the apex if there is
J. On the lateral radiograph, draw the joint orienta- translation and/or more than one angular
tion lines. deformity.
K. Measure the lateral joint orientation angles. B. The CORA is the intersection of the proximal
1. PDFA axis with the distal axis of a deformed bone
2. PPTA (Fig. 3-19).
3. ADTA C. The angle formed by the intersection of the
L. Measure the LFTA. proximal and distal axes is the magnitude of
CORA
Bisector
CORA
Apex of
deformity
FIGURE 3-19 CORA and bisector for a varus angulation
deformity of the tibia. (Reprinted with permission from
Brinker MR, O’Connor DP. Principles of malunions.
In: Bucholz, RW, Court-Brown CM, Heckman JD, et al.,
eds. Rockwood and Green’s Fractures in Adults. 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
FIGURE 3-18 Apex of the deformity and CORA are IX. Measurement of AP Plane Angular Deformity
different in this case, due to posterior translation of the
A. Femur—In the AP plane, either the mechanical
distal fragment.
or anatomic axis planning method may be used.
Theoretically, the two methods should yield
the angular deformity in the plane in which the identical results for the magnitude and level of
deformity is being measured. the deformity. The two methods must not be
D. The level at which the axes intersect at the mixed for measuring the AP femoral angulation,
CORA is the level or location of the deformity. that is, using the distal femoral mechanical axis
E. The three angular components in the three or- with the proximal femoral anatomic axis or vice
thogonal planes determine the magnitude of versa. Since one of the two goals (see III. A and B)
the resultant angle in an oblique plane, which of deformity correction is to restore the mechan-
differs from the orthogonal planes. ical axis, it is preferable to use the mechanical
F. There is an infinite number of CORAs for an an- axis method if possible. If portable intraopera-
gular deformity. Any point on the bisector line tive radiographs do not include the entire femur
of the supplementary angle to the angle of de- or if the deformity is purely diaphyseal, such as a
formity is a CORA (Fig. 3-19). diaphyseal malunion, the anatomic axis method
1. Points on the concavity of the deformity are may be used.
shortening CORAs. 1. AP femur—mechanical axis method
2. Points on the convexity of the deformity are • Draw the proximal femoral axis.
lengthening CORAs. (a) If the contralateral femur is normal, draw
3. A mid-diaphyseal CORA is a neutral CORA. a line from the center of the femoral
G. A line perpendicular to the plane of the defor- head extending distally to form a LPFA
mity, passing through the CORA, is called the equal to the LPFA of the normal femur.
axis of correction of angulation (ACA). When us- (b) If the contralateral femur is abnormal,
ing a hinged external fixator to correct angula- draw a line from the center of the fem-
tion, the ACA is the axis of the hinge (Fig. 3-20). oral head extending distally to form
• Draw the distal femoral mechanical axis.
(a) If the ipsilateral tibia is normal, extend
the tibial mechanical axis proximally.
(b) If the ipsilateral tibia is abnormal and
the contralateral femur is normal, draw
a line extending proximally from the
center of the intercondylar notch to
Osteotomy form a mLDFA equal to the contralateral
extremity.
(c) If the ipsilateral tibia and contralateral
femur are abnormal, draw a line extend-
ing proximally from the center of the
CORA/ axis
of correction
intercondylar notch to form a mLDFA
equal to 88° (population normal value).
• The intersection point of the proximal and
distal axes is the CORA. The angle formed
by the intersection of the axes defines the
magnitude of the angular deformity. The
level of the intersection of the axes identi-
fies the location.
2. AP femur—anatomic axis method.
• Draw the proximal anatomic axis.
(a) Long segment—Draw a straight line
connecting a series of mid-diaphyseal
points.
(b) Short segment—If the proximal femur
(head, neck, and greater trochanter) is
normal, the following method is used:
• If the contralateral femur is normal,
draw a line extending distally from the
proximal femoral joint orientation line
to form an aMPTA equal to the contra-
FIGURE 3-20 When the ACA passes through the opening lateral femur.
wedge CORA on the convex cortex, an opening wedge • If the contralateral femur is abnormal,
angulation results. (Reprinted with permission from draw a line extending distally from the
Brinker MR, O’Connor DP. Principles of malunions. In:
proximal femoral joint orientation line
Bucholz, RW, Court-Brown CM, Heckman JD, et al., eds.
Rockwood and Green’s Fractures in Adults. 7th ed.
to form an aMPFA equal to 84° (popu-
Philadelphia, PA: Lippincott Williams & Wilkins, 2010.) lation normal).
• If the proximal segment is too short
to draw a mid-diaphyseal line and the
a LPFA equal to 90° (population normal proximal femur is abnormal, use the
value). mechanical axis method.
(c) If the femoral head and/or neck is ab- • Draw the distal anatomic axis.
normal or the patient is skeletally imma- (a) Long segment—Draw a line connecting
ture with incomplete ossification of the a series of mid-diaphyseal points. Mea-
greater trochanter, draw a line through sure aLDFA to identify any hidden addi-
the center of the femoral head, extend- tional juxtaarticular deformity.
ing distally parallel to the anatomic axis. (b) Short segment—If the distal segment
Then draw a line through the center of is too short to draw a straight line
the head lateral to the first line drawn connecting a series of mid-diaphyseal
through the center of the head to form points and/or the aLDFA is abnormal,
an angle of 7° (the difference between the following method is used:
the anatomic distal joint orientation an- • If the contralateral femur is normal,
gle and the mechanical distal joint orien- draw a line extending proximally
tation angle). The latter line represents from the distal femoral joint orienta-
the proximal femoral mechanical axis. tion line, starting at a point medial to
the center of the intercondylar notch the center of the ankle mortise to form
identical to the contralateral femur to a LDTA equal to 89° (population normal
form an aLDFA identical to the contra- value).
lateral femur. 3. The intersection point of the proximal and dis-
• If the contralateral femur is abnormal, tal axes is the CORA.
draw a line extending proximally from
the distal femoral joint orientation X. Measurement of Lateral Plane Angular Deformity.
line starting at a point 1 cm medial to A. Femur
the center of the intercondylar notch 1. Proximal axis—Draw a straight line connecting
to form an aLDFA equal to 81° (popu- a series of mid-diaphyseal points of the proxi-
lation normal value). mal and distal segments. Because there is a
• The intersection point of the proximal and normal femoral bow in the sagittal plane, these
distal axes is the CORA. lines are drawn as best fit lines. The normal
B. Tibia—Since the mechanical and anatomic axes angle of intersection is 10° apex anterior.
of the tibia are essentially identical, it is not nec- 2. Distal axis
essary to describe two different methods. • Long segment—Draw a straight line con-
1. Draw the proximal axis. necting a series of mid-diaphyseal points.
• Long segment—Draw a line connecting a se- Measure the PDFA to identify any hidden ad-
ries of mid-diaphyseal points. Measure the ditional juxtaarticular deformity.
MPTA at the knee to identify any hidden ad- • Short segment—If the distal segment is too
ditional juxtaarticular deformity. short to measure a series of mid-diaphyseal
• Short segment—If the proximal segment is lines and/or the PDFA is abnormal, the fol-
too short to draw a straight line connecting lowing method is used:
a series of mid-diaphyseal points and/or the (a) If the contralateral femur is normal,
MPTA is abnormal, the following method is draw a line extending proximally from
used: the distal femoral joint orientation line,
(a) If the ipsilateral femur is normal, extend starting at a point one-third the width of
the distal femoral mechanical axis dis- the femur at the level of the joint orien-
tally through the proximal tibia. tation line to form a PDFA equal to the
(b) If the ipsilateral femur is abnormal and opposite side.
the contralateral tibia is normal, draw a (b) If the contralateral femur is abnormal,
line extending distally from the center draw a line extending proximally from
of the tibial spines to form a MPTA equal the joint orientation line as described
to the contralateral side. above to form a PDFA equal to 83° (pop-
(c) If the ipsilateral femur is abnormal and ulation normal value).
the contralateral tibia is abnormal, draw 3. The intersection point of the proximal and dis-
a line from the center of the tibial spine tal axes is the CORA.
extending distally to form a MPTA equal B. Tibia
to 87° (population normal value). 1. Proximal axis
2. Draw the distal axis. • Long segment—Draw a straight line con-
• Long segment—Draw a straight line connect- necting a series of mid-diaphyseal points.
ing a series of mid-diaphyseal points. Mea- Measure the PPTA at the knee to identify the
sure the LDTA at the ankle joint to identify any presence of any hidden additional juxtaar-
hidden additional juxtaarticular deformity. ticular deformity.
• Short segment—If the distal segment is too • Short segment—If the proximal segment
short to draw a straight line connecting a is too short to draw a mid-diaphyseal line
series of mid-diaphyseal points and/or the and/or the PPTA is abnormal, the following
LDTA is abnormal, the following method is method is used:
used: (a) If the contralateral tibia is normal,
(a) If the contralateral tibia is normal, draw draw a line extending distally from the
a line extending proximally from the proximal tibial joint orientation line
center of the ankle mortise to form a starting at a point one-fifth the width
LDTA equal to the opposite side. of the tibial plateau at the joint orienta-
(b) If the contralateral tibia is abnormal, tion line to form a PPTA identical to the
draw a line extending proximally from opposite side.
(b) If the contralateral tibia is abnormal, the axis (either mechanical or anatomic) of one
draw a line extending distally as de- segment to a point on the axis of the other seg-
scribed above from the proximal joint ment (Fig. 3-21).
orientation line to form a PPTA equal to 1. In a fracture, the point from which the per-
81° (population normal value). pendicular line is drawn on the first frag-
2. Distal axis ment is usually the proximal end of the distal
• Long segment—Draw a straight line connect- fragment since, by convention, orthopedic
ing a series of mid-diaphyseal points. Mea- deformities are described as the distal frag-
sure the ADTA to identify the presence of any ment with respect to the proximal (reference)
hidden additional juxtaarticular deformity. fragment.
• Short segment—If the distal segment is too 2. Translation can also be measured as the
short to draw a line connecting a series of perpendicular distance from a point on the
mid-diaphyseal points and/or the ADTA is proximal fragment to the axis of the distal
abnormal, the following method is used: (reference) fragment.
(a) If the contralateral tibia is normal, draw B. If angulation is also present, the magnitude of
a line extending proximally from the dis- translation will vary, depending on the choice of
tal tibial joint orientation line starting at the reference fragment or the location at which
a midway between the anterior and pos- it is measured. The choice of the reference frag-
terior corners of the distal tibia at the ment and the effect on the magnitude of transla-
distal joint orientation angle to form an tion is relevant when using a hexapod external
ADTA equal to the opposite tibia. fixator (Taylor Spatial Frame).
(b) If the contralateral tibia is abnormal,
draw a line extending proximally from
the distal tibial joint orientation, start-
ing at a point midway between the ante-
rior and posterior corners of the distal
tibia on the distal joint orientation line
to form an ADTA equal to 80° (popula-
tion normal value).
3. The intersection point of the proximal and dis-
tal axes is the CORA.
XI. Measurement of Horizontal Plane Angular Deformity Translation = 20 mm

(Axial Rotation)
A. Radiographic Methods—computerized tomog-
raphy
B. Clinical Methods—physical examination
1. Femur
• Measure hip rotation with the hip extended
and the patient prone.
• In the normal adult, internal and external
rotations are approximately equal.
• Half the difference between internal and ex-
ternal rotation is an approximation of femo-
ral axial rotation.
• The accuracy of this method can be affected
FIGURE 3-21 Method for measuring the magnitude
by intraarticular hip pathology or juxtaar- of translational deformities. In this example, with
ticular distal femoral or proximal tibial an- both angulation and translation, the magnitude of the
gular deformity. translational deformity is the horizontal distance from the
2. Tibia—The foot–thigh angle (as viewed from proximal segment’s anatomic axis to the distal segment’s
above with the patient prone and the knee anatomic axis at the level of the proximal end of the distal
flexed 90°) is an estimate of tibial rotation. segment. (Reprinted with permission from Brinker MR,
O’Connor DP. Principles of malunions. In: Bucholz, RW,
XII. Measurement of Translation Court-Brown CM, Heckman JD, et al., eds. Rockwood
A. The magnitude of translation in millimeters is and Green’s Fractures in Adults. 7th ed. Philadelphia, PA:
the length of the line drawn perpendicular from Lippincott Williams & Wilkins, 2010.)
XIII. Measurement of Orientation of Deformity: Oblique by drawing two perpendicular lines.

Plane Deformity The length of the horizontal line
represents the magnitude of the AP
If an angular and/or translation deformity exists in
angular deformity. The length of the
the AP (xy) plane and lateral (yz) plane, the defor-
vertical line represents the magni-
mity is an oblique plane deformity, not a biplanar
tude of the lateral angular deformity.
deformity. The deformity is in a single plane; it is
The magnitude of the oblique plane
just not in the AP or lateral plane. The plane of
angular deformity is the length of
the deformity is the plane in which the deformity
the resultant line, the diagonal of the
is a maximum. This oblique plane determines the
rectangle formed by the two perpen-
orientation of the deformity, as measured by the
dicular lines (Fig. 3-22 and 3-23).
angle between this oblique plane and the AP (xy)
(b) Trigonometric method
plane. There is a plane orthogonal (perpendicular)
• Yields the exact magnitude of the an-
to this oblique plane of maximum deformity where
gular deformity in the oblique plane.
there is no deformity.
• Calculated from the equation
A. Oblique Plane Angular Deformity
1. Magnitude
θ tan1 √ tan2θAP tan2θlat
• Magnitude of the oblique plane angular
deformity can be determined by either the where tan1 arc tangent
graphic or the trigonometric method. tan the tangent of the angle of de-
(a) Graphic method formity in the AP and lateral
• Based on the Pythagorean theorem planes
• The graphic method is easier and
θ = θ 2AP + θ 2lat yields an approximation that is usu-
ally within two degrees of the true
where θ the magnitude of true deformity for physiologic angular
or resultant angle in the deformities.
oblique plane 2. Orientation—The oblique plane (the plane of
θAP the magnitude of the angular maximum angulation) can be determined by
deformity AP plane either the graphic or trigonometric method.
θlat the magnitude of the angular • Graphic method—Similar to the magnitude
deformity lateral plane of the oblique plane angulation, the orien-
• Using the graphic method, θ can be tation calculated by the graphic method
measured without any calculation is only an approximation but is quite
Anterior Lateral (pr)

A
AL
25
°
32
L=
20°
OB
25°
51°
20
M L
(vl) (vr)
P
(re)
FIGURE 3-22 Graphic method for determining deformity FIGURE 3-23 Graphic method for determining deformity
magnitude. orientation.
accurate within the range of physiologic where β the orientation of the oblique
deformities. plane of the translation defor-
(a) Similar to the method discussed earlier mity, the angle between the
for measuring θ, can be measured us- oblique plane and the AP plane
ing the graphic method without any
calculation by drawing two perpen- • The angle β can be measured without any
dicular lines. The angle between the calculations by drawing two perpendicular
resultant diagonal line and the horizon- lines as described in the last bullet of sec-
tal line is the orientation of the oblique tion XIII.B.1. The angle β is the angle be-
plane deformity (Fig. 3-23). tween this resultant diagonal line and the
• Trigonometric method—Yields the exact horizontal line.
orientation in the oblique plane. • Oblique plane angular deformity may exist
The equation for calculating the plane of with or without oblique plane translation
the deformity is deformity, and vice versa.
• The orientation of the oblique plane an-
tan θlat gular deformity α and the orientation of
α = tan −1 the oblique plane translation deformity
tan θ AP
β may differ, especially in high-energy
trauma.
B. Oblique Plane Translation Deformities
1. Magnitude of translation deformities XIV. Deformity Correction Truisms
• If a translation deformity is visualized on A. Any angular deformity (with or without trans-
both the AP and lateral radiographs, there lation) can be accurately corrected by rotating
is a translation deformity in an oblique around the ACA through the CORA.
plane of maximum translation. There 1. An osteotomy at the level of the CORA needs
is a plane at 90° to this plane with no only to be angulated, not translated.
translation. 2. An osteotomy performed at a level other
• Unlike oblique plane angular deformity than the CORA and rotated around the ACA
calculations, the graphic method for at the osteotomy site must be angulated and
oblique plane translation deformity is not translated at the osteotomy site to achieve
an approximation but yields the exact accurate correction. This level of osteotomy
magnitude. at a level other than the CORA may be desir-
• The graphic method equation is based on able due to:
the Pythagorean theorem • Soft tissue pathology at the CORA
• Hardware considerations of external
fixation equipment or internal fixation
t = t AP
2
+ t lat
2
implants
3. As the distance between the osteotomy
where t true translation in mm
and CORA increases, increasing amounts of
tAP the translation in mm on the AP view
translation must be performed.
tlat the translation in mm on the lateral
4. The amount of translation can be calculated
view
• Using the graphic method, t can be mea- 2π rθ
t=
sured without any calculation by drawing 360
two perpendicular lines. The length of the
horizontal line represents the magnitude where r the distance from the CORA to the
of the translation. The length of the verti- osteotomy
cal line represents the lateral translation. q the magnitude of angulation
The magnitude of the oblique plane trans- The equation can be simplified to t 0.017rq.
lation is the length of the resultant line, the
diagonal of the rectangle formed by the 5. If an osteotomy is performed at the CORA
two lines. but rotated around an axis not at the CORA
2. Orientation of oblique plane translation (i.e., an axis that is not the ACA), iatrogenic
• Can be calculated from the formula: secondary translation will occur.
B. If the CORA does not “make sense,” there is:
tan lat
β = tan −1 1. Translation in addition to angulation
tan AP
2. More than one angular deformity
3. Both 1 and 2 Compensatory No Aggravating

4. Examples of a deformity that does not “make translation translation translation
sense” include:
• The CORA is at different levels on the AP
and lateral radiographs.
• The CORA is not at the apex of the angular
deformity.
• The CORA is in the diaphysis when there is
no diaphyseal angulation.
• The CORA is proximal or distal to the bone.
C. Any translation deformity can be resolved into
two angular deformities (Fig. 3-24).
D. Any angular deformity (with or without transla-
tion) can be resolved into two or more angular
deformities.
1. One or more additional axis lines can be
drawn to intersect the proximal or distal axes
to form two or more angular deformities.
2. The placement of the additional line(s) is
chosen by its intersections with the proximal
and distal axes where an osteotomy is to be
performed.
3. Useful when correcting bowing or multiapi-
cal deformities.
E. Translation Deformities
1. Only present in deformities due to trauma
(fractures or malunions) or previous surgery.
2. Not seen in developmental or congenital
deformities.
FIGURE 3-25 Angular deformities of the tibia lead to
varying degrees of mechanical axis deviation, depending
on the degree of angulation, the level of malunion, and the
magnitude and direction of any associated translational
deformity. These three varus deformities differ only in the
magnitude and direction of the translational component
of the deformitiy. The center example has pure angulation
without translation of the bone ends. The example to the
left of center has the same degree of angulation combined
–a with translation toward the convexity of the deformity.
The example to the right of center has the same degree of
angulation combined with translation toward the concavity
t of the deformity. Notice the amount of mechanical axis
deviation in all three examples. The mechanical axis
deviation is decreased when the translation is toward the
convexity and increased when it is aggravating translation.
a Notice the point of intersection of the mechanical axis
lines of the proximal and distal tibia. When there is
no translation, the intersection is at the level of the
deformitiy. When there is a compensatory translation the
intersection point is distal to the deformitiy. When there is
aggravating translation the intersection point in proximal
to the deformitiy. The intersection point is considered to
be the true apex of the angulation/translation deformity,
while the deformitiy is considered to be the apparent
apex. (Adapted from Paley D, Tetsworth KD. Deformity
FIGURE 3-24 Two equal but opposite angular correction by the Ilizarov technique. In: Chapman MW,
deformities (a) in the same plane have the same effect as ed. Operative Orthopaedics. 2nd ed. Philadelphia, PA: J.B.
one translational deformity (t). Lippincott Company; 1993, with permission.)
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mity may be present by itself or they may limbs: preoperative planning of multiapical frontal plane an-
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must be generated when performing distraction
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Brouwer GM, van Tol AW, Bergink AP, et al. Association be-
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1987;69A:3238. Sharma L, Song J, Felson DT, et al. The role of knee alignment
Hsu RW, Himeno S, Coventry MB, et al. Normal axial alignment and disease progression and functional decline in knee os-
of the lower extremity and the load-bearing distribution at teoarthritis. J Am Med Assoc. 2001;286:188–195.
the knee. Clin Orthop Relat Res. 1990;255:215227. Song KM, Halliday SE, Little DG. The effect of limb-length dis-
Kettelkamp DB, Hillburg BM, Murrish DE, et al. Degenera- crepancy in gait. J Bone Joint Surg. 1997;79A:1690–1697.
tive arthritis of the knee secondary to fracture malunion.
Clin Orthop Relat Res. 1988;234:159169.
Krackow KA. Approaches to planning lower extremity align- Review Article
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knee. Adv Orthop Surg. 1983;7:6988. tion and surgical correction. J Am Acad Orthop Surg.
McKellop HA, Llinas A, Sarmiento A. Effects of tibial ma- 2003;11:302–311.
lalignment on the knee and ankle. Orthop Clin North Am.
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Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of Textbooks
the axial alignment of the lower extremity. J Bone Joint Surg Brinker MR, O’Connor DP. Principles of malunions. In: Rock-
Am. 1987;69A:745749. wood and Green’s Fractures in Adults. Philadelphia, PA: Lip-
Murphy SB. Tibial osteotomy for genu varum. Orthop Clin pincott Williams & Wilkins; 2010.
North Am. 1994;25:477482. Ilizarov GA. Transosseous Osteosynthesis. Berlin, Germany:
O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory insta- Springer-Verlag; 1992.
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Paley D, Herzenberg JE, Tetsworth K, et al. Deformity planning matic Deformities. New York, NY: Stuttgart, Thieme; 2008.
for frontal and sagittal plane corrective osteotomies. Orthop Paley D. Principles of Deformity Correction. Berlin, Germany:
Clin North Am. 1994;25:425465. Springer-Verlag; 2002.
CHAPTER 4
Biomechanics and Biomaterials

Frank A.B. Gottschalk
BIOMECHANICS 2. The rate of change of momentum is proportional

to the resultant force producing it and takes
place in the direction of that force (Force
I. Introduction—Biomechanics of the musculoskeletal
Mass Acceleration).
system is the study of the effect of forces on the
3. Every action has an equal and opposite reaction.
musculoskeletal system. Forces may be generated
C. Forces
by muscle contractions or from externally applied
1. A force is the quantity that changes velocity and/
sources. When a force is applied by an outside source,
or the direction of an object (i.e., the vectors
acceleration occurs and thus movement of an extrem-
having magnitude and direction). The magni-
ity. External forces can be explained using Newton’s
tude of a force is equal to the mass of the object
laws of motion. The application of external loads on
multiplied by the acceleration of the object. The
materials and their effect is determined by the stress
unit of force is kg m/s2, which is a newton (N).
and strain of the material.
A. Definitions 2. Forces, stresses, and strains can be resolved
1. Biomechanics—Biomechanics is the study of into normal and shear components with respect
the effects of forces on the musculoskeletal to any arbitrary plane at any point of applica-
system. tion on the structure.
2. Statics—Statics is the branch of physics con- 3. Normal stress—Normal means perpendicular to
cerned with the analysis of loads (Force a particular plane. Normal stress may be com-
Torque/Moment) on physical systems in static pressive or tensile.
equilibrium. 4. Shear stress—Shear means parallel to a particu-
3. Kinematics—Kinematics is a branch of dynam- lar plane.
ics that describes the motion of objects with- D. Moment
out consideration of the circumstances leading 1. A moment is the quantity that changes the an-
to the motion. Motions may be within the body gular velocity. It is the action of a force that
(joint kinematics) or may be during gait. tends to rotate an object about an axis.
4. Scalars—Scalars have magnitude but no direc- 2. Moments are vectors. The magnitude of a
tion. These include mass, age, time and height. moment force perpendicular distance to
5. Vectors—Vectors have magnitude and direc- the axis of rotation; that is, it is equal to the
tion. These include force, velocity, acceleration, mass moment of inertia of the object and its
torque, stress, and strain. Vectors may be re- angular acceleration. The unit of the moment
solved into components that are perpendicular is the newton-meter (Nm). The direction of the
to each other, so that one is normal (perpendic- moment is given by the right-hand rule.
ular) and the other is parallel to a plane. E. Equilibrium
B. Newton’s Laws—Newton’s laws form the basis of 1. The concept of static equilibrium is used for solving
biomechanical principles; they are: problems related to orthopaedic biomechanics.
1. A physical body will remain at rest, or continue 2. Static equilibrium is the situation in which no
to move at a constant velocity along a straight acceleration occurs in the system. (The system
path, unless an external net force acts upon it. is at rest or moving at a constant velocity.)
54
C H A P T E R 4 | B I O M E C H A N I C S A N D B I O M A T E R I A L S 55
3. Carrying objects—A weight held by the arm when the stress is removed. The rate of appli-
creates a moment about the elbow, the magni- cation of the load does not have an effect. If
tude of which is calculated as the product of the stress is plotted against strain, the relationship
force acting on the hand and the perpendicular between the calculated stress and the measured
distance between the line of action of the force strain is linear, so the ratio of stress to strain is
and the center of rotation of the joint (Fig. 4-1). constant. The ratio of stress to strain depends
4. Stance—The forces acting about the hip joint on the material being tested and not the shape
during single leg stance include the body of structure being tested.
weight, abductor muscle force to counteract 2. Stress elastic modulus strain. Stress is the
the body weight, and the vector sum of these internal reaction to an externally applied force
forces acting through the hip joint (joint reac- (or torque) distributed over the cross section
tion force). The abductor muscle force acts of the material ( Eε). Testing of a material is
through a shorter moment arm than the body usually done as an axial tensile load. The load
weight force; thus, the abductor muscle forces is resisted internally over the surface of the
are approximately twice the body weight force. material’s cross section. Stress on a small piece
The result is the joint reaction force and is 3 to of cross section is defined as internal force di-
4 times body weight. Using a cane in the oppo- vided by surface area over which it acts; that
site hand reduces the abductor muscle force is, stress force / area. Unit of stress is N/m2;
and thus the joint reaction force by provid- 1 N/m2 is a Pascal (Pa). A force perpendicular to
ing a moment that counters the body weight the cross section is called normal stress. Cross
moment. sections that are not perpendicular to the ap-
5. Stair climbing—Stair climbing with the knee plied load have the force acting parallel to the
less flexed reduces the moment arm of the body surface of the cross section and this produces
weight force. shear stress.
F. Linear Elasticity 3. Strain—Strain is internal deformation of a
1. Linear elasticity is the model for material behav- material in response to an applied stress;
ior and has three basic assumptions: stress and strain the change in a dimension / the origi-
strain are proportional to each other; this pro- nal dimension (Fig. 4-2). This may also be writ-
portionality constant is the modulus of elastic- ten as the following: normal strain change
ity, E (Young’s modulus); and strain is reversible in length / unit length. If positive, it is tensile
and if negative, it is compressive. Strain is a
ratio without units and is presented as a per-
centage or micro strain. Shear strain occurs
when there is a change in the angle between
two adjacent surfaces that were perpendicu-
lar to each other. Shear strain is expressed in
units of radians.
G. Geometric Properties
1. Cross-sectional area is important in resisting
axial loading (tension or compression).
• Axial load is the simplest loading that a
structure can experience. As an example,
ligaments support loads in tension and this
10 N
L L
FIGURE 4-2 When load is applied parallel to the face of

a cube of material, the cube distorts, so that the edges
20 cm of the cube are no longer right angles. The distortion
FIGURE 4-1 A 10-N weight in the hand creates a 2-N m (approximately equal to L, divided by L in radians) is
moment about the elbow. the shear strain, where L is the length.
FIGURE 4-3 A patellar ligament is

Slope = structural stress
subjected to a uniaxial tensile test. The
stiffness is the slope of the linear portion
of the resulting force–displacement
graph. If load is converted to stress
Force
Moving grip
and displacement to strain, the slope
Linear region of the stress–strain graph is the elastic
modulus of the ligament tissue. The
strength is the maximum stress that the
ligament can withstand before rupture.
Displacement
The change in
length of two
marks
Slope = modulus
Failure
Force
Linear region
Fixed grip
Toe region
Displacement
is called tensile axial loading. The ligament • Bending loads produce stresses in a mate-

elongates because the fibers elastically de- rial (e.g., bone, and therefore distribution
form (Fig. 4-3). of the loads through the structure).
(a) Structural stiffness is the ability of the (a) Application of a bending load to a rectangu-
structure to maintain its shape while lar structure results in the slight deforma-
under load. Structural stiffness can be tion of the material such that there is tension
altered by changes in geometry or by on the convex side and compression on the
elastic modulus. concave side. The mid portion of the struc-
(b) The strength of a structure is defined as ture (the neutral axis) experiences no ten-
the maximum load that the structure can sile or compressive stress (Fig. 4-4).
withstand without material failure. (b) Material in the rectangular structure away
• C
entroid is the geometric center of the area from the midline has higher stresses than
or of the volume. material at the midline (no stress).
mc
Neutral axis (mn)
mt
mc FIGURE 4-4 Under the influence of bending

loads, the longitudinal lines curve and the
Neutral axis (mn) transverse lines are no longer parallel. The line
segment mt lengthens, mc shortens, and mn does
mt not change in length. The pattern of stress is
therefore a linear distribution. Material further
away from the midline has higher stress than the
neutral axis, which experiences no stress.
(c) The distribution of mass about the mid- the shear modulus, which, in metallic al-
line is described by the area of moment loys, is related to the elastic modulus. An
of inertia (I). This is calculated by adding example is that stainless steel 316L has
each increment of cross-sectional area in twice the elastic modulus as titanium;
the structure multiplied by the square of therefore, stainless steel shear modulus
the distance from the increment of cross is twice as great as titanium.
section to the neutral axis. I (1/12) (c) Torsional strength also depends on the
wd3 where w is width and d is thickness. material property and the cross-sectional
Doubling the thickness of the rectangular property. The material property is the
structure increases resistance to bending ultimate shear stress and the cross-sec-
by a factor of 8. tional property is the ratio of the polar
(d) The strength of a beam is the largest moment of inertia to the radius of the cyl-
bending moment a beam can carry with- inder (Fig. 4-5).
out causing stress in the material to ex- • Polar moment of inertia (J) measures the
ceed a critical limit. In biologic structures average of the square of the perpendicular
and implants that undergo cyclic bend- distance of each minute section of material
ing loads, the critical limit is the fatigue from the axis of torsion. It is always positive.
strength of the material. Its importance is in describing resistance to
(e) Bending loads applied to long bones torsion.
usually result in the intensities of the in- (a) For a solid cylinder, J ½ r4 where r
duced compressive and tensile stresses radius of the cylinder. Doubling the
to be almost equal because of the relative radius of a cylinder increases the resis-
symmetry of the bones. Bone is weaker tance to torsion by a factor of 16.
under tension (tensile loading) than • Centroid is the geometric center of the area
under compression (compressive load- or volume. Because the strength of the cross
ing), and failure starts in the region of section depends on the radius, torsional
highest tensile stress.
• Torsional load is another mode of loading.
Torsional loads produce moments that tend
to twist the structure.
(a) A common occurrence is torsional load-
ing of the tibia that occurs while skiing.
A load applied perpendicular to the ski
tip produces a torsional moment, result-
ing in external rotation of the tibia. Using
static equilibrium, there is a moment ap-
plied to the internal cross section of the
tibia proximally that is equal to the exter-
nal applied moment but in the opposite
direction. The internal torque is constant
along the length of the tibia. This is differ-
ent from bending moments, which vary
along the length of the bone.
(b) Torsional load applied to a beam or cyl-
inder leads to one end rotating relative to α
the other. A straight longitudinal line on
the surface will twist into a helix provid-
ing a helix angle α. The total deformation
(θ) is proportional to the applied torque
and the length of the structure (L). The Torque
proportional constant between the
torque and the angle of deformation (tor-
sional stiffness) depends on the mate- FIGURE 4-5 A cylinder is fixed at one end and has a
rial property and geometric property of torque applied to the other end. The torque causes an
the structure. The material property is angular twist to the rod.
fractures start at the surface of the cross sec- impaction. They are best used for reverse obliq-
tion that is closest to the centroid (the part uity intertrochanteric fractures.
with the smallest radius). 5. External fixators provide best stability by al-
H. Application to Bone—Fractures resulting from tor- lowing fracture ends to be in contact with each
sional loading occur most often in the distal third other. Other factors that improve stability are
of the tibia. This can be explained by the axis of the increased pin diameter (second most important
tibia and that the bone in the middle and proximal factor), bending is proportional to the fourth
parts of the tibia are farther away from the axis power of diameter; additional pins; decreased
of the tibia and are better able to resist torsional bone-rod distance (pin stiffness is proportional
loading. Another example would be a pin or screw to the third power of bone-rod distance); pins
hole in the distal third of the tibia, which weak- in different planes; stacked rods; increased dis-
ens the bone more than if the location was in the tance between pins.
proximal third where the bone has a larger radius. 6. Circular external fixators use thin 1.8-mm wires
A bending load applied at the mid-tibia produces fixed under tension. The optimum orientation
strains that are greater than those when a bending of implants on the ring is at 90° to one another
load applied at the proximal tibia, thus increasing where possible. Half pins provide better pur-
the fracture potential. If a hole is located at the chase in diaphyseal bone. The bending stiff-
bending loading site, the weakening effect is more ness of the frame is independent of the loading
profound. direction because the frame is circular. Ten-
I. Orthopaedic Implants—All orthopaedic implants sioned wires should be positioned opposite
will have bone contact at certain points, so as to to each other and not on the same side of the
be able to transmit or receive loads. Loads may be ring. Enhanced stability of circular external
transmitted over large areas or at localized points. fixators includes the use of larger diameter
Load transmission may be load sharing or load wires and half pins, smaller ring diameter, olive
transfer. wires, wires that cross at 90°, increased wire
1. Bone plates resistance to bending is propor- tension up to 130 kg, placement of the two cen-
tional to the thickness cubed; thus doubling the tral rings close to the fracture site, decreased
plate thickness increases bending resistance spacing between adjacent rings and the use of
by a factor of 8. Plates resist tensile forces and more rings.
should be placed where possible on the tensile
side of bone. They may also be used for com-
pression or graft support. Screws placed close BIOMATERIALS
to the fracture site reduce the unsupported
length of the plate. The term “biomaterials” refers to synthetic materials
2. Bone screws have a major and minor (root) used to augment or replace tissues and their functions.
diameter and the pitch (distance between A. Mechanical Properties of Material
threads). The screw’s hold in bone is deter- 1. Generalized Hooke’s law—It states that in a par-
mined by the major diameter and the pitch. ticular direction, stress is proportional to strain.
Screw strength is determined by the minor The proportionality constant is the material’s
diameter. elastic modulus in that direction.
3. Intramedullary devices resist torsion by having 2. Measurements of properties of materials are
the material distributed away from the axis of done using standardized specimens that are
loading; larger implants resist torsional load- subjected to tension, compression, and shear
ing better. Reaming affects the fracture healing (torque) by a mechanical testing machine.
biology; and fracture comminution and implant • S tress–strain curves describe material behav-
diameter impact fracture stability. Solid intra- ior, and force–displacement curves describe
medullary devices are stiffer compared to open structural behavior.
(slotted) designs. • I n experimental conditions, converting a
4. Hip screws are subject to bending loads as a force–displacement curve to a stress–strain
result of the moment arm from the femoral curve is not always possible.
head to the side plate or intramedullary device. B. Material Properties
Smaller bending moments are noted in the inta- The stress–strain relationships for an isotropic ma-
medullary device. Compression hip screws, de- terial are characterized by the elastic modulus and
pending on the angle of the side plate, allow for Poisson’s ratio. In the study of mechanical proper-
some impaction of the fracture fragments. Blade ties of materials, “isotropic” means having identi-
plates resist torsion but do not provide fracture cal values of a property in all crystallographic
directions (from Greek: Iso means equal and tropos between stress and strain for that particular ma-
means direction). Poisson’s ration is the ratio of terial (Fig. 4-6). Elastic modulus is characteristic
the relative contraction strain, or transverse strain of the material and cannot be changed without
(normal to the applied load), divided by the relative changing the material itself.
extension strain, or axial strain (in the direction of 2. Poisson’s ration (ν) for a specimen in tension
the applied load). is the ratio of the transverse strain to the axial
1. Elastic, or Young’s, modulus (E) is the slope strain (see above).
of the initial linear portion of the curve on a • ν (change in diameter / original diameter) /
stress–strain graph. It is the proportionality (change in length/original length) If ν 0, the
Materials testing machine
Bending
Crosshead
Displacement Force
transducer cell Elastic region
Bone implant
construct
Support Plastic region
Table
Permanent deformation
Setup for testing construct stiffness
Force
Elastic Plastic Ultimate load
region region
Yield point
or
Elastic limit Failure load
or
Proportional limit
Area under curve = work done
Permanent
Slope deformation
Displacement
FIGURE 4-6 Top left: A fixation construct (bone–fixation–bone) set up in a mechanical testing machine. In this example,
a long bone is fixed with a plate and subjected to bending. Top right: The construct during loading in the elastic region,
plastic region, and with permanent deformation. Bottom: The resulting measurements from the testing machine, which
measures foced applied and displacement at the point of the applied load. The graph demonstrates the elastic region,
in which the construct acts like a spring, returning to its original shape after the load is released; the plastic region, in
which the plate may have permanently bent; and the failure load, in which the fixation fails. (Adapted from Tencer AF.
Biomechanics of fractures and fracture fixation. In: Bucholz RW, Court-Brown CM, Heckman JD, et al., eds. Rockwood
and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010, with permission.)
material is highly compressible and if ν 1, from stress occurs after the application of a
the material incompressible. displacement load, and after some time with
3. Yield point (or region) is the point at which the same displacement, the stress decreases.
the material behavior deviates from elastic to Creep and stress relaxation describe similar
plastic deformation (Fig. 4-6). Strains applied behavior. Examples of materials which are
beyond the yield point are not completely re- subject to creep include vertebral discs, poly-
versible since plastic deformation has occurred. ethylene, bone, skin, and glass.
4. Failure point is the point at which the material 14. Viscosity (η) is a fluid’s resistance to flow and
fails (Fig. 4-6). is analogous to the modulus of elasticity. Vis-
5. Ductility is a measure of a material’s ability to cosity (η) shear strain / shear rate.
deform plastically before failure. • N
ewtonian fluids—Viscosity is independent
6. Resilience is the amount of energy returned on of shear rate (e.g., water and plasma).
release of a strain while the material is elasti- • N
on-Newtonian fluids—Viscosity depends
cally deformed. In Figure 4-6, it is the area under on shear rate.
the linear portion of the stress–strain curve. (a) Shear-thickening or dilatant fluids ex-
7. Toughness is the amount of energy per unit hibit increasing viscosity with increas-
volume a material can absorb before failure. In ing shear rate (e.g., emulsions).
Figure 4-6, it is the area under the entire stress (b) Shear-thinning or thixotropic fluids ex-
strain curve. hibit decreasing viscosity with increas-
8. Fatigue is the property of a material that ing shear rate (e.g., synovial fluid, blood).
causes it to fail at a relatively low load applied C. Molecular Structure Influence on Material
many times and is usually a load much lower Properties
than that which causes failure in a single cycle. 1. Metals have a crystal structure and metallic
Several biologic materials fail by fatigue. bonding. They may be commercially pure (e.g.,
• E
ndurance limit is the theoretic upper limit titanium) or they may be alloys (mixtures of two
of stress for which a material will not fail or more metals, e.g., Ti-6Al-4V).
by fatigue. Fatigue is a cumulative phenom- 2. Polymers are chains of molecules covalently
enon and is accelerated by corrosion. Bone bonded together. Secondary bonding may oc-
remodeling prevents failure in bone material cur by hydrogen chains or van der Waals forces.
that is damaged as a result of fatigue. 3. Ceramics are materials created by ionic bonding
9. Isotropic properties denote that the material of a metallic ion and a nonmetallic ion (oxygen).
properties do not vary with the direction of They are hard, strong, and brittle (e.g., alumi-
loading. Stress–strain relationships are char- num oxide, zirconium).
acterized by two material properties: elastic 4. Composites involve mechanical bonding between
modulus and Poisson’s ratio. materials. Chemical, physical, or true mechanical
10. Anisotropic properties indicate that the mate- bonding may occur (e.g., laminates, bone).
rial properties do vary with the direction of D. Tribology
loading. Stress–strain relationships are diffi- 1. Friction is a coefficient of force / applied load.
cult to characterize. μ frictional force / applied load. Static coef-
11. Orthotropic properties mean that the mate- ficient describes the condition in which the
rial properties do not change appreciably in object is at rest and the dynamic coefficient
a particular direction. Cortical bone is con- describes the friction when the object has be-
sidered orthotropic with properties that do gun to move. Wear properties depend on the
not change in the axial direction, across a particular materials in contact, lubricant, and
transverse section, or in a radial direction relative velocity.
within a specific sample of bone. 2. Lubrication
12. Viscoelasticity indicates that a material’s prop- • H
ydrodynamic—Surfaces are fully separated
erties vary with the rate of loading. Loading and by the lubricant. The viscosity of the lubri-
unloading curves are not identical and not all cant is primary.
energy applied to the material during loading is • H
ydrostatic—Lubricant is pressurized to
recovered on unloading. The loss of strain en- maintain separation of surfaces.
ergy (in the form of heat) is called hysteresis. • B
oundary layer—A thin, slippery surface ad-
13. Creep (cold flow) is the phenomenon of a ma- herent layer that minimizes contact. Higher
terial exhibiting increasing strain (deforma- wear can occur than in situations where the
tion) under a constant applied load. Relaxation surfaces are completely separated.
• Elastohydrodynamic—Elasticity of the bear- These materials are not used for implantation
ing surfaces allows adaptation of surface ir- (e.g., iron).
regularities without plastic deformation. This • Galvanic corrosion occurs when two different
allows for a thicker film of lubricant. Low metals in direct contact are immersed in an
wear rates occur but subsurface fatigue may electrolyte. In order for galvanic corrosion to
occur with breakdown of the material (e.g., occur, an electrically conductive path and an
knee polyethylene). ionically conductive path are necessary. Of the
• Weeping—One surface is porous and fluid is two metals, one is the anode giving up electrons
forced out of the surface (e.g., normal joints). and is reduced by oxidation. The other metal is
3. Wear mechanisms the cathode and is protected. Combinations of
• Adhesive—Particles of each bearing surface other metals with stainless steel are bad.
can adhere to the other surface. • Crevice corrosion is a localized form of corro-
• Abrasive—The harder material abrades the sion occurring in spaces in which the access
softer material’s surface. of the working fluid from the environment is
• Transfer is similar to adhesive wear but with limited, and, as a result, concentration of me-
a film of material transferred from one to the tallic ions (positive) and chloride or hydro-
other. gen ions (negative) results.
• Fatigue of the softer material is usually due to • Pitting is a localized occurrence of corrosion,
subsurface stresses. It occurs with polyethyl- similar to crevice corrosion. It is usually seen
ene delamination. with breakdown of the passivation process.
• Third body wear occurs when particles from • Intergranular corrosion is corrosion within a
a different source are interspersed between metal, at the boundaries between the metal
two bearing surfaces (e.g., cement in a total grains, as a result of a localized galvanic cell.
hip or knee). The presence of debris in the metal is a con-
• Corrosive wear is seen when electrochemical tributing factor. Low-carbon steel used in sur-
reactions occur around a bearing surface. gical application reduces the precipitation of
• Fretting wear is seen with cyclic loading with chromium carbides and minimizes intergran-
very small oscillations (e.g., screw head in ular corrosion.
contact with plate). • Stress corrosion cracking is the cracking of a
E. Corrosion material in a corrosive environment. Stress-
Corrosion is the gradual breaking down of a mate- induced cracks may accelerate the corrosion
rial due to chemical reactions with its surround- process, and cyclic loading may interfere with
ings. This means the loss of electrons of metals the material’s ability to re-form a passive layer.
reacting with water and oxygen. Corrosion can be F. Mechanical Properties of Orthopaedic Materials
concentrated locally to form a pit or crack, or it 1. Modulus of elasticity (Fig. 4-7)—The values are
can extend across a wide area to produce general ranked from lowest to highest. Cancellous bone
deterioration. has the lowest modulus of elasticity, followed
1. Metals are degradable by corrosion. by polyethylene and polymethylmethacrylate
2. Polymers undergo chemical degradation usu- up to aluminum oxide.
ally observed by discoloration. 2. Ultimate strength of a material is shown in
3. Ceramics may also undergo corrosion but this Figure 4-8. The values are ranked from minimum
is usually a longer and very slow process. to maximum, from cancellous bone to cobalt
4. Passivation is a thin film of corrosion products chrome.
that form on a metal’s surface spontaneously, 3. Values of elastic modulus and ultimate strength
acting as a barrier to further oxidation. This are shown in Table 4-1. The values are approxi-
layer stops growing at less than a micrometer mate because testing conditions may vary.
thick and can be used under conditions to mini- 4. Bone as a material.
mize surface wear. Commercially pure titanium • Composite material—Bone is formed pre-
and some stainless steels form passivation lay- dominantly of type I collagen and has a min-
ers spontaneously. Implants are manufactured eralized matrix of hydroxyapatite.
with a passivation layer by treatment in a weak • Anisotropic properties—Bone is modeled as
acid solution. transverse isotropic and has continuous re-
5. Types of corrosion modeling of its mineral content by resorption
• Uniform corrosion is the continuous degra- and deposition. Fatigue damage is minimized
dation of a material throughout its surface. by the remodeling process.
FIGURE 4-7 Bar graph comparing the modulus of FIGURE 4-8 Bar graph comparing the ultimate strength
elasticity for various biomaterials. The values shown are for various biomaterials. The value shown for PMMA
not exact. See Table 4-1 for approximate values. Co–Cr–Mo, bone cement is compressive strength; the values shown
Cobalt–chromium–molybdenum; UHMWPE, ultrahigh- for ZrO2 and Al2O3 are for bending strength. The values
molecular-weight polyethylene. shown are not exact. See Table 4-1 for approximate
values. Co–Cr–Mo, Cobalt–chromium–molybdenum;
UHMWPE, ultrahigh-molecular-weight polyethylene.
TA B L E 4 - 1
Material Properties for Various Biomaterials
Modulus of Elasticity (GPa)a
Cancellous bone 0.5–1
Polyethylene (ultrahigh molecular weight) 1
PMMA bone cement 2
Cortical bone 15–20
Ti-6Al-4V 100
316L stainless steel 200
Cobalt–chromium–molybdenum alloy 220
ZrO2 220
Al2O3 300
Ultimate Strength (MPa)a
Cancellous bone 2
Polyethylene (ultrahigh molecular weight) 25
PMMA bone cement 70 (compressive strength)
Cortical bone 100
Al2O3 400 (bending strength)
316L Stainless steel 500–800
Ti-6Al-4V 850
ZrO2 900 (bending strength)
Cobalt–chromium–molybdenum alloy 650–1,100
Note: Values are representative and are not intended to be exact.
aThe SI unit for stress is the pascal (Pa). 1 GPa (gigapascal) 109 Pa; 1 MPa (megapascal) 106 Pa; 1 MPa 145 psi (pounds per
square inch).
• Mineral component—This varies throughout SUGGESTED READINGS

the bone and continuously over time.
• Structural adaptation attempts to compen- Recent Articles
sate for weakening of bone. The diameter of Brinker MR, O’Connor DP. Biomaterials and biomechanics.
the inner and outer femoral cortex increases In: Miller MD, ed. Review of Orthopaedics. Philadelphia, PA:
with age. Mechanically, the structural resis- Saunders Elsevier; 2008.
Mow VC, Flatow EL, Ateshian GA. Biomechanics. In: Buckwal-
tance to bending is increased, as is the tor-
ter JA, Einhorn TA, Simon SR, eds. Orthopaedic Basic Sci-
sion resistance while the bone becomes ence. Rosemont, IL: American Academy of Orthopaedic
weaker due to the loss of mineral content. Surgeons; 2000.
• Strength and modulus are approximately pro- Wright TM, Li SL. Biomaterials. In: Buckwalter JA, Einhorn TA,
portional to the square of the density. This is Simon SR, eds. Orthopaedic Basic Science. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 2000.
used in quantitative computed tomography
Wright TM, Maher SA. Musculoskeletal biomechanics. In:
and dual-energy X-ray absorptiometry bone Orthopaedic Knowledge Update 9. Rosemont, IL: American
mineral measurements. Academy of Orthopaedic Surgeons; 2008.
• Fractures occur along haversian canals, ce-
ment lines, and lacunae. When the strain rate Textbooks
is very high, fracture patterns become ran- Black J. Orthopaedic Biomaterials in Research and Practice.
dom. Failure increases 10% for every tenfold New York, NY: Churchill Livingstone; 1988.
increase in strain rate. Comminution results Brinker MR. Basic sciences. In: Miller MD, Brinker MR, eds.
Review of Orthopaedics. 3rd ed. Philadelphia, PA: WB
from the release of energy stored in bone be-
Saunders.
fore fracture. Chao EYS, Aro HT. Biomechanics of fracture fixation. In:
• Fracture patterns may indicate the mecha- Mow VC, Hayes WC, eds. Basic Orthopaedic Biomechanics.
nism of loading resulting in fracture. New York, NY: Raven; 1991.
(a) Transverse fracture pattern indicates ten- Cochran GVB. A Primer of Orhtopaedic Biomechanics. New York,
NY: Churchill Livingstone; 1982.
sile loading.
Kaplan FS, Hayes WC, Keaveny TM, et al. Form and func-
(b) Spiral fracture pattern indicates torsional tion of bone. In: Simon SR, ed. Orthopaedic Basic
loading. Science. Rosemont, IL: American Academy of Orthopaedic
(c) Transverse fracture pattern with butter- Surgeons.
fly fragments indicates bending load as Litsky AS, Spector M. Biomaterials. In: Simon SR, ed. Ortho-
paedic Basic Science. Rosemont, IL: American Academy of
seen with the case of a pedestrian hit by
Orthopaedic Surgeons; 1994.
a car bumper resulting in tibial fracture. Mow VC, Flatow EL, Foster RJ. Biomechanics. In: Simon SR,
(d) Oblique fracture pattern indicates com- ed. Orthopaedic Basic Science. Rosemont, IL: American
pressive loading. Academy of Orthopaedic Surgeons; 1994.
SECTION II
Adult Trauma
PART I THE LOWER EXTREMITY
CHAPTER 5
Fractures of the Femoral Neck

and Intertrochanteric Region
Robert Victor Cantu and Kenneth J. Koval
I. Introduction—Osteoporosis and resulting hip frac- shortened and externally rotated position. With
tures have a substantial economic and social impact. nondisplaced fractures, the injured extremity
It is estimated that worldwide, 323 million people suf- lacks these obvious deformities.
fer from osteoporosis and that number is projected to • Elderly population—In elderly patients who
be 1.55 billion by the year 2050. It has been predicted have sustained a fall and resulting hip frac-
that the number of hip fractures in the year 2050 will ture, the cause of the fall should be eluci-
be 6.3 million. Despite improvements in patient care dated. Nonmechanical reasons for falling
and operative technique, hip fractures account for a such as syncope, presyncope, myocardial
significant amount of health care expenditure. infarction, and stroke are all possible eti-
II. Femoral Neck Fractures ologies. The patient should be evaluated for
A. Overview—Femoral neck fractures are intracap- other injuries. The distal radius and proximal
sular fractures that occur in the region from just humerus are regions commonly affected by
above the intertrochanteric region to just below osteoporosis, and should be evaluated for
the articular surface of the femoral head. There possible fracture.
is a bimodal distribution of femoral neck frac- • Younger population—Hip fractures in younger
tures, with the majority occurring in the geriatric patients typically result from high-energy
population from low energy falls, and a smaller mechanisms. These patients require a com-
number occurring in younger individuals from plete primary and secondary survey with spe-
high-energy mechanisms. The approach to treat- cial attention paid to the ipsilateral femoral
ment is different in these two groups, in that an shaft. Approximately 2.5% of femoral shaft
attempt is made to reduce and fix almost all fem- fractures are associated with an ipsilat-
oral neck fractures in young adults, while most eral femoral neck fracture.
displaced fractures in elderly patients are treated 2. Radiographic evaluation—The standard radio-
with arthroplasty. graphic evaluation for patients suspected to
B. Evaluation have a hip fracture includes an anteroposterior
1. Physical examination—If a patient is suspected (AP) view of the pelvis and hip and a cross-ta-
of having a femoral neck fracture, range of ble lateral view of the hip. The AP pelvis view
motion of the hip should be avoided until allows for comparison with the contralateral
radiographs of the proximal femur have been hip; this comparison may reveal subtle impac-
obtained, to avoid displacement of the fracture. tion or fracture displacement. The cross-table
Patients who have a displaced femoral neck lateral is preferred to the frog lateral, since the
fracture will present with the affected leg in a latter can result in increased pain and fracture
66
C H A P T E R 5 | F R A C T U R E S O F T H E F E M O R A L N E C K 67
of the proximal femur. This view can help diag-

nose nondisplaced fractures. If all radiographs
appear normal but the clinical suspicion for
hip fracture is high, a technetium bone scan
or magnetic resonance image (MRI) should be
obtained (Fig. 5-1). The MRI is sensitive for oc-
cult hip fracture within 24 hours, whereas the
bone scan may take 48 to 72 hours to demon-
strate the fracture.
C. Injury Classification—The Garden classification is
commonly used and consists of four grades: Grade
1 is an incomplete or valgus impacted fracture,
Grade 2 is a complete and nondisplaced fracture,
Grade 3 is a partially displaced fracture, and a Grade
4 is completely displaced (Fig. 5-2). The risk of non-
union and osteonecrosis is substantially higher for
FIGURE 5-1 T1-weighted MRI showing a nondisplaced
Grades 3 and 4. The Pauwel classification is based
femoral neck fracture.
on the angle formed by the fracture line and a hori-
zontal line with simulated standing. Pauwel’s clas-
displacement. Ideally, the AP hip view should be sification consists of three types: Type 1 has an
obtained with the hip in 15° of internal rotation angle less than 30°, Type 2 has an angle between
to compensate for the anatomic anteversion of 30° and 50°, and Type 3 has and angle greater than
the femoral neck and provide an en face view 50° (Fig. 5-3). The more vertical the fracture line
FIGURE 5-2 Garden’s classification of femoral neck fractures. (From Keating J.

Femoral neck fractures. In: Bucholz RW, Heckman JD, Court-Brown C, et al., eds.
Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2010, with permission.)
68 S E C T I O N I I | A D U L T T R A U M A P A R T I | T H E L O W E R E X T R E M I T Y
FIGURE 5-3 The Pauwel classification of femoral neck fractures is based on the angle
the fracture forms with the horizontal plane. As fracture type progresses from Type 1
to Type 3, the obliquity of the fracture line increases and, theoretically, the shear forces
at the fracture site also increase. (From Keating J. Femoral neck fractures. In: Bucholz,
RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults.
7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010, with permission.)
is, the higher the Pauwel’s angle, and the higher emergently with ORIF to help reduce the
the shear forces across the fracture. risk of osteonecrosis.
D. Associated Injuries • Anesthetic considerations—For patients un-
1. Elderly population—In elderly patients a cere- able to undergo early surgery, femoral nerve
bral vascular accident or myocardial infarction block catheters should be considered to as-
may precipitate the fall resulting in fracture. sist in pain control and limit narcotic use in
Common associated injuries include distal ra- the elderly. Studies have not shown a con-
dius and proximal humerus fractures. Closed sistent difference in perioperative mortality
head injury such as subdural hematoma can with general versus regional anesthesia.
also result from a fall. • Nondisplaced femoral neck fractures—
2. Younger population—In young patients the Recommended treatment for nondisplaced
high-energy mechanisms can result in associ- femoral neck fractures consists of internal
ated orthopaedic injuries of the ipsilateral tibia, fixation with multiple lag screws placed in a
femur, and pelvis/acetabulum. Injuries to the parallel fashion. Either three or four screws
head, chest, and abdomen are also common. should be used. If three screws are used, an
E. Treatment Options and Rationale inverted triangle pattern can be used with
1. Nonoperative treatment—Nonoperative treat- the inferior screw adjacent to the inferior
ment is generally limited to elderly nonam- neck and the posterior superior screw adja-
bulators who are considered too high risk for cent to the posterior femoral neck.
surgery or who have minimal pain with mobi- (a) Open capsulotomy—Some authors have
lization. The goal for these patients should be recommended open capsulotomy for non-
early bed to chair mobilization in attempt to displaced femoral neck fractures, with
limit the complications of prolonged recum- the theory that capsulotomy relieves
bence: atelectasis, thromboembolic disease, pressure from the intracapsular hema-
urinary tract infection, and decubitus ulcers. toma and in turn reduces the risk of osteo-
2. Operative treatment necrosis. Controversy exists as to whether
• Timing of surgery—Patients should undergo capsulotomy actually lowers the rate of
surgery as soon as they are deemed medi- osteonecrosis; however, it does have its
cally stable. In elderly patients, surgery may advocates, especially for young patients.
need to be delayed until fluid and electro- Prior to surgery, allowing the leg to as-
lyte imbalances are corrected. Recent stud- sume a flexed, abducted, and externally
ies have shown some benefit to the model of rotated position has also been shown
orthopaedic and geriatric medicine cocare in to decrease intracapsular pressure.
reducing complications such as delirium and • Displaced femoral neck fractures—Treatment
improving survival. In young patients, dis- of displaced femoral neck fractures largely
placed femoral neck fractures are treated depends on the patient’s age and activity
FIGURE 5-4 Preop and 3-month postop X-rays of a displaced femoral neck fracture in a 26-year-old man treated with
open reduction and internal fixation.
level. In younger patients, closed or open prosthesis has a theoretic advantage

reduction is performed followed by internal over the unipolar, as the second articu-
fixation (Fig. 5-4). The goal is anatomic relation in the bipolar has been suggested
duction and it may be necessary to perform to decrease acetabular wear. In practice,
either a Smith-Petersen or a Watson-Jones ap- however, it has been shown that the sec-
proach to ensure proper reduction. In older, ond articulation in a bipolar often ceases
less active patients, most authors recom- to function and it essentially becomes a
mend prosthetic replacement of the femoral unipolar construct. Additionally, unlike
head. Trials comparing ORIF to hemiar- the monopolar, the bipolar typically has
throplasty for displaced femoral neck a metal-polyethylene articulation, which,
fractures in the elderly have consistently if it does function as designed, can lead
shown improved outcomes and lower reop- to polyethylene wear and osteolysis.
eration rates for the arthroplasty group. For most low-demand elderly patients,
(a) Internal fixation—When internal fixation the unipolar replacement is the recom-
is chosen, anatomic reduction is essential mended prosthesis (Fig. 5-5).
to try to minimize complications such as (c) Total hip replacement—Patients with
nonunion and osteonecrosis. If attempts pre-existing degenerative disease of the
at closed reduction do not clearly result hip (i.e., rheumatoid arthritis, Paget’s
in anatomic reduction, then open reduc- disease, osteoarthritis) and a femoral
tion should be performed and fixation neck fracture should be considered for
achieved typically with multiple parallel total hip arthroplasty. Some studies have
screws. For basi-cervical fractures, fixa- suggested improved outcomes regarding
tion with a sliding hip screw is another pain and function for total hip arthro-
alternative. plasty compared with hemiarthroplasty
(b) Prosthetic replacement of the femoral even for elderly patients without arthritis.
head—Prosthetic replacement can take On the other hand, total hip replacement
the form of either hemiarthroplasty with does have a higher dislocation rate and
a monopolar or a bipolar prosthesis, generally should be avoided in patients
or total hip arthroplasty. The bipolar with dementia who are unable to comply
FIGURE 5-5 Preop and postop hip radiographs of an

elderly patient with a displaced femoral neck fracture
treated with hemiarthroplasty.
with hip precautions. Patients with neu- F. Complications of the Injury

rologic conditions such as Parkinson’s or 1. Nonunion—The nonunion rate for femoral neck
paralysis from a prior cerebrovascular fractures is determined largely by fracture dis-
accident are also at increased risk of displacement. Nondisplaced or impacted femoral
location and generally should be treated neck fractures have a nonunion rate of approxi-
with a hemiarthroplasty. mately 5% or less after fixation. Displaced frac-
• Postoperative management—Recommenda- tures have a nonunion rate closer to 30% after
tions regarding weight-bearing status after ORIF. For young patients who have undergone
femoral neck fixation have ranged from com- ORIF, nonunion is the most common complica-
plete nonweight bearing to weight bearing as tion. Additional risk factors for nonunion include
tolerated. Biomechanical studies have shown nonanatomic reduction and metabolic condi-
that even when a person attempts to be non- tions such as dialysis dependent renal failure.
weight bearing, there are substantial joint re- Nonunion typically presents with groin or thigh
active forces across the hip and knee due to pain. Most femoral neck nonunions require fur-
muscular contractions. Many elderly patients ther surgery. For young patients attempt is usu-
cannot comply with restricted weight bear- ally made to preserve the femoral head with a
ing. For these reasons, it is recommended valgus intertrochanteric osteotomy with plate
that elderly patients be allowed to weight fixation. In older patients nonunion is treated
bear as tolerated to assist with mobilization with hemiarthroplasty of the hip.
and avoid the complications of prolonged re- 2. Osteonecrosis—Due largely to its retrograde
cumbence. For younger patients restriction blood supply, the femoral head is prone to os-
of weight bearing may be considered if frac- teonecrosis after femoral neck fracture. Similar
ture fixation is in question. to nonunion, osteonecrosis rates are strongly
correlated with the degree of fracture displace- conversion to an intramedullary hip screw. Ei-
ment. Nondisplaced or impacted fractures have ther option requires care to maintain anatomic
an osteonecrosis rate of 8% or less, while Gar- reduction of the femoral neck.
den’s Grade 4 fractures have a rate of 30% or 3. Failed arthroplasty—Prosthetic replacement can
more. Magnetic resonance imaging is more sen- fail due to aseptic loosening, infection, or acetab-
sitive than plain radiographs at demonstrating ular wear. Superficial infections can be treated
early signs of osteonecrosis. Late changes can with wound debridement and IV antibiotics,
be seen on X-rays which include subchondral while deep infections may require staged revi-
collapse and femoral head deformity. Symp- sion or resection arthroplasty. Acetabular wear
toms include groin or thigh pain and about 33% can occur with either a unipolar or a bipolar
of patients require further surgical procedures. hemiarthroplasty. Studies have shown many bi-
In younger patients, attempts to revascular- polar implants function essentially as a unipolar
ize the femoral head such as drilling and bone within the first year. Advanced acetabular wear
grafting can be considered. In older patients after a hemiarthroplasty typically results in groin
with advanced osteonecrosis, the treatment is pain and treatment generally consists of conver-
typically prosthetic replacement. sion to a total hip replacement. Femoral stem
3. Mortality—For elderly patients, in hospital mor- loosening can often be seen radiographically be-
tality from hip fracture is approximately 3% to fore symptoms such as thigh pain develop.
5% in most studies. The 1-year mortality after H. Special Considerations
hip fracture is substantially higher than age 1. Femoral neck stress fractures—In patients with
matched controls and ranges between 20% and osteopenic bone, femoral neck stress fractures
40%. Risk factors for increased mortality include can occur with repetitive loading from normal
pre-existing cardiac or pulmonary disease, cog- daily activities. In younger patients with healthy
nitive impairment, pneumonia, and male gender. bone, stress fractures can result from unusually
4. Thromboembolic disease—Even with prophy- heavy and repetitive load such as seen in mili-
laxis, the rate of thromboembolic disease after tary recruits or long distance runners. Stress
hip fracture is substantial, with some reports fractures result in new onset groin pain. Plain
as high as 23%. Multiple agents have been used radiographs may not demonstrate the fracture
to prevent deep venous thrombosis (DVT) acutely and either MRI or bone scan should be
and pulmonary embolism (PE), including low- obtained if the diagnosis is in question.
molecular weight heparin, warfarin (Couma- 2. Ipsilateral femoral neck and femoral shaft frac-
din), aspirin as well as pneumatic compression tures—Ipsilateral femoral neck fractures oc-
boots. For patients suspected of having a DVT, cur in about 2.5% of femoral shaft fractures.
ultrasonography is the least invasive means of Assuming the femoral neck fracture is nondis-
diagnosis. For diagnosis of PE, spiral CT has placed, secure internal fixation of the femoral
largely replaced ventilation/perfusion scan as neck should be obtained before insertion of
the modality of choice. intramedullary nails to prevent displacement.
G. Complications of Treatment A sliding hip screw can be used to obtain fix-
1. Fixation failure—Risk factors for implant fail- ation of the femoral neck fracture, followed
ure include osteopenia, fracture comminution, by reamed retrograde nailing of the femoral
and nonanatomic reduction. Patients typically shaft fracture. Displaced femoral neck fractures
present with groin pain, buttock pain, or both. in younger patients often require open reduction
Treatment options consist of revision internal through either a Smith-Petersen or a Watson-
fixation, valgus osteotomy, hemiarthroplasty, or Jones approach to ensure anatomic reduction.
total hip arthroplasty. The revision/osteotomy 3. Neurologic impairment—In patients with severe
options are generally performed on younger neurologic impairment such as advanced
patients, while prosthetic replacement is gener- Parkinson’s disease, paralysis from previous
ally the preferred options for elderly patients. stroke, or severe dementia an anterior ap-
2. Subtrochanteric femur fracture—Subtrochan- proach to the hip should be considered when
teric femur fracture can result from multi- performing hemiarthroplasty. This helps pre-
ple unfilled drill holes in the lateral femur, vent both wound contamination as well as hip
or starting holes for fracture fixation that dislocation from noncompliance. Some patients
are distal to the lesser trochanter. Treat- have a significant adductor contracture and
ment options for the fracture include revision should undergo adductor release at the time of
to a sliding hip screw with a long side plate, or arthroplasty.
4. Chronic renal disease—Patients with advanced E. Treatment

renal failure often have poor bone quality mak- 1. Nonoperative treatment—Nonoperative treat-
ing them poor candidates for internal fixation. In ment should only be considered in nonam-
these patients, even nondisplaced fractures may bulators who are deemed too high-risk for
best be treated with femoral head replacement. operative intervention or who have minimal
5. Paget’s disease—Patients with Paget’s disease pain with mobilization. If nonoperative treat-
are prone to proximal femoral deformity and ex- ment is elected, it is an option to mobilize the
cessive bleeding at surgery. If the acetabulum is patient with early bed to chair activity, with
involved, treatment should consist of total hip the goal of preventing the sequelae of pro-
arthroplasty. longed bedrest (e.g., thromboembolic disease,
6. Pathologic fracture—A pathologic fracture is a atelectasis, pneumonia). If fracture deformity
contraindication to internal fixation. Patients occurs, a reconstructive procedure may be in-
should be evaluated for metastases before sur- dicated later on if the patient’s medical condi-
gery, including full pelvis and femur films. Be- tion improves. The other option is to maintain
fore surgery, it should be clear as to whether the patient in skeletal traction in an attempt
the fracture is from a primary tumor or a metas- to maintain fracture alignment during healing.
tasis, as the treatment may be quite different. The latter form of treatment makes nursing
care very difficult and carries with it all the
III. Intertrochanteric Femur Fractures risks of prolonged recumbence.
A. Overview—The majority of intertrochanteric 2. Operative treatment—Surgery is the treatment
fractures occur in elderly patients from low en- for virtually all patients who can tolerate an op-
ergy falls. The intertrochanteric region consists eration. Surgery should be performed as soon
of the extracapsular bone running between the as all comorbid medical conditions, including
greater and lesser trochanters. The bone in this cardiopulmonary, fluid, and electrolyte imbal-
area is primarily cancellous and has an excellent ances have been assessed and optimized.
blood supply, thereby making the risk of non- • History—Some of the earliest devices used
union lower than with femoral neck fractures. to treat intertrochanteric hip fractures
The calcar femorale is the proximal continuation were fixed angle nail-plate implants such
of the linea aspera found in the posteromedial as the Jewett nail. These devices provided
femoral shaft and the posterior femoral neck. It fracture fixation, but did not allow for frac-
receives substantial forces during weight bear- ture impaction. Failure tended to occur as a
ing as stress is transferred from the hip region to result of nail penetration into the hip joint,
the femoral shaft. nail “cutout” from the femoral head, or
B. Evaluation—The physical examination and ra- hardware breakage. In an effort to combat
diographic evaluation for patients with intertro- the high failure rate for unstable fractures,
chanteric fractures is the same as for patients reduction techniques were developed in an
with femoral neck fractures. Patients with inter- attempt to restore the posteromedial but-
trochanteric fractures tend to have more tender- tress. Examples included the Hughston–Di-
ness over the greater trochanter. mon medial displacement osteotomy, the
C. Injury Classification—The Evans classification Sarmiento valgus osteomy, and the Wayne
of intertrochanteric fractures was developed County lateral displacement reduction. The
in 1949; it stresses the importance of an intact next generation of implants, such as the
posteromedial cortex for maintaining a stable Massie nail, allowed for the nail fixation in
reduction. The classification has not been the femoral head to telescope within the
shown to have good reproducibility and it may barrel of the side plate, similar to pres-
be better to simply classify fractures as stable ent day sliding hip screws. This design
or unstable. Unstable fractures include those improved osseous contact but still risked
with comminution of the posteromedial cortex, nail cutout because of poor fixation in the
subtrochanteric extension, or reverse obliquity femoral head and sharp edges on the nail.
patterns. The modern sliding hip screw provides im-
D. Associated Injuries—Common associated in- proved fixation in the femoral head with
juries in elderly patients include distal radius the large outside thread diameter of the lag
fracture, proximal humerus fracture, subdural screws (Fig. 5-6).
hematoma, myocardial infarction, and cerebro- • Sliding hip screw—Before inserting a slid-
vascular accident. ing hip screw, fracture reduction should be
FIGURE 5-6 Preop and 3-month

postop X-rays of a stable
intertrochanteric fracture treated
with a sliding hip screw.
obtained. This is typically done on the frac- disadvantages include difficulty with screw
ture table with the affected leg in traction. placement in the center of the femoral head
The leg is internally rotated and reduction and an increased cortical stress riser be-
examined using fluoroscopy on AP and lat- cause of the necessity for a distal starting
eral views. Care should be taken to avoid hole for screw placement. The most com-
malrotation, varus alignment, and poste- mon angle used is the 135° side plate which
rior sag. Posterior sag can be corrected by allows for proper lag screw placement and
placing a crutch under the hip or by using minimizes the cortical stress riser. Newer
an elevator during surgery. After reduc- implants have the ability to adjust the bar-
tion, a lateral approach to the proximal fe- rel plate angle to match the patient’s anat-
mur is performed. Lag screw placement is omy. Side plate application is performed
performed next with care to position the next. Although biomechanical studies
screw in the center of the femoral head have shown that a two-hole side plate
on both the AP and lateral views. Screws may provide adequate fixation, this as-
should be placed within 1cm of the sub- sumes both screws have good purchase
chondral bone as a tip–apex distance of in bone. If there is any question, a four-
greater than 2.5 cm has been associated hole plate should be used. If there is com-
with increased risk of failure. Plate angles minution or displacement of the greater
between 130° and 150° are most commonly trochanter, reduction and fixation can be
used. The advantages of higher angle plates achieved with a tension band technique. If
are improved sliding characteristics be- the greater trochanter is not reduced, the
tween the screw and barrel and decreased abductor mechanism may be compromised
varus moment acting on the implant. The with resulting Trendelenburg gait pattern.
• Intramedullary hip screw—The intramed- include revision ORIF, conversion to joint ar-
ullary hip screw consists of a sliding hip throplasty, or acceptance of the deformity in
screw coupled to an intramedullary nail. nonambulatory, pain-free patients.
Theoretic advantages include limited frac- 2. Malrotation deformities—Malrotation can occur
ture exposure and a lower bending moment with either excessive internal or external rota-
than with the sliding hip screw. Studies have tion of the distal fragment. During reduction of
shown no consistent difference between IM unstable fracture patterns, excessive internal ro-
hip screws and sliding hip screws with re- tation of the distal fragment should be avoided
spect to operating time, blood loss, infec- and fixation should generally be performed with
tion rate, screw cutout, or screw sliding. the leg in neutral or slight external rotation.
Recent studies have shown, however, a dra- 3. Nonunion—The risk of nonunion of intertro-
matic increase in the use of IM hip screws chanteric fractures using a sliding hip screw is
for intertrochanteric fractures. Short IM hip approximately 2%. Symptoms include buttock
screws do have an increased risk of femoral or groin pain. Treatment consists of either re-
shaft fracture at the nail tip or at the distal vision internal fixation or conversion to a joint
locking screw insertion points. arthroplasty.
• Prosthetic replacement—Prosthetic replace- 4. Screw-barrel disengagement—Screw-barrel dis-
ment has been used for comminuted, unsta- engagement is a rare complication that can be
ble intertrochanteric fractures. Prosthetic prevented by the use of a compression screw if
replacement is a more extensive surgical there is insufficient screw-barrel engagement. If
procedure with increased blood loss and a compression screw is left in place, however,
does introduce the risk of hip dislocation. there is a risk of the screw backing out, becom-
For some patients, particularly those with ing symptomatic, and requiring a second opera-
advanced osteoporosis as seen in renal dis- tion for removal.
ease, prosthetic replacement may provide 5. Bleeding—With the lateral approach to the
a more predictable result than ORIF. Pros- proximal femur for fixation of an intertrochan-
thetic replacement can also be used as a sal- teric fracture, bleeding encountered as the vas-
vage for failed internal fixation. tus lateralis muscle is elevated is most likely
• Postoperative management—Postopera- from a branch of the profunda femoris artery.
tively patients are mobilized as soon as H. Special Considerations
possible and generally are allowed to 1. Basilar neck fractures—Basilar femoral neck
weight bear as tolerated. Thromboprophy- fractures are extracapsular, and behave more
laxis should be administered until patients like intertrochanteric fractures. Fixation can
are ambulatory. be achieved with either cannulated screws
F. Complications of the Injury—The risk of thrombo- or a sliding hip screw. If a sliding hip screw is
embolic disease and mortality are essentially the used, there is a tendency for the femoral head
same as for patients with femoral neck fractures. Due to rotate, especially in patients with good bone
largely to the improved blood supply to the intertro- quality. To prevent the rotation, an antirotation
chanteric region, the risk of osteonecrosis and non- screw is placed superior to the lag screw guide
union is much less than for femoral neck fractures. wire before insertion of the lag screw.
G. Complications of Treatment 2. Reverse obliquity fractures—In reverse obliq-
1. Varus displacement of the proximal fragment— uity fractures, the fracture line runs from
Varus displacement of the proximal fragment superomedial to inferolateral (Fig. 5-7). The
is usually associated with unstable fractures sliding axis of the hip screw is parallel to the
with a lack of restoration of the posteromedial fracture line in reverse obliquity fractures, as
buttress. This may result in implant breakage, opposed to perpendicular with standard inter-
screw cutout, screw penetration into the joint, trochanteric fractures. The impaction benefits
and dissociation of the side plate from the fe- of the sliding hip screw are lost and the result
mur. Potential causes of this complication in- is suboptimal fixation with the potential for
clude anterosuperior femoral screw placement, medialization of the femoral shaft relative to
improper reaming creating a second lag screw the proximal fragment. This fracture pattern
channel, lack of stable reduction, excessive is better treated with either an intramedul-
fracture collapse (exceeding the sliding capac- lary hip screw or a fixed angle device such
ity of the device), and severe osteopenia lead- as a 95° dynamic condylar screw or a blade
ing to poor screw fixation. Management options plate.
FIGURE 5-7 Preop and postop X-rays of an intertrochanteric hip fracture with reverse obliquity
subtrochanteric extension treated with a cephalomedullary IM nail.
3. Severe osteopenia—With severe osteopenia, fix- resulting in avulsion of the lesser trochanteric
ation in the femoral head and the femoral shaft apophysis. Treatment is usually symptom-
may be compromised. Methylmethacrylate has atic. In elderly patients, isolated lesser tro-
been used to improve implant fixation. Locked chanteric fractures should be considered
plates designed for the proximal femur can be pathognomonic for a pathologic lesion of
used. Alternatively, joint arthroplasty can be the proximal femur. Treatment is based on the
performed. nature and extent of the pathologic process. If
4. Isolated greater trochanteric fractures— it turns out there is no pathologic involvement,
Isolated greater trochanteric fractures are rare treatment is symptomatic.
and typically occur in elderly patients who have
sustained a direct blow to the greater trochan-
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1979;61A:216–221. nal fixation and clinical outcome in displaced femoral neck
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cases. Clin Orthop. 1987;318:58–62. hip fractures in healthy older patients. J Bone Joint Surg Am.
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CHAPTER 6
Fractures of the Femoral Shaft

and Subtrochanteric Region
Sean E. Nork
I. Overview observed in all age groups. However, younger

A. Divisions of the Femur—The femur may be di- patients with high-energy blunt mechanisms
vided into five general anatomic regions: head and are most common. The majority (70%) occurs
neck, intertochanteric, subtrochanteric, shaft, and in male patients with an average age below
supracondylar/intercondylar. 30 years. Transverse and oblique patterns are
1. Subtrochanteric region—The subtrochanteric the most common configurations in young
zone of the femur is typically defined as the patients. Older patients, especially females,
area extending from the lesser trochanter to may sustain a femoral shaft fracture due to a
a point 5 cm distally. Fractures with a compo- lower energy mechanism such as a fall from
nent occurring within this region are usually standing. Spiral patterns are commonly seen in
reported as subtrochanteric fractures, even if older patients.
fracture extensions proximally and distally are C. Anatomy—Subtrochanteric and shaft regions of
observed. the femur are encased in a thick muscular enve-
2. Femoral shaft—The shaft of the femur begins lope. The muscular attachments typically deter-
at the top of the femoral isthmus and extends mine the primary displacements following fracture.
to the distal metadiaphyseal junction, an in- Subtrochanteric fractures occurring entirely below
distinct transitional zone contiguous with the the lesser trochanter have the typical deformities
supracondylar region. of flexion, abduction, and external rotation of the
B. Incidence and Mechanisms of Injury proximal segment. Shortening is common in both
1. Subtrochanteric fractures—Subtrochanteric fra- shaft and subtrochanteric patterns. The osseus
ctures may occur across all age groups. There anatomy of the proximal femur has considerable
is an asymmetric age- and gender-related bi- variation. The femoral neck is anteverted an aver-
modal distribution of fractures. High-energy age of 13° ± 7° and is translated 1.0 to 1.5 cm ante-
injuries are typically seen in young males and rior to the axis of the femoral shaft. The neck–shaft
low-energy injuries are frequently observed in angle averages 133° ± 7° in women and 129° ± 7° in
elderly females. Subtrochanteric fracture ex- men. The adult femur has an asymmetrical anterior
tensions occur commonly in elderly patients bow with an average radius of curvature between
who sustain a hip fracture due to a fall. Typi- 109 and 120 cm. The linea aspera is the posterior
cal high-energy mechanisms that predominate cortical thickening of the femoral diaphysis, is a
in younger patients result from motor vehicle muscular attachment site, and buttresses the con-
crashes, falls from heights, and penetrating cavity of the femoral shaft.
trauma. Although uncommon, fractures can oc-
cur in the subtrochanteric region as a complica- II. Evaluation
tion of screw fixation for a femoral neck fracture, A. Initial Management—Due to the high-energy
especially if screws are placed below the level mechanisms observed in young patients, associ-
of the lesser trochanter, or if an apex proximal ated injuries are common. The initial management
triangle configuration of three screws was used. includes adequate resuscitation using advanced
2. Femoral shaft fractures—Similar to subtro- trauma life support guidelines and should include
chanteric fractures, femoral shaft fractures are fluid replacement for blood loss (up to three units
77
of blood loss can be expected per femur fracture). 1. Russell-Taylor classification—The Russell-
For older patients with low-energy mechanisms Taylor classification (Fig. 6-1) has gained accep-
of injury, pathologic (including metabolic) etiolo- tance because it is a useful guide in selecting
gies should be investigated. the best type of internal fixation from both a
B. Physical Findings—Typical findings on physi- biomechanical and a biological perspective.
cal examination include pain, swelling, and de- 2. Orthopaedic Trauma Association (OTA) clas-
formity. Associated injuries can be distracting. sification based on the AO/ASIF
A visual inspection should include a circumfer- • Types 32-A1.1, 32-A2.1, and 32-A3.1 are
ential evaluation of the limb as well as palpation elementary patterns without comminution
of all extremities, the pelvis, and the spine. The (spiral, oblique, and transverse).
ipsilateral knee and hip should be examined to • Types 32-B1.1, 32-B2.1, and 32-B3.1 have but-
determine if there are associated noncontiguous terfly comminution (spiral wedge, bending
fractures or ligamentous injuries. Subtrochan- wedge, fragmented wedge).
teric fractures tend to shorten and present with • Types 32-C1.1, 32-C2.1, and 32-C3.1 are
fracture extension (the iliopsoas causes flexion comminuted versions of the elementary
of the proximal fragment) and varus (the hip patterns.
muscles cause abduction and external rotation 3. Fielding and Magliato classification
of the proximal fragment). Shaft fractures present • Type I fractures occur at the level of the
with limb shortening and variable rotation and lesser trochanter.
translation. • Type II fractures occur within 1 inch below
C. Emergency Treatment—Emergency treatment the lesser trochanter.
should include realignment of the injured extrem- • Type III fractures occur 1 to 2 inches below
ity using skeletal traction (preferable at the distal the lesser trochanter.
femur using a small diameter tensioned wire) to 4. Older classifications—Older classifications
prevent additional soft-tissue injury, to decrease include those of Seinsheimer, Waddell, and
muscle spasm, to limit ongoing blood loss, and to Boyd and Griffin.
decrease pain. Open wounds should be irrigated B. Femoral Shaft Fractures—Femoral shaft fractures
and a sterile dressing should be applied. Pulses are initially described according to location,
should be symmetrical, and the ankle–arm index pattern (e.g., transverse, oblique, spiral), and
(AAI) should be equal in both extremities. An AAI any associated soft-tissue injury. The location
of less than 0.9 is an indication for vascular con- is typically described as proximal third, middle
sultation and arterial imaging. third, or distal third; or at the junctions of these
D. Radiographic Imaging—Imaging should allow approximate locations. Additionally, the location
visualization of the entire femoral shaft, the of the fracture relative to the isthmus is important
ipsilateral hip, and the ipsilateral knee joint in for communication.
both the anteroposterior and lateral planes. The 1. OTA classification—The OTA (AO/ASIF) classi-
femoral neck should be scrutinized for fracture fication (Fig. 6-2) describes fractures based on
in both subtrochanteric and femoral shaft frac- morphology and suggests the mechanism of
tures. This can be accomplished with dedicated the applied force. Type A fractures are simple
hip radiographs, after review of a pelvic CT or in configuration and are divided into spiral,
both if applicable. The fracture configuration and oblique, and transverse patterns. Type B frac-
location, as well as the femoral anatomy can be tures have components of comminution and
determined primarily from biplanar radiographs. include spiral and bending wedge patterns;
Bone loss, bone quality, and the femoral canal dias well as fragmented wedge patterns. Type C
ameter can be determined. Contralateral femur fractures have segmental comminution.
radiographs can be useful in segmental or highly
2. Winquist-Hansen classification—The Winquist-
comminuted patterns, in anticipation of difficulty
Hansen classification was devised to describe
with length and rotational determination at the
comminution as related to the need for inter-
time of treatment.
locking screw fixation in early nail designs
(Fig. 6-3). Grade 0 and I fractures were consid-
III. Injury Classifications ered axially stable and interlocking was there-
A. Subtrochanteric Fractures—There are numerous fore not necessarily needed. Grade III, IV, and
classifications for fractures of the subtrochan- V fractures were considered axially unstable
teric region. and therefore required interlocking to prevent
C H A P T E R 6 | F E M O R A L S H A F T A N D S U B T R O C H A N T E R I C R E G I O N F R A C T U R E S 79
I-B
I-A
II-A II-B
FIGURE 6-1 Russell-Taylor classification of subtrochanteric fractures. Type 1A, Fracture extension with any degree of
comminution from below the level of the lesser treochanter to the isthmus with no extension into the piriformis fossa.
Type 1B, Fracture extension involving the lesser trochanter to the isthmus with no extension into the piriformis fossa.
Type IIA, Fracture extension into the piriformis fossa without lesser trochanter involvement (with medial cortex
stability). Type IIB, Fracture extension into the piriformis fossa and involving the lesser trochanter (without medial
cortex stability). (Reprinted with permission from Haidukewych G, Langford J. Subtrochanteric fractures. In: Bucholz
RW, Heckman JD, Court-Brown C, et al, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006.)
shortening and rotational malunion. However, 4. Type IIIB signifies periosteal stripping with in-
because of the possibility of unrecognized adequate soft-tissue coverage of the fractured
comminution and the currently predictable bone.
performance of statically locked nails, this 5. Type IIIC is an open fracture associated with an
classification system is now largely used for arterial injury requiring repair.
the purpose of describing communication.
C. Open Fractures—The soft-tissue injuries associ- IV. Associated Injuries
ated with open fractures are extrapolated from A. Open Fractures—Open fractures may occur from
the original system of Gustilo and colleagues. indirect trauma (e.g., motor vehicle crashes)
Although not a perfect translation to the femur, or from penetrating trauma (e.g., gunshot inju-
it is still used. ries). These injuries are typically the result of
1. Type I is an open fracture with a clean wound high-energy mechanisms and associated vas-
shorter than 1 cm. cular injuries are commonly observed. Intra-
2. Type II is an open fracture with a wound lon- medullary stabilization remains the treatment
ger than 1 cm and without extensive soft-tissue of choice for most open fractures. Exceptions
damage, flaps, or avulsions. include gross contamination that cannot be ad-
3. Type IIIA open fractures have adequate soft- equately debrided and substantial surgical delay
tissue coverage of the bone despite extensive to treatment. In these cases, a period of skeletal
soft-tissue laceration or flaps; these include traction with repeated debridements until soft-
open fractures with segmental comminution tissue contamination is reduced is recommended
and fractures caused by a gunshot. prior to definitive intramedullary stabilization.
FIGURE 6-2 OTA (AO-ASIF) classification of femoral

diaphyseal fractures. Type A fractures have simple
patterns: A1, spiral; A2, oblique; and A3, transverse.
Type B fractures have wedge patterns: B1, spiral
wedge; B2, bending wedge; and B3, fragmented wedge.
Type C fractures have complex patterns: C1, spiral
Simple A1 A2 A3
comminution; C2, segmental comminution; and C3,
fracture Spiral Oblique Transverse
30° irregular comminution.
Wedge B1 B2 B3
fracture Spiral Bending Fragmented
Complex C1 C2 C3
fracture Spiral Segmental Irregular
Low-velocity gunshot injuries do not require an with intramedullary nailing. The femur should
open debridement before intramedullary nail- be stabilized first. In the event that the patient
ing assuming that no foreign material has been becomes medically unstable during surgery and
brought into the wound with the projectile. both surgeries cannot be completed, femoral fixa-
Brumback had no infections in 62 Gustilo Type tion allows the patient to sit upright (decreasing
I, II, and IIIA open fractures and only three infec- the risk of pulmonary complications) and controls
tions in 27 Type IIIB injuries (two had delayed pain. The presence of a tibia fracture should not
treatment). Grosse reported three infections in affect the method or direction (antegrade versus
115 open femoral shaft fractures, all of which retrograde) of medullary stabilization.
were treated with early IM nailing. D. Fat Embolism—Fat embolism occurs in many
B. Ipsilateral Femoral Shaft and Neck Injuries—Con- trauma patients with long bone fractures, but
comitant femoral neck fractures occur in 3% to is usually subclinical. In young patients, a delay
10% of patients with femoral shaft fractures. in medullary stabilization is associated with an
The femoral neck fracture is often nondisplaced increased incidence of clinically significant fat
and is missed in 30% to 50% of cases. Most com- embolism syndrome.
monly, the femoral neck fracture is basicervical in E. Knee Ligamentous and Meniscal Injuries—
location (55%), although vertically oriented intra- Ipsilateral knee ligamentous and meniscal inju-
capsular patterns are seen in approximately 35% of ries occur commonly in association with femoral
patients. Because of the high incidence of missed shaft fractures. Ligamentous laxity on physical
femoral neck fractures, all patients should undergo examination is seen in approximately 50% of
a careful review of all available radiographic stud- patients and meniscal tears occur in approxi-
ies and dedicated hip radiographs. Treatment mately 30% of patients. Ligamentous stability
should be prioritized based on the patient’s overall is best assessed under anesthesia immediately
condition. An accurate reduction and treatment of after fracture stabilization.
the femoral neck should take precedence. F. Nerve Injuries—Nerve injuries occur rarely and
C. Floating Knee Injuries—Floating knee injuries (ipsi- are more likely following penetrating trauma.
lateral femoral and tibial fractures) are best treated G. Vascular Injuries—Associated vascular injuries
with early stabilization of both injuries, ideally are rare, but they represent a surgical emergency.
head injury remains controversial. The primary

concern is the impact of any associated intra-
operative hypotension (and hypoxia) on the
neurological outcome in these patients. While
intraoperative hypotension and decreased
cerebral perfusion pressure is common during
femoral nailing procedures, the association with
neurological injury has yet to be demonstrated.
There is an increased rate of pulmonary compli-
cations when femoral stabilization is delayed due
to an associated head injury.
Grade 0 Grade I Grade II J. Skeletal Immaturity and Open Physes—Skeletal
immaturity and open physes alter the treatment
decision. An open capital femoral epiphysis is
usually a contraindication to treatment with a
piriformis entry reamed nail. Younger patients
(depending on the patient’s weight and the frac-
ture location) may be treated with flexible (elastic)
intramedullary nails. External fixation and plates
also have a role depending on the patient’s asso-
ciated injuries and the fracture pattern.
V. Treatment and Treatment Rationale

A. Overview—Fractures of the femoral shaft and sub-
Grade III Grade IV Grade V
trochanteric region will heal with immobilization.
FIGURE 6-3 Winquist and Hansen’s classification of However, traction and casting are associated with
femoral shaft fracture comminution. Grade 0 has no numerous problems including knee stiffness, mal-
comminution. Grade I has a small butterfly fragment.
union (shortening, angulation, rotational malalign-
Grade II has a large butterfly fragment of less than 50% of
the width of the bone (leaving 50% or more of the cortex
ment), prolonged recumbency, and pulmonary
of the proximal fragment in contact with the cortex of the demise. Operative treatment is standard for virtu-
distal fragment). Grade III has a large butterfly fragment of ally all femoral shaft and subtrochanteric fractures.
more than 50% of the width of the bone (leaving less than B. Multiple Injuries—The timing and type of treatment
50% of the cortex of the proximal fragment in contact of the polytraumatized patient with a femoral shaft
with the cortex of the distal fragment). Grade IV has fracture remains controversial. Early stabilization
segmental comminution. Grade V has a segmental bone of the femoral shaft is necessary. However, the
defect. method of stabilization is dependent on multiple
factors including any associated chest, head, or
Vascular flow to the extremity should be reestab- other injuries. In most patients, early and definitive
lished within 6 hours if possible to maximize limb stabilization with a reamed intramedullary nail can
salvage rates. Temporary shunting followed by be performed. In a prospective and randomized
orthopaedic stabilization and definitive vascular study by Bone et al. in 1989, early (<24 hours) and
repair may be necessary if a time delay exists. late stabilization (>48 hours) were compared. Early
In most instances, definitive femoral stabilization stabilization was associated with a lower incidence
can be performed during the same surgical pro- of acute respiratory distress syndrome (ARDS), fat
cedure as the vascular repair. embolism, and pulmonary dysfunction in patients
H. Bilateral Injuries—Patients with bilateral femur with an injury severity score (ISS) higher than 18.
fractures have a worse overall prognosis and Length of care in both the intensive care unit and
higher mortality than patients with unilateral frac- the hospital, as well as hospital costs, were reduced
tures. This is likely due to increased blood loss, a in the early stabilization group. However, there
higher risk of respiratory distress syndrome, and may exist a subgroup of patients, typically termed
a higher prevalence of associated injuries. Treat- “borderline” patients or patients in extremis, who
ment with reamed nails can be safely performed may benefit from early stabilization with external
even in patients with bilateral fractures. fixation followed by delayed (typically 5 to 7 days
I. Associated Head Injury—Timing for femoral later) conversion to internal fixation. This has been
stabilization in patients with an associated shown to be a safe approach and may be indicated
in some patients with an associated pulmonary E. Subtrochanteric Fracture Stabilization—Many

injury or in patients who will not tolerate a lengthy subtrochanteric fractures can be similarly man-
operative procedure. aged with antegrade femoral nailing. However,
C. IM Nailing for Femoral Shaft Fractures—Most fem- the location and configuration of the subtrochan-
oral shaft fractures can be treated with intramed- teric fracture is useful for determining the type of
ullary nailing. This is the treatment of choice for nail and the location of the interlocking screws.
femoral shaft fractures as it can typically be per- For fractures that are located entirely below the
formed in a closed fashion, thereby maintaining the level of the lesser trochanter (Type IA fractures),
fracture hematoma and the associated soft-tissue antegrade interlocked nailing with standard inter-
envelope. Results of reamed, antegrade, statically locking screws has been shown to be successful.
locked intramedullary nailing for femoral shaft For fractures with involvement of the lesser tro-
fractures has shown union rates that range from chanter or the posteromedial buttress (Type IB),
94% to 100%. In Winquist and Hansen’s series of cephalomedullary nails (nails with proximal in-
520 femoral shaft fractures, the rate of union was terlocking screws that are directed obliquely and
99% with an infection rate of less than 1%. More into the femoral head) are typically indicated. For
recently, in a series of 551 fractures reported by subtrochanteric fractures with extension into the
Wolinksy et al., fracture healing after the index in- piriformis fossa, nailing may be more complicated.
tramedullary procedure was 94%. Including minor Although intramedullary techniques using a cepah-
secondary procedures and exchange nailings, lomedullary nail (either trochanteric entry or piri-
union was ultimately achieved in 99% of patients. formis entry) can still be useful, care must be taken
D. Alternative Treatments for Femoral Shaft Fractures— to maintain the reduction of the proximal fracture
Although intramedullary nailing is considered the extension (typically with an open technique) prior
optimal treatment for most femoral shaft frac- to reaming and nail insertion). Alternatively, plate
tures, an alternative treatment approach may be devices may be useful in these patterns. Blade
necessary in some patients. This decision may be plates, the dynamic condylar screw, and locking
influenced by the availability of implants and fluo- plate devices may all be useful for complex and
roscopy, the size of the medullary canal, and other simple patterns. Submuscular plate application,
factors. indirect reduction techniques, and avoidance of
1. Skeletal traction and bracing—The use of a any additional medial dissection all contribute to
period of traction, roller traction, cast braces a higher success rate with lateral plate devices.
and other methods are usually reserved for the Acute bone grafting is not necessary with plate fix-
rare situation where the patient cannot toler- ation in these fractures. The results of treatment of
ate a surgical procedure. Young children may subtrochanteric femur fractures with a 95° angled
be treated with a period of traction followed by blade in experienced hands can be favorable. In
casting. a longitudinal cohort study by Kinast et al., indi-
2. External fixation—In an adult patient, it is rare rect reduction techniques and avoidance of acute
to use external fixation as a definitive treat- bone grafting was associated with a decrease in
ment method. However, external fixation may nonunion rates (from 16.6% to 0%) by avoiding an
be useful as a temporary form of stabilization extensive surgical dissection for placement of the
in the severely injured patient or in cases where implant. Whether a plate or nail is chosen, the sur-
severe contamination necessitates a deep sec- gical goals are identical and include restoration of
ondary debridement. Conversion to a medul- length, alignment and rotation of the femur with
lary implant at the appropriate time (preferably re-establishment of the normal neck-shaft angle of
within 2 weeks) is optimal. the proximal femur.
3. Plate stabilization—The relative indications for
plate stabilization of a femoral shaft fracture VI. Anatomic and Biomechanical Considerations and
include: associated ipsilateral femoral neck Surgical Techniques
fracture, a narrow medullary canal that cannot A. Anatomic Considerations—In subtrochanteric
be treated with a nail, previous malunion, and fractures, the deforming forces on the proximal
skeletal immaturity. fragment make the reduction using longitudinal
4. Flexible IM nails—Flexible IM nails are gener- traction difficult. The proximal fragment is usu-
ally reserved for fractures in the skeletally im- ally flexed, abducted, and externally rotated,
mature patient. These may be inserted either while the distal segment is typically shortened
retrograde or antegrade, avoiding the femoral and medially displaced. This makes identifica-
growth plates. tion and delivery of the starting point for an
intramedullary nail difficult. The displacement C. Surgical Techniques

patterns for femoral shaft fractures are more 1. IM nailing—The patient may be positioned
variable and are dependent on the level of the either supine or lateral for antegrade IM nail-
fracture relative to the muscular origins and ing. Supine positioning is used for retrograde
insertions. nailing. A fracture table can be used for IM
B. Biomechanical Considerations—Important bio- nailing with the patient positioned either su-
mechanical considerations include the nail ra- pine or lateral. Alternatively, the injured leg
dius of curvature (relative to the femoral bow), can be prepped free and intramedullary nail-
the nail entry site (see the section on surgical ing can be performed on a radiolucent table.
techniques), and the nail stiffness and strength. The supine position may be advantageous in
1. IM nail curvature—The normal femur has an patients with multiple injuries or where ac-
anterior bow with a radius of curvature of ap- cess to the abdomen and chest is desirable.
proximately 120 cm. Most nail designs have a Placement of an IM femoral nail with the pa-
larger radius of curvature (i.e., a less bowed tient in the lateral position is associated with
design) with a range from 150 to 300 cm. As valgus deformity, especially in fractures dis-
a result, care must be taken, especially in tal to the femoral isthmus.
proximal shaft or subtrochanteric fractures, • Antegrade piriformis starting point—The
to avoid penetration of the anterior cortex piriformis fossa was identified by Johnson
distally. This is especially relevant in elderly and Tencer as the ideal starting point be-
patients and in cases where there is a signifi- cause it coincides with the neutral axis of
cant mismatch between the nail and the femo- the medullary canal. Anterior displacement
ral anatomy. of the starting point by more than 6 mm is
2. IM nail stiffness—The bending stiffness of an associated with high-hoop stresses, poten-
IM nail increases with the nail diameter, in- tially resulting in bursting of the femoral
creasing wall thickness, and interlocking ca- cortex with nail insertion. This is especially
pabilities. Torsional stiffness is increased in important in stiff or large diameter intra-
closed section nails compared with open sec- medullary nails. Lateral and medial starting
tion nails. Stiffness is also a function of nail point displacements are associated with
composition: steel is stiffer than titanium. varus and valgus deformities, especially in
3. Small diameter nails—The use of small di- proximal or subtrochanteric fractures. One
ameter nails typically requires placement of difficulty associated with the use of a cepha-
smaller interlocking screws. These screws are lomedullary nail that does not have a lateral
at a higher risk for fatigue failure. bend is the alignment of the nail with the
4. IM nail breakage—Larger diameter nails with medullary canal while simultaneously align-
larger locking screws are associated with a de- ing the proximal interlocking screws with
creased incidence of nail breakage. However, the neck of the femur. The femoral neck is
with the improved designs from most implant typically offset anteriorly relative to the
manufactures, early fatigue failure is rare femoral shaft. For subtrochanteric fractures,
when the implant is appropriately matched to especially those with proximal extension,
the femoral canal. Extensive reaming to allow the starting point may be biased anteriorly
placement of an extremely large nail is now (by up to 5 mm), since hoop stresses are
rarely required. Fatigue failure of nails is usu- dissipated by the proximal fracture.
ally an indication of nonunion. Ideally, 5 cm • Antegrade trochanteric starting point—
should separate the nearest extension of the Trochanteric entry nails were designed be-
fracture from the interlocking screws; but this cause of perceived difficulties identifying the
is not absolutely imperative depending on the piriformis fossa. Each nail manufacturer has
reduction and the patient’s size. a specific lateral bend which ranges from
5. Plates—Because of the eccentric location 4° to 10°. If the starting point is placed too
of the plate relative to the mechanical and laterally, a varus malreduction is likely
anatomical axes of the femur, greater me- in proximal fracture patterns.
chanical demands are placed on a plate than • Retrograde starting point—The location
on an IM nail. As a result, plates usually re- of the proper starting point is anterior to
quire weight bearing restrictions that are un- the posterior cruciate ligament and at the
necessary in most patients treated with an intercondylar sulcus in line with the canal
intramedullary nail. of the femur. Radiographically, this is at the
anterior extension of Blumensaat’s line on If temporary spanning external fixation of a

the lateral view. The entrance should be high-subtrochanteric fracture is necessary
collinear with the longitudinal axis of the and proximal femoral fixation cannot be ob-
femoral canal on the anteroposterior radio- tained, the external fixation can be extended
graphic projection and not perpendicular to to the pelvis to span the hip joint.
the knee joint femoral articulation (which is
VII. Acute Injury Complications
in valgus). Knee flexion of 35° to 50° is nec-
A. Pulmonary Complications—Fat emboli syn-
essary to allow identification of the starting
drome (FES), ARDS, and pulmonary dysfunc-
point. Proximally the nail should be placed
tion are complications associated with femoral
so that the most proximal portion of the
shaft fractures. Patients with multiple injuries,
nail extends above the level of the lesser
especially concomitant thoracic or pulmonary
trochanter.
trauma, are at particular risk. Early fracture
• Reaming—Sharp, flexible reamers with deep
stabilization is associated with a decreased
flutes and a thin flexible shaft should be
risk of FES.
used to decrease the risk of thermal injury
B. Thigh Compartmental Syndrome—Thigh com-
and elevated intramedullary pressures. The
partmental syndrome is rare. However, because
canal is usually reamed 1.0 to 1.5 mm larger
of the potential consequences of missing this
than the chosen nail diameter. There is no
entity, early diagnosis is critical. Clinical signs
need for excessive reaming with current in-
and symptoms include severe and tense swell-
terlocking nail designs.
ing, pain with passive knee motion, and pain
• Interlocking—All femoral fractures should
out of proportion to the injury. However, all of
be statically locked. There is no evidence
these indicators are present with any femur
that dynamic interlocking offers any advan-
fracture, making diagnosis difficult. Pressure
tage with regards to healing. Additionally, in
measurements can helpful if the diagnosis is
patients with unrecognized fracture commi-
questionable or in an unconscious patient.
nution, shortening is a concern.
Thigh compartmental syndrome is treated by
2. Plating—For plating of subtrochanteric and
immediate fasciotomies.
femoral shaft fractures, open extensile and
minimally invasive techniques are both use- VIII. Complications of Treatment and Long-Term
ful. No matter the technique, the deep dissec- Sequelae
tion should be limited as much as possible. A. Pulmonary Dysfunction or FES—The process of
For an open approach to the femur, a lateral instrumenting the femoral canal, either with a
subvastus approach is used, reflecting the medullary implant, a reamer, or a starting awl;
vastus lateralis from the lateral intermuscu- is associated with embolization of marrow or
lar septum. Perforating branches of the pro- fat into the venous circulation. Although con-
funda femoris artery should be identified and troversial, this has been hypothesized to con-
ligated. For comminuted fracture patterns, tribute to pulmonary dysfunction, especially in
bridge plating using biological principles patients with thoracic or pulmonary injuries.
should be used with indirect reduction of any However, a retrospective study by Bosse et al.
intercalary fragments. A broad, large fragment demonstrated no difference in pulmonary com-
compression plate is typically required. There plications when femoral plating versus reamed
are very few disadvantages to using a longer nailing was retrospectively compared at two
plate; the number of cortices on each side of institutions.
the fracture is less important than the plate B. Nerve Injury—Iatrogenic nerve injury is infre-
length. quent following femoral nailing. The primary
3. External fixation—External fixation of the fe- nerves at risk are the femoral, sciatic, peroneal,
mur can be performed with a unilateral con- and pudendal. Patient positioning on a traction
figuration using 5- or 6-mm pins. The pins table can injure the pudendal nerve due to di-
are usually placed from lateral to medial rect pressure from the perineal post. Prolonged
with two pins on either side of the fracture. and sustained traction should be avoided. Over
Anterolateral and anterior entry sites can be distraction or vigorous reduction maneuvers
used as well. Since external fixation is usu- can put the sciatic nerve at risk.
ally a temporizing measure until a definitive C. Muscle Weakness—In antegrade femoral nail-
procedure can be performed, maximization of ing, injury to the hip abductors and external
the biomechanical strength is not necessary. rotators may occur and is related to the site of
nail insertion. Trochanteric entry nails injure the identification of the starting point through
the abductor insertion, although studies have the placement of interlocking screws) to ensure
not shown an increased risk of abductor dys- proper alignment.
function following trochanteric nailing. Quadri- I. Rotational Malalignment—The amount of fem-
ceps impairment is common following femoral oral rotation that is well tolerated is largely
fracture, although this is likely due to the injury unknown, but there appears to be increased
and not the method of treatment. symptoms with over 15° of rotational malalign-
D. Knee Stiffness, Knee Pain, Hip Pain—Temporary ment. Femoral rotation can be determined
knee stiffness is common following treatment of intraoperatively using several methods of clini-
a femoral shaft fracture. Treatment with plate cal and radiological evaluation. Symmetry of
fixation has been assumed to contribute to knee the cortical thicknesses is useful but not reli-
stiffness, although several larger studies have able. The shape and appearance of the lesser
failed to identify this relationship. Retrograde trochanter in known rotation (compared with
nailing may be associated with knee stiffness, the uninjured femur) is a reliable method of
although several prospective and randomized determining rotation of the femur. A CT scan
studies have failed to demonstrate this. Knee following stabilization can be used if there is a
pain is associated with retrograde nailing; and question regarding rotational alignment. This
hip pain is associated with antegrade nailing. CT is performed by binding bilateral lower ex-
The incidence of hip pain following antegrade tremities together with straps so that the legs
nailing ranges from 10% to 40%. The incidence can not move and scanning both proximal and
of knee pain following retrograde nailing ranges distal femurs to compare their relative rota-
from 30% to 40%. tions (proximal versus distal on the injured and
E. Heterotopic Ossification (HO)—The formation uninjured side).
of heterotopic bone at the nail entry site follow- J. Femoral Nail Removal—The need and timing of
ing antegrade nailing ranges from 9% to 60%; femoral nail removal following fracture healing
however, clinically significant bone formation remains unknown. Complete radiographic and
is uncommon and is reported in 5% to 10% of clinical healing should be assured prior to re-
patients. Heterotopic bone formation is loosely moval. Nail removal should likely be restricted
associated with male gender, a delay to surgery, to symptomatic patients only as the procedure
prolonged intubation, and an associated head is associated with complications and the im-
injury. There is a higher incidence of HO follow- provement in discomfort is inconsistent. In a
ing reamed nails than with unreamed nails. study on over 100 patients followed for 2 years
F. Refracture—Refracture following plating is un- after femoral nail removal, over 20% of patients
common and is usually an indication of non- were no better or worse.
union. Fracture can occur at the end of a plate,
although this usually requires a substantial IX. Nonunion
injury. Nonunion is uncommon following intramedullary
G. Implant Complications—Broken nails, screws: nailing of femoral shaft and subtrochanteric frac-
With advances in nail design, fatigue failure tures. However, the incidence is likely more frequent
prior to healing occurs infrequently. Broken than some studies indicate. Several larger series
nails are indicative of nonunion. Broken screws indicate delayed or nonunion in 6% to 12% of pa-
and nails can be challenging to remove and nu- tients. Treatment options include femoral exchange
merous techniques have been described to al- nailing, conversion to a plate with or without bone
low for successful extraction. grafting, and plating around the nail. Dynamization
H. Angular Malalignment—An angular deformity is has not been shown to be consistently effective for
usually defined as 5° in either the coronal or the treatment of femoral nonunions. Femoral ex-
sagittal plane. This is more common in proxi- change nailing involves nail removal, reaming, and
mal or distal fractures where the intimate fit insertion of a larger diameter implant, typically 1 to
between the medullary implant and the femo- 3 mm larger than the original nail. Success varies
ral isthmus is not present. For proximal frac- and ranges from 53% to 96%. Conversion from a nail
tures, the starting point of the nail is critical to plate, with or without bone grafting depending on
for ensuring proper alignment. In subtrochan- the type of nonunion, has been successful in over
teric fractures treated with intramedullary 90% of patients as reported by Bellabarba et al. Fi-
nails, the alignment should be corrected and nally, augmentative plating around a nail has been
maintained throughout the procedure (from associated with a high success rate. This is thought
to be primarily due to the increased torsional sta- Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary
bility in fractures/nonunions that had some persis- nailing of femoral shaft fractures. Part II: Fracture-healing
with static interlocking fixation. J Bone Joint Surg Am.
tent rotational instability following intramedullary
1988;70(10):1453–1462.
nailing. Johansen K, Lynch K, Paun M,et al. Non-invasive vascular tests
reliably exclude occult arterial trauma in injured extremi-
X. Malunion
ties. J Trauma. 1991;31(4):515–519; discussion 519–522.
Angular femoral malunion is more commonly associ- Kinast C, Bolhofner BR, Mast JW, et al. Subtrochanteric frac-
ated with closed fracture treatment than with opera- tures of the femur. Results of treatment with the 95 degrees
tive fixation. However, subtrochanteric fractures are condylar blade-plate. Clin Orthop. 1989;(238):122–130.
more difficult to accurately reduce and control than Michelson JD, Myers A, Jinnah R, et al. Epidemiology of hip
fractures among the elderly. Risk factors for fracture type.
shaft fractures, thus resulting in a larger incidence
Clin Orthop Relat Res. 1995;(311):129–135.
of angular malunion. Limb length inequality may be O’Brien PJ, Meek RN, Powell JN, et al. Primary intramedul-
associated with an angular malunion or may occur in lary nailing of open femoral shaft fractures. J Trauma.
isolation. Angular corrections typically require treat- 1991;31(1):113–116.
ment with a femoral osteotomy. Limb length inequal- Riemer BL, Butterfield SL, Burke CJ 3rd, et al. Immediate plate
fixation of highly comminuted femoral diaphyseal fractures in
ity may be treated with a lengthening procedure on
blunt polytrauma patients. Orthopedics. 1992;15(8):907–916.
the affected side or a closed shortening of the con- Riemer BL, Butterfield SL, Ray RL, et al. Clandestine femoral
tralateral side. Torsional malunions can occur with neck fractures with ipsilateral diaphyseal fractures. J Orthop
fractures in any location. Correction of torsional Trauma. 1993;7(5):443–449.
deformities should be considered if the rotational Tencer AF, Sherman MC, Johnson KD. Biomechanical factors
affecting fracture stability and femoral bursting in closed
malalignment is greater than 15° as compared to the
intramedullary rod fixation of femur fractures. J Biomech
normal side. Eng. 1985;107(2):104–111.
Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedul-
XI. Other Issues and Special Coniderations lary nailing of femoral fractures. A report of five hundred
A. Pathologic Fractures—The femur may be weak- and twenty cases. J Bone Joint Surg Am. 1984;66(4):529–539.
ened by pathologic (e.g., metabolic, neoplastic) Wiss DA, Brien WW. Subtrochanteric fractures of the femur.
processes, resulting in a fracture or impending Results of treatment by interlocking nailing. Clin Orthop.
fracture. Cephalomedullary nails are particularly 1992;(283):231–236.
Wiss DA, Brien WW, Stetson WB. Interlocked nailing for treat-
useful for pathologic fractures of the femur, as ment of segmental fractures of the femur. J Bone Joint Surg
these implants simultaneously stabilize the fem- Am. 1990;72(5):724–728.
oral shaft and femoral neck. Wolinsky PR, Sciadini MF, Parker RE, et al. Effects on pulmonary
B. Periprosthetic Fractures—There are several physiology of reamed femoral intramedullary nailing in an
classification systems for periprosthetic frac- open-chest sheep model. J Orthop Trauma. 1996;10(2):75–80.
tures; the most often used is the Vancouver
system which takes into account the fracture Recent Articles
location, the integrity of the prosthesis, and any Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect
associated bone deficiencies that need to be ad- reduction and plating of femoral shaft nonunions after in-
tramedullary nailing. J Orthop Trauma. 2001;15(4):254–263.
dressed. In general, fractures proximal to the tip
Bhandari M, Guyatt GH, Tong D, et al. Reamed versus non-
of a hip arthroplasty are treated with revision reamed intramedullary nailing of lower extremity long bone
while fractures distal to the tip of a well-fixed fractures: a systematic overview and meta-analysis. J Orthop
femoral prosthesis can be treated with stan- Trauma. 2000;14(1):2–9.
dard fracture reduction techniques. Multiple Bosse MJ, MacKenzie EJ, Riemer BL, et al. Adult respira-
tory distress syndrome, pneumonia, and mortality follow-
techniques are described for obtaining fixation
ing thoracic injury and a femoral fracture treated either
around the prosthesis. with intramedullary nailing with reaming or with a plate.
A comparative study. J Bone Joint Surg Am. 1997;79(6):799–809.
Brinker MR, O’Connor DP. Exchange nailing of ununited frac-
tures. J Bone Joint Surg Am. 2007;89-A:177–188.
SUGGESTED READINGS Brumback RJ, Toal TR Jr, Murphy-Zane MS, et al. Immediate
weight-bearing after treatment of a comminuted fracture
Classic Articles of the femoral shaft with a statically locked intramedullary
Benirschke SK, Melder I, Henley MB, et al. Closed interlocking nail. J Bone Joint Surg Am. 1999;81(11):1538–1544.
nailing of femoral shaft fractures: assessment of technical Buttaro M, Mocetti E, Alfie V, et al. Fat embolism and related
complications and functional outcomes by comparison of effects during reamed and unreamed intramedullary nailing
a prospective database with retrospective review. J Orthop in a pig model. J Orthop Trauma. 2002;16(4):239–244.
Trauma. 1993;7(2):118–122. Canadian Study Group. Nonunion following intramedullary
Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed nailing of the femur with and without reaming. Results of a
stabilization of femoral fractures. A prospective randomized multicenter randomized clinical trial. J Bone Joint Surg Am.
study. J Bone Joint Surg Am. 1989;71(3):336–340. 2003;85-A(11):2093–2096.
Dora C, Leunig M, Beck M, et al. Entry point soft tissue dam- Roberts CS, Nawab A, Wang M, et al. Second generation intra-
age in antegrade femoral nailing: a cadaver study. J Orthop medullary nailing of subtrochanteric femur fractures: a bio-
Trauma. 2001;15(7):488–493. mechanical study of fracture site motion. J Orthop Trauma.
Egol KA, Chang EY, Cvitkovic J, et al. Mismatch of current 2002;16(4):231–238.
intramedullary nails with the anterior bow of the femur. Salminen ST, Pihlajamaki HK, Avikainen VJ, et al. Population
J Orthop Trauma. 2004;18(7):410–415. based epidemiologic and morphologic study of femoral
French BG, Tornetta P 3rd. Use of an interlocked cephalom- shaft fractures. Clin Orthop. 2000;(372):241–249.
edullary nail for subtrochanteric fracture stabilization. Clin Scalea TM, Boswell SA, Scott JD, et al. External fixation as a
Orthop. 1998;(348):95–100. bridge to intramedullary nailing for patients with multiple in-
Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion juries and with femur fractures: damage control orthopedics.
of the femoral diaphysis. The influence of reaming and J Trauma. 2000;48(4):613–621.
non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. Starr AJ, Hay MT, Reinert CM, et al. Cephalomedullary nails
2000;82(5):655–658. in the treatment of high-energy proximal femur fractures in
Kloen P, Rubel IF, Lyden JP, et al. Subtrochanteric fracture af- young patients: a prospective, randomized comparison of
ter cannulated screw fixation of femoral neck fractures: a trochanteric versus piriformis fossa entry portal. J Orthop
report of four cases. J Orthop Trauma. 2003;17(3):225–229. Trauma. 2006;20(4):240–246.
Lundy DW, Acevedo JI, Ganey TM, et al. Mechanical compari- Starr AJ, Hunt JL, Chason DP, et al. Treatment of femur
son of plates used in the treatment of unstable subtrochan- fracture with associated head injury. J Orthop Trauma.
teric femur fractures. J Orthop Trauma. 1999;13(8):534–538. 1998;12(1):38–45.
Meyer RS, White KK, Smith JM, et al. Intramuscular and blood Stephen DJ, Kreder HJ, Schemitsch EH, et al. Femoral intra-
pressures in legs positioned in the hemilithotomy position: medullary nailing: comparison of fracture-table and manual
clarification of risk factors for well-leg acute compartment traction. A prospective, randomized study. J Bone Joint Surg
syndrome. J Bone Joint Surg Am. 2002;84-A(10):1829–1835. Am. 2002;84-A(9):1514–1521.
Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of Tornetta P 3rd, Tiburzi D. Reamed versus nonreamed anterograde
external fixation to intramedullary nailing for fractures of femoral nailing. J Orthop Trauma. 2000;14(1):15–19.
the shaft of the femur in multiply injured patients. J Bone Watson JT, Moed BR. Ipsilateral femoral neck and shaft frac-
Joint Surg Am. 2000;82(6):781–788. tures: complications and their treatment. Clin Orthop.
Oakey JW, Stover MD, Summers HD, et al. Does screw con- 2002;(399):78–86.
figuration affect subtrochanteric fracture after femoral neck Weresh MJ, Hakanson R, Stover MD, et al. Failure of exchange
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son of retrograde and antegrade femoral intramedullary Wolinsky PR, McCarty E, Shyr Y, et al. Reamed intramedullary
nailing. J Orthop Trauma. 2000;14(7):496–501. nailing of the femur: 551 cases. J Trauma. 1999;46(3):392–399.
Ostrum RF, Marcantonio A, Marburger R. A critical analysis of
the eccentric starting point for trochanteric intramedullary
femoral nailing. J Orthop Trauma. 2005;19(10):681–686. Textbooks
Pape HC, Grimme K, Van Griensven M, et al. Impact of in- Court-Brown CM. Femoral diaphyseal fractures. In: Browner
tramedullary instrumentation versus damage control for BD, Jupiter JB, Levine AM, eds. Skeletal Trauma: Basic Sci-
femoral fractures on immunoinflammatory parameters: pro- ence, Management and Reconstruction. 3rd ed. Philadelphia,
spective randomized analysis by the EPOFF Study Group. PA: Saunders; 2003:1879–1883.
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from early total care to damage control orthopedic surgery. JD, Court-Brown C, eds. Rockwood and Green’s Fractures
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after intramedullary nailing of femoral shaft fractures. Lippincott Williams & Wilkins; 2005:1845–1914.
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CHAPTER 7
Fractures of the Supracondylar

Femoral Region
Milan K.Sen
I. Evaluation 2. Vascular—Palpable pulses are a good indicator

A. History—As with all extremity injuries, prelimi- of limb perfusion. If the pulses are not pal-
nary evaluation of fractures of the supracondy- pable, then a Doppler examination should
lar femoral region must include an account of be performed. Realignment of the limb using
the mechanism of injury, assessment of comor- traction and splinting can help with restora-
bidities, history of prior surgery in the affected tion of pulses and limb perfusion. If pulses are
area, preinjury symptoms, and preinjury level unequal, or not detectable on Doppler exami-
of function. Often these patients fall into two nation, an ankle–brachial index (ABI) or arte-
categories: riogram should be performed. An ABI of less
1. The elderly or osteopenic patient with a frac- than 0.9 warrants further workup. If pulses are
ture after a low-energy injury due to a fall from initially absent but return after manipulation
standing or a twisting injury. of the limb, an arteriogram should strongly
2. The younger, healthier patient who sustains a be considered to rule out an intimal tear that
high-energy injury due to a motor vehicle ac- could lead to thrombosis.
cident or a fall from a significant height. 3. Soft tissues—Initial evaluation should in-
In either case, the force is usually transmitted clude documentation of open wounds. Atten-
through a flexed knee. Additional clues as to the tion should be paid to the posterior aspect of
energy of the injury can be obtained from the the limb to make certain that wounds on the
physical findings and X-ray pattern. Together, this back of the leg are not missed. Patients with
information allows the surgeon to make appropri- open fractures should receive antibiotic cov-
ate management decisions, look for associated erage for gram-positive organisms. Grossly
injuries, and prevent complications. contaminated wounds should also receive
B. Physical Examination—In the setting of poly- gram-negative coverage. Wounds contami-
trauma, initial examination includes ATLS proto- nated with dirt should receive anaerobic cov-
col, prioritizing the ABCs (airway, breathing, and erage as well.
circulation). Once this assessment is complete, 4. Compartment syndrome—Compartment Syn-
evaluation of the extremities is performed. Defor- drome should be ruled out in all patients with
mity in and around the knee, bruising, swelling, extremity injuries. Special attention should be
and open wounds should be noted. In addition, a paid to the polytrauma patient who may have
proper neurovascular exam is critical. distracting injuries or is sedated. If the clinical
1. Neurologic—Evaluation of motor and sensory exam is suggestive of compartment syndrome,
function of the tibial nerve, superficial pe- fasciotomies should be performed. If the pa-
roneal, and deep peroneal nerves should be tient is not examinable, compartment pressure
performed, and the results documented. Of- measurements should be performed. If the pa-
ten, the exam is limited by pain, level of con- tient undergoes a revascularization procedure,
sciousness, sedation, or neurologic injury, and prophylactic fasciotomies should be performed
this should also be documented in the patient to account for edema associated with reperfu-
record. sion injury.
88
C H A P T E R 7 | F R A C T U R E S O F T H E S U P R A C O N D Y L A R F E M O R A L R E G I O N 89
5. Associated injuries—Particularly in the set- 4. If a ligamentous knee injury or dislocation is

ting of polytrauma, associated injuries should suspected, an MRI should be considered prior
be ruled out. Often, these are not obvious on to instrumentation and after consultation with
the secondary survey and must be evaluated a specialist.
on tertiary survey or on exam under anesthe- 5. If a vascular injury is suspected—Often in as-
sia in the operating room. Musculoskeletal in- sociation with a knee dislocation—A CT angio-
juries commonly seen in the ipsilateral limb gram should be performed.
include tibial shaft fractures (floating knee), D. Classification—Orthopaedic Trauma Association
femoral neck fractures or hip dislocations, pa- Classification (Fig. 7-2)
tella fractures, and ligamentous knee injuries
II. Initial Management
or dislocations. Falls from significant height
A. Reduction using traction and splinting is usually
may also result in calcaneus or pilon frac-
sufficient for temporary stabilization of isolated
tures, or fractures of the pelvis, acetabulum,
supracondylar femur fractures. Skeletal traction
or spine.
is usually not necessary.
C. Radiographs
B. External fixation spanning the knee is indicated
1. AP and lateral X-ray images of the hip, femur,
when definitive fixation is delayed due to soft tis-
and knee should be obtained. X-rays should
sue injury or wound contamination, and in the
be scrutinized for intra-articular fractures, and
setting of a vascular repair. Ideally, external fixa-
Hoffa fragments (Fig. 7-1).
tion should be converted to definitive internal
2. More comminuted fractures and those with ex-
fixation within 2 weeks to decrease the infection
tension into the diaphysis are often the result of
risk secondary to pin track colonization.
higher-energy mechanisms of injury and should
prompt the surgeon to look for other associ- III. Definitive Treatment
ated injuries. A. Principles of ORIF
3. Intrarticular fractures should be imaged with The goal of open reduction and internal fixation
CT scan. This is more valuable if provisional is to restore anatomic alignment of the limb while
realignment has been performed with traction providing a stable environment for healing and suf-
and splinting, or external fixation. ficient stability to allow for early range of motion.
This is accomplished by following these steps:
1. Anatomic reduction of the articular surface—
In fractures with intra-articular extension, the
first goal should be to restore articular con-
gruity. This is best achieved using interfrag-
mentary screws. Cancellous, and sometimes
cortical screws, ranging from 3.5 to 6.5 mm
are commonly used. Smaller screws (2.0 to
3.0 mm) should also be available for fixation
of smaller fragments in the setting of fracture
comminution. Care must be taken to keep the
starting point and trajectory of these screws
from interfering with a subsequent intramed-
ullary nail, or plate and screw positioning. One
must consider the three-dimensional struc-
ture of the distal femur to avoid violation of
the notch anteriorly and also the fossa poste-
riorly. Prominent screw penetration medially
may also lead to irritation of the soft tissues
along the medial condyle.
2. Restoration of mechanical axis—Realignment
of the axis of the femur can be achieved with
FIGURE 7-1 Sagittal cut from a CT scan of the distal the use of plates and screws, or an intramed-
femur demonstrates the fracture of the posterior condyle ullary implant such as a supracondylar nail.
of the femur (Hoffa fragment). This fracture line is easily In the setting of intra-articular fractures, a
missed on plain X-rays. plate-and-screw construct is often preferred
Bone: femur 3 Location: distal segment (33)
Types
A. Extra-articular (33-A) B. Partial articular (33-B) C. Complete articular (33-C)
Groups: Femur, distal, complete articular (33-C)

Femur, distal, extra-articular (33-A) Femur, distal, partial articular (33-B) 1. Articular 2. Articular 3. Multifrag-
simple, meta- simple, meta- mentary
1. Simple 2.Metaphyseal 3. Metaphyseal 1. Lateral 2. Medial 3. Frontal physeal simple physeal multi- articular
(33-A1) wedge complex condyle, condyle, (33-B3) (33-C1) fragmentary fracture (33-C3)
(33-A2) (33-A3) sagittal (33-B1) sagittal (33-B2) (33-C2)
FIGURE 7-2 The Orthopaedic Trauma Association classification of distal femur fractures. The alphanumeric code used
to classify these fractures is made up of a number for the bone segment—in this case 33 (for femur, distal)—followed
by a letter to describe the general type of fracture. Fractures classified as 33-A are extra-articular fractures in the
metadiaphyseal region. 33-B refers to partial articular fractures, where at least one portion of the articular surface is
in continuity with the diaphysis. 33-C fractures are complete articular fractures, where no part of the articular surface
remains in continuity with the diaphysis. More extensive classification is possible, with subdivision into groups. (From
Collinge CA, Wiss DA. Distal femur fractures. In: Bucholz RW, Court-Brown CM, Heckman, JD, et al, eds. Rockwood and
Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010, with permission.)
to avoid displacing the articular reduction or expense of the soft-tissue envelope, as greater
fixation. Ultimately, implant selection depends dissection is required for insertion.
on surgeon experience and preference. 1. Plate fixation is usually achieved from the lat-
B. ORIF with Plate Fixation eral side. In simple fracture patterns, this is
Fixed angle plates provide excellent fixation for sufficient, as stability of the medial column of
maintaining reduction, but this comes at the the femur is provided by restoration of bony
alignment and contact. In comminuted frac- comminution, avoiding the need for additional
tures, no stability is provided by restoration medial plates, and with easier insertion than
of bony alignment alone. older fixed-angle devices (Fig. 7-3).
2. Locking plates now play an important role in 3. The development of minimally invasive plate
the management of these types of fractures. osteosynthesis (MIPO) techniques have also
Their fixed angle construct has allowed for been helped by the design of these plates,
stable fixation of fractures in the setting of which are very amenable to MIPO insertion.
A B FIGURE 7-3 A. AP and lateral

X-ray of a supracondylar
fracture stabilized with a
95° blade plate. B. AP X-ray
of an intercondylar femur
fracture stabilized with a Less
Invasive Stabilization System
(LISS) plate. C. AP X-ray of a
periprosthetic distal femur
nonunion stabilized with a
locking condylar plate. (Part
A from Collinge CA, Wiss DA.
Distal femur fractures. In:
Bucholz RW, Court-Brown
CM, Heckman, JD, et al,
eds. Rockwood and Green’s
Fractures in Adults. 7th ed.
Philadelphia, PA: Lippincott
Williams & Wilkins, 2010, with
permission.)
C. ORIF with Intramedullary Implant—Intramedul- devitalized tissue (including bone), and for-
lary nails can also be used for realignment of the eign material. Wounds must be extended to
femur but have several limitations. allow for removal of all debris, and exposure
1. Theoretically, their insertion causes additional of the bone for proper debridement. No
injury to the articular surface. amount of irrigation or antibiotics will com-
2. Intramedullary nails are not canal filling at the pensate for an inadequate debridement.
level of the distal femur. Fixation is minimal, • In clean wounds with good soft-tissue cov-
and the nail is not as capable of controlling erage, immediate ORIF may be considered.
motion in the varus–valgus plane, which can • In the majority of cases, serial debridements
lead to a “windshield wiper” effect. being performed every 48 hours is pre-
3. Special “supracondylar nails” are available and ferred. ORIF is delayed until a clean wound
offer more points of fixation for these types of is obtained. Negative pressure wound ther-
fractures. Blocking screws can also be used to apy or an antibiotic bead pouch can be used
control alignment and increase the stability of for provisional wound coverage between
the construct (Fig. 7-4). debridements.
D. Special Considerations
1. Periprosthetic fractures IV. Perioperative Plan
The first thing that needs to be determined in A. Instrumentation and Equipment
the setting of a periprosthetic fracture of the It is important to make certain that all of the nec-
distal femur is whether the implant is loose. essary instrumentation is pulled for your case.
If it is loose, infection must be ruled out. If a This includes:
cruciate sparing total knee prothesis was used, 1. The desired implant—Typically a locking plate
either a plate and screw construct or a supra- or an intramedullary nail.
condylar nail may be used (Fig. 7-5). If a cruci- 2. Multiple screw options in the case of an intra-
ate sacrificing prosthesis was used, the CAM articular fracture.
will not allow for placement of a supracondylar 3. Various reduction clamps, including large peri-
nail. Similarly, the CAM will block the trajec- articular reduction tenaculums.
tory of some of the locking screws, and this 4. Kirschner wires.
needs to be taken into consideration in the se- 5. A radiolucent operating table.
lection and positioning of a fixed-angle implant. 6. C-arm fluoroscopy.
If the prosthesis is loose, consultation with an 7. Equipment for adjustment or removal of an ex-
arthroplasty specialist is recommended. ternal fixator, if present.
2. Pre-existing knee arthritis 8. A femoral distractor should be available to
Primary TKA in a patient with pre-existing assist with reduction of the femur. When
knee arthritis is an option. One must consider spanning the knee, the distractor can greatly
the severity and duration of the symptoms improve the visualization of the articular
preoperatively, the patient’s pre-existing level surface.
of function, and whether the fracture pattern B. Positioning
is amenable to this form of treatment. Often 1. The patient is positioned supine.
these are more challenging cases than a typi- 2. A bump is placed under the distal femur at the
cal primary TKA, as the prosthesis will require level of the apex of the fracture. This helps re-
augments and/or stems for stability of the im- duce the apex posterior deformity by allowing
plant. Comminuted intra-articular fractures in the knee to flex and reduces the tension on
osteopenic bone are a better indication for pri- the gastroc’s origin, which pulls the distal frag-
mary TKA than extra-articular fractures are. In ment into extension. It also elevates the femur
the majority of cases, it is preferable to obtain for fluoroscopic visualization of the fracture
anatomic realignment of the femur to allow for site on a lateral projection.
healing with enough bone stock for a primary 3. Alternatively, blankets layered underneath
TKA in the future, if needed. the tibia, elevating and supporting it in a
3. Open fractures plane horizontal to the ground may be used
• Antibiotics need to be started on presenta- (Fig. 7-6). Prefabricated “triangles” are also
tion in the emergency room. available in a variety of material and serve the
• Tetanus status must be verified. same purpose.
• A thorough surgical debridement is 4. Prepping out the uninjured leg allows for in-
paramount, removing all contaminated and traoperative assessment of bilateral limb
A B FIGURE 7-4 When a
femoral nail is used for
fixation of distal femur
fractures, it is important
that the construct is
stable enough to maintain
reduction. A. AP image
of a supracondylar nail
with minimal fixation.
Not enough stability is
obtained, and the nail
is akin to a “pencil in
a trashcan.” B. This
goes on to catastrophic
failure. A properly used
intramedullary nail with
multiple points of fixation
can provide good stability.
C. Radiographs show stable
fixation of the condyles
using a modern nailing
system that allows for
maintenance of alignment.
(Part C from Collinge CA,
Wiss DA. Distal femur
fractures. In: Bucholz RW,
Court-Brown CM, Heckman,
JD, et al, eds. Rockwood
and Green’s Fractures in
Adults. 7th ed. Philadelphia,
PA: Lippincott Williams &
Wilkins, 2010, with
permission.)
A B
C D
FIGURE 7-5 A. AP and B. Lateral images of a periprothetic supracondylar femur fracture stabilized with a locking plate.
C. AP and D. Lateral images of a periprothetic supracondylar femur fracture stabilized with an intramedullary nail.
alignment; this is particularly useful for evalu- a plate and screw construct, or when intra-
ating rotational alignment. articular visualization is necessary. An incision
C. Exposure is made extending in a curvilinear fashion from
1. A lateral approach to the knee and distal femur the lateral condyle to Gerdy’s tubercle. The IT
is the workhorse for this fracture when using band is incised longitudinally along with the
fashion and positioned under fluoroscopy.

Distal fixation is obtained through the surgi-
cal wound, and proximal fixation is obtained
with the use of a jig or guide connected to the
plate. This allows for accurate targeting of the
proximal screws and insertion through small
stab incisions (Fig. 7-7). Special attention must
be paid to the fluoroscopic images when using
this technique.
3. Positioning of the plate on the anterior half
of the lateral femoral condyle is necessary to
avoid medialization of the distal fragment. The
plate must be positioned so as not to pull the
femur into varus or valgus malalignment.
4. At the proximal end, care must be taken to
make sure that the plate is positioned against
FIGURE 7-6 Blankets positioned under the leg can help
the lateral cortex of the femur and well cen-
reduce the deformity in the saggital plane while also
tered on the lateral X-ray (Fig. 7-8). There is a
elevating the leg for easier intraoperative imaging.
tendency for the plate to drift anteriorly along
the proximal diaphysis, leading to prominence
joint capsule. The capsule can be elevated an- of the plate and poor screw purchase, which
teriorly to allow for retraction of the patella may lead to instability and failure of fixation.
and exposure of the articular surface of the dis- E. Postoperative Protocol
tal femur underneath the extensor mechanism. 1. Patients should begin immediate ROM exer-
2. If a closed reduction is obtainable, the frac- cises for the hip, knee, and ankle. This is espe-
ture may be amenable to intramedullary nail cially important for nutrition of the articular
fixation. Again, the knee is positioned in slight cartilage; it also helps regain motion in the
flexion to improve alignment. This also allows injured joint.
access to the starting point for nail insertion. If 2. An extension splint should be worn between
the knee is flexed too little, the starting point is exercises and at night to maintain knee exten-
not accessible. If the knee is flexed too much, sion and prevent contracture.
the inferior pole of the patella may limit access. 3. Hinged knee braces are sometimes useful to
An incision through the medial retinaculum of protect against varus/valgus forces.
the patella is made. Alternatively, the patellar 4. The use of sequential compression devices and
tendon may be split. The incision needs be routine thromboprophylaxis is recommended.
large enough for nail insertion. Some surgeons
prefer larger incisions to allow for adequate
removal of reaming debris from the joint. The
ideal starting point is centered in the notch
on the AP view, and 1 to 2 mm anterior to
the tip of Blumenstat’s line on the lateral to
avoid inadvertent injury to the PCL origin.
D. MIPO
MIPO techniques and principles are often em-
ployed when performing ORIF with plate and
screws for the fractures.
1. A lateral exposure is used. The exposure
needs to be sufficient for the use of direct and
indirect reduction techniques to obtain ana-
tomic reduction of the articular surface, and
for realignment of the femur. The fracture line
and comminution in the metaphyseal region is FIGURE 7-7 MIPO technique for distal femoral fracture
often not exposed. fixation. The external targeting device allows for the
2. A locking plate is then slid submuscularly placement of proximal locking screws through small stab
underneath the vastus lateralis in retrograde incisions.
A B
FIGURE 7-8 A. Intraoperative lateral fluoroscopic image demonstrates proper central positioning of the proximal
portion of the plate on the lateral aspect of the femur. B. AP X-ray of a different patient with a supracondylar femur
fracture properly stabilized with a locking plate.
V. Preventing Complications of Treatment • Joints do not tolerate immobilization well,

A. Infection and so initiation of active, active–assisted,
1. Respecting the soft tissues and gentle passive exercises is important for
• No surgical incision should be made through regaining range of motion of the knee.
a compromised soft-tissue envelope. In the • Movement of the knee joint also helps with
setting of contusion, edema, or fracture blis- nutrition of articular cartilage.
ters, surgery should be delayed until these 3. Extension splinting—The use of static exten-
conditions improve. sion splints, often at nighttime, can help pre-
• Dissection should minimize additional vent flexion contractures of the knee.
trauma to the soft tissues. Care must be C. Nonunion
taken not to devitalize bone fragments that 1. Prevent infection (see above).
can then become a nidus for infection. 2. Maintain soft-tissue attachments—The use of
• Proper debridement of open fractures—Open indirect reduction techniques and meticulous
fractures must be extensively debrided. This handling of the soft tissues prevent devitaliza-
includes exposure and debridement of the tion of bone, which can lead to nonunion.
fracture site. ORIF should be deferred until 3. Stable fixation—Too much motion at the frac-
the wound is clean and free of necrotic tissue ture site can contribute to nonunion, especially
and debris. in simple fracture patterns.
2. Early detection and treatment—Early postoper- D. Malunion
ative wound infection often presents between 7 1. Careful preoperative planning is essential.
and 14 days postoperatively. Superficial wound • Scrutinize X-rays and identify all fracture
infections, when treated early, are often suc- lines and fragments.
cessfully managed with oral antibiotics. • Contralateral X-rays can be useful as a tem-
B. Loss of Motion plate for reconstruction and alignment.
1. Stable fixation—Whatever fixation construct is • CT scan should be obtained for intra-articu-
chosen, one of the main goals is to obtain enough lar fractures.
stability to allow for early range of motion. • Preoperative drawings are a very useful way
2. Early range of motion to walk through the steps of the surgery and
to plan for reduction techniques and implant arthroplasty. A report of four cases. J Bone Joint Surgery Am.
selection and insertion. 1995;77:924–931.
Sanders R, Regazzoni P, Ruedi T. Treatment of supracondylar-
2. Intraoperative assessment of alignment
inlraarticular fractures of the femur using the dynamic con-
• Comparison to the uninjured leg is a valuable dylar screw. J Orthop Trauma. 1991;3:214–346.
way to assess alignment, particularly rota- Sanders R, Swiontkowski M, Rosen H, et al. Double-plating
tion. This can be accomplished by prepping of comminuted unstable fractures of the distal part of the
out both legs. femur. J Bone Joint Surg. 1991;73A:341–346.
Simon RG, Brinker MR. Use of Ilizarov external fixation for a
• Intraoperative fluoroscopy is prone to dis-
periprosthetic supracondylar femur fracture. J Arthroplasty.
tortion of alignment at the periphery of the 1999;14:118–121.
beam. Formal radiographs should be per-
formed intraoperatively to verify alignment. Review Articles
3. Familiarity with the implants—Modern im- Warner JJ. The Judet Quadricepsplasty for management of
plants have particular methods of insertion severe post-traumatic extension contracture of the knee: a
and techniques to assess orientation of the report of a bilateral case and review of the literature. Clin
Orthop. 1990;256:169–173.
implants. Familiarizing yourself with these im-
plants, the insertion tools, and the particulars Textbooks
of the implant’s design will make proper inser-
Clemente CD, ed. Gray’s Anatomy. 30th ed. Philadelphia, PA:
tion and positioning of these implants easier. Lea & Febiger; 1985.
This leads to fewer problems with malalign- Femur: Trauma. In: Poss R, Buchholz RW, Frymoyer JW, et
ment and/or loss of fixation. al, eds. Orthopaesdic Knowledge Update 4: Home Study Syl-
labus. Rosemount, IL: American Academy of Orthopaedic
Surgeons; 1993.
Helfet DL. Fractures of the distal femur. In: Browner BD, Jupiter
SUGGESTED READINGS JB, Levine AM, et al, eds. Skeletal Trauma: Fractures, Disloca-
tions, Ligamentous Injuries. Vol 2. 2nd ed. Philadelphia, PA:
WB Saunders; 1992.
Classic Articles Johnson KD. Femoral shaft fractures. In: Browner BD, Jupiter
Daoud H, O’Farrell T, Cruess RL. The Judet technique and re- JB, Levine AM, et al, eds. Skeletal Trauma: Fractures, Disloca-
sults of six cases. J Bone Joint Surg Br. 1982;64(2):194–197. tions, Ligamentous Injuries. Vol 2. 2nd ed. Philadelphia, PA:
Thompson TC. Quadricepsplasty to improve knee function. WB Saunders; 1992.
J Bone Joint Surg. 1944;26A:366–379. Taylor JC Delayed union and nonunion of fractures. In Cren-
shaw, A.M., ed. Campbell’s Operative Orthopaedics. Vol 2. St.
Recent Articles Louis, MO: Mosby; 1992:1287–1345.
Rolston LR, Christ DJ, Halpern A, et al. Treatment of supra-
condylar fractures of the femur proximal to a total knee
CHAPTER 8
Knee Dislocations, Fracture-

Dislocations, and Traumatic
Ligamentous Injuries of the Knee
Bryon Hobby, Kris Moore, Krishna Tripuraneni,
Dustin Richter, and Robert C. Schenck Jr.
I. Introduction—Knee trauma involves a continuum of occur only with tearing of both cruciate liga-
velocity and energy that changes a knee injury from ments, but dislocations have since been shown
what is classically considered sports injury (low to occur with an intact anterior cruciate liga-
velocity, low energy) to motor-vehicle injury (high ment (ACL) or poster cruciate ligament (PCL)
velocity, high energy). Frequently, there is blurring (Figs. 8-1 and 8-2).
of this distinction based on either energy or veloc- B. Classifications—In the literature, three systems
ity, since overlap of injury type exists in both groups. are used regularly to classify KDs and involve
Associated injuries, such as soft-tissue injuries (open one of three types: (a) joint position after disloca-
vs. closed), fractures, and neural or vascular injuries, tion, (b) velocity or energy of the injury, and most
are more frequent in motor vehicle trauma, but can recently, (c) anatomic structures torn. All three
be present in sporting injuries as well. The terms dis- systems are useful but serve different purposes
location and fracture-dislocation can be confusing, but in diagnosis and treatment.
are important to distinguish. Fracture-dislocation can 1. Joint position after dislocation—Initially
be considered part of a continuum of fracture and described by Kennedy, joint position after
ligamentous injuries, from the classic tibial plateau dislocation places dislocations in one of five
fracture (in which the ligaments are not torn), to frac- groups: (a) anterior, 40%, (b) posterior, 33%,
ture-dislocation (usually a tibial or femoral condyle (c) medial, 4%, (d) lateral 18%, and (e) rotatory,
fracture with a ligament injury), to pure ligamentous 5%. Position is based on standard orthopaedic
injuries (knee dislocations [KDs]). These distinctions nomenclature and is named by the position
are important clinically, especially in recognition of of the distal articulating structure (tibia) as
an associated vascular injury in regards to the surgi- related to the proximal one (femur). Joint po-
cal treatment. Lastly, approximately 20% of KDs fre- sition is useful in classifying KDs, especially
quently reduce spontaneously after the initial injury, as related to reduction maneuvers. Rotatory
and may not be recognized on cursory plain radio- dislocation most commonly involves a pos-
graph inspection. The concepts of examination under terolateral dislocation (torn ACL, PCL, or me-
anesthesia (EUA) and acute versus chronic manage- dial collateral ligament [MCL]), is a complex
ment of knee ligament injuries (e.g., repair or reat- dislocation (that requiring open reduction due
tachment vs. reconstruction) are important in the to interposed soft tissue preventing closed re-
management of knee trauma. duction as seen in a posterolateral KD with an
invaginated MCL and medial knee skin furrow-
II. Knee Dislocations ing), is associated with peroneal nerve palsy,
A. Introduction—Knee dislocations (KDs) classically and is at high risk for soft tissue necrosis. Over
involve pure ligamentous injuries (but also in- 20% of KDs spontaneously reduce after injury,
clude avulsions of ligaments) of the knee wherein and hence cannot be classified by position. Fur-
the tibiofemoral joint is completely displaced thermore, position does not determine what
at the time of injury. Initially, KDs were felt to ligaments are torn (i.e., anterior dislocations
98
C H A P T E R 8 | D I S L O C A T I O N S A N D L I G A M E N T O U S I N J U R I E S O F T H E K N E E 99
FIGURE 8-1 Lateral radiograph revealing an anterior KD FIGURE 8-2 Lateral radiograph of a PCL-intact KD. Note
that reduced with axial traction. The widened distance the proximity of the patella to the femur as compared
between the patella and the femur is characteristic of a to that in Figure 8-1. (Reprinted with permission from
KD with both an ACL and a PCL injury. There is greater Stannard JP, Schenck RC Jr, Fanelli GC. Knee dislocations
anterior translation of the tibia on the femur. (Reprinted and fracture-dislocations. In: Bucholz RW, Heckman JD,
with permission from Stannard JP, Schenck RC Jr, Court-Brown C, et al., eds., Rockwood and Green’s
Fanelli GC. Knee dislocations and fracture-dislocations. Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott
In: Bucholz RW, Heckman JD, Court-Brown C, et al., eds., Williams & Wilkins; 2006.)
Rockwood and Green’s Fractures in Adults. 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.)
with all dislocations, even those with sponta-
neous reduction (those unclassifiable by the
can occur with or without tearing of the PCL), joint position system). The anatomic classi-
and treatment depends on the ligaments and fication requires a standard ligamentous
tendons injured. Thus the position classifica- examination to determine which ligaments
tion is useful, but has limitations, especially in are torn (Table 8-1). The numeric system uses
directing definitive ligamentous treatment. the two cruciates and two corners (medial or
2. Velocity or energy of the injury—High-energy, lateral) in combination to describe what can
high-velocity motor vehicle injuries account potentially be torn. Increasing numbers in the
for over 50% of all KDs, and low-energy, low- anatomic system usually implies increasing se-
velocity sporting injuries account for approxi- verity/energy of injury. The anatomic classifi-
mately one-third (33%). Although velocity and cation uses four classes with five basic injury
energy are not interchangeable, sports KDs are patterns: KD-I, a single cruciate ligament-
considered low velocity or low energy and are intact KD, such as a PCL-intact KD in which
considered to have a lower incidence of associ- the ACL and posterolateral corner are torn,
ated vascular injury as compared with motor or the ACL-intact KD (tibia is dislocated pos-
vehicle injuries. Regardless of the energy of in- teriorly, PCL is torn), which has also been de-
jury (high or low), the risk of popliteal arterial scribed but is rare; KD-II, ACL and PCL torn
injury still exists and must be ruled out with and the collaterals are structurally/clinically
the initial clinical evaluation. intact (rare); KD-IIIM (medial) ACL, PCL, and
3. Anatomic structures torn—The anatomic clas- MCL and posteromedial corner torn and the
sification was developed by Schenck to clas- lateral side is clinically intact (most com-
sify KDs by the ligaments torn and thus help mon); KD-IIIL (lateral), ACL, PCL, and pos-
direct treatment, compare injuries, and use terolateral corner torn, and the medial
side is intact; KD-IV, all four ligaments torn further evaluated with vascular consul-
(highest energy of injury). The distinction of a tation, ultrasonography (if available) or
clinically intact corner, such as the posterolat- arteriography.
eral corner in the KD-IIIM, is based on EUA. For • Arteriography—The indications for use of
example, the KD-IIIM on MRI may have subtle arteriography have become controversial,
injury changes to the posterolateral corner, but but arteriography still remains the gold stan-
on EUA, the lateral ligaments are structurally dard for ruling out an arterial injury. Deci-
competent, thus its distinction from a KD-IV in- sion making in the presence of vascular
jury. The increasing number implies increasing insufficiency usually involves a one-shot
severity and energy of injury. The modifiers C intraoperative arteriogram before vascu-
and N are used for arterial or neural injuries, lar exploration and revascularization. In
respectively (C as in Gustilo type IIIC injury and the past, decision making in the presence
N as in nerve injury). Although surgical tech- of normal pulses has always required arte-
niques change over time, basing the classifica- riography. More recently, clinical observa-
tion on what is torn directs treatment and the tion of normal palpable pulses and the use
appropriate surgical exposure (Fig. 8-3). of noninvasive arterial Doppler studies with
C. Associated Injuries—KDs have a wide variation ankle–brachial indices have been shown as
of associated injuries and include vascular inju- reliable in the presence of a normal vascular
ries, neurologic injuries, fractures, soft-tissue in- examination. Ankle–brachial indices of less
juries, tendinous injuries, meniscal and hyaline than 0.90 are strongly predictive for vascular
injuries, and of course ligamentous injuries. injury. Arteriography is still frequently used,
1. Vascular injuries especially in patients with multiple injuries
• Popliteal artery—Anatomically, the popli- or in the patient with closed head trauma.
teal artery is rigidly fixed at the adductor The onus is on the clinician to rule out an
hiatus proximally and at the soleus arch dis- arterial injury.
tally; tibiofemoral displacement can injure • Compartment syndrome—Severe leg pain
the vessel by traction or direct transection. in the presence of a KD or stocking-glove
Collateralization is rich about the knee but paresthesias of the leg (indicating a late
insufficient to perfuse the extremity. Limb compartment syndrome) implies a com-
loss is imminent if revascularization is partment syndrome. Vascular examination
not performed within 6 to 8 hours from should involve consideration of compart-
the time of popliteal artery injury. The ment syndrome and if indicated requires
overall incidence of arterial injury is compartment pressure measurement and a
20% and varies dependent on population fasciotomy if pressures are above 35 mm Hg.
studied. Low-velocity KDs have a lower inci- (The indications for fasciotomy change if the
dence of arterial injury (approximately 8%). systemic blood pressure is low or if revascu-
• Clinical examination—An initial clinical vas- larization is performed.)
cular examination of the knee is absolutely 2. Neurologic injuries—Injury to nerves from
necessary (Fig. 8-4). The presence of pulses simple mechanical displacement produces
does not rule out an arterial injury, espe- neurologic injury, most commonly axonotme-
cially if there is an intimal injury or collateral sis. Complete disruption of the nerve (neurot-
rupture. However, the absence of pulses (or mesis) can occur but is much less common.
equivocal findings of vascularity) implies an The peroneal nerve is most commonly
arterial injury and cannot be considered a involved (20% of all KDs) and is most com-
temporary finding of spasm that will resolve monly associated with lateral-sided injuries
with time. After adequate joint reduction (KD-IIIL) or a posterolateral KD. Tibial nerve
has been emergently performed, the pres- involvement is rare, but can be seen with vas-
ence of continued vascular insufficiency cular injury. Loss of protective sensation of
requires emergent revascularization, the foot (the sole of the foot) with a complete
which should not be delayed for arteriog- tibial nerve injury associated with a vascular
raphy. Recent studies have documented injury may result in amputation. In contrast,
the usefulness and safety of sequential peroneal nerve involvement is a functional
clinical examinations (pulses) to rule problem from the motor abnormalities and is
out arterial injury. However, any evi- frequently a significant factor in the patient’s
dence of vascular insufficiency must be disability.
TA B L E 8 - 1
Physical Examination of the Knee
Examination Method Significance
McMurray External/internal rotation and varus/valgus Meniscal pathology or
stress-extension chondromalacia of the articu-
lar surface
Varus/valgus stress 30° MCL/LCL laxity (Grades I–IV)
Varus/valgus stress 0° MCL/LCL and PCL/posterior cap-
sule laxity
Apley’s Prone-flexion compression DJD, meniscal pathology
Lachman Tibia forward at 30° of flexion ACL (most flexible)
Stabilized Lachman Examiner’s thigh under the patient’s knee ACL (use the posterior Lachman
test to guage the PCL)
Finacetto Same as Lachman test, with the tibia subluxing ACL (severe)
beyond the posterior horns of the menisci
Anterior drawer Tibia forward at 90°of flexion ACL
Internal rotation driver Foot internally rotated with drawer Tighter, normal, looser, ALRI
External rotation driver Foot externally rotated with drawer Loose, normal, looser, AMRI
Pivot shift Flexion with the internal rotation and valgus ALRI
Flexion-rotation drawer Shift with axial load, less valgus ALRI
Slocum Supine-side flexion and pivot ALRI
Pivot jerk Extension with internal rotation and valgus ALRI
Posterior drawer Tibia backward at 90° of flexion PCL
Tibial sag Flexion at 90°, observation PCL
90°quadriceps active Extension of flexed knee PCL
External rotation recurvatum Picking up of great toes PLRI
Reverse pivot shift Extension with external rotation and valgus PLRI
External rotation at 30 and 90 Increased external rotation associated with PLRI PLRI
Posterolateral drawer Posterior drawer, lateral medial PLRI
MCI, Medial collateral ligament; LCL, lateral collateral ligament; PCL, posterior cruciate ligament; DJD, degenerative joint disease;
ACL, anterior cruciate ligament; ALRI, anterolateral rotatory instability; AMRI, anteromedial rotatory instability; PLRI, posterolat-
eral rotatory instability.
Source: Modified from Miller M. Review of Orthopaedics. 3rd ed. Philadelphia, PA: W B Saunders; 2000, with permission.
3. Fractures—Joint-surface fractures of the tibia presence of multiple trauma, a lower thresh-

or femur create an injury best described and old for arteriography may be necessary, as
classified as a fracture-dislocation. Ligamen- the treatment (i.e., immediate femoral nail
tous avulsions are common in KDs and change fixation) in such situation does not readily al-
the character of the injury and can often low for the observation of noninvasive stud-
simplify treatment. ies. Furthermore, a noncooperative patient in
• Multitrauma KDs are commonly seen in mul- light of a closed head injury often pushes the
titrauma (multiple fractures severe trauma) clinician to consider arteriography in evalua-
and can be missed when there are multiple tion of the vascular tree in the dislocated knee.
complex injuries. As noted previously, spon- The treatment of musculoskeletal injuries in
taneous reduction of KDs can make a multi- multiple trauma is frequently prioritized, and
ligamentous knee injury less obvious, and the ligamentous management of dislocations
careful attention during the skeletal survey is is frequently delayed for days to weeks and
important to evaluate for a severe knee injury. follows stabilization of long-bone fractures.
Gross knee swelling in the presence of mul- KDs in multiple trauma are also accept-
tiple trauma necessitates consideration of a ably stabilized with external fixation, which
dislocation, despite the presence of a reduced will facilitate patient transfer and allows for
knee joint on radiographic evaluation. In the visualization of the knee and extremity.
102
Ligamentous
Treatment Plan:
Dislocated Knee
MRI
Examination under anesthesia
Arterial injury ruled out
KD-I KD-II KD-IIIM KD-IIIL KD-IV

ACL/PCL torn, ACL/PCL/MCL ACL/PCL/LCL All four
S E C T I O N I I | A D U L T T R A U M A
PCL intact,
(i.e., ACL/LCL torn) Collaterals intact torn, LCL intact torn, MCL intact Ligaments torn
Irreducible complex Consider intial

Acute LCL repair, Early ROM Early ROM Early repair of LCL versus definitive
Early ROM Posterolateral with simultaneous
delayed ACL external fixation in
dislocation versus delayed
reconstruction multiple trauma
ACL/PCL
reconstruction
delayed ACL/PCL
delayed ACL Delayed ACL + and-
PCL reconstruction Immediate reconstruction Routinely requires
reconstruction
medial-sided and medial reconstruction of all 4
and appropriate
collateral ligaments: PCL/
treatment of PCL approach with
reconstruction as LCL/ACL/MCL
MCL repair,
delayed ACL/PCL indicated
reconstruction
FIGURE 8-3 Suggested ligamentous management plan for KDs based on the anatomic classification system. Delayed surgical treatment is usually 6 to 8 weeks
P A R T I | T H E L O W E R E X T R E M I T Y
following injury or until full ROM is attained. When combining ACL/PCL reconstruction, one should tension the PCL repair before the ACL; tensioning the ACL
first will result in posterior tibiofemoral knee subluxation. LCL, Lateral collateral ligament but includes structures of the posterolateral corners; MRI, magnetic
resonance imaging; ROM, range of motion.
Knee dislocation
FIGURE 8-4 Suggested
vascular evaluation algorithm
for managing KDs.
Yes
Hx of NV compromise
No
Decreased pedal Yes

pulses, lower
No
Yes
Expanding hematoma
Serial neurovascular
No
Yes
ABI < 0.9
No
Angiography
• Microfractures—Bone bruises occur, but, in • Meniscus—With the multiple ligamentous

the past, have been underreported because involvement in producing a KD, meniscal
of the need for magnetic resonance imag- tears are variable in presentation and include
ing (MRI) to document the injury. Chondral displaced bucket-handle tears, peripheral
injuries are classified according to standard tears, crush injuries with nonreconstructa-
grading systems but are usually observed ble meniscal damage, and coronary ligament
unless a reparable surface fracture exists. avulsions with gross meniscal instability.
4. Soft-tissue injuries—Soft-tissue injuries include Intraoperative evaluation requires inspec-
the soft tissue envelope and the menisci. tion of both menisci and repair if possible.
• Soft-tissue envelope—With any high-energy The inspection of medial and lateral meniscal
or motor-vehicle trauma, the status of the injuries and the meniscofemoral ligaments is
soft tissues is extremely important. Even important.
with a closed KD, the magnitude of the dis- 5. Tendinous injuries—Ruptures of supporting
placement frequently separates the knee tendinous structures about the knee are fre-
joint proper from its attachments to the sub- quent and should be suspected. Avulsions or
cutaneous tissues. Gross and widespread ruptures of the patellar, biceps femoris, iliotib-
ecchymosis, as well as subcutaneous crepi- ial band, and popliteus tendons are common;
tus from the soft tissue separation, is a com- the last three are usually associated with lat-
mon finding. As an aside, exploration for eral sided injury. Patellar tendon injuries are
open ligamentous repair is frequently sim- problematic if missed and should be evaluated
plified by the underlying displacement and clinically with a straight leg lift, radiographs
soft tissue injury. Open joint injuries occur, (patella alta), MRI, or a combination thereof.
especially with high-energy trauma, and can Quadriceps tendon ruptures can occur and are
compound the eventual ligamentous man- usually associated with an open injury.
agement with the need for external fixation 6. Ligamentous injuries—Ligamentous injuries
and eventual soft tissue coverage. Open knee are not truly associated injuries but are the pri-
joint injuries from a dislocation require care- mary reason for the other injuries. As noted in
ful evaluation for vascular and neural injuries the section on avulsions, ligamentous involve-
as a result of the degree of displacement re- ment in KD is usually more complex, extensive,
quired to cause an open injury. Treatment of and severe than subluxation injuries involving
an open KD requires the standard approach the isolated collaterals or cruciates.
of debridement, pulsatile lavage, and bony • Specific injuries—As noted previously, KDs
joint stabilization, which frequently requires present with varying combinations of liga-
external fixation, with delayed ligamentous ment involvement. KD (complete tibiofemo-
reconstruction. ral displacement) can occur with an intact
PCL or ACL. Thus it is important to clinically occur commonly with a dislocated

diagnose the ligaments torn, especially with knee. Ligamentous reconstruction is
the current well-defined clinical tests for the complicated when both cruciates are
ligament evaluation (see Table 8-1). Clinical torn in their midsubstance, and it re-
examination is crucial and frequently requires quires knowledge of treatment tech-
an anesthetic for complete patient relaxation. niques and graft options. As a general
(a) The cruciate ligaments—Clinically the recommendation, simultaneous cruci-
two patterns of injury, avulsion and more ate reconstruction with allograft tis-
commonly midsubstance tears, and mul- sues is the mainstay of treatment after
tiple combinations with the collateral obtaining knee range of motion (ROM).
ligaments are seen. Noyes showed biomechanically
• Avulsion—Avulsion can be frequently that very slow rates (strain rate of
seen in high-energy trauma. Bone frag- 0.67% per second) of injury in the
ments can be associated with the avul- laboratory produce bony avulsion
sion, but, frequently (and especially and faster rates (strain rate of 67%
with the PCL), the ligament is stripped per second) produce midsubstance
from the femoral origin (“peel-off le- tears. Clinically, midsubstance
sion”) (Table 8-2). The presence of tears occur at the sports injury
avulsion allows for the reattach- rates (clinically slow), with avul-
ment and may avoid the need for sions occurring more commonly
reconstruction of the involved cruci- in high-velocity (clinically fast)
ates. The “peel-off lesion” of the PCL injuries. Clinically fast rates are much
can be reattached with heavy, non- higher that what can be produced in
absorbable, braided sutures using the laboratory, and avulsions occur
the Krackow locking suture tech- from the higher, clinically applicable
nique if recognized early (Fig. 8-5). injury strain rate.
Repair techniques can be performed (b) Collateral ligaments and capsule—Un-
arthroscopically, but are most easily like combined injuries of the ACL and
performed open using drill tunnels and MCL, the collateral and capsular inju-
suture anchors. MRI is useful in iden- ries in KDs are frequently complete, ex-
tifying avulsions/midsubstance tears, tensive, and require operative attention.
and is especially useful for preopera- Clinical examination is important to de-
tive planning used in conjunction with termine partial versus complete tears of
careful EUA. EUA allows for determi- the corners, especially when evaluating
nation of ligament function and when varus and valgus stability in extension
combined with MRI can allow for and 30° of flexion. MRI can reinforce
thorough preoperative planning. these findings of collateral injury, es-
• Midsubstance—Commonly seen in pecially with retraction of the MCL,
the isolated rupture of the ACL, mid- LCL, and popliteus tendon. Although
substance tears of the cruciates also injury to a collateral ligament can
be seen on MRI, the clinical EUA is
paramount in determining treatment.
TA B L E 8 - 2 Surgical exploration and reconstruction
or repair of capsular, collateral, and ten-
ACL and PCL Avulsions in KDs
dinous (popliteus) structures is neces-
No. (%) of Cases with
sary and can be performed only with
No. of Avulsed Ligament
open surgery (Fig. 8-6). Most treatment
Author (Year) Knees ACL PCL algorithms recommend early lateral cor-
Sisto and Warren 16 10 (63%) 14 (88%) ner repair (KD-IIIL) and allow for early
(1985) range of motion of the KDIIIM with the
Frassica et al. (1991) 13 6 (46%) 10 (77%) treatment of medial sided structures
Total 29 16 (55%) 24 (83%) as indicated at the time of bicruciate
reconstruction.
From Schenck RC Jr, Burke RL. Perspect Orthop Surg.
1991;2:119–134, with permission. • Examination—Careful examination is manda-
tory and includes a vascular and neurologic
FIGURE 8-5 Sequential steps of placing Krakow locking loop ligament sutures for tendon or ligament repair.
examination, evaluation of the soft tissue

envelope, extensor mechanism, and liga-
ments. Gross swelling is frequent, and such
a finding on secondary survey (i.e., gross
knee swelling, normal radiographs) should
alert one to a KD with spontaneous reduc-
tion. Initial examination usually requires
examination of the knee in extension and
at 30° of flexion. The posterior drawer test
Popliteus tendon is very specific for injury to the PCL, but is
frequently too painful to perform without
anesthesia at the time of injury. In contrast,
Fibular collateral varus and valgus stability in full extension
ligament and partial flexion (30°) in comparison to the
normal knee is usually tolerated well by the
patient. The Lachman test, and more com-
monly a stabilized Lachman test (examiner’s
FIGURE 8-6 Anatomic posterolateral corner left thigh supporting the patient’s right knee
reconstruction (popliteus, popliteofibular ligament, lateral and vice versa), allows evaluation of the
collateral ligament) using Achilles allograft. anterior and posterior cruciate ligament
translation endpoints. The stabilized Lach- tubercle (iliotibial band avulsion). In

man test is useful in examining ligaments spontaneously reduced KDs, tibiofemo-
in an acute presentation in which patient ral widening on anteroposterior knee
comfort and relaxation can be difficult. films may be one subtle sign of a sponta-
Placing the examiner’s thigh under the neously reduced KD. Although more use-
injured knee allows for a relatively com- ful for ruling out joint-surface fractures
fortable examination. Gross medial or and avulsions, radiographs are helpful
lateral opening in full extension implies in evaluating subtle degrees of sublux-
tearing of both cruciates, the affected col- ation. Lastly, intraoperative radiographs
lateral ligament, and the posterior cap- are extremely important for document-
sule. Subtle changes (improvement) in varus ing tibiofemoral reduction after surgical
or valgus stability while extending to knee reconstruction.
from a partially flexed to an extended posi- (c) MRI—The use of MRI before surgery can
tion can imply integrity of one of the cruciate determine ligament involvement and in-
ligaments. jury type (avulsion vs. midsubstance),
(a) EUA—EUA is an extremely important meniscal tears, location of collateral
facet of surgical treatment of the knee ligament injury (femoral, tibial, or fibu-
as the integrity of a ligament deter- lar), tendon involvement (especially pa-
mines the need for reconstruction or tellar and popliteus), bone bruises, or
repair. Furthermore, determining the extensive microfractures (Figs. 8-7, 8-8,
integrity of the PCL is necessary for and 8-9). MR findings in a dislocated
evaluating the order of ligamentous knee are wide ranging and depend on
reconstruction (PCL tensioning is first, the ligaments involved. Classic find-
ACL is second), and in the situation of a ings in a KD-IIIM involve a peel-off in-
PCL-intact KD, integrity of the PCL can jury of the PCL from its femoral origin
direct treatment to early ROM followed (see Fig. 8-8), avulsion of the tibial col-
by an ACL reconstruction once motion lateral ligament from the tibial inser-
is reestablished. With combined cru- tion (see Fig. 8-7), and a midsubstance
ciate and collateral ligament injuries, ACL tear. The peel-off or stripped ap-
the results of the drawer test are more pearance of the PCL on MR images
dramatic than those with an isolated corresponds clinically to an avulsed
cruciate injury. Establishing a neutral PCL with minimal bone fragments
point of tibiofemoral position based with extension of Sharpies fibers onto
on condyle anatomy as well as com- the articular surface. Inspection of the
parison to the normal knee is impor- MR image for the integrity of the patellar
tant for clarifying the drawer position tendon is important (for early repair).
(whether it is anterior or posterior). Locked meniscal tears can be seen on
Translation of 20 mm is common in a MR images and require early operative
complete bicruciate KD when the ante- intervention. MRI cannot replace a clini-
rior and posterior limits of the drawer cal examination, but can be useful in pre-
are tested. Pivot-shift phenomenon is dicting avulsions, graft needs, tendinous
frequently not as instrumental in the injuries, and long-term sequelae such as
clinical examinations of KDs, since the bone bruises.
diagnosis is usually based on Lachman, D. Treatment—KDs have a long history of treatment
drawer, and varus and valgus stress options. Vascular injury, as previously noted, re-
testing. Furthermore, pivot shift testing quires immediate management to salvage the limb,
may redislocate the knee. ligamentous management is secondary. As with
(b) Radiographs—Radiographic study is any vascular injury about an extremity, prompt
important for verifying reduction, ruling skeletal stabilization is necessary to provide sta-
out joint surface fractures, and identify- bility for the vascular repair. Ligamentous man-
ing avulsion injuries such as Segond’s agement requires a discussion of both closed and
fracture (avulsion of the mid-third lat- open treatments (and their comparisons for out-
eral capsule implying a complete tear come), complications, and prognosis. Many op-
of at least one cruciate) or the Gerdy tions exist for the treatment of bicruciate injuries
FIGURE 8-7 MRI image revealing a tibial avulsion of the

FIGURE 8-9 MRI image of the notch of a low-velocity
MCL in a KD. (With permission from Schenck RC Jr.
KD (KD IIIM) revealing midsubstance tears of both the
Orthopaedic Special Edition. 1998;4(3):1–4.)
ACL and PCL. (With permission from Schenck RC Jr.
randomized trials comparing closed vs. open

treatment of KDs. In a 1972 retrospective, non-
randomized study evaluating closed and open
treatment of KDs, closed treatment gave sat-
isfactory results when the knee was immo-
bilized for 4 to 6 weeks. Open treatment was
performed only for open concomitant vascu-
lar injuries, and as expected, open treatment
fared poorly as compared with the less com-
plicated injuries that were treated closed. Cur-
rent arthroscopic techniques, the knowledge
of ligament anatomy, and reconstructive and
rehabilitative options create a different envi-
ronment for operative management from that
in the 1970s. Furthermore, the complications
of prolonged knee immobilization must be
recognized with osteopenia, muscle atrophy,
FIGURE 8-8 MRI image of a reduced KD, revealing a and arthrofibrosis. Nonetheless, in the patient
femoral avulsion of the PCL. The ligamentous injury is who has multiple injuries and a KD or a KD
that of a stripping or peel-off from the medial condylar complicated by an arterial repair, immobiliza-
notch without a bony fragment. Frequently a portion of tion as outlined by Taylor et al. (1972) can be
the hyaline cartilage surface is stripped in continuity
a useful guideline. More recently, Wong et al.
with the ligament. (With permission from Schenck RC Jr.
showed no statistical difference in ROM in
a retrospective review comparing 11 KDs
treated closed to 15 operatively treated
KDs; however, operatively treated patients
and frequently depend on surgeon experience and did have higher IKDC scores and a greater
patient presentation (Table 8-3). flexion contracture. In general, closed treat-
1. Closed treatment—Although closed treatment of uncomplicated KDs will have a sig-
ment has been maligned in the orthopaedic nificant degree of laxity and lower IKDC knee
literature, there have been no prospective scores.
TA B L E 8 - 3
The Dislocated Knee: Literature Review
No. of
Author (Year) Patients Content
O’Donoghue (1955) 5 Advocated surgical ligament treatment
Quinlan and Sharrard (1958) 5 Discussed mechanism of injury with posterolateral dislocation
Hoover (1961) 14 Reported that eight of nine vascular injuries (89%) required amputation
Kennedy (1963) 22 Discussed classification system and cadaveric study and advocated
surgical treatment
Shields et al. (1969) 24 Advocated surgical ligament repair
Reckling and Peltier (1969) 15 Discussed associated injuries
Meyers and Harvey (1971) 18 Advocated surgical ligament repair
Taylor et al. (1972) 41 Advocated nonsugical ligament treatment for uncomplicated KDs
Meyers et al. (1975) 53 Reemphasized surgical ligament repair
Green and Allen (1977) 41 Defined an average incidence of popliteal arterial injury in KDs
Jones et al. (1979) 22 Emphasized peripheral pulses as unreliable in verifying vascularity
Moore (1981) 132 Classified fracture-dislocation of the knee
Sisto and Warren (1985) 19 Advocated surgical ligament repair and emphasized the high incidence
of ligament avusions
Frassica et al. (1991) 17 Advocated surgical repair
Kendall et al. (1993) 32 Discussed the clinical examination of KDs and the role of arteriography
Walker et al. (1994) 13 Advocated surgical repair based on the anatomic classification system
Fanelli et al. (1996) 20 Discussed delayed arthroscopic bicruciate ligament reconstruction
Wascher et al. (1997) 50 Bicruciate ligament injuries are equivalent to knee dislocation
Fanelli et al. (2002) 35 Advocated combined arthroscopic treatment of ACL/PCL injuries
Twaddle et al. (2003) 60 Described injury patterns and associated injuries
Mills et al. (2004) 38 Established ABI as important role in assessing for vascular injuries
Harner et al. (2004) 31 Advocated acute surgical ligament treatment
Tzubakis et al. (2006) 44 Advocated acute surgical ligament treatment
2. Open treatment—With the advent of ligament a vascular injury must always be ruled out. In
surgery about the knee, several authors have any traumatic injury to the extremity, associ-
documented improved stability with early open ated injuries must be considered in designing
surgery of a KD. Meyers and Harvey were the a treatment plan. With a KD, the focus can be
first to show (retrospectively) poorer results placed on ligamentous injuries, but must ini-
with nonoperative treatment and more pre- tially be focused on the vessels, nerves, and
dictable results with operative treatment. soft tissues. Once associated injuries are de-
Sisto and Warren also showed improved re- termined, the identification of the ligaments
sults with operative treatment, but with a small injured is crucial to treatment. The treatment
but significant chance for permanent stiffness. of a PCL-intact KD (KD-I) is much different from
Current recommendations for KD ligament that of an injury with involvement of the ACL,
surgery involve early ligament repair (7 to 10 PCL, and posterolateral corner (KD-IIIL). Also,
days after the injury) versus early ROM and the type of ligament injury present, avulsion
simultaneous delayed cruciate reconstruction or midsubstance, determines the surgical op-
in the simple uncomplicated KD. Ligament sur- tion of reattachment versus reconstruction.
gery is always secondary to limb salvage, and With a functioning PCL, early ROM and delay
of arthroscopic ACL reconstruction until ROM discussed delayed, simultaneous ACL/PCL

is obtained is useful. The surgical options and allograft reconstructions, after initial ROM
timing depend on the ligaments involved spe- exercises. The placement of simultaneous
cifically and not simply on the dislocation. Clin- tibial tunnels for ACL and PCL grafts requires
ical examination (frequently required under an appropriate bone bridge for a successful
anesthesia), plain radiographs, and MRI define reconstruction. Nonetheless, early simulta-
the treatment algorithm (see Fig. 8-3). Because neous ACL/PCL reconstructions can result in
of the presence of a capsular injury and the significant arthrofibrosis and are ideally per-
risk of fluid extravasation with KDs, use of formed once ROM has been reestablished
the arthroscope is avoided in early surgery and knee inflammation has resolved.
(delayed until 7 to 10 days). Open surgery • Chronic dislocations—Very difficult prob-
is recommended early, and arthroscopic re- lems can be treated with joint reduction and
construction is delayed. A complete injury to external fixation (hinged type also has been
the posterolateral corner is best treated early reported). A common scenario is a missed
and requires open surgery. Basic concepts for posterolateral dislocation (ACL, PCL, and
the order of ligament repair are as follows: first MCL) with an invaginated MCL and a dislo-
the PCL and the affected corner are reestab- cated patellofemoral joint. This injury may
lished, and second the ACL injury is addressed. have a concomitant peroneal nerve injury
The PCL forms the cornerstone of the knee, and requires open reduction to extract the
and in a KD with a complete PCL and ACL MCL in what is defined as a complex disloca-
injury, the PCL must be treated first. Tight- tion. Results are often poor.
ening of an ACL graft before reestablishing 3. Closed versus open treatment—In the only
normal PCL mechanics will subluxate the study comparing closed versus operative
tibia posteriorly on the femur. Many dislo- treatment of KDs, Taylor et al. noted better
cations are PCL-intact (including some partial results with closed treatment. The operative
PCL injuries) dislocations and can be treated treatment was performed only in open, com-
with early ROM followed by a delayed ACL plex, or KDs with a vascular injury. (Similar in-
reconstruction. juries were not compared.) However, in most
• Open surgery—Early open surgery is rec- studies, operative treatment gives the most
ommended, especially when there is a com- predictable results in the complete bicruciate
plete injury to the posterolateral corner KD injury. Either initial repair and delayed ACL
and a complete injury to the PCL and ACL. reconstruction (staged cruciate reconstruc-
Some controversy currently exists regard- tion) or early ROM and simultaneous cruciate
ing posterolateral corner repair versus reconstruction after obtaining knee joint ROM
reconstruction. Most studies have sup- is currently recommended. Initial ROM exer-
ported primary repair of a complete in- cises followed by delayed ACL reconstruction
jury to the posterolateral corner. In the gives a predictable result in PCL-intact KDs.
patient with multiple injuries, a complete In patients with multiple trauma with com-
ACL/PCL/posterolateral corner injury may plicated KDs (vascular injuries, open KD-IV),
best be initially stabilized with an external external fixation with an anterior frame with
fixator followed by eventual reconstruction. the knee reduced is an effective initial manage-
The success of KD ligamentous surgery de- ment option. The external fixator (depending
pends on the associated injuries, and the on injury and circumstance) is used for im-
surgery is best performed in the patient who mobilization for 4 to 6 weeks, followed by fix-
has one or two isolated injuries. ator removal, manipulation of the knee under
• Delayed arthroscopic surgery— Arthroscopic an epidural anesthesia, arthroscopic anterior
surgery usually is performed on a delayed release, and postoperative continuous passive
basis once range of motion is reestablished. motion (CPM) with an epidural for 48 to 72
Staged reconstructions where the PCL and hours. Late instability is reconstructed once
posterolateral corner are reconstructed motion is reestablished.
followed by delayed ACL reconstruction 4. Complications—In the treatment of KDs, com-
have been reported with successful results plications are frequent and are related to the
in the past. However, most surgeons fol- initial severity of the injury. Late instabil-
low the recommendations of Fanelli et al. ity, arthritis, arthrofibrosis, and long-term
and Wascher et al., who in separate reports peroneal nerve palsy are common.
• Stiffness—Clearly noted by Sisto and Warren, younger than 40 years of age, a group not

permanent stiffness of the knee can result well suited for knee-replacement surgery.
with any operative treatment. Open sur- • Late instability—Late instability is usually
gery must be followed by immediate ROM not a difficulty with early surgery. Arthrofi-
exercises; otherwise the combination of the brosis (stiffness) is usually the associated
soft tissue injury from the dislocation and complication with early surgery. Late insta-
the immobilization can lead to permanent bility usually occurs with midsubstance cru-
knee stiffness (despite attempts to correct ciate repairs, early ROM, or no treatment with
this with arthroscopy, manipulation, and poor ligamentous healing. Combined PCL or
epidural-CPM). A fixed flexion contracture posterolateral corner injuries are difficult to
is a particularly difficult problem to man- manage late and are best treated with early
age and is functionally debilitating. Flexion surgery. Abnormalities of gait (thrust, hyper-
loss was commonly noted after operative extension) can be seen as a result of the in-
management. Stiffness is uncommon after stability pattern. Stiffness and late instability
closed treatment and usually results in an are opposing complications in the treatment
unstable knee with good range of motion. of KDs.
One of the benefits of early ROM and de- 5. Prognosis—The variety of KDs as well as the
layed cruciate surgery is the prevention range of severity equates to a varied prognosis
of knee stiffness after eventual operative in ultimate function, ROM, arthritis, and stabil-
reconstruction. In most series of operative ity. Comparing like injuries based on what is
treatment of KDs, the need for post-recon- torn (anatomic system, KD-I to IV) allows one
struction manipulation under anesthesia is to prognosticate. Walker et al. (1994) noted that
approximately 20%. KD-IIIL injuries fared poorer than KD-IIIM inju-
• Vascular injury and limb loss—Vascular ries. Furthermore, in that study, KD-IV injuries
injury and limb loss is a disastrous com- had a higher incidence of neural and vascular
plication that can be avoided with early involvement and resulted from higher-energy
recognition, vascular exploration and repair, trauma.
and fasciotomy as needed. DeBakey and
Simeone (from WWII data) noted an 80% III. Fracture Dislocations of the Knee
amputation rate if repair of a popliteal arte- A. Introduction—Fracture-dislocation, or fracture-
rial injury was not performed within 6 to 8 subluxation, is an important concept in the diag-
hours of injury. Vascular repair requires joint nosis and management of injuries about the knee.
stabilization, and a simple anterior (external Initially described by Tillman Moore, the concept
fixation) frame is useful for managing such of a knee fracture-dislocation is useful for recog-
injuries. nizing fractures about the knee that involve lig-
• Neurologic injury—Long-term disability from amentous injuries. A review from Robertson et
peroneal nerve palsy is common. Sisto and al. found the incidence of fractures of either the
Warren noted improvement after neurolysis distal femur or proximal tibia with associated KD
in two of eight patients with KDs. Peroneal was 16%. A fracture-dislocation implies that
nerve injuries most commonly occur with repair of both the fracture and ligament is
lateral injuries (KD-IIIL), and in such situ- often necessary for surgical management.
ations, repair of the posterolateral corner B. Tibial-Sided Fracture-Dislocations
requires exploration of the peroneal nerve. 1. Classification (Fig. 8-10)—Moore et al. described
Tibial nerve involvement is less common a classification of tibial-sided fractures consist-
and frequently involves associated injuries ing of five types. Type 1 and 2 involve varia-
(such as a vascular injury or open wounds) tions of medial tibial condyle fractures (similar
or gross joint displacement as would be seen to a Schatzker IV injury). Type 1 has a coro-
with a KD-IV. There should be suspicion of a nal split of the medial condyle seen on a lat-
compartment syndrome if there is any sen- eral radiograph. Type 2 involves the entire
sory or motor nerve involvement. condyle and although most commonly medial,
• Arthritis—Arthrosis of the knee is common can also be an isolated lateral condyle fracture.
in KDs and is most likely the result of severe Type 3, or “rim avulsion” (rim of the tibial
chondral contusions (bone bruises) associ- plateau), is an enlarged lateral joint rim
ated with the injury. A difficult problem is fracture, either an avulsion of the Gerdy’s
that KDs frequently occur in a population tubercle or an enlarged Segond’s fracture
(also known as the lateral capsular sign). fixation, should be performed at the time of
Type 4, or “rim compression” with contra- revascularization.
lateral ligamentous injury, usually involves 3. Treatment—Operative management involves
compression of the lateral tibial plateau stable internal fixation of the tibial condyle
edge with tearing of the MCL. Type 5 is de- and repair of the injured ligaments. Ligamen-
scribed as a fracture involving four parts: tous involvement depends on the type of
both condyles, the tibial eminence, and the fracture-dislocation present. Knee instabil-
tibial shaft (the Schatzker V bicondylar ity occurs in 60% of type 1 and type 2 inju-
fracture and/or the Schatzker VI metaphy- ries and 90% to 100% of type 3 to 5 injuries.
seal diaphyseal dissociation). As with the Ligament instability is best treated at the time
Schatzker classification, the energy and sever- of fracture fixation. Type 1 and 2 injuries can
ity of injury increase with the number (type), be treated with standard AO plate techniques
so the prognosis is poorer for higher classifica- and screws. (If the soft tissues are grossly
tion numbers. swollen, cannulated screws and external fixa-
2. Vascular injury—A fracture-dislocation of the tion should be considered.) Displacement of
knee has a significant risk for vascular injury the medial condyle and a varus deformity can
and should be suspected much like with KDs, occur when only cannulated screws are used.
especially with displacement of a large tibial In high-energy medial condyle fractures, a me-
condyle fracture. The risk of vascular injury dial buttress plate and screws are necessary
depends on the type of fracture-dislocation: considerations in fracture treatment. A direct
from Moore’s study, type 1: 2%, type 2: 12%, posterior or posteromedial approach may
type 3: 30%, type 4: 13% and type 5: 50%; frac- be used to fix type 1 fractures. Type 3 in-
ture-dislocation of the knee often requires juries require reattachment of avulsions and
arteriography to rule out a vascular injury. repair of ligaments. Type 4 injuries (rim com-
Clinical examination is important, especially pression) can involve a large segment of the
in considering compartment syndrome in ad- lateral plateau and may require open reduc-
dition to frank popliteal artery injury. Revas- tion with internal fixation of the compressed
cularization guidelines are similar to those for lateral plateau (with or without bone grafting)
KD, and fracture fragment fixation and joint in addition to repair of the MCL. Type 5 inju-
stabilization, with either internal or external ries are high energy and are associated with
FIGURE 8-10 Classification
of tibial-sided fractures of
fracture-dislocations of the
knee.
Medial Lateral
Type 1 Type 2
Medial Lateral
Type 3 Type 4 Type 5
vascular injury. Consideration of the soft tis-

sue envelope is necessary in determining the
surgical plan for type 5 injuries. Cannulated
screw after joint-surface reduction is less in-
vasive than standard plating and can be com-
bined with external fixation to stabilize the
condyles to the shaft. Injury of the cruciates
in Type 5 injuries is related to the eminence
fracture and may require late reconstruction.
Locking plate technology has emerged as
an excellent choice for internal fixation of
proximal tibia fractures (Figs. 8-11 and 8-12).
4. Prognosis and complications—Fracture-dis-
location “involves some degree of long-term
disability in almost all cases,” as noted by
Moore. Type 1 injuries have the best progno-
sis with rare neurovascular or ligamentous
injuries. Type 5 injuries have the highest
rate of vascular injury and have the worst
prognosis. As noted by Moore, “patients with
fracture-dislocations ultimately do better than
those with classic dislocations, but not as well FIGURE 8-12 Postoperative radiograph after open
as those with plateau fractures.” reduction internal fixation (with a locking plate) of the
C. Femoral-Sided Fractures—A rarer injury but medial tibial condyle fracture of the Type 2 fracture-
dislocation shown in Figure 8-11. Additional spanning
seen in high-energy knee trauma and usually in-
external fixation was required to adequately correct joint
volving a direct blow to the knee, Femoral-sided
subluxation.
fracture-dislocations involve a fracture of the

femoral condyle at the level of Blumensaat’s
line with an associated ligamentous injury.
These injuries can present with an open injury
as well as disruption of the extensor mechanism.
Diagnostic and treatment philosophies are simi-
lar to those of tibial-sided fracture-dislocations;
management requires the recognition of an arte-
rial injury, if present, and operative stabilization
of the fractured femoral condyle and ligamentous
repair. Internally fixing the fractured femoral
condyle requires that the operative approach in-
clude intraarticular (buried) cannulated screws
and ligamentous repair. PCL injury is frequently
associated with this injury type. Locking plate
technology is also available for the treatment of
distal femur fracture-dislocations.
1. Femoral shaft fracture—KDs and knee liga-
mentous injury has been reported with ip-
silateral femoral shaft fractures. One series
reported five KDs associated with an ipsilat-
eral femoral shaft fracture. The mechanism of
injury is one of high-energy trauma. Treatment
FIGURE 8-11 Preoperative radiograph revealing a Type involves fixation of the femoral shaft fracture,
2 fracture-dislocation (medial tibial condyle fracture) with evaluation of knee ligament stability, and ad-
subluxation of the tibiofemoral joint. dressing the ligamentous injury.
IV. Proximal Tibiofibular Dislocations 2. Classification—Ogden described four types

A. Introduction—Proximal tibiofibular dislocations of dislocations. Type I is a subluxation which
are rare and frequently missed. Treatment is results in increased anteroposterior motion
usually simple if recognized early. Dislocations of the fibular head within the joint. This is
can be acute or chronic in nature. Dislocation most commonly seen in young children and
of the proximal tibiofibular joint has also been adolescents and resolves with time. Type II is
described as a Maisonneuve fracture equivalent. an anterolateral dislocation. This is the most
B. Injury Pattern common type (accounts for 85% of these dis-
1. Anatomy—The proximal tibiofibular joint is a locations) and is commonly seen in the sports
synovial joint between the fibular head and the population (Figs. 8-13 and 8-14). The mecha-
lateral tibial condyle. Ogden described two nism of injury is knee flexion, external rotation
proximal tibiofibular joint types, oblique of the leg, coupled with plantar flexion and in-
and horizontal, with 20° as the borderline ternal rotation of the foot. Type III dislocations
between the two types. The horizontal joint result from a direct blow to the fibular head
type has more resistance to rotary forces. with posteromedial dislocation. Type IV is a
The tibiofibular joint capsule condenses ante- superior dislocation often the result of high-
riorly and posteriorly to create the proximal energy trauma.
tibiofibular ligaments. Stability of the joint 3. Diagnosis—Diagnosis of proximal tibiofibular
is rendered by the competence of the fibular dislocations is a clinical and radiographic diag-
collateral ligament (FCL). Other stabilizers of nosis. A high index of suspicion is necessary.
the joint include the biceps femoris tendon, AP and lateral radiographs of the knee are of-
popliteal tendon, arcuate ligament, fabellofibu- ten sufficient, but comparison view of the con-
lar ligament and popliteofibular ligament. Ex- tralateral knee may be needed. CT scan also
perimental models have shown dislocations to may be necessary to make the diagnosis.
occur when the knee is flexed greater than 80°, 4. Treatment—Most dislocations can be treated
relaxed FCL and when the FCL is sectioned. with closed reduction. The knee is usually
FIGURE 8-13 AP radiograph
of a collegiate softball
player with left knee Type
II anterolateral proximal
tibiofibular dislocation. Note
the widening of the proximal
tibiofibular joint on the left
compared to the right.
A B
FIGURE 8-14 A. Prereduction lateral radiograph of the left knee from the athlete in Figure 8-13. Note the anterior
displacement of the proximal tibiofibular joint. B. After closed reduction of the proximal tibiofibular joint with
reestablished anatomic alignment.
placed in a flexed position, and direct reduc- the multiple ligament injured knee: 2 to 10 year follow-up.
tion of the fibula is performed depending on Arthoscopy. 2002;18(7):703–714.
Frassica FS, Franklin HS, Staeheli JW, et al. Dislocation of the
the direction of the dislocation. Superior dis-
Knee. Clin orthop. 1992;263:200–205.
locations (rare) require manipulation of the Green NE, Allen BL. Vascular injuries associated with disloca-
fibula, pushing the fibular head in a distal tion of the knee. J Bone Joint Surg Am. 1977;59(2):236–239.
direction to reduce the joint. The reduced Harner CD, Waltrip RL, Bennett CH, et al. Surgical manage-
tibiofibular joint is stable and rarely requires ment of knee dislocations. J Bone Joint Surg. 2004; 86-A(3):
262–273
surgical treatment. Open reduction with tem-
Hughston JC, Bowden JA, Andrews JR, et al. Acute tears of the
porary internal fixation is indicated for failed posterior cruciate ligament. Results of operative treatment.
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with peroneal nerve, irritation resection of the Kennedy JC. Complete dislocation of the knee joint. J Bone
proximal fibula is recommended. Joint Surg Am. 1963;45:889–904.
Meyers MH, Harvey JP Jr. Traumatic dislocation of the knee
joint. A study of eighteen cases. J Bone Joint Surg Am.
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CHAPTER 9
Extensor Mechanism Injuries

of the Knee
Luke S. Choi, Peter W. Ross, and Mark D. Miller
I. Patellar Fracture C. Classification—Patellar fractures are most com-

A. Anatomy—The patella is the largest sesamoid bone monly classified based on the morphology of the
in the body. Its subcutaneous location leaves it fracture (Fig. 9-1). The most common mechanisms
susceptible to injury from direct blows (e.g., falls, of injury consist of direct blows to the patella
dashboard injuries). Three-fourths of the patella’s (e.g., dashboard injury), indirect trauma (e.g., sud-
proximal posterior surface is covered with some of den, rapid flexion of the knee against a maximally
the thickest articular cartilage found in the human contracted quadriceps), or a combination thereof.
body. Its articular surface is divided by a longitudi- Direct trauma typically results in minimally dis-
nal ridge separating it into medial and lateral facets. placed comminuted fractures, whereas indirect
The bulk of the quadriceps tendon inserts directly trauma usually results in displaced transverse
into the proximal pole. Longitudinal extensions of fractures. Osteochondral injuries that can occur
the quadriceps tendon pass medial and lateral to with patellar dislocations usually involve the me-
the patella and insert directly on the anterior tibia. dial patellar facet. They are caused by impaction of
A thin layer of the fibers pass anterior to the patella the facet with the lateral ridge of the lateral femoral
and becomes confluent with the patellar tendon. condyle, sometimes avulsing an osteochondral frag-
Deep, transversely oriented fibers pass from the ment from the lateral condylar ridge as well. A small,
femoral epicondyles to the patella, making up the sometimes radiographically benign-appearing distal
patellofemoral ligaments.
B. Biomechanics—The extensor apparatus consists
of the quadriceps muscle and tendon, the patella,
and the patellar tendon. Secondary extensors of
the knee include the iliotibial tract and the medial
and lateral patellar retinacula. The patella func-
tions to improve the lever arm of the extensor Undisplaced Transverse Lower or Multifragmented
mechanism. Its contribution increases toward upper pole undisplaced
extension, increasing the force by nearly 30% at
maximal extension. Through the patella, the quad-
riceps exerts an anteriorly directed translational
force on the tibia that is exposed to complex load-
ing consisting of tensile, bending, and compressive
forces. The magnitudes of these forces vary with
the degree of flexion, with maximal tensile forces Multifragmented Vertical Osteochondral
occurring at 45° to 60° of flexion. Joint contact displaced
forces of 3.3-times body weight occur during stair
FIGURE 9-1 Classification of patellar fractures. (From
climbing and up to 7.6-times body weight occur- Bedi A, Karunakar MA. Patella fractures and extensor
ring during squatting. The size of the patellofemo- mechanism injuries. In: Bucholz RW, Court-Brown CM,
ral contact area is 2 to 4 cm2, or 13% to 38% of the Heckman JD, et al, eds. Rockwood and Green’s Fractures
articular surface, and is oriented in a transverse in Adults. 7th ed. Philadelphia, PA: Lippincott Williams &
band through most of the range of motion. Wilkins, 2010, with permission.)
116
C H A P T E R 9 | E X T E N S O R M E C H A N I S M I N J U R I E S O F T H E K N E E 117
pole fragment, which can include a significant piece strengthening. Almost 90% of patients heal with
of articular cartilage, is termed a sleeve fracture; it normal or slightly impaired function.
occurs in the skeletally immature patient. 2. Operative treatment—Operative treatment is
D. Evaluation indicated for displaced fractures with loss of
1. History—A direct blow to the anterior knee or extensor function. The goals of surgery should
forced and rapid knee flexion against a con- be preservation of patellar function and ana-
tracted quadriceps, anterior knee pain, and an tomic reduction of the articular surface. A lon-
inability to forcibly extend the knee suggest the gitudinal midline incision is recommended, as
diagnosis. it is useful for other knee procedures in case
2. Examination—Patients should be examined for they become necessary. A defect in the medial
an extensor lag or a palpable defect suggest- and lateral retinaculum is usually noted during
ing disruption of the extensor mechanism. The exposure of the fracture, and it should be re-
anterior knee soft tissues should be inspected, paired with the fracture. The reduction should
since they are frequently compromised after not be based on the anterior patellar cortex
direct trauma. The knee and lower extremity because significant plastic deformation can oc-
should also be examined for any associated cur from the injury. Instead, the reduction of
injury suggested by the mechanism of injury. the articular surface can be inspected through
3. Imaging—The patella can be difficult to discern a medial parapatellar mini-arthrotomy or with
on anteroposterior (AP) radiographs. However, arthroscopic assistance. Additional injury to
it is well visualized on lateral radiographs, and compromised soft tissues should be reduced by
articular step-off and diastasis can be assessed. avoiding compressive dressings and prolonged
Tangential views can be useful for evaluating contact with ice. Consideration should be given
marginal or the rare vertical fracture. Bilat- to aspiration of anterior hematomas if the skin
eral films are useful when a bipartite (acces- is tense and surgery will be delayed. Several
sory ossification center) patella is suspected, options for fixation are available (Fig. 9-3).
since these rarely occur unilaterally (Fig. 9-2). • Modified tension band wiring—Popularized
Computed tomography (CT) is usually unnec- by the AO/ASIF group, modified tension band
essary. Magnetic resonance imaging (MRI) may wiring is indicated for distracted, transverse,
be used to diagnose sleeve fractures. Bone and some comminuted fractures. It consists
scintigraphy may be useful for diagnosing oc- of provisional fixation of the fracture with
cult fractures. two 2.0-mm Kirschner wires, followed by aug-
E. Treatment—Despite largely favorable results of mentation with an 18G wire passed around
both conservative and operative management of the Kirschner wires and across the anterior
patellar fractures, some loss of knee flexion usually aspect of the patella to serve as the tension
occurs; an increase of up to 40% in patellofemo- band component of the construct. The wire
ral arthrosis may also occur. can be placed in a “figure-eight” or a circu-
1. Nonoperative treatment—Nonoperative treat- lar fashion. The anterior tension wire then
ment is indicated for nondisplaced fractures, converts the distractive force across the
which are defined as less than 2 mm of step- anterior patella into compressive force on
off and less than 3mm of diastasis without the articular side of the patella. This tech-
an extensor lag. Treatment consists of a long nique requires early motion to work properly.
leg cylinder cast, weightbearing as tolerated The most common technical error occurs
for 4 to 6 weeks, and then careful progressive when the tension wire is not brought into
range of motion with subsequent quadriceps direct contact with the patellar poles.
FIGURE 9-2 Saupe’s classification of

accessory ossification centers of the patella.
Type 1, inferior pole, 5%; Type II, lateral
margin, 20%; Type III, superolateral pole, 75%.
Lateral Medial
Type I Type II Type III
A B C D E
FIGURE 9-3 Techniques of patellar fracture fixation. A. Modified tension band wiring using a
circular configuration. B. Modified tension band wiring using a figure-eight configuration.
C. Lag-screw fixation. D. Combination cannulated lag screw and tension band wiring. E. Partial
patellectomy. Note: The tendon is reapproximated at the level of the articular surface of the
patella.
The intervening soft tissues gives way with sagittal plane. A load-sharing wire passed
loading, allowing the fracture to distract. through the patella and the tibial tubercle can
• Lag-screw fixation—Lag-screw fixation can be be used to protect the repair. Problems with
used to stabilize fragments in comminuted this technique include patella baja, altered
patellar fractures, thereby creating a fracture patellar mechanics, weakened quadriceps,
amenable to tension band wiring. It can be and decreased patient satisfaction rates.
used as an alternative to tension band wiring, • Total patellectomy—Total patellectomy may
with comparable stability reported. There be the only alternative in severely commi-
must be good quality bone for this technique nuted displaced patellar fractures without
to be used alone. There is concern that lag- any significant remaining articular fragments.
screw fixation alone may be less able to with- The remaining defect can be repaired with a
stand bending forces. purse-string, vertical, or transverse closure. In
• Combination lag-screw fixation and tension addition, the repair may be reinforced with a
band wiring—More recently, a technique quadriceps flap (Fig. 9-4). Loss of range of mo-
combining cannulated lag-screw fixation and tion, extensor lag, quadriceps weakness, and
tension band wiring has been described. The discomfort after patellectomy are common.
fracture is initially stabilized with two 4.0- or F. Postoperative Management—Postoperative man-
4.5-mm cannulated lag screws. An 18G wire is agement includes initial immobilization and imme-
then passed through the center of the screw diate weightbearing as tolerated. There is evidence
and across the anterior patella to act as a that tensile forces across the patella are greater dur-
tension band. This technique results in a con- ing attempts at nonweightbearing ambulation as the
struct with a greater load to failure compared patient tries to keep the leg off the ground. Emphasis
with either lag-screw fixation or tension band is placed on early range of motion (as the quality of
wiring alone. fixation allows). Early range of motion is an essential
• Partial patellectomy—Partial patellectomy is principle in tension band fixation and is important
reserved for fragments not amenable to in- in decreasing postoperative stiffness. The repair can
ternal fixation. It usually consists of a commi- be protected with the use of a locked hinge knee
nuted distal pole and an intact proximal pole. brace in which the amount of flexion is increased
The irreparable fragments can be resected, every 2 weeks (as the patient tolerates and as range
and the patellar tendon repaired with sutures of motion and quadriceps strength return).
through bony tunnels to the proximal frag- G. Complications
ment. The tendon should be repaired close 1. Infection—Infection is rare. The risk may be
to the articular surface to minimize articu- increased by injury-compromised soft tissues
lar step-off and prevent patellar tilt in the and host factors.
FIGURE 9-4 Miyakawa
technique of patellectomy.
A. Excision of the patella and
outline of the incision in the
quadriceps. B. Partial-
thickness flap of the
quadriceps tendon turned
distally. C. Quadriceps flap
passed through incisions in
the area previously occupied
A B
by the patella. D. Proximal
reconstruction with the
vastus medialis obliquus and
the vastus lateralis brought
together over the quadriceps
flap.
C D
2. Loss of fixation—Loss of fixation may be sec- tendons demonstrated degenerative changes

ondary to underestimated fragment comminu- such as mucoid degeneration and calcific tendi-
tion most commonly involving the distal pole. If nopathy. Most commonly, ruptures occur at the
caught early, it can be treated with immobiliza- proximal insertion of the patellar tendon. Most
tion. If significant displacement occurs, partial often, they are unilateral but can occur bilater-
patellectomy may be the best option. ally, especially in patients with impaired colla-
3. Loss of range of motion—Slight loss of range gen strength (e.g., rheumatoid arthritis, systemic
of motion is common. The incidence can be lupus erythematosus, diabetes mellitus, and
reduced with secure internal fixation allowing chronic renal failure) and patients on systemic
early range of motion (within 1 or 2 weeks). corticosteroid therapy. They also occur after local
4. Posttraumatic arthrosis—Posttraumatic arthr- steroid infiltration. Another common mechanism
osis is relatively common. One long-term study for patellar tendon rupture may be direct trauma.
demonstrated a 70% incidence of arthrosis in In one study of 35 patellar tendon ruptures, 27
patellar fracture compared with a 31% incidence occurred in motorcycle accidents. Finally, patel-
in the contralateral, noninjured knee. lar tendon rupture can occur as a complication
5. Nonunion—Nonunion was common when all of total knee arthroplasty, patellar tendon harvest
patellar fractures were treated nonoperatively for ligament reconstruction, and devasculariza-
(up to 55%). With modern operative techniques, tion after lateral retinacular release procedures.
the nonunion rate is reported to be 1% or less. B. Anatomy—The patellar tendon is approximately
6. Symptomatic Hardware—Symptomatic hard- 4 mm thick at the midsubstance and 5 to 6 mm
ware is common secondary to the subcutane- thick as its insertion on the tibial tubercle. It nar-
ous location of the patella. rows slightly from proximal to distal. The distal
expansions of the vastus medialis and vastus late-
II. Patellar Tendon Rupture ralis form the medial and lateral retinacula, respec-
A. Overview—Patellar tendon rupture is an uncom- tively. Some 70% to 80% of the dry weight of the
mon injury and in contrast to quadriceps tendon patellar tendon is collagen, of which 90% is Type I
rupture, typically occurs in younger patients and approximately 10% is Type III. The blood supply
(younger than age 40). Thought to be the result originates from the medial and lateral geniculate ar-
of recurrent microtrauma and chronic tendon de- teries and the recurrent tibial artery, which branches
generation, patellar tendon rupture is associated through the fat pad and retinaculum to enter the ten-
with jumping sports (e.g., basketball), hence the don at its proximal and middle portion. The proxi-
term jumper’s knee. In face, in one large study, mal and distal insertions, being relatively avascular,
97% of biopsy specimens from ruptured patellar are also the most common sites of rupture.
C. Biomechanics—The largest tensile stress within tendon is repaired using a No. 5 nonabsor-
the tendon occurs at 60° of flexion and is esti- able suture woven through the tendon us-
mated to be 3.2 times the body weight during stair ing a Bunnell or Krakow technique, and the
climbing. Strain at the insertion sites is three to suture is then passed through bone tunnels
four times greater than that at the midsubstance. at the approximate site (Fig. 9-6). Intraopera-
D. Classification—Patellar tendon ruptures have tive lateral radiographs are recommended
been classified according to the morphology of before final tightening of the sutures to ver-
the tear, the location of the tear, and temporal fac- ify proper position of the patella. The reti-
tors. One classification, based on the age of the nacular tears should be repaired as well. The
tears, was found to be useful with regard to prog- repair can then be reinforced using an 18G
nosis and treatment options. Acute tears, less cerclage wire (McLaughlin wire), umbilical
than 2 weeks old, can be repaired primarily and tape, or a large suture proximal to the pa-
have an excellent prognosis. In contrast, chronic tella and through a bone hole in the tibial
tears, more than 2 weeks old, tend to require more tubercle. An absorbable, braided polydioxa-
extensive surgical procedures for repair and are none (PDS) suture cable is preferred for this
associated with a more guarded prognosis. purpose (Figs. 9-7 and 9-8).
E. Evaluation 2. Late repair—Late repair is associated with a
1. History—Acutely, the patient usually gives a greater operative challenge and a worse out-
history consistent with forced knee flexion come. Primary repair is often not possible after
against a maximally contracted quadriceps. The a delay of more than 6 weeks. After a delay of
patient may describe a ripping sensation or an several months, a period of patellar traction may
audible pop associated with pain and an inabil- be needed to combat a chronic quadriceps con-
ity to immediately bear weight. Chronically, the traction. With time, degenerative changes may
patient may complain of weakness, instability, occur within the patellofemoral articulation,
and an inability to fully extend the leg. and the ruptured tendon becomes contracted
2. Examination—Acutely, a hemarthrosis, a palpa- and bound in scar. Reconstructive choices in-
ble defect, patella alta, and either a partial or a clude primary repair with hamstring or fascial
complete active extension loss may be found. lata autograft augmentation or in salvage cases,
Chronically, the defect may be filled with orga- extensor mechanism allografts (Fig. 9-8 and 9-9).
nized reparative tissue; in addition, the patient G. Postoperative Management—Postoperative man-
may have significant quadriceps atrophy and a agement includes immediate gentle passive
gait abnormality characterized by forward fling- range of motion followed by gentle active flexion
ing of the affected leg during the swing phase. at 2 weeks after surgery and active extension at
3. Imaging—Plain radiographs are helpful, with 3 weeks. Initial toe-touch, protected weightbear-
the lateral view being most diagnostic because ing progresses to full weightbearing by 6 weeks.
it can demonstrate patella alta (Fig. 9-5). The During this time, the repair is protected in a
use of ultrasonography in the diagnosis of hinged knee brace, which is progressively opened
chronic tears of tendinitis has been described, as range of motion returns. Unrestricted activity
but is operator dependent. MRI may be use- is allowed after 4 to 6 months, when complete
ful when another intraarticular injury is sus- healing has occurred and quadriceps strength is
pected or if the diagnosis is in question. within 90% of the unaffected extremity.
F. Treatment and Treatment Rationale—The treat- H. Complications—Knee stiffness and quadriceps
ment of patellar tendon rupture is surgical. Non- weakness are the most common complications af-
operative treatment cannot restore complete ter patellar tendon repair. They can be combated
extensor function. with a well-supervised rehabilitation program
1. Acute repair—Acute repair is most desirable be- emphasizing range of motion and quadriceps
cause the tendon can usually be repaired primar- strengthening. Other complications include per-
ily. This treatment is associated with the best sistent hemarthrosis, rerupture, and patella baja.
restoration of function and overall outcome.
• Surgical technique—A midline longitudi- III. Quadriceps Tendon Rupture
nal skin incision is used for the surgical A. Overview—Quadriceps rupture, as opposed to
approach and is extended to fully expose patellar tendon rupture, typically occurs in older
the rupture and either the patella or tibial patients, over 40 years old (average 47 years),
tubercle depending on the site of rupture. and is typically associated with preexisting tendi-
The dissection is carried medially and lat- nopathy. This condition results from repetitive mi-
erally to expose the retinacular tears. The crotrauma associated with jumping sports (e.g.,
FIGURE 9-5 A and B. AP and lateral

radiographs demonstrating a high-
riding patella consistent with a patellar
tendon rupture. Note the distal pole
avulsion fragment. C. Sunrise view of
the same knee. Note the absence of the
patella in the trochlear groove.
basketball). The level of the tear is also associated quadriceps aponeurosis. The rectus femoris
with age. In one study, rupture at the tendon-bone tendon broadens distally to insert on the proxi-
junction occurred in 75% of patients over the age mal pole of the patella and forms the most su-
of 40, whereas midsubstance tears occurred in perficial layer of the tendon. In addition, a layer
71% of patients younger than 40 years. Bilateral extends anterior to the patella to become contig-
ruptures have been reported in association with uous with the patellar tendon. The aponeuroses
anabolic steroid use and chronic metabolic dis- of the vastus lateralis and vastus medialis insert
orders such as diabetes mellitus, inflammatory into the superolateral border and superomedial
arthropathies, and chronic renal failure. border of the patella, respectively, forming the
B. Anatomy—The quadriceps tendon is a layered middle layer of the tendon. The vastus interme-
structure formed by the convergence of the dius aponeurosis merges with the deep surface
FIGURE 9-6 Patellar tendon repair. A. A midline longitudinal incision exposes the frayed end of the proximal
patellar tendon stump and the medial and lateral retinacular tears. B. The tendon has been reapproximated
to the distal pole of the patella using a large, nonabsorbable suture through bone tunnels in the patella.
A B
FIGURE 9-7 Suture technique of patellar tendon repair. A. A suture passer is used to guide the
core sutures through the drill holes. B. The suture is retrieved and tied at the superior margin of the
patella. (From Bedi A, Karunakar MA. Patella fractures and extensor mechanism injuries. In: Bucholz
RW, Court-Brown CM, Heckman, JD, et al, eds. Rockwood and Green’s Fractures in Adults. 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2010, with permission.)
Acute FIGURE 9-8 Patella tendon repair.

A. Direct repair to the inferior
pole of the patella through three
parallel drill holes. B. Addition
of a cerclage wire for protection
of the tendon repair. C. Chronic
rupture reconstructed using
semitendinosus-gracilis graft.
A B
Chronic
Gracilis
Semitendinosus
FIGURE 9-9 A. Neglected
rupture reconstructed with
a semitendinosus-gracilis
autograft woven through the
patella and the tibial tubercle.
B. Use of a patellar tendon
allograft, with attached patellar
and tibial bone blocks, for
end-to-end repair of a chronic
rupure with inadequate local
tissue. C. Use of an external
fixator made of two Steinmann
pins and a Charnley clamp
connecting the patella and
tibial tubercle. This may be
added to prevent proximal
patellar migration while
protecting the reconstruction
of a neglected rupture.
A B C
of the rectus femoris, vastus medialis, and vastus

lateralis, forming the deepest layer of the tendon.
The layered appearance of a normal quadriceps
tendon can be delineated on MRI; approximately
10% have four layers, 60% have 3 layers; and 30%
have 2 layers.
C. Biomechanics—See section on Patellar Fracture.
D. Evaluation
1. History—The patient’s history may be simi-
lar to that of a patient with a patellar tendon
rupture: a sensation of a pop or a tear when A
applying stress to the extensor mechanism of
the knee. With a complete tear, the patient may
report an immediate inability to bear weight.
Rupture may be preceded by a history of
chronic inflammatory symptoms.
2. Examination—Acutely, quadriceps tendon rup-
ture presents with generalized swelling about
the knee and tenderness on palpation at the
proximal pole of the patella. Flexing the knee B C
demonstrates (asymmetric) patella baja because
FIGURE 9-10 Marti technique for quadriceps tendon
the patellar tendon is intact. The patient is un-
repair. Sutures are passed through vertical drill holes in the
able to maintain knee extension against gravity.
patella and are tied at the inferior pole. The retinaculum is
A massive hematoma and preservation of knee repaired directly.
extension through an intact extensor (patella)
retinaculum may obscure the clinical diagnosis.
fascia lata. One author described the use of Dacron
3. Imaging—In complete ruptures, plain radio-
vascular grafts, passed circumferentially around
graphs demonstrate distal displacement of the
the repair through the patellar tendon and the
patella. Tendon calcification, proximal patellar
myocutaneous junction of the quadriceps tendon,
enesthesiopathy, or elongation of the proxi-
to protect the repair and allow early active range
mal pole is often present, suggesting chronic
of motion. Chronic tears may require V-Y advance-
inflammation and tendon degenerations as the
ment of a contracted quadriceps tendon with a
etiologic factors. Periosteal reaction on the
partial-thickness turn-down aponeurotic flap to
anterior surface of the patella is the so-called
augment the repair (Codvilla tendon-lengthening
tooth sign and also represents long standing
technique). A delay in repair is associated with a
inflammation. Bony avulsion fractures may
less satisfactory outcome.
also be present. MRI or ultrasonography may
G. Postoperative Management—A cylinder cast or
be helpful when the diagnosis is in question.
a locked brace is worn for 5 to 6 weeks. Non-
E. Treatment and Treatment Rationale—Like the treat-
weightbearing is continued for 3 weeks, after
ment for patellar tendon rupture, the treatment for
which weightbearing as tolerated is allowed in
a complete quadriceps tendon rupture is operative
the cast. Afterward, the patient is placed in a
to restore full, active extension and quadriceps
hinged knee brace opened up to 50°. The brace
function. Nonoperative treatment is reserved for
is subsequently opened 10° to 15° weekly until
partial tears and strains. Long-term results are of-
90° of motion and sufficient quadriceps strength
ten compromised by persistent pain from quadri-
are achieved for ambulation. An aggressive
ceps tendinitis. Results can also be compromised
quadriceps-strengthening program is important
by preexisting patellofemoral chondromalacia.
for good functional recovery.
F. Surgical Technique—Repair usually involves sutur-
H. Complication—Complications include postoper-
ing of the tendon back to the proximal patella with
ative hemarthrosis, rerupture, persistent quadri-
large, nonabsorbable sutures through bony tun-
ceps atrophy (75%), quadriceps weakness (53%),
nels (Fig. 9-10). Care must be taken to repair the
and loss of knee range of motion.
tendon close to the articular surface to prevent
“snowplowing” of the patellar into the troch- IV. Tibial Tubercle Fracture (In Children)
lear groove. The repair may be augmented with A. Overview—Tibial tubercle fractures represent
biologic grafts such as a flap of rectus femoris apo- 1% to 3% of all physeal injuries. These injuries
neurosis, as in the Scuderi technique (Fig. 9-11), or typically are seen most commonly in athletic
TA B L E 9 - 1
Classification of Fibial Tubercle Avulsion Fractures
According to Ogden
Type 1A Fracture line leads through the ossification
center of the tubercle without displacement
Type 1B The fragment is displaced anteriorly and
proximally
Type 2A Fracture line leads through the junction of
A
the ossification of the proximal end of the
tibia and the tubercle
Type 2B The tubercle fragment is comminuted
Type 3A Fracture line extends to the joint and is asso-
ciated with discontinuity of the joint surface
Type 3B The tubercle fragment is comminuted
1. Watson-Jones classification—Type I: Small

B fragment is avulsed and displaced proximally.
Type II: Secondary ossification center already
coalesced with proximal tibial epiphysis; frac-
ture is at this junction. Type III: Fracture line
passes proximally through the tibial epiphysis
and into the joint.
2. Ogden classification—Modification of the
Watson-Jones classification (described above);
subdivides each type into A and B categories
to account for the degree of displacement and
C
comminution (Table 9-1).
FIGURE 9-11 Scuderi technique for the repair of quadriceps D. Evaluation—Patients typically present with a
tendon ruptures. A. A partial-thickness triangular flap of
limited ability to extend the knee, as well as an
quadriceps tendon is turned down to reinforce the surgical
extensor lag. Because the insertion of the medial
repair. B. Bunnell pullout sutures and wires are placed on
the medial and lateral portions of the tendon. C. Sutures and retinaculum extends beyond the proximal tibial
wires are pulled down and tied over padded buttons. physis into the metaphysis, limited active exten-
sion of the knee is still possible after tibial tubercle
males from 14 to 16 years of age near skeletal fracture, although patella alta and extensor lag are
maturity. The mechanism of injury typically present. Swelling and tenderness over the tibial tu-
involves a violent contraction of the quadriceps bercle are typically present, often with a palpable
during extension, as in jumping. The injury may defect. Hemarthrosis is variable. Patella alta may
also occur with acute passive flexion of the knee be observed if severe displacement has occurred.
against a contracting quadriceps, such as with Anteroposterior and lateral views of the knee are
landing after a jump or a fall. Predisposing fac- sufficient for the diagnosis; a slight internal rota-
tors include patella baja, tight hamstrings, pre- tion view best delineates the injury, as the tibial
existing Osgood-Schlatter disease, and disorders tubercle lies just lateral to the tibial axis.
with physeal anomalies. E. Treatment and Treatment Rationale
B. Anatomy and Biomechanics—The tibial tubercle 1. Nonoperative treatment—Nonoperative treat-
physis, which is continuous with the tibial pla- ment is indicated for Type IA fractures. Treat-
teau, is most vulnerable between the ages of ment consists of manual reduction followed
14 and 16 years when it closes from posterior by immobilization in a long-leg cast with the
to anterior. The ossification centre of the tibial knee extended and patellar molding. The cast
tuberosity is connected to the metaphysis by is continued for 4 to 6 weeks at which time the
fibrocartilage, which during skeletal maturation patient may be placed in a posterior splint for
is gradually replaced by more fragile columnar an additional 2 weeks. Gentle active range-of-
cartilage, which is weak in resisting traction. motion exercises and quadriceps strengthen-
C. Classification—Description based on the displace- ing exercises are instituted and advanced as
ment of the avulsed fragment of bone. the symptoms decrease.
2. Operative treatment—Operative treatment is location of bony contusions on MRI, it has been hy-
indicated for Type IB, II, and III fractures. A ver- pothesized that dislocation occurs at 60° to 70° of
tical midline approach is used to access the flexion, at which point the patella comes into con-
fractured tubercle, which may be addressed tact with the sulcus terminalis of the lateral femo-
with smooth pins (more than 3 years from ral condyle. Although less common, medial patellar
skeletal maturity), screws, threaded Steinmann dislocation may occur as a postoperative complica-
pins, or tension bands. Cancellous screws tion (overzealous lateral release, medial reefing, or
placed horizontally through the tubercle into following a distal realignment procedure). Rarely,
the metaphysis afford stable fixation. Some intraarticular dislocation associated with quadri-
have recommended the use of 4.0-mm cancel- ceps rupture or rotational dislocation in the sagit-
lous screws rather than larger implants, such as tal plane associated with degenerative joint disease
6.5-mm screws, to lessen the incidence of bur- (locking of patellar osteophytes on the proximal
sitis that may develop over prominent screw femoral articular ridge) may occur.
heads. Washers may be helpful to prevent the B. Anatomy and Biomechanics
screw head from sinking below the cortical sur- 1. Medial restraints of the patella—The medial patel-
face. The patellar ligament and avulsed perios- lofemoral ligament (MPFL) is a distinct structure
teum is also repaired. If severe comminution is in the majority of knees. Located in the second
present, a tension-holding suture may be neces- layer of the medial knee, it spans from the medial
sary to secure the repair. Postoperatively, the epicondyle to the medial patella (Fig. 9-12). It has
patient is placed in a long-leg cast in extension additional attachments to the vastus medialis
with patellar molding for 4 to 6 weeks at which obliquus (VMO) and the adductor tubercle. It
time the patient may be placed in a posterior contributes 53% of the medial restraint to the
splint for an additional 2 weeks. Gentle ac- patella, making it the major medial restraint.
tive range-of-motion exercises and quadriceps Other structures contributing to the medial re-
strengthening exercises are instituted and ad- straint of the patella include the patellomeniscal
vanced as the symptoms decrease. ligament and associated retinacular fibers (22%).
F. Complications
1. Genu recurvatum—This is secondary to pre-
mature closure of the anterior physis and is
rare because the injury typically occurs in ado-
lescent patients near skeletal maturity.
2. Knee stiffness—Loss of flexion may be related
to scarring or postoperative immobilization.
Loss of extension may be related to nonana- Vastus medialis m.
tomic reduction and emphasizes the needs for
operative fixation of Type IB, II, and III fractures.
Medial patellofemoral
3. Patella alta—This may occur if reduction is ligament
insufficient.
4. Osteonecrosis of fracture fragment—This is Superficial medial
collateral ligament
rare due to the soft-tissue attachments and the
related blood supply. Deep medial
5. Compartment syndrome—Although this is collateral ligament
rare, it may occur with concomitant tearing of
Popliteus m.
the anterior tibial recurrent vessels that retract Gracilis m.
into the anterior compartment when torn. Semitendinosis
V. Patellar Dislocation
A. Overview—Patellar dislocation can occur during
soccer, baseball, gymnastics, karate, track, and other
sports. The mean age at injury is in the mid-20s and
occurs in women slightly more often than in men.
The mechanism of injury is a valgus load applied to FIGURE 9-12 The first layer and the part of the second
a flexed, weightbearing, externally rotated knee, and layer anterior to the superficial medial collateral ligament
the injury can occur with pivoting on a planted foot (MCL) are reflected forward to expose the underlying
that results in a laterally dislocated patella. Based medial patellofemoral ligament (MPFL) and the
on physical examination under anesthesia and the underlying capsule. VMO, Vastus medialis obliquus.
C. Evaluation—Acutely, the patient may give a his- side. AP, lateral, and tunnel views are use-
tory similar to that of a rupture of the anterior ful for ruling out fractures and evaluating for
cruciate ligament, reporting giving way, an audible patella alta. Merchant views are useful for
pop, rapid swelling, and an initial inability to am- ruling out marginal fractures and evaluating
bulate without assistance. If the knee is visualized lateral tilt and displacement and the femoral
immediately after injury, the patient may localize sulcus angle. Bilateral Merchant views are
the dislocation to the medial aspect of the knee very useful for comparison. Several radio-
because they are misled by the prominence of graphic angles and ratios have been used to
the medial femoral condyle. Chronically, patients assess patellofemoral instability.
complain of various degrees of recurrent patellar (a) Patellofemoral sulcus angle—The Patel-
subluxation and dislocation. lofemoral sulcus angle is measured on a
1. Examination—Acutely, approximately 80% of Merchant view taken with the knee flexed
knees have an effusion, 40% have a positive 30° to 35°. Two lines are drawn along the
apprehension sign with the knee flexed at 30°, slopes of the medial and lateral femo-
and 70% have tenderness on palpation over ral condyles. An angle greater than 144°
the medial retinaculum, posterior medial soft formed between the two lines is associ-
tissues, and the adductor tubercle (Bassett’s ated with patellar instability.
sign). Reflexive quadriceps inhibition and (b) Congruence angle of Merchant—The con-
weakness may be caused by the acute hemar- gruence angle of Merchant is measured
throsis. Anatomic findings that may indicate on a Merchant view taken as previously
a predisposition to patellar dislocation and described, and the Patellofemoral Sulcus
instability include a Q angle greater than 20° Angle is drawn as previously described.
(normal is 10° in men and 15° in women), genu This angle is then bisected. A fourth line
valgus, patella alta, a shallow patellofemoral is then drawn from the apex of the patel-
sulcus angle, VMO dysplasia, generalized liga- lofemoral sulcus angle through the lowest
mentous laxity, and pes planus. Other physical portion the medial ridge of the patella. If
findings include an increased lateral patellar this last line falls medial to the bisector,
tilt and an increased ability to laterally displace the angle formed between the bisector and
the patella at 30° of knee flexion (as compared this line is expressed as negative degrees
with the contralateral side). Medial mobility (it is expressed as positive degrees if it
less than one quadrant indicates a tight lateral falls lateral to the bisector) (Fig. 9-14).
retinaculum and correlates with an abnormal
passive patellar tilt test. Conversely, lateral
mobility greater than three quadrants indicates
insufficient medial restraints (Fig. 9-13). O X
2. Imaging
• Plain films—AP, lateral, tunnel, and Merchant
Lateral Medial
views should be obtained on the involved (+) (–)
C
B
FIGURE 9-14 Congruence angle of Merchant. Line BO

is the bisector of angle ABC. Line BX passes through
the lowest point on the median ridge of the patella.
FIGURE 9-13 Assessment of patellar mobility medially Angle OBX is the congruence angle. If line BX falls to the
and laterally. The patellofemoral joint can be divided into medial side of line BO, the angle is expressed as negative
quadrants, and patellar mobility can be assessed in both degrees. If it falls to the lateral side of line BO, it is
directions. expressed as positive degrees.
A B FIGURE 9-15 Measure of the lateral patellofemoral

X
angle. Line YY is drawn across the most anterior
X
portions of the femoral trochlea in the axial view of
X X this left knee. Line XX follows the slope of the lateral
Y Y Y Y
patellar facet. A. Normal angle in which the angle
opens laterally. B. Abnormal angle with the angle
open medially.
A congruence angle of 6° to 8° is nor- lateralization of the tibial tubercle can be
mal; greater than 16° is abnormal. evaluated with CT. Lateralization of the tibial
(c) Lateral patellofemoral angle—The lateral tubercle greater than 9 mm has been closely
patellofemoral angle is also measured associated with patellar malalignment.
on a Merchant view. A line is drawn con- • MRI—MRI may be useful for evaluating the
necting the most anterior portions of the integrity of the MPFL and for assessing asso-
femoral condyles. A second line is drawn ciated chondral injuries. Proximal retraction
along the slope of the lateral patellar of the VMO is consistent with disruption of
facet. Normally, the angle formed opens the MPFL from the medial femoral epicon-
laterally. A neutral angle or one that dyle. In one study, the incidence of findings
opens medially is abnormal (Fig. 9-15). on MRI in the setting of acute patellar disloca-
(d) Blumensaat’s line—With the knee flexed tion was as follows; effusion, 100% avulsion
30°, the distal pole of the patella should of the MPFL from the medial epicondyle,
lie on a line extended from the roof of the 87%; signal change in the VMO, 78%; lateral
intercondylar notch (Blumensaat’s line) femoral condyle bone contusion, 87%; and
on the lateral radiograph. The location of medial patellar bone contusion, 30%.
the distal pole of the patella above and D. Associated Injuries—Devastating osteochondral
below this line is considered patella alta injuries can occur to the medial patellar facet or
and baja, respectively. the lateral condylar ridge as the patella laterally
(e) Insall-Salvati index—The Insall-Salvati index
is measured on a lateral view at 30° of knee
flexion. The index is the ratio of the patellar
tendon length to the length of the patella
itself. A ratio of greater than 1.2 is consid-
ered patella alta, and a ratio of less than 0.8
is considered patella baja (Fig. 9-16).
(f) Blackburne and Peele index—The Black-
burne and Peele Index is also measured
on a lateral view of the knee at 30° of
flexion. A line is extended anteriorly level
with the tibial plateau. A second perpen-
dicular line is then drawn to the distal
articular margin of the patella. The ratio
of the length of this line to the length of
the articular surface of the patella is nor-
mally 0.8. A ratio of greater than 1.0 is
considered patella alta (Fig. 9-17).
• CT—Bilateral CT scans with the knees flexed
at 10° are useful for measuring and comparing
lateral patellar tilt. Three types of subluxation
have been described (Fig. 9-18): Type I, lat-
eral subluxation without patellar tilt; Type II, FIGURE 9-16 Lateral view of the knee with the Insall-
subluxation with lateral tilt; and Type III, Salvati index lines indicating a normal ratio (patellar
lateral tilt without subluxation. In addition, tendon length to the patellar length of 1.2.
Lateral dislocation
Medial patellar
Lateral femoral facet fracture
condyle fracture
FIGURE 9-19 Osteochondral fracture of the lateral

femoral condyle and medial patella in association with
lateral patellar dislocation.
E. Treatment and Treatment Rationale—Whether

nonoperative or operative, early treatment is as-
sociated with better results. A poorer prognosis
is associated with late presentation, inadequate
prior treatment, bilateral injury, and female gen-
FIGURE 9-17 Lateral view of the knee with the der. Aspiration of a large hemarthrosis should be
Blackburne and Peele measurements indicating a normal considered for pain relief, and evaluation for fat
ratio (height above the tibial plateau line [A] divided by globules (suggesting occult osteochondral frac-
the patellar articular surface length [B]).
ture) should be performed.
1. Nonoperative treatment
• Immobilization and rehabilitation— Immobili-
A B C zation and rehabilitation involves 6 weeks of
strict immobilization in a cylinder cast or im-
mobilizer, followed by aggressive physical
therapy to regain motion and strength. Pub-
lished data have reported a recurrent instabil-
ity rate of greater than 40% with this protocol
and 50% to 60% unsatisfactory results overall.
Other reported problems include persistent
FIGURE 9-18 Three types of abnormal findings on axial muscular (quadriceps) atrophy, prolonged
CT scan as described by Fulkerson and associates. A. disability, and patellofemoral problems. There
Type I, lateral subluxation without patellar tilt. B. Type II, are also theoretical disadvantages to immobi-
subluxation with lateral tilt. C. Type III, lateral tilt without lization as a treatment in regards to ligament
subluxation. strength and cartilage integrity.
• Functional treatment—Functional treatment
involves early range of motion with patellar
dislocates or relocates into the trochlear groove support bracing. Good results (66%), patient
(Fig. 9-19). Osteochondral injuries involving either satisfaction rates (73%), and decreased rates
the patella or the lateral femoral condyle have been of recurrent instability (26%) have been
found in 68% of patients with acute patellar dislo- reported with this technique.
cations. The lateral condylar lesion is located just 2. Operative treatment—In general, the indica-
anterior to the sulcus terminalis. The patella con- tions for operative intervention have been
tacts the sulcus terminalis at approximately 70° to dislocation associated with fractures or loose
80° of flexion. Because of this, it has been suggested osteochondral fragments as well as recurrent
that patellar dislocation occurs in this 70° to 80° de- patellar subluxation or dislocation following
gree range of flexion. Attempts should be made to nonoperative management. More recently,
repair osteochondral injuries if feasible. Another in- because of the high rate of recurrent instability
jury associated with patellar dislocation is avulsion with nonoperative management, there is now a
of the MPFL from the medial femoral epicondyle trend towards acute operative intervention and
(94% in one study), which is discussed below. repair of the primary pathologic lesion.
• Acute Operative Treatment • Proximal “tube” realignment of the

(a) MPFL repair—Rupture of the MPFL has patella—A lateral release is performed
been identified as the primary lesion in initially. The vastus medialis is then
patellar dislocation, so acute repair of freed and advanced laterally and distally
the MPFL has been proposed. The MPFL and secured to the free edge of the lat-
avulses from its femoral attachment in eral release. This creates a tube of ten-
the majority of cases. It also tears from don anterior and proximal to the patella.
its patellar attachment and ruptures or • VMO advancement—Several tech-
attenuates within its midsubstance. A niques of VMO advancement have been
preoperative MR scan is recommended to described. The technique of Madigan
confirm the location of the lesion and thus involves the transfer of a division of
define the operative approach. A diagnos- the VMO laterally and suturing of the
tic arthroscopy is performed initially to division to the patella and the quadri-
document and address associated inju- ceps tendon. More commonly, a simple
ries and remove loose bodies. If the MPFL medial reefing of the VMO and medial
has been avulsed from its femoral inser- retinaculum is combined with a lateral
tion, an approach is made over the medial release (Fig. 9-21).
epicondyle, the distal margin of the VMO (b) Distal procedures—Considered recon-
is elevated, and the proximal edge of the structive, distal procedures are asso-
MPFL is identified and secured back to the ciated with unpredictable changes in
medial epicondyle with suture anchors. Be- patellofemoral contact pressures and
fore and after the repair, patellar tracking are associated with late degenerative
may be evaluated arthroscopically via the changes. These procedures are not rec-
superior medial portal. Initial reports of this ommended in the presence of a normal
procedure have been encouraging; there Q angle (15°).
was no incidence of recurrent dislocation • Roulx-Goldthwait procedure—The Roux-
after 34 months of follow-up in one study. Goldthwait Procedure was first de-
• Operative treatment of chronic cases scribed by Cesar Roux in 1888 and later
(a) Proximal soft tissue procedures modified by Joel Goldthwait in 1899.
• Lateral retinacular release—The indi- The lateral half of the patellar tendon is
cations for lateral retinacular release released distally, transferred medially,
include a patient with a tight lateral reti- and secured at the sartorial insertion.
naculum (neutral or negative tilt) and This procedure is usually performed in
minimal or no subluxation, whose symp- conjunction with a proximal soft tissue
tomatic condition has failed to respond procedure.
to conservative management. The proce- • Hauser procedure—First described in
dure may also be performed in conjunc- 1938, the Hauser Procedure involves
tion with realignment procedures for the direct medial transfer of the tibial
chronic subluxation or recurrent disloca- tubercle. However, this results in pos-
tion. A passive medial patellar tilt of 60° terior displacement of the tubercle as
to 90° (the turn-up test) is the goal at the a result of the posterior medial slope
completion of the procedure (Fig. 9-20). of the proximal tibia. This is turn leads
A Before release B After release FIGURE 9-20 Turn-up test. At the completion of

the lateral retinacular release, passive patellar tilt is
performed to achieve a goal of 60° to 90° of medial tilt.
60°– 90°
B A
C B
A
FIGURE 9-21 Proximal patellar realignment includes FIGURE 9-23 Elmslie-Trillat procedure. A lateral
both a lateral release and medial reefing. A. Planned retinacular release is performed first. A. An osteotome
incisions. B. Procedure. C. Final result. is inserted in the retropatellar bursa from the lateral
side and directed distally and medially. Care is taken
to produce a 4- to 6-cm osteotomy and to preserve the
integrity of the distal pedicle. B. The fragment is fixed with
a single screw in the desired position. A medial plication
may be added if sufficient stability is not restored after the
distal transfer.
b
a hinge distally and is rotated medially.

The intact periosteal hinge limits the
amount of posterior and distal displace-
ment of the tibial tubercle (Fig. 9-23).
• Fulkerson procedure (anteromedial tibial
tubercle transfer)—The Fulkerson Pro-
A B cedure is a modification of the Elmslie-
Trillat Procedure. Using a long, oblique
osteotomy, the surgeon medializes and
FIGURE 9-22 Transfer of the tibial tuberosity according anteriorly displaces the tibial tubercle,
to the Hauser technique. Because of the triangular shape which corrects the Q angle and unloads
of the proximal tibia, medial displacement (a) causes a the patellofemoral joint (Fig. 9-24).
posterior displacement (b) as well. This in turn decreases • Hughston procedure—This is essen-
the lever arm of the patellar tendon and increases tially an Elmslie-Trillant Procedure with
the compressive forces on the patellofemoral joint, a proximal realignment. The Hughston
predisposing it to degenerative changes. Procedure combines a lateral release,
a distal tibial tubercle transfer, and a
to increased patellofemoral contact medial plication (Fig. 9-25).
forces and a predisposition to articular • Galleazzi procedure—After a lateral
degeneration (Fig. 9-22). release, the semitendinosus tendon is
• Elmslie-Trillat procedure—The Elmslie- released proximally and then passed
Trillat Procedure is a modification of through the patella and sutured to it-
the Hauser Procedure. The tibial tu- self. This technique is applicable in
bercle is left attached to a periosteal skeletally immature patients.
B A
B
C
A
FIGURE 9-24 Fulkerson technique of anteromedialization
of the tibial tuberosity. A. Outline of a generous shingle
to be raised from the tibial crest. B. Osteotomy after
placement of multiple Steinmann pins in the plane of the
cut. C. Completed displacement of the shingle with internal
fixation.
(c) Patellectomy—A patellectomy is a last- FIGURE 9-25 Hughston technique to realign the

resort salvage procedure. The results extensor apparatus. A lateral release is performed first.
A. In knees with an increased Q angle, the tibial insertion
are described in the section on Patellar
of the patellar tendon is detached with a thin wafer of
Fractures.
bone. B. Displacement in a distal and medial direction
F. Complications—Complications from patellar dislo- as required and fixed with a Stone stable. C. The VMO is
cation undergoing nonoperative treatment include then advanced in line with its fibers a few millimeters and
recurrent instability (40%), loss of knee range of sutured in place with nonabsorbable sutures. The smooth
motion, and symptomatic patellofemoral degen- movement of the patella is checked every stitch or two,
erative changes. Such treatment usually results in and if any abnormality is noted, the stitches are removed
overall low satisfaction rates. Complications from and the advancement redone.
operative treatment include overcorrection (with
medial dislocation or adverse alteration in patel-
lofemoral mechanics leading to early degenera- B. Classification—A quadriceps contusion is classi-
tive changes), nonunion, wound complications, fied into three grades of severity 24 to 48 hours
and compartment syndrome (following distal after initial hemorrhage and swelling cease.
procedures). A mild contusion is characterized by local ten-
derness, ability to flex the knee more than 90°,
VI. Quadriceps Contusion and the ability to perform a deep knee bend. The
A. Overview—The quadriceps has a broad attach- average time of disability is 13 days. A moder-
ment to and lies directly over the femur. The ate contusion is characterized by tenderness
position of the quadriceps renders it susceptible and swelling, ability to flex the knee more than
to crushing injuries between an external force 45° but less than 90°, and inability to perform
and the underlying bone. A quadriceps contusion a deep knee bend or rise from a chair without
is an injury to the quadriceps mechanism sus- significant pain. The average time of disability is
tained by a direct blow that damages the muscle 19 days. A severe contusion is characterized by
but does not eliminate its function completely. marked tenderness and swelling that obscures
the contour of the muscle, inability to flex the effusion, and a delay in treatment of longer than
knee more than 45°, and a severe limp. Often, 3 days. In the same study, in those patients who de-
there is a sympathetic effusion of the ipsilateral veloped myositis ossificans it was attached to the
knee. The average time of disability is 21 days. femur by either a narrow stalk or a broad-based
C. Evaluation—If a quadriceps rupture is suspected attachment or was separated from the femur by a
on clinical examination, plain films, MRI, and narrow line of tissue. Usually, a distinct history of
ultrasound may all be useful as discussed in the trauma and zoning of the lesion (peripheral matu-
section on quadriceps tendon rupture. Myositis ration) makes the diagnosis of myositis ossificans
ossificans may be diagnosed as early as 2 to 4 clear, so no further workup is necessary. Rarely
weeks with plain films and usually involves the is the heterotopic bone of any functional signifi-
middle third of the thigh. cance and the initial treatment is conservative and
D. Treatment and Treatment Rationale—Quadriceps includes active stretching. However, it should be
contusions should be observed closely until remembered that synovial sarcoma, parosteal os-
hemorrhage and edema have ceased. Although teosarcoma, and periosteal osteosarcoma might
rare, thigh compartment syndrome after quadri- each be mistaken for myositis ossificans.
ceps contusion has been reported. With the ex-
ception of a compartment syndrome, treatment
is nonoperative and is divided into three phases.
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1. Phase I—The goal of Phase I treatment is to
limit hemorrhage. This phase consists of rest, Classic Articles
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Weber MJ, Janecki CJ, McLeod P, et al. Efficacy of various forms
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CHAPTER 10
Tibial Plateau Fractures

Mark R. Brinker, Daniel P. O’Connor,
and Roman Schwartsman
I. Overview 3. Mechanism of injury—The mechanism of

A. Mechanism of Injury—The fracture is usually a injury and any other influencing factors should

result of a compressive force: a direct axial com- be determined from the history.

pressive force, an indirect coronal compressive B. Physical Examination

force, or a combined axial and coronal compres- 1. Inspection—The skin condition of the extremity

sive force. The most common cause is a fall or a should be noted. Specifically, internal deglov-
motor-vehicle accident. ing as well as open wounds should be noted.
B. Factors Influencing Fracture Patterns All open wounds must be examined to rule out

1. Position of the leg relative to the direction of communication with the joint. The joint should

force application and degree of knee flexion at be injected with 50 mL of sterile saline under
the time of force application. sterile conditions to determine whether any
• Medial plateau fractures—Medial plateau suspicious wounds communicate with the joint.

fractures result from a combination of com- 2. Palpation—The neurovascular status of the

pression and varus stress. extremity should be assessed.

• Lateral plateau fractures—Lateral plateau • Compartment syndrome—Compartment syn-

fractures result from a combination of valgus drome, although a rare entity with these types
stress and a force applied from the lateral of fractures, must always be ruled out. Direct
side of the joint. measurement of compartment pressures
2. Bone quality and the patient’s physiologic age. should be carried out if the clinical assess-

• Young patients—Because of the good qual- ment is unreliable.

ity of their bone, young patients are prone • Pulses—The presence or absence of pop-

to ligamentous injuries in combination with liteal, dorsalis pedis, and posterior tibial
simple split fractures. pulses must be documented. Doppler studies
• Older patients—Older patients are more likely or arteriograms are indicated if these pulses

to have depression-type or split-depression are absent.
fracture without associated ligamentous injury. • Ligamentous injury—A strong suspicion

for ligamentous injury should be main-
II. Evaluation tained on examination because as many as

A. History 30% of these fractures may have an associ-

1. Knee pain—Clinical suspicion for a tibial pla- ated ligamentous injury. For example, pain

teau fracture should be high whenever a pa- and swelling over the medial collateral liga-
tient complains of pain about the knee after ment (MCL) with a displaced lateral plateau
sustaining an injury. fracture should be strongly suspicious for an
2. Hemarthrosis with extension of the hematoma associated MCL tear.

into the soft tissues—The presence of a hem- • Meniscal injuries—Meniscal injuries are an

arthrosis with extension of the hematoma into associated finding in as many as 50% of tibial
the soft tissues, particularly at the sites of liga- plateau fractures. The initial clinical examina-
mentous attachments, should heighten clinical tion is unreliable for diagnosing meniscal in-
suspicion for a tibial plateau fracture. juries in patients with tibial plateau fractures.
135
C. Radiographic Evaluation 5. Type V fractures are bicondylar (Fig. 10-2).

1. Initial radiographic series—The knee trauma

Typically, these fractures involve a split of both
series, the initial radiographic series, should in- the medial and the lateral plateaus without any
clude an anteroposterior view, a lateral view, two associated articular depression.
oblique views, and a 15° caudal tilt view. These 6. Type VI fractures are characterized by the

films should be evaluated for shaft extension, ar- presence of an associated proximal tibial
ticular depression, bone avulsions, and widening shaft fracture (i.e., metaphyseal-diaphyseal
of the joint space. The 15° caudal view provides separation). They are almost always high-
a more accurate assessment of joint depression energy injuries with extensive comminution.
than the anteroposterior view, since it accounts There may be an associated popliteal artery
for the posterior slope of the tibial plateau. disruption.
2. Varus/valgus stress views—Varus/valgus stress B. AO/OTA Classification (Fig. 10-3)

views can be obtained as a supplement to the 1. Advantages and disadvantages—The advan-

knee trauma series and may aid in the identifi- tage of the AO/OTA classification is that it is
cation of associated ligamentous injuries. A col- a unified, consistent approach to the classifi-
lateral ligament disruption is suggested when cation of fractures that appears to have good
the medial or lateral clear space is widened by intraobserver reliability. The disadvantage is
more than 1 cm compared with that of the con- that it is a cumbersome system that is imprac-
tralateral limb stressed in the same way. tical to apply to the acute clinical setting. The
3. Computed tomography (CT)—CT serves as an AO/OTA classification distinguishes fractures

adjunct to plain radiographs in preoperative by type, group, and subgroup.
planning. The degree of articular displacement 2. Correspondence to the Schatzker classification—

is best evaluated on a CT scan with sagittal and The AO/OTA type B fractures correspond to
coronal reconstructions. Schatzker Types I to IV. The AO/OTA Type C frac-
4. Magnetic resonance imaging—Magnetic reso- tures correspond to Schatzker Types V and VI.

nance imaging does not yet have a clear role in
the evaluation of tibial plateau fractures, although IV. Associated Injuries

it may serve as an adjunct to plain radiographs A. Meniscal Tears—Meniscal tears occur in as many

in certain cases and it may aid in identifying as 50% of tibial plateau fractures. Meniscal tears
associated meniscal and ligamentous injuries. that cannot be repaired should be excised at the
time of definitive surgical treatment. Peripheral

III. Classification meniscal tears identified at the time of open re-
duction should be repaired with suture just be-

A. Schatzker Classification—The Schatzker classifica-
fore closure.

tion (Fig. 10-1) is the most widely used and accepted
system of classifying tibial plateau fractures. B. Ligamentous Injuries—Associated ligamentous

1. Type I fractures are a split of the lateral pla- injuries are noted in as many as 30% of tibial pla-
teau fractures. Treatment should be individual-

teau. They occur predominantly in the young
patients with strong bone and may be associ- ized according to the injury. The need for repair
ated with a trapped meniscus at the fracture remains controversial since it is not entirely clear
site. There is a high risk of ligamentous injury which combinations of ligament injury and frac-
with these fractures. ture result in knee joint instability.
2. Type II fractures are split-depressions of the 1. Collateral ligament repair—Collateral ligament

repair in the acute setting requires an undesir-

lateral plateau. An axial load caused by the
femoral condyle first splits the plateau and able amount of soft tissue stripping. Evidence
then depresses its edge. in the literature supports the nonoperative
management of MCL injuries since most heal
3. Type III fractures are pure central depressions
satisfactorily.

of the lateral plateau. They are more likely the
result of a low-energy injury, and they occur 2. Repair of avulsions of the intercondylar emi-

predominantly in older patients. There is a nence—Avulsions of the intercondylar emi-
low risk of ligamentous injury associated with nence should be repaired, reattaching the
these fractures. cruciate ligament with a bone block.
4. Type IV fractures involve the medial tibial pla- V. Treatment and Treatment Rationale

teau. They are usually high-energy injuries. A. Indications—The specific indications for op-

There may be an associated traction lesion of erative vs. nonoperative management remain
the peroneal nerve. controversial.
C H A P T E R 1 0 | T I B I A L P L A T E A U F R A C T U R E S 137
Schatzker type I Schatzker type II Schatzker type III
Schatzker type IV Schatzker type V Schatzker type VI
FIGURE 10-1 Schatzker classification of tibial plateau fractures. Type 1 fracture: a split fracture

of the lateral plateau without any joint depression. More or less displacement may be present. Even
if displacement is slight, there may be an associated peripheral tear of the lateral meniscus, which
can be incarcerated in the fracture. Arthroscopy may be required to exclude a meniscus injury.
Type I fractures can be fixed with lag screws (often with washers) if the bone is of good quality. In
older, osteoporotic patients, a buttress plate may be advisable. Type II fracture: a split-depression
fracture. The depressed fragment may undergo severe fragmentation. These injuries generally occur
in patients with decreased bone density. With a Type II fracture, the lateral plateau is exposed beneath
the meniscus, and depressed articular surface fragments are carefully elevated en masse by opening
the peripheral fracture defect. Sufficient bone graft is inserted into the remaining metaphyseal void.
Then the split fragment is reduced and fixed with a buttress plate and lag screws. Allograft may be
used in elderly patients. Type III fracture: a pure depression fracture. The depressions vary in size
and degree and may be central, or less commonly, peripheral. Instability may not be present when
the depressed area is small or centrally located. An examination under anesthesia may be required
to assess the stability of a knee with a Type III fracture. If instability is present in a Type III fracture,
the depressed portion of the tibial plateau is elevated via an appropriately placed window in the
metaphysis. Bone graft is packed into the resulting defect. If a large window is required, the cortex
must be buttressed with a plate to prevent a split fracture. Type IV fracture: a fracture of the medial
plateau, which is frequently associated with a fracture of the intercondylar eminence. This high-
energy injury may be associated with neurovascular or other significant soft tissue injury. Definitive
fixation of Type IV (medial plateau) fractures usually requires a medial buttress plate to supplement
the lag screws. Lag screws or a wire suture may be needed to anchor an intercondylar eminence
fragment. Type V fracture: a bicondylar fracture that may involve the articular surface. Occasionally,
the fracture lines are so close to the intercondylar eminence that the weightbearing surfaces of the
plateaus are not affected. The fracture lines may resemble an inverted Y. Lag screws with medial and
lateral buttress plating provides optimal fixation for Type V plateau fractures. Buttress plates are
important in preventing axial collapse. Hallmark of a Type VI fracture: separation of the metaphysis
from the diaphysis. Usually, the lateral plateau has a depressed or comminuted area, whereas the
medial plateau tends to be more intact. Such impaction may involve both plateaus. Two plates are
required for optimal fixation of a Type VI fracture. Both act as buttresses, but one (a DCP-type plate)
must reconnect the metaphysis to the diaphysis, supplementing lag-screw fixation if possible. Thus
this plate is used for either compression or neutralization.
A D
B E
C
FIGURE 10-2 This 49-year-old man injured his leg while

playing softball. The anteroposterior (A) and lateral
(B) radiographs and computed tomography (CT) scan
(C) revealed a Schatzker Type V fracture, with bicondylar
involvement, an anterior fragment, and medial translation
of the medial plateau. The condylar components of the
fracture were treated using a medial locking plate, and the
anterior fragment was stabilized using a lag screw (D and E).
At 4 months after surgery, the patient was pain-free, full
weightbearing, and had full extension and flexion to 100°.
Type B1 Type B2 Type B3 • Plateau fractures with an associated shaft

fracture—Plateau fractures with an asso-
ciated tibial shaft fracture are inherently
unstable and do not lend themselves to
nonoperative treatment.

3. Injuries requiring emergent surgery—There is no

controversy regarding the requirement for emer-
gent surgical management of open fractures, frac-
tures with an associated vascular injury, or those
with an associated compartment syndrome.
B. Nonoperative Treatment—Nonoperative treat-

ment is reserved for stable, minimally displaced
plateau fractures.
1. Protected mobilization—Protected mobiliza-

Type C1 Type C2 Type C3 tion in a hinged cast brace with partial weight-
bearing for 8 to 12 weeks is recommended. Full
weightbearing can begin later as tolerated. Un-
restricted activity is allowed at 16 to 26 weeks.
2. Exercises—Progressive knee range-of-motion

exercises and isometric quadriceps and ham-
string exercises are initiated during the pro-
tected-weightbearing stage.
C. Operative Treatment

1. Preoperative planning—Preoperative planning

gives the surgeon insight into the “personality”
of the fracture. A radiograph of the contralat-
FIGURE 10-3 AO classification of fractures of the long eral extremity may be used as a template. Trac-

bones, tibia/fibula, proximal segment. B1, partial articular tion radiographs allow for better visualization
fracture, pure split. B2, partial articular fracture, pure of the individual fracture fragments.
depression. B3, partial articular fracture, split depression. 2. Timing of surgery—The timing of surgery is

C1, complete articular fracture, articular simple, influenced by the condition of the soft tissues.

metaphyseal simple. C2, complete articular fracture, The soft tissues may become edematous within
articular simple, metaphyseal mulifragmentary. C3,
8 to 12 hours of injury to the point where it
complete articular fracture, multifragmentary.
may be judicious to let the swelling subside.
The limb can be immobilized in a bulky Jones
1. Articular surface displacement—Some authors splint or with a knee-spanning temporary ex-

advocate nonoperative management for frac- ternal fixator during this time. In high-energy
tures with as much as 1 cm of articular surface injuries, it may take up to two weeks for the
depression. Advocates of operative treatment soft tissue swelling to subside.
are willing to accept only minimal displace-
ment (≤2 mm) of the articular surface. VI. Anatomic Considerations and Surgical Techniques

2. Varus/valgus instability—There is general con- A. Limited Open-Reduction Techniques, Indirect-

sensus that varus/valgus instability (with the Reduction Methods, and Fluoroscopy—The use
knee in extension) of 10° or more, relative to of limited open-reduction techniques, indirect-
the contralateral knee, is an indication for op- reduction methods, and fluoroscopy, rather than
erative management of the fracture. direct joint visualization, to assess articular sur-
• Split fractures—Split fractures are likely to face congruence is advocated in cases of soft tis-

be unstable, since they involve the rim of the sue compromise. This approach provides good
tibial plateau. visualization in the treatment of split fractures
• Split-depression fractures—Split-depression (Schatzker Types I, IV, and V). With depressed

fractures carry a higher risk of instability. fracture fragments, visualization on the image
• Pure depression fractures—Pure depres- intensifier is limited by the remaining plateau.

sion fractures are generally stable because B. Arthroscopy—Arthroscopy can serve as a less

the intact cortical rim provides varus/valgus invasive method of assessing articular surface re-
stability. duction. It is advocated by some authors for the
140 S E C T I O N I I | A D u l t T r a u m a P a r t I | T h e Lo w e r E x t r e m it y
treatment of split fractures because of the theo-

retical possibility of the meniscus being trapped
in the fracture at the time of indirect reduction.
It is most useful for the treatment of central de-
pression fractures (Schatzker Type III). There is
the potential danger of compartment syndrome
from fluid extravasation. High-pressure inflow
is to be avoided. The compartments should be
evaluated frequently during arthroscopic sur-
gery in patients with tibial plateau fractures.
C. Surgical Treatment of Split Fractures (Schatzker

Types I, IV, and V)
1. Fragment reduction—A tenaculum clamp may

be used to reduce fractures displaced only
medially or laterally.
2. Ligamentotaxis—In fractures in which there

is a split, ligamentotaxis with a femoral dis- FIGURE 10-4 Use of a femoral distractor to aid in the
tractor (Fig. 10-4) attached on the same side

reduction of a tibial plateau fracture via ligamentotaxis.
as the fragment may be used as a reduc- In the sample case shown here, one limb of the AO
tion aid. (This requires intact soft tissue distractor is inserted into the medial femoral condyle
attachments.) while the other is inserted into the subcutaneous
3. Bone grafting—Bone grafting is typically not anteromedial surface of the tibia. Five-millimeter Schantz

necessary in these types of fractures, and screws should be used to anchor the distractor to bone.
may, in fact, hinder reduction. The AO tubular external fixator can also be substituted
4. Fixation—Definitive fixation is accomplished for the distractor.

with either screws or buttress plates, depend-
ing on bone quality.
D. Surgical Treatment of Depression Type Fractures (a) Midline—A midline incision facilitates

(Schatzker Type III) later knee arthroplasty or arthrodesis.
1. Fragment elevation—The depressed fragment (b) Dual incision—Anterolateral and pos-

can be elevated with a bone tamp through a teromedial approaches advocated by
fenestration of the cortex. some authors, particularly for Schatzker
2. Bone grafting—The resultant metaphyseal Type VI injuries.

defect should be filled with graft material to • Coronary ligament—The coronary ligament

prevent articular collapse. is incised horizontally to create the arthrot-
3. Fixation—Percutaneous large-fragment scr omy (Fig. 10-5).

ews should be inserted parallel to the joint • Additional joint visualization—Additional

and just below the graft to stabilize and sup- joint visualization can be obtained by par-
port the construct. tially sectioning the iliotibial band.
E. Surgical Treatment of Split Depression Fractures • Z-plasty—If even more visualization is nec-

and Fractures with Metaphyseal-Diaphyseal Sep- essary, a Z-plasty of the patellar tendon
aration (Schatzker Types II and VI) should be considered. (The tendon should
1. Open reduction and internal fixation tech- be protected with a tension band after the

niques—Open reduction and internal fixation repair.)
techniques provide the best means of establish- 4. Specific techniques for Schatzker Type II

ing an anatomic reduction of the joint surface, fractures
restoring axial alignment, and instituting an • Fragments—The fragments should be

early functional knee range-of-motion program. hinged outward like the pages of a book
2. Femoral distractor—The femoral distractor to preserve their soft tissue attachments.

(see Fig. 10-4) can be used as a supplemen- Depressed articular fragments should be
tal reduction aid in these types of fractures. elevated from below as large cancellous
The distractor is placed on the ipsilateral side blocks.
of the fracture. Two femoral distractors may • Bone grafting—Bone grafting of the me-

need to be used in Schatzker Type VI fractures. taphyseal defect can either precede or fol-
3. Surgical approach low reduction and stabilization of the split

• Incision fragment at the discretion of the surgeon.

(d) Circular thin wire (Ilizarov) external

fixation—Ilizarov fixation is recom-
mended for fractures in which the level
of separation between the tibial shaft

and metaphysis is very proximal. It is
alternatively recommended as a means
of definitive fixation in open fractures.
Circular external fixation has been
reported to have similar clinical out-
comes as ORIF with fewer and less se-
vere complications.
(e) Circular thin wire external fixation com-

bined with minimal internal fixation—
Several recent reports have advocated
that limited internal fixation using mini-
mally invasive techniques may be used
to reduce and stabilize the articular
surface with external fixation used to
stabilize the remaining fragments in high-
energy, highly comminuted fractures.
VII. Complications of the Injury

A. Posttraumatic Arthritis—Posttraumatic arthri-

tis can occur either as a result of residual joint
FIGURE 10-5 The arthrotomy should be made by incising incongruity or as a result of cartilage damage

the coronary ligament transversely below the meniscus. sustained at the time of the initial injury.
B. Loss of Meniscal Tissue—Loss of meniscal tis-

sue contributes to excessive load bearing by
the underlying articular surfaces, also leading
to premature posttraumatic arthritis.
• Stabilization—Definitive stabilization of the
C. Loss of Joint Motion—Loss of joint motion oc-

fracture is accomplished using large, can-

curs as a result of periarticular soft tissue in-
cellous lag screws inserted parallel to the
juries and can be exacerbated by prolonged
joint line and a metaphyseal buttress plate
immobilization.
of appropriate size.
D. Rare Complications—Rare complications in-
5. Specific techniques for Schatzker Type VI

clude compartment syndrome, peroneal, neu-

fractures
ropathy, popliteal artery injuries, deep vein
• Medial plateau fragment—The medial pla-
thrombosis, and avascular necrosis.

teau fragment is usually the larger of the
two and lends itself as a starting place for VIII. Complications of Treatment

attachment of the lateral fragments and the A. Infection—Infection is a potentially devastating

tibial shaft. complication that occurs in as many as 12% of
• Metaphyseal fracture components—The tibial plateau fractures. Infection may be related

metaphyseal components should be re- to either the initial condition of the fracture or
duced first, followed by reduction and stabi- the surgical intervention.
lization of the metaphysis to the diaphysis. B. Skin Slough—Skin slough at the fracture site,

This can be accomplished by either: the result of poor surgical timing, poor soft tis-
(a) Dual plates—Low profile plates inserted sue technique, or the used of bicondylar plates,

with minimal dissection are preferred. is a major risk factor for later infection.
(b) Single plate—A single plate is sufficient C. Peroneal Neuropathy—Peroneal neuropathy

in cases in which the fracture line is can occur iatrogenically as a result of surgery
transverse. or casting.
(c) Single plate with a contralateral exter- D. Malunions and Nonunions—Malunions and

nal fixator—A single plate with a con- nonunions are relatively rare complications.
tralateral external fixator is used to An increasing number of malunions and non-
neutralize shear forces when oblique unions have been noted in Schatzker Type VI
fracture lines are present. fractures treated by “hybrid” external fixation.
SUGGESTED READINGS Kayali C, Ozturk H, Altay T, et al. Arthroscopically assisted per-

cutaneous osteosynthesis of lateral tibial plateau fractures.
Can J Surg. 2008;51:378–382.
Classic Articles Levy BA, Herrera DA, Macdonald P, et al. The medial approach
Burri C, Bartzke G, Coldeway J, et al. Fractures of the tibial for arthroscopic-assisted fixation of lateral tibial plateau
plateau. Clin Orthop Relat Res. 1979;138:84–93. fractures: patient selection and mid- to long-term results.
Marsh JL, Smith ST, Do TT. External fixation and limited in- J Orthop Trauma. 2008;22:201–205.
ternal-fixation for complex fractures of the tibial plateau. Rossi R, Bonasia DE, Blonna D, et al. Prospective follow-
J Bone Joint Surg Am. 1995;77:661–673. up of a simple arthroscopic-assisted technique for lat-
Rasmussen PS. Tibial condylar fractures: impairment of knee eral tibial plateau fractures: results at 5 years. Knee.
joint instability as an indication of surgical treatment. 2008;15:378–383.
J Bone Joint Surg Am. 1973;55:1331–1350. Stevens DG, Beharry R, McKee MD, et al. The long-term func-
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: tional outcome of operatively treated tibial plateau frac-
the Toronto experience, 1968–1975. Clin Orthop Relat Res. tures. J Orthop Trauma. 2001;15:312–320.
1979;138:94–104. Toro-Arbelaez JB, Gardner MJ, Shindle MK, et al. Open reduc-
Tscherne H, Lobenhoffer P. Tibial plateau fractures— tion and internal fixation of intraarticular tibial plateau non-
management and expected results. Clin Orthop Relat Res. unions. Injury. 2007;38:378–383.
1993;292:87–100. Weigel DP, Marsh JL. High-energy fractures of the tibial pla-
Waddell JP, Johnston DWC, Neidre A. Fractures of the tibial teau. Knee function after longer follow-up. J Bone Joint Surg
plateau—a review of 95 patients and comparison of treat- Am. 2002;84-A:1541–1551.
ment methods. J Trauma. 1981;21:376–381.
Watson JT. High-energy fractures of the tibial plateau. Orthop
Clin North Am. 1994;25:723–752.
Review Articles
Berkson EM, Virkus WW. High-energy tibial plateau fractures.
Recent Articles J Am Acad Orthop Surg. 2006;14:20–31.
Mahadeva D, Costa ML, Gaffey A. Open reduction and internal
Barei DP, Nork SE, Mills WJ, et al. Functional outcomes of se- fixation versus hybrid fixation for bicondylar/severe tibial
vere bicondylar tibial plateau fractures treated with dual in- plateau fractures: a systematic review of the literature. Arch
cisions and medial and lateral plates. J Bone Joint Surg Am. Orthop Trauma Surg. 2008;128:1169–1175.
2006;88:1713–1721. Musahl V, Tarkin I, Kobbe P, et al. New trends and techniques
Canadian Orthopaedic Trauma Society. Open reduction and in- in open reduction and internal fixation of fractures of the
ternal fixation compared with circular fixator application for tibial plateau. J Bone Joint Surg Br. 2009;91:426–433.
bicondylar tibial plateau fractures. Results of a multicenter,
prospective, randomized clinical trial. J Bone Joint Surg Am.
2006;88:2613–2623. Textbooks
Catagni MA, Ottaviani G, Maggioni M. Treatment strategies Browner BD, Levine AM, Jupiter JB, et al, eds. Skeletal Trauma:
for complex fractures of the tibial plateau with external Basic Science, Management, and Reconstruction. Philadel-
circular fixation and limited internal fixation. J Trauma. phia, PA: WB Saunders; 2003.
2007;63:1043–1053. Bucholz RW, Heckman JD, Court-Brown CM, et al, eds. Rock-
Chan YS, Chiu CH, Lo YP, et al. Arthroscopy-assisted surgery wood and Green’s Fractures in Adults. Philadelphia, PA: Lip-
for tibial plateau fractures: 2- to 10-year follow-up results. pincott Williams & Wilkins; 2001.
Arthroscopy. 2008;24:760–768. Rüedi TP, Murphy WM, eds. AO Principles of Fracture Manag-
Katsenis D, Dendrinos G, Kouris A, et al. Combination of fine ment. New York, NY: Thieme Medical Publishers; 2001.
wire fixation and limited internal fixation for high-energy tib- Wagner M, Frigg R, eds. AO Manual of Fracture Management:
ial plateau fractures: functional results at minimum 5-year Internal Fixators. New York, NY: Thieme Medical Publishers;
follow-up. J Orthop Trauma. 2009;23:493–501. 2006.
CHAPTER 11
Tibial Shaft Fractures

Catherine A. Humphrey and John T. Gorczyca
I. Introduction—Tibial shaft fractures are one of the amount of swelling present should serve as
most common diaphyseal fractures treated by a preliminary index of the severity of injury
orthopaedic surgeons. The majority of these frac- to the tissues.
tures heal without complication and most patients • Color—The color of the extremity reveals
return to their preinjury level of functioning. Specific essential information about a limb’s per-
types of tibial shaft fractures are more prone to com- fusion. A pinkish color indicates oxygen-
plication and require the expertise of a well-trained ated blood in the capillaries of the skin but
orthopaedist to avoid complication and optimize reveals little about the deep circulation.
functional outcome. A gray or dusky color, however, indicates
circulatory compromise and a potential for
II. Evaluation limb loss if proper treatment is not pro-
A. History and Physical Examination vided promptly.
1. History—Patients with tibial shaft fractures ex- • Movement—After visually inspecting the
perience pain in the leg after sustaining a low- leg, the physician should observe what the
or high-energy injury. Information about the patient can do with the leg before the phy-
nature and timing of the accident, any reduc- sician palpates or manipulates it. Attention
tion or manipulation performed on the extrem- should be directed at flexion and extension
ity and the patient’s significant medical history of the knee, ankle, and toes. Occasionally,
should be obtained. the patient is too uncomfortable to comply
2. Visual examination—All clothing should be with this part of the examination.
removed from the extremity. The overall ap- 3. Palpation
pearance of the extremity should be noted for • Pulses—An effort should be made to feel for
open wounds, alignment, contusions, swelling, pulses of the popliteal, dorsalis pedis, and
and color. Wounds should be assessed for size, posterior tibial arteries. If strong pulses are
location, degree of contamination, and severity not appreciated, Doppler ultrasound should
of tissue injury. be used to evaluate the dorsalis pedis and
• Deformities—Often a significant deformity is posterior tibial arteries. If triphasic pulses
present at the level of the fracture. Contu- are not present on Doppler ultrasound and
sions may indicate the point where a force the leg is deformed, traction should be ap-
was applied to the leg to create the fracture, plied to the extremity and the pulses re-
or they may be incidental. The location of evaluated. If the pulses remain abnormal,
a significant contusion is important because emergent arteriography and/or consultation
it can necessitate a change in the treatment with a vascular surgeon should be obtained.
plan to avoid incising through badly trauma- • Direct palpation—Occasionally, the injured
tized tissue. leg appears fairly normal, and the results of
• Comparison to the contralateral leg— Com the neurovascular exam are unremarkable.
parison of the injured leg to the contralateral Direct palpation of the fracture, however,
leg usually reveals a large amount of swell- elicits pain and possible crepitation, which
ing. This swelling progresses with time. The are indicative of a tibial shaft fracture.
143
4. Compartment syndrome—After ruling out vas-

cular injury, the physician must evaluate for
compartment syndrome. If the patient can ac-
tively flex and extend the ankle and toes with-
out severe pain, compartment syndrome is not
likely to be present at that time. Compartment
syndrome can, however, evolve with time; thus
serial examination and attention to the pa-
tient’s symptoms are necessary.
• Signs and symptoms—The alert patient com-
monly has a significant amount of pain from FIGURE 11-1 Clinical photograph of a young man
the fracture, and so ruling out compartment involved in a coal mining accident showing severely
syndrome becomes more difficult. Pain out contaminated wounds overlying his tibia fracture.
of proportion to the injury should make Because of the significant tissue destruction this is a
Gustilo type IIIb open tibia fracture.
the physician suspicious. The most sensi-
tive sign on physical examination is pain
delineating subtle fracture extension in very distal
on passive stretch of the muscles in the
and very proximal shaft fractures. Stress fractures
involved compartment. Other significant
of the tibial shaft may not be visible on plain X-
signs are tight compartments, decreased
ray films. In this instance, an MRI scan or a three
sensation, and muscle weakness, although
phase bone scan assists in making the diagnosis.
these signs may not always be present. Ex-
amination of the pulses is misleading since III. Classification
pulses may be palpable when compartment A. Fracture—Several classification systems exist for
syndrome is present. the tibial shaft fracture. The importance of any
• Compartment Pressure—Evaluation of the system is its ability to differentiate fractures into
compartments in the unconscious, intoxi- treatment groups and its ability to predict out-
cated, or otherwise mentally impaired patient come. For the closed tibial shaft fracture, the clas-
is more difficult because the patient has an sification of Johner and Wruhs is straightforward
altered response to pain. If there is any sus- and simple (Fig. 11-2). This classification system
picion of compartment syndrome, then slit- is based on the fracture location, the mechanism
catheter measurement of pressure in all four of injury, and the amount of energy dissipated in
compartments is necessary to confirm or the fracture (i.e., the fracture comminution). The
rule out the diagnosis. The exact pressure at Arbeitsgemeinshaft für Osteosynthesfragen (AO)
which compartment syndrome occurs is vari- or Orthopaedic Trauma Association (OTA) clas-
able. In general, a compartment-diastolic sification is somewhat similar in scope but more
pressure difference of less than 30 mm Hg detailed and complex. This classification is prob-
in any compartment is an indication for ably best used for accurately classifying fractures
emergent four-compartment fasciotomy. for research purposes because it allows for mean-
5. Open fractures—It must be assumed that open ingful evaluation and comparison of fractures in
wounds in the vicinity of a tibial shaft fracture different patients from different studies.
communicate with the fracture, and urgent ir- B. Open Fracture—Open fractures are best de-
rigation and debridement should be planned scribed using Gustilo’s grading system. Type I
(Fig. 111). Open wounds a distance away from open fractures have small (1 cm), clean wounds;
the fracture may communicate with the frac- minimal injury to the musculature; and no signifi-
ture. Probing or inspection of extremity wounds cant stripping of periosteum from bone. Type II
for communication with the fracture should be open fractures have larger (1 cm) wounds but
performed in the operating room after sterile no significant soft-tissue damage, flaps or avul-
preparation and draping of the extremity. sions. Type III open fractures have larger wounds
B. Radiographic Evaluation—Radiographic evalua- and are associated with extensive injury to the
tion of a tibial shaft fracture requires anteroposte- integument, muscle, periosteum, and bone. Gun-
rior and lateral X-ray films. These X-ray films must shot injuries and open fractures caused by a farm
include the entire tibia in addition to the distal injury are special categories of Type III open frac-
femur and ankle, since associated fractures may tures on account of their higher risk of compli-
be present and could alter the treatment plan. cations, particularly infection. Type IIIa injuries
Computed tomography is occasionally helpful in have extensive contamination and/or injury to
C H A P T E R 1 1 | T I B I A L S H A F T F R A C T U R E S 145
Simple Butterfly Comminuted

A1 A2 A3 B1 B2 B3 C1 C2 C3
Fracture pattern Spiral Oblique Transverse Butterfly Butterfly Butterfly Comminuted Segmental Crush
by torsion (one) (several) by torsion fracture
by bending by bending
Typical cause Slipping, Vehicle Soccer, Slipping, Car bumper, High Car bumper, Industry,
skiing crash motorcycle skiing motorcycle Speed motorcycle MVA,
skiing War
Torsion Uneven Pure Torsion + Bending + compression High 4-point Crush

Mechanism
bending bending bending Low High Speed bending
speed speed torsion
Fracture by torsion (A1, B1, C1): One spiral fracture line, the others ± longitudinal fibular fracture are usually at a different level
Fracture by bending (A2, A3, B2, B3, C2): Transverse on tension side (i.e., opposite fulcrum). Fibular fracture is usually at the same level
Fracture by crushing (C3)

FIGURE 11-2 Johner and Wruh’s classification system for tibial shaft fractures.
the underlying soft tissue, but adequate viable soft-tissue injury. Grade 0 injuries have negligible
soft tissue is present to cover the bone and neu- soft tissue injury. Grade 1 closed fractures have
rovascular structures without a muscle transfer. superficial abrasions or contusions of the soft tis-
Type IIIb injuries have such an extensive injury sues overlying the fracture. Grade 2 closed frac-
to the soft tissues that a rotational or free muscle tures have significant contusion to the muscle
transfer is necessary to achieve coverage of the and/or deep contaminated skin abrasions. The
bone and neurovascular structures. These inju- bony injury is usually severe in these injuries.
ries usually have massive contamination. Type Grade 3 closed fractures have a severe injury to
IIIc injuries are any open fractures with an as- the soft tissues, with significant degloving, crush-
sociated vascular injury that requires an arte- ing, compartment syndrome, or vascular injury.
rial repair. Often, what appears to be a Type I or The influence of the soft-tissue injury on treat-
Type II open fracture on initial examination in the ment is discussed later.
emergency room is noted to have significant peri-
osteal stripping and muscle injury at the time of IV. Associated Injuries
operative debridement and may require muscle A. Fractures—Most tibial shaft fractures result from
transfer for coverage with serial debridements. low-energy trauma and do not have associated
Thus there is a tendency for the Gustilo classifi- injuries. As the severity of the tibial fracture
cation type to increase with time. increases, the incidence of associated injuries
C. Soft-Tissue Injury—Tscherne has classified clo- increases to greater than 50%. Injuries to the
sed fractures according to the severity of the ipsilateral extremity, including knee ligament
disruption, femur fracture, and ankle fracture, to detect and treat these injuries as expediently
are among the most common associated injuries. as possible.
Thus physical examination should be directed at
ruling out these injuries before and after treat- V. Treatment and Treatment Rationale (Table 11-1)
ment of the tibial shaft fracture. A. Nonoperative Treatment—Closed treatment of
1. Ipsilateral fibula—Fracture of the ipsilateral most tibial shaft fractures produces good-to-
fibula occurs with most tibial shaft frac- excellent results. Because it is inexpensive and
tures. This fracture can occasionally signify fairly quick to perform, and because it carries lit-
a significant injury to the ankle or proxi- tle risk of complication, closed treatment should
mal tibiofibular articulation, so the impor- be the treatment considered first for most stable
tance of a fibula fracture should not be tibial shaft fractures.
underestimated. 1. Reduction—The technique of closed treat-
B. Neurovascular Injuries—Injury to the neu- ment begins with the administration of seda-
rovascular structures is also common; thus tion or anesthesia to perform closed reduction
thorough serial examination of the circulation, of the fracture, if necessary. Reduction is
sensation and motor function is necessary achieved by hanging the leg over the stretcher
to detect these injuries early and to provide and applying longitudinal traction. Manipula-
proper treatment. tion of the fracture may be required to achieve
C. Other Injuries—Associated injuries to the head, proper alignment. X-ray films should be ob-
chest, and abdomen occur most commonly in pa- tained after manipulation to ensure accept-
tients with severe tibial fractures sustained from able reduction.
high-energy trauma. These patients require a 2. Immobilization—The fracture should ini-
thorough, systematic evaluation according to the tially be placed in a well-padded long leg
advanced trauma life support (ATLS) guidelines splint. Circumferential casting will not
TA B L E 1 1 - 1
Treatment Options for Tibial Shaft Fractures
Treatment Method Advantages Disadvantages Best Uses
Casting Noninvasive nature Difficulty in maintaining Minimally displaced closed
Inexpensive procedure alignment fractures
Compromise in mobility Sedentary patients
Standard external Minimally invasive nature Pin loosening with time Severely contaminated open
fixation Quick procedure Difficulty in maintaining fractures
alignment Life- or limb threatening condi-
Avoidance of traumatized
tions requiring rapid skel-
tissue Patient dissatisfaction
etal stabilization
Ring external fixation Minimally invasive nature Technically challenging Complex high energy closed
Wires that are less likely to procedure fractures
loosen Patient dissatisfaction Tibial shaft fractures extending
Ability to stabilize fractures High incidence of pin tract into or near a joint
in proximity to joints infection
Open reduction with Achievement of stable Incision in area of trauma Tibial shaft fractures extending
internal fixation fixation Strength of fixation not as to the metaphysis
Early joint motion good as with intramed-
ullary nailing
Intramedullary nailing Ease of alignment Limited fixation strength Displaced tibial shaft fractures
Strength of fixation with metaphyseal (open or closed)
Avoidance of traumatized fractures
tissue
accommodate swelling and can lead to 4. Assessment of healing—The patient in a pa-

increasing pain and parasthesias subse- tella-tendon bearing cast should have radio-
quent to reduction. If a cast is applied, it graphic evaluation of the fracture every 6 or
must be bivalved to allow for soft-tissue 8 weeks. When the healing appears complete
swelling. The long leg splint or cast can be on X-ray films and the patient has clinical evi-
changed to a patella-tendon bearing (PTB) dence of healing (i.e., no motion or pain with
cast when soft callus has formed at the force applied across the fracture), then the
fracture site, at which time the fracture site cast is no longer required. This may be as early
will not have tenderness when pressure is as 8 weeks after the injury but most commonly
applied. This may take as little as 8 to 10 occurs 12 to 16 weeks after the injury. At this
days or, with some fractures, as long as 3 to point, a rehabilitation program, including gait
4 weeks. X-ray studies in the PTB cast are es- training, ankle rehabilitation, and strengthen-
sential to confirm proper alignment. At this ing of the quadriceps and gastrocsoleus mus-
point, the patient may begin to bear weight cles, quickens the return to normal function.
on the extremity. B. Operative Treatment
3. Alignment—There is considerable controversy 1. Indications
regarding how much malalignment of a tibia • Absolute—There are several absolute indi-
fracture can be tolerated. Certainly, anatomic cations for operative stabilization of tibial
alignment with no angulation on the antero- shaft fractures. Open fractures should
posterior and lateral X-ray films is the goal, have stabilization of the fracture to provide
but this is not always achieved. Angulation in a stable environment for soft-tissue healing
the sagittal plane is tolerated better than an- and to facilitate wound care. Fractures with
gulation in the coronal plane. This increased a vascular injury require skeletal stabiliza-
tolerance is due to the fact that the knee and tion to protect the vascular repair. Fractures
ankle move in the sagittal plane, so this mo- with compartment syndrome should have
tion “makes up for” some angulation. Coronal skeletal stabilization to provide a stable
plane angulation, however, results in varus or environment for the injured tissues. Stabi-
valgus malalignment, which produces asym- lization of the tibia should be performed in
metric loading of the ankle and knee joints. tibial shaft fractures in patients with mul-
• Angulation—It is not clear how much angu- tiple injuries to improve patient mobility,
lation is required to produce osteoarthritis, minimize pain, and possibly reduce the re-
since multiple factors influence the progres- lease of pro-inflammatory mediators.
sion of osteoarthritis, including the location • Relative—Relative indications for operative
of the fracture and the age of the patient. In stabilization include significant shortening
general, angulation of more than 10° in of the fracture on initial X-ray studies, sig-
the sagittal plane and more than 5° in nificant comminution, a tibia fracture with
the coronal plane are significant enough an intact fibula (Fig. 11-3), and a displaced
to warrant remanipulation of the frac- tibia fracture with a fibula fracture at the
ture or wedging of the cast. On the other same level. In each of these fractures, there
hand, some surgeons argue that a tibia is a high incidence of malunion or nonunion
fracture that heals with as much as 20° with nonoperative treatment.
angulation can be tolerated by most 2. External fixation
patients. (The authors do not agree with • Standard—External fixation of a tibial shaft
these surgeons.) fracture is a quick and technically easy way
• Shortening—Shortening of 1 cm or less is to achieve fracture stability. For this reason,
rarely symptomatic, and shortening of 2 or it is useful in a patient with multiple injuries
3 cm can be made tolerable with a 1.25 cm who is hemodynamically unstable (“damage
(0.5 in) shoe insert. control”) or in a patient who would ben-
• Rotational malalignment—The amount of efit from quick fracture stabilization before
rotational malalignment that can be toler- emergent repair of an arterial injury. It also
ated varies from patient to patient. In gen- can be used if an open fracture wound is
eral, if the rotational malalignment affects severely contaminated and the surgeon has
gait or causes knee or ankle symptoms, op- reservations about putting hardware in the
erative correction should be considered. wound. An external fixator can be applied
so these fixators are useful for treating frac-

tures that are likely to heal slowly.
3. Open reduction with internal fixation (ORIF)—
ORIF is an excellent means by which to achieve
stable fixation of a tibial shaft fracture and al-
low early postoperative motion. Successful
healing is usually the rule. The chief risk of
the procedure is wound-healing problems. In
fractures with significant injury to the soft tis-
sues of the leg, the use of a plate and screws
may not be appropriate because the risk of
wound-healing problems with this treatment
may be too high. Severely traumatized legs
with open tibial fractures (Gustilo type III)
have a high incidence of wound-healing
complications and deep infection when
treated with ORIF.
• Fracture fragments—When ORIF of a tibial
fracture is performed, the surgeon must
respect the biology and physiology of all
of the tissues. It is unnecessary and un-
wise to attempt to reduce and stabilize
every fracture fragment, since attempts
to do this often require extensive dissec-
tion and periosteal stripping. The result
FIGURE 11-3 Anteroposterior X-ray film of a
will be an attractive postoperative X-ray
leg demonstrating a segmental tibia fracture
with an intact fibula, a very unstable fracture. film of a tibia that lacks the ability to heal.
It is preferable to obtain proper alignment
through small incisions, thus avoiding addi- and secure fixation of the proximal and dis-
tional trauma to tissues that may lack the tal tibia. The intervening bone fragments
ability to heal. should be gently reduced with a dental
• Ring fixators—Ring fixators, including Ilizarov pick, leaving their soft-tissue attachments
and hybrid fixators (which use half-pins on alone so that they maintain their capacity
one side of the fracture and rings with wires to heal.
on the other side), offer the same advan- • Postoperative treatment—After ORIF of a
tages of traditional external fixators. These tibial fracture, the incision should be closed
fixators obtain fixation with wires passed over a suction drain and the leg splinted in
through bone. The wires are then placed on neutral position to protect the soft tissues
tension and attached to a ring. The ring is in the early healing phase. In 3 to 5 days,
then attached to the external fixation frame, active motion of the knee and ankle should
which may consist of a single bar or multiple, be initiated. Weightbearing should be pro-
smaller threaded rods. The bars are secured hibited until in the judgment of the sur-
to half-pins inserted into the bone. The advan- geon, sufficient healing has occurred and
tage of wires and rings is that they provide a the bone-plate construct can tolerate this.
relatively noninvasive means of fracture fixa- Often, a tibial fracture that has been treated
tion, and obtain good fixation strength, par- with ORIF heals with minimal fracture callus
ticularly with metaphyseal proximal or distal (primary cortical healing). In these patients,
tibia fractures. Ring fixators require more ex- a useful radiographic sign of fracture heal-
pertise than traditional external fixators do, ing is “fading” or “blurring” of the fracture
but can be used to fix fractures that are more lines as new bone grows across the fracture
complex and fractures with intraarticular ex- line (Fig. 11-5) Weightbearing should begin
tension without spanning the associated joint with a protective orthosis, from which the
(Fig. 11-4). Furthermore, the wires of these patient can be weaned as healing nears
fixators do not loosen as quickly as the half- completion and the patient becomes more
pins used with traditional external fixators, comfortable.
FIGURE 11-4 A. Anteroposterior X-ray film of a multifragmentary tibial shaft fracture caused by

a gunshot wound. B. Postoperative X-ray film demonstrating excellent alignment achieved with an
Ilizarov external fixator. C. Clinical photograph demonstrating minimal dissection of the skin in the
fracture region.
• Minimally Invasive Plate Osteosynthesis maintains proper length and rotation of

(MIPO)—Techniques and devices have been even an unstable, comminuted fracture un-
developed that allow plate and screw fixa- til healing has occurred.
tion of tibial shaft fractures through small • Disadvantages—The main concern with in-
incisions and with limited dissection. This tramedullary nailing is that placement of
technique has the advantage of minimizing the nail in the intramedullary canal disrupts
disruption of the peripheral blood supply to the endosteal circulation to the cortical
the bone, and potentially decreases wound bone. Certainly, this occurs, but its effect is
healing problems. However, acceptable frac- short-lived (2 to 3 weeks), and it is probably
ture reduction and stable fixation must be not clinically significant.
achieved if this technique is to be successful. • Reaming
4. Intramedullary nailing (a) Advantages—Intramedullary reaming
• Advantages—Intramedullary nailing has can be performed to enlarge the intra-
emerged as the most popular method for medullary canal and allow placement
stabilizing displaced tibial shaft fractures. of a nail with a larger diameter. This
The advantages of intramedullary nailing are achieves stronger fixation and may al-
that proper alignment of the fracture is not low placement of interlocking screws
difficult to achieve and the intramedullary with a larger diameter. This can be a
location of the nail makes it more resistant very important step, since the inter-
to fixation failure (Fig. 11-6). Intramedullary locking screws of small diameter nails
nails are inserted through incisions near the are the weak link in the fixation. Ream-
knee, so badly traumatized tissues in the ing before intramedullary nailing of
mid-leg can be avoided. Placement of inter- closed tibia fractures reduces the rate
locking screws can be performed percuta- of nonunion.
neously through small incisions. The use (b) Disadvantages—Reaming of the tibial ca-
of proximal and distal interlocking screws nal has raised concerns for two reasons.
FIGURE 11-5 Anteroposterior X-ray film (A) demonstrating a tibial shaft fracture with extension into the
weightbearing articular surface of the distal tibia. CT scan (B) demonstrating depression of the articular surface of
the distal tibia. X-ray film (C) demonstrating good alignment of the tibia after ORIF. Anteroposterior (D) and lateral
(E) X-ray films at 2 months show fading of the fracture lines, indicative of the healing process. Anteroposterior X-ray
film (F) at 6 months shows complete healing of the tibial fracture in good alignment.
• Disruption of endosteal circulation—Ream- the circulation of the bone. There is animal

ing of the canal disrupts the endosteal circu- study evidence that reamed intramedullary
lation to a greater extent than passage of a nailing causes more harm (50% to 80% cen-
smaller nail without reaming. Thus injuries tral cortical necrosis) to the bony circula-
that have already caused significant trauma tion than unreamed intramedullary nailing
to the periosteal (extramedullary) circula- (30% to 50% central cortical necrosis).
tion such as the type IIIb open tibial frac- A practical compromise between strength
ture are at risk for suffering more damage to of fixation and preservation of the osseous
FIGURE 11-6 A. Anteriorposterior X-ray film demonstrating a displaced distal tibial shaft

fracture. B. Postoperative X-ray film demonstrating good alignment after intramedullary
nailing. The stability of the fixation is limited in this example because the intramedullary
nail is much smaller than the distal intramedullary canal. This leg should be protected from
weightbearing until significant healing has occurred.
circulation is “limited” reaming, whereby patients with limb threatening leg injuries.
the reaming is performed to allow place- The findings of the LEAP study are summa-
ment of a slightly larger-diameter nail and rized in Table 11-2. The 2- and 7-year out-
is discontinued when interference from the comes for patients treated with either limb
hard cortical bone (“chatter”) occurs. reconstruction or amputation are similar.
• Compartment syndrome—There has been Significant disability occurs in most patients,
concern that when reaming is performed whether they have been treated by limb sal-
within 2 or 3 days of injury, it increases vage or by amputation. The LEAP study does
the risk of compartment syndrome. There not provide support for the concept that early
are several cases in which this has been primary amputation of a mangled extremity
reported, but is not clear whether the results in an improvement in patient function.
compartment syndrome resulted from Unless a patient is hemodynamically unstable
prolonged intraoperative traction or from secondary to his leg injury and amputation is
intramedullary reaming (if it is the result a life-saving measure, immediate amputation
of either of these). The reported associa- should be avoided and a definitive treatment
tion, however, underlies the importance of plan should be formulated only after thorough
postoperative examination of the extrem- discussion with the patient and his family.
ity to detect and treat this complication as 6. Flap coverage—Flap coverage becomes neces-
quickly as possible. sary if there is inadequate soft tissue to cover
5. Amputation—Amputation is a consideration the bone, tendons, nerves, vessels, and ortho-
for a severe tibia fracture with associated neu- paedic hardware. The type of flap used depends
rologic, vascular and soft-tissue compromise. on the location of the injury. Soft-tissue defects
The LEAP study is a large-scale multi-centered in the proximal third of the leg can be cov-
prospective cohort study that compared func- ered with a medial gastrocnemius muscle
tion and psychological outcomes for those flap. Defects of the middle third of the leg
TA B L E 1 1 - 2
Findings of LEAP Study
When compared to population norms, patients who present to Level I trauma centers with mangled lower
extremities are more extroverted, less agreeable, more likely to drink alcohol, more likely to smoke cigarettes
and more likely to be blue collar, uninsured, neurotic and poor.
No injury severity scoring system provides valid predictive data for when to amputate.
The absence of plantar foot sensation on presentation is not predictive of function of the extremity or presence of
foot sensation at 2 yr follow up.
Patients who sustain a mangled extremity have poor outcomes at 2 yr.
Patients continue to worsen between 2 yr and 7 yr follow up. Factors most associated with poor outcomes include
older age, female gender, nonwhite race, lower level of education, current or previous smoking, living in a poor
household, low self-efficacy, poor health status before the injury and involvement in the legal system for the pur-
pose of obtaining disability.
Patients who underwent below knee amputation including those with free flap coverage functioned better than above
knee amputations. Thru knee amputations had the poorest functional outcomes and required the highest energy
expenditure to ambulate.
Patients treated with limb salvage have results comparable to patients treated with amputation.
can be covered with a soleus muscle flap. 1. Gustilo type I and II open fractures—Gustilo
Defects of the distal third of the leg require type I and II open tibial shaft fractures require
a free vascularized muscle flap. A free vascu- the same prophylaxis as closed tibial frac-
larized flap may also be necessary for proximal tures treated surgically but the administration
or middle-third defects if the soleus or gastroc- of antibiotics begins as soon as possible in the
nemius muscles are injured and inappropriate emergency room.
for transfer. Alternatively, distally based sural 2. Gustilo type III open fractures—Type III open
island pedicle flaps can be tunneled subcutane- fractures require intravenous administration
ously to provide full-thickness coverage of small of a first-generation cephalosporin aimed at
or medium sized tissue defects of the distal leg Gram-positive cocci, and an aminoglycoside
without necessitating suture anastomosis of or fluoroquinolone aimed at Gram-negative
the vessel or significant donor site morbidity. rods, beginning as soon as possible. Duration
Flap coverage should not be performed at of postdebridement antibiotic prophylaxis is
the first debridement but in general should undergoing increased scrutiny, and recom-
be performed within 1 week of injury. mendations range from 24 to 72 hours after
7. Negative Pressure Wound Therapy (NPWT)— debridement. The pre- and postoperative an-
Use of the VAC® or another negative pressure tibiotics are administered each time the pa-
device to temporarily cover traumatic wounds tient undergoes operative debridement of the
allows controlled use of sub-atmospheric wound.
pressure (typically 125 mm Hg below ambient 3. Contaminated or dirty fractures—If the open
pressure) to a large surface of the wound, refracture occurs on a farm or if it is contami-
sulting in removal of hematoma and exudate, nated with dirt, intravenous penicillin should
reduction of edema, and perhaps early granu- be added for prophylaxis against anaerobes.
lation. In other parts of the body, NPWT has A patient who has sustained an open frac-
been associated with earlier wound closure, ture in a swamp or another large body of
decreased infection, and fewer free flaps to water should be treated with a third genera-
cover wounds. tion cephalosporin to minimize the risk of
C. Antibiotics—Surgical treatment of closed tibial Aeromonas infection.
shaft fractures warrants antibiotic prophylaxis 4. Antibiotic-impregnated polymethylmethacra-
consisting of a first-generation cephalosporin ad- late (PMMA) beads—Some surgeons have
ministered intravenously before surgery and for reported excellent experience with antibiotic-
24 to 48 hours after surgery. impregnated PMMA beads, which are placed
in the traumatic wound after initial debride- the distance between pins in each fragment of
ment and removed at the final debridement. bone, and increasing the number of half-pins.
This allows one to achieve a higher level of • Lag screws—Lag screws should not be used
antibiotic (tobramycin or vancomycin) in to supplement the external fixator because
the injured region than one could safely tol- this will increase the risk of nonunion and
erate systemically (with intravenous antibi- refracture, probably as a result of the devi-
otics) and may lower the infection rate after talization of bone performed in the process
open fracture. Antibioticsimpregnated PMMA of reduction and screw fixation.
beads should not be used alone in treating 3. Hybrid fixation—The use of a ring fixator al-
open fractures, since intravenous prophylaxis lows the placement of pins and wires in the
is still the gold standard. metaphyseal bone of the tibial plateau and
D. Biologics—Research into the role of biologics to plafond. Precise knowledge of the local cross-
augment healing of tibia fractures has exploded sectional anatomy is necessary to prevent in-
over the last several years. Both osteoconduc- jury to the neurovascular structures.
tive and osteoinductive agents are available to 4. Healing—Assessment of fracture healing in
fill segmental defects. BMP-7 has been reported a patient treated in an external fixator is of-
to be equivalent to autogenous bone grafting ten very difficult. One clinical sign of fracture
in the treatment of tibial nonunions. How- healing is painless weightbearing on the af-
ever, no product on the market has been shown fected extremity, but this sign can be mislead-
to be superior to autogenous bone grafting. In a ing. When in doubt, it is safest to “dynamize”
largescale clinical trial, BMP2 was applied at the the external fixator, which will result in higher
time of wound closure to open tibia fractures. It axial load with weightbearing, and thus may
proved to decrease re-operation rates when used stimulate further healing. Alternatively, the
with unreamed tibial nails. In another study that fixator can be removed and the patient pro-
combined data from new patients with patients hibited from bearing weight until further heal-
from a previous study, there was no demon- ing has occurred.
strated benefit when applied in conjunction with B. ORIF
reamed nailing. 1. Timing—When ORIF is considered as a treat-
ment option, careful assessment of the soft
VI. Anatomic Considerations and Surgical Techniques tissues is necessary to avoid incising through
A. External Fixation badly traumatized skin. Swelling of the leg in-
1. Standard—Placement of external fixator half- creases for 2 or 3 days after the injury, so sur-
pins should be performed perpendicular to gical timing is also critical. If ORIF cannot be
the anteromedial surface of the tibia (i.e., at performed within 6 to 8 hours after injury, it
45° to the sagittal plane) to obtain bicortical is best to wait until the swelling has subsided.
purchase and to avoid “burning” of the dense Occasionally, one must wait 7 to 10 days, until
cortical tibial bone with the drill bit. The skin the swelling and inflammation have subsided.
should be incised, and the subcutaneous tis- 2. Approach—The incision should be longitu-
sues should be spread with a small clamp to dinal and approximately 1 cm lateral to the
avoid injury to the superficial structures, par- spine of the tibia. In the event of significant
ticularly the greater saphenous vein, which swelling during surgery, this incision allows
can be injured with placement of pins in the tension-free approximation of the medial der-
distal tibia. Predrilling the tract is strongly mis to the tibialis anterior muscle, thereby
recommended before insertion of the external providing coverage of the plate, neurovascu-
fixator pin. lar structures, and bone.
2. Stability—The stability of fixation achieved • Plate placement—If the surgeon chooses
with an external fixator can be increased by al- to place the plate on the lateral side of
lowing the fracture ends to contact (the most the tibia, the anterior compartment fas-
important factor), increasing the diameter of cia should also be incised 1 cm lateral to
the half-pins (the next most important factor, the spine and the tibialis anterior muscle
since stiffness is proportional to the fourth should be bluntly freed from the lateral
power of diameter), decreasing the distance tibial surface. The plate can also be placed
between the bar and the bone (the stiffness of on the anteromedial surface of the tibia,
each pin is inversely proportional to the third but medial plates cause more symptoms
power of the bone-to-bar distance), increasing after the fracture has healed and require
elevation of the thin subcutaneous tissue proximally and distally, leaving the inter-
layer from the tibia, which carries a risk of vening fragments free and “loose” but with
wound complications. the best capacity to heal.
• Extension of the incision—The incision can • Locked plating—Fixed angle plates should
be extended proximally, continuing just lat- be used judiciously in the tibial diaphysis.
eral to the tibial tuberosity, and even far- Osteoporotic fractures benefit from the
ther proximally as the lateral approach to additional fixation strength afforded by the
the femur. For distal extension, the incision plate with locking screws, which function as
crosses the anteromedial ankle and con- a fixed angle device. Fractures with a zone
tinues to curve posteromedially along the of segmental comminution are effectively
medial malleolus, allowing exposure of the stabilized using a locked plate applied in a
tibial plafond and medial malleolus. The ex- bridge fashion.
tensor tendons will be visualized, but the C. Intramedullary Nailing
tenosynovium should not be violated and 1. Approach—Intramedullary nailing can be
should be repaired with suture if they are performed with the nail placed medial or
injured. Otherwise, in the event of a wound lateral to the patella tendon, or through a
breakdown, the tendons will be exposed to patella tendon splitting incision. Placement
the environment and will be less resistant of the nail with the patella tendon-splitting
to bacterial contamination and infection. approach is straightforward and fairly easy,
3. Technical details but one should avoid this temptation, since
• Contouring—Proper contouring of the plate it could contribute to patella tendon symp-
is essential to achieve proper alignment of a toms. Whichever position for nail placement
tibial shaft fracture. The majority of the lat- is chosen, the approach is through a midline
eral surface is straight, but its distal surface or parapatellar incision. As the incision is ex-
rotates anteriorly. Thus the plate may require tended through the subcutaneous tissue, the
a twist distally to match the tibial surface margin of the patella tendon should be noted
and to avoid the distal tibiofibular articula- and the retinaculum incised next to this. An
tion. The medial surface is flared proximally awl or a guide wire is then inserted in the
and distally; if this is not taken into consider- center of the proximal tibia at the “corner”
ation with proper plate contouring, the tibia where the anterior border of the tibia meets
will be stabilized in valgus malalignment. the plateau. Anteroposterior and lateral ra-
• Largefragment screws and plates—ORIF of diographic (fluoroscopic) confirmation of
tibial shaft fractures should be performed correct positioning and aim is helpful before
using large-fragment (4.5-mm cortical and proceeding. Next, the awl, a drill, or a can-
6.5 mm cancellous) screws and plates. The nulated cutting tool is used to create a hole
narrow plates have sufficient strength for in the proximal tibia. This is performed most
the tibia. At least six cortices of screw pur- easily if the knee is flexed 90° or more, which
chase are necessary on each side of the frac- can be achieved with a bolster, with a metal-
ture to achieve stable fixation and permit lic triangle designed for this purpose, or with
early postoperative knee and ankle motion. a fracture table.
• Lag screws—Lagscrew placement to 2. Reaming—If reaming is to be performed, a
achieve interfragmental compression is ball-tipped guide wire must be advanced
useful with simple fractures if it can be across the fracture before reaming. Passage of
performed without significant elevation of the guide wire is easiest if the fracture can be
the periosteum from the bone. Multifrag- reduced to anatomic alignment. If anatomic
mentary fractures, however, should not be reduction of the fracture is difficult to achieve
treated with lag screws because the addi- by closed methods, then placement of a curve
tional trauma to the osseous circulation far near the tip of the wire will make wire passage
outweighs the benefit of the additional fixa- easier. The wire should be advanced to the
tion. Multifragmentary tibial shaft fractures center of the distal tibial metaphysis, as con-
treated with ORIF should be reduced with firmed by fluoroscopy. A tourniquet should
traction and the comminuted pieces then not be used during the reaming process be-
gently reduced with a dental pick, taking cause this may allow the reamer to burn
care to preserve all soft-tissue attachments the bone. Reaming is performed with succes-
to the bone. The plate is then secured sively larger reamers until the interference of
the cortical bone occurs, which is evident by At this point, the surgeon should detach the
a “chattering” sound. Reaming beyond this drill from the drill bit and confirm proper di-
point is seldom necessary and may result in rection of the drill bit using fluoroscopy. The
thermal necrosis of the bone. The tibial nail drill bit is then advanced through the nail and
diameter should be 1.5 to 2 mm smaller than through the far cortex. The drill is removed
the diameter of the last reamer. The length and a depth gauge inserted through the holes
of the tibial nail is best determined before to determine screw length. Fluoroscopic con-
surgery by using fluoroscopy and a radi- firmation that the depth gauge actually passes
opaque ruler on the contralateral extremity. through the nail should be obtained before
Alternatively, one may measure the length of screw placement. Next, the appropriate-sized
the guide wire that protrudes from the intra- screw is advanced across the bone, and the
medullary canal and subtract this figure from proper position is again confirmed before a
the length of the guide wire to determine nail second screw is placed in the same manner.
length. The latter technique, however, can be 5. Proximal and distal fractures—Juxta-articular
misleading if the fracture has many fragments fractures present a technical challenge. Frac-
and is shortened. tures of the proximal tibial shaft are notori-
3. Unreamed nailing—The surgeon may choose ous for resisting proper reduction. Typically,
to insert the intramedullary nail without ream- the fracture has apex-anterior angulation
ing. If a cannulated nail is available, a smooth with a large anterior step (translation) at
guide wire is passed across the fracture and the anterior cortex. Valgus malalignment is
into the center of the distal tibial metaphysis also common. Multiple techniques exist to
and the nail is advanced over the wire. Main- attempt to address this deformity. A more
taining manual reduction of the fracture will lateral entry point (i.e., lateral parapatel-
facilitate advancement of the nail into the lar) can be used in order to prevent valgus
distal fragment. Solid (noncannulated) nails positioning of the reamers. The leg may be
require vigilant surveillance as the nail is ad- maintained in a semi-extended position over
vanced into the distal tibia to ensure that it the course of reaming to maintain an anterior
passes in the center of the bone. Otherwise trajectory for the nail. Metadiaphyseal tibial
a “nail tunnel” is created in the incorrect po- shaft fractures that have been treated by in-
sition, complicating subsequent attempts at tramedullary nailing often have marginal fixa-
nail passage and decreasing the stability of tion strength, since the nail itself offers little
fixation. resistance to motion from the large, cancel-
4. Interlocking screws—Placement of proximal lous proximal tibial canal. Some authors have
interlocking screws is best achieved using reported excellent alignment of these frac-
the drill guides attached to the nail assem- tures after using a small fragment plate and
bly. Distal interlocking screws can be placed screws to obtain provisional reduction and
using a variety of methods. The “free-hand” stabilization of the fracture and then placing
technique is very versatile but requires a the intramedullary nail.
sharp drill bit and a steady hand. The first If a proximal tibia shaft fracture has
step is to adjust the position of the leg and been nailed and the reduction is unaccept-
the beam of the fluoroscope until the beam able, the alignment can be improved by re-
passes through the center of the hole, which moving the proximal drill guide assembly
is confirmed by the presence of “perfect cir- from the nail, and applying an extension and
cle” on the fluoroscope. At the medial aspect varus force to the leg to correct the align-
of the distal tibia, a small, longitudinal inci- ment. The proximal interlocking screws are
sion is made centered at this point. The sub- then placed with the freehand technique.
cutaneous tissues are dissected bluntly with Others have described the use of Poller
a small clamp. If the saphenous vein is cut, or blocking screws to reestablish an intra-
it should be ligated or repaired. Next, the medullary canal that better fits the nail. This
tip of the drill bit is placed on the bone and technique requires thoughtful placement
the position adjusted until it is in the center of of screws to block the nail from following
the circle by fluoroscopy. Without moving the an undesirable trajectory (Fig. 11-7). Addi-
tip of the drill bit from this point, the surgeon tional reduction aids include drilling schantz
then aims the drill in the axis of the fluoro- pins into the metaphyseal fragment to pro-
scope ray and drills through the near cortex. vide percutaneous control of the fragment.
Poller screws
Poller screws
Fulcrum
A B C D
FIGURE 11-7 With the aid of Poller screws malalignments can be prevented or corrected,
while stability is simultaneously increased. A. Example of a distal femoral fracture: Due
to the large discrepancy between medullary canal and nail diameter, the intramedullary
nail may move a few millimeters sideways along the interlocking screws, which results
in varus or valgus deformity. B. Placement of one (distal) or two (distal and proximal)
Poller screws prevents malalignment and increases stability. C. Example of a distal tibial
fracture: Despite the presence of an AP screw, displacement in the coronal plane can occur
in cases of short distal fragments or poor bone stock. The AP screw acts as a fulcrum
in these cases. D. Closed reduction and either unilateral or bilateral support with Poller
screws placed bicortically in the sagittal plane prevents angulation in the coronal plane.
(Redrawn with permission from Rüedi TP, Buckley RE, Moran CG. AO Principles of Fracture
Management. Dübendorf, Switzerland: AO Foundation Publications; 2007.)
If operative assistance is limited, a femoral out. The two-incision technique uses a medial
distractor can be applied to maintain the longitudinal incision 1.5 cm posterior to the pos-
fracture reduction while instrumentation teromedial crest of the tibia and a lateral lon-
proceeds. gitudinal incision 1.5 cm anterior to the fibula.
Proximal tibial shaft fractures that Through the medial incision, the deep poste-
have been treated by intramedullary nailing rior and superficial posterior compartments
often have marginal fixation strength, as the can be incised through their entire length.
nail itself receives little resistance to motion The lateral incision allows release of the an-
from the large, cancellous proximal tibial terior and lateral compartments of the leg.
canal. In these cases, the fracture should be Some surgeons favor performing release of all
protected with a hinged knee brace or knee four leg compartments through a single lateral
immobilizer when the patient is not perform- incision, which is technically more difficult but
ing active knee range-of-motion exercises. preserves the medial skin.
B. Deep Infection—The incidence of deep infection
VII. Complications of the Injury should be less than 1% with closed fractures but
A. Compartment Syndrome—Perhaps the most is higher in open fractures and can be as high as
significant complication of a tibial shaft frac- 25% to 50% with Gustilo type IIIb open tibial frac-
ture is compartment syndrome. As discussed tures. Treatment can be extremely complex and
earlier, it is essential to rule this out early and time consuming but is based on debridement of
to perform serial physical examinations. If com- nonviable bone and tissue, dilution of bacteria
partment syndrome is diagnosed, emergent with successive irrigations and debridements in
four-compartment fasciotomy should be per- the operating room, maintenance of the stabil-
formed and delayed wound closure planned. ity of the bone, and eradication of bacteria with
There are several means by which fasciotomy long-term intravenous antibiotics directed at
of the four leg compartments can be carried the causative organisms. Secondary closure
of the wound is necessary to cover the bone, occurred. If the bone, a metallic implant, or a
metallic implants, and neurovascular structures neurovascular structure lacks soft-tissue cover-
with healthy tissue. Rotational flaps or vascular- age in the wound, flap coverage is necessary.
ized pedicle flap grafts are used for coverage if Tendons exposed in the wound may be treated
necessary. Bony reconstructive procedures are with negative pressure wound therapy or dress-
performed when the infection is cleared. ing changes if the tenosynovium is intact and
C. Vascular Injury—Tibial fractures with associ- viable.
ated vascular injuries can result in widespread C. Osteomyelitis—Osteomyelitis is an uncommon
necrosis of the extremity tissue, necessitating but severe complication that can occur from op-
amputation of the extremity if the arterial injury erative stabilization of a tibial fracture. The inci-
is not recognized and treated quickly. dence is approximately 1% with closed fractures
D. Malreduction/Malalignment—Malreduction of but can be as high as 25% to 50 % with type IIIb
a fracture treated nonoperatively can usually open fractures. Treatment requires thorough
be predicted based on the initial X-ray films of debridement of all devitalized soft tissue and
the leg. Tibial fractures with significant dis- bone, maintenance of stability with internal or
placement, shortening, comminution, or an external fixation, soft-tissue coverage, and long-
intact fibula are prone to malunions when term (4- to 8-week) administration of appropri-
treated nonoperatively. Operative manage- ate intravenous antibiotics.
ment of these fractures decreases the risk D. Compartment Syndrome—Compartment syn-
of malunion. Likewise, tibial fractures with drome has been described as a complication
associated fibular fractures at the same level of reamed intramedullary nailing of tibial shaft
are highly unstable. Maintaining anatomic align- fractures. This complication has been reported
ment may be extremely difficult or impossible after prolonged intraoperative traction applied
with these fractures. Thus a thorough assess- to a leg with a fracture table. Compartment
ment of the patient’s needs and the fracture syndrome may also result from the underlying
characteristics is essential to determine how trauma, regardless of the operative intervention
much angulation can be accepted and to deter- performed. In any event, routine postoperative
mine which fractures will benefit from surgical clinical examination is necessary to detect and
stabilization. treat this complication early. Epidural anes-
thesia during surgery may compromise the
VIII. Complications of Treatment patient’s clinical findings postoperatively,
A. Knee Pain—The most common complication thereby making compartment syndrome
of intramedullary nailing of the tibia is an- more difficult, if not impossible, to diag-
terior knee pain. As many as 57% of patients nose by the patient’s symptoms and clinical
complain of some knee discomfort in long term examination.
follow up. Careful assessment of the starting
point and protection of the soft tissues during IX. Nonunions—Like most other complications of tibial
reaming minimizes trauma to the patella tendon shaft fractures, nonunion occurs more frequently as
and fat pad. Always confirm appropriate nail the severity of the fracture increases. Transverse
position with a lateral fluoroscopic view at fractures, open fractures, fractures with more
the knee to ensure that the nail is not pro- than 3 mm of distraction after intramedullary
truding from the bone. nailing, and fractures with less than 50% corti-
B. Wound-Healing Problems—Problems with cal contact after stabilization have higher rates
wound healing can be a devastating conse- of reoperation to achieve union.
quence of a tibial shaft fracture. Thorough as- Consensus has not been reached for the defi-
sessment of the condition of the skin and soft nition of nonunion, but a practical definition is a
tissues before making any incision is necessary tibial fracture that in the judgment of the treating
to minimize the occurrence of this complica- Orthopaedic Surgeon has not healed and lacks the
tion. If there is any concern about the healing ability to heal without specific intervention. There
capacity of the tissues due to significant contu- are several common scenarios in which nonunion
sion, fracture blisters, or decreased capillary occurs, and it is important to identify the scenario
perfusion, an incision should not be made and so that correct treatment can be delivered.
stabilization, if necessary, should be performed A. Infected Nonunion—Before performing surgery
using external fixation. Wound-healing prob- for any tibial nonunion, the treating orthopae-
lems are treated locally with soft-tissue debride- dist must consider and rule out infection. The
ment and dressing changes until healing has preoperative studies should include a white
blood cell count, erythrocyte sedimentation Nonunion presenting as plate breakage is

rate and C reactive protein. When these labora- the most common serious complication of
tory indices are evaluated in combination, they this procedure.
have the highest sensitivity in detecting bone E. Nonunion after Intramedullary Nailing—Non-
infections. The practical importance is that a unions of tibial shaft fractures that were initially
formal irrigation and debridement must be per- treated with intramedullary nailing can be man-
formed if infection is present. Bone graft and aged in a number of ways. Removing proximal
bone graft substitute should not be implanted or distal interlocking screws to “dynamize” a
until the infection is treated. nail (increase the transmission of force across
B. Inadequate Stability—If gross motion is pres- a fracture) is frequently used. This is a low-risk
ent, bone will have difficulty in bridging across procedure, but the scientific evidence showing
a fracture. This scenario most often presents a benefit to this procedure does not exist. When
as a hypertrophic nonunion, with bone forming a hypertrophic nonunion is present, the optimal
on each side of the fracture but not uniting the treatment is “exchange nailing,” in which the
fracture. These fractures require mechanical nail is removed, the tibia is reamed, and a larger
stability to heal. Of course, infection must be and stiffer intramedullary nail is placed. The
ruled out, and the surgery that is undertaken to fracture benefits from the improved stability of
provide stability should not devitalize the bone. the larger nail and perhaps from the bone graft
Most hypertrophic nonunions do not require created and the “stimulation” to healing created
bone grafting to heal, but if a large bony defect by the reaming.
is present, bone grafting should be considered
X. Deformities
in order to decrease the healing time.
A. Malunion—Malunion refers to a fracture that
C. Poor Capacity to Heal—An atrophic nonunion is
has healed in an unacceptable position. A tibial
a fracture nonunion in which the bone ends pro-
malunion can have an unacceptable position in
duce minimal, if any, bone. This may result from
the coronal plane (varus/valgus), the sagittal
significant devitalization of tissue as a result of
plane (recurvatum, procurvatum), axial length
the injury (e.g., highly comminuted fractures),
(shortening/distraction), axial rotation (internal/
poor perfusion of the tissues (e.g., peripheral
external rotation), or any combination of these.
vascular disease), or poor patient health. These
The patient’s tolerance for deformity varies, de-
nonunions require bone grafting to supplement
pending on activity level, associated deformities,
the patient’s deficient fracture healing capacity
ability to compensate, and individual expecta-
and require a stable environment as well. It may
tions. A symptomatic malunion is one that affects
be recognized early in the treatment of a frac-
a patient’s walking ability or that causes pain in
ture that it has a poor capacity to heal. Early
an associated joint. Coronal plane, sagittal plane,
prophylactic bone grafting of these “impending
axial rotation, and axial lengthening malunion
nonunions,” when performed judiciously, de-
can be corrected with an osteotomy and stabili-
creases the healing time of complex fractures.
zation using internal fixation, intramedullary nail-
Most surgeons wait until 6 weeks after the
ing, or external fixation (Fig. 11-8). Symptomatic
injury before performing prophylactic bone
axial shortening can be corrected with an oste-
grafting of high-energy open tibial shaft
otomy and distraction using an external fixator.
fractures.
Predictably better healing can be achieved with
D. Nonunion after External Fixation—Nonunions
an osteotomy and shortening of the contralateral
of tibial shaft fractures that have been treated
extremity, but this may be unacceptable to some
with external fixators represent an interesting
patients.
dilemma. The strongest means of fixation for
these fractures is intramedullary nailing, but XI. Special Considerations
this has been associated with an unacceptably A. Periprosthetic Fractures—Closed treatment or
high infection rate, particularly when the exter- ORIF is the most viable treatment option for tibial
nal fixator has been in place for more than 2 shaft fractures distal to a total knee arthroplasty.
weeks and when the external fixation has been Treatment depends on the needs of the patient
complicated by a pin tract infection. A better and the requirements of the fracture. External
alternative is ORIF (plate and screw fixation) fixation, in general, should be avoided because it
with bone grafting when necessary, which has has a fairly high risk of pin tract infection, which
been associated with an excellent healing rate theoretically could spread infection to the pros-
(90%) and a low infection rate (3% to 6%). thetic joint. Tibial shaft fractures in the proximity
FIGURE 11-8 A. Lateral and anteroposterior X-ray films of a tibia following an open fracture that has healed
in more than 20° of varus malalignment, causing ankle pain. B. After partial excision of the fibula and a tibial
osteotomy, this fracture was stabilized with an intramedullary nail. A portion of the excised fibula was used as
bone graft. C. Lateral and anteroposterior X-ray film 8 months after surgery, demonstrating excellent alignment and
healing. The patient is now asymptomatic.
of a loose prosthetic joint can, in certain cases, C. Pathologic Fractures—Pathologic fractures of

be treated with a long-stem revision arthroplasty, the tibial shaft are uncommon. If after obtaining
with the stem of the prosthesis stabilizing the a tissue diagnosis, the surgeon believes that limb
fracture. This treatment, however, is more ac- amputation is not necessary, the fracture should
ceptable for tibial metaphyseal fractures than for be stabilized. Intramedullary nailing is the stron-
tibial shaft fractures. gest and most practical fixation method, and
B. Floating Knee—Ipsilateral femur and tibia frac- should be used if possible. Postoperative radia-
tures are commonly referred to as a floating tion therapy or chemotherapy can be initiated
knee. When treated nonoperatively, these inju- when sufficient skin healing has occurred, which
ries result in an unacceptable rate of malunion is generally 5 days after surgery.
and knee stiffness. The femur fracture demands
operative stabilization. Although many of the as-
sociated tibial fractures would heal nicely with
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CHAPTER 12
Fractures of the Tibial Plafond

Mark R. Brinker and Daniel P. O’Connor
I. Overview B. Physical Examination

A. Definition—Intraarticular fracture of the distal end 1. Neurovascular examination—The neurovas-
of the tibia, also known as a tibial pilon fracture, cular examination includes evaluation of
involves disruption of the distal tibial weightbear- the distal pulses and capillary refill, a motor
ing articular surface. It represents a wide spectrum examination, and a sensory examination.
of injury severity and accounts for approximately 2. Soft tissues
5% to 7% of all tibia fractures and less than 1% of • Closed fractures—Closed fractures may be
all lower-extremity fractures. These injuries are classified using the method of Tscherne.
distinctly different from ankle fractures. Anatomic • Open fractures—Open fractures may be
areas injured include the weightbearing articular classified using the method of Gustilo.
surface of the distal tibia (epiphysis) and the distal C. Imaging
tibial metaphysis, as well as the distal fibula (in- 1. Plain radiographs—Plain radiographs show the
jured in approximately 75% of cases) and, some- extent of damage to the weightbearing articu-
times, diaphyseal extension into the tibial shaft. lar surface. Anteroposterior (AP), lateral, and
B. Mechanism of Injury—Most commonly, the mech- mortise views of the ankle are taken. AP and
anism of injury is axial loading, but it may be ro- lateral views of the tibial shaft are obtained to
tation (shear loading) or a combination of axial assess for diaphyseal extension. Complemen-
loading and rotation. Axial loading injuries gen- tary views of the opposite ankle may also be
erally result in greater disruption of the articular helpful for comparisons.
surface (than rotational injuries) and commonly 2. CT scanning (Fig. 12-1)
occur as a result of a fall from a height or a mo- • Evaluation of the injury—CT provides fur-
tor-vehicle accident; pure rotational injuries are ther evaluation of the extent of articular
lower-energy injuries that result in a lesser degree disruption, including the size and location
of articular cartilage disruption. (These injuries of the articular fragments, the extent of me-
commonly occur as a result of a ski accident.) The taphyseal injury, the location and orienta-
direction of force applied to the distal tibia and tion of die punch articular fragments, and
the position of the foot and ankle at the time of the orientation of the fracture lines that ex-
injury determine the injury pattern. tend into the diaphysis.
1. Axial loading while the ankle is plantar flexed— • Preoperative planning—CT helps determine
Posterior articular comminution predominates. the orientation in which the hardware, in-
2. Axial loading while the ankle is dorsiflexed— cluding interfragmentary screws and tran-
Anterior articular comminution predominates. sosseous implants of thin wire circular
3. Shear forces (rotational)—Shear forces result external fixators, should be placed. It also
in a wide array of injury patterns. helps determine open surgical approaches.
3. Plain tomography
II. Evaluation
A. Clinical Presentation—Signs and symptoms in- III. Injury Classifications
clude an inability to bear weight, marked pain, A. Overview—The variation in classification
marked swelling, and evidence of soft tissue injury. schemes reported in the literature makes the
162
C H A P T E R 1 2 | F R A C T U R E S O F T H E T I B I A L P L A F O N D 163
FIGURE 12-1 CT scan demonstrating a comminuted high-energy tibial plafond fracture. A. CT cross-sectional image.
B. CT coronal reconstruction. C. CT three-dimensional reconstruction.
comparison of clinical series very difficult. • Type III—It involves impaction and commi-
The key distinctions between the various nution of the articular surface.
injury patterns and classifications are rota- 2. Kellam and Waddell (1979)
tional (usually low-energy) versus axial load- • Type A—Rotational fractures consist of min-
ing (usually high-energy) mechanisms and the imal or no cortical comminution of the tibia,
extent of injury of the articular surface of the two or more large tibial articular fragments,
distal tibia. and usually a transverse or short oblique
B. Specific Classifications Systems fracture of the fibula above the plafond.
1. Rüedi and Allgöwer (1979)—The system of • Type B—A compressive fracture pattern
Rüedi and Allgöwer (Fig. 12-2) is perhaps from axial loading demonstrates marked
the most widely used classification of tibial cortical comminution of the anterior tibia,
plafond fractures reported in the literature. multiple tibial fracture fragments, superior
• Type I—It involves a cleavage fracture of migration of the talus, and narrowing of the
the distal tibia without major displacement ankle joint seen on the X-ray film.
of the articular surface. 3. Ovadia and Beals (1986)
• Type II—It involves significant displacement • Type I— It involves a nondisplaced articular
of the joint surface without comminution. fracture.
Type I
Type II
Type III
FIGURE 12-2 The Rüedi and Allgöwer classification for pilon fractures. Type I is undisplaced with splitting fracture
lines. Type II has displacement of the articular surface, with split type fractures. Type III is a crush or impacted injury
with comminution and displacement of the articular surface.
• Type II—It involves a minimally displaced (b) Partial articular (43-B)

articular fracture. (c) Complete articular (43-C)
• Type III—It involves a displaced articular • Groups and subgroups
fracture with several large fragments. (a) Metaphyseal simple (43-A1)
• Type IV—It involves a displaced arti cular • Spiral (43-A1.1)
fracture with multiple fragments and a large • Oblique (43-A1.2)
metaphyseal defect. • Transverse (43-A1.3)
• Type V—It involves a displaced articular (b) Metaphyseal wedge (43-A2)
fracture with severe comminution. • Posterolateral impaction (43-A2.1)
4. AO/ASIF and the Orthopaedic Trauma Asso- • Anteromedial wedge (43-A2.2)
ciation (OTA) (1996) • Extending into diaphysis (43-A2.3)
• Types (c) Metaphyseal complex (43-A3)
(a) Extra-articular (43-A) • Three intermediate fragments (43-A3.1)
• More than three intermediate frag- lumbar spine fractures, vertical shear pelvic
ments (43-A3.2) fractures, and other long bone fractures.
• Extending into diaphysis (43-A3.3) B. Soft-Tissue Injuries
(d) Pure split (43-B1) 1. Open fractures
• Frontal (43-B1.1) 2. Closed fractures—Because tibial plafond frac-
• Sagittal (43-B1.2) tures may result from a high-energy injury,
• Metaphyseal multifragmentary (43-B1.3) there may be a massive soft-tissue injury de-
(e) Split depression (43-B2) spite the absence of an open wound.
• Frontal (43-B2.1) C. Neurovascular Injuries
• Sagittal (43-B2.2) D. Injuries to Other Body Parts—Injuries (those
• Of the central fragment (43-B2.3) related to high-energy trauma) can occur to the
(f) Multifragmentary depression (43-B3) head, thorax, abdomen, and other parts.
• Frontal (43-B3.1)
• Sagittal (43-B3.2) V. Treatment and Treatment Rationale
• Metaphyseal multifragmentary (43-B3.3) A. Treatment Goals—Treatment goals include ana-
(g) Articular simple, metaphyseal simple tomic restoration of the distal tibial articular sur-
(43-C1) face and early ankle range of motion.
• Without impaction (43-C1.1) B. Treatment Options
• With epiphyseal depression (43-C1.2) 1. Nonsurgical—Cast and splints may be used
• Extending into diaphysis (43-C1.3) to manage nondisplaced fractures but result
(h) Articular simple, metaphyseal multifrag- in unacceptable outcomes for displaced tibial
mentary (43-C2) plafond fractures.
• With asymmetric impaction (43-C2.1) 2. Surgical—Displaced tibial plafond fractures re-
• Without asymmetric impaction (43-C2.2) quire surgical reconstruction.
• Extending into diaphysis (43-C2.3) (a) Historical methods—Pins and plaster,
(i) Articular multifragmentary (43-C3) calcaneal traction (as a definitive treat-
• Epiphyseal (43-C3.1) ment), and transarticular pin fixation are
• Epiphysiometaphyseal (43-C3.2) no longer used because of poor results.
• Epiphysiometaphysiodiaphyseal (b) Modern methods—Current methods in-
(43-C3.3) clude open reduction with internal fixa-
• Fibula tion (ORIF) and external fixation with or
(a) Fibula intact without limited internal fixation, includ-
(b) Simple fracture of fibula ing bridging external fixation and thin
(c) Multifragmentary fracture of fibula wire circular external fixation (Ilizarov).
(d) Bifocal fracture of fibula C. Bony Considerations
C. Assessment of Classification Systems 1. Tibia
1. Martin et al. (1997) (a) Comminution—Lower-energy injuries
• The AO/ASIF classification has good interob- with a small number of large articular frag-
server and intraobserver agreement at ments may be amenable to ORIF. High-
the type level. energy injuries with a large number
• The AO/ASIF classification has poor interob- of small articular fragments are best
server and intraobserver agreement at treated with external fixation (with or
the group level. without limited internal fixation).
• The Rüedi and Allgöwer classification has (b) Diaphyseal extension—Typically the
worse interobserver and intraobserver agree- epiphyseal and metaphyseal portions of
ment than the AO/ASIF method when the clas- the fracture heal more rapidly than the
sification is by type but better agreement than diaphyseal portion of the fracture. (Can-
when the AO/ASIF classification is by group. cellous bone heals more rapidly than
• CT scanning does not improve agreement cortical bone.) The use of interfragmen-
on classification but does improve agree- tary diaphyseal screws is associated
ment on articular surface involvement. with an increased rate of refracture.
2. Fibula—Although the classic teaching of Rüedi
IV. Associated Injuries and Allgöwer in the treatment of the tibial pla-
A. Skeletal fond fracture is to begin with open plating of
1. Other injuries—Injuries that commonly result the fibula, it must be remembered that the most
from axial loading include calcaneus fractures, important treatment goal is to restore and
maintain tibial length and alignment. There E. Timing of Surgery

is no consensus on the indications for the 1. ORIF of closed tibial plafond fractures—The
various types of treatments for fibular frac- timing of ORIF is a critical issue in high-en-
ture in the setting of a pilon fracture. Treat- ergy tibial plafond fractures and their associ-
ment options for fixation of the fibula include ated soft tissue and bone injuries. ORIF may
ORIF with plates and screws (the classic teach- be performed in the first 6 to 12 hours after
ings), intramedullary pin or nail fixation (main- injury. After 12 hours, ORIF may be hazard-
tains reduction of alignment of the fibula with ous because of profound swelling. If the soft
minimal soft-tissue dissection as compared tissues are such that the surgeon believes
with plates and screws, but does not control ORIF may be associated with a high risk of
rotation of the fibula), and nonoperative treat- complication, a staged approach using cal-
ment, most commonly used in cases in which caneal pin traction or an external fixator
the tibia is treated with external fixation. may be applied as temporary measures. At 7
D. Soft-Tissue Considerations—Although the injury to to 10 days (or more) after injury, the soft-tissue
bone is immediately obvious in a tibial plafond frac- swelling may have subsided, and ORIF may be
ture, the injury to the soft tissues may take days to contemplated. Waiting longer than 10 days
weeks to manifest. The extent of bone injury and to perform ORIF reduces risk of wound com-
comminution is a good indication of the energy plications, but otherwise has no effect on
transmitted to the limb and is therefore a good in- outcome.
dication of the extent of injury to the soft tissues. 2. Open fractures—Open fractures require emer-
1. Low-energy injuries—A lesser injury to the soft gent irrigation and debridement in the operat-
tissues may be amenable to ORIF. ing room.
2. High-energy injuries—Both open and closed 3. External fixation—Surgical timing for the place-
high-energy fractures are best treated initially ment of an external fixator is much less of an
with external fixation with or without limited issue than the timing for ORIF.
internal fixation. F. Results of Treatment (Table 12-1)
TA B L E 1 2 - 1
Review of the Literature on Tibial Plafond Fractures
Author (Year) No. of Cases Findings/Conclusions
Rüedi and Allgöwer (1969) 84 The four operative principles for ORIF of tibial plafond fractures were
outlined. ORIF with bone grafting was recommended (74% good or
excellent results)
Rüedi (1973) 54 At 9-yr average follow-up after ORIF of comminuted intra-articular tibial
plafond fractures, good or excellent results were seen in 70% of
cases
Kellam and Waddell (1979) 26 The results of operative treatment of Kellam and Waddell Type A and B
tibial plafond fractures were superior to those of nonoperative treat-
ment. Acceptable results after operative treatment were seen in 84%
of Type A injuries and 53% of Type B injuries
Rüedi and Allgöwer (1979) 75 At 6-yr average follow-up after ORIF of tibial plafond fractures, 70% of
cases had a good or excellent result
Bourne et al. (1983) 42 Rüedi and Allgöwer Types I and II tibial plafond fractures did well after
ORIF (80% satisfactory results). Type III fractures did poorly after
ORIF (only 44% had a satisfactory result)
Dillin and Slabaugh (1986) 11 “Internal fixation (of tibial plafond fractures) should be considered
only when anatomic reduction and rigid fixation are goals that
appear realistic after evaluation of the degree of comminution and
soft-tissue injury. Otherwise, the results of closed reduction and
immobilization are preferable to the serious complications that are
risked with ill-advised internal fixation”
TA B L E 1 2 - 1 (continued)
Ovadia and Beals (1986) 145 Rigid ORIF produced the best results in this series of tibial plafond
fractures
Etter and Ganz (1991) 41 At 8-yr average follow-up after ORIF of tibial plafond fractures, 90% of
cases had a good or fair result
Murphy et al. (1991) 5 This study reported the results of a small series of tibial plafond inju-
ries treated with the Monticelli-Spinelli circular external fixator
McFerran et al. (1992) 52 The overall local complication rate in treating tibial plafond fractures
was 54% (88% of cases were treated with ORIF)
Bonar and Marsh (1993) 21 In the treatment of tibial plafond fractures using unilateral external
fixation (15 cases also had limited internal fixation), 19 out of 21
fractures healed and 2 went on to nonunion. The authors reported
few complications and advocated this technique
Bone et al. (1993) 20 There were favorable results with a low complication rate when external
fixation with ORIF of severely comminuted and open tibial plafond
fractures was used. Open fractures were managed with a Delta-framed
external fixator across the ankle joint with screw or plate and screw
fixation; closed fractures were treated with a Delta-framed external
fixator across the ankle joint with ORIF at 3–7 days after the injury
Leone et al. (1993) 15 The authors concluded, “This retrospective study (of tibial plafond
fractures) has demonstrated that primary closure of the medial
wound, followed by delayed primary closure, or primary or delayed
split-thickness skin grafting of the fibular wound in the presence
of skin tension, is a judicious and responsible means to treat these
delicate periarticular tissues”
Saleh et al. (1993) 12 The authors advocated articulated distraction (via a bridging unilateral ex-
ternal fixator) with limited internal fixation (during the same operative
setting) for Rüedi and Allgöwer Type II and III tibial plafond fractures
Teeny and Wiss (1993) 60 In this review of the results of tibial plafond fractures treated with ORIF,
25% had good or excellent results, 25% had fair results, and 50% had
poor results. There were no infections in Rüedi and Allgöwer Type
I and II fractures, but there was a 10% ankle fusion rate. Type III
fractures had a 37% infection rate and a 26% ankle fusion rate
Tornetta et al. (1993) 26 In the treatment of tibial plafond fractures using combined internal and
external fixation, all fractures healed (11 required bone grafting.)
Results were judged to be good or excellent in 81% of cases (69% of
Rüedi and Allgöwer Type III injuries)
Helfet et al. (1994) 34 In this review of high-energy tibial plafond fractures (26 Rüedi and
Allgöwer Type II injuries and 8 Rüedi and Allgöwer Type III injuries),
28 had ORIF and 6 had external fixation. Fracture healing was unevent-
ful in 88% of cases; there were two delayed unions, one below-the-knee
amputation, and one hardware failure. Excellent functional results
were reported in 65% of Type II injuries and 50% of Type III injuries
Crutchfield et al. (1995) 38 This study compared the results of three different treatments of tibial
plafond fractures: external fixation only (13 cases), external fixa-
tion with limited internal fixation (11 cases), and internal fixation
only (14 cases). Clinical results by treatment type were as follows:
external fixation only—23% excellent, 23% good, 54% poor; external
fixation and limited internal fixation—27% excellent, 18% good, 55%
poor; and internal fixation only—57% excellent, 29% good, 14% poor
Marsh et al. (1995) 49 In the treatment of tibial plafond fractures using an articulated exter-
nal fixator (40 cases also had interfragmentary screw fixation and
14 had bone grafting), all fractures healed; the average duration of
external fixation was 12 wk. There were no infections over the tibial
incision or wound; there were two wound infections over the fibula
continued
Barbieri et al. (1996) 34 In the treatment of tibial plafond fractures using hybrid external fixa-
tion combined with limited internal fixation, the average time to
healing was 4.6 mo (range, 2.5–15 mo), and all fractures united.
Good or excellent results were seen in 62% of cases; fair or poor re-
sults were seen in 38% of cases
DiChristina et al. (1996) 9 In a small series of high-energy tibial plafond fractures treated with an
articulated external fixator, the union rate was 100%. All nine pa-
tients had complications associated with the external fixator. (Seven
had drainage from the calcaneus half pins, and two had instability of
the fracture in the frame.)
Gaudinez et al. (1996) 14 In the treatment of high-energy (Rüedi and Allgöwer Type II and III)
tibial plafond fractures using hybrid external fixation (Monticelli-
Spinelli), good or excellent subjective results were seen in 64% of
cases, and good or excellent objective results were seen in 71% of
cases. The authors concluded, “On the basis of these early results,
by limiting additional trauma to the soft and bony tissues and al-
lowing early ankle range of motion, indirect reduction and applica-
tion of a hybrid external fixator is useful, particularly if the fracture
fragments are so comminuted that anatomic reduction cannot be
expected despite surgical intervention”
Griffiths and Thordarson 16 In the treatment of tibial plafond fractures using limited internal fixa-
(1996) tion and hybrid external fixation, all fractures healed, and fixators
were removed at an average of 15.5 wk (range, 9–28 wk). Major com-
plications were seen in 12% of cases, and minor complications were
seen in 25% of cases. Ankle range of motion was good or excellent in
50% of cases and fair or poor in 50% of cases
McDonald et al. (1996) 13 Ilizarov external fixation is an effective treatment option for tibial
plafond fractures
Rommens et al. (1996) 28 These authors recommended a step-wise reconstruction of AO Types
C2 and C3 tibial plafond fractures to avoid soft-tissue complications
and infection
Step 1: Primary bridging external fixation
Step 2: Secondary internal fixation when the soft tissues are stable
Wyrsch et al. (1996) 39 In this randomized, prospective study that compared the results of
two methods of operative stabilization of tibial plafond fractures, 19
patients (group I) had ORIF of the tibia and fibula through two sepa-
rate incisions. (One of these patients only had fixation of the tibia
as the fibula was intact.) A total of 20 patients (group II) had exter-
nal fixation with or without limited internal fixation. Complications
(such as infection or amputation) were more frequent and more
severe in the group treated with ORIF
Babis et al. (1997) 67 This study compared the results of three different treatments of tibial
plafond fractures: 50 fractures were treated with ORIF (using the AO
principles), 9 had limited internal fixation, and 8 had external fixation.
Patients treated with ORIF (performed using the AO principles) had
the final outcome at an average follow-up of 8.1 yr. A better reduction
achieved at surgery was associated with a more favorable clinical result
Kim et al. (1997) 21 In the treatment of tibial plafond fractures using a ring fixator and ar-
throscopy, good results were seen in 71% of cases, fair results were
seen in 19%, and poor results were seen in 10%
Sands et al. (1998) 64 In ORIF of tibial plafond fractures, complications included deep infec-
tion (5%), iatrogenic nerve injury (2%), malunion (6%), failure of
fixation (6%), delayed union (5%), and nonunion (2%)
Williams et al. (1998) 54 Routine plating of the fibula was unnecessary in tibial plafond fractures
treated with external fixation that spans the ankle joint
Court-Brown et al. (1999) 24 In patients with AO Type A or C plafond fractures, results of half-ring
external fixation with half-pins were comparable with small wire
fixators when interfragmentary screw fixation was used for the ar-
ticular component of the fractures. 75% of the patients had good or
excellent results
Patterson et al. (1999) 21 Patients with Type C3 plafond fractures underwent fibular fixation
and placement of a medial spanning external fixator, followed by
removal of the external fixator and ORIF at an average of 24 days.
Union rate was 95% at an average of 4.2 mo, with 77% good results,
73% had anatomic reduction, and there were no infections or soft-
tissue complications. The ultimate arthrodesis rate was 9%
Pugh et al. (1999) 60 This retrospective review comparing half-pin external fixation, single-
ring hybrid external fixation, and ORIF reported no statistically sig-
nificant difference in complication rates but a higher malunion rate
with external fixation
Sirkin et al. (1999) 56 This retrospective study evaluated AO Type C plafond fractures which had
been treated with a staged protocol involving ORIF of the fibula within
24 hours of injury and spanning external fixation. Once soft-tissue swell-
ing had diminished, the articular surface was reconstructed using ORIF.
Time to ORIF of the tibia ranged from 4 to 31 days. Three patients (5%)
developed deep infections; there were no other major complications
Blauth et al. (2001) 51 This retrospective study compared 15 cases of primary ORIF in 15
patients; 28 cases of reconstruction of the articular surface and ex-
ternal fixation for at least 4 wk; and 8 cases of a two-stage procedure
involving minimally invasive reduction and reconstruction of the
articular surface and temporary external fixation followed by defini-
tive medial plate stabilization. Of the 23% who ultimately required
arthrodesis, none had undergone the two-stage technique. The au-
thors recommended the two-stage procedure
Letts et al. (2001) 8 This review of eight pediatric (ages, 13–17 yr) plafond fractures treated
by ORIF found good to excellent outcomes in 63% of cases at an
average of 16 mo after injury; two patients had posttraumatic osteo-
arthritis and one patient had physeal arrest
Manca (2002) 22 Type C fractures (16 closed, 2 Gustilo I, 3 Gustilo II, 1 Gustilo III) were
treated by routing a Kirschner wire down the tibial intramedullary
canal to reduce the articular surface under fluoroscopy, followed by
percutaneous screw fixation and hybrid external fixation. 21 out of
22 cases healed at an average of 16 wk, 14 patients had excellent or
good results, and 1 case later required arthrodesis for posttraumatic
arthritis
Mitkovic et al. (2002) 28 Closed reduction and dynamic external fixation was used to treat Type
C3 plafond fractures. The mean time to fracture union was 14 wk;
there were no nonunions or deep infections. At a minimum of 2 yr
after surgery, three cases had deformity, and 19 cases had excellent
or good outcomes
Conroy et al. (2003) 32 Open plafond fractures were treated with debridement, immediate
ORIF, and vascularized muscle flap. Two cases required amputation;
none of the remaining required arthrodesis. Physical function at a
minimum of 1 yr after injury was below that of the healthy popula-
tion, but better than patients with lower extremity amputations
Lin et al. (2003) 30 The authors reviewed 22 closed, 3 Gustilo I, and 5 Gustilo II fractures
treated using minimally invasive ORIF. At follow-up ranging from 17
to 39 mo, satisfactory results were reported in 83.3% of cases. There
was one nonunion and one deep infection
continued
Marsh et al. (2003) 35 In an investigation of long-term (5–12 yr after injury) consequences of
plafond fracture treated with monolateral hinged external fixation
and screw fixation of the articular surface reported that general
health and ankle function was lower than the respective age-
matched populations. 26 patients had grade 2 or 3 osteoarthritis of
the ankle, and 27 patients reported being unable to run, although 25
patients reported their ankle function as excellent or good
Pollak et al. (2003) 80 This study of the health outcomes associated with plafond fracture at an
average of 3 yr after injury reported that general health, ankle func-
tion, and employment were adversely affected by the injury. Other
health conditions, being married, low income, less education, and
treatment with external fixation were associated with lower outcomes
Okcu and Aktuglu (2003) 44 This retrospective study compared 24 cases of nonspanning Ilizarov ex-
ternal fixation with 30 cases of ankle-spanning monolateral articulated
external fixation in the treatment of plafond fracture; limited ORIF was
concomitantly performed when necessary. At 3–9 yr after injury, func-
tional outcomes, radiographic results, and complication rates were
similar in the two groups, the Ilizarov group had better ankle motion
Sirkin et al. (2004) 46 This retrospective study included 29 closed and 17 open fractures
treated with immediate ORIF of the fibula, application of temporary
spanning external fixation, and open reconstruction after soft-tissue
swelling subsided. All patients were followed for at least 12 mo.
There were three deep infections, one resulting in amputation, and
no other substantial wound problems
Syed and Panchbhavi (2004) 7 Patients with closed plafond fractures were treated with closed reduction
and percutaneous cannulated screw fixation. Subjective functional
outcomes were good to excellent at an average follow-up of 30.6 mo
Williams et al. (2004) 32 In a study of determinants related to outcomes at 24–129 mo after pla-
fond fracture, the presence of radiographic posttraumatic arthritis
was associated with injury severity and accuracy of reduction. None
of these variables was related to the clinical ankle score, SF-36 scores,
or return to work status. These outcomes were associated with
socioeconomic factors such as education and work-related injury
Kapukaya et al. (2004) 12 Patients with open tibial plafond fractures (eight Type III, 2 Type IVA, 2
Type IVB) were treated with a circular external fixation, including bone
transport for Type IVB fractures; postoperative articular reduction was
fair in eight patients and poor in four. At an average follow-up period
of 55 mo, seven cases had grade 2 arthritis and four cases had grade
3 arthritis. AOFAS scores ranged from 28 to 90. Poor joint reduction
appears to have negative impact on clinical and patient outcomes
Aggarwal and Nagi (2006) 21 Patients with plafond fractures were treated by debridement (if open)
and hybrid external fixation. At 12–67 mo after injury, 16 cases had
good to excellent subjective outcomes, 3 had fair outcomes, and 2
had poor outcomes
Harris et al. (2006) 79 This retrospective study compared the results of ORIF vs. limited open
reduction and external fixation in patients with high-energy plafond
fractures (43 OTA Type 43-C3, 5 Type 43-B1, 4 Type 43-B2, 2 Type
43-B3, 15 Type 43-C1, and 10 Type 43-C2); 71% underwent a staged
procedure. At 24–38 mo after injury, there were two nonunions
(3%), four malunions (5%), and 31 cases with posttraumatic arthritis
(39%). Complications and lower Foot Function Index scores and MFA
scores were more common after open injuries, which were more
likely to be treated by external fixation, possibly indicating a bias
toward treating more severe injuries with external fixation
Marsh et al. (2006) 41 This multicenter randomized trial compared fixed to mobile-hinge
ankle-spanning external fixation in the treatment of plafond
fractures. At 1 and 2 yr after injury, there were no differences
between groups with respect to ankle motion, pain, disability, or
patient-reported health-related quality of life, although the sam-
ple size may have limited the ability to detect clinically relevant
differences
Vidyahara et al. (2006) 21 Eight patients with Type B and 13 with Type C plafond fractures were
treated with the Ilizarov external fixator. At 2 yr after injury, there
were no nonunions and the AOFAS scores were excellent in 11 pa-
tients, good in five, fair in four, and poor in one
Bahari et al. (2007) 42 Patients treated with the AO distal tibia locking plate and minimally
invasive percutaneous plate osteosynthesis were followed for an av-
erage of 20 mo after injury. All fractures healed in acceptable align-
ment. Physical health status and function were good to excellent,
89% reported returning to their preinjury functional level, and 95%
returned to work
Chen et al. (2007) 128 At a mean follow-up of 10 yr for patients with Rüedi-Allgöwer Type I
(n 39), Type II (n 62), and Type III (n 27) injuries, Type III
injuries had lower reduction and functional outcome scores, Types
II and III had more ankle arthritis, and open fractures had lower out-
comes in general. Fixation of a fractured fibula was associated with
higher outcomes
Grose et al. (2007) 44 Patients were treated with delayed ORIF using a lateral approach.
Anatomic or near-anatomic reduction was achieved in most (93%)
cases. There were two deep infections (4.5%) and four nonunions
(9%). The authors concluded that the lateral approach was a viable
technique for internal fixation of plafond fractures
Koulouvaris et al. (2007) This retrospective study compared three treatments for plafond
fracture: half-pin, spanning external fixation, ankle-sparing hybrid
external fixation, and staged internal fixation. The average follow-
up ranged from 38 to 132 mo. Spanning external fixation resulted
in longer time to union and a lower rate of return to activities;
these associations were present even after stratifying by fracture
type
Salton et al. (2007) 19 Patients were treated with limited incision percutaneous plate fixation
using either a single procedure or a staged protocol. One patient
went on to nonunion, and another had malunion, neither requiring
surgical treatment. Four patients underwent late symptomatic hard-
ware removal
Bacon et al. (2008) 42 AO Type C plafond fractures were treated either by temporary external
fixation followed by ORIF (n 28) or by Ilizarov external fixation
(n 14). ORIF resulted in a longer time to union, but lower rates of
nonunion, malunion, and infection, although these differences did
not reach statistical significance
Gardner et al. (2008) 10 Patients with open AO Type C3 plafond fractures were treated using a
three-stage protocol: debridement and external fixation; ORIF and
antibiotic bead placement at 1–3 wk after injury; and bone grafting
several months after injury. Two cases had deep infection after bone
grafting, and one required amputation. The other nine cases healed
at an average of 24 wk
FIGURE 12-3 A. Injury film of a high-

energy tibial plafond fracture. B. The
fracture has been stabilized with a
unilateral external fixator that spans the
ankle joint. Note that the fibula has been
stabilized with an intramedullary nail.
VI. Anatomic Considerations and Surgical Techniques B. External Fixation

A. ORIF—Rüedi and Allgöwer’s four classic prin- 1. Types
ciples are: • Unilateral external fixation (Fig. 12-3)—
1. Reconstruct the fibula (restore fibula length). Unilateral external fixation spans the ankle
2. Reconstruct the articular surface of the tibia. joint. Fixation is performed proximally in the
3. Perform cancellous bone grafting of the distal tibia and distally in the talus and calcaneus.
tibial metaphysis. • Ilizarov external fixation (Fig. 12-4)—Ilizarov
4. Stabilize the medial aspect of the tibia (medial external fixation consists of fine wires
buttress plate). (1.8 mm) for interfragmentary fixation. It
FIGURE 12-4 A. Early postoperative AP view after Ilizarov external fixation of the high-energy tibial plafond fracture shown
in Figure 12-1. Note that thin wire fixation was used in the calcaneus for added stability (the ankle joint was immobilized),
and the patient began full weightbearing as tolerated on the first postoperative day. B. Lateral X-ray film at 4 week after the
injury, showing anatomic restoration of the articular surface of the distal tibia. Note that the foot fixation has been removed
and the patient began ankle range of motion exercises. C. Clinical photograph of the patient ambulating in the frame.
allows early weightbearing and early ankle neurovascular injury, malalignment or malreduc-
joint range of motion. tion of the ankle joint, amputation, malunion,
• Hybrid external fixation—In hybrid exter- nonunion, decreased ankle joint range of motion,
nal fixation, a ring with wires distally at the chronic edema, and posttraumatic arthritis.
articular fragments is connected to bars at-
tached to half pins in the proximal fragment.
C. Soft Tissues—The skin bridge between the tibia SUGGESTED READINGS
incision and the fibula incision should be a
minimum of 7 cm (Fig. 12-5). Careful soft-tissue Classic Articles
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CHAPTER 13
Injuries of the Ankle

Donald S. Stewart II and William C. McGarvey
I. Bony Injuries of the Ankle the malleolar projections and those involving the
A. Anatomy and Biomechanics (Figs. 13-1 to 13-3)— tibial plafond.
The normal ankle is a three-bone articulation sta- 1. Malleolar fractures—Malleolar fractures can in-
bilized on both sides by ligamentous structures. clude bimalleolar, trimalleolar, or isolated me-
The tibia joins the fibula and houses the talus dial or lateral malleolar fractures.
in a mortise configuration held fast by four syn- • Examination—There is a history of a twisting
desmotic ligaments and the interosseous mem- injury or a low-energy fall, local swelling, ec-
brane. The medial malleolus yields the deltoid chymosis, occasional deformity, or rare neu-
ligament, which is divided into two layers: the rovascular compromise (the risk increases
superficial layer, and the shorter, stouter, stron- with higher-energy injuries).
ger, deep layer. The fibula gives rise to the three • Classification—The fractures are classified
components of the lateral collateral ligamentous based on radiographic findings. Two popu-
complex: the anterior talofibular ligament (ATFL), lar systems exist. The Danis-Weber (AO/
the calcaneofibular ligament (CFL) (the stron- ASIF) classification is based on the level of
gest lateral ankle ligament), and the posterior the fibular fracture. The Lauge-Hansen clas-
talofibular ligament (PTFL). The talus is wider sification (older and more complex) is based
anteriorly and causes widening and deepening on the position of the foot at the time of the
of the mortise in dorsiflexion to enhance stabil- injury, combined with the applied deforming
ity of the joint. Motion is predominantly sagittal forces; it describes the initial point of injury
but not purely hinged because dorsiflexion also and the path it will take. Both classifications
yields slight external rotation, whereas plantar are commonly used, but neither is univer-
flexion also causes internal rotation of the talus sally accepted, although they overlap some-
with respect to the tibia. The articulation between what. A Weber A type fracture corresponds
the tibial roof (plafond) and the talar dome is not to a Lauge-Hansen supination-adduction in-
flat, but demonstrates a shallow bicondylar ap- jury, whereas a Weber B is the equivalent of
pearance dorsally with corresponding indenta- a Lauge-Hansen supination-external rotation
tions on the plafond. This configuration is rather or a pronation-abduction injury. A Weber C
stable, but subtle shifts in the articulation lead type fracture corresponds to a Lauge-Han-
to extreme decreases in contact area and corre- sen pronation-external rotation type injury
sponding increases in contact stress. A 1 mm talar (Fig. 13-4).
shift can reduce the contact surface 42%. This • Treatment—Treatment is based on the
effect can be quite extraordinary because the amount of distortion of the anatomic struc-
normal joint reaction force in a one-legged stance tures and articular incongruity. Goals include
can be as high as four times the body weight, with the restoration of proper anatomy, articular
only 6% to 16% of this being borne on the fibula congruity, and biomechanical function.
and the remainder absorbed through the tibiota- (a) Isolated lateral malleolar fractures—In
lar articulation. the absence of a medial injury, isolated
B. Fracture Types—Ankle fractures can be subdi- lateral malleolar fractures do not alter
vided into several categories: those that involve tibiotalar mechanics and therefore can
175
FIGURE 13-1 The medial collateral

A B (deltoid) ligament of the ankle includes
both superficial and deep components.
Superficial
A. The superficial components include
Deep anterior
talotibial the superficial talotibial, naviculotibial,
talotibial
and calcaneotibial components.
B. The deep deltoid ligament fibers
Medial run transversely from the posterior
malleolus colliculus of the tibia to the talus.
Deep posterior
talotibial
Naviculotibial
Calcaneotibial
to 15%) with over 2 mm of displace-

ment. Therefore all but nondisplaced
fractures should be treated with
Lateral malleolus open reduction with internal fixation
(ORIF). Vertically oriented fracture lines
Anterior are more unstable and are associated
Posterior talofibular talofibular with stress fractures. (Strong consider-
ations should be given to operative man-
Calcaneofibular
agement of vertically oriented fractures
as they tend to be stress fractures and
may fall into varus with casting. Two
cancellous screws or one screw and a
K-wire are required to control rotation in
addition to applying a compressive force
across the fracture site.
(c) Bimalleolar fractures and equivalents—
FIGURE 13-2 The lateral ankle ligaments include the Bimalleolar fractures and equivalents
anterior talofibular (the most important stabilizer and create loss of both medial and lateral sup-
the most commonly injured), the calcaneofibular, and the port (with a fractured distal fibula and
posterior talofibular. either a fracture of the medial malleolus
or a deltoid ligament rupture). These are
unstable fractures, and therefore there is
be treated with protected weightbear- poor control of reduction with nonopera-
ing in a walking cast or brace as soon as tive treatment. ORIF of both fragments
symptoms allow. Ligamentous structures is the treatment of choice. Bimalleolar
and medial stability prevent displace- equivalents are Weber B fracture pat-
ment of the fracture and more important, terns (aka SER- IV equivalents) with an
lateral shift of the mortise. Care must be associated deltoid ligament injury. Clues
taken to rule out the possibility of a me- to a bimalleolar equivalent are medial
dial ligamentous or syndesmotic injury hindfoot ecchymosis, medial ankle ten-
(Fig. 13-5). derness, bone flecks off the distal tip
(b) Isolated medial malleolar fractures— of the medial malleolus, and a widened
Isolated medial malleolar fractures have medial clear space. Stress views should
a relatively high risk of nonunion (5% be performed to evaluate opening of the
C H A P T E R 1 3 | I N J U R I E S O F T H E A N K L E 177
FIGURE 13-3 The
Posterior syndesmotic ligaments
include the anteroinferior
tibiofibular ligament (AITFL),
the posteroinferior tibiofibular
ligament (PITFL), the inferior
transverse ligament (ITL),
Anterior and the interosseous
ligament (IOL).
Posteroinferior
tibiofibular
Inferior transverse
Interosseus
Lateral
Anteroinferior
tibiofibular
Posteroinferior
tibiofibular
Anteroinferior
tibiofibular
medial clear space and a medial clear However, with a bimalleolar equiva-
space greater than 4 mm is an indication lent, syndesmotic fixation should be
for surgery. Magnetic resonance imaging incorporated when the fibular frac-
(MRI) may be helpful to evaluate the del- ture is more than 4.5 cm from the joint
toid if stress views are unclear. It is un- line and when the deltoid ligament is
necessary to repair the deltoid ligament not repaired. Recent studies have shown
in a bimalleolar equivalent; anatomic re- that fracture pattern does not reliably
duction of the fibular yields restoration predict a syndesmotic injury. Intraopera-
of the mortise in about 90% of cases. In tive stress testing should be performed
the remaining 10% of cases a medial ar- after definitive fixation of ankle fractures.
throtomy is required for extraction of an Intraoperative radiographs at the time of
incarcerated deltoid ligament. Occasion- surgery help assess medial stability af-
ally, the tibialis posterior tendon is inter fibular fixation to determine the need
terposed between the medial fragments; for syndesmotic screw fixation, but the
this is sometimes suggested radiographi- most reliable indication is attempt-
cally by a posteromedial flake of bone on ing manual displacement of the fibula
the injury films. Nonoperative care is ac- from the tibia while under direct visu-
ceptable when there is no injury to the alization. Careful attention should be
deltoid ligament and no talar shift (one paid to proper replacement of the fibula
can accept up to 2 mm of fibular displace- in the tibial groove posterior to the mid-
ment). A high fibular fracture suggests line to avoid malreduction while applying
a syndesmotic ligament injury. These syndesmotic fixation. Contralateral ankle
are stable after repair of both malleoli. films and possible open repair of the
A B C
Danis-Weber
IV
III III
Lauge-Hansen II I
II
II
IV
or I
or I II
III
or I
Supination-external
Supination-adduction rotation (stages I-IV) Pronation-external rotation
(stages I and II) (stages I-IV)
Pronation-abduction
(stages I-III)
FIGURE 13-4 Danis-Weber (AO/ASIF) and Lauge-Hansen classifications of ankle fractures.
syndesmosis may be necessary. Because the same as those for bimalleolar frac-
of the shape of the talus, the ankle should tures. The posterior fragment frequently
be maximally dorsiflexed before place- maintains its attachment to the fibula by
ment of a syndesmotic screw; failure to the posteroinferior tibiofibular ligament
do this results in limited ankle dorsi- (PITFL) and therefore reduces once the
flexion. Syndesmotic screws have been lateral malleolus is repaired. The pos-
shown to alter the mechanics of the dis- terior malleolar fragment should be
tal tibiofibular joint (especially external fixed if over 25% of the posterior dis-
rotation), so they should be removed tal tibial articular surface is involved
but no sooner than 8 to 12 weeks to allow on the lateral radiograph and the frag-
for ligamentous healing. Weightbearing ment is still more than 2 mm displaced
may begin after 6 weeks if the screw has after reduction of the fibula. Contact
captured three cortices. stresses at the ankle do not increase until
(d) Trimalleolar fractures—Trimalleolar frac- 25% to 40% of the posterior joint surface
tures represent a bimalleolar fracture is removed. Anterior or posterior surgi-
combined with a bony injury to the cal approaches for ORIF are acceptable.
posterior tibial plafond (posterior mal- 2. Pilon fractures—Higher-energy injuries involv-
leolus). ORIF is necessary because these ing the tibial plafond are discussed in detail in
injuries are unstable. The principles are Chapter 12.
Mortise view A B C FIGURE 13-5 Restoration of the ankle

mortise requires anatomic reduction of
the lateral malleolus so that its articular
surface is congruous with the reduced
talus. A. On a mortise radiograph, the
condensed subchondral bone should form
a continuous line around the talus, and
there should be no proximal displacement,
≤ 4 mm malrotation, or angulation of the lateral
malleolus. B and C. A proper talocrural
angle and normal joint space width also
indicate normality. On the mortise view, the
Normal Talocrural angle Medial
(83° ± 4°) joint space
medial joint space should be less than or
equal to 4 mm, and the superior joint space
should be within 2 mm medially of its width
D
Anteroposterior laterally. D. Adequate tibiofibular overlap
view on the anteroposterior view indicates a
proper syndesmotic relationship. The
space between the medial wall of the
fibula and the incisural surface of the tibia
should be less than 5 mm. The anterior
tubercle of the tibia should overlap the
fibula by at least 10 mm. E and F. Talar
malalignment is indicated by the talus’s
lateral displacement or tilt into valgus.
= < 5 mm = ≥ 10 mm G. Although the talus may be reduced
by external pressure, its alignment is not
maintained by a shortened, malrotated
E F G lateral malleolus, as shown.
Talar Talar tilt Short fibula

subluxation (≤ 2 mm) mismatched
subchondral surfaces
3. Open ankle fractures—Treatment depends on C. Techniques for Fixation of Ankle Fractures—The

the soft tissue injury. Gustilo Type I, II, and technique used for the fixation of ankle fractures
sometimes IIIA open injuries can be treated depends on the type of fracture sustained. Fixation
by the same principles as described for usually begins with lateral stabilization because,
closed injuries as long as thorough and ex- usually, this is simpler and provides enough fixa-
tensive debridement is performed. Closure tion to hold the mortise reduced. Care should be
or coverage is preferable within 5 days. More taken to avoid the superficial peroneal nerve
severe soft-tissue injuries are frequently asso- and less commonly the sural nerve. Lag-screw
ciated with greater bony destruction as well. fixation of the fibular fracture is incorporated
These often necessitate a combination of inter- when possible. Liberal use of intraoperative radio-
nal and external fixation and multiple debride- graphs is a must to assess reduction.
ments with secondary soft tissue coverage such Fracture dislocations should undergo emergent
as a muscle pedicle flap. Antibiotics should be reduction followed by immediate internal fixation,
given for at least 48 hours after closure. splinting with very close follow up, or a spanning
external fixator. Fractures that remain dislocated If fracture blisters are present, or there is diffi-
or subluxated can lead to skin compromise and/ culty in maintaining the reduction, a temporary
or further cartilaginous injury. external fixator may be placed.
1. Difficult repairs in osteoporotic fibulae— Open fractures with inadequate soft tissues
Difficult repairs in osteoporotic fibulae are for closure pose a difficult problem. Irrigation
sometimes better approached with a posteri- and debridement should be performed fol-
orly applied antiglide plate. This can obviate lowed by a VAC prior to definitive soft tissue
the need for screws in the distal fragment by coverage. VAC therapy continued after soft tis-
acting as a buttress and preventing proximal sue coverage can further increase the survival
migration of the fibula. It appears that a lock- of a free flap. Fractures tend to have the lowest
ing plate offers at least the same biomechanical rate of infection when definitive soft tissue cov-
strength as a conventional plate. erage occurs within 5 to 7 days after injury.
2. Severe fibular comminution—Severe fibular 2. Ankle fractures in diabetes—The clinician
comminution may be treated by reducing the must rule out a Charcot process; if a Charcot
distal fragment to the talus with K-wire fixa- process is present, total contact casting
tion, applying a plate, and bone grafting the should be considered. If this fails, arthrodesis
resultant defect. Contralateral ankle films and should be performed. Healing of bone and soft
preoperative templating can prevent malreduc- tissue in patients with diabetes takes two to
tion, which is most commonly shortening of the three times as long as healing in patients with-
fibula. out diabetes.
3. Seriously ill patients—Seriously ill patients with 3. Malunions—Malunions usually occur through
isolated fibular fractures may be treated with a rotational deformity of the lateral malleo-
intramedullary rods (e.g., Rush rods). The obvi- lus. (This deformity is frequently subtle and
ous limitation is the lack of rotational control. leads to abnormal joint forces.) They are re-
4. Small medial malleolar fragments—Small me- pairable with a fibular derotational osteotomy
dial malleolar fragments may be difficult to sta- and sometimes an interpositional bone graft to
bilize with screws, and tension band wiring is a restore length.
useful alternative. 4. Posttraumatic arthritis—The best treatment
5. Syndesmotic fixation—Syndesmotic fixation is for painful posttraumatic arthritis is ar-
obtained with a 30° anteriorly directed cortical throdesis in neutral dorsiflexion, 5° of hind-
screw (a positioned screw, not a lag screw). foot valgus, and rotation equal to that on
The ankle should be maximally dorsiflexed, the unaffected side.
and clamped, and a set screw placed. A lag 5. Nerve injury
screw should not be placed across the syn- • Lateral malleolus—The direct lateral ap-
desmosis. The optimal position is 2 cm prox- proach has the highest incidence of injury to
imal to the joint and 3.5 or 4.5 mm screws the superficial peroneal nerve (SPN). It exits
may be used in a bicortical or unicortical its fascial hiatus about 9 cm above the tip
fashion. of the lateral malleolus but its location may
D. Associated Injuries—Any open reduction should vary between 4 and 13 cm. The posterolat-
be accompanied by direct visualization of the eral approach decreases the risk of injury to
joint because osteochondral lesions are common. the SPN but increases the risk of injury to the
Also, plafond extension or lateral ligament disrup- sural nerve.
tion should be addressed if encountered. • Medial malleolus—The saphenous nerve is a
E. Complications very consistent structure and runs with the
1. Soft tissue problems—Fracture blisters are man- saphenous vein about 1 cm anterior to the
aged by delaying treatment until it is reasonable medial malleolus. A direct medial approach
and safe to proceed with surgery. Pneumatic can minimize injury to the nerve.
compression is sometimes helpful in reduc- 6. Return to function—A return to normal auto-
ing edema and decreasing the time to surgery. mobile braking time following ORIF of an ankle
Clear fracture blisters are relatively safe and fracture is about 9 weeks.
may be debrided at the time of surgery. Blood-
filled blisters should be avoided for their high II. Soft-Tissue Injuries of the Ankle
risk of necrosis and slough. The risk of slough A. Ankle Sprains—The most common ligamentous
is also increased as much as 10% to 20% by injury in the human body is an ankle sprain; it
delaying closed reduction of a dislocated ankle. accounts for 15% of all athletic injuries. Some
20% to 40% of all ankle sprains proceed to chronic focusing on proprioception and pero-
instability. Peroneal tendon weakness is the num- neal strengthening are useful.
ber one cause of recurrent ankle sprains in ballet (b) Grade II and III injuries require functional
dancers. bracing or short-term immobilization
1. Anatomy—The ankle is stable when loaded in a cast in dorsiflexion (2 to 6 weeks),
and unstable when unloaded. Ankle ligaments followed by gradual return to activity.
include the deltoid ligament medially (see Rehabilitation is instituted, as previ-
Fig. 13-1), and the ATFL (which is intracap- ously described.
sular), CFL, and PTFL laterally (see Fig. 13-2). 3. Deltoid ligament sprains—Isolated sprains of
Subtalar ligaments include the lateral talocal- the deltoid ligament are rare. They are more
caneal ligament, cervical ligament, interos- commonly seen in conjunction with a syndes-
seous talocalcaneal ligament (between the motic injury. Isolated injuries are treated with
middle and the posterior calcaneal facets), 6 to 8 weeks of casting, with a gradual return
CFL (spans both the ankle and subtalar joint), to normal activity.
and inferior extensor retinaculum. Syndes- 4. Syndesmosis sprains—Syndesmosis sprains
motic ligaments include the interosseous mem- account for 10% of all ankle ligament injuries.
brane, the anteroinferior tibiofibular ligament • History and physical examination—There is a
(AITFL), posteroinferior tibiofibilar ligament history of a twisting injury; pain occurs with
(PITFL), the interosseous ligament, and the in- dorsiflexion and eversion. The results of the
ferior transverse ligament (ITL) (see Fig. 13-3). squeeze test (ankle pain on compressing the
2. Lateral ligament sprains—The ATFL is the mid-tibia and fibula together) are positive.
most common injury of the lateral ankle liga- Check for a Maisonneuve injury with palpa-
ments (about 70% of cases). The mechanism of tion of the fibular neck and X-rays of the prox-
injury is usually a rollover of a plantar-flexed imal tibia and fibula if clinically appropriate.
inverted foot; the talus is in its most vulnera- Inability to perform a single leg hop is the best
ble position, so the ATFL is at risk for injury. indicator for a syndesmotic sprain without di-
• Physical examination—The lateral ankle is astasis at the initial point of injury. Other find-
tender and ecchymotic. A positive anterior ings may not present until a day later.
drawer sign is diagnostic of an ATFL injury. • There are four ligaments involved in the
A positive talar tilt (best tested with the foot syndesmosis.
in the neutral position) is diagnostic of a CFL (a) Anterior inferior tibiofibular ligament
injury. (AITFL)—This is the ligament most com-
• Radiography—There is no consensus in the monly involved in syndesmotic external
literature regarding the most important ra- rotation injuries.
diographic findings. Stress X-ray studies are (b) Posterior inferior tibiofibular ligament
helpful only with contralateral views. The (PITFL).
talar tilt should be considered abnormal if (c) Interosseous ligament (IOL).
there is a difference of 10° or more from the (d) Transverse osseous ligament (TOL).
normal side. The anterior drawer is abnor- • Radiography (see Fig. 13-5)—Radiographs
mal radiographically if there is a difference can appear normal; often, there are subtle
of more than 3 mm from the normal side. abnormalities. More than 5 mm of tibiofibu-
Occasionally, ligaments may avulse a small lar clear space is abnormal. More than 4 mm
piece of bone in the subfibular region, of medial joint space is abnormal. Late find-
which may be visualized on radiographs. ings demonstrate calcification of the interos-
• Classification seous membrane in 90% of cases.
(a) Grade I involves an ATFL sprain. • Classification
(b) Grade II involves an ATFL rupture and a (a) Type I involves straight lateral talar
partial CFL tear. subluxation.
(c) Grade III involves a complete ATFL and (b) Type II is a type I injury plus plastic de-
CFL tear. formation of the fibula.
• Treatment—Some 95% of acute sprains re- (c) Type III involves posterior rotary dis-
spond well with appropriate therapy. placement of the fibula and talus.
(a) Grade I injuries are treated with rest, (d) Type IV involves complete diastasis
ice, compression, and elevation (RICE). with migration of the talus superiorly
Early weightbearing and rehabilitation between the tibia and fibula.
• Treatment attenuated ligaments or following a

(a) Stable injuries—Stable injuries (less failed Broström procedure.
than 5 mm of medial joint space) (b) Nonanatomic procedures
are treated with RICE and return to • Peroneal “sacrificing” procedures—
weightbearing as tolerated with activ- Peroneal sacrificing procedures in-
ity modification. clude those of Larsen, Watson-Jones,
(b) Unstable nondisplaced injuries—Unstable Chrisman-Snook, and Evans. These
injuries with spontaneous reduction as procedures sacrifice half or all of
seen on radiographs are treated with the peroneus brevis to reconstruct the
casting for 4 to 6 weeks and protected lateral ligaments (provides a check-
weightbearing thereafter. These injuries rein). Limitations of this type of repair
take twice as long to heal as a typical are that it can easily be overtightened
lateral ankle sprain. and is nonanatomic. The Evans is
(c) Unstable displaced injuries—Unstable sometimes used for augmentation in
displaced injuries require syndes- “unskilled” positions in athletics or in
motic reduction and screw fixation very heavy athletes.
followed by cast immobilization for 6. Thickening of the AITFL (with soft-tissue im-
4 to 6 weeks. Irreducible injuries may pingement) as a result of an inversion ankle
even necessitate opening the joint medi- injury—The thickened AITFL rubs over the
ally to remove an incarcerated deltoid anterolateral tibia.
ligament. With type II injuries, a fibular • Diagnosis—There is persistent pain at
osteotomy is necessary because the the ankle joint line (especially the lateral
plastic deformation of the fibula results joint line) without instability. The pain
in inability to reduce the ankle mortise. is usually relieved by injection of steroids.
ORIF may be performed up to 1 year This problem is not well visualized on imag-
from the time of injury, provided that ing studies.
there is no radiographic evidence of • Treatment—The injection of steroids is oc-
arthritis. casionally therapeutic. Arthroscopic de-
5. Chronic lateral ankle instability—Chronic lat- bridement is often required.
eral ankle instability is characterized by persis- B. Peroneal Tendon Dislocations
tent lateral ankle pain, giving way, weakness, 1. Anatomy—Normally, the peroneal tendons
and recurrent sprains. course in a groove behind the fibula; the pero-
• Diagnosis—The diagnosis is made via a his- neus brevis is anterior to the peroneus longus.
tory, physical examination, and radiographic The tendons are kept in place by the supe-
studies (MRI and ultrasound). Conservative rior peroneal retinaculum. It originates
treatment with bracing and therapy is effec- from the posterolateral rim of the fibula
tive in 50% of cases. and inserts into the lateral calcaneus.
• Treatment—Treatment involves surgery 2. Mechanism of injury—Hyperdorsiflexion and
when conservative treatment has failed. It eversion occur; 75% of cases occur as a result
is imperative to rule out a varus hindfoot or of snow skiing.
a cavovarus deformity; if these are present, 3. Examination—Examination findings of a pe-
osteotomies are required at the time of soft roneal tendon dislocation differ from those
tissue reconstruction to prevent recurrence. of an ankle sprain because the pain is more
(a) Anatomic procedures posterior. Occasionally, the examiner can
• Modified Broström procedure—The provoke a dislocation with resisted dorsiflex-
most anatomic procedure is the ion and eversion from a plantar flexed and
modified Broström procedure, which inverted position. Plain X-ray films show a
is direct ATFL and CFL repair, includ- lateral flake of bone in 15% to 50% of cases
ing augmentation with the inferior (Rim Fracture of the fibula). MRI is useful
extensor retinaculum to augment and for defining the intratendinous pathologic
control the subtalar joint. This proce- process.
dure has a greater than 90% success 4. Treatment
rate. • Nonsurgical management—Is the correct
• Free tissue graft—Allograft or auto- treatment for most cases, but has only a
graft semitendinosus may be used for 50% success rate.
• Surgical management is the treatment of patients and those with compromised skin
choice for patients needing a quick return or poor wound-healing ability (i.e., patients
to activity. This consists of acute repair with peripheral vascular disease or diabe-
of the superior peroneal retinaculum and tes) and patients being treated with steroids
possible fibular groove deepening. or chemotherapy. Nonoperative treatment
5. Chronic dislocations—Chronic dislocations is associated with a higher incidence of
require surgical treatment. Multiple opera- rerupture (18%).
tive procedures have been described. Fibular • Operative—Operative treatment is generally
groove deepening with a retinacular repair considered more effective by US surgeons.
has the best success rate with the fewest Operative treatment is a better choice for
complications. active athletic patients who are reliable and
C. Subtalar Injuries—Subtalar injuries can mimic strong. Operative treatment is associated
an ankle sprain. They are diagnosed by physi- with a higher incidence of infection but a
cal examination. There should be a high index lower incidence of rerupture (2%).
of suspicion for a subtalar injury in the pa- (a) Treatment goal—The goal is to restore
tient with persistent lateral ankle pain and the anatomy of the Achilles tendon.
tenderness in the sinus tarsi. The treatment (b) Wound slough and nerve injury—Careful
principles are the same as those for a true ankle soft tissue technique helps avoid risks
sprain. of wound slough and sural nerve in-
D. Achilles Tendon Rupture—Achilles tendon rup- jury. The sural nerve is the nerve at
ture is the third most common of the major ten- greatest risk during percutaneous
don disruptions. repair of the Achilles tendon. Casting
1. Mechanism of injury—The mechanism of in- the patient in 20° of plantarflexion
jury is severe force and acceleration/decel- allows for the greatest tissue perfu-
eration secondary to forceful dorsiflexion of sion. Perfusion of the skin decreases
the plantar-flexed ankle. The rupture usually with increased dorsiflexion or
occurs 2 to 6 cm from the insertion site of the plantarflexion.
Achilles tendon. Prerupture tendinosis some- (c) Suture technique—End-to-end repair us-
times exists; possible causes include overuse, ing a locked suture technique (Krakow)
chronic steroids, gout, and fluoroquinolones. is stronger than other suture techniques
2. Diagnosis (Bunnel, Kessler).
• History—The patient relates a history of a (d) Plantaris tendon—The repair may be
pop, a snap, and the feeling of being hit in augmented with the plantaris tendon if it
the back of the heel. Adolescents and young is present. Some 70% to 80% of patients
adults are at increased risk of spontane- have a plantaris tendon.
ous Achilles tendon rupture if taking fluo- (e) Acute repair—An acute repair may be
roquinolones with an increased relative performed up to 3 months after the
risk of 3.7. injury with good results.
• Examination—There is heel cord tender- • Chronic tears—Injuries neglected longer
ness and a palpable defect. Thompson’s than 3 to 6 months usually require recon-
test (lack of full plantar flexion in response struction (rather than a direct repair).
to a calf squeeze with the patient prone) is (a) Treatment options—Treatment options
positive. for the reconstruction of chronic tears
• Radiography—Ultrasound and MRI are include the use of the flexor hallucis
the studies of choice if the diagnosis is in longus (strongest), the flexor digitorum
question. longus, the peroneus brevis, free grafts,
3. Treatment or a turn-down procedure.
• Nonoperative—Nonoperative treatment is • Gaps less than 4 cm can be recon-
popular in Europe. The technique involves structed with a V–Y advancement
gradually reapproximating the tendon • Gaps greater than 5 cm should be
ends by plantar flexing the ankle, gradually reconstructed with a turndown and
bringing the foot to neutral position over FHL transfer for augmentation.
2 to 3 months. Progression to healing may (b) Skin slough—There is a relatively high
be followed with ultrasound studies. This risk of skin slough as a result of retrac-
treatment is good for nonactive and elderly tion of the posterior soft tissues and
poor local vascularity (preoperative tis- Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence

sue expanders should be considered). of acute ankle sprains in volleyball after the introduction of
an injury prevention program: a prospective cohort study.
• Laceration—The patient should undergo im-
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energy trauma.
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B. Diagnosis—Usually, there is an obvious defor- Boden SD, Labropoulos PA, McCowin P, et al. Mechanical con-
mity. There may be open or tenting skin over a siderations for the syndesmotic screw: a cadaver study.
fracture fragment. The articular surface is at risk J Bone Joint Surg. 1989;71A:1548–1555.
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tal tibia, creating a focal pressure point.
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the normal architecture of the ankle joint via tion and delayed fixation. Clin Orthop. 1989;240:47–52.
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CHAPTER 14
Injuries of the Foot

Donald S. Stewart II and William C. McGarvey
I. Talus Fractures and Dislocations • Superomedial half—The superomedial

A. Anatomy half is supplied by branches from the

1. Parts—The talus comprises three distinct parts: anterior tibial artery (dorsalis pedis

the head, which articulates with the navicular; artery).
the neck, which is nonarticular; and the body, • Inferolateral half—The inferolateral

which has articulations with the tibia above half is supplied by the arteries of the
and the calcaneus below. Approximately 50% tarsal sling (artery of the tarsal canal
of the talus is covered by articular cartilage. and artery of the tarsal sinus).
The talus has no muscular or tendinous attach- (b) Talar body—The main blood supply is

ments. The talar dome is wider anteriorly. The the anastomosis between the artery of
posterior process of the talus contains the me- the tarsal canal and the artery of the tar-
dial and the lateral tubercles, between which sal sinus.
the flexor hallucis longus courses. The lateral B. Injury Types

tubercle is larger and may exist as a separate 1. Talar head fractures—Talar head fractures ac-

ossicle (the os trigonum), attached only by liga- count for 5% to 10% of all talus fractures.
mentous structures. • Mechanism of injury

2. Blood supply—The talus receives its blood sup- (a) Axial loading with the ankle in plantar

ply from two main sources: extraosseous and flexion or compression of the head of
intraosseous (Fig. 14-1). the talus against the distal tibia with the
• Extraosseous supply ankle in dorsiflexion

(a) Posterior tibial artery (b) Shear fracture of the navicular as it medi-

• Artery of the tarsal canal—The artery ally dislocates over the talar head during

of the tarsal canal gives off a deltoid an inversion injury
branch, which passes through the del- • Associated injuries—Metatarsal fractures are

toid ligament and supplies the medial common associated injuries; midfoot instabil-
body of the talus. ity is common.
• Calcaneal branches • Treatment

(b) Anterior tibial artery (dorsalis pedis (a) Nondisplaced fractures—Most fractures

artery) are nondisplaced because of the strong
• Medial tarsal branches capsular and ligamentous attachments.

• Anterolateral malleolar artery—The Treatment involves a short leg cast and

anterolateral malleolar artery contrib- nonweightbearing for 4 to 8 weeks
utes to the artery of the tarsal sinus. (b) Displaced fractures—No good evidence

(c) Peroneal artery—The peroneal artery exists to guide treatment in regards to

contributes to the artery of the tarsal fragment excision versus open reduction
sinus. and internal fixation. If the fragment is
• Intraosseous supply large enough, standard practice is to in-

(a) Talar head ternally fix it and excise small fragments.

187
Dorsalis pedis branches FIGURE 14-1 A. Sagittal sections

through the talus in planes 1 and 2.
1 Branches from the Note that the body of the talus is
artery of the tarsal canal supplied mainly by branches from
the artery of the tarsal canal and
Posterior tubercle
A branches the posterior tubercle branches
(2), whereas the head of the talus
Artery of the tarsal sinus is supplied by branches from the
1 dorsalis pedis and the tarsal sinus
2 2 arteries (1). B. In the coronal plane,
Dorsalis pedis branches the lateral two-thirds of the talar
body is supplied by branches
from the artery of the tarsal canal
Posterior tubercle
branches
and the medial one-third by the
branches entering through the
Artery of the tarsal canal deltoid ligament insertion.
Branches from the artery
of the tarsal sinus
B
1
2 Artery of the tarsal canal
1 Deltoid branch
Tarsal sinus branches

2
Deltoid branch
Posterior tibial artery
Artery of the tarsal canal

Tarsal sinus branches
• Complications—Complications include ar- (a) Type 1 is nondisplaced.

thritis due to malalignment, osteonecrosis (b) Type 2 involves a displaced talar neck

(approximately 10% of cases), and osteo- fracture and subluxation or dislocation
chondral fractures. of the subtalar joint.
2. Talar neck fractures—Talar neck fractures (c) Type 3 involves a displaced talar neck

are also called aviator’s astragalus. fracture and dislocation of both the ankle
• Overview—Talar neck fractures are high- and subtalar joints.

energy injuries usually occurring as a result (d) Type 4 involves a displaced talar neck

of hyperdorsiflexion in which the talus im- fracture and dislocation of the ankle
pinges on the distal tibia. Approximately 15% and subtalar joints with a talonavicular
to 20% of these injuries are open fractures. dislocation.
They are frequently associated with mal- • Radiography—A foot and ankle series is ob-

leolar fractures (25% of cases); injury to the tained. The talar neck profile is best seen on
medial malleolus is more common. There is a the Canale view (maximum plantar flexion
high risk of soft-tissue injuries and compart- with 15° of pronation with the beam directed
ment syndrome. 75° cephalad from the horizontal).
• Classification—According to the Hawkins • Treatment—Treatment is determined by

classification (Fig. 14-2), talar neck fractures the Hawkins type. The goal of treatment
are classified into four types. is anatomic reduction; historically, early
C H A P T E R 1 4 | I N J U R I E S O F T H E F O O T 189
1 2 FIGURE 14-2 Hawkins (and Canale) classification

of talar neck fractures. (1) Nondisplaced; (2) with
subtalar subluxation or dislocation; (3) with talar
body dislocation; and (4) with talar body and
head dislocation.
3 4
reduction of displaced fractures was thought Type II fractures should undergo internal
to reduce the risk of osteonecrosis. Recently, fixation to avoid late displacement. Open
a study has shown that approximately 60% of reduction may be carried out through an
orthopedic traumatologists find it acceptable anterolateral (least vascular risk) or an-
to operate after 8 hours, and 46% find it ac- teromedial arthrotomy, or through a pos-
ceptable to operate after 24 hours. terolateral approach. Fixation is usually
(a) Hawkins Type 1—Type 1 injuries are tre via screws placed across the talar neck.

ated with 4 to 6 weeks of non weightbear- The surgical approach is determined by
ing in a short leg cast, followed by 1 to the location of the fracture fragments,
2 months in a walking cast. If joint stiff- open wounds, contused skin, and ad-
ness or late fracture displacement is a jacent fractures. The anteromedial ap-
concern, percutaneous fixation may be proach is the most frequently used, but
contemplated. carries the greatest risk of injury to the
(b) Hawkins Type 2—Type 2 injuries consti- artery to the tarsal canal. Sometimes,

tute an orthopaedic emergency. Immedi- both the anteromedial and anterolateral
ate manipulation of the fragments with approaches are necessary to allow for
traction and plantar flexion to realign cross screw fixation. The posteromedial
the talar head fragment with the talar approach should be avoided because
body is recommended. If the reduction is of the high incidence of painful se-
anatomic (reported to occur in approxi- quelae. Intraoperative radiographs are
mately 50% of cases), the injury may be necessary to ensure proper bony reduc-
treated in the same manner as a Hawkins tion and avoid malalignment (especially
Type I injury. Residual deformity must be a varus deformity of the talar neck).
corrected to accept no more than 5 mm Posterior-to-anterior–directed screws
of displacement, with angulation of 5° demonstrate the largest strength of
or less. One study by Sangeorzan (1992) fixation compared with K-wires or an-
showed that as little as 2 mm of displace- terior-to-posterior directed screws.
ment of the talar neck significantly af- (c) Hawkins Type 3—Treatment of Type 3 in-

fects articular pressures. Most agree that juries is similar to that of Type 2 injuries.
However, soft-tissue problems are more commonly with a Type 2 injury (up to
frequent, and results are generally poorer. 50% of cases). Clinically, patients pres-
Manipulation less frequently results in an ent with decreased subtalar motion
acceptable reduction, and therefore ORIF and stand on the lateral border of
is more commonly required. Sometimes the foot. Identifying malalignment using
skeletal traction through the calcaneus is proper X-ray studies after manipulation
necessary to gain reduction of the talar or ORIF helps reduce the risk of varus
body fragment. If the talar body is ex- malunion. Using only a medial approach
truded, primary Blair fusion may be per- may increase the risk of a varus malunion
formed, as replacement of the talus leads due to limitations of fracture reduction
to a notoriously high rate of infection. visualization.
The deltoid branch of the posterior (d) Posttraumatic arthritis—Posttraumatic

tibial artery may be the only remain- arthritis occurs at the subtalar joint
ing blood supply to the talus. Attention (50% of cases), tibiotalar joint (33% of
must be directed toward minimizing cases), or both joints (25% of cases). It
soft-tissue stripping of the deltoid liga- results from articular damage at the time
ment. The talus may spin on the del- of injury, osteonecrosis with late seg-
toid ligament and must be derotated to mental collapse, malunion, or prolonged
maintain the blood supply. immobilization leading to fibrosis. Local
(d) Hawkins Type 4—Type 4 is a rare injury. injections may be necessary to identify

Treatment principles follow those out- specific joint involvement. Conservative
lined for a Type 2 injury. treatment is frequently effective, but if it
• Complications—Patients report a high rate is unsuccessful, arthrodesis may be the

of dissatisfaction as a result of the numerous only alternative.
sequelae. (e) Osteonecrosis—The incidence is related

(a) Skin necrosis and infection—The dorsal to injury type (Table 14-1). “Hawkins

skin envelope is particularly at risk for sign” (Fig. 14-3), if present, is seen on
necrosis and infection. A delay in fracture plain X-ray films at 6 to 8 weeks, and
reduction if it is tenting the skin increases signifies revascularization and atrophic
the risk of ischemia. Osteomyelitis is changes in the body of the talus. Hawkins
common in open injuries and requires ex- sign appears as a subchondral luceny in
cision of infected bone and subsequent the dome of the talus on the anteroposte-
arthrodesis. rior view. Its presence signifies that os-
(b) Delayed union or nonunion teonecrosis will not occur; its absence

• Delayed union—Delayed union oc- does not indicate that osteonecrosis

curs in approximately 10% of cases will definitely occur. MRI or nuclear
and is defined as failure to heal after medicine studies are sometimes helpful
6 months. It occurs secondary to the in determining this in equivocal cases.
tenuous blood supply of the talus with In cases of osteonecrosis, an increase
slow revascularization. Weightbearing in the radiographic density of the talar
should be limited until bridging callus body is not seen for 3 months or more.
is seen. If osteonecrosis is present, weightbearing
• Nonunion—Frank nonunion is rare.

The incidence of both nonunion and
delayed union is reduced with imme-
diate internal fixation. Fractures that TA B L E 1 4 - 1
have failed to unite 1 year after the in- Incidence of Osteonecrosis after Talar Neck
jury should be treated with ORIF and Fractures
bone grafting. Hawkins Classification Incidence
(c) Malunion—Varus malunion is the
Type 1 Up to 13%

most common malunion and com-
monly results from closed manipulation Type 2 20% to 50%
without internal fixation. This deformity Type 3 Virtually 100%
ultimately leads to degenerative arthri- Type 4 Virtually 100%
tis of the subtalar joint and occurs most
is controversial. Bony union of the frac- to 36 months by creeping substitution).

ture does not appear to be delayed by A late segmental collapse is a difficult
osteonecrosis. Weightbearing, however, problem from a management standpoint;
should be delayed until union of the talar tibiocalcaneal fusion, Blair fusion, and
neck fracture. In cases with documented modified Blair fusion (maintaining the
osteonecrosis, some injuries heal well head and neck of the talus) are treatment
as long as late segmental collapse is options.
avoided. Offloading in a patellar tendon- (f) Nerve injury

bearing brace should be maintained until • Posterolateral approach—Damage to

revascularization of the talus occurs (up the sural nerve is most likely.
• Anteromedial approach—Damage to

the saphenous nerve is most likely
• Anterolateral approach—Damage to

the dorsal intermediate cutaneous
branch of the superficial peroneal
nerve is most likely.
3. Talar body fractures—Talar body fractures in-

clude fractures involving the superior articular
surface or the trochlear region. These frac-
tures can occur in any plane and have a
much poorer prognosis than talar neck frac-
tures. The classification (Fig. 14-4) is based on
the plane of the fracture and fracture fragment
displacement. Treatment involves surgery in
all but those with minimal displacement. The
medial surgical approach with a malleolar os-
teotomy gives wide exposure for fixation. The
FIGURE 14-3 Hawkins sign. Note the atrophy in the lateral approach carries less risk of vascular

subchondral area of the talus, which suggests vascularity. compromise. Fracture fixation may be achieved
(This is a good prognostic sign for viability of the talus.) with cancellous screws, K-wires, or Herbert
(Reprinted with permission from Mann RA, Coughlin screws. The overall incidence of osteonecro-
MJ, Surgery of the foot and ankle, ed 6, St. Louis, 1993, sis is approximately 50% and in general is not
Mosby).
FIGURE 14-4 Fractures of the

talar body.
Type IA Type IB Type IIA
Type IC Type ID Type IIB
related to fracture type for talar body fractures. (a) Diagnosis—There may be a history of

(The incidence of osteonecrosis is related to trauma or pain of insidious onset. The
fracture type for talar neck fractures.) The pain may be vague and nonspecific and
treatment of osteonecrosis after a talar body may localize to the posterior ankle. The
fracture is similar to that for osteonecrosis af- pain is usually aggravated by forced
ter a talar neck fracture. equinus of the ankle. Hallux motion
4. Talar process fractures may reproduce the painful symptoms

• Lateral process fractures (Snowboarder’s as the flexor hallucis longus courses

fracture)—The mechanism of injury is dor- adjacent to the tubercles then through
siflexion, inversion, external rotation, and a groove under the sustentaculum tali.
axial loading. The lateral process of the ta- (b) Mechanism of injury—Two mechanisms

lus contains the attachments for the cervical, of injury have been proposed: hyper-
bifurcate, anterior talofibular, and lateral talo- dorsiflexion and/or inversion, leading
calcaneal ligaments. to tightening of the posterior talofibular
(a) Examination—The physical findings ligament with avulsion of the lateral tu-

mimic those of a lateral ankle sprain. bercle, and forced plantar flexion, caus-
A history of an inversion injury is ing compression of the lateral tubercle
characteristic. A high index of suspi- between the tibia and the calcaneus.
cion is needed to make the diagnosis. (c) Stress fractures—Stress fractures lead-

Radiographs often demonstrate subtle ing to failure of the lateral ossicle to
or no obvious findings. Evaluation with unite may occur as a result of repeti-
computed tomography (CT) is often tive activity.
helpful. (d) Radiography—The lateral ankle view

(b) Radiography provides the best delineation of the frac-

• Plain films—AP view of the ankle and ture. It is difficult to distinguish between

view with the leg internally rotated 20° an acute fracture of the trigonal process
are the views that best visualize the (roughened edges) and discontinuity of
lateral process in order to look for a the os trigonum (smooth edges). A bone
fracture. scan can be helpful.
• CT—Coronal slices (e) Treatment—Treatment involves a non-

(c) Treatment—Treatment depends on the weightbearing cast for 4 weeks, followed

size of the fragment, displacement, and by a walking cast for 2 weeks. Persis-
comminution. tent pain is treated with further casting.
• Nondisplaced fractures—Nondisplaced Symptoms lasting over 6 months indi-

fractures may be treated in a short leg cate nonunion. A bone scan may be use-
cast (nonweightbearing) for 4 weeks, ful for documenting localized metabolic
followed by weightbearing in a short activity. Excision through a postero-
leg cast for two more weeks. lateral approach (between the flexor
• Displaced fractures without comminu- hallucis longus and the peroneals) is

tion—Displaced fractures without com- recommended for cases of nonunion.
minution are amenable to ORIF with Athroscopic excision has also been
small fragment fixation or a Herbert described.
screw. 5. Osteochondral defects of the talus—These are

• Comminuted fractures—Comminuted intra-articular fractures of the talar dome artic-

fractures are best addressed with exci- ular surface. Impaction injuries may leave the
sion and early subtalar motion with no overlying cartilage intact while shear injuries
weightbearing. may cause a flap tear of the cartilage. Osteo-
(d) Complications—A delay in diagnosis chondral defects of the talus occur in 6.5% of all

causes the greatest problems. Healed dis- ankle sprains. After trauma, 55% of the lesions
placed fragments can give rise to subta- involve the medial portion of the talus, and 45%
lar arthritis. If excision does not provide involve the lateral talus.
relief, subtalar arthrodesis is the treat- • Mechanism

ment of choice. Lateral—dorsiflexion and inversion of
• Posterior process fractures (Shepherd’s the ankle cause impaction and anterolateral

fractures) shear.
Medial—Plantar flexion and inversion arthroscopically. Larger lesions involv-

cause the superomedial ridge of the talus to ing over one-third of the articular surface
rub on the tibial plafond, resulting in a medial are treated with operative reduction and
lesion. fixation of the fragment. The use of bone
• Diagnosis—Symptoms mimic those of an an- graft is controversial. Medial or lateral

kle sprain; this injury may have the sensation arthrotomies are usually satisfactory, but
of a foreign body. large posteromedial lesions may require
• Radiography—A lateral lesion is usually a malleolar osteotomy. Nonweightbear-

flatter and more wafer-like as opposed to ing with aggressive range-of-motion exer-
a medial lesion, which is deep and cup- cises is continued for 8 to 12 weeks.
shaped. CT can help delineate the depth and • Chronic lesions—Chronic lesions should be

size of the lesion, but MRI is more accurate suspected in patients with persistent symp-
in determining the overlying cartilage separa- toms after appropriate conservative treat-
tion and dissociation of the fragment from its ment for an ankle sprain. Symptoms are
subchondral bed. MRI can also identify asso- usually activity-related and include pain,
ciated soft-tissue injuries. locking, and swelling. These lesions may not
• Classifications be visible on plain X-ray films, and a bone

(a) Berndt and Harty classification—The scan, an MRI, or both modalities may be

Berndt and Harty classification (Table 14-2) helpful. MRI can assess stability by demon-

is the original and most widely used strating the presence or absence of a fibrous
classification. attachment or fluid in the base of the frag-
(b) Ferkel CT classification ment and in the fragment bed. The treatment

(c) Anderson MR classification for unstable chronic lesions is similar to that

• Treatment (based on the Berndt and Harty for acute lateral Stage III and Stage IV lesions.

classification) Ankle stiffness and arthritis are common with
(a) Stage I and II lesions and medial Stage III chronic lesions.

lesions—Stage I and II lesions and medial 6. Dislocations involving the talus—Talar disloca-

Stage III lesions are treated by cast immo- tions are high-energy injuries; 10% to 15% of
bilization for 6 to 12 weeks. If symptoms these injuries are open.
persist over 4 to 6 months, injuries are • Subtalar dislocation—These are relatively

treated surgically as described next. rare injuries accounting for about 1% of all in-
(b) Stage IV and lateral Stage III lesions— juries to the foot. Subtalar dislocations occur

Stage IV lesions and lateral Stage with dislocation of both the subtalar and talo-
III lesions are treated surgically. navicular joint. They are usually high-energy
Smaller lesions are treated by surgical injuries, but may occur after small injuries. It
excision and drilling of the base of the is important to distinguish subtalar disloca-
lesion. This can be done either open or tions based on energy (high or low) and di-
rection of dislocation in terms of treatment
and prognosis.
• Anatomic classification:
TA B L E 1 4 - 2

(a) Medial subtalar dislocations occur with
Berndt and Harty Classification of Osteochondral

forceful inversion of the foot while in
Lesions of the Talus plantar flexion. These are the most com-
Classification Description mon, and 40% have an open injury.
Stage I There is a small area of compressed (b) Lateral subtalar dislocations occur with

subchondral bone. forceful eversion of the foot while in
Stage II There is a partially detached plantar flexion. These are usually higher
osteochondral fragment. energy with higher incidence of open in-

Stage III There is a completely detached juries with over half being open.
osteochondral fragment that is (c) Posterior dislocations may occur with

located in the talar crater. hyper plantar flexion

Stage IV There is a completely detached (d) Anterior dislocations are very rare and

osteochondral fragment that is loose may result from a traction injury.
• Radiographs—Plain radiographs including

within the joint.

three views of the foot and ankle are required
for full evaluation. After reduction, plain films • Unstable joints are common with high-

should be repeated to look for concentric energy injuries. External fixation of the
reduction of the subtalar and talonavicular ankle and/or the subtalar joint may be
joint. Broden’s views can demonstrate re- required for at least 4 weeks. An alter-
duction at the subtalar joint. Postoperative native is Steinmann pin fixation of the
plain films and CT scans can further assess subtalar joint and casting for 6 weeks.
for associated impaction fractures or osteo- (f) Complications

chondral fractures that may occur at the ta- • Skin necrosis

lonavicular or subtalar joint or evaluation of • Subtalar arthritis

incarcerated fragments. • Continued instability

• Treatment • Avascular necrosis

(a) Documentation of a complete neuro- • Infection

vascular exam is crucial both pre- and • Neurovascular injury usually occurs

postreduction. in higher energy injuries (Usually in-
(b) Reduction consists of knee flexion, volves the posterior tibial artery or

traction/countertraction at the foot, tibial nerve)
recreation of the injury force, and direct • Posterior tibial tendon injury

pressure to the talar head as the calca- • Total talar dislocation—Total talar disloca-

neus is gently manipulated back into po- tion represents a rare injury; most are open.
sition. This should be done in a timely They are treated by reduction after irrigation
fashion to reduce tenting of the skin and and debridement, if possible. Occasionally,
possible skin necrosis. contamination is severe enough that com-
(c) Open injuries plete talar extrusion may require talectomy.

• Irrigation and debridment (Treatment, in such a case, is by primary tib-

• Since lateral dislocations are higher- iocalcaneal arthrodesis.)

energy injuries, many require second-
ary grafting or flap procedures. II. Calcaneal Fractures and Subtalar Dislocations

(d) Irreducible joints—If the joint cannot A. Historical Perspective—There is no consensus

be reduced closed, then open reduction regarding the optimal treatment of calcaneal
must be performed through an anterome- fractures. Management includes nonreduction,
dial or anterolateral approach to the talus closed reduction, ORIF, and primary arthrodesis,
• Medial dislocations and there are no formal indications or agreement

• Buttonholing of the talar head on approach or outcome criteria.

through the extensor retinaculum B. Anatomy—The calcaneus is the largest, most ir-

• Entrapment of the extensor digitorum regularly shaped bone in the foot; it contains a

brevis large amount of cancellous bone and has multiple
• Entrapment of the lateral branch of processes. The tuberosity serves as the site of at-

the deep peroneal nerve tachment for the broad, expansive Achilles ten-
• Impaction of the navicular onto the don posteriorly and the plantar fascia inferiorly.

talar head The posterior facet is the largest articular surface
• Lateral dislocations and supports the lateral process and body of the

• Impaction of the navicular onto the talus. The sustentacular fragment houses the

talar head middle facet and the stout interosseous talocal-
• Entrapment of the talar head by caneal ligament. The flexor hallucis longus runs

the posterior tibial tendon or flexor in a groove just below the sustentaculum tali. The
digitorum longus anterior process is protuberant just superior to

(e) Postreduction the cuboid articulation, which contains the bifur-

• If the joint is stable and concentri- cate ligament attachments to the navicular and

cally reduced then casting for at least cuboid. Approximately 60% of foot fractures in-
1 month is recommended with early volve the calcaneus. Approximately 2% of all frac-
range-of-motion exercises. tures involve the calcaneus.
• If the joint is incongruent, then again C. Fracture Classification—No consensus regarding

check for impediment to reduction or the optimal classification exists.
impaction fragments in the joint. This 1. Essex-Lopresti (Table 14-3)—The most commonly

may require formal open reduction. used classification is that of Essex-Lopresti. It
to evaluate intraoperative posterior facet

TA B L E 1 4 - 3 reduction.
Essex-Lopresti Classification of Calcaneal Fractures • CT Scan—CT helps assess involvement of

the posterior facet and the extent of com-
Extra-articular calcaneal fractures (≈25% of cases)
minution. CT is also useful for evaluating
Anterior process fractures
involvement of the calcaneocuboid joint.
Tuberosity fractures As previously described above, a CT clas-
Medial process fractures sification has been described by Sanders
Sustentaculum tali fractures (see Fig. 14-5). The CT cuts should be done
Body fractures without involvement of the subtalar
perpendicular to the posterior facet, and
joint sagittal cuts should he parallel to the plan-
tar aspect of the foot. CT cuts should be
Intra-articular calcaneal fractures (≈75% of cases)
3 mm thick. CT helps demonstrate the typi-
Nondisplaced fractures cal shortening, widening, and varus and
Joint depression fractures medial displacement of the heel.
Tongue-type fractures • Soft-tissue management—Intra-articular frac-

Severely comminuted fractures tures of the calcaneus are associated with
tremendous swelling. Operative interven-
tion is best performed within 12 hours of
the injury or 1 to 2 weeks after the injury,
separates fractures into intra-articular (75% of when the swelling resolves. Sequential com-
cases) and extra-articular (25%). pression devices may be helpful in reducing
2. Sanders (Fig. 14-5)—The Sanders system is a edema. Fat pad explosion or atrophy can

CT classification; it has become very popular cause long-term problems. Tendons (flexor
and carries prognostic implications. hallucis longus, peroneus longus) can be in-
D. Associated Injuries—Calcaneal fractures are usu- carcerated within the fracture fragments or

ally the result of a fall from a height or other high- dislocated. Compartment syndrome is com-
energy mechanisms. Approximately 10% of these mon and must be addressed by compart-
fractures are associated with a lumbar spine frac- ment pressure monitoring and fasciotomy.
ture, particularly of L1. Approximately 10% of cal- This occurs in the deep central compart-
caneal fractures are bilateral. ment which houses the lateral plantar nerve
E. Specific Injury Types and quadratus plantae. Clinical exam of pain

1. Intra-articular fractures—Two general types of out of proportion to exam is unreliable and

intra-articular fractures have been described compartmental pressure monitoring is rec-
(joint depression and tongue type). ommended. In the “wrinkle test,” the skin
• Mechanism of injury—The mechanism of appears wrinkled, indicating that swelling

injury is most commonly axial loading. The has subsided; this test is used to determine
lateral process of the talus acts as a wedge, surgical timing from the soft-tissue stand-
creating a primary fracture line (vertical) point. Fractures should be reduced within
and a secondary fracture line (more poste- 3 weeks if possible as fracture consolidation
riorly directed), which determines the type after 3 weeks can make reduction and fixa-
of fracture. tion extremely difficult.

• Diagnosis—Tenderness, tremendous swell- • Associated injuries—There is approximately

ing at the heel, and ecchymosis occur; evi- a 10% incidence of lumbar spine injury and
dence of neural compromise (tarsal tunnel 25% incidence of other lower-extremity
distribution) may also occur. injury.
• Radiography—Plain lateral X-ray films of the • Treatment—Treatment depends on the se-

foot and an axial heel view usually demon- verity of the fracture and the extent of ar-
strate shortening and widening of the cal- ticular comminution.
caneus, usually with a varus orientation (a) Nondisplaced articular fractures—Non-

of the tuberosity. Loss of Bohler’s and Gis- displaced articular fractures are man-
sane’s angles is also diagnostic. The primary aged in a bulky (Robert-Jones) dressing.
and secondary fracture lines are sometimes Once ankle control is restored and swell-
well visualized. Broden’s views demonstrate ing subsides, active subtalar range of
subtalar joint involvement and are used motion is instituted, but weightbearing
FIGURE 14-5 CT classification of intra-

articular calcaneal fractures. It is important
that the coronal section analyzed include
the widest point of the articular surface (the
A BC sustenaculum tali).
Lateral
Central
Medial
Sustenacular fragment
A B C
Type IIA Type IIB Type IIC
AB A C BC
Type IIIAB Type IIIAC Type IIIBC
A BC
Type IV
is still prohibited. Usually, walking can The lateral extensile approach is the
start at about 8 to 12 weeks, depending most popular, but a modified subtalar ap-
on comminution. proach, a medial approach, or combined
(b) Displaced intra-articular fractures with approaches are also acceptable. With the

large fragments—Displaced intra-articular lateral approach, care must be taken

fractures with large fragments should un- to make full-thickness soft-tissue flaps
dergo ORIF when the soft tissues allow. and avoid the sural nerve. The lateral
The surgical approach is based on the approach is made with the vertical limb
surgeon’s preference and familiarity. 0.5 cm anterior to the Achilles. This ex-
Percutaneous fixation may be used tends to the junction of the lateral and
in certain instances especially large plantar skin. The horizontal limb runs
tongue type fractures. An Essex Lopresti along the line formed by the lateral and
maneuver with the patient in the prone plantar skin. The lateral calcaneal artery
position may help unlock and reduce is critical in maintaining flap viability and
the tuberosity fragment. runs 1.5 cm anterior to the Achilles in the
vertical limb. The “constant fragment” is reconstructible, and the likelihood of

held reduced by the strong talocalcaneal posttraumatic subtalar arthritis is high,
ligament, and the joint can be recon- primary arthrodesis is recommended.
structed by using subcortical cancellous Attention should still be paid to restor-
screw fixation. The next step is to correct ing the heel width and height.
the morphology of the calcaneus to re- (d) Open fractures are especially prob-

store height and width. Skeletal traction lematic as they commonly arise from
via a Steinmann pin in the tuberosity is high-energy trauma. Up to 70% wound
sometimes helpful. The anterolateral complications have been reported with
fragment is usually superiorly displaced greater than 50% incidence of osteo-
and may need to be rotated and de- myelitis. Reports with early irrigation,
pressed into position. This restores the IV antibiotics debridement, and provi-
angle of Gissane, and the anterolateral sional fixation with delayed reconstruc-
fragment can be provisionally pinned. tion show better results with 10% to 20%
Lateral buttress plating with fixation into incidence of infection, wound complica-
the tuberosity joint fragment and ante- tion, or osteomyelitis.
rior process usually hold the calcaneus • Complications

in an appropriate position. Bone grafting (a) Soft-tissue breakdown—Soft-tissue break-

is optional, but has not been shown to down remains the most common and a
speed healing or alter results. severe complication, particularly related
The medial approach provides bet- to the lateral extensile approach. Typi-
ter visualization of the sustentaculum cally, it occurs at the apex of the incision
tali. Articular reduction is performed and can occur as long as 4 weeks from
using the sustentacular fragment as injury. Systemic factors, such as diabetes
the key under direct visualization. mellitus, peripheral vascular disease, al-
The difficulty with the medial approach cohol abuse, and smoking, contribute to
is how to address the posterior facet. A wound complications.
limited approach and potentially percu- (b) Local infection—Local infection is also

taneous elevation of the fragment are common and should be addressed with
options. To successfully mobilize frag- early debridement and antibiotics. If the
ments with the medial approach, the wound is infected with Staphylococcus
fracture should be addressed within 1 aureus and there is early healing, then
week. the treatment is hardware removal and
Use of a ring external fixator system irrigation and debridement.
is another alternative to difficult frac- (c) Subtalar arthrosis—Subtalar arthrosis

tures or open fractures. McGarvey et continues to be problematic even after
al. recently reported outcomes using an a good articular reduction. University of
Ilizarov fixator and limited incisions for California at Berkley Laboratory-type or-
displaced calcaneal fractures. Sanders thotic devices may be helpful. Persistent
Type II to IV fractures (both open and pain that does not respond to conserva-
closed fractures) were included. Thirty- tive treatment is managed with subtalar
three fractures were evaluated and arthrodesis. Factors associated with
there was only one deep wound infec- likelihood of late arthrosis and need for
tion. There were no deep infections or a subtalar arthrodesis are: work-related
wound complications in the open sub- injury, Sanders Type IV fractures, initial
group after initial wound management Bohler’s angle less than 0°, and initial
and free flaps if necessary. At an average nonoperative treatment.
2-year follow up, no subsequent revision (d) Anterior ankle impingement—Anterior

procedures had been performed. ankle impingement may occur if the
(c) Displaced intra-articular fractures with fracture has not been reduced and the

severe comminution—Increasing intra- talus settles. In these cases, a bone

articular comminution leads to less block distraction arthrodesis of the
satisfactory results. Therefore, al- subtalar joint may be beneficial.
though an initial attempt at ORIF may (e) Lateral impingement—Lateral impinge-

be reasonable, if the joint surface is not ment of the fibula on the peroneal
tendons is also the result of inadequate fractures are often confused with lat-
reduction because the prominent lateral eral ankle sprains, but tenderness is
wall of the calcaneus abuts the fibula more distal over the sinus tarsi. Ra-
with weightbearing (causing compres- diographic findings can be subtle. The
sion of the peroneal tendons as they treatment of fractures with a small bony
pass through the groove). In these cases, fragment is short leg casting for 4 to 6
lateral wall exostectomy will be benefi- weeks with weightbearing as tolerated.
cial with possible tenolysis and repair or The treatment of fractures with a large
excision of peroneal tendon tears. bony fragment, a displaced fragment,
(f) Cutaneous neuromas—Cutaneous neu- or an injury involving a portion of the

romas, particularly of the sural nerve, calcaneocuboid articular surface is

can arise after surgery using the lateral ORIF. Fractures that were treated nonop-
approach to the calcaneus. Treatment eratively and that failed to unite may be
involves resection and burying of the excised if they are symptomatic.
nerve into the peroneal muscle belly. (b) Tuberosity fractures of the calcaneus—

(g) Heel pad pain is very common due to Tuberosity fractures involve avulsion

injury to the specialized plantar fat pad of a bony fragment when the Achilles
with resultant scarring and fibrosis. No tendon is loaded beyond the tensile
good solutions exist and currently cush- strength of its attachment. Sometimes
ioned inserts are recommended. such a large fragment is avulsed that
• Results of the operative treatment of calca- the articulation of the posterior facet

neal fractures—The results are disappoint- becomes involved. Treatment is based
ing even in the best of hands. Calcaneal on the degree of displacement. Non-
fractures account for a large number of days displaced or minimally displaced frac-
missed from work and require lengthy peri- tures are treated with immobilization
ods of rehabilitation. Even with anatomic in equinus for about 3 weeks. Displaced
restoration of the posterior facet, subta- fractures require ORIF to restore the in-
lar stiffness continues to be troublesome. tegrity of the Achilles tendon and reduce
The most predictable outcome is restora- the potential for soft-tissue compromise,
tion of heel height and width. In a random- which can be caused by tenting of the
ized prospective multicenter study, patients fragment against the tenuous posterior
with operative treatment had an overall skin. Failure to repair the injury may
significantly better outcome than nonopera- lead to plantar flexion weakness.
tively treated patients when worker’s com-
pensation patients were removed. III. Injuries of the Midfoot

(a) Operative versus nonoperative compli- A. Navicular Fractures—Injuries of the navicular

cations of calcaneal fractures in order of are classified into four types: dorsal lip (cortical
frequency at 2-year follow up. avulsion), tuberosity, body, and stress fractures.
• Nonoperative 1. Dorsal lip fracture—Dorsal lip fractures are

• Post traumatic arthrosis (16%) the most common type; they are usually me-

• Lateral ostectomies (0.8%) chanically insignificant. They occur with twist-

• Compartment syndrome (0.8%) ing and inversion. Treatment involves casting

• Operative if the injury is symptomatic. If the fracture

• Wound slough (16%) heals with exuberant callus with a dorsal exos-

• Malposition (6%) tosis, it can irritate the deep peroneal nerve,

• DVT (1.2%) which courses directly above it. Treatment of

2. Extra-articular fractures—Extra-articular frac an exostosis causing painful symptoms is shoe

tures are usually avulsion fractures of a modification or excision of the prominence.
process of the calcaneus. 2. Tuberosity fracture—A tuberosity fracture is

• Types usually an avulsion injury from a sudden force-

(a) Anterior process fractures of the ful contraction of the tibialis posterior tendon.

calcaneus—The mechanism of injury Because the insertion site of the tibialis pos-

is plantar flexion and inversion. The terior is broad, the displacement is usually
bifurcate ligament attaches to the an- minimal. Treatment involves short leg casting
terior process of the calcaneus. These with an arch mold. This fracture should not be
confused with an accessory navicular (which grafting and possibly external fixation
is present in 12% of the population). Painful to preserve length.
nonunion is rare, but if it occurs, resection of (c) External fixation is also a good option

the ossicle with reattachment of the tibialis when the soft tissues are too swollen
posterior tendon is usually successful. Ad- for open reduction and internal fixation,
vancement of the tendon in combination with when additional fixation is needed to
excision (modified Kidner procedure) is usu- augment internal fixation, and for liga-
ally unnecessary. mentotaxis of comminuted fractures.
3. Body fracture—A body fracture usually oc- (d) Primary arthrodesis may be necessary

curs from axial loading of the navicular in for extremely comminuted fractures.
plantar flexion. It involves the talonavicular (e) Often, late arthrodesis of the naviculo-

and the naviculocuneiform joints. Inadequate cuneiform and talonavicular joints is
management may lead to debilitating collapse necessary for symptomatic relief.
and arthrosis. 4. Stress fractures—Stress fractures are com-

• Classification of Sangeorzan (Fig. 14-6): monly found in athletes performing repetitive

(a) Type I involves a transverse coronal stressful activities; they often go unrecog-

fracture (,50% of the body). nized. Poor radiographic representation leads
(b) Type II is the most common. The frac- to delay in diagnosis (average, 4 months after

ture courses dorsal lateral to plantar symptoms begin).
medial. The plantar medial fragment is • Diagnosis—The diagnosis is suggested by

often smaller and comminuted. a history of repetitive stress athletics (e.g.,
(c) Type III involves central or lateral com- jumping, running) and focal tenderness. If

minution, often with lateral displace- plain X-ray films are negative or nondiagnos-
ment of the forefoot leading to an tic, an MRI or a bone scan may be helpful. Plain
abduction deformity. Sometimes calca- radiographs characteristically show vertical
neocuboid joint subluxation occurs. fracture lucency in the central third of the na-
• Treatment vicular, but CT scanning should be performed

(a) Nondisplaced fractures can be casted to further characterize the fracture pattern.

for 6 weeks in a short leg nonweight- • Treatment—Treatment is based on the

bearing cast. amount of displacement and CT can help
(b) In displaced fractures, ORIF is indicated determine this.

with strict attention to preserving me- (a) Nondisplaced fractures can be

dial column length and preventing ab- treated in a non-weightbearing short
duction deformities of the forefoot that leg cast for 6 to 8 weeks.
can lead to late arthrosis. Typically, (b) Displaced fractures require ORIF with

open reduction is necessary, and inter- grafting of the fracture site, preferably
nal fixation with cancellous screws is from a lateral approach with lateral to
used for large fragments. Severe com- medial screw fixation because the lat-
minution requires interposition bone eral fragment is most often smaller.
FIGURE 14-6 Classification of navicular body fractures.

B. Cuboid Injuries This impacts the talonavicular and calca-

1. Minimally displaced avulsion fractures of the neocuboid joints and leads to an array of in-

cuboid—The majority of cuboid fractures jury patterns. Fracture lines usually extend
are minimally displaced and insignificant. vertically through the navicular based on a
These usually result from inversion strain. medial or middle column line of force.
The fracture is best visualized on the antero- • Medial force results in a spectrum of injury

posterior radiograph at the lateral border of patterns and may be the precursor to a
the foot. Conservative treatment is 4 weeks of full subtalar dislocation. A “medial swivel”
weightbearing in a hard-soled shoe. injury occurs when the rotational force is
2. “Nutcracker fracture”—The nutcracker frac- around the talocalcaneal interosseous liga-

ture is frequently missed. ment causing dislocation of the talonavicu-
• Mechanism of injury—A high-energy abduc- lar joint with an intact calcaneocuboid joint

tion force leads to crushing of the cuboid and subluxation of the subtalar joint.
with potential plantar extrusion of bone and • Lateral force—an abduction injury to the

lateral subluxation of the forefoot as a result midfoot leads to the classic “nutcracker” in-
of a shortened lateral column. jury as described above. Another variant is
• Treatment—Open reduction with bone graft the “lateral swivel” injury leading to talona-

ing is usually necessary for preserving length. vicular dislocation with an intact calcaneo-
Occasionally an H-plate may be applied to cuboid joint and subluxation of the subtalar
support the length, but fixation is often dif- joint. Look for the avulsed tuberosity of the
ficult because of comminution; therefore, ex- navicular as a clue to these injury patterns.

ternal fixation tends to be more reliable for • Plantar force—hyperplantarflexion injuries

the restoration of lateral column length. may cause injury to the dorsal talonavicu-
• Late sequelae—Arthrosis is common. Treat- lar joint complex. X-rays may show a dorsal

ment is by calcaneocuboid arthrodesis. Fu- fleck at the talonavicular joint capsule.
sion of the cuboid metatarsal joint should • Crush—see crush injury section.

not be attempted because results are rou- 3. Treatment—Early recognition is the key to a

tinely poor; this joint tends not to be symp- good outcome. If the joint is concentrically
tomatic. Interpositional arthroplasty may be reduced, then 6 weeks of casting can be initi-
effective as a salvage procedure. ated. Irreducible dislocations require open re-
3. Calcaneocuboid subluxation—Calcaneocuboid duction and possible excision versus internal

subluxation is seen predominantly in danc- fixation of fragments. Continued pain or insta-
ers; it results from overuse. The injury is self- bility may warrant future arthrodesis.
limited and is treated symptomatically with E. Tarsometatarsal (Lisfranc’s) Fracture-Dislocations

physical therapy and orthoses. 1. Anatomy of the tarsometatarsal joint

C. Cuneiform Fractures—Cuneiform fractures are (Fig. 14-7)—The tarsometatarsal joint comprises

rare, isolated injuries. They are usually found in the bases of the first through the fifth metatar-
conjunction with other high-energy injuries such sals; the medial, middle, and lateral cuneiforms;
as tarsometatarsal fracture-dislocations. Cu- and the cuboid. Joint stability is derived from
neiform fractures are frequently overlooked be- the “keystone effect” at the base of the second
cause of the more obvious adjacent pathologic metatarsal, which is recessed between the me-
condition. A bone scan is helpful in making the dial and the lateral cuneiforms. The bases of
diagnosis. Injuries surrounding this area are pre- the second through the fifth metatarsals are
dominantly ligamentous in nature and therefore bound together by dense interosseous liga-
require prolonged immobilization. Displaced ments (transverse metatarsal ligaments); the
fractures and dislocations are treated with ORIF. plantar ligaments are stronger than the dorsal
D. Midtarsal Joint Injuries ligaments. The medial cuneiform is joined to

1. These injuries occur between the talonavicular the second metatarsal base by a large stout

and calcaneocuboid joints. These injuries are plantar oblique ligament, or Lisfranc’s liga-
commonly missed initially in up to 30% of cases. ment. The transverse arch is stabilized by the
2. Classification is usually anatomic and based osseous configuration at the metatarsal bases

on the direction of force. and supporting structures such as the plantar
• Longitudinal force, usually from high-energy fascia, intrinsic muscles, and extrinsic tendons.

injuries, with the foot plantar flexed and an 2. Mechanisms of injury—There are two mecha-

axially based force on the metatarsal heads. nisms of injury: direct and indirect.
C h a p t e r 1 4 | I n j u r i e s o f t h e F o o t 201
• Direct forces—Direct forces are less com-

mon than indirect forces.
• Indirect forces

(a) Axial loading and loading with the foot

in a plantar-flexed position. Such forces
lead to predictable patterns of injury.
Continued loading leads to accentuation
of the longitudinal arch and destruction
Second metatarsal Transverse of the weak dorsal tarsometatarsal liga-
metatarsal
ligaments
ments with dislocation or avulsion frac-
tures of the metatarsal bases.
Medial cuneiform (b) A new mechanism of injury is arising

in collegiate and professional athletics
Lisfranc’s ligament probably due to shoe and turf changes.
With the foot planted and a rotational
force applied, diastasis at the medial cu-
neiform and second metatarsal occurs.
The energy then propagates between the
medial and middle cuneiform. This is im-
Figure 14-7 Tarsometatarsal articulation (plantar
portant to distinguish, as a screw should

view). Note the “keystone effect” at the base of the
second metatarsal. be placed through the Lisfranc ligament
and between the cuneiforms.
3. Classification—The

classification distin-
guishes the amount of rotation and force ap-
plied (Fig. 14-8).
Type A: Type B: Figure 14-8 Classification

Total incongruity Partial incongruity of tarsometatarsal fracture-
dislocations. L, lateral; M, medial.
L M L M
Lateral Medial Medial Lateral

dislocation dislocation dislocation dislocation
Type C:
Divergent
Lateral Medial
Total Partial
displacement displacement
4. Associated injuries—Because of the position treatment with low-energy injuries that are

of the foot, it is common to see metatarsal less than 1 week old.
neck fractures or metatarsophalangeal joint • Open reduction and internal fixation with

dislocations with indirect force injuries. Vas- solid or cannulated screws is the gold
cular injury is common and involves the standard. The base of the second metatar-
perforating branch of the dorsalis pedis sal should be reduced; this occasionally
artery. This can occasionally cause a com- requires debridement of a bone fragment
partment syndrome. or extraction of an incarcerated tibialis an-
5. Diagnosis—Physical examination demonstrates terior tendon (dorsal), peroneus longus

tremendous swelling, tenderness of the mid- tendon (plantar), or a portion of Lisfranc’s
foot, and ecchymosis. Abduction or pronation ligament. Once Lisfranc’s joint has been
stress to the forefoot elicits pain at the midfoot reduced, the remainder of the foot usually
in more subtle injuries. Motion of the second follows because of the attachments of the in-
metatarsal head frequently elicits midfoot pain. terosseous ligaments to the lesser metatar-
Compartment syndrome is possible. sals. (No intermetatarsal ligament exists
6. Radiography—High-energy Lisfranc’s injuries between the first and second metatarsals

are usually well demonstrated on plain radio- so they must be reduced independently).
graphs. However, these injuries may be subtle. Screw fixation (usually 3.5 or 4.0 mm) is
(There is a 20% reported incidence of missed recommended over pins to maintain proper
diagnoses on review of plain X-ray films.) At- position and prevent late loss of reduction,
tention should be directed toward the base especially with pure ligamentous injuries,
of the second metatarsal to detect a bony which require longer periods of healing.
avulsion, or “fleck sign,” signifying liga- An exception to this rule is the lateral
mentous disruption. In addition, the medial joint complex (metatarsals 4 and 5), which
border of the second metatarsal should should have motion maintained and which
align with the medial border of the middle is better treated with K-wires. Screws should
cuneiform on the anteroposterior plain ra- be left in place for at least 16 weeks before
diograph. Oblique films demonstrate align- removal.
ment of the medial border of the fourth • Primary arthrodesis may be used for older

metatarsal paralleling the medial border of patients, high-energy injuries with severely
the cuboid. Lateral view X-ray films should damaged articular surfaces, and potentially
reveal an unbroken line along the dorsum purely ligamentous injuries. In addition, in a
of the first and second metatarsals and recent randomized prospective study looking
the respective cuneiforms. Also, look for at outcomes between primary open reduction
opening at the plantar aspect of the first and internal fixation versus primary arthrode-
tarsometatarsal joint. Weightbearing antero- sis, the primary arthrodesis group had signifi-
posterior radiographs with corresponding cantly better outcome scores at 2 years. The
contralateral foot radiographs for comparison primary arthrodesis group had a 92% return
often reveal the unstable joint that has spon- to function while the ORIF group had 65% re-
taneously relocated. Stress radiographs may turn to function. Caution was advised at the
also be helpful in these instances. (Proper end of the paper arguing against performing
analgesia should be administered.) an arthrodesis on all Lisfranc injuries.
7. Treatment—Because of the poor outcome 8. Delayed diagnosis—Frequently, Lisfranc in-

associated with these injuries, even when juries are missed or overlooked because of
properly fixed early, aggressive treatment is other, more obvious skeletal injuries. Only
indicated. after the patient begins weightbearing may
• Nondisplaced stable fracture-disloca- this injury become symptomatic (sometimes

tions can be managed in a short leg cast 7 to 8 weeks after injury). In these cases, poor
with no weightbearing. ORIF is still the outcomes are the norm even after treatment,
gold standard for more than 1 to 2 mm of and consideration should be given to primary
displacement. arthrodesis of the medial column (the first
• Closed reduction and internal fixation is an through the third tarsometatarsal joints).

option but controversy exists as to its abil- 9. Late sequelae—Anatomic reduction is the

ity to properly align the tarsometatarsal best predictor of a good outcome. Even when
joints. This is a more reasonable method of properly treated in an appropriate and timely
fashion, the results of the treatment of Lis- Surgical correction should be consid-
franc’s injuries are poor, and there is a high ered for angulation greater than 10° in
rate of degenerative arthrosis (approximately any plane or displacement greater than
25%) and fixed deformity. Purely ligamentous 3 or 4 mm. Sagittal plane displacement
injuries tend to have a worse outcome. After is poorly tolerated. Plantar displace-
hardware removal, these injuries may “spring ment can give rise to excessive meta-
open.” Arthrodesis is a useful and reliable tarsal overload and may cause a painful
procedure and should include all involved plantar keratosis; excessive dorsal an-
tarsometatarsal joints except those at the gulation may lead to a prominence that
base of the fourth and fifth metatarsals, results in corns and shoe-wear prob-
which tend not to fuse reliably and lead lems. Transverse plane displacement is
to long-term pain. Pain arises predominantly better tolerated, although if it is great
from the joints of the medial column, and this enough, it can lead to intermetatarsal
can be confirmed by selective injections. impingement and neuroma formation.
• Post traumatic arthritis occurs in 25% of Reduction of a displaced metatarsal

injuries neck or shaft fracture may be performed
(a) Anatomical reduction is associated with open or closed. Longitudinal traction

a better radiographic and functional may be applied (Chinese finger traps)
outcome and manipulation performed. If the frac-
(b) There is a trend toward worse outcomes ture is stable, a cast may be applied, and

with purely ligamentous injuries management is the same as that for non-
displaced fractures. Unstable fractures
IV. Forefoot Injuries are treated operatively.

A. Metatarsal Fractures—The majority of metatar- (c) Irreducible fractures—Irreducible frac-

sal fractures are low-energy injuries, so an ortho- tures require open treatment. Direct
paedic surgeon is frequently not consulted. exposure of the fracture is performed,
1. Metatarsal neck and shaft fractures— and fixation is with crossed pins or mini

Metatarsal neck and shaft fractures usually fragment screws.
result from direct trauma but less commonly (d) Multiple metatarsal fractures—Multiple

can occur as a stress fracture. metatarsal fractures are unstable inju-
• Diagnosis—The history is compatible with ries that generally occur as the result

either direct trauma or pain from repetitive of higher-energy trauma. (Soft-tissue
use. Traumatic injuries are often associ- complications can occur.) Attempts at
ated with focal swelling and tenderness that closed manipulation may be successful,
can increase significantly when there are and if they are, the fracture may be held
multiple fractures, leading to compartment with K-wire fixation. If it is not reducible
syndrome. using closed means, ORIF is performed
• Radiography—The lateral foot radiograph with K-wires, mini fragment screws, or

is most important for detecting a sagittal plate fixation.
plane deformity, which will be the most (e) Metatarsal fractures with bone loss—

symptomatic. Maintenance of length is important, es-
• Treatment pecially if there are multiple metatarsal

(a) Nondisplaced fractures—The majority fractures. Transfixation pins from the

of nondisplaced fractures are treated head of the involved metatarsal to the
conservatively with shoe wear modi- adjacent stable metatarsal head, or ex-
fication, casts, or a hard-soled shoe, ternal fixation, are useful. Open bone
with activity modification advancing to grafting is performed when the soft tis-
weightbearing as tolerated. Overtreat- sues allow. Failure to maintain length
ment should be avoided. Protected im- can result in abnormal loading and the
mobilization or nonweightbearing can development of painful keratoses.
give rise to late sequelae such as osteo- (f) Nonunions—Nonunions generally oc-

penia, atrophy, and reflex sympathetic cur in proximal metatarsal fractures.
dystrophy (RSD). They are frequently hypertrophic and
(b) Displaced fractures—No absolute indi- asymptomatic and therefore need no

cations for operative intervention exist. treatment. For symptomatic metatarsal
nonunions, open bone grafting is gener- that the fracture occurs at the insertion of
ally successful. the ligament at the base of the fifth meta-
(g) First metatarsal fractures—The first tarsal, which acts as a tether. The fracture

metatarsal is integral in maintenance fragment is proximal to the tuberosity and
of the medial column and supports is contained within the attachment of the
one-third of the forefoot’s pressure. If peroneus brevis.
malunion occurs then transfer meta- (a) Treatment—Treatment involves weight

tarsalgia and further collapse of the bearing as tolerated in a hard-soled
medial column may occur. Therefore, shoe. These fractures typically are clini-
displaced first metatarsal fractures cally healed by 3 to 4 weeks.
should undergo ORIF. (b) Nonunion—Nonunion is rare, but if

(h) Open metatarsal shaft fractures require symptomatic, it can be treated with ex-

open reduction and internal fixation cision of the fragment.
usually with K-wires to allow stability • Zone II—Metaphyseal–diaphyseal junction

for soft-tissue healing. fractures (Jones fracture) can arise as a re-
2. Metatarsal head fractures—Metatarsal head sult of acute trauma or chronic stress (more

fractures are rare injuries and are usually the common). The fracture occurs in a water-
result of direct trauma. shed zone, which leads to a delay in healing
• Associated injuries—The clinician should or nonunion. It is important to distinguish be-

rule out tarsometatarsal joint injuries and tween the acute and chronic Jones fracture.
proximal metatarsal fractures. Radiographs of the foot will characterize
• Deforming forces—Displacement is usually the fracture. Bone scans may be important

plantar and lateral. to evaluate for an impending stress fracture.
• Treatment—Manipulation with traction is The incidence of delayed union and non-

often successful; if the fracture is unstable, union is relatively high. Hypertrophic non-

interosseous pinning may be necessary. Frac- unions may be treated with intramedullary
tures devoid of soft-tissue attachments may screw fixation if the medullary canal is still
require ORIF. Symptomatic osteochondral open. If the medullary canal is sclerotic or
lesions may require open debridement. the nonunion is atrophic, open inlay bone
• Complications and late sequelae—Stiffness grafting is necessary. Results are generally

and arthritis occur; osteonecrosis has not good.
been reported. (a) Nonoperative treatment of acute

3. Fractures of the proximal fifth metatarsal fracture—A short leg nonweightbear-

(Fig. 14-9): ing cast is worn for 6 to 8 weeks. The
• Zone I—Avulsion fractures occur when the patient then may transition to a fracture

peroneus brevis contracts against a sud- boot. It is common for the fracture to
den inversion stress. Another theory is take 3 months or more to heal.
FIGURE 14-9 Lateral forefoot and the important

soft-tissue-supporting structures inserting on the
proximal fifth metatarsal.
Peroneus tertius
tendon
Peroneus brevis
tendon
Lateral band of
plantar fascia
(b) Operative treatment of acute fracture— flexor tendons laterally and the lumbricals

Highly competitive athletes are treated medially. These injuries may require open
with single intramedullary screw fixa- reduction with division of the transverse
tion because inactivity is debilitating metatarsal ligament and the plantar plate.
and the refracture rate is higher in this • Specific injuries

population. (a) Metatarsophalangeal joint disloca-

• Zone III—Diaphyseal fractures (Dancer’s tions—The most common site of

fractures) result from a rotation injury. dislocation in the lesser toes is the
Treatment is with shoe-wear modifica- metatarsophalangeal joint.

tions or casting with weightbearing as (b) Recurrent, chronic metatarsophalangeal

tolerated in acute fractures. Union may joint dislocations—Recurrent disloca-
take up to 20 weeks. tion of the metatarsophalangeal joint re-
B. Toe Injuries quires a dorsal metatarsophalangeal joint

1. Phalangeal fractures—Phalangeal fractures capsulotomy and split flexor-to-extensor

occur most commonly in the proximal pha- tendon transfer (Girdlestone-Taylor pro-

lanx and most often in the fifth toe. The most cedure). If arthrosis or plantar callus-
common mechanism of injury is direct trauma ing is present, resection arthroplasty of
(stubbing). the metatarsal heads or the base of the
• Treatment proximal phalanx is necessary.

(a) Nondisplaced fractures—Treatment con (c) Interphalangeal joint dislocations—

sists of symptomatic management of Dislocations of the interphalangeal joint
pain and swelling and usually requires are rare; closed reduction and buddy-
only shoe-wear modifications. taping is usually successful. Chronic
(b) Displaced fractures—They tend to dis- problems require resection arthro-

place with plantar apex angulation. Dis- plasty, which may be combined with
placed fractures are often amenable to syndactylization.
manipulation; digital block is sufficient 3. Hallux interphalangeal dislocations—Hallux

anesthesia. Once properly aligned, the interphalangeal dislocations result from di-
toe is buddy-taped to the adjacent toe. rect trauma or push-off. They are often irre-
Firm-soled shoes or sandals are used ducible. Treatment requires open reduction
until symptoms abate. with removal of the entrapped plantar plate
(c) Open fractures—Treatment involves lo- and the interphalangeal sesamoid if present.

cal incision and drainage with primary Joint stiffness is a common long-term sequela.
closure and management as previously 4. Turf toe injuries—Injury of the plantar plate

discussed. and sesamoid complex (Fig. 14-10).
(d) Intra-articular fractures—Intra-articular • Mechanism—Seen in push off sports with

fractures usually involve the condyle hyperextension of the first MTP. May also be
at the base of the phalanx. They may seen with posterior axial force on the heel
require open treatment and K-wire fixa- causing a hyperextension of the MTP
tion. Failure to treat may lead to joint • Presentation—Painful, swollen first MTP

subluxation or painful arthrosis requir- joint with pain reproduced with passive hy-
ing resection arthroplasty. perextension. May have increased anterior
2. Lesser toe dislocations drawer of the first MTP.

• Mechanism—A stubbing injury causes hy- • X-rays—Demonstrate concentric reduction of

perdorsiflexion with a residual dorsal and the joint. Significant findings are proximal mi-
lateral deformity. The plantar plate is in- gration of the sesamoids. Increased diastases
jured, and the toe is displaced proximally. of a bipartite sesamoid or a sesamoid fracture
• Treatment—Manual reduction is usually suf- are common findings. Stress views will show

ficient for simple dislocations. Buddy-taping a lag of the sesamoid as the toe extends.
is used for 1 to 2 weeks. Complex disloca- • Treatment

tions of the metatarsophalangeal joints oc- (a) Nonoperative—Plantar flexion taping.

cur when the plantar capsule (and plantar Rigid orthotic. Rest.
plate) and the deep transverse metatarsal (b) Operative—Excision or bone grafting of

ligament are displaced over the head of the the sesamoid and repair of the plantar
metatarsal and become trapped between the plate complex.
This section deals with compartment syndrome

of the foot; however, many of the principles are
the same as for compartment syndrome of other
parts of the body. Compartment syndrome of the
foot commonly results from a crush injury.
B. Anatomy—There are five major foot compart-

ments: medial, lateral, central, interosseous, and
calcaneal; at least nine have been reported using
injection studies. Each compartment has sepa-
rate and distinct boundaries. The calcaneal com-
partment communicates with the deep posterior
compartment of the leg through an opening for
tendinous and neurovascular structures behind
the medial malleolus.
C. Diagnosis—Diagnosis is less specific than for

compartment syndrome of the forearm and leg.
(Symptoms of pain on passive stretch, pain out
of proportion with the severity of injury, and
dysesthesia are less reliable indicators.) A high
index of suspicion is necessary in the patient
with a tense swollen foot. Confirmation of the di-
agnosis may be made by compartment pressure
measurement. (Abnormal values are the same as
those for the other compartments of the body:
pressure within 30 mm Hg of the systemic dia-
stolic pressure.)
D. Treatment—Treatment involves fasciotomy. The

FIGURE 14-10 Turf toe injuries. (Reprinted with technique and approach are determined by asso-
ciated osseous or soft-tissue injuries. The classic

permission from Pedowitz WJ, Pedowitz DI. Hallux valgus
in the athlete. In: Johnson DH, Pedowitz RA, eds. Practical description is two dorsal incisions and one
Orthopaedic Sports Medicine & Arthroscopy. Philadelphia: medial incision. When associated with a Lis-
Lippincott Williams & Wilkins, 2007: 922.) franc injury or metatarsal fractures, two dorsal
incisions along the second and fourth metatar-
sals allow access to all compartments. When no
C. Lawnmower Injuries—Lawnmower injuries usu- dorsal repair is required or trauma is limited to

ally occur when children play too close to a the hindfoot, a plantar medial approach provides
lawnmower or adults attempt to cut grass on an access to all compartments. Fasciotomy incisions
inclined wet surface. They usually result in much are initially left open for 5 to 7 days, and either a
tissue destruction. primary repair is performed or a split-thickness
1. Treatment—Aggressive debridement is im- skin graft is used for coverage. Splint, do not

perative because these injuries tend to be cast compartment syndromes or one can com-
highly contaminated. Multiple trips to the promise limb viability.
operating room and multiple procedures are E. Sequelae—Sequelae include late contractures;

often necessary. Early skin grafting is often claw toes are the most common because of the
helpful after bony stabilization. loss of function of the intrinsic muscles. A cavus
2. Antibiotic coverage—A first-generation cepha- foot may also occur. Treatment is directed at the

losporin and an aminoglycoside should be ad- specific deformity. Reconstructive procedures are
ministered. If the wound is contaminated with more reliable than simple soft-tissue releases.
dirt (or other contaminants), a penicillin-class
drug should be added. VI. Complex Regional Pain Syndrome (Formerly RSD)

A. Definition—CRPS is a pain syndrome that occurs

V. Compartment Syndrome with trophic changes of the involved extremity. It

A. Overview—Compartment syndrome results from is believed to be caused by inappropriate hyper-

increased tissue pressure within one or more of activity of the sympathetic nervous system. This
the tight osseofascial compartments of the body. section deals with CRPS of the foot; however,
many of the principles are the same as for CRPS D. Diagnosis—The clinical findings have been de-

of other parts of the body. scribed above. They can occur after a relatively
B. Clinical Syndrome—The classic presentation mild injury. Radionuclide studies may be helpful,

involves distal extremity pain associated with particularly with the presence of diffuse periar-
smooth, shiny skin; diffuse swelling; abnormal ticular uptake in the third phase of a triple-phase
skin color and temperature; allodynia (hyper- technetium bone scan. Sympathetic blockade is
sensitivity); and joint pain and tenderness. the diagnostic study of choice. The response is
Radiographs demonstrate osteopenia (especially monitored based on pain sensation and pinprick,

periarticular) and a moth-eaten appearance of motor function, skin temperature, and blood
the bone. Not all signs and symptoms are uni- pressure fluctuations. In true RSD, the response
formly present. There are three stages. to the blockade outlasts the return of somatic
1. Stage I (,3 months)—In Stage I, pain is out sensation.

of proportion to the original injury; the skin E. Treatment—The best results occur when treat-

temperature changes; and allodynia, guard- ment is initiated early, so the key is a prompt
ing, and edema occur. diagnosis. The basis for treatment is to interrupt
2. Stage II (3 to 9 months)—In Stage II, tro- sympathetic nerve function. A multidisciplinary

phic changes lead to stiffness and abnor- treatment regimen is vital and should address
mal posturing of the limb. Abnormal color the psychologic components of the problem as
and sweating may be present. Radiographs well.
reveal osteopenia, and a bone scan demon- 1. Pharmacologic therapy—Nonsteroidal anti-

strates increased uptake, especially diffuse inflammatory drugs, calcium channel block-

periarticular uptake. ers, alpha- and beta-adrenergic blocking

3. Stage III (.1 year)—In Stage III, the limb be- agents, serotonin antagonists, and antidepres-

comes cool and undergoes skin color, texture, sants have all been used for symptom man-
and temperature changes. Joint stiffness be- agement. The best results for RSD of the foot
comes more significant, and contractures are are usually obtained by sympathetic blockade
common. via a series of lumbar injections. If this treat-
C. Pathophysiology—The abnormal response to ment is ineffective, the diagnosis must be

pain is caused by persistent sympathetic tone, questioned. Regional blocks can also be effec-
which stimulates primary afferent nociceptors tive. Sympathetic antagonists (e.g., reserpine,
in normal and damaged peripheral tissues. An guanethidine, and phentolamine) are some-
abnormal feedback cycle is initiated and ex- times effective.
pands to involve more normal tissues. Exces- 2. Physical therapy—Physical therapy is the

sive sympathetic tone increases the amount of first-line treatment; it restores motion and
edema and causes impaired capillary flow, isch- increases pain tolerance. Tactile desen-
emia, and pain. It also prevents the removal of sitization, gentle assistance with exercise,
ischemic by-products from the injured site. This transcutaneous electric nerve stimulation,
stimulates further sympathetic flow and an ever- whirlpool, massage, and contrast baths are
increasing feedback loop. effective. Aggressive or forceful manipulation
1. Central nervous system involvement (gate can aggravate the hypersensitivity. Compres-

theory)—Pain sensation is regulated in the sion stockings are helpful for edema control.
spinal cord; small afferent Type C fibers trans- 3. Surgical sympathectomy—Sympathectomy

mit pain sensation, thus “opening the gate.” may be indicated when pharmacotherapy pro-
These fibers can be inhibited by small cells in vides only transient but significant relief.
the substantia gelatinosa. Large afferent Type
A fibers stimulate the substantia gelatinosa fi- VII. Crush Injuries of the Foot—Crush injuries occur

bers that block central pain stimulators, thus when extrinsic compressive or shear force is ap-
“closing the gate.” Modalities such as physi- plied to the foot over a variable period. Persistent
cal therapy, transcutaneous electrical stimu- neuritis is the number one reason for a poor out-
lation, and massage stimulate Type A fibers. come following a crush injury.
2. Peripheral nervous system involvement— A. Types—There are four types: compressive, con-

Experiments have shown that damaged nerves tusion, shear/degloving, and mangling.
respond to sympathetic activity. Prostaglan- 1. Compressive—A compressive injury involves

din is released in response to norepinephrine fracture or dislocation with or without a
release at sympathetic terminals. break in the soft-tissue envelope.
2. Contusion—A contusion is a closed soft- performed. The most common organism is

tissue injury predominantly involving the S. aureus; Pseudomonas aeruginosa is the

skin and subcutaneous tissue without frac- most characteristic organism.
ture or dislocation. 3. Late sequelae—Late sequelae include osteo-

3. Shear/degloving—Shear/degloving involves myelitis and gas gangrene.

a soft-tissue avulsion caused by the applica- 4. Miscellaneous—It is important to look at

tion of tangential force to the foot surface. the patient’s overall health status as well
4. Mangling—Mangling involves marked disrup- as the mechanism. In a healthy person with

tion of the bones and soft tissues. a puncture wound, local debridment with
B. Evaluation—Neurovascular status is deter- antibiotic coverage is adequate. When the

mined by physical examination, and osseous puncture occurs through the sole of a shoe
structures are evaluated via radiographic stud- beware of pseudomonas and treat appropri-
ies. The soft tissues are evaluated, and the com- ately. If the wound fails to respond then MRI
partment pressures are measured. is recommended to rule out osteomyelitis
C. Treatment and a surgical debridment is performed.

1. Appropriate and aggressive soft-tissue Diabetic patients often have a delayed pre-

debridement sentation due to neuropathy. If seen in a de-

2. Rigid fracture fixation layed fashion an MRI is again recommended

3. Fasciotomies when there is compartment to rule out osteomyelitis or a deep abscess.

syndrome If osteomyelitis is present, irrigation and de-
4. Early soft-tissue coverage, preferably within bridement versus partial/complete amputa-

48 hours tion must be considered.
5. Split-thickness skin excision (to treat and

evaluate for acute soft-tissue necrosis)—
Split-thickness skin excision is performed in
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PART II T H E P E LV I S A N D A C E TA B U L U M
CHAPTER 15
Pelvic Ring Injuries

David J. Hak
PELVIC FRACTURES 4. Sacrospinous ligament—Runs from the lateral

edge of the sacrum and coccyx to the sacrotu-
I. Anatomy berous ligament and inserts on the ischial spine.
A. Ring Structure of Three Bones—Two innominate Triangular in shape. Separates the greater and
bones and the sacrum. Innominate bone is formed lesser sciatic notches.
by fusion of three ossification centers—ilium, 5. Iliolumbar ligaments—Run from L4 and L5
ischium, and pubis. transverse processes to the posterior iliac crest
B. Sacroiliac (SI) Joint is Comprised of Two Parts: stabilizing the spine to pelvis.
1. Articular portion—Located anteriorly. Not a 6. Lumbosacral ligaments—Run from L5 trans-
true synovial joint. Articular cartilage on sacral verse process to the sacral ala.
side. Fibrous cartilage on iliac side. D. Pubic Symphysis
2. Fibrous or ligamentous portion—Located 1. Hyaline cartilage on medial (articular) aspect
posteriorly. of pubis.
C. Ligaments 2. Surrounded by fibrocartilage and a thick band
1. Posterior SI ligaments—Considered to be the of fibrous tissue.
strongest ligaments in the body (Fig. 15-1). E. The iliopectineal line (pelvic brim) separates the
• Short component—Oblique fibers that run from false pelvis (above) from the true pelvis (below).
the posterior ridge of the sacrum to the pos- 1. False pelvis—Iliac wings and sacral ala; sur-
terosuperior and posteroinferior iliac spines. rounds the intra-abdominal contents; contains
• Long component—Longitudinal fibers that iliacus muscle.
run from the lateral sacrum to the postero- 2. True pelvis—Pubis, ischium and small portion
superior iliac spines; merges with sacrotuber- of ilium; contains floor of true pelvis (coccyx,
ous ligament. coccygeal and levator ani muscles, urethra,
2. Anterior SI ligaments—Runs from ilium across rectum, vagina) and obturator internus muscle.
sacrum (Fig. 15-2). F. Neural Structures
3. Sacrotuberous ligaments—Strong band running 1. Sciatic nerve—Formed by roots from the lum-
from posterolateral sacrum and dorsal aspect bosacral plexus (L4, L5, S1, S2, S3). Exits the
of the posterior iliac spine to the ischial tuber- pelvis deep to the piriformis muscle.
osity. Along with the posterior SI ligaments, 2. Lumbosacral trunk—Formed from anterior
these ligaments maintain vertical stability of rami of L4 and L5, crosses the anterior sacral
the pelvis (Fig. 15-3). ala and SI joint. Fractures of the sacral ala or
210
C H A P T E R 1 5 | P E L V I C R I N G I N J U R I E S 211
Posteriosuperior dislocations of the SI joint are most likely to

iliac spine injure the lumbosacral trunk.
Interosseous
3. L5 nerve root—Exits below L5 transverse pro-
sacroiliac ligaments cess and crosses the sacral ala 2 cm medial to
the SI joint. May be injured during anterior
approach to the SI joint.
G. Vascular Structures
1. Median sacral artery—Continuation of the
aorta, which travels along the vertebral column.
Small caliber and not of major significance.
2. Superior rectal artery (hemorrhoidal artery)—
Continuation of the superior mesenteric artery.
Rarely involved in pelvic trauma.
3. Common iliac artery—Divides into internal and
FIGURE 15-1 Cross section through the sacroiliac joint, external iliac arteries.
showing the direction of the interosseous sacroiliac 4. Internal iliac artery (hypogastric artery)—
ligaments. Major importance in pelvic trauma.
• Anterior division
(a) Inferior gluteal artery—Exits the pelvis
through the greater sciatic notch inferior
to the piriformis (between piriformis
Iliolumbar ligament and superior gamelli). Supplies the
gluteus maximus.
Anterior (b) Internal pudendal artery—Crosses the
SI ligament ischial spine and exits through the lesser
sciatic notch. Commonly injured in pelvic
fractures.
Sacrospinous (c) Obturator artery—May be disrupted in
ligament pubic rami fractures.
• Superior vesical artery—A branch of
the obturator artery that supplies the
bladder.
Sacrotuberous (d) Inferior vesical.
ligament (e) Middle rectal artery.
FIGURE 15-2 Anterior view of the pelvis showing the • Posterior division
anterior SI ligament and the sacrospinous ligaments (a) More prone to damage due to posterior
that is a strong triangular ligament anterior to the pelvic displacement.
sacrotuberous ligament. (b) Superior gluteal artery—Largest branch
of the internal iliac artery. Courses across
Posterior SI FIGURE 15-3 Posterior view of the pelvis

ligament Iliolumbar ligament showing the posterior sacroiliac ligament,
iliolumbar ligament, sacrospinous ligament and
the sacrotuberous ligament.
Sacrotuberous
ligament Sacrospinous
ligament
212 S E C T I O N I I | A D U L T T R A U M A P A R T I I | T H E P E L V I S A N D A C E T A B U L U M
the SI joint, and exits through the greater • Female urethra—Short, not rigidly fixed to
sciatic notch superior to the piriformis. pubis or pelvic floor, more mobile and less
Supplies gluteus medius, gluteus mini- susceptible to injury from shear forces.
mus, and tensor fascia lata muscles. Most 2. Urethral injuries—More common in males.
commonly injured vessel in pelvic frac- Stricture is the most common complication
tures with posterior ring disruptions. seen in patients sustaining a urethral in-
Can be injured in obtaining a posterior jury. Impotence may be present in 25% to 47%
iliac crest bone graft if you stray infe- of patients with urethral rupture. Cause is un-
riorly. Can also be injured when passing certain but is probably due to damage to para-
a gigli saw through the sciatic notch dur- sympathetic nerves (S2 to S4).
ing a pediatric innominate osteotomy. • Obtain retrograde urethrogram to rule out
(c) Iliolumbar artery. urethral injury prior to insertion of a Foley
(d) Lateral sacral artery. catheter if there is anterior pelvic disrup-
5. Corona mortis (Fig. 15-4) tion or any sign of urethral injury.
• Common anastomosis between the obturator • Signs of urethral injury: (a) inability to void
and external iliac systems. Incidence: venous despite a full bladder, (b) blood at the urethral
anastomosis (70%), arterial anastomosis meatus (c) high-riding or abnormally mobile
(34%), venous and arterial anastomosis (20%). prostate, and (d) elevated bladder on IVP.
• Crosses the superior pubic ramus in a verti- • Absence of meatal blood or a high-riding
cal orientation at an average of 6.2 cm (range, prostate does not rule out urethral injury.
3 to 9 cm) from the pubic symphysis. • Passing a Foley may turn a small perforation
• If accidentally cut, the vessels may retract in- into a large perforation.
feriorly into the obturator foramen and cause I. Bladder
serious bleeding. 1. Anatomy
6. Pelvic veins—Massive venous plexus that drain • Males—Bladder neck is attached to the pubis
into the internal iliac vein. Major source of by puboprostatic ligaments and is contigu-
hemorrhage in most pelvic fractures. ous with the prostate.
H. Urethra • Females—Bladder lies on the pubococcygeal
1. Anatomy portion of levator ani muscles.
• Male urethra has three portions—Prostatic, • Superior and upper posterior portion of the
membranous, and bulbous. Bulbous ure- bladder are covered by peritoneum.
thra is located inferior to the urogenital dia- • Remainder of the bladder is extraperitoneal
phragm; if ruptured retrograde urethrogram and covered with loose areolar tissue. Space
dye extravasates into the perineum. of Retzius is located anteriorly.
2. Bladder injuries
• May be caused by bony spicules from pubic
rami fractures, blunt force injuries causing
rupture, or shearing injuries.
• Intraperitoneal ruptures—Require operative
repair.
• Extraperitoneal ruptures—Managed nonop-
Rectus abdominis eratively unless undergoing ex lap for other
muscle reasons or a bony spicule invading the blad-
der. Catheter drainage and broad-spectrum
antibiotics. Cystogram prior to catheter re-
Inferior epigastric a. moval to verify healing. About 87%, healed
by 10 days. Virtually all healed by 3 weeks.
II. Evaluation
Corona mortis A. History
1. Mechanism of injury determines energy of in-
Obturator a.
jury and likelihood of associated injuries.
2. Low-energy injuries
FIGURE 15-4 Schematic drawing showing the arterial • Occur in elderly osteoporotic patients as a
and venous anastomsis between the external iliac and result of a fall from standing height. Treat-
obturator systems known as the corona mortis. ment: analgesia, weight bearing as tolerated.
• Stress fractures may occur without an iden-
tified fall. Bone scan is useful for diagnosis.
3. High-energy injuries
• Common mechanisms are motor vehicle ac-
cidents (MVA), motorcycle accidents, pedes-
trian versus MVA, or fall from height.
• Associated injuries are common.
• High incidence of hemorrhage and hypovo-
lemic shock.
• Require emergent evaluation and treatment.
B. Physical Examination
1. First priority is to assess for other life-threat-
ening injuries using Advanced Trauma Life
Support (ATLS) protocols. FIGURE 15-7 Outlet view of pelvis.
2. Bimanual compression and distraction of the
iliac wings.
3. Manual leg traction can aid in determination of
C. Radiographic Examination
vertical instability.
1. Anteroposterior pelvis (Fig. 15-5)—Part of the
4. Careful palpation of the posterior pelvis in awake
initial trauma series along with a chest and
patients can identify posterior pelvic injuries.
lateral cervical spine X-ray. Can identify up to
5. Rectal examination—High-riding prostate may
90% of pelvic injuries.
indicate urethral tear. Positive guaiac test
2. Pelvic inlet view (Fig. 15-6)—40° to 45° caudal
may indicate visceral injury. Palpation of the
tilt. Shows anterior–posterior displacement.
sacrum for irregularity.
3. Pelvic outlet view (Fig. 15-7)—40° to 45° ceph-
6. Vaginal examination—Bleeding or lacerations
alad tilt. Shows superior–inferior displace-
indicating open fractures.
ment and visualizes the sacral foramen.
7. Perineal skin—Lacerations may indicate open
4. CT scan—Provides best visualization of the
fracture. May be caused by hyperabduction of
SI joint. May identify sacral fractures not well
the leg.
visualized on plain films.
5. Lateral sacral view—Identifies transverse
sacral fractures.
D. Abdominal Injury Evaluation
1. Computed tomography (CT) scan—Extravasation
of contrast can also aid identification of associ-
ated arterial injuries.
2. Ultrasound—Focused Abdominal Sonogram for
Trauma (FAST)—Widely used to evaluate for
intra-abdominal fluid and solid organ injuries.
3. Diagnostic peritoneal lavage (DPL)—If a pel-
vic fracture is present the location should be
supraumbilical to avoid a false positive result
FIGURE 15-5 Anterior posterior view of pelvis. due to a pelvic hematoma.
III. Classification
A. Tile Classification (Table 15-1 and Figs. 15-8 to
15-11)
1. Combines mechanism of injury and stability
• Type A: stable
• Type B: rotationally unstable
• Type C: vertically unstable
2. Aids in determining prognosis and treatment
options.
B. Young and Burgess Classification (Table 15-2)
1. Based on mechanism of injury
• Anterior–posterior compression
FIGURE 15-6 Inlet view of pelvis. • Lateral compression
TA B L E 1 5 - 1
Tile Classification
Type A Stable pelvic fractures
Type A1 Typically an avulsion fracture
Pelvic ring intact
Type A2 Nondisplaced pelvic ring fracture
Type A3 Transverse fractures of sacrum and coccyx
Pelvic ring intact
Type B Rotationally unstable, vertically stable
Type B1 Anterior–posterior compression injury
“Open book” pelvic fractures
Divided into three stages:
Stage 1: Pubic symphysis diastasis 2.5 cm
No involvement of posterior pelvic ring
Unilateral posterior pelvic ring injury
Bilateral posterior pelvic ring injuries
Type B2 Lateral compression injury—Ipsilateral
The rami are commonly fractured anteriorly
The posterior complex is crushed
Type B3 Lateral compression—Contralateral (bucket handle)
The major anterior lesion is usually on the opposite side of the posterior lesion, but all four rami may
be fractured anteriorly
The affected hemi-pelvis rotates anteriorly and superiorly (like the handle of a bucket)
Flexion of hemi-pelvis results in leg length discrepancy
Reduction requires derotation of hemi-pelvis
Usually caused by a direct blow on the iliac crest
Type C Rotationally and vertically unstable
Type C1 Ipsilateral anterior and posterior pelvic injuries
Type C2 Bilateral hemi-pelvic disruptions
Type C3 Any pelvic fracture with an associated acetabular fracture
• Vertical shear 3. Type III—Complete disruption of the SI joint

• Combined mechanism (including the posterior SI ligaments) with dis-
2. A spectrum of associated injuries is produced placement of the hemipelvis.
based on the direction and magnitude of the
injury force. IV. Pelvic Stability
3. Alerts surgeon to potential resuscitation A. Decision Making (operative versus nonoperative,
requirements and associated injury patterns. weight bearing status) is based on pelvic stabil-
C. Bucholz Classification—Based on severity of pos- ity and degree of displacement.
terior pelvic ring injury. 1. Stable pelvis is defined as a pelvis that can
1. Type I—Anterior ring injury, stable or intact withstand normal physiological forces with-
posterior ring (may have a nondisplaced sacral out deformation.
fracture or injury to the anterior SI ligaments). 2. Pelvic instability has two components—
2. Type II—Anterior ring injury along with partial Rotational instability and vertical instability.
disruption of the SI joint, but the posterior SI 3. Associated bony injuries may mimic pure liga-
ligaments remain intact. mentous injuries and lead to pelvic instability.
A1 A2 A3
FIGURE 15-8 Tile classification of pelvic fracture. Type A1 avulsion fracture. Type A2 nondisplaced pelvic ring fracture.
Type A3 transverse sacral or coccyx fracture.
B1- stage 1 B1- stage 2 B1- stage 3
FIGURE 15-9 Tile classification of pelvic fracture. Type B1, stage 1 symphysis pubis disruption. Type B1, stage 2
symphysis pubis disruption. Type B1, stage 3 symphysis pubis disruption.
B2 B3 FIGURE 15-10 Tile classification of pelvic

fracture. Type B2 lateral compression
injury (ipsilateral). Type B3 lateral
compression injury (contralateral).
C1 C2 C3
FIGURE 15-11 Tile classification of pelvic fracture. Type C1 pelvic injury. Type C2 pelvic injury. Type C3 pelvic injury.
TA B L E 1 5 - 2
216
Young and Burgess Classification of Pelvic Ring Injuries

Classification Associated Injuries Subclassification Radiographic/Anatomic Features Treatment/Comments
APC Increased incidence of APC Type I Symphysis widened 1–2 cm Usually treated nonoperatively
brain, abdominal, SI ligaments intact 6.5% pelvic vascular injury
visceral and pelvic
vascular injuries
Death is usually due to APC Type II Symphysis widened 2 cm Emergent external fixator for hemodynamic
hemorrhage from Anterior SI ligaments disrupted instability
visceral and pelvic May be definitively treated in external fixator
Sacrotuberous ligaments ruptured
vascular structures or by symphysis plating
Posterior SI ligaments intact
10% pelvic vascular injury
Death is usually due to APC Type III Complete separation of hemipelvis from APC-III is the most common severe injury seen
hemorrhage pelvic ring (no vertical displacement in pedestrians
from visceral and as seen in LC-III) Greatest 24-h fluid resuscitation requirements

pelvic vascular
structures Emergent external fixator for hemodynamic
instability
Definitive fixation requires both anterior and
posterior fixation
LC High incidence of LC Type I Anterior pelvic ring injury Usually result from a MVA
associated brain and Impaction of sacrum on side of injury Usually treated nonoperatively—weight bear-
abdominal injuries ing on unaffected side
Death usually related to Occasionally external fixator applied for hemo-
brain injury rather dynamic instability or to permit early mobi-
than hemorrhage lization in polytrauma patient
LC Type II Anterior pelvic ring injury Usually result from a MVA
“Crescent fracture” of iliac wing or near Emergent external fixator for hemodynamic
SI joint instability
Definitive treatment with internal fixation
P A R T I I | T H E P E L V I S A N D A C E T A B U L U M
LC Type III LC-I or LC-II on side of injury, with LC-III injuries usually occurs as a result of a
addition of open book type injury of SI crush, and injuries are usually isolated to
joint on opposite side the pelvic region—brain, lung, spleen, or
liver injuries are not seen or rare
Pelvic ring internally rotated on injury Emergent external fixator for hemodynamic
side, opposite side is externally instability
(continued) rotated Definitive treatment with internal fixation
VS Associated injuries Vertical displacement of hemipelvis Usually occurs as a result of a fall
similar to LC Usually occurs as rupture of SI joint, but Emergent external fixator for hemodynamic
occasionally occurs as fracture through instability
sacrum or ilium Traction acutely if patient hemodynamically
stable
Definitive treatment with internal fixation
Combined Combination of LC and VS, or LC and APC Emergent external fixator for hemodynamic
Mechanism instability
Definitive treatment based on primary
component of injury
APC, Anterior–Posterior Compression; LC, Lateral Compression; VS, Vertical Shear.
C H A P T E R 1 5 | P E L V I C R I N G I N J U R I E S
217
4. Common radiographic signs of pelvic • APC-III or Tile C injury—Superior gluteal

instability: artery is most commonly injured.
• Displacement of the posterior SI complex • LC pattern—Obturator artery or a branch of
greater than 5 mm in any plane the external iliac artery are most commonly
• Presence of posterior fracture gap, rather injured.
than impaction C. Open pelvic fractures—High mortality rate (30%
• Avulsion of the L5 transverse process or the to 50%). Potential for major vascular injury
sacral ischial end of the sacrospinous process with hemorrhage. High incidence of gastroin-
5. Intraoperative traction/stress examination may testinal and genitourinary injuries. May require
occasionally be required to determine stability. diverting colostomy for intestinal injuries. Re-
B. Ligament Sectioning Studies quires aggressive multidisciplinary treatment.
1. Sectioning of the pubic symphysis results in pubic
diastasis less than 2.5 cm, but the intact sacrospi- VI. Emergent Treatment
nous ligaments prevents further displacement. A. Pelvic Binder—Commercial device that can be
The pelvis is rotationally and vertically stable. used for prehospital and emergent stabilization
2. Sectioning of the pubic symphysis and sacro- of pelvic fractures. In APC (“open-book”) frac-
spinous ligaments results in pubic diastasis tures, use of a pelvic binder will close the ring
greater than 2.5 cm. Further external rotation and tamponade venous bleeding. Prolonged
of the hemipelvis is limited by the posterior use is associated with skin necrosis complica-
iliac spine abutting the sacrum. The pelvis is tions. An improvised binder can be made using
rotationally unstable, but vertically stable. a sheet to provide circumferential compression
3. Section of the pubic symphysis, sacrospinous, around the pelvis.
sacrotuberous, and posterior SI ligaments B. Medical Antishock Trousers (MAST)—Commonly
causes the pelvis to become both rotationally used in the past for prehospital stabilization—
and vertically unstable. now mostly replaced by use of a pelvic binder.
Complications include limited access for exam,
V. Associated Injuries decrease lung expansion, and may contribute to
A. High-Energy Injuries Commonly Have Associated lower extremity compartment syndrome.
Injuries C. Skeletal Traction—May be used to correct verti-
1. Major central nervous system, chest and cal displacement of the hemipelvis.
abdominal injuries D. Resuscitation of Patients in Hypovolemic Shock
2. Hemorrhage 75% 1. Two large bore intravenous lines (16G or
3. Associated musculoskeletal injuries 60% to 80% larger) in the upper extremities. Lower ex-
4. Urogenital injuries 12% tremity lines may be less efficient due to pel-
5. Lumbosacral plexus injuries 8% vic venous injuries.
6. Mortality rate 15% to 25% 2. Administer at least 2 L of crystalloid solution
B. Hemorrhage—Occurs in up to 75% of pelvic over 20 minutes and determine response.
fractures. 3. If only a transient improvement or no response
1. Hemorrhage is a leading cause of death in then begin blood administration. Universal do-
patients with pelvic fractures. nor O negative blood is immediately available
2. Requires aggressive fluid resuscitation. Shock for exsanguinating hemorrhage. Type specific
from hypovolemia is associated with the high- blood is usually available within ten minutes.
est mortality rate following pelvic fractures. Fully crossmatched blood is preferred but takes
3. Three sources of bleeding—Osseous, vascular, approximately 1 hour to complete crossmatch.
and visceral. 4. 50% to 69% of unstable pelvic fractures will
4. Intra-abdominal source of bleeding is present require four or more units of blood; 30% to
in up to 40% of cases. 40% will require 10 or more units.
5. Arterial source of bleeding is present in only 5. Platelets and fresh frozen plasma will be re-
10% to 15% of cases. quired with massive transfusions to correct
6. Major source of bleeding is from venous plexus dilutional coagulopathy.
leading to large retroperitoneal hematoma. 6. Avoid or correct hypothermia. Warm fluids,
7. Retroperitoneal space can hold up to 4 L of increase ambient temperature, and avoid heat
blood. loss. Hypothermia can lead to coagulation
8. Location of arterial injuries can be predicted problems, ventricular fibrillation and acid–
based on pelvic fracture pattern. base disturbances.
7. Adequate volume replacement should pro- product transfusion and can decrease the
duce urinary output of approximately 50 cc need for emergent angiography.
per hour in an adult (ATLS guidelines).
E. External Fixation VII. Definitive Surgical Treatment
1. Emergently placed in hemodynamically un- A. External Fixation
stable patient who does not respond to initial 1. Temporary use for emergent stabilization
fluid resuscitation. and resuscitation.
2. Function 2. May be used definitively for “open book” (Tile
• Stabilizes pelvis preventing redisruption of type B1, Young and Burgess APC-II, Bucholz
clots type II) injuries in which the posterior SI liga-
• May decrease pelvic volume ments are intact.
3. Anterior external fixation alone does not pro- 3. External fixation alone does not provide ade-
vide adequate posterior stabilization if the quate stabilization if the posterior pelvic ring
posterior ring is disrupted. is disrupted.
4. Place skin incisions at right angles to the pel- B. Internal Fixation—Numerous techniques are
vic brim in line with the direction of the reduc- available depending on fracture pattern. Fractures
tion (avoids the need for additional releasing that are unstable posteriorly require posterior
incisions; pin travels along the incision line as stabilization. Plating of a symphyseal dislocation
the pelvis is reduced). should be performed first if the innominate bones
5. Spinal needle or thin K-wire can assist in are intact as it may help reduce displacement in
determining the orientation of the pelvic brim. the posterior pelvic ring; otherwise, the posterior
6. Place bars far enough away from the abdomen reduction is usually performed first.
to allow for abdominal distention. C. Anterior Pubic Symphysis Plating—Reduction
F. Pelvic C-Clamps—In original design, points of and fixation of a simple pubic symphysis diasta-
clamp applied to posterior ilium in line with sis greater than 2.5 cm may be done acutely prior
the sacrum. Requires fluoroscopy and techni- to or following laparotomy by extending the lap-
cal expertise. Higher risk of iatrogenic injury arotomy incision distally, or in delayed manner
than standard anterior external fixator. Newer using a Pfannenstiel incision. Identify the midline
designs can be applied to the trochanteric raphe and separate two bellies of rectus abdomi-
area decreasing potential complications from nis muscle. The insertion of the rectus may have
malposition. been traumatically avulsed from the pubic ramus
G. Angiographic Embolization—Indicated for pa- but otherwise does not need to be released.
tients who remain hemodynamically unstable 1. Reduction with a Weber tenaculum for “open
following resuscitation, application of exter- book” type injuries (Fig. 15-12). Clamp is
nal fixator, and after other sources of bleeding placed anteriorly through the rectus muscle.
(abdomen, chest) are ruled out. Arterial source Points of the tenaculum are placed at the
of bleeding is present in only 10% to 15% of same level of the pubic body.
patients. 2. If the hemipelvis is posteriorly displaced an an-
H. Peritoneal Packing—Popularized in European teriorly directed force may be obtained using a
trauma centers. Significantly reduces blood Jungbluth pelvic reduction clamp (Fig. 15-13).
FIGURE 15-12 A. For reduction of a pubic

symphysis diastasis, reduction is obtained using
a Weber tenaculum placed anterior to the rectus
muscles. The insertion of the rectus is not divided.
B. The points of the clamp are placed at the same
level on the pubic body so that with closure, any
sagittal plane rotation of the symphysis is reduced.
A B
FIGURE 15-13 A. Jungbluth pelvic reduction clamp

may be used to provide a strong anterior reduction
force when the hemipelvis is posteriorly displaced.
Screw cutout may be prevented with an anchoring
plate and nut placed from inside the pelvis. B. Once
the hemipelvis is reduced, the clamp is tightened
and held while standard anterior fixation is applied.
A B
Anchoring plate and nut may be placed behind two parallel plates or special four-hole quad

the pubis to prevent clamp pullout. plate. Allows direct visualization of the joint
3. Fixation hardware—Several different plate but anterior plating may result in posterior
and screw options may be used. Matta rec- joint opening. Fixation is not as secure as il-
ommends a six-hole, 3.5-mm curved recon- iosacral screws. May allow primary SI joint
struction plate. Double plating has been fusion. Recommended when there is a se-
described to improve stability if posterior vere posterior soft tissue injury.
fixation cannot be performed. Residual sym- 2. Iliosacral screws—May be performed in the
physis motion may lead to screw loosening supine or prone position. Placed percuta-
or plate breakage. neously along with closed reduction or fol-
D. Pubic Rami Fractures—Most are treated non- lowing open reduction of SI joint or sacral
operatively. Unstable fractures may be plated fracture. Requires good C-arm visualization
through an ilioinguinal approach. Another alter- (Fig. 15-14). Use washers in older patients to
native is placement of a retropubic medullary prevent screw penetration through the cor-
superior pubic ramus screw. tex. Solid screws are stronger than cannu-
E. Posterior Pelvic Ring Fixation lated and allow use of an oscillating drill that
1. Displaced SI joint disruptions require open provides better proprioceptive feedback.
reduction. Nonanatomic SI reduction is as- One or two screws are placed depending on
sociated with long-term pain. Vertically dis- anatomy and stability.
placed malunions may result in leg length 3. Posterior transiliac plate—4.5 mm reconstru-
discrepancy and sitting imbalance. ction plate tunneled subcutaneously secur-
• Posterior approach—Prone position. Sim- ing fixation to both posterior iliac spines.
pler exposure and secure fixation with F. Crescent Fractures—Fracture dislocations of the
iliosacral screws. Wound healing complica- SI joint may involve a portion of the sacrum or
tions reported as high as 25% in some se- ilium.
ries but less than 3% in other series. 1. Fixation with interfragmentary lag screws if
(a) Matta angle jaw forceps can be used to the intact portion of the ilium is large and
obtain reduction—One tip placed in the firmly attached to the sacrum (iliosacral
sciatic notch, the other placed on outer screws not needed).
ilium. 2. If the fragment is small or the posterior liga-
(b) Cephalad displacement—Reduction may ments are injured then internally fix with ilio-
be achieved with Weber tenaculum, or a sacral screws.
femoral distractor may be used by placing G. Iliac Wing Fractures—Displaced or unstable
Shantz pins in the posterior iliac spines. fractures of the iliac wing may require fixation
• Anterior approach—Supine position. Higher through an ilioinguinal approach. Iliac wing
risk of neurologic injury (L5 nerve root lies is very narrow except along the crest or as it
2 cm medial to the SI joint). Fixation with widens near the acetabulum. Fixation along the
AP FIGURE 15-14 Patients may be positioned

prone as shown here or supine for placement
of iliosacral fixation screws. A long radiolucent
40° caudad 40° cephalad board or table is required to allow positioning of
the image intensifier to obtain anteroposterior,
cephalad, and caudad projections.
crest with plates (on the inner or outer aspect partially or completely. Permanent nerve injury
of the ilium) or fixation with long 3.5 mm lag has a major effect on patients’ functional outcome.
screws placed between the tables. B. Thromboembolism
1. Deep venous thrombosis—Incidence, 35% to
VIII. Nonoperative Treatment
50%. Can occur in the pelvic or lower-extrem-
A. Stable nondisplaced or minimally displaced
ity veins.
fractures may be treated nonoperatively. Lat-
2. Pulmonary embolism (PE)—Symptomatic PE
eral compression injuries (Young and Burgess
incidence 2% to 10%. Fatal PE incidence 0.5%
LC-I, Tile B2) in which the sacral fracture is im-
to 2%.
pacted are often stable and may be treated with
3. Numerous prophylaxis and treatment op-
weight bearing only on the unaffected side.
tions—Low dose heparin, low molecular
B. Simple “open book” (Tile type B1 stage 1, Young
weight heparin, Coumadin, mechanical com-
and Burgess APC-II, Bucholz type II) injuries in
pression devices, inferior vena caval filters.
which pubic diastasis is less than 2.5 cm can be
4. Diagnosis—Contrast venography, duplex ul-
treated nonoperatively.
trasound, magnetic resonance venography.
C. Nonoperative treatment of unstable or severely
C. Closed Internal Degloving Injuries—Morel
displaced fractures requires prolonged immo-
Lavallée Lesions. Occurs as a result of a shear
bility and yields poor results.
injury to the soft tissues in which the subcuta-
D. Early mobilization prevents complications re-
neous tissue is torn from the underlying fascia.
lated to prolonged bedrest.
Occurs most commonly over the greater tro-
E. Vertically unstable fractures in which there is
chanter, but also over the flank and thigh. Signs
a contra-indication to operative treatment may
and symptoms include swelling, contour defor-
be treated with skeletal traction.
mities, skin hypermobility and a loss of sensa-
IX. Complications of Injury and Treatment tion over the affected area. May be colonized by
A. Nerve Injury—May occur from the initial injury bacteria. Treatment: Serial debridement.
as a result of tension or compression. Iatrogenic D. Hardware Failure
injury may occur from surgical manipulation, sur- 1. Fatigue failure of hardware following sym-
gical approach, or misdirected drills or screws. physeal plating is common. In asymptomatic
Overall prevalence, 10% to 15%. Many recover patients, treatment consists of only observation.
1
2 SACRAL FRACTURES
3
I. Denis Classification (Fig. 15-15)
A. Zone I (alar region)—Neurologic injury rare (5.9%).
L5 nerve root injury is most common.
B. Zone II (foraminal)—28.4% rate of neurologic in-
jury. Unilateral injury to L5, S1, or S2 nerve roots.
C. Zone III (central sacral canal)—56.7% rate of
neurological damage most commonly involv-
ing bowel, bladder and sexual function (cauda
equina). Surgical decompression results in better
neurological recovery. Zone III injuries are associ-
ated with the highest incidence of neurogenic
FIGURE 15-15 Denis classification of sacral fractures. bladder injury. Cystometrogram should be ob-
tained to evaluate bladder function. Mechanism
is frequently a fall from a height. Associated with
thoracolumbar burst fractures.
X. Nonunions and Malunions
A. Occur most commonly as a result of inadequate II. Transverse Sacral Fractures—May be missed on
initial treatment of displaced and unstable pelvic CT and AP views. Best visualized with a true lateral
ring injuries. X-ray of the sacrum. Classified as Denis Zone III inju-
B. Cranial displacement—Results in leg length dis- ries. Potential to develop a kyphotic deformity.
crepancy and sitting imbalance. III. Minimally displaced impacted fractures (Lateral
C. Treatment is complicated—Average OR time compression injuries)—Stable and may be treated
7 hours (by highly experienced surgeon). Average nonoperatively unless nerve root decompression is
blood loss: 1,977 cc. 19% complication rate. Risk required.
of neurovascular injury.
D. Three-stage reconstruction often required— IV. Surgical Treatment—Displaced fractures are reduced
(a) anterior approach—to release structures or under direct vision using the posterior spines to aid
perform osteotomies; (b) posterior approach— manipulation. If fracture is transforaminal, the loose
to release structures or perform osteotomies, bone fragment should be removed and the nerve
followed by reduction and internal fixation; and roots visualized during reduction. Fully threaded
(c) repeat anterior approach—for reduction and iliosacral screws avoid overcompression of the frac-
internal fixation. Depending on the deformity one ture, which may cause nerve root compression in
may alternatively begin posteriorly. zone II transforaminal injuries.
E. Nonunions or malunions are often resistant to
correction of deformity due to soft tissue con-
straints. Normal internal fixation hardware may
be inadequate to prevent loss of reduction. May SUGGESTED READINGS
require activity limitations for up to 5 months
after surgical correction.
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suspension surgery. May be activity-induced Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in mul-
tiple trauma: classification by mechanism is key to pattern
overuse injury in athletes due to repetitive ad- of organ injury, resuscitative requirements and outcome.
ductor and rectus abdominis muscle contrac- J Trauma. 1989;29(7):981.
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tumors or stress fractures show unilateral problem: retrospective analysis of 236 cases. Clin Orthop.
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CHAPTER 16
Fractures of the Acetabulum

Kyle F. Dickson
I. Introduction—Fractures of the acetabulum generally B. The 45° Oblique Views—The 45° obturator oblique
occur in younger individuals as a result of high-energy radiograph is taken with the fractured acetabulum
motor-vehicle accidents. Radiographic analysis and clas- rotated toward the X-ray beam, showing the ob-
sification of displaced acetabular fractures by Letournel’s turator foramen and profiling the anterior col-
classification allows the surgeon to choose better the ap- umn medially and the posterior wall laterally
propriate surgical approach. Displaced fractures of the (Fig. 16-2B). The 45° iliac oblique radiograph is
acetabulum require operative anatomic reduction. In- taken with the fractured acetabulum rotated away
congruity of the acetabulum, even as small as 1 mm, re- from the X-ray beam, showing the iliac wing and
sults in posttraumatic arthritis characterized by erosion profiling the posterior column (greater and lesser
of the femoral head and loss of articular cartilage. This sciatic notch) medially and the anterior wall later-
condition is often misdiagnosed as avascular necrosis, ally (Fig. 16-2C).
which is characterized by collapse of the femoral head C. Analysis of the Fractured Acetabulum
with maintenance of the joint space. 1. Incongruency—Besides fracture displace-
ment, congruency of the femoral head within
II. Bony Anatomy—The acetabulum is part of the in-
the acetabulum is analyzed. Subtle anterior
nominate bone and is formed by the ilium, ischium,
subluxation can be seen on the obturator
and pubis. Letournel described the acetabulum as
oblique view, and subtle posterior subluxation
an inverted “Y” with anterior and posterior columns
can be seen on the iliac oblique view (medi-
(Fig. 16-1). The anterior column includes the pelvic
alization of the femoral head with respect to
brim, anterior wall, superior pubic ramus, and ante-
the dome of the acetabulum). Comparing the
rior border of the iliac wing. The posterior column
injured side with the unaffected side on the
includes the greater and lesser sciatic notch, poste-
AP and 45° oblique views of the pelvis helps
rior wall, ischial tuberosity, and most of the quadri-
detect any incongruency. Minimally displaced
lateral surface.
fractures of the acetabulum can be diagnosed
III. Radiographic Evaluation by detecting these subtle subluxations of the
A. Views and Radiographic Landmarks—Radio- femoral head.
graphic evaluation includes the following views: 2. Roof arc measurements—Roof arc measure-
anteroposterior (AP) (Fig. 16-2A), 45° obturator ments are defined as the angle formed by a line
oblique (Fig. 16-2B), and the 45° iliac oblique parallel to the patient passing through the cen-
(Fig. 16-2C). Six radiographic lines on the AP rater of the acetabulum and a line from the center
diograph represent the tangency of the X-ray of the acetabulum to the fractured area of the
beam to the pelvis, not necessarily the anatomic dome. The medial roof arc (MRA) measurement
landmarks (Table 16-1). Disruption of the normal is made on the AP radiograph (Fig. 16-3), the
radiographic lines represents a fracture to that anterior roof arc (ARA) measurement is made
area of bone. The anatomic area responsible for on the obturator oblique radiograph (Fig. 16-4),
each line is described in Table 16-1. For a fracture and the posterior roof arc (PRA) measure-
to be truly nondisplaced, no displacement of the ment is made on the iliac oblique radiograph
radiographic landmark must be seen on at least (Fig. 16-5). Roof arc measurements of 45° cor-
two of the three radiographic views. respond roughly to 10 mm of the dome on a
224
C H A P T E R 1 6 | F R A C T U R E S O F T H E A C E T A B U L U M 225
FIGURE 16-1 Delineation of the anterior and posterior

columns of the acetabulum on the inner (left) and outer
(right) aspects of the innominate bone.
Anterior Posterior Anterior

column column column
computed tomography (CT) scan (Fig. 16-6). correspond to column fractures (Fig. 16-7). Three-
These roof arc measurements are used for mak- dimensional CT can provide a useful overall pic-
ing decisions for surgery and are important in ture of the fracture configuration, but because of
T-shaped and transverse fractures (see Treat- smoothing artifacts in the computer reconstruc-
ment section). tions, nondisplaced fractures and fractures in the
D. CT Scan—Congruency of the femoral head in the plane of the CT scan can be missed. Computer
acetabulum and classification of the fracture type systems that can remove the femoral head from
can usually be performed with plain radiographs the images are more useful for evaluation of the
alone. CT is useful in defining: posterior pelvic acetabulum.
injuries (e.g., sacroiliac joint, sacral fractures),
fractures of the quadrilateral surface, marginal IV. Classification—Letournel’s classification of ac-
impactions of the posterior wall, rotation of the etabular fractures (Fig. 16-8 and Table 16-2) sepa-
articular pieces, and intraarticular free fragments. rates the fractures into simple fractures (posterior
The CT scan is used to classify fractures by look- wall, posterior column, anterior wall, anterior col-
ing at the orientation of fracture planes. Vertical umn, and transverse fractures) and complex asso-
fracture planes on CT correspond to transverse ciated fracture patterns that combine two of the
or T-shaped fractures, and horizontal lines simple patterns (associated posterior column and
AP view Obturator oblique Iliac oblique

view view
4
3
1
4 1
1
5 2 2
2
6 3
4
A B C
FIGURE 16-2 Normal radiographic landmarks of the acetabulum. A. AP radiographic
view. 1, Iliopectineal line; 2, ilioischial line; 3, radiographic U, or teardrop; 4, acetabular
roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum. B. Obturator
oblique view. 1, Iliopectineal line; 2, posterior rim of the acetabulum; 3, obturator
foramen; 4, anterior superior iliac spine. C. Iliac oblique view. 1, Posterior border of the
innominate bone; 2, anterior rim of the acetabulum, 3, anterior border of the iliac wing;
4, posterior rim of the acetabulum.
TA B L E 1 6 - 1
Radiographic Views and Landmarks of the Acetabulum
Radiographic Views and Landmarks Anatomic Representation Column
AP View
Iliopectineal line Inferior three fourths: pelvic brim Anterior
Superior one fourth: superior quadrilateral surface and the
greater sciatic notch
Ilioischial line Posterior portion of the quadrilateral surface and the Ischium Posterior
Radiographic U, or teardrop External limb: outer aspect of the cotyloid fossa Usually
Internal limb: outer wall of the obturator canal, which anterior
merges with the quadrilateral surface
Dome of the acetabulum Small area of the superior surface of the acetabulum corre- Anterior and
sponding to the medial roof arc posterior
Anterior rim of the acetabulum Lateral border of the anterior wall contiguous with the infe- Anterior
rior margin of the superior pubic ramus
Posterior rim of the acetabulum Lateral border of the posterior wall contiguous with the in- Posterior
ferior articular surface of the acetabulum
Obturator Oblique (45°) View
Iliopectineal line Pelvic brim Anterior
Posterior rim of the acetabulum Lateral border of the posterior wall Posterior
Dome of the acetabulum Small area of the superior surface of acetabulum Anterior
corresponding to the anterior roof arc
Iliac Oblique (45°) View
N/A Posterior border of the innominate bone Posterior
(greater and lesser sciatic notch)
Anterior rim of the acetabulum Lateral border of the anterior wall Anterior
N/A Anterior border of the iliac wing Anterior
Dome of the acetabulum Small area of the superior surface of the acetabulum Posterior
corresponding to the posterior roof arc
N/A, Not Applicable (no named radiographic landmark has been described).
32°
MRA
FIGURE 16-3 The medial roof arc angle is formed by a line passing through the center of
the acetabulum parallel to the patient and another line from the center of the acetabulum
medially to the fractured dome as seen on an AP radiograph. The angle in this case is 32°.
26°
ARA
FIGURE 16-4 The anterior roof arc angle is formed by a line passing through the center of the
acetabulum parallel to the patient and another line from the center of the acetabulum medially
to the fractured dome as seen on the obturator oblique radiograph. The angle in this case is 26°.
posterior wall, associated transverse and posterior fracture may involve the greater and lesser
wall, T-shaped, associated anterior wall or column sciatic notch, but the ilioischial line on the AP
and posterior hemitransverse, and both column). view remains intact. Occasionally, a gull sign
A. Simple Fractures is present where the displaced posterior wall
1. Posterior wall fractures (Figs. 16-8 and 16-9 remains hinged medially, with superior and
and Table 16-2)—Posterior wall fractures in- posterior displacement of the lateral aspect of
volve various amounts of the articular and ret- the posterior wall giving the appearance of a
roacetabular surfaces. Posterior wall fractures gull wing (Fig. 16-9).
have displacement of the posterior rim line on 2. Posterior column fractures (Fig. 16-8 and Ta-
both the AP and obturator oblique views. The ble 16-2)—Posterior column fractures involve
40°
PRA
FIGURE 16-5 The posterior roof arc angle is formed by a line passing through the center of the
acetabulum parallel to the patient and another line from the center of the acetabulum medially
to the fractured dome as seen on the iliac oblique radiograph. The angle in this case is 40°.
A B
45°
10mm
R=34.5 mm
45°
CT sections cut
at 2-mm intervals
FIGURE 16-6 CT scan of the acetabular dome. A. This right acetabulum
illustrates the location of the three acetabular roof arcs. These arcs are lines
representing the portion of the subchondral bone tangent to the X-ray film
in the AP, obturator oblique, and iliac oblique views. The anterior roof arc
begins at the posterior lip of the acetabulum, crosses the vertex and extends
to the anteroinferior articular surface. The medial and posterior arcs begin
at the mid and anterior lip of the acetabulum, cross the vertex, and extend to
the acetabular fossa and posteroinferior articular surface, respectively. The
inset illustrates a globe with three arcs at 45° intervals, shown from above and
obliquely. These lines are analogous to three lines of longitude on a globe 45°
apart. B. The line shown in the acetabulum represents the level of the CT image
10 mm inferior to the vertex of the acetabulum. The circle along the subchondral
bone 10 mm inferior to the vertex is equivalent to a fracture line for which all
three roof arc measurements are 45° in almost all cases. The inset illustrates
evaluation of the superior acetabulum by CT to 10 mm inferior to the vertex
in 2-mm intervals.
A B C
Anterior
wall fracture
Posterior
wall fracture
Fracture of Transverse
1 or 2 columns fracture
FIGURE 16-7 CT scan cross section. A. A transverse fracture plane represents a column-type fracture. B. A vertical
fracture plane represents a transverse-type fracture. C. A 45° oblique fracture plane represents a wall-type fracture.
D. CT scan demonstrating an associated transverse and posterior wall fracture.
A B C D E
F G H I J
FIGURE 16-8 Classification of acetabular fractures according to Letournel. A. Posterior
wall fracture. B. Posterior column fracture. C. Anterior wall fracture. D. Anterior column
fracture. E. Transverse fracture. F. Associated posterior column and posterior wall
fracture. G. Associated transverse and posterior wall fracture. H. T-shaped fracture.
I. Associated anterior wall or column and posterior hemitransverse fracture. J. Both-
column fracture.
the ischial retroacetabular surface. The fracture Depending on the size of the posterior column
line exits the bone in the greater sciatic notch, fragment, the fracture may involve part of the
traverses the articular surface, and usually ex- teardrop or brim of the pelvis anteriorly.
its through the obturator foramen and the in- 3. Anterior wall fractures (Fig. 16-8 and Ta-
ferior pubic ramus. Occasionally, the fracture ble 16-2)—Anterior wall fractures involve the
line runs vertically, splitting the ischial tuber- central portion of the anterior column, disrupt-
osity, without entering the obturator foramen. ing the anterior rim of the acetabulum on the
Gull sign
FIGURE 16-9 Gull sign. AP radiograph and drawing of a posterior wall fracture. The displaced
posterior wall fracture remains hinged medially, with superior and posterior displacement of the
lateral aspect of the posterior wall giving the appearance of a gull wing.
TA B L E 1 6 - 2
230
Letournel’s Classification of Acetabular Fractures

Cases with Good to
Excellent Results
Fracture Pattern Radiographic Features Typical Surgical Approach (%)
Posterior wall Disruption of the posterior rim; the fracture can extend to part of the Kocher-Langenbeck 82
greater and/or lesser sciatic notch; the ilioischial line remains intact
on the AP radiograph; occasionally the gull sign is seen
Posterior column Disruption of the ilioischial line and the posterior border of the innomi- Kocher-Langenbeck 91
nate bone (greater and lesser sciatic notch); the obturator foramen
is usually disrupted; the fracture can involve part of the teardrop and
the anterior brim of the pelvis
Anterior wall Disruption of the iliopectineal line on both the AP and obturator oblique Ilioinguinal 78
views; disruption of the anterior rim of the acetabulum on the AP and
iliac oblique views
Anterior column Disruption of the iliopectineal line on the AP and obturator oblique views; Ilioinguinal 88
disruption of the anterior rim of the acetabulum on the AP and iliac
oblique views; usually there is an inferior rami fracture; occasionally
medial translation of the dome on the AP view is observed
Transverse Disruption of the ilioischial and iliopectineal lines; disruption of the an- Kocher-Langenbeck 98
terior and posterior rims of the acetabulum; the obturator foramen is
usually intact
Associated posterior column Disruption of the posterior rim of the acetabulum and the ilioischial line Kocher-Langenbeck 47
and posterior wall (segmental disruption of the posterior rim of the acetabulum); usu-
ally disruption of the obturator foramen is observed
Associated transverse and Disruption of the iliopectineal and the ilioischial lines, also disruption of Kocher-Langenbeck 74
posterior wall the anterior and posterior rims of the acetabulum (segmental disrup- (occasional use of an ex-
tion of the posterior rim of the acetabulum); the obturator foramen is tended approach
usually intact [see text])
T-shaped Disruption of the iliopectineal and ilioischial lines, also disruption of the Kocher-Langenbeck 77
anterior and posterior rims of the acetabulum; the vertical compo- (occasional use of an
nent of this fracture usually disrupts the obturator foramen but may extended approach [see
pass posteriorly, splitting the ischial tuberosity; the obturator fora- text])
men is usually disrupted
Associated anterior wall or Disruption of the iliopectineal and the ilioischial lines, also disruption of Ilioinguinal 88
column and posterior the anterior and posterior rims of the acetabulum; the obturator fora-
hemitransverse men is disrupted
Both column Disruption of the iliopectineal and ilioischial lines; disruption of the Ilioinguinal (occasional use 77
anterior border of the iliac wing and posterior border of the in- of an extended approach
nominate bone; the spur sign may be seen; the obturator foramen is [see text])
disrupted
AP and iliac oblique views without disrupting the obturator foramen, which differentiates the
the inferior pubic ramus. Disruption of the ilio- T-shaped fracture from the transverse fracture.
pectineal line occurs on the AP and obturator The vertical fracture line occasionally descends
oblique views. more posteriorly, splitting the ischium, keeping
4. Anterior column fractures (Fig. 16-8 and Ta- the obturator foramen intact.
ble 16-2)—Anterior column fractures can exit 4. Anterior wall or column and posterior hemi-
the bone very high (iliac crest) or very low (su- transverse fractures (Fig. 16-8 and Table 16-2)—
perior pubic rami). Disruption of the iliopectin- Anterior wall or column fractures associated
eal line on the AP and obturator oblique views with a posterior hemitransverse fracture com-
occurs with these fractures. The fracture in- bine either an anterior wall or an anterior col-
volves the inferior pubic ramus and may be as- umn fracture with a transverse fracture through
sociated with medial translation of the dome the posterior column. The difference between
on the AP view. this fracture and the T-shaped fracture is often
5. Transverse fractures (Fig. 16-8 and Table 16-2)— subtle. The difference is in the orientation of
Transverse fractures divide the acetabulum the fracture pattern anteriorly. T-shaped frac-
into two portions. The upper portion contains tures have an anterior transverse fracture line
the roof of the acetabulum, and the lower por- that corresponds with a vertical orientation on
tion contains a portion of the anterior and the CT scan, whereas the anterior component
posterior wall and an intact obturator foramen of the anterior wall or anterior column fracture
(unless the obturator foramen is disrupted by associated with a posterior hemitransverse
an associated pelvic injury). Letournel sub- fracture is horizontal for an anterior column
divided transverse fractures based on where fracture and approximately 45° for an anterior
the fracture line traversed the acetabulum: (a) wall fracture (Fig. 16-7). Furthermore, an ante-
transtectal, the fracture line crosses the articu- rior column fracture often involves the crest,
lar surface of the superior acetabulum; (b) jux- which does not occur in T-shaped fractures.
tatectal, the fracture line crosses the junction 5. Both-column fractures (Figs. 16-8 and 16-10
of the articular surface and the superior coty- and Table 16-2)—In both-column fractures,
loid fossa; and (c) infratectal, the fracture line both the anterior and posterior columns are
crosses through the cotyloid fossa. The trans- disrupted, as in the transverse fractures, asso-
verse fracture line crosses both columns, but ciated transverse and posterior wall fractures,
is not considered a both-column fracture. In associated anterior wall or column and poste-
transverse fractures, the two columns are not rior hemitransverse fractures, and T-shaped
separated from each other. Transverse frac- fractures. The both-column fracture also has
tures have disruption of the anterior rim, pos- separation of the two columns similar to that
terior rim, iliopectineal line, and ilioischial line, in T-shaped fractures and the associated ante-
but the obturator foramen is usually intact. rior wall or column and posterior hemitrans-
B. Complex Fractures—Complex or associated frac- verse fractures. However, in the both-column
tures usually combine two of the simple fracture fracture, the articular surface has been com-
patterns. pletely separated from the posterior portion
1. Associated posterior column and posterior of the intact innominate bone. All the other
wall fractures (Fig. 16-8 and Table 16-2)—The fracture patterns have some articular surface
ilioischial line is displaced from the teardrop, that remains in its original anatomic position
and the iliopectineal line is intact. Even 1 mm attached to the intact portion of the posterior
of displacement can lead to severe arthrosis. ilium. Because the two columns (with the en-
2. Associated transverse and posterior wall frac- tire articular surface) are displaced medially
tures (Fig. 16-8 and Table 16-2)—An associated from the intact portion of the posterior ilium, a
transverse and posterior wall fracture involves radiographic spur sign can be seen best on the
a simple transverse pattern associated with a obturator oblique view and represents the in-
posterior wall fracture. The obturator foramen tact portion of the posterior ilium that remains
is usually intact. in its anatomic position (Fig. 16-10). This sign is
3. T-shaped fractures (Fig. 16-8 and Table 16-2)— pathognomonic of a both-column fracture.
T-shaped fractures are transverse fractures that C. Additional Fracture Patterns—In any classifica-
have an additional vertical fracture line separat- tion system, there is some overlap in the fracture
ing the lower anterior column from the lower pos- patterns. Furthermore, to reduce the number of
terior column. The vertical line usually disrupts fracture patterns to ten, some of the associated or
Spur sign
FIGURE 16-10 Spur sign. Obturator oblique radiograph and drawing of a both-column fracture.
Note the medial translation of the dome of the acetabulum and the femoral head. The spur sign
represents the intact portion of the iliac wing that remains in its anatomic position.
complex fracture patterns are put into one of the portion of the ilium. If the articular surface remains
larger groups because their treatment is very similar nondisplaced or minimally displaced and congru-
to one of the simple fracture patterns; that is, associ- ent around the femoral head, then secondary
ated anterior wall and column fractures are grouped congruence exists, and nonoperative treatment
with the anterior column fractures, and the associ- can be considered. Relative contraindications to
ated posterior column and anterior hemitransverse surgery include advanced age, associated medical
fractures are grouped with the T-shaped fractures. conditions, and associated soft tissue and visceral
injuries.
V. Treatment C. Surgical Approaches—The choice of surgical ap-
A. Operative Indications—Indications for operative proach depends on the fracture configuration.
treatment include displaced fractures (≥2 mm) of The Kocher-Langenbeck approach provides ac-
the acetabular dome (MRA 45°, ARA 35°, PRA cess to the posterior column, and the ilioinguinal
65° in transverse and T-shaped fractures), pos- approach provides access to the anterior column.
terior wall fractures causing hip instability (frac- Extended approaches (extended iliofemoral, trira-
tures involving anywhere between 20% and 65% diate, and simultaneous and sequential Kocher-
of the posterior wall), and loss of congruency or Langenbeck and ilioinguinal approaches) are
parallelism between the curvature of the femoral needed for some transtectal transverse fractures,
head and the acetabular articular surface on any T-shaped fractures, associated anterior wall or col-
of the three views (AP, obturator oblique, iliac umn and posterior hemitransverse fractures, and
oblique). Closed reduction is not applicable for both-column fractures with significant displace-
the treatment of displaced articular fractures of ment of both the anterior and posterior columns.
the acetabulum. Ideally, the surgeon chooses one approach that
B. Nonoperative Indications—Nonoperative treat- can be used to reduce and fix the entire fracture.
ment of acetabular fractures is indicated in pa- If a combined anterior ilioinguinal and posterior
tients with local or systemic infection, severe Kocher-Langenbeck approach is required for the
osteoporosis, nondisplaced fractures of the ac- fracture, the author’s choice is to perform them
etabulum, displaced fractures with a large portion sequentially, not concurrently, because of some
of the acetabulum intact (intact superior 10 mm of limited access of each approach if they are per-
the dome on CT or roof arc measurements of MRA formed simultaneously. The surgical approaches
45°, ARA 65°, PRA 35° in transverse and that are performed about the hip are listed in
T-type fractures), or secondary congruence of the Table 16-3 with their dissection intervals, struc-
acetabulum and femoral head in both-column fractures at risk, complications, and anatomic con-
tures. In both-column fractures only, the articular siderations. Cross-sectional anatomy around the
surface is completely dissociated from the intact hip (CT scans and magnetic resonance images) is
TA B L E 1 6 - 3
Surgical Approaches about the Hip
Approach Surgical Interval Structures at Risk Complications Anatomic Considerations
Kocher-Langenbeck The gluteus maximus is split Sciatic nerve (protected by the obturator Sciatic nerve palsy 10% The superior gluteal nerve
(distal to the branching internus) Heterotopic bone formation exits superior to the pir-
and innervation by the Ascending branch of the medial femoral cir- without prophylaxis 23% iformis, and the sciatic
inferior gluteal nerve) cumflex artery and the medial femoral cir- (8% incidence of hetero- nerve exits inferior to
cumflex artery (taking down the quadra- topic bone formation that the piriformis. The infe-
tus femoris from the femur instead of the causes a significant de- rior gluteal nerve exits
ischium or taking down the piriformis or crease in hip range of mo- the pelvis below the
obturator interims 1 cm from their in- tion [i.e., 90° of flexion]) piriformis through the
sertion can damage these vessels) Infection 3% greater sciatic notch
Inferior gluteal artery
Inferior gluteal nerve (damaged when
splitting the gluteus maximus too far
proximally, midway between the greater
trochanter and the PSIS)
Femoral nerve (placement of a retractor on
the anterior wall of the acetabulum)
Obturator artery (during hip arthroplasty
the obturator artery can be injured if a
retractor is placed beneath the transverse
acetabular ligament in the acetabulum)
Superior gluteal neurovascular bundle (exits
the greater sciatic notch and is injured
with aggressive retraction of the abduc-
tors anteriorly and superiorly)
Ilioinguinal There are three windows: Lateral femoral cutaneous nerve (runs Direct hernia 1% A direct hernia is medial to
(1) medial to the lym- up to 3 cm from the ASIS deep to the the inferior epigastric ar-
phatics and the external inguinal floor) tery; an indirect hernia
iliac artery and vein, is lateral to the inferior
(2) between the external epigastric artery. The
iliac vessels and the inferior epigastric artery
iliopsoas, and (3) lateral is deep to the deep
to the iliopsoas inguinal ring
(continued)
C H A P T E R 1 6 | F R A C T U R E S O F T H E A C E T A B U L U M
233
T A B L E 1 6 - 3 (continued)
234

Ilioinguinal Femoral artery (injured with a retractor Significant lateral femoral cuta-
(continued) in the second window) neous nerve numbness 23%
Femoral vein (injured with a retractor in External iliac artery throm-
the second window and may lead to a bosis 1%
deep vein thrombosis) Hematoma 5%
Femoral nerve (protected with the psoas Infection 2%
muscle, although vigorous retraction Heterotopic bone formation
of the psoas muscle may cause injury 4% (2% significant de-
to the nerve) crease in range of motion
Inferior epigastric artery (deep to the in- [90° of hip flexion])
guinal ligament and is the last branch
of the iliac artery before it passes un-
derneath the inguinal ligament)
Spermatic cord (vas deferens and testicu-

lar artery as a result of overretraction)
Bladder (lies behind the symphysis pubis)
Extended Proximal—The interval is Posterior branches of the lateral femoral Heterotopic bone formation The gluteal muscle flap is
iliofemoral between the gluteus cutaneous nerve (are cut with the inci- without prophylaxis 70% based off both the su-
maximus and the ab- sion) (20% significant decrease perior and the inferior
dominal muscles Lateral femoral circumflex vascular bundle in motion [90° of hip gluteal neurovascular
Distal and the ascending branch of the lateral flexion]) bundles. The inferior
Superficial—The interval is femoral circumflex artery (must be Sciatic nerve palsy 1% gluteal nerve supplies
between the sartorius ligated) Hematoma 8% the gluteus maximus.
(femoral nerve) and the Superior gluteal artery, vein, and nerve Deep vein thrombosis 5% The superior gluteal
tensor fascia lata (supe- (exiting from the greater sciatic notch, Infection 1% nerve supplies the glu-
rior gluteal nerve) excessive anterosuperior retraction of teus medius and mini-
Deep—The interval is the abductors) mus and the tensor
between the rectus fascia lata. The upper
femoris (femoral nerve) third of the blood
and the gluteus medius supply of the gluteus
(superior gluteal nerve) maximus comes from
the superior gluteal ar-
tery, and the lower two
thirds comes from the
inferior gluteal artery

Combined Kocher- See Kocher-Langenbeck See Kocher-Langenbeck and Ilioinguinal See Kocher-Langenbeck and See Kocher-Langenbeck
Langenbeck and and Ilioinguinal Approaches Ilioinguinal Approaches and Ilioinguinal
ilioinguinal and Approaches Approaches
triradiate expo-
sures
Smith-Petersen (an- Superficial—The interval is Lateral femoral cutaneous nerve (espe- Lateral femoral cutaneous The lateral femoral cuta-
terior approach) between the sartorius cially if a retractor is placed superfi- nerve palsy 5% neous nerve pierces
(femoral nerve) and the cial to the rectus) Infection 2% the sartorius approxi-
tensor fascia lata (supe- Lateral femoral circumflex artery and the Femoral nerve palsy 1% mately 2.5 cm below
rior gluteal nerve) ascending branch of the lateral femoral the ASIS and lies very
Deep—The interval is circumflex artery (need to be ligated) close to the interval
between the rectus between the sartorius
femoris (femoral nerve) and the tensor fascia
and the gluteus medius lata. The lateral femo-
(superior gluteal nerve) ral circumflex artery
is deep to the rectus,
lying in its sheath
close to the femoral
nerve. The lateral
femoral circumflex ar-
tery has an ascending
branch that lies within
the psoas sheath.
These arteries cross
the gap between the
muscles of the tensor
fascia lata and the sar-
torius below the ASIS
and must be ligated
Watson-Jones The interval is between Femoral nerve (retract or placed anterior Abductor weakness (as a The profunda femoris
(anterolateral the gluteus medius to the rectus or too-vigorous retrac- result of the abductors artery branches from
approach) (superior gluteal nerve) tion) being taken down by a the femoral artery and
and the tensor fascia Femoral artery and vein (retraction on tenotomy or a greater tro- passes deep to the
lata (superior gluteal top of the rectus vs. deep to it) chanter osteotomy) femoral artery and lies
nerve). The superior Profunda femoris artery (lies on the psoas Femoral shaft fracture (dur- on top of the psoas
gluteal nerve enters the muscle deep to the femoral artery and ing dislocation in a total muscle
muscles proximal to may be injured with a poorly placed hip arthroplasty)
the incision retractor)
(continued)
C H A P T E R 1 6 | F R A C T U R E S O F T H E A C E T A B U L U M
235
T A B L E 1 6 - 3 (continued)
236

Hardinge (lateral The gluteus medius (inci- Femoral nerve, artery, and vein (retrac- Weakness of the hip abduc- —
approach) sion distal to the supe- tors) tors
rior gluteal nerve inner- Transverse branch of the lateral femoral
vation) and the vastus circumflex artery (cut when the vastus
lateralis (well away from lateralis is released)
the more anterior and Gluteus medius (abductors damaged
medial femoral nerve in- through retraction)
nervation) are split Superior gluteal nerve (too-proximal split-
ting of the gluteus medius)
Ludloff (medial The superficial interval is Obturator nerve (vigorous retraction) Obturator nerve palsy The anterior division of the
approach) between the adductor Medial femoral circumflex artery (lies on obturator nerve passes
longus (anterior divi- the medial side of the psoas tendon downward in front of
sion of the obturator and can be injured when cutting the the obturator externus
nerve) and the gracilis psoas tendon in children) and adductor brevis
(anterior division of the and behind the pectin-
obturator nerve). Both eus and adductor lon-
muscles are proximally gus. It sends muscular
innervated, and there- branches to the gracilis,
fore the interval is safe. adductor brevis, adduc-
The deep interval is tor longus, occasionally
between the adductor to the pectineus, and
brevis (anterior and/ to the articular branch
or posterior divisions of the hip joint. The
of the obturator nerve) posterior division of
and the adductor mag- the obturator nerve
nus (posterior division pierces the obturator
of the obturator nerve externus and passes
and the tibial portion of downward behind the
the sciatic nerve) adductor brevis and
in front of the adduc-
tor magnus. It sends
muscular branches to
the obturator externus,
to the adductor part of
the adductor magnus,

and occasionally to the
adductor brevis. Its ter-
minal branch is to the
knee joint
PSIS, Posterosuperior iliac spine; ASIS, anterosuperior iliac spine.
• A scending branch of the medial femoral cir-

cumflex artery—Preserving the ascending
branch of the medial femoral circumflex ar-
tery supplying the femoral head is very im-
portant for preventing avascular necrosis.
The artery runs deep to the quadratus femo-
ris and superficial to the obturator externus.
It then runs deep to the conjoined tendon
(gemellus superior and inferior and obtura-
tor internus) and piriformis tendon next to
the greater trochanter before attaching to the
femoral arterial ring at the base of the femo-
ral neck.
• P atient positioning—The patient is usually
FIGURE 16-11 Anatomy of the hip as seen on CT scan. positioned prone to help the femoral head
Ac, Acetabulum; B, urinary bladder; F, head of femur. FA, reduce to the anterior wall of the acetabu-
femoral artery; FV, femoral vein; GM gluteus maximus; lum. This positioning allows easier reduction
GMe, gluteus medius; GMi, gluteus minimus; Ip, iliopsoas; of posterior wall and column fractures. The
ITB, iliotibial band; R, rectum; RF, rectus femoris; Sr;
Judet fracture table is used for traction and
sartorius; SV, seminal vesicles; TFL, tensor fascia lata.
(Reprinted with permission from Bo Wi, Wolfman NT,
allows the knee to remain flexed at 60° to 90°,
Krueger WA, et al. Basic Atlas of Sectional Anatomy: relaxing the sciatic nerve. If a Judet table is
With Correlated Imaging. 3rd ed. Philadelphia, PA: WB unavailable, the patient is placed in a lateral
Saunders; 1998.) decubitus position with the entire leg draped
free. In this position, medial subluxation of
the femoral head, especially in transverse
shown in Figures 16-11 and 16-12. The three main
fractures, may cause difficulty with anatomic
approaches for acetabular fractures include the
reduction.
Kocher-Langenbeck, the ilioinguinal, and the ex-
• I ncision and dissection (Fig. 16-13)—The
tended iliofemoral.
incision starts 5 cm lateral to the posterior
1. Kocher-Langenbeck approach—The Kocher-
superior iliac spine (PSIS), proceeds to the
Langenbeck approach for acetabular fractures is
greater trochanter, and then continues along
different from that used in total hip arthroplasty.
the axis of the femur for 20 cm. The gluteus
maximus is split along its fibers until the
branches of the inferior gluteal nerve, which
are approximately halfway between the
greater trochanter and the PSIS, are identi-
fied. The fascia lata is split along the axis of
the femur. The tendinous portion of the glu-
teus maximus insertion or sling is released
5 mm from the femur and reapproximated
at the end of the procedure. A branch of the
posterior circumflex artery is deep to the ten-
don and may be accidentally cut (retracting
deep into the leg) if release of the tendon is
too aggressive. The sciatic nerve is identified
on the quadratus femoris and followed proxi-
FIGURE 16-12 Anatomy of the hip as seen on magnetic mally below the piriformis to ensure that it
resonance imaging. B, Urinary bladder; F, head of is not caught in the fracture site. A branch
femur; FA, femoral artery; FV, femoral vein; GM, gluteus
of the inferior gluteal artery may lie lateral
maximus; GMe, gluteus medius; GT, greater trochanter;
to the sciatic nerve and require coagulation
Ip, iliopsoas; ITB, iliotibial band; R, rectum; RF, rectus
femoris; Sr, sartorius; SV, seminal vesicles; TFL, tensor or ligation. The tendons of the piriformis and
fascia lata; arrow, sacrospinous ligament. (Reprinted with obturator internus are separately tagged and
permission from Browner BO, Jupiter JB, Levine AM, et al, cut sharply 1 cm from the greater trochan-
eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous ter. This ensures protection of the ascend-
Injuries. 2nd ed. Philadelphia, PA: WB Saunders; 1998.) ing branch of the medial femoral circumflex
B C
FIGURE 16-13 Kocher-Langenbeck approach. A. Skin incision. B. Splitting of the gluteus

maximus muscle and transection of its tendon. The sciatic nerve is visible on the posterior
aspect of the quadratus femoris. C. The completed exposure of the retroacetabular surface.
Transection and reflection of the obturator internus tendon gives access to the ischial
tuberosity and the lesser sciatic notch. A capsulotomy can be made at the acetabular rim.
artery. The tendons are retracted posteriorly, 2. Ilioinguinal approach—The ilioinguinal ap-
with the obturator internus tendon leading proach allows full access to the anterior column
to the lesser sciatic notch, which protects and limited access to the posterior column. It is
the sciatic nerve. The piriformis leads to the required for anterior column and wall fractures,
greater sciatic notch. The joint capsule can most associated anterior wall or column and
be opened along the rim, protecting the la- posterior hemitransverse fractures, and both
brum to visualize the hip joint. In posterior column fractures.
wall fractures, the capsule is reflected with • P atient positioning—The ilioinguinal ap-
the piece of the posterior wall, maintaining proach is performed with the patient in the
the blood supply to the fragments. A tro- supine position with the hip flexed 20° to 30
chanteric osteotomy can be used for addi- on the Judet fracture table. Flexion of the hip
tional exposure of the joint and the superior relaxes the iliopsoas tendon. If a Judet table
acetabulum; the ascending branch of the is not available, the entire leg is prepared and
medial femoral circumflex artery needs to be draped free to allow flexion of the hip to relax
protected when the osteotomy is performed. the iliopsoas tendon.
Exposure of the quadrilateral surface through • I ncision and dissection (Fig. 16-14)—The inci-
the greater sciatic notch allows palpation of sion starts at the midline two fingerbreadths
the fracture lines that cross this surface and above the symphysis pubis, proceeds to the
is used to assess reductions of transverse anterosuperior iliac spine (ASIS), and then
fractures. After reduction and fixation, the continues along the iliac crest past its wid-
tendons are reattached anatomically, and a est dimension. The abdominal muscles and
Hemovac is used deep to the fascia lata. iliacus muscle are released from the crest
A D
C
FIGURE 16-14 Ilioinguinal approach. A. Skin incision. B. Internal iliac fossa has been
exposed, and the inguinal canal has been unroofed by distal reflection of the external oblique
aponeurosis. C. An incision along the inguinal ligament detaches the abdominal muscles and
transversalis fascia, giving access to the psoas sheath, the iliopectineal fascia, the external
aspect of the femoral vessels, and the retropubic Retzius space. D. Oblique section through
the lacuna musculorum and lacuna vascularum at the level of the inguinal ligament.
through their tendinous attachment, and the requires complete division of this fascia. The
iliacus is mobilized from the internal iliac obturator nerve and artery are visualized
fossa to the sacroiliac joint and pelvic brim. entering the obturator foramen. Anomalous
Distally, the external oblique aponeurosis branches or origin of the artery occurs in
is split in line with the skin incision and is 50% of patients. The obturator artery usu-
folded back, unroofing the inguinal canal. ally originates from the internal iliac artery.
The spermatic cord or round ligament and Anomalous branches or origins may come
the ilioinguinal nerve are isolated with a rub- from the external iliac or the inferior epi-
ber drain. The floor of the inguinal canal is gastric artery. In less than 5% of cases, this
incised with caution, watching for the lateral anomalous branch is the main obturator ar-
femoral cutaneous nerve running distally up tery and needs to be ligated to prevent tear-
to 3 cm from the ASIS. The incision through ing during the procedure; (The anomalous
the floor of the inguinal canal leaves 2 mm of branch is called the corona mortis, “crown of
tendon attached to the transverse abdominis death”). The incision provides access to the
and obliquus internus muscles for closure innominate bone through three surgical win-
and prevention of a direct hernia. Medially, dows: (1) the retropubic Retzius space (me-
the rectus is released approximately 1 cm dial to the lymphatics and the external iliac
from lateral to medial, or alternatively the artery and vein), (2) the quadrilateral surface
two heads of the rectus are split (similar to and anterior wall (between the external iliac
a Pfannenstiel approach) performing a modi- vessels and the iliopsoas muscle), and (3) the
fied Stoppa approach. The iliopectineal fas- internal iliac fossa and the sacroiliac joint
cia separates the psoas muscle and femoral (lateral to the iliopsoas muscle).
nerve from the external iliac artery and vein 3. Extended iliofemoral approach—The extended
and lymphatics. This thick, fibrous sheath iliofemoral approach allows access to both
runs along the pelvic brim to the sacroiliac the anterior and posterior columns simulta-
joint and separates the true pelvis from the neously. The approach is required for some
false pelvis. Adequate exposure of the bone transtectal associated transverse and posterior
wall fractures and transverse fractures. This maximus, and this muscle is elevated from
approach is also required for some associated the outer wing of the ilium. The tensor fas-
anterior wall or column and posterior hemi- cia lata muscle compartment is opened along
transverse fractures and T-shaped fractures the entire length of the muscle. The muscle
with significant anterior and posterior column is retracted posteriorly, exposing the rectus
displacement. Although most both-column frac- muscle fascia. This fascia is opened longitu-
tures are repaired through the ilioinguinal ap- dinally, retracting the rectus anteriorly and
proach, the extended iliofemoral approach is exposing the fascia of the iliopsoas muscle.
used in both column fractures with segmental This fascia is carefully split, ligating the as-
greater sciatic notch pieces, those with displace- cending branch of the lateral femoral cir-
ment of fracture lines that enter into the sacro- cumflex vessels. The tendons of the gluteus
iliac joint, and those with complex displaced minimus, gluteus medius, obturator internus,
posterior column fractures. Furthermore, some and piriformis are sequentially tagged and
of these fractures older than 3 weeks require an released. Alternatively, a greater trochanteric
extended approach because of extensive callus osteotomy is performed, releasing the glu-
formation. teus minimus and medius (the piriformis and
• P atient positioning—The patient is placed obturator internus are tagged separately).
in the lateral decubitus position on a Judet This exposes the posterior column, similar
fracture table. If a Judet fracture table is not to the exposure in the Kocher-Langenbeck
available, the patient is placed in the lat- approach. Differential exposure to the ante-
eral decubitus position and the entire leg is rior column can be performed by release of
draped free. the rectus femoris from the anterior inferior
• I ncision and dissection (Fig. 16-15)—The iliac spine (AIIS), the sartorius muscle from
incision starts at the PSIS and follows the the anterior superior iliac spine (ASIS), or the
iliac crest to the ASIS and proceeds down iliopsoas muscle from the iliac fossa. The sur-
the lateral side of the thigh for 20 cm to- geon must ensure that adequate soft-tissue
ward the lateral border of the patella. The attachments and vascular supply exists for
knee is flexed more than 60° to relax the sci- all fracture fragments. After anatomic reduc-
atic nerve. The iliac crest incision is taken tion and fixation of the acetabulum, the ten-
through the tendinous portion of the gluteus dons are anatomically reattached.
B C
FIGURE 16-15 Extended iliofemoral

approach. A. Skin incision. B. The gluteal
muscles have been elevated from the
iliac wing. The lateral femoral circumflex
vessels are ligated and transected. C. The
tendons of the gluteus minimus and medius
are transected in midsubstance at their
A trochanteric insertions. D. The completed
exposure of the external aspect of the bone
with a capsulotomy along the acetabular rim.
D E E. The completed exposure of the internal
aspect of the bone.
D. Treatment of Specific Fracture Types—Reduction anterior column fractures through the ilioingui-
of the fractured acetabulum is one of the most nal approach. Reduction and fixation is similar
challenging problems facing the orthopaedic sur- to that of posterior wall and posterior column
geon. The reduction maneuvers are fracture de- fractures. Around the pectineal eminence, the
pendent but are greatly facilitated by use of the acetabulum is easily penetrated with screws;
Judet fracture table. Various reduction forceps therefore, placement of screws should be close
may be used to reduce the acetabulum. Fixation to the brim and directed parallel or toward
is also individualized to the fracture type, but the the quadrilateral surface. Anterior column
most secure fixation is a combination of lag screws fractures often have a free brim fragment that
and buttress plating. Screw penetration of the joint should be reduced and fixed before reduction
must be avoided and can be checked with the C- and fixation of the anterior column fragment.
arm at the end of the procedure. In a concave joint 4. Transverse fractures—The techniques for
such as the acetabulum, only one view is needed reducing transverse fractures are similar to
to prove that the screw is not in the hip joint. those for reducing posterior column fractures.
1. Posterior wall fractures—Posterior wall frac- Often, a half-pin is used in the ischial tuberos-
tures are often associated with marginal ar- ity to help with rotational reduction. Fixation
ticular impaction fractures next to the major is performed with a combination of lag screws
fracture lines. The impacted articular pieces and a buttress plate. Although most transverse
are elevated with 5 to 10 mm of cancellous bone fractures are treated through the Kocher-Lan-
to the reduced femoral head. Cancellous bone genbeck approach, those with greater displace-
graft from the greater trochanter is packed be- ment of the anterior column than the posterior
hind the elevated fragments. Alternatively, an column or those with a high anterior column
injectable calcium phosphate can be used be- fracture line (i.e., through the dome) and a low
hind the reduced marginal impaction. The cor- posterior column fracture are best approached
tical posterior wall is reduced and held with a through the ilioinguinal approach.
ball spike. Initial fixation is with lag screws and 5. Associated transverse and posterior wall frac-
is followed by a buttress plate. When commi- tures—Associated transverse and posterior
nuted or small bony fragments attached to the wall fractures are reduced and fixed as previ-
acetabular labrum are present, a spring plate ously described. Occasionally, the posterior
(one-third tubular plate) under a reconstruction wall involves the entire retroacetabular surface,
plate is used. The keys to successful surgery on making the reduction quite difficult to assess.
posterior wall fractures are leaving as much of In these cases, as well as cases with significant
the capsule attachment (blood supply) to the displacement of the anterior column, those in
posterior wall fragments as possible and per- which the fracture line passes through the dome,
forming an anatomic reduction of the fragments. and those with a separate greater sciatic notch
2. Posterior column fractures—Posterior column piece, the extended iliofemoral approach may
fractures have a rotational deformity of the be indicated. These fractures have the highest
posterior column around the femoral head as incidence of preoperative sciatic nerve palsy.
the head pushes medially. Reduction involves 6. T-shaped fractures—T-shaped fractures can
removing the hematoma and debris from the often be reduced using the posterior Kocher-
fracture line and placing reduction screws and Langenbeck approach. If the anterior column
occasionally a half-pin in the ischial tuberosity. cannot be reduced, the surgeon first fixes the
The reduction screws are used with the pelvic posterior column; the patient is then turned over
reduction clamps (Farabeuf and Jungbluth). for an ilioinguinal approach and the anterior col-
In addition, an angled reduction clamp can be umn is reduced and fixed. Alternatively, an ex-
placed with one tong on the quadrilateral sur- tended iliofemoral approach can be preformed
face, and the other on the supra-acetabulum for transtectal displaced T-type fractures.
on the anterior column. This clamp helps to 7. Associated anterior wall or column and posterior
de-rotate the posterior column. The reduction hemitransverse fractures—Associated anterior
is checked both on the retroacetabular surface wall or column and posterior hemitransverse
as well as on the quadrilateral surface. Fixation fractures are usually reduced and fixed through
is performed with a combination of lag screws the ilioinguinal approach. The posterior column
and a buttress reconstruction plate. is usually minimally displaced or nondisplaced
3. Anterior wall and anterior column fractures— and can be reduced with a laterally directed force
Surgery is performed on anterior wall and on the posteroinferior quadrilateral surface.
Rarely, the posterior column requires reduction extraarticular infections may ultimately have a
and fixation (after the anterior column has been good functional result; deep or intraarticular infec-
reduced and fixed) through a separate Kocher- tions are usually associated with a poor outcome.
Langenbeck approach. C. Iatrogenic Nerve Palsy—Iatrogenic nerve palsy is
8. Both-column fractures—Both-column fractures the result of vigorous or prolonged retraction of
usually can be reduced and fixed through an the sciatic nerve, usually involving the peroneal di-
ilioinguinal approach. The fractures that enter vision. Keeping the knee flexed to at least 60 with
the sacroiliac joint have associated marginal the hip extended during the posterior approach
impactions, or have complex posterior column decreases the tautness of the sciatic nerve. In
fractures (i.e., segmental, displaced posterior some centers, somatosensory-evoked potentials or
wall fractures; associated greater sciatic notch motor-evoked potentials are monitored during sur-
fragments; or significant displacement) and are gery to watch for changes in amplitude or latency
better reduced and fixed through an extended to prevent iatrogenic injury. The role of monitoring
iliofemoral approach. Alternatively, reduction in acute acetabular surgery has not been estab-
of the anterior column may be performed first lished. Postoperative footdrop may resolve for up
with internal fixation through an ilioinguinal ap- to 3 years after surgery, and tendon transfer proce-
proach (with care taken not to block later reduc- dures should not be contemplated until this time.
tion of the posterior column). This is followed D. Heterotopic Bone Formation—Heterotopic bone
by a posterior approach. Reduction is obtained formation is usually painless. It is most common
with a combination of clamps and forceps. At after the extended iliofemoral approach and least
the time of injury, the two columns often rotate common after the ilioinguinal approach. Proven
out as the head pushes in through the acetabu- risk factors for heterotopic bone formation in-
lum like the opening of a saloon door. There- clude T-shaped fractures, associated head or
fore, the reduction is performed by rotating the chest trauma, and male patients. Indomethacin,
columns back, like closing a saloon door. 25 mg three times a day for 8 weeks, decreases
9. Postoperative care—Postoperative care in- the incidence of heterotopic ossification. Postop-
volves toe-touch weightbearing ambulation erative radiation (700 cGy, one-time dose), as well
training as soon as possible. At 8 weeks, physi- as the combination of the two modalities, has also
cal therapy is initiated with exercises, range of been shown to be effective. Debriding necrotic
motion, and weightbearing-as-tolerated ambu- muscle and reducing the amount of soft-tissue
lation training. Assistive ambulation devices stripping off of the lateral aspect of the innomi-
are used until strength has improved enough to nate bone can help reduce the risk of heterotopic
prevent a limp. bone formation. The correlation of heterotopic
bone formation and range of motion is important
VI. Complications—The most common complications because patients with apparent complete bone
include wound infections, iatrogenic nerve palsy, bridging on the AP X-ray film may have more than
heterotopic bone formation, posttraumatic arthri- 110° of hip flexion. The 45° oblique views and CT
tis, and thromboembolic complications. Further- scanning may be helpful for assessing the sever-
more, a closed degloving injury over the greater ity of heterotopic bone formation and should be
trochanter containing hematoma and liquified fat used if excision is indicated (hip flexion 90° or
between the subcutaneous tissue and deep fascia a fixed rotational malalignment). When possible,
(Morel-Lavallee lesion) can occur. These lesions can surgery for removal of heterotopic bone should be
lead to infection in up to 30% of cases and therefore delayed for 6 to 12 months until the heterotopic
need to be drained and debrided before or at sur- bone has matured. A bone scan can be ordered to
gery to decrease the risk of infection. determine the activity of the bone.
A. Posttraumatic Arthritis—Assuming the fracture E. Deep Vein Thrombosis—Deep venous thrombosis
is classified correctly and the proper approach is and pulmonary embolism can occur. Although con-
chosen, accuracy of the reduction is the most im- troversial, the author uses pneumatic compression
portant factor in the clinical outcome and in pre- boots from the time of admission until the patient
venting post traumatic arthritis. is fully ambulatory after surgery. Once the drains
B. Wound Infections—Bloody discharge may occur are removed, pharmacologic prophylaxis (low–
for 1 to 2 days after surgery and clear drainage molecular-weight heparin) is also started. Con-
may continue for up to 10 days. If drainage ei- traindications to pharmacologic prophylaxis are
ther increases or changes to a cloudy discharge, splenic rupture and a severe head injury. In these
immediate incision and debridement of possible cases and those with established deep vein throm-
infection or hematoma is indicated. Patients with bosis, a Greenfield filter is indicated before surgery.
SUGGESTED READINGS Moed BR, McMichael JC. Outcomes of posterior wall frac-
tures of the acetabulum. J Bone Joint Surg Am. 1989;89(6):
1170–1176.
Classic Articles Olson SA, Matta JM. The computerized tomography subchon-
Fassler PR, Swiontkowski MF, Kilroy AW, et al. Injury of the sci- dral arc: a new method of assessing acetabular articular
atic nerve associated with acetabular fracture. J Bone Joint continuity after fracture (a preliminary report). J Orthop
Surg. 1993;75A:1157–1166. Trauma. 1993;7:402–413.
Hak DJ, Olson SA, Matta JM. Diagnosis and management of Thomas KA, Vrahas MS, Noble JW Jr, et al. Evaluation of hip
closed internal degloving injuries associated with pelvic and stability after simulated transverse acetabular fractures.
acetabular fractures: the Morel-Lavallee lesion. J Trauma. Clin Orthop Relat Res. 1997;340:244–256.
1997;42:1046–1051.
]udet R, Judet J, Letournel E. Fractures of the acetabulum:
classification and surgical approaches for open reduction. Recent Articles
J Bone Joint Surg. 1964;46A:1615–1638. Griffin DB, Beaulé, Matta JM. Safety and efficacy of the ex-
Letournel E. Fractures of the Acetabulum. 2nd ed. New York, NY: tended iliofemoral approach in the treatment of complex
Springer-Verlag; 1993. fractures of the acetabulum. J Bone Joint Surg. 2005;87B(10):
Matta JM, Anderson L, Epstein H, et al. Fractures of the acetabu- 1391–1396.
lum: a retrospective analysis. Clin Orthop. 1986;205:220–240. Qureshi AA, Archdeacon MT, Jenkins MA, et al. Infrapectin-
Matta JM. Fractures of the acetabulum: reduction accuracy eal plating for acetabular fractures: a technical adjunct to
and clinical results of fractures operated within three weeks internal fixation. J Orthop Trauma. 2004;18(3):175–178.
of injury. J Bone Joint Surg. 1996;78A:1632–1645. Olson SA, Kadrmas MW, Hernandez JD, et al. Augmentation of
Matta JM, Mehne D, Roffi R. Fractures of the acetabulum: early posterior wall acetabular fracture fixation using calcium-
results of a prospective study. Clin Orthop. 1986;205:241–250. phosphate cement: a biomechanical analysis. J Orthop
Matta JM. Operative indications and choice of surgical approach Trauma. 2007;21(9):608–616.
for fractures of the acetabulum. Tech Orthop. 1986;1:13–22.
Matta JM. Operative treatment of acetabular fractures through
the ilioinguinal approach: a ten year perspective. Clin Textbook
Orthop. 1994;305:10–19. Letournel E. Fractures of the Acetabulum. 2nd ed. New York, NY:
Matta JM, Letournel E, Browner B. Surgical management of ac- Springer-Verlag; 1993.
etabular fractures. Instr Course Lect. 1986;35:382–397.
CHAPTER 17
Hip Dislocations and Fractures

of the Femoral Head
Steven C. Lochow and Steven A. Olson
I. Introduction—Hip dislocations and fracture-dislocations long-term disability. Early literature showed poor
occur across all age groups and represent a spec- results with frequent early arthritis and avascu-
trum of injuries that can result when abnormal load lar necrosis (AVN). These early reports predated
is placed on the hip. The position of the femur modern imaging modalities and current under-
when the force is applied determines the pattern standing of the vascularity of the femoral head. It
of injury. The force can be dissipated by any combi- is hoped that by incorporating recent advances,
nation of femur fracture, intertrochanteric fracture, the results of the treatment of patients with these
femoral neck fracture, hip dislocation, acetabular injuries can be improved.
fracture, femoral head fracture, and pelvic fracture. 1. Historical overview—The modern phase in
Hip dislocations and femoral head fractures are con- the management of dislocations of the hip
sidered together because a fracture of the femoral dates from Henry Jacob Bigelow’s publica-
head cannot occur without subluxation or dislocation in 1869. The clinical presentations and
tion of the hip and the treatment rationale for both reduction maneuvers described are the same
is similar. as those used today. In the 1950s, Thompson
and Epstein’s classification system and Stew-
II. Hip Dislocations art and Milford’s classification system were
A. Overview—Dislocations of the hip usually result devised. Trueta’s description of the vascular-
from moderate to severe trauma. The majority of the femoral head was also published in
ity (42% to 84%) occur as the result of a motor- this time period. It was not until the advent of
vehicle accident. The remainder are associated computed tomography (CT) in the 1970s that
with falls from a height, sports injuries, and in- the treatment of hip dislocations evolved to its
dustrial accidents. Posterior dislocations occur present state.
much more commonly than anterior dislocations B. Evaluation—The patient must be examined com-
(89% to 92%). Thirty percent of patients with a pletely for associated injuries, particularly when
hip dislocation do not have an acetabular frac- the patient is unable to cooperate. Any injury to
ture, and most dislocations without fractures are the pelvis, femur, or knee should raise suspicion
posterior (approximately 80%). Dislocations with of an injury to the hip. The position of the leg is
acetabular or femoral fractures are almost always often an indicator of hip dislocation, but this
posterior (approximately 90%). Historically, the sign may be absent if there is a concomitant
assumed mechanism for posterior dislocation ipsilateral femoral neck or shaft fracture.
was dashboard impact. However, newer reports 1. Clinical examination
have shown that many of these injuries occur in • Observation—Injuries to the soft tissues
the right hip, and the mechanism of such injuries near the femur can localize the point of im-
is now believed to be related to the driver press- pact. Since dashboard injuries can cause hip
ing on the brake with the right foot with the hip dislocations, the physician should look for
held in flexion, adduction, and internal rotation. bruising about the knee. The resting position
Anterior dislocations often have an associated of the leg often indicates a dislocation. With
femoral head fracture and/or impaction. Hip a posterior dislocation, the leg is short-
dislocations have the potential for significant ened and is held in flexion, adduction,
244
C H A P T E R 1 7 | H I P D I S L O C A T I O N S A N D F R A C T U R E S O F T H E F E M O R A L H E A D 245
and internal rotation. However, often

with an irreducible posterior dislocation,
the leg may rest in a neutral position.
With an anterior dislocation, the leg is
held in external rotation, abduction, and
mild flexion or extension. The amount of
flexion/extension depends on whether the
dislocation is superior (pubic) or inferior
(obturator).
• Palpation—A feeling of fullness in the soft
tissues in the direction of displacement of
the femoral head may be palpable.
• Neurovascular examination—Sciatic nerve
injuries occur in 8% to 19% of posterior dis-
locations, mandating documentation of neu-
ral function at presentation. The peroneal
distribution of the sciatic nerve is involved
more often and usually more severely af-
fected than the tibial distribution.
2. Radiographic evaluation—Plain films should
FIGURE 17-1 AP Radiograph demonstrates typical
always be obtained to look for associated appearance of an anterior hip dislocation on the patient’s
fractures before any reduction attempt. right and a posterior fracture-dislocation on the left.
A CT scan should be obtained, if time per-
mits, before irreducible dislocations are
taken to the operating room (OR) and after
all reductions. • CT—A CT scan of the hip should be obtained
• Plain films—An initial screening anteropos- after reduction to assess the congruency of
terior (AP) pelvis radiograph is required to the hip joint. This assessment is best done
evaluate for a suspected dislocation. When by looking for lateral subluxation in the more
evaluating the plain films, the clinician proximal cuts that show the hip joint and
should first look for associated injuries, pay- by comparing the joint space in the more
ing particular attention to the femoral neck, distal cuts of the affected hip to that of the
femoral shaft, and acetabulum. The clinician uninjured hip. The postreduction CT scan
should then carefully compare the congru- is also the best means for checking for free
ency of the hip joints. The head of an an- osteochondral fragments within the joint
teriorly dislocated hip appears larger on (Fig. 17-3). Small foveal fragments may be
plain radiographs than the contralateral left, but interposed fragments need to be ad-
normal hip; a posteriorly dislocated hip dressed. If a hip cannot be closed reduced,
appears smaller (Fig. 17-1). If a disloca- and if time permits, an emergent preopera-
tion is suspected, films of the entire femur, tive CT scan is recommended to determine
including the knee joint, are needed. These whether there are fragments within the joint
films should be carefully evaluated to rule that will necessitate an open reduction. After
out ipsilateral fractures, in particular non- open reduction, even if a prereduction CT
displaced fractures of the femoral head, scan was obtained, a postreduction CT scan
the femoral neck, or the acetabulum. An- is advisable if there is any question regard-
teromedial femoral head fractures are most ing the concentricity of the reduction.
common and will be demonstrated by Judet • Magnetic resonance imaging (MRI)—MRI
oblique radiographs. Postreduction plain can be useful for assessing the hip that
films in at least two planes (AP and lateral or has been reduced and has been found to
AP and Judet obliques) must be obtained to be incongruent but without interposed tis-
evaluate joint congruency and to look for the sue on CT scan. The MR image is better at
presence of associated fractures (Fig. 17-2). evaluating the labrum, the muscles, and the
A postreduction CT is still required because capsule that may be incarcerated within
small interposed fragments may be missed the joint. The role of MRI in the assessment
on plain films. of early AVN, bone bruises, and chondral
FIGURE 17-2 Postreduction radiograph of

the patient shown in Figure 17-1.
FIGURE 17-3 Axial CT scan

demonstrates an incarcerated
femoral head fragment.
injuries after hip dislocations has yet to be systems (Comprehensive system and Brumback
established. MRI may also show damage to et al. system) guide clinicians more in terms of
the obturator externus muscle, which may treatment than prognosis. The two historical sys-
represent injury to the medial circumflex tems (Thompson and Epstein system and Stewart
femoral artery and possibly an increased and Milford system) were introduced before the
risk of avascular necrosis. advent of CT. If there is an associated fracture re-
C. Classification (Tables 17-1 to 17-4)—A classifica- quiring treatment, the prognosis of the injury is
tion system should help guide treatment and have usually determined by the quality of the reduc-
prognostic value. The two modern classification tion of the associated fracture. The prognosis of
TA B L E 1 7 - 1 TA B L E 1 7 - 4
Thompson and Epstein’s Classification of Posterior Brumback et al’s Classification of Hip Dislocations
Hip Dislocations Type Description
Type Description 1 Posterior hip dislocation with femoral head
I With or without minor fracture of the acetabulum fracture involving the inferomedial, non-
II With a large, single fracture off the posterior weightbearing portion of the femoral head
acetabular rim 1A With minimum or no fracture of the acetabular
III With comminuted fractures of the acetabular rim rim and stable hip joint after reduction
(with or without a major fragment) 1B With significant acetabular fracture and hip
IV With fracture of the acetabular rim and floor joint instability
V With fracture of the femoral head 2 Posterior hip dislocation with femoral head
fracture involving the superomedial weigh-
Source: From Thompson VP, Epstein HC. Traumatic dislocation bearing portion of the femoral head
of the hip: a survey of two hundred and four cases covering
a period of twenty-one years. J Bone Joint Surg. 1951;33A: 2A With minimum or no fracture of the acetabular
746–778, with permission. rim and stable hip joint after reduction
2B With significant acetabular fracture and hip
joint instability
TA B L E 1 7 - 2 3 Dislocation of the hip (unspecified direction)
with associated femoral neck fracture
Stewart and Milford’s Classification of Hip Dislocations
3A Without fracture of the femoral head
Type Description
3B With fracture of the femoral head
I No acetabular fracture or only a minor chip
4 Anterior dislocation of the hip with fracture of
II Posterior rim fracture that is stable after reduction the femoral head
III Posterior rim fracture with hip instability after 4A Indentation type; depression of the superolat-
reduction eral weight bearing surface of the femoral
IV Dislocation accompanied by fracture of the fem- head
oral head or neck 4B Transchondral type; osteocartilaginous shear
Source: From Stewart M, Milford LW. Fracture-dislocation of the fracture of the weightbearing surface of the
hip: an endresult study. J Bone Joint Surg. 1954;36A:315–342, with femoral head
permission.
5 Central fracture-dislocation of the hip with
fracture of the femoral head
Source: From Brumback RJ, Kenzora JE, Levitt LE, et al.
TA B L E 1 7 - 3 Proceedings of the Hip Society 1986. St. Louis, MO: Mosby; 1987,
with permission.
Comprehensive Classification of Hip Dislocations
Type Description
I No significant associated fractures: no clinical
a pure dislocation is determined by the incidence
instability after concentric reduction
of AVN and chondral injuries, both of which are
II Irreducible dislocation without significant
difficult to determine in the immediate postreduc-
femoral head or acetabular fractures (re-
tion period.
duction must be attempted under general
anesthesia) 1. Thompson and Epstein (1951)—The classifica-
tion system of Thompson and Epstein is based
III Unstable hip after reduction or incarcerated
on the severity of the acetabular and/or femo-
fragments of cartilage, labrum or bone
ral head fracture (Table 17-1).
IV Associated acetabular fracture requiring re- 2. Stewart and Milford (1954)—The classification
construction to restore hip stability and
system of Stewart and Milford is based on the
joint congruity
stability of the hip after reduction and the con-
V Associated femoral head or femoral neck dition of the femoral head (Table 17-2).
injury (fractures or impaction) 3. Comprehensive classification—The Compre-
Source: From Levin PE. In: Browner BD, Jupiter JB, Levine AM, hensive classification system is based on the
et al, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous
Injuries. Vol 2. 2nd ed. Philadelphia, PA: WB Saunders; 1998, reducibility of the hip, the presence of inter-
with permission. posed fragments, the stability of the reduced
hip, and associated fractures (Table 17-3).
4. Brumback et al.—The classification of Brum- common than anterior dislocations.

back et al. is based on the direction of disloca- However, a higher percentage of ante-
tion and associated fractures (Table 17-4). rior dislocations have an associated
D. Associated Injuries—Associated injuries fall into femoral head fracture (68%) as com-
two categories: those associated with the disloca- pared to posterior dislocations (7%).
tion and those associated with the precipitating (c) Femoral neck fractures—Femoral neck
trauma. Additional organ-system injuries occur fractures are uncommon in patients with
in 95% of patients with a traumatic hip disloca- hip dislocation. Prereduction films
tion secondary to a motor vehicle crash; 33% of need to be carefully assessed for dis-
patients have other orthopaedic injuries, 15% placed and nondisplaced fractures
have abdominal injuries, 24% have closed-head along the femoral neck.
injuries, 21% have thoracic injuries, and 21% have (d) Femoral shaft fractures—Femoral shaft
craniofacial injuries. fractures are uncommon in patients with
1. Injuries associated with the dislocation—The hip dislocation. These fractures make
injury to the hip is determined by the vector leg position no longer predictive of dis-
of the traumatic load, the rate of load translocation, and the leg cannot be used as a
mission, the point of load transmission, and lever arm during reduction maneuvers.
the position of the leg at the time of impact. (e) Patellar fractures and knee disloca-
A centrally directed force on an abducted leg tions—Patellar fractures and knee dis-
fractures the pelvis, the acetabulum, the fe- locations highlight the importance of
mur, or a combination thereof. As the force is X-ray films of the joint above and below
directed more posteriorly and the leg moves the injury. If knee pathology is identified
into adduction and flexion, a posterior frac- and the mechanism of injury is a motor-
ture-dislocation is created; with more adduc- vehicle accident, there is a high inci-
tion, a pure dislocation occurs. A posterior dence of ipsilateral hip injuries.
impact or a force on an abducted and extended • Soft tissue injuries
leg creates an anterior dislocation. As the rate (a) Blood supply to the femoral head—
of load transmission decreases, the pelvis can Multiple sources supply blood to the
rotate, and pure dislocations become more femoral head. However, the medial
likely. Conversely, when the rate of load trans- femoral circumflex artery (MFCA) is
mission is rapid, the pelvis cannot rotate and a the essential vessel. This vessel anasto-
fracture of the acetabulum or the femoral head moses with a branch of the inferior glu-
is more likely. The incidence of femoral head teal vessel at the inferior border of the
fractures is higher with anterior disloca- piriformis and then pierces the capsule
tions because the strong anterior ligaments do deep to the piriformis insertion to run
not easily allow for subluxation of the hip. The within the synovial reflection to enter
anterior wall of the acetabulum is substantial the head at the superolateral articular
and resists fracturing more than the posterior margin (Fig. 17-4). The MFCA vascular-
wall, so the femoral head becomes the weak izes areas not supplied by other ves-
link and is fractured by the shear force. sels and can supply the entire femoral
• Local bony injuries head. Injury to this vessel by avulsion,
(a) Acetabular fractures—One study reported transection, thrombosis, or spasm leads
that 70% of patients with hip disloca- to AVN. Posterior dislocations put this
tions had an associated acetabular frac- vessel at risk, whereas anterior dislo-
ture. Fracture of the posterior wall is cation relaxes the vessel, thus explain-
most common, but as force is directed ing the 2% to 17% rate of AVN with
more medially, any fracture pattern is posterior dislocations and the rare
possible. incidence with anterior dislocations.
(b) Femoral head fractures—Femoral head Additionally, the MCFA may arise from
fractures are covered in more detail either the common femoral or more of-
later in this chapter but can include im- ten from the profundus femoral artery.
pactions as well as fractures. Most fem- When the MCFA arises from the common
oral head fractures (90%) are seen femoral artery, a posterior dislocation
with posterior dislocations since pos- causes a greater decrease in blood flow
terior dislocations are so much more to the femoral head. This is theorized to
tethered by the piriformis. At least par-

tial sciatic nerve recovery occurs in 60%
to 70% of patients, with no clear correla-
tion with injury or treatment.
(c) Ligamentum teres injuries—The liga-
mentum teres is torn during a disloca-
tion. It can tear mid-substance, or more
commonly, it can avulse a small piece of
bone from the fovea. If the avulsed piece
of bone is interposed between the artic-
ular surfaces after reduction, it needs to
be removed. However, if it remains in the
fovea and does not impinge on the head,
it may be left.
(d) Acetabular labrum injuries—The ace-
tabular labrum can be avulsed from the
bony acetabular rim on either the side
of or the opposite side from the dislo-
cation and can become interposed dur-
ing reduction. Labral injury can be a
source of symptoms even after a suc-
cessful reduction.
FIGURE 17-4 Posterosuperior view of the proximal
(e) Joint capsule injuries—The joint capsule
femur. Note the medial femoral circumflex artery (white
will be injured during all dislocations.
arrowhead), the lateral trochanteric vessel (white arrow),
and the insertion of the terminal branches into the When the femoral head has button-holed
femoral head (black arrow). (Reprinted with permission through the capsule, reduction can be
from Gautier E, Ganz K, Krügel N, et al. Anatomy of diificult. The capsule may also become
the medial femoral circumflex artery and its surgical interposed during reduction.
implications. J Bone Joint Surg Br. 2000;82(5):679–683.) (f) Muscle injuries—The short external rota-
tors are frequently torn during posterior
dislocations and may become interposed
contribute to the variability in AVN rates during reduction. The gluteus medius
after dislocation. may be partially avulsed from its femoral
(b) Sciatic nerve injuries—Reported rates insertions during obturator dislocations.
of sciatic nerve injury range from 7% (g) Arterial injuries—Pulses should be eval-
to 27%. The incidence is approximately uated during the physical examination
5% in children. These occur exclusively because the femoral artery can be com-
with posterior dislocations, with the pressed during anterior dislocations.
highest rate being seen in posterior frac- 2. Injuries associated with the trauma—It is im-
ture-dislocations as would be expected portant to establish the mechanism of injury to
from the direction of the displaced pos- give insight into possible associated injuries.
terior wall fragments. The peroneal dis- • Load transmission—The involved limb must
tribution of the sciatic nerve is more be carefully examined from the point of im-
frequently involved than the tibial pact all the way to the hip. Foot, ankle, leg,
distribution for unknown reasons, knee, and thigh injuries have all been re-
although the posterior portion of the ported. If the impact was posterior, the pelvis
peroneal branch has been implicated and lumbar spine should be evaluated.
because it would be stretched more. • Distant injuries—Dislocation of the hip is
The mechanism of injury is proposed to frequently the result of high-energy trauma,
be direct blunt trauma, stretching of the and 85% of patients have more than one
nerve around the posteriorly displaced injury (so the entire patient must be evalu-
head, or both. The sciatic nerve variant ated). These patients have often sustained a
where the peroneal division branches deceleration injury, and damage to the chest
through the piriformis muscle may cavity or abdomen can occur. Seat belt inju-
place the nerve at increased risk as it is ries can also occur.
E. Treatment—The treatment of associated fractures 1. Treatment of associated injuries—After the

is covered in detail in the chapters covering the entire patient is thoroughly evaluated, in-
specific injuries. Treatment is mentioned here juries that are life threatening or need to be
only if it is altered by the presence of the hip dis- addressed are treated before reduction of the
location. The treatment of hip dislocations follows hip. A femoral shaft fracture needs to be tem-
a stepwise process that is outlined in Figure 17-5. porized, and a femoral neck fracture needs to
These injuries represent an orthopaedic emer- be stabilized before a hip reduction can be
gency requiring prompt reduction of the hip to attempted. When open reduction is required,
protect the femoral head blood supply from fur- fractures of the proximal femur should be sta-
ther compromise. Additionally, urgent reduction bilized before hip reduction, whereas fractures
minimizes further stretching of the sciatic nerve. of the acetabulum can be treated after hip joint
The length of time to relocation has a direct influ- reduction.
ence on the severity of associated nerve injuries. 2. Closed reduction—Except in cases with as-
The incidence of major sciatic nerve injuries was sociated femoral neck fractures, a closed
higher in patients transferred with the hip still reduction should be attempted on all hip
dislocated, and in patients with a nerve injury dislocations. An associated femoral head
who had a significantly longer time to reduction. fracture and/or a small posterior wall rim avul-
A dislocation of the hip is an emergency of even sion may indicate an associated labral avulsion
greater urgency than an open fracture. The rates which can become a mechanical block during
of AVN and early arthritis are increased if the closed reduction. A reduced hip with fragments
hip is left dislocated for more than 6 hours. in the joint is safer to the vascularity than a
Yes No FIGURE 17-5 Algorithm for

Is the femoral
neck fractured? treatment of a hip dislocation.
Urgent closed
Is the femoral reduction of hip
head fractured? dislocation
Yes No AP Pelvis
Anterior Aproach Anterior, Is hip reduced?

Anterolateral, or
1. Fix femoral neck fracture
Lateral Approach Judet Yes No
2. Fix femoral head fracture Urgent
1. Fix femoral neck Views,
CT scan
3. Reduce Hip fracture CT scan
2. Reduce Hip
Are there Urgently to
No
Start Rehabilitation Protocol associated operating room
fractures?
Yes
Skeletal traction while Approach Options:
awaiting surgery
Unstable Posterior 1. Anterior
wall of acetabulum Femoral head fracture 2. Posterior
+/– femoral head or joint incongruent approach with
fracture digastric osteotomy
and hip dislocation
Reduce hip and
treat femoral head
Approach options: Approach options: as indicated
1. Posterior approach +/– digastric 1. Anterior approach
osteotomy with hip dislocation 2. Posterior approach +/–
2. Staged approach with posterior digastric osteotomy with hip
approach followed by anterior dislocation
approach if needed
dislocated hip. Ideally, only one attempt at re- superior iliac spine (ASIS). The leg is
duction is required, so variables such as pa- held with the knee flexed. Inline traction
tient sedation, patient position, the experience is applied, and the leg is slowly flexed,
of the reducer, and the amount of assistance internally rotated, and adducted. Relax-
should be maximized in favor of a successful ing the anterior ligaments sometimes
reduction. Reduction maneuvers in the emer- requires that the hip be flexed beyond
gency department should be limited to one at- 90° and the knee be pointed in the direc-
tempt. Iatrogenic fractures of the femoral neck tion of the contralateral hip. With maxi-
have been reported after forceful attempts at mal traction the leg is gently rocked in
reduction. The two described techniques for internal and external rotation. Reduc-
posterior hip dislocation reduction have not tion of the hip is not subtle and is easily
changed from the time of Bigelow. palpable and occasionally audible. The
• Techniques for posterior dislocations reduced hip is stabilized by external ro-
(a) Allis and Bigelow techniques (Fig. 17-6)— tation, extension, and abduction. A slow
The patient is supine. Countertraction progression of the traction force is
is applied to the ipsilateral anterior more effective than an abrupt tug.
A B
FIGURE 17-6 Reduction maneuvers for posterior dislocation of the hip. A. Allis. B. Bigelow.
FIGURE 17-7 Stimson gravity-reduction

technique for posterior dislocation of
the hip.
General anesthesia is preferred, but con- in the inguinal region or if in the operat-
scious sedation is acceptable. ing room a Schanz pin in the proximal
(b) Stimson technique (Fig. 17-7)—The pa- femur. The anterior capsule is usually
tient is placed in the prone position the block to reduction.
with the hips flexed 90° off of the edge 3. Assessment of stability—The traditional
of the stretcher. The ipsilateral knee is teaching has been to clinically assess the sta-
bent 90°, and force is applied to the back bility of the hip joint immediately after reduc-
of the proximal calf. The reduction mation of the joint. This has come into question
neuvers are the same as those used in with the ability of CT to predict stability if
the supine technique. The prone tech- there is a large posterior acetabular fracture.
nique is contraindicated in the patient Subtle instabilities may be difficult to detect
with multiple trauma but can be used clinically. If the reduced hip is grossly un-
for an isolated injury when full sedation stable, skeletal traction should be placed. If
is unavailable because it may be easier the reduced hip remains located, the postre-
for the patient to relax the leg under the duction CT scan can be evaluated to deter-
influence of gravity. mine if the hip will be definitely unstable (i.e.,
• Techniques for anterior dislocations 50% posterior wall involvement). In cases
(a) Anterior dislocations are harder to in which stability cannot be predicted by CT
reduce than posterior dislocations. If (i.e., 50% posterior wall involvement), the
one or two attempts with optimal se- evaluation for stability should be performed
dation are unsuccessful, the patient in the OR with the patient fully relaxed and
should be taken to the OR. The method with fluoroscopy to detect small degrees of
of reduction differs from that previously subluxation.
described (for posterior dislocation) in • Posterior stability—The hip is flexed to 90°,
that the position of the leg is reversed. and while it is held in neutral rotation and
With the leg in external rotation, abduc- neutral abduction, a posteriorly directed
tion, and flexion, inline traction is ap- force is applied to the leg. If the hip sub-
plied. The leg is rocked in internal and luxes, it is unstable.
external rotation to walk the head over • Anterior stability—The hip is abducted,
the anterior acetabular rim. A lateraliz- flexed, and externally rotated. If gravity can
ing force on the proximal femur may as- dislocate the hip, it is unstable.
sist with the reduction. This can be done • Hip instability—If the hip is unstable, the
by direct pressure over the femoral head bony injury producing the instability needs
to be fixed by open reduction and internal Chapter 16 and are only summarized in the
fixation. The bony acetabulum covers ap- next section.
proximately 40% of the femoral head, and 6. Postreduction management—Weightbearing
the labrum extends the coverage to just status is dictated by associated fractures if any
over 50%. If there is no fracture, instability are present. In a pure dislocation, weightbear-
is unlikely. ing is as tolerated with crutches until leg con-
4. Assessment of congruency—All reductions trol has been regained. Early weightbearing
should have immediate postreduction films. does not predispose to the development of
If the hip is not reduced, another reduction AVN as previously contended. Appropriate hip
is performed, preferably in the OR. If the hip precautions are recommended for 6 weeks fol-
is reduced, a CT scan is obtained to assess lowing dislocation.
the congruency and look for fragments. The F. Relevant Anatomy and Surgical Techniques—The
joint space on the involved hip should be hip joint is a ball-and-socket configuration. The
identical to that on the uninvolved hip. joint is highly constrained by soft tissues, includ-
A posteriorly dislocated hip may need a sup- ing the stout fibrocartilaginous labrum, the trans-
port under the greater trochanter to keep verse acetabular ligament, and the joint capsule.
gravity from laterally subluxing the hip. If In a typical posterior dislocation without fracture,
the hip is not congruent, the cause must be the posterior capsule is avulsed from its attach-
identified. If no bony cause is seen on CT, ment to the labrum and the femoral head extrudes
MRI may be performed to identify any soft through the superior gemellus muscle or passes
tissue that has been interposed. Removal through the interval between the piriformis and
of the interposed tissue is mandatory. The the obturator internus. Complete coverage of the
operative approach is dictated by the loca- anatomy about the hip and of all the useful surgi-
tion of the interposed tissue and its site of cal approaches is beyond the scope of this chap-
origin. There has been recent success with ter (see Chapter 16). Salient anatomic features
the use of hip arthroscopy to remove these and the three most common surgical approaches
fragments. The patient with interposed frag- are highlighted.
ments or tissues in the hip joint should be 1. Anatomy—The primary landmarks are the sci-
placed in skeletal traction while waiting for atic nerve, the location of the MFCA, and the
operative removal/fixation. structure of the labrum and capsule.
5. Open reduction—Inability to obtain a closed • Sciatic nerve—The sciatic nerve divides into
reduction is usually the result of inadequate two branches (the peroneal and the tibial)
relaxation/paralysis, blockage by the hip within the pelvis. These exit the greater sci-
capsule and/or short external rotators, or a atic notch in a common sheath. A total of
femoral fracture that makes control of the hip 85% of the time, the entire nerve exits infe-
difficult. Failure to obtain a closed reduction riorly to the piriformis, and 15% of the time,
is an indication for an urgent and immediate a portion of the nerve may pass through or
open reduction. During an open procedure, it superior to the piriformis. The nerve then
is paramount to protect the vascularity. Hips runs superficial to the short external rota-
that cannot be reduced closed, hips with as- tors (the gemelli and the obturator internus)
sociated fractures that are unstable after re- and lateral to the ischial tuberosity.
duction, and hips that are not congruent after • Blood supply to the femoral head—The
reduction all need open treatment. If the dislo- blood supply to the femoral head has al-
cation, the instability, or the interposed frag- ready been mentioned. It can be damaged
ment is posterior, a posterior approach should at the time of injury. It can also be injured
be chosen. However, in the rare case of an ir- during anterior or posterior approaches to
reducible posterior dislocation with a femoral the hip. The MFCA is at risk at several loca-
neck and/or femoral head fracture an anterior tions along its course. The vessel enters the
approach can be used. If the dislocation, the surgical field along the inferior border of the
instability, or the interposed fragment is ante- obturator externus. It then runs superiorly
rior, an anterior approach should be chosen. along the insertion of the short external rota-
Choice of approach is covered in more detail tors, approximately 1 cm from their insertion
under the femoral head fracture section. The onto the intertrochanteric ridge (Fig. 17-8). It
surgical approaches are covered in detail in anastamoses with the branch of the inferior
not usually tear but is instead avulsed from

its acetabular attachment. When labral inju-
ries are encountered during open reduction,
it is unclear as to whether repair or resec-
Obturator tion is appropriate.
internus • Capsule—The capsule is composed of two
B layers. The layers are not separable but do
C serve distinct functions. The inner fibers
Obturator are longitudinal and run from the acetabu-
externus lum parallel to the femoral neck to insert
A on the proximal femur, and they limit lateral
subluxation. The outer fibers run obliquely
in three identifiable groups: the two anterior
bands and the posterior band. The anterior
bands (the Y-shaped Bigelow’s ligament)
are more substantial; these are the iliofemo-
ral ligament and the pubofemoral ligament.
The posterior ligament is the ischiofemoral
ligament. These outer fibers limit flexion and
extension. The capsule is also strengthened
by the reflected head of the rectus anteriorly
FIGURE 17-8 Anatomic location of the MFCA along and by the gluteus minimus superiorly.
the posterior neck of the femur. The vessel passes 2. Surgical approach—The surgical approach
posterior to the obturator externus and anterior to the chosen depends on the location of the injury
short external rotators, including the obturator internus. being addressed. A Kocher-Langenbeck ap-
A, Proximity to the lesser trochanter; B and C, proximity proach is used for posterior exposure. Ante-
to the muscular insertions. rior exposure can be gained through a true
anterior, an anterolateral, or a direct lateral
approach.
gluteal artery that runs along the inferior • Posterior (Kocher-Langenbeck) Approach—
border of the piriformis. The vessel distal to Most of the salient points have been
the anastamosis runs deep to the piriformis reviewed. The sciatic nerve must be pro-
and perforates the capsule at the level of the tected, and only blunt retractors should be
piriformis insertion. The vessel then runs in used. Protection of the MFCA requires that
the synovial reflection (this vessel has sev- the dissection not go distally through the
eral different names depending on the au- obturator externus because the vessel runs
thor, and it is described here not by name along its inferior border. If the short external
but by location intentionally) up the lateral rotators must be taken down, it should be
border of the neck to insert just distal to the done 1.5 to 2 cm away from their insertion.
articular margin (see Fig. 17-4). Injuries to If the capsule is to be incised, it should be
the MFCA are most likely to occur when tak- done from inside the joint along the acetabu-
ing down the short external rotators, when lar rim under direct vision so as to not injure
opening the capsule, or when placing a re- the vessel or the labrum. A retractor should
tractor around the lateral femoral neck. never be placed along the lateral border of
• Labrum—The labrum attaches to the bony the neck, as is frequently done during total
acetabular rim, except inferiorly, where it hip arthroplasty, because it can damage the
attaches to the transverse acetabular liga- artery running within the synovial reflexion.
ment. The inner surface of the labrum is • Anterolateral (Watson-Jones, Hardinge, Dall,
flush with the cartilage, and on its outer or Trochanteric Slide) Approach—Because
surface, there is a recess between it and the of the laterally placed skin incision, the an-
capsule. The labrum extends the coverage terolateral approach works well if access to
of the acetabulum to slightly over 50% but both the anterior and posterior aspects of
does not participate in the static load trans- the hip is required, for example with an as-
mission across the hip. The deep fibers are sociated intertrochanteric fracture or femo-
circular and very strong, so the labrum does ral neck fracture. The trochanteric slide is
a more extensive dissection, but it allows for series do not report the possible differences in
surgical dislocation of the hip and full access rates between surgical and nonsurgical cases
to the acetabulum and the femoral head. or between pure dislocations and those with
This can also be accomplished through a associated injuries. The rates of AVN increase
posterior approach with a digastric trochan- if the hip is left dislocated for longer than 6 to
teric osteotomy as will be discussed later. 12 hours. This suggests that most injuries to
The opening of the capsule should be per- the vessel are not avulsions or transections
formed as previously stated, and again, no but are compressions, kinks, spasms, or a
retractors should be placed along the lateral combination thereof. One report showed that
femoral neck. Branches of the lateral femoral the rate of AVN increased from 4.8% with a re-
circumflex vessel are encountered along the duction within 6 hours to 52.9% after greater
anteromedial neck and may be sacrificed. than 6 hours. Recent investigators suggest that
• Anterior (Smith-Petersen) approach—The the present rates of traumatic AVN may be on
anterior approach is advocated in anterior the lower end of the reported spectrum and
dislocations or dislocations with anterior that the higher rates previously reported may
femoral head fractures because the more reflect damage to the vascularity during open
medial dissection plane allows for easier procedures. If done carefully, open reduction
placement of compression screws into the should not increase the rate of AVN.
fracture fragment. Comparatively less dis- 3. Arthritis—Arthritis is the common final path-
section occurs with this approach. In the way for all injuries to the articular surface. Dam-
interval between the tensor laterally and the age to the cartilage can occur via many means.
sartorius medially, the lateral femoral cuta- The progression to arthritis depends on the
neous nerve should be protected. This can extent of the injury to the mechanical and bio-
be done by locating the nerve at the level chemical properties of the articular cartilage.
of the superficial circumflex iliac artery, Likewise, fracture malunions and nonunions
which penetrates the fascia just anterior to may be major contributors to long-range dis-
the nerve, or by staying within the fascia ability in patients with fracture-dislocations.
of the tensor. In the deeper dissection, the Anterior dislocations are typically more prone
vessel overlying the rectus femoris is the to developing arthritis secondary to higher
ascending branch of the lateral femoral rates of impaction injuries.
circumflex artery, which may be sacrificed. • Third-body wear—Interposed bone (from
G. Complications of Injury—Complications may be the femoral head or the acetabulum), carti-
either local or systemic. The systemic complica- lage (labrum or articular surface), or soft tis-
tions are more often a result of the overall trauma sue (muscle, tendon, or capsule) generates
than of the dislocation. The local complications third-body wear within the hip and leads to
include sciatic nerve injuries, AVN, arthritis, and early arthritis.
recurrent dislocations. • Direct pressure—If the instantaneous load
1. Sciatic nerve injury—Sciatic nerve injury oc- on the cartilage exceeds a certain threshold,
curs in 7% to 27% of posterior hip dislocations. direct chondral death can occur. This can oc-
It is more common in fracture-dislocations than cur at the time of impact or as the dislocated
in pure dislocations. As previously mentioned, femoral head presses against the ilium.
the prognosis for recovery is variable. Nerve • Shearing—As the hip dislocates, it is scraped
injury is not an indication for open reduc- along the acetabular rim and can shear off a
tion. Electromyography at 3 months can be portion of the articular cartilage.
used to determine prognosis but usually does • Nutritional deficiencies—The articular carti-
not change the management, which is to wait lage receives its nutrition from the synovial
18 to 24 months and then address the residual fluid, and it is not bathed in synovial fluid
deficiency. Patients who lack ankle dorsiflex- when in a dislocated position.
ion should receive an ankle-foot orthosis early 4. Recurrent dislocations—Recurrent disloca-
to avoid equinus contractures. No surgery to tions are very rare. Most are posterior. Causes
address the disability should be undertaken may include a combination of femoral version,
for at least 1 year. acetabular version, soft-tissue impingement,
2. AVN—AVN is reported to occur in 2% to 17% of labral avulsion, and capsular laxity. Treat-
cases of posterior dislocation of the hip (AVN ment is directed toward the structures found
is much rarer after anterior dislocation). These responsible.
5. Heterotopic ossification—Heterotopic ossifi- III. Femoral Head Fractures

cation in the soft tissues surrounding the hip A. Overview—Femoral head fractures always occur
joint may occur with and without open treat- as the result of hip dislocation or subluxation.
ment. This may or may not have an affect on Pertinent information about anatomy, presenta-
range of motion. tion, evaluation, and management was presented
6. Persistent pain—Excluding the factors men- in the previous section on hip dislocations. A to-
tioned previously, the most common causes of tal of 82% to 92% of hip dislocations are posterior
continued pain after dislocation are labral inju- and 4% to 18% are associated with femoral head
ries, ununited acetabular rim avulsion fractures, fractures. Between 68% and 77% of anterior hip
and dynamic instability. All cause intermittent dislocations have an associated femoral head
symptoms and occasional clicking or catching. fracture. Despite this high incidence, only 10% of
The diagnoses of labral injuries and avulsion femoral head fractures result from anterior dis-
fractures can be made with a positive impinge- location because of the preponderance of poste-
ment test, which correlates with the appropri- rior dislocation. The two types of femoral head
ate MR findings. Treatment should be tailored injuries are shear or cleavage injuries, which can
to the pathologic condition found. Arthroscopy occur with anterior or posterior dislocations,
has been advocated for many of these lesions. and impaction or crush injuries, which usually
H. Complications of Treatment occur with anterior dislocations. The location,
1. Infection—The infection rate is 3% to 5% for comminution, and displacement patterns are re-
the surgical approaches described. Because of lated to the position of the hip and the load ap-
the capsular injury, if a deep infection occurs, plied to the hip during the traumatic event. The
a septic joint must be assumed and appropri- position of the leg at time of impact determines
ately treated. whether the hip dislocates with or without os-
2. Sciatic nerve injury—The rate of injury as seous injury. If the hip is flex and adducted, it is
a result of the treatment of dislocations likely to dislocate without osseous injury. If the
is unknown, but the rate with the Kocher- hip is extended and abducted, the axial force is
Langenbeck approach for acetabular fractures directed more into the hip joint and results in a
is 11% (range 2% to 17%). The nerve may be- femoral head or acetabular fracture. With poste-
come entrapped in heterotopic ossification rior dislocation, femoral head fractures typically
and present as a delayed sciatic neurapraxia. involve the anteromedial aspect of the head.
3. AVN—The rate of AVN resulting from the treat- Impaction of the intact cancellous surface may
ment of hip dislocations is unknown, but the occur as the dislocated hip rests on the retroac-
higher rates from earlier series may be par- etabular surface. For anterior dislocations, the
tially attributed to delays in reduction and to fracture is typically an infrafoveal impaction.
intraoperative damage to the MFCA. B. Evaluation—The evaluation is the same as that
4. Thromboembolism—Patients with hip disloca- outlined in the section on hip dislocation.
tion generally require prophylaxis. C. Classification—There are two classifications sys-
I. Outcomes—The outcomes of pure dislocations tems for femoral head fractures. The Pipkin clas-
largely depends on the development of AVN, ar- sification (Table 17-5 and Fig. 17-9), published
thritis, and heterotopic ossification. Reported in 1957, is an elaboration of the Thompson and
series show a range of good or excellent results Epstein Type V posterior hip dislocation. It in-
from 48% to 95%. The outcome of a hip dislocation cludes associated injuries and provides prognos-
with an associated fracture is often determined tic information. The Pipkin classification system
by the outcome of the fracture. The most impor- is the most commonly used system. Type I frac-
tant prognostic factor in dislocations of the tures are infrafoveal and are characterized by
hip is the time to reduction (6 to 12 hours) disruption of the ligamentum teres. Type II frac-
to avoid ongoing damage to the blood sup- tures are suprafoveal and are characterized by
ply to the femoral head. One report indicated maintenance of the ligamentum teres to the frac-
88% good or excellent functional outcomes in hip ture fragment. Type III fractures represent any
dislocations reduced within 6 hours. For hips re- head fracture with an associated femoral neck
duced greater than 6 hours, only 42% had good or fracture. Type IV fractures represent any head
excellent results. The second most important fac- fracture with an associated acetabular fracture.
tor is to ensure that there is absolute congruency Brumback et al. introduced a classification sys-
of the reduced joint to avoid ongoing damage to tem (see Table 17-4) in 1987 that included ante-
the articular cartilage. rior and posterior fracture-dislocations. No large
series has yet been published using this newer

TA B L E 1 7 - 5 system. Impaction fractures of the femoral head
Pipkin’s Classification of Posterior Hip Dislocations do not have a classification system but do occur.
Associated with Femoral Head Fractures D. Anatomy—In addition to the musculature and
osseous structure of the hip, the capsule and
Type Description
ligament teres are restraints to dislocation. The
I Hip dislocation with fracture of the femoral
ligamentum teres represents a strong attachment
head caudad to the fovea capitis femoris
between the acetabulum (cotyloid fossa) and the
II Hip dislocation with fracture of the femoral femoral head (fovea centralis). During a disloca-
head cephalad to the fovea capitis femoris tion, the ligamentum may be torn or may remain
III Type I or II injury associated with fracture of attached to the femoral head fragment if the frac-
the femoral neck ture exits cephalad to the fovea centralis (Pipkin
IV Type I or II injury associated with fracture of II). Additionally, the ligamentum teres contains
the acetabular rim an arterial branch from the obturator artery and
Source: From Pipkin G. Treatment of grade IV fracture- supplies 10% to 15% of the femoral head blood
dislocation of the hip: a review. J Bone Joint Surg. supply.
1957;39A:1027–1042, with permission.
E. Associated Injuries—Associated injuries include
damage to the sciatic nerve, the femoral neck,
the acetabulum, the knee, and the femoral shaft.
Type I Type II The acetabular labrum may also be injured. An
avulsion of the labrum from the posterior ac-
etabular rim may prevent a closed reduction in a
posterior dislocation.
F. Treatment—Most femoral head fractures will
require operative treatment. When the femoral
head is fractured or dislocated, the femoral neck
needs to be carefully evaluated for an injury. If
the femoral neck is uninjured, a hip dislocation
should be emergently reduced irrespective of the
presence of a femoral head fracture. If closed re-
duction fails or if there is a femoral neck injury,
open reduction is indicated. If a preoperative
CT scan can be obtained with less than an hour’s
delay, it is helpful in elucidating loose bodies, soft
tissue interposition, and impaction injuries and
Type III Type IV
in selecting the appropriate surgical approach.
After a reduction has been confirmed by plain
films, a postreduction CT scan is required to as-
sess the adequacy of the reduction of the hip
joint and of the fracture fragments. Oblique Judet
radiographs of the pelvis can also help elucidate
the head fracture.
1. Pipkin type I—Closed treatment can be con-
sidered for isolated and small infrafoveal
fractures. Closed management consists of pro-
tected weight bearing with appropriate hip
precautions. If the fragment impinges the la-
brum or the acetabular cartilage and has more
than a 1 mm step-off, the fragment should be
FIGURE 17-9 Pipkin’s classification of posterior hip
excised if it is small or should be fixed if it is
dislocations associated with femoral head fractures.
Type I is a fracture fragment below the ligamentum teres. large. The displacement of the piece is typi-
Type II is a fracture fragment including the ligamentum cally caudal and anterior. Malunited infero-
teres. Type III is either a type I or II injury with an medial femoral head fractures may block hip
associated femoral neck fracture. Type IV is either a motion. Large infrafoveal head fractures con-
type I or II injury with an associated acetabular fracture. tribute to hip instability. For Type I fractures,
either an anterior or posterior approach may be preserved. Fairly unique to these injuries is
be used. The posterior approach may be used the fixation of the fracture through the articu-
for small fragment excision but is less desir- lar surface. Countersunk standard screws or
able for fragment fixation. The details of the variable-pitch headless screws may be used.
approaches are in the following section on The screws are typically of small diameter.
Type II fractures. The ligamentum teres may be transected to
2. Pipkin type II—Suprafoveal fractures involve assist with open reduction. The ligamentum
the weightbearing dome and the quality of the teres is often debrided to prevent interposi-
reduction is paramount. Minor incongruities tion after reduction. With any approach, the
are not tolerated by the hip joint. These inju- capsule should be repaired and suture an-
ries are treated with open reduction and inter- chors may be used if necessary.
nal fixation if not anatomically reduced. The 3. Pipkin type III—A Pipkin type III injury is the
choice of approach is somewhat controver- least common injury. Closed reduction of the
sial. The Smith-Peterson approach (anterior) hip dislocation is contraindicated. All patients
is the most commonly advocated approach should undergo surgical evaluation via an
and can be performed supine on a radiolu- anterolateral (Watson-Jones) or anterior ap-
cent table or a traction table designed for proach (Smith-Peterson) that allows access
acetabular surgery (Fig. 17-10). The fracture to both the anterior and posterior aspects of
location is most commonly anteromedial, and the hip joint. The femoral neck fracture must
this approach optimizes fracture reduction be stabilized before reduction of the hip dislo-
while preserving the posterior blood supply. cation. If the head fragment is large, often re-
The fracture fragment can often be visualized duction of the neck and head fragments must
without redislocation. A surgical dislocation occur simultaneously. If the patient is physi-
may be necessary for fracture visualization/ ologically older and the reduced femoral head
fixation as the fracture is more cephalad. Ef- does not bleed from a 2-mm drill hole in the
fort should be made to retain any soft-tissue head, a hemiarthroplasty or a total hip arthro-
attachment to the head fragment. The antero- plasty may be considered.
medial position of the fragment makes visu- 4. Pipkin type IV—The type and location of the
alization and fixation very difficult through a acetabular fracture dictates the surgical ap-
posterior approach. proach for the acetabulum. The acetabular
For an irreducible posterior dislocation exposure must not be compromised. The con-
with a femoral head fracture, a Kocher- comitant femoral head fracture can be treated
Langenbeck approach may be used. As men- through a separate anterior approach (Smith-
tioned previously, the femoral head may be Peterson) if necessary. However, often a pos-
buttonholed through the posterior capsule terior Kocher-Langenbeck approach will allow
or through the short external rotators. These visualization of the posterior acetabulum, and
structures are difficult to access through an then a digastric trochanteric osteotomy with
anterior approach. After making the stan- anterior surgical dislocation can be done to
dard posterior approach and releasing the access the femoral head. The femoral head
short external rotators 1 to 2 cm from their fracture should either be fixed or excised to
insertion (the quadratus femoris must not be allow for early hip motion. Hip stability should
taken down to preserve the blood supply to be carefully considered especially after frag-
the femoral head), the hip can often be dis- ment excision. If possible, impaction injuries
located through the traumatic capsulotomy to either the acetabulum or the femoral head
for femoral head visualization and fragment should be elevated and stabilized during the
excision/fixation. The capsulotomy may be operative procedure.
extended along the rim of the acetabulum to G. Rehabilitation—The patient should undergo ag-
increase visualization if necessary. Following gressive ROM exercises after open fixation of
the Kocher-Langenbeck approach, an addi- a Pipkin fracture. Toe-touch weight bearing is
tional anterior approach may be needed for typically used for the first 8 weeks and then pro-
fragment fixation. An alternative approach is gressed to weight bearing as tolerated.
to use a digastric trochanteric osteotomy with H. Surgical Techniques—The surgical approaches
an anterior dislocation through a posterior have been described. The following details the
Kocher-Langenbeck approach. With either ap- technique of using a digastric trochanteric os-
proach, the femoral head blood supply must teotomy for dislocation and exposure of the
C
FIGURE 17-10 A, B. Intraoperative pictures demonstrating an anterior Smith-Peterson approach with hip dislocation.
Large Pipkin type II injury is shown. C. The fragment was fixed with three headless screws.
femoral head and acetabulum. A standard in- greater trochanter but lateral to the insertion of
cision for a Kocher-Langenbeck approach is the short external rotators. The osteotomy ex-
made. The fascia lata is split in line with the tends distally to the posterior border of the vas-
skin. The posterior border of the gluteus me- tus lateralis ridge. The osteotomized fragment
dius is located, and the leg may be internally ro- is then rotated 90° and retracted anteriorly. The
tated to make this easier. An osteotomy is made hip is then flexed and externally rotated. The
with an oscillating saw just medial to tip of the plane between the piriformis and the gluteus
minimus is located, and the minimus is reflected of heterotopic ossification increases in poly-
off the posterior, posterosuperior and anterior traumatized and brain injured patients.
capsule. A Z-type capsulotomy is then made 4. Fracture malreduction and nonunion—The
along the long axis of the femoral neck. The hip goal is to achieve less than 1 mm of articular
can then be dislocated with further flexion and step-off, but this is often difficult to obtain be-
external rotation and placed in a sterile bag on cause of initial fracture comminution. If the
the opposite side of the table. By manipulation fragment is not in the weightbearing dome,
of the leg, a full view of the femoral head and ac- fragment excision can be considered. The an-
etabulum can be obtained. If needed, the short terior approach has shown to allow better frac-
external rotators can be released 2 cm from ture reduction. Fixation failure occurs most
their insertion to gain access to the posterior commonly with osteonecrosis or nonunion.
acetabulum. 5. Hip joint malreduction—A malreduction is an
I. Complications—The complications are a result absolute indication for repeat open reduction.
of both the injury and the surgical treatment. The 6. Degenerative arthritis—Posttraumatic arthri-
main complications are posttraumatic arthritis, tis occurs in 0% to 72% of femoral head frac-
heterotopic ossification, sciatic nerve palsy, and tures. Up to 50% of patients with Pipkin type II
avascular necrosis. or IV posterior fracture-dislocations and most
1. AVN—AVN is reported at rates of 0% to 24%. patients with Pipkin type III injuries develop
AVN can be caused by injury to the MFCA and degenerative arthritis. Fracture comminution
its terminal branches as a result of the dislo- and peripheral impaction increase the risk of
cation or by injury to the interosseous blood posttraumatic arthritis.
supply as a result of the femoral head frac- J. Outcomes—The comparison of treatments is
ture. The incidence of AVN correlates with the difficult because of the lack of a standardized
length of time that the hip remains dislocated. evaluation system and the varying severities of
When the large series are combined, the liter- these injuries. Present knowledge about results
ature shows posterior dislocations to have a of treatment comes from retrospective series
13% incidence of AVN, which increases to 18% with small numbers and varying injuries with
if there is an associated femoral head fracture. varying approaches. Few studies with long-term
One study showed the Kocher-Langenbeck outcomes have been reported for hip disloca-
approach resulted in a 3.2-fold increase in tions with femoral head fractures. Follow-up
osteonecrosis when compared to an anterior studies of 2 to 5 years have shown fair or poor
approach. Surgical incision of an intact liga- results in 57%. Good or excellent outcomes have
mentum teres does not appear to increase the only been reported in 40% to 70% of all patients.
rate of avascular necrosis. Ideally, similar injuries that have had different
2. Sciatic nerve palsy—The sciatic nerve is at treatments would be compared, but because of
risk for palsy during posterior dislocations. the rarity of these injuries, this has not been pos-
The incidence of sciatic nerve injury is 7% to sible. The reports over the last 40 years span the
27% for femoral head fractures. Motor loss advent of CT and the use of different interven-
that persists for longer than 3 months after tions but consistently show that up to 50% of pa-
hip fracture-dislocation has a poor prognosis. tients with Pipkin type II or IV injuries and most
3. Heterotopic ossification—The incidence of patients with Pipkin type III injuries develop de-
formation of heterotopic ossification is 2% to generative arthritis. Direct comparison between
54% in femoral head fractures. The extent of anterior and posterior surgical approaches for
the heterotopic ossification increases with the Pipkin I and II fractures showed the anterior
severity of the bone and soft tissue trauma and approach was associated with less blood loss,
the surgical approach chosen. There is a higher shorter operating room time, and better visu-
rate of heterotopic ossification with the Smith- alization and fixation. The anterior approach
Petersen approach than with the Watson-Jones was also associated with more functionally sig-
approach, and both have a higher risk than nificant heterotopic ossification. Most current
the Kocher-Langenbeck approach. However, literature supports the idea that an anatomic re-
functionally significant ectopic bone forma- duction gives the best chance for good long-term
tion rarely occurs. This may be minimized by results and treatment should focus on restoring
sharp dissection. Additionally, the formation the normal joint anatomy.
SUGGESTED READINGS Hougaard K, Thomsen PB. Traumatic posterior fracture-

dislocation of the hip with fracture of the femoral head or
neck, or both. J Bone Joint Surg. 1988;70A:233–239.
Classic Articles Olson SA, Matta JM. The computerised tomography subchon-
Shim SS. Circulatory and vascular changes in the hip follow- dral arc: a new method of assessing acetabular articular
ing traumatic hip dislocation. Clin Orthop. 1979;140:255–261. continuity after fracture—A preliminary report. J Orthop
Stewart M, Milford LW. Fracture-dislocation of the hip: an end- Trauma. 1993;7:402–413.
result study. J Bone Joint Surg. 1954;36A:315–342. Yang RS, Tsuany YH, Hang YS, et al. Traumatic dislocation of
Thompson VP, Epstein HC. Traumatic dislocation of the hip: a the hip. Clin Orthop. 1991;265:218–227.
survey of two hundred and four cases covering a period of
twenty-one years. J Bone Joint Surg. 1951;33A:746–778.
Trueta J, Harrison MHM. The normal vascular anatomy of the Review Article
femoral head in adult man. J Bone Joint Surg. 1953;35B:442–461.
Tornetta P 3rd, Mustatari H. Hip dislocation: current treatment
regimens. J Am Acad Orthop Surg. 1997;5:27–36.
Recent Articles
Baird RA, Schobert WE, Pais MJ, et al. Radiographic identifica-
tion of loose bodies in the traumatized hip joint. Radiology. Textbooks
1982;145:661–665. Geller JA, Reilly MC. Hip dislocations and femoral head frac-
Brumback RI, Kenzora JE, Levirt LE, et al. Fractures of the fem- tures. In: Stannard JP, Schmidt AH, Kregor PJ, eds. Surgical
oral head. In: Proceedings of the 1986 Hip Society. St Louis, Treatment of Orthopaedic Trauma. New York, NY: Thieme;
MO: Mosby; 1987. 2007.
Dreinhofer KE, Schwarzkopf SR, Haas NP, et al. Isolated trau- Goulet JA, Levin PE. Hip dislocations. In: Browner BD, Jupi-
matic dislocation of the hip: long-term results in 50 patients. ter JB, Levine AM, et al, eds. Skeletal Trauma. Vol 2. 3rd ed.
J Bone Joint Surg. 1994;76B:6–12. Philadelphia, PA: WE Saunders; 2003.
Gardner MJ, Suk M, Helfet DL, et al. Surgical dislocation of Koval KJ, Cantu RV. Hip trauma. In: Fischgrund JS, ed. Ortho-
the hip for fractures of the femoral head. J Orthop Trauma. paedic Knowkdge Update 9: Home Study Syllabus. Rosemont,
2005;19:334–342. IL: American Academy of Orthopaedic Surgeons; 2008.
Ganz R, Gill TJ, Gautier K, et al. Surgical dislocation of the Nork, SE, Cannada LK. Hip dislocations and femoral head and
adult hip. J Bone Joint Surg Br. 2001;83-B:1119–1124. neck fractures. In: Baumgaertner MR, Tornetta P, eds. Ortho-
Henle P, Kloen P, Sibenrock KA. Femoral head injuries: paedic Knowledge Update Trauma 3. Rosemont, IL: American
which treatment strategy can be recommended? Injury. Academy of Orthopaedic Surgeons; 2005.
2007;38:478–488. Tornetta P. Hip dislocations and fractures of the femoral head.
Hougaard K, Lindequist S, Nielsen LB. Computerised tomogra- In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood
phy after posterior dislocation of the hip. J Bone Joint Surg. and Green’s Fractures in Adults. Vol 2. 6th ed., Philadelphia,
1987;69B:556–557. PA: Lippincott-Raven.
PART III THE UPPER EXTREMITY
CHAPTER 18
Fractures and Dislocations of the

Shoulder Girdle
Gregory N. Drake and T. Bradley Edwards
I. Fractures of the Scapula B. Mechanism of Injury

A. Overview 1. Injury may occur from a direct blow to the scap-
1. Function of the scapula—The scapula plays ula or with force acting through the humerus.
an important role in the mechanics of the As a general rule, scapular injuries require high-
shoulder girdle. It has 18 muscular attach- energy trauma and when seen should raise sus-
ments, which link the axial skeleton to the picion for other associated injuries including rib
appendicular skeleton. Dyskinesis can lead fractures, hemo/pneumothorax, pulmonary
to painful upper extremity use and if not contusion, brachial plexus injury, cervical spine
treated, can be chronic in nature. The scap- fracture, clavicle fracture, and arterial injury.
ula is important for rotator cuff function, C. Imaging
which is translated to upper extremity mo- 1. Orthogonal—High-quality orthogonal views are
tion. It has several articulations, including the most helpful when evaluating scapular frac-
the scapulothoracic, acromioclavicular, and tures. The AP scapula and transscapular Y view
glenohumeral joints. are the most helpful.
2. Frequency of injury—Fractures to the scapula 2. Computed tomography (CT) scans—CT scans,
are rare and account for 0.5% to 1.0% of all frac- particularly with three-dimensional reconstruc-
tures and 3% to 5% of shoulder girdle injuries. tions, may aid in diagnosis, and help with pre-
3. Biomechanics—Shoulder elevation is com- operative planning of periarticular and articular
posed of glenohumeral motion (120°) and fractures.
scapulothoracic motion (60°). The scapula is 3. Stryker view—If a coracoid fracture is sus-
the foundation for all complex upper extrem- pected, a 45° cephalic tilt view (Stryker view) is
ity motions with its multiple muscle attach- useful. If soft-tissue injury is diagnosed, an MRI
ments. It acts as a fulcrum for the deltoid may be useful.
while allowing the rotator cuff muscles to D. Classification (Fig. 18-1)
keep the humeral head centered in the gle- 1. Mayo
noid during abduction. The coracoid main- • Type I—Involvement of the anteroinferior
tains vertical stability through soft-tissue glenoid; the injury may be associated with
attachments with the clavicle and muscles complete dislocation or subluxation of the
of the chest and arm. The acromioclavicu- humeral head. The scapular body is intact.
lar joint allows for horizontal and vertical • Type II—Involvement of the superior third
stability. to half of the glenoid; the superior fragment
262
C H A P T E R 1 8 | F R A C T U R E S A N D D I S L O C A T I O N S O F T H E S H O U L D E R G I R D L E 263
Type IV with acromion with superior with coracoid

fragment articular fragment fragment
Type V
FIGURE 18-1 Mayo’s modification of the Ideberg classification of intraarticular fractures of the glenoid distinguishes
five types. The figure shows Types I through IV and three variants of Type V. Type V is a Type IV pattern plus an
additional coracoid, acromion, or free superior articular fragment.
contains the intact coracoid. The scapular fractures with displacement, and ipsilat-
body is intact. eral fractures of the clavicle and glenoid
• Type III—Involvement of the inferior or infero- neck or a fracture of the glenoid neck as-
posterior glenoid; the injury includes the lateral sociated with disruption of the soft tissues
scapular border. The scapular body is intact. attaching the clavicle to the scapula.
• Type IV—Involvement of the inferior glenoid 2. Scapular body fractures—Although scapulo-
with extension into the scapular body. thoracic motion is important in preservation of
• Type V—Type IV with the addition of a coracoid, normal motion, scapular body fractures do
acromion, or free superior articular fragment. well with nonsurgical management. Almost
E. Treatment all of these fractures heal due to the abundant
1. Types blood supply and musculature covering the
• Nonoperative—Indications include scapular surface of the scapula. If dyskinesis exists, it
body fractures and periarticular/articu- typically responds to therapy. If the fracture ex-
lar fractures with only minimal displace- tends into the scapular spine and displacement
ment. These will generally heal well without is greater than 5 mm, open reduction and inter-
complications. nal fixation (ORIF) is recommended. Be aware
• Surgical—Indications include displaced that these are typically high-energy injuries
glenoid fossa fractures and fracture- and are associated with a high incidence of
dislocations, glenoid neck fractures with life-threatening injuries, including scapulo-
displacement, coracoid and acromion thoracic dissociation.
264 S E C T I O N I I | A D U L T T R A U M A P A R T I I I | T H E U P P E R E X T R E M I T Y
3. Acromion fractures—Any significant displace- the spinoglenoid notch, is at risk during this ex-
ment of the acromion warrants ORIF. Acromio- posure and should be identified and protected.
nectomy should be avoided as this may lead Mayo Types III to V injuries are typically treated
to deltoid weakness and loss of function as the using this approach; however, some fractures
tension is lost across the glenohumeral joint. may require a combined approach.
If the injury was transmitted through the hu-
merus, a rotator cuff tear should be suspected II. Scapulothoracic Dissociation
and treated simultaneously. A. Description—A scapulothoracic dissociation is a
4. Coracoid fractures—Coracoid fractures occur rare entity caused by high-energy trauma.
most commonly through the base and are best B. Mechanism—The mechanism of injury is most
visualized with the Stryker view (45° cephalad likely a traction injury caused by a blunt force to the
tilt). Because it serves as an important attach- shoulder girdle, which leads to a complete, traumatic
ment for the arm flexors and coracoacromial dissociation of the scapulothoracic articulation the
ligaments, displacement of greater than 1 cm shoulder girdle, which leads to a complete, traumatic
requires ORIF. If displacement is less, analge- dissociation of the scapulothoracic articulation.
sics with a simple arm sling is indicated with re- C. Clinical Presentation—The skin is typically intact,
turn to motion at approximately 6 weeks if the and there is massive soft-tissue swelling, which is
pain has subsided. If an associated AC separa- caused by an avulsion of the deltoid, pectoralis
tion exists, this should be fixed in conjunction. minor, rhomboids, levator scapulae, trapezius,
5. Glenoid neck fractures—Isolated glenoid neck and latissimus dorsi muscles, as well as a fracture
fractures with less than 1 cm of displacement of the clavicle, AC dislocation, or SC dislocation.
can be treated conservatively. Because the AC Scapulothoracic dissociation is typically accom-
joint and clavicle are spared, the glenoid will panied by a severe neurovascular insult. The
heal in the position of original displacement. subclavian artery and vein are usually torn, and the
Surgical indications include more than 1 cm of axillary artery and brachial artery are at risk as
displacement of the glenoid, more than 40° of well. The neurologic deficit is most often the result
rotation of the glenoid, and a floating shoulder. of a complete avulsion of the brachial plexus. An
If displacement of greater than 1 cm is left un- incomplete neuropraxia is possible and cannot be
treated, abductor weakness can persist, and the excluded.
patient may end up with pseudoparalysis. With D. Radiographic Findings (Fig. 18-2)—Diagnosis is
a floating shoulder, the weight of the extremity based on a clinical and radiologic exam. The upper
will most likely lead to further displacement; extremity is often flail and pulseless. The shoulder
therefore, surgical treatment is recommended. girdle exhibits massive soft-tissue swelling. The
6. Glenoid fossa fractures—Glenoid fossa fractures chest X-ray will show lateral displacement (mea-
require ORIF if greater than 25% of the anterior sured as more than 50%) of the affected scapula.
glenoid surface is fractured, if more than one-third The measurement may be performed as the distance
of the posterior glenoid surface is fractured, if any from the sternal notch to the glenoid fossa or more
subluxation of the humeral head exists, or if there commonly from the inferior angle of the scapula to
is more than 5 mm displacement of the articular the midline. Close scrutiny of the chest X-ray must
surface (in any of these instances are treated non- be performed to ensure that the image it is not
operatively, a poor outcome is likely). Good to rotated. Often there will be an associated clavicle
excellent results with surgical intervention are ob- fracture, AC dislocation, or SC dislocation.
tained in 80% of cases. Poor outcomes are related E. Treatment—Initial resuscitation should be fol-
to iatragenic nerve palsies. The goal of surgery is lowed by an emergent angiography if a pulse-
anatomic restoration of the articular surface. less extremity is diagnosed. Rapid evaluation
F. Surgical Approaches by a vascular surgeon is necessary and emergent
1. Anterior deltopectoral approach—This approach surgical repair is required in the unstable patient.
is used for Mayo Types I and II injuries. Following vascular repair, the clavicle and AC/SC
2. Posterior Judet approach—This approach uses joints should be surgically stabilized. Exploration
the internervous plane between the infraspina- of the brachial plexus, and cervical myelography
tus and the teres minor. The deltoid is released should be done to determine the prognosis of the
from the posterior acromion and retracted lat- upper extremity. If a complete avulsion of the
erally giving a view of the posterior glenoid and brachial plexus is found, a primary above-
lateral scapula. A posterior arthrotomy may be elbow amputation with early prosthetic fitting
made to inspect the joint. The suprascapular should be considered, as functional recovery is
nerve branch to the infraspinatus, which exits unlikely. Partial injuries have a fair prognosis and
D. Classification (Fig. 18-3)—Allman described the

Left Right initial classification; however, it was modified
by Neer, Rockwood, and later Craig. The Craig
classification combines the Allman and Neer
types, providing more descriptive and functional
information.
1. Group I (80% of all clavicule fractures)—Fracture
of the middle third
2. Group II (12% to 15% of all clavicule fractures)—
Fracture of the distal third
• Type I—Minimal displacement (inter lig amen-
tous)
• Type II—Displaced secondary to a fracture
line medial to the CC ligaments
(a) Conoid and trapezoid attached (fracture
medial to CC ligaments)
(b) Conoid torn, trapezoid attached (frac-
ture between the CC ligaments)
• Type III—Fractures of the articular surface
• Type IV—Periosteal sleeve fracture
(children)
FIGURE 18-2 Scapulothoracic dissociation demonstrating • Type V—Comminuted with ligaments attached
lateral displacement (of at least 50%) on the injured left neither proximally nor distally, but to an infe-
side as compared with the normal right side. rior comminuted fragment
3. Group III (5% to 8% of all clavicule fractures)—
Fractures of the proximal third
musculotendinous transfers may be performed at • Type I—Minimal displacement
a later time. • Type II—Displaced (ligaments ruptured)
• Type III—Intraarticular
III. Fractures of the Clavicle • Type IV—Epiphyseal separation (children
A. Anatomy—The clavicle is the first bone to ossify and young adults)
(intramembranous ossification) in the fifth week • Type V—Comminuted
of development and the last to fuse (medially). It E. Diagnosis
is an S-shaped structure, which changes from a 1. Clinical examination—A thorough physical
prismatic shape medially to a flattened shape lat- exam should be performed, as an injury to the
erally. It is anchored to the scapula via the AC and brachial plexus and/or subclavian artery or
CC ligaments and to the trunk via the SC ligaments. vein may be present. Pneumothorax occurs in
B. Function—The clavicle acts as a strut and is 3% of clavicle fractures.
responsible for bracing the shoulder against 2. Radiographic evaluation
motions, which would otherwise cause it to col- • Plain X-ray—An apical oblique view is help-
lapse. It also permits optimal muscle–tendon unit ful in the acute setting. This is done by
length to allow the thoracohumeral muscles to placing a bump under the contralateral
maintain optimal working distance. The clavicle scapula, so the injured side will lie flat
acts to suspend the scapula both dynamically against the cassette. Angle the beam, 20°
with an upward force from the trapezius through cephalad, will isolate the image away from
the CC ligaments and with a static force via the the thoracic cage. To view an internally
SC ligaments. It also affords protection for the fixed clavicle, the abduction-lordotic view
closely related neurovascular structures. Biome- is helpful. To obtain this, have the patient
chanically, the clavicle rotates 50° on its axis abduct the arm 135° and angle the beam
when the arm is elevated to 180°. 25° cephalad.
C. Mechanism of Injury—Approximately 87% of • Serendipity view and CT—A serendipity
clavicle fractures occur as a result of a fall onto view and CT scan should be obtained if a SC
the shoulder. Another 6% fracture secondary to injury is suspected. This will help determine
a direct blow, and the remainder occur via indi- if there is posterior displacement of the me-
rect injury with force being transmitted up the dial clavicle that threatens neurovascular
humerus. structures.
Subclassification Subclassification
of Group II of Group III
clavicular fractures clavicular fractures
Group II Group I Group III

Distal Middle Proximal
third third third Type I
Stable
Type II Unstable Displaced

A
Unstable
Type III
Intraarticular
Type IV
Pediatric
FIGURE 18-3 A. Classification of clavicular fractures with a detailed description of fractures of the distal third and the
proximal third. B. Radiograph of a displaced fracture of the middle third of the clavicle.
F. Treatment of neurovascular structures, surgery is

1. Adults recommended.
• Medial third fractures—Medial third frac- • Middle third fractures—Middle third frac-
tures are generally treated nonopera- tures are most commonly treated in a sling
tively. If there is posterior displacement or figure of eight immobilization. Although
with potential or apparent compromise the rate of fracture healing is quite high with
nonoperative treatment, several authors is adequate for healing and remodeling occurs
have suggested that the nonunion rate is over time.
much higher than previously thought. 3. Children (2 to 12 years)—Immobilization for
(a) Factors leading to nonunion 3 weeks or until the patient is pain free with
• Advancing age motion is usually sufficient for healing.
• Female gender 4. Adolescents (13 to 16 years)—Treatment
• Absence of cortical contact between is similar to adult’s with 4 to 6 weeks of
the fracture ends immobilization.
• Comminution G. Complications
(b) Surgical indication—A relative indication 1. Nonunion—Nonunion occurs in 0.9% to 5% of all
for surgery includes any clavicle fracture fractures. It is most common in the middle third.
with greater than or equal to 20 mm of Nonunions that show callus formation may
shortening. These have a 91% nonunion respond to a bone stimulator; however, symp-
rate, and consideration for ORIF must tomatic atrophic nonunions require ORIF with
be given. Factors affecting absolute ver- autogenous bone graft. Asymptomatic non-
sus relative indications for surgery are unions are common and do not require treatment.
as follows: 2. Malunion
• Absolute indications for operative 3. Neurovascular insult—If problem persists af-
treatment ter fracture healing, an osteotomy and ORIF
1. Shortening of greater or equal to may be required.
20 mm
2. Open injury IV. AC Joint Injuries
3. Impending skin disruption with an A. Anatomy (Fig. 18-4)—The acromioclavicular (AC)
irreducible fracture joint is a diarthrodial joint with a fibrocartilagi-
4. Vascular or progressive neurologic nous disk that varies in shape and size. It has a
loss thin capsule that is stabilized by superior, infe-
5. Scapulothoracic dissociation rior, anterior, and posterior ligaments. The most
• Relative indications for operative robust ligament is the superior AC ligament,
treatment which is primarily responsible for horizontal
1. Displacement greater than 20 mm AC joint stability. Vertical stability is provided
2. Neurologic disorder by the CC ligaments, which also act as the pri-
3. Parkinson’s disease mary support through which the scapula is sus-
4. Seizure disorder pended by the clavicle. Normal AC joints are 0.5
5. Head injury to 6 mm in width. Anything greater than 6 mm is
6. Multitrauma considered abnormal. The normal CC distance
7. Floating shoulder is 1.1 cm to 1.3 cm
8. Bilateral fractures B. Mechanism of Injury—Classically, the AC joint is
9. Cosmesis injured by a direct blow to the acromion with the
• Distal third fractures—Most distal third humerus in adduction. The magnitude of the blow
fractures heal well with nonoperative care. will determine the severity of injury. Because of
However, Type II fracture treatment is con- the inherent stability of the SC joint, the force is
troversial. The nonunion rate for this type of transmitted laterally, and the AC ligaments, CA
fracture is quite high; however, the majority ligament, and possibly the deltotrapezial fascia
of them are asymptomatic without functional can be injured. An indirect injury can occur as
limitations. Therefore, current literature sug- well; however, this is much less common. Rugby
gests nonoperative management for type II and hockey players frequently sustain this injury.
distal third fractures, unless there is dis- C. Classification (Fig. 18-5)
placement greater than 20 mm. Type III frac- 1. Type I—Sprain of the AC ligament only.
tures are generally treated nonoperatively, 2. Type II—AC ligaments and the joint capsule
and if chronic pain develops, the distal clav- are disrupted. CC ligaments are intact. There
icle can be excised. Type IV fractures in chil- is less than or equal to 50% vertical sublux-
dren can generally be treated nonoperatively; ation of the clavicle. The CC interval is only
however, if posterior or inferior displacement slightly increased.
exists, surgery should be considered. 3. Type III—The AC ligaments, joint capsule, and
2. Infants—The clavicle has a high incidence of CC ligaments are disrupted. There is an AC
fracture at birth. A sling and swath for 2 weeks joint dislocation with the clavicle displaced
Acromioclavicular CC ligament FIGURE 18-4 Normal anatomy of the AC joint.

ligament/capsule
Trapezoid ligament
Conoid ligament
Coracoacromial ligament
Coracoid process
Lesser tuberosity
Bicipital groove
Normal
Type I Type II
Type III Type IV
Type V Type VI
Conjoined tendon of
biceps and coracobrachialis
FIGURE 18-5 AC joint injury classification. Type 1, AC ligament sprain, AC and CC ligaments intact. Type II, AC
ligament disrupted, CC ligament intact (usually sprained). Type III, AC and CC ligaments disrupted. Type IV, AC and CC
ligaments disrupted, the distal (lateral) clavicle is displaced posteriorly through the trapezius muscle. Type V, AC and
CC ligaments disrupted, attachments of the deltoid and trapezius muscles on the clavicle are disrupted, the clavicle is
displaced superiorly. Type VI, AC and CC ligaments disrupted, the clavicle is displaced inferiorly (subcoracoid).
superiorly and there is complete loss of con- • Primary CC ligament fixation—Bosworth
tact between the acromion and the clavicle. was the first to describe transfixing the clav-
The CC interval is increased from 25% to 100%. icle to the coracoid. There have been prob-
4. Type IV—The AC ligaments, joint capsule, and lems with pull out, thus the repair should
the CC ligaments are disrupted. There is an AC be augmented by reconstructing the CC
joint dislocation with the clavicle displaced ligaments.
posteriorly into the trapezius. • Excision of the distal clavicle—Weaver and
5. Type V—The AC ligaments, joint capsule, and the Dunn presented this type of repair, and cur-
CC ligaments are disrupted. There is an AC joint rently, variations of this technique are the
dislocation with superior elevation of the clav- most widely used method to reconstruct
icle in relation to the acromion (100% to 300% the AC joint. The CA ligament is often trans-
of normal). There is complete detachment of the ferred to the undersurface of the clavicle
deltoid and trapezius from the distal clavicle. and the repair is protected with a loop of
6. Type VI—The AC ligaments, joint capsule, and tissue from the clavicle to the coracoid.
the CC ligaments are disrupted. There is an AC
joint dislocation with the clavicle displaced infe- V. SC Joint Injuries
rior to the acromion and the coracoid process. A. Incidence—SC joint dislocations are rare and ac-
D. Diagnosis count for only 3% of all shoulder girdle injuries.
1. Clinical examination—Clinical diagnosis with Anterior dislocations are more common due to
prominence, pain, and soft-tissue swelling the strong posterior SC ligaments. The majority
over the distal clavicle are caused by motor vehicle accidents and con-
2. Radiographic evaluation—An AP view and tact sports.
Zanca view (15° cephalic tilt) are recommended B. Anatomy—The SC joint is a diarthrodial joint,
to evaluate for joint displacement and intra- which has the least amount of osseous stability
articular fractures. An axillary view is man- of all the major joints in the body. The medial
datory to determine AP displacement. Stress clavicular epiphysis is the last to fuse at 23 to
radiographs are no longer routinely used. 25 years of age. Strong ligaments may cause a
E. Treatment fracture through the physis, which may be misdi-
1. Based on type agnosed as a dislocation.
• Types I and II—Nonoperative care with cryo- 1. Ligaments
therapy and analgesics. Sling for comfort • Intra-articular disk ligament—Dense, fibrous
and early range of motion (ROM). Return to structure that acts as a check-rein against
sports when pain free. medial displacement
• Type III—Controversial. If professional base- • Costoclavicular ligament—Provides stability
ball pitcher or heavy laborer, surgery may of the joint during rotation and elevation of
be the best option. All others should be the clavicle
treated nonoperatively with return to activi- • Interclavicular ligament—Aids in suspend-
ties within 4 to 6 weeks. Most authors report ing the shoulder
excellent results, whether repair is early or • Capsular ligament—Covers the anterosupe-
late; therefore, a trial of nonoperative care rior and posterior portions of the SC joint
may be in the patient’s best interest. C. Biomechanics—The SC joint is able to move in all
• Types IV, V, and VI—Surgical repair with re- planes. It has approximately 35° of motion supe-
construction of the CC ligaments. rior, anterior, and posterior, and is able to rotate
2. Surgical options about the clavicle’s long axis 45° to 50°.
• Dynamic muscle transfer—The tip of the D. Mechanism of Injury—A high-energy mechanism
coracoid is transferred to the undersurface is needed for a SC joint dislocation to occur. A
of the clavicle along with the coracobrachi- direct or indirect force may be the cause. Ante-
alis and the short head of the biceps. The rior dislocations are more common because the
rate of nonunion is high, and this procedure posterior capsular ligaments are stronger.
has generally fallen out of favor. E. Diagnosis
• Primary AC joint fixation—Bioabsorbable 1. Clinical examination—Pain and soft-tissue
materials are now being used more often, swelling at the SC joint. The patient may pres-
as a second operation does not need to be ent carrying the injured extremity in the con-
performed to remove hardware. Smooth tip tralateral arm. The patient may have trouble in
K-wires are not recommended as migration breathing, a choking sensation, or difficulty in
may occur. swallowing.
2. Radiologic examination—AP and lateral X-rays • Moderate sprain (Type II injury)—The cap-
are difficult to interpret. Therefore, other views sular, intra-articular disk, and costoclavicu-
are used to evaluate the SC joint. lar ligaments are partially disrupted with
• Hobbs view—90° cephalocaudal view that is subluxation of the joints—reduce by draw-
taken with the patient leaning over the table ing the shoulders backward; sling and swath
so the anterior and lower rib cage is against to prevent motion of the arm. Protect for 4 to
the table. 6 weeks with gradual return to motion.
• Serendipity view (Fig. 18-6)—40° cephalic • Severe dislocation (Type III injury)
tilt view of both SC joints and the medial (a) Anterior SC dislocation—If the patient
clavicles. If the medial clavicle is dislocated presents within 7 to 10 days after in-
anteriorly, the clavicle will appear to be dis- jury, an attempt at reduction can be
placed superiorly when compared with a performed. These are typically unstable
horizontal line drawn from the normal clav- and will dislocate again. If the reduction
icle. If the medial clavicle is dislocated pos- stays in place, immobilization should be
teriorly, the clavicle will appear displaced maintained for at least 6 weeks. Opera-
below the horizontal line. tive management of irreducible ante-
• CT (Fig. 18-7)—CT is the best study to evalu- rior dislocations is not recommended.
ate the SC joints. This can distinguish be- (b) Acute posterior dislocation—If the pa-
tween fractures and dislocations, and both tient presents within 7 to 10 days of
joints can be visualized at the same time for injury, an attempt at closed reduc-
comparison. tion is advised. Initially, a thorough
F. Treatment exam should be performed to rule out
1. Traumatic injuries pulmonary or vascular problems and if
• Mild sprain (Type I injury)—The ligaments necessary a thoracic surgeon should be
are intact and the joint is stable. Treatment present during reduction should a com-
is with cryotherapy and a sling for comfort plication occur. If the reduction is suc-
with early ROM. cessful, the SC joint is typically stable.
R L FIGURE 18-6
A. Positioning for
the serendipity view
for evaluation of the
SC joints. B to D.
Interpretation of the
serendipity view. L, left;
B Normal R, right. B. Normally, both
40°
R L
clavicles are in the same
60 inches for adults
plane. C. In a patient with
40 inches for children
an anterior dislocation
of the medial end of the
clavicle (anterior SC
dislocation), the clavicle
appears to be displaced
C superiorly. D. In a
A Anterior dislocation of posterior SC dislocation,
right clavicle the clavicle appears to be
R L displaced inferiorly.
D
Posterior dislocation of
right clavicle
FIGURE 18-7 CT scan showing a posterior SC

dislocation (arrow) with compression of the subclavian
artery (arrowhead). (From Brinker MR, Miller MD.
Fundamentals of Orthopaedics. Philadelphia, PA: WB
Saunders; 1999. Courtesy Fondren Orthopedic Group
LLP, Texas Orthopedic Hospital, Houston.)
(c) Chronic posterior SC dislocation—If Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced
closed reduction fails or a chronic middle-third fractures of the clavicle gives poor results.
1997;79B(4):537–539.
posterior dislocation presents, an
Lansen E, Bjerg-Mielson A, Christensen P. Conservative or
operative procedure should be per- surgical treatment of acromioclavicular dislocation: a pro-
formed, because most adult patients spective, controlled randomized study. J Bone Joint Surg.
cannot tolerate compression of the 1986;68A:552–555.
mediastinum. A thoracic surgeon Leung KS, Lam TP. Open reduction and internal fixation of ip-
silateral fractures of the scapular neck and clavicle. J Bone
should be part of the surgical team as
Joint Surg. 1993;75A:1015–1018.
the risk of fatal complications is high. Mayo KA, Benirschke SK, Mast JW. Displaced fractures of the
The operation can be aimed at stabiliz- glenoid fossa. Clin Orthop. 1998;347:122–130.
ing the SC joint or performing a medial Nuber GW, Bowen MK. Acromioclavicular joint injuries
clavicle resection with stabilization to and distal clavicle fractures. J Am Acad Orthop Surg.
1997;5:11–18.
the first rib. Never attempt a fixation of
Rockwood CA. Reconstruction of chronic and complete
the SC joint with metallic pins, Stein- dislocations of the acromio-clavicular joint. Clin Orthop.
mann pins, Kirschner wires, threaded 1998;347:138–149.
pins with bent ends, or Hagie pins, as Simpson NS, Jupiter JB. Clavicular nonunion and malunion:
all are associated with migration and evaluation and surgical management. J Am Acad Orthop
Surg. 1996;4:1–8.
serious complications.
Recent Articles
Herscovici D. Scapula fractures: To fix or not to fix? J Orthop
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Robinson CM, Cairns DA. Primary nonoperative treatment of
displaced lateral fractures of the clavicle. J Bone Joint Surg
Classic Articles Am. 2004;86:778–782.
Boyer MI, Axelrod TS. Atrophic nonunion of the clavicle, treat- Robinson CM, Court-Brown CM, McQueen MM, et al. Estima-
ment by compression plate, lag-screw fixation and bone ting the risk of nonunion following nonoperative treat-
graft. J Bone Joint Surg Br. 1997;79-B:301–303. ment of a clavicular fracture. J Bone Joint Surg Am.
Brinker MR, Bartz RL, Reardon PR, Reardon MJ. A method for 2004;86:1359–1365.
Open Reduction and Internal Fixation of the Unstable Pos-
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Deafenbaugh MK, Dugdale TW, Staeheli JW, et al. Nonoperative Wirth MA, Rockwood CA. Acute and chronic traumatic inju-
treatment of Neer type II distal clavicle fractures: a prospec- ries of the sternoclavicular joint. J Am Acad Orthop Surg.
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Ebraheim NA, An HS, Jackson WT, et al. Scapulothoracic dis-
sociation. J Bone Joint Surg Am. 1988;70:428–432. Textbooks
Froimson AI. Fracture of the coracoid process of the scapula. DeLee JC, Drez D. DeLee & Drez’s Orthopedic Sports Medi-
J Bone Joint Surg Am. 1978;60:710–711. cine Principles and Practice. 2nd ed. Philadelphia, PA: WB
Herscovici D, Fiennes AGT, Allgower M, et al. The floating Saunders.
shoulder: ipsilateral clavicle and scapular neck fractures. Rockwood CA, Matsen FA, Wirth MA, et al, eds. The Shoulder.
J Bone Joint Surg. 1992;74B:362–366. 3rd ed. Philadelphia, PA: WB Saunders.
CHAPTER 19
Proximal Humerus Fractures

and Dislocations and Traumatic
Soft-Tissue Injuries of the
Glenohumeral Joint
Jerry S. Sher and Philip R. Lozman
I. Proximal Humerus Fractures with immobilization and early range of motion.

A. Overview—Fractures of the proximal humerus Displaced fractures are optimally treated by
are classified according to the patterns of dis- closed or open reduction to restore anatomic
placement of the four major segments. These in- alignment. In some cases, prosthetic replacement
clude the humeral head, the greater and lesser is the treatment of choice based on the disruption
tuberosities, and the humeral shaft. A proximal of the blood supply to the humeral head.
humerus fracture is considered displaced if any B. Physical Examination
major segment is displaced more than 1.0 cm or 1. Shoulder—The shoulder must be well visu-
angulated greater than 45°. As described by Neer, alized. Gowns are used to expose the entire
this classification system is based on anteropos- shoulder for women, while men can be un-
terior and lateral radiographs. Recently, the use dressed from the waist up.
of three right-angle trauma series radiographs has 2. Cervical spine—The cervical spine should be
improved the accuracy in diagnosing fracture dis- examined prior to the shoulder, and radio-
placement. Computed tomography (CT) can be graphs obtained if there is any concern of con-
helpful in preoperative planning by delineating comitant injury.
the degree of displacement and rotation of the 3. Neurovascular examination—The neurovascu-
fracture fragments, especially with fractures that lar evaluation of the extremity is essential and
involve the tuberosities and humeral head. can usually be obtained in a fractured extremity
Proximal humerus fractures comprise 4% to with gentle motion and isometric contraction.
5% of all fractures. In younger patients, these The presence of sensibility in the axillary dis-
fractures are commonly associated with violent tribution (lateral arm) is not a reliable test of
trauma, whereas in older patients, minor trauma the integrity of axillary motor function. Neuro-
and decreased bone mineral density lead to the vascular injuries occur in 5% to 30% of complex
majority of proximal humerus fractures. proximal humerus fractures.
The proximity of the neurovascular bundle to C. Imaging
the glenohumeral joint makes it subject to injury 1. Radiographs
with proximal humeral fractures, and necessitates a • Trauma series (Fig. 19-1)—Three right angle
thorough neurovascular examination. The finding views of the shoulder are essential to de-
of a palpable distal pulse does not eliminate the termine the relationship of the four major
possibility of a vascular injury due to the rich segments of the shoulder in space. These
collateral circulation of the proximal humerus. views are taken in the sagittal, coronal, and
The majority of proximal humerus fractures axial planes of the scapula, rather than the
are minimally displaced and can be treated body.
272
C H A P T E R 1 9 | P R O X I M A L H U M E R U S F R A C T U R E S & R E L AT E D I N J U R I E S 273
FIGURE 19-1 Trauma series views of the shoulder (From Norris TR. In: Chapman MW, Madison M, eds. Operative
Orthopaedics. Philadelphia, PA: JB Lippincott; 1988, with permission.)
• Rotational anteroposterior (AP) views—Sup- These images allow depiction of the relation-
plement to the trauma series, these views ship of the fractures in any direction.
reveal the greater tuberosity in external rota- 3. MRI scanning—MRI is used in the determina-
tion and humeral head impression fractures tion of soft-tissue injuries involving the rotator
with internal rotation. cuff and the neurovascular structures around
2. CT scanning the shoulder. MRI also allows early assessment
• Low-dose CT scanning—Low-dose CT provides of osteonecrosis following trauma, which may
extremely accurate imaging to evaluate com- not be evident on plain films for a number of
plex proximal humeral fractures, and in some years.
cases can change the treatment plan as con- 4. Arteriography and venography—Arteriography
templated, based on the initial radiographs. and venography are required when a vas-
• Three-dimensional CT scanning—3D CT is cular injury is suspected, as the finding of a
now available in many institutions using the distal pulse does not rule out an arterial in-
standard data obtained from the initial scan. jury. The circumflex vessels connect with
the profunda brachii through the ascending in indicated for suspected injuries to the
deltoid vessels and feed the distal arteries. subclavian or axillary vein.
Arterial injuries are more likely to be seen D. Injury Classification and Treatment (Figs. 19-2
with traumatic dislocations in the elderly and 19-3)
secondary to noncompliant, atherosclerotic 1. One-part fractures—Fractures without displace-
vessels. Venous duplex ultrasound scanning ment of 1 cm are not likely to disrupt the blood
FIGURE 19-2 Four-part classification of proximal humerus fractures and fracture-dislocations. AN, Anatomic neck; GT, greater
tuberosity; LT, lesser tuberosity; SN, surgical neck. (Redrawn from Browner BD, Jupiter JB, Levine AM, et al., eds. Skeletal
Trauma: Fractures, Dislocations, Ligamentous Injuries. Vol 2, 2nd ed. Philadelphia, PA: WB Saunders; 1998, with permission.)
Isolated closed proximal

humerus fractures
Stable one-part fractures Unstable

(nondisplaced and minimally displaced)
Sling and gentle early motion

as pain and fracture security permit
Closed reduction ORIF (two-and three-part fractures Prosthetic replacement

(two-part SN fractures, and LT and fracture-dislocations and valgus
fracture-dislocations) impacted four-part fractures)
If converted to a minimally Unstable or Minimal internal fixation, Fractures with significant

displaced or nondisplaced irreducible plate and screws, IM rods, risk of AVN (fractures
fracture, immobilize until and suture tension bands through the AN, four-part
early healing enables the fractures and fracture-
dislocations, head splitting
head, shaft, and tuberosities
fractures, articular impression
to moves as a unit Stable fixation, RC repair; Unstable fractures, >40%), and three-or
protect for early healing; four-part fractures with an
begin motion at 2-3 wk associated shaft fracture
Closed reduction Proceed Accept if the patient is Accept and Prosthetic Repair tuberosities, RC;
and percutaneous with ORIF or psychologically unable supplement with replacement restore humeral length,
fixation prosthetic to undergo rehabilitation; external support and version; cemented
replacement anticipate malunion or prosthesis for stability
nonunion with residual
pain, stiffness, and
poor function
FIGURE 19-3 Algorithm for isolated closed proximal humerus fractures. AN, Anatomic neck; AVN, avascular necrosis;
IM, intramedullary; LT, lesser tuberosity; ORIF, open reduction with internal fixation; RC, rotator cuff; SN, surgical neck.
(Reprinted with permission from Browner BD, Jupiter JB, Levine AM, et al., eds. Skeletal Trauma: Fractures, Dislocations,
Ligamentous Injuries. Vol 2, 2nd ed. Philadelphia, PA: WB Saunders; 1998.)
supply to the humeral head and are referred to dislocation and are associated with longitu-
as minimally displaced. The surrounding soft dinal tears of the rotator cuff. Surgical treat-
tissues (periosteum, capsule, and rotator cuff) ment is indicated for fractures with more
tend to hold the fragments together and allow than 0.5 cm of displacement or 45° of rota-
near anatomic healing. These fractures are opti- tion, with repair of the rotator cuff.
mally treated by immobilization and early func- • Two-part surgical neck fractures—Classified
tional exercises to avoid stiffness. Functional as impacted and stable or displaced and un-
outcome improves if physical therapy is initi- stable. Treatment for displaced fractures in-
ated within 2 weeks of the injury. cludes open reduction and internal fixation
2. Two-part fractures—Isolated two-part fractures versus percutaneous pin fixation.
involving the tuberosities are rare, and usu- 3. Three-part fractures—Include displacement of
ally occur as a consequence of a glenohumeral three segments including the humeral head, the
dislocation. shaft, and one tuberosity. Closed reduction is
• Two-part lesser tuberosity fractures—Usually difficult to obtain due to the unopposed muscle
associated with posterior glenohumeral pull on the remaining tuberosity. Axillary radio-
dislocation. Axillary radiographs and CT graphs allow best visualization of the rotation
scanning are useful in confirming the diagno- of the articular surface of the humeral head.
sis. Displaced fragments require open reduc- Open reduction and internal fixation using ten-
tion and internal fixation. sion band wiring which incorporates the rotator
• Two-part greater tuberosity fractures—May cuff tendon provides good fixation. Prosthetic
accompany an anterior glenohumeral replacement is indicated when secure fixation
cannot be obtained, usually in elderly patients 2. Malunion—Malunions are often associated

with osteoporotic bone. with stiffness of the shoulder or blocked range
4. Four-part fractures—Each major segment is of motion. Treatment involves correcting the
displaced, and the articular surface is devoid underlying restriction whether involving the re-
of soft tissue, increasing the risk of osteone- lease of soft tissues or osteotomies to restore
crosis. Open reduction and internal fixation normal anatomy. In cases where traumatic ar-
is indicated in young patients with good bone thritis has developed, or inadequate bone stock
quality, or with valgus impacted four-part remains after correction, hemiarthroplasty or
fractures where the impacted head still total shoulder replacement may be indicated.
has an intact medial soft-tissue hinge. Pros- 3. Avascular necrosis—Avascular necrosis usually
thetic replacement is often the preferred occurs following three- or four-part fractures
method of treatment. In patients with signifi- treated either closed or open, where the blood
cant preexisting glenoid arthrosis, glenoid supply to the humeral head is compromised.
resurfacing is also indicated. Proper ten- The primary blood supply to the humeral
sion of the cuff musculature with near an- head is the arcuate artery, which is a con-
atomic positioning of the tuberosities and tinuation of the ascending branch of the
restoration of humeral length is critical for anterior humeral circumflex artery. Open
functional recovery. Following prosthetic re- procedures using plates and screws are associ-
placement, early passive motion is imperative ated with a higher incidence of avascular ne-
to prevent stiffness. Active motion should be crosis than tension band wiring or pinning due
delayed for 8 to 12 weeks until the tuber- to extensive soft-tissue stripping. Treatment
osities have firmly united to the humeral is based on the presentation of symptoms as
shaft. a consequence of the avascular necrosis. Col-
5. Fracture-dislocations—Often the result of high- lapse of the humeral head may lead to the de-
energy injuries, these fractures are distinct velopment of traumatic arthritis and disabling
from the previously classified fractures in that pain. Early prosthetic replacement may elimi-
they carry a higher risk of neurovascular injury. nate the need for soft-tissue releases, which
Posterior fracture dislocations are often may be necessary after longstanding collapse
missed due to poor radiographic evaluation, of the humeral head.
thus necessitating the three view trauma series 4. Neurologic injury—The musculocutaneous
in all shoulder injuries. nerve is at risk of injury from proximal hu-
6. Head-splitting fractures—Head-splitting frac- merus fractures, dislocations, or excessive
tures are most commonly treated with hemi- traction of the conjoint tendon during open
arthroplasty; however, if large fragments and reduction and internal fixation. Symptoms
good bone quality are present, open reduction can present as numbness and tingling along the
and internal fixation can be attempted. Articu- anterolateral aspect of the forearm, which is
lar impression fractures are commonly associ- supplied by the terminal branch of the muscu-
ated with chronic dislocations, and stability locutaneous nerve, the lateral antebrachial
usually depends upon the percentage of articu- cutaneous nerve.
lar surface defect. Defects less than 20% tend 5. Arthrodesis—Indications include a young pa-
to be stable after immobilization, whereas de- tient with nonfunctioning shoulder muscu-
fects up to 40% or more may require soft-tissue lature, prior deep infection, loss of articular
transfers or hemiarthroplasty. cartilage, and severe pain refractory to con-
E. Complications servative treatment. The shoulder should be
1. Nonunion—A number of factors can lead to positioned in such a way that the arm rests
nonunion of proximal humerus fractures in- comfortably without winging of the scapula
cluding inadequate fixation or immobilization, and the hand can be used functionally: 20° of
traction at the fracture site, soft-tissue inter- flexion, 30° of abduction and 40° of internal
position, and osteonecrosis. Nonunion most rotation is the optimal position for a shoul-
commonly occurs in patients with two-part der arthrodesis.
surgical neck fractures. Treatment is aimed
at anatomic reduction and stable fixation of the II. Acute Dislocations of the Shoulder (Glenohumeral
fracture fragments as described for acute frac- Joint)
tures. When this goal cannot be met, prosthetic A. Overview—Approximately 30% of the humeral
replacement is the treatment of choice. head articulates with the glenoid at any given
arm position (angle). The minimally constrained arm elevation that disappears with a pal-
design of the glenohumeral joint affords it a wide pable clunk during terminal elevation
arc of motion at the expense of inherent instability and abduction.
of the shoulder. Unlike the hip joint, the osseous 3. Physical examination—The evaluation of pa-
structures of the glenohumeral joint contribute tients with acute dislocations should include
only a small portion to the joint’s overall stabil- a thorough neurovascular examination both
ity. Rather, the surrounding soft tissues, which before and after any attempts at closed reduc-
include the rotator cuff, glenoid labrum, and tion. Injuries to the axillary nerve and artery
glenohumeral capsular ligaments, are of par- occur infrequently, but they should be noted.
amount importance in maintaining stability Few patients have an expanding subdeltoid
of the articulation. hematoma, indicating an underlying vascular
B. Evaluation injury. Palpable distal pulses may be pres-
1. Mechanism of injury—Patients with acute ent despite an injury to the axillary artery
dislocations commonly note an episode of because of the abundant collateral circula-
significant trauma. In the case of anterior dis- tion surrounding the shoulder.
locations, force applied to an abducted and ex- 4. Radiographic evaluation—Standard radio-
ternally rotated arm is usually involved. Such graphs should be obtained to confirm the
injuries can occur after a fall or motor-vehicle direction of the dislocation and evaluate the
accident, or during contact sports. Poste- shoulder for associated fractures and any pos-
rior dislocations typically involve significant sible obstructions to reduction. An AP view
trauma and also can occur secondary to falls, in the plane of the scapula, an axillary view,
car accidents, or seizure disorders. and the scapular lateral (Y) view can aid in
2. Presentation the detection of glenoid rim fractures, articu-
• Anterior dislocations—Patients with ante- lar impression fractures of the humeral head,
rior dislocations typically manifest a loss of and fractures of the tuberosities. A standard
the normal deltoid contour. Palpation of the AP radiograph alone may not be sufficient for
shoulder demonstrates prominence of the detecting posterior dislocations because the
acromion process laterally and posteriorly, displacement typically occurs at a right angle
and a prominent humeral head can often to the plane of the film. On a normal AP ra-
be felt anteriorly. The arm is often main- diograph, the humeral head typically fills the
tained in a partial externally rotated and glenoid fossa. A vacant glenoid sign refers to
abducted position. a partial vacancy of the glenoid fossa, and a
• Posterior dislocations—Posterior disloca- positive rim sign refers to a space between
tions are not as common and represent the anterior glenoid rim and humeral head
approximately 5% of dislocations of the of greater than 6 mm. These signs suggest a
shoulder. Clinical deformities are not as evi- posterior dislocation as viewed on the AP film.
dent, but can include prominence of the hu- The axillary radiograph remains the single
meral head posteriorly and of the coracoid most important X-ray film in assessing the
process anteriorly. There may be a mild loss presence and direction of a glenohumeral
of the normal deltoid contour with notable dislocation.
flattening anteriorly. The arm is typically 5. Classification (Table 19-1)—Glenohumeral in-
held in an adducted and internally ro- stability has commonly been categorized into
tated position. Patients typically experi- one of two groups: traumatic unidirectional
ence a loss of arm external rotation as the and atraumatic multidirectional. However,
humeral head is wedged against the poste- instability can also be considered as a con-
rior aspect of the glenoid. tinuum with these categories at the extremes
• Posterior subluxation—Recurrent posterior and varying forms in between. For example,
subluxation can occur after an initial an athlete with global glenohumeral ligamen-
posterior directed force on the humeral tous laxity may develop symptoms after a
head relative to the glenoid in the elevated traumatic event and manifest findings con-
arm such as a baseball player sliding sistent with both traumatic and atraumatic
into base. It can also be a sequela after forms of instability. When glenohumeral in-
a primary posterior dislocation. Clini- stability is described, the timing, frequency,
cal findings typically include a posterior degree, direction, and volition should all be
prominence during midranges of forward considered.
fracture of this ligament will result in a bony

TA B L E 1 9 - 1 Bankart lesion and occurs less frequently
Classification of Glenohumeral Instability than an isolated soft tissue avulsion of the
Description Group
anteroinferior labrum from the glenoid rim
(Bankart lesion). Malunion of such fractures
Timing Acute vs. chronic
also disrupts the concavity of the already shal-
Frequency Recurrent vs. isolated event low glenoid fossa, further compromising joint
Degree Subluxation vs. dislocation stability. Surgical treatment with anatomic re-
Direction Unidirectional vs. bidirectional vs. duction and fixation of the fractured fragments
multidirectional is recommended (Fig. 19-4).
Volition Involuntary vs. voluntary vs. positional 4. Rotator cuff tear—Rotator cuff tears occur in
14% to 63% of patients after acute anterior or
inferior dislocations. The incidence increases
in older persons and has been reported in
C. Associated Injuries 63% of patients over 50 years of age. Patients
1. Axillary nerve palsy—The axillary nerve is should be reevaluated 7 to 10 days after the
vulnerable to injury as it courses along the initial injury to look for associated soft-tis-
anteroinferior aspect of the glenohumeral sue injuries. By 10 days the acute symptoms
joint. The nerve may be subject to excessive will have subsided to some degree and may al-
compression and traction with luxation of the low for better evaluation of the rotator cuff. Typi-
humeral head. The incidence of axillary nerve cally, patients are unable to sufficiently elevate
injuries after acute dislocation has been re- the arm in the post-injury period. There may be
ported to range from 5% to 33%. Age, degree
of trauma at the time of injury, and duration of
the dislocation all appear to have an impact on
both the incidence and prognosis of nerve in-
jury. In addition, proximal humerus fractures,
blunt trauma, and gunshot injuries all have
been associated with axillary nerve palsy. EMG
studies are indicated and can document
the status of recovery 3 months after injury
when physical examination reveals persis-
tent absence of deltoid muscle function.
2. Vascular injury—Vascular injury is more com-
monly seen in elderly patients after acute dislo-
cations. Stiffer, less pliable vessels predispose
these patients to such injuries, which can in-
volve the axillary artery or vein or branches of
the axillary artery, including the subscapular,
thoracoacromial, and circumflex arteries. Ves-
sel damage may occur at the time of injury or
during reduction. A loss or decrease in the ra-
dial pulse may not always be present because
of the abundant collateral circulation. An ex-
panding subdeltoid hematoma may be evident,
and arteriography should be performed if the
diagnosis is suspected.
3. Glenoid rim fracture—Displaced fractures in-
volving more than 20% of the glenoid rim de-
crease the effective surface area of glenoid
articulation and can predispose patients to
recurrent instability. The anterior band of FIGURE 19-4 Preoperative (A) and postoperative
the inferior glenohumeral ligament inserts (B) AP radiographs of a patient with a fracture of the
onto the glenoid labrum at the anteroinfe- anteroinferior glenoid rim associated with a traumatic
rior aspect of the glenoid rim. An avulsion anterior glenohumeral dislocation.
weakness in external rotation. The supraspina- subscapularis is commonly seen. Repeated

tus is commonly torn with variable degrees of in- mechanical stress causes failure of the
fraspinatus involvement. Patients with recurrent glenohumeral static restraints and places
anterior instability generally have disruption of increased demands on the dynamic stabi-
the subscapularis tendon. An MRI is the study lizers. The rotator cuff is subject to injury
of choice when a rotator cuff tear is sus- through both repetitive tensile loading and
pected. Satisfactory treatment can be achieved secondary impingement mechanisms.
with primary repair of the tendon without re- 5. Tuberosity fractures—Fractures of the greater
construction of the capsulolabral complex. The tuberosity may occur in association with ante-
“lift-off test” described by Gerber can be per- rior dislocations. Although tearing of the rotator
formed to assess the functional integrity of cuff is not typically seen with posterior disloca-
the subscapularis. The arm is placed behind tions, avulsion fractures of the lesser tuberosity
the back and the patient is asked to lift the hand may occur. Recurrent instability is rare after
from his back through further internal rotation these injuries, and ranges from 1% to 4%.
of the arm. Inability to maintain the arm in this Fracture-dislocations of the shoulder are gen-
lifted position is a positive test suggestive of a erally more stable after healing compared with
subscapularis tendon tear (Fig. 19-5). simple dislocations. In a simple shoulder dislo-
• Tensile failure—Traumatic lesions of the ro- cation, all of the energy of the injury is used to
tator cuff may also occur secondary to oc- tear the capsular and ligamentous structures.
cult underlying instability. Such findings are In a fracture-dislocation, some of the energy is
more commonly seen in throwing athletes. dissipated by the bone (tuberosity fracture), so
It has been suggested that the rotator cuff the ligamentous component of the injury is less,
lesions are the result of a continuum pro- and therefore there are fewer long-term prob-
gressing from instability to subluxation, im- lems with shoulder instability.
pingement, and tension overload of the cuff D. Treatment and Treatment Rationale
with resultant tearing. Articular surface par- 1. Initial management—Initial treatment of an
tial-thickness tearing of the supraspinatus or acute glenohumeral dislocation should follow
a complete physical and radiographic evalua-
tion, including assessment of the patient’s neu-
rovascular status before and after reduction.
Closed reduction should be performed in a
relaxed and sedated patient. Intravenous seda-
tion with a narcotic agent and benzodiazepine
is routinely used in an emergency department
setting before reduction. Inadequate seda-
tion can lead to a traumatic reduction, incit-
ing further injury to an already-compromised
joint. Various reduction techniques have been
described and include traction-counter trac-
tion methods, the modified Stimson maneuver
(application of weight to the flexed arm in the
prone patient [anterior dislocation]), and digi-
tal reduction of the humeral head within the
axilla during applied traction on the partially
abducted and externally rotated arm (Milch
technique). The decision to proceed with surgi-
cal or nonsurgical management should include
consideration of the patient’s age, activity
level, type of injury, number of prior disloca-
tions, chronicity of the injury, and anticipated
demands after treatment. Many of these in-
juries can be effectively treated with nonop-
FIGURE 19-5 Lift-off test demonstrated clinically. erative measures. Patients with traumatic
Inability to maintain the arm in the lifted position is anterior subluxation events may describe
a positive test suggestive of a subscapularis tendon tear. a sensation of the shoulder “popping out
and then back into place.” MRI studies may can often be successfully treated with ob-
not always demonstrate a labrum tear or servant management.
Hill-Sachs lesion. Initial treatment should 3. Operative management
include a short period of rest and immobi- • Open treatment—Techniques for both acute
lization followed by a physical therapy re- primary anterior dislocations and recurrent
habilitation program. Patients with recurrent anterior instability demonstrate consistently
dislocations, dislocations associated with dis- good results, with recurrence rates under
placed tuberosity or glenoid rim fractures, irre- 5%. Direct repair of any Bankart lesions and
ducible dislocations by closed means, chronic capsulorrhaphy are carried out depending
dislocations, and young patients with acute on the surgical findings. Displaced tuberos-
primary anterior dislocations can be consid- ity fractures are also addressed and inter-
ered candidates for surgical treatment. nally fixed with screws or sutures as needed.
2. Nonoperative management—Nonoperative treat- • Arthroscopic treatment—Arthroscopic sta-
ment typically includes a period of immobili- bilization techniques for acute, traumatic,
zation followed by a progressive rehabilitation first-time anterior dislocations in young
program. Prolonged immobilization does not patients have been performed with satis-
decrease recurrence rates in anterior instabil- factory results in experienced hands. In
ity and may contribute to joint stiffness, espe- patients who sustain an acute anterior
cially in older patients. However, recent data dislocation that requires a manual reduc-
suggests that a short period of immobilization tion, a Perthes-Bankart lesion (avulsion
of up to 3 weeks with the arm in external rota- of the anterior capsulolabral complex
tion for first time anterior dislocations may re- rather than an isolated labrum detach-
sult in lower recurrence rates as arm position ment [Bankart]) will be observed in 80%
in external rotation can effect better coapta- to 95% of patients. Patients under 25 years
tion of a torn anteroinferior labrum against the of age with acute Bankart lesions, hemar-
glenoid neck. A progressive rehabilitation pro- throsis, good soft-tissue quality, and a lack
gram beginning with range of motion exercises of undue capsular stretching obtain favor-
should be initiated as soon as possible. End able results after arthroscopic methods.
arcs of abduction and external rotation should Moreover, candidates for such treatment
be avoided initially in anterior dislocators should have high activity demands that
to afford adequate soft-tissue healing while they are unwilling to modify after treatment,
minimizing the chance of contracture. Subse- have no prior shoulder instability, and have
quent therapeutic measures include rotator no associated fractures or neurologic inju-
cuff and periscapular muscle strengthening ries. Conversely, patients with generalized
in an attempt to restore dynamic stability. Ini- ligamentous laxity, recurrent instability with
tial treatment for patients with multidirec- capsular stretching, and large Hill-Sachs
tional instability should consist of physical lesions are best treated with open (not ar-
therapy to include scapular stabilization throscopic) methods. Arthroscopic treat-
and rotator cuff strengthening exercises. ment using bioabsorbable devices for direct
Posterior dislocations should be initially im- labral repair and/or capsulorrhaphy yields
mobilized in a neutral rotation arm sling after successful results in experienced hands.
successful closed reduction. If the joint is un- While arthroscopic transglenoid fixation has
stable, then immobilization in an orthosis in been commonly used in the past, this tech-
10° to 20° of abduction, external rotation, and nique has been supplanted more recently by
extension is recommended for approximately direct repair using suture anchors. Recent
6 weeks to allow for adequate soft-tissue heal- data suggests that newer techniques using
ing. Placement of the extremity in internal suture anchors affords improved outcomes
rotation should be avoided for the first 4 to with fewer complications when compared
6 weeks. A supervised physiotherapy program to transglenoid repairs. Decreased recur-
is then initiated to regain shoulder motion and rence rates after arthroscopic stabilization
strength and to restore function. Patients, es- have been reported; however, in some se-
pecially the elderly, who have had a chronic ries, failure rates have been as high as 40%.
posterior dislocation for several months or Therefore, proper patient selection and suf-
years and who demonstrate functional use ficient experience with arthroscopic tech-
of the extremity with minimal symptoms niques necessitates good functional results.
Complications associated with trans- a sealed compartment with a limited volume,

glenoid fixation include articular carti- and distraction of the joint increases its nega-
lage and suprascapular nerve injuries. tive pressure, resisting further displacement.
The suprascapular nerve is vulnerable as This concept is analogous to pulling on the
it traverses the spinoglenoid notch. At this plunger of a plugged syringe. It is generally
level, the nerve has already innervated the accepted that the negative-pressure effect pro-
supraspinatus muscle and begins to branch, vides restraint at low loads or at rest, since the
supplying the infraspinatus muscle. An im- forces generated in the shoulder with muscle
properly directed transglenoid pin (too activity far exceed those provided by this
horizontal) can impale the nerve causing property. The negative-pressure effect acts
partial or complete denervation of the in- to limit inferior translation in the adducted
fraspinatus muscle. arm at rest.
E. Anatomic Considerations and Surgical Techniques 4. Glenoid labrum (Fig. 19-7)—The glenoid la-
1. Introduction—Numerous properties contrib- brum is a fibrous ring that encompasses the
ute to the stability of the glenohumeral joint. glenoid and serves as an anchor point for the
Abnormalities in any of these structures or glenohumeral ligaments and biceps tendon. It
properties may predispose a patient to an in- extends the load bearing area of the glenoid
stability event or may be the consequence of and increases its depth as much as 50%. An
a traumatic episode. No one essential lesion is intact superior labrum stabilizes the shoulder
associated with all instability patterns. There- by increasing its ability to withstand external
fore, a broad approach with consideration of rotation forces by an additional 32%. Tears of
osseous, labral, and capsular injuries should the superior labrum anterior and posterior
be used. Rotator cuff and neural function must (SLAP lesions) increases the strain on the
also be evaluated. inferior glenohumeral ligament by greater
2. Osseous factors (Fig. 19-6)—The glenoid ar- than 100%.
ticulates with approximately 25% to 30% of 5. Glenohumeral ligaments (Fig. 19-8)—The gle-
the humeral head at any given arm position. nohumeral ligaments have been described as
Gross and radiographic inspection of a normal areas of thickening within the joint capsule.
joint suggests an apparently flat glenoid and They act as static restraints to excessive
a larger, convex humeral head. However, the translation and rotation at the extremes of mo-
radius of curvature of the glenoid closely ap- tion. Much of their function has been learned
proximates that of the humeral head (confor- through biomechanical testing and selective
mity), and the differences observed represent sectioning in anatomic specimens.
a mismatch in the surface areas of the two • Superior glenohumeral and coracohumeral
articular surfaces (constraint). Thus, the mini- ligaments—The superior glenohumeral and
mally constrained architecture affords the coracohumeral ligaments lie within the ro-
glenohumeral joint a wide arc of motion at tator interval, which is bordered by the su-
the expense of inherent stability. perior aspect of the subscapularis and the
3. Negative intraarticular pressure—A slightly anterior aspect of the supraspinatus. The
negative intraarticular pressure is present in superior glenohumeral ligament is variable
the glenohumeral joint. Moreover, the joint is in size and course. These structures act as
a static restraint to excessive inferior trans-
lation in the adducted arm. Other potential
functions include limitation of external ro-
tation in the adducted arm and restraint
against excessive posterior translation in the
flexed, adducted, and internally rotated arm.
• Middle glenohumeral ligament—The middle
glenohumeral ligament is part of the anterior
capsule and typically courses past the intra-
articular portion of the subscapularis ten-
FIGURE 19-6 The bony glenoid is relatively flat; the don at an acute angle. It may be absent in up
articular cartilage is thinner in the center and thicker at to 30% of individuals and can demonstrate
the periphery. The articular cartilage of the humeral head a sheet-like or cord type of morphology. It
is thicker in the center and thinner in the periphery. functions as a primary restraint against
FIGURE 19-7 The inferior glenoid labrum can

be thought of as a wedge (chock) preventing a
wheel (the humeral head) from rolling downhill.
anterior instability of the partially abducted inferior glenohumeral ligament is the pri-
arm and a secondary restraint to inferior in- mary stabilizer against anterior instabil-
stability in the adducted arm. ity in the abducted and externally rotated
• Inferior glenohumeral ligament complex— arm (see Fig. 19-8).
The inferior glenohumeral ligament complex 6. Rotator Cuff—The rotator cuff is made up of
consists of an anterior band, posterior band, four muscles that act through coordinated and
and an interposed axillary pouch. This com- synchronous action to provide dynamic sta-
plex lies at the inferior aspect of the glenohu- bility to the glenohumeral joint. The muscles’
meral joint and remains lax in the adducted close proximity to the center of rotation of
arm. In the abducted arm, the complex be- the joint makes them well suited to maintain a
comes taut and supports the humeral head stable glenohumeral fulcrum during active mo-
in a hammock-type fashion in which the axil- tion of the arm. Dynamic stability is achieved
lary pouch cradles the humeral head directly through direct joint compression in addition to
inferiorly and the anterior and posterior asymmetric contraction and “steering” of the
bands provide stability against excessive humeral head into the glenoid during active
anterior and posterior humeral translations, arm movement. Compression is achieved by
respectively. The anterior band of the the perpendicular vector pull of the humeral
FIGURE 19-8 Glenohumeral ligaments

in the abducted arm. Note the reciprocal Superior glenohumeral
tightening of the inferior glenohumeral ligament
ligament complex (both the posterior
Middle glenohumeral
band of the inferior glenohumeral ligament ligament
and the anterior band of the inferior
glenohumeral ligament tighten) and the Anterior
relative loosening of the superior and
middle glenohumeral ligaments.
Inferior glenohumeral
ligament (anterior band)
Posterior
Inferior glenohumeral
ligament (posterior band)
head into the glenoid, which minimizes ten- also carried out in cases in which redundancy
dencies toward joint subluxation. The infraspi- of the capsule is noted.
natus and the smaller teres minor muscles are 9. Capsular reconstruction—Avulsion of the gle-
the primary external rotators of the humerus. nohumeral ligaments and joint capsule from
The supraspinatus and subscapularis muscles their humeral insertion can lead to recurrent
contribute to arm abduction and internal rota- instability. This injury is found less frequently
tion, respectively. than Bankart lesions and was reported in 7%
7. Anatomic course of the axillary nerve—The of patients undergoing surgery for recurrent
proximity of the axillary nerve to the glenohu- instability. Patients tended to be older, on
meral capsule predisposes the nerve to injury average, than those with instability for other
through both traumatic and iatrogenic mecha- causes. Diagnosis can be made by MRI, and
nisms. Open shoulder operations that require open repair of the lateral joint capsule dis-
anterior capsulotomy can result in inadvertent ruption has been successful in preventing
injury to the nerve if care is not taken to iden- recurrent symptoms.
tify its location and protect it during dissec- F. Complications of the Injury
tion. Posterior approaches to the shoulder, 1. Recurrence—Age at the time of the initial
which are utilized infrequently, may also result dislocation appears to be the most impor-
in nerve injury if dissection is mistakenly car- tant determinant in predicting the likeli-
ried out in the interval between the teres mi- hood of recurrence. Reports on the frequency
nor and major. of recurrence fall within a variable range. First-
The axillary nerve takes a circuitous path time dislocators under the age of 20 dem-
before innervating the deltoid and teres minor onstrate the highest recurrence rate, with
muscles. It arises from the posterior cord of frequencies ranging up to 95%. Patients 20
the brachial plexus and courses across the to 25 years of age have demonstrated recur-
inferolateral border of the subscapularis ap- rence rates of 28% to 75%. Patients older than
proximately 3 to 5 mm medial to the muscu- 25 have recurrence rates less than 50%, and
lotendinous junction. It passes inferior to the persons over the age of 40 demonstrate recur-
glenohumeral axillary recess and along with rence rates less than 10%. However, a rotator
the posterior humeral circumflex artery, exits cuff tear is the most common cause of re-
the quadrangular space, where it divides into current instability following first time dis-
two branches. The posterior branch splits and locations in patients over 40 years of age.
innervates the teres minor and posterior del- While the incidence of recurrence does not
toid before terminating as the superior lateral seem to be affected by the type and duration
cutaneous nerve. The anterior branch winds of immobilization after the initial dislocation,
around the humerus and innervates the re- some recent data suggests that there may be
maining deltoid muscle. It becomes subfascial a role for short-term immobilization of the arm
and intramuscular at a point between the ante- in external rotation for first time anterior dislo-
rior and middle heads of the deltoid. cators (this position may better reduce a torn
8. Bankart reconstruction—The Bankart repair anteroinferior labrum to the glenoid neck).
can be performed through an inferior axillary 2. Arthrofibrosis—Arthrofibrosis is more likely to
incision. The deltopectoral interval is devel- develop in patients over 30 years of age. Inade-
oped and the cephalic vein mobilized. The quate rehabilitation, poor patient compliance,
subscapularis tendon is divided medial to its and the degree of trauma at the time of injury
insertion on the lesser tuberosity and is dis- are all factors predisposing to joint stiffness.
sected from the underlying capsule. Care is
taken to preserve the anterior humeral cir- III. Other Traumatic Soft-Tissue Injuries of the Shoulder
cumflex vessels at the junction of the upper A. Rotator Cuff Tears—Acute rotator cuff tears
two-thirds and lower one-third of the subscap- can occur after a fall directly onto the shoul-
ularis. The capsular incision can be laterally der or outstretched upper extremity, sudden
based adjacent to the humeral head or medially extreme hyperextension or hyperabduction,
based at the glenoid margin. On exposure of lifting a heavy object, or catching a heavy fall-
the joint, transosseous repair of labral detach- ing object. Subsequent swelling and ecchymosis
ments can be accomplished, and glenoid rim in the upper arm can often develop. In younger
fractures, if present, can be reduced and inter- patients, a small avulsion fracture of the greater
nally fixed. Capsulorrhaphy or capsular shift is tuberosity may be present as the insertion of the
supraspinatus to the greater tuberosity is robust glenohumeral joint. Repetitive stress such as
and typically less prone to failure than the osse- pitching can also progressively toggle the supe-
ous greater tuberosity itself. Patients typically rior labrum from the glenoid neck (like extracting
develop acute pain and a precipitous loss of a root from the ground by repetitively pulling it
function with either difficulty or an inability from side to side rather than straight up). The su-
to elevate the arm. Those patients demonstrat- perior labrum serves as the anchor for the long
ing significant loss of function are best treated head of the biceps tendon that in turn is attached
with surgical repair of the rotator cuff. Initial to the superior glenoid neck. Several types of su-
postoperative management in the immediate perior labrum tears have been described that
postoperative period includes passive for- range from isolated tears of the superior labrum
ward elevation and external rotation within to those also involving the anterior and posterior
a safe zone determined at surgery. Early active labrum and/or capsule with associated instabil-
range of motion or resistive exercises increases ity (Fig. 19-9). T2 weighted MRI findings may
the risk of failure of the tendon repair. show increased signal between the superior
Patients with chronic massive rotator cuff labrum and glenoid neck.
tears may have pain with variability in observed C. Tears of the Pectoralis Major Tendon—Tears of
shoulder function. Those with long-standing tears the pectoralis major tendon are relatively un-
may demonstrate functional use of the arm with common and can occur after a fall that causes
sufficient compensatory action of the remaining excessive eccentric contraction of the muscle.
intact rotator cuff and surrounding musculature. Use of anabolic steroids can predispose patients
If there is significant extension of a supraspinatus to tendon rupture and this possibility should
tear into the posterior rotator cuff (infraspinatus) be considered. Typical findings in acute cases
or concomitant tearing of the subscapularis ante- include deformity of the anterior axillary fold,
riorly, then considerable loss of shoulder strength weakness in internal rotation and adduction and
and function can be anticipated. Cephalad migra- ecchymosis of the upper arm. The treatment of
tion of the humeral head relative to the glenoid choice in young patients is open exploration
may ensue. In these patients, the coracoacromial and surgical repair. Tears occurring within
ligament acts as a static secondary restraint to the pectoralis muscle or at the myotendinous
further cephalad and anterior migration of the junction are best treated nonsurgically and the
humeral head. If attempts at surgical repair diagnosis can be confirmed by MRI.
are undertaken and the rotator cuff is found D. Dislocation of the Long Head of the Biceps Ten-
to be irreparable, then in addition to debride- don—The biceps tendon is supported within
ment, the coracoacromial ligament should be the bicipital groove by the medial aspect of the
preserved. Moreover, patients with shoulder subscapularis tendon, the transverse ligament
pain, irreparable rotator cuff tears, cepha- and coracohumeral ligament-superior glenohu-
lad migration of the humeral head and gle- meral ligament pulley. Medial dislocation of
nohumeral arthritis are best treated with a the tendon can occur with an injury to these
humeral head arthroplasty. supporting structures that lie in the region of
Arthroscopic techniques for repair of large the rotator interval. Patients with a rupture
rotator cuff tears include single or double row of the subscapularis tendon and dislocation
repairs with the use of suture anchors and at- of the long head of the biceps are best treated
tempts at restoration of the anatomic footprint with primary repair of the subscapularis and
of the torn tendon onto the greater tuberosity tenodesis of the biceps.
of the humerus. After carrying out soft-tissue E. Latissimus Dorsi Injury—Tears of the latissimus
releases, as in open techniques, initial side- dorsi tendon have been reported as a cause of
to-side closure of large L-shaped or U-shaped pain in the thrower’s shoulder. The mechanism of
tears (margin convergence) is recommended. injury involves an eccentric overload during the
Margin convergence decreases the size of the follow-through phase of throwing. Tenderness
overall tendon defect and also decreases the along the posterior axillary fold and pain and
stress in the rotator cuff at the free margin weakness with resisted extension of the shoul-
and greater tuberosity interface. der can be found on physical examination in
B. Tears of the Superior Glenoid Labrum—Tears patients with complete tears of the latissimus
of the superior labrum can occur after a di- dorsi tendon. Current treatment recommenda-
rect fall onto the involved extremity resulting tions are nonoperative and include a short period
in either traction or compression forces to the of rest, followed by physical therapy.
Type II Type III
Type IV Type V
Type I
Type VI Type VII

FIGURE 19-9 Types of Superior Glenoid Labrum Tears. Type I. Lesion is characterized by fraying or degeneration of
the superior labrum and a normal biceps tendon. Type II. Notable for detachment of the superior labrum and biceps
anchor from the superior rim of the glenoid. Type III. There is a bucket handle tear of the superior labrum with an
intact biceps anchor. Type IV. There is a bucket handle tear of the superior labrum with tearing of the biceps tendon.
Type V. There is a type II detachment that also extends into the anterior labrum. Type VI. There is a type II detachment
with a parrot beak or flap tear of the labrum. Type VII. There is a type II detachment with extension into the middle
glenohumeral ligament.
F. Biceps Brachii Transection—Transection of of brachial plexus anatomy aids in the clinical

the biceps brachii muscle has been reported evaluation of these lesions and allows the devel-
and can occur as a result of a cord wrapped opment of appropriate treatment strategies.
around the upper arm. A posterior subcutane- B. Anatomy (Figs. 19-10 and 19-11)—This complex of
ous hematoma can be found on physical exami- nerves extends from the cervical spine into the
nation and confirmed on MRI. Patients should be axilla, supplying motor, sensory, and sympathetic
evaluated for concurrent neurovascular injury. nerve fibers to the upper limb. The brachial
plexus is formed by the ventral rami (Fig. 19-10)
IV. Brachial Plexus Injuries of nerves from C5 to T1, which lie between the
A. Overview—Trauma to the brachial plexus in- scalenus anterior and medius muscles. The ven-
volves a spectrum of injuries that varies in both tral rami from C5 and C6 unite to form the upper
the extent and degree of neurologic compromise. trunk of the brachial plexus. The ventral ramus
Less severe injuries may result in isolated sen- of C7 continues as the middle trunk, and the ven-
sory abnormalities. Higher-energy mechanisms tral rami of C8 and T1 form the lower trunk of
can produce significant motor deficits and loss the brachial plexus. Each of the trunks divides
of functional use of the arm. An understanding into anterior and posterior divisions behind the
trunk continues as the medial cord. Each cord

then divides into two terminal branches. The
lateral cord divides into the musculocutaneous
Dorsal root
nerve and the lateral root of the median nerve.
Dorsal root ganglion The medial cord divides into the ulnar nerve and
the medial root of the median nerve. The pos-
terior cord divides into the axillary and radial
Spinal n. nerves. The branches of the brachial plexus can
Dorsal ramus be divided into supraclavicular and infraclavicu-
lar portions. The supraclavicular branches in-
clude the dorsal scapular nerve, the long thoracic
Ventral ramus nerve, the nerve to the subclavius, and the su-
Ventral root prascapular nerve. The infraclavicular branches
of the cords include those of the lateral cord
(three branches): the lateral pectoral nerve, the
Rami musculocutaneous nerve, and the lateral root
communicantes
of the median nerve; those of the medial cord
FIGURE 19-10 Organization of the spinal nerve. The (five branches): the medial pectoral nerve, the
spinal nerve receives contributions from both the ventral medial brachial cutaneous nerve, the medial an-
root and the dorsal root. The spinal nerve then divides
tebrachial cutaneous nerve, the ulnar nerve, and
into the ventral ramus and the dorsal ramus. The ventral
rami of C5 to T1 form the brachial plexus.
the medial root of the median nerve; and those
of the posterior cord (five branches): the up-
per subscapular nerve, the thoracodorsal nerve,
clavicle, with the anterior division supplying the the lower subscapular nerve, the axillary nerve
flexors and the posterior divisions supplying the (which runs through the quadrangular space),
extensors of the upper limb. The three posterior and the radial nerve (which runs through the
divisions form the posterior cord; the anterior triangular interval) (Fig. 19-12). The axillary
divisions of the upper and middle trunks form nerve (posterior cord) is commonly injured in
the lateral cord; the anterior division of the lower anterior dislocations of the glenohumeral joint.
FIGURE 19-11 Organization of the brachial plexus.

(Reprinted with permission from Jenkins DB. Hollinshead’s
Functional Anatomy of the Limbs and Back. 7th ed.
Philadelphia, PA: WB Saunders; 1998.)
FIGURE 19-12 Important anatomic

relationships. The quadrangular space is
bordered by the teres minor (superiorly), the
teres major (inferiorly), the long head of the
triceps (medially), and the proximal humerus
(laterally). The posterior humeral circumflex
vessels and axillary nerve pass through this
Quadrangular space space. The triangular space is bordered
by the teres minor (superiorly), the teres
Triangular space
major (inferiorly), and the long head of the
Triangular interval triceps (laterally). It contains the circumflex
scapular vessels. The triangular interval,
Teres minor m. Long head of bordered by the teres major (superiorly), the
triceps m. long head of the triceps (medially), and the
humerus (laterally), allows visualization of
Teres major m. the profunda brachii artery and radial nerve.
Severe stretch injuries to the lower portions of represents one option that may afford an im-
the brachial plexus (C8 and T1) can result in in- proved outlook for functional recovery.
jury to preganglionic (proximal to the dorsal • Infraclavicular peripheral nerve injuries—
root ganglion) sympathetic fibers for head and The brachial plexus may be vulnerable to
neck innervation to the spinal nerves and stellate injury in its infraclavicular region by direct
ganglion, resulting in ptosis, anhidrosis, and pap- compression or pressure from fracture frag-
illary dilation (Horner’s syndrome). Penetrating ments or joint dislocations. The mechanism
wounds to the axilla resulting in interosseous typically involves lower-energy events as
wasting and hand weakness are likely second- compared with those seen in the supracla-
ary to injuries to the inferior trunk emanating vicular cases. Accordingly, the injuries tend
from the C8 and T1 nerve roots and giving rise to be more confined and of a lesser degree
to the ulnar nerve. of severity. They carry a relatively better
C. Evaluation prognosis than the supraclavicular injuries.
1. Mechanism of injury—The majority of closed • Burners (stingers)—Burners or stingers
injuries occur as a result of inferior-directed represent a transient injury to the brachial
traction applied to the superior aspect of the plexus that typically occurs during contact
shoulder. The head and shoulder are force- sports. Sports such as American football
fully separated, placing undue traction on the and wrestling commonly give rise to this
brachial plexus. Motorcycle accidents are one injury. The head and neck are characteristi-
common mechanism for such injuries. cally impacted or moved to one side result-
2. Types of injuries ing in a stretch and/or compression to the
• Root avulsion—A root avulsion represents a brachial plexus. Sharp pain, radiating from
central nervous system injury and carries a the neck to hand, with burning, numbness,
poor prognosis. To date, there is no reliable tingling, and weakness may occur. Unilat-
method of restoring continuity and function eral arm symptoms are typical. The symp-
of the nerve root to its avulsed portion of toms usually last for seconds to minutes in
the spinal cord. most patients and can persist for days in 5%
• Supraclavicular peripheral nerve injuries— to 10% of cases. Recurrent episodes may
The injury occurs distal to the nerve root be associated with cervical spinal stenosis.
(commonly in the supraclavicular fossa). Initial treatment includes removal from con-
This category carries a more favorable tact sports until symptoms have completely
prognosis compared with a nerve root avul- resolved. Persistent weakness, neck pain,
sion. Because this represents a peripheral bilateral symptoms, or recurrent episodes
nervous system injury, surgical explora- require further evaluation that may include
tion and repair with possible nerve grafting radiographs, MRI, and neurologic testing.
Uncomplicated cases benefit from strength- proximal injuries. The prognosis for incom-

ening and conditioning of the cervical and plete motor loss is more favorable than that
shoulder musculature. for complete motor loss, and the prognosis
3. Physical examination—Careful evaluation of for a confined or focal injury is more favorable
all upper-extremity muscle groups, including than that for a broader injury (the incidence
the shoulder, helps determine the location of neuropraxia is higher in the more focal in-
and extent of the injury. Physical examina- juries). If there is no clinical or electrodiag-
tion may demonstrate a flail arm; however, nostic evidence of recovery within 9 months,
the presence or absence of rhomboid (dor- the prognosis for significant improvement re-
sal scapular nerve) and serratus anterior mains poor.
(long thoracic nerve) activity should be E. Treatment—Treatment strategies should be tai-
carefully noted. Absence of function of the lored to each patient based on specific clinical
rhomboids (major and minor) and the serra- findings. Initial management should include func-
tus anterior, in addition to absence of functional splinting and physical therapy to minimize
tion of the rotator cuff and deltoid, suggests the potential for joint contractures while main-
a nerve root avulsion (the long thoracic and taining functional arcs of motion. If surgical man-
dorsal scapular nerves arise from the proximal agement may benefit the patient, consideration
trunks of the plexus where the spinal nerves can be given to nerve exploration and repair with
exit the intervertebral foramina). Presence of possible grafting, muscle transfers, and arthrode-
function of the rhomboids and the serratus an- sis. Operative treatment is best performed before
terior muscles suggests a more peripheral le- 6 months following injury have elapsed. Beyond
sion distal to the innervation of these muscles. 6 months, irreversible changes in the muscles be-
4. Electrodiagnostic studies—Electromyography gin to occur, further decreasing the chance of sig-
(EMG) and nerve conduction tests performed nificant functional recovery. Most patients with
at least 1 month after the injury may help fur- traction injuries undergoing nerve exploration re-
ther delineate the extent and location of the quire nerve grafting, since primary repair of the
plexus injury. A myelogram with a follow-up neural elements is typically not possible. Results
CT scan can also help determine the presence after such procedures can be unpredictable and
of a nerve root avulsion. depend on the nature and extent of the injury.
D. Prognosis Multiple tendon transfers have been described in
1. Root avulsions—Root avulsions of the upper an attempt to restore elbow flexion and shoulder
trunk are fortunately rare and carry a bleak function. Such transfers offer a viable alternative
chance of spontaneous functional recovery. to neural reconstructions, which have yielded
Surgical reconstruction of root avulsions is not unpredictable results in adult traumatic injuries.
possible, and fusion of the glenohumeral joint Transfers of the pectoralis major, trapezius, bi-
for the management of a flail arm is generally ceps, triceps, teres major, and latissimus dorsi
unsuccessful because of the loss of function of have all been reported. Treatment should be tai-
important scapular stabilizers. lored to an individual’s specific clinical findings.
2. Upper-trunk injuries—injuries involving the Glenohumeral arthrodesis for a flail arm remains
upper trunk commonly occur proximal to the a viable treatment option in attempt to restore
suprascapular nerve origin. Loss of function some degree of upper extremity function and
of the supraspinatus and posterior rotator minimize painful subluxation of the joint. Neural
cuff as well as the deltoid muscle can be ex- innervation of the scapular stabilizers (trapezius
pected with a resultant loss in the ability to and serratus anterior) should be protected from
elevate the arm. Moreover, treatment of inju- injury if reasonable function is to be expected af-
ries of the upper trunk fare better with regard ter surgery. Fusion of the glenohumeral joint
to return of elbow flexion than to restoration should be in 30° of arm abduction, 20° of for-
of functional shoulder activity. In general, the ward flexion, and 40° of internal rotation. In
prognosis for adult brachial plexus injuries is a healthy individual, the ratio of glenohumeral to
not as promising as that typically described scapulothoracic motion during elevation of the
for birth palsies. arm is approximately 2:1.
3. Guidelines—Consideration of some general
guidelines can help categorize various injuries V. Long Thoracic Nerve Palsy
with respect to prognosis. The prognosis for A. Overview—Injury to the long thoracic nerve re-
distal injuries is more favorable than that for sults in paralysis of the serratus anterior muscle
studies before operative management is contem-

plated. Nerve exploration and reconstruction
might be considered as an alternate surgical op-
tion; however, poor accessibility of the long tho-
racic nerve, extended time involved between the
injury and ultimate anticipated return of nerve
function, and the uncertain return of serratus
activity can add significant morbidity and likely
exceed the potential pitfalls of pectoralis major
transfer.
VI. Quadrangular Space Syndrome—Quadrangular space

syndrome represents an uncommon entity; the diag-
nosis is often difficult to make and is also frequently
overlooked.
A. Anatomy—The quadrangular space is bor-
dered superiorly and inferiorly by the teres mi-
nor and major, respectively. The humeral shaft
and the long head of the triceps make up the
FIGURE 19-13 Clinical example of scapular winging lateral and medial borders, respectively (see
(arrow) in a patient with along thoracic nerve palsy. Fig. 19-12). Both the posterior humeral circum-
(From Miller MD, Cooper DE, Warner JJP. Review of Sports flex artery and axillary nerve travel through the
Medicine and Arthroscopy. Philadelphia, PA: WB Saunders;
quadrangular space, where they may be subject
1996, with permission.)
to abnormal compression.
B. Evaluation
1. Signs and symptoms—Symptoms of poorly
and is clinically manifested by the presence of localized shoulder pain, paresthesias not nec-
shoulder pain, scapular winging (Fig. 19-13), essarily of a dermatomal distribution, and
and difficulty in arm elevation. Causes are mul- focal tenderness overlying the quadrilateral
tiple and in addition to trauma include mechan- space characterize the disorder. Symptoms
ical, toxic, and infectious etiologies. Up to 15% may be exacerbated with forward flexion or
of cases are of unknown etiology. Nerve com- abduction and external rotation of the arm.
pression as a result of anterior scapular motion Clinically, deltoid weakness or atrophy is
or traction associated with posterior scapular not always present, since pain may precede
movement is felt to be responsible, in part, for any objective decrease in deltoid strength or
injury to the relatively unprotected nerve at mass. Furthermore, such findings can demon-
the inferior angle of the scapula in susceptible strate considerable variability among individ-
individuals. uals and are likely related to the degree and
B. Treatment—Although the majority of cases of duration of nerve compression. Individuals
isolated palsy of the long thoracic nerve resolve between 22 and 35 years of age are typically
within 12 months, a few patients fail to improve afflicted, and symptoms may be mistaken
with expectant management. Surgery can be confor thoracic outlet syndrome or other shoul-
sidered in patients who continue to have symp- der disorders. This disorder has also been
toms refractory to conservative measures with observed in throwing athletes with shoulder
no evidence of spontaneous recovery. Transfer pain and paresthesia.
of the pectoralis major tendon (extended with a 2. Diagnostic studies—Diagnostic studies may
fascia lata graft) to the inferior pole of the scap- include electrodiagnostic tests, arteriograms,
ula has demonstrated consistently good results and MRI. The role of arteriography is not
in most cases. Opinions differ as to the optimal clearly established but can be of value in se-
time for operation after the initial neurologic in- lected cases. Occlusion of the posterior hu-
sult; however, it is generally recommended that meral circumflex artery may be evident when
surgery be delayed for at least 6 to 12 months. the arm is abducted and externally rotated.
Consideration should be given to the mecha- Positive findings on arteriography provide in-
nism of injury, residual symptoms, functional direct evidence of neuropathy as the axillary
deficit, physical demands, and electrodiagnostic nerve exits the quadrangular space with the
posterior humeral circumflex artery. Electro- elevation and occur as a result of compression
diagnostic studies are helpful in confirming of the neurovascular structures as they travel
the presence of axillary nerve compression through a narrowed thoracic outlet. Venous
when results are positive; however, a negative compression occurs in 2% to 3% of cases and
EMG does not preclude the diagnosis. A few arterial compression occurs in 1% to 2% of
patients have quadrangular space syndrome cases. Contributing factors include obesity,
despite normal EMG findings. MRI, although poor posture, cervical muscular contracture,
expensive, can provide useful information, es- trauma, pregnancy or congenital factors (cervi-
pecially when the diagnosis is equivocal. MRI cal rib). Possible sites of compression include:
can help rule out alternate sources of shoul- (a) the superior thoracic outlet secondary to
der pain and also may aid in revealing early the presence of a cervical rib; (b) the scalene
deltoid atrophy, which is not otherwise dis- interval, formed by the scalene anterior and
cernable on clinical examination. middle attachments onto the first rib (this
C. Treatment—Considering the infrequency of the can be a site of compression of the subcla-
diagnosis and the fact that many patients do not vian vein or surrounding neurovascular
demonstrate sufficient symptoms to warrant structures through scalene muscle hypertro-
neurolysis, only a few individuals ultimately re- phy in well-developed athletes); (c) the costo-
quire surgical intervention. Patients with clini- clavicular space, or interval between the first
cal evidence of this syndrome in the absence of rib and the clavicle (this can be narrowed sec-
deltoid denervation or dysfunction may benefit ondary to inferior depression of the clavicle by
from activity modification and stretching exer- factors including hypertrophy of the subclavius
cises alone. Those with symptoms refractory to muscle, clavicle fracture with callus formation,
conservative measures or manifestations of del- and muscular weakness resulting in drooping or
toid denervation and positive findings on EMG downward depression of the upper extremity);
or arteriography should be considered as candi- and (d) the subcoracoid region (the final poten-
dates for nerve decompression. Optimal timing tial site for compression prior to the neurovas-
of surgical decompression becomes difficult to cular structures entering the axilla).
outline in consideration of the variable stages B. Evaluation—Diagnosis can be elusive as symp-
of presentation and the indeterminate natural toms are often vague and physical signs are in-
history of this disorder. However, nerve explo- distinct. Affected patients typically show signs
ration before 6 months from the time of injury of lower brachial plexus involvement involv-
is generally preferred, since it may minimize ing C8 and T1. Symptoms include paresthesias
the potential for irreversible changes within the along the medial aspect of the arm and hand
deltoid muscle and axillary nerve. Surgical de- and loss of fine motor hand dexterity. Provoca-
compression of the axillary nerve can be ade- tive tests such as the Adson test (loss of radial
quately achieved through a posterior approach pulse with the arm at the side and with exten-
without detachment of the deltoid origin from sion and rotation of the head and neck to the
the scapular spine. With the arm in abduction, involved side) and Wright hyperabduction test
the posterior border of the deltoid can be easily (loss of pulse with arm abduction to 90° and
identified and gently retracted cephalad to ex- external rotation) require the reproduction of
pose the underlying quadrangular space. Care symptoms to be considered positive. Diagnos-
should be taken to avoid injury to the poste- tic studies may include cervical radiographs to
rior humeral circumflex artery on exploration. evaluate the presence or absence of a cervical
Satisfactory results have been reported in the rib and MRI exams to evaluate the anatomy and
majority of patients after the use of an extensile course of the brachial plexus. Noninvasive vas-
surgical approach. cular studies and angiography may also be of
benefit to assess arterial and venous patency.
VII. Thoracic Outlet Syndrome Lastly, electrodiagnostic studies may aid in as-
A. Overview—Thoracic outlet syndrome is typi- sessing nerve compression and help in estab-
cally characterized by neurologic symptoms lishing the diagnosis.
radiating along the upper extremity that can C. Treatment—Treatment is directed at reducing
include pain, numbness, tingling, burning compression at the thoracic outlet. Stretch-
and weakness. Hand or arm swelling and ach- ing exercises to minimize contractures at the
ing along the neck or shoulder can also oc- thoracic outlet and cervical and shoulder
cur. Symptoms may be aggravated with arm strengthening aimed at improving posture can
be helpful. Carrying heavy objects over the Turkel SJ, Panio MW, Marshall JL, et al. Stabilizing mechanisms
shoulder should be avoided to minimize further preventing anterior dislocation of the glenohumeral joint.
outlet compression. Surgery is indicated for re-
fractory cases with significant pain that have
failed conservative treatment and that demon- Recent Articles
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CHAPTER 20
Fractures of the Humeral Shaft

Robert Probe and Ian Whitney
I. Overview—Humeral shaft fractures represent C. Nerves

approximately 3% of all fractures. Multiple treatment 1. Musculocutaneous nerve—The musculocuta-

options are available and include both operative and neous nerve pierces the coracobrachialis
nonoperative management. The majority of humeral muscle 5 to 8 cm distal to the coracoid
shaft fractures may be treated via nonsurgical means process and then branches to supply the
with a high success rate. Most low-energy fractures coracobrachialis, the biceps brachii, and the
may be amenable to closed treatment because of in- brachialis muscles. It continues distally and
ternal soft-tissue splinting and the biologic potential becomes the lateral antebrachial cutaneous
of the humerus. In high-energy fractures, soft-tissue nerve.
disruption and extensive fracture comminution are 2. Median nerve—The median nerve accompa-

frequently observed rendering closed treatment less nies the brachial artery medial to the humeral
predictable. shaft and crosses lateral to medial (in relation
to the artery) in the distal arm. It lies medial
II. Anatomy
to the artery in the antecubital fossa.

A. Osteology—The humeral shaft can be defined
3. Radial nerve—The radial nerve, formed from

as extending from the pectoralis major insertion

the posterior cord of the brachial plexus, spi-
proximally to the supracondylar ridge distally.
rals around the humerus in a medial to lateral
The shaft of the humerus assumes a more triangu-
direction. It supplies the triceps as well as
lar shape distally. The anterolateral surface of the
innervation to the lateral portion of the bra-
humerus contains the deltoid tuberosity as well
chialis muscle. It emerges through the inter-
as the sulcus for the profunda brachii artery and
muscular septum between the brachialis and
the radial nerve. The spiral groove located on the
the brachioradialis muscles.
posterior humeral shaft contains the radial nerve
4. Ulnar nerve—The ulnar nerve travels down the
as it passes distally.

arm medial to the brachial artery. It traverses
B. Musculature—The humeral musculature is di-
behind the medial epicondyle of the humerus.

vided by medial and lateral intermuscular septa
D. Vasculature—The endosteal blood supply of the
into anterior and posterior compartments. The

humeral shaft comes from branches of the bra-
triceps brachii muscle fills the posterior com-
chial artery. Periosteal branches may arise from
partment. The anterior compartment contains
the brachial artery, the profunda brachii artery,
the biceps brachii, the coracobrachialis, and the
and the posterior humeral circumflex artery. In
brachialis muscles. Deforming muscle forces of-
addition, numerous small muscular branches
ten lead to predictable patterns of fracture dis-
contribute to the periosteal circulation.
placement. Fractures that occur between the
pectoralis major insertion and the deltoid III. Clinical Examination—The majority of patients with

insertion display adduction of the proximal humeral shaft fractures have the common signs and
fragment and lateral displacement of the dis- symptoms of fracture, including swelling, pain, defor-
tal fragment. Humeral shaft fractures distal mity, and crepitation. Motor-vehicle accidents, direct
to the deltoid muscle insertion often result in blows, and falls on the upper extremity are com-
abduction of the proximal fragment. mon mechanisms of injury. The humeral shaft also
293
concentrates rotational force applied to the upper ex- V. Treatment

tremity and is subject to fracture under these loading A. Closed Treatment—The majority of fractures

conditions. A complete physical examination is per- of the humeral shaft are treated adequately via
formed before concentrating on the upper extremity. closed methods. The fracture character, the pa-
A complete neurovascular examination of the en- tient’s age and occupation, and the presence of
tire upper extremity is performed. Because of the associated injuries all influence fracture manage-
high incidence of injury, the function of the radial ment. Transverse and oblique humeral shaft frac-
nerve must be documented before any reduction tures are commonly best treated closed. Options
maneuver or surgical intervention. The joints for closed treatment include hanging arm cast,
above and below the humerus, as well as the ipsi- shoulder spica cast, Velpeau dressing, coaptation
lateral wrist, are examined to exclude other injuries. splint, and a functional brace. Because of low
The skin should be examined for abrasions, lacera- cost, effectiveness and minimal complications,
tions, contusions or a combination thereof. The the use of a functional brace has become the pre-
compartments of the arm should be palpated to as- ferred method of treatment. The ideal humeral
sess for the possibility of a compartment syndrome. shaft fracture amenable to a functional brace is
the long oblique shaft fracture with soft-tissue
IV. Radiographic Evaluation—A complete radiographic stability provided by an intact medial and lateral

evaluation is mandatory in the workup of a humeral intramuscular septum. A functional brace is gen-
shaft fracture. An anteroposterior radiograph and erally applied to the humerus after 3 to 14 days of
a lateral radiograph that includes both the elbow fracture splinting. Active elbow flexion and exten-
joint and the glenohumeral joint are essential. While sion are required to assist fracture healing during
obtaining radiographs, the examining physician bracing. This method has been reported to result
should place the X-ray cassette in various positions in humeral shaft fracture healing in more than
about the upper extremity rather than manipulating 90% of patients. Functional bracing has proven a
the patient’s fractured limb. Simple limb rotation reliable method of treatment for extraarticular su-
does not provide orthogonal views of the proximal pracondylar fractures but is less effective in the
humeral shaft and results in an incomplete radio- treatment of proximal humeral fractures because
graphic analysis. Pathologic fractures may require of the physical constraints of the axilla. The hang-
other imaging studies, before definitive treatment, ing arm cast is used less frequently because it re-
to evaluate a neoplasm and exclude occult lesions. quires that the patient stay erect the majority of
A. Fracture Classification—There are numerous clas- the time. Additionally, frequent follow-up is man-

sification strategies for describing and reporting on datory to monitor for excessive fracture distrac-
humeral shaft fractures. Most fracture classification. The Velpeau (or sling-and-swathe) dressing
tion schemes are based on plain radiography and may be useful in children under the age of 8 years.
rely on fracture geometry. In practice, treatment The coaptation splint may be used before applica-
for humeral shaft fractures frequently depends on tion of the functional fracture brace. In summary,
other variables, including bone quality, concomi- whenever possible, closed treatment should be
tant injuries, soft-tissue injuries, or neurovascu- performed with the functional brace.
lar insult. Simple fracture patterns include those B. Operative Treatment—Despite the success of

of transverse, oblique, and spiral geometry. More closed treatment, a number of relative indications
complex patterns include segmental fractures, se- for operative treatment exist. These are listed in
verely comminuted fractures, open fractures, and Table 20-1. If surgical stabilization is chosen for
humeral shaft fractures with dislocation of either one of these indications, a number of surgical op-
the shoulder or the elbow. The Holstein-Lewis tions exist.
fracture is a spiral fracture in the distal third of 1. Plate osteosynthesis

the humeral shaft that typically presents with a • Open reduction and plate osteosynthesis has

lateral spike on the distal fragment. This pat- proven a reliable method of achieving union
tern has been associated with a radial nerve in- in humeral shaft fractures. Advantages of
jury because of proximity and tethering of the plate osteosynthesis include the ability to
nerve adjacent to this lateral spike. Open frac- explore the radial nerve during fixation,
tures should be evaluated according to the Gustilo minimal morbidity to the shoulder joint,
and Anderson Classification. Moreover, pathologic low complication rates, early restoration
conditions such as osteoporosis, metastatic or pri- of function, and the opportunity to apply
mary tumors, and other associated conditions are direct reduction techniques to the frac-
important in regards to fracture description. ture fragments. Furthermore, bone defects
C H A P T E R 2 0 | F R A C T U R E S O F T H E H U M E R A L S H A F T 295
• Locked plating—Locked screws have dra-

TA B L E 2 0 - 1 matically expanded the utility of plating as
Relative Indications for Operative Treatment of a treatment of humeral shaft fractures. The
Humeral Shaft Fractures opportunity to gain stable fixation in
Segmental fractures
osteoporotic bone and in fractures with
short metaphyseal segments has broad-
Lower-extremity fractures that require arm use for
ened the range of fractures amenable
mobilization
to plate fixation. In both of these clinical
Open fractures situations, the locked relationship of the
Vascular injury screw to the plate prevents screw toggle,
Bilateral humeral shaft fractures which translates into improved longevity of
Floating elbow injury fixation. Locking plates are most commonly
used on the humerus with a “hybrid” con-
Most pathologic fractures
struct. In this mode, conventional screws
Inability to obtain and maintain an acceptable closed are placed first creating stability through
reduction
traditional plate/bone friction generated
Fractures associated with radial nerve palsy after a by the compressing effect of the tightened
closed reduction screw. This stability is then maintained by
Large body habitus the addition of a sufficient number of lock-
Parkinson’s disease ing screws that are relatively protected
Ipsilateral brachial plexus lesion(s) from loosening. An alternative use of a lock-
ing plate is in the “internal–external fixator”
mode. In this technique, the plate is not com-
pressed to the bone but held off of the bone
may be addressed with autologous bone with locking screws. While this technique
graft, bone substitutes, or allograft in the has the theoretical advantage of minimizing
rare cases when a biological adjunct is felt periosteal disruption, superior clinical re-
to be necessary to accomplish healing. Plate sults have not yet been documented. While
osteosynthesis may be equally successful locking plates have proven advantageous in
with either absolute stability or relative sta- osteoporotic bone, they do not offer benefit
bility. In cases without significant comminu- in cases of normal bone quality.
tion, lag screw placement neutralized with 2. Intramedullary fixation

a plate is the preferred technique. Alterna- • Rigid intramedullary interlocking nails—

tively, when lag screw placement is imprac- Antegrade intramedullary nail fixation is ap-
tical, compression plating is acceptable. As plicable to proximal and middle third frac-
the fracture pattern increases in complexity, tures. In the distal third, the flattening shape
bridge fixation should be considered. With of the medullary canal precludes sufficient
this technique, length, alignment and rota- insertion depth and presents a contraindica-
tion of the arm is restored with the plate se- tion. The advantages of intramedullary nails
cured to the proximal and distal segment to include limited exposure and the preserved
maintain this position. This technique may fracture biology with indirect reduction.
be applied through traditional open expo- Static interlocking is generally recom-
sure or with a percutaneous technique. mended to enhance both rotational and axial
• Dynamic compression plates—The AO group stability. Complications associated with

recommends a 4.5-mm broad dynamic antegrade nailing of humeral shaft frac-
compression (DC or LC-DCP) plate with a tures include rotator cuff injury, shoulder
minimum of six (preferably eight) cortices pain, and proximal prominent hardware.
both proximal and distal to the humeral In an attempt to avoid these shoulder com-
shaft fracture. The rationale for broad DC plications, retrograde nail placement has
use is that it allows multiplanar screw place- been utilized with a posterior starting point
ment, increasing fixation strength. Humeral above the olecranon fossa. While avoiding
shafts with a smaller bone diameter may not shoulder complications this off axis starting
accept a 4.5-mm broad plate and use of a 4.5- point presents difficulty passing a nail and
mm narrow or 3.5-mm plate is acceptable in places a large stress riser in the supracon-
these circumstances. dylar region. Pathologic fractures present
296 S E C T I O N i I | a d u l t t r a u m a P a r t I I I | T h e Uppe r E x t r e m it y
a relative indication for intramedullary flexible implants. Flexible intramedullary de-

stabilization as this stabilizes longer sec- vices may be inserted in an anterograde or
tions of bone that are at risk for future retrograde fashion. When utilized, multiple
oncologic weakening. Patients with con- nails are recommended for rotational con-
comitant lower-extremity injuries that are trol. Complications with flexible nails include
expected to require crutch assistance have implant migration, nonunion and rotational
traditionally been treated with intramed- instability.
ullary fixation. It has been presumed that 3. External fixation—Open fractures, infected non-

this affords fixation better suited to weight unions, burn patients, and cases with segmental
bearing activity. However, recent clinical bone loss may be best stabilized with an exter-
series have also supported plate fixation nal fixator. External fixation pins should be
in these situations. Intramedullary reaming inserted in a controlled fashion under direct
in humeral shaft fractures remains a con- vision to guard against neurovascular injury.
troversial topic. The soft-tissues, exposed In Gustilo Type III open fractures, external fixa-
by fracture displacement, should never be tion is an excellent option. However, Type I and
subjected to revolving reamers because of Type II open fractures may be stabilized using
the potential for radial nerve injury. Open plate osteosynthesis or an intramedullary nail.
nailing decreases the risk of neurovascular The external fixator is usually placed as a tempo-
injury but also decreases the benefit of indi- rizing device during soft-tissue healing and before
rect reduction and limited exposure. functional bracing or definitive fixation. External
• Flexible intramedullary nail fixation—Flexible fixation is generally not recommended as the de-

intramedullary nails may be useful in both finitive fracture management in the humeral shaft.
adult and pediatric humeral shaft fractures. C. Surgical Approaches

Many surgeons prefer the lower morbidity 1. Posterior approach to the humeral shaft

and simpler techniques associated with these (Fig. 20-1)—The posterior approach uses the
FIGURE 20-1 Posterior approach to the

humeral shaft.
Lateral head of
Long head of triceps
triceps Humerus
Olecranon
Medial (deep) head
of triceps Periosteum
interval between the long and lateral heads of VI. Complications—Complications that may occur

the triceps muscle. The deep (medial) head is while treating humeral shaft fractures include
subsequently divided, and the humeral shaft osteomyelitis, malunion, delayed union or non-
is exposed. Dangers associated with this ap- union, vascular injury, and radial nerve injury.
proach include damage to the radial nerve and A. Osteomyelitis—Osteomyelitis of the humerus

damage to the profunda brachii artery. These is rare but may accompany open fractures or
two important structures must be identified and operative treatment. The diagnosis may be dif-
protected. In addition, care should be taken not ficult unless gross signs of infection are present.
to injure the ulnar nerve or the lateral brachial Open fractures and immune suppression place a
cutaneous nerve. patient at risk. Irrigation and debridement and
2. Anterolateral approach to the humeral shaft the administration of organism-specific antibi-

(Fig. 20-2)—In the anterolateral approach, otics with or without hardware removal remain
the humeral shaft is exposed by develop- the cornerstone of treatment. Nuclear medicine
ing the plane between the deltoid muscle and studies, including a combined indium-111-labeled
the pectoralis major muscle proximally and leukocyte and technetium-99m methylene diphos-

through the brachialis muscle distally. Dangers phonate scintography, may be useful during the
associated with this approach include the mus- diagnostic workup for infection. The placement

culocutaneous nerve and the radial nerve as it of antibiotic-impregnated polymethylmethacry-
enters the anterior compartment distally. late may be required to eliminate an infection. In
3. Posterolateral approach to the humeral shaft the event that sequestrum removal is necessary,

(Fig. 20-3)—This approach essentially follows the arm is able to preserve function with resec-
the lateral intermuscular septum and allows tion of up to 3 cm of bone making acute shorten-
humeral exposure from the lateral condyle to ing a viable option for limb reconstruction.
the proximal crossing of the axillary nerve. In B. Malunion—A large amount of angular and ro-

addition to this being an extensile exposure, tational deformity may be tolerated in the hu-
its major advantage is the ability to explore the merus before it limits function of the upper limb.
radial nerve in both the posterior and anterior Generally, up to 20° to 30° of angular defor-
compartments. mity and 15° of rotational malalignment are
FIGURE 20-2 Anterolateral

approach to the humeral shaft.
Pectoralis major
Deltoid
Brachialis
Humerus Biceps
Periosteum
FIGURE 20-3 Posterolateral

approach to the humeral shaft
allows for extensile exposure and
visualization of the radial nerve
in both the posterior and anterior
compartments of the arm.
Axillary n.
Lateral head
of triceps
Branch to medial
head of biceps
Lower lateral brachial
Medial head cutaneous n.
of triceps
Open region of
intermuscular septum
considered acceptable. Surgical correction fasciotomies should be considered because

of a malunion frequently requires a corrective of the risk of reperfusion compartment syn-
osteotomy, which may be stabilized with either drome. Collateral blood flow may maintain distal
an intramedullary nail or plate osteosynthesis. pulses in patients with brachial artery injuries;
C. Nonunion—A humeral shaft nonunion most com- therefore, the presence of distal pulses does

monly occurs in cases of severe bony devascular- not preclude brachial artery damage.
ization, segmental fractures, transverse fractures, E. Radial Nerve Injury—Most radial nerve inju-

poor fracture fixation, high-energy trauma or in ries are secondary to neurapraxia (90%), and
patients with significant medical comorbidities. spontaneous recovery is frequently observed.
Humeral shaft nonunion develops in only 2% to However, open fractures, Holstein-Lewis spiral
5% of fractures. The keys to management are fractures, and penetrating trauma may result
reduction of the fracture fragments, assuring in a nerve laceration. The indications for pri-
adequate biologic potential and stable fixation. mary nerve exploration include open frac-
Open reduction with internal fixation using tures with radial nerve palsy and distal third
a 4.5-mm DC plate with supplemental cancel- spiral fractures with loss of nerve function
lous autogenous bone graft is the treatment of after closed reduction. In cases of complete
choice for nonunion. Segmental defects likely radial nerve dysfunction, electromyography
require an advanced reconstruction with vascu- and nerve conduction velocity tests should be
larized fibular graft, cancellous graft, or acute performed between 6 and 12 weeks following
shortening. Intramedullary fixation alone and ex- injury. If motor function is displayed (action
change nailing have generally proven to be poor potentials), continued observation is indicated.
choices for humeral nonunion treatment. The clinician may elect to explore and repair
D. Vascular Injury—Vascular injuries associated the radial nerve if studies display no evidence

with humeral shaft fractures are exceedingly of reinnervation (denervation fibrillation). Elec-
rare. Prioritization between skeletal stabilization tive tendon transfers may be performed after
and vascular repair is directed by the timing of documented radial nerve palsy has failed to
injury and residual limb perfusion. Prophylactic resolve.
SUGGESTED READINGS Heineman DJ, Bhandari M, Poolman RW. Plate fixation or intra-
medullary fixation of humeral shaft fractures—an update.
Acta Orthop. 2012.
Classic Articles Kurup H, Hossain M, Andrew JG. Dynamic compression
Healy WL, White GM, Mick CA, et al. Nonunion of the humeral plating versus locked intramedullary nailing for humeral
shaft. Clin Orthop. 1987;219: 206–213. shaft fractures in adults. Cochrane Database Syst Rev.
Holstein A, Lewis GB. Fractures of the humerus with radial- 2011;(6):CD005959.
nerve paralysis. J Bone Joint Surg. 1963;45A:1382–1388. Shin SJ, Sohn HS, Do NH. Minimally invasive plate osteosynthe-
Ingman AM, Waters DA. Locked intramedullary nailing of hu- sis of humeral shaft fractures: a technique to aid fracture re-
meral shaft fractures: implant design, surgical technique, duction and minimize complications. J Orthop Trauma. 2012.
and clinical results. J Bone Joint Surg. 1994;76B:23–29.
Sarmiento A, Kinman PB, Calvin EG, et al: Functional brac- Textbook
ing of fractures of the humeral shaft. J Bone Joint Surg.
1977;59A:59–601. Zagorski JB, Zych GA, Latta LL, et al. Modern concepts in func-
tional fracture bracing: the upper limb. Instr Course Lect.
1987;36:377–401.
Recent Articles
Gosler MW, Testroote M, Morrenhof JW, et al. Surgical versus
non-surgical interventions for treating humeral shaft frac-
tures in adults. Cochrane Database Syst Rev. 2012;1:CD008832.
CHAPTER 21
Fractures and Dislocations

of the Elbow
O. Alton Barron and Damien Davis
I. Overview—The elbow provides the critical linkage respect to the humerus and inclines laterally 5°
as the shoulder moves the hand through space. The to 8°, thereby creating the valgus carrying angle
normal elbow has an average extension to flexion arc of the extended elbow. In the male, the mean car-
of 0° to 145°. Normal pronation and supination are ap- rying angle is 11° to 14°, and in the female, it is
proximately 80° and 85°, respectively. Functional arcs 13° to 16°. The roughly hemispheric capitellum is
fall within these limits, with activities of daily living centered 1 to 1.5 cm anterior to the central axis
requiring 50° each of pronation and supination and a of the humeral shaft. The humerocapitellar angle
100° arc of extension to flexion between 30° and 130°. in the adult is 30°. The medial column diverges at
Less than 130° of elbow flexion diminishes the ability an angle of 45° with the humeral shaft, whereas
to feed and groom oneself. Fractures and dislocations the lateral column diverges 20° to 25°. The medial
of the elbow should be evident on routine anteropos- epicondyle, forming the distal extent of the me-
terior (AP), lateral, and oblique radiographs. The radial column, lies just posterior to the rotational
diocapitellar view provides an additional and clearer axis of the trochlea. Thus a cam effect is created,
view of this joint. Information from these plain radio- with different portions of the medial collateral
graphs is almost always sufficient for the surgeon to ligament (MCL) becoming taut at different angles
decide between operative and nonoperative treat- of flexion. Conceptualizing distal humerus frac-
ment. Once a decision is made to pursue operative tures as involving one or both columns simplifies
treatment, plain radiographs with gentle traction ap- accurate identification and management. Isolated
plied to the arm after anesthesia may further clarify capitellar fractures are discussed separately.
fracture anatomy, especially in the case of distal B. One-Column Fractures—These fractures involve
humerus fractures. Computed tomography (CT) is part or all of the trochlea. Milch and Jupiter have
indicated to assess the articular surfaces when the classified these, depending on how much of the
decision to pursue operative treatment on the basis trochlea remains with the involved column. High-
of articular displacement is equivocal after plain ra- columnar fractures involve the majority of the
diographs. It is also more ideal to assess fragment trochlea, and the radius and ulna are displaced
size and configuration prior to surgery. with the fractured column. Low-columnar frac-
tures involve a smaller portion of the trochlea,
II. Distal Humerus Fractures (Fig. 21-1) and the radius and ulna remain with the intact
A. Anatomy—The distal humerus consists of an humeral column and shaft. For fractures dis-
obliquely oriented articular surface comprised placed more than 2 mm, anatomic reduction
of the spool-like trochlea and the hemispheric with stable internal fixation allows for early mo-
capitellum, each supported by a condylar col- tion and yields consistently better results than
umn. The olecranon fossa lies between these closed management. For nondisplaced fractures,
columns proximal to the articular surface. Its the position of immobilization should relax
sometimes paper-thin floor is the confluence the musculature originating from that column
between the anterior and posterior cortices of (i.e., pronation for medial column fractures, su-
the distal humerus and contributes little osse- pination for lateral column fractures). Rigid
ous support. The longitudinal axis of the spool- fixation of high columnar fractures with plates
shaped trochlea is internally rotated 3° to 8° with provides improved rigidity over screws alone; low
300
C H A P T E R 2 1 | F R A C T U R E S A N D D I S L O C A T I O N S O F T H E E L B O W 301
Lateral epicondyle fracture Columnar, intraarticular fracture

Surgical approach—Lateral Surgical approach—Olecranon osteotomy
Treatment—ORIF Treatment—ORIF, ulnar nerve transposition
Type of hardware—Screw, suture anchors Type of hardware—Plates and screws
Radial head/neck fracture Medial epicondyle fracture

Surgical approach—Kocher, Kaplan, Surgical approach—Medial
Pankovich Treatment—ORIF
Treatment—ORIF vs. excision Type of hardware—Screw, suture anchor
Type of hardware—T-plate, screws,
prosthesis
Capitellum fracture Supracondylar fracture

Surgical approach—Lateral Surgical approach—Olecranon osteotomy
Treatment—ORIF vs. excision Treatment—ORIF with or without ulnar
Type of hardware—PA lag or headless screw nerve transposition
Type of hardware—Plates and screws
Coronoid fracture
Surgical approach—Injury/fixation Olecranon tip fracture
dependent Surgical approach—Posterior
Treatment—ORIF if indicated Treatment—Excision
Type of hardware—Lag screw, anchor, Type of hardware—None
suture
Monteggia injury Olecranon fracture

Surgical approach—Posterior Surgical approach—Posterior
Treatment—ORIF Treatment—ORIF
Type of hardware—Compression plate Type of hardware—Tension band wire
FIGURE 21-1 Treatment of elbow fractures. Although there may be alternative treatments of equal merit, this is the
standard information at this time. ORIF, Open reduction with internal fixation; PA, Posteroanterior.
columnar fractures without comminution may be rare in adults (except perhaps in osteoporotic
adequately stabilized with screws. In either case, older individuals). Fixation in the presence of
the articular reduction must be anatomic. This closed physes is similar to that used in intraar-
can be achieved through indirect reduction at ticular fractures. In adults, efforts must be made
times, but may require an olecranon osteotomy in to achieve anatomic reductions and rigid internal
certain cases. For lateral column fractures where fixation, despite the allure of percutaneous pin
the lateral trochlea is fractured off with the capi- fixation. Shear forces are too great, and postoper-
tellum, a chevron olecranon osteotomy can be le- ative fracture displacement occurs too often with
vered open on a medial (ulnar) soft-tissue hinge. limited fixation. Intra-articular bicolumnar frac-
This provides for adequate articular visualiza- tures frequently result from high-energy trauma
tion and anatomic restoration while leaving the and may be extensively comminuted. Common
medial structures (i.e., the ulnar nerve and MCL) fracture patterns include the T, Y, H, and the later-
undisturbed. This also simplifies reduction and ally or medially inclined “lambda” fractures. The
fixation of the osteotomy. high risk for stiffness and loss of motion after
C. Two-Column Fractures—Fractures involving both such fractures is best minimized by stable fixation
columns are either intra-articular or extra-articular. and early motion. If sufficient stability to permit
While common in children, extra-articular colum- early range of motion (ROM) cannot be achieved,
nar fractures (i.e., supracondylar fractures) are then anatomic restoration of the articular surface
should take precedence. Joint contractures in the osteotomy if TEA is necessary, as this can result
presence of healed, congruent articular surfaces in inadequate fixation of the ulnar prosthesis.
can be effectively treated with a soft-tissue re- In higher-demand elbows, however, the surgeon
lease. Two-column distal humerus fractures are should strive for optimal fracture fixation and
best approached posteriorly. Given the relatively bone healing (even if a later contracture release
high incidence of ulnar neuropathy associated becomes necessary). Postoperative care should
with these injuries (early and late), some recom- include active motion as soon as it is appropriate,
mend anterior transposition of the ulnar nerve at depending on the fixation achieved (immediately
the time of fracture fixation. This can be easily if at all possible).
performed from the posterior approach.
III. Capitellum Fractures ( Fig. 21-1)—Fractures of the
An olecranon osteotomy, most reliably and
capitellum are rare. The usual configuration is a
inexpensively stabilized with a tension band wir-
shear fracture in the coronal plane with superior
ing technique, affords access to the entire artic-
displacement of the articular surface. Bryan and
ular surface. The osteotomy should be an apex
Morrey have classified these as Type I, complete
distal osteotomy centered over the bare articu-
fractures; Type II, osteochondral fractures; and
lar area of the trochlear notch. Larger fragments,
Type III, comminuted fractures (Table 21-1). Type I
whether columnar or intraarticular, should be
fractures consist of the hemisphere of the articular
stabilized first. The columns are most rigidly fixed
surface and the underlying cancellous bone (typi-
with plates along their posterior aspects. Dual
cally referred to as the Hahn-Steinthal fracture).
plating along the columns is stronger than Y plat-
Occasionally, Type I fractures may be amenable to
ing or other constructs. The lateral column, with
closed reduction if attempted early. However, it is
its gently curved posterior aspect, usually accom-
difficult to achieve and subsequently maintain ad-
modates 3.5-mm dynamic compression plates
equate reduction. When required and possible,
(stronger torsional forces and bending moments).
internal fixation is best accomplished with lag
The more malleable 3.5-mm reconstruction plates
screws from posterior to anterior into the pos-
are better for more distal fractures requiring plate
terior portion of the lateral condyle. A lateral ap-
bends with smaller radii of curvature. The use of
proach with subperiosteal release of the common
two plates along the lateral column (one poste-
extensor origin is used to expose the capitellum and
rior, one lateral) has also been described. The
posterior aspect of the distal lateral column. Type
contour of the medial epicondyle usually requires
II fractures are less common and consist of an os-
a reconstruction plate posteriorly or a one-third
teochondral shell of the anterior capitellar cartilage
tubular plate along its medial ridge. Alternatively,
(i.e., the Kocher-Lorenz fracture). Occasionally,
“prebent” plates are available and can be used in
these fractures are amenable to fixation with head-
a similar fashion. The trochlea, which is usually
less anterior-to-posterior compression screws if
fractured in the sagittal plane, is best stabilized
there is enough cancellous subchondral bone for
with screws along its axis; these may be passed
stable fixation. Highly comminuted (Type III) and
through the various plates for added stability.
osteochondral fractures may not be amenable to
Since the articular cartilage of the trochlea covers
stable internal fixation. Excision of fragments is
270° of its surface, fixation of articular fragments
then recommended as long as the integrity of the
is best accomplished with headless compression
radioulnar interosseous ligament and MCL has
screws or lag screws countersunk below the sub-
been confirmed. In the presence of longitudinal
chondral bone. Provisional pin fixation and pa-
radioulnar instability, excision of the capitellum is
tience, with accurate contouring of plates, greatly
analgous to excision of a nonrepairable radial head.
facilitate stable fixation. Even prebent plates of-
In either case, proximal radial migration leads to
ten require some additional bending to conform
positive ulnar variance and ulnocarpal impaction.
to each patient’s unique anatomy.
Although avascular necrosis (AVN) of the fragment
Total elbow arthroplasty (TEA) has been
is rare, delayed excision of a necrotic fragment is ap-
used to treat primarily elderly, low-demand os-
propriate. Excision of capitellar fragments, whether
teoporotic patients with comminuted bicolum-
performed initially or delayed, may lead to elbow
nar fractures not amenable to open reduction
stiffness. Arthroscopic excision results in improved
and internal fixation. Such elbow fractures
motion compared with open excision.
in patients with pre-existing degenerative
conditions of the elbow, such as rheumatoid IV. Elbow Dislocation (Fig. 21-2)
arthritis, are also candidates for primary A. Anatomy—Dislocation of the elbow joint in the
TEA. It is important not to perform an olecranon adult population has an annual incidence of
TA B L E 2 1 - 1
Important Elbow Injury Classifications
Type Description Treatment or Age Group
Radial head fractures
Mason Classification
I Nondisplaced Nonoperative
II Displaced ORIF vs. excision
III Comminuted Excision with or without replacement
IV Associated with elbow dislocation Replacement based on stability
Hotchkiss Classification
I Marginal fracture or minimally displaced Nonoperative
with no motion block
II 2-mm displacement and amenable to ORIF
fixation
III Comminuted fracture not amenable to Excision with or without replacement
fixation
Coronoid fractures
Regan and Morrey Classification
I Tip avulsion None
II 50%, MCL insertion intact Usually non-operative
III ≥50%, MCL disrupted ORIF
Monteggia Lesions
Bado Classification
I Anterior dislocation of the radial head Children to young adults
II Posterior dislocation of the radial head Elderly
III Lateral dislocation of the radial head Children
IV With a radial shaft fracture Adults
Capitellum fractures
Bryan and Morrey Classification
I Complete fracture Closed reduction vs. ORIF
II Osteochondral (shear) fracture Excision
III Comminuted fracture Excision
ORIF, Open reduction with internal fixation.
13 per 100,000 people. That is about the same in- ulnohumeral articulation provides 55% of the re-
cidence as proximal interphalangeal joint dislo- sistance to varus with the elbow extended and
cations, but less than shoulder dislocations at 17 75% of the resistence with the elbow flexed 90°.
per 100,000. The osseous anatomy of the elbow is The radiocapitellar joint, though transmitting up
inherently stable and contributes the majority of to 60% of the axial force from the hand to the
resistance to varus and valgus forces. The column humerus, contributes only 30% of the resistance
model (Greek temple) of elbow stability depicts to valgus force at the elbow. In cases of ligament
the humerus as spanning the articular surfaces disruption, the osseous columns contribute more
of the radial head and the coronoid process of of the resistance to varus and valgus loads. The
the ulna. Valgus forces are resisted primarily at anterior band of the MCL originates from the an-
the radiocapitellar joint (the lateral column), terior portion of the medial epicondyle (the cen-
whereas varus forces are resisted primarily at ter of the ulnohumeral motion axis) and inserts
the ulnohumeral joint (the medial column). The onto the medial base of the coronoid. The lateral,
FIGURE 21-2 Elbow dislocations. Note that

the classification is based on the direction of
displacement of the forearm bones.
Posterior Anterior
Lateral Medial Divergent
or radial, collateral ligament (LCL) originates “clunk” is felt during valgus testing. The collat-
from the lateral epicondyle of the humerus at eral ligaments usually fail in their midsubstance,
the axis of ulnohumeral motion and inserts into although avulsion fractures, especially later-
the annular ligament and into the proximal ulna ally, may occur, usually in adults. An attenuated
just lateral to the lesser sigmoid notch (Fig. 21- MCL has been associated with valgus instabil-
3). Classically, the anterior band of the MCL is ity but not with recurrent dislocation, whereas
considered the primary stabilizer of the ulnohu- an incompetent LUCL has been associated with
meral joint, but the role of the LCL, especially the subluxation and recurrent dislocation. An incom-
ulnar portion, has been clearly delineated. The petent LUCL leading to PLRI can frequently be
MCL contributes 70% of the resistance to valgus detected by the pivot shift test. A supination val-
loads in the intact elbow. The anterior capsule gus moment is applied to the flexed elbow with
also provides some resistance to both valgus and the patient supine. The subluxation is felt as the
varus stress, primarily with the elbow in exten- elbow is extended and a reduction clunk is felt
sion. Clinically, the MCL may provide adequate as the elbow is flexed again. The flexor-pronator
stability against valgus force even in the case group and the extensor group of muscles serve as
of radial head resection. Biomechanical stud- secondary dynamic stabilizers of the elbow joint,
ies of the LCL, however, suggest that stability to as do the triceps, brachialis, and biceps muscles.
varus force depends on both an intact LCL and a These muscles span the elbow joint, resisting
competent coronoid process (50% intact). The applied moments, and increasing joint reactive
lateral ulnar collateral ligament (LUCL) cradles forces (thereby increasing the osseous stability).
the radial head and prevents its posterior sub- Grossly unstable elbow dislocations are often as-
luxation along with preventing lateral opening of sociated with rupture of these dynamic stabiliz-
the ulnohumeral joint. Such instability is termed ers as well as the static ligamentous restraints.
posterolateral rotatory instability (PLRI). Injuries B. Evaluation and Treatment—Despite the inher-
to the LCL complex have been created biome- ently stable osseous configuration of the joint,
chanically with application of a supination, hy- dislocations of the elbow represent 20% of all
perextension load. Testing of elbow stability with dislocations. The injury occurs most often in
the forearm in pronation to tighten the LCL has young people as a result of relatively high-energy
been suggested; testing in supination may lead trauma but can nevertheless occur after a seem-
to confusion between PLRI and MCL laxity if a ingly minor fall onto an outstretched hand. Some
FIGURE 21-3 Elbow joint.

A. Medial collateral ligament
with its important anterior
band. B. Lateral collateral
A ligament (LCL).
Anterior band
Annular ligament
B
Posterior band
Transverse ligament
LCL (radial portion)

Annular ligament
LCL
(ulnar portion)
90% of elbow dislocations are posterior. An- appropriate for early rehabilitation. Blocked
terior, medial, or lateral dislocations are rare; di- motion usually indicates an incarcerated
vergent dislocations (radius and ulna displaced osteochondral fragment. Stability to varus
in different directions with disruption of the and valgus stress should be tested in 30° of
proximal radioulnar joint) are extremely rare. As flexion and full pronation. The simple elbow
the ulnohumeral joint dislocates, the radial head dislocation stable beyond 45° of flexion
and coronoid are sometimes fractured (in up to should generally be splinted in 90° of flex-
10% and 18%, respectively, of all elbow disloca- ion and neutral pronation/supination. Pro-
tions); more rarely the olecranon tip is fractured. nation tightens the LCL and may be used to
At surgical exploration, over 90% of elbow dis- improve postreduction stability. However,
locations demonstrate osteochondral fractures certain patients, especially younger athletes,
that may be attributed to the initial trauma or to may enjoy a more rapid recovery of function
subsequent overzealous reduction maneuvers. if open repair of critical ligaments and muscle
The humeral epicondyles may fracture as well, tendon units is performed acutely.
representing avulsion of the collateral ligaments. 2. Repair of ruptured ligaments—Repair of rup-
These fragments, along with injured soft tissue, tured ligaments in an elbow that is stable
can become incarcerated within the joint, neces- past 45° of extension does not improve re-
sitating operative intervention. True lateral and sults. If, however, the elbow requires im-
AP X-rays are required to confirm a congruent mobilization in extreme flexion, then the
reduction. A CT scan is also informative as to the LCL and/or MCL should be repaired. The
exact location of the fragment and more subtle flexor/pronator and extensor origins are gen-
impaction and shear fractures, especially those erally ruptured in these cases and should be
involving the medial coronoid. An incongruent reattached to the humerus at the time of liga-
reduction is an indication for surgical explora- ment repair. If the elbow remains unstable even
tion with open reduction. after ligament repair (rare but more common
1. Reduction—Reduction under appropriate se- when associated with unstable fractures), the
dation that provides sufficient muscle relax- surgeon should consider a dynamic external
ation should be followed by an examination fixator. Devices now available allow for control
of joint stability and ROM. This allows the of varus and valgus, flexion and extension, and
examiner to gauge the extent of injury to vari- joint distraction. Still the trend continues to be
ous stabilizers as well as the limits of motion toward anatomic repairs and reconstruction
of critical stabilizers such that the need for of the elbow are required to accurately assess these
dynamic fixators is minimized. injuries. Articular impaction fractures of the troch-
3. Associated fractures—The treatment of asso- lear notch or fracture extension into the coronoid
ciated fractures (radial head, capitellum, coro- process may occur and must be identified.
noid process, and olecranon) is discussed in A. Undisplaced Fractures—Colton classified an “un-
each of those sections. displaced” olecranon fracture as having less than
4. Active motion—Active motion should be 2 mm of displacement, being stable with elbow
instituted 5 to 10 days after an elbow dislo- flexion to 90°, and allowing active extension of the
cation to minimize stiffness and heterotopic elbow. Careful follow-up of such fractures treated
ossification. Early passive motion may lead to nonoperatively is needed to detect subsequent
redislocation and heterotopic ossification. Pa- fracture displacement.
tient apprehension is overcome by having the B. Displaced Fractures—Displaced olecranon frac-
patient lie supine with the injured arm held tures should be treated operatively except when
above the chest (i.e., with the shoulder in 90° the patient cannot tolerate any surgery. Displaced
of forward elevation). From this position, ac- noncomminuted fractures are generally amenable
tive extension of the elbow against gravity is to treatment with a tension band wiring con-
allowed. This position is most advantageous struct, with the pins best placed into the anterior
in that if the patient loses control of the arm, it cortex of the ulnar shaft to minimize the risk of
will fall into elbow flexion, a position of greater pin migration. However, great care must be exer-
stability. This can decrease patient apprehen- cised to avoid injury to the anterior interosseous
sion of redislocation and facilitate rehabilita- neurovascular bundle, which lies adjacent to the
tion. Dynamic extension splints should be anterior proximal ulna. The tension wire should
considered if extension is not improving by 5 be passed deep to the triceps tendon to rest
weeks following the injury. against the cortex of the olecranon while main-
C. Associated Injuries—Neurovascular injury is taining an awareness of the nearby ulnar nerve
fairly rare in association with elbow dislocation. within the cubital tunnel. Tension band wiring
The ulnar nerve is most commonly involved may be insufficient for complex olecranon frac-
because of excessive traction during posterior tures associated with comminution, instability, or
dislocations. The median nerve, the second substantial extension into the coronoid process.
most commonly injured, may become entrapped The most common complication associated
after reduction, emphasizing the importance of with tension band wiring of the olecranon is
prereduction and postreduction neurovascular prominence of the Kirschner wires at the inser-
examinations. Brachial artery disruptions are tion site into the olecranon. This irritates the
rare and are usually associated with open inju- triceps tendon, necessitating hardware removal.
ries. Doppler evaluation or arterial imaging is Avulsion fractures may sometimes be fixed with
recommended in cases of asymmetric pulses a heavy nonabsorbable suture. Comminuted
or other signs of arterial compromise. Examina- fractures of the olecranon may require plate
tion of distal pulses may be unreliable because fixation if the proximal piece is large enough
of collateral circulation around the elbow. Since to accommodate two or three screws, or exci-
elbow dislocations frequently result from a force sion if the fragments cannot be reconstructed.
applied to the outstretched hand, other injuries A plate placed laterally (when possible) minimizes
resulting from this mechanism may occur and the risk of painful and/or prominent hardware be-
should be sought radiographically and clinically. cause the medial and posterior aspects of the
Carpal fractures and dislocations, distal radius olecranon are frequently used to rest the arm or
fractures, and injuries to the interosseous mem- to bear weight. In the rare cases requiring exci-
brane of the forearm have been reported. sion, advancement of the triceps mechanism into
cancellous bone of the ulnar shaft results in ade-
V. Olecranon Fractures (Fig. 21-1)—Intra-articular frac- quate function in older individuals. The literature
tures of the olecranon most commonly result from suggests that excision of as much as two-thirds
a direct blow to the posterior elbow sustained dur- of the olecranon has yielded good results in very
ing a fall. The less common extra-articular (avulsion) low-demand elbows. However, resection of 25%
fractures are usually smaller fragments. These most of the olecranon process reduces the resistance
often occur via indirect trauma (e.g., an eccentric tri- to valgus load by 50%. Thus, excision is contra-
ceps contraction against a fixed forearm as in a fall indicated in the presence of anterior soft-tissue
onto an outstretched hand). True lateral radiographs damage, when the fracture involves the coronoid
process, or in younger, active patients. After via an intact annular ligament. Recognition of these
excision, the triceps should be advanced so that injuries as fracture-dislocations facilitates an ap-
the tendon is congruent with the articular sur- propriate approach to restoring elbow stability. In
face of the trochlear notch. Immediate or early cases of transolecranon fracture-dislocation of
motion after stable internal fixation of olecranon the elbow, anatomic restoration of the olecranon
fractures engenders the best results. After exci- is critical to restore osseous resistance to ante-
sion, the repair of the triceps to the proximal ulna rior translation of the forearm. Simple trans-
should be protected as necessary. Intraoperative verse or oblique fractures may be treated via
assessment of the stability of this repair should tension-band wiring or other fixation based on
be used to guide postoperative rehabilitation. sound biomechanical principles. If the trochlear
notch is comminuted, the ulnar fracture is generally
VI. Proximal Ulna Fractures—Olecranon fractures that amenable to plate fixation, since the olecranon frag-
extend into the coronoid are better regarded as ment is usually of sufficient size to allow for rigid
proximal ulna fractures, since they represent a more fixation with two or three cancellous screws. Resto-
complex injury to the elbow and require different ration of the articular surface of the trochlear notch
fixation techniques. Comminution is frequent. These (with bone graft as necessary), including fixation of
fractures are termed trans-olecranon fracture-dislo- the coronoid process (which restores the integrity
cations of the elbow and occur when a high-energy of the MCL), may then allow for early motion.
direct posteroanterior blow is applied to the dorsal A. Monteggia Fractures (Fig. 21-4)—Monteggia frac-
aspect of the forearm with the elbow in mid-flexion. tures represent only 1% to 2% of forearm frac-
This results in an olecranon fracture and an anterior tures. Disruption of the annular ligament with
dislocation of the forearm with respect to the distal dislocation of the proximal radioulnar joint,
humerus. A transolecranon fracture-dislocation is combined with an associated fracture of the
often misdiagnosed as an anterior Monteggia lesion. proximal ulna, distinguishes the Monteggia le-
The transolecranon fracture-dislocation is differ- sion from fracture-dislocations of the elbow.
ent from a Bado I Monteggia lesion, because in the The radial head may be displaced anteriorly
former, there is loss of stability in the ulnohumeral (Bado Type I), posteriorly (Bado Type II), or lat-
joint but the radioulnar relationship is preserved erally (Bado Type III). Injuries with an associated
FIGURE 21-4 Classification of Monteggia injuries

(Bado). Type I. Anterior angulation of the ulnar
fracture and anterior dislocation of the radial head.
Type II. posterior angulation of the ulnar fracture
and posterior dislocation of the radial head. Type III.
fracture of the proximal ulna metaphysis and lateral
dislocation of the radial head. Type IV. anterior
dislocation of the radial head and fracture of both the
radius and ulna.
Type I Type II
Type III Type IV
fracture of the radial shaft have been designated

as Bado Type IV (see Table 21-1). Associated ulnar
fractures are generally distal to the coronoid pro-
cess but may involve the trochlear notch. Dislo-
cation of the radial head, especially posteriorly
or laterally, may include disruption of the LCL,
possibly leading to late instability of the elbow I
if unrecognized. Posterior interosseous nerve II III
(PIN) palsy is most commonly seen in Bado
Type I (anterior) fractures and may occur in
a delayed fashion if the radial head is not
promptly reduced. Appropriate management of
these injuries is predicated on anatomic reduc-
tion and fixation of the ulna fracture. If stable
anatomic fixation of the ulna with reduction of FIGURE 21-5 Coronoid fracture classification (Regan and
the proximal radioulnar joint is achieved, early Morrey). Note that Type I and Type II fractures involve
motion should be instituted to minimize stiff- less than 50% of the coronoid and are usually amenable
ness. Proximal radioulnar instability is rare in to nonoperative treatment, whereas Type III fractures
this setting, and annular ligament reconstruction involve 50% of more of the coronoid and usually require
operative stabilization.
is unnecessary. Ulnohumeral stability should be
tested during surgery to detect possible injury to
the LCL; repair of the LCL should be performed stability by disrupting the osseous integrity of
in the presence of any lateral instability. Mal- the ulnohumeral articulation, by disrupting the
reduction of the ulna fracture can lead to anterior capsule, and by rendering the MCL
persistent radial head subluxation, valgus in- incompetent. They are associated with instabil-
stability, and post-traumatic arthrosis. Other, ity to anterior, valgus, and varus forces (even in
less common causes of persistent radial head the case of an intact LCL and radial head) as well
subluxation include interposition of soft- as elbow extension. Therefore, Type III coronoid
tissue in the joint and lateral ligamentous fractures should be repaired. Although fracture
injuries. fixation is preferred, when a large fragment of the
B. Coronoid Fractures (Figs. 21-1 and 21-5)—Coro- coronoid is extensively comminuted (rarely), it
noid fractures are classified according to the may be partially or completely excised and the
percentage of the coronoid that is fractured (see brachialis advanced into the cancellous trough
Table 21-1). Fractures of the tip of the coronoid in the proximal ulna. Many authors recommend
(Regan and Morrey Type I) do not cause instabil- suture fixation of the largest coronoid fragment
ity and do not require treatment unless one or without excision of other small fragments if these
more fragments become incarcerated within the are attached to the capsule. In this case, these
joint. The anterior capsule inserts 6.4 mm distal to smaller fragments may promote osseous healing.
the tip of the coronoid process. Therefore, Type I Recently, fractures of the anteromedial facet of
injuries do not signify capsular avulsion but may the coronoid process have been recognized as
be a sign of previous elbow instability (i.e., an an important and underappreciated type of coro-
elbow dislocation or subluxation that spontane- noid fracture. Fractures of the anteromedial facet
ously reduced). Fractures involving more than have been associated with varus posteromedial
the tip but less than half the height of the coro- rotatory instability-pattern elbow injuries and re-
noid signify a capsular avulsion injury (Regan quire special attention at surgery. The benefits of
and Morrey Type II). These Type II injuries are stabilizing these fragments in addition to repair
not frequently associated with elbow instability of the LCL complex are now clearly evident. Col-
and can usually be treated nonoperatively. How- lateral ligament repair should be performed when
ever, some Type II injuries of the coronoid may a coronoid fracture is associated with residual
result in posterior subluxation of the elbow when elbow instability after reduction. In rare cases,
tested in more than 45° of elbow extension; these an articulated external fixator may be required to
fractures should be stabilized with screws, heavy maintain reduction of the elbow through the re-
sutures through drill holes, or suture anchors. habilitation period. Fractures of the coronoid are
Fractures involving 50% or more of the coronoid frequently found in conjunction with fractures
(Regan and Morrey Type III) compromise elbow of the radial head. In this case, both the medial
and lateral columns of the elbow are disrupted. exists with regard to the treatment of the Ma-
When these fractures are associated with son Type II injury (displaced fractures), and this
elbow dislocation (the “unhappy triad” of the system does little to guide treatment. Hotchkiss
elbow), recurrent instability and posttrau- has classified these injuries more practically as
matic arthrosis often result. In this setting, those not requiring operative treatment (Type
smaller fractures of the coronoid may require I), those requiring either open reduction with
fixation to provide additional stability. internal fixation (ORIF) or excision (Type II),
and those that are too comminuted to be ame-
VII. Radial Head Fractures (Figs. 21-1 and 21-6)—Radial nable to ORIF and should be excised (Type III).
head fractures are generally created by the axial In the case of excision, the intact MCL provides
load sustained during a fall on an outstretched arm adequate resistance to valgus force. Isolated
and are often associated with other injuries sus- radial head fractures should be reduced and
tained by this mechanism (e.g., wrist). The PIN lies stabilized if possible and excised if not. Elderly
in close proximity and may also be injured. Care- patients with low-demand elbows may lower the
ful evaluation of neurovascular status and motion threshold for excision, but the current trend is
is necessary, with the latter often difficult due to towards ORIF whenever feasible. Any suspicion
the fracture hemarthrosis. Intra-articular injection of valgus instability should lead the surgeon to
of local anesthetic through the posterolateral “soft seriously consider prosthetic radial head re-
spot” and subsequent aspiration of the hemarthro- placement rather than simple excision. Compli-
sis provides dramatic joint decompression with cations following excision of the radial head
pain reduction, and greatly improved motion. In this include muscle weakness, wrist pain, valgus
manner, joint crepitus and loose fracture fragments elbow instability, heterotopic ossification,
can be identified. The forearm and wrist should be and arthritis. Displacement of fragments
evaluated both clinically and radiographically for more than 2 mm increases the risk of arthro-
possible radioulnar dissociation (i.e., the Essex- sis and is an indication for ORIF. Failure to
Lopresti lesion). Posteroanterior radiographs in achieve functional ROM after administration
neutral forearm rotation of both wrists should be of a local anesthetic block is an indication
used to assess ulnar variance and possible distal for operative treatment as well. Impacted
radioulnar joint widening. radial neck fractures are generally stable and
A. Classification and Treatment (Table 21-1)— amenable to treatment with early motion. Angu-
Mason classified these injuries according to lated fractures of the radial neck with an intact
the degree of displacement or comminution of radial head are more frequently encountered in
the radial head. Type I fractures are nondis- children but when encountered in adults, may
placed and may not be seen on radiographs. require operative treatment, especially if angu-
A posterior fat-pad sign is pathologic and lated more than 30°. For comminution leading
should warrant further radiographs, includ- to shortening or displacement, fixation with ap-
ing a radial head-capitellar view. Mason Type propriate hardware is advisable.
II fractures involve less than 30% of the articular Radial head fractures associated with elbow
surface but have more than 2 mm of fracture dis- dislocation (10% of all radial head fractures)
placement. Mason Type III fractures involve com- are more difficult to treat. Excision after dis-
minution of the entire radial head. Controversy location has been associated with high rates
FIGURE 21-6 Mason
classification of
radial head fractures.
(Type IV [radial head
fracture with an elbow
dislocation] fracture is
not shown.)
of degenerative arthrosis and recurrent dislo- soft tissue restraints to the humeral epicondyle
cation. Inadequate restoration of radial length (with suture through bone tunnels or suture an-
(with either ORIF or replacement) alters the chors). If instability is demonstrated, repair of
tension of the healing soft tissues. The res- the MCL and the medial soft tissues should fol-
toration and maintenance of appropriate ra- low. An external fixator is rarely required, but
dial length may be more difficult in cases of should be used if the elbow remains unstable
interosseous membrane/ligament disruption after repair or reconstruction of the medial soft
(Essex-Lopresti lesion). More than 1 cm of tissues.
shortening of the radial shaft indicates dis-
ruption of the interosseous membrane. Open VIII. Complications of Elbow Injuries
treatment with internal fixation or prosthetic A. Neurovascular Injury—Isolated or combined
replacement with a metallic implant in this set- injuries to the median, ulnar, radial, and poste-
ting is critical to avoid the late sequelae of the rior and anterior interosseous nerves, and the
Essex-Lopresti lesion. brachial artery may occur as a result of the ini-
Approaches to the radial head include the tial trauma or very infrequently, may have an
Kocher (between the anconeus and the exten- iatrogenic origin. The PIN is located adjacent
sor carpi ulnaris), the Kaplan (between the ex- to the radial neck, placing it at risk for a
tensor carpi radialis brevis and the extensor traction injury with dislocation of the proxi-
digitorum communis, with pronation to protect mal radius, as seen with Monteggia injuries.
the PIN), and the Pankovich (between the ulna The PIN is also the most at risk from iatrogenic
and the supinator, from posterior). injury, specifically during plating of radial neck
When the radial neck is intact, headless self- fractures. Ulnar neuropathy is commonly seen
compressing screws can secure radial head after elbow trauma. Acutely, the ulnar nerve is
fragments to the remaining head and neck at risk for traction neuropathy or from shards
while being countersunk below the articular of bone. Late compressive neuropathy oc-
cartilage. In cases of radial neck comminution, curs within the cubital tunnel as the scar tis-
mini-fragment plates can be placed more eas- sue matures. Controversy still exists regarding
ily through the Kaplan approach. The point di- prophylactic ulnar nerve transposition during
rectly opposite the radial notch when the radius open reduction and internal fixation of distal
is halfway between maximal pronation and su- humerus fractures. The nerve should be trans-
pination indicates the center of the “safe zone” posed subcutaneously if any hardware places
for the placement of plates. Articular fragments it at risk.
should be supported with bone graft as neces- As in other musculoskeletal injuries, the
sary. AVN and nonunion may complicate highly likelihood of neurovascular insult is tied to the
comminuted fractures. Fixation of the radial mechanism of injury and the amount of energy
head should be adequate enough to allow for imparted to the tissues. The ulnar, radial, and
a period of ligamentous healing. Excision of the posterior interosseous nerves usually sustain
radial head in the case of nonunion or AVN may neurapraxic and occasionally axonotmetic
be safely performed after the ligamentous integ- injuries as a result of direct blunt trauma or
rity of the elbow is restored. In cases of elbow the cavitary effects of low-velocity gun shot
dislocation and an unreconstructable radial wounds. Although the median and anterior in-
head, excision of the radial head followed by terosseous nerves also commonly sustain such
prosthetic replacement is appropriate. Silas- injuries, these two nerves along with the bra-
tic replacement does not restore valgus stability chial artery and its branches are more suscep-
but yields better short-term results than simple tible to macroscopic injury as a result of their
excision. However, silastic implants have anterior midline location. The shards of bone
been associated with synovitis and wear dispersed from the distal humerus and proxi-
debris, and are rarely indicated. Metallic im- mal ulna in higher-energy injuries can impale
plants restore more stability to valgus and have these structures, especially in posterior frac-
been shown to improve results, with more re- ture-dislocations and Monteggia lesions. Since
cent designs better recapitulating native radial these latter fractures usually require operative
head and neck anatomy. treatment, this allows for intraoperative inspec-
Intraoperative stability of the elbow should tion and surgical repair as indicated. Other spe-
be demonstrated after radial head ORIF or cifics of neurovascular injuries are discussed in
replacement and repair of the LCL, and lateral the sections on the specific fractures.
B. Posttraumatic Stiffness—Loss of motion is standard, late excision. Serum alkaline phos-

a common sequela of elbow injuries. Simple phatase levels, total serum protein levels,
elbow dislocations frequently result in loss of and bone scans are less accurate and do not
the terminal 15° of extension. Loss of motion need to be monitored. Surgical excision is
is more common after complex elbow disloca- reserved for cases of functional impairment.
tions (i.e., those with associated fractures). Ex-
tension seldom improves more than 6 months IX. Summary—Elbow fractures and dislocations occur
after injury. Arthrofibrosis, particularly involv- in the context of a unique articulation with complex
ing the anterior joint capsule, is frequent unless biomechanics. A full understanding of the osseous
early motion is instituted. and ligamentous anatomy of the elbow is neces-
If 6 months have passed since the injury or sary for effectively evaluating and treating elbow
motion gains have reached a plateau, and the trauma. More recent efforts at anatomic reduction
elbow lacks extension beyond 35° or flexion and stable internal fixation of fractures with repair
beyond 100°, then operative release should be of soft-tissue stabilizers are proving superior to non-
considered. Good results have been reported operative or limited surgical techniques. Residual
with open (i.e., medial, lateral, or combined ap- elbow stiffness is a frequent sequela to these inju-
proaches) and arthroscopic releases. In cases ries regardless of treatment and often must be ad-
of stiffness after minimal trauma (e.g., isolated dressed with additional surgical procedures.
radial head fractures), arthroscopic release af-
fords good results. The MCL and LCL should be
preserved during open release. Symptomatic SUGGESTED READINGS
instability has been reported after lateral re-
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Restoration of osseous anatomic structures in J Bone Joint Surg Am. 1997;79:826–832.
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operatively and nonoperatively. Increasing se- graphic comparison of tension-band wiring and plate fixa-
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cation, forced passive motion, central nervous damage. Acta Orthop Scand. 1975;46:601–609.
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weeks of treatment, and burns all have been as- simple dislocation of the elbow. J Bone Joint Surg Am.
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ossification. Early motion, nonsteroidal anti- gia lesion. Trauma. 1991;5:395–402.
inflammatory agents (efficacy documented in King GJ, Lammens PN, Milne AD, et al. Plate fixation of commi-
the hip but not the elbow), and postoperative nuted olecranon fractures: an in vitro biomechanical study.
radiation (up to 1,000 cGy but with an increased J Shoulder Elbow Surg. 1996;5:437–441.
risk of radiation-associated neuritis at the elbow Macko D, Szabo RM. Complications of tension-band wiring of
olecranon fractures. J Bone Joint Surg Am. 1985;67:1396–1401.
as a result of the subcutaneous position of the McKee MD, Jupiter JB, Bamberger HB. Coronal shear frac-
nerves) decrease the incidence of heterotopic tures of the distal end of the humerus. J Bone Joint Surg Am.
ossification. Radiographic maturation of 1996;78:48–54.
heterotopic bone (cortical and trabecular Moor TJ. Functional outcome following surgical excision of
patterns) is the best predictor of an accept- heterotopic ossification in patients with traumatic brain
injury. J Orthop Trauma. 1993;7:11–14.
able risk of recurrence after excision in the O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation
absence of risk factors. Early excision yields and dislocation: a spectrum of instability. Clin Orthop.
satisfactory results compared with the more 1992;280:186–197.
Peters CL, Scott SM. Compartment syndrome in the forearm Maeda H, Yoshida K, Doi R, et al. Combined Monteggia and
following fractures of the radial head or neck in children. Galeazzi fractures in a child: a case report and review of the
J Bone Joint Surg Am. 1995;77:1070–1074. literature. J Orthop Trauma. 2003;17(2):128–131.
Stein F, Grabias SL, Deffer PA. Nerve injuries complicating Mehdian H, McKee M. Management of proximal and distal
Monteggia lesions. J Bone Joint Surg Am. 1971;53:1432–1436. humerus fractures. Orthop Clin North Am. 2000;31:115–127.
Moushine E, Akiki A, Castagna A, et al. Transolecranon
anterior fracture dislocation. J Shoulder Elbow Surg.
Recent Articles 2007;16(3):352–357.
Agarwal A. Type IV Monteggia fracture in a child. Can J Surg. Nalbantoglu U, Kocaoglu B, Gereli A, et al. Open reduction and
2008;51(2):E44–E45. internal fixation of Mason type III radial head fractures with
Bae DS, Kadiyala RK, Waters PM. Acute compartment syn- and without an associated elbow dislocation. J Hand Surg
drome in children: contemporary diagnosis, treatment and Am. 2007;32(10):1560–1568.
outcome. J Pediatr Orthop. 2001;21:680–688. Obremskey WT, Bhandari M, Dirschl DR, et al. Internal fixation
Chalidis B, Papadopoulos P, Sachinis N, et al. One-stage versus arthroplasty of comminuted fractures of the distal
shoulder and elbow arthroplasty after ipsilateral fractures humerus. J Orthop Trauma. 2003;17:463–465.
of the proximal and distal humerus. J. Orthop Trauma. Papandrea RF, Morrey BF, O’Driscoll SW. Reconstruction for
2008;22(4):282–285. persistent instability of the elbow after coronoid fracture-
Clare DJ, Corley FG, Wirth MA. Ipsilateral combination Monteg- dislocation. J Shoulder Elbow Surg. 2007;16(1):68–77.
gia and Galeazzi injuries in an adult patient: a case report. Pugh DM, Wild LM, Schemitsch EH, et al. Standard sur-
J Orthop Trauma. 2002;16(2):130–134. gical protocol to treat elbow dislocations with radial
Deuel CR, Wolinsky P, Shepherd E, et al. The use of hinged exter- head and coronoid fractures. J Bone Joint Surg Am.
nal fixation to provide additional stabilization for fractures 2004;86:1122–1130.
of the distal humerus. J Orthop Trauma. 2007;21(5):323–329. Ring D, Hannouche D, Jupiter JB. Surgical treatment of per-
Doornberg JN, de Jong IM, Lindenhovius AL, et al. The antero- sistent dislocation or subluxation of the ulnohumeral joint
medial facet of the coronoid process of the ulna. J Shoulder after fracture-dislocation of the elbow. J Hand Surg [Am].
Elbow Surg. 2007;16(5):667–670. 2004;29(3):470–480.
Duckworth AD, Kulijdian A, McKee MD, et al. Residual sublux- Ring D, Jupiter J, Gulotta L. Articular fractures of the distal
ation of the elbow after dislocation or fracture-dislocation: part of the humerus. J Bone Joint Surg Am. 2003;85:232–238.
treatment with active elbow exercises and avoidance of Ring D, Jupiter JB, Sanders RW, et al. Transolecranon
varus stress. J Shoulder Elbow Surg. 2008;17(2):276–280. fracture-dislocation of the elbow. J Orthop Trauma.
Duckworth AD, Ring D, Kulijdian A, et al. Unstable elbow dislo- 1997;11:545–550.
cations. J Shoulder Elbow Surg. 2008;17(2):281–286. Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults.
Dunning CE, Zarzour ZD, Patterson SD, et al. Muscle forces and J Bone Joint Surg Am. 1998;80:1733–1744.
pronation stabilize the lateral ligament deficient elbow. Clin Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the
Orthop. 2001;388:118–124. elbow with fractures of the radial head and coronoid. J Bone
Egol KA, Immerman I, Paksima N, et al. Fracture-dislocation Joint Surg Am. 2002;84-A(4):547–551.
of the elbow functional outcome following treatment Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone
with a standardized protocol. Bull NYU Hosp Jt Dis. Joint Surg Am. 1998;80:566–580.
2007;65(4):263–270. Ring D, Quintero J, Jupiter JB. Open reduction and internal
Esser RD, Davis S, Taavao T. Fractures of the radial head fixation of fractures of the radial head. J Bone Joint Surg Am.
treated by internal fixation: late results in 26 cases. J Orthop 2002;84:1811–1815.
Trauma. 9:318–323. Ring D, Tavakolian J, Kloen P, et al. Loss of alignment af-
Forthman C, Henket M, Ring DC. Elbow dislocation with intra- ter surgical treatment of posterior Monteggia fractures:
articular fracture: the results of operative treatment with- salvage with dorsal contoured plating. J Hand Surg Am.
out repair of the medial collateral ligament. J Hand Surg Am. 2004;29(4):694–702.
2007;32(8):1200–1209. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process
Frankle MA, Herscovici D Jr, DiPasquale TG, et al. A compari- and radial head as posterolateral rotatory stabilizers of the
son of open reduction and internal fixation and primary elbow. J Bone Joint Surg [Am]. 2004:86-A(5):975–982.
total elbow arthroplasty in the treatment of intra-articular Strauss EJ, Tejwani NC, Preston CF, et al. The posterior Mon-
distal humerus fractures in women older than 65. J Orthop teggia lesion with associated ulnohumeral instability. J Bone
Trauma. 2003;17:473–480. Joint Surg Br. 2006;88(1):84–89.
Furry KL, Clinkscales CM. Comminuted fractures of the radial Van Riet RP, Morrey BF. Documentation of associated injuries
head: arthroplasty versus internal fixation. Clin Orthop. occurring with radial head fracture. Clin Orthop Relat Res.
1998;353:40–52. 2008;466(1):130–134.
Judet T, Marmorat JL, Mullins MM. Effective treatment of frac- Villanueva P, Osorio F, Commessatti M, et al. Tension-band
ture-dislocations of the olecranon requires a stable troch- wiring for olecranon fractures: analysis of risk factors for
lear notch. Clin Orthop Relat Res. 2005;(435):276–277. failure. J Shoulder Elbow Surg. 2006;15(3):351–356.
Kälicke T, Muhr G, Franger TM. Dislocation of the elbow with
fractures of the coronoid process and radial head. Arch Or-
thop Trauma Surg. 2007;127(10):925–931. Review Articles
Konrad GG, Kundel K, Kreuz PC, et al. Monteggia fractures in Boyer MI, Galatz LM, Borelli J Jr, et al. Intra-articular fractures
adults: long-term results and prognostic factors. J Bone Joint of the upper extremity: new concepts in surgical manage-
Surg Br. 2007;89(3):354–360. ment. Instr Course Lect. 2003;52:591–605.
Lindenhovius AL, Felsch Q, Doornberg JN, et al. Open reduc- Cohen MS, Hastings H 2nd. Acute elbow dislocations: evalua-
tion and internal fixation compared with excision for unsta- tion and management. J Am Acad Orthop Surg. 1998;6:15–23.
ble displaced fractures of the radial head. J Hand Surg Am. Hotchkiss RN. Displaced fractures of the radial head: Internal
2007;32(5):630–636. fixation or excision? J Am Acad Orthop Surg. 1997;5:1–10.
Textbooks Kellam JF, Fischer TJ, Tornetta P 3rd, et al, eds. Orthopedic
Knowledge Update: Trauma 2. Rosemont, IL: American
Jupiter JB, Kellam JF. Diaphyseal fractures of the forearm.
Academy of Orthopaedic Surgeons; 2000.
In: Broward B, Jupiter J, Levine A, et al, eds. Skeletal
Morrey BF. Radial head fracture. In: Morrey BF, ed. The elbow
Trauma. 2nd ed. Philadelphia, PA: WB Saunders;
and Its Disorders. 3rd ed. Philadelphia, PA: WB Saunders; 2000.
1992:1421–1454.
CHAPTER 22
Forearm Injuries
Lisa K. Cannada
I. Forearm fractures are a common injury often occur- of grip strength and forearm motion correlates

ring from a fall or a direct blow. Twenty six percent of with restoration of the normal radial bow.
fractures involving both bones of the forearm occur 2. Ulna

in children younger than 15 years of age. B. Interosseous Membrane—The interosseous mem-

The treatment for these injuries depends on a brane is between the two bones and is very im-

number of factors. These include the patient’s age, portant in assisting with forearm function as well.
bone quality, physiologic health, specific injury pat- The interosseous membrane is of key importance
tern, associated injuries, and physical demands. There for forearm stability. The interosseous membrane
are four main types of forearm fractures: (a) an iso- can be considered as proximal, middle, and distal
lated fracture of the radius or ulna, (b) fracture of the thirds with the middle third being the strongest
radius with a distal radial ulnar joint (DRUJ) disloca- and most significant contributor to longitudinal
tion (Galeazzi fracture), (c) fracture of the ulna with a stability of the forearm.
radial head dislocation (Monteggia fracture), and (d) a C. Muscles

both bone forearm fracture of the radius and ulna. The 1. Volar

treatment of most fractures of the forearm, except • The mobile wad consists of the brachioradia-

some isolated ulnar shaft fractures, is operative. lis, the extensor carpi radialis longus (ECRL)
and the extensor carpi radialis brevis (ECRB)
II. Anatomy—The forearm is complex with two mobile The radial nerve provides innervation.

parallel bones, which essentially function as a joint • The flexor pronator group is arranged in

with a proximal and distal radioulnar joint (DRUJ). three layers. The median and ulnar nerves
There are several muscles that originate in the fore- provide innervation.
arm and insert on the hand and provide hand func- (a) The superficial layer—The superficial

tion. Thus, it is of paramount importance following layer has four muscles arising from the
a forearm fractures to restore rotation of the fore- medial humeral epicondyle spanning out
arm, range of motion of the wrist and elbow, and grip across the forearm. It is easy to remem-
strength. ber these in their orientation if you place
A. Bones your hand at the medial epicondyle with

1. Radius—Proximally the radius has a radial the palm on the anterior surface of the

notch for articulation with the ulna, and distally forearm. The thumb represents a pro-
there is a notch for articulation as well. There nator teres. The index finger represents
is a tuberosity in the proximal portion of the the flex carpi radialis, the middle finger
radius for insertion of the biceps. The radius represents the palmaris longus (which is
has a bow, which must be restored during frac- absent in approximately 10% of the popu-
ture treatment. Every 5° loss of radial bow relation), and the ring finger represents the
sults in a 15° loss of pronation and supination. flexor carpi ulnaris.
After open reduction internal fixation (ORIF) (b) The middle layer is the flexor digitorum

of a both bone forearm fracture, the recovery superficialis.
314
C H A P T E R 2 2 | F O R E A R M I N J U R I E S 315
(c) The deep layer is the flexor digitorum between the two heads of the supinator and

profundus, flexor pollicus longus, and emerges distally over the origin of the abduc-
pronator quadratus. tor pollicis longus lying along the interosse-

2. Dorsal ous membrane. In 25% of patients, the PIN is

• Superficial—The superficial extensor mus- directly on bone near the biceps tuberosity.

cles fan out from the lateral epicondyle of the (a) To protect the nerve, do not place retrac-

humerus. From the ulnar side to the radial tors on the posterior surface of the proxi-
side, they are the: mal radius.
(a) anconeus (b) With proximal exposure of the fore-

(b) extensor carpi ulnaris arm, supinate the forearm to protect

(c) extensor digiti minimi the nerve.

(d) extensor digitorum communis 2. Median nerve—The median nerve enters the

• Deep forearm and antecubital fossa region and splits
(a) The abductor pollicis longus, extensor the pronator teres running between the flexor

pollicis longus and extensor pollicis bre- digitorum superficialis and the flexor digitorum
vis provide motor function to the thumb profundus.
and cross the forearm from the ulnar to 3. Ulnar nerve—The ulnar nerve travels under the

the radial side in an oblique manner. flexor carpi ulnaris and lies on the flexor digito-
(b) The remaining deep muscles are the su- rum profundus in the forearm. The ulnar artery

pinator and the extensor indicis. lies on the radial side of the nerve.
D. Nerves E. Arteries—The radial and ulnar arteries are

1. Radial nerve branches of the brachial artery.

• The radial nerve has a superficial sensory 1. Radial artery—Proximally, the radial artery lies

branch along the lateral aspect of the fore- just medial to the biceps tendon and angles
arm. It runs under the brachioradialis muscle. across the arm lying on the supinator, the prona-
• The anterior branch of the radial nerve sup- tor teres and the origin of the flexor pollicis lon-

plies the mobile wad muscles (brachioradialis, gus. The radial artery is palpable on the distal

ECRL, ECRB). anterior radius.
• The deep branch is the posterior interosse- 2. Ulnar artery—The ulnar artery runs between

ous nerve (PIN) (Fig. 22-1). The PIN passes the flexor digitorum profundus and superficialis;
Biceps FIGURE 22-1 Course of the

Median nerve posterior interosseous nerve
Brachialis in the proximal forearm.
Brachioradialis
Radial nerve
Superficial branch
of radial nerve
Posterior interosseous
nerve
Arcade of Frohse
Extensor carpi radialis
Supinator
Pronator teres
Flexor carpi ulnaris
distally, it runs between the flexor carpi ulnaris B. Ulnar Shaft Fractures—Isolated ulna fractures

and the flexor digitorum superficialis. often occur as the result of an altercation with
the ulna broken when the forearm is used in self-
III. Surgical Approaches
defense. These injuries are therefore commonly
A. Volar (Henry) Approach—This extensile approach
known as a nightstick fracture.

uses an internervous plane between the radial
1. The recommended treatment for an isolated
nerve and the median nerve. The muscular inter-

ulnar fracture that is stable is functional brac-
val is between the brachioradialis and the prona-
ing. The key here is that the central third of
tor teres/flexor carpal radialis.
the interosseous membrane remains intact.
B. Dorsal (Thompson) Approach—The internervous
2. Ulnar shaft fractures that are displaced with

plane is between the radial nerve and the PIN. The

more than 10° of angulation or more than 50%
dorsal approach of Thompson utilizes the inter-
fracture displacement require ORIF.
val between the extensor carpal radialis brevis
C. Both-Bone Forearm Fractures
and the extensor digitorum communis/extensor

1. Pediatric—Closed reduction and splinting fol-
pollicis longus.

lowed by casting is an acceptable treatment

C. Approach to the Ulna—The ulnar is approached
method in the pediatric population. In chil-

between the extensor carpi ulnaris and the flexor
dren younger than age 9, up to15° of angula-
carpi ulnaris right along the bone. The interner-
tion and 45° of malrotation is acceptable. In
vous plane is between the PIN and the ulnar nerve.
children older than age 9, up to 10° of angula-
D. Cross-Sectional Anatomy of the Forearm (Fig. 22-2).
tion and 30° of malrotation is acceptable. In

IV. Physical Evaluation—The patient with a forearm children with forearm fractures, there have

fracture often has obvious signs and symptoms of been case reports of scarring or tendinous
a fracture, with deformity and crepitus. The physi- entrapment. Close physical examination is
cal examination should include the elbow and wrist. the key to diagnosis.
Close evaluation of the soft tissue is necessary to 2. Adult—For the adult population, casting does

assess for any evidence of open fracture, soft-tissue not allow for maintenance of reduction and
injury, and injury of the median, radial, and ulnar thus is not an accepted form of treatment. The
nerves. It is also important to evaluate the patient treatment of choice for an adult both bone
for compartment syndrome (discussed later in this forearm fracture is ORIF with plate and screw
chapter). fixation. Currently there are several plate op-
tions available.
V. Radiographic Evaluation—Radiographic evaluation
• Compression plate with a Limited Contact

of the forearm includes an anteroposterior (AP) and

Dynamic Compression plate (LCDC)—LCDC
lateral view of the forearm as well as AP, lateral and
is recommended to be used for both the
oblique views of the elbow and wrist. If there is a
radius and ulna with at least six cortices
fracture of the radial head, a special radial head
purchased with screws on each side of the
radiographic view may be obtained as well. It is not
fracture.

necessary to include computer tomography and
• Locking plates represent a newer type of fix-
magnetic resonance imaging for routine forearm

ation. With the advent of locked plates, cer-
fractures. Magnetic resonance imaging may provide
tain indications have evolved—the main
further information regarding ligamentous disrup-
one being osteoporotic bone. If a combi-
tion and joint involvement.
nation plate is used, one may also achieve
VI. Specific Injury Patterns and Treatments compression across the fracture site. How-
A. Radial Shaft Fractures ever, there is not yet much data regarding

1. Nondisplaced radial shaft fractures—Nondis- clinical outcomes using this technique.

placed radial shaft fractures may be treated in a • One-third tubular plates and pelvic recon-

cast until the fractures is healed. Initially a long- struction plates fail and should not be used
arm cast is used until the fracture becomes for diaphyseal fractures in both bones of
“sticky” and then a short-arm cast may be used. the forearm.
2. Displaced radial shaft fractures—Displaced • Intramedullary fixation of forearm fractures

radial shaft fractures require ORIF and care- is not a standard treatment. It functions
ful assessment of the DRUJ. The treatment of as an internal splint only and requires ad-
DRUJ injuries is discussed in the section on ditional bracing or casting. Intramedullary
Galeazzi fractures. nailing may be of benefit in the treatment of
Brachial artery, vein

and median nerve Brachialis
Biceps tendon Pronator teres
Brachioradialis Palmaris longus
Flexor carpi
Radial nerve
radialis
Extensor carpi Flexor digitorum
radialis longus superficialis
Radial head Ulnar nerve
Flexor carpi
Extensor carpi ulnaris
radialis brevis Flexor digitorum Median nerve
Extensor digitorum Ulna profundus Pronator teres Palmaris longus
Anconeus
Flexor carpi radialis Flexor digitorum superficialis
Radial artery, vein Ulnar artery and vein
Superficial radial nerve Flexor carpi ulnaris
Brachioradialis Ulnar nerve
Flexor pollicis brevis Flexor digitorum
Radius profundus
Ulna
Extensor carpi
radialis longus and brevis Extensor carpi ulnaris
Posterior interosseus nerve Extensor
Supinator pollicis longus
Extensor
Radial head Median nerve Extensor digitorum digiti minimi
Brachial artery, vein
Pronator
Extensor carpi ulnaris teres Median nerve
Radial artery, vein Radial artery, vein Palmaris longus
Ulnar nerve Flexor digitorum superficialis
Brachioradialis
Posterior interosseus nerve Flexor pollicis longus
Ulnar nerve,
Ulnar artery Superficial radial nerve artery and vein
and vein Extensor digitorum
Superficial radial nerve Flexor pollicis brevis profundus
Radius Ulna
Extensor carpi ulnaris
Extensor carpi radialis longus
Extensor pollicis longus
Extensor carpi radialis brevis
Extensor digiti minimi
Extensor digitorum Extensor pollicis
Posterior
interosseus brevis
nerve
Median nerve Flexor digitorum

Flexor carpi radialis superficialis
Radial artery, vein Flexor digitorum
profundus
Superficial radial nerve
Ulnar nerve,
Radius artery and vein
Extensor pollicis brevis
Abductor pollicis
longus Pronator quadratus
Flexor digitorum superficialis Extensor pollicis Ulna
Median nerve Extensor carpi ulnaris
longus
Flexor digitorum
Flexor pollicis longus profundus Extensor Extensor indicis proprius
digitorum Posterior interosseus
Radial artery, vein Interosseus
Ulnar nerve, nerve
membrane
artery and vein
Superficial radial nerve Flexor carpi ulnaris
Ulna
Radius Posterior interosseus
Extensor pollicis longus nerve
Pronator quadratus Extensor digitorum
FIGURE 22-2 Cross-sectional anatomy of the forearm.

segmental fractures, pathologic fractures, the radius and ulna in the proximal one-
and comminuted fractures, especially due third of the forearm.
to a gunshot injury. Intramedullary fixation 2. Treatment—The standard of care is ORIF

is best used for fractures of the diaphysis of the ulna. With restoration of the ulnar
and should not be used for injuries near the anatomy, the radial head often reduces with
proximal or distal end of the bone. Intra- closed methods. If the radial head does not
medullary nail fixation is more commonly reduce through closed methods, then open
used in pediatric forearm fractures. reduction is indicated, as there may be soft-
• External fixation—The use of external fixa- tissue interposition. Associated injuries in-

tion for forearm fractures is generally not include up to 20% incidence of a PIN injury.
dicated. There is significant risk of injury to The correct technique for a comminuted
neurovascular structures in addition to pin proximal ulnar fracture is a posterior
site complications. External fixation should plate that acts as a tension band. The plate
typically be reserved for extremely unstable should not be applied medially, as it will not
patients or those with significant open con- resist the compressive forces.
taminated injuries. E. Galeazzi Fracture

• Other techniques—Various techniques 1. Description—A Galeazzi fracture is a radial

have been described regarding plate fixa- shaft fracture in conjunction with disruption
tion of the forearm and the standard treat- of the DRUJ. The fracture most commonly oc-
ments have been described above. Another curs in the distal third at the metaphyseal/

strategy that has gained popularity is the diaphyseal junction. Closed reduction is not
use of longer plates (such as those used an acceptable treatment option because of the
with a bridge plating technique) with fewer multiple muscle attachments and deforming

screws. Two recent studies support the use forces. The deforming forces include the pro-

of long plates with screws capturing only nator quadratus, brachioradialis, thumb ex-
four cortices on either side of the fracture tensors and the weight of the hand (gravity).
with two cortices being close to the fracture 2. Treatment—This fracture is also known as

on each end and two being further away a “fracture of necessity” because the injury
from the fracture. Long-term results of this necessitates ORIF with plate and screw fixa-
technique are pending. tion and reduction of the distal radialulnar
3. Bone grafting in both-bone forearm fractures— joint. It is very important to evaluate the

Bone graft is necessary only if there is no cor- DRUJ after plating of the radius. The joint of-
tical contact. Previously it was recommended ten is reduced in a supinated position where
that bone grafting be completed at the time of it should be casted for 6 weeks. A Muenster
fixation if comminution exceeded one third of cast is an excellent cast to be used for this
the bone’s diameter. However, there was a re- type of injury as it allows elbow flexion and
view of 319 diaphyseal forearm fractures with extension but discourages pronation and su-
variable comminution which were treated with pination. If the DRUJ cannot be maintained
open reduction and internal fixation without with closed methods, percutaneous reduc-
bone grafting (although significant comminution and pinning should be performed. The
tion was present in ,5% of the cases). Those most common reason for inability to ob-
fractures which had significant comminution tain a closed reduction is interposition
had a prolonged time to union but still man- of the extensor carpi ulnaris in the DRUJ.
aged to heal. The location of the radial shaft fracture may
D. Monteggia Fracture Dislocations give some clue as to whether the distal ra-

1. Classification—The classification system most dial joint is unstable. In a recent study, the

commonly used is the Bado classification which DRUJ was unstable in 55% of patients when
describes the direction of the dislocation of a radial shaft fracture occurred less than the
the radial head. This type of fracture does not 7.5 cm from the mid-articular surface of the
reduce with closed reduction techniques. radius. If the radial fracture was more than
• An anterior dislocation is a Type I 7.5 cm from the mid articular surface of the

• A posterior dislocation is a Type II radius, the DRUJ was unstable in only 6% of
• A lateral dislocation is a Type III patients.
• A Type IV injury involves anterior disloca- F. Floating Elbow/The Polytraumatized Patient—A

tion of the radial head with fracture of both floating elbow injury occurs if the radius or ulnar
or both are fractured along with the humerus; are the dorsal compartment and the mobile

ORIF is the treatment of choice. In the pediat- wad compartment.
ric population, there is a significant increased B. Infection—The surgical infection rate in forearm

risk of compartment syndrome with a floating fractures is generally low, anywhere from 0.8% to
elbow injury. 7%. With open fractures, the rate may increase
In the polytraumatized patient, operative up to 20%. The treatment is irrigation and de-

intervention should be considered early in or- bridement and intravenous antibiotics, which are
der to permit mobilization. culture specific. Whenever possible, hardware
should be retained until fracture healing occurs.
VII. Complications of Forearm Injuries C. Fracture Nonunion—The rate of nonunion of fore-

A. Compartment Syndrome arm fractures is 12% or more, depending upon

1. Overview—Compartment syndrome is a rare many factors. An increased risk of nonunion is

complication in patients with forearm frac- seen in open fracture, severely comminuted frac-
tures but should not to be missed. The inci- tures, segmental fractures, fractures with bone
dence is low, under 3%. However, there is a loss, cases of plate fixation mismatch, and those
higher incidence with proximal ulna fractures treated with an intramedullary nail. The most
caused by high-energy trauma. Compartment common treatment of a fracture nonunion of the
syndrome can also occur with gunshot forearm is autogenous bone graft. It is important
wounds to the forearm without fracture. that the bone graft be laid just about the non-
2. Etiology union site after it is taken down and not across

• High-energy comminuted fractures the interosseous membrane as that increases the

• Significantly displaced fractures risk of synostosis.

• Severe soft injuries D. Nerve Injuries—Nerve injuries are more related

• Crush injuries to the complications in the soft-tissue stresses

• Vascular injuries due to excessive swelling or iatrogenic due to

• Tight closure of the fascial compartments retraction of the soft tissues during surgical

after surgery exposure. Injury to the median nerve with a di-
• Prolonged tissue compression aphyseal fracture has been reported but is un-

• Casting which is too tight common. The most common risk during surgical

• Patient physiology (anti-coagulation exposure of the middle and distal thirds of the

medication) forearm is the superficial radial nerve. The PIN
2. Clinical Evaluation—A high index of suspicion is at risk during exposure of the proximal fore-

for compartment syndrome is warranted in arm. The clinical presentation of specific mus-
the patient with progressive forearm pain. cles lost in the various nerve injuries is shown in
The pain is characteristically out of propor- Table 22-1 and Figures 22-3 through 22-6.

tion to the patient’s injuries. The arm may E. Functional Outcome—Recovery of grip strength

be tense and swollen. Passive stretch of the and forearm motion following ORIF corre-
muscles in the involved compartment causes lates best with restoration of the radial bow
significant discomfort. The deepest muscles (long-term outcomes have not yet been well
are affected first and are abnormal earliest documented). McKee evaluated patients with
in the physical examination, thus the flexor both bone forearm fractures treated with open
digitorum profundus and flexor pollicis lon- reduction and internal fixation at an average of
gus are commonly affected first as they are 5.4 years following surgery; compared to the un-
the deepest muscles. The next muscles af- injured arm, the injured arms had approximately
fected are the flexor digitorum superficialis a 30% decrease in forearm pronation and supi-
and pronator teres. The patient may pres- nation. There was also a significant decrease in
ent with a compartment syndrome or it may wrist flexion (16%), wrist extension (37%) and
develop over time so close monitoring is grip strength (25%). These deficits were found
essential. despite the patients being several years out from
3. Treatment—The immediate treatment is urgent their injury.

fasciotomy. Most often, it is the volar compart- F. Synostosis—Synostosis is more common in pa-

ment in the forearm that develops compartment tients with head injuries, burns, genetic predispo-
syndrome. It is important to completely release sition to soft-tissue injury or if bone fragments or
the volar compartment including the carpal bone graft is in the area of the interosseous mem-
tunnel. The additional forearm compartments brane. The likelihood of radial-ulnar synostosis
TA B L E 2 2 - 1
Nerve Injuries
Injured Nerve Clinical Presentation Specific Muscle Lost
Radial nerve (see Fig. 22-3)
High Wrist-drop deformity EDC
EPL
APL
ECRB
ECRL
BR
Low Wrist-drop deformity EDC
EPL
APL
Ulnar nervea
High Ulnar clawhand deformity (intrinsic-minus Adductor pollicis
deformity) (see Fig. 22-4) Interossei
FDP (to the ring and small fingers)
FCU
Lumbricals (to the ring and small
fingers)
Low Severe ulnar clawhand deformity Adductor pollicis
Interossei
Lumbricals (to the ring and small
fingers)
Median nerve
High Ape-hand deformity (see Fig. 22-5) PT
FCR
FDP (to the index and long fingers)
FPL
APB
Lumbricals (to the index and long
fingers)
Low Thenar wasting (see Fig. 22-5) APB
Lumbricals (to the index and long
fingers)
aNote: A low-ulnar nerve injury paradoxically results in a worse deformity than a high-ulnar injury because in a low-ulnar nerve
injury, the FDP to the ring and small fingers retains innervation and results in an even worse clawing deformity. EDC, Extensor
digitorum communis; EPL, Extensor pollicis longus; APL, Abductor pollicis longus; ECRB, Extensor carpi radialis brevis; ECRL,

Extensor carpi radialis longus; BR, Brachioradialis; FDP, Flexor digitorum profundus; FCU, Flexor carpi ulnaris, PT, Pronator teres;
FCR, Flexor carpi radialis; FPL, Flexor pollicis longus; APB, Abductor pollicis brevis.
Source: From Brinker MR, Miller MD. Fundamentals of Orthopaedics. Philadelphia, PA: WB Saunders; 1999, with permission.
is increased with high-energy fractures with ex- synostosis within 4 months of injury and then
tensive comminution or when there is violation utilizing a protocol postoperatively including ra-
of the interosseous membrane with screws or the diation or Indomethacin. Occurrence of a forearm
surgical approach. This can lead to loss of prona- synostosis in the proximal one-third in general
tion and supination. Compared with heterotopic leads to more disability and less favorable results.
ossification around other joints, the treatment G. Refracture after Plate Removal—This may oc-

in the forearm is early excision. Excellent results cur with the use of large plates, removal of the
have been reported with resection of a forearm plate too early in the postoperative period and
Normal pinch
Abnormal pinch
of anterior interosseous
nerve syndrome
FIGURE 22-3 Wrist-drop deformity of a radial nerve

injury.
FIGURE 22-6 Deficit of the anterior interosseous nerve

is manifested by loss of active flexion of the index distal
interphalangeal and thumb interphalangeal joints, giving
a characteristic abnormal pinch.
decreased physical activities for 8 to 12 weeks

FIGURE 22-4 Clawhand (intrinsic-minus) deformity. following plate removal.

Loss of intrinsic muscle function (usually from ulnar
[and median] nerve injury) and overpull of the extrinsic
extensors on the metacarpophalangeal joints lead to
extension at the metacarpophalangeal joints and flexion
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CHAPTER 23
Fractures and Dislocations

of the Wrist
R. Jay French
I. Fractures of the Distal Radius combination with a distal radius fracture (see
A. Overview—Fractures of the distal radius are the later section on the DRUJ).
most common fractures of the upper extremity, • Biomechanics—The radius normally carries
representing 17% of all fractures treated each year. 80% of the axial load across the wrist. This
Although they are seen most frequently among percentage may change after fracture if there
older women (ages 60 to 70), young adults make is radial shortening or dorsal tilt of the radial
up a significant portion of cases. For those pa- articular surface. As fracture deformity in-
tients older than 60 years of age, almost 70% creases, greater loads are shifted to the
will have significant osteoporosis of the hip or ulnar side of the wrist. A dorsal tilt of 30°
spine. High-energy injuries resulting in complex results in 50% load transmission to the ulna.
fracture patterns have led to the development of • Wrist range of motion—Normal ranges of
newer treatment modalities. Residual articular motion of the wrist joint are as follows:
incongruity greater than 2 mm leads to post- dorsiflexion, up to 80°; palmar flexion, up
traumatic arthritis in most, if not all, patients. to 85°; radial deviation, up to 25°; ulnar de-
As a result, traditional methods of nonoperative viation, up to 35°; and pronation/supination,
treatment of high-energy injuries have been aban- up to 90°. These ranges often decrease after
doned in favor of surgical techniques that restore injury as a result of fracture deformity, pro-
articular anatomic structures. longed immobilization, or both.
B. Mechanism of Injury—Approximately 90% of all 2. Ligamentous anatomy—The extrinsic liga-
distal-radius fractures are caused by compres- ments of the wrist stabilize the carpus to the
sive loading on the dorsiflexed wrist. The degree distal radius and ulna. The intrinsic ligaments
of comminution is proportional to the energy of the wrist link the individual carpal bones and
transferred to the bone, with high-energy inju- are discussed later in this chapter.
ries causing more comminution and increas- • Volar ligaments—The volar extrinsic liga-
ingly complex fracture patterns. ments are stronger and clinically more
C. Anatomy important. They include the radioscapho-
1. Bony anatomy capitate (RSC), long radiolunate (LRL), short
• Distal radius—The distal radius is composed radiolunate (SRL), ulnolunate (UL), and ul-
of three concave articular surfaces: scaph- notriquetral (UT) ligaments (Fig. 23-2). The ra-
oid fossa, lunate fossa, and sigmoid notch dioscapholunate ligament (ligament of Testut)
(Fig. 23-1). is now believed to be a neurovascular pedicle
• Articulation between the distal radius and and does not provide ligamentous support.
the ulna—The articulation between the dis- • Dorsal ligaments—The dorsal extrinsic liga-
tal radius and the ulna occurs at the sigmoid ments are less well defined and include the
notch, forming the distal radioulnar joint dorsal radiocarpal (DRC) and dorsal intercar-
(DRUJ) and allowing forearm rotation. pal (DIC) ligaments (Fig. 23-3). Because they
• Triangular fibrocartilage complex (TFCC)— are less well defined, they are not very effec-
The TFCC has multiple attachments to the tive at restoring palmar tilt during fracture
ulna and carpus and may be injured in reduction (by ligamentotaxis).
323
A B
• Radial inclination—The normal range is 15°
to 30°; the average is 23° (posteroanterior
[PA] view).
• Radial length—The normal range is 11 to
12 mm; the average is 12 mm (PA view).
• Volar tilt—The normal range is up to 20°; the
average is 11° (lateral view).
D. Classification of Fractures
C D 1. Common eponyms—Although eponyms are im-
precise, they continue to be used by orthopae-
dists to describe distal radius fractures.
• Colles’ fracture (Colles, 1814)—Colles’ frac-
ture is typically extra-articular with dorsal
comminution, dorsal displacement, and ra-
dial shortening (Fig. 23-5).
• Smith’s fracture (Smith, 1847)—Smith’s frac-
ture is a “reverse Colles’ fracture” with volar
FIGURE 23-1 Distal radius. A. Dorsal view of Lister’s displacement. There are three types: Types I,
tubercle. B. Palmar view of the scaphoid and lunate II, and III (Fig. 23-6).
fossae distally as well as the sigmoid notch ulnarly.
• Barton’s fracture (Barton, 1838)—Bar-
Vascular foramina can be noted on the palmar and dorsal
ton’s fracture is an intra-articular fracture
aspects of the distal radius. C. End-on view of the distal
radius and radioulnar joint showing the scaphoid fossa, (a fracture-dislocation of the wrist). These
lunate fossa, and ulnar head resting in the sigmoid notch. fractures can be volar or dorsal and are
D. Sigmoid notch from the ulnar aspect. usually unstable (see Fig. 23-6). (A Smith
Type II fracture is the same as a volar Bar-
ton’s fracture.)
• Triangular fibrocartilage (TFC)—The TFC at- • Chauffeur’s fracture (Edwards, 1910)—A
taches to the carpus through the volar UT and Chauffeur’s fracture is an intra-articular frac-
UL ligaments (see Fig. 23-2). The TFC with its ture of the radial styloid. It may be associ-
accompanying attachments is called the TFCC. ated with disruption of the scapholunate
3. Radiographic measurements (Fig. 23-4)— ligament (Fig. 23-7).
Radiographic measurements are important in as- • Die-Punch (Lunate Load) fracture (Rutherford,
sessing fracture reduction and residual deformity. 1891; Scheck, 1962)—A die-punch fracture is
FIGURE 23-2 Volar extrinsic
ligaments of the wrist.
Triquetrum
Capitate
Ulnotriquetral
ligament
Radial collateral Exterior carpi Triangular

ligament ulnaris sheath fibrocartilage
Ulnolunate complex
Radiocapitate ligament
ligament
Radioscapholunate Triangular
ligament fibrocartilage
Radiotriquetral
ligament
C H A P T E R 2 3 | F R A C T U R E S A N D D I S L O C A T I O N S O F T H E W R I S T 325
Lateral
Radiotriquetral
ligament
Triangular Radioscaphoid
fibrocartilage ligament
complex
Anteroposterior
FIGURE 23-3 Dorsal extrinsic ligaments of the wrist.
FIGURE 23-5 Typical deformity seen in a Colles’
fracture, showing dorsal comminution and displacement
with shortening of the radius relative to the ulna.
Smith type I
23° 12mm
Smith type II/

volar Barton’s
Dorsal Barton’s
11°
FIGURE 23-4 Radiographic measurements important

Smith type III
in assessing fracture reduction and residual deformity:
radial inclination (shown here as a normal 23°), radial
length (shown here as a normal 12 mm), and volar tilt
(shown here as a normal 11°).
FIGURE 23-6 Thomas’ classification of Smith’s fractures.
Type I. extra-articular fracture with volar tilt and
an intra-articular depression fracture of the displacement of the distal fragment. Type II. intra-articular
fracture with volar and proximal displacement of the distal
lunate fossa of the distal radius (Fig. 23-7).
fragment along with the carpus (the same as a volar Barton’s
2. Modern classification systems—Modern clas-
fracture). A dorsal Barton’s fracture is illustrated for
sification systems are treatment-oriented and comparison, showing the dorsal and proximal displacement
more specific. of the carpus and distal fragment on the radial shaft. Type
• Frykman classification (1937)—Frykman III. extra-articular fracture with volar displacement of the
Types I to VIII are classified according to frac- distal fragment and carpus. (In Type III, the fracture line is
ture pattern (Fig. 23-8). more oblique than in Type I.)
Type I Type II
FIGURE 23-7 Left, Chauffeur’s fracture with the carpus
displaced ulnarly by the radial styloid fracture. Right,
Lunate load (die-punch) fracture with depression of the
lunate fossa of the radius that allows proximal migration
of the lunate and/or proximal carpal row.
• Melone’s classification (1984)—Melone’s

Types I to V are determined by the orienta-
tion of the four main intra-articular fragments
(Fig. 23-9). Type III Type IV
• AO/ASIF classification (1986)—The AO/ASIF
system is a comprehensive system of clas-
sification. Fractures are classified as one of
three possible types: A, extra-articular; B,
partial articular; and C, complete articular
(Fig. 23-10).
E. Evaluation
1. Plain radiographs—PA and lateral views are
standard and demonstrate most fractures. Ra-
diographic measurements can be made (see
previous section) to calculate initial displace-
ment and to assess reduction. Standard views Type V Type VI
also facilitate classification of fractures and
choice of treatment. Oblique views detect
occult carpal fractures (12% incidence),
whereas the PA ulnar-deviation view shows
the scaphoid more clearly. Facet lateral views
are taken with a 20° proximal tilt to give a better
view of the articular surface.
2. Special studies—Special studies are helpful
when complex fracture patterns must be as-
sessed or when associated soft-tissue injuries
are suspected.
• Computed tomography (CT)—The 1- to 2-mm Type VII Type VIII
sections in the sagittal plane are most effec-
FIGURE 23-8 Frykman classification of distal radius
tive in demonstrating articular depression
fractures. Types I, III, V, and VII do not have an associated
(die-punch) fractures. Axial views are best
fracture of the ulnar styloid. Fractures III through VII are
for evaluating the distal radioulnar joint intra-articular fractures. (Types III and IV involve the
and should include the opposite, uninjured radiocarpal joint, Types V and VI involve the radioulnar
wrist for comparison. Three-dimensional re- joint, and Types VII and VIII involve both the radiocarpal
constructions provide anatomic images and and the radioulnar joints.) Higher-classification fractures
can be useful in surgical planning. have a worse prognosis.
FIGURE 23-9 Melone’s
classification of subtypes of
2 four-part intra-articular fractures.
4 4
4
3 3
3 3
1
1 1
Type I Type IIA Type IIB
4
3 4
3
1 1
Type III Type IV Type V
• Magnetic resonance imaging (MRI)—MRI to scapholunate instability and if untreated,

should be reserved for suspected soft-tissue carpal collapse and posttraumatic arthritis.
injuries (TFCC or scapholunate ligament 5. Tendon injury—Acute tendon laceration is rare
tears). but may be seen in fractures with gross dis-
• Radionuclide bone imaging—Radionuclide placement. Attritional rupture of the exten-
bone imaging may have a role in the detec- sor pollicis longus (EPL) tendon may be a
tion of occult fractures or the evaluation of late sequela (see later section).
reflex sympathetic dystrophy (RSD) as a late 6. Arterial injury—A rare but serious complica-
complication. tion, arterial injury (radial or ulnar artery) re-
F. Associated Soft-Tissue Injuries—Associated soft- quires emergent evaluation and repair.
tissue injuries are common in high-energy fractures. 7. Compartment syndrome—Compartment syn-
1. Open fracture—Management should include drome is seen in approximately 1% of distal
emergent irrigation and debridement, ad- radius fractures. The cardinal signs of pain
ministration of intravenous antibiotics, and (with passive finger motion), paralysis, and
early fracture stabilization (external fixation). paresthesia should alert the treating physician
Wound coverage may require skin grafting or to this condition. Appropriate fasciotomy of
local flap. the involved compartments (volar forearm is
2. Median nerve injury—Median nerve injury, usu- the most common) is mandatory and most suc-
ally a neurapraxic injury, commonly improves cessful when performed early.
after fracture reduction. If there is no improve- G. Treatment
ment after 48 hours of observation, exploration 1. Principles
and carpal tunnel release are indicated. • Assessment of stability—The stability of
3. TFCC injury—TFCC injury has been docu- the fracture is the most important point
mented in up to 50% of cases of distal radius to consider when determining treatment.
fractures when there is an associated ulnar Hallmarks of an unstable fracture in-
styloid fracture. It often causes late ulnar- clude articular depression greater than
sided wrist pain. When the ulnar styloid frac- 2 mm, radial shortening greater than
ture occurs at the base and is displaced, DRUJ 5 mm, and dorsal tilt greater than 20°.
instability is likely present and should be Metaphyseal comminution involving both
treated. the volar and dorsal cortices is also in-
4. Carpal ligament injury—A complete tear of the dicative of an unstable fracture pattern.
scapholunate ligament (most common) can lead In general, a stable fracture can be treated
Type A1 Type A2 Type A3
Type B1 Type B2 Type B3
Type C1 Type C2 Type C3

FIGURE 23-10 AO/ASIF classification of distal radius fractures based on the ABC system. The subgroups are not
shown. Type A is an extra-articular metaphyseal fracture. The junction of the metaphysis and diaphysis is identified
by the “square” or “T” method (the greatest width on the frontal plane of the distal forearm; illustrated on A1). Type
A1 is an isolated fracture of the distal ulna. Type A2 is a simple distal radius fracture. Type A3 is a radius fracture
with metaphyseal impaction. Type B is an intra-articular rim fracture (preserving the continuity of the epiphysis and
metaphysis). Type B1 is a fracture of the radial styloid. Type B2 is a dorsal rim fracture (dorsal Barton’s). Type B3 is a
volar rim fracture (volar Barton’s is the same as a Smith Type II). Type C is a complex intra-articular fracture (disrupting
the continuity of the epiphysis and metaphysis). Type C1 is a metaphyeal fracture with radiocarpal joint congruity
preserved. Type C2 has articular displacement. Type C3 has diaphyseal–metaphyseal involvement. Injury of the distal
radioulnar joint is possible in any of these fractures.
by closed reduction and plaster immobiliza- and maintaining a near anatomic reduc-
tion, whereas an unstable fracture requires tion when treating distal radius fractures in
some form of internal or external fixation. younger patients. Guidelines for an accept-
Certain fracture patterns are known to able reduction are (in order of importance)
be unstable by nature, and as a result, articular step-off less than 2 mm, radial
should almost always be treated surgi- shortening less than 5 mm, and dorsal
cally. These include displaced articular tilt less than 10°. Failure to achieve and
margin fractures: Barton’s and Chauf- maintain an adequate reduction results in
feur’s fractures (AO Types B1 to B3). DRUJ predictable sequelae and potential long-term
stability also needs to be assessed on injury disability.
radiographs. Widening of the DRUJ or ulnar 2. Methods of reduction
styloid fracture displacement is indicative of • Closed reduction—Closed reduction relies
instability. on ligamentotaxis to restore alignment
• Assessment of reduction—Recent studies and correct fracture deformity. Traction/
have highlighted the importance of achieving countertraction is used and can be combined
with varying degrees of palmar flexion, ulnar under fluoroscopic control. Fixation is
deviation, and pronation of the distal frag- achieved with percutaneous K-wires
ment. Volar tilt cannot be reliably restored (oblique or transverse) and may be sup-
by longitudinal traction alone because of the plemented with bone graft.
nature of the radiocarpal ligaments (the vo- (b) Formal dorsal approach (through the
lar ligaments tighten first). Alternatively, third dorsal compartment and combined
palmar displacement of the carpus improves with a dorsal arthrotomy)—The formal
volar tilt by using the dorsal periosteal hinge dorsal approach is indicated for complex
(Fig. 23-11). However, this maneuver requires joint involvement requiring direct visual-
an intact volar cortical strut without commi- ization of the articular surface. Fixation
nution. Postreduction radiographs should be is achieved with either K-wires or a dor-
carefully inspected to identify any residual sal plate. Several low-profile plates have
articular step-off or fragment depression (die- been developed for this specific applica-
punch type). tion. Bone graft or bone graft substitute
• Open reduction—Open reduction is indicated is usually necessary to support the el-
when closed reduction has failed to achieve evated fragments. SL ligament injuries
an acceptable result. Articular depression can also be repaired using the dorsal
and die-punch fractures often require open approach.
reduction through a limited dorsal approach (c) Standard volar approach (the interval
and manual elevation of fragments. Other sur- is between the flexor carpi radialis
gical approaches are recommended for differ- tendon and the radial artery)—The
ent fracture patterns. standard volar approach is indicated
(a) Limited dorsal approach (proximal to for volarly displaced articular margin
Lister’s tubercle)—The limited dorsal (Barton’s) fractures. Fixation is usually
approach is indicated for a simple de- achieved with a T-plate. This approach
pressed fragment that can be elevated is now commonly used to fix dorsally
FIGURE 23-11 In a dorsally displaced

Traction distal radius fracture, reduction can
A be obtained by two distinct and
separate forms of ligamentotaxis.
A. The ligamentotaxis obtained by
forces of longitudinal traction restores
skeletal length, but the distal fragment
remains dorsally tilted. B and C. A
palmar translating force (applied by
the physician) attempts to sublux the
Force
midcarpal joint, creating a force that is
Traction
transmitted through the proximal carpal
B row via capsular ligaments to the distal
radial fragment, tilting its articular
surface palmarly.
Force
Traction
C
displaced fractures as well. Fixed angle have been recommended in different combi-
locking plates can be employed to sup- nations, depending on the fracture type and
port these fractures. amount of displacement. Regardless of the
(d) Extensile volar approach (the interval is specific choice, serial radiographs (at 1- to
between the ulnar artery and nerve and 2-week intervals) are necessary to check for
the carpal canal)—The extensile volar subsequent displacement. Fractures that
approach is indicated for treatment of displace in plaster are by definition unsta-
complex articular fractures involving the ble and should be treated by other means.
DRUJ and lunate fossa. This approach • Pins and plaster—Pins and plaster has be-
also allows for carpal tunnel release. come less popular with the advent of external
(e) Dorsal radial approach (the interval is fixation frames. Complication rates may be as
between the first and second dorsal com- high as 50%.
partments)—The dorsal radial approach • Percutaneous pin fixation—Percutaneous
is indicated for displaced radial styloid pin fixation is indicated for unstable extra-
fractures. Fixation is achieved with pins articular fractures after successful closed
or screws. reduction. Certain intra-articular fractures
(f) Combined volar and dorsal approach— may also be amenable to this treatment, partic-
The combined volar and dorsal approach ularly those without significant comminution.
is indicated only in the most severe high- Various techniques of pinning have been de-
energy fractures with both volar and scribed and are often combined with external
dorsal articular fragmentation. fixation. They include radial styloid pinning,
• Bone grafting—The use of bone graft or bone combination radial styloid and dorsal pinning
graft substitute is indicated when there has (usually crossed), and intrafocal (Kapandji)
been significant depression of the radial artic- pinning placed through the fracture site.
ular surface. After elevation of the fragments, • External fixation—Once the treatment of
bone graft is used to fill the metaphyseal de- choice for unstable, comminuted distal ra-
fect. This technique prevents late collapse dius fractures, external fixation has become
and may allow for earlier mobilization of less popular with the advent of locking fixed
the radiocarpal joint. Cancellous autograft angle plates. Newer external fixator designs
(iliac crest) has been used traditionally but allow for multiplanar fracture reduction, in-
may be replaced by allograft or graft substi- cluding palmar translation, which can be
tute in certain cases. Bone graft can be used used to restore volar tilt. External fixation
with either pin or plate fixation as long as frames are often combined with pin fixation
adequate bone stock is available for implant to improve fracture stability and reduce dis-
purchase. In addition to allograft cancellous traction forces across the carpus. Overdis-
chips (osteoconductive effect), new formula- traction may lead to finger stiffness and
tions are now marketed with demineralized delayed union, and should be avoided.
bone matrix (DBM) which may have osteoin- Depressed articular fractures usually re-
ductive properties. Graft substitutes are pro- quire limited open reduction, bone grafting,
duced from a variety of ceramics including and supplemental pin fixation in addition
calcium sulfate, calcium phosphate, hydroxy- to external fixation (Fig. 23-12). When this
apatite and silicone dioxide (bioactive glass). combination is used, the fixator frame may
More recent products have been produced be removed earlier (4 to 6 weeks vs. 6 to
using recombinant technology to create 8 weeks), reducing wrist stiffness. The open
bone morphogenic proteins (BMPs), which technique of fixator pin placement re-
have the ability to induce bone forming cells duces the incidence of eccentric drilling,
(osteogenic potential). pin loosening, and radial sensory nerve
3. Methods of stabilization—Stabilization tech- injury. Additional complications may include
niques can be used alone or in combination as pin tract infection, pin breakage, and com-
dictated by the fracture type. plex regional pain syndrome. Median nerve
• Plaster cast or splint—A plaster cast or compression can occur when the wrist is im-
splint is the traditional method of treating mobilized in extreme flexion (Cotton-Loder
nondisplaced and stable displaced frac- position), so the fixator should be locked
tures after closed reduction. Sugar tong in a neutral or slightly extended wrist po-
splints and long-arm and short-arm casts sition. In rare cases of combined volar and
FIGURE 23-12 A. Depressed fracture of

A the distal radius with a portion of the lunate
fossa of the radius dorsally and proximally
displaced. B. Treatment of the fracture with
application of an external fixation device,
carpal distraction, elevation of the depressed
fragment and fixation with two K-wires, and
cancellous bone grafting of the bony defect
left behind by elevation of the depressed
fracture fragment.
Cancellous
bone graft
dorsal articular involvement, the external Percutaneous pins or lag screws may be
fixator must be applied in combination with used for fracture fixation.
open reduction with internal fixation (ORIF) (b) Articular margin fractures (Barton’s, AO
of the articular fragments. The plate is usu- Types B2 and B3)—An AO T-plate is ap-
ally applied volarly (as a preliminary step) plied either volarly or dorsally depending
and is followed by dorsal fragment reduction on the direction of fracture displacement.
using ligamentotaxis. These fractures are inherently unsta-
• Internal fixation—ORIF has become more ble and require buttress plate fixation
popular since the development of volar across the oblique fracture line.
locking plates. These plates utilize fixed angle (c) Complex articular fractures (AO types
screws or pegs to support the intact subchon- C1 to C3)—Often, complex articular
dral bone of the distal radius. Even in cases fractures cannot be reduced by other
of severe comminution the locked screws means, necessitating ORIF. The surgi-
prevent collapse and hold the fragments out cal approach is dictated by fracture lo-
to length. The plate is usually applied to the cation. For volar articular fragments,
volar aspect of the bone where it is well tol- an extensile volar approach, followed
erated and tendon problems are minimized. by buttress plate fixation, is recom-
Elevation of depressed articular fragments mended. Of particular concern is the
and bone grafting can be performed through volar ulnar fragment of the distal radius,
the fracture site by pronating the proximal which may be difficult to reduce and fix
fragment. Use of these plates has allowed through a standard volar approach. Fail-
earlier wrist motion and produced better ure to stabilize this fragment may lead
results when compared to external fixation. to persistent volar collapse. This type
Although most distal radius fractures are of lunate facet fracture should be ap-
amendable to volar plating, certain fractures proached through an extended carpal
will still require a dorsal or radial approach. tunnel incision. Dorsal fragmentation
(a) Radial styloid fractures (Chauffeur’s, AO requires a formal arthrotomy and fixa-
Type B1)—When displaced, radial sty- tion with a low-profile plate specifically
loid fractures must be reduced anatomi- designed for this location. Dorsally ap-
cally through a dorsal radial approach. plied plates still carry a higher risk
of tenosynovitis than volar plates 3. Tendon problems—Tendon problems are rela-
and many (30% to 50%) will need to tively common after distal radius fracture and
be removed after fracture healing is include tendon adhesion, tendinitis (from a dor-
complete. These fractures are the most sal plate), and tendon rupture. The EPL tendon
challenging to treat and occasionally reis most often involved and may rupture as a
quire combinations of internal and ex- result of mechanical attrition within a narrowed
ternal fixation and combined volar and third dorsal compartment. The incidence of
dorsal approaches. tendon rupture is greater in nondisplaced
• Arthroscopic evaluation and treatment— fractures, suggesting that stripped perios-
Techniques of wrist arthroscopy have re- teum, as in the case of a displaced fracture,
cently been applied to the treatment of distal protects the EPL tendon. Direct repair of the
radius fractures. Indications have not fully EPL tendon is usually not possible; therefore,
evolved, but several points can be made. treatment involves extensor indicis proprius
Arthroscopy provides an excellent view of tendon transfer.
the distal radial articular surface; during 4. Complex regional pain syndrome (CRPS)—
reduction maneuvers, the joint surface can Also known as RSD, this condition has been
be visualized directly, avoiding residual ar- reported after distal radius fracture in varying
ticular step-off. Associated carpal ligament percentages (2% to 20%). Overdistraction by an
and TFCC tears can be easily identified and external fixator has been implicated in some
treated. Arthroscopic evaluation is not with- studies. Disabling pain, swelling, finger stiff-
out risk, which may include fluid extravasa- ness, and osteopenia may develop and require
tion and neurovascular injury. long-term treatment. Avoidance of this problem
• Treatment of ulnar styloid fractures— by aggressive hand therapy, edema control, and
Treatment of these associated fractures fixator removal (as early as possible) helps pre-
has traditionally received little attention. vent permanent sequelae. When present, CRPS
However, in cases of ulnar styloid base should be treated by a combination of therapy,
fractures, particularly if widely displaced, medications, and stellate ganglion blockade.
instability of the DRUJ will be present. In
I. Rehabilitation—Postfracture rehabilitation should
these cases, ORIF of the styloid fracture is
begin early, with finger range of motion exercises
recommended either by tension band wiring
starting as soon as the cast or fixator is applied. Over-
or by mini-screw fixation. Because of its at-
distraction of the fixator may limit tendon excursion
tachments to the ulnar styloid, fracture fixa-
and should be avoided. Similarly, a cast that impedes
tion will generally stabilize the TFCC.
finger motion may lead to permanent stiffness. After
H. Late Complications—For acute complications, see
cast or fixator removal, exercises may be advanced as
earlier section on associated soft-tissue injuries.
the patient tolerates. Removable splints are helpful in
1. Malunion—Extra-articular malunion usually
allowing intermittent wrist motion while still protect-
involves dorsal tilt and loss of radial length.
ing a healing fracture. Some patients may require a
These deformities in turn lead to ulnocarpal
more formal program supervised by an occupational
impingement, DRUJ incongruity, and mid-
or physical therapist. Plate fixation may improve
carpal instability. Chronic symptoms can
wrist function by allowing earlier range of motion.
include pain, weakness, and loss of motion.
Functional limitations can be disabling, espe- II. Fractures of the Carpal Bones
cially in younger patients. Corrective surgery A. Fractures of the Scaphoid
is indicated in these cases and involves ra- 1. Overview—Scaphoid fractures are the
dial opening wedge (triplanar) osteotomy most common carpal fracture and are typi-
with corticocancellous bone graft. Intra- cally seen in young men. Radial deviation and
articular malunion is even more serious, with wrist dorsiflexion greater than 90° may lead
an early onset of radiocarpal arthritis in 90% to scaphoid fracture during a fall on the out-
of wrists with more than 2 mm of articular stretched hand. Fractures of the scaphoid
step-off. Surgical treatment usually involves a waist are most frequent. Early evaluation and
salvage-type procedure such as arthrodesis or appropriate treatment are important in avoid-
arthroplasty. ing nonunion, avascular necrosis (AVN), and
2. Nonunion—Nonunion is a rare complication late carpal collapse.
that has occasionally been reported as a result 2. Anatomy—The proximal pole of the scaph-
of overdistraction by external fixation. oid is completely intra-articular (with no
capsular attachments) and receives all of 5. Treatment—Treatment is determined by loca-
its blood supply from distal (volar and dor- tion and degree of displacement.
sal) branches of the radial artery (Fig. 23-13). • Nondisplaced fractures—Nondisplaced frac-
Fractures of the proximal pole depend on in- tures are usually stable and can be treated
traosseous arterial flow and heal more slowly by closed methods. The use of a short-arm
than distal fractures. They also have a higher thumb spica cast is standard and usually
risk of nonunion and AVN. results in healing within 6 to 12 weeks.
3. Evaluation—“Snuffbox tenderness” is a clas- Proximal pole fractures heal more slowly
sic sign and should alert the physician to the (12 to 24 weeks). Long-arm cast immobi-
possibility of scaphoid fracture. The diagnosis lization (for the initial 6 weeks) has been
is confirmed radiographically with standard PA, recommended for proximal pole fractures
lateral, and oblique views of the wrist. A PA view and waist fractures with a vertical oblique
with ulnar deviation (scaphoid view) shows pattern.
the scaphoid in profile and should be ordered • Displaced fractures—Fractures with more
when the appearance of the initial radiographs than 1 mm of displacement or any angu-
is equivocal. Associated ligamentous injuries lation are considered unstable and re-
must be ruled out by careful radiographic as- quire operative treatment. ORIF is usually
sessment or arthrography. When no fracture is performed through a volar (Russe) approach
seen initially, the wrist should be splinted for between the flexor carpi radialis tendon and
1 to 2 weeks, and another X-ray study should the radial artery. The volar blood supply is
be performed after fracture resorption has oc- compromised in this approach, but is not
curred. Occult fractures may be detected in as crucial as the dorsal arterial branch,
this manner or through the use of bone isotope which feeds 80% of the scaphoid. Reduc-
scanning or MRI. CT scanning has proved tion of the fracture should be anatomic and
useful in the assessment of established fixation achieved with either K-wires or
nonunions with carpal collapse. screws. The Herbert screw is headless, mul-
4. Classification systems—Most systems high- tipitched (to provide fracture compression),
light the importance of fracture location in and well suited for this purpose. Newer ver-
regard to treatment and risk of late complica- sions include cannulated and tapered screw
tions. Waist fractures are most common (65%), designs. When rigid fixation is achieved, im-
followed by proximal pole (25%) and distal pole mediate range of motion is possible. If there
(10%) fractures. is significant comminution, however, K-wires
• Russe system—The Russe system divides may be indicated either with or without
scaphoid fractures into transverse, horizon- supplemental bone graft. When K-wires are
tal, oblique, and vertical oblique patterns. used, a short period of immobilization (2 to
Vertical oblique fractures are considered 3 weeks) is recommended.
unstable. • Special considerations—In cases of displaced
• Herbert system—The Herbert system is more proximal pole fractures, a dorsal approach is
comprehensive and also includes delayed required. This is carried out through the third
union and nonunion (Fig. 23-14). dorsal compartment using careful technique
Volar Dorsal
Dorsal carpal
branch of the
radial artery
Superficial
palmar branch
of the radial artery
Radial artery
FIGURE 23-13 Blood supply of the scaphoid.
A1 A2
Type A
Stable acute
fractures
Fracture of Incomplete fracture

tubercle through waist
B1 B2 B3 B4
Type B
Unstable acute
fractures
Distal oblique Complete fracture Proximal pole Transscaphoid-perilunate

fracture of waist fracture fracture-dislocation
of carpus
C D1 D2
Type C Type D
Delayed Established
union nonunion
Delayed union Fibrous union Pseudarthrosis
FIGURE 23-14 Classification system of Herbert for scaphoid fractures, delayed unions, and nonunions.
to preserve the dorsal arterial branches. Fixa- (a) Radiographic assessment—Thin-cut (1- to

tion is with K-wires or screws. 2-mm) CT scans show more detail than
6. Complications conventional tomograms (Fig. 23-15). Sag-
• Nonunion—The incidence of scaphoid non- ittal views are helpful in determining the
union for undisplaced fractures is approxi- degree of carpal collapse and “humpback
mately 5% to 10%. The incidence increases deformity” (Fig. 23-16).
to up to 90% for displaced proximal pole (b) Treatment
fractures. Other risk factors include initial • Bone grafting—Two types of bone
delay in diagnosis, inadequate immobiliza- grafting are indicated for the treatment
tion, and associated ligamentous instability. of a scaphoid nonunion: inlay and
Failure to heal after 6 months establishes the interpositional. For stable nonunions
diagnosis of nonunion. Recent studies have the inlay (Russe) technique is used to
indicated that virtually all unstable non- place corticocancellous struts across
unions lead to carpal collapse and posttrau- the fracture line. Usually, K-wires are
matic arthritis. For this reason, treatment is added to secure the construct. Healing
recommended for all scaphoid nonunions, rates of 85% to 90% have been reported
even if asymptomatic. with this method. Angulated nonunions
FIGURE 23-15 A. Lateral polytome showing an obvious fracture line across the waist of the scaphoid. B. CT scan
showing the scaphoid waist fracture, with angulation. (From Browner BD, Jupiter JB, Levine AM, et al, eds. Skeletal
Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, PA: WB Saunders; 1998, with permission.)
Lunate
Scaphoid
Capitate Radius
A B C D
FIGURE 23-16 Correction of dorsal intercalary segment instability and humpback deformity. A. Normal alignment.
B. Fractured humpback scaphoid with a dorsiflexed lunate. C. Opening wedge in the scaphoid showing placement of the
interpositional graft. D. Grafted scaphoid with correction of the instability and deformity.
with a dorsal humpback deformity styloidectomy and scaphoid interpo-

require interpositional grafting (see sition arthroplasty may be combined
Fig. 23-16). Fernandez has described with other procedures or performed
the use of a trapezoidal iliac crest graft independently in the younger pa-
to correct the angulation and carpal tient with less severe symptoms. Sili-
collapse pattern. Fixation is achieved cone implants have been used in the
with screws or K-wires. In both types of past but are now avoided because of
grafting procedures, a volar approach silicone synovitis. Newer techniques
is used, and care is taken to preserve include the use of collagen grafts (ten-
the vascularity of the fragments. don or fascia), allografts, or titanium
• Salvage procedures—Salvage proce- spacers.
dures are indicated when nonunion • Proximal pole excision—When a small
has led to carpal collapse and sec- proximal fragment is not amenable
ondary degenerative changes. Proxi- to bone grafting, proximal pole exci-
mal row carpectomy, intercarpal sion and fascial hemiarthroplasty are
arthrodesis, or radiocarpal arthrod- recommended.
esis is recommended in patients with • Electric stimulation—Pulsed electro-
chronic wrist pain and stiffness. Radial magnetic field stimulation has been
investigated as a noninvasive treat- images usually show a decreased signal

ment for scaphoid nonunion. Although corresponding to a loss of marrow ele-
controversial, there appears to be ments. Surgical biopsy with the absence
some benefit (shorter healing time) of punctate bleeding bone is the most de-
when electrical stimulation is com- finitive test for AVN.
bined with bone grafting procedures. (c) Treatment—When AVN occurs in a nondis-
• Malunion—Malunion of the scaphoid may oc- placed fracture or after operative fixation
cur when a displaced or angulated fracture is of a displaced fracture, revascularization
allowed to heal without anatomic reduction. can occur by creeping substitution. This
In most cases, there is apex dorsal angulation process is slow and may take longer than
resulting in a fixed humpback deformity. A 1 year to complete. In the majority of
dorsal intercalated segmental instability cases, AVN is associated with scaphoid
(DISI) pattern of carpal collapse ensues, re- nonunion. When AVN and nonunion occur
sulting in pain, loss of motion, and decreased together, the treatment is more difficult,
grip strength (see Fig. 23-16). Treatment in and the results less encouraging. Usually
a young patient includes osteotomy, volar bone grafting (inlay or interpositional) is
wedge bone graft, and internal fixation. Once combined with internal fixation. Healing
degenerative arthritis has begun, treatment is rates vary between 50% and 90% depend-
limited to a salvage procedure such as proxi- ing on the vascularity of the proximal frag-
mal row carpectomy, intercarpal arthrodesis, ment as evidenced by punctate bleeding.
or complete wrist fusion. Other treatments include vascularized
• Posttraumatic arthritis—As previously noted, bone grafting, proximal pole excision, and
articular degeneration can occur when the pulsed electromagnetic field stimulation.
normal carpal kinematics are disturbed. When vascularized bone grafting is used
Scaphoid nonunion and malunion result in for proximal pole AVN, a dorsal pedicle is
abnormal stress across the radiocarpal joint, elevated from the 1,2 intracompartmen-
leading to predictable patterns of carpal ar- tal supraretinacular artery (1,2 ICSRA).
thritis. Scaphoid nonunion advanced col- Volarly, a pedicle from the pronator qua-
lapse is analogous to scapholunate advanced dratus and underlying bone can be used
collapse (SLAC) and describes a pattern of for more distal AVN and nonunions. Sal-
posttraumatic arthritis (see section on car- vage procedures are again indicated once
pal dislocations and instability patterns). Sal- the degenerative process has progressed.
vage procedures are indicated for the painful • Carpal instability—Carpal instability may
wrist with scaphoid nonunion or advanced persist after scaphoid fracture as a result
collapse. of concurrent ligament disruption. Usually
• AVN this occurs as a result of a perilunate injury
(a) Incidence—The incidence of AVN of the (discussed later in this chapter). These inju-
scaphoid depends on the location of the ries need to be identified early and repaired
fracture, with those of the proximal one surgically.
fifth leading to osteonecrosis in 90% to B. Isolated Carpal Fractures (Excluding Scaphoid)—
100% of cases. Fractures of the scaphoid Fractures of the carpal bones are often associated
waist have an AVN incidence of 30% to 50%. with dislocation patterns referred to as greater
The reason for this phenomenon is that the arc injuries (Fig. 21-17). In these cases, the carpal
tenuous blood supply that enters the scaph- fracture represents an avulsion injury indicative
oid distally is disrupted during fracture (see of a more serious carpal dislocation. The treating
Fig. 23-13). The displacement of fragments physician must be aware of these injuries and sus-
more than 1 mm increases the chance of pect ligamentous involvement when an isolated
AVN by 50%. fracture is seen on radiographs. These combined
(b) Evaluation—The diagnosis of AVN can of- fracture-dislocations are discussed further in
ten be made with plain films when there the section on carpal dislocations and instability
is evidence of a relatively radiodense patterns.
proximal scaphoid fragment. MRI is the 1. Fractures of the lunate—Isolated fractures of
most sensitive and specific test and is the lunate are rare and must be distinguished
indicated when the appearance of ra- from Kienböck’s disease (see later section).
diographs is equivocal. T1-weighted MR Volar pole fractures are most common and
When symptomatic, the fragment should be

excised. Carpal tunnel views or a CT scan dem-
onstrates the acute fracture or nonunion. Frac-
tures of the hamate body are often associated
with dislocation of the fourth and fifth metacar-
pal bases. These injuries require open reduc-
tion and pinning of the fracture as well as the
involved carpometacarpal joints.
Greater arc 5. Fractures of the trapezium—Fractures of the
Lesser arc trapezial ridge are analogous to hook of hamate
fractures and are treated similarly (by exci-
sion) if they progress to nonunion. As in other
carpal fractures, displaced body fractures re-
quire ORIF, whereas nondisplaced fractures are
treated closed.
FIGURE 23-17 Johnson described the “vulnerable zone 6. Fractures of the trapezoid—Trapezoid frac-
of the carpus,” the shaded area of the carpus in which tures are rare as isolated injuries, but may oc-
most of his experimentally produced injuries occurred. cur with dislocation of the index metacarpal.
Greater arc injuries occurred through bone, and lesser Interpretation of routine radiographs is diffi-
arc injuries were purely ligamentous. Many possible cult, and tomography or CT scanning may be
combinations and variants of these “pure” injury patterns necessary to make the diagnosis. ORIF is indi-
can be seen clinically.
cated for fracture-dislocation of the metacarpal
base. Nondisplaced body fractures are treated
may require ORIF if displaced. Marginal chip nonoperatively.
fractures are treated nonoperatively. C. AVN of the Carpal Bones
2. Fractures of the triquetrum—Fractures of 1. Scaphoid—AVN of the scaphoid as a post-
the triquetrum most commonly occur as im- traumatic complication has been discussed
paction fractures of the proximal pole. Dur- previously. When osteonecrosis occurs with-
ing forced dorsiflexion and ulnar deviation, out apparent trauma, the diagnosis is Preiser’s
the ulnar styloid may shear off a small frag- disease. The etiology has been debated and may
ment termed a chisel. Chisel fractures may be include steroid use, microtrauma, or a connec-
treated closed, whereas displaced body frac- tive tissue disorder. Because of the rarity of this
tures require ORIF. condition, formal treatment guidelines are not
3. Fractures of the capitate—Capitate fractures available. In general, all conservative measures
may occur in combination with scaphoid frac- should be exhausted before aggressive bone
tures (scaphocapitate syndrome) during ex- grafting or scaphoid excision is contemplated.
treme dorsiflexion of the wrist. This represents a 2. Capitate—Displaced fractures of the capitate
serious injury in which the proximal pole of the can lead to AVN of the vulnerable proximal
capitate may rotate out of position by up to 180°. pole. This is analogous to AVN of the scaph-
Because the fragments remain colinear, the diag- oid. Treatment should be symptomatic unless
nosis is difficult and may be missed. Treatment degenerative changes progress and involve the
includes ORIF of both the scaphoid and capi- midcarpal joint. Scaphocapitate arthrodesis or
tate fractures. The complications of nonunion proximal pole excision has been recommended
and AVN may occur as a result of the disrupted when nonoperative treatment fails.
blood supply to the proximal capitate. 3. Lunate—Osteonecrosis of the lunate, or
4. Fractures of the hamate—Fractures of the ha- Kienböck’s disease, has been well described
mate can be divided into hook (hamular pro- in the orthopaedic literature. Theories of cau-
cess) fractures and body fractures. Hooks of sation vary and include both vascular and trau-
hamate fractures are caused by a direct blow matic etiologies. The current consensus is that
to the hand and are often seen in baseball play- microtrauma may lead to AVN in a susceptible
ers or golfers. The diagnosis may be missed lunate. Predisposing factors include negative
initially and may lead to chronic symptoms and ulnar variance of the wrist and a one-vessel
nonunion. Occasionally, these fractures may lunate vascular pattern. Negative ulnar vari-
affect the flexor tendons to the ring or small ance is thought to increase the load across
finger causing tendinitis or tendon rupture. the lunate. Negative ulnar variance is found in
only 23% of normal individuals but in almost B. General Concepts—The geometry of the seven
80% of those with Kienböck’s disease. The lu- carpal bones (excluding the pisiform, which is a
nate vascularity pattern has also been im- sesamoid) has been described in terms of theo-
plicated with a one-vessel lunate (20% of the retic models. Of the various concepts, the row
population) at a higher risk than a two-vessel theory has been most popular and best explains
lunate (80% of the population). carpal dynamics.
• Diagnosis—The diagnosis of Kienböck’s 1. Row theory—The row theory, the traditional
disease is made radiographically with the model of the wrist, divides the carpal bones
appearance of a sclerotic, fragmented, or col- into proximal and distal rows separated by the
lapsed lunate. The stages of the disease fol- midcarpal joint. The proximal row includes the
low a predictable pattern of degeneration and scaphoid, lunate, and triquetrum, each held
are summarized in Table 23-1. together by intrinsic interosseous ligaments.
• Treatment (see Table 23-1)—Initial treatment The distal row consists of the trapezium, trap-
is conservative, with splinting and rest help- ezoid, capitate, and hamate, also connected
ful in 50% of cases. Surgical intervention in by intrinsic ligaments. The midcarpal joint is
the early stages (I or II) involves joint-leveling spanned by the extrinsic ligaments and ac-
procedures such as ulnar lengthening or ra- counts for 50% to 60% of total wrist motion.
dial shortening. Stage III is defined by lunate Some motion occurs within the proximal row,
collapse and is treated with scaphotrapezial- but the distal row bones are relatively fixed.
trapezoid fusion, lunate excision arthroplasty, The scaphoid functions as a link between
or combined procedures. After degenerative the two rows, integrating motion and pro-
changes become extensive, stage IV treat- viding stability. No tendinous attachments
ment is limited to proximal row carpectomy occur on the bones of the proximal row. In-
or complete wrist fusion. stead distal forces act on the proximal row
as an intercalated segment. Their motions
III. Carpal Dislocations and Instability Patterns are guided by their unique bony anatomy and
A. Overview—The bony and ligamentous structures ligamentous support.
of the wrist together form a complex mechanism 2. Ligamentous anatomy—The ligaments of the
that allows for the transmission of force and a wrist are divided into intrinsic and extrinsic
stable range of motion. When injury occurs, the structures.
delicate balance can be altered, resulting in loss of • Intrinsic ligaments—The intrinsic liga-
function and instability. The successful treatment ments of the wrist run between adjacent
of carpal injuries requires an understanding of the carpal bones within the same row. The
intricate anatomy and kinematics of the wrist joint. most important of the intrinsic ligaments
are the scapholunate and lunotriquetral
interosseous ligaments. They are located
TA B L E 2 3 - 1 on either side of the lunate and hold it in
a balanced position. The scapholunate liga-
Stages of Kienböck’s Disease ment is stronger dorsally, and the lunotriqu-
Stage Radiography Treatment etral ligament is stronger volarly.
I Sclerosis Conservative/splinting
• Extrinsic ligaments—The extrinsic liga-
ments of the wrist span carpal bones in
II Fragmentation Joint leveling (radial short-
different rows and attach to the distal ra-
ening or ulnar lengthening)
dius and ulna. The volar extrinsic ligaments
III Collapse Controversial (most treat (see Fig. 23-2) are thicker and functionally
like stage II ± scaphocapi-
more important than the dorsal extrinsic
tate or triscaphe [STT] and
ligaments. These volar ligaments form a
capitohamate fusion)
double V pattern (apex distal) with a weak
IV Radiocarpal and Salvage (wrist fusion or area over the capitolunate joint known as
intercarpal DJD proximal row carpectomy)
the space of Poirier. The RSC (also called
STT, Scaphotrapezial-trapezoid; DJD, degenerative joint the radiocapitate) ligament spans both the
disease.
Source: From Bruce JF. In: Miller MD, ed. Review of
radiocarpal and the midcarpal joints and is
Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1996, an important stabilizer of the scaphoid. The
with permission. radioscapholunate ligament is mostly
a mesentery of vessels and has little
mechanical function. Dorsally, the extrin- 1. Dorsal and volar instability patterns
sic ligaments converge on the triquetrum in • DISI—DISI refers to a pattern in which the
a Z configuration (see Fig. 23-3). The most scaphoid and lunate become disconnected
important of these are the DRC ligament and or disassociated as the result of a scaphoid
the DIC ligament. fracture or a scapholunate ligament tear. Be-
3. Kinematics—Carpal movements are complex cause the lunate is separated from its scaph-
and occur in three planes at both the radio- oid attachment, it rotates dorsally under the
carpal and the midcarpal joints. A unique influence of the triquetrum (via the lunotri-
mechanism allows the proximal row to flex quetral ligament). Similarly, the scaphoid is
with radial deviation and extend with ulnar unsupported and rotates (collapses) into
deviation. This normally occurs in a synchro- flexion. This is also termed rotatory sub-
nous fashion but may be impaired in certain luxation of the scaphoid. Radiographically,
instability patterns (see later section). this pattern leads to an increased scaph-
C. Patterns of Injury—No single classification sys- olunate angle (60°) as measured on the
tem can easily describe all the various carpal in- lateral radiographic film (Fig. 23-19, A). The
juries. Specific patterns, however, are well known normal scapholunate angle ranges from
and can be used to guide treatment and predict 30° to 60° (average, 47°). In addition, the
outcomes. capitolunate angle (normal, up to 15°) and
1. Progressive perilunar disruption—Four stages radiolunate angle (normal, up to 15°) are
have been described as a mechanism for sequen- also increased. The PA view shows widen-
tial ligamentous failure: Stage I, scapholunate ing of the scapholunate interval (3 mm) or
ligament tear (scapholunate dissociation); evidence of a scaphoid fracture. Other find-
Stage II, capitolunate ligament tear; Stage III, lu- ings include the “cortical ring” sign of the
notriquetral ligament tear (perilunate disloca- scaphoid and a triangular appearance of the
tion); and Stage IV, dorsal radiolunate ligament lunate (Fig. 23-20). With time, the DISI pat-
tear (lunate dislocation). This system explains tern leads to proximal migration of the capi-
how lunate dislocation can occur as the result tate as it subluxes dorsally over the rotated
of a perilunate injury. lunate. This results in degenerative wear
2. Lesser arc and greater arc patterns and arthrosis. Eventually, SLAC occurs with
(see Fig. 23-17)—Perilunar injury can involve its progressive arthritic changes.
ligamentous failure, carpal fracture, or a com- • Volar intercalated segmental instability
bination of both. When an injury is purely liga- (VISI)—VISI is much rarer than DISI and
mentous, it is termed a lesser arc pattern. A less well understood. In the VISI pattern,
greater arc pattern, on the other hand, in- there is a disruption of the lunotriquetral
volves a carpal fracture. The most common of ligament and probably also a disruption of
these injuries is the transcaphoid perilunate the DRC ligaments. The net result is volar
fracture-dislocation. Various combinations flexion of the lunate and a volar shift of the
of these two patterns can exist simultaneously. carpus. Lateral radiographs demonstrate a
3. Axial disruption patterns—Axial or longitudi- decreased scapholunate angle (30°) as
nal injuries have recently been classified ac- well as increased capitolunate and radiolu-
cording to their lines of cleavage through the nate angles (Fig. 23-19, B).
carpus (Fig. 23-18). These rare injuries usually 2. Dissociative and nondissociative and complex
result from a blast or severe crush of the hand and adaptive instability patterns
and wrist. • Carpal instability dissociative (CID)—Carpal
D. Patterns of Instability—Instability patterns may instability dissociative refers to intrinsic liga-
develop after an injury (see previous section) ment disruptions that occur between carpal
or may be nontraumatic in etiology (such as in bones of the same row. Examples include
rheumatoid arthritis). Commonly, a carpal in- scapholunate ligament tears causing scaphol-
jury may occur and go unnoticed until it pro- unate dissociation and lunotriquetral ligament
gresses to a more severe and symptomatic form tears causing lunotriquetral dissociation.
of instability (such as a scapholunate ligament • Carpal instability nondissociative (CIND)—
tear progressing to advanced collapse). For Carpal instability nondissociative refers to
this reason, there is considerable overlap be- extrinsic ligament disruptions that occur be-
tween acute injury and chronic posttraumatic tween carpal rows. Midcarpal instability
instability. is an example in which there is disruption
Peritrapezoid Peritrapezium Transtrapezium

peritrapezium
Transhamate Perihamate Perihamate

peripisiform peripisiform transtriquetrum
FIGURE 23-18 The most common patterns of axial (longitudinal) carpal instability.
(or laxity) of the extrinsic ligaments that 3. Static and dynamic instability patterns—
connect the proximal and distal carpal rows. Recently, the terms static and dynamic have
Because the appearance on radiographs is been used to separate and classify instability
usually normal, the diagnosis must be made patterns.
by physical examination or by the use of • Static instability—Static instability patterns
fluoroscopy. are fixed and can be identified on plain ra-
• Carpal instability complex (CIC)—Carpal diographs. Examples include most DISI and
instability complex is a combination of both VISI patterns with their characteristic angu-
the dissociative and the nondissociative lar measurements (see previous section).
types and includes all types of perilunate • Dynamic instability—Dynamic instability re-
dislocations. fers to functional instability that is transient
• Carpal instability adaptive (CIA)—Carpal and intermittent. These abnormalities are not
instability adaptive refers to carpal instabil- present on routine radiographs but can be
ity that develops as an adaptive response identified with stress views (e.g., clenched-
to some prior malalignment. The most com- fist PA view showing dynamic scapholunate
mon example is midcarpal instability caused instability) or fluoroscopy (e.g., midcarpal
by the dorsal articular tilting of a malunited instability). The history and physical ex-
distal radius fracture. amination are also important in diagnosing
dynamic instability that may present as a

45°
painful “clunk” with radial and ulnar devia-
A 105° tion of the wrist.
E. Evaluation—As previously noted, carpal injuries
may be acute or chronic. In an acute situation,
there is associated swelling and deformity, and
the diagnosis may be obvious. Chronic injuries,
45°
however, may present with milder symptoms,
and the diagnosis may be missed. Although acute
27°
and chronic instabilities may have similar radio-
B 31°
graphic appearances, their treatment and progno-
sis are very different.
1. Acute injury—With an acute wrist injury, the
history and physical examination may be
48°
straightforward. The most common mecha-
nism is a fall on the dorsiflexed wrist with as-
sociated ulnar deviation. For these injuries, a
FIGURE 23-19 A. Dorsal intercalated segmental thorough examination is important to rule out
instability. The scapholunate angle is high (105°), the neurovascular compromise or compartment
capitolunate angle is high (45°), and the radiolunate angle
syndrome of the hand. Plain radiographs (PA,
is high (45°). The intercalated segment is represented by
lateral, and oblique views) show displacement
the lunate. B. Volar intercalated segmental instability. The
scapholunate angle is low (27°). of the carpus (e.g., perilunate dislocation) or
malalignment (e.g., scapholunate dissocia-
tion, DISI). Rarely, stress views are needed to
demonstrate an occult injury. A clenched-fist
PA view may highlight subtle scapholunate
dissociation.
2. Chronic injury—Additional studies are of-
ten needed in the evaluation of a chronic or
subacute injury. Arthrography has been used
extensively to diagnose tears of the scapholu-
nate and lunotriquetral ligaments. Triple-in-
jection techniques are important in evaluating
the flow of dye between the radiocarpal, mid-
carpal, and DRUJs. When abnormal flow is
present, a ligamentous tear is suspected. Un-
fortunately, arthrograms are helpful only in
evaluating the intrinsic ligaments, so extrinsic
ligament disruptions may be missed. Also,
as many as 70% of asymptomatic wrists may
have some abnormality noted on an arthro-
gram. MRI has become more popular in evalu-
ating the wrist as techniques and image detail
has improved. Cineradiography and fluoros-
copy are indicated in the workup of dynamic
instability. In many of these cases, all other
test results are normal, but fluoroscopy dem-
FIGURE 23-20 The key radiographic features of onstrates a midcarpal shift corresponding to a
rotatory subluxation of the scaphoid (scapholunate
painful clunk on physical examination. Wrist
dissociation) are seen on this anteroposterior view of
arthroscopy now allows the most compre-
the wrist: widening of the space between the scaphoid
and lunate, a foreshortened appearance of the scaphoid, hensive and direct evaluation of the car-
and the “cortical ring” shadow, which represents an axial pal ligaments. The exact type and degree
projection of the abnormally oriented scaphoid. (From of ligament disruption can be identified and
Green DP, ed. Operative Hand Surgery. 3rd ed. New York, in some cases treated arthroscopically. Also,
NY: Churchill Livingstone; 1993, with permission.) arthroscopy can provide information about
articular wear, chondral fractures, and syno- (b) Chronic treatment—Chronic scapholu-
vial hypertrophy. nate dissociation (8 weeks old) with-
3. Special tests—A number of maneuvers have out arthrosis is treated operatively with
been developed to help diagnose specific pat- either a soft-tissue procedure or lim-
terns of instability. The Watson test is per- ited arthrodesis. After reduction of the
formed by applying dorsally directed thumb scaphoid, ligament repair with capsular
pressure over the volar scaphoid tubercle augmentation is performed. K-wires are
during radial and ulnar deviation of the wrist. again used to hold the reduction and are
A palpable clunk that often elicits pain is left in place for 8 to 12 weeks. In cases of
diagnostic of scapholunate dissociation. insufficient soft tissue or irreducibility,
Another test is the ballottement or shuck limited arthrodesis is recommended. Dif-
test in which the triquetrum and lunate are ferent options include scaphotrapezial–
shifted volarly and dorsally in an attempt to trapezoid fusion, scapholunate fusion,
elicit any instability or pain. A positive bal- or scaphocapitate fusion.
lottement test is indicative of lunotriquetral (c) Treatment of SLAC with associated ar-
dissociation. Both of these tests should be throsis—SLAC with arthrosis is treated
performed on the opposite, uninvolved wrist with some type of salvage procedure.
as well as the injured wrist to rule out normal The most popular technique combines
variants. scaphoid excision with a midcarpal
F. Treatment (four-corner) fusion. Other surgical op-
1. Lesser arc injuries—Lesser arc injuries are tions include proximal row carpectomy,
purely ligamentous and may involve disrup- wrist arthroplasty, and complete wrist
tion of the intrinsic or extrinsic ligaments. fusion.
• Scapholunate dissociation—Tear of the • Lunotriquetral dissociation—Lunotriquetral
scapholunate interosseous ligament dissociation results from disruption of the
leading to dissociation is the most com- lunotriquetral ligament. Unlike scapholu-
mon carpal injury. Early diagnosis and nate dissociation, lunotriquetral dissocia-
appropriate treatment are important in pre- tion is rare and not very well understood.
venting midcarpal changes (DISI) and late A staging system has been developed to
collapse (SLAC arthrosis). guide treatment of these injuries. Stage I
(a) Acute treatment—Acute treatment con- represents isolated tears of the lunotriqu-
sists of ORIF with ligament repair. The etral interosseous ligament without midcar-
surgical approach is dorsal, between the pal (VISI) involvement. These injuries are
third and fourth dorsal compartments. treated nonoperatively with splinting, anti-
Reduction is achieved under direct visu- inflammatory medications, and local injec-
alization by manipulation of the scaph- tions. Stage II injuries have disruption of the
oid using thumb pressure (volarly) and lunotriquetral interosseous ligament and are
K-wire joysticks to “derotate” the flexed associated with a dynamic VISI. Stage III in-
scaphoid. Pins are used to hold the re- juries are more severe and are characterized
duction and are usually passed from the by a static VISI collapse pattern. Treatment
scaphoid into the lunate and capitate. of Stage II and III injuries is controversial
The ligament should be repaired back to but may include soft-tissue reconstruction
bone (usually the scaphoid) with suture (using dorsal capsule or tendon graft) or
anchors or through drill holes. When limited arthrodesis (lunotriquetral or four-
sufficient ligament is not present, the corner fusion).
repair is augmented with dorsal capsule • Perilunate dislocation—Staging of perilu-
used to stabilize and suspend the scaph- nate injuries (as described in the section on
oid (Blatt capsulodesis). Other types progressive perilunar disruption) includes
of ligament reconstructions have been Stage I to IV, with Stage III representing peri-
described, most using tendon grafts or lunate dislocation and Stage IV represent-
bone-ligament constructs. Postopera- ing lunate dislocation. These two injuries
tive regimens vary, but protected motion are closely related and are treated as one
can be started after a period of immobi- entity by most authors. For example, dorsal
lization. Pins are usually removed after perilunate and volar lunate dislocations are
8 to 12 weeks. considered together, and volar perilunate
and dorsal lunate dislocations are grouped lunate dislocations are much less com-
as one. mon but are treated in a similar fashion.
(a) Dorsal perilunate and volar lunate dislo- Again, combined volar and dorsal ap-
cation—Dorsal perilunate and volar proaches are used to restore the nor-
lunate dislocations are the most com- mal anatomic relationships and allow
mon types of perilunate injury. When for ligamentous repair.
they occur, there is complete disruption 2. Greater arc injuries—Greater arc injuries
of all perilunar ligaments except the SRL are distinguished by an associated carpal
ligament, which remains attached to the fracture. Treatment is directed at restoring
volar aspect of the lunate. The lunate normal carpal alignments in addition to reduc-
may remain in its fossa (Stage III, perilu- ing and fixing the fractures. They may occur
nate dislocation) or be displaced volarly separately or in various combinations.
into the carpal canal (Stage IV, true lunate • Transscaphoid perilunate fracture- dislocation—
dislocation). These displacements may A transscaphoid perilunate fracture-dis-
be seen on lateral radiographs as a con- location combines fracture of the scaph-
tinuum of the injury pattern (Fig. 23-21). oid with perilunar dislocation and is the
Treatment consists of emergent closed most common greater arc pattern. The ini-
reduction and splinting followed by de- tial treatment is similar to that for lesser arc
finitive ORIF. Some patients may pres- injuries, with emergent closed reduction and
ent with acute carpal tunnel syndrome splinting performed to avoid neurovascular
caused by the displaced lunate. These compromise. Definitive treatment should in-
cases require emergent carpal tunnel clude ORIF of the scaphoid fracture, usually
release and fixation. Although closed re- carried out through a volar (Russe) approach.
duction and percutaneous pinning have The fracture is fixed with a screw or K-wires,
been recommended by some authors, and attention is then directed to the align-
more reliable results can be achieved us- ment of the lunate and capitate. If there is a
ing open methods, usually through com- VISI deformity as a result of lunotriquetral
bined volar and dorsal approaches. The ligament disruption, a dorsal approach is
dorsal approach is between the third and added to reduce and pin the carpus. Of the
fourth dorsal compartments, whereas two variations, volar and dorsal, volar dislo-
the volar approach proceeds through cations are more severe and more likely to
the carpal canal. In a complete lunate require two approaches. Postoperative care
dislocation, the lunate is found within is the same as that for ligamentous injuries
the carpal canal and can be reduced with but with added complications because of the
a small elevator. The “rent” through the scaphoid fracture. These include nonunion
volar capsule and ligaments should be re- and AVN of the scaphoid, both of which are
paired in both lunate and perilunate dislo- more likely when there is an associated
cations. Dorsally, the normal alignments perilunar dislocation.
of the scaphoid, lunate, and capitate are • Transradial styloid perilunate fracture-
restored and the bones pinned in place dislocation—Treatment of transradial sty-
using K-wires. Ligamentous repair dor- loid perilunate fracture-dislocation includes
sally is not as simple as the volar repair ORIF of the radial styloid fracture in addi-
but should be attempted and augmented tion to reduction and pinning of the peri-
with capsule if necessary. Postoperative lunar joints. When fracture comminution
management is variable, but there is gen- precludes adequate fixation, the fragments
eral consensus that the pins should re- should be excised and the soft tissues reat-
main in place for at least 8 weeks. Final tached to bone. Failure to do this may re-
range of motion is limited because of the sult in residual instability of the radiocarpal
extensive damage and may not reach joint.
50% of normal in many cases. Late cases • Scaphocapitate syndrome—As the name
of perilunate dislocations (8 weeks) implies, scaphocapitate syndrome com-
may not be reparable and are usually bines fracture of the capitate and perilunar
treated by proximal row carpectomy. dislocation either with or without a scaph-
(b) Volar perilunate and dorsal lunate dis- oid fracture. Often, the proximal pole of the
locations—Volar perilunate and dorsal capitate rotates 90° to 180° and is seen on
FIGURE 23-21 Carpal dislocations make up a spectrum of injury, and the initial lateral radiograph in a patient with a
carpal dislocation may depict a configuration at any point in the spectrum. A. “Pure” dorsal perilunate dislocation.
B. Intermediate stage. C. “Pure” volar lunate dislocation. (From Green DP, ed. Operative Hand Surgery. 3rd ed. New York,
NY: Churchill Livingstone; 1993, with permission.)
anteroposterior radiographs as a squared-off joint is critical in the evaluation and treatment of

fragment. ORIF is indicated for all fractures these injuries.
along with appropriate restoration of carpal B. Anatomy—The DRUJ is a diarthrodial trochoid ar-
alignment. AVN may occur in the proximal ticulation between the concave sigmoid notch of
fragment of the capitate fracture. the radius and the convex head or “seat” of the dis-
• Transtriquetral perilunate fracture- disloca- tal ulna (Fig. 23-22). Two-thirds of the distal ulna is
tion—Transtriquetral perilunate fracture- covered by articular cartilage, but its nonarticular
dislocation occurs when the fracture line dorsal surface is grooved to accommodate the
extends into the triquetrum, leaving its prox- extensor carpi ulnaris (ECU) tendon (sixth dorsal
imal pole attached to the lunate. Treatment compartment). Pronation and supination occur
and postoperative care are similar to those through an arc of 180°, of which approximately
for the other greater arc injuries. 30° is due to translational movement. Because
3. Axial disruption injuries—Axial disruption in- the radius of curvature of the sigmoid notch is
juries are rare, usually caused by high-energy larger than that of the ulnar seat, the radius slips
trauma to the hand and wrist. Disruption and volarly during full pronation and dorsally
dislocation occur along an axial plane perpen- during full supination. At these extremes of ro-
dicular to the lines of perilunar injury. Different tation, there is only 10% contact between the ar-
patterns have been described and classified ticular surfaces, and stability must be provided by
according to their location (see Fig. 23-18). the soft-tissue (ligamentous) restraints. The most
Axial radial disruptions involve the first and important of these ligamentous stabilizers
second metacarpals as well as the trapezium is the TFCC. The TFCC is composed of the fol-
and trapezoid. Axial ulnar injuries usually re- lowing structures (Fig. 23-23): TFC, ulnocarpal
sult in a separation between the capitate and ligaments (including the UL, UT, and ulnocapi-
hamate and the third and fourth metacarpals. tate ligaments), volar and dorsal radioulnar
They are treated by ORIF through a dorsal ap- ligaments, meniscal homologue, sheath of the
proach. Many of these injuries are associated ECU tendon, and ulnar collateral ligament.
with extensive soft-tissue damage. The TFC is at the heart of this complex and
4. Midcarpal instability—Different types of mid- forms a load-bearing component that transmits
carpal instability have recently been identi- compressive force between the carpus and ulna.
fied. These instability patterns are considered It attaches to the distal radius at the sigmoid
nondissociative because they involve the ex- notch and runs to the fovea at the base of the
trinsic ligaments (between carpal rows) and ulnar styloid. The thickness of the TFC varies
not the intrinsic ligaments (within a carpal from 2 mm at its center to 5 mm at its periphery.
row). Often, they develop insidiously over Typically, there is an inverse relationship between
time and are seen in patients with general- ulnar variance and TFC thickness; ulna-negative
ized ligamentous laxity. Occasionally, they wrists have a thicker TFC, and ulna-positive wrists
may result from a perilunar injury. Clinically, have a thinner TFC. The vasculature of the TFC
midcarpal instability may present with a pain-
ful clunk as the proximal and distal rows shift
suddenly. Treatment of this problem is con-
troversial but may include soft-tissue recon-
Volar
structive procedures or ultimately, midcarpal
arthrodesis.
Hilum
IV. Injuries of the DRUJ
A. Overview—Fractures, dislocations, and soft- Dorsal view End-on
tissue injuries of the DRUJ have received more view
attention recently as the importance of this joint
FIGURE 23-22 Radioulnar articulation in neutral or zero
has become evident. Failure to treat these injuries
rotation as viewed from the dorsum and from end on.
appropriately can lead to disabling pain, instabil- Note that the arc of the notch circumscribes a circle of
ity, or loss of motion. Treatment should include greater diameter than that of the ulnar head. (Illustration
restoration of normal joint alignment and repair by Elizabeth Roselius. From Green DP, ed. Operative Hand
of the soft tissues that may lead to late instability. Surgery. 4th ed. New York, NY: Churchill Livingstone;
A thorough understanding of the anatomy of this 1999, with permission.)
radioulnar ligaments. Fractures at the base of

the ulnar styloid disrupt these attachments
and result in DRUJ instability. When displaced,
Triquetrum these fractures require ORIF to prevent chronic
Lunate instability.
Pisiform
C. Evaluation
1. Physical examination—Acute injuries of the
Ulnotriquetral DRUJ may occur as isolated events or may
ligament be associated with fractures of the wrist and
Ulnolunate forearm. Accordingly, the examination must
ligament Meniscus include the elbow and forearm as well as the
homologue
TFCC articular wrist. Swelling, tenderness, and limitation of
disc motion may accompany these injuries and
Dorsal radioulnar be associated with deformity. When the ulna
ligament is dislocated dorsally, there may be a promi-
Extensor carpi nence of the ulnar head. Conversely, a depres-
ulnaris Radius sion may be seen and felt when a volar ulna
Ulna dislocation has occurred. Pronation and supi-
nation may be limited or completely blocked
depending on the degree of injury. Chronic
FIGURE 23-23 Anatomy of the ulnocarpal joint and the problems associated with the DRUJ may be
TFCC, including the pisiform, triquetrum, lunate, ulna, more difficult to diagnose. In these cases, a
radius, TFCC-articular disc, meniscus homologue, extensor careful examination of each structure is nec-
carpi ulnaris, dorsal radioulnar ligament, ulnotriquetral
essary. Palpation may elicit tenderness, and
ligament, and ulnolunate ligament. The volar radioulnar
provocative maneuvers can identify instabil-
ligament and ulnar collateral ligament are not shown.
ity of the DRUJ. Clicks or clunks are consid-
ered significant if they are associated with
pain and if they are not found on the opposite,
is provided by volar and dorsal branches of the uninvolved wrist. The piano key sign refers to
anterior interosseous artery, which perfuses the a prominent and unstable distal ulna. It is in-
outer 20%; the central area remains avascular. dicative of dorsal instability.
The volar and dorsal radioulnar ligaments are in- 2. Diagnostic imaging
timately associated with the TFC and are the pri- • Plain radiographs—Plain radiographs should
mary stabilizers of the DRUJ. These ligaments include PA and lateral views of the wrist
provide support during full pronation and supina- taken in neutral forearm rotation. The PA
tion. The ulnocarpal ligaments, of which the most view should demonstrate both the radial
important are the UL and UT, connect the TFC to and ulnar styloids and allow for the calcula-
the carpus and support the volar side of the joint. tion of ulnar variance. (Note that variance
The ulnar collateral ligament runs from the fovea changes with forearm rotation.) The PA
to the base of the fifth metacarpal and includes view may show separation of the radius and
the vestigial meniscal homologue, which can vary ulna, indicating a dislocation of the joint. A
in its presentation. When fully developed, the me- true lateral view shows dislocation of the
niscus may include an ossicle known as a lanula, DRUJ and distinguishes between volar and
which is present in 4% of wrists. The major dorsal dorsal displacement of the ulna. Radiographs
support of the TFCC is the ECU tendon sheath. It is of the forearm and elbow should also be in-
composed of a fibroosseous tunnel separate from cluded to check for radial shaft and radial
the extensor retinaculum. Although not included head fractures.
in the TFCC, the pronator quadratus muscle is • CT—CT scanning, especially with three-
thought to be an important dynamic stabilizer of dimensional reconstruction, provides use-
the DRUJ. During pronation and supination, this ful information about complex fracture
muscle contracts to provide compressive force patterns. Axial cuts can identify subtle joint
across the joint. The fovea is described as the disruptions and should include both wrists
axis of rotation of the forearm. It is located at for comparison purposes.
the base of the ulnar styloid and forms the im- • MRI—MRI has been used to identify soft-
portant attachment site for the volar and dorsal tissue injuries of the wrist, including
ligament disruption and tears of the TFC.

Areas of injury are usually represented by a TA B L E 2 3 - 2
low-intensity signal on T1-weighted images, TFCC Abnormalities
whereas fluid around a tear appears bright
Class 1: Traumatic
on T2-weighted images. Newer machines
A. Central perforation
with dedicated wrist coils have improved
the accuracy of MRI to greater than 90%. B. Ulnar avulsion
• Radionuclide bone imaging—Radionuclide With distal ulnar fracture
bone imaging is an important tool in the Without distal ulnar fracture
evaluation of unexplained wrist pain. It is a C. Distal avulsion
sensitive test that can be used to detect oc- D. Radial avulsion
cult fracture, infection, tumor, or CRPS. With sigmoid notch fracture
• Arthrography—Arthrography has been used Without sigmoid notch fracture
extensively in the evaluation of the DRUJ. Class 2: Degenerative (ulnocarpal abutment syndrome)
Triple-injection techniques instill dye into A. TFCC wear
the DRUJ as well as the radiocarpal and mid-
B. TFCC wear lunate and/or ulnar chondromalacia
carpal joints. When combined with serial
radiographs or fluoroscopy, the flow of dye C. TFCC perforation lunate and/or ulnar chondroma-
can demonstrate ligamentous and TFC tears. lacia
A drawback of arthrography is the existence D. TFCC perforation lunate and/or ulnar chondroma-
of asymptomatic “communicating defects,” lacia lunotriquetral ligament perforation
which may be demonstrated and confused E. TFCC perforation lunate and/or ulnar chondro-
with pathologic tears. Normal findings with malacia lunotriquetral ligament perforation
DRUJ injection include the prestyloid recess ulnocarpal arthritis
and pisotriquetral joint communication. Source: From Buterbaugh GA. In: American Society for Surgery
3. Arthroscopy—The use of arthroscopy in the of the Hand: Hand surgery Update. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 1996, with permission.
diagnosis and treatment of wrist pathology has
grown tremendously. It is now considered the
gold standard for evaluation of the TFC and the
carpal ligaments. Arthroscopic evaluation has dislocations) or pronation (for volar dislo-
led to the development of a classification sys- cations). Complex dislocations are character-
tem for TFCC abnormalities (Table 23-2). Class ized by irreducibility or instability after closed
1 lesions are traumatic, whereas class 2 lesions reduction. This is due to interposed soft tissue,
are degenerative. Many of these problems can usually the ECU tendon and sheath. These inju-
now be treated arthroscopically or be combined ries must be treated open. A dorsal approach
with minimally open techniques. Evaluation of is used to free the trapped ECU tendon and re-
the DRUJ itself is more difficult, but arthroscopy duce the DRUJ. Reduction is followed by repair
can provide diagnostic information about the of the TFC back to the ulna and pin fixation of
articular cartilage of the joint. the DRUJ. If an ulnar styloid fracture is present,
D. Treatment—Problems of the DRUJ include isolated it should be fixed with a K-wire, a tension band,
dislocations, combined fracture-dislocations, soft- or interosseous wiring. Postoperative manage-
tissue injuries, and chronic joint disorders. The ment should include long-arm cast immobiliza-
treatment of each problem is different; therefore, tion for 6 weeks, followed by pin removal and
each needs to be addressed separately. joint rehabilitation.
1. Isolated dislocations of the DRUJ— 2. Fractures of the ulna with an associated DRUJ
Hyperpronation may lead to dorsal dis- injury—Fractures of the ulnar styloid need to
location of the ulna (more common), whereas- be evaluated in terms of DRUJ stability. Be-
hypersupination may cause volar dislocation. cause of the TFCC attachments, fractures at
As the injury occurs, there is sequential disrup- the styloid base (fovea) result in greater in-
tion of the radioulnar ligaments, the TFCC, and stability than those at the tip. These injuries
the capsule of the DRUJ. Simple dislocations are usually seen in combination with displaced
are those that can be reduced closed and that fractures of the distal radius. In this situation,
are usually stable after reduction. Treatment the distal radius fracture needs to be reduced
consists of long-arm cast immobilization for 4 and stabilized first, followed by evaluation
to 6 weeks in either supination (for dorsal of the DRUJ. If the joint is unstable to manual
stress or with forearm rotation, ORIF of the

ulnar styloid fracture should be considered.
Alternatively, the ulnar styloid fracture can be
reduced closed and the DRUJ stabilized by pin
fixation or by inclusion into an external fixation
frame. Fractures of the ulnar head may also re- Type A
sult in instability of the DRUJ. These articular
fractures, if displaced, need to be treated surgi-
cally to restore joint congruency and stability.
In rare situations, a severely comminuted frac-
ture of the ulnar head may require partial or
complete excision.
3. Fractures of the distal radius with an associ-
ated DRUJ injury—Fracture of the distal ra-
dius with DRUJ injury is seen when the distal
radius fracture line extends into the DRUJ or
when there is an associated TFCC disruption or Type B
ulnar styloid fracture. In each of these cases,
treatment of the DRUJ injury should not be ig-
nored. Recent studies have shown a correlation
between distal radius malunion and late ulnar-
sided wrist pain. Fractures that heal with
more than 25° of dorsal tilt or more than
5 mm of shortening cause DRUJ disruption
and lead to decreased forearm rotation and
ulnocarpal impaction. Similarly, fractures of
the lunate fossa involving the sigmoid notch
should be anatomically reduced to avoid intra-
Type C
articular malunion and posttraumatic arthritis
of the DRUJ. This can be carried out using lim-
ited open reduction and pin fixation or formal
ORIF. Another problem is late instability due
to TFCC rupture or ulnar styloid base fracture.
As previously noted, these injuries need to be FIGURE 23-24 The classification of Fernandez allows
treated surgically (by ORIF) when the DRUJ is ulnar-sided lesions to be categorized and incorporated as
unstable. A classification system by Fernan- part of the overall treatment plan.
dez divides ulnar-sided injuries into Types A
(stable), B (unstable), and C (potentially un-
stable) (Fig. 23-24). Type A injuries are treated of the DRUJ. When a simple dislocation or sub-
closed, whereas Types B and C injuries usually luxation is present, the DRUJ injury is treated
require operative fixation. closed and immobilized in either supination
4. Fractures of the radial shaft with an associ- (for dorsal dislocations) or pronation (for
ated DRUJ injury—Also known as Galeazzi volar dislocations) for 6 weeks. In rare cases
fractures; fractures of the radial shaft with DRUJ of unstable simple dislocations, a transfixing
injury account for 5% to 7% of all forearm frac- pin is placed across the joint and removed after
tures. Because of their association with DRUJ 6 weeks. Complex dislocations cannot be re-
injuries, radial shaft fractures should always duced closed and are treated by open reduction
raise the suspicion of a more distal problem. and repair of the TFCC back to the ulna. A pin is
Careful clinical and radiographic evaluation of usually added to protect the repair and stabilize
the wrist may show subluxation or dislocation the DRUJ for 4 to 6 weeks.
of the DRUJ. In general, a radial shaft fracture 5. Fractures of the radial head with an associated
within 7.5 cm of the wrist joint is more likely DRUJ injury—Known as the Essex-Lopresti
to be associated with dislocation of the DRUJ. injury, fractures of the radial head with DRUJ
Treatment includes ORIF of the radial shaft injury occur when an axial load is applied to
fracture, followed by reduction and evaluation the forearm, causing disruption of the DRUJ
and interosseous membrane and fracture of is usually necessary for 6 to 8 weeks to allow
the radial head. Again, careful examination of healing of the repaired structures.
the wrist should be performed in every patient E. Complications
with a radial head fracture. The significance 1. Late instability—Chronic instability may be
of this injury is the destabilization of the seen after injury of the DRUJ and its stabilizing
entire radius. Failure to appreciate and treat structures. In cases of mild subluxation, reat-
this problem can lead to the late complications tachment of the TFC to the ulna can be accom-
of instability, pain, and loss of forearm rota- plished with suture repair through drill holes
tion. In addition, comminuted fractures of the or by use of suture anchors. If a styloid non-
radial head are at risk for proximal migration of union is present, it can be reduced and fixed to
the radius and should not be excised. ORIF is the ulna with a K-wire, screw, or tension band
the preferred treatment and is combined with wire. For small nonunions, excision of the frag-
distal pin fixation of the radius and ulna. In ment and repair of the soft tissues are recom-
the event that radial head excision is unavoid- mended. In cases of gross instability, TFC repair
able, a silastic or titanium spacer should be im- may be augmented with a tendon graft recon-
planted to prevent proximal radial migration. struction. Various procedures are available for
Because the interosseous membrane heals reconstructing the radioulnar or ulnocarpal
very slowly, these patients should be followed ligaments depending on the site of instability.
for at least 2 years. If removal of the spacer 2. Posttraumatic arthritis—Posttraumatic arthri-
is planned, it should be delayed for the same tis may result from intra-articular malunion of
amount of time. the DRUJ or chronic instability. Initial treatment
6. Injuries of the TFC—Acute tears of the TFC is conservative with long-arm splinting (pre-
may result from rotational forces acting on the vents forearm rotation), oral anti-inflammatory
wrist or from an axial load sustained during a medications, and local corticosteroid injections.
fall. If there is no associated fracture or dislo- Many patients respond to these treatments.
cation, initial treatment consists of splinting Patients for whom conservative care fails are
followed by gradual mobilization. If symptoms candidates for operative treatment. Surgical
persist despite conservative management, fur- options include distal ulnar resection (Darrach
ther workup is indicated. Patients with painful procedure), hemiresection arthroplasty, and
clicking and evidence of a TFC tear on MRI or distal radioulnar fusion. Of these procedures,
arthrogram may be candidates for arthroscopic hemiresection arthroplasty of the ulna has be-
treatment. Traumatic tears of the TFC have come the most popular. It has evolved from the
been classified into four subgroups based on more radical Darrach procedure into a tech-
their anatomic location (see Table 23-2). Class nique that preserves the TFC and limits bone
1A lesions are central tears of the articular disc excision to the joint margins only. A free ten-
and when symptomatic, are usually treated by don graft is used as an interpositional spacer to
arthroscopic debridement. Because they occur prevent contact between the remaining distal
in the avascular central region, they are not ulna and the radius. The Darrach procedure is
amenable to repair. Class 1B injuries are as- still recommended for cases of DRUJ arthritis
sociated with DRUJ dislocation and represent with an unreconstructable TFC. Radioulnar fu-
complete tears from the fovea or fracture of the sion combined with proximal pseudarthrosis
styloid base. Management of these tears usually (Suave-Kapandji procedure) is another option
includes suture repair of the TFC (using suture for symptomatic arthritis.
anchors or drill holes) or ORIF of the ulnar sty- 3. Ulnocarpal abutment—Ulnocarpal abut-
loid fracture. Class 1C tears are located distally ment is characterized by positive ulnar vari-
and include disruption of the UL ligament, the ance that leads to symptomatic overload of
UT ligament, or both. Class 1D lesions represent the ulnocarpal joint. Progressive degeneration
avulsions of the TFC from its radial attachment of the TFC may result. This condition may
at the sigmoid notch. These injuries are often develop after distal radius malunion. Treat-
associated with a distal radius fracture of the lu- ment includes opening wedge (lengthening)
nate fossa and require anatomic reduction and radial osteotomy or shortening of the ulna
fixation. The treatment of many of these tears (depending on the degree of malunion). Other
remains controversial. Most can be treated treatment options are “wafer” resection of the
either using arthroscopic or open repair. Re- distal pole of the ulna (open or arthroscopic)
gardless of the method chosen, immobilization and Darrach excision.
4. Posttraumatic contracture of the DRUJ— Cooney WP 3rd, Dobyns JH, Linscheid RL. Fractures of the
Posttraumatic contracture leads to limited scaphoid: a rational approach to management. Clin Orthop
Rel Res. 1980;149:90–97.
forearm rotation after DRUJ injury as a result
Cooney WP, Berger RA. Treatment of complex fractures of the
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Essex-Lopresti PA. Fractures of the radial head with distal
partial or complete capsulectomy with preser-
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vation of the TFC. Surg. 1951;33B:244–247.
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or dislocation can occur in association with in- in adults by osteotomy, bone grafting and internal fixation.
juries of the TFC. Alternatively, this condition J Bone Joint Surg. 1982;64A:1164–1178.
Fernandez DL. Anterior bone grafting and conventional lag
may be confused with an isolated tear of the
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Gelberman, RH, Menon J. The vascularity of the scaphoid
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CHAPTER 24
Injuries of the Hand

Thomas L. Mehlhoff, C. Craig Crouch, and James B. Bennett
I. Joint Injuries of the Hand the finger joint. Intra-articular fractures, includ-
A. Overview ing avulsion fractures and fracture-dislocations,
1. Anatomy (Figs. 24-1 through 24-4)—The small may be associated with these injuries.
joints of the hand are hinged joints. The meta- 3. Evaluation—Swelling, tenderness, or ecchymo-
carpophalangeal (MCP) joints have a cam con- sis of a finger should raise suspicion for a joint
figuration, whereas the proximal interphalangeal injury. Stress testing may reveal instability as
(PIP) and distal interphalangeal (DIP) joints a result of underlying fracture or ligamentous
have a spherical shape. Stability depends on injury. Comparison stress testing to the nonin-
the articular contour, collateral ligaments, and jured opposite side is helpful in cases of liga-
volar plate. The volar plate has strong lateral mentous laxity. Limited motion of a joint may
attachments, but a weak distal attachment. result from joint subluxation or a displaced ar-
2. Small joint injuries—A partial or complete tear of ticular fragment. Evaluation of these injuries re-
the collateral ligaments, volar plate, or extensor quires excellent quality radiographs, including
tendon results in subluxation or dislocation of an anteroposterior (AP) X-ray view, a true lat-
eral X-ray view centered on the injured articula-
tion, and one or two oblique views. Tomograms
may occasionally be necessary to obtain better
visualization of a centrally depressed fracture.
4. Treatment and outcome—Pain-free motion and
joint stability are the treatment goals for these in-
juries. Treatment must correct subluxation and re-
PIP joint
store an acceptable joint surface. Studies suggest
that pain and motion may improve for up to
1 year after injury to a small joint of the hand.
B. DIP Joint Injuries
1. Mallet finger (Fig. 24-5)—A sudden forceful flex-
MCP joint ion to the DIP joint may rupture the extensor
Dorsal
Volar
FIGURE 24-1 Metacarpophalangeal joints are
unicondylar, and proximal interphalangeal joints are FIGURE 24-2 Collateral ligaments have a cordlike dorsal
bicondylar, giving the PIP joints more stability. component and a fan-shaped volar component.
353
Dorsal joint. X-ray films demonstrate a flexed DIP

joint and may demonstrate a fracture frag-
ment still attached to the extensor tendon.
Volar subluxation of the distal phalanx may
accompany the fracture, particularly if the
fragment is large.
Volar • Classification of Mallet Finger
(a) Type I—It involves closed or blunt
trauma with loss of tendon continuity,
with or without a small chip fracture.
A A1 (b) Type II—It involves a laceration at or
proximal to the DIP joint with loss of ten-
don continuity.
(c) Type III—It involves a deep abrasion with
loss of skin, subcutaneous cover, and ten-
A2 don substance.
(d) Type IV—It involves a physeal fracture
in children, a hyperflexion injury with a
fracture involving 20% to 50% of the artic-
FIGURE 24-3 The shape of the metacarpal head is
ular surface, or a hyperextension injury
eccentric. This creates a cam effect that makes the
collateral ligaments more taut in flexion than in extension with a fracture of the articular surface
(the distance from A to A1 is less than the distance from usually greater than 50% and with early
A to A2. or late volar subluxation of the distal
phalanx.
• Treatment
tendon from the distal phalanx, with or without (a) Closed treatment—Splinting or casting is
a bone fragment. Large fracture fragments in- indicated for mallet finger injuries with
volving more than 30% of the articular surface small fracture fragments that involve less
are at risk for volar subluxation of the distal than 30% of the articular surface or are
phalanx. displaced less than 2 mm. The mallet fin-
• Evaluation—Examination may reveal pain, ger is treated in extension for 6 weeks
swelling, and a dropped finger at the DIP full time, followed by another 4 weeks at
night (Fig. 24-6).
FIGURE 24-4 Structures about the MCP and
interphalangeal joints.
Volar plate
Articular Collateral
capsule ligament
Volar plate Articular
capsule
Collateral
Articular ligament
capsule
Articular
Volar plate capsule
Proximal
phalanx Proximal
phalanx
Deep
Lumbrical Collateral
transverse
muscle ligament
carpal
ligament Articular
Extensor Interosseous capsule
hood muscle
Extensor
tendon
Palmar Lateral Lateral
MCP joint
C H A P T E R 2 4 | I N J U R I E S O F T H E H A N D 355
than 30% of the joint surface, are dis-

placed more than 2 mm, or are asso-
ciated with volar subluxation of the
distal phalanx. Volar subluxation of the
DIP joint is the strongest indication for
surgery. Open reduction with internal
fixation (ORIF) of the fracture fragment
is recommended to correct the volar
subluxation of the DIP joint with a lon-
gitudinal K-wire in extension (Fig. 24-7);
tendon repair is performed as needed.
The use of a pullout button may lead to
skin slough (beneath the button). Suture
anchor fixation may be preferable.
• Complications—Complications include per-
sistent mallet deformity, secondary swan-
FIGURE 24-5 Mallet finger. Soft-tissue (terminal extensor neck deformity (Fig. 24-8), and traumatic
tendon tear) mallet (top) and bony mallet (bottom). arthritis of the DIP joint as a result of an in-
congruent joint or volar subluxation.
2. Dorsal dislocation of the DIP joint—A hyperex-
tension force at the tip of the finger may dis-
rupt the volar plate and the collateral ligaments,
whereas the insertion of the profundus tendon
remains intact. These injuries are frequently as-
sociated with a volar laceration (64% of cases),
since the skin is firmly bound to the underlying
bone.
• Evaluation
(a) Clinical examination—There is tenderness
FIGURE 24-6 Extension splinting of the DIP joint for and deformity at the DIP joint. The patient
mallet injuries. The dorsal padded aluminum splint uses is unable to flex or extend the joint.
the three-point fixation principle (arrows). (b) Radiographic evaluation—AP and true
lateral X-ray studies should be taken be-
(b) Surgery—Mallet finger deformities re- fore manipulation. Dislocations are usu-
quire surgery when they are associ- ally dorsal and rarely lateral. Associated
ated with fracture fragments greater avulsion fractures should be identified.
FIGURE 24-7 A. X-ray film showing

a mallet finger of bony origin.
B. Postoperative film showing
stabilization using a suture anchor
and a Kirschner wire.
FIGURE 24-8 Swan-neck deformity from dorsal subluxation of the lateral bands.
• Classification—Types include closed disloca- • Complications—Complications include post-

tion, open dislocation, and fracture-dislocation. traumatic stiffness, recurrent instability,
• Treatment posttraumatic arthritis, and infection (septic
(a) Closed reduction—Gentle closed reduc- arthritis and osteomyelitis).
tion is performed under metacarpal block C. PIP Joint Injuries
anesthesia. The distal phalanx is extended 1. Collateral ligament sprain of the PIP joint—An
and then reduced over the condyle. Stabil- abduction or adduction force to the extended
ity after reduction should be assessed, al- finger may result in tearing of the radial or ulnar
though there is usually little tendency for collateral ligament at the PIP joint. The radial
redislocation. Postreduction X-ray studies collateral ligament is injured more fre-
should demonstrate a congruent reduc- quently than the ulnar collateral ligament.
tion and no associated fractures. A short • Diagnosis—Clinical examination demon-
period of immobilization (10 to 14 days) strates point tenderness over the specific
is usually adequate. Thorough irrigation site of injury. Ligament failure usually oc-
and debridement of any open laceration curs at the proximal phalanx or less fre-
should be performed before reduction. quently, in the mid-portion of the ligament.
(b) Surgery—Irreducible dislocations of the Stress testing should be performed with the
DIP joint may result from interposition joint in extension or 20° of flexion. Lack of
of the volar plate, interposition of the a firm end point is diagnostic of a complete
profundus flexor tendon, or a displaced tear. Angulation greater than 20° on an AP
osteochondral fracture fragment. In stress X-ray film is also diagnostic of a com-
these cases, open reduction may be neces- plete tear. Small chip fractures may be noted
sary to extract the interposed volar plate, at the origin of the collateral ligament. Digital
sesamoid bone, or fracture fragment. Inter- block may facilitate examination.
position of the profundus tendon should • Treatment
imply rupture of at least one collateral (a) Closed treatment—Partial tears and most
ligament, and in this case, immobilization complete tears can be treated with static
should be continued for 3 weeks. splinting for 7 to 14 days, followed by
buddy-taping to the adjacent digit for 3 the middle phalanx may be seen, identify-
weeks. Active motion is encouraged from ing the distal location of the volar plate.
the outset. Residual joint discomfort and • Treatment—Closed reduction is performed
thickening of the collateral ligament as a under a metacarpal block anesthesia with
result of underlying scar tissue formation longitudinal traction. Most dorsal disloca-
are common, lasting for 3 to 6 months. tions are easily reduced. With stable reduc-
(b) Surgery—Indications for surgery include tion, range of motion may begin early with
radiographic evidence of soft-tissue in- continuous buddy-taping for 3 to 6 weeks.
terposition, a displaced condylar fracture Less stable injuries may require an extension
of the phalanx, or continued instability blocking splint to prevent the last 20° of exten-
after 3 weeks of static splinting. Surgery sion for 3 weeks. If the volar fracture fragment
for the radial collateral ligament to the contains more than 15% of the volar surface,
index finger may be necessary to restore operative intervention may be needed. Open
lateral key-pinch strength. dislocation should be thoroughly irrigated
2. Volar plate injury of the PIP joint—Hyperexten- in the operating room, with extension of the
sion injury to the PIP joint may cause the volar skin lacerations if needed. Rotational defor-
plate to tear from the middle phalanx, with or mity of the finger may suggest entrapment
without a bone fragment. of the middle phalanx condyle between the
• Diagnosis lateral band and the central slip. This situ-
(a) Clinical examination—There is fusiform ation is often irreducible with closed traction
swelling of the PIP joint, with point ten- and may require open reduction with repair
derness greatest over the volar plate. of the extensor mechanism.
(b) Radiographic evaluation—Lateral X-ray • Complications—Complications include pos
films may show a small avulsion fracture ttraumatic flexion contracture, pseudo-
fragment at the base of the middle pha- boutonnière deformity, and hyperextension
lanx, usually less than 10% of the joint instability.
surface. The PIP joint is usually reduced
without subluxation.
• Treatment—Closed management is indicated.
Stable injuries are immobilized in a dorsal
splint with 20° of flexion for 1 week, followed
by an active range-of-motion program using
buddy-taping.
• Complications—Complications include post-
traumatic flexion contracture, pain with lim-
ited range of motion, and late swan-neck
deformity.
3. Dorsal dislocation of the PIP joint—One of the
most frequently encountered articular injures of
the hand is dorsal dislocation of the PIP joint.
Hyperextension of the PIP joint forces the finger
backward, resulting in dislocation of the middle
phalanx dorsally relative to the proximal pha-
lanx, tearing the volar plate.
• Diagnosis
(a) Examination—The finger usually has an
obvious deformity as a result of the dislo-
cation, unless it has already been reduced FIGURE 24-9 PIP joint dislocation. A. Dorsal dislocation
(most common) can usually be treated by closed
by a trainer or a bystander. Hyperextension
reduction and buddy-taping. Loss of reduction in
stress testing determines residual instabil-
extension may require extension block splinting. B. Volar
ity. Collateral ligament stability may be sat- dislocation (unusual) may require operative repair of the
isfactory with a pure dorsal dislocation. extensor tendon central slip. (Reprinted with permission
(b) Radiographic evaluation—X-ray films dem- from Green DP, Strickland JW. In: DeLee JC, Drez D Jr,
onstrate the dislocation of the PIP joint eds. Orthopaedic Sports Medicine: Principles and Practice.
(Fig. 24-9). A small avulsion fracture from Philadelphia, PA: WB Saunders; 1994.)
4. Volar dislocation of the PIP joint—The cen- Central slip

tral slip insertion on the proximal phalanx is (central extensor tendon)
ruptured.
• Diagnosis
(a) Examination—Deformity and limited mo-
tion are usually obvious. If the joint has
spontaneously reduced, lack of active
extension of the middle phalanx against
resistance should suggest rupture of the Lateral band
central slip. An irreducible dislocation
FIGURE 24-10 Central slip injuries, if left untreated, can
can occur if the lateral bands or central result in volar displacement of the lateral bands and a
slip becomes trapped under the head of boutonnière deformity. Volar dislocations of the PIP joint,
the proximal phalanx. although uncommon, can result in central slip injuries.
(b) Radiographic evaluation—X-ray films Splinting the PIP joint (not the DIP joint) in extension and
demonstrate volar dislocation of the PIP encouraging passive DIP flexion is the correct treatment
joint (see Fig. 24-9). A small avulsion frac- for acute central slip injuries as long as the patient has
ture may be seen at the dorsum of the active PIP joint extension to within 30° of full extension.
middle phalanx as a result of the rup-
tured central slip insertion. is helpful for assessing the relocation po-
• Treatment—Closed reduction may be at- tential of the PIP joint in flexion.
tempted with longitudinal traction and flexion • Treatment—Effective treatment modalities may
of the MCP and PIP joints. The stability and include dorsal extension block splinting, skel-
strength of the central slip are tested after re- etal traction, ORIF, and volar plate arthroplasty.
duction. If the central slip is intact, a short (a) Closed management—Stable PIP joints in
period of immobilization can be followed by a flexion may be managed with dorsal ex-
carefully controlled range-of-motion program. tension block splinting. Full active flexion
A disrupted central slip must be treated is allowed; progressively more extension
with static splinting in extension for 6 is allowed over 4 weeks. Fracture frag-
weeks or open operative repair of the dis- ments less than 30% of the articular sur-
rupted central slip mechanism. face are well suited to this approach.
• Complications—Complications include ex- (b) Surgery
tension contracture, PIP or DIP joint stiffness, • ORIF—Large fracture fragments involv-
and progressive boutonnière deformity. Fail- ing 50% or more of the joint surface may
ure to diagnosis the central slip rupture re- be repaired with surgery, using a pullout
sults in progressive volar subluxation of the wire, a Kirschner pin, or a compression
lateral bands of the extensor mechanism and screw. Pilon fractures with depressed
a resulting boutonnière deformity (Fig. 24- joint surfaces may require elevation,
10). Global instability is another complication. bone grafting, and K-wire stabilization.
5. Fracture-dislocation of the PIP joint—Hyperex- • Volar plate arthroplasty—Comminuted
tension, impaction, shear, and pilon fracture- fractures may require excision of the
dislocation may occur. These injuries are the volar fragments and advancement of
most disabling PIP joint injuries. the volar plate to the middle phalanx
• Diagnosis to restore stability and resurface the
(a) Examination—Swelling, pain, and limited damaged articular surface.
motion, often without severe deformity, • Skeletal traction—With highly com-
is seen. This injury is commonly mis- minuted fractures, there may be no
taken as a sprain. option but continuous longitudinal dis-
(b) Radiographic evaluation—Radiographic traction until the fracture has molded.
evaluation is imperative. In a true lat- • Complications—Complications include
eral X-ray film centered on the injured recurrent subluxation, limited joint
joint, articular fracture fragments are motion (hinged motion on a subluxed
seen; they range from a small fleck to up PIP joint), and posttraumatic arthritis.
to 50% of the joint surface, with a vari- D. MCP Joint Injuries
able degree of dorsal subluxation of the 1. Thumb MCP ulnar collateral ligament injury—
middle phalanx. A lateral view in flexion An injury to the ulnar collateral ligament of the
thumb is also known as gamekeeper’s thumb or

ski-pole thumb. A competent ulnar collateral
ligament of the MCP joint is critical for effec-
tive lateral key pinch.
• Evaluation
(a) Examination—Tenderness is noted over
the ulnar aspect of the MCP joint. A palpa-
ble fullness may suggest Stener’s lesion
(interposition of the adductor pollicis apo-
neurosis between the torn end of the ulnar
collateral ligament and the proximal pha-
lanx). Stress testing of the ulnar collateral
ligament with radial stress in some flexion
should be compared with the opposite
noninjured thumb. Stress in some flex-
ion tests the proper collateral ligament.
Stress in extension tests the more volar
accessory ligament. A poor endpoint in
both flexion and extension confirms a
complete tear of the ligament, and an
unstable joint. A digital block may be re-
quired before the examination.
(b) Radiographic evaluation—Radiographs
FIGURE 24-11 A thumb MCP ulnar collateral ligament
of the thumb should be taken before
stress test demonstrates significant radial deviation
stress testing to look for associated frac- (and angulation) at the thumb MCP joint (as seen on
tures. Stress radiographs demonstrating this stress radiograph). (Reprinted with permission
more than 35 ° of opening should suggest from O’Donoghue DH. Treatment of Injuries to Athletes.
complete tear of the ligament (Fig. 24-11). Philadelphia, PA: WB Saunders; 1986.)
• Treatment
(a) Closed treatment—Partial tears of the MCP joint of the thumb is less common. How-
ulnar collateral ligament that have good ever, the diagnosis is often missed, so treatment
endpoints and do not open 35° with stress may be delayed.
can be treated with cast immobilization • Evaluation
or with a functional brace with the MCP (a) Examination—There is localized swelling
joint held in slight flexion for 3 to 4 weeks. and tenderness on the radial aspect of
(b) Surgery—A complete tear of the ulnar col- the thumb MCP joint. Stress testing elic-
lateral ligament associated with instability its pain or demonstrates opening on the
of the MCP joint (opening 35° with stress) radial aspect of the joint. Volar sublux-
or a displaced fracture fragment requires ation is commonly associated with ra-
surgery to reattach the ulnar collateral dial collateral ligament injury of the
ligament. In these cases, Stener’s lesion is thumb MCP joint.
usually present and will not heal back to (b) Radiographic evaluation—Two views of
the proximal phalanx without surgery. Op- the thumb are needed to evaluate for an
erative repair of the ligament can be per- associated fracture. A small osteochon-
formed with a suture anchor or a pullout dral fracture fragment from the metacar-
button. Chronic injuries of the ulnar collat- pal is frequently noted.
eral ligament may require ligament recon- • Treatment
struction or advancement of the adductor (a) Cast—Almost all injuries of the radial col-
pollicis to the proximal phalanx. lateral ligament can be treated conserva-
• Complications—Complications include re- tively with a cast or thumb spica splint
sidual instability with pain, decreased lateral for 4 to 6 weeks if diagnosed acutely. The
key-pinch strength, volar subluxation of the cast must prevent volar subluxation of
MCP joint, and late arthritic changes. the MCP joint.
2. Thumb MCP radial collateral ligament injury— (b) Surgery—If the MCP joint is unstable or
Injury to the radial collateral ligament of the has volar subluxation, surgery to repair
the radial collateral ligament may be re- • Evaluation

quired. The ligament is usually torn (a) Simple dislocation—There is a notable de-
from the metacarpal head and requires formity with marked MCP joint hyperexten-
repair with a suture anchor or a pullout sion. X-ray films demonstrate the proximal
button. phalanx at 60° to 90° of hyperextension on
• Complications—Complications are the same the dorsum of the metacarpal head.
as those listed for thumb MCP ulnar collat- (b) Complex dislocation (Fig. 24-12)—Deformity
eral ligament injury. is not as obvious, with the joint only slightly
3. Finger MCP collateral ligament injury—Forced hyperextended. A common finding is a skin
spreading into the web space may result in in- dimple (puckering) at the distal palmar
jury to the radial or ulnar collateral ligament of crease. Radiographs demonstrate nearly
a finger MCP joint. The collateral ligament at parallel alignment of the proximal phalanx
the MCP joint usually fails at its attachment to and the metacarpal. The presence of a ses-
the proximal phalanx and at times includes an amoid in a widened MCP joint indicates
avulsed bone fragment. volar plate entrapment.
• Diagnosis • Treatment
(a) Examination—Subtle swelling is noted in (a) Simple dislocation—Gentle closed re-
the web space between the two metacarpal duction should be performed by hyper-
heads. Local tenderness confirms the site extending the joint before pushing the
of injury. Gentle stress testing to the MCP proximal phalanx onto the metacarpal
joint, in both extension and flexion, may head. Straight longitudinal traction
reproduce pain or demonstrate instability. should be avoided because it may con-
(b) Radiographic evaluation—X-ray films vert a simple to a complex dislocation.
may demonstrate a small avulsion frac- (b) Complex dislocation—A single attempt at
ture fragment from the metacarpal head. closed reduction may be performed, but
• Treatment most complex dislocations require open
(a) Closed treatment—The majority of collat- reduction in the operating room. Open re-
eral ligament injuries to the MCP joints duction can be achieved through either a
of the fingers can be treated with conser- dorsal or a volar approach and requires
vative management. Buddy-taping of the extraction of the interposed volar
fingers to protect the collateral ligament plate. The radial digital nerve may be
of the MCP joint is recommended, with tented over the index metacarpal head,
intermittent use of a splint incorporat- or the ulnar digital nerve may be tented
ing 50° or more of flexion for unstable over the metacarpal head of the little fin-
injuries. Slow improvement in symptoms ger, when performing the volar approach.
may be expected over 3 months. The volar plate can be split longitudinally
(b) Surgery—Surgical treatment may be con- to assist reduction of the joint if needed.
sidered for an avulsion fracture fragment The dorsal approach eliminates the risk
that involves 20% of the articular surface of damage to the digital nerves and al-
or is displaced more than 2 mm. Relative lows treatment of any associated meta-
indications for surgical repair include carpal head fracture. After reduction, the
injury to the radial collateral ligament MCP joint is typically stable and allows
of the index finger or the little finger. early active range-of-motion exercises
• Complications—Complications include insta- with buddy-taping.
bility, laxity, and weakness or pain. Chronic (c) Complications—Complications can in-
pain and secondary adhesions are more clude digital nerve damage, stiffness, and
frequent sequelae than instability, and it is arthritis (if associated with a metacarpal
suggested that static splinting should not head fracture).
exceed 3 weeks. Extension contracture may E. Carpometacarpal (CMC) Joint Injuries
also occur. 1. Dislocation (and fracture-dislocation) of the
4. Dorsal dislocation of the MCP joint—MCP joint CMC joint—The CMC joints of the index, middle,
dislocations most often occur in a dorsal direc- and ring fingers are stable (fixed) joints that al-
tion and most commonly involve the index finger, low minimal gliding motion and are classified as
thumb, and little finger. Dorsal dislocation may arthrodial diarthroses. The CMC joint of the little
be simple (reducible) or complex (irreducible). finger is more mobile and is similar to the thumb
FIGURE 24-12 Complex dorsal dislocation of the MCP joint. A. Diagram demonstrating how the volar plate can become
displaced dorsally, blocking reduction of the MCP joint dorsal dislocation. B. Clinical photograph demonstrating
puckering (arrow) of the palmar skin. C. Radiograph showing entrapment of a sesamoid within the (widened) MCP
joint. (B and C reprinted with permission from Green DP, Strickland JW. In: DeLee JC, Drez D Jr, eds. Orthopaedic Sports
Medicine: Principles and Practice. Philadelphia, PA: WB Saunders; 1994.)
CMC joint. As a saddle joint, the CMC joint of the severe force. Dislocation is generally in the dor-
little finger allows motion not only in a gliding sal direction (unless the dislocation results from
but also in rotation to allow its opposability to a direct blow from the dorsal direction, causing
the thumb. The CMC joints are stabilized by very a volar CMC dislocation). Volar dislocations are
strong intermetacarpal and CMC ligaments that much rarer than dorsal dislocations but are rela-
support the dorsal and volar aspects of the joint. tively more common in the CMC joint of the little
Fracture-dislocation of the CMC joint occurs with finger because of its increased mobility.
• Evaluation—Because of the overlap of the ad- • Complications—Complications include recur-
jacent bone structures, X-ray interpretation rent dislocation, pain, weakness, and arthritis.
of the CMC joint is often difficult, and various Posttraumatic arthritis of the CMC articulation
views are required for accurate interpreta- can be effectively treated with arthrodesis.
tion. Radiographs demonstrate a subluxated
or dislocated CMC joint (with or without a II. Fractures of the Hand—Phalangeal and metacarpal
fracture fragment involving the CMC joint fractures are common, comprising nearly 10% of all
surface) (Fig. 24-13). Computed tomography fractures.
(CT) may be indicated for more difficult diag- A. Phalangeal Fractures
nostic problems. A 30° pronated view of the 1. Classification—Extra-articular phalangeal frac-
hand may be necessary for assessing the tures are described by location, including base,
congruency of the joint surfaces. shaft, or neck for the middle and proximal pha-
• Treatment—Closed reduction is easily ob- langes, as well as tuft fracture for the distal pha-
tained with longitudinal traction but cannot lanx. These injuries may be further described as
be maintained in a cast alone. Percutaneous displaced or nondisplaced, as open or closed,
transarticular K-wire fixation, in addition as associated with a rotational or angular defor-
to cast immobilization, is necessary. Redis- mity; they may have associated injuries to the
location or incomplete reduction of the CMC skin, nerve, digital artery, or tendons.
joint often occurs in index- and little-finger 2. Deforming forces—The bony anatomy is an in-
CMC fracture-dislocations as a result of the tercalated osseous chain. Fracture of a phalanx
pull of the extensor carpi radialis longus in this chain results in a predictable deformity.
tendon to the index metacarpal and the • Middle phalanx
extensor carpi ulnaris to the metacarpal (a) Fracture proximal to flexor digitorum
of the little finger. Closed reduction and cast superficialis (FDS) insertion causes the
immobilization often result in recurrence of middle phalanx to angulate dorsally.
the CMC dislocation because of the instabil- (b) Fracture distal to the FDS insertion
ity and significant swelling that occur with causes the middle phalanx to angu-
these injuries. late volarly.
FIGURE 24-13 A. Injury film showing dislocation of the CMC joint of the index and long fingers. B. Postoperative film
after reduction of the dislocations and stabilization with Kirschner wires.
• Proximal phalanx—Interosseous attach- phalanges may lead to tendon adhesions

ments to the proximal phalanx flex the to the bone. Tenolysis may be required to
proximal fragment, whereas the central improve motion after fracture healing. PIP
slip extends the distal portion, resulting flexion contracture is also common with pha-
in volar angulation at the fracture. langeal fractures. If not improved with ther-
3. Evaluation—Swelling, pain, limited motion, or apy, joint release may be required.
deformity should suggest fracture and merit ra- • Malunion—A closing wedge osteotomy of the
diographic evaluation. Some 30% of phalangeal phalanx may be needed to correct an angular
fractures may be open. Associated flexor tendon deformity. Rotational deformity with overlap
or digital nerve injuries should be identified. of the digits may require a transverse derota-
Nonunion and infection rates are higher with tional osteotomy of the phalanx.
open fractures. A splay lateral X-ray study of • Infection
the digits with various amounts of flexion is • Nonunion
required to prevent overlap of the phalanges • Symptomatic hardware—Exposed Kwires
during radiographic examination. may be complicated by superficial pin-tract
4. Treatment infection. Plate and screw fixation for a
• General principles—Accurate fracture reduc- phalangeal fracture is often complicated
tion is recommended, followed by remobiliza- by symptomatic hardware, requiring de-
tion of the injured finger as early as allowed layed removal after fracture healing, with
by fracture stability. Uninvolved fingers tenolysis of the extensor mechanism.
should be mobilized early to prevent stiff- B. Metacarpal Fractures—Metacarpal fractures ac-
ness. The PIP joint is the most important count for 36% of all fractures of the hand.
joint for motion and function of the digit. 1. Classification—Metacarpal fractures are de-
• Stable fractures—Stable phalangeal fractures scribed by location, including metacarpal head
with good radiographic alignment can be fractures, metacarpal neck fractures, meta-
treated with buddy-tape, a splint, or a cast. carpal shaft fractures, and metacarpal base
X-ray studies should be repeated in 7 to 10 fractures. These fractures are typically further
days. described as nondisplaced or displaced, as
• Displaced fractures—Displaced fractures that closed or open, or as associated with angula-
can be reduced and converted to a stable tion, rotation, or a shortening deformity.
position can be treated with closed manage- 2. Evaluation—X-ray studies define fracture align-
ment, including a cast or splint, followed by ment. The Brewerton X-ray view is particularly
protected range-of-motion exercises. Percuta- useful for evaluating metacarpal head fractures.
neous pinning may be necessary to prevent 3. Treatment
fracture displacement. • Metacarpal head fractures—Nondisplaced
• Unstable fractures—Fractures that cannot be metacarpal head fractures can be treated
reduced or have persistent instability despite with cast protection or buddy-taping. Dis-
attempted closed reduction require ORIF placed oblique fractures require ORIF with
with skeletal fixation. Treatment options in- K-wires or small screws. Small osteochondral
clude K-wire fixation, intraosseous wiring, fractures may be excised. Avascular necro-
interfragmentary screws, and plate and screw sis of the metacarpal head may occur after
fixation. even a nondisplaced transverse fracture.
• Segmental bone loss—Segmental bone loss is • Metacarpal neck fractures (Fig. 2414)—Meta-
frequently associated with a severe soft-tissue carpal neck fractures are also referred to as
injury. Primary treatment should include soft- boxer, fighter, or frustration fractures. A direct
tissue management with thorough irrigation blow on the metacarpal head of the little or
and debridement, followed by open packing. ring finger may result in fracture with angu-
These fractures are typically highly commi- lation at the metacarpal neck. If angulated
nuted and may require external fixation to less than 15°, the fracture can be treated in
maintain length until definitive bony recon- an ulnar gutter splint for 2 weeks, followed
struction can be performed with bone graft. by range-of-motion exercises. If angulated
Delayed flap coverage may be required as well. 15° to 40°, the fracture should be reduced,
5. Complications followed by ulnar gutter splint treatment. If
• Loss of motion—Close adherence of the angulated more than 40° with unaccept-
flexor and extensor tendons over the able clinical deformity, closed reduction
and percutaneous pinning of the fracture is

recommended. A total of 40° of dorsal angula-
tion for a fracture of the metacarpal neck of
the little finger can be accepted, with good
resulting function, because of the compensa-
tory motion at this metacarpal’s CMC joint.
Residual angulation greater than 15° for
metacarpal neck fractures of the index and
long fingers is unacceptable because of the
lack of compensatory CMC motion for these
metacarpals.
• Metacarpal shaft fractures—Transverse
metacarpal shaft fractures are often caused
by a direct blow, resulting in dorsal angula-
tion. These fractures are often amenable to
closed reduction, followed by cast treatment.
Spiral and long oblique fractures of the
metacarpal shaft are inherently unstable
with shortening and rotation. Rotational
deformity manifests as overlap of the dig-
its when making a fist (Fig. 24-15). ORIF is
recommended for metacarpal shaft fractures
with (a) malrotation, (b) dorsal angulation
greater than 10° for the index and long
finger metacarpals, (c) dorsal angulation
greater than 20° for the ring and little fin-
ger metacarpals, and (d) any shortening
greater than 3 mm. Multiple displaced meta-
FIGURE 24-14 Boxer’s fracture of the metacarpal neck of
carpal shaft fractures are an indication for
the little finger. (Reprinted with permission from Gartland
JJ. Fundamentals of Orthopaedics. 4th ed. Philadelphia, PA: internal fixation as well. Treatment options
WB Saunders; 1987.)
FIGURE 24-15 Assessment for rotational deformity of the fingers.

A. Normally, the four flexed fingers converge at the scaphoid tubercle, and
the nails are aligned. B. Rotational malalignment cannot be appreciated
with the fingers extended. C. Same patient as in (B) with the fingers flexed.
Note malrotation of the ring finger. (B and C reprinted with permission
from Culver JE, Anderson TE. Clin Sports Med. 1992;11:101–128.)
may include K-wires, interosseous wiring, C. Fractures at the Base of the Thumb Metacarpal—
interfragmentary screws, and screws and Fractures at the base of the thumb metacarpal can
plates. Long oblique and spiral fractures impair effective lateral key pinch and opposition of
are well suited to interfragmentary screw the thumb to the other digits.
fixation. Short oblique and transverse 1. Classification (Fig. 24-18)
fractures require a neutralization plate • Bennett’s fracture—dislocation
and screw fixation (Fig. 24-16). Open meta- • Rolando’s Y or T condylar fracture
carpal fractures require treatment of the • Epibasal fracture
associated soft-tissue injuries and may • Comminuted fracture
require external fixation if highly commi- 2. Evaluation
nuted or associated with segmental bone • Clinical examination—There is swelling and
loss (Fig. 24-17). pain at the base of the thumb, often with
• Metacarpal base fractures—Stable metacar- bruising in the thenar region.
pal base fractures can be treated with a cast • Radiographic evaluation—AP, lateral, and
alone. Displaced metacarpal base fractures oblique views are obtained. Oblique views
require closed reduction and percutaneous are necessary to assess for congruency of the
pinning. CMC joint.
4. Complications 3. Treatment
• Malunion—Dorsal angulation of a metacar- • Nondisplaced fractures—Nondisplaced well
pal shaft fracture may disturb the intrinsic aligned fractures can be treated with a cast
or extrinsic tendon balance. Dorsal closing for 4 weeks, followed by a removable splint.
wedge osteotomy or volar opening wedge • Displaced fractures—Surgery is required
osteotomy may be necessary to correct for displaced fractures with an incongruent
this angular deformity. Derotational oste- or a subluxed CMC joint. Only 1 to 3 mm
otomy through the base of the metacarpal of CMC joint incongruity can be accepted.
corrects a rotational deformity. Other com- A displaced Bennett’s fracture-dislocation
plications include nonunion, MCP joint con- may be treated with longitudinal traction
tractures, intrinsic muscle contractures, and and percutaneous K-wire fixation if the vo-
refracture. lar ulnar fragment is small. A large bone
FIGURE 24-16 A. Injury film showing transverse/short oblique fractures of the index, long, and ring finger metacarpal
shafts. B. Postoperative film after stabilization with plate and screw fixation. (Reprinted with permission from Jupiter
J, Silver MA. In: Chapman M, ed. Operative Orthopaedics. Philadelphia, PA: J.B. Lippincott Company; 1988.)
FIGURE 24-17 A. Injury film showing a comminuted fracture of the metacarpals of the ring and little fingers (also
with involvement of the carpus) as the result of a handgun injury. B. Postoperative film showing stabilization with an
external fixator.
fragment may require ORIF with K-wires or

small lag screws. A comminuted fracture
may require transarticular K-wires or exter-
nal fixation to maintain length through indi-
rect reduction.
4. Complications—Complications include mal-
union, nonunion, and posttraumatic arthritis.
Accurate reduction of the articular surface
Lateral Frontal Lateral Frontal minimizes posttraumatic arthritis. Up to 3 mm
Bennett’s Rolando’s “Y” Rolando’s “T” of incongruity may be accepted as long as a sta-
ble union of the fracture fragments is achieved
without subluxation of the CMC joint.
D. Physeal Fractures in Children—More than 34% of
hand fractures in children involve the epiphyseal
growth plate. Common locations for such fractures
are the base of the proximal phalanx, the base of
the distal phalanx, and the base of the index, long,
and ring finger metacarpals.
1. Classification—The Salter-Harris classification
Transverse Oblique Comminuted
is used for physeal injuries of the hand.
Epibasal • Type I injuries are usually seen in early child-
FIGURE 24-18 Classification of fractures at the base of hood and result from a shear injury. The
the thumb metacarpal. prognosis is good.
• Type II injuries are usually seen after age 10, Volar
again as a result of a shear or angular force.
The prognosis is also good.
• Type III injuries are also seen after age 10, al-
though with intraarticular extension. This in-
jury requires accurate reduction of the joint
surface to avoid posttraumatic arthritis.
• Type IV injuries also have intraarticular ex- A1 A2 C1 A3 C2 A4 C3
tension but with associated metaphyseal
displacement as well. Anatomic reduction of
the fracture must be achieved. The progno-
sis is poor without anatomic alignment.
• Type V injuries may occur at any age but are FIGURE 24-19 Flexor tendon pulley system—there
extremely rare in the hand. These fractures are five annular (A1, A2, A3, A4, A5) and three cruciate
are thought to be the result of a severe axial (C1, C2, C3) pulleys. Note that A2 and A4 are the most
load to the growth plate. The prognosis is important pulleys to preserve. The odd-numbered
poor and is not improved with surgery. annular pulleys overlie joints: A1 (first annular pulley)
2. Complications—Complications include mal- overlies the MCP joint, A3 (third annular pulley) overlies
the PIP joint, A5 (fifth annular pulley) overlies the DIP
union, traumatic arthritis, residual deformity,
joint (not shown). The even-numbered annular pulleys
and growth plate arrest. Although growth and the cruciate pulleys overlie the phalanges, A2
disturbance may occur in a nondisplaced (second annular pulley) overlies the proximal phalanx,
Salter-Harris Type II fracture, the worse prog- A4 (fourth annular pulley) overlies the middle phalanx,
nosis is clearly found in Salter-Harris Types IV C1 (first cruciate pulley) is distal to A2 on the proximal
and V fractures. phalanx, C2 and C3 (second and third cruciate pulleys)
are proximal (C2) and distal (C3) to the A4 pulley on the
III. Soft-Tissue Injuries of the Hand middle phalanx.
A. Flexor Tendon Injuries
1. Anatomy—Tendons are composed primar-
ily of Type I collagen fibers. Most blood ves-
sels to the flexor tendons are located in the
epitenon, which is continuous with the endo-
tenon surrounding individual bundles of colla-
gen within the tendon. The FDS splits around
the flexor digitorum profundus (FDP) to insert
onto the middle phalanx. The FDP tendon in-
serts onto the distal phalanx. Excursion of A2 A4
the FDS tendon at the mid palm is 26 mm and Normal
over the proximal phalanx is 16 mm with com-
posite flexion. FDP excursion is 23 mm at the
mid-palm, 17 mm over the proximal phalanx,
and 5 mm over the middle phalanx with com-
posite flexion. In the distal palm and digits, the
flexor tendons are enclosed within a synovial
sheath. The visceral synovial layer covers
the flexor tendons, and a parietal layer is con-
tinuous with the annular and cruciate pulleys.
A fibroosseous tunnel extends from the MCP A4
joint to the distal phalanx to ensure efficient A2
Bowstringing
digital flexion. The annular pulleys provide
mechanical stability, and the cruciate pulleys
permit flexibility at the joints (Fig. 24-19). It is
imperative to preserve the A2 pulley over
the proximal phalanx and the A4 pulley
over the middle phalanx to prevent a bow- FIGURE 24-20 Bowstringing of the flexor tendons may
stringing deformity (Fig. 24-20). The A1, A3, result from disruption of the A2 and A4 pulleys.
and A5 pulleys arise from the palmar plates of (b) Zone II is within the fibroosseous tun-
the MCP joints, PIP joints, and DIP joints, re- nel. Both the FDP and the FDS tendons
spectively. The thumb has an A1, an oblique, are contained within one tight fibroosse-
and an A2 pulley. ous tunnel. This area is the most diffi-
2. Nutrition—Tendon nutrition is via both a direct cult in which to obtain a good result;
vascular supply and synovial diffusion. A seg- hence it was referred to as “no man’s
mental vascular supply is provided to both land” by Dr. Sterling Bunnell.
the superficialis and the profundus tendons with (c) Zone III is the palm. At this level, although
short and long vincular connections. The vas- both tendons may be injured, direct re-
cular area of the digital flexor tendon is richer pair has a good prognosis because of the
on the dorsal aspect than the volar aspect. Syno- absence of fibroosseous pulleys.
vial diffusion is an alternative nutritional path- (d) Zone IV includes the carpal tunnel. Flexor
way for flexor tendons and may function more tendon injuries are frequently protected
rapidly and completely than vascular perfusion. by the carpal bones but are often com-
Nutrients of the synovial fluid are pumped into plicated by injury to the median or ulnar
the tendon by imbibition through conduits in nerve.
the tendon surface, enhanced by tendon gliding. (e) Zone V includes the wrist and forearm.
3. Flexor tendon healing—Flexor tendons have Proximal to the carpal ligament, the
both an intrinsic and an extrinsic ability to heal. flexor tendons are less constrained and
The healing process involves an inflammatory are surrounded by loose areolar tissue,
phase, a fibroblastic (or collagen-producing) so repairs in this zone also have a more
phase, and a remodeling phase. The inflam- favorable prognosis. Associated injuries
matory phase predominates during the first to major peripheral nerves and vessels
3 to 5 days. During this phase, the strength of are also common in this zone.
the repair is almost entirely that imparted by • Examination—The resulting posture of the
the suture itself. The fibroblastic, or collagen- digits should be observed. The tenodesis ef-
producing, phase begins on day 5 and extends fect of intact tendons can be demonstrated
to day 21. During this phase, the strength of the with wrist flexion and extension. Isolated
repair increases rapidly while granulation tissue testing of the FDS and FDP tendon with gen-
bridges the defect. Controlled forces on a ten- tle blocking should be performed (Fig. 24-21).
don with passive mobilization in this phase Pain on resisted motion may suggest partial
lead to a more rapid realignment of the col- laceration.
lagen fibers with greater tensile strength, • Treatment
fewer adhesions, and improved excursion. (a) Surgery—Primary surgical repair is
The remodeling phase follows after day 21, with indicated for nearly all flexor tendon
complete maturation at the repair site and re- lacerations, even when in Zone II.
version of the fibroblasts to normal tenocytes • Timing—Primary or delayed primary repair
by day 112. By 8 weeks, the collagen is mature may be performed. Repair requires a tidy
and realigned in a linear fashion. Adhesions wound. Appropriate soft-tissue coverage
around the flexor tendon form in proportion to should be available at the repair site. The re-
the extent of tissue crushing or the number of pair is performed as soon after the injury as
surface injuries to the tendon. Nonsteroidal an- feasible, although it may be delayed as long
tiinflammatory drugs (ibuprofen and indometh- as 2 or 3 weeks without compromising the
acin) decrease adhesion formation but also ultimate result. Associated fractures are not
create a significant reduction in repair strength a contraindication to flexor tendon repair.
while healing. Tetanus prophylaxis must be considered for
4. Laceration of the flexor tendons—Poorly treated all penetrating injuries of the hand; see Chap-
digital flexor tendon injuries may result in seri- ter 1 for further details regarding tetanus
ous disability. prophylaxis.
• Classification—Flexor tendon injuries are di- • Technique—Woundextending incisions are
vided into zones (Verdan Zones I to V) that necessary, since the tendon retracts from
have a specific anatomic characteristic. the injury site. The muscle pulls the proximal
(a) Zone I is distal to the FDS insertion. At this end, whereas extension of the digit pulls the
level, only the profundus flexor tendon is distal end. Bruner zig-zag or midlateral inci-
contained within the fibroosseous tunnel. sions are used. Atraumatic technique during
to retain independent finger motion and

stronger flexor power. Repair of the su-
perficialis prevents the occasional hyper-
extension deformity at the DIP joint and
provides a smooth gliding bed for the
FDP.
(c) Zone III—Multiple flexor tendons may
be injured and may be complicated by a
vascular injury to the superficial palmar
arch or an injury to the common palmar
digital nerves. In selected cases with a
heavily contaminated wound or a crush
injury, repair of only the FDP tendon may
be preferable to repair of both tendons.
(d) Zone IV—Although uncommon, stab
wounds to this zone may result in flexor
tendon and median nerve injury. Sur-
gical exploration may be necessary to
diagnose partial laceration of the flexor
tendons.
(d) Zone V—Slash injuries to this level com-
monly involve multiple flexor tendons, as
well as the median and ulnar nerves and
the radial or ulnar arteries; an injury to
FIGURE 24-21 Testing finger flexors. A. The FDP can be this zone is also known as the spaghetti
tested by holding the PIP joint in extension and testing wrist.
for DIP joint flexion. In this example, the FDP is intact. B.
(e) Thumb—The thumb has only one extrin-
The FDS can be tested by holding the adjacent digits in
sic flexor tendon. Surgical repair is some-
extension and testing for PIP joint flexion of the affected
digit. In this example, the FDS in intact. (Reprinted with what simpler, except for a Zone III repair,
permission from Rettig AC. Clin Sports Med. 1992;11:77–99.) where the flexor pollicis longus (FPL) ten-
don is difficult to access because of the
thenar musculature. This often requires a
flexor tendon repair is imperative, since dam- separate incision at the carpal tunnel to
age to the epitenon stimulates adhesions. safely retrieve the retracted flexor tendon.
The flexor tendon sheath is preserved, and • Prognostic factors—A clean laceration has a
it is imperative to maintain the A2 and A4 better prognosis than a crush injury. Asso-
pulleys for composite flexion without a bow- ciated injuries such as fracture or skin loss
stringing deformity. Suture technique uses a worsen the prognosis. Zone II injuries carry
3–0 or 4–0 nonabsorbable synthetic suture as the worst prognosis. Younger patients gener-
a core suture to prevent gapping during the ally have a better prognosis than have older
early postoperative period. A circumferen- patients, although children present special
tial suture is then added to the core suture management problems because of the small
to smooth the tendon surface. Sheath repair size of the injured structures and the pa-
may also improve tendon gliding and the ini- tient’s ability to cooperate.
tial synovial tendon nutrition, although this • Flexor tendon rehabilitation protocol—
remains controversial at this time. Postoperative management includes a dorsal
• Repair by zone hood splint and controlled mobilization for
(a) Zone I—The FDP tendon is advanced for 6 weeks. Complete immobilization may be
direct repair. If less than 1.0 cm of tendon appropriate for the young or uncooperative
is still attached to the distal phalanx, the patient. The wrist is held in 35° of flexion and
tendon is reinserted to the bone with a the MCP joint in 45° of flexion, with the inter-
pullout button. The tendon should not be phalangeal joints extended. Controlled mobi-
advanced more than1.0 cm. lization may limit the formation of restricting
(b) Zone II—Simultaneous repair of both the adhesions. Early mobilization programs
FDS and the FDP tendons is attempted include passive motion (Duran’s program)
or a combined gentle passive/active tendon (b) Tendon rupture—Tendon rupture after

excursion with rubber bands (Kleinert’s pro- primary repair should undergo imme-
gram). This program is usually initiated 3 to diate re-repair when identified. The re-
5 days after surgical repair. Active flexion and sults may still approach those of a primary
extension exercises may begin 4 to 6 weeks repair. Rupture of a flexor tendon during
after repair. Isolated blocking exercises or or after tenolysis surgery may require
electric stimulation of the flexors is delayed staged reconstruction with free grafts.
for 6 weeks. For smaller children, rehabili- (c) Quadriga effect—Decreased active mo-
tation of flexor tendon repairs should be- tion in an uninjured digit may result when
gin with cast immobilization for 4 weeks. the digit has a common muscle origin
• Results—In spite of ongoing improvement in to an adjacent injured digit, such as the
flexor tendon repair, the restoration of nor- FDP tendons to the fingers. Verdan ex-
mal function is difficult to achieve. Good re- plains this effect with the analogy of a
sults often follow surgical repair in Zones I, Roman chariot in which the reins of all
III, IV, and V. Functional results are much less four horses are controlled in unison. The
certain in Zone II. Results are often reported four FDP tendons have a common muscle
in terms of total active motion (TAM), which belly, and therefore DIP flexion of any fin-
sums total active flexion for the MCP, PIP, and ger normally results in DIP flexion of the
DIP joints minus the total extension deficit in other three fingers. A limitation of DIP
degrees for these same three joints. flexion in any finger (such as from ex-
• Partial lacerations—Unrecognized partial lac- cessive shortening of the FDP tendon
erations may lead to mechanical triggering or following repair of amputation) re-
rupture. Tendon lacerations involving less sults in a limitation of DIP flexion in
than 25% of the cross-sectional area can be the other three fingers. This is in con-
treated with resection of any oblique flap. trast to the FDS, which maintains inde-
Lacerations involving up to 50% of the cross- pendent muscle function to each finger.
sectional area can be treated with a running 5. FDP rupture
suture around the periphery. Lacerations • Overview—Avulsions of the FDP occur most
greater than 50% of the cross-sectional area frequently in young adult men playing foot-
should be repaired with a core suture and a ball and rugby. The ring finger is affected in
running circumferential stitch. most cases. The rupture occurs when the
• Secondary repair—Delayed primary repair finger is forcefully extended during maximal
may no longer be possible later than 4 weeks contraction of the profundus muscle. The
after injury. Secondary repair may require pathognomonic feature of this diagnosis is
flexor tendon grafting or staged tendon recon- the inability to actively flex the DIP joint
struction with a Silastic Hunter rod, including of the injured finger.
possible pulley reconstruction. Patients with • Classification—Avulsions of the FDP insertion
multiple surgical failures may be poor candi- have been classified by Leddy and Packer.
dates for staged reconstruction and may re- (a) Type I—The FDP tendon retracts all the
quire PIP joint arthrodesis or even amputation. way into the palm and is held there by
• Complications the lumbrical origin. Both vincula have
(a) Adhesions—Adhesion may limit active ruptured, and therefore a substantial por-
flexion despite normal passive range of motion of the blood supply to the profundus
tion. Tenolysis of the flexor tendons may tendon is lost.
improve active motion. Tenolysis should (b) Type II—The FDP tendon retracts to the
rarely be performed before 3 months level of the PIP joint, leaving the long
from the injury, and requires a moti- vinculum to the FDP tendon intact, pre-
vated patient. Local anesthesia is recom- serving more of the blood supply and re-
mended when possible to evaluate gains taining more of the length. Occasionally,
in motion as the procedure progresses. If a small bony flake can be seen at the level
general anesthesia is used, an additional of the PIP joint on a lateral radiograph.
proximal incision may be required for (c) Type III—The FDP tendon ruptures with a
traction/excursion check of the tendon. large bone fragment, holding the FDP ten-
Immediate active range of motion should don out to length distal to the A4 pulley.
begin within 24 hours after tenolysis. The large fragment may be associated
with a comminuted intraarticular frac- of the profundus tendon. Rehabilitation must

ture of the DIP joint. be carefully supervised to avoid creating a PIP
• Treatment—Surgical repair of the FDP tendon flexion contracture, especially after delayed
is recommended as soon as the diagnosis is advancement for a ruptured tendon.
made, preferably less than 2 weeks from injury. B. Extensor Tendon Injuries
(a) Type I—Surgical repair should be under- 1. Anatomy (Fig. 24-23)—Extension of the fingers
taken within 7 to 10 days, advancing the is a complex and more intricate motion than
FDP tendon to the distal phalanx with a finger flexion, incorporating both (a) extrinsic
pullout button. If treatment is delayed, extensor tendons and (b) intrinsic muscles of
the tendon becomes contracted and ne- the hand. The extensor tendon is stabilized over
crotic as a result of loss of its nutri- the MCP joint by the sagittal bands, which in-
tional supply, and it can no longer be sert on the proximal phalanx and volar plate of
advanced to the distal phalanx. the MCP joint. The extensor digitorum com-
(b) Type II—Surgical repair of the FDP tendon munis tendon divides into three slips distal to
to the distal phalanx is recommended. In the MCP joint, with the central slip extending
contrast to Type I injuries, these injuries onto the middle phalanx to actively extend the
can be reinserted at a later date, pos- PIP joint. The two lateral slips diverge to meet
sibly 4 weeks or longer, because of the the interossei and lumbrical bands and then
better blood supply and preservation of form the lateral bands to the terminal slip
length of the tendon. (terminal extensor tendon), which inserts on
(c) Type III—ORIF of the bone fragment is the distal phalanx for DIP joint extension. Over
necessary to restore a congruent DIP the proximal phalanx, the common exten-
joint and to reinsert the flexor tendon. sor tendon is particularly prone to adher-
In rare instances, the profundus tendon ence after fracture or laceration. The lateral
may also be ruptured from the large bone bands are similarly vulnerable to adherence
fragment, and will need to be advanced over the middle phalanx after fracture or
as with a Type I or II injury (Fig. 24-22). laceration. The interosseous muscles include
(d) Neglected injury—Cases seen too late for four dorsal interossei that abduct the index,
reinsertion may best be left alone or may middle, and ring fingers, as well as three volar
require excision of the retracted profun- interossei that adduct the index, ring, and little
dus tendon, with tenodesis or arthrod- finger. All interossei pass volar to the axis of
esis of the DIP joint if unstable. the MCP joint, providing effective MCP joint
• Complications—Misdiagnosis of this injury as flexion and interphalangeal joint extension.
a sprained or jammed finger delays treatment All interossei are innervated by the deep branch
and substantially jeopardizes the result. Despite of the ulnar nerve. Retinacular ligaments also
repair, flexor tendon adhesions may still limit assist digital function. The transverse retinac-
composite flexion. A 10° to 15° loss of extension ular ligament proceeds from the flexor ten-
at the DIP joint is common after readvancement don sheath to the lateral edges of the conjoint
FIGURE 24-22 A. Injury film slowing

an avulsion fracture (Leddy and Packer
Type III injury) from an FDP avulsion.
B. Postoperative film showing reduction
and stabilization of the bony fragment
with a Kirschner wire and a pullout wire.
Dorsal FIGURE 24-23 Extensor

aponeurosis apparatus.
Extensor digitorum (Sagittal bands)
communis tendon (Oblique fibers)
Central extensor tendon (Central slip)
Lateral extensor tendon
Terminal extensor tendon
Interosseous
muscle
Lateral
Lumbrical
Transverse band Transverse Oblique
muscle retinacular retinacular
metacarpal ligament ligament
ligament
Oblique retinacular Terminal extensor tendon

ligament
Triangular ligament
Lateral extensor tendon
Dorsal Central extensor tendon

aponeurosis (Central slip)
(Oblique fibers)
(Sagittal bands)
Lumbrical muscle
Interosseous
muscle
Extensor digitorum
communis tendon
lateral band, serving to prevent excessive dor- (d) Zone IV is the proximal phalanx.
sal shift of the lateral bands. The oblique reti- (e) Zone V is the MCP joint.
nacular ligament runs from the volar crest of (f) Zone VI is the metacarpal.
the proximal phalanx to the lateral terminal ex- (g) Zone VII is the dorsal wrist retinaculum.
tensor tendon, linking the motion of the PIP and (h) Zone VIII is the distal forearm.
DIP joints. The triangular ligament holds the (i) Zone IX is the mid and proximal forearm.
lateral bands over the middle phalanx, prevent- • Diagnosis and examination—Limited active
ing excessive volar shift of the lateral bands. extension after traumatic laceration should
Grayson’s ligament is volar to the neurovas- suggest partial or complete extensor tendon
cular bundle, holding it in place and prevent- injury.
ing bowstringing of the digital artery and nerve • Treatment
when the fingers flex, and Cleland’s ligament is (a) Zone I—Laceration of the terminal slip at
dorsal to the neurovascular bundle. the DIP joint results in a mallet deformity.
2. Extensor tendon lacerations—Management of Although passive extension is present,
lacerations to the extensor mechanism requires active extension is lost. Hyperextension
the same amount of skill and knowledge as of the PIP joint may be observed as a
flexor tendon injuries. result of unopposed central slip tension
• Classification—Extensor tendon lacerations and PIP volar plate laxity. Open tendon
have been classified according to injury lacerations should be repaired with un-
Zones I to IX. dyed suture and with internal K-wire
(a) Zone I is the DIP joint. fixation of the DIP joint in extension, fol-
(b) Zone II is the middle phalanx. lowed by a supplemental splint. Limited
(c) Zone III is the PIP joint. motion may begin at 6 weeks, although a
night splint should still be used for per- mechanism and hood, followed by dy-
haps another 2 months. Deep abrasions namic splinting. The sagittal bands must
with loss of skin, subcutaneous tissue, be repaired to the extensor tendon, or
or tendon substance may require a ten- the tendon may sublux from the dorsum
don graft or arthrodesis of the DIP joint. of the joint, and the finger will still exhibit
(Closed tendon avulsion of the terminal loss of active extension. Injuries of the ex-
slip is discussed in the next section.) tensor mechanism at the MCP joint may
(b) Zone II—Injuries to the extensor mecha- often be secondary to a human bite
nism over the middle phalanx usually wound. A high index of suspicion should
result from laceration rather than avul- be present when examining lacerations in
sion. Partial laceration of the tendon is this area. Human bite wounds are at high
common because of the wide expanse risk for wound infection, septic arthritis,
and curved shape of the tendon over and laceration of the extensor tendon.
the middle phalanx. Partial lacerations This wound must be irrigated and de-
(50% of the tendon) can be treated with brided, the extensor tendon repaired,
skin wound care, followed by gentle ac- and the patient given appropriate antibi-
tive motion in 7 to 10 days. Complete lac- otics. If heavily contaminated, the tendon
erations require suture repair and static laceration may have to be repaired sec-
splinting in full extension for 6 weeks, ondarily 5 to 7 days later. Dynamic splint-
possibly with K-wire fixation of the DIP ing is particularly effective in managing
joint in extension. lacerations at the MCP joint level.
(c) Zone III—Disruption of the central slip (f) Zone VI—Extensor tendon lacerations
of the extensor tendon at the PIP joint of the dorsal aspect of the hand have a
results in volar migration of the lateral better prognosis than finger lacerations.
bands and a boutonnière deformity (see Tendons in Zone VI are located in the
Fig. 24-10). Compensatory hyperexten- subcutaneous tissues without close rela-
sion may occur at the DIP joint. Open ten- tionship to the metacarpal bones, have
don lacerations should be repaired with a sufficient cross-sectional diameter to
suture, with internal fixation of the PIP accept buried core-type sutures, and are
joint with a K-wire in extension but not effectively rehabilitated with dynamic
hyperextension, and with supplementary splinting because of greater tendon ex-
splinting for up to 6 weeks. The DIP joint is cursion. Dynamic splinting may begin 3
left free for flexion to maintain excursion to 5 days after repair.
of the lateral bands. After K-wire removal, (g) Zone VII—Injures to the extensor mecha-
continued splinting is advised, and range nism at the wrist level are associated
of motion begins. Techniques to augment with injuries to the extensor retinacu-
the central slip repair with portions of the lum. Limited excision of portions of the
lateral band have been described. (Closed retinaculum may be needed to facilitate
tendon avulsion of the central slip is dis- tendon exposure and prevent mechanical
cussed in the next section.) triggering or adhesions after repair. Pre-
(d) Zone IV—These extensor tendon lacera- serving a portion of the retinaculum pre-
tions are similar to those in Zone II in that vents bowstringing in the mobile wrist.
they are usually partial lacerations as a Again, early dynamic splinting has dem-
result of the tendon width and underly- onstrated excellent results.
ing curvature of the osseous phalanx. (h) Zone VIII—Repair of extensor tendon
Lacerations of an isolated lateral band lacerations over the distal forearm may
can be repaired, followed by immediate require approximation of the distal ten-
protected motion. Complete lacerations don to the proximal muscle belly. A fi-
require direct repair, with stabilization of brous tissue raphe in the muscle belly
the PIP joint in the extended position for should be repaired with multiple sutures
6 weeks, either with a static splint or with and without strangulation of the muscle.
a K-wire. Dynamic traction may be used Postoperative management may require
in some patients. static immobilization of the wrist in 45° of
(e) Zone V—Lacerations over the MCP joint extension for 4 to 5 weeks if a significant
require open repair of the extensor muscle belly repair has been required.
(i) Zone IX—Lacerations of the extensor ten- more than 30% of the joint surface is dis-
don in the proximal forearm may be com- cussed earlier in this chapter under the
plicated by injury to the radial nerve. If section Joint Injuries of the Hand.
the injury involves only the muscle belly, (c) Complications
a careful repair of the muscle belly is per- • Complications of splinting—Complica-
formed; tendon weaving with the palmaris tions after splint treatment for a mallet
longus may be an effective technique for finger may be as high as 40%, usually
muscles with more than 50% of their sub- including transient skin problems such
stance lacerated. The radial nerve should as dorsal maceration, skin irritation, or
be explored and repaired if injured. After tape allergy. Other complications can
surgery, the wrist is immobilized in 45° of include transverse nail grooves, pain
extension, and the elbow is immobilized while wearing the splint, or skin necro-
in 90° of flexion if the injured muscles sis if the DIP joint is hyperextended. A
originate above the lateral epicondyle. residual extensor lag may result and
Immobilization is continued for 4 weeks, may require longer full-time splinting.
followed by protective range of motion • Complications of surgery—A greater
for another 4 weeks. than 50% complication rate has
3. Extensor tendon ruptures (closed injuries) been noted in patients treated surgi-
• Terminal slip rupture (mallet finger) (see cally for mallet finger. Complications
Fig. 24-5)—Closed injury or blunt trauma may include permanent nail deformity, joint
avulse the extensor tendon from the distal incongruities, infection, pin or pullout
phalanx, resulting in a mallet deformity. This wire failure, posttraumatic arthritis,
injury may be referred to as a mallet finger, subluxation, and residual extensor lag.
baseball finger, or dropped finger. In one series, additional surgery was re-
(a) Evaluation—Extensor droop is noted at quired in 7 out of 45 patients, including
the DIP joint, although full passive exten- arthrodesis in 4 and amputation in 1.
sion is present. Hyperextension of the • Swanneck deformity (see Fig. 248)—A
PIP joint may be observed, particularly mallet finger deformity that coexists
in cases with PIP volar plate laxity. Mi- with PIP volar plate laxity allows the
crovascular anatomy of the distal digital PIP joint to hyperextend, resulting in
extensor tendon reveals a deficient blood a swan-neck deformity. Correcting the
supply over the DIP joint, explaining vul- mallet finger deformity usually restores
nerability to rupture and poor results the correct balance to the central slip
with open suture repair of the ruptured at the PIP joint and the terminal slip at
tendon or inappropriately applied splints. the DIP joint. One technique for cor-
(b) Treatment—Closed tendon avulsion of the recting this problem is a spiral oblique
extensor tendon at the PIP joint is treated retinacular ligament reconstruction
with external splinting to maintain the using the palmaris longus tendon. Al-
DIP joint in the extended (not hyperex- ternatively, a Fowler extensor tendon
tended) position for 8 weeks, followed central slip release may be considered
by gradual splint removal over the next to rebalance the extensor mechanism.
4 weeks. Excellent-to-good results are an- • Neglected mallet deformity—Manage-
ticipated in 80% of cases when treatment ment of chronic mallet deformity seen
is provided early. Fair or poor results fol- late may include arthrodesis or sec-
low delayed treatment or improper wear- ondary extensor tendon reconstruc-
ing of splints. Direct repair of tendon tion. If a satisfactory joint is present
injuries without a bone fragment is not without arthritis, the extensor tendon
indicated. A buried transarticular K-wire can be advanced 2 to 3 mm, followed
may be used for 6 weeks in patients who by stabilization of the DIP joint in
cannot wear a splint, such as a dentist, the extended position with a K-wire
surgeon, or professional athlete, although for 6 weeks. If significant degenerative
a splint may still need to be worn the ma- arthritis is present, the only viable sur-
jority of the time to protect the pin from gical option is arthrodesis.
breakage. Operative treatment for mallet • Central slip rupture (boutonnière finger)
fingers with fracture fragments involving (see Fig. 24-10)
(a) Overview—Closed injury that ruptures initial evaluation, failure to achieve full
the central slip at the PIP joint results PIP extension before surgery, or a pa-
in a boutonnière deformity as the lateral tient age greater than 45 years.
bands migrate in a volar direction. There • Traumatic Dislocation of the Extensor Ten-
is loss of extension of the PIP joint, with don (Rupture of the Sagittal Band)-Rupture
compensatory hyperextension at the DIP of the radial sagittal band at the MCP joint
joint. An acute forceful flexion at the PIP may result in subluxation or dislocation
joint may cause this injury. Volar dislo- of the extensor tendon off the metacar-
cation of the PIP joint may also result in pal head. The long finger is most commonly
avulsion of the central slip. involved.
(b) Evaluation—Initially, the PIP joint has (a) Evaluation—The extensor tendon usu-
swelling, with perhaps only a mild exten- ally dislocates in an ulnar direction, as-
sor lag. The boutonnière deformity may sociated with incomplete finger extension
not be apparent until 10 to 21 days after and ulnar deviation of the involved digit.
injury. A 15° to 20° extensor loss at the PIP With extension, the extensor tendon may
joint, or weak extension against resistance, realign once again over the dorsal meta-
should suggest rupture of the central slip. carpal head, only to sublux again with at-
(c) Treatment tempted active flexion.
• Closed acute injury—An acute central (b) Treatment—Acute tears are satisfacto-
slip rupture that has not yet developed rily repaired by primary suture of the
volar subluxation of the lateral bands can defect. If primary repair is not pos-
be treated with static splinting of the PIP sible, then a distally based slip of the
joint in full extension for 6 weeks. Active extensor tendon from the ulnar side
and passive DIP joint flexion exercises may be passed to the radial collateral
are encouraged to centralize the lateral ligament to stabilize the extensor ten-
bands, prevent oblique retinacular liga- don, as described by Carroll. Several case
ment tightness, and advance the central reports of successful closed treatment by
slip. A variety of means are available to cast immobilization with the MCP joint
maintain extension of the PIP joint, in- in extension for 4 weeks have been de-
cluding a static splint, a cast, or a tran- scribed. Conservative treatment is more
sarticular Kirschner wire. If the central likely to be successful with treatment
slip has been avulsed with a bone frag- instituted immediately after injury.
ment over the PIP joint, open repair is C. Nerve Injuries
indicated, with excision of the bone frag- 1. Anatomy—Peripheral nerves are composed of
ment or repair of the central slip to the motor, sensory, and sympathetic nerve fibers.
middle phalanx; the PIP joint is trans- Digital nerves contain primarily sensory and sym-
fixed with a K-wire for 2 to 6 weeks. pathetic fibers. Connective tissue supports the
• Delayed treatment—Delayed treatment neural tissue. The external epineurium forms
for an established boutonnière defor- the outer covering of the peripheral nerve. The
mity begins with stretching and splint- extension of this connective tissue into the nerve
ing. Any tendon procedure is best done that separates the fascicular groups is called the
after the joint has regained full passive internal epineurium. The perineurium is the
extension. Stiffness that does not re- connective tissue that wraps the fascicles, and
spond to splinting may require capsular the endoneurium is the fine connective tissue
contracture release, followed by repair between nerve fibers. Segmental nutrient vessels
or advancement of the central slip. Sur- supply longitudinally oriented nerves through
gical treatment is considered only after the epineurium. An intrinsic longitudinal blood
failure of prolonged conservative treat- supply facilitates the safe elevation of a nerve
ment. Surgical options include central from its tissue bed over a long distance.
slip advancement to the middle pha- 2. Nerve regeneration—When the axon is severed,
lanx (Kilgore), lateral band transfers the distal nerve undergoes Wallerian degenera-
(Matev), and extensor tenotomy over tion. Schwann cells proliferate and phagocytize
the middle phalanx (Fowler). Poor re- the axon and myelin debris in the distal nerve
sults are associated with a PIP contrac- segment. This process clears the degraded my-
ture greater than 30° at the time of the elin from the Schwann cell tube, providing a
favorable environment for regenerating axons. • Neurotmesis, or fifth-degree injury, repre-

The cell body responds to injury by increasing sents complete transection of the nerve. Di-
in size, migrating the nucleus to the periphery rect nerve repair or nerve graft is necessary
of the cell, and producing materials required to obtain recovery. Without repair, there will
for neurotransmitter function and repair of the be no functional recovery.
nerve. The production of growth-associated • Mixed Injury, or sixth-degree injury, com-
proteins is increased 100-fold. Axonal sprout- bines the various patterns of injury from
ing occurs at the site of injury up to 24 hours fascicle to fascicle within a nerve and varies
after laceration. Most sprouts are generated at along the length of the nerve as well.
the most distal intact node of Ranvier. Multiple 4. Evaluation—Preoperative evaluation after lac-
collateral sprouts from each axon then advance eration is critical to planning surgery. Static or
distally as a regenerating unit, which then may moving two-point discrimination demonstrates
enter separate and often unrelated Schwann cell sensory deficits. The absence of sweating
tubes in the distal nerve stump. Once entered, demonstrates the interruption of sympathetic
the repair pathway follows the neural tube to nerve function. Digital nerve function should
the end organ. The growth cone at the tip of be tested, not at the tip of the finger but over
the regenerating axon samples the surround- the proximal third of the distal phalanx. Palmar
ing terrain and pulls the axon into its most suit- cutaneous nerve branches of the median nerve
able environment. The Schwann cell is critical can be tested near the thenar eminence. Dorsal
to growth cone elongation. Several products cutaneous branches of the ulnar nerve should
contribute to growth cone elongation, including be tested over the dorsal ulnar surface of the
laminin in the Schwann cell membrane. hand. Radial nerve function should be tested
3. Classification—Several classification systems over the dorsal first web space. Median nerve
have been described. Seddon’s classification function can be tested over the pulp of the
includes neurapraxia, axonotmesis, and neu- thumb and index finger. Ulnar nerve function
rotmesis. Sunderland’s classification includes can be tested over the pulp of the little finger.
first-, second-, third-, fourth-, and fifth-degree 5. Treatment
injury. Mackinnon’s classification adds sixth- • Nerve repair
degree, or mixed, nerve injury. (a) Technique—Microsurgical technique with
• Neurapraxia, or first-degree injury, repre- appropriate magnification, instrumenta-
sents a bruise or contusion to the nerve. The tion, and suture material is required for
prognosis for recovery is excellent without successful nerve repair. The nerve repair
surgery. There is a local conduction block must be tension free. If not, an interposi-
with no axonal disruption. Treatment is tion nerve graft or collagen conduit may
observation, awaiting recovery over several need to be considered. Primary repair of
days to 12 weeks. the nerve provides the best results. The
• Axonotmesis or second-degree injury—Axonal proximal and distal extent of the nerve
injury has occurred with Wallerian degeneration should be mobilized, appropriate scar
distally. However, the neural tube is still intact. tissue is resected from the ends of the
Axonal sprouting occurs within the appropri- damaged nerve to visualize the fascicles,
ate endoneural tube. Excellent recovery is an- and the nerve is repaired without ten-
ticipated without surgery; however, the rate of sion. Extreme postural positioning of
recovery is slower, perhaps 1 inch per month. the extremity to facilitate end-to-end re-
• Third-degree injury—Axonal injury occurs, pair should be discouraged. Epineural
with varying degrees of scarring within the repair is satisfactory for most mixed
endoneurium. Recovery varies from complete sensory nerves in the hand. Group fas-
recovery to no recovery depending on the de- cicular repair is not indicated for these
gree of endoneurial scarring and mismatching sensory nerves, since increased surgical
of the regenerating sensory and motor fibers. manipulation of fascicles may result in
• Fourth-degree injury—The nerve is physi- more scarring than epineural repair alone.
cally intact, but scar tissue prevents any (b) Timing—The majority of acute nerve in-
nerve regeneration across the area of injury. juries should be repaired primarily when
This represents a neuroma-in-continuity. No a skilled surgeon and appropriate instru-
recovery can occur without excision of the mentation are available and the patient
scar tissue and nerve repair or nerve graft. is medically stable with an adequate
nothing-by-mouth status. Delayed primary expectant observation for 3 months. If there

repair of the nerve is still possible after 3 or is no evidence of clinical recovery, surgical
more weeks with mobilization of the nerve, exploration may be warranted, especially
but becomes progressively more difficult. if localized to an area of nerve entrapment,
(c) Rehabilitation—After completion of the which may benefit from early decompression
repair, the amount of movement allowed of the nerve.
by the digit is noted (intraoperatively) 6. Results—The results of nerve repair and nerve
and is incorporated into the postopera- grafting have improved since World War II. Al-
tive plans for protected motion. Postop- though results can be variable, patients can ex-
erative motor and sensory reeducation pect sensory recovery of S3 or greater in 86% of
maximizes the potential surgical result. cases with nerve repair and S3 sensory recov-
• Nerve graft—When nerve repair without ten- ery in 80% of cases with nerve grafting (Hyatt’s
sion is not possible, a nerve graft should be method of end result evaluation; S3 indicates
considered. Potential donor sites for a nerve return of superficial cutaneous pain and tactile
graft include the sural nerve for reconstruct- sensibility [proprioception and sensation]). Fur-
ing a large peripheral nerve and the medial thermore, children have better neurologic re-
antebrachial cutaneous nerve for digital covery following nerve injuries than adults; age
nerve defects. The clinical role of vascular- is the best prognostic indicator of recovery.
ized nerve grafts has not been established. D. Vascular Injuries
• Neuroma-in-continuity—Intraoperative eval- 1. Anatomy (Fig. 24-24)—The ulnar artery gener-
uation of the neuroma-in-continuity is help- ally is more dominant than the radial artery
ful with decision making. After neurolysis and provides the primary arterial contribution
of the neuroma, a disposable nerve stimula- to the superficial palmar arch. The radial ar-
tor is used to identify motor function distal tery passes deep in the snuffbox between the
to the neuroma. Working motor fibers are thumb and index metacarpals to form the deep
protected, and silent sensory fascicles can palmar arch. Regarding the digital arteries, the
be resected and reconstructed with nerve ulnar digital artery is generally larger than the
graft if needed. If the sensory fascicles are radial digital artery, except for the little finger.
intact and motor function is absent, ten- 2. Evaluation
don transfers may be more appropriate. • History—Presenting signs for ischemia may
• Closed nerve injuries—A patient with a be pain, pallor, and absence of pulse. The pa-
closed injury to a nerve is treated with tient may note a pulsatile mass at the previous
Volar
Digital nerve
Digital artery
Radial nerve Dorsal

Radial artery
Superficial palmar
arch
Deep palmar
arch
Ulnar artery
Median nerve
FIGURE 24-24 Anatomy of the arteries and nerves of the hand. The digital nerves are the terminal branches of the
median and ulnar nerves and are volar to the digital arteries in the fingers.
A B C D
FIGURE 24-25 Allen’s test. A. The patient is instructed to open and close the hand several times and squeeze tightly.
B. The examiner occludes both the radial and ulnar arteries. C. The patient is instructed to open the hand, and one
of the arteries is released. D. If the artery is competent, normal color will return to the hand. Both arteries should be
selectively tested. If one artery allows quicker return of normal color, the patient may be classified as radial or ulnar
dominant.
site of laceration or may experience cold in- 4. False aneurysm—Partial injury of an arterial
tolerance, ulceration, or symptoms of Rayn- wall may lead to the formation of a false aneu-
aud’s disease. Exposure to vibratory tools and rysm. The false aneurysm may present as a pul-
known collagen diseases should be sought. satile mass. An arteriovenous fistula may also
• Physical examination—The limb should be result from partial injury to an artery. A false
observed for color, capillary refill, or possible aneurysm should be resected, with or without
splinter hemorrhages in the nailbed. The pe- arterial reconstruction, as dictated by the distal
ripheral pulses are palpated, and Allen’s test circulation.
is performed for the radial and ulnar arteries 5. Cannulation injury—Direct injury to the ves-
at the wrist (Fig. 24-25), as well as for the digi- sel wall during arterial cannulation may occur
tal vessels (Fig. 24-26). Areas of tenderness or with needles, such as when drawing an arterial
any pulsatile mass are noted. blood gas or placing a radial artery catheter.
• Noninvasive diagnosis—A Doppler scan is Distal ischemia of the hand may be a problem
performed to map out arterial topography if the ulnar artery is hypoplastic or absent.
and to record pulse volume. A cold stress test
may be useful in patients with symptoms of
Raynaud’s disease.
• Invasive diagnosis—An arteriogram allows
study of the entire upper extremity from the Step 1
axillary artery to the digits. Digital subtrac-
tion studies provide good detail with a smaller
amount of contrast. Tolazoline (Priscoline)
or urokinase can be instilled at the time
of arteriogram for vasodilation if needed.
3. Penetrating trauma—Penetrating trauma result- Step 2
ing in arterial injury may require surgical ex-
ploration for partial or complete injury to the
vessel. Immediate bleeding after injury should
be managed with direct pressure. No attempt
should be made to probe the wound or to li- Step 3
gate a vessel in the emergency department. At-
tempted ligation with poor visualization may
injure a nerve or compromise possible repair
of the vessel in the operating room. Digital ar-
teries constrict and clot, requiring no further
treatment, except for associated injuries to the FIGURE 24-26 Digital Allen’s test. Note the similarity to
digital nerves or tendons. Allen’s test at the wrist (see Fig. 24-25).
Treatment may require vasodilators, stellate • Ischemia time—Replantation is usually not
ganglion block, or surgery to repair the artery recommended if the warm ischemia time is
and thrombectomy with a Fogarty catheter. greater than 6 hours for an amputation proxi-
6. Acute injection injury—Spasm and occlusion mal to the carpus or greater than 12 hours for
of a major vessel may occur with intraarte- an amputated digit, whereas cold ischemia
rial injection. Pharmacologic management in- times for amputated parts can be extended to
cludes intraarterial urokinase at the time of 10 to 12 hours for an amputation proximal to
arteriogram, systemic vasodilators, or stellate the carpus and 24 hours for a digit (because
ganglion block. Persistent clots may require re- they have no muscle).
moval with a Fogarty catheter. 2. Indications—Factors that influence the deci-
7. Ulnar artery thrombosis—Repetitive trauma in sion to attempt replantation include the level of
the hypothenar region of the palm may result amputation; the type of injury (such as sharp,
in thrombosis of the ulnar artery. The throm- crush, avulsion, or the presence of a segmen-
bosis may present with a tender hypothenar tal injury); length of warm or cold ischemia
mass, cold intolerance, and possible vascular time; the age, general health, and occupation
insufficiency to the fingers. The ulnar artery of the patient; and the potential for rehabili-
demonstrates no flow with Allen’s test. A Dop- tation. Good indications for replantation
pler study or an arteriogram confirms the include (a) the thumb at almost any level
diagnosis. Treatment options include sympa- (since a successful replantation is superior to
thectomy, resection without reconstruction, any other method of reconstruction after am-
and possible interposition vein graft for the putation), (b) individuals with multiple digit
ulnar artery. amputations (in whom less severely damaged
8. Ring avulsion injuries—Urbaniak has classified digits can often be replanted), (c) metacar-
ring avulsion injuries. pal amputations through the palm (since
• Class I—Circulation is adequate. Standard replantation will have a better outcome than
bone and soft-tissue treatment is sufficient. that achieved with a prosthesis), (d) almost
• Class II—Circulation is inadequate, but any body part of a child, and (e) individual
bones, tendons, and nerves are intact. Vessel digit amputations distal to the superficialis
repair will preserve viability. Revasculariza- insertion. The patient must understand that
tion is recommended for the arteries, with the functional and cosmetic limitations of the
vein grafting if needed. amputated part will persist despite successful
• Class III—Complete degloving or a complete replantation of the digit.
amputation injury occurs. These injuries 3. Contraindications—Contraindications for re-
have the worst prognosis for replantation plantation include severely crushed or man-
and are often best managed with surgical gled parts, amputations with a prolonged
amputation of the digit. If the amputation warm ischemia time, and amputations with
is distal to the superficialis insertion, vein multiple levels of injury. Furthermore, patients
and nerve grafts may be indicated for re- with serious arteriosclerotic disease or pa-
plantation. If the PIP joint is damaged or the tients who are mentally unstable are not good
proximal phalanx is fractured, amputation is candidates. Replantation of individual fin-
recommended. ger amputations proximal to the FDS inser-
E. Replantation tion in the adult, particularly for the index
1. Overview—Technical advances in microvascu- finger, do not improve hand function, and
lar surgery now make it possible to reattach the patient may be better served with a ray
parts of a digit at almost any level, provided resection.
that it has been sharply amputated. 4. Emergency department—The amputated parts
• Replantation—Replantation is the reattach- should not be placed directly on ice and should
ment of a body part that has been totally sev- not be frozen. The digits should be placed in a
ered from the body without any soft-tissue sterile plastic specimen cup filled with physi-
attachment. ologic lactated Ringer solution, and then the
• Revascularization—Revascularization is the entire container placed on ice. The patient’s
repair or reconstruction of blood vessels that medical condition is evaluated and stabilized
have been damaged to restore circulation in the emergency department. The amputated
to a body part that has had an incomplete part is taken to the operating room for initial
amputation. dissection and tagging of structures.
5. Surgical technique amputation, shortening the period of recovery, and

• Shortening of the bone—Bone shortening of earlier return to function.
0.5 to 1.0 cm in the digit will enable primary 1. Principles—Amputation should strive to preserve
repair of the arteries and veins. Fixation can functional length while maintaining function
be obtained with crossed K-wires, intraosse- and cosmesis. Stabile and nontender soft-tissue
ous wires, or plates. coverage is necessary, with sensibility (pro-
• Repair of the extensor tendons. prioception and sensation). Symptomatic neu-
• Repair of the flexor tendons—A Tajima or a romas must be avoided. Early mobilization of the
modified Kessler technique is suggested. proximal joints minimizes adjacent contractures.
• Anastomosis of the digital arteries—At least Physical therapy and a psychologist for selected
one artery should be repaired for each digit. patients may be necessary for early acceptance
A vein graft may be required for a significant of the injury and return to independence.
segmental defect. 2. Level of amputation
• Repair of the digital nerves. • Distal phalanx (fingertip amputations are dis-
• Anastomosis of the veins—Two dorsal veins cussed later)—If traumatic amputation occurs
should be anastomosed in each digit. through the DIP joint, the bone may be short-
• Skin repair—Loose approximation of the ened and contoured for primary closure. The
wound is performed. Skin coverage may be digital nerves are resected away from the cu-
achieved with split-thickness skin grafts or lo- taneous scar to prevent neuroma. The flexor
cal rotation flaps if necessary. tendon should not be sutured to the exten-
6. Postoperative management—The extremity is sor tendon. A volar skin flap is preferable.
elevated. The patient remains in bed in a quite, • Middle phalanx—The bone is shortened and
warm room; the patient should be well hy- contoured for primary closure. The superfi-
drated and should not have any nicotine or cialis insertion is preserved for active PIP
caffeine products. Anticoagulants such as as- flexion and strength.
pirin, dipyridamole (Persantine), low–molecu- • Proximal phalanx—The bone is shortened
lar-weight dextran, or heparin may be used. The and contoured for primary closure. The in-
replant is monitored. The first step if there is trinsics control flexion of the MCP joint. Ray
decreased skin temperature postoperatively is resection may be considered, especially for
to loosen the bandage and inspect for any con- the index finger if the thumb readily transfers
striction. Venous congestion may require treat- to the middle finger for function.
ment with medical leeches. A failing replant • Ray resection—If the amputation includes
requires careful evaluation. If not improved in the MCP joint, ray amputation may be indi-
4 to 6 hours, a return to the operating room cated primarily. Ray amputation can also be
may be required to evaluate and revise the performed later as an elective procedure if
anastomoses. Technical problems may in- desired by the patient. The cosmetic result
clude a back wall suture, thrombosis, or poor of a ray amputation is often less conspicuous
proximal inflow resulting from spasm. Technical than a short amputated digit, especially for
problems are most successfully managed within the index finger.
the first 48 hours after surgery. Revision of the 3. Thumb amputation
anastomosis may often require vein grafting. • Overview—The opposable thumb provides
7. Results—An 85% viability rate can be expected 50% of hand function. Any shortening of the
with modern microsurgical technique. Sensation thumb results in greater impairment.
may not be normal, but protective sensation • Treatment
with two-point discrimination of 10 mm or less is (a) Replantation—Replantation of an am-
seen in 50% of adults. Although cold intolerance putated thumb should be performed
symptoms are common, symptoms improve in whenever possible, since alternative re-
2 to 3 years. Range of motion is not normal, but construction is inferior in cosmesis and
patient acceptance of the digit after replantation function. The viability for replantation of
is good. Best results are seen in replantations a sharply amputated thumb ranges from
distal to the FDS insertion. Epiphyseal plates in 75% to 90%, whereas the viability rate for
children remain open and continue to grow. replantation of an avulsion amputation
F. Amputation—Amputation may be necessary when falls to 40%. Aggressive debridement of in-
a digit is not salvageable. Patients with severely jured tissue and the use of vein grafts have
mutilated digits may be best served by early improved thumb replantation survival.
(b) Amputation—Only patients with an ampu- (b) Direct closure—For direct closure to be
tation distal to the interphalangeal joint successful, the wound must not have
can demonstrate normal key-pinch activ- any tension on closure. If necessary, the
ity. If replantation is not an option, the bone is trimmed and shortened. The
bone should not be shortened, and sen- nail matrix should not extend past the
sate stable coverage should be provided. bone or a hooked nail results. The main
(c) Pollicization—If the thumb metacarpal is advantage of this technique is that it is
traumatically absent, pollicization of the a one-stage procedure.
index finger to the thumb position pro- (c) Skin grafting
vides an opposable digit. • Splitthickness skin graft—Splitthick-
(d) Toe-to-thumb transfer—For amputation at ness skin graft gives coverage over soft
the MCP joint, with an absent proximal pha- tissue and contracts to reduce wound
lanx, microsurgical transfer of a great toe or size with healing. This graft is easy to
the second lesser toe to the thumb will pro- obtain from the forearm or wrist, but
vide an opposable structure for grasping. may leave a scar at the donor site; it is
not useful over exposed bone.
IV. Fingertip and Nailbed Injuries—Fingertip and • Fullthickness skin graft—Fullthickness
nailbed injuries are common hand injuries that skin graft is more durable than split-
may lead to significant disability. The goals of treat- thickness skin graft but is more prone to
ment are to maintain adequate sensibility without failure. The donor site is usually better
hypersensitivity and to recover a normal range of cosmetically. A full-thickness skin graft
motion for the finger. The clinician should consider also cannot be used on exposed bone.
age, gender, occupation, and the involved digit when • Composite graft—A composite graft is
making treatment decisions. best reserved for use in children but
A. Fingertip Injuries still remains unpredictable and may
1. Classification delay more definite treatment. It pro-
• Simple laceration—The skin and dermis are vides excellent results if it works.
affected. (d) Replantation—Replantation has the best
• Tissue loss—There is loss of tissue with or outcome for amputations between the
without bone involvement. FDS insertion and the DIP joint. It has
(a) Transverse—The injury is straight the potential for normal appearance and
across. good sensibility but can result in cold in-
(b) Oblique dorsal—The tissue loss is pri- tolerance, hypersensitivity, or a hypotro-
marily dorsal. phic tip. Replantation is more expensive
(c) Oblique palmar—The tissue loss is pri- with a much longer recovery period.
marily palmar. (e) Local and regional flaps
2. Treatment • V–Y advancement—The lateral (Kut-
• Simple laceration—Treatment should in- ler) and palmar (Atasoy) flaps are
clude local wound cleansing with appropri- technically demanding but provide
ate debridement, followed by direct closure. innervated coverage for transverse
In adults, the clinician should normally use and dorsal oblique skin and soft-
a 5–0 nonabsorbable suture to minimize tissue loss. These flaps usually work
scar formation. In children, an absorbable for less than 1 cm of advancement. It
suture is appropriate. is important not to devascularize the
• Tissue loss—It is always important to ad- flap during dissection.
equately clean and debride the wound. • Volar advancement—The Moberg flap
(a) Open treatment—Open treatment is pre- is used only for the thumb. It can be
ferred in adults with a defect less than 1 used to cover approximately a 1.5-cm
cm2 and in children with slightly larger de- deficit but may cause a flexion con-
fects. This technique allows direct epithe- tracture. The biggest complication is
lization, with resultant scar contracture necrosis of the tip of the flap if the
that reduces the area and gives excellent vascularity is damaged.
results. The disadvantage of this tech- • Cross finger flap—This flap can cover
nique is the length of time to complete oblique palmar defects on the fin-
healing. ger, especially the volar surface, and
is very reliable. This flap may also be There is deep erythema and extensive blis-
innervated. Its disadvantages are that tering. These burns are painful and have a
it may cause stiffness and an unsightly higher risk of infection.
donor site. • Thirddegree burns—With thirddegree burns,
• Thenar flap—The thenar flap is es- there is loss of the complete thickness of
pecially useful in children and young skin. The skin is anesthetic, and hence it is
adults but is less useful in older adults not painful. It may appear to have a dirty
because of joint stiffness. The flap is cream to charred color.
limited in donor site availability. 2. Treatment
B. Nailbed Injuries—The best results follow prompt • Firstdegree burns—Firstdegree burns should
treatment. be treated with cool water, gentle cleaning,
1. Classification and localized treatment as for a sunburn.
• Subungual hematoma—After a crush injury, • Seconddegree burns—Seconddegree burn
the patient complains of throbbing pain. Ex- treatment includes an anti-infection agent
amination shows blood under the nail, with such as 1% Silvadene cream. (The blisters
the nail intact. should be allowed to rupture spontaneously.)
• Nailbed laceration—There is damage to the The wound should be cleaned daily and cov-
nailbed, but the matrix is still present. ered with a protective dressing. Early range
• Loss of the nail matrix. of motion, as well as splinting, is necessary
2. Treatment to minimize contractures.
• Subungual hematoma—The subungual hema- • Thirddegree burns—Third-degree burns
toma exceeding 50% of the nailbed should be require debridement, escharectomy, and
drained with a drill, cautery, or hot needle to soft-tissue coverage. The prognosis depends
relieve pressure. This should be followed by on the extent and depth of thermal injury.
soaks, and then it is allowed to drain. Treat- Occasionally, a split-thickness skin graft is re-
ment should be performed using sterile tech- quired if no healing occurs over 2 weeks; this
nique because the injury could be associated helps to prevent scar formation.
with an exposed bone tuft fracture of the dis- 3. Complications
tal phalanx. • Early—Early complications include fluid loss
• Nailbed lacerations—Nailbed lacerations in- and compartment syndrome.
clude any laceration or a crushed nailbed. The • Late—Contractures of the fingers, wrist, or
nail should be removed and the nailbed re- elbow can result in the need for surgical
paired with a 6–0 plain absorbable suture. The release. Heterotrophic bone formation at
nail can be reapplied as a protective cover. the elbow is another late upper-extremity
• Loss of the nail matrix—The wound associ- complication.
ated with loss of the nail matrix should be ir- B. Electrical Burns—It is important to distinguish be-
rigated, cleaned, and repaired if possible. It tween the thermal component (heat) and the elec-
usually requires a nailbed graft from another trical injury caused by the passage of current. The
finger or toe. extent of injury is determined by the amount of
3. Complications—Complications include split current, the type of current, the pathway, and the
nail, nonadherent nail, ingrown nail, osteomy- duration of exposure to the current.
elitis, ridging, and hypersensitivity. 1. Diagnosis—The severity of injury is always the
greatest at the entrance and the exit wounds,
V. Burns—Burns are the nonmechanical destruction of which are usually “charred” with a zone of in-
tissue, by heat, electricity, or chemicals. tact but necrotic tissue. It is usually difficult to
A. Thermal burns—Thermal burns are most effec- assess the extension of tissue necrosis, since
tively treated by realizing the extent of destruc- the current flows along the pathway of least
tion early and treating the wound appropriately. resistance with nerve having the least resis-
1. Classification tance and bone having the most.
• Firstdegree burns—Firstdegree burns are 2. Treatment—Initial treatment is debridement of
superficial burns associated with erythema obvious nonviable tissue, with fasciotomy and
and often a few small blisters. These burns nerve decompressions as indicated. This should
are quite painful. be followed by a “second-look” operation at 48
• Seconddegree burns—Seconddegree burns hours (for a second debridement). The clinician
involve partial-thickness injury to the skin. may see progressive necrosis, which requires
further debridement. When the patient’s con- substance, especially if it has a metallic
dition is stable, definitive treatment, including component.
flaps or even amputation, may be required. (b) Antibiotics and tetanus prophylaxis
C. Chemical Burns—The severity of a chemical burn (c) Steroids
is determined by the concentration, duration of 2. Operating room—These patients must go to
contact, amount, mechanism of action, and pen- the operating room for thorough debride-
etrability of the chemical. Tissue destruction ment, copious irrigation, and nerve and fore-
continues until removal or neutralization of the arm decompression if necessary.
material. Therefore, the first course of treatment 3. Postoperative treatment—Postoperative treat-
of any chemical burn is water irrigation (i.e., run- ment includes safe positioning in the intrinsic
ning tap water). The recommendations for spe- plus position to prevent or minimize contrac-
cific chemical burns are shown in Table 24-1. ture, sympathetic blocks for pain control and
circulation, and a second-look procedure for
VI. High-Pressure Injection Injuries—These commonly
further debridement. These cases commonly
occur in young men in a new job and most com-
require multiple operative procedures.
monly involve the nondominant hand.
A. Evaluation—The initial examination reveals an
VII. Infections of the Hand—Most hand infections are
innocuous-looking entrance wound with the pa-
surgical rather than medical problems. Antibiot-
tient complaining of a variable amount of pain.
ics are an adjunct to surgical management. For any
Swelling is related to the site, amount, and time
infection, a history as to the underlying cause, as
since the injection. There can be both physical
well as contributor factors such as diabetes, infec-
distention and chemical irritation.
tion by the human immunodeficiency virus, gout,
B. Prognosis
or systemic infections, is important. The clinician
1. Material—The type of material injected is
should be aware that the deep lymphatics drain to
most commonly paint or grease. Paint causes
the palm, whereas the superficial lymphatics drain
necrosis and grease causes fibrosis. There is
dorsally and palmarly. The epitrochlear nodes
a 60% amputation rate with paint and a
drain the ulnar side of the hand, and the axil-
25% amputation rate with grease.
lary nodes drain the radial side of the hand. All
2. Pressure—The pressure involved with injec-
of these nodes should be checked.
tions may range from 3,000 to 10,000 psi. If
A. Paronychia—Paronychia is a common infec-
greater than 7,000 psi, there is a 100% am-
tion of the periungual tissue. Paronychia is
putation rate.
commonly associated with nail biting and man-
3. Site involved—The digits have a poorer prog-
icuring. The most common organism is Staphy-
nosis than the palm.
lococcus aureus. (Anaerobes are also common.)
4. Amount—The amount injected bears a direct
If the diagnosis is made early, this infection may
relationship to a worsening prognosis.
respond to appropriate antibiotics and soaks.
5. Time—The longer the time to treatment, the
1. Diagnosis—Findings include pain, redness,
worse the prognosis.
and swelling about the nail.
C. Treatment
2. Treatment—Drainage, either by incision or
1. Emergency department
by nail elevation, is followed by soaks and
(a) Radiographic evaluation—X-ray stud-
antibiotics.
ies can show the extent of soft-tissue in-
3. Complications—Complications include nail
volvement or proximal infiltration of the
deformity and the possibility of osteomyelitis.
4. Other considerations—Individuals who are
frequently in contact with the oral mucosa of
TA B L E 2 4 - 1 others (dentists, anesthesiologists, wrestlers)
Recommendations for Chemical Burns are at increased risk of developing paronychia
from the herpes simplex virus (herpetic whit-
Chemical Treatment
low). These patients have vesicles that con-
Acid Dilute topical sodium bicarbonate tain clear fluid. The treatment of choice is
Alkali Dilute topical acetic acid acyclovir; there is no need to debride the ves-
Phenol Topical ethyl alcohol icles. Individuals who engage in activities that
Hydrofluoric acid 10% calcium gluconate by local involve prolonged immersion in water (such
injection as dishwashers) are at increased risk of devel-
oping an infection from Candida organisms.
The treatment for such an infection is topical D. Palmar Space Infections

clotrimazole. 1. Diagnosis—The mid palmar and thenar spaces
B. Felon—Felon is a deep infection in the pad of the can develop an abscess after penetrating trauma.
finger and is usually associated with a history of The mid palmar space is the potential space
a puncture wound or another open injury. between the flexor tendons and the metacarpals
1. Diagnosis—There is intense, throbbing pain on the ulnar aspect of the hand. The thenar
at the tip of the finger, with a swollen pad space is the potential space between the index
that is tight and tender on palpation. finger and the thumb. The main symptoms are
2. Treatment—The treatment involves incision pain and swelling in these areas. Deep palmar
and drainage, making sure to open the septa space infections require incision and drainage.
that compartmentalize the infection. The in- 2. Treatment—Incision and drainage are per-
cision should be made midlateral to avoid formed; care should be taken to avoid neuro-
the pad, unless the abscess is pointing vascular structures in the palm. Antibiotics are
superficially. Once again, treatment after administered intravenously.
incision and drainage includes soaks and 3. Complications—The most common complica-
antibiotics. tion is incomplete drainage of the space without
C. Tendon Sheath Infections—Tendon sheath in- going deep into the area, such as for a button-
fections are usually the result of a penetrating hole abscess, in which the presenting abscess
wound, frequently an innocuous puncture. is superficially drained, but the palmar space
1. Diagnosis—The patient has a painful and swol- infection is not.
len finger with positive Kanavel’s sign, which E. Septic Arthritis—Septic arthritis may occur sec-
include symmetric swelling along the flexor ten- ondary to penetrating trauma or bloodborne sep-
don sheath, tenderness and erythema along the sis. The most notorious inoculation is the human
flexor tendon sheath, semi-flexed position of the bite, usually after a fist-to-mouth injury to an MCP
finger, and severe pain on passive extension joint.
of the finger. This last sign is the most diagnos- 1. Diagnosis—Signs and symptoms include ery-
tic of tendon sheath infections. This infection thema, tenderness in the joint, and pain with
may also extend into the mid palmar space. motion. X-ray studies may show bony changes.
2. Treatment 2. Treatment—Treatment includes aspiration of
• Surgical drainage the joint for diagnosis and culture, incision and
(a) Midlateral incision technique—The drainage, and culture and sensitivity tests, fol-
midlateral incision technique allows the lowed by the intravenous administration of ap-
scar to be off the palmar surface and propriate antibiotics (for 3 to 6 weeks).
still obtains full exposure. This incision 3. Complications—Complications include joint de-
can be left open and allowed either to struction, stiffness, and osteomyelitis.
heal or to be closed secondarily later.
(b) Limited incision with catheter irriga- VIII. Reflex Sympathetic Dystrophy (Regional Pain
tion—With limited incision with cath- Syndrome)
eter irrigation, the sheath is opened A. Overview—Reflex sympathetic dystrophy (RSD)
over the middle phalanx and then in is a catchall term that covers a wide spectrum
the distal palm. A catheter is placed to of dystrophic responses to trauma. There is no
irrigate the tendon sheath with 5 mL of physiologic basis for these dystrophies, but all
saline every 2 hours for 48 hours. appear to be a normal response of prolonged du-
• Intravenous antibiotics—Intravenous an- ration. The natural history is poorly understood
tibiotics are administered pending culture but may result in permanent disability. The de-
and sensitivity tests. parture from the expected recovery for an injury
• Range of motion—Range of motion is or surgery with associated pain, stiffness, and
started early. anatomic dysfunction are early clinical hallmarks
• Atypical infections—If the infection does of RSD. Chronic regional pain syndrome (CRPS)
not respond, an atypical infection, includ- Types I and II have been introduced to replace
ing mycobacterium, fungus, or anaerobes, the term RSD. CRPS Type I corresponds to the
should be considered. classic RSD without an identifiable nerve in-
• Human bites—Infection from human bites jury. CRPS Type II occurs after an identifiable
usually has a rapid onset and should be nerve injury. Either type may be sympathetically
treated aggressively. mediated or sympathetically independent.
B. Evaluation • Therapy—Therapy involves active and

1. Classification passive range of motion, below the thresh-
• First stage—The first stage is the first old of pain, with splints and stimulation, as
3 months and is sometimes referred to as well as stress loading (Watson).
the acute stage. • Medications—The clinician may adminis-
• Second stage—The second stage is from 3 ter amitriptyline, a corticosteroid, nifedip-
to 12 months, and is referred to as the dys- ine, or phenytoin.
trophic stage. • Stellate ganglion blocks—A series of stel-
• Third stage—The third stage is longer than late ganglion blocks can sometimes break
1 year and is called the atrophic stage. the RSD cycle.
2. Examination—Although RSD has a vari- • Sympathectomy—Sympathectomy is espe-
able presentation, there is always a history cially useful when a good, but temporary, re-
of trauma, although this may be very mild. sponse is noted after a stellate ganglion block.
Signs and symptoms include pain out of • Psychotherapy
proportion to what is expected, stiffness,
delayed recovery, trophic skin changes, IX. Late Effects of Traumatic Injuries
and autonomic dysfunction. A. Intrinsic-Plus Deformity (Fig. 24-27)—Intrinsic-
3. Diagnostic tests plus deformity is caused by foreshortening of the
• Plain Xrays—Plain Xray studies may be di- intrinsic muscles. Treatment involves operative
agnostic in established RSD, showing juxta- soft-tissue release.
articular osteopenia. B. Intrinsic-Minus Deformity (see Chapter 22,
• Bone scan—A threephase bone scan is Fig. 22-4)—Intrinsic-minus deformity is due to an
recommended, although the significance injury to the ulnar nerve (with or without a median
is still being debated (unknown prognostic nerve injury) that causes a claw-hand deformity
significance). (hypertension of the MCP joint and flexion at the
• Stellate ganglion blocks—Stellate ganglion PIP joint). This results from loss of the intrinsic
blocks are an important diagnostic tool. muscles that are normally responsible for flexion at
Significant relief in the presence of a con- the MCP joint and extension at the PIP joint and the
firmed block is diagnostic for sympatheti- unopposed action of the extrinsic muscles (FDS,
cally mediated pain. FDP, and extensor digitorum communis). Treat-
4. Treatment ment typically includes tendon transfers that re-
• Early intervention—The key to treatment route a functional tendon to correct the deformity.
is early diagnosis. Some 80% of cases C. Extrinsic Tightness (Fig. 24-28)—The PIP joint
treated in the first 12 months show im- can passively flex with the MCP joint held in ex-
provement, whereas only 50% of cases tension but is unable to do so with the MCP joint
starting treatment in the second year show held in flexion because the extensor digitorum
improvement. communis is scarred to the bone or retinaculum
MCP joint FIGURE 24-27 Test for intrinsic tightness. Note that

the PIP joint cannot be flexed with the MCP joint held
in extension when there is intrinsic muscle tightness.
PIP joint
MCP joint
PIP joint
FIGURE 24-28 Test for extrinsic tightness. Note MCP joint

that the PIP joint cannot be flexed with the MCP
joint held in flexion when there is extrinsic muscle PIP joint MCP joint
tightness.
PIP joint
FIGURE 24-29 Lumbrical-plus deformity. With MCP joint

the MCP joint in extension and the PIP joint in
flexion, active flexion of the MCP joint will cause PIP joint MCP joint
paradoxical extension of the PIP joint.
PIP joint
at the wrist or the dorsal metacarpal; this tendon

lacks the necessary excursion to allow simulta- SUGGESTED READINGS
neous flexion of both the MCP and the PIP joints.
D. Lumbrical-Plus Deformity (Fig. 24-29)—Lum- Review Articles
brical-plus deformity is caused by lumbrical Jebson P, Louis D, eds. Hand Infections. Hand Clin. 1998;14(4).
tightness. It can occur as a late effect of an FDP Posner M, ed. Ligament injuries in the wrist and hand. Hand
laceration distal to the lumbrical origin. Physi- Clin. 1992;8(4).
Schaw Wilgis EF, ed. Vascular disorders. Hand Clin. 1993;9(1).
cal examination reveals paradoxical extension of Schenck RR, ed. Intraarticular fractures of the phalanges. Hand
the PIP joint when he MCP joint is actively flexed Clin. 1994;10(2).
(with the PIP joint beginning in the flexed posi- Scheider LH, ed. Extensor tendon injuries. Hand Clin.
tion) (see Fig. 24-29). Treatment is operative soft- 1995;11(3).
tissue release and repair. Strickland JW, ed. Flexor tendon injuries. 1985;1(1).
E. Boutonnière Deformity (see Fig. 24-10)—Bouton-
nière deformity can occur as a late effect of a Textbooks
central slip injury. Treatment is discussed in the American Society for Surgery of the Hand. Hand Surgery Up-
prior sections. date. Rosemont, IL: American Academy of Orthopaedic Sur-
geons; 1996.
F. SwanNeck Deformity (see Fig. 248)—Swanneck
Brinker MR, Miller MD. Fundamentals of Orthopaedics. Phila-
deformity can occur as a late effect of a mallet injury, delphia, PA: WB Saunders; 1999.
a volar plate injury of the PIP joint, or an FDS rup- Green DP, ed. Operative Hand Surgery. 3rd ed. Vol 2. New York,
ture. Treatment is discussed in the prior sections. NY: Churchill Livingstone; 1993.
PART IV THE SPINE
CHAPTER 25
Spinal Cord and Related Injuries

Michael Fehlings, Marcus Timlin, and Nicolas Phan
I. Introduction—Few conditions are as devastating as of a single patient may overestimate the actual rate
spinal cord injury (SCI). Patients with SCI usually while misclassification of SCI when the patient pres-
face several medical problems related to their initial ents with multiple injuries may underestimate it. The
immobilization, prolonged rehabilitation periods, sig- incidence of SCI, defined as the number of new cases
nificant readjustment in their lifestyle, and potential in a given population in a discrete geographical re-
complications in the chronic stages of their disease. gion within a specific time frame is estimated to be
The earliest description of SCI as an entity was re- around 40 per million per year. The prevalence of
ported by the Egyptians in 1700 BC. Even at that time, SCI, that is, the number of individuals with SCI within
patients were described with injuries so severe that a specific population at a specific point in time, av-
they were considered to harbor an “ailment not to be erages 70 per 100,000 or approximately 200,000 to
treated.” At the beginning of the century, the mortal- 250,000 total patients in the United States.
ity of SCI was around 90%. At the end of World War I, As in most traumatic injuries, the incidence of
special care of the urinary tract, respiratory system, SCI is significantly higher in males than in females
and skin of patients with SCI led to a significant im- (75% of cases occurring in males). The average age
provement of their survival. Despite this improved for both males and females at the time of injury is
survival, patients were left with significant disabili- around 35 years old. Peak age of incidence is 20 to
ties, and their recovery did not seem to benefit from 24 for males compared with 25 to 29 for females. The
any kind of therapy. Early studies on dogs by Allen incidence among males increases dramatically after
showed that the spinal cord’s secondary response to age 15, declines after age 30, and increases again
injury was responsible for a progression of the tissue steadily in the later decades. The initial peak for
damage created by the initial insult and that in cer-
tain cases, active early treatment such as decompres-
sion, could improve the neurological recovery. Goals
TA B L E 2 5 - 1
of SCI treatment in recent decades have therefore
been focused toward early aggressive treatment and Epidemiology of Spinal Cord Injury in North
prevention of secondary injury mechanisms. America
Parameter Value
II. Epidemiology—The incidence and prevalence of SCI
in North America have been studied in detail over the Incidence (cases/million/yr) 40
past two decades (Table 25-1). The exact figures are Prevalence (cases/100,000) 70
difficult to determine because of inherent method- Male–female ratio 3:1
ological limitations. For example, multiple admissions
387
388 S E C T I O N I I | A D U L T T R A U M A P A R T I V | T H E S P I N E
cord to the inner surface of the dural tube. These

TA B L E 2 5 - 2 structures are called denticulate ligaments. The
Causes of Spinal Cord Injury in North America arachnoid matter is located between the dura
and the pia mater, and extends to the proximal
Etiological Factor Frequency (%)
roots of spinal nerves. The space between the pia
Motor vehicle accidents 50 and arachnoid is termed subarachnoid space. It
Falls 20 is in this space that the cerebrospinal fluid circu-
Violent assaults 15–20 lates. The spinal cord has two enlargements situ-
ated at the cervical and lumbar areas, which are
Sports and recreational activities 10–20
associated with the spinal roots innervating the
upper and lower limbs. The termination of the spi-
nal cord has a conical shape and is termed conus
medullaris. The conus is attached to a condensa-
females is approximately 5 years later than it is for
tion of pia mater, the filum terminale. The filum
males.
extends caudally until it becomes invested by the
The causes of acute SCI are varied but have
end of the dural sac and forms the coccygeal liga-
remained relatively consistent over the past two de-
ment, which continues to the coccyx where it be-
cades (Table 25-2). Motor-vehicle accidents are still
comes continuous with the periosteum.
the most frequent etiology of SCI, accounting for ap-
B. Blood Supply—The arterial blood supply to the
proximately 50% of all cases. Falls, either accidental
spinal cord consists of descending branches
or from suicide attempts, also account for a significant
of the vertebral arteries and multiple radicular
proportion of SCI cases at approximately 20%. Violent
arteries derived from segmental blood vessels.
assaults in urban areas have increased dramatically
There are two posterior spinal arteries, each
over the past 15 years and are now estimated to be
arising from its respective vertebral artery
the etiological factors in 15% to 20% of SCI. The vast
posteriorly. They descend on the posterior sur-
majority of penetrating injuries of the spinal cord
face of the spinal cord, just medial to the dorsal
involve firearms. Acute SCI occurs in the context of
roots. They receive a variable amount of supply
sports and recreational activities in approximately
from the segmental posterior radicular arter-
10% to 20% of cases. Diving injuries account for
ies along the way down, forming two plexiform
two-thirds of these injuries. Because of widespread
channels. Together, they supply the posterior
awareness campaigns and media coverage, sports-
third of the spinal cord. Paired anterior spinal
related SCI has been steadily decreasing since 1975.
arteries unite caudally just after they branch off
In addition to the significant physical and psy-
their respective vertebral artery and descend as
chological impact of SCI, the financial burden related
a single vessel that enters the anterior median
to hospitalization, rehabilitation, and environment
fissure of the spinal cord. Branches from anterior
modification of victims is tremendous. The lifetime
radicular arteries anastomose with the anterior
costs for SCI range from $600,000 to $1 million, de-
spinal arteries at different levels in order to form
pending on its cause. Based on the incidence of SCI,
one continuous vessel, although it may become
total direct costs for all causes of SCI in the United
discontinuous or very small at certain levels. The
States are as high as $8 billion.
anterior spinal artery supplies the anterior two
III. Anatomy of the Spinal Cord thirds of the spinal cord. The radicular arteries
A. Meningeal Layers—The adult spinal cord lies in arise from segmental vessels such as the ascend-
the vertebral canal and extends from the foramen ing cervical, deep cervical, intercostal, lumbar
magnum, where it is continuous with the medulla, and sacral arteries. Once it enters the interver-
to the first lumbar vertebra (Fig. 25-1). Three tebral foramen, a radicular artery becomes an
meningeal layers cover it. The spinal dura, the anterior radicular or posterior radicular artery
outermost layer, is a tubular continuation of the or divides into both branches. Radicular arter-
meningeal layer of the cranial dura. In contrast ies usually arise from the left side in the thoracic
to its cranial counterpart, the spinal dura is sepa- and lumbar region, while both sides supply the
rated from the inner periosteum of adjacent verte- cervical cord equally. The thoracic cord has
brae by the epidural space. This space contains the greatest distance between each of its sup-
a variable amount of loose areolar tissue (epidural plying radicular arteries, rendering it more
fat) and the internal vertebral venous plexus. The prone to ischemia in the event of an occlusion
pia mater is adherent to the surface of the spinal of one of these vessels. The artery of Adamkie-
cord and forms a triangular-shaped condensations wicz is an anterior radicular artery found in the
on each side, at regular interval, which attach the thoracolumbar area and is appreciably larger
C H A P T E R 2 5 | S P I N A L C O R D A N D R E L A T E D I N J U R I E S 389
C1 than all others. It usually arises between T8 and

C1 1
2 L2, mostly from the left.
2
2 C. Segmental Anatomy—An understanding of the
3 3 segmental anatomy of the spinal cord is essential
3 4 4 in order to interpret the different neurological
5
4 5 syndromes that patients with SCI present with.
6
5
7 6 A complete anatomical description is beyond the
6 8 7
scope of this chapter, and only the relevant struc-
7 T1 tures and pathways will be described. Figure 25-2
8
2 illustrates a transverse section of the spinal cord.
T1
3 T1 The gray matter consists of a symmetrical but-
2 terfly-shaped structure in the middle of the cord.
4 2
The dorsal horn is in the posterolateral position
3 5 3 and contains mainly sensory neurons that receive
6 4 afferents from sensory fibers whose cell bodies
4 are located in the ipsilateral dorsal root ganglion.
5
7 The anterior horn contains motoneurons that
5
8
6 send axons to respective segmental skeletal mus-
cle fibers and to intrafusal muscle fibers via the
6 7
9 ventral root. In the thoracic cord, there is a lateral
8 horn, which extends from C8 to L2. It consists of
7 10 preganglionic sympathetic neurons. The sympa-
8 9 thetic fibers from these cell bodies exit with the
11
anterior root at the T1 to L2 levels and give white
9 10
12 rami to sympathetic chain nuclei located on each
10 L1 side of the spine. There they synapse with post-
11
2 ganglionic sympathetic neurons and the sym-
11
3 pathetic fibers travel with blood vessels to the
4 12
5 viscera and vascular beds they innervate.
12 1. Sensory pathways—Two main pathways carry
L1
sensation. The discriminative touch pathway
L1 carries sensations for two-point discrimina-
2 tion, proprioception, and vibration via large
2 fibers in the dorsal root. Most of the fibers
3
enter the cord and ascend immediately in
3 the ipsilateral dorsal columns located in the
posterior midline of the cord. They synapse
4 4 with second-order neurons in the brainstem
and then cross the midline, course cranially,
5 and synapse in the contra-lateral thalamus.
5 The third-order neurons in the thalamus send
their projections to the somatosensory cor-
S1 tex. The pain and temperature pathway car-
2
ries sensations of nociception, heat, cold and
simple (primitive) touch via smaller fibers in
3
the dorsal root. The fibers enter the cord and
4
synapse with second-order neurons located
5
in the dorsal horn. The axons of the second
Coc. 1 order neurons, after ascending or descend-
ing one or two segments, cross the midline
within the spinal cord. The crossing fibers
FIGURE 25-1 Human spinal cord in vertebral column
form the anterior commissure, ventral to the
seen in mid-sagittal section. Note the position of the
central canal, and reach the spinothalamic
spinal cord segments with reference to the bodies and
spinous processes of the vertebrae. Locations of entrance tract located in the ventro-lateral aspect of the
and exit of spinal roots are indicated. cord. They then ascend to synapse with third-
order neurons in the contralateral thalamus.
Dorsal
Central canal Dorsal column
Dorsal (posterior)
Corticospinal
horn
tract
Intermediate zone Lateral column
Ventral (anterior)
horn Spinothalmic tract
White matter
Gray matter Ventral column
Ventral
FIGURE 25-2 Segmental anatomy of the spinal cord. The white matter is organized in three columns (dorsal, lateral
and ventral) running in the log axis of the cord. The dorsal columns are involved in touch, proprioception and vibration
sensation and the spinothalmic tracts, located ventrolaterally are involved in pain and temperature sensation. The
corticospinal tracts, located laterally, carry the axons of upper motor neurons. The central gray matter is divided into
the dorsal horn, comprising sensory cells, and the ventral horn, which contains motoneurons. The intermediate zone,
between the dorsal and the ventral horns contains the preganglionic neurons of the sympathetic (thoracic cord) and sacral
parasympathetic systems. The main components of the central gray matter and the surrounding white matter are illustrated.
The third-order neurons in the thalamus send clear that such a somatotopic organization
their projections to the somatosensory cortex. may not exist in the corticospinal tract (see
Since the first pathway crosses the midline later section).
above the spinal cord and the second within 4. Dermatomes and myotomes—Each segment
the cord, dissociate sensory loss may occur in of the spinal cord innervates a certain sen-
partial cord syndromes where only one side of sory area of the body called dermatome and
the cord is affected (see later section). specific groups of skeletal muscles called myo-
2. Motor pathway—The motor pathway originates tome. Figure 25-4 illustrates the major myo-
in the cerebral motor cortex, as well as from tomes and all dermatomes of the human body.
deeper extra pyramidal nuclei. The bulk of the
fibers travel caudally in the internal capsule and IV. Classification of SCI—Consensus in classification of
enter the brainstem, where they form the corti- SCI based on neurological examination is essen-
cospinal tracts located ventrally. In the medulla, tial to determine prognosis as well as for follow-
the fibers form the pyramids, which are located up examinations and longitudinal studies. The
ventrally. In the lower medulla, approximately most recent classification, The International
80% of the fibers cross the midline just before Standards for Neurological and Functional
entering the spinal cord. The corticospinal tract Classification of Spinal Cord Injury was devel-
in the spinal cord is located in the mid-lateral oped in 1992 by the American Spinal Injury As-
position and its fibers synapse with motoneu- sociation (ASIA) and the International Medical
rons of the ventral horn at appropriate levels. Society of Paraplegia (IMSOP). This system is
3. Lamination of fibers—Fibers in the different now widely used internationally by all teams
tracts of the spinal cord are organized in a involved in the treatment of SCI (Table 25-3 and
specific pattern. Figure 25-3 illustrates the lo- Fig. 25-4).
cation of the axons supplying the arms and A. ASIA/IMSOP Impairment Scale—The ASIA/IMSOP
legs in the dorsal columns and spinothalamic impairment scale shown in Table 25-3 consists of
tracts. Although this lamination of fibers helps five grades of impairment. Grade A is defined as
understanding the clinical presentation of cer- complete injury, while Grades B, C and D repre-
tain incomplete syndromes in SCI, it is now sent varying degrees of incomplete injuries, and
Dorsal
Lower Upper
Leg trunk trunk
Arm
Neck
Occiput
Leg
Trunk
Arm
Neck
Ventral
FIGURE 25-3 Segmental anatomy of the spinal cord illustrating the lamination of fibers
in the main white matter tracts. The dorsal columns and the spinothalamic tracts are
somatotopically organized.
Grade E denotes a normal neurological examina- or 5. This statement led to some confusion in
tion. Complete SCI is defined as an absence interpreting the neurological level in certain pa-
of motor and sensory function in the lowest tients, especially those with incomplete injuries.
sacral segments, S4 and S5. As can be seen in A revision to the classification was thus made
Figure 25-4, this system requires the examination in 1996 where the motor level is defined as the
of 10 key muscle groups on the left and right as lowest key muscle that has a grade of at least 3.
well as 28 dermatomes on the left and 28 on the Since the motor and sensory examination may
right. The scoring system for the motor function differ on each side of the body, there may be up
uses the MRC scale from 0 to 5 (see Fig. 25-4), to four different levels identified. If dermatomes
with a maximum possible score of 100. The sen- and myotomes remain partially innervated below
sory examination is based on a scale of 0 to 2 for an identified level, they are classified as a zone of
pinprick with a maximum possible score of 112. partial preservation.
In order to determine if a lesion is complete, B. Spinal Shock—Spinal shock is defined as the
the sensory and motor functions of the lowest loss of somatic motor, sensory, and sympa-
sacral segments S4 and S5 have to be tested. thetic autonomic function after SCI. The loss
Sensory function is assessed at the perianal re- of somatic motor function results in flaccid paral-
gion and at the musculocutaneous junction while ysis and areflexia. Sensory loss may be complete
deep anal sensation and voluntary contraction to all modalities. The loss of autonomic func-
of the external anal sphincter must be examined tion, mainly sympathetic innervation, can
during digital rectal examination. Determination manifest in hypotension, bradycardia as well
of the completeness of a lesion needs to be made as skin warmth and hyperemia. The severity
early because the prognosis for recovery is much and duration of spinal shock varies, but it cor-
better in incomplete injuries. relates with the severity of the SCI and the level
The neurological level of a SCI is determined of the injury. Thus, is it usually most severe in
by both the sensory and the motor exam, on complete cervical and upper thoracic cord inju-
both sides of the body. The sensory and the ries, less severe in incomplete injuries, and mini-
motor levels are defined as the most caudal mal in lumbar injuries. In its most severe form,
(lowest) segment with normal sensory or mo- the loss of sympathetic tone (to the heart and
tor function, respectively. The 1992 classifica- vasculature) results in sustained hypotension
tion defined normal motor function as Grade 4 and bradycardia which leads to neurogenic
392
C1
C2
C3
C2
C3
C4
T2 T2
T3 C5
C5
T4
T5
T6
T7
T8
S3 T9
C6 T1 T1
C6
T10
S4–5 T11
T12
Palm L1 L1 Palm
L2 L2
S2 S2
C8 C6 C8
C6
C L3 L3 C
7 7
Dorsum Dorsum
L4 L4
S1 S1
L5 L5
L5 L5
Key sensory points
S1 S1
S1
P A R T I V | T H E S P I N E
FIGURE 25-4 ASIA/IMSOP classification of SCI. The diagram illustrates the principal information about motor, sensory
and sphincter function required for accurate classification and scoring of acute spinal cord injuries. The 10 key muscle
groups to be tested are shown on the left along with the MRC grading system, and the 28 dermatomes to be tested
on each side for the sensory examination are shown on the right. (Courtesy: American Spinal Injury Association,
International Medical Society for Paraplegia: International standards for neurological and functional classification of SCI,
revised 1996, Chicago, 1996, The Association and The Society.)
shock. The etiology of spinal shock is unknown,

although suspected mechanisms include imbal- TA B L E 2 5 - 3
ances in transmembrane ionic concentrations Classification of SCI Based on the International
and permeabilities secondary to local tissue Standards for Neurological and Functional
trauma, such as an increase in extracellular po- Classification of SCI by the ASIA/IMSOP
tassium concentration resulting in inhibition of
ASIA/IMSOP Impairment Scale
local neuronal excitability. The presence of spi-
nal shock can cause a significant amount of Grade A Complete No motor or sensory function
confusion in the initial neurological assess- is preserved in the sacral seg-
ment of the patient. It is therefore recommended ments S4–S5.
to assume that its effect on the somatic motor Grade B Incomplete Sensory but not motor func-
and sensory exam have resolved by 1 hour after tion is preserved below the
the initial injury and that the autonomic and re- neurological level and ex-
tends through the sacral seg-
flex dysfunctions may persists for days to weeks.
ments S4–S5.
Acute SCI has been associated with pulmo-
nary edema in a number of cases. Its mechanism Grade C Incomplete Motor function is preserved
is uncertain but it is suspected that massive sym- below the neurological level,
and the majority of key
pathetic discharge at the time of injury results
muscles below the neurologi-
in a catecholamine surge. The rapid rise in cat- cal level have a muscle grade
echolamines leads to acute left ventricular fail- less than 3.
ure from a sudden increase in afterload as well as
Grade D Incomplete Motor function is preserved
fluid shifts from the periphery to the pulmonary
below the neurological level,
vasculature. and the majority of key
muscles below the neurologi-
V. Incomplete Spinal Cord Syndromes—When there is cal level have a muscle grade
preservation of sensation or motor function in greater than or equal to 3.
the lowest sacral segments S4 and S5, a SCI is Grade E Normal Motor and sensory function
said to be incomplete. It therefore falls in the B, C, is normal.
or D category of the ASIA/IMSOP classification. Pa-
tients with incomplete SCI often present with specific
patterns of neurological deficits. The incomplete
syndromes are generally classified according to patients presenting with this syndrome due to an
the anatomic location of the injury in the trans- increase in survivors. The mechanism of injury
verse section of the spinal cord. This classifica- usually consists of traction on the high cervi-
tion is useful in understanding the pathophysiology cal cord and medulla caused by dislocation or
and mechanisms involved in specific types of injury, anteroposterior compression from a displaced
which can help direct treatment in the early phase. fracture or intervertebral disc rupture. The
Since the potential for neurological recovery differs vertebral artery enters the transverse foramen
for different syndromes, this classification also helps of C6, ascends vertically through each vertebral
in the assessment of prognosis upon presentation. foramen, exits at C2, and courses over the lateral
A. Cervicomedullary Syndrome—This syndrome oc- mass of C1. Entrapment at any point along its way
curs in cervical spinal injury, where the high cer- may occur during cervical spine injury. It is partic-
vical cord and medulla are involved, although it ularly susceptible in cases of fracture-dislocation
can extend caudally as far as C4 and rostrally to and acute torsion of the upper cervical spine.
the pons. It is caused either by direct injury to the The clinical presentation of the cervicome-
cord or medulla or concomitant disruption of the dullary syndrome has two important charac-
vertebral arteries during cervical spine trauma. teristics.
Other terms have been used for this presentation 1. Dejerine pattern of anesthesia—Patients can
such as “bulbar-cervical dissociation.” In its most present with the classic Dejerine pattern of
severe form, this syndrome results in respiratory anesthesia of the face (anesthesia of the outer
arrest, hypotension, tetraplegia and anesthesia, periphery of the face with sparing of the middle
usually below C4. Without immediate first-aid portions including the nasal alae to the vermil-
treatment, death occurs shortly after the ini- ion border of the lips). This peculiar presenta-
tial injury from cardiopulmonary arrest. Im- tion occurs because the sensory fibers of the
proved on-site emergency airway management face course downward in the spinal trigeminal
and cardiac resuscitation has led to an increase in tract after entering the brainstem and synapse
with the spinal trigeminal nucleus as low as C4.
The fibers supplying the periphery of the face the upper cervical spine (C1 to C3) in eight pa-
travel the furthest down while those supply- tients. In each of the eight patients with frac-
ing the center of the face synapse almost im- tures, the C2 vertebra was involved. Of the
mediately after entering the brainstem, which seven patients who had MRI studies performed,
explains why they are spared when the injury three demonstrated contusions or edema local-
is at the level of the cervical cord. Anesthesia ized to the anterior or anterolateral segments
is present below the level of injury but there of the cervicomedullary junction and superior
can be sparing of the collar area supplied by C2 cervical cord; this supports the concept that
to C4. This is thought to be due to the fact that the injury must be mild to moderate, damaging
the sensory fibers from these levels are carried motor function (subserved by the corticospinal
via two different pathways; the classic lateral tracts in the pyramids) yet preserving life.
spinothalamic tract and the spinal trigeminal B. Central Cord Syndrome—This syndrome was also
tract, which ascends caudally before cross- described initially by Schneider. It is character-
ing in the brainstem. The second tract may be ized by a disproportionately greater loss of
spared from injury because of the difference in motor power in the upper extremities than
the level of crossing. A complete sensory exam, in the lower extremities, bladder dysfunction
including the face, is thus essential in the as- usually in the form of urinary retention, and a
sessment of all patients with cervical spinal in- varying degree of sensory loss below the lesion.
juries in order to recognize this pattern. Pathological reports of patients presenting with
2. Cruciate paralysis of Bell—Cervicomedullary this condition who succumbed after the initial
syndrome may also mimic central cord syn- injury revealed that the spinal column and liga-
drome in producing more significant weakness ments were intact and that the cord often had
in the arms than the legs. This form of weakness a central area of hemorrhage. Taylor has shown
pattern is termed cruciate paralysis of Bell. that it is possible to have compression of the spi-
The neuroanatomical explanation proposed to nal cord without damage to the vertebral column.
account for this syndrome was outlined in 1901 He performed cervical myelography on cadavers
by Wallenberg. He suggested that the somato- with their necks in different positions and demon-
topic organization of the corticospinal fibers strated that in the forced extension position, there
in the pyramids resulted in different decussa- were a series of indentations on the posterior sur-
tion locations for the leg fibers compared with face of the spinal column at the level of the in-
the arm fibers. However, no neuroanatomic terlaminar spaces. These indentations appeared
evidence has ever been presented to support to be caused by inward bulging of the ligamen-
this but the theory prevailed. It is now thought, tum flavum, resulting in a narrowing of the spi-
based on several lines of evidence, that the nal canal by as much as 30%. The narrowing was
reason why hand function is more affected is even more marked when osteophytic protrusion
that the corticospinal tracts are more impor- in the posterior vertebral bodies were present. It
tant for hand function. Detailed studies of the is thus believed that the major mechanism of
corticospinal tract organization confirm that injury involved in central cord syndrome con-
a somatotopic organization is lacking. Marchi sists of hyperextension of the cervical spine re-
degeneration studies as well as modern neu- sulting in acute anteroposterior compression
roanatomic tracers have shown that the cor- of the spinal cord. In his analysis of spinal cord
ticospinal fibers serving the upper and lower segments of patients with central cord syndrome,
extremities are diffusely distributed within the Holmes found a significant amount of edema in
pyramids and their decussation and within the tissue located at the level of the injury.
the corticospinal tract of the spinal cord. In Schneider postulated that the syndrome is
his review of spinal cord syndromes, Schnei- caused by hematomyelia and surrounding edema
der found that the pyramids are susceptible in the central cord and suggested that the dis-
to compression by the odontoid process dur- crepancies in arm and leg weakness is due to the
ing fracture of the odontoid or atlantooccipital lamination of fibers in the corticospinal tracts. He
and atlantoaxial dislocations, or other lesions also postulated that the involvement of anterior
in the vicinity of this structure, such as tumors. horn cells in the cervical cord could account for
Localized injury to the pyramids could explain the more pronounced weakness of the arms. As ex-
the disproportionate hand weakness of cruci- plained earlier, modern studies have failed to show
ate paralysis of Bell. In a review of 14 patients a somatotopic organization of the corticospinal
with a clinical diagnosis of cruciate paralysis, tracts in the spinal cord. An alternative explanation
Dickman and coworkers reported fractures of may be that the function of the corticospinal tract
in the human is more important for hand and arm suggested that they resulted from anterior spinal
function than it is for lower extremity use. Several artery compression and insufficiency. However,
studies examined the effect of discrete lesioning the lack of pathological correlation made it less
of the corticospinal tracts. Most of them involved plausible. Kahn originally postulated a mechanism
sectioning the medullary pyramids. The common for chronic myelopathy from anterior cord com-
results were surprising. There were relatively few pression secondary to calcified disc protrusion.
motor deficits and the animals showed significant He proposed that chronic traction on a cord fixed
recovery with time. The most consistent and spe- in place by the dentate ligaments was responsible
cific motor deficit was the production of substan- for the clinical presentation of affected patients
tial hand dysfunction, which was more prominent consisting in hyperreflexia, spasticity, gait dis-
than arm and leg dysfunction. The motor recovery turbance, weakness more severe in the lower ex-
was similar to what is seen in humans with cen- tremities and subjective sensory disturbances.
tral cord syndrome (i.e., the recovery began in the He believed that the corticospinal tracts were
proximal musculature and progressed to the dis- more susceptible to this stress compared with
tal musculature as the lower extremities usually the spinothalamic tracts because of their larger
recovered before the upper extremities). A recent fibers. He also thought that the lateral fixation of
radiological study investigated MRIs of patients di- the cord from the dentate ligaments caused a form
agnosed with acute central cord syndrome. None of lateral sclerosis within its substance, thereby af-
showed the MRI features characteristic of hemor- fecting the corticospinal tracts to a greater extent.
rhage. Three post-mortem specimens were avail- Schneider applied this theory to the acute setting
able for histological study, ranging from 3 days to of anterior cord compression in order to explain
7 weeks after the injury. Again, there was no evi- the clinical findings. He also recommended that
dence of blood or blood products within the pa- patients presenting with this syndrome be consid-
renchyma of the spinal cord. The primary finding ered for early surgical management. The recovery
was diffuse disruption of axons, especially within from anterior cord syndrome varies considerably
the lateral columns of the cervical cord in the refor both the sensory and motor functions.
gion occupied by the corticospinal tract. More- D. Brown-Séquard Syndrome—The syndrome of
over, 10 out of the 11 patients showed evidence of Brown-Séquard, or hemisection syndrome, is
a prior underlying bone or disc abnormality lead- characterized by loss of one lateral half of
ing to narrowing of the cervical spinal canal. the spinal cord functions. In its pure form, there
The syndrome of central cord syndrome is is loss of the motor function, discriminative
important to recognize because its prognosis is touch, proprioception and vibration senses ip-
usually good compared with other syndromes. silaterally to the injury and loss of pain and
There have been some cases of rapid complete temperature sensation on the opposite side.
spontaneous recovery. The recovery usually fol- Mechanisms of injury include hyperextension in-
lows a specific pattern. Motor power returns juries, compression fractures, herniated discs, and
in the lower extremities first, bladder function penetrating injuries. It occurs more frequently in
recovers next, and finally movement in the up- the cervical cord than the thoracic cord and conus
per extremities returns. Hand and finger mo- medullaris. It is often seen in combination with
tion are the very last to return, and may not other incomplete syndromes and may be appar-
recover completely, while sensory recovery ent only days after the initial presentation of an
occurs in a non-specific pattern. Because of incomplete injury. Although a significant number
the spontaneous recovery, treatment is usually of patients presenting with the Brown-Séquard
conservative but cases have to be examined in- syndrome become ambulatory, prognosis for neu-
dividually. If instability or persisting compression rological recovery varies widely.
are present, early surgical management may be E. Conus Medullaris Syndrome—The conus medul-
indicated in order to optimize recovery. laris comprises the tapering distal end of the spi-
C. Anterior Cord Syndrome—This syndrome, also nal cord. The lower segments of the spinal cord
described initially by Schneider, consists of pa- are condensed in the region of the conus. Indeed,
ralysis and hypalgia below the level of the almost all of the lumbar segments are opposite to
lesion with sparing of discriminative touch, the vertebral body of T12 while most of the sacral
proprioception and vibration sense. The cases segments are opposite the vertebral body of L1
he described had either ruptured cervical discs, (see Fig. 25-1). The change in spinal anatomy,
fracture dislocations, or both causing anterior from the stiff thoracic spine to the more mo-
compression of the spinal cord. Initial theories on bile lumbar spine, makes the thoracolumbar
the mechanism of tissue damage in these injuries area prone to instability when submitted to
severe stresses. Burst fractures and fracture- made. After an acute injury, the spinal cord under-
dislocations are common at the T11 to T12 and goes changes in its epicenter. If the injury is severe,
T12 to L1 area, which puts the conus medul- a central cavitation develops after hemorrhagic ne-
laris at a greater risk of direct injury. The syn- crosis and ischemia of the cord.
drome is characterized by a combination of A. Syringomyelia—Syringomyelia refers to a cavi-
lower motoneuron deficits causing flaccid pa- tation in the spinal cord tending to extend in
ralysis of the lower extremities, and sphincter a longitudinal direction. The syndrome of sy-
dysfunction. Sensory deficits are variable. In ringomyelia manifests itself in approximately 3%
the chronic phase, upper motor neuron findings of SCIs. The time of onset varies from months to
may develop, such as spasticity, hyperreflexia years (as long as 30 years), and usually presents
and extensor plantar response. The prognosis is with some type of deafferentation pain. This is
usually not very good; this may be related to the followed by progressive loss of sensory and mo-
destruction of the lower motor neurons cell bod- tor function, on top of the already existing deficit
ies located in the conus, which do not have the from the original injury. The deficits are some-
potential to regenerate. what similar to the central cord syndrome with
F. Cauda Equina Syndrome—The spinal cord termi- the spinothalamic tracts affected to a greater de-
nates at the L1 to L2 disc space. The cauda equina gree than the dorsal columns. The motor deficit
consists of the roots of the lumbar and sacral seg- usually involves the lower motor neurons at the
ments extending caudally below the termination level of the injury or above. The exact mechanism
of the cord. Injury below the L1 to L2 disc space by which the syrinx expands is not known. Ab-
will therefore affect the cauda equina. Like spinal normal transmission of intraspinal CSF pressures
cord injuries, cauda equina injuries can be clas- during periods of increased pressure such as
sified as complete or incomplete according to during a Valsalva maneuver may cause the fluid
the same criteria. Mechanisms of injuries include cavity to expand. Obstruction of normal intraspi-
fracture-dislocation, burst fracture and acute nal CSF flow by arachnoiditis is also thought to
disc herniation. Acute central disc herniation play some role in the progression of a syrinx.
causes damage to the more centrally placed B. Microcystic Myelomalacia—Post-traumatic micro-
sacral roots, often sparing the lumbar and the cystic myelomalacia has a similar clinical pre-
S1 roots. The resulting clinical picture consists sentation to post-traumatic syringomyelia. The
of perianal anesthesia, sphincter dysfunction, cord shows microcystic degeneration without
normal leg strength and the absence of radicu- a continuous cavity like in syringomyelia. The
lar pain. The sacral roots are very susceptible to first reports of “myelomalacic cores” at the level
injury and tend not to recover after prolonged of injury expanding caudally and rostrally, were
compression. Urgent surgical decompression is described at the beginning of the century in pa-
therefore mandated with this particular presenta- tients with gunshot wounds to the spine and ex-
tion. In general, however, cauda equina injuries perimental models of SCI. The cystic lesions can
usually have a better prognosis than spinal cord extend for several levels above and below the
injuries because of the greater regenerative po- injury and their continuity can be interposed by
tential of lower motor neuron axons and their rel- segments of normal cord. Microcystic degenera-
ative resilience to trauma and secondary injuries. tion is sometimes difficult to distinguish from sy-
ringomyelia, even with MRI, and it too has been
VI. Chronic Posttraumatic Syndromes—Patients who
associated with arachnoiditis.
have suffered spinal cord injuries can also develop
C. Arachnoiditis—Arachnoiditis can occur after any
a number of important syndromes in the subacute
type of SCI, of any severity. It consists of con-
and chronic stages (Table 25-4). A complete analy-
nective tissue adhesions between the spinal
sis of these syndromes is beyond the scope of this
cord and its surrounding arachnoid, often
chapter and thus only brief descriptions will be
involving the dura. Neurological deterioration
associated with arachnoiditis can be step wise
TA B L E 2 5 - 4 or gradual. Tethering of the spinal cord, vascular
congestion, ischemia due to fibrosis of arachnoid
Chronic Posttraumatic Syndromes after SCI vessels, as well as obstruction of intraspinal CSF
Syringomyelia flow have been postulated to explain the mecha-
Microcystic myelomalacia nism by which arachnoiditis causes neurological
Arachnoiditis deterioration.
Deafferentation pain D. Deafferentation Pain Syndromes—Deafferenta-
tion pain syndromes can affect as much as 25%
of SCIs patients in the chronic stage and are the against checking from behind, neck muscle con-
result of abnormal nociceptive impulses gener- ditioning programs, player education, and hel-
ated at different levels such as injured nerve met redesign, led to an overall decrease of SCI in
roots, spinal cord, and brain after injury. hockey by 50% since 1984.
C. Pathophysiology—The pathophysiology of
VII. Sports-Related SCI—Sports-related SCI is an impor- sports-related SCI appears to be similar regard-
tant group because of its predilection for specific less of the sport involved. The vast majority of
activities and the significant role that prevention cases involve the cervical spine and this is best
plays in reducing the number of such injuries. illustrated by the fact that in football-related
Sports considered to bear the highest risk include SCI, all documented cases have occurred in the
auto and motorcycle racing, diving, hand gliding, cervical spine. Careful analysis of these injuries
football and gymnastics. Other high-risk sports by Torg and coworkers clearly demonstrated
include horseback riding, ice hockey, mountain that the most common mechanism of injury
climbing, parachuting, ski jumping, snowmobile, involves axial loading to the cervical spine.
trampoline and wrestling. The incidence of severe Indeed, the normal lordosis of the cervical spine
SCI associated with sports has declined dramati- allows for absorption of the energy transmitted
cally over the past 20 years. In 1977, the National during axial loading as well as transmission and
Collegiate Athletic Association (NCAA) provided dissipation of this energy via the neck muscles.
funding to initiate a national survey of catastrophic When the neck is slightly flexed, the cervical
football injuries. This was expanded in 1982 to in- spine becomes straight and loses this abil-
clude all sports for both men and women. ity to absorb and transmit mechanical energy
A. Football-Related Injuries—Of the school sports, efficiently, and the load is mainly transmitted to
football is associated with the greatest number the bones, ligaments and intervertebral discs. If
of catastrophic injuries. However, its incidence the tolerance of the bones, ligaments or discs
has been considerably reduced when compared is exceeded, they fail, resulting in various types
with early 1970s data (cervical spine injuries of SCIs. The validity of this mechanism of injury
4.1 per 100,000, permanent quadriplegia 1.58 has been emphasized by many authors and can
per 100,000). Evaluation of the data provided be applied to almost any sports or recreational
by surveys at that time led to the conclusion activities such as hockey and diving. Under-
that one of the main contributing factors was standing the pathomechanics of cervical spine
the helmet redesign performed to provide bet- injury in these activities allows for better train-
ter head protection. As a result of the improved ing, physical conditioning, and preventive mea-
helmet design, players started using the head as sures that limit the occurrence of severe SCIs.
a major contact point for blocking and tackling,
leading to an increase in cervical spinal cord VIII. Early Treatment of Patient with SCI
injuries. This provided the primary incentive A. Acute Medical Interventions—Every patient with
for the NCAA to ban the use of the head as an any type of SCI, with or without other associated
offensive weapon in football. The incidence of trauma, has to be treated promptly by both the
spine injuries and quadriplegia then decreased on-site primary care team and the medical team
significantly and has remained relatively stable in the emergency room. The absolute primacy of
(1.3 per 100,000 and 0.4 per 100,000, respectively). the ABCs cannot be overemphasized. Adequate
B. Hockey-Related Injuries—In the mid-1970s, a sig- perfusion and oxygenation of injured tissue are
nificant increase in hockey-related spine injuries essential for optimal recovery. Even brief peri-
was observed and led to the formation of the ods of hypoperfusion can increase mortality and
Canadian Committee on the prevention of Spine decrease the neurological recovery of patients
and Head injuries Due to Hockey. The Committee with SCI. Stabilization of the spine during extri-
found that there were virtually no reported cases cation, transportation, and transfer of any pa-
of spinal injuries in hockey from 1948 to 1973 tient with a history of significant trauma is done
whereas it became the second most common with the assumption that the victim has a spinal
cause of SCI in sports and recreational activities column injury until proven otherwise. Complete
from 1977 to 1981. It was found that most cases immobilization of the entire spine from the begin-
resulted from a direct blow to the vertex of the ning is essential to prevent further injury to an
head from being pushed or checked against un- already damaged spinal column/cord. If endotra-
cushioned boards. Based on these findings, sev- cheal intubation is required, the cervical spine
eral modifications such as better enforcement of is maintained in position without extension by
rules against boarding and crosschecking, rules applying gentle in-line traction. These important
measures have contributed to a reduction in the

ratio of quadriparesis to paraparesis in multiple TA B L E 2 5 - 5
trauma patients. Primary and Secondary Injury mechanisms
Restoration of any systemic hypotension to of acute SCI
normotension is an emerging principle of first
Primary Injury Mechanisms
aid management in SCI based on the recogni-
tion that there is vascular compromise of the Acute compression
Impact
injured cord by local microcirculatory events
Missile
including vasospasm and small vessel throm-
Distraction
bosis. Initial resuscitation in hypotensive pa- Sheer
tients consists of volume replacement with a
Secondary Injury Mechanisms
balanced electrolyte solution (e.g., Ringer’s
lactate) and blood replacement if persistent Systemic events
bleeding is suspected. Hypotension from spinal Systemic hypotension
Neurogenic shock
shock is much less common than hypovolemia,
Hypoxia
even in patients with SCI, and is considered Hyperthermia
only after adequate volume replacement has Vascular changes
been achieved and potential sources of ongo- Loss of autoregulation
ing bleeding have been ruled out. Treatment Hemorrhage
of hypotension in this case involves the use of Loss of microcirculation
vasopressor agents, such as dopamine, dobu- Reduction in blood flow
tamine and noradrenaline. Early and aggressive Vasospasm
medical management (volume resuscitation Thrombosis
and blood pressure augmentation) of patients Electrolyte changes
with acute spinal cord injuries has been shown Increased intracellular calcium
Increased extracellular potassium
to optimize the potential for neurological recov-
Increased sodium permeability
ery after sustaining trauma. Biochemical changes
B. Concept of Primary and Secondary Injury in Neurotransmitter accumulation
Acute SCI (Table 25-5)—The spinal cord is dam- Catecholamines (noradrenaline, dopamine)
aged after SCI by a primary mechanical injury Exitotoxic amino acids (glutamate)
and by a secondary injury involving a series of Arachidonic acid release
molecular and cellular events which cause fur- Free-radical production
ther tissue destruction. Eicosanoid production (prostaglandins)
1. Primary injury—The primary injury involves Lipid peroxidation
one or more of the following forces: com- Endogenous opioids
pression, contusion, distraction, laceration, Cytokine excess
Edema
sheer, or missile injury. The primary injury
Loss of energy metabolism
then sets in motion a cascade of secondary Decreased ATP production
injury as summarized in Table 25-5. Following Apoptosis
an acute injury, the spinal cord undergoes
a series of changes including hemorrhage,
edema, axonal and neuronal necrosis, apop-
tosis (genetically programmed cell death), in neuronal cultures, reports of hypoxic white
demyelination, and cavitation. By 24 to 48 matter injury and white matter compression
hours after major trauma, the injury site is injury, ultrastructural studies of calcium ac-
necrotic, especially the central zone previ- cumulation in axons after spinal cord trauma
ously occupied by hemorrhage. Following and confocal imaging studies provide strong
several days, the hemorrhagic zone shows support for the calcium hypothesis of neural
cavitation and the adjacent areas demon- injury. Apoptosis is a form of programmed
strate patchy necrosis. These cavitations are cell death seen in a variety of circumstances
the result of coagulative necrosis. such as immune cell selection and develop-
2. Secondary injury—The secondary injury ment. Apoptosis has very recently been ob-
mechanisms include ischemia, intracellular served after traumatic SCI in both animal
calcium influx, free-radical-associated lipid models and human studies, suggesting that
peroxidation, and glutaminergic toxicity. In active cell death may mediate damage after
particular, studies of glutamate cytotoxicity CNS injury. This type of cell death has been
observed in both neuronal and non-neuronal methylprednisolone followed by tirilazad

cells, such as oligodendrocytes which are re- mesylate bolus infusions of 2.5 mg per kg
sponsible for myelinization of the CNS axons. every 6 hours for 48 hours. For patients re-
C. Pharmacological Therapies for Patients with ceiving the initial bolus within 3 hours of
Acute SCI—Patients with SCI, even when injury, there was no difference in neurologi-
complete, usually have some preservation cal recovery between the three groups. For
of neural elements at the site of injury. patients who received the bolus between 3
Recordings of somatosensory evoked potentials and 8 hours after injury, the group receiv-
through the cord of patients with complete SCI ing the 48 hours infusion of methylpred-
have led to the hypothesis of a “discomplete” nisolone had a statistically significant
SCI syndrome where anatomical and functional better neurological recovery than the
elements are preserved. It is therefore conceiv- 24-hour infusion group. Patients receiving
able that limiting secondary injury to nervous the tirilazad showed similar recovery to the
tissue after the initial insult can enhance neu- 24-hour methylprednisolone infusion group.
rological recovery after SCI. It has been shown This study thus stressed the importance
that an increase in neural tissue survival of 10% of starting the initial bolus as soon as
to 20% may be sufficient to allow return of clini- possible after the injury, and that for pa-
cally significant neurologic function. The aim tients receiving the initial bolus between
of pharmacological agents is thus to alter the 3 and 8 hours of injury, an infusion of 48
response of nervous tissue to injury in order hours of methylprednisolone should be
to improve its survival. Only a few agents have administered. The protocol is summarized
been subjected to clinical trials to date and in Table 25-6. Since the benefits in neurologi-
only one has made it to routine clinical use. cal recovery after methylprednisolone occur
1. National Acute Spinal Cord Injury Study I mostly below the level of injury, it is thought
(NASCIS I)—The first National Acute Spinal that it exerts its beneficial effect by limiting
Cord Injury Study (NASCIS I) was completed damage to the major long tracts of the spi-
in 1984 and compared the effect of two dif- nal cord. The mechanism of action is likely
ferent regimens (high-dose and low-dose) related to suppression of lipid peroxidation
of methylprednisolone after SCI. There was and hydrolysis of neuronal and endothelial
no statistical difference in the neurological membranes by free radicals.
recovery between the two groups, but the The NASCIS trials have received intense criti-
study was criticized because (a) the dose of cism over the last number of years. It should
methylprednisolone was too low based on be noted that the guidelines committee of the
the 30 mg per kg dose-relationship already American Association of Neurological Sur-
established and (b) the lack of a placebo arm. geons and Congress of Neurological Surgeons
2. NASCIS II—The NASCIS II was thus initiated, Joint Section on Disorders of the Spine and
comparing methylprednisolone 30 mg per Peripheral Nerves on reviewing the evidence
kg bolus followed by 5.4 mg/kg/hour for 23 regarding the use MPSS in the treatment of
hours, naloxone 5.4 mg per kg bolus fol- acute SCI in adults concluded that the use of
lowed by 4.0 mg/kg/hour for 23 hours, and this medication could only be supported at
placebo. The results were published in 1990. the level of a treatment option (AANS/CNS,
It was found that patients treated with 2002). However, it is the authors’ view that
methylprednisolone within eight hours the intense criticism directed at the NASCIS II
of injury showed evidence of statistically
significant recovery of both sensory and
motor function compared with naloxone TA B L E 2 5 - 6
and placebo, regardless if the injury was Methylprednisolone Therapy for Acute Spinal
initially complete or incomplete. Cord Injury Based on Time of Presentation
3. NASCIS III—The latest study, NASCIS III, (NASCIS II and III Protocol)
which was published in 1997, compared
Time of Initial Maintenance
two regimens of methylprednisolone, the
Presentation after Bolus Infusion
standard 30 mg per kg bolus followed by Injury
5.4 mg/kg/hour for 24 hours, and 30 mg per
3 h after injury 30 mg/kg 5.4 mg/kg/h × 24 h
kg bolus followed by a 48-hour infusion of
5.4mg/kg/hour. A third arm was added with 3–8 h after injury 30 mg/kg 5.4 mg/kg/h × 48 h
patients receiving a 30 mg per kg bolus of
and III trials must be balanced by the current investigation of SCI patients has demonstrated that
lack of alternative neuroprotective strategies the degree and extent of spinal cord compression
for acute SCI. Moreover, the modest thera- is the most important predictor for neurological
peutic benefit demonstrated by MPSS may recovery. Guttman, using postural techniques and
potentially prove to impart a major benefit on bedrest to achieve reduction and spontaneous fu-
cervical SCI patient’s functional independence sion, first advocated conservative management of
and quality of life. patients with SCI. At that time, it was believed that
D. Emerging Drugs for SCI—A number of promising surgical intervention after SCI in the form of lami-
pharmacological therapies are currently under nectomy led to a higher incidence of neurological
investigation for neuroprotective abilities in complications. Spontaneous improvement in neuro-
animal models of SCI. These include the sodium logical status after conservative management has
channel blocker riluzole, the tetracycline deriva- been observed in many studies. Most of the studies
tive minocycline, the fusogen copolymer poly- on nonoperative management are limited to non-
ethylene glycol (PEG), and the tissue-protective controlled, retrospective analyses and thus provide
hormone erythropoietin (EPO). Moreover, clini- limited evidence. Furthermore, laminectomy alone
cal trials investigating the putative neuroprotec- as a treatment for SCI often fails to decompress the
tive and neuroregenerative properties ascribed spinal cord completely and can lead to spinal insta-
to the Rho pathway antagonist, Cethrin® (Bio- bility and subsequent neurological deterioration.
Axone Therapeutic, Inc.), and implantation of Modern medical intensive care management and
activated autologous macrophages (ProCord®; surgical techniques in the treatment of SCI have
Proneuron Biotechnologies) in patients with tho- evolved considerably over the years and have al-
racic and cervical SCI are now underway. We an- lowed earlier surgery to be performed with mini-
ticipate that these studies will harken an era of mal hemodynamic and systemic complications.
renewed interest in translational clinical trials. Although some studies have shown a trend toward
better neurological recovery when surgery is per-
IX. Timing of Surgical Intervention after SCI—Despite formed early, there is no good statistical data sup-
the widespread use of surgery in patients with SCI porting this approach. Most studies are indeed
in North America, the role of this intervention in im- retrospective, case series with historical controls.
proving neurological recovery remains controversial Review of these studies reveals no clear consensus
because of the lack of well-designed and executed as to the appropriate timing of surgery after SCI, nor
randomized controlled trials. Early decompression is there significant evidence that decompression af-
and stabilization of spinal column fractures has sev- fects neurological recovery after SCI. There is only
eral potential advantages: (a) allows early patient one randomized prospective control trial reported
mobilization in order to prevent systemic complica- to date regarding the timing of surgical decompres-
tions of prolonged immobilization such as pulmo- sion in SCI. This was a single center trial in which
nary infections, decubitus ulcers, thrombophlebitis, 62 patients were randomized to either early or late
and pulmonary embolism; (b) improves neurologi- surgery. Early surgical treatment was defined as less
cal recovery after SCI, especially in patients with than 72 hours after the initial trauma, with a mean
incomplete SCIs; (c) reduces hospital stay; and (d) time of decompression of 1.8 days. The late group
improves rehabilitation. was defined as surgical decompression later than 5
Prompt stabilization of long bones and pelvic days after injury, and had a mean of 16.8 days. There
fractures in multiple trauma victims has been shown was no difference in motor recovery at approxi-
to significantly reduce patient morbidity and mor- mately 1-year follow up. Also, the investigators did
tality. Recent studies comparing early versus de- not find any differences between the groups in the
layed spinal surgery on patients with complete and length of ICU stay or in-patient rehabilitation time.
incomplete SCI did not show any increase in medi- However, 20 of the 62 patients were lost to follow up.
cal complications in the early group. Some studies Contemporary studies have shown that early
have shown a trend toward a decrease in systemic surgery for SCI does not increase the systemic
complications. There has also been a trend toward complication rate compared with delayed surgery.
shorter hospital stay and earlier rehabilitation in Based on this assumption, early decompression and
patients treated with aggressive surgical therapy. stabilization may provide patients with SCI an op-
Although it seems intuitive that early decompres- timal window for early mobilization and rehabilita-
sion after SCI may improve neurological recovery, tion. The question regarding neurological recovery
the question remains for the most part unanswered. in early versus late surgical decompression in SCI
Animal studies have shown that mechanical fac- thus far remains unanswered. This question is be-
tors are important in the pathogenesis of SCI. MRI ing addressed with the Surgical Treatment for Acute
Spinal Cord Injury Study (STASCIS) study, a multi- foot orthoses to stabilize the foot and ankle.
centre prospective randomized trial. Early data pre- Crutches are usually required to assist gait and
sented by the senior author at the Canadian Spine patients can walk only for a limited duration; a
Society in 2008 suggests a benefit to early surgical wheelchair is required for long distances.
decompression of the spinal cord. Neurological 2. Quadriplegia—The exact level of function is
worsening associated with persistent spinal cord critical in quadriplegic patients. Lesions above
compression by disc and bone fragments is a widely the C4 level often create respiratory impair-
accepted indication for early surgery. ment and if patients survive, they remain
ventilator dependent. If diaphragm paralysis
X. Recovery after SCI results from an upper motor neuron impair-
A. Somatic Motor Recovery—Neurological improvement, phrenic nerve stimulators may allow the
ment always occurs after SCI, even when it is patient to use their own diaphragm for ventila-
complete. In complete SCI, recovery occurs mainly tion. Patients can operate in wheelchairs onto
at the zone of injury and continues for up to 2 years. which respiratory equipment is attached and
It has been shown that when some strength is pres- they can perform desktop assisted tasks with
ent in the spinal segment below the level of injury, the use of a mouth-stick. Ventilation is pro-
recovery to Grade 4 or 5 occurs in 80% to 90% of vided via a tracheotomy, allowing the patients
patients. When no strength is present in that seg- to talk with exhalation.
ment, only 25% to 35% show recovery to Grade 3 Table 25-7 illustrates muscle functions corre-
to 5. If the injury remains complete for longer than sponding to functional levels below C4 in quad-
a week, there is usually no useful neurological re- riplegic patients. At the C5 level, the deltoid
covery below the zone of partial preservation. In and elbow flexors allow shoulder and elbow
an extensive review of neurological recovery of flexion. An orthosis fixing the wrist allows
complete cases, Hansebout found that approxi- grasp between the thumb and other fingers via
mately 1% of complete cases recover the ability a passive closing mechanism. Patients can
to ambulate. Stover and coworkers found the best then feed themselves independently.
recovery in the B and C categories of incomplete The acquisition of C6 musculature provides
injuries in which 30% to 50% of patients improved a major increment in the functional status of
one grade. Presently, 50% to 60% of patients have quadriplegic patients. Wrist extensors allow
incomplete injuries. Patients with incomplete cer- patients to propel themselves in a wheel-
vical lesions usually recover sooner at the zone chair, transfer from bed to chair manually,
of injury as well as distal to the site. Over 80% of and live independently. A wrist-hand orthosis
patients who have any voluntary movement in the can be used in order to improve wrist exten-
lower extremities distal to the injury will recover sion if the wrist extensors are weak. Another
useful motor function (ASIA class D or better). wrist orthosis linking the wrist to the metacar-
B. Functional Status of Patients after SCI—Paraple- pophalangeal joints drives finger flexion when
gia is defined as the neurological state when the wrist is extended, allowing active grasp be-
the most rostral muscle with no contraction is tween the thumb and fingers.
below the first dorsal interosseus (C8-T1) with C7 level function gives patients the use
no muscle contraction distally. of their triceps. All patients with intact C7
Quadriplegia is defined as the neurological functions should be able to transfer and
state when the most rostral muscle with no live independently. Wrist flexion and exten-
contraction is the first dorsal interosseus sion, as well as some finger extension are also
(C8-T1) or higher. preserved. Thumb and finger flexion is absent.
1. Paraplegia—Paraplegic patients are usually able The key muscles at the C8 functional level are
to stand if sufficient strength is generated in the the thumb and finger flexors, and enable gross
arms to bring them to an upright position with grasp and lateral pinching between the
crutches. If quadriceps strength is less than thumb and index finger.
Grade 3, orthoses for knee stabilization during C. Autonomic Recovery after SCI
standing are required. Gait is then assisted with 1. Bladder and bowel function—Because of the
crutches in a swinging motion. Gait assisted initial period of spinal shock, which can
with crutches in paraplegic patients requires a last between days to weeks, it is usually
significant amount of energy and is not practi- impossible to predict bladder and sexual
cal. Most patients will prefer the wheelchair. If function recovery after SCI. After spinal
hip and knee strength is greater than Grade 3, shock subsides, reflex activity and spastic-
patients are able to stand and only require ity may appear in the lower extremities, and
TA B L E 2 5 - 7
Functional Levels of Quadriplegia
Functional Level Key Muscles Innervated Functional Capacity
C5 Deltoid Shoulder and elbow flexion
Biceps Arm lifting
Feeding and grasping with orthoses
C6 Brachioradialis Wrist extension
Extensor carpi radialis longus and brevis Wheelchair propelling
Pronator teres Transfers
Grasping with orthoses
Independent living possible
C7 Triceps Full transfers
Extensor digitorum communis Independent living
Flexor carpi radialis
C8 Flexor digitorum profundus Fine grasping
T1 Intrinsic hand muscles Intrinsic hand muscle function
reflex bladder and bowel function may return. cutaneous or mucous membrane stimulation
If reflex sacral activity returns after a complete from areas below the level of the lesion. A com-
injury, reflex bladder emptying will be retained plete erection is obtainable when the lesion is
in most patients. Triggering of reflex bladder above T11. If the injury is below T11, only the
emptying can be done by maneuvers such as corpora cavernosa will be involved, and not
suprapubic taping, stroking of the thighs, and the corpus spongiosum. Psychogenic erection
Valsalva maneuver. An areflexic bladder can is thought to be mediated by a cortically acti-
void by application of pressure on the blad- vated sympathetic system located in segments
der either externally or by Valsalva maneuver. T11 to L2 and can be induced by visual, audi-
Residual volumes can be high despite reflex tory, olfactory or psychic stimuli. This type of
bladder emptying and this can be facilitated erection is maintained with injuries below L2,
by anticholinergic drugs that decrease smooth but results only in swelling of the penis with-
muscle spasm of the internal sphincter at the out rigidity thereby preventing coitus. When
bladder neck, or antispasmodic drugs that the lesion is between L2 and S2, mixed types of
decrease skeletal muscle tone in the external erections can be induced. The return of erec-
sphincter. External sphincter spasticity some- tion after SCI ranges between 54% and 95%
times necessitates sphincterectomy to allow after 2 years but its quality is usually not as
proper bladder emptying. Indwelling catheters good as in normal subjects. This is illustrated
are usually contraindicated because they lead by a poorer successful coitus rate (5% to 75%).
to bladder constriction, which in turn leads to Patients with cervical and thoracic SCI tend to
the formation of renal calculi and early renal have a higher and quicker rate of recover than
failure. For the male, external condom catheter patients with lumbar injuries. Several methods
is the method of choice while in women, pad- can be utilized to enhance erection in patients
ding or diapering is recommended. with SCI such as vacuum devices, intracav-
2. Sexual function—For a long time, patients who ernous or cutaneous injections of vasoactive
lost sexual function after SCI were thought to drugs, penile prosthesis, and sacral anterior
remain asexual for the rest of their life. Recent root stimulators.
advances in the understanding of sexual neu- 3. Ejaculation—In men, ejaculation is mediated
rological mechanisms and methods to enhance by the sympathetic, parasympathetic, and
sexual activity have led to a significant improve- somatic pathways. A sympathetic center
ment in sexual function, especially in men, after located in T11 to L2 is responsible for semi-
SCI. Erection in men is mainly mediated via the nal emission from the vasa deferentia, seminal
parasympathetic system located in segments vesicles, and prostate, as well as closure of
S2 to S4. It is reflexogenic in nature, requiring the bladder neck. The parasympathetic center
an intact reflex arc, and can be induced by located at S2 to S4 supplies the prostate and
helps in the formation of seminal fluid. The spinal cord injury: a preliminary report. Johns Hopkins Med
somatic center at S2 to S4 is responsible for J. 1979;145:115–125.
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the clonic contractions of the bulbospongio-
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Bracken MB, Shepard MJ, Collins WF, et al. A randomized,
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penis, electroejaculation from electric stimula- treatment of acute spinal-cord injury. Results of the Second
tion delivered from a probe, and surgical aspi- National Acute Spinal Cord Injury Study [see comments].
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CHAPTER 26
General Principles of Vertebral

Bony, Ligamentous, and
Penetrating Injuries
Robert Greenleaf, Jory D. Richman and Daniel T. Altman
I. Cervical Spine the atlas by the strong transverse ligament,

A. Clinical Anatomy which inserts on the lateral masses of C1. The
1. Occipitoatlantoaxial complex—The cervical alar ligaments originate from the occipital
spine consists of two atypical vertebrae, the condyles, attach to the tip of the dens, and limit
atlas (C1) and axis (C2), and five lower cervi- excessive lateral flexion and rotation. The api-
cal vertebrae. The occipitoatlantoaxial complex cal ligament originates at the ventral surface
functions as a unit, being composed of synovial of the foramen magnum and inserts on the tip
joints surrounding the articulations and devoid of the odontoid. It is only a minor stabilizer of
of any intervertebral discs. The atlas consists the craniocervical junction. The odontoid may
of an anterior and posterior arch and two lat- fracture alone or occasionally in combination
eral masses. The superior surfaces of the with ligamentous disruption. Isolated rupture
lateral masses articulate with the occipital of the transverse ligament, although common in
condyles, allowing 25° of flexion and exten- patients with rheumatoid arthritis, is relatively
sion and 5° of lateral bending and rotation. uncommon, secondary to trauma. At the C1–C2
The inferior aspect of the lateral masses of level the space available for the spinal cord
C1 articulates with the superior facets of C2, is greater than at any other level of the cervi-
allowing rotation. Approximately 50% of the cal spine. Steel’s rule of thirds states that the
rotatory movement of the entire cervical spine area inside the atlas is equally occupied in
occurs at the atlantoaxial articulation. In the thirds by the dens, spinal cord, and space.
upper cervical spine, flexion is limited by bony The space is primarily occupied by cerebro-
anatomy, and extension is limited by the tecto- spinal fluid. This accounts for the low inci-
rial membrane. Rotation and lateral bending are dence of spinal cord injuries associated with
restricted by the contralateral alar ligament. C1 and C2 fractures. Complete spinal cord in-
The axis, or second cervical vertebrae, consists juries at this level are rarely survivable events.
of a vertebral body, an odontoid process (dens), 3. Anatomy of the subaxial cervical spine—The
pedicles, laminae, and a spinous process. The subaxial cervical vertebrae (C3 to C7) are
synchondrosis between the dens and the body relatively uniform in their morphologic char-
of the axis generally closes by age 6 years, but acteristics. The vertebral body is connected
may persist into adulthood as a thin sclerotic posteriorly to the neural arch by the pedicles.
line that may resemble a nondisplaced fracture. The pedicles connect the vertebral body to the
2. Odontoid process—The odontoid process lateral masses. Within the lateral masses are
(dens) with its attached ligamentous struc- superior and inferior facets, which form diar-
tures is the major stabilizer of the atlantoaxial throdial joints. The facet joints are oriented 45°
articulation. The atlantoaxial joint depends on in the sagittal plane and neutrally in the coronal
a complex of ligaments for stability (Fig. 26-1). plane. The superior articular facet (of the lower
The dens is held against the anterior arch of vertebrae) is anterior and inferior to the inferior
406
C H A P T E R 2 6 | G E N E R A L P R I N C I P L E S O F V E R T E B R A L I N J U R I E S 407
Apical (dental)
Tectoral membrane (divided)
ligament
Alar (dental) Spinous process
ligament of axis
Accessory Transverse
ligaments (atlantal)
ligament Superior articular
facet of atlas
Body of axis
Odontoid
Tectoral membrane
(divided) Anterior arch of atlas
A B
FIGURE 26-1 Atlantoaxial joint and cranium (the occipitoatlantoaxial complex). A. Posterior coronal view. Note the
alar, transverse, and apical ligaments. B. Superior view of the atlantoaxial articulation.
articular facet of the vertebra above. The un- intervertebral discs between the bodies of the
cinate processes are small, bony ridges that vertebrae consist of a central nucleus pulpo-
project from the posterolateral aspect of the su- sus and a strong outer annulus fibrosis, which
perior end plate of the vertebral body. They ar- also provides stability and limits motion at each
ticulate with indentations on the inferior surface level of the subaxial cervical spine.
of the adjacent vertebral body, which form the B. Injuries of the Cervical Spine
uncovertebral joints of Luschka. The trans- 1. Injuries involving the occiput, atlas, and axis
verse foramina from C2 to C7 are surrounded • Atlanto-occipital dislocation—Atlanto-occipital
by the pedicles, transverse processes, and fac- dislocation usually results from a high-energy
ets. Spinous processes from C2 to C6 are usually injury in a patient with concomitant head
bifid. The C7 spinous process is usually nonbi- trauma; the injury is often fatal. These rare in-
fid and the most easily palpable. The vertebral juries are often associated with significant de-
arteries originate from the first branch of the lays in diagnosis.
subclavian arteries and usually enter the spine • Occipital condyle fractures—Anderson and
at the foramen transversarium of C6. The ar- Montesano classified occipital condyle frac-
tery passes through the foramen of C1 and then tures seen on CT based on mechanism of
turns sharply medially and superiorly into the injury.
foramen magnum. Although rare, fractures of (a) Type I injuries are impaction fractures of
the transverse process or fracture-dislocations the condyle secondary to an axial load.
of the cervical spine may cause injury to the (b) Type II injuries are basilar skull fractures
vertebral artery. associated with fractures of the condyle.
4. Stability of the subaxial cervical spine—The (c) Type III injuries are avulsion fractures
lower cervical spine has little intrinsic bony of the alar ligaments. This type of injury
stability. Spinal ligaments include the anterior represents a more unstable injury with a
and posterior longitudinal ligaments, the liga- higher association with atlanto-occipital
mentum flavum, and the supraspinous, inter- dissociation.
spinous, and intertransverse ligaments. The • Atlas (C1) fractures—Atlas (C1) fractures
anterior longitudinal ligament covers the an- are generally felt to be secondary to an axial
terior surface of the vertebral body and resists load. Fracture of the C1 ring can involve the
extension moments to the vertebral column. anterior arch, the posterior arch, the lateral
The posterior longitudinal ligament is nar- masses, or most commonly the anterior and
rower than the anterior longitudinal ligament posterior arches (Jefferson’s fracture).
and is continuous with the tectorial membrane. Fractures of the atlas are usually not as-
It covers the posterior surface of the vertebral sociated with neurologic symptoms and
body and resists hyperflexion moments. The most are stable. Injuries are considered
interspinous and supraspinous ligaments insert radiographically unstable if the open-
on the spinous processes and limit flexion. The mouth AP radiograph reveals a combined
lateral mass step-off larger than 7 mm. (d) Type IV injuries are the least common and
This amount of step-off suggests rupture of include posterior displacement of the at-
the transverse ligament, the strongest and las and associated rotatory subluxation.
the most important ligament for stability be- • Odontoid fractures—Odontoid fractures may
tween C1 and C2. Posterior arch fractures are occur when flexion forces cause anterior dis-
usually the result of extension forces and are placement or when extension forces cause
often associated with odontoid fractures or posterior displacement of the odontoid.
traumatic spondylolisthesis of C2. These motions result in impingement of the
• C1–C2 subluxation—C1–C2 subluxation re- dens against either the anterior arch of the
sulting from acute transverse ligament rup- atlas or the transverse ligament. The clas-
ture is rare and as with atlanto-occipital sification system most often used is that by
dislocation is often fatal. The mechanism is Anderson and D’Alonzo (Fig. 26-3).
disruption of the transverse ligament with (a) Type I fractures are extremely uncommon
a resultant increase in the anterior atlanto- and occur at the tip of the odontoid, prob-
dens interval. According to Fielding, if there ably as the result of avulsion of the alar
is less than 3 mm of anterior displacement ligaments. Type I fractures may be associ-
the transverse ligament is intact; if there is 3 ated with craniocervical dislocation and
to 5 mm of anterior displacement the trans- must be ruled out radiographically and
verse ligament is ruptured; and if there is clinically.
more than 5 mm of anterior displacement (b) Type II fractures are the most common
the transverse and alar ligaments are likely and occur at the junction of the base of
ruptured. Further, if the ADI is greater than the odontoid and the body of C2. The
7 mm, there is probable rupture of the tecto- fracture does not extend into the C1–C2
rial membrane. articulation. Type II fractures have a high
• A
tlantoaxial rotatory subluxation—Atlanto- rate of nonunion and pseudoarthrosis be-
axial rotatory subluxation is often difficult to cause the blood supply to the cephalad
diagnose, which may cause a delay in treat- fragment is disrupted.
ment. In adults, the injury is usually related to (c) Type III fractures occur within the cancel-
motor-vehicle trauma and may be associated lous bone of the body of the axis.
with fracture of the lateral mass as a result of • Traumatic spondylolisthesis of the axis—
flexion and rotation. In children, the injuries Traumatic spondylolisthesis of the axis
are usually self-limited and are the result of a (hangman’s fracture) is usually a combined
viral illness. Fielding divides rotatory sublux- hyperextension and axial loading injury,
ation into four types (Fig. 26-2). causing fracture of the C2 pars interarticu-
(a) Type I injuries are the most common. laris. As with other fractures of the upper
Radiographic findings reveal fixed ro- cervical spine, traumatic spondylolisthesis
tational deformities without anterior of the axis tends to decompress the neural
displacement or disruption of the trans- canal, and thus neurologic involvement is un-
verse ligament. common. The most widely used classification
(b) Type II injuries demonstrate transverse is by Levine and Edwards and is based on a
ligament insufficiency with 3 to 5 mm of lateral cervical spine radiograph (Fig. 26-4).
anterior displacement of the atlas. (a) Type I fractures are usually secondary
(c) Type III injuries have more than 5 mm of to hyperextension and axial loading with
anterior displacement of the atlas. The less than 3 mm of displacement of C2
transverse ligament is typically ruptured. on C3.
FIGURE 26-2 Four types of

atlantoaxial rotatory subluxation
according to Fielding.
Type I Type II Type III Type IV
Type
yp I Type
yp II Type
yp III
FIGURE 26-3 Anderson and D’Alonzo classification of odontoid fractures.
Type I Type II Type IIa Type III
FIGURE 26-4 Classification of traumatic spondylolisthesis of the axis as described by Levine and Edwards.
(b) Type II injuries also result from hyperexten-

sion and axial loading but have significant
angulation, translation, or both. Type IIa
fractures are the result of a flexion force
and have minimal translation but severe
angulation.
(c) Type III fracture-dislocations are second-
ary to a flexion force and result in severe
angulation and displacement as well as
concomitant unilateral or bilateral facet
dislocations at C2–C3. Type III injuries are
the pattern most commonly associated
with neurologic deficits.
(d) Stability—Type I fractures are stable,
whereas Types II, IIa, and III are unstable
disruptions of the C2–C3 motion segment. Spinolaminar line
2. Injuries involving the lower cervical spine—
Anterior vertebral
The lateral cervical spine radiograph is impor- body line
tant to evaluate for gross bony or ligamentous Posterior vertebral
injury by ensuring continuity of the longitu- body line
dinal “lines” (Fig. 26-5). A comprehensive FIGURE 26-5 Radiographic lines seen on the lateral
classification system of closed fractures and cervical spine film to evaluate for bony or ligamentous injury.
dislocations of the lower cervical spine based The facets appear as stacked blocks or parallelograms.
FIGURE 26-6 Mechanistic Distraction

classification of fractures and
dislocations of the lower Distraction/flexion Distraction/extension
cervical spine as described
by Allen and Ferguson.
Flexion Extension
C2
C3
Flexion/compression C4 Extension/compression
C5
C6
C7
Compression
on mechanism of injury has been described • Distractive flexion injuries—Distractive flex-

by Allen and Ferguson (Fig. 26-6). This classifi- ion injuries usually result in posterior liga-
cation describes both the major injury vector mentous disruption without fracture. These
and the position of the head and neck at the injuries occur most often from motor-vehicle
time of injury. There are six basic categories. accidents or falls and produce distractive or
• Compressive flexion injuries—Compressive tensile forces on the posterior ligamentous
flexion injuries result from axial loading structures.
forces such as diving and football injures and (a) Stage I injuries are simple flexion sprains.
motor-vehicle accidents. These injuries are (b) Stage II injuries usually occur with rota-
subclassified into five stages with increasing tion and result in unilateral facet disloca-
vertebral comminution and disruption of the tion and approximately 25% translation
posterior elements. of the vertebral body.
• Vertical compression injuries—Vertical com- (c) Stage III injuries produce a bilateral facet
pression fractures are the result of an axial dislocation and have approximately 50%
load and are sometimes referred to as burst translation. Prior to reduction in the ob-
fractures. This injury is caused by compres- tunded or anesthetized patient, an MRI
sion to the vertebral body with the posterior is often necessary to evaluate for con-
ligaments remaining intact. comitant disc herniation.
(d) Stage IV injuries demonstrate 100% ver- oriented 90° in the sagittal plane and 45° ante-
tebral body translation. rior in the coronal plane.
• Compressive extension injuries—Compressive 3. Superior articular facet—In both thoracic and
extension injuries result from a frontal force to lumbar spines, the superior articular facet
the head or face and are frequently associated (from the lower vertebrae) of the facet joint is
with maxillofacial trauma. These injuries have anterior and lateral to the inferior articular facet
been subdivided into five stages based on the of the vertebra above.
degree of disruption of the posterior elements 4. Supporting ligaments of the thoracic and lum-
and vertebral body translation. bar spines (Fig. 26-8).
• Distractive extension injuries—Distractive • Entire length of the spine
extension injuries are less common than (a) Anterior longitudinal ligament
compressive extension injuries. The mecha- (b) Posterior longitudinal ligament
nism of injury causes a failure of the ante- (c) Supraspinous ligament
rior longitudinal ligament or a transverse • Each level of the spine
fracture of the vertebral body. These injuries (a) Ligamentum flavum
may be difficult to diagnose because they (b) Interspinous ligament
primarily involve soft tissue and may sponta- B. Injuries of the Thoracolumbar Spine
neously reduce when the head is in a neutral 1. Classification—Several classifications exist for
position. Distractive extension injuries are thoracolumbar injuries; they are based on frac-
frequently associated with central cord syn- ture morphology, fracture mechanism, or both
drome in the elderly patient with preexisting factors. With improved imaging techniques,
spondylolysis and central canal stenosis. classification schemes have been further de-
• Lateral flexion injuries—Lateral flexion inju- fined to address the issue of spine stability.
ries are the least common injuries and are White and Panjabi have defined spinal insta-
caused by asymmetric compression of the bility clinically as the loss of the ability of the
vertebral body. There may be an associated spine to maintain structure under physiologic
fracture of the neural arch. conditions. In Holdsworth’s initial two-column
model of the spine, the integrity of the poste-
II. Thoracolumbar Spine rior ligamentous complex determined the sta-
A. Clinical Anatomy bility of the spine. Denis further classified the
1. Thoracic spine—The thoracic spine consists spine into a three-column model with the use
of 12 vertebrae. The facet joints are oriented of computed tomography (Fig. 26-9). The ante-
60° in the sagittal plane and 20° posterior in rior column includes the anterior longitudinal
the coronal plane. ligament and the anterior half of the vertebral
2. Lumbar spine—The lumbar spine consists of body and disc. The middle column consists
five vertebrae (Fig. 26-7). The facet joints are of the posterior longitudinal ligament and the
Pedicle
Superior articular
process
Transverse process
Body
Pars interarticularis
Spinous process
Facet
B Inferior articular
process
FIGURE 26-7 Lateral view of a lumbar vertebra (A) and a schematic drawing (B) demonstrating the superior and
inferior articular processes (and facets). (A, reprinted with permission from Weissman BNW, Sledge CB. Orthopedic
Radiology. Philadelphia, PA: WB Saunders; 1986.)
Anterior longitudinal Lamina

ligament
Articular
Intervertebral disc capsule
Interspinous Ligamentum
ligament flavum
Cut surface
of pedicle
Supraspinous
ligament
Posterior
longitudinal
ligament
FIGURE 26-8 Supporting ligaments of the spine.
posterior half of the vertebral body and disc. major spinal injuries into four different groups:
The posterior column includes the bony neu- compression fractures, burst fractures, flexion-
ral arch (pedicles, lamina, facets, and spinous distraction injuries, and fracture-dislocations.
process) and the associated ligamentous struc- Gertzbein has introduced a comprehensive clas-
tures, including the facet capsules, ligamentum sification with three broad mechanistic patterns:
flavum, and spinous ligaments. compression, distraction, and multidirectional
2. Mechanism of injury—The thoracolumbar junc- with translation. Each of these is further divided
tion is the most frequently affected area for ver- by fracture pattern (Fig. 26-10).
tebral fractures because it is the transitional zone • Compression fractures—Compression frac-
between the rigid thoracic spine and the more tures by definition involve the anterior col-
flexible lumbar spine. In addition, axial forces umn and typically result from a flexion force
are concentrated at the thoracolumbar junction, to the spine. If compression of the vertebral
since the sagittal alignment of the spine is neutral body exceeds 50%, the posterior ligamen-
between thoracic kyphosis and lumbar lordosis. tous structures may be disrupted. Denis
The most common mechanisms associated with classified compression fractures into four
thoracolumbar injuries are axial compression, types. Fractures may involve both end plates
flexion, shear, and flexion-distraction. Denis de- (Type A), the superior end plate (Type B),
veloped a classification system that categorizes the inferior end plate (Type C), or central
FIGURE 26-9 Denis three-column

model of the thoracolumbar spine
with involved structures.
Posterior column Middle column Anterior column
FIGURE 26-10 Gertzbein
classification of thoracolumbar
fractures. Type A involves
compression of the vertebral body.
Type B involves distraction with
anterior and posterior element
injury. Type C involves anterior
and posterior element injury
with translation and rotation.
(From Gertzbein SD. Fractures of
the Thoracic and Lumbar Spine.
Baltimore, MD: Williams &
Wilkins; 1992, with permission.)
Type A Type B Type C
failure of the body with both end plates intact involve all three columns, and often cause
Type D). Type B injuries are the most com- neurologic deficit. These injuries may result
mon. Compression fractures are common in from combined compression, tension, rota-
the elderly population, especially in osteo- tion, or shear forces (Fig. 26-11). Often, the in-
porotic postmenopausal women. Short tau jury presents as a fracture-dislocation of the
inversion recovery (STIR)-weight MRI is the spine, and less commonly, a pure dislocation
best method to evaluate for an acute com- (ligamentous injury without fracture) may
pression fracture. The presence of an intra- occur. Radiographic signs of translational
vertebral vacuum cleft on plain radiographs
and a high T2 signal on MRI suggest nonunion
of the vertebral fracture with osteonecrosis.
• Burst fractures—Burst fractures cause dis-
ruption of the anterior and middle columns
and most frequently occur at the thoraco-
lumbar junction. They are caused primarily
by an axial loading mechanism. Approxi-
mately 50% of patients with burst fractures
have neurologic deficits. Attempts have been
made to classify these fractures into stable
and unstable based on the integrity of the
posterior ligamentous structures.
• Flexion-distraction injuries—Flexion distrac-
tion injuries are caused by a flexion force that
results in distractive failure of all three verte-
bral columns and may occur through bone, soft
tissues, or both structures. These injuries are
sometimes referred to as seat belt injuries or
chance fractures and have classically occurred
in passengers restrained by a lap belt without a
shoulder harness. The “seat belt” sign, an ab-
dominal ecchymosis caused by the lap belt,
may be present and should raise suspicion for
an underlying abdominal injury. Injuries with
primarily ligamentous involvement may create
chronic instability, whereas flexion-distraction
injuries with predominantly bony involvement
have an excellent capacity for healing.
FIGURE 26-11 Anteroposterior radiograph
• Translational injuries (fracture-dislocation)—
demonstrating an unstable translational injury at T5–T6
Translational injuries are highly unstable, as a result of a motor-vehicle accident.
injuries include fractures of the transverse 4. Temporary and permanent cavitation—

processes, dislocation of the rib heads, spi- Another critical element of wound ballistics
nous process widening, and subtle listhesis concerns the mechanism of temporary and
of the vertebral bodies, especially with lat- permanent cavitation. Temporary cavitation
eral offset. These complex injuries have the occurs when a high-velocity projectile acceler-
highest incidence of neurologic deficit and ates the tissues forward and sideways, causing
the physician must be alert to the possibility an expanding cavity that enlarges on passage
of a reduced or partially reduced dislocation. of the bullet. The cavity formed is at subat-
mospheric pressure, which sucks air and ma-
III. Penetrating Injuries of the Spine terial into the entrance and exit wounds. The
A. Ballistics temporary cavity rapidly collapses to form the
1. Overview—Ballistics is the science of the permanent cavity, which is the tissue perma-
motion and impact of projectiles discharged nently macerated or crushed by the projectile.
from firearms. The damage created by a Temporary cavitation explains why nerves and
projectile depends on mass, velocity, and blood vessels at a distance from the immediate
bullet composition and design. The amount bullet path can incur significant damage. Tempo-
of tissue damage caused by a bullet depends rary cavitation is more dramatic in high-velocity
on its kinetic energy (KE), which is defined by injuries, whereas lower velocity injuries in-
the formula KE = ½ MV2, where M is mass and volve more of a crushing mechanism.
V is velocity. Low velocity generally refers to 5. Shotgun injuries—Shotgun injuries differ from
a firearm that can project a bullet at 1,000 ft gunshot wounds in that the mass of the projec-
per second or slower. High-velocity bullets tile is far greater, releasing much more kinetic
travel at velocities in excess of 2,000 ft per energy when fired at close range. In addition to
second. There has been a gradual blurring of the pellets, shotgun charges contain wadding,
the distinction between civilian and military which often becomes embedded in the wound,
firearms, and an increasing percentage of complicating wound management. This wad-
civilian firearm injuries are caused by high- ding material, consisting of paper or plastic
velocity weapons. Most handgun injuries, particles, must be thoroughly debrided to pre-
however, should be considered low-velocity vent secondary infection and wound necrosis.
ballistic trauma. B. Epidemiology—Approximately 14% of spinal cord
2. Wounding capacity—The composition and de- injuries are caused by penetrating trauma, al-
sign of a bullet affect its wounding capacity. though this figure is higher in many urban trauma
Military ammunition, under international law, centers. Gunshot wounds are now the second
must be fully jacketed with a hard metal such leading cause of spinal cord injuries after motor-
as copper to prevent expansion and unneces- vehicle accidents. In a recent study, male victims
sary deformation of the projectile. Jacketed outnumbered female victims by nearly 10 to 1.
bullets are designed for maximal penetration Unfortunately, most victims of penetrating spinal
and minimal deformation. Civilian weapons cord trauma are young, with a peak incidence in
and many of those used by law enforcement the third decade of life. More than half of spinal
officials are not under the same constraints. cord injuries caused by penetrating trauma
Nonjacketed, hollow-tipped, or soft-nosed bul- are complete injuries.
lets deform significantly on impact, imparting C. Patient Evaluation—A patient with a suspected
more tissue damage than comparable jacketed gunshot wound to the spine should be evaluated
bullets of similar mass and velocity. according to standard trauma protocols. Spinal
3. Secondary missiles—A bullet striking the body immobilization is essential until clinical and radio-
creates secondary missiles such as bone frag- graphic assessment is made of the vertebral column.
ments or articles of clothing, which may also 1. History—The history should determine, if pos-
impart significant tissue damage. Shattered sible, the type of weapon that caused the in-
bone fragments can cause more damage to jury. The conscious and alert patient should be
neural elements in the spinal canal than the questioned for the presence of paresthesias or
actual bullet because their course is erratic numbness. A complaint of transient paralysis
and unpredictable. Bullets fired at high veloc- after the injury is highly significant.
ity have a tendency to yaw or tumble, which 2. Physical examination—The physical exami-
also increases the probability of fragmentation nation should begin with inspection of the
on impact. entrance and exit wounds. The presence of a
large wound should alert the physician to the pedicle and one facet remain intact. Surgery is
probability of significant wound cavitation. A rarely necessary for restoring spinal stability.
detailed neurologic examination is performed Spinal arthrodesis may be indicated for two or
to assess motor function, reflexes, and sensa- three-column injuries when bullet removal is
tion. Any deficits must be documented and being contemplated for other reasons.
reassessed at frequent intervals for possible 3. Treatment of bullets in the spinal canal and
worsening or progression to a more cephalad disc space
level. A rectal examination with assessment • Bullet removal—A multicenter review of
of the bulbocavernosus reflex should be per- 90 patients with retained bullets in the spi-
formed to determine whether spinal shock is nal canal revealed that bullet removal had
present. Priapism is a poor prognostic sign for a positive effect on neurologic outcome
neurologic recovery when it is present. for gunshot wounds between T12 and
3. Radiographs—AP and lateral radiographs of L4. For lesions between T1 and T11, there
the vertebral column are obtained to assess was no significant difference in outcomes
the degree of missile and bone fragmentation. for patients with either complete or incom-
Significant bullet fragmentation indicates a plete injuries whether or not the bullet was
large permanent cavity. A CT scan is recom- removed. Similarly, in the cervical spine,
mended for assessing the extent of spinal canal bullet removal does not appear to affect the
encroachment by bone or bullet fragments of ultimate neurological outcome. Removal of
the three spinal columns. Other imaging stud- bullets in the cervical spinal canal may be
ies such as barium swallows, arteriography, indicated to improve neurologic function of
and intravenous pyelography may be neces- the exiting nerve root, similar to removing
sary to assess the integrity of adjacent visceral bone or disc fragments in patients with cer-
or vascular structures. vical spinal cord injury from other causes.
D. Treatment of Gunshot Wounds to the Spine • Timing of surgery—The timing of surgery for
1. Wound management—Penetrating wounds to spinal cord or cauda equina injury remains
the chest, thorax, and abdomen require imme- controversial. Emergent surgery is indicated
diate surgical exploration if there is evidence only for the rare cases with neurologic de-
of vascular, tracheal, esophageal, or visceral terioration in the presence of cord com-
injury. Large or contaminated wounds to the pression from an enlarging hematoma or
torso, especially shotgun injuries, may require retained fragments of bone, disc, or foreign
surgical debridement. Empiric antibiotic treat- bodies. For patients whose results of neuro-
ment is begun with a first or second-generation logic examination are stable, bullet removal,
cephalosporin for 48 to 72 hours for uncon- if indicated, should be performed after a
taminated wounds without hollow viscus delay of several days or longer. This delay
perforation. Grossly contaminated wounds, allows for more complete trauma resuscita-
especially if the bullet may have traversed the tion and evaluation and also simplifies the
colon, should be treated aggressively with 1 to repair of dural lacerations. In the absence
2 weeks of parenteral antibiotics with broad- of a deteriorating neurologic picture,
spectrum coverage for intestinal organisms. there is no indication for emergent sur-
2. Assessment of spinal stability—Civilian gun- gery to remove retained bullet fragments.
shot wounds to the spine rarely cause spinal • Lead poisoning—Retained bullets or frag-
column instability. For cervical spine injuries, ments in an intervertebral disc may be ob-
immobilization with an orthosis is recom- served. Lead poisoning has been reported
mended if the anterior spinal column or poste- from retained bullets in a disc or synovial
rior facets are injured. Halo-vest immobilization joint. For that reason, baseline serum lead
may be required for both-column injuries. For levels should be obtained. If serum lead lev-
thoracolumbar spinal injuries, the anterior, els rise or if clinical signs of plumbism de-
middle, and posterior columns as described velop, bullet removal should be performed.
by Denis are evaluated with CT imaging. A rigid If the disc is compromised, consideration
orthosis is recommended for injuries that de- should be given to concomitant arthrodesis.
stabilize two or more columns. An additional Bullet removal and spinal fusion are also
potentially destabilizing injury involves a trans- indicated if the patient develops symp-
verse path injuring the pedicles or facets. How- tomatic mechanical back pain refractory
ever, instability is unlikely when at least one to conservative measures.
E. Complications of Gunshot Wounds to the Spine to exclude the presence of any retained foreign bod-
1. Cerebrospinal fluid-cutaneous fistulas—A ce- ies. Strong consideration should be given to the
rebrospinal fluid-cutaneous fistula complicates removal of foreign bodies from stab wounds,
approximately 6% of spinal gunshot wounds if since the incidence of wound contamination is
laminectomy, debridement, and bullet removal are higher than for gunshot wounds. Patients with
performed. Fistulas are quite rare in the absence spinal impalement injuries should undergo surgical
of surgical intervention. If a surgical debridement debridement if the wound is large. Wound infections
or bullet removal is performed, a watertight repair and cerebrospinal fluid-cutaneous fistulas are more
of the dura is important to avoid development of common with stab wounds than gunshot wounds
this complication. Consideration should also be and should be managed aggressively with surgical
given to the use of a fibrin glue or a lumbar sub- debridement and prolonged parenteral antibiotics.
arachnoid drain to supplement dural repair.
2. Infection—Spinal infections, including osteomy-
elitis, discitis, and meningitis, have all been re-
ported after gunshot wounds to the spine that SUGGESTED READINGS
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CHAPTER 27
Cervical Spine Trauma

Jens R. Chapman and Sohail K. Mirza
I. Overview motion between its contributing segments and

A. Anatomy—For functional and anatomic reasons, provides minimal intrinsic stability between the
the cervical spine can be divided into anatomic re- skull base and the LCS. Anatomic alignment of
gions: the upper cervical spine (UCS) and the lower the bony segments of the UCS is maintained
cervical spine (LCS). by several important ligamentous structures
1. Upper cervical spine—The UCS (Fig. 27-1) ex- (Table 27-1; see Fig. 26-1). Occipito-cervical sta-
tends from the skull base to the lower endplate bility is provided by a few key ligaments, which
of C2. It includes the occipital condyles and the are listed in Table 27-1 and are depicted in their
bony aperture surrounding the foramen mag- functional arrangement in Figure 26-1.These
num, the C1 segment (atlas) and the C2 segment ligaments allow for approximately half of the
(axis). Conceptually, the C1 segment functions C-spine motion in rotation and flexion/extension
as a “washer” between the skull base and the C2 while protecting the spinal cord and vertebral
segment. The axis consists of the odontoid with arteries. It is important to remember that these
its tip resting between the lateral masses of the ligaments together form the functional unit of
atlas and its narrow waste. The superior articu- the UCS, with any bony or ligament injury to this
lar processes of the atlas are convex and rest area representing a more serious injury.
below the concave inferior facets of the atlas. 2. Lower cervical spine—The LCS begins with the
They are connected through a bone bridge (pars caudal half of the C2 vertebral body and ends
interarticularis) on either side to the inferior with the Tl segment. Similar to the upper C-
articular processes. With its unique anatomic spine, the lower C-spine requires functional in-
configuration, the UCS allows for extensive tegrity of its soft-tissue components (Table 27-2)
Dens
Occipital
condyle
Occipital condyle Lateral mass
of C1
Lateral mass
of C1
Superior facet
Superior facet
of C2
of C2
A B
FIGURE 27-1 Osseous anatomy of the upper cervical spine. Note the functional unit that is formed by the occipital
condyles and C2; C1 serves as an “intercalary washer.” The bony elements offer no inherent stability toward one
another. A. Important articulations as seen on a lateral projection plane. B. Posterior to anterior cutaway view with the
posterior elements of C1 and C2 removed through the pedicles.
418
C H A P T E R 2 7 | C E R V I C A L S P I N E T R A U M A 419
TA B L E 2 7 - 1
Ligaments of the Upper Cervical Spine
Name of Ligament Location Function Structural Contribution
Tectorial membrane Clivus to posterior vertebral Resists traction and Key ligament
body of C2 (rostral continu- flexion
ation of ligamnetum flavum
into skull base)
Alar ligament (paired) Lateral aspect of Cranio-cervical If bilateral injury, it is
odontoid tip to the medial rotation and very concerning;
aspect of the occipital lateral tilt isolated unilateral
condyle injury may not cause
major instability
Transverse atlantal liga- Medial aspects of C1 lateral Locates the odon- Key ligament
ment (TAL); also known masses (left to right) toid tip between
as Transverse ligament C1 lateral masses
while allowing its
rotation
Anterior cranio-cervical Anterior skull base to anterior Prevents hyperexten- Key structure
membranes (deep and longitudinal ligament (ALL) sion
superficial)
Posterior occipito-cervical Connects opisthion (posterior Resists flexion Accessory function
membrane & atlanto- foramen magnum) to laminae
axial membranes of C1 and C2 (rostral continu-
ation of ligamentum flavum)
Apical ligament Basion (anterior rim of the Resists axial Residual ligament
foramen magnum) to the distraction
tip of odontoid
Cruciate ligament Attenuation to TAL and Multidirectional Accessory function
tectorial membrane to TAL and tectorial
(composite of TAL and ligament
Tectorial membrane fibers)
Articular capsules Joint capsules Multidirectional Accessory function
(occipito-cervical and
atlanto-axial—paired)
to maintain a balanced alignment and to protect B. Incidence and Injury Mechanism—The neck and its
neurological elements. A healthy C-spine has a surrounding soft-tissue structures are more prone to
lordotic alignment of approximately 20° between injury than the lower thoracolumbar spine due its
the inferior vertebral body of C2 and the inferior exposed location, permissiveness to an extensive
C7 vertebral body. This assures balanced distri- range of motion, relatively small size, and proportion-
bution of loads between vertebral bodies and ally frail ligamentous restraint structures. The rela-
lateral masses (tripod concept). The uncoverte- tively large mass of the head tethered to the rostral
bral processes are unique to the cervical spine. cervical spinal column exposes the cervical spine to
They arise out of the lateral margins of the supe- injury due to indirect mechanisms. Important deter-
rior aspects of the vertebral bodies and secure minants of the type and magnitude of injury sustained
the spinal column against excessive lateral tilt. are the position of the head at the time of impact and
Well-functioning extensor muscles are necessary the direction and magnitude of the kinetic energy act-
to provide active neck control and maintain bal- ing on the C-spine. A large number of variables con-
ance. All together, the anatomic arrangements tribute to the severity of the injury, including the age
of the LCS allow for considerable motion while of the patient, bone mineral health, pre-existent liga-
maintaining usually less than 11° flexion/ex- mentous laxity, spinal ankylosis, and spinal canal size.
tension and less than 3.5-mm translational In general, flexion and bursting type injuries affect the
motion between each adjacent segment. LCS most commonly in a younger more active age
TA B L E 2 7 - 2
Important Soft-Tissue Structures of the Lower Cervical Spine
Name of Structure Location Function Importance
Anterior longitudinal Coats anterior vertebral bodies Limits hyperextension High
ligament (ALL)
Longus colli muscles Antero-lateral vertebral bodies Flexion, lateral tilt, rotation Intermediate, little
(paired) structural limita-
tions
Intervertebral discs Connect vertebral bodies Intervertebral cushion, align- Key
ment and centering struc-
ture
Disco-vertebral Connects lateral margin of the Locks intervertebral disc to Key
ligaments annulus fibrosus to the super- vertebral bodies, resists
olateral margins of vertebral extension/flexion and lat-
bodies. They are thicker in an- eral tilt depending upon
terior and posterior regions. location
Posterior longitudinal Coats posterior vertebral bodies Limits flexion Low
ligament (PLL) within the spinal canal
Facet capsules Connects posterior facets Limits flexion Moderate
Interspinous and Connects posterior interspinous Limits flexion High
supraspinous liga- processes
ments
Exensor muscles Skull base to various posterior Neck extension/rotation/tilt. High (active
(several layers) and posterolateral bony Actively resists hyperflex- only—no passive
elements of the LCS ion and rotation component)
Nuchal ligament Superficial thickening of the pos- Prevents hyperflexion Low
terior extensor muscle fascia
group due to deceleration trauma, while elderly pa- fracture), (3) has a nonfocal neurologic exami-
tients are more commonly affected by hyperextension nation and nonpainful full neck range of mo-
injuries commonly sustained from ground level falls. tion does not require radiographic assessment.
Direct trauma to the cervical spine usually results Although these criteria have been shown to be
from penetrating injuries, especially in North Ameri- highly predictive of absence of neck trauma, they
can urban regions. The spectrum of C-spine injuries rarely apply in a trauma setting.
ranges from mild soft-tissue sprains to life-threatening The basic principle in the evaluation of a
high-grade fracture dislocations. Some 2% to 5% of pa- trauma patient is to assume the presence of an un-
tients with blunt trauma can be expected to have sus- stable spinal injury and then to rule it out based
tained a fracture or dislocation of the cervical spine. on clinical evaluation and imaging studies. As in
Increasingly elderly and frail patients with concomi- all trauma patients, spine precautions, including
tant degenerative C-spine disorders and multiple co- C-spine immobilization, are maintained during re-
morbidities suffer from serious C-spine injuries, which suscitation and evaluation until a determination
can be easily missed and for which there commonly of spine stability has been made.
are no simple treatment options. B. Clinical Evaluation—Clinical evaluation starts
with the history of injury mechanism (if avail-
II. Evaluation able) and review of basic vital signs. After suc-
A. Overview—Systematic clinical evaluation forms cessful resuscitation using the advanced trauma
the basis of C-spine injury evaluation. The NEXT life support ABC principles, a more comprehen-
criteria identify that a patient who (a) is cogni- sive patient evaluation, including assessment
tively unimpaired, (b) has not sustained a high for spinal injuries, is performed. Inspection and
kinetic injury mechanism (i.e., motorized vehi- palpation of a traumatized patient’s spine are
cle crash 35 mph, fall 4 ft, presence of acute performed from occiput to sacrum using a log-
cranio-cervical fractures, long-bone or pelvic roll maneuver. Any manipulation of the neck is
avoided outside life-saving efforts. Particular at- attempted, but is commonly limited. Withdrawal
tention is directed to areas of bruising, focal ten- responses and the presence of deep tendon re-
derness, or interspinous gaps along the posterior flexes and long tract signs are important compo-
midline. In conscious and cooperative patients, nents in the evaluation. Assessment for priapism
a formal examination includes assessment of the in males, detailed rectal examination, and assess-
Glasgow Coma Scale (see Table 1-1), cranial nerve ment of the bulbocavernosis reflex should be
function, and evaluation of extremity motor, sen- performed in patients with suspected spinal cord
sory, and reflex function. Testing of these func- injury and in unconscious patients.
tions is performed according to the guidelines C. Radiographic Evaluation (Fig. 27-2 and Table 27-3)
of the American Spinal Injury Association (ASIA) 1. Plain radiographs—Radiographic evaluation of
(see Fig. 25-4). In unconscious sedated patients, the cervical spine is suggested in patients with
segmental motor and sensory testing should be neck pain after a significant injury mechanism,
Posterior axis line
PAL-B
DBI
ADI
Spinal laminar line

LADL
Occiput to C1
B C joint space
The prevertebral C1 to C2 lateral

soft tissues of C1 mass joint space
through the
C4-5 disc space
should not
No overhang
exceed 6 mm
FIGURE 27-2 Accurate interpretation of the landmarks of the upper cervical spine is important for injury assessment
in this region. A. On the lateral radiographic image the most posterior cortical margin of the bony spinal canal of C1,
C2, and C3 should form a line (spinal laminar line) of which no point deviates more than 1 mm. The anterior cortex of
the odontoid should lie in close proximity (and parallel) to the posterior cortex of the anterior arch of C1; this distance
of atlas to dens is referred to as the ADI and should measure less than 3 mm in a normal adult and less than 5 mm in
a normal child. The ADI is maintained primarily by the transverse atlantal ligament. Two important reference lines for
the physiologic craniocervical articulation are the dens-basion interval (DBI), which should be less than 12 mm, and the
distance of the basion to the posterior axis line (PAL-B), which should not exceed 12 mm, with the basion not protruding
posteriorly beyond 4 mm. B. The prevertebral soft tissues of C1 through the C4 to C5 disc space should not exceed
6 mm of thickness (as seen on the lateral radiograph) in normal individuals. Artifacts may be caused by endotracheal or
esophageal tubes and crying. C. On an open-mouth odontoid or coronal CT reformatted view the C1 lateral masses should
not overhang C2. In addition, the occiput to C1 and the C1 to C2 joint spaces should be nearly uniformly equidistant
(occiput to C1 joint space, 1 to 2 mm; C1 to C2 lateral mass joint space, 2 to 3 mm). The odontoid should be centered
symmetrically between the C1 lateral masses. (The lateral atlas-dens interval [LADI] should not vary by more than 2 mm.)
TA B L E 2 7 - 3
Radiographic Reference Lines for the Upper and Lower Cervical Spine
Reference Line Location Meaning
Upper cervical spine
Harris lines Measure from the clivus to the tip of the dens Potential for cranio-cervical disso-
and from the clivus to a line running superi- ciation
orly along a line along the posterior aspect of
the dens (should be less than 12 mm for both)
Wackenheim’s line A line drawn along the posterior aspect of the Aids in assessing for cranio-cervical
clivus and assessed with respect to the tip of dissociation
the dens. The line should lie essentially at the
tip of the dens
Power’s ratio This is a ratio of the distance from the basion to Aids in assessing for cranio-cervical
the anterior aspect of the posterior ring of C1 dissociation
compared to the distance from the anterior
aspect of the ring of C1 to the opisthion
(abnormal at values greater than 1)
Atlanto-Dens interval The gap between the posterior aspect of the Assessment for C1–C2 instability
(ADI) C1 ring and the anterior aspect of the dens
(should be 3 mm in adults and 4 mm in
children)
Prevertebral soft-tissue Above C4 5 mm (variable due to screaming, Potential for hemorrhage (indirect
swelling age, intubation, infection) injury sign)
Spinal laminar line Connects the anterior cortical margins of the There should be 4 mm transla-
(SLL) laminae of each level. tion of each segment of this line.
Presence of larger translation
could indicate instability
Rule of Spence On open mouth odontoid view or coronal CT If greater than 7 mm, this is highly
reformat, the overhang of the sum of C1 suggestive of a transverse alar
lateral masses over the C2 lateral masses ligament (TAL) disruption.
should be less than 7 mm
Lower cervical spine
Prevertebral soft-tissue Above C4 5 mm (variable due to screaming, Potential for hemorrhage (indirect
swelling age, intubation, infection) injury sign)
Anterior vertebral body Smooth continuous lordotic arch immediately Assessment for step off between
line (AVBL) anterior to the vertebral bodies segments, reminds of preverte-
bral swelling
Posterior vertebral Continuous lordotic line posterior to the verte- Should be parallel to AVBL, runs along
body line (PVBL) bral bodies the posterior vertebral bodies and
should be of smooth contour
Spinal laminar line Connects the anterior cortical margins of the There should be 4 mm transla-
(SLL) laminae of each level. tion of each segment of this line.
Presence of larger translation
could indicate instability
Interspinous process Absence of focal “gapping” between spinous Focal gapping at a single level could
spacing (ISPS) processes. There are no specific degrees or represent an interspinous liga-
distances described ment tear
Intervertebral dis- Distance between vertebral bodies (anterior vs. Excessive gapping of one disc
tance (IVD) posterior and from one to other) space compared to others could
indicate a distractive injury.
Focal kyphosis of one disc in
contrast to others may indicate
more advanced disc degenera-
tion or segmental instability
Reference Line Location Meaning

Intervertebral angula- In general, adjacent vertebral endplates of the Focal angulation 11° kyphosis is
tion (IVA) LCS should be parallel. of concern regarding excessive
instability or potential injury
Facet joint apposition Each lateral mass should be in close and paral- Gapping or excessive unroofing of
lel alignment to the next higher and lower facet joints can represent insta-
segment bility due to injury
Torg/Pavlov ratio Shortest AP distance of spinal canal (posterior Screening line, which can indicate
vertebral body to anterior laminar cortex) spinal stenosis
expressed as ratio over shortest AP distance
of the vertebral body in millimeters
in the presence of facial fractures, polytrauma, have normal plain radiographs, X-ray studies
neurologic deficits, or symptoms, and in pa- taken with maximum pain-free neck extension
tients with altered mental status and a history and flexion may provide helpful early determi-
of possible significant trauma. The plain lat- nation of spinal stability. In patients who do not
eral C-spine radiograph remains the most im- meet these prerequisites and have continued
portant imaging test for identifying fractures neck pain, delayed reevaluation with a second
and dislocations of the neck and ideally visu- clinical and radiographic examination using
alizes the skull base to the C7–Tl motion seg- flexion and extension radiographs on a delayed
ment. Due to common limitations of visualizing nonacute basis is mandated.
the cervico-thoracic junction, swimmer’s views 3. Computed tomography (CT)—Noncontrast CTs
or shoulder pull-down views are necessary to of the neck have largely surpassed plain ra-
assess the cervicothoracic junction on a lateral diographs as the imaging modality of choice
radiograph. Open-mouth odontoid views are in assessing and diagnosing cervical spine in-
used to assess the odontoid and the Cl lateral juries. Helical CT scans with sagittal and coronal
masses. An anteroposterior (AP) C-spine ra- reformats can be rapidly obtained and are more
diograph usually allows for assessment of the sensitive than plain radiography. Noncontrast
C3 segment to the UCS. Trauma oblique radio- head CT scans have become the common ini-
graphs can be helpful in visualizing the neuro- tial screening study for patients presenting
foramina and the facet joints of the LCS. with cognitive impairment. Adding a cervical
Due to their time- and resource-intensive na- spine screening from the skull base to T4 is time-
ture, such plain radiographs have increasingly and cost-effective. It is also considered more
been replaced by helical CT-scan with coronal sensitive and cost-effective than plain radiogra-
and sagittal reformatted views with comprehen- phy, however, at higher radiation exposure. In
sive visualization of the entire C-spine from the an obtunded patient, a CT scan without any ab-
skull base to the upper thoracic spine. normality can also be used to clear the cervical
Among many subtle findings, a normal lat- spine without the addition of controlled flexion-
eral cervical spine radiograph is expected extension radiographs or the addition of MRI.
to demonstrate maintenance of physiologic 4. Magnetic resonance imaging (MRI)—MRI is rec-
lordosis, absence of vertebral subluxation ommended for patients with spinal cord injury,
or kyphosis, symmetrically maintained disc especially in the presence of progressive or
heights, congruous, overlapping facet joints unexplained neurologic deficits or discrepant
without subluxation, and a narrow prevertebral skeletal and neurologic injury. Controversy per-
soft-tissue shadow. Although plain cervical ra- sists as to the timing of an MR scan relative to
diographs are still used today, they are rapidly reduction attempts in a displaced spinal column
being surpassed by helical CT scans with refor- injury. It is widely accepted to proceed with a
mats as a faster and more sensitive modality. closed reduction of a dislocated spinal column
2. Lateral flexion-extension radiographs— using sequential cranial traction in an awake
Lateral flexion-extension radiographs remain patient before performing MRI; this approach
a controversial but efficient way for assessing is intended to minimize the duration of ongoing
cervical spine stability. In awake, fully coopera- spinal cord compression and optimize chances
tive patients who are neurologically intact and for cord regeneration. If readily available, an
MRI scan can be considered in neurologi- artery injuries. CT angiography (CT-A) is rec-
cally intact patients or in the presence of an ommended with fractures into the transverse
unknown neurological status before reduc- foramina or in patients with significant post-
tion to rule out the presence of a large disc traumatic malalignment or displacement as in
herniation, which may cause postreduction the case of facet dislocation. CT angiography
spinal cord compression. MRI can also detect has largely displaced invasive arteriography
posterior interspinous ligament and facet cap- as a screening tool. Transcranial Doppler tests
sule injury, especially within the first 72 hours, and MR angiography are usually secondary-tier
and can allow differentiation of full-thickness tests for patients with unclear CT-A or in the
tears and sprain. The additional cost and imag- presence of unexplained mental status changes.
ing time poses a limitation to this modality on a Although the sensitivity of these tests is high,
routine screening basis. MRI scans in the pediat- the specificity remains well below that of arte-
ric population are limited by lack of compliance riography. Routine use of noninvasive vascular
issues. Usually monitored sedation or preferably tests and treatment of suspected vertebral ar-
general endotracheal intubation are required tery injuries remain in a state of evolution.
for a quality study. This should be duly consid-
ered prior to ordering a MRI in these patients. III. Injury Classifications—Injury classifications of the
MRI may not be useful in the morbidly obese spine attempt to predict spinal stability by describ-
patient (who cannot fit into the MRI gantry), ing neurologic injury, bony injury, and disruption of
patients with significant fixed deformities due disco-ligamentous structures. There are descriptive
to inflammatory spinal conditions, and patients systems, which identify the injured anatomic com-
with pacemakers or implantable stimulators. ponents of the injured segment. Finally, there are
5. Bone scans—Bone scans are rarely used in the systems that ascribe an injury mechanism to the im-
assessment of acute cervical spine trauma. aging tests. Spinal cord injury classifications are de-
They have a limited role in the evaluation of scribed in Chapter 25. In the upper C-spine, there are
occult spine fractures, especially in skeletally level-specific well-established classifications. Unfor-
immature patients. Typically, this modality is tunately, there is no such consensus for the lower
not useful until at least 48 hours after injury; C-spine. Many variations of descriptive anatomic
further enhancement with single photon emis- and mechanistic models continue to persist, thus
sion CT (SPECT) may be necessary to increase impeding, among other things, study, and testing.
image resolution of the small bony structures of A. UCS Injuries
the cervical spine. With the advent of current 1. Occipital condyle fractures (Fig. 27-3)
technology and imaging resolution with CT and The major classification scheme used to dif-
MRI imaging, bone scans are essentially obso- ferentiate occipital condyle fractures is that of
lete in traumatic conditions. Anderson and Montesano described in 1988.
6. Other tests—Noninvasive vascular tests can • Type 1—Impaction mechanism: commi-
be of value in the assessment of vertebral nution of the occipital condyle with an
FIGURE 27-3 Occipital condyle fractures. The alar ligaments provide important structural support for the
craniocervical junction. Type I injuries are relatively stable and demonstrate comminution of the occipital condyle. Type
II injuries are basilar skull fractures extending into the occipital condyle; they are relatively stable. Type III injuries are
potentially unstable avulsion injuries of the alar ligament with the tip of the occipital condyle.
impaction mechanism; these fractures are sufficient biomechanical stability retained

stable and are managed conservatively. that these can be treated conservatively.
• Type II—Shear mechanism: basilar skull • Type II—Complete CCDs with initial lateral
fracture with occipital condyle involvement; radiographs showing borderline screening
these fractures are stable and are usually measurement values. These injuries, how-
managed in accordance with the basilar ever, feature a complete disruption of key
skull fracture. ligaments of the craniocervical junction and
• Type III—Distraction: avulsion of the alar lig- are innately unstable. A spontaneous par-
ament with the tip of the occipital condyle; tial reduction of the cranium to its cervical
these fractures may be unstable and an as- location through some remaining residual
sociated craniocervical dissocation (CCD) ligamentous attachments may provide false
or atlantooccipital dissociation (AOD) must reassurance to a reviewer.
be ruled out. • Type IIIa—Complete disruption of craniocer-
2. AODs or CCDs (Fig. 27-4) vical ligaments with obvious major displace-
These injuries are always generally considered ment on plain radiographs with survival of at
unstable. There are two main classifications least 24 hours.
used. The first is that described by Traynelis • Type IIIb—Criteria as in IIIa with death from
in 1986 and is descriptive of the position of the AOD in the first 24 hours following injury.
skull with respect to the C1 articulation. 3. Cl ring fractures—Levine and Edwards (1991)
• Type I—Anterior displacement of the occiput used descriptive anatomic terms to differenti-
on the cervical spine (11%) ate between fracture subtypes.
• Type II—Vertical displacement of the occiput • Posterior arch fracture—stable.
on the cervical spine (3%) • Transverse process fracture—stable.
• Type III—Posterior displacement of the oc- • Simple lateral mass fracture—A simple frac-
ciput on the cervical spine (2%) ture is generally stable; however, a unilat-
• Type IV—Oblique displacement of the occiput eral sagittal split fracture may progressively
on the cervical spine (84%) subluxate, leading to a “cock-robin type
A more recent classification is the Harbor- deformity.”
view classification, which provides stratifica- • Anterior arch fracture—A segmental anterior
tion based on the severity of ligament injury arch fracture is unstable.
irrespective of location of the occiput with re- • Comminuted lateral mass fracture—Usually
spect to the adjoining C1 articulations. unstable.
• Type I—Incomplete ligament injuries, such • Three- or four-part burst fracture (Jefferson
as unilateral alar ligament tears. There is fracture)—A three- or four-part burst fracture
Normal Type I Type II Type III
Parasagittal view
FIGURE 27-4 Classification of occipitocervical dissociation (AOD) according to Traynelis (the bottom row is a
parasagittal representation). A Type I injury has anterior displacement of the occiput on the cervical spine. A Type II
injury has vertical displacement, and a Type III injury has posterior displacement of the occiput on the cervical spine.
Type IV injuries are the most common and display displacement in an oblique plane (not shown). Occult ligamentous
damage has to be cautiously evaluated.
is unstable when the TAL is disrupted. This (c) Type C—ADI greater than 5 mm with fail-
is typically the case if the lateral masses ure of the alar ligaments
overhang those of C2 by a total of 7 mm (d) Type D—Complete posterior displace-
or more on an open mouth odontoid view. ment of the atlas
This well-known finding was originally de- 5. Fractures of the odontoid (Fig. 27-5)—Classi-
scribed by Spence in 1970; although help- fication schemes for fractures of the odontoid
ful, it was refuted by Dickman et al. in 1996, are generally based on the level of the frac-
who showed that many injuries previously ture as described by Anderson and D’Alonzo
thought to be stable really are unstable. in 1974.
4. Atlantoaxial instability—Atlas-dens interval • Type I—A Type I fracture occurs at the tip of
(ADI) in adults should be less than 3 mm; the odontoid. It is an uncommon injury. Sta-
3 to 7 mm has the potential for a transverse lig- bility is questionable. The clinician should
ament tear, and more than 7 mm is a complete rule out AOD. The differential diagnosis in-
tear. ADI in children should be less than 3 to cludes os odontoideum.
5 mm; 5 to 10 mm is a transverse ligament tear; • Type II—A Type II fracture occurs at the waist
and with 10 to 12 mm, all ligaments have failed. of the odontoid. It is the most common type
• Transverse ligament injury and is easily missed. This fracture is usually
(a) Type I—A Type I transverse ligament unstable. Clinically relevant variables in-
injury is a midsubstance or purely liga- clude fracture pattern, displacement, distrac-
mentous tear. It usually requires surgical tion, angulation, and the age of the patient.
management with C1–C2 fusion. There is an increased risk of nonunion with
(b) Type II—A Type II injury is a bony this fracture pattern.
avulsion. Nonoperative treatment is • Type III—A Type III fracture occurs through
possible. the cancellous body of the axis. This fracture
• Atlantoaxial dissociation—Atlantoaxial dis- can be relatively stable.
sociation represents a variant of AOD and is 6. C2 ring fractures (Hangman’s fractures)—C2
highly unstable. Usually, the dissociation oc- ring fractures involve traumatic spondylolis-
curs in a vertical direction and is accompa- thesis of the axis (Fig. 27-6). The classifica-
nied by disruption of the alar ligaments. tion scheme used was originally described by
• Rotatory translation Effendi in 1981 and further modified by Levine
(a) Type A—ADI less than 3 mm and the TAL and Edwards in 1985.
is intact • Type I—Type I fractures have less than 3 mm
(b) Type B—ADI 3–5 mm with the TAL of displacement; there is no angulation. These
insufficient fractures are relatively stable.
FIGURE 27-5 Classification of odontoid fractures (Anderson and D’Alonzo). Type I, avulsion of the tip (unstable);
Type II, waist-line fracture (unstable); Type III, fracture through the vertebral body (conditionally stable).
Type I Type II Type IIa Type III
FIGURE 27-6 Levine classification of traumatic spondylolisthesis of the axis (see text for details).
• Type II—Type II fractures have more than • Anterior elements destroyed or unable to
3 mm of displacement and angulation. They function (2 points)
are potentially unstable. • Posterior element destroyed or unable to
• Type IIa—Type IIa fractures are a variant of function (2 points)
C2–C3 flexion-distraction injuries and have • Sagittal displacement radiographically of
significant angulation. These fractures are more than 3.5 mm (2 points)
unstable. • Sagittal angulation of more than 11° (2 points)
• Type III—Type III fractures are facet fracture- • Positive Stretch Test (2 points)
dislocations. They are highly unstable. • Spinal cord damage (2 points)
B. LCS Injuries—As stated earlier, there is no univer- • Nerve root damage (1 point)
sally accepted LCS injury classification system. • Abnormal disc space narrowing (1 point)
Each system has inherent limitations and draw- • Dangerous load anticipated (1 point)
backs. Familiarity with at least one descriptive A cumulative point value of 5 or more sug-
anatomic system, one mechanistic model, and ba- gests clinical instability of the cervical spine.
sic cervical spine stability concepts is suggested 2. Descriptive anatomic (Table 27-4)
(Fig. 27-7). 3. Mechanistic model—There are six basic
1. Stability of the lower C-Spine—Lower C-spine injury types; stages have increasing instability.
stability is defined as the “ability of the spine These were described by Allen and Ferguson
to bear loads under physiologic conditions.” in 1982.
A useful checklist for clinical instability of the • Distractive flexion (stages I to IV)—Ventral
lower C-spine as described by White and Pan- compression and dorsal disruption
jabi in 1990 remains well accepted and includes • Vertical compression (stages I to III)—Axial
the following factors: load
FIGURE 27-7 Translational
> 3.5 mm
displacement greater than 3.5 mm
or angulation greater than 11° on a
flexion-extension lateral radiographs
C4 is associated with cervical spine
instability.
C5 > 11°
C6
TA B L E 2 7 - 4
AO/ASIF and Orthopedic Trauma Association Classification of Lower Cervical Spine Injuries
Type A Type B Type C
“Axial” Load “Bending” Injuries “Circumferential” injuries
Usually stable Unstable Highly unstable
Simple Compression Fx Unilateral facet dislocation Flexion teardrop
Isolated Spinous Process Fx Bilateral facet dislocation Displaced distractive ligamentous injury
Lamina Fx Unilateral facet Fx/disloc Unstable burst fracture
Simple lateral mass Fx Bilateral Facet Fx/disloc Extension/Avulsion Teardrop Fx
Extension/Avulsion Teardrop Fx Unstable Extension Fx/Disloc
Note: Multiple subtypes of the basic three injury types exist and are listed in an alphanumeric system. These are not presented here
for clarity sake and are unlikely to be the subject of test material.
• Compressive flexion (stages I to V)—Progres- • Neurological status (maximum of 4)
sively worsening vertebral body comminution (a) Intact (0)
• Compressive extension (stages I to V)— (b) Nerve root deficit (1)
Posterior compression and ventral distraction (c) Complete spinal cord injury (2)
• Distractive extension (stages I and II)— (d) Incomplete spinal cord injury (3)
Posterior compression and global distraction (e) Add on: persistent compression or steno-
• Lateral flexion (stages I and II)—Lateral sis with spinal cord injury (1)
compression At this point of time, for practical pur-
4. Cervical Spine Injury Severity Score—The Cervi- poses, it appears most advisable to be knowl-
cal Spine Injury Severity Score was described by edgeable about the basic components of the
Moore, Anderson, and coworkers in 2006; it uses AO/OTA system since it uses terms commonly
a measuring scale for the two lateral columns used and provides relatively straightforward
and the anterior and posterior column to assess grouping of injuries into reproducible catego-
the amount of displacement of a fracture or dis- ries. However, scientifically validated severity
traction through the disc space or joints. This scales, such as the SLIC score, will likely be-
displacement is measured in millimeters for each come increasingly prevalent in the near future
column with a minimum of 0 mm and a maximum due to their more systematic approach and
of 5 mm. The four columns are then added to- comprehensive nature.
gether giving a total possible score of 0–20 mm. A
total score of greater than 7 is cause for concern IV. Associated Injuries
regarding the possibility of an unstable injury. A. Penetrating Trauma—For penetrating trauma,
5. Subaxial Cervical Spine Injury Classification Sys- the primary concern of the initial treating physi-
tem (SLIC)—The SLIC was published in 2007 by cians is the management of life-threatening vas-
Vaccaro and consists of the sum of three differ- cular and upper-airway injuries.
ent elements of the injury. A score of less than B. Autoimmune Diseases—In diseases such as an-
4 merits consideration for conservative care, kylosing spondylitis or rheumatoid arthritis, frac-
a score equal to 4 could go either way, while a tures of the spine can occur more readily and can
score of greater than 4 suggests an unstable in- be missed easily due to disease-specific osseous
jury meriting surgical management. abnormalities. Fractures in an ankylosing spine
• Injury morphology (maximum of 4) are usually highly unstable and susceptible to sec-
(a) Compression (1) ondary neurologic deterioration if left untreated.
(b) Burst (2) Primary traumatic injuries to the esophagus have
(c) Distraction (3) been described in patients with C-spine fractures in
(d) Translation/rotation (4) the presence of ankylosing spondylitis. (Large pre-
• Disco-ligamentous complex (maximum of 2) vertebral osteophytes may injure the surrounding
(a) Intact (0) soft-tissue structures [such as the esophagus]).
(b) Indeterminate (1) C. Spondylotic Cervical Spine Stenosis—Spondy-
(c) Disrupted (2) lotic cervical spinal stenosis is associated with
an increased likelihood of spinal cord injury. cervical spine and are mainly intended for brief
“Spear-tackler’s spine” identifies a clinical and periods of symptomatic treatment for neck mus-
radiographic condition consisting of loss of cer- cle soreness.
vical lordosis and profound foraminal stenosis 5. Rigid neck collars—Rigid neck collars reduce
with propensity toward nerve root impaction in cervical spine motion in a limited fashion and
athletes who use the head for physical impact. are therefore indicated for minor fractures or in-
Athletes with signs of a “spear-tackler’s spine” or juries only; they can also be used as an adjunct
symptomatic cervical spondylotic myelopathy to operative stabilization.
should abstain from athletic activities that place 6. Cervicothoracic braces—Cervicothoracic
the head or neck at increased injury risk because braces, such as sternal–occiput–mandibular im-
of an increased risk of neurologic injury. mobilization (SOMI) and Minerva devices, are
D. Vertebral Artery Injuries—Vertebral artery inju- the most effective external noninvasive devices
ries have an estimated incidence of 5% to 30% in limiting cervical spine flexion and extension.
in C-spine trauma. Presenting symptoms range Their efficacy relies on a close fit of the brace to
from mental status changes to symptoms of se- the mandible and occiput as well as a snug fit of
vere stroke. Work-up and monitoring consist of the vest to the torso. These braces can be con-
CT angiography and if a vertebral artery injury is sidered as definitive treatment for patients with
detected, then serial trans-cranial Doppler should injuries such as minimally displaced atlas frac-
be performed to assess for emboli. Treatment tures, nondisplaced Type III odontoid fractures,
is based on the individual patient presentation and stable-appearing burst or facet fractures.
and may consist of observation, aspirin adminis- Compliance with brace wear and a body habitus
tration, formal anticoagulation, or angiographic suitable for brace wear are further prerequisites
embolization. for this treatment.
7. Skeletal traction—In patients with a spinal
V. Treatment and Treatment Rationale canal compromised by dislocation or retro-
A. Rogers’ Rule—The tenets of care for spinal inju- pulsed vertebral body fragments, indirect
ries follow Rogers’ rules: reduction of deformity, reduction by means of appropriately applied
decompression of impinged neural tissues, and skeletal traction is highly successful and the
prevention of further injury by immobilization of most effective early intervention strategy at
the injured segment. the disposal of the treating surgeon. Early
B. Nonoperative Treatment closed reduction of fracture-dislocations or
1. Overview—Most bony injuries to the cervical burst fractures of the C-spine for patients with
spine can be expected to heal with appropri- acute spinal cord injury can lead to dramatic
ate immobilization. External devices such as neurologic improvement. Therefore, patients
braces or a halo-vest assembly offer varying with manifest spinal cord injury preferably are
degrees of spinal column immobilization. considered for early reduction using an estab-
2. Unstable bony injuries—Nonoperative manage- lished traction protocol. Contraindications to
ment of truly unstable bony injuries is not sup- traction are certain skull fractures, distractive
ported by clinical studies or basic science and neck injuries, and ankylosing spinal disorders
is therefore not recommended. Thus, surgical (traction may lead to secondary neurologic de-
fusion with bone graft and instrumentation is terioration). A delay in fracture reduction may
usually recommended for such injuries. be associated with increased cord swelling,
3. Unstable injuries of the ligaments and discs—In ischemia, and a widened zone of secondary
contrast to the appendicular skeleton, unstable cord injury. In patients with facet dislocations,
injuries to the ligaments and discs of the cervical case reports of neurologic deterioration after
spine heal poorly with nonsurgical management, closed reduction, presumably resulting from
even with prolonged external immobilization. dislodgment of a disc fragment into the spi-
Surgical repair of disrupted ligaments of the nal canal, have led to suggestions to perform
spine is not supported by clinical studies or ba- an MRI scan before reduction efforts. The in-
sic science and is therefore not recommended. cidence of a herniated nucleus pulposus has
Thus, surgical fusion with bone graft and instru- been reported to be 13% in bilateral facet
mentation is commonly recommended for such dislocations compared with 23% in unilateral
injuries. facet dislocations. Hence, prereduction MR
4. Soft neck collars—Soft neck collars offer no scans are recommended for unconscious pa-
structural support or immobilization of the tients and in cases of planned open reduction
under general anesthesia. In neurologically 9. Methylprednisolone—The use of methylpred-

intact and conscious patients with facet dislo- nisolone given in high intravenous doses has
cation, an MR scan can be considered before been reported to improve neurologic outcomes
reduction if this study will not delay realign- in patients with spinal cord injury if given within
ment efforts. There is, however, ongoing con- 8 hours of injury according to the NASCIS trials.
troversy surrounding prereduction MRIs due Current dose recommendations are as follows:
to inherent delays in getting these studies and bolus, 30 mg/kg over 1 hour; followed by in-
necessary further manipulation during the ad- fusion at the rate of 5.4 mg/kg per hour for
ditional patient transfers in the presence of a 23 hours if administered less than 3 hours
compromised spinal cord. from the time of the injury or for 48 hours if
8. Halo ring—A halo ring relies on skull fixation the bolus was administered 3 to 8 hours from
using at least four pins tightened to 6 to 8 in/ the time of the injury. Currently, the medical
lb in adults and six to eight pins tightened to literature does not support the use of steroids
2 to 6 in/lb, depending on size and age factors, if given more than 8 hours after injury; it also
for children. Correct halo pin placement is im- does not support their use for peripheral nerve
portant. The anterior pins should be placed injuries. An increased incidence of gastrointesti-
approximately one fingerbreadth above the lat- nal bleeding and sepsis has also been reported
eral third of the eyebrows. (The patient’s eyes as a side effect of high dose steroid treatments.
should be closed during pin insertion.) The In the recent years, the use of steroids for spinal
anterior pins should be located lateral to the cord injury have increasingly been called into
supraorbital nerve and frontal sinus and ante- question and are increasingly falling out of favor
rior to the temporal fossa. The posterior pins due to lack of a clear clinical benefit to patients.
are ideally placed diametrically opposed to the At this time, the use of steroids is labeled as a
anterior pins (posterior to the ear lobe and “treatment option” based on a large-scale re-
superior to the mastoid process). The biome- view of the scientific literature.
chanical stability of a halo ring vest assem- 10. Other treatments—Other pharmacologic agents
bly is most significantly influenced by secure such as naloxone, lazaroids (tirilizad), and gan-
vest fit about the torso. Halo vest assemblies gliosides (GM-l) are investigational and are not
limit rotation of the spine more effectively than the standard of care. Similarly, cooling of the
cervical braces. spinal cord and anticoagulant treatment are not
• Indications—A halo orthosis can be reason- part of recommended care for spinal cord inju-
ably considered in most patients with stable ries. However, relatively straightforward trauma
occipitocervical injuries, unstable atlas frac- resuscitation measures are recommended for
tures, hangman’s fractures of the axis, Types patients with spinal cord injury, such as main-
II and III odontoid fractures, neurologically taining normotension while avoiding secondary
intact burst fractures, and some unilateral, hypotension, maintaining a normal hematocrit
anatomically reduced facet fractures. Non- and providing adequate oxygenation.
displaced cervical spine fractures in patients C. Operative Treatment
with ankylosing spondylitis require at least a 1. Indications—In general, surgical care is recom-
halo vest assembly, if not treated with opera- mended for patients with neurologic injury, dis-
tive stabilization. coligamentous disruption (dislocations), highly
• Results of treatment—Loss of reduction has comminuted burst fractures, displaced Type II
been reported in patients in whom the frac- odontoid fractures, and multisegmental spine
ture reduction was achieved with a halo ring fractures or multiple trauma in which stabiliza-
held in distraction to the vest. “Snaking” and tion of one or more spinal fractures can expe-
other alignment changes have been reported dite mobilization and care of the patient. Usually
at a frequency of 20% to 77% of patients surgical stabilization is also recommended for
treated with a halo vest. patients with concurrent neck deformities and
• Contraindications—The application of cra- ankylosing spine conditions due to the inad-
nial tong traction or a halo ring in patients equacy of external bracing.
with skull fractures can be dangerous and 2. Anesthesia—General endotracheal anesthesia
should usually be avoided. In general, the in a patient with an unstable cervical spine is
application of cervical traction is also con- preferably performed while avoiding neck ma-
traindicated in patients with distractive or nipulation. Manual inline traction has been rec-
hyperextension injuries to the C-spine. ommended to minimize manipulation. However,
awake nasal intubation and fiberoptic intubation 8. Posterior approach—The posterior approach
(while maintaining external neck immobilization) offers the advantage of a more extensile expo-
offer a chance at airway access with the least risk sure with access to the occiput and thoracic
of inadvertent neck manipulation. However, this spine as needed. Posterior instrumentation
technique may not always be applicable. Moni- systems usually offer more rigid stabiliza-
toring spinal cord function with clinical checks or tion than anterior instrumentation.
electrophysiologic monitoring is helpful to iden- 9. Cervical laminectomy—Cervical laminectomy
tify possible emerging neurologic deterioration. may be indicated for patients with depressed
3. Timing of surgery—The timing of surgery for laminar fractures and foraminal obstruction
cervical spine fractures remains controversial. from facet fractures. A cervical laminectomy,
Currently there is no consensus as to the defini- however, destabilizes the spine and does not
tion of “early” surgery. Previously held beliefs lead to a meaningful anterior spinal cord de-
that early surgical intervention for cervical compression. It is therefore not recommended
spine trauma is potentially dangerous because as a stand-alone procedure for patients with
of an increased risk of neurologic deterioration C-spine trauma, and therefore is usually com-
have largely been refuted. However, there is no bined with multisegmental posterior fixation
consensus as to the benefits gained from early and fusion.
surgical intervention either with respect to neu- 10. Spinal instrumentation—The goal of spinal
rological function. There is substantial evidence, instrumentation is to maintain fracture reduc-
however, that early fixation allows for early motion and column alignment while providing
bilization and decreased complications such as a stable environment for timely bony union.
pulmonary complications and decubitus ulcers. In surgically treated C-spine trauma, supple-
4. Emergent surgery—Emergent surgical interven- mental instrumentation is commonly used to
tion in the C-spine is usually indicated for patients achieve a predictable fusion result.
with a cord compression due to a herniated nu-
cleus pulposus or bone fragments, an expanding VI. Anatomic and Biomechanical Considerations and
epidural mass (such as an epidural hematoma), an Operative Techniques
unreducible fracture-dislocation with spinal cord A. Anterior Cervical Surgery
compression, and in the presence of cord swelling 1. Anterior exposure—Standard anterior expo-
with a progressive neurodeficit (controversial). sure techniques usually allow for access from
5. Surgical approach—Surgical treatment options in the base of C2 to the T1 vertebra.
C-spine trauma consist of an anterior, posterior, • Smith-Robinson approach—The concept that
or combined anterior–posterior approaches. a left-sided Smith-Robinson approach can re-
With present day techniques, most operatively duce the risk of a recurrent laryngeal nerve
treated C-spine injuries no longer require com- palsy because of the more predictable ana-
bined approaches, but are sufficiently treated tomic course of the nerve has remained de-
with anterior or posterior approaches alone. bated, but is increasingly called in doubt. The
6. Bone graft—As in any arthrodesis, C-spine fu- recurrent laryngeal nerve is a branch of
sions generally require bone graft. This can be ob- the vagus nerve.
tained from local, autologous, or allograft sources • Landmarks—Along with radiographic con-
and can be of morsellized or structural nature as firmation, the carotid tubercle, which is
needed. For trauma, the use of xenografts or pros- located at the C6 segment, provides a use-
thetic devices is not considered standard of care. ful bony landmark for level determination.
7. Anterior approach—Anterior cord decompres- The cricoid cartilage ring usually is ante-
sion via discectomy or corpectomy achieves rior to the C6 segment as well. The thoracic
a more complete and neurologically relevant duct enters the neck on the left side of the
decompression compared with posterior tech- esophagus and runs posterior to the ca-
niques for most conditions. This approach is rotid sheath. The vertebral artery is located
relatively atraumatic and can be accomplished in the foramina transversaria from the C2
without manipulating the patient. However, it to C6 segments and is covered anteriorly
is more limited in its biomechanical fixation by the longus colli muscle. The vagal nerve
strength especially in the presence of osteope- lays anterolateral to the longus colli muscle.
nia and unsuitable for highly unstable patients 2. Tricortical iliac crest autograft—Anterior fu-
or patients with ankylosing spinal disorders as sions are most commonly accomplished with
a stand-alone approach for fixation. structural tricortical iliac crest autograft. Fusion
rates well above 90% have been reported with setting due to instability concerns. Although
this technique. Segmental fibula allografts have these implants can be placed anywhere from the
been increasingly used as an alternative to iliac C2 to the T1 vertebral bodies, multilevel anterior
crest autograft in an effort to minimize donor fusion with these devices remains controversial
site morbidity, but have slightly lower union and more prone to complications. Fortunately,
rates as compared with autograft. Increasingly, the majority of LCS injuries requiring surgical
structural cages made of a variety of biomate- stabilization do not require fusion beyond one
rials filled with bone graft material of allograft or two motion segments. Translational plates
are being used to avoid the morbidity and time are rarely indicated in the setting of trauma.
required for bone graft harvesting. 6. Anterior compression screw fixation—Anterior
3. Anterior fusions performed for traumatic indi- compression screw fixation has been described
cations—In this setting, rigid supplemental fixa- specifically for Type II odontoid fractures. This
tion with a plate–screw construct has become technique may be contemplated if nonoperative
a recommended treatment component in addi- treatment with a halo vest seems unlikely to suc-
tion to an arthrodesis to (a) maximize chances ceed and if a fusion of the C1–C2 segment is un-
for fusion, (b) maintain restored physiologic desirable. Single screw fixation seems to afford
alignment, and (c) protect decompressed neu- sufficient fracture fixation compared with the
ral alignment. As previously stated, an anterior more traditional two-screw construct. Anterior
procedure offers a less traumatic chance to pro- screw fixation is not recommended in patients
vide effective neural decompression and fixa- with os odontoideum or delayed or established
tion with the patient in a supine position. There nonunions of odontoid fractures. There is also
remain relatively few indications for combined strong concern that in a debilitated elderly pop-
anterior and posterior surgery. For instance, a ulation, anterior screw fixation may have an in-
patient with a locked facet dislocation and con- creased complication rate due to dysphagia and
current large disc herniation can pose a treat- there may be significant swallowing difficulties
ment challenge due to the risk of postreduction leading to aspiration. Because of these issues,
cord impingement. In this situation, an anterior many support posterior instrumentation so as
discectomy with placement of an interverte- to avoid any proximal anterior dissection.
bral bone graft is followed by open posterior 7. Anterior C1–C2 fusion—Anterior C1–C2 fusion
reduction and instrumented fusion. Of course, can be accomplished through the facet joints
an alternative to this treatment sequence would and stabilized with interfragmentary compres-
consist of an anterior discectomy with attempts sion screws or an anterior plate placed through
at subsequent open reduction, followed by ante- a transoral approach. While this procedure is a
rior fusion and stabilization with a locking plate. technical possibility, it is rarely used due to in-
4. Anterior implant biomechanics—Anterior increased risk of dysphagia from retraction of the
strumentation systems are typically less stiff superior laryngeal plexus and retraction of the
than posterior instrumentation except in ex- upper esophagus.
tension loading. This may be the reason for 8. Anterior decompression of C1 or C2—Anterior
the slightly higher nonunion rates in cervical decompression of C1 or C2 structures is very
spine trauma, where the anterior approach is rarely indicated in the treatment of acute neck
generally preferred (better patient recovery). fractures in the absence of comorbid condi-
Anterior approaches are also limited in terms of tions. It may be considered for symptomatic
multilevel fixation and occipito-cervical as well malunions or nonunions of odontoid fractures.
as cervico-thoracic instrumentation options. B. Posterior Cervical Surgery
5. Anterior plate fixation—Currently, anterior plates 1. Posterior cervical fusion—Posterior cervical fu-
are of a low-profile design and are usually made sion for trauma is typically accomplished with
of titanium to minimize esophageal impinge- autologous cancellous bone graft, allograft,
ment. Screws featuring a locking mechanism al- and/or bone substitute extenders placed into
low for a unicortical screw design and minimize the desired facet joints and along the laminae (if
the risk of screw back-out or toggle loosening. present). For trauma indications, supplemental,
The surface of the screw–plate construct should posterior instrumentation is recommended to
be devoid of any sharp edges or protuberances promote a successful union with restored ana-
to facilitate unencumbered esophageal motility. tomic alignment.
There are few (if any) advantages for “dynamic” 2. Interspinous wire fixation—Interspinous wire
or compressible” anterior plates in the trauma fixation of the cervical spine, as popularized by
Rogers, can be an efficient technique for achiev- construct achieves only limited biomechani-
ing posterior reduction and fusion over one or cal rigidity. Fusion is accomplished with an
two motion segments in cases of facet disloca- autologous clothespin-shaped corticocancel-
tions. In trauma, interspinous wire fixation may lous bone graft. The Brooks technique offers
be considered in patients with unstable facet increased biomechanical stiffness, especially
injuries. Limitations of this simple and inex- in flexion and translation, as compared to the
pensive instrumentation option are patients Gallie technique. However, it requires one or
with laminar or spinous process fractures, two sublaminar wire passages on either side of
laminectomies, multilevel fusion needs, severe the posterior arches of C1 and C2. Usually an
osteoporosis, and rotationally unstable injuries. oval corticocancellous bone graft is secured
With the advent of today’s modern instrumenta- to either side of the spinous processes to
tion, there is rarely an indication for the use of allow for fusion.
interspinous wiring alone given the higher rate • Transarticular screws—A more stable form
of nonunion and failure. of C1–C2 stabilization can be achieved with
3. Posterior cervical segmental fixation—Poste- transarticular screws placed bilaterally
rior cervical screw and rod or plate fixation has from posterior through the inferior articular
become the preferred form of posterior fixation process of C2 into the lateral mass of C1. If
due to fixation strength and ability to provide executed correctly, this technique offers sat-
stability in transition zones (occipito-cervical isfactory stabilization even in patients with
and cervico-thoracic regions) even in the pres- deficient laminae at C1 and C2. Posterior fu-
ence of impaired posterior segments or across sion can be performed via a technique similar
multiple levels. Screw purchase is obtained in a to the Gallie or Brooks technique or by means
unicortical or bicortical fashion within the lat- of a facet arthrodesis if the C1–C2 laminae
eral masses of C3 to C6 using specific trajecto- are deficient or fractured. Improper drilling
ries, such as those described by Roy Camille, or screw passage may cause vertebral artery
Magerl, and others. Key structures to avoid in- injury. Minimizing this risk requires preopera-
clude the spinal cord medially, the vertebral ar- tive evaluation of a fine-cut CT scan to look
tery anteriorly, and the nerve roots laterally and for an abnormally medialized vertebral fora-
inferiorly. At C2 and C7, and in the upper tho- men and placement of the screws by an ex-
racic spine, the lateral masses are either absent perienced surgeon using an adequate C-arm
or unsuitably small. In these vertebral segments, technique. Approximately 15% of patients
screws can be placed within the vertebral ped- will have vertebral artery anatomy not con-
icle aiming toward or into the vertebral body ducive to safe placement of these screws.
as per the specific bony anatomy of these lev- • Harms technique—Though initially de-
els. Compared with interspinous wire fixation, scribed by Goelle, this technique is com-
segmental posterior cervical instrumentation monly referred to as the Harms technique.
offers increased rotational stiffness, and much This technique consists of placement of C1
improved fixation stiffness in all dimensions in lateral mass screws linked via a rod to C2
cases of multilevel fixation. These instrumenta- pedicle screws. This technique is biomechan-
tion techniques require intricate knowledge of ically equivalent to transarticular screws but
the spinal anatomy and therefore are preferably allows for more versatility in patients with
preformed by trained spine surgeons. vertebral artery anatomy not conducive to
4. Posterior atlantoaxial fusion—In cases of trau- transarticular screws. This technique can be
matic instability of the C1–C2 complex result- used with deficient or traumatized lamina.
ing from fracture or dislocation, a posterior Again, careful preoperative planning is in-
atlantoaxial fusion with instrumentation is dicated with careful evaluation of axial and
indicated. A variety of techniques have been sagittal CT scans.
described. 5. Occipitocervical fusion—In exceptional circum-
• Gallie and Brooks wiring techniques—The stances, occipitocervical fusion may have to
C1–C2 fusion techniques using wire or cable be considered if adequate C1–C2 stabilization
constructs basically employs either a Gallie cannot be achieved. Occipitocervical fusion is
or a Brooks technique, with many variations also the treatment of choice for any displaced
of each having been described. The Gallie occipitocervical dissociation. Surgical options
technique consists of a sublaminar C1 wire consist of structural corticocancellous bone
loop secured to the C2 spinous process. This graft with stabilization using occiptocervical
plating or wire fixation with a halo. New con- and treat these patients appropriately in an
structs allow for the use of locking plates secured expeditious fashion.
to the occiput and linked via a rod to top-load- 3. Cervicothoracic injuries—Injuries in this
ing, poly-axial screws in the UCS. transition zone have been missed or under-
6. Sublaminar hooks and clamps—Sublaminar hooks estimated in severity in 50% to 70% of pa-
and clamp constructs are generally contraindi- tients as a result of difficulties in visualizing
cated in the subaxial cervical spine because they the area with conventional radiographs. CT
can encroach on the spinal cord. In light of the with reformatted views is helpful in visual-
high success rates with standard wire constructs izing this area.
or transarticular screws and in the absence of 4. Occult ligament injuries—Despite the advent
biomechanical advantages, posterior cervical of MRI, ligamentous injuries of the cervi-
clamps and compression claws are unnecessary. cal spine continue to pose a diagnostic and
treatment challenge. Upright lateral radio-
VII. Complications of Cervical Spine Injuries graphs, lateral dynamic motion studies, and
A. Missed C-Spine Injuries—Before CT, more than MRI may help in assessing the integrity of the
33% of C-spine injures were missed on comple- cervical spine ligaments. In general, if a heli-
tion of the initial workup. In the C-spine, the main cal CT scan with axial, coronal, and sagittal
areas of concern for missed injuries are the transi- reformats does not show any abnormalities,
tion zones (occipitocervical and cervicothoracic the cervical spine can be cleared. The diffi-
spine) and occult ligamentous injuries. Missed culty with this algorithm is in patients with
C-spine injuries may result from a variety of fac- degenerative changes, and in these cases,
tors, including most commonly, failure to order a MRI is helpful and indicated.
study, failure to visualize or recognize an injury, 5. Presence of ankylosing conditions—The
and less commonly, failure of the patient to report presence of ankylosing spondylitis or other
an injury. Neurologic deterioration after a missed ankylosing conditions make the spine, es-
C-spine injury occurs in about 30% of patients. A pecially the neck, more prone to fractures.
variety of patient conditions such as a short neck 90% of these injuries will be extension-type
with a stout body habitus, radiographic osteope- injuries with anterior widening or disruption,
nia, skeletal immaturity, preexisting skeletal de- most commonly in the C5/6 or C6/7 region.
formity or advanced degenerative changes, and Frequently, fracture lines follow unusual pat-
an altered or diminished mental state can make terns and can be easily missed because of
the diagnosis of a C-spine injury very difficult. radiographic distortion caused by the under-
1. Odontoid fractures—In the upper C-spine, lying disease process. Most fractures in anky-
odontoid fractures can be easily missed. An losing spondylitis are inherently unstable. If
odontoid fracture may not be visible on an missed, a 75% incidence of secondary neu-
axial plane CT scan since the fracture is in rologic deterioration has been described.
the same plane as the study. Displaced Type B. Neurologic Deterioration
II odontoid fractures that are left untreated 1. Injury severity—A number of factors determine
are not expected to heal. The presence of os- the occurrence of spinal cord injury in cervical
teophytes or an ostepenic skeleton can make spine trauma. The magnitude and direction of in-
a correct diagnosis challenging. A CT with re- jury force are obvious contributing factors. Simi-
formatted sagittal and coronal views usually larly, the duration of neural element compression
allows for reliable diagnosis. may have some effect on the severity of neuro-
2. Atlantooccipital injuries—Atlantooccipital logic deficit and recovery potential. Small spinal
injures are rare injuries and are missed 60% canal dimensions relative to the cord size have a
to 75% of the time. Spontaneous partial re- high prognostic correlation with the occurrence
duction and suboptimal radiographic visu- of spinal cord injury. Further pathomechanisms
alization of the occiptocervical junction are include cord ischemia and cord swelling. The
potential causes. Severe neurologic deterio- severity of neurologic injury is related to the
ration has been reported in patients with presence and magnitude of abnormal cord
missed atlantooccipital injures. Historically signal on early postinjury MRI.
these patients did not survive, however, with 2. Mental status changes—Vertebral artery inju-
increasing awareness of this injury many pa- ries may cause ongoing cranial infarction by
tients are now surviving. Careful scrutiny is embolization or can be associated with stroke
necessary to accurately make the diagnosis or even death in the case of vertebral artery
flow obstruction in patients with an incomplete more common complications such as pin tract
Circle of Willis. loosening or infection can easily be handled.
C. Musculoskeletal Function—Neck sprains such With respect to loss of reduction, it is impor-
as whiplash-type injuries are commonly associ- tant to develop an understanding of which in-
ated with temporarily decreased motion and jury patterns can appropriately be managed
pain. The expected course of neck sprains in the with a halo and which ones will develop loss
absence of more serious structural trauma is be- of reduction and are therefore better handled
nign. Persistent neck pain should prompt clinical surgically from the start.
and, if indicated, radiographic reevaluation such 1. Loss of cervical spine alignment—Specific
as flexion-extension radiographs or MRI. Patients treatment recommendations for this sce-
who have sustained fractures or dislocations of nario cannot be given here. The basic treat-
the neck are overwhelmingly most affected by the ment concept of nonoperative care of the
neurologic injury and the extent of neurologic re- particular patient should be reevaluated;
covery. To date, there is no established correlation readjustment of the halo assembly can be
between injury severity, type of treatment, and the considered. Alternatively, a return to closed
presence of neck pain in these patients. reduction with recumbent traction care or
surgical stabilization may be considered.
VIII. Complications of the Treatment of Cervical Spine 2. Pin tract infections—Pin tract infections are
Injuries frequently associated with pin loosening.
A. Early Perioperative Neurologic Deterioration— Prevention by insisting on antiseptic place-
This is a feared but fortunately rare compli- ment technique at correct skeletal locations
cation. Regularly documented postoperative and avoiding bunching of the skin are pre-
neurologic status checks are important for requisites. Correct daily pin care and patient
early recognition of neurologic deterioration. education are very important. In the case of in-
In the case of unexpected neurologic status fection or loosening, local wound care, antibi-
deterioration, expedient further workup with otic treatment, and pin retightening should be
neuroimaging such as plain CT or MRI with con- considered. Pin retightening can usually be
trast is recommended. In the early postopera- undertaken once (to 8 in/lb) if resistance
tive phase (up to 2 to 3 weeks after surgery), is met within the first two turns. Recurrent
a variety of possible causes should be consid- loosening is preferably treated by pin re-
ered. Causes of early postoperative neurologic moval and reinsertion at another safe site.
deterioration include malreduction of the neu- 3. Injury of the supraorbital nerve—The su-
ral canal or foramina, hardware interference, praorbital nerve is the structure most com-
loss of reduction, graft displacement, epidural monly injured by improperly placed anterior
hematoma, cord swelling, cord ischemia, and halo pins. Anterior halo pins should be
epidural infection. Cord ischemia can have last- placed anterior to the temporalis fossa and
ing adverse effects on neurologic function and temporalis muscle and lateral to the frontal
is commonly poorly understood. sinus and the supraorbital nerve. The supra-
B. Late Posttreatment Neurologic Deteriora- trochlear nerve is medial to the supraorbital
tion—The onset of late neurologic deteriora- nerve just above the eyebrow.
tion begins on completion of injury healing, D. Anterior Cervical Surgery—Complications of
and should be investigated with neuroimaging anterior cervical spine surgery are mainly re-
studies. Causes of late neurologic deterioration lated to surgical exposure, patient comorbidity,
include adjacent level stenosis, nonunion or and graft healing.
malunion of the fracture (or fusion) with loss 1. Anterior neck exposures—complications
of alignment, syrinx, perineural cysts, loss of of anterior surgical neck exposures include
alignment, and osteomyelitis or discitis. hoarseness (recurrent laryngeal nerve
C. Halo Treatment—The most common complica- palsy), dysphagia (esophageal laceration,
tions of halo treatment are loss of reduction, excessive retraction, denervation), sympa-
pin tract loosening in 36%, pin tract infection in thetic plexus injury (Horner’s syndrome),
20%, and loss of reduction in 15%. Despite the vascular injures (carotid arteries, vertebral
relatively common incidence of complications, arteries, jugular veins), and restrictive air-
halo vest assemblies maintain a key role in the way problems. All of these complications
nonoperative management of many cervical together are reported in less than 5% of
spine injuries in North America. Generally, the patients.
• Injury of the recurrent laryngeal nerve— rates of 50% have been reported. Primary atlan-

Injury of the recurrent laryngeal toaxial (C1–C2) fusions have the lowest nonunion
nerve is the most common neurologi- rates for Type II odontoid fractures. Mixed results
cal complication after anterior cervi- have been reported with anterior internal fixation
cal spine surgery. The most common of odontoid fractures using compression screws.
cause is a traction-induced neuropraxic Increased nonunion rates of Type II odontoid frac-
injury. If hoarseness persists beyond tures have been associated with poor technique,
6 weeks after surgery, laryngoscopy is osteoporosis, elderly patients, segmental com-
indicated. Surgical exploration is usu- minution, and reverse obliquity of the fracture
ally delayed for more than 6 months line. A nonunion of an odontoid fracture usually
after surgery. requires an atlantoaxial fusion with instrumenta-
• Retropharyngeal hematoma—Retropha- tion and autologus corticocancellous bone graft.
ryngeal hematoma formation can occur An occipitocervical fusion can usually be avoided
in the early postoperative phase. Pre- but remains an option.
senting clinical symptoms can range C. Ring Fractures of the Axis—Nonunions of the
from swallowing difficulty to difficulty axis (Hangman’s fracture) are uncommon if the
in breathing. injury is identified and properly immobilized.
2. Anterior neck fusion—Complications of an- D. Lower C-Spine—Nonunions of lower C-spine frac-
terior neck fusion include graft migration, tures are relatively uncommon with nonopera-
graft subsidence, hardware breakage, hard- tive treatment.
ware pullout, nonunion, and malunion. In
X. Malunions and Deformities
general, these complications occur in less
A. Atlas—Intra-articular fracture extension can be
than 5% of patients. Increasing complica-
associated with pain and loss of range of motion.
tions rates may be expected in anterior
B. Odontoid—Regardless of treatment type, atlanto-
treatment series with multilevel corpecto-
axial rotational motion rarely returns to normal,
mies without posterior fusion, in the pres-
even in the event of anatomic fracture union.
ence of poor bone structure, or in patients
Atlantoaxial rotation commonly remains dimin-
with impaired bone healing.
ished by at least 30% because of scarring and het-
E. Posterior Cervical Surgery—Complications of
erotopic bone formation within the atlantoaxial
posterior cervical instrumentation are infre-
articulations.
quent, with a 0.6% incidence of iatrogenic root
C. Ring fractures of the Axis—Malunions without lig-
injury and a 2.4% incidence of delayed union
amentous instability after treatment of displaced
or nonunion associated with instrumentation
hangman’s fractures are usually well tolerated.
failure. There is a trend toward higher surgical
D. Lower C-Spine—The most common type of post-
exposure-related musculoskeletal pain and de-
traumatic malunion of the lower C-spine is
creased neurologic recovery in patients under-
cervical kyphosis. Causes for kyphosis include
going posterior cervical surgery as compared
compression fractures or burst injuries, and in-
with anterior cervical surgery. Nonunions and
terspinous ligament failure. Unrecognized injury
iatrogenic vertebral artery injuries have been
to the interspinous and supraspinous ligaments
reported occasionally.
may result in interspinous widening, vertebral
translation, and pain. The assessment of instabil-
IX. Nonunion
ity includes clinical evaluation, dynamic motion
A. Atlas—Nonunions of the atlas are uncommon and
studies, and neural imaging. Instability param-
thus are infrequently a cause for concern. Splaying
eters (see earlier section on lower C-spine stabil-
of the C1 lateral masses a total of 7 mm or more
ity) can be used as an aid in the decision-making
beyond the C2 lateral masses is usually associated
process. If instability or unacceptable malalign-
with a transverse ligament injury and unacceptable
ment is identified, the suggested treatment usu-
atlantoaxial instability. Unilateral C1 lateral mass
ally consists of fusion and an attempt at deformity
sagittal splits may also progress to a nonunion with
correction with posterior, anterior, or combined
settling of the occiput onto C2 causing C2 radicular
surgical techniques depending on the severity of
symptoms and a cock-robin type deformity.
displacement and the timing of presentation.
B. Odontoid—Type II odontoid fractures are at an
increased risk of nonunion with displacement XI. Special Circumstances
of more than 5 mm. Nonoperative treatment of A. Ankylosing Spondylitis and Diffuse Idiopathic
these fractures usually requires closed reduction Hyperostosis—Fractures in patients with anky-
with a halo vest for at least 3 months. Nonunion losing conditions occur more readily, are more
easily missed, and are inherently unstable. Given of three methods of detecting occipitovertebral relation-
the patient population with this condition, these ships on lateral radiographs of supine subjects. AJR Am J
Roentgenol. 1994;162:887–892.
fractures are more prone to develop secondary
Herkowits HN, Rothman R. Subacute instability of the cervical
complications, including spinal cord compromise. spine. Spine. 1984;9:348–357.
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in about 20% of cases and therefore an MRI is often spondylitis. Am Intern Med. 1978;88:546–549.
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study comparing their effectiveness in restricting cervical mo-
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Levine AM, Edwards CC. The management of traumatic spondy-
B. Spinal Cord Injuries without Radiographic Ab-
lolisthesis of the axis. J Bone Joint Surg Am. 1985;67(2):217–226.
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entity has become increasingly rare in light of participation in tackle football and collision activities that
expose the cervical spine to axial energy inputs. AM J Sports
MRI scans. The assessment of patients with un-
Med. 1993;21:640–649.
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out an occult fracture or ligamentous injury. If ries of the cervical spine. J Bone Joint Surge. 1976;58B:322–327.
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losing spondylitis: diagnosis, treatment and complications. Bono CM, Vaccaro AR, Fehlings M, et al. Measurement
Spine. 1989;14:803–807. techniques for upper cervical spine injuries: consen-
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ation of four different posterior atlantoaxial fixation techniques for lower cervical spine injuries: consensus statement
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of traumatic occipitovertebral dissociation: 2. Comparison trauma. J Am Acad Orthop Surg. 2006;14(2):78–89.
CHAPTER 28
Thoracolumbar Spine Fractures

and Dislocations
C. Chambliss Harrod, Michael Banffy, and Mitchel B. Harris
I. Overview nerves, minimal correlation has been demonstrated

A. Anatomy—The kyphosis of the thoracic spine between the degree of neurologic injury and the
is produced and maintained by the wedge shape degree of canal compromise.
of the vertebral bodies (taller posteriorly than B. Epidemiology—Most common site of vertebral
anteriorly). Normal kyphosis of the thoracic spine fractures (T10–L2—50% all spinal fractures).
ranges from 20° to 50°. In contrast, the lordosis of the 1. Age—bimodal—most common 30 years old
lumbar spine ranges from 40° to 70° (average 50°) and geriatric
and is principally created by the intervertebral 2. Motor vehicle accidents (young) and falls
disc configuration, taller anteriorly than posteri- (elderly)
orly. Unique to the thoracic spine is its anatomic 3. Gunshot wounds are increasing in frequency
continuity with the rib cage and sternum; pro- (Fig. 28-1)
viding significant added stiffness and thus spinal 4. Gender—Males Females
cord protection. This stiffness contrasts with the 5. Noncontiguous injuries—5-15%
mobile lumbar spine, and thus produces a transi- 6. Other injuries—pulmonary injuries (20%), peri-
tion zone at the thoracolumbar junction (T10–L2). toneal and retroperitoneal bleeding (10%—liver/
This zone is marked with the loss of ribs, and a spleen)
transition from a small thoracic spinal canal diame- C. Mechanisms
ter to a larger lumbar canal diameter. Concurrently, 1. Axial compression—Axial loading produces
the facet joint orientation transitions from coronal compressive loading to the vertebral bodies.
(thoracic) to sagittal (lumbar). This portion of the With sufficient loads, failure occurs initially at
spine is distinctly “straight” from T10–T11 through the end plates (end-plate impaction fractures—
L1 to L2. perhaps due to the intervertebral disc driven
Of all fractures, 6% involve the spine and 90% in- through the end plates). The common verte-
volve the thoracic and lumbar regions. Most occur in bral body compression fractures (wedge frac-
the T10-L2 transitional area with 40% of these having tures—Figs. 28-2 and 28-3) occur anteriorly with
a spinal cord injury. In the presence of high-energy relative sparing of the middle and posterior
mechanisms, there is a 6:1 ratio of complete/incom- body portions. A transition to burst fractures
plete neurologic injuries. (Figs. 28-3 and 28-4) occurs with further axial
The spinal cord generally terminates around the and, subsequent, flexion loading. A pincer frac-
L1 to L2 interspace; thus in addition to it being the ture (Fig. 28-5) is a unique vertebral body frac-
structural transition area, the thoracolumbar spine ture characterized by the same axial loading
is also a neurological transition area. Injuries at the mechanism; however, disc implosion through
conus medullaris and the cauda equina often have a the vertebral body creates a coronal splint
more favorable prognosis than the more rostral spi- with separate anterior and posterior frag-
nal cord areas due to the presence of spinal nerves ments. The disc below and above the involved
in addition to the terminal spinal cord. Spinal nerves vertebrae is in contact. This combined disc and
are generally more resilient with improved capacity vertebral body injury creates poorer healing.
for recovery compared to the spinal cord. Due to 2. Flexion—Tensile forces are created posteriorly
this highly variable mix of spinal cord and spinal while compressive forces act at the vertebral
438
C H A P T E R 2 8 | T H O R A C O L U M B A R S P I N E F R A C T U R E S A N D D I S L O C A T I O N S 439
FIGURE 28-1 Sagittal computed tomography (CT) image FIGURE 28-3 Midsagittal Short Tau Inverted Recovery
demonstrating a missile (GSW) lodged in the right T3–T4 (STIR)-weighted magnetic resonance image demonstrating
spinal canal. The patient had a Brown Sequard syndrome multiple acute and chronic osteoporotic compression
and the foreign body was removed via laminectomy. and burst fractures in a caucasian obese 70-year-old
female on steroids for chronic lung disease. A chronic
T3 burst, acute T4 compression (mild), acute T5 burst,
body. When there is a loss of greater than 50% and acute T6 compression fracture are noted with edema
of the vertebral body height, the posterior liga- (increased signal intensity) denoting acute fractures.
mentous integrity needs to be carefully evalu-
ated. With an intact posterior osteoligamentous instability with angular deformity and potential
complex, this injury pattern is deemed mechan- neurologic injury. MRI is the study of choice to
ically “stable.” Failure to diagnose and treat directly assess the integrity of these structures
posterior ligamentous injuries can result in (T2 and STIR images).
FIGURE 28-2 Vertebral compression fracture. FIGURE 28-4 Vertebral burst fracture.
A B
C D
FIGURE 28-5 Burst Fracture with incomplete traumatic cauda equina syndrome, ventral and dorsal traumatic
durotomies treated with posterior open reduction, decompression, and fusion with durotomy repair. MRI (A) and CT
(B) demonstrate a burst fracture with pincer morphology with retropulsion, severe canal and cauda compromise,
ligamentous injury, and lamina fracture. Operative photos demonstrate intradural fragments (C, D), which after dural
repair were reduced via tamping fragments anteriorly away from the neural elements. Post-reduction CT is seen in
Figure 28-12B with adequate reduction and no need for anterior decompression with strut grafting.
3. Lateral compression—Lateral compression and facet capsule failure. The resultant anterior
forces create lateral vertebral body fractures and posterior column involvement typically
with or without contralateral or posterior liga- makes these unstable injuries. Pure dislocation
mentous disruption. These are best seen on at the thoracolumbar level is uncommon due to
anteroposterior (AP) X-rays. Unrecognized inju- facet orientation; when it does occur, it is usu-
ries can lead to subacute deformity, pain syn- ally associated with a significant spinal cord
dromes, and neurologic deterioration. injury.
4. Flexion-rotation—Flexion-rotation forces usu- 5. Flexion-distraction (FDI)—Also known as “Chance
ally include an anterior bony injury with an Fractures” (Figs. 28-6 and 28-7) or “seat belt in-
increased probability of posterior ligamentous juries” are classically seen in patients wearing
FIGURE 28-6 Flexion-distraction (Chance) injuries.

A. One-level injury with the injury through bone.
B. One-level injury with the injury through soft tissues.
A B
only a lap belt during a motor vehicle collision. aware of these injury patterns and associated
The generally accepted mechanism involves a fractures in patients with stiff spines such as
flexion injury with the axis of rotation anterior those with Diffuse Idiopathic Skeletal Hyperos-
to the spinal column creating posterior to ante- tosis (DISH) or Ankylosing Spondylitis (AS).
rior tensile (distractive) forces across the entire
spinal segment with resultant posterior ligamen- II. Evaluation
tous or posterior bony avulsion injuries. Forces A. Associated Injuries—50% of patients with tho-
then continue anteriorly to create either injury racolumbar fractures have non-spinal injuries.
to the disc, vertebral body, or both. Vertebral Forty-five percentage of flexion-distraction inju-
body injury usually exits into the adjacent disc ries have intraabdominal injuries (i.e., splenic
spaces across the end plate (“osseoligamen- or liver lacerations). Noncontiguous injuries oc-
tous” chance fracture) or exits the anterior cor- cur 20% of the time. Head injuries and extremity
tex of the body, creating a pure “bony” chance injuries are also common in falls from a height.
fracture. Isolated bony chance fractures, most B. Overview—The primary trauma survey should
common at L1 to L3, generally heal with proper be conducted with the “ABCs” (airway, breath-
immobilization while osseoligamentous injuries, ing, circulation) and Advanced Trauma Life Sup-
most common at the thoracolumbar junction, port (ATLS) with identification of life-threatening
heal significantly poorer. In addition, secondary injuries, oxygen, and hypotension management.
axial loading thought to be related to decelera- Cervical collar placement and full spine immobili-
tion forces with instantaneous displacement of zation precedes the secondary survey.
the axis of rotation can produce vertebral body 1. History—Mechanism with likelihood of asso-
fractures on a continuum from compression to ciated injuries may be determined. Witnesses
burst fractures as noted by Court Brown and are helpful as are full details of motor vehicle
Gertzbein who devised a flexion-distraction accidents (speed, location of impact, restraint
classification based on anterior or posterior use). Evaluation of neurologic symptoms may
fracture involving disk and soft tissue elements provide insight into spinal cord or neural ele-
and/or bony elements. ment pathology.
6. Extension—Rare shearing injuries (“lumbarjack” 2. Physical examination—“Log rolling” with full
injuries): extension and distraction (ED) have spine visualization and palpation for tender-
opposite injury patterns and mechanisms com- ness, spinal process step-offs or soft tissue
pared to flexion injuries. Anterior tensile fail- defects, and crepitus. Concomitant rectal ex-
ure with posterior compressive forces leads to amination should be performed with notice of
posterior element fractures including laminae, tone, perianal sensation, evaluation of anal wink
facets, and/or spinous processes (Fig. 28-8). and bulbocavernosus reflex. Fifty percentage of
Retrolisthesis of cephalad on caudad vertebral spinal injuries are missed on initial evaluation.
body and anterior disc injury (due to tension) Serial neurologic exams include motor and sen-
can lead to angular deformities. One must be sory testing, and reflex examination. Careful
B C
FIGURE 28-7 Parasagittal CT (A) image demonstrates a flexion-distraction injury with superior facet fracture with
dislocation. Midsagittal MRI (B) demonstrates severe spinal cord compression with edema. This patient had a T9
ASIA B injury (see Table 25-3) with only sacral sparing. Treatment was via posterior open reduction with compression
instrumentation (C) with iliac crest autograft.
evaluation of the trauma patient in shock is C. Clinical Evaluation and Steroid Use
necessary to determine the etiology includ- 1. Spinal shock and complete versus incom-
ing consideration of spinal shock as causative. plete injury—Spinal shock is a physi-
Abdominal tenderness and ecchymosis should ologic spinal cord dysfunction occurring
raise suspicion for a “seatbelt” injury. below the level of anatomic cord injury with
FIGURE 28-8 Midsagittal CT (A) and postoperative lateral radiograph (B) demonstrate an unstable T9–T10 extension-
distraction fracture in a patient with Diffuse Idiopathic Skeletal Hyperostosis (DISH). MRI did not show epidural
hematoma. Positioning on a Wilson frame on a Jackson table facilitated reduction in flexion followed by posterior
compression instrumentation.
flaccid paralysis, areflexia, and absent sen- process, and intervertebral foramina align-
sory modalities resolving in 99% of cases by ment and assessment. Loss of vertebral body
48 hours. Re-examination with return of the height (50%) and cortical margins also de-
bulbocavernosus reflex hails the end of spinal note compressive spinal injury patterns. Par-
shock. Total absence of motor (Frankel system ticular care should be noted to the posterior
grades 0 to 5) and sensory function below the vertebral line or angle as this can differentiate
anatomic injury level denotes complete neuro- burst (from compression) fractures with spi-
logic injury whereas incomplete injuries main- nal canal compromise. AP views may demon-
tain residual cord or root function below the strate lateral compression fractures, spinous
injury level. The American Spinal Injury Asso- process and pedicular alignment or widening
ciation (ASIA) has devised the standards for allowing diagnosis of posterior element injury
describing spinal cord injuries based on motor and secondary evaluation of spinal posterior
and sensory levels in addition to the presence ligamentous complex (PLC) instability (30°
or absence of sacral sparing. kyphosis). Lateral radiographs also allow
2. Incomplete spinal cord injury patterns (see Cobb measurements of sagittal kyphotic de-
Chapter 25) formities, translation anteriorly or posteriorly
D. Steroids—(see Chapter 25) (2.5 mm). Close attention to the endplates
E. Imaging—After clinical evaluation, multiple moon the AP view will also identify subtle injuries
dalities can be utilized to effectively visualize missed on lateral views. Plain films are becom-
thoracolumbar fractures. One must remember to ing increasingly less popular due to low sensi-
image the entire spinal column once spinal frac- tivities and the utility of screening CT scans for
tures are found in order to avoid missing noncon- chest, abdomen, and pelvis. However, stable
tiguous fractures (typically CT). fractures treated nonoperatively should have
1. Radiographs—AP and lateral views combined standing lateral radiographs in an orthosis to
with swimmer’s views that are occasionally ensure a good baseline radiograph as well as
necessary to visualize the cervicothoracic no collapse or kyphosis once mobilized.
junction tend to define vertebral anatomy. The 2. Computed tomography (CT)—CT allows ideal
lateral view allows vertebral, facet, spinous characterization of bony fracture patterns with
sagittal, coronal, and 3-D reconstructions. In rotational torque or sectioning of the posterior
polytrauma evaluations, screening CT scans aspect of the anterior column (posterior annu-
serve well for both visceral and bony injury lus) was needed to produce instability.
as Inaba and coworkers demonstrated supe- 4. Denis proposed a three-column theory identify-
rior sensitivity and interobserver variability ing a middle column injury to deem an injury
of reformatted CT scans compared with plain unstable and needing operative intervention.
radiographs for localizing, classifying, and The middle column is an osseoligamentous
delineating the thoracolumbar spinal injuries segment including the posterior half of the ver-
(25% injuries are missed on radiograph alone tebral body, nucleus pulposus, annulus, and
with gross underestimation of burst spinal posterior longitudinal ligament (PLL).
canal compromise). Abdominal CT is recom- 5. Denis classified thoracolumbar spine fractures
mended when a FDI is suspected to evaluate into four categories: (a) compression fractures,
for intraabdominal injury. (b) burst fractures, (c) flexion-distraction inju-
3. Magnetic resonance imaging (MRI)—MRI is the ries, and (d) fracture-dislocations.
modality of choice for visualization of disc her- 6. Mechanical instability is defined as the pres-
niation, epidural hematoma, ligament injury ence of injuries to two or more of the three
and SCI. Injury to ligamentous and neurologic columns, which allows abnormal motion across
structures can be characterized and classi- the injured spinal segment. However, burst frac-
fied regarding presence of disruption, edema, tures involving the anterior and middle column
hematoma, traumatic disc herniation, and can have an intact PLC, maintaining sufficient
presence of cysts or syrinx. Discontinuity of ligamentous integrity to allow nonoperative
the “black stripe” (classically the ligamentum treatment. This demonstrates the weakness of
flavum) with focal stripe of T2 fluid extending the three-column approach.
superficially indicates instability with tension 7. Others such as Panjabi and White maintain a
band disruption. Spinal cord edema or hemor- vague yet pragmatic method defining clinical
rhage can easily be seen on T2 or T1 weighted stability present when under normal physio-
images. Use of MRI is controversial in GSW logic loading the spinal column can maintain its
patients. normal pattern without displacement creating
F. Spinal Stability any additional neurologic deficit, incapacitating
1. Injury classifications generally relate to the con- pain or deformity.
cept of spinal stability. White and Panjabi de-
fine clinical instability as “loss of the ability of III. Injury Classifications
the spine under physiologic loads to maintain A. Holdsworth Classification—This early clas-
relationships between vertebrae in such a way sification system conceptualizes the spine as
that there is neither damage nor subsequent ir- composed of two columns (anterior/posterior).
ritation to the spinal cord or nerve roots and Holdsworth believed that the PLC ultimately de-
no development of incapacitating deformity or termined stability at each segment. All posterior
pain”. column injuries were hence unstable.
2. Holdsworth predominately identified the poste- B. Denis Classification—The three-column classifi-
rior ligamentous complex as the key structure(s) cation scheme involves structures of the ante-
to thoracolumbar spinal stability. He classified rior (ALL, anterior ½ body/disk/annulus), middle
fracture-dislocations and shear injuries as un- (posterior ½ body/disk/annulus, PLL), and poste-
stable, whereas all other fracture patterns were rior (all posterior bony and ligamentous struc-
deemed stable. The two-column theory arose tures including pedicles/laminae/facets/spinous
from belief that the vertebral body and disc process/ ligamentum flavum/spinous ligaments)
were more important as a weightbearing col- columns. Injuries were described as minor (15%
umn with a tension band column posteriorly to 20% of fractures involving the spinous and
(facet capsules and interspinous ligaments). transverse processes, pars interarticularis, and
3. James et al. confirmed biomechanically the im- facet articulations) and major (compression
portance of the posterior (instead of middle) fractures, burst fractures, flexion-distraction
column in 1994 emphasizing nonoperative injuries and fracture-dislocations). Definitions
treatment in neurologically intact individuals of stability and instability are described above.
without posterior column involvement. In vitro Middle column injury essentially defined stabil-
studies demonstrated that in addition to pos- ity. Criticism has evolved due to lack of insight in
terior ligamentous complex (PLC) disruption, a determining stable/unstable injuries especially in
light of modern biomechanical studies question- than 5, surgical intervention is recommended. If

ing middle column importance, advances in im- the score is 4, injuries might be handled opera-
aging modalities, and inability to direct fracture tively or nonoperatively. In addition, TLICS guides
management. the surgical approach to injuries as seen in Ta-
C. McAfee Classification—McAfee’s classification ble 28-1. General principles include (a) anterior
(wedge-compression, stable and unstable burst, procedure for incomplete neurologic injuries in
Chance, flexion-distraction, and translational) which neural elements are compressed from ante-
arose in response to criticisms of Denis’ classi- rior spinal elements, (b) posterior procedure for
fication by utilizing CT to describe the mode of PLC disruption, and (c) combined approaches for
failure of the middle column, and the classifica- combined incomplete neurologic injury and PLC
tion emphasizes various injuries as stable/un- disruption.
stable with emphasis on the importance of the 1. Injury morphology—Fracture patterns are simi-
PLC. The “stable burst fracture” was coined by lar to the AO classification and described as com-
McAfee and involves the anterior and middle col- pression, translation/rotation, and distraction.
umns with compression fractures but an intact
PLC whereas unstable burst fractures involve
disruption of the PLC. Chance fractures consist TA B L E 2 8 - 1
of a horizontal vertebral avulsion injury with the The Thoracolumbar Injury Classification
axis of rotation anterior to the ALL. The other and Severity Score (TLICS)
two modes include flexion-distraction and trans- Parameter Points
lational injuries.
Morphology
D. AO/ASIF and OTA Classification (Magerl and co-
workers)—The AO/ASIF classification is based Compression 1
on the three primary forces applied to the spine. Burst 2
Type A injuries are those caused by compressive Translational/
loads, Type B injuries are distractive injuries, rotational 3
and Type C injuries are rotational and multidi- Distraction 4
rectional. Each fracture type is divided into three
Neurologic status
subtypes depending on the severity of load ap-
Intact 0
plied and structure(s) compromised (bone vs.
soft tissue). The classification provides rationale Nerve root injury 2
for determining treatment and prognosis but is Spinal cord/conus medul-
limited due to its complex scheme yielding low laris injury
interobserver reliability. Complete 2
E. McCormack “Load Sharing”—Assesses vertebral Incomplete 3
body comminution, fragment displacement, and
Cauda equina 3
kyphosis to predict which injuries can be treated
with nonoperative management, short-segment Posterior ligamentous
complex
transpedicular constructs, or additional anterior
column support. Total points greater than 6 re- Intact 0
quire additional anterior column support. Bio- Indeterminate 2
mechanical and clinical reports have validated Disrupted 3
its use.
Treatment
F. Thoracolumbar Injury Classification and Severity Recommendations
Score (TLICS)—TLICS was developed by Vaccaro
Total Score Treatment
and coworkers as a practical comprehensive sys-
tem to aid in decision making regarding opera- ≤3 Nonoperative
tive versus nonoperative care in unstable injury 4 Indeterminate (nonop-
patterns. TLICS is based on three injury charac- erative vs. operative)
teristics: (1) injury morphology on radiographic ≥5 Operative
appearance, (2) integrity of the posterior liga- From Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new
mentous complex, and (3) neurologic status of classification of thoracolumbar injuries: the importance of
the patient. Each characteristic is assigned points injury morphology, the integrity of the posterior ligamentous
complex, and neurologic status. Spine. 2005;30:2325–2333,
and if the sum totals less than 3, nonoperative with permission.
treatment is recommended. If the sum is greater
• Compression (1 point, 2 points for burst)— D. General Guidelines

Compression fractures include axial, flexion, 1. Typically orthoses are worn for 12 weeks.
and lateral compression or burst fractures 2. Nonoperative cases must still be followed for
secondary to vertebral body failure under progressive deformity, nonunion, late neuro-
axial loading. logic compression, and chronic pain, which
• Rotation/translation (3 points)—These frac- may necessitate late surgical management.
ture patterns include translation/rotation 3. Standing lateral radiographs are recommended
compression or burst fractures, and unilat- after orthosis fitting to diagnose physiologic
eral or bilateral facet dislocations with or instability which would indicate a fracture re-
without compression or burst characteris- quiring surgical stabilization.
tics. These patterns generally occur under 4. Orthoses—Plaster casts or jackets have been
torsional and shearing forces. replaced.
• Distraction injuries (4 points)—Distraction
5. Jewett (Hyperextension appliances)—resist
injuries are subdivided into flexion or exten-
flexion but are less effective in resisting rota-
sion injuries with or without compression or
tion or lateral bending.
burst components. Distraction injuries gen-
6. Thoracolumbosacral orthosis (TLSO)—
erally leave one part of the spinal column
“Clamshell” orthosis.
separated by a space between another area
• Prefabricated or custom fit—TLSO reduces
of the spinal column.
motion in multiple planes.
2. Integrity of the posterior ligamentous
• Limited to T6 and below.
complex—The PLC or “posterior tension
7. Leg extensions—Addition of leg extensions
band” protects the spine from flexion, rotation/
is indicated when L5-S1 immobilization is
translational, and distraction forces and heals
required.
poorly generally necessitating surgical treat-
ment. Plain radiographs, CT, and MRI imaging 8. Cervicothoracic orthoses (CTO)—TLSO with a
are useful in determining whether the PLC is CTO extension is indicated in fractures above T5.
intact (0 points), suspected/indeterminate
(2 points), or disrupted (3 points). V. Spinal Decompression—Decision Making, Timing,
3. Neurologic status—Neurologic injury denotes Techniques
severe spinal injury and neurologic status in in- A. General Surgical Treatment Pearls
creasing severity can be classified as intact (0 1. Goals—Spinal stability, deformity correction,
points), nerve root or complete (ASIA A) cord neurologic decompression, early rehabilita-
injuries (2 points), or incomplete (ASIA B, C, tion, minimization of medical complications
and D) cord or cauda equina injuries (3 points). (pneumonia, deep vein thrombosis, decubitus
ulcers).
IV. Nonoperative Management 2. Indications—Patients with unstable fractures
A. Overview—TL fracture management goals are to with progressive kyphosis or translation, in-
restore spinal stability, correct coronal or sagit- complete neurologic deficits with persistent
tal deformities, optimize neurologic recovery, de- cord compression or PLC disruption benefit
crease pain, and allow early rehabilitation. from surgical management.
B. Indications for Nonoperative Treatment—In gen- 3. Early surgical management—Early surgical
eral, fractures without neurologic compression management (72 hours) has been shown to
or instability. Also, neurologically and ligamen- minimize ventilator and ICU days and maxi-
tously intact burst fractures, and some bony FDI mize respiratory function.
(bony Chance) fractures. 4. Obese patients (unable to tolerate bracing)
C. Contraindications for Nonoperative Treatment— and polytrauma patients often benefit from
Ligamentous FDI, fracture-dislocations, fractures surgical treatment to allow early mobilization
with neurologic deficits. Note most AS or DISH and rehabilitation.
patients with subtle appearing extension distrac- 5. Ligamentotaxis—distraction instrumentation
tion (most often) fractures can actually have can aid in canal clearance in patients with
significant three-column injuries requiring sta- greater than two-third canal compromise with
bilization. Late neurologic decline after hospital- an intact posterior annulus attached to bony
ization is not uncommon as epidural hematoma fractures. Postoperative CT scans and postop
in addition to instability can cause neurologic neurologic assessments can aid in determining
injury. the need for additional anterior decompression.
B. Decision Making—Surgical intervention depends

on the mechanical stability/alignment of the frac-
ture, the neurologic status, and general medical
condition. General surgical principles of thoraco-
lumbar fracture management tend to maximize
function, shorten hospital stay, improve nursing
care, and prevent deformity, instability, and pain.
Specific surgical goals focus on reconstructing
spinal alignment and stabilization of unstable frac-
tures in addition to decompressing neural struc-
tures in the setting of neurological deficits. TLICS
has been useful at not only classifying and guiding
operative versus nonoperative management but
also suggesting the surgical approach required.
1. Operative Versus nonoperative treatment
• TLICS less than 4—nonoperative treatment
indicated (exceptions: AS, DISH, neurologic
deficit)
• TLICS equal to 4—nonoperative versus oper-
ative treatment based on surgeon experience
• TLICS greater than 4—operative treatment FIGURE 28-9 Axial CT image demonstrates a lamina
indicated fracture associated with burst fractures. This patient did
2. Anterior Versus Posterior Surgical Approach have an entrapped root with lacerated dura, which was
• Posterior approach repaired via open posterior approach.
(a) Fracture reduction, malalignment re-
alignment, decompression of epidural
hematoma, and biomechanically supe- • Anterior approach (Fig. 28-10)
rior (increased axial, rotational, and (a) Most other patients with neuro-
pull-out strength) transpedicular instru- logic compression require anterior
mentation are the major benefits of the decompression.
posterior approach. (b) Anterior-only decompression and recon-
(b) Disruption of PLC—requires restoration struction can be performed in nonosteo-
of the tension band is best done posteri- porotic burst fractures with neurologic
orly (see Figs. 28-7C and 28-8B). compromise whose posterior ligaments
(c) FDI, Facet dislocations, translational remain intact (TLICS 4 or 5).
injuries. (c) Patients with severe deformity or loss
(d) Nerve root injuries are associated with of anterior column support require an-
lamina fractures in burst injuries in addi- terior interbody strut grafting or cage
tion to traumatic dural tear and require placement.
posterior decompression. (Figs. 28-5 C & (d) Subacute fractures (5 to 7 days) often
D, 28-9). require anterior treatment as reduction
(e) Kyphotic deformities—best treated with and ligamentotaxis is often not possible
a posterior approach within 3 to 5 days at this point.
of injury (prior to fracture consolida- • Posterolateral approach
tion) with compression instrumentation (a) Recently, transpedicular, costotransver-
(distraction instrumentation increases sectomy, and the lateral extracavitary
the rate of nonunion). approach has allowed simultaneous
(f) Osteoporotic patients—longer con- superior posterior reduction, instru-
structs with cement augmentation or mentation with anterior decompression
transpedicular bone grafting can de- and reconstruction via an all posterior
crease construct failures. approach.
(g) Complete SCI—best managed via pos- C. Timing of Surgery—Urgent decompression is indi-
terior only approach to minimize future cated in injuries with progressive neurologic defi-
deformity, achieve solid fusion, and al- cits and mechanically unstable fracture patterns
low early rehabilitation. with cord compression.
D. Techniques—Indirect, anterior, posterolateral,

combined
1. Indirect reduction (Fig. 28-11)—Indirect reduc-
tion utilizes a posterior approach through liga-
mentotaxis via application of distractive forces
via segmental instrumentation. Laminectomy
alone has been shown to be ineffective in alle-
viating anterior compression unless an isolated
laminar fracture exists with neurologic deficit
from a suspected fracture. Indirect reduction
requires an intact annulus and maintains that
infringing fracture fragments can be reduced
to near pre-injury state if done within 2 days
with removal of fragments from the spinal ca-
nal. If performed late (10 to 14 days), minimal
reduction occurs. Gertzbein and coworkers
showed that posterior distraction can provide
effective canal clearance when carried out in
the first 4 days with initial canal compromise
of between 34% and 66%. The extent of canal
clearance was notably less in patients with ini-
FIGURE 28-10 Postoperative CT midsagittal image
tial compromise less than 33% or greater than
following anterior L1 corpectomy with expandable
67% and in patients whose operation was done
interbody cage placement with anterior bicortical screw-
rod instrumentation for a burst fracture with neurologic after 4 days from injury.
deficit but without PLC disruption. 2. Anterior (see Fig. 28-10)—Anterior approach is
the most direct and consistently successful ap-
proach for decompression. Corpectomy with
1. Animal studies demonstrate recovery of elec- direct removal of offending bone/soft tissue
trophysiologic function if spinal cord decom- fragments is usually performed. The key ben-
pression occurs within 1 to 3 hours suggesting efit is minimal neural tissue manipulation with
a possible critical window of opportunity excellent load sharing reconstructive options.
though not corroborated in human studies. Approaches are usually right sided for injuries
2. Gaebler and coworkers found in one retro- above T6 due to the location of the heart and
spective study greater return of neurologic great vessels, and are left sided for thoracoab-
function when treated surgically less than dominal approaches (vena cava, liver). Antero-
8 hours from injury. lateral approaches via transthoracic (T4–T9),
3. McLain and Benson found that urgent thoracoabdominal (T10-L1), or retroperitoneal
(24 hours) spinal stabilization is safe and (T12-L5) usually involve resection of the rib at
appropriate in polytrauma patients (ISS 26 the level or one to two levels above the injured
in their study) when there is progressive neu- vertebral body for visualization. After resec-
rologic deficit, thoracoabdominal trauma, or tion of the rib, the parietal pleura is incised
fracture instability. They reported no venous over the vertebral body with radiographic
thromboses, pulmonary emboli, neurologic in- confirmation of level. Segmental vessels are li-
juries, decubiti, deep wound infections, or epi- gated as needed with subperiosteal exposure
sodes of sepsis in patients undergoing urgent of the vertebral body. Diskectomies above and
or early (24 to 72 hours) treatment. Chipman below are performed with subsequent pedicle
and coworkers found similar decreased com- removal and nerve root identification. The
plications and shorter hospitalizations when root can be traced to the thecal sac. Removal
treated within 72 hours. of the vertebral body occurs with rongeours,
4. Bohlman and coworkers found that late (aver- curettes, and burs down to the PLL and to the
age 4.5 years from injury) anterior decompres- medial border of the contralateral pedicle,
sion in patients with chronic pain and evidence which completes the anterior decompression.
of spinal cord and cauda equina compression A portion of the anterior wall is left to protect
can still have substantial pain relief and neuro- against graft displacement. Reconstruction
logic improvement (1 Frankel grade). can then be undertaken.
FIGURE 28-11 Burst fracture without neurologic deficit but 35° of kyphosis preoperatively is treated with posterior
open reduction with instrumentation with distraction ligamentotaxis without fusion.
3. Posterolateral (Fig. 28-12)—Decompression can canal decompression. Ultrasound can identify

be undertaken with segmental posterior instru- the canal and neural elements from the pos-
mentation without need for a subsequent ante- terior viewpoint. Postoperative CT scan with/
rior procedure. Preoperative axial CT images without myelography (or MRI as hardware
allow localization of the side and degree of ca- artifact has decreased with higher resolution
nal compromise. Direct posterior approaches scans) remains the procedure of choice for as-
have a high incidence of iatrogenic neurologic sessing adequacy of decompression, and the
injury due to inability to decompress ventral potential need for subsequent anterior cor-
dura without manipulation of the spinal cord. pectomy. With the posterolateral approach, re-
After midline or paramedian skin incision, in- construction with placement of an expandable
strumentation typically extends 2 to 3 levels cage is often utilized when the anterior column
above and below the injured level; distractive is significantly destabilized.
reductive forces can then be applied to assist 4. Combined—Combined anterior and posterior
with reduction. Transpedicular decompression approaches are useful in the treatment of dis-
after hemilaminectomy and facetectomy at the placed fracture-dislocations with incomplete
injured level is then undertaken after pedicle injury as initial reduction is accomplished
boundaries are identified. While protecting the posteriorly with subsequent anterior decom-
nerve root with a Penfield instrument, superior pression and fusion. Combined procedures are
and lateral then inferior and medial cortices useful when initial posterior realignment and
are removed via burring then rongeuring with stabilization fails to provide adequate decom-
curetting to access the posterolateral verte- pression or when open spinal fractures, anky-
bral body. Fragments can then be excised or losing spondylitis or diffuse idiopathic skeletal
anteriorly translated into the vertebral bodies. hyperostosis are present.
Costotransversectomy or lateral extracavitary
approaches can be utilized with more lateral VI. Spinal Reconstruction and Instrumentation
exposure to allow more room for anterior A. Anterior Surgery and Instrumentation
decompression and reconstruction though 1. Indications—Indications for anterior surgery
pleural violation is more common. The major include unstable fractures with significant
drawback is difficulty assessing intraoperative compromise (50%) of the anterior column
FIGURE 28-12 Direct posterior reduction is demonstrated intraoperatively with fluoroscopy (A) and on postoperative
CT imaging (B) from the patient in Figure 28-5.
support, spinal cord compression via fracture via ligamentotaxis. Long segment con-
fragments or discs, unstable burst fractures structs typically provide the best fixation.
with neurologic injury, and to preserve mo- McCormack and coworkers identified the
tion segments. best candidates for short segment pedicle
• Advantages—Safest and most effective screw constructs (one level above and be-
method to address cord compression. low injury) to include flexion-distraction or
Anterior surgery allows for optimal biome- lower lumbar burst fractures with less than
chanical reconstruction (approximately 80% 2 mm of fracture fragment displacement, less
of axial load is transmitted through the ver- than 10° of kyphosis, and less than 30% body
tebral body). Direct access for cage or inter- comminution.
body device placement allows for improved • Advantages—Significant reduction forces
sizing and fit with lower rates of displace- can be applied via posterior instrumen-
ment and subsequent injury/deformity. tation. Pedicle screw systems facilitate
• Reconstructive devices—Reconstruction of improved realignment relative to earlier
the anterior column usually combines al- hook-rod or sublaminar wiring techniques.
lograft or autograft with metallic or poly- • Disadvantages—Multiple motion seg-
etheretherketone (PEEK) interbody or ments must be fused to ensure stable
vertebral body spacers. Structural allografts constructs with pedicle screws. Short
include tricortical iliac crest, and femoral or segment fixation has been associated
humeral shaft. In general, autograft provides with increased construct failures in osteo-
higher fusion rates but allograft gives initial porotic patients as well as those with sig-
increased structural stability without associ- nificant anterior comminution or kyphotic
ated harvest site morbidity. Additional inter- deformities.
nal fixation with plates and screws or dual C. Minimally Invasive Techniques
rods decreases rates of nonunion, resultant 1. General
deformity and graft dislodgement rates. Cur- • No prospective evidence demonstrates ben-
rent implants are now low profile and rates of efit over open approaches.
great vessel injury are declining. • Concept is decreased tissue disruption, less
B. Posterior Surgery and Instrumentation blood loss, shorter hospitalizations, which
1. Indications—Posterior surgery allows spi- will lead to improved long-term outcomes.
nal realignment and indirect reduction • Steep learning curves are expected.
• Relative contraindications—significant ca-

nal compromise with incomplete neurologic
injuries.
2. Endoscopically-assisted thoracoscopic cor-
pectomy
3. Lateral access approaches—Lateral access
approaches (Far-lateral transthoracic or retro-
peritoneal approaches) via mini-open expand-
able or tubular retractors (Fig. 28-13).
4. Cement augmentation (Figs. 28-13 and 28-14)
• Concept—Cement infiltration into fractured
vertebral bodies for restoration of anterior
support with improved weight-bearing ca-
pacity of the anterior column used with or
without supplemental fixation.
• Concern—Cement extravasation through
posterior vertebral wall defects can cause
iatrogenic neurologic injury as well as respi-
ratory embolization with hypotension and
hemodynamic compromise.
• Vertebroplasty—transpedicular insertion of
FIGURE 28-14 Pedicle screw augmentation with
cement.
cement. Note the left pedicle screw lateral breach
• Balloon-assisted kyphoplasty—vertebral
brushing the descending thoracic aorta.
height and angulation are attempted to be
restored with balloon reduction then ce-

ment infiltration.
VII. Complications
A. Medical
1. GI related—Ileus, gastroesophageal reflux dis-
ease, constipation.
2. Thromboembolic disease—Deep vein throm-
bosis and pulmonary embolism (up to 2%
symptomatic in SCI patients).
• Consider mechanical compression de-
vices, TED stockings, chemical anticoagu-
lation or vena cava filter placement in SCI
patients.
3. Prolonged hospitalization, pneumonia, decu-
bitus ulcers, malnutrition.
B. Surgical
1. Iatrogenic neurologic injury—1% with poste-
rior operations.
2. Hardware malposition (Fig. 28-15)—visceral,
vascular, neural, and dural injuries.
3. Infection—10%.
FIGURE 28-13 A 65-year-old woman with severe 4. Cerebrospinal fluid leaks—primary watertight
rheumatoid arthritis on steroids with multiple chronic
repair is best although subarachnoid lumbar
osteoporotic compression fractures sustained a L3
drain placement with bedrest for 5 days typi-
burst fracture with ligamentous disruption and was
treated with an anterior minimally invasive direct cally allows resolution.
lateral retroperitoneal approach with L3 corpectomy, 5. Pseudarthrosis—Pseudarthrosis with con-
expandable cage placement, L2 and L4 vertebroplasty struct pullout or failure (see Fig. 28-15), re-
(with cement) to augment endplate strength, and anterior current deformity, unrelenting pain. Revision
and posterior fusion with percutaneous posterior fixation. surgery is often required.
1. Nonoperative treatment—Nonoperative
treatment is recommended for less than
50% height loss and less than 30° of kypho-
sis. Treatment with orthotics typically in-
cludes thoracolumbosacral orthosis (TLSO)
or Jewett type hyperextension orthosis.
Cervical extension to the brace should be
added if cephalad to T7. Activity can be
as tolerated while wearing the brace and
treatment generally takes 3 months. Brace
weaning and PT then proceeds. Interval
AP and lateral radiographs taken at ap-
proximately 12 weeks determines motion
segment stability and the presence of a
kyphotic deformity. If early follow up films
shows increasing angular deformity or the
patient experiences unrelenting pain, in-
creased consideration for surgery should be
given.
2. Operative treatment—Operative treatment
is usually not indicated in compression frac-
FIGURE 28-15 Construct failure with caudal T8 tures without PLC injury unless significant
pedicle screw pullout. The laterally placed right T7-8 anterior column deficiency or incomplete
screws were inadequate to stabilize the T5 and T6
neurologic injury exists in which case an-
burst fractures in this neurologically intact patient with
terior decompression and reconstruction
a ligamentous injury. Revision posterior fixation with
extension in addition to anterior column strut grafting is the procedure of choice. Compression
was subsequently performed. fractures with PLC injury are treated primar-
ily with posterior segmental instrumenta-
tion with a combination of pedicle screws
6. Anterior approach related complications— and rods. Constructs typically span 2 or 3
pneumothorax, poor respiratory function, in- levels above and below the injured motion
tercostal neuralgia. segment as short segment constructs typi-
cally have increased rates of loss of fixation
VIII. Treatment of Specific Thoracolumbar Injuries and postoperative deformity. After internal
A. Outcomes fixation, the use of a hyperextension ortho-
1. Classic measures—Fusion rate, sagittal sis or body cast for 3 months is optional but
alignment, return to work should be considered particularly in the set-
2. Patient-centered outcomes ting of compromised bone quality.
• General health—SF-36, SF-12: allow a util- 3. High versus low energy compression frac-
ity score/cost effectiveness analysis. tures—Differentiation between low energy
• D isease-specific—Oswestry-Disability osteoporotic fractures (elderly) and high
Index (ODI)—allows identification of lum- energy fractures is important as low energy
bar function and disability. fractures rarely require operative interven-
B. Compression Fractures—A compression frac- tion due to an intact PLC.
ture is a failure of the anterior column with an 4. Contiguous compression fractures—Contigu-
intact middle column. Mechanism is axial load- ous compression fractures “act differently”
ing with or without flexion and lateral bending than singular fractures. Total percentage
moments. PLC integrity determines treatment loss of anterior column height should be
but is usually intact. Compression fractures measured as deformity across contiguous
with greater than 50% anterior column height levels can dictate operative intervention of
loss or kyphosis greater than 30° have a higher injuries that would be amenable to bracing
likelihood of an associated PLC injury (strain, if occurring in isolation.
attenuation or true disruption). General treat- C. Burst Fractures—The integrity of the PLC and
ment principles using the following criteria neurologic status are the driving factors for
have been recommended. treatment of thoracolumbar burst fractures. In
neurologically intact patients, treatment is near reliable return to premorbid sagittal contour.
identical to compression fracture management Neurologically intact individuals with sig-
regardless of the presence of retropulsed frag- nificant anterior injury (50% height loss)
ments. With less than 20° of kyphotic deformity, can be treated via anterior reconstruction
less than 50% anterior vertebral body height or combined anterior and posterior recon-
loss, no facet subluxation or posterior inter- struction (typically short segment posterior
spinous widening and intact neurologic exam, construct) with more severe PLC injuries.
brace treatment with full contact orthosis for 3. Treatment—As described and outlined
12 weeks including early ambulation is reason- above with either nonoperative bracing (or
able. Bedrest for initial pain relief may be neces- casting for noncompliant patients) versus
sary preceding ambulation and bracing. operative intervention with variable ap-
1. Neurologic status—Neurologically in- proaches. Studies by Cantor and cowork-
tact individuals with burst fractures ers and Reid and coworkers (prospective)
with an intact PLC can be treated non- evaluated thoracolumbar burst fractures
operatively. Neurologic injury remains treated with TLSO bracing and noted no sig-
the key factor guiding management of nificant change in sagittal alignment at an
thoracolumbar burst fractures. Neu- average of 19 months followup in 18 and 21
rologic deficits may manifest as subtle patients, respectively. Progression of kypho-
bowel or bladder changes and dysfunc- sis was noted to range between 1° and 4.6°
tion instead of gross sensorimotor deficits. with loss of vertebral height at 6%. Pain was
Loss of anal sphincter function, perirec- noted to be minimal and the vast majority of
tal or perineal sensation or residual urine patients returned to pre-morbid activities.
volume (50 mL is normal) may be the Nicholl, McAfee, Mumford, and Weinstein,
only noted signs of a subtle neurologic demonstrated that residual sagittal defor-
(conus) injury. Incomplete neurologic inju- mity and canal compromise do not corre-
ries in the presence of imaging documen- late with functional outcomes, pain scores,
tation of spinal cord compression provide and ability to work. In cadaveric studies,
significant impetus for surgical decompres- Oda and Panjabi found that near anatomic
sion. Anterior decompression and recon- reduction typically can be accomplished
struction with instrumentation is usually with a combination of distraction (5 mm)
sufficient without evidence of injury to the and lordosis/extension (6°) applied through
PLC. Patients with significant PLC disrup- posterior pedicle screw-rod constructs.
tion should be decompressed and stabi- Controversy still persists with regard to
lized anteriorly with a strong consideration optimal management of burst fractures re-
for additional posterior stabilization. An- garding decompression of neurologically
terior decompression, reconstruction and complete injuries.
stabilization can successfully address this D. Flexion-distraction injuries—These injuries are
global instability pattern while simultane- better known as “seat belt injuries” and typi-
ously restoring sagittal alignment as shown cally involve one or two levels. As the mecha-
by Sasso and McGuire. Late anterior de- nism implies, these injuries involve posterior
compression (up to 4.5 years after injury) column disruption with some intact anterior ele-
of incomplete injuries in patients in whom ments acting as a hinge or fulcrum with the axis
acute decompression of the spinal cord or of rotation generally anterior to the spine. How-
cauda equina was not performed has been ever, secondary axial loading often occurs with
shown (by Bohlman and coworkers) to im- deceleration and the axis of rotation can exist
prove neurological function (50%) and re- within the vertebral body. Flexion-distraction
lieve chronic pain (90%). injuries can occur through bone only, soft tis-
2. Posterior ligamentous complex—The PLC is sue only, or multilevel injuries through a combi-
the second key determinant in thoracolum- nation of bony and ligamentous/disk elements.
bar burst fracture management. Complete Management typically is nonoperative for
injury to the PLC in neurologically intact pure bony injuries (as excellent healing typi-
individuals is a relative surgical indication. cally occurs) and operative for ligamentous
Neurologically intact individuals with less or combined injury due to slow and unpre-
than 50% loss of height are generally treated dictable healing rates. Stabilization is typi-
via posterior reconstruction effecting a cally performed via posterior instrumented
techniques involving the level above and be- realign, decompress and stabilize the spine.
low the injury. Safe monitoring while the patient is positioned
1. Nonoperative treatment—Nonoperative is possible with awake intubation and prone
treatment of bony flexion-distraction injuries positioning with close monitoring of the neuro-
consists of initial bedrest followed by mobi- logic status prior to anesthesia. Identification
lization in a TLSO molded in hyperextension. of shear injuries is a necessity as management
In the initial postop period, it is important does not involve distraction.
to remember the association of seat-belt in-
juries with retroperitoneal visceral injuries;
therefore, serial abdominal examinations
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injury severity score: a proposed treatment algorithm. J Spi- overview with emphasis on the burst fracture. Orthopedics.
nal Disord Tech. 2005;18:209–215. 1992;15(3):329–337.
Wood K, Buttermann G, Mehbod A, et al. Operative compared
with nonoperative treatment of a thoracolumbar burst frac- Textbooks
ture without neurological deficit. A prospective, random- Dick W. Internal Fixation of Thoracic and Lumbar Spine Frac-
ized study. J Bone Joint Surg Am. 2003;85-A:773–781. tures. Berne, Switzerland, Hans Huber, 1989.
Wood KB, Bohn D, Mehbod A. Anterior versus posterior treat- Eismont FJ, Garfin SR, Abitbol JJ. Thoracic and upper lumbar
ment of stable thoracolumbar burst fractures without neu- spine injuries. In: Browner BD, Jupiter JB, Levine AM, et al,
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Disord Tech. 2005;18 Suppl:S15–S23. Injuries. Vol 1. Philadephia, PA: WB Saunders; 1992.
Fredrickson B, Yuan H. Nonoperative treatment of the spine:
Reviews external immobilization. In: Browner BD, Jupiter JB, Levine
Anderson PA. Nonsurgical treatment of patients with thoraco- AM, et al, eds. Skeletal Truama: Fractures, Dislocations, Liga-
lumbar fractures. Instr Course Lect. 1995;45:57–65. mentous Injuries. Vol 1. Philadephia, PA: WB Saunders; 1992.
Bohlman HH. Treatment of fractures and dislocations of the tho- Haher TR, Felmly WT, O’Brien M. Thoracic and lumbar frac-
racic and lumbar spine. J Bone Joint Surg. 1985;67A:165–169. tures: Diagnosis and treatment. In: Bridwell KH, DeWald RL,
Gertzbein SD, Court-Brown CM. Rationale for the manage- eds. The Textbook of Spinal Surgery. 2nd ed. Vol 2. New York,
ment of flexion-distraction injuries of the thoracolum- NY: Lippincott-Raven; 1997.
bar spine based on a new classification. J Spinal Disord. Levine AM, Eismont FJ, Garfin SG, et al, eds. Spine Trauma.
1989;2(3):176–183. Philadelphia, PA: WB Saunders; 1998.
Hurlbert RJ. The role of steroids in acute spinal cord injury: an Kostuick JP, Huler RF, Esses SI, et al. Thoracolumbar spine
evidence-based analysis. Spine. 2001;26(24 Suppl):S39–S46. fractures. In: Frymoyer JW, ed. The Adult Spine: Principles
Inaba K, Munera F, McKenney M, et al. Visceral torso com- and Practice. Vol 2. New York, NY: Raven Press Ltd.
puted tomography for clearance of the thoracolumbar Stauffer ES, ed. Thoracolumbar Spine Fractures Without Neuro-
spine in trauma: a review of the literature. J Trauma. logic Deficits. Rosemont, IL 1993. Thoracolumbar spine inju-
2006;60(4):915–920. ries. In: Errico TJ, Bauer RD, Waugh T, eds. Spinal Trauma.
Jacobs RR, Asher MA, Snider RK. Thoracolumbar spinal inju- Philadelphia, PA: JB Lippincott; 1991.
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Levine AM, McAfee PC, Anderon PA. Evaluation and emergent
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Course Lect. 1995;44:33–46.
SECTION III
Pediatric Trauma
CHAPTER 29
General Principles of Pediatric

Trauma
William D. Murrell, Michael W. Wolfe, Fredric H. Warren, and Howard R. Epps
I. Child with Multiple Injuries who abuse drugs, children of parents who were
A. Incidence of Injuries abused, children of unemployed parents, and
1. Trauma—Trauma is the most common cause of children of families of lower economic status.
death in children and adolescents in the United Approximately one-third of abused children
States and costs over $1 billion annually. Trau- are eventually seen by an orthopaedic surgeon.
matic injuries account for 20,000 deaths, 600,000 A clear and thorough history and physical ex-
hospital admissions, and 16 million visits to the amination should be performed. Knowledge of
emergency room. Mechanisms of injury include a child’s social environment, age, injury pattern,
child abuse, falls, and motor-vehicle accidents and stated mechanism of injury are all impor-
(either in them or hit by them). Head injury is tant factors in the evaluation.
the most common reason for death from trauma Knowledge of injury patterns suggestive
in children; the ratio of boys to girls is 2:1. Death of nonaccidental trauma in children is es-
occurs most often from blunt trauma. Alcohol sential. Child abuse must be suspected in all
plays an increasingly important role in the in- cases of multiple injuries in children younger
jury of adolescents. than 2 years if there is no obvious witnessed
2. Fractures—Fractures are common in children explanation for the trauma. Skeletal injuries
with multiple injuries. About 9% of fractures in that have a high specificity for child abuse
such children are open. include posterior rib fractures, sternal frac-
3. Child abuse—The annual incidence of child tures, spinous process avulsion fractures,
abuse in the United States is 15 to 42 cases per and scapular fractures. Skeletal injuries
1,000 children; the incidence is increasing (or that have a moderate specificity for child
cases are being better recognized). More than abuse include multiple fractures, fractures
2 million children each year are victims of phys- in various stages of healing, vertebral com-
ical abuse or neglect, and over 150,000 suffer pression fractures, and epiphyseal separa-
serious injury or impairment (Neglect is more tions. Long-bone fractures are commonly seen
common than physical abuse.) Children of all in cases of child abuse, but have a low specific-
socioeconomic backgrounds suffer physical ity. Some authors have suggested that the most
abuse or neglect; however, the incidence does common fracture seen in child abuse is a single
appear to be related to family income. (Chil- transverse fracture of the femur or humerus.
dren in homes with a family income of less than (Other authors disagree.)
$15,000 per year are 25 times more likely to The differential diagnosis in cases of sus-
suffer abuse compared with children in homes pected child abuse includes true accidental
with a family income greater than $30,000 per injury, osteogenesis imperfecta, and metabolic
year.) bone disease.
Children with the highest risk for abuse in- A skeletal survey is a useful initial imaging mo-
clude first-born children, unplanned children, dality and may be repeated 2 to 3 weeks after
premature children, and stepchildren. Children the child’s initial presentation. Nuclear medicine
with an increased risk for abuse include chil- bone scanning may be helpful when the skeletal
dren in a single-parent home, children of parents survey is negative.
458
C H A P T E R 2 9 | G E N E R A L P R I N C I P L E S O F P E D I A T R I C T R A U M A 459
The most important aspect of management 2. Glasgow Coma Scale (GCS)—Head injury is
is the establishment of the diagnosis of child rated using the GCS. For further details, see
abuse. (The history of injury must be clearly Chapter 1.
detailed, documented, and understood.) An in- 3. Abdominal examination
strument for detection of nonaccidental trauma 4. Extremity examination—Every joint is palpated,
called the screening index for physical child and range of motion is assessed. A neurovascu-
abuse (SCIPA) has been validated; it can assist lar examination is performed.
with diagnosis. By law, all suspected cases of 5. Open fractures
child abuse must be reported to Child Protec- • Assessment—The nature and extent of the
tive Services. open wound is assessed without probing.
B. Initial Resuscitation—Resuscitation can be cost ef- The patient should not be subjected to mul-
fective and adequately provided at a general level I tiple examinations. The injury is then provi-
trauma center. The ABCs of trauma are the same as sionally stabilized. Neurovascular status is
those for an adult. checked after stabilization.
1. Cervical spine—The cervical spine must be • Treatment—If there is profuse bleeding, a
stabilized. Special transport spine boards compression dressing or a tourniquet should
are recommended for children younger than be applied. Tetanus prophylaxis and an initial
6 years. Other (“distracting”) injuries such dose of broad-spectrum intravenous antibiot-
as long-bone fractures, abdominal injuries, ics should be given to prevent early wound
and crush injuries can mask cervical spine sepsis. After appropriate radiographic studies
injuries. and other lifesaving measures have been per-
2. Intravenous access—In the child, intravenous formed, the patient should be quickly taken
access may be difficult; intraosseous fluid infu- to the operating room for a formal irrigation
sion can be considered. and debridement and skeletal stabilization.
3. Blood pressure—A child’s blood pressure must 6. Imaging studies
be maintained at an adequate level because • Plain radiographs—In the trauma cervical
death is more common in children than in spine series (lateral from C1 to the top of
adults if hypovolemic shock is not quickly T1, anteroposterior [AP], open-mouth odon-
reversed. (Injuries are usually internal.) Atten- toid views), the clinician should watch for
tion to volume administration in a child with pseudosubluxation of C2 on C3 or of C3 on
a severe head injury is paramount unless hy- C4, which are normal variants. An AP chest,
potension is present from obvious internal or AP pelvis, and appropriate extremity films
external blood loss. Adolescent girls with trau- should also be obtained.
matic shock have significantly decreased risk of • Computed tomography (CT)—CT of the head
death as compared to boys. is performed without contrast if warranted.
4. Aggressive fluid replacement—Aggressive fluid • Retrograde urethrography—Retrograde ure-
replacement may lead to internal fluid shifts thrography is performed if there is urethral
and thus decrease blood oxygenation levels sec- obstruction. Urethral injury is common with
ondary to interstitial pulmonary edema. pelvic fractures.
C. Evaluation and Assessment—After initial resuscita- • Magnetic resonance imaging (MRI)—If spinal
tion and stabilization, a thorough check for other cord injury is suspected, MRI can be valuable,
injuries is initiated. especially in children who have signs and
1. Injury Severity Score (ISS)—The ISS is a valid, symptoms of compromise without radio-
reproducible method for pediatric multitrauma. graphic abnormality.
It classifies injuries as moderate, severe, seri- • Ultrasonography—Ultrasonography is a fast
ous, critical, and fatal for each of the five major and accurate way of detecting hemoperito-
body systems. Each level of severity is given a neum. In some centers, it has replaced lapa-
numerical code (1 to 5). Systems include gen- roscopy and diagnostic peritoneal lavage, but
eral, head and neck, chest, abdomen, and ex- accuracy depends on user experience.
tremities. The ISS is the sum of the squares of D. Nonorthopaedic Conditions
the three most injured body systems. The range 1. Head injury
of severity is from 0 to 75. The New Injury Se- • Recovery—Head injury is the leading cause
verity Score (NISS) has been shown to be a of morbidity and mortality in pediatric
better predictor of outcome in severely injured trauma patients. Recovery from signifi-
patients. cant head injury, however, is substantially
460 S E C T I O N I I I | P E D I A T R I C T R A U M A
better in children than in adults. Even in Skeletal injury should be stabilized to facilitate
children with severe head injuries, full func- mobilization and management of the patient.
tional recovery is likely. Poor oxygenation 2. Open fractures
on arrival to the emergency department and • Classification (Table 29-1)
a low GCS at 72 hours after head injury have • Treatment
been correlated with a poorer functional result (a) Stages
and a greater neurologic deficit. Failure to treat • Emergency treatment—Emergency tre-
orthopaedic injuries in a child with a head atment includes tetanus prophylaxis,
injury is inappropriate. It must be assumed appropriate antibiotics, a compression
that a full functional recovery will occur, and dressing to stop bleeding, and applica-
optimal orthopaedic care should be provided tion of a splint.
when the child is able to undergo surgery. • Initial treatment in the operating room
• Complications—Abundant callus forms in (OR)—Initial OR treatment includes ad-
fractures of patients with head injuries. Other equate debridement of devitalized tissue
complications after head injury include spas- and pulsatile lavage with saline solution
ticity, contractures, and the formation of het- with or without antibiotics. The wound is
erotopic ossification. left open if markedly contaminated or if
2. Thoracic injuries—Thoracic trauma has a mor- a large soft-tissue defect exists; if a more
tality rate of 25% in children less than 5 years viable soft-tissue envelope is present,
of age. When there is concomitant head trauma, primary closure may be performed after
children with chest trauma have significantly adequate débridement.
higher morbidity and mortality. Rib fractures are • Definitive treatment—Wound cultures are
less frequent due to their intrinsic flexibility, and obtained at the second debridement. Lo-
chest contusions can occur without external evi- cal soft tissue is used to cover a neuro-
dence of trauma. vascular bundle, tendons, and exposed
3. Injuries to abdominal viscera—Injuries to both cortical bone. Wound debridement is
solid and hollow abdominal viscera are often repeated at 48- to 72-hour intervals until
associated with multiple skeletal injuries. Liver the wound can be closed or covered with
and spleen injuries together comprise 75% of
abdominal injuries in children. Multiple pelvic
fractures correlate strongly (80%) with abdomi- TA B L E 2 9 - 1
nal or genitourinary injury. Abdominal trauma Classification of Open Fractures
should not delay fracture care if the child’s med- Type Description
ical condition is stable.
I Open fracture with a wound 1 cm long and
4. Fat embolism syndrome—Fat embolism syn-
clean (usually inside out)
drome is unusual in children, but it presents the
same as it does in adults. Radiographic changes II Open fracture with a laceration 1 cm long
of pulmonary infiltrates that appear within without extensive soft-tissue damage, flaps,
or avulsions
several hours of a long-bone fracture, axillary
petechiae, and hypoxemia should indicate the III Massive soft-tissue damage, compromised vas-
diagnosis, even in a child. cularity, severe wound contamination, and
marked fracture instability
5. Nutritional requirements—Nutritional require-
ments can be determined based on the patient’s IIIA Adequate soft-tissue coverage despite exten-
weight and age. The daily nitrogen requirement sive soft-tissue laceration or flaps: high-
in the acute phase of injury for a child is ap- energy trauma irrespective of the size of the
wound (e.g., gunshot wound)
proximately 250 mg/kg.
E. Orthopaedic Management—Orthopaedic injuries IIIB Extensive soft-tissue injury or loss with perios-
are rarely life threatening in children, and skeletal teal stripping and bone exposure (usually
associated with massive contamination)
stabilization is initially accomplished with a splint.
(e.g., farm injury)
1. Closed fractures—Early skeletal stabilization can
decrease the risk of acute respiratory distress syn- IIIC Open fracture associated with a vascular injury
requiring repair
drome in children with multiple injuries. Specific
guidelines for operative fixation (e.g., intramedul- From Beaty J, Kasser J, eds. Rockwood and Wilkins’ Fractures
lary fixation, compression plate fixation, and exter- in Children. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2006, with permission.
nal fixation) are beyond the scope of this chapter.
either a split-thickness skin graft or a lo-

cal of free flap. TA B L E 2 9 - 3
(b) Antibiotic treatment (Table 29-2) Incidence of Pediatric Fractures
(c) General principles of management—
Type Percentage
General principles of open fracture man-
Children sustaining at least one fracture
agement include early skeletal stabilization
up to 16 yr of age
allowing access to wounds for debride-
ment, allowing weightbearing when appro- Boys 42
priate, and allowing range of motion of the Girls 27
surrounding joints. Splints and casts can Children sustaining a fracture in 1 yr 1.6–2.1
be used for most Type I and stable Type Children who are hospitalized because
II open fractures with minimal soft-tissue of a fracture
damage. External fixation is usually the
During the entire childhood (up to 16 yr 6.8
treatment of choice for Type II and III open of age)
fractures in children (allows easy access
Each year 0.43
to the wound for debridement, allows flap
reconstruction, and preserves the length Children with injuries (all types) who 17.8
of the injured limb while allowing mobili- have fractures
zation and weightbearing). Open reduction From Beaty J, Kasser J, eds. Rockwood and Wilkins’ Fractures
in Children. 6th ed. Philadelphia, PA: Lippincott Williams &
with internal fixation is usually reserved Wilkins; 2006, with permission.
for open intra-articular fractures. Hybrid
external fixation may be used for fractures
that involve the diaphysis and metaphysis.
(d) Bone loss—Bone loss can be managed by
immediate or delayed bone grafting. Nonaccidental trauma is the leading cause of
(e) Free flaps—Free flaps are more prob- fractures in the first year of life. This high inci-
lematic in children than in adults. dence extends to age 3.
D. Gender—More boys than girls sustain fractures.
II. Fractures in Children—Attempting to globally define
The ratio of boys to girls in all groups is 2.7:1.
the incidence of pediatric fractures is difficult be-
The incidence of fractures in girls peaks before
cause of many cultural, climatic, and age differences.
adolescence and then decreases. The incidence
A. Incidence of Pediatric Fractures (Table 29-3)
of fractures from pedestrian versus motor-vehicle
B. Age Group—There is a linear increase in the an-
accident peaks in both boys and girls from 5 to
nual incidence of fractures with age. The annual
8 years of age. Again, the incidence of these inju-
incidence of pediatric fractures peaks at age 12,
ries is higher in boys.
with a decline until age 16.
E. Side of the Body—Left-sided fractures are more
C. Child Abuse—There is a high incidence of pe-
common by a ratio of 1.3:1.
diatric fractures resulting from nonacciden-
F. Frequency by Season—Fractures are more com-
tal trauma (such as battered child syndrome).
mon during the summer. The most consistent cli-
matic factor is the number of hours of sunshine.
G. Long-Term Trends
TA B L E 2 9 - 2 1. Increase in the number of cases of minor
Guidelines for Antibiotic Treatment of Open trauma (seen by physicians)—The increase in
Fractures by Type in Children the number of cases of minor trauma can be
Type Description attributed to the introduction of subsidized
medical care. Expense is no longer a factor;
I First-generation cephalosporin for 48–72 h
parents are more inclined to seek medical
II Combination of a first-generation cephalosporin
attention for less serious problems.
and an aminoglycoside for 72 h
2. Increase in child abuse—One study showed
III Combination of a first-generation cephalo- that the number of fractures from abuse
sporin and an aminoglycoside for 72 h; for increased almost 150 times from 1984 to 1989.
farm injuries (Type IIIB) add penicillin
This increase may be attributed to a combi-
From Beaty J, Kasser J, eds. Rockwood and Wilkins’ Fractures nation of improved recognition, better social
Wilkins; 2006, with permission. resources, and an increase in the number of
cases of child abuse.
H. Specific Fractures number of fractures that occur in motor-vehicle

1. Supracondylar humerus fractures—Supracon- accidents is very low.
dylar humerus fractures are most common
in the first decade of life, and their incidence III. General Fracture Management
peaks at age 7. A. Anatomic Features
2. Femoral fractures—Femoral fractures are most 1. Bone—Pediatric bone is more porous, is less
common up to age 3 years. dense (because of less mineralization), and
3. Physeal fractures—Physeal fractures are most has more vascular channels as compared with
common just before skeletal maturity. The per- adult bone.
centage of fractures that involve the physis is 2. Periosteum—A child’s periosteum is thicker
21.7%. and stronger than an adult’s. In the metaphy-
4. Long-bone fractures (Table 29-4) seal–epiphyseal region, the physis is stabilized
5. Specific fractures by anatomic site (Table 29-5) by the firm attachment of the periosteum.
6. Open fractures—The percentage of fractures 3. Other differences—The physis (growth plate)
in children that are open fractures is 2.9%. and the secondary ossification center (epiphy-
7. Multiple fractures—The percentage of chil- sis) are the other differences from adult bone.
dren with fractures that have multiple frac- B. Biomechanical Features
tures is 3.6%. 1. Bone—The modulus of elasticity of immature
I. Common Environments of Childhood Fractures— bone is lower than that of adult bone. There
The percentage of fractures that occur at home is greater plasticity of immature bone. Less en-
is 37%, that occur during sports is 18% to 20%, ergy is required to break immature bone. The
and that occur during school is 5% to 10%. The bones of children can fail in tension or com-
pression. Greenstick or incomplete fractures
occur only in immature skeletons; other pat-
TA B L E 2 9 - 4 terns of fractures include longitudinal, bowing,
torus (compression), and stress. Comminuted
Relative Frequency of Fractures of the Long Bones fracture patterns are less commonly seen
Long Bone Percentage because pediatric bone breaks with far less
Radius 45.1 energy applied.
Humerus 18.4 2. Epiphysis and physis—Epiphyseal fractures
Tibia 15.1
are rare in younger age groups, but as ossi-
fication occurs, epiphyseal fractures become
Clavicle 13.8
more common. Intra-articular fractures, joint
Femur 7.6 dislocations, and ligamentous disruptions
From Beaty J, Kasser J, eds. Rockwood and Wilkins’ Fractures are less common in children. The bone usu-
in Children. 6th ed. Philadelphia, PA: Lippincott Williams & ally fails before the soft tissues. Fractures that
Wilkins; 2006, with permission.
involve physeal separations or the metaphy-
seal region are common because these areas
are relatively weaker than the surrounding
ligaments.
TA B L E 2 9 - 5 C. Physiologic Features
Relative Frequency of Specific Fractures by 1. Healing—Children heal more rapidly than
Anatomic Site adults because of increased blood flow and
Anatomic Site Percentage
increased cellular activity. Some fractures can
be allowed to heal in an overlapped position
Distal radius (including physis) 23.3
because of the great remodeling potential
Hand 20.1 found in children.
Elbow 12.0 2. Periosteum—The periosteum has osteogenic
Radial Shaft 6.4 activity that leads to rapid healing. An intact
Tibial Shaft 6.2 periosteal tube can regenerate lost bone. Peri-
osteal damage or loss can lead to significant
Other 32.0
delays in fracture healing in children.
From Beaty J, Kasser J, eds. Rockwood and Wilkins’ Fractures 3. Healing rates and times—Younger children heal
Wilkins; 2006, with permission. faster than adolescents and adults. The heal-
ing rate is related to the area of bone injured.
Physeal injuries heal faster than metaphy- • Second zone—The second zone is the pro-
seal injuries, which heal faster than diaph- liferative zone and is where longitudinal
yseal injuries. Nonunion in children is rare. growth occurs by the stacking of chondro-
4. Remodeling—Perfect alignment is not neces- cytes on one another.
sary for good results in extraarticular fractures • Third zone—In the third zone (hypertro-
because of remodeling capabilities. Remodel- phic zone), chondrocytes hypertrophy as
ing potential depends on growth remaining they begin the transformation from carti-
(more time for remodeling) and the location lage to bone matrix. (They have a decreased
of the fracture. The capacity to remodel is ability to resist shear forces). The hypertro-
as follows: periphyseal better than me- phic zone may be divided into the zones of
taphyseal better than diaphyseal. Deformity maturation, degeneration, and provisional
is more acceptable in the plane of motion of calcification. The hypertrophic zone is
the adjacent joint. Remodeling potential is strengthened by the mineralization process
greatest in areas at the end of the bones that (zone of provisional calcification) but is still
contribute the most to longitudinal growth. weaker than the first two zones. Physeal
Significant remodeling may be expected to fractures tend to occur in the third zone.
occur in the proximal humerus (80% of longi- B. Statistics—The peak age of physeal injury is 11
tudinal growth), distal femur (70% of longitudi- to 12 years. Boys injure their physes twice as of-
nal growth), distal radius (75% of longitudinal ten as girls do. Only about 20% of all children’s
growth), and fractures of the elbow (which fractures involve the physis.
display less remodeling, so alignment must be C. Physeal Fractures
kept within a narrower threshold). In general, 1. Classification—The Salter-Harris classification
children younger than 10 years of age have a far is used (Fig. 29-2).
greater potential for remodeling than children 2. Treatment considerations
10 years or older have. In many anatomic sites, • Assessment—The fracture type must be
completely displaced and severely angulated properly identified. The fracture patterns
fractures in young children can heal without a that usually require operative intervention
functional deficit. However, accepting fracture (i.e., Tillaux fracture, triplane fracture) must
displacement in the young child must be tem- also be identified.
pered by parental concern regarding cosmetic • Technique—Repeated reduction attempts
deformity. may increase the incidence of growth
plate disturbance. Internal fixation
IV. Physeal Injury should not cross the physis whenever
A. Physeal Anatomy possible. The placement of compression
1. Growth—The physis contains cells respon- screws across epiphyseal fragments, par-
sible for the growth of long-bone and is lo- allel to the physis, is an effective means
cated at the end of all long bones. These cells of restoring stable articular congruity.
are oriented perpendicular to the long axis. When implants must cross the physis,
Longitudinal growth is the primary function the clinician should use the smallest pin
of the physis and occurs through the process feasible.
of enchondral bone formation. The periph- D. Physeal Arrest (Fig. 29-3)—Trauma is the most
ery of the physis also produces latitudinal common cause of physeal arrest. Arrest occurs
growth. when a bridge of bone (“bony bar”) forms be-
2. Relationship to the capsule—The physis and tween the metaphysis and the epiphysis. The
metaphysis of the proximal femur, proximal magnitude of the resultant deformity is deter-
humerus, radial neck, and distal fibula are mined by the remaining growth of the child as
within their respective joint capsules. In all well as the location of the bar.
other locations, the physis and metaphysis 1. Types
are extracapsular. • Partial arrest—Three different patterns of
3. Ultrastructure—There are three distinct partial physeal arrest may occur. Partial
zones of the physis (Fig. 29-1). physeal arrest is most commonly recog-
• First zone—The first zone has abundant nized on plain radiographs 3 to 6 months
cartilage matrix and is relatively strong. It after physeal injury. It may appear as a blur-
consists of the germinal or growth cells and ring and narrowing of the physis or as an
is known as the reserve zone. area of reactive bone condensation.
Articular cartilage
Epiphyseal growth plate

(poorly organized)
Secondary (epiphyseal)
ossification center
Epiphyseal artery Reserve zone
Proliferative zone
Ossification groove
Maturation zone
of Ranvier Hypertrophic
Degeneration zone zone
Perichondral fibrous
Zone of provisional
ring of La Croix
calcification
Perichondral artery
Primary spongiosa
Metaphysis
Last intact transverse Secondary spongiosa
cartilage septum
Periosteum
Metaphyseal artery
Diaphysis
Nutrient artery
FIGURE 29-1 Structure and blood supply of a typical growth plate. (Redrawn from The CIBA Collection of Medical
Illustrations, Vol 8, part 1, 1987. Illustrated by Frank H. Netter, with permission.)
(a) Peripheral bars—Peripheral bars pro- 2. Common areas for growth arrest—The most
duce an angular deformity; this is the common areas for growth arrest are the distal
most common pattern. femur, distal tibia, proximal tibia, and distal
(b) Central bars—Central bars result in radius.
tenting of the physis and epiphysis and 3. Diagnosis—MRI and CT imaging are useful for
lead to articular surface distortion. diagnosing a physeal arrest.
(c) Linear bars—Combined arrests (lin- 4. Treatment
ear bars) are often the result of a • Conversion of partial arrest into complete
Salter-Harris Type IV injury that has arrest—Partial physeal arrest can be con-
healed in a displaced position. Com- verted into a complete arrest to prevent fur-
bined arrests lead to articular incongru- ther angulation, but limb length discrepancy
ity and angular deformity. results if much skeletal growth remains.
• Complete arrest—Complete arrest is usually • Contralateral limb epiphysiodesis—Contra-
seen after a crush-type injury to the growth lateral limb epiphysiodesis is performed to
plate (Salter-Harris Type V injury). prevent possible limb length discrepancy
Type I Type II Type III Type IV Type V

FIGURE 29-2 Salter-Harris classification of physeal fractures. Type I, Transverse fracture through the physis. Type II,
Fracture through the physis with a metaphyseal (Thurston-Holland) fragment (arrow). Type III, Fracture through the
physis and into the epiphysis (intra-articular). Type IV, Fracture through the epiphysis, physis, and metaphysis. Type
V, Crush injury of the physis. (Redrawn from Salter RB, Harris WR. J Bone Joint Surg. 1963;45A:587–622. From Tachdjian
MO. Pediatric Orthopedics. 2nd ed. Vol 4. Philadelphia, PA: WB Saunders; 1990, with permission.)
or eliminate the need for lengthening of the (b) Central bars—The surgeon approaches
shortened (arrested) limb. through a metaphyseal window while
• Bar resection—If more than 2 years of preserving the periphery of the physis
growth remains and less than 30% to 50% of to maintain longitudinal growth.
the physis is damaged, bar resection can be • Results of treatment—Unfortunately, in-
considered. jured physeal plates tend to close prema-
• Surgical approaches turely, before the normal contralateral side,
(a) Peripheral bars—The overlying peri- despite the successful restoration of growth.
osteum is directly approached and ex- Bar recurrence and incomplete resection
cised, and abnormal bone is removed have been shown to be factors contributing
until normal physeal cartilage is uncov- to poor results.
ered. Interpositional material such as
fat or Cranioplast may be used to pre-
vent recurrence. Corrective osteotomies SUGGESTED READINGS
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of 1,025 open fractures of long bones: retrospective and pro-
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Hynes D, O’Brien T. Growth disturbance lines after injury
of the distal tibial physis: their significance in prognosis.
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growth plate. J Pediatr Orthop. 1981;1:3–11.
Lichtenburg R. A study of 2,532 fractures in children. Am J
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Salter R, Harris W. Injuries involving the epiphyseal plate.
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Cuff S, DiRusso, S, Sullivan T, et al. Validation of a relative Wareham K, Johansen A, Stone M, et al. Seasonal variation in
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Surg. 2003;138:142–145. paedics. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
CHAPTER 30
Pediatric Lower Extremity Injuries

Howard R. Epps
I. Introduction—Pediatric lower-extremity injuries high-energy trauma. The remaining 15% consist of

occur much less frequently than upper extremity in- pathologic fractures, usually through tumors. The

juries. Long-bone fractures occur after high-energy capital femoral epiphysis appears between 4 and
trauma such as motor-vehicle accidents and sports 6 months of age, and the physis fuses between 14
injuries or after simple falls in younger children. Un- and 16 years of age. The proximal femur con-
fortunately, child abuse may be the etiology, particu- tributes 13% of the length of the leg, or 3 to
larly in younger children. The clinician must always 4 mm per year. The blood supply is tenuous
consider this possibility. Sequelae of fractures, such and therefore susceptible to injury.
as growth arrest, leg length discrepancy, malunion, B. Evaluation—The child usually has hip pain and

neurovascular injury, and compartment syndrome, refuses to walk. If the fracture is displaced, the
can profoundly affect the child’s function. Attention leg may appear shortened and externally rotated.
to detail when managing lower-extremity injuries can Plain films are the best initial study. If plain films
lessen the frequency of these undesirable outcomes. are negative, a bone scan or magnetic resonance
Because lower-extremity fractures can result from imaging (MRI) can detect occult fractures.
high-energy trauma, the patient must have a system- C. Classification—The Delbet classification is most

atic evaluation. The primary survey is performed to commonly used (Fig. 30-1).
exclude life-threatening injuries and is followed by 1. Type I—Type I fractures (transepiphyseal frac-

the secondary survey. Management of specific mus- tures [transphyseal separations]) occur more
culoskeletal injuries depends largely on the age of the often in younger children. Some 50% are as-
patient and the associated injuries. sociated with hip dislocations. There is a high
Open fractures are irrigated and meticulously de- incidence of avascular necrosis (AVN), espe-
brided in the operating room before skeletal stabi- cially with dislocations.
lization. Prophylactic antibiotics are administered 2. Type II—Type II fractures (transcervical) are

in weight-appropriate doses. Tetanus prophylaxis the most common, representing 46% of pediat-
should be given if necessary. Depending on the ric hip fractures. The risk of AVN is related to
mechanical stability and extent of soft-tissue dam- the amount of initial displacement.

age, some fractures can be managed in a cast that is 3. Type III—Type III fractures (cervicotrochan-

windowed for wound care. External fixation, internal teric) represent 34% of hip fractures. A good
fixation, or traction is used for more extensive inju- outcome is likely if the fracture is not dis-
ries. As with adult patients, surgical (skeletal) stabi- placed. AVN is related to both fracture severity
lization is generally preferred in cases of pediatric and amount of initial displacement.
multiple trauma and in cases of head injury. 4. Type IV—Type IV fractures (intertrochanteric)

have the best prognosis. Complications are
II. Fractures of the Hip less common.

A. Overview—Hip fractures, defined as injuries to D. Treatment—Hip fractures, particularly displaced

the portion of the femur proximal to the lesser ones, require expeditious treatment. In general, in
trochanter, are rare. Such fractures represent addition to internal fixation, all fractures require
less than 1% of all pediatric fractures. Approxi- cast immobilization for at least 6 weeks if the
mately 85% of pediatric hip fractures result from child is younger than 10 years of age.
467
should be applied for 6 to 12 weeks for children

who require immobilization.
3. Type III fractures—Type III fractures also re-

quire an anatomic reduction and stable fixation.
Achieving anatomic reduction requires that an
anterolateral open reduction be performed if
necessary. The benefit of decompressing the
intracapsular hematoma is controversial, but
the procedure is advocated by some as a pos-
sible means of decreasing the risk of AVN.
4. Type IV fractures—Type IV fractures can usu-

ally be treated by closed techniques. Reduc-
tion can be achieved under anesthesia or with
Type I Type II
traction and followed by the application of an
abduction spica cast. If the fracture is irre-
ducible or unstable in a cast, internal fixation
should be used with a pediatric screw and side
plate system. In patients with multiple injuries,
Type IV fractures should be treated with open
reduction and internal fixation.
E. Complications

1. AVN—AVN is the most common complication,

occurring in 6% to 47% of cases. AVN usually
occurs during the first 12 to 24 months after
injury and is related to initial fracture dis-
placement with the consequent compromise
of blood supply. AVN has also been shown to be
associated with increasing age, time to reduc-
tion, and quality of reduction. The treatment
Type III Type IV of AVN of the pediatric hip is controversial but
FIGURE 30-1 Delbet classification of pediatric hip includes restricted weightbearing, bed rest,
soft-tissue releases, and containment. There

fractures. Type I, transepiphyseal fracture; Type II,
transcervical fracture; Type III, cervicotrochanteric are three types of AVN (Fig. 30-2).
fracture; Type IV, intertrochanteric fracture. • Type I involves the whole head. It has the

worst prognosis.
• Type II involves part of the head. The prog-

1. Type I fractures—Type I fractures should nosis is fair.

undergo a gentle closed reduction and inter- • Type III occurs from the fracture line to the

nal fixation. Fixation is achieved with smooth physis. The prognosis is good.
pins or with cannulated screws in older chil- 2. Coxa vara—The incidence of coxa vara after

dren. If the child is younger than 2 years of age, pediatric hip fractures ranges from 14% to 30%
reduction and spica cast immobilization with- but is consistently lower and even absent in
out internal fixation is a reasonable treatment series using internal fixation. Coxa vara re-
for stable fractures. With dislocations, a single sults from malunion, AVN, inadequate fixation,
attempt at closed reduction is warranted. If or partial physeal closure. Observation for
unsuccessful, open reduction should be per- 2 years is acceptable because the deformity of-
formed from the direction of the dislocation. ten remodels with time. If the neck-shaft angle
2. Type II fractures—Type II fractures require is less than 110° or the child is over 8 years of

anatomic reduction and stable fixation. A age, a subtrochanteric valgus osteotomy may

gentle closed reduction may be attempted. If be performed.
unsuccessful, an open reduction through an 3. Growth arrest—Growth arrest occurs when AVN

anterolateral approach should be performed. is present or when fixation necessitates cross-
Stable fixation is essential. Although the phy- ing the physis. Type II and III AVN most often

sis should be avoided, stable fixation takes lead to arrest. Leg length measurements and
precedence over protecting the physis. Casts bone age should be followed. Epiphysiodesis
C H A P T E R 3 0 | P E D I A T R I C L O W E R E X T R E M I T Y I N J U R I E S 469
FIGURE 30-2 Patterns of AVN of the pediatric

hip. A.Total involvement of the capital femoral
epiphysis, physis, and metaphysis (Type I).
B. Anterolateral involvement (Type II).
C. Metaphyseal involvement (Type III).
A B C
or lengthening may be performed if a large leg with cyclic loading. The differential diagnosis
length discrepancy is anticipated. includes a slipped capital femoral epiphysis,
4. Nonunion—Nonunion, an infrequent complica- synovitis, Perthes’ disease, avulsion fracture,

tion, has an incidence of 6% to 10%. An incom- and neoplasm. Plain films may be negative for
plete reduction is often the cause. As soon as several weeks; bone scan and MRI are there-
it is recognized, nonunion should be treated fore helpful for early diagnosis. Stress frac-
operatively with subtrochanteric valgus oste- tures occur in two types: tension fractures
otomy with or without bone graft. occur on the superior femoral neck, whereas
F. Special Considerations compression fractures occur on the inferior

1. Pathologic fractures (Fig. 30-3)—Fractures that femoral neck. Tension fractures are at risk

occur through benign or malignant tumors for displacement; therefore, internal fixation
pose difficult problems. The objective is man- is recommended. Compression fractures are
agement of the fracture concurrent with the more stable and can be managed with either
underlying problem if possible. In some cases,
the fracture must heal before tumor manage-
ment. A guide for management is outlined in
Table 30-1. TA B L E 3 0 - 1
2. Stress fractures—Stress fractures are rare but
Treatment for Fractures Associated with Tumors

can occur in children engaged in activities
and Tumor-like Lesions
Priority for Treatment Tumor or Tumor-like Lesion
Fracture (lesion may Nonossifying fibroma
heal spontaneously) Unicameral bone cyst
Eosinophilic granuloma
Fracture—then lesion Unicameral bone cyst
(if necessary) Aneurysmal bone cyst
Eosinophilic granuloma
Nonossifying fibroma
Fibrous dysplasia
Enchondroma
Chondromyxoid fibroma
Fracture and lesion Angiomas of bone
(simultaneous) Giant cell tumor

Malignant bone tumors
Lesion (fracture may Metastatic neuroblastoma
heal with lesional Leukemia
treatment) Selected malignant bone
tumors (chemosensitive)

FIGURE 30-3 Anteroposterior radiograph of the pelvis of
Source: From Green NE, Swiontkowski MF, eds. Skeletal

a 10-year-old girl shows a radiolucent lesion (aneurysmal Trauma in Children. 2nd ed. Philadelphia, PA: WB Saunders;
bone cyst) of the right proximal femur with a pathologic 1998, with permission.
femoral neck fracture.
restricted weightbearing or a spica cast in a injuries, open fractures, multiple trauma, and
less compliant patient. head injury require operative stabilization. In
3. Slipped capital femoral epiphysis—An general, isolated injuries in young children

unstable acute slipped capital femoral epiph- may be managed with an immediate spica

ysis presents similarly to a transepiphyseal cast; the injuries of children close to maturity are
fracture. Questioning may reveal a history of managed with locked intramedullary nails. For
chronic hip pain, knee pain, or a limp. Radio- children between 6 and 12 years, there is consid-
graphs of the hip may demonstrate remodel- erable controversy. All the techniques described
ing of the femoral neck in slips with a chronic have advocates and support in the literature.
component. Stable slips can be stabilized with 1. Immediate spica casting—Children younger

a cannulated screw inserted percutaneously. than 6 years or weighing less than 60 pounds
Displaced unstable slips should have a gentle with isolated closed injuries can be treated
reduction by traction or under anesthesia. The with an immediate spica cast. Single leg, one
femoral head is then stabilized internally in the and one half, and double leg spica casts have
chronic slip position. Another option is surgi- been reported. If there is more than 2 cm of
cal hip dislocation with anatomic restoration shortening, some recommend a brief period of
of alignment and internal fixation performed skin or skeletal traction before casting. Strict
by experienced hands. attention to detail is essential for immediate
spica casting. Length must be restored, and the
III. Fractures of the Femoral Shaft cast must be carefully molded to prevent late

A. Overview—Femoral shaft fractures, which oc- varus or recurvatum angulation. Radiographic

cur in the region between the lesser trochan- studies are done weekly for the first 2 to 3
ter and the supracondylar metaphysis, almost weeks to rule out loss of reduction and exces-
always unite. The challenge is achieving union sive shortening, which occur in approximately
with acceptable length, alignment, and rotation. 20% of cases. Loss of reduction may be cor-

Femoral fractures represent 1.6% of all pediatric rected with cast wedging or cast reapplication.
fractures and 7.6% of all pediatric long-bone frac- Children who develop unacceptable shorten-
tures. The incidence of child abuse, in children ing should be placed in skeletal traction until
with a femur fracture, approaches 80% in infants length is restored and then recasted. The cast
younger than walking age, and 30% in children is worn for 6 weeks.
younger than 4 years of age. Young children 2. Traction-delayed spica—Traction with de-

may sustain femoral fractures with simple falls, layed spica cast application yields uniformly
whereas older children may be involved in high- good results. The child is placed in skin or
energy trauma such as that from motor-vehicle skeletal traction for 2 to 3 weeks until the frac-
accidents. ture becomes more stable. Radiographs must
B. Evaluation—Most patients have severe pain be checked every few days for excessive short-

and are unable to walk. There may be obvious ening or over-distraction. A spica cast is then
deformity, swelling, tenderness, and crepitation. applied. The technique can present social (and

Isolated fractures do not cause hypotension. Chil- economic) difficulties because of the lengthy
dren with signs of hypovolemia should be care- hospitalization.
fully evaluated for additional injuries. Plain films 3. Locked intramedullary nail—The injuries of

are the preferred initial studies and should include adolescents close to maturity are managed like

the knee and hip to rule out other fractures. those of adults: with a rigid locked intramedul-
C. Classification—There is no formal classification lary nail. If the capital femoral physis is open,

system. Descriptors such as transverse, spiral, care should be taken to avoid the piriformis
oblique, segmental, comminuted, closed, and fossa when inserting the nail. Damage to the
open are used. lateral ascending arteries in the piriformis
D. Treatment—The management of pediatric fossa can cause AVN of the femoral head; a

femoral shaft fractures depends on many fac- more anterior or trochanteric starting point is

tors, including age, the mechanism of injury, as- therefore advised. Recently designed pediatric
sociated injuries, economic considerations, and nails avoid the piriformis fossa and the greater
psychosocial issues. The goal is to achieve bony trochanteric apophysis. The nail should not
union without excessive shortening or malalign- violate the distal femoral physis.
ment. Current trends attempt to avoid lengthy 4. External fixation—Unilateral external fixation

hospitalization. Fractures with neurovascular allows early mobilization. The fixator is applied

to the lateral side of the leg; full knee motion treated with lengthening and/or deformity
must be achieved while in the operating room. correction. Smaller projected discrepancies
The family must be vigilant about pin care be- without deformity are treated with epiphyse-
cause there is a high rate of pin tract infection. odesis (of the ipsilateral extremity in the case
Refracture is another complication. A total of of overgrowth and of the contralateral extremity
12 weeks may be required before adequate in the case of shortening).
bridging callus is present. Dynamization is im- 2. Angular deformity—Angular deformity frequen

portant and must be done early. tly occurs, and there are several recommen-
5. Flexible intramedullary nails—Flexible intra- dations for acceptable amounts of deformity.

medullary nails (Enders, Nancy) allow early Femoral shaft fractures remodel considerably in
mobilization and therefore avoid the problems younger children. Lateral view angulation of 30°
of prolonged traction and casting. The nails is acceptable in children younger than 2 years,
may be inserted in a retrograde fashion; the but the limit decreases to 10° in children 11 years
starting point is proximal to the distal femoral and older. In the coronal plane, valgus angulation
physis. The nails may also be inserted in an is better tolerated in general than varus angula-
antegrade fashion; the starting point is distal tion. Anteroposterior (AP) view angulation of
to the greater trochanter. A second operation 20° to 30° is acceptable in infants, 15° in children
is necessary to remove the nails after fracture younger than 5 years, 10° up to 10 years of age,
healing. With titanium nails, poor outcomes and 5° in children 11 years and older.
have been associated with age greater than 3. Rotational malunion—Rotational malunion oc-

11 years, weight greater than 49 kg, and commi- curs in up to one third of children. There is less
nution or long oblique fracture patterns. Stain- remodeling potential than with angular deformi-
less steel nails had fewer complications than ties, but up to 30° of malrotation is usually well
titanium nails in one series. tolerated in children. Derotation osteotomy
6. Compression plates—Compression plating is corrects malunions that require intervention.

technically simple, convenient for the family, 4. Neurovascular injuries—Neurovascular inju-

and conducive to early mobilization. It requires ries are rare, occurring in less than 2% of fem-
large incisions, extensive dissection, and pro- oral shaft fractures. Fractures with vascular
tected weightbearing after insertion. Plate injuries should be stabilized rapidly, followed
removal is mandatory, and protected weight- by vessel repair. Most nerve injuries associ-
bearing is continued for 6 weeks. ated with the fracture spontaneously recover.
7. Submuscular bridge plates—Submuscular plat- 5. Compartment syndrome—compartment syn-

ing provides all the advantages of compression drome can occur after application of a 90/90
plating, with less dissection, scarring, blood spica cast. Application of the short leg portion
loss, and more rapid healing. The technique of the cast first with subsequent application of
is particularly advantageous for comminuted traction is believed to be the etiology.
fractures that are not amenable to treatment F. Special Considerations

with other types of fixation. Achieving an 1. Floating-knee injuries—defined by fractures of

acceptable reduction is critical before applying the femur and the ipsilateral tibia, are usually

the plate percutaneously. The plate can then high-energy injuries. Most authors agree that
be secured with regular or locking screws, the at least one of the fractures should be man-
latter providing greater stability. aged operatively.
E. Complications 2. Stress fractures—stress fractures of the femo-

1. Leg length discrepancy—Leg length discrep- ral diaphysis are rare in children. The history

ancy is the most common complication. It of an increase in activity may not be present.
can be secondary to fracture union in a short- Radiographs may be normal, or show perios-
ened position or limb overgrowth. Overgrowth teal new bone suggestive of a neoplasm. MRI is
is poorly understood, but it occurs in children helpful in making the diagnosis.
between 2 and 10 years of age during the first
2 years after injury. The amount of overgrowth IV. Fractures of the Distal Femoral Metaphysis and

ranges from 0.5 to 2.5 cm. Leg lengths should Epiphysis
be followed for at least 2 years after the union A. Overview—The distal femoral physis is the larg-

of a pediatric femoral shaft fracture. Projected est and fastest growing in the body. It is respon-
shortening discrepancies greater than 6 cm sible for 70% of the femoral length and 37% of the
or those with significant deformity can be leg length. It grows approximately 1 cm a year,
fusing between 14 and 16 years of age in girls and usually occur with high-energy injuries in
16 and 18 years in boys. Because the physis un- younger children. The risk is greater if fracture
dulates, an accurate reduction is important for displacement is greater than 50% of the width
preventing physeal bar formation in displaced of the bone. Treatment options are those that
fractures. Fractures involving the distal femoral are standard for leg length discrepancy.
physis are relatively uncommon, representing 2. Angular deformity—Angular deformity (in-

only 7% of all physeal fractures. Injuries usu- cidence, 24%) occurs most frequently after
ally result from sports or motor vehicle ac- Salter-Harris Type II fractures. It is usually
cidents. The fracture typically occurs during due to direct physeal injury on the side of the
periods of rapid growth such as the adolescent physis opposite the metaphyseal spike. Man-
growth spurt. In children before walking age, agement may include epiphysiodesis or osteot-
there is a strong association between complete omy depending on the child’s age. The former
fractures and child abuse. is performed when a child is close to the end
B. Evaluation—The child has an acute onset of pain of growth.

and is usually unable to walk. The thigh may be an- 3. Physeal bars—Physeal bars can be assessed

gulated or shortened. The knee is tender, with an with tomograms or computed tomograms
effusion and ecchymosis. Careful attention to the (CT) to determine the size. Bars measuring
neurovascular examination is essential for ruling less than 50% of the physeal area can be
out an associated injury. AP and lateral plain films resected, with fat interposition. Resection is
are the best initial studies. Oblique films may de- contraindicated if the patient has fewer than
tect a fracture if the initial films are negative. Gen- 2 years of growth remaining. Extensive bars
tle-stress views or an MRI can be used for difficult in children near skeletal maturity can be
cases. treated with epiphysiodesis of the unin-
C. Classification—The Salter-Harris classification, jured leg.

although not prognostic, is most commonly 4. Neurovascular injuries—Neurovascular inju-

used. Salter-Harris Types I and II fractures have a ries (incidence, 2%) are rare and usually result
more frequent incidence of growth disturbance. from hyperextension injuries. The popliteal ar-
The most important prognostic factors are the tery is injured with anterior displacement, and
magnitude of displacement, age, adequacy of the peroneal nerve is injured with varus angula-
reduction, and severity of trauma. tion. Fractures with suspected neurovascu-

D. Treatment—Nondisplaced fractures should be lar injuries should be reduced emergently

stabilized percutaneously with smooth pins with prompt reassessment of vascular sta-
because of the high risk of displacement. Dis- tus. If the vascular supply is restored, the pa-
placed Salter-Harris Types I and II fractures re- tient should be observed for 48 to 72 hours to
quire reduction and percutaneous fixation. The rule out an intimal tear with thrombosis. If the
reduction maneuver is primarily traction with fracture is irreducible, an open reduction is
gentle manipulation. Percutaneous fixation is performed through a posteromedial approach,
performed with either smooth wires or screws, and the neurovascular structures are directly
followed by a cast for 6 weeks with the knee in assessed.
10° of flexion. Anatomic reduction is desirable. In 5. Extension contracture of the knee—Extension

children near maturity, up to 5° of varus or valgus contracture of the knee rarely follows severe
angulation is acceptable. In children younger than supracondylar femur fractures. Cases fail-
10 years, 20° of posterior angulation is acceptable. ing rehabilitation are managed with Judet
Displaced Salter-Harris Types III and IV fractures quadricepsplasty.
necessitate anatomic reduction with internal fixa-
tion by closed or open methods. Fixation is ac- V. Fractures of the Intercondylar Eminence

complished with screws followed by a cast for 6 A. Overview—The intercondylar eminence lies be-

weeks. Pathologic fractures through benign le- tween the anterior horns of the menisci. Fractures
sions should receive standard fracture care, of the intercondylar eminence are most common
with management of the neoplasm secondarily in children between 8 and 14 years of age. Injuries
after healing. occur after hyperextension of the knee, a fall from
E. Complications a bicycle or motorbike, or a direct blow to the

1. Leg length discrepancy—Leg length discrep- knee.

ancy is the most common complication (32%). B. Evaluation—The child typically has pain, an

The age at injury is important; discrepancies effusion in the knee, and an inability to bear
weight. An aggressive examination should be vascularized at birth. With maturation, the vas-
avoided before radiographic studies to pre- cular supply to the inner two thirds diminishes.
vent displacement of the fragment. AP and lat- The discoid meniscus is an uncommon congeni-
eral plain films are the best diagnostic studies; tal anomaly occurring in 3% to 5% of the popu-
the most useful information is obtained from lation. Meniscal tears are rare in prepubescent
the lateral view. Stress views can be added if children unless a discoid meniscus is present.
an associated physeal or ligamentous injury is Injuries occur primarily in adolescents.
suspected. B. Evaluation—The child typically complains of

C. Classification—The Myers and McKeever classifi- activity-related pain, possibly mechanical symp-

cation is standard (Fig. 30-4). toms. Acutely the child may have an effusion
1. Type I—Type I is nondisplaced. of the knee, but it usually develops over a few

2. Type II—Type II is one-third to one-half dis- hours after injury. There may be joint-line ten-

placed and is hinged. derness, or the results of McMurray’s test may
3. Type III—Type III is completely displaced. be positive. Plain films should be done to rule

D. Treatment—For Types I and II fractures, first out osteochondritis dissecans or a loose body.

the hemarthrosis is aspirated. The knee is hy- MRI is the test of choice.
perextended to reduce the fragment, and a long C. Classification—Injuries are classified by the

leg cast in 10° to 15° of flexion is worn for 4 to anatomy of the tear: radial, flap, longitudinal,
6 weeks. Irreducible Type II and III fractures may horizontal cleavage, and bucket handle.
have a meniscus blocking reduction. Reduction is D. Associated Injuries—Associated injuries include

performed open or with arthroscopic assistance. cruciate ligament tears.
Fragment fixation should be done with absorbable E.
Treatment—In children, some meniscal tears
sutures in young children. In older children, non- can be managed nonoperatively. Indications for
absorbable sutures or an intraepiphyseal screw is nonoperative management are tears 10 mm or
used. smaller in the outer 30% of the meniscus, ra-
E. Complications—Loss of knee extension occurs in dial tears smaller than 3 mm, and stable partial

up to 60% of cases but is rarely a functional prob- tears. Cast immobilization is required for 6 to
lem. Anterior laxity of the knee occurs in 75% of 8 weeks. Tears requiring surgical treatment are
cases, probably as a result of plastic deformation managed by partial meniscectomy or repair. Re-
of the anterior cruciate ligament (ACL) before pair is considered if the tear is located in the
fracture. Patients generally have good outcomes outer 10% to 30% of the meniscus, displaced less
despite residual laxity. than 3 mm, and lacking a complex component.

VI. Meniscal Injuries VII. Ligamentous Injuries of the Knee

A. Overview—The menisci are semilunar cartilagi- A. Overview—The exact incidence of ligamentous

nous cushions in the medial and lateral com- tears in children is unknown, but is thought to
partment of the knee. They are completely be increasing. Studies suggest that roughly 4%
FIGURE 30-4 Myers and McKeever

classification of intercondylar eminence fractures.
Type I, Nondisplaced. Type II, Displaced with a
posterior hinge. Type III, Completely displaced.
of all ACL tears occur in skeletally immature may be present if there is a meniscal injury.
patients. Injuries of the posterior cruciate liga- Plain films are obtained first to rule out a bony
ment (PCL) and the collateral ligaments are avulsion fracture. MRI is the best test for detect-
less common. Both the ACL and the PCL origi- ing purely ligamentous injuries.
nate from the intercondylar notch. The ACL C. Classification

inserts anterior to the tibial spine, whereas 1. First-degree sprain—First-degree sprain

the PCL inserts on the posterior aspect of the involves tenderness without instability.
tibial epiphysis. The medial collateral ligament 2. Second-degree sprain—Second-degree sprain

(MCL) and lateral collateral ligament (LCL) involves loss of function without instability.
originate from the distal femoral epiphysis and 3. Third-degree sprain—Third-degree sprain

insert onto the proximal tibia epiphysis and involves complete rupture with instability.

metaphysis and the fibular epiphysis, respec- D. Associated Injuries—Associated injuries include

tively. ACL tears result from hyperextension, other ligamentous tears.
sudden deceleration, or valgus and rotation E. Treatment

forces with a planted foot. PCL ruptures result 1. ACL tears—Before the management plan is

from hyperextension or forceful posterior dis- determined, many factors must be consid-
placement of the tibia with the foot planted. ered: the patient’s age, skeletal maturity,
Ligamentous injuries in young children usually and the expectations of function after treat-
result from multiple trauma. ment. Studies suggest that children treated
B. Evaluation—The patient is often unable to walk. nonoperatively have greater difficulty re-

The knee usually has a large effusion unless the turning to their previous level of function;
capsule has been disrupted. There is significant there is a high incidence of subsequent
muscle spasm. Lachman’s test may be positive meniscal injuries, chondral injuries, and
with ACL tears, although it is difficult to dem- episodes of instability. Intra-articular surgi-
onstrate acutely secondary to pain. The best cal reconstruction necessitates violating the
test for acute PCL tears is the quadriceps active physis, particularly if the surgeon attempts
test (Fig. 30-5). The collateral ligaments should to achieve isometric placement of the graft.
be palpated at the origins and insertions. Varus Extra-articular reconstruction avoids the
and valgus stability should be checked in full physis, but the techniques preclude isomet-
extension and 30° of flexion and then compared ric graft placement. Nonoperative treatment

with the uninjured side. Joint-line tenderness consists of bracing, rehabilitation, and activ-
ity limitation. This approach is particularly
desirable in younger children and is used as
a method to delay surgery until skeletal ma-
turity. Operative intra-articular techniques
include reconstruction with hamstrings or
the middle third of the patellar tendon. ACL
reconstruction using the patellar tendon is
done only in adolescents close to maturity to
avoid epiphysiodesis. Several extra-articular
techniques have been described, but none
are isometric. ACL tears with MCL injuries in
adolescents can be treated with delayed ACL
reconstruction after treatment with a hinged

knee brace.
2. PCL tears—PCL tears should be managed

with hinged knee braces for 6 weeks. Surgi-
cal management of PCL tears in children is
controversial. No long-term data exist dem-
onstrating that surgical reconstruction is
FIGURE 30-5 Quadriceps active test. The knee is flexed
superior to rehabilitation. PCL disruptions

to 90°. Slight resistance is applied to the foot. The patient
then contracts the quadriceps muscle, which pulls the with bony fragments can be secured with
tibia anteriorly from its resting, posteriorly subluxed screws.
position to a neutral but not an anteriorly displaced 3. Collateral ligament sprains—First- and sec-

position. ond-degree collateral ligament sprains may
be treated with hinged knee braces for 1

to 3 weeks. Complete disruptions require
6 weeks in hinged braces. Third-degree
sprains combined with ACL injuries should
be surgically repaired. Injuries with bony
fragments off the tibia or femur may be
fixed with screws.
F. Complications—Knee instability, meniscal

injuries, and neurovascular injuries are the

most common complications of ligamentous in-
juries of the knee.
G. Special Considerations—Knee dislocations are

characterized by extensive ligamentous injury.
Usually, both cruciate ligaments are disrupted,
and the collateral ligaments may also be in-
volved. The popliteal artery may be damaged.
Fortunately, the injury is unusual in children
because such trauma is more likely to cause
physeal fractures. The child with a knee dis-
location should have a careful neurovascular
examination followed by emergent reduction.
The vascular supply should be closely fol-
FIGURE 30-6 Sleeve fracture of the patella.
lowed after reduction for 48 to 72 hours. Dis-

locations in younger children can be managed
in a long leg cast for 6 weeks, after the acute
swelling has subsided. The injuries of children (Fig. 30-6) is another variant; it is defined by a
close to maturity are managed like those of small, visible bony fragment with a large portion

adults: with repair of the collateral ligaments of the cartilaginous articular surface attached.
and reconstruction of the cruciate ligaments as D. Treatment—The objective of treatment is res-

indicated. toration of the extensor mechanism and the
articular surface. If there is less than 3 mm of
VIII. Fractures of the Patella displacement and active knee extension is pos-

A. Overview—The patella is the largest sesamoid sible, the child can be immobilized in a cylin-

bone. The secondary center of ossification ap- der cast for 4 to 6 weeks. Displaced fractures
pears between 3 and 6 years of age. There may require open reduction and internal fixation.
be up to six ossification centers, which ordinar- Several techniques have been described for fix-
ily coalesce. The bipartite patella is a normal ation, including a wire loop, tension band wir-
variant (0.2% to 6%) resulting from incomplete ing, nonabsorbable sutures through drill holes,
coalescence. The line of demarcation is usually and screws. Displaced fractures at the margins
superolateral, and fractures may occur through can be excised.
this junction. Pediatric patellar fractures are E. Complications—Most complications result from

uncommon because of the high ratio of carti- improper restoration of the normal anatomic re-
lage to bone, increased patellar mobility, and lationships. Extensor lag, patella alta, and quad-
soft-tissue resilience. Fractures result from a di- riceps atrophy have been reported.
rect blow to the patella or a forceful contraction
of the extensor mechanism. Over half of patel- IX. Patellar Dislocation

lar fractures in children occur in motor vehicle A. Overview—Dislocation of the patella is a rela-

accidents. tively common injury in children and occurs
B. Evaluation—The child has a tender, swollen more frequently in girls. Up to 60% of patients

knee with an effusion. If the fracture is displaced, develop recurrent dislocation. The Q angle is the
active knee extension is impossible. Plain films angle subtended by lines from the anterosuperior
of the knee demonstrate most fractures. iliac spine to the center of the patella and from
C. Classification—Patellar fractures are classi- the center of the patella to the tibial tubercle.

fied by the fracture pattern: transverse, longi- Patients with recurrent patellar dislocation typi-
tudinal, or comminuted. The sleeve fracture cally have a larger than normal Q angle. Injuries
usually occur during sports, commonly from a lateral retinacular release with or without medial
twisting force with the foot planted. imbrication, semitendinosus tenodesis, medial
B. Evaluation—Many dislocations reduce spontane- transfer of the lateral half of the patellar tendon

ously or with extension of the knee before the (RouxGoldthwait), or medial transfer of the tibial
child seeks medical attention. The patient, how- tubercle (Elmslie-Trillat). The latter is only done
ever, can often describe the dislocation. The knee when the physis is closed.
is swollen and diffusely tender around the patella. G. Special Considerations—Habitual dislocation

A large effusion may be present. Ligamentous in- of the patella is an atraumatic condition char-
juries and physeal fractures should be excluded. acterized by painless dislocation whenever the
Plain radiographs should be obtained to identify knee is flexed. Management requires quadriceps
possible osteochondral fractures of the patella or lengthening proximal to the patella and lysis of
the femoral condyles. If an osteochondral fracture adhesions.
is the suspected but only a small ossified fragment
is seen, MRI helps demonstrate the actual size. X. Fractures of the Tibial Tubercle

C. Classification—Injuries are classified by the A. Overview—The tibial tubercle, where the patel-

direction of displacement: lateral, medial, or in- lar tendon inserts, is the most anterior and distal

tra-articular. The majority are lateral. portion of the proximal tibia epiphysis. Active
D. Associated Injuries—Associated injuries include children older than 8 years frequently develop

osteochondral fractures of the patella or femur. pain in this area, a condition called Osgood-
E. Treatment—The hemarthrosis should be aspi- Schlatter disease. Superficial microfractures

rated for pain relief and inspected for fat drop- of the cartilage at the insertion of the tendon
lets. The latter suggest an osteochondral fracture, cause the syndrome. Failure of cartilage deeper
which may be primarily cartilaginous and not to the secondary centers of ossification results
visualized on radiographs. Simple dislocations in tibial tubercle fractures. Injuries usually result
should be immobilized in a cylinder cast or knee from jumping or a rapid quadriceps contraction
immobilizer for 4 weeks, followed by a rehabili- against a flexed knee. Adolescents most com-
tation program. Osteochondral fragments can be monly sustain the fracture.
removed with the arthroscope. Particularly large B. Evaluation—Children have pain, swelling, and

fragments can be repaired open, with either Her- tenderness over the tibial tubercle. With undis-
bert screws or countersunk minifragment screws. placed fractures, there may not be an effusion,
F. Complications—Recurrent dislocation and in- and the child is capable of limited active knee

stability are the most common complications. extension. Displaced fractures render active knee
Deficiency of the vastus medialis obliquus, extension impossible; an effusion is present, and
patellofemoral dysplasia, and increased Q-angle the fragment is often palpable. Plain films, par-
predispose patients to instability. Aggressive re- ticularly the lateral view, demonstrate the injury.
habilitation of the vastus medialis obliquus and C. Classification—Ogden has described a classifica-

the quadriceps is the first approach. Several pro- tion system, based on the location of the fracture
cedures are described for those in whom non- line (Fig. 30-7). In Type I fractures, the fracture
operative management has failed. Options are line crosses the secondary center of ossification
FIGURE 30-7 Classification of tibial tubercle

fractures in children. Type I, fracture through
the secondary center of ossification; Type II,
fracture through the junction of the primary
and secondary centers of ossification; Type III,
intra-articular fracture.
of the tibial tubercle. The fracture line exits more compromise should be urgently reduced and the
proximally in Type II fractures, between the cen- vascular status reassessed. If the fracture is irre-
ters of ossification for the tibial tubercle and the ducible or a vascular injury is present, open re-
proximal tibial epiphysis. Type III fractures have duction is mandatory. After reduction, the safest
intra-articular involvement. course is to splint the leg in 10° to 20° of flexion;
D. Treatment—Nondisplaced Type I fractures can a cast should be applied only when the risk of

be immobilized in a long leg cast in extension for compartment syndrome has decreased.
4 to 6 weeks. Displaced Type I fractures and Type F. Complications—Complications include knee in-

II and III fractures require open reduction and instability, leg length discrepancy, arterial injury,
ternal fixation with screws and washers. Postop- and nerve injury. (Peroneal nerve injury is most
erative immobilization is used for 4 to 6 weeks. common.)
E. Complications—Genu recurvatum can occur

late after the injury from an anterior growth XII. Fractures of the Shaft of the Tibia and Fibula

arrest. Compartment syndrome can occur due A. Overview—The tibial shaft, defined by the

to tearing of the anterior tibial recurrent ves- region between the proximal and distal physes,

sels, which retract into the anterior compartment is the third most common long bone fractured
when torn. in children. Fractures may result from either
indirect or direct trauma. Injury may follow a
XI. Fractures of the Proximal Tibial Epiphysis low-energy fall in a young child or higher-energy

A. Overview—These fractures are uncommon, trauma. Approximately 10% of tibial fractures

comprising only 3% of epiphyseal injuries of are open. The four compartments of the leg
the lower extremity. The physis is infrequently (anterior, lateral, posterior superficial, and pos-
injured because few ligaments attach to the terior deep) are at risk for developing an acute
epiphysis. The proximal tibial epiphysis appears compartment syndrome.
during the first 3 months of life, and the second- B. Evaluation—The child may have pain and swell-

ary center of ossification of the tibial tubercle ap- ing, but deformity is less common because the
pears at 8 years. Ossification does not reach the fibula is frequently uninjured. Young children may
intercondylar eminence until adolescence. The simply stop walking. Point tenderness may be
proximal tibial physis provides 55% of the length the only physical finding in this group. The skin
of the tibia, 25% of the entire length of the limb, should be carefully inspected for lacerations, and
or roughly 0.6 cm per year. The popliteal artery the neurovascular status of the lower extremity
lies close to the epiphysis in the popliteal fossa, should be documented. Orthogonal plain films
becoming tethered as the anterior tibial artery are the preferred first studies, although oblique
courses into the anterior compartment. The ar- views may be helpful in young children whose ini-
tery is at risk for injury with displaced proximal tial radiographs reveal no problems. The fracture
tibia fractures. may be invisible in toddlers and infants. A bone
B. Evaluation—The child has pain, swelling, de- scan may be used if the diagnosis is equivocal.

creased knee range of motion, and sometimes C. Classification—No formal classification system

a visible deformity. A careful neurovascular as- exists. Injuries are grouped by anatomic loca-
sessment should be performed, especially with tion: proximal metaphysis, diaphysis, and distal
displaced fractures. AP and lateral plain films metaphysis.
are the recommended initial studies, followed D. Treatment

by oblique or stress views if necessary. An ar- 1. Proximal metaphyseal fractures—Proximal

teriogram should be done if a vascular injury is metaphyseal fractures are potentially trou-
suspected. blesome because of the poorly understood
C. Classification—The Salter-Harris classification is complication of late valgus alignment.

used. There are several theories for the patho-
D. Associated Injuries—Associated injuries include genesis of the valgus deformity (Table 30-

popliteal artery and peroneal nerve injury. 2). The deformity occurs within 6 months
E. Treatment—Salter-Harris Types I and II fractures and is largest 2 years after the injury. After

require closed reduction followed by immobiliza- the fracture, any valgus angulation should
tion for 4 to 6 weeks. Closed reduction and fixa- be corrected before casting. If soft-tissue
tion with percutaneous pins or cannulated screws interposition prevents the correction of val-
is recommended for Salter-Harris Type III and IV gus malalignment, open reduction is neces-
fractures. Displaced fractures with vascular sary. A long leg cast should be molded into
maintain alignment. A shorter cast with the

TA B L E 3 0 - 2 foot in neutral position may be applied later
Theories of the Pathogenesis of Valgus Deformity to allow weightbearing for the remainder of
after Proximal Tibia Fracture in Children fracture healing.
Asymmetric physeal growth
E. Complications

1. Compartment syndrome—Compartment
Tethering effect of the fibula

syndrome is a potentially devastating com-
Poor reduction plication that can accompany both closed
Soft-tissue interposition and open fractures. The complication re-
Early weightbearing sults from increased pressure in the fascial
Hypertrophic callus
compartments of the leg, ultimately leading
to irreversible nerve and muscle damage if
Lateral physeal injury
not treated early. A high index of suspicion
Dynamic muscle action is essential, particularly in patients who
may have difficulty verbalizing their symp-
toms. Poorly controlled pain is the earli-
est sign; it is accompanied by increased
varus and worn for 4 to 6 weeks. Alignment is discomfort during passive stretch of mus-
followed with weekly radiographs for the first cles in the involved compartments. Split-

few weeks; any loss of reduction should be ting the cast and underlying padding may
corrected. Some authors also restrict early reduce pressures by 50%. Compartment
weightbearing. pressures should be measured and fas-
2. Closed diaphyseal fractures—Closed diaphy- ciotomies performed if indicated. A two-

seal fractures can almost always be managed incision, four-compartment fasciotomy is
nonoperatively. Angular and rotational defor- recommended; partial fibulectomy has been
mity should be corrected and a long leg cast described as a method of decompressing all
applied. If present, associated plastic defor- four compartments of the leg but can lead
mation of the fibula should be corrected to to a valgus deformity in children and should
prevent recurrent deformity. Radiographs not be performed.
are obtained weekly for the first few weeks to 2. Delayed union or nonunion—Delayed union

monitor the reduction, and the cast is wedged or nonunion, defined by failure to heal within
if necessary. Acceptable alignment is greater 6 months, is unusual. The mean time for
than 50% of fragment apposition, less than healing is 10 weeks in closed fractures and
10° of angulation seen on AP and lateral ra- 5 months in open fractures. Severe open in-
diographs, less than 20° of rotation, and less juries are the ones most likely to result in de-
than 1 cm of shortening. Isolated fractures layed and nonunion. Iliac crest bone grafting
of the tibia tend toward varus malalignment. is usually successful in healing the nonunion
Fractures that fail closed management are in children.
stabilized operatively. 3. Angular deformity—Angular deformity may

3. Open fractures—Open fractures are managed result from poor alignment or overgrowth.

according to the principles of all open frac- Valgus deformity from fractures of the proxi-
tures. Immobilization can be achieved with a mal tibia metaphysis frequently corrects
windowed cast in stable low-energy injuries. spontaneously over several years. Observa-
External fixation, smooth pins, or limited in- tion is recommended. Varus osteotomy per-
ternal fixation are used in fractures with more formed close to maturity corrects severe
extensive soft-tissue damage. Soft-tissue cov- valgus deformities that fail to resolve.
erage should be accomplished within 7 days. 4. Rotational deformity—Rotational deformity

Use of subatmospheric pressure dressings results from inadequate reduction and does
can decrease the need for free tissue transfer not spontaneously correct. If the deformity
for coverage. exceeds 20°, rotational osteotomy may be
4. Distal metaphyseal fractures—Distal metaph- necessary.

yseal fractures frequently malalign in recur- 5. Proximal tibial physeal closure—Proximal

vatum as a result of impaction of the anterior tibial physeal closure is a rare complication
cortex. After closed reduction, a long leg cast that causes a genu recurvatum deformity.
is applied with the foot in plantar flexion to It occurs gradually over the first few years
after injury and is corrected with an opening cortical lucency on radiographs. If plain films
wedge osteotomy. are negative, MRI or a bone scan is diagnos-
6. Leg length discrepancy—Leg length discrep- tic. Activity restriction or casting for 2 to

ancy may occur but it is less of a problem 4 weeks is usually sufficient.
than with femur fractures. Overgrowth is usu- 4. Child abuse—Child abuse must always be

ally the cause. Treatment options are those considered. The tibia is the third most com-
that are standard for leg length discrepancy. monly fractured long bone with child abuse.
F. Special Considerations Corner or bucket-handle metaphyseal frac-

1. Toddler’s fractures—Toddler’s fractures are tures are pathognomonic for child abuse

isolated, oblique, distal tibia fractures that (Fig. 30-8).
occur after low-energy trauma in young chil- 5. Congenital pseudoarthrosis of the tibia—

dren. The fall is often unwitnessed; the child Congenital pseudoarthrosis of the tibia is a
may simply stop ambulating. Swelling, defor- rare condition characterized by abnormal
mity, and ecchymosis are usually absent on bone that is at risk for fracture. The condi-
examination. Point tenderness may be the tion is frequently associated with neurofi-
only sign. The appearance of plain films may bromatosis. The tibia is usually tapered and
be normal. The first evidence of fracture may has sclerosis and cysts. An anterolateral bow
be periosteal bone formation seen on X-ray is typical. If the child comes to medical at-
film 10 days after injury. A short leg cast for tention before fracture, indefinite bracing is
4 weeks is sufficient treatment. recommended. After the bone has fractured,
2. Bicycle spoke injuries—Bicycle spoke inju- union is extremely difficult to achieve. Intra-

ries occur when the foot of a child riding on medullary fixation with bone graft, vascular-
the back of a bicycle catches in the wheel. ized fibula grafts, and resection with bone
The injury may seem innocuous, but exten- transport have been reported.
sive soft-tissue injury may manifest over the 6. Isolated fractures of the fibular diaphysis—

first 48 hours. The child should be admitted Isolated fractures of the fibular diaphysis
for bedrest, elevation, and serial examina- occur after direct trauma to the leg. Immobi-
tions of the soft tissues. Surgical debride- lization is all that is necessary for treatment.
ment may be necessary as the zone of injury 7. Proximal tibia–fibular joint dislocations—

demarcates. Proximal tibia–fibular joint dislocations
3. Stress fractures—Stress fractures occur in are rare injuries, and over 30% are initially

children participating in activities to which missed. Displacement is anterolateral, pos-
they are not accustomed. The most frequent teromedial, or superior. There may be an
sites are the posteromedial and postero- associated proximal tibia fracture or knee lig-
lateral aspects of the proximal tibia. Point ament injury. Reduction and immobilization
tenderness is present, and there may be a in a cylinder cast is recommended.
FIGURE 30-8 Metaphyseal avulsion fractures

occurring at the junction of the metaphysis and the
physis seen in child abuse. The injuries are caused
by sudden twisting of the limb. The fracture may be
a simple corner fracture (left) or a so-called bucket-
handle fracture (right).
Epiphyseal
ossification
center
Physis
XIII. Fractures of the Ankle developed for adult injuries. Tachdjian and Dias

1. Overview—Approximately 10% to 25% of all modified this classification for pediatric injuries

physeal fractures occur around the ankle. The (Fig. 30-9).
deltoid ligament and the three lateral ligaments 4. Treatment—Ankle fracture treatment depends on

are less likely to fail than the growth plates. In- the age of the patient and the extent of the injury.
juries usually result from indirect forces. The Most authors feel that a maximum of 2 mm of in-
distal tibia physis begins to close at 12 years in tra-articular displacement is acceptable, although
girls and 13 years in boys. Closure occurs over anatomic restoration of the joint surface is ideal.
18 months. The physis closes in the central por- The mechanism of injury classification guides the
tion earliest, followed by the medial portion, reduction maneuver. Because the injuries involve
and finally the lateral portion. This progression the physis, forceful repeated attempts at reduc-
explains the unique Tillaux and triplane injuries tion should be avoided. Open reduction follows
seen in adolescents. if closed attempts fail. Immobilization in a short-
2. Evaluation—The child often has difficulty de- or long-leg cast depends on fracture stability, the

scribing the exact mechanism of injury. The presence or absence of internal fixation, and the
injury is characterized by pain, swelling, ten- reliability of the patient and family.
derness, and sometimes a deformity. AP, lateral, • Salter-Harris Type I distal tibia fractures—

and mortise radiographic views adequately Salter-Harris Type I distal tibia fractures can
demonstrate most injuries. CT scanning is help- be immobilized in a short leg walking cast for
ful for precisely delineating complex patterns 4 to 6 weeks if nondisplaced. Malrotation of
and intra-articular fractures. the foot is frequently overlooked with this
3. Classification—Ankle fractures are usually clas- injury. Displaced fractures are reduced and

sified by anatomic pattern or mechanism of in- placed in a long leg cast for 3 weeks, followed
jury. The Salter-Harris classification describes by a short leg walking cast.
the anatomic patterns of injury sufficiently. The • Salter-Harris Type II distal tibia fractures—

Lauge-Hansen mechanism of injury system was Salter-Harris Type II distal tibia fractures
A. Supination- B. Pronation- C. Supination- D. Supination-

inversion eversion-external rotation plantar flexion external rotation
FIGURE 30-9 Tachdjian-Dias classification of pediatric ankle fractures. A. Supination-inversion. B. Pronation–eversion–

external rotation. C. Supination–plantar flexion. D. Supination–external rotation.
are the most common type and are usually

associated with a fibular fracture. A closed re-

duction is performed, attempting to achieve
less than 5° of varus or valgus angulation. A
long leg cast is worn for 2 weeks, followed by
a short leg walking cast until union.
• Salter-Harris Type III and IV distal tibia frac-
3

tures—Salter-Harris Types III and IV distal
tibia fractures may be treated by closed
means if undisplaced. Fractures that can be 1
2
reduced to less than 2 mm of displacement
may be treated closed as well. Percutaneous
fixation with pins or cannulated screws can
supplement casting. Irreducible fractures
require open reduction and internal fixation.

• Salter-Harris Type V distal tibia fractures— Juvenile Tillaux Triplane

Salter-Harris Type V distal tibia fractures, FIGURE 30-10 Special types of ankle fractures that

which are extremely rare, are diagnosed ret- occur in adolescents include the juvenile Tillaux
rospectively. There are no formal recommen- and Triplane. Note the three fragments involved in
dations for treatment. the Triplane fracture: 1, anterolateral physis (Salter-Harris
• Tillaux fractures—Tillaux fractures (Fig. 30-10) Type III); 2, remaining physis (Salter-Harris Type IV); 3,

are Salter-Harris Type III fractures caused by tibial metaphysis.
an external rotation force in a child close
to maturity. In a small percentage of cases,
significant deformity at the end of growth, a
closed reduction can be achieved by inter-
supramalleolar osteotomy is performed.
nal rotation of the foot and direct pressure
• Growth arrest—Growth arrest is most com-
over the fragment. The adequacy of reduc-

mon with Salter-Harris Types III and IV
tion should be confirmed by a CT scan. The
fractures. For Salter-Harris Type I and II
6 weeks of immobilization is divided equally
fractures, premature physeal closure may
between long and short leg casts. Irreduc-
be related to interposition of periosteum.
ible fractures require open reduction with
Physeal bars can be resected with fat in-
internal fixation to restore joint congruity.
terposition and combined with a corrective

• Triplane fractures—Triplane fractures (see
osteotomy.

Fig. 30-10) are multiplanar, Salter-Harris
• Arthritis
Type IV injuries also occurring near maturity.

The exact anatomic structures are often dif- XIV. Injuries of the Foot—Foot injuries usually result

ficult to visualize; CT scanning helps assess from direct trauma. In young children, the bones
displacement and plan surgery if needed. Less are primarily cartilaginous and therefore pliable
than 2 mm of displacement must be achieved and less susceptible to fracture. Ossification is
by closed or open means. Open reduction variable in pattern, but progression with growth
may require two approaches or a transfibu- makes fractures more common with age. The foot
lar approach. The posteromedial fragment is consists of 26 bones plus the sesamoids. The talus
generally reduced first, followed by the intra and calcaneus make up the hindfoot; the navicular,
articular fragment. cuneiforms, and cuboid make up the midfoot; and
• Salter-Harris Type I fractures of the distal the metatarsals and phalanges make up the fore-

fibula—Salter-Harris Type I fractures of the foot. Over half of the entire length of the foot is

distal fibula are common in children. Up to 50% achieved by age 2 years, leaving less potential for
displacement is acceptable. Immobilization in remodeling with growth.
a short leg walking cast or a removable ankle A. Talus Fractures

brace for 4 weeks is adequate. The removable 1. Overview—Talus fractures usually result from

brace has been shown to hasten functional re- forced dorsiflexion of the foot, sometimes
covery and is better tolerated by families. combined with inversion or eversion. The in-
5. Complications jury is rare in children. The blood supply is

• Malunion—Malunion occurs if an ankle frac- precarious as in adults, and AVN may follow

ture is inadequately reduced. If there is a displaced fractures. In younger children, the
blood supply is less dependent on a single B. Calcaneus Fractures

system, but this changes with growth. 1. Overview—The calcaneus is the largest bone

2.
Evaluation—The child has pain, swelling, in the foot and the earliest to ossify. Frac-
tenderness, and difficulty bearing weight. Ra- tures are fairly common, but diagnosis is dif-
diographs of the foot demonstrate the injury. ficult and frequently delayed. Most authors
3. Classification—Talus fractures can be classi- report that the clinical course is benign, par-

fied according to Hawkins, as in adults. ticularly in young children.
4. Treatment—Nondisplaced fractures are 2. Evaluation—A history of a fall is common.

treated with a nonweightbearing cast for The foot may be swollen and tender. The ex-
6 to 8 weeks, followed by a weightbearing act area of tenderness is frequently difficult
cast for 2 weeks. A closed reduction may to locate. The appearance of radiographs is
be attempted for displaced fractures; up to often normal. Initial studies should include
5 mm of displacement may be accepted. Oth- lateral, axial, and dorsoplantar views. Intra-
erwise, open reduction with internal fixation articular depression is best judged on the
is recommended. Postoperative immobiliza- lateral view. If there is a significant intra-ar-
tion is similar to that for nondisplaced frac- ticular injury, a CT scan should be performed
tures. All talus fractures should be monitored as well.
with periodic radiographs to rule out AVN. 3. Classification—Injuries are classified as by

5. Complications—AVN is the most serious Rowe (Table 30-3).

complication following a talus fracture. It 4. Treatment—The majority of calcaneus frac-

usually occurs during the first 6 months after tures in children may be treated in a cast.
injury. Hawkins’ sign, a subchondral lucency Outcomes are always good for extra-articular

visualized on plain films, signifies an intact fractures. Intra-articular displacement fre-
blood supply to the body of the talus. The quently remodels over time, particularly in
absence of Hawkins’ sign, however, does not young children. Weightbearing in the cast
indicate AVN in children. Authors therefore depends on the surgeon’s preference. Older
recommend MRI to screen for AVN. AVN is children and adolescents have less poten-
difficult to treat. Nonweightbearing in a pa- tial for remodeling. Significantly displaced
tellar tendon-bearing articulated orthosis is intra-articular fractures should be reduced
recommended until revascularization, which percutaneously or open and should be stabi-
may take years, occurs. lized. Weightbearing is usually avoided for at
6. Special considerations

• Lateral and medial talar process frac-

tures—Lateral and medial talar process
TA B L E 3 0 - 3
fractures are tender beneath the malleoli
on examination. Immobilization with avoid- Calcaneal Fracture Patterns
ance of weightbearing is recommended. Type Description
• Osteochondral fractures—Osteochondral 1 Fracture of the tuberosity

fractures result from plantar flexion or Fracture of the sustentaculum tali
dorsiflexion combined with inversion. Pos-
Fracture of the anterior process
teromedial fragments are more common
than posterolateral fragments. MRI pro- 2 “Beak” fracture
vides the most information. Undisplaced Avulsion fracture of the insertion of the
fragments may be treated in a cast. There achilles tendon
are four stages. 3 Oblique fracture in the posterior portion not
(a) Stage I involves subchondral involving the subtalar joint (corresponds to a

compression. metaphyseal fracture of a longitudinal bone)
(b) Stage II involves a partially detached 4 Fracture involving the subtalar region with or

fragment. without actual articular involvement
(c) Stage III involves a completely de- 5 Central depression with varying degrees of

tached fragment remaining in its cra- comminution
ter fragment. 6 Involvement of the secondary ossification center
(d) Stage IV lesions should be surgically
Source: From Rowe CR, Sakellandes HT, Freeman AT, et al.

excised with drilling or curettage of JAMA. 1963;184:920–923, with permission.
the crater.
least 6 weeks with displaced intra-articular and oblique radiographs allow the clinician to
fractures. make the diagnosis. The lateral view is essen-
5. Associated injuries—Lumbar spine injuries tial for excluding plantar flexion of the distal

are associated with calcaneus fractures, par- fragment. Fractures of the second, third and
ticularly after falls from a height. Some rec- fourth metatarsals are frequently associated
ommend a lumbar spine series in all patients with additional metatarsal fractures.
with displaced intra-articular fractures. 3. Classification—There is no specific classifi-

C. Navicular Injuries—Injury of the navicular is cation system.

unusual, but a dorsal chip fracture is the most 4. Treatment—Most metatarsal fractures heal

common type. Cast immobilization is suffi- uneventfully in a short leg weightbearing
cient. Stress fractures of the navicular bone, cast. Lateral angulation or translation does
which can occur in adolescents, are a more dif- not affect outcome. Plantar displacement
ficult problem. Immobilization in a nonweight- should be corrected because metatarsalgia
bearing cast for 6 to 8 weeks is recommended. can ensue. If reduction is necessary, finger-
The accessory navicular bone is a normal vari- trap traction or open reduction is performed.
ant occurring in up to 15% of the population. Smooth wires are suitable for fixation if nec-
The fibrocartilaginous junction can fracture, essary. In cases with significant swelling, the
causing medial foot pain. A total of 4 weeks possibility of compartment syndrome should
in a short leg cast cures the problem. Surgery be considered.
should be considered only after conservative 5. Special considerations

measures fail. • Avulsion fractures—Avulsion fractures of

D. Injuries of the Tarsometatarsal Joints the base of the fifth metatarsal are com-

1. Overview—Injuries of the tarsometatarsal mon. The injury is hypothesized to be

joints or Lisfranc’s joint result from direct or secondary to pull of the peroneus brevis
indirect trauma. The injury follows an impact or the abductor digiti minimi. Usually, lo-
while on tiptoe, heel-to-toe compression, or a cal pain and tenderness occur, but the ap-
fall backward while the foot is fixed. The sec- pearance of radiographs may be normal.
ond tarsometatarsal joint is a true mortise, The apophysis of the metatarsal, or os
which provides stability for the other rays. vesalianum, is present between 8 and 12
2. Evaluation—Patients have pain, swelling, and to 15 years. It should not be confused with

difficulty bearing weight. The involved joints a fracture. A short leg walking cast for 3 to
are tender. Plain films are recommended. 6 weeks is curative.
The oblique view assesses the joints, and the • Jones fractures—Fractures at the metaph-

lateral view excludes dorsal dislocation. yseal-diaphyseal junction of the fifth meta-
3. Classification—Classification is by Hardcastle, tarsal, or Jones fractures, are problematic.

as with adults. Most represent chronic stress fractures
4. Treatment—Nondisplaced injuries are man- and must be managed more aggressively.

aged in a short leg cast. Displaced fractures Jones fractures may have antecedent pain.
are reduced closed or open and fixed with Sclerosis of the medullary cavity may be
threaded pins or screws. present on radiographs. The best results
5. Complications—Angular deformity can be a are with intramedullary screw fixation or

complication. open bone grafting.
E. Metatarsal Fractures F. Phalangeal Fractures

1. Overview—Metatarsal fractures are com- 1. Overview—Fractures of the phalanges are

mon injuries that result from direct or indi- fairly common in children and usually result
rect trauma. Injuries occur most frequently from direct trauma. The proximal phalanx
at the metatarsal neck because the diameter is most frequently injured. The majority of
is smallest. Children under 5 years most these injuries heal without complication.
commonly fracture the first metatarsal, usu- 2. Evaluation—Patients have pain and swell-

ally after a fall from a height. Children over ing and may also have a visible deformity.
5 years fracture the fifth metatarsal most Plain films are sufficient for making the
often, and sustain the injury most commonly diagnosis.

from a fall on a level surface. 3. Classification—There is no classification

2. Evaluation—Patients have pain, swelling, system, although the Salter-Harris system

difficulty bearing weight, and tenderness. AP applies to physeal injuries.

4. Treatment—Nondisplaced fractures can common; the latter is most characteristic

be managed with buddy taping and a hard- when the nail has punctured through the
soled shoe. Displaced fractures can be re- sole of a sneaker. Initial management af-
duced with traction and then buddy taped. ter the injury includes debridement of the
Displaced Salter-Harris fractures of the distal skin, irrigation, and tetanus prophylaxis.
phalanx should be carefully evaluated. Often No data support routine prophylactic anti-
the nail bed is disrupted; thus the frac- biotic coverage. If pain does not subside af-
ture is open. Irrigation and debridement, ter 2 or 3 days, warm soaks, elevation, and
antibiotics, and nail bed repair are neces- oral antistaphylococcal antibiotic coverage
sary. A pin is sometimes used to counteract are started. Injuries not responding to this
the long flexors pulling the distal fragment regimen require surgical debridement and
into flexion. intravenous antibiotics. Pseudomonas osteo-
G. Special Considerations myelitis always requires aggressive surgical

1. Lawn-mower injuries—Lawn-mower injuries debridement and parenteral antibiotics for

are severe crush injuries to the lower ex- eradication. Sometimes a piece of shoe is
tremity that are usually grossly contami- found during wound debridement.
nated. Aggressive irrigation and debridement 5. Metatarsophalangeal and interphalangeal

must be performed every 2 to 3 days until joint dislocations—Metatarsophalangeal and
the wound is clean and all tissue is viable. interphalangeal joint dislocations are rare.
Antibiotic prophylaxis requires a cephalo- Reduction and buddy taping for 3 weeks are
sporin, aminoglycoside, and penicillin. The adequate.
challenge is deciding between amputation 6. Cuboid and cuneiform fractures—Fractures

and salvage, but waiting until the wound has of the cuboid and cuneiforms are generally
been adequately debrided over a few days is treated with cast immobilization.
a judicious approach. Salvage requires soft- 7. Heel pain—Sever’s disease is the most com-

tissue coverage by a skin graft or free mus- mon cause of foot pain in active children. It
cle flap. Amputation rates in most series represents an overuse syndrome of the cal-
approach 70%. caneal apophysis. Treatment includes heel

2. Tendon lacerations—Tendon lacerations cups, Achilles stretching, the application

usually follow a benign course in children. of ice, activity modification, and the admin-
The Achilles, tibialis anterior, and tibialis istration of nonsteroidal antiinflammatory
posterior tendons should be repaired to medications.
prevent secondary deformity. The lesser
tendons may be managed by casting in a po- XV. Traumatic Amputations—Traumatic amputations

sition that minimizes stress on the injured most often result when children play around trains,
tendon. farm equipment, and other heavy machinery. Acute
3. Compartment syndrome—Compartment sy surgical amputation is indicated for Type IIIC open

ndrome should be considered in any child fractures with unreconstructible nerve or vessel in-
with extensive swelling of the foot, particu- juries. The limb should be irrigated and debrided of
larly after crush injuries. Unrecognized, it all devitalized tissue. Care should be taken to pre-
causes a clawed foot. One sign of compart- serve as much length as possible. Soft-tissue cover-
ment syndrome is pain that worsens with age is performed when the tissue bed is healthy.
passive stretch of the muscles of the af- With amputations around the foot, residual muscle
fected compartment. Compartment pres- imbalance may necessitate tendon transfers to pre-
sures should be measured and fasciotomies vent late deformity. Stump overgrowth is a com-
performed if indicated. There are nine common complication of traumatic amputations.
partments in the foot, but all can be reached Below-the-knee amputations overgrow more fre-
through two dorsal incisions plus one medial quently than above the-knee amputations.
incision.
4. Puncture wounds of the foot—Puncture

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CHAPTER 31
Pediatric Upper Extremity Injuries

Brian E. Grottkau and Umesh S. Metkar
I. Scapular Fractures—Fractures of the body of the views with weights (for suspected lateral
scapula in children occur infrequently, result from fractures) may be helpful.
high-energy trauma, and are often associated with 3. Associated injuries—Associated injuries are
concomitant injuries of the thorax and chest. Treat- uncommon and are primarily neurovascular.
ment is generally nonsurgical (except for open inju- Venous distention, absent pulses or numb-
ries) and consists of an arm sling and range of motion ness should be evaluated. Concomitant ob-
exercises of the shoulder to decrease stiffness. stetric brachial plexus palsies can occur in the
newborn.
II. Injuries of the Clavicle and the Sternoclavicular and 4. Treatment—The primary purpose of the clav-
Acromioclavicular Joints icle is to connect the trunk to the shoulder
A. Clavicle—The clavicle is the first bone to ossify in girdle. Because of the excellent healing and
the human embryo and one of the last to fuse its remodeling potential in children, open surgi-
epiphyses to its diaphysis. The medial epiphysis cal treatment of clavicle fractures is rarely
ossifies at 12 to 19 years of age and fuses at 22 to indicated with the exception of open fractures,
25 years of age. The lateral epiphysis fuses to the fractures with severe tenting of the skin that
diaphysis at 19 years of age, is thin and difficult may become open and fractures associated
to see on plain radiographs. with neurovascular compromise. Parents
1. Mechanisms of injury—The clavicle is the should be warned about a visible residual
most frequently fractured bone in children. bump of healing callus at the fracture site that
Fractures are generally caused by a direct will likely persist over time. Most fractures re-
blow, a fall on the point of the shoulder or out- quire simple immobilization of the shoulder
stretched arm or during delivery. girdle. This can generally be accomplished
2. Evaluation with a Velpeau sling or shoulder immobilizer
• Physical examination—In the newborn, the in children and adolescents. In neonates, the
fracture may present only as pseudoparal- affected extremity should be bound to the tho-
ysis of the upper extremity. This must be rax by safety pinning the arm of the onesie to
distinguished from a brachial plexus palsy. the vest of the onsie or by fashioning a custom
The fracture may not be apparent on plain immobilizer out of stockinette.
radiographs until callus appears 1 to 2 weeks 5. Complications—Cosmetic bump.
after injury. Other findings may include those 6. Differential diagnoses
seen in toddlers and children including crepi- • Congenital pseudoarthrosis of the clavicle
tation, swelling, point tenderness, decreased usually occurs on the right side except in
shoulder motion, and the head turning away newborns with situs inversus. There will be
from the fracture. no history of trauma.
• Imaging—Anteroposterior (AP) and 30° ce- • Cleidocranial Dysostosis affects the clavi-
phalic tilt radiographs (serendipity view) cle and other bones of intramembranous
can be obtained. If inconclusive, computed ossification including the skull, mandible,
tomographic (CT) scan, tomograms or stress and vertebrae.
487
B. Sternoclavicular Joint—The clavicle articulates thereby distracting, while simultaneously

medially with the sternum and the first rib. Inju- grasping the medial clavicle percutaneously
ries in this region in children are usually Salter- with a pointed reduction forceps or towel clip
Harris Types I or II physeal fractures rather than under a general anesthetic. Some advocate hav-
true joint dislocations. Posterior displacement of ing a pediatric or vascular surgeon available in
the medial clavicle can cause impingement on the case the displacement is tamponading a vessel.
innominate artery and vein, vagus and phrenic Open reduction is reserved for symptomatic ir-
nerves, trachea, esophagus and/or brachial reducible posteriorly displaced injuries and is
plexus. Anterior displacement is more common. rarely required.
1. Evaluation C. Acromioclavicular Joint—Injuries of the acromio-
• Physical examination—A lump or depres- clavicular joint in children are usually fractures,
sion at the sternoclavicular joint may be evi- not dislocations. The coracoclavicular and acro-
dent with tenderness, possible hoarseness, mioclavicular ligaments remain attached to the
dyspnea, dysphasia, diminished affected up- thick periosteal sleeve.
per extremity pulses or venous engorgement 1. Classification (Dameron and Rockwood)
of the extremity. (Fig. 31-1)
• Imaging—On Serendipity view, posteriorly • Type I—Mild sprain without periosteal disrup-
displaced separation will appear more caution.
dad and anterior displacement will appear • Type II—Partial disruption of the dorsal
more cephalad. Because the medial epiphy- periosteal tube with some distal clavicle
sis may not ossify until 19 years of age, CT instability.
scan may be required to adequately visualize • Type III—Large longitudinal dorsal split in
the bony anatomy. the periosteum with gross instability.
2. Treatment—Anterior sternoclavicular injuries • Type IV—Similar to Type III; the distal clavi-
generally require only symptomatic treatment cle is displaced posteriorly and buttonholed
with sling and swathe due to excellent remod- through the trapezius.
eling potential. Asymptomatic posteriorly dis- • Type V—Complete dorsal periosteal split
placed injuries are closed reduced by placing with superior subcutaneous displacement
a blanket roll longitudinally between the shoul- through the deltoid and trapezius.
der blades and placing posteriorly directed • Type VI—Inferior dislocation of the distal
pressure on the lateral clavicle or shoulder clavicle beneath the coracoid.

FIGURE 31-1 Acromioclavicular
separation in children (Dameron
and Rockwood classification).
Type IV Type V Type VI
C H A P T E R 3 1 | P E D I A T R I C U P P E R E X T R E M I T Y I N J U R I E S 489
2. Evaluation—Serendipity and AP radiographs radiographs. Because the proximal epiphy-

or a CT scan can be obtained; stress views sis does not ossify until 6 months of age,
may be required due to bony overlap on the newborn physeal separations may appear
AP radiograph. as an abnormal relationship between the
3. Treatment—Closed treatment with sling and scapula and humerus on plain radiographs.
swathe for Types I and II. Open reduction is Ultrasonography is beneficial in these pa-
indicated for Types III to VI in adolescents. tients. Pathologic fractures through bone
cysts can be confirmed by MRI.
III. Injuries of the Humerus and Glenohumeral Joint 4. Treatment—Most proximal humerus fractures
A. Glenohumeral Dislocations—Glenohumeral dis- can be treated by closed means. Eighty per-
locations are uncommon in children but appear cent of the longitudinal growth of the humerus
to be increasing with increasing sports participa- comes from the proximal physis resulting in
tion. Treatment is similar to that for adults. The significant remodeling potential. In addition,
two primary predictors of recurrent dislocation the large range of motion of the shoulder joint
are (a) number of prior dislocations and (b) age allows for minimal loss of function despite
at first dislocation. Recurrence in children is very nonanatomic reduction. Acceptable limits of
common. reduction in adolescent proximal humeral frac-
B. Proximal Humerus Fractures—Fractures of the tures include angulation of 35° and bayonet
proximal humeral physis occur most commonly in apposition. If the displacement exceeds these
adolescents secondary to high-energy sports partic- recommendations, closed reduction should
ipation and a weak perichondrial ring; in newborns, be attempted. The shoulder should be immo-
this injury most often results from a complicated bilized in a shoulder immobilizer if stable, in
delivery or child abuse. The distal fragment nor- a spica cast in the “salute position,” or with
mally displaces anteriorly and laterally because of percutaneous pinning. Open reduction may
the strong posteromedial periosteum; the proximal be needed in severely displaced fractures and
fragment flexes, abducts, and externally rotates. in open fractures. Common impediments to
Salter I and II fractures and fractures of the proxi- closed reduction include the biceps tendon
mal humerus metaphysis occur most commonly and periosteum. If no reduction is required, the
between 5 and 12 years of age. Pathologic fractures extremity should be immobilized in a sling and
may occur secondary to unicameral bone cysts of swathe, or stockinette in newborns and infants,
the proximal humeral metaphysis. as previously described for obstetric clavicle
1. Mechanism of injury—Mechanisms of injury fractures. Minimally displaced pathologic frac-
to the proximal humerus include birth trauma tures through cysts are initially treated symp-
(usually Salter I) and falls on an outstretched tomatically with a sling. Latent and active cysts
arm (usually Salter I or II or metaphyseal). are treated with serial aspiration and steroid
2. Classification injections or bone marrow injection until they
• Neer and Horwitz classification—based on resolve. Curettage and bone grafting results in
displacement. more reliable healing but may lead to growth
(a) Grade I—displaced less than 5 mm arrest in active cysts.
(b) Grade II—displaced at least one-third of 5. Complications—Complications include growth
the shaft width arrest, diminished shoulder motion, malunion,
(c) Grade III—displaced at least two-thirds recurrence of a cyst, and refracture.
of the shaft width C. Humeral Shaft Fractures—Fractures of the hu-
(d) Grade IV—displaced more than two- meral shaft are uncommon. Fractures involving
thirds of the shaft width the proximal and distal metaphyses are more
• Pathologic fractures—Primarily occur through common.
simple bone cysts of the proximal metaphysis. 1. Incidence—Humeral shaft fractures occur
Active cysts are within 1 cm of the physis and more commonly in infants and toddlers and in
latent cysts are greater than 1 cm from the adolescents older than 12 years.
physis. 2. Mechanism of injury—Pediatric humeral shaft
3. Evaluation fractures may result from birth trauma, tor-
• Physical examination—Pseudoparalysis, ten- sional forces (child abuse), direct trauma, falls,
derness, swelling, and pain may be present. or from throwing activities.
• Imaging—Fractures with or without dis- 3. Evaluation—In newborns or infants, irrita-
placement are frequently seen on plain bility and pseudoparalysis may be the only
indicators of a recent fracture. The only physi-

cal finding may be a palpable lump that mani-
fests 7 to 10 days after the initial injury. In a
child or toddler, there may be pain, swelling,
and an inability to use the extremity. Although
most of these fractures result from accidental
trauma, other evidence of child abuse should
be sought if there is a suspicion of nonacci-
dental trauma. Fractures of the humeral shaft
can also occur through areas of compromised
5-8
bone strength such as a cyst, nonossifying
fibroma or other lesions. De novo spiral frac- 7-9
8-11
tures of the humerus can occur in adolescent
throwing athletes. The fracture is typically
9-13
long, and the degree of displacement is small 7-11
1-11 months
due to a thick periosteum.
8-13
4. Treatment 1-26 months
• Infants and children—A shoulder immobi-
lizer, sling and swathe, or hanging arm cast
is usually sufficient. Skeletal traction is rarely FIGURE 31-2 Age of appearance of the ossification
indicated. All states mandate reporting of sus- centers around the elbow.
pected child abuse by attending physicians,
residents, physician assistants, and nurses.
• Adolescents—Nonsurgical treatment includ-
ing functional bracing, hanging arm cast, or
coaptation splinting should allow for accept-
able healing in the vast majority of cases
including fractures resulting from throwing.
Open treatment including plating or intra-
medullary nailing is rarely indicated unless
an acceptable closed reduction is not achiev-
able or in multitrauma patients. Frequently,
unacceptably angulated and displaced hu-
meral shaft fractures will reduce to an ac-
ceptable position over the course of one
week as the muscle spasm relaxes secondary
to gravity and a sling or coaptation splint.
5. Complications
• Overgrowth—Mild overgrowth occurs in
80% of humeral shaft fractures in children A B
but is rarely significant.
• Radial nerve injury—Radial nerve injuries FIGURE 31-3 Radiographic lines for the evaluation of
may occur with fractures at the junction of pediatric elbow injuries. A line drawn along the long axis of
the middle 1/3 and distal 1/3, but are infre- the proximal radius should bisect the capitellum on both
quent. Radial nerve dysfunction that is pres- the AP (A) and lateral (B) views. A line drawn along the
anterior cortex of the distal humerus on the lateral view
ent initially after injury should be observed
(B) (anterior humeral line) should bisect the capitellum.
for recovery on physical examination (likely
Disruption of these normal radiographic relationships
a stretch injury). Nerve dysfunction that oc- is suggestive of injury. (Reprinted with permission from
curs only following attempted closed reduc- Brinker MR, Miller MD. Fundamentals of Orthopaedics.
tion may prompt consideration for surgical Philadelphia, PA: WB Saunders, 1999, with permission.)
exploration of the radial nerve (possible en-
trapment). These guidelines remain contro-
A. Transphyseal Fractures (Distal Humeral Physeal
versial, however.
Separation) (see Fig. 31-6)
IV. Injuries of the Elbow Region (Figs. 31-2 Through 1. Incidence—Transphyseal fractures generally
31-10) occur in children 3 years old and younger.
2. Mechanism of injury—Transphyseal fractures • Type B—A Salter I or II fracture with a small

occur as a result of a fall on an outstretched fleck of lateral metaphysis generally occurring
arm or from birth trauma but may occur sec- between the ages of 7 months and 3 years.
ondary to child abuse in up to 50% of children • Type C—A fracture that includes a large
under 2 years of age. metaphyseal fragment (Salter II) either me-
3. Classification (DeLee) dially or laterally, and generally occurring
• Type A—A Salter I fracture occurring before between ages 3 and 7 years.
ossification of the lateral condyle epiphysis, 4. Evaluation
usually before age 1 year. • Physical examination—This injury should
be suspected in any infant with a swollen
elbow and irritability. This fracture has a
larger surface area than the comparable
supracondylar humerus fracture, and so ro-
tation and angulation tend to be less. This
injury must be differentiated from an elbow
dislocation.
• Imaging—the proximal radius and ulna are
in anatomic relationship with each other but
tend to displace posteromedially with lend
respect to the distal humerus. The key to
distinguishing this injury from an elbow
dislocation is maintenance of the radial
head–capitellar relationship (see Fig. 31-5).
In children younger than 3 years of age, the
capitellum may not be ossified making the di-
agnosis difficult. An ultrasound, a MRI, or an
arthrogram may be required.
5. Treatment—Closed reduction and percutane-
ous smooth K-wire fixation (see technique for
supracondylar humerus fractures) diminishes
the occurrence of cubitus varus that has been
reported following closed reduction and cast
FIGURE 31-4 Posterior fat-pad sign (arrow) suggests the immobilization, especially in patients younger
presence of an intra-articular effusion and fracture of than 2 years of age. The arm should be im-
the elbow. (Reprinted with permission from Brinker MR, mobilized in a long arm cast postoperatively.
Miller MD. Fundamentals of orthopaedics. Philadelphia, Open reduction is rarely required. Healing nor-
PA: WB Saunders, 1999, with permission.) mally occurs by 3 weeks.
A B C D E
FIGURE 31-5 Radiocapitellar relationships. A. Normal elbow in which the long axis of the radius extends into
the center of capitellum. B. Separation of the entire distal humeral physis (transphyseal fracture) in which
the radiocapitellar relationship remains intact but the ossification center of the capitellum is posteromedial to the
metaphysis of the distal humerus. C. Supracondylar fracture in which the radiocapitellar relationship is maintained.
D. Fracture of the lateral condyle in which the capitellum is lateral to the long axis of the radius. E. Dislocation of
the elbow in which the long axis of the radius is lateral to the capitellum.
Type A: 0-12 months Type B: 1-3 years Type C: 3-7 years
No ossification of Ossification of the lateral Ossification of the lateral

the lateral condyle, condyle, can be SH I condyle, usually SH II
usually SH I or SH II with a small with a large metaphyseal
metaphyseal fragment fragment
FIGURE 31-6 Transphyseal fractures of the distal humerus (DeLee classification): Type A, Type B, and Type C fractures.
6. Complications—Neurovascular injuries are • Flexion injuries—Flexion supracondylar

less common than in supracondylar humerus fractures are caused by a fall on the poste-
fractures. Cubitus varus occurs following rior aspect of a flexed elbow.
closed reduction and long arm cast immobi- 3. Classification (Gartland)
lization and is diminished with percutaneous • Type I—Nondisplaced or minimally displaced
pin fixation. Avascular necrosis has also been • Type II—Displaced but with an intact poste-
reported. rior cortical hinge
B. Supracondylar Humerus Fractures (see Fig. 31-5) • Type III—Completely displaced without cor-
1. Incidence—Supracondylar humerus fractures tical contact
most commonly occur between 3 and 10 years 4. Evaluation
of age. They are responsible for 50% to 70% of • Physical examination—Patients with Type I
elbow fractures in children. They occur more or II fractures will complain of pain in the
frequently in boys than in girls. Injuries on the elbow especially with attempts at range of
left side are more common than on the right. motion. Swelling is usually evident but may
2. Mechanisms of injury be minimal. In Type III fractures, there may
• Extension injuries—Represent approxi- be an obvious S-shaped deformity with sig-
mately 95% of supracondylar fractures. nificant amounts of swelling and ecchymo-
They are caused by a fall on an outstretched sis. Puckering of the anterior skin generally
arm with the elbow in hyperextension. indicates severe displacement with fracture
Posteromedial displacement occurs in ap- penetration into the subcutaneous tissues.
proximately 75% while posterolateral dis- This may evolve into an open fracture. De-
placement occurs in approximately 25%. tailed neurologic examination is required as
The articulating surfaces of the distal hu- there is a 10% to 15% incidence of neurologic
merus are connected to the shaft through injury. In addition, there is a 5% incidence of
a medial and lateral column. These two col- concomitant ipsilateral fracture, usually of
umns are separated by a thin area of bone the distal radius.
formed anteriorly by the coronoid fossa and • Imaging—AP and lateral elbow views should
posteriorly by the olecranon fossa. This be obtained. The lateral should be obtained
area is vulnerable to fracture when forced in external rotation, as these fractures most
into hyperextension with the olecranon act- frequently are unstable in internal rotation.
ing as a fulcrum. On the lateral X-ray, the anterior humeral line
(a line extending distally from the anterior displacement. Ulnar nerve injuries can oc-
humeral cortex) should intersect the middle cur with flexion supracondylar fractures but
third of the capitellum (see Fig. 31-3). Com- more commonly occur iatrogenically as a
parison views of the opposite elbow can also result of medial pin placement.
be obtained. Multidetector CT (MDCT) scan- 6. Treatment—There are no standard guidelines
ning can be obtained in the presence of a pos- for the amount of displacement and angula-
itive posterior fat pad sign (see Fig. 31-4), pain tion acceptable for a supracondylar humerus
with range of motion, and a history of trauma fracture.
if no fracture is readily identified. The scan • Extension injuries
can be obtained in a cast with comparable ra- (a) Type I—These nondisplaced or mini-
diation exposure to a standard elbow series mally displaced fractures require long
(minimal scatter with CT) when the arm is arm casting with the elbow in approxi-
held above the head with the head tilted out mately 90° of flexion for 3 to 4 weeks.
of the field in the prone position. The rapidity (b) Type II—There is considerable debate
of the MDCT scanning technique obviates the over the proper treatment of these dis-
need for sedation even in the youngest child. placed fractures with an intact posterior
5. Associated injuries cortical hinge. These have been tradi-
• Vascular—The brachial artery can be torn tionally treated with closed reduction
or, more commonly, set into spasm in and and long arm casting. In order to avoid
a Type III extension fracture. In a cold, pale, repeat displacement, studies have sug-
and pulseless extremity with a displaced gested that elbow flexion of 120° in the
supracondylar humerus fracture, initial cast is necessary. Unfortunately, this
management should include urgent fracture may lead to ischemia of the distal fore-
reduction in order to reconstitute the blood arm and hand because of swelling and
flow to the distal extremity. Preoperative may increase the incidence of compart-
arteriograms are contraindicated because ment syndrome. In addition, malunion
they only delay treatment and do not alter and cubitus varus are more common
the treatment plan. Capillary refill and pulse in the Type II fractures that are treated
oximetry are unreliable in this situation. with closed reduction and casting. Many
Doppler and manual palpation of the radial surgeons now prefer closed reduction
and ulnar arteries should be undertaken. If and percutaneous pinning (CRPP) for all
the ischemia does not resolve with closed displaced supracondylar fractures. The
reduction, open exploration is required. Bra- advantage is that the elbow can then
chial artery lacerations should be repaired be immobilized at 90° of flexion or less
or bypassed by a pediatric vascular sur- which facilitates venous return. This au-
geon. Arterial spasm can often be quelled by thor performs a closed reduction and
use of papaverine or 20% lidocaine directly assesses the vascularity of the distal ex-
applied to the area of spasm (not injected) tremity with the elbow flexed at 120°. If
under direct visualization. there is evidence of vascular embarrass-
• Neurologic—Documentation of a thorough ment in this position, he proceeds to
motor and sensory examination of the in- percutaneous pin fixation (see below).
volved extremity should be undertaken. (c) Type III—CRPP is the current standard
This evaluation should include anterior in- of care. Many recent studies suggest
terosseous nerve (AIN) function (ability to that this does not need to be undertaken
flex the distal interphalangeal joint of the emergently in a patient with an uncom-
index finger and the interphalangeal joint of promised neurovascular status.
the thumb; remember this is a motor branch • CRPP technique—The patient is
so there is no sensory loss). Nerve injuries placed under a general anesthetic on
occur in 7% to 15% of these fractures. AIN a standard operating room table with
palsy is the most commonly occurring lead covering the testicles/ovaries,
nerve injury with extension-type supra- breasts, and thyroid. Two arm boards
condylar fractures. Radial nerve injury are placed longitudinally along the op-
has been reported more commonly with erative side of the table. An image in-
posteromedially displaced fractures and tensifier positioned vertically with the
median nerve injuries with posterolateral large flat collector portion pointing up
from below is brought into the space the two lateral pins are supplemented
between the two arm boards and left with a medial pin placed with the elbow
slightly lower than these. The child is in extension by milking the ulnar nerve
then moved to the edge of the table posteriorly into the ulnar groove and
so that the elbow is centered over the making a small incision over the me-
center aspect of the image intensifier dial epicondyle and spreading down to
collector. A closed reduction is then bone with a snap. The stability is then
undertaken first applying longitudi- reassessed on the lateral view. The
nal traction followed by correction of pins are then cut and bent external to
varus or valgus angulation, then ro- the skin for incorporation under a cast
tation. The surgeon’s thumb is then or splint. A posterior splint can then be
placed over the olecranon, and the el- placed for one week or, alternatively, a
bow is flexed and the forearm pronated. long arm cast can be placed with the
Image intensification views are then elbow in approximately 70° of flexion
obtained in the lateral position (exter- to facilitate venous return. This is pos-
nally rotated) and oblique views are sible because of the stability achieved
obtained to assess the medial and lat- with percutaneous pinning. If concerns
eral column reduction. Once reduction over swelling exist, the cast can be ei-
is obtained, the elbow is assessed for ther univalved down the volar aspect
stability in approximately 120° of flex- or bivalved. Three to four weeks of im-
ion. If the hand blanches or the pulses mobilization is required, and the pins
are absent, the surgeon proceeds to can be removed in the office setting.
percutaneous pin fixation. (If accept- No further immobilization is needed.
able reduction cannot be achieved, Cross-pinning of the supracondylar
the surgeon proceeds to open reduc- fracture (one medial and one lateral)
tion.) With the elbow in extension, is the most biomechanically stable, fol-
the author then preps and drapes the lowed by two parallel lateral pins, fol-
entire affected upper extremity includ- lowed by two lateral pins crossing at
ing the axilla and the deltoid region us- or near the fracture site. A medial pin
ing split sheets. The image intensifier places the ulnar nerve at risk either
is draped in as part of the table. The during insertion or postoperatively by
surgeon then repeats closed reduction. chronic tenting of the nerve over the
Once anatomic reduction is achieved, wire with the elbow in flexion. The risk
the surgeon pronates the forearm and to the ulnar nerve during insertion can
tapes the arm to the distal forearm be diminished by inserting the pin un-
in maximal flexion with sterile Coban der direct vision with a small incision
wrap. A smooth K-wire (usually 0.062) or by placing the pin with the elbow in
appropriate for the size of the elbow extension as described above.
is inserted under biplanar fluoroscopy • Open reduction—Indications for open
from the lateral epicondyle percutane- reduction include open fractures, vas-
ously across the fracture site and an- cular compromise, or a fracture that
chored just through the contralateral cannot be adequately reduced closed.
proximal humeral cortex. A second The surgical approach should be based
comparably sized smooth K-wire is on the surgeon’s opinion as to what is
then placed parallel to the first ap- obstructing fracture reduction. The
proximately 1 cm apart from it in the approach may be medial, lateral, com-
same manner. The Coban wrap is then bined, or anteriorly based. A posterior
released and the elbow is allowed to triceps splitting incision is contrain-
extend, and true AP and lateral image dicated in extension supracondylar
intensification views are obtained. As- fractures.
suming that these are satisfactory, the • Traction—Indications for traction in-
surgeon then externally rotates the el- clude an inability to reduce or to stabi-
bow and, under real-time fluoroscopy, lize a fracture and severe swelling. The
flexes and extends the elbow to assess advantage is the ability to check vascu-
for instability. If any motion is present, lar status. The disadvantages include
difficulty in controlling the position of extension and lack of active digital ex-
the child in bed, difficulty of obtaining tension. Classically the five P’s (pain,
AP X-ray imaging, difficulty achieving pallor, pulselessness, paresthesias, and
fracture reduction and cost of hospital- paralysis) have been conveyed as diag-
ization. In general, a manual reduction nostic criteria; however, most of these
under general anesthesia will still be occur late in the course of the disease
required. after irreparable damage may have oc-
• Flexion injuries—Similar principles apply as for exten- curred. A high index of suspicion is re-
sion injuries except that flexion injuries are reduced quired to make the diagnosis in a timely
and stabilized in extension given the greater likeli- manner. Once considered, all circum-
hood of an intact anterior periosteal hinge. Because ferential dressings should be split and
of the difficulties in achieving an adequate reduction, casts should be completely bivalved in-
operative intervention is frequently indicated. cluding under cast padding. Manometry
7. Complications of the muscle compartments and clini-
• Neurologic complications—Most neuro- cal examination determine the need for
logic complications involve a neurapraxia emergent fasciotomies of the forearm.
and recover spontaneously over weeks to In general, a volar compartment fasci-
months. If no improvement is seen 3 months otomy alone adequately decompresses
after injury, exploration of the nerve can be both forearm compartments.
considered. The AIN is a branch of the me- • Cubitus varus (gunstock deformity)—A cu-
dian nerve that provides motor innervation bitus varus deformity is the result of a mal-
(no sensory) to the flexor pollicis longus union of a supracondylar fracture rather
(thumb IP joint flexion) and the flexor digi- than an acquired growth deformity. While
torum profundus to the index finger (index this deformity is primarily a cosmetic one,
DIP joint flexion). AIN function should be some recent evidence suggests it may pres-
tested pre-and postreduction as it is the ent functional issues including the late de-
most frequently injured nerve seen in velopment of a tardy ulnar nerve palsy.
extension-type supracondylar humerus Nonetheless, supracondylar osteotomy for
fractures. correction of a cubitus varus deformity will
• Vascular complications primarily result in improved cosmesis rather
(a) If the extremity is pulseless, fracture re- than improved function over the short term.
duction and stabilization are performed Initial fracture treatment with CRPP de-
emergently. If the radial pulse is not re- creases the incidence of cubitus varus.
stored by reduction and stabilization, • Stiffness—Almost all children eventually
an intraoperative arteriogram or direct regain a normal range of motion following
exploration should be performed. If supracondylar humerus fracture. If signifi-
the radial pulse is absent but perfu- cant stiffness persists beyond 3 weeks after
sion of the extremity appears normal cast removal, physical therapy is indicated.
(pink, pulseless hand) after reduction Occasional permanent stiffness may result
and stabilization, treatment options are from fibrosis of the muscles or elbow cap-
controversial. These options include ob- sule or heterotopic ossification, especially
servation, immediate exploration, and in markedly displaced fractures.
delayed arteriogram. C. Medial Epicondyle Fractures
(b) Compartment syndrome—Volkmann’s 1. Incidence—Medial epicondyle fractures gen-
ischemic contracture was first de- erally occur between 9 and 14 years of age.
scribed in 1881 as a consequence of Approximately half of these fractures are as-
the treatment of upper extremity frac- sociated with an elbow dislocation, which may
tures including supracondylar humerus reduce spontaneously. This may be the origin
fractures. This debilitating condition of the elbow stiffness so commonly seen fol-
was later found to be the sequela of lowing this injury.
an unrecognized forearm compart- 2. Mechanism of injury—Mechanisms of injury
ment syndrome. Signs and symptoms for a medial epicondyle fracture include a di-
of compartment syndrome of the fore- rect blow to the medial aspect and the elbow,
arm include pain out of proportion a valgus stress placed on the elbow and a
to the injury, pain with passive digital sudden flexion-pronation muscle contraction
resulting in avulsion. The ulnar collateral liga- with 5 to 15 mm of displacement heal well with
ment of the elbow and the common flexor ten- brief immobilization (2 weeks) in a long arm
don of the forearm take origin from the medial cast.
epicondyle. The flexor-pronator mass serves 6. Differential diagnosis
as a deforming force on the fracture fragment. • Medial condyle fracture—Medial condyle
3. Evaluation fractures are uncommon. A medial condyle
• Physical examination—The medial aspect of fracture is an intra-articular fracture that
the elbow will be tender and swollen, and produces an elbow hemarthrosis. A medial
may be ecchymotic. If an elbow dislocation is epicondyle fracture is extra-articular and
present, there will be a visible deformity in the rarely produces a hemarthrosis (posterior
sagittal plane. Valgus stressing of the elbow fat pad sign). The trochlea ossification center
under either anesthesia or sedation in 15° of appears at 9 years of age. Prior to this age, a
flexion (in order to eliminate the stabilizing ef- medial condylar fracture may be difficult to
fect of the olecranon) can be undertaken to differentiate from a medial epicondyle frac-
assess the stability of the medial structures. ture. A metaphyseal fragment indicates that
• Imaging—A comparison elbow radiograph the fracture involves the medial condyle.
of the contralateral side may be needed to • Multiple Ossification Centers of the Trochlea
determine the normal ossification pattern 7. Complications—Complications of medial epi-
and for evaluating the position of the medial condyle fractures include valgus elbow insta-
epicondyle if the apophysis is not readily bility and ulnar neurapraxia.
seen. The medial epicondyle can be eas- D. Lateral Condyle Fractures (see Fig. 31-7)
ily confused with the multiple ossification 1. Incidence—Lateral condyle fractures occur in
centers of the trochlea (the mnemonic is children 5 to 10 years of age.
“CRMTOL”). Congruity of the elbow joint on 2. Mechanism of injury—Lateral condyle frac-
a lateral X-ray should be assessed. Beware of tures result from a fall on an outstretched arm
the inability to obtain a true lateral X-ray of that produces a varus stress on the elbow.
the elbow, as this may portend an entrapped Alternatively, a valgus force acting through
medial epicondyle fragment within the joint. the radial head can directly impact the lateral
4. Associated injuries—Associated injuries in- condyle fracturing it.
clude elbow dislocation, radial neck fracture, 3. Classification
olecranon fracture, coronoid process fracture, • Milch Type I—The fracture extends through
and ulnar nerve injury secondary to stretch- the secondary ossification center of the cap-
ing (neurapraxia). itellum entering the joint just lateral to the
5. Treatment—Current controversy exists re- trochlea groove (Salter IV fracture). This is
garding the proper treatment of medial epi- a stable fracture pattern.
condyle fractures. This fracture involves an
apophysis (a growth plate under tension) not
an epiphysis (a growth plate under compres-
sion) and so no longitudinal or angular growth Lateral ridge
disorder occurs as a result. Displacement is of trochlea
tolerated unless the elbow is subject to force-
ful valgus loading such as during throwing
Capitellum
activities or gymnastics. The ulnar collateral
ligament remains lax with the elbow in ex-
tension if the medial epicondyle is displaced
anteriorly. Open reduction is associated with
increased stiffness of the elbow. Ogden has
recommended ORIF for displacement of more
than 5 mm and rotation of 90° or if the elbow is
unstable to valgus stress. Absolute indications
for open reduction include incarceration of the
fragment within the elbow joint, ulnar nerve
dysfunction, or demonstration of elbow insta- Type I Type II
bility. Long-term studies have demonstrated FIGURE 31-7 Lateral condylar fracture of the humerus
that isolated medial epicondyles fractures (Milch Classification): Milch Type I and Type II fractures.
• Milch Type II—The fracture extends medial 7. Complications

to the trochlea groove (Salter II) resulting • Nonunion/delayed union—Lateral condyle
in an unstable joint (intact medial articular fractures in children are associated with
hinge is key to stability and congruity). a high incidence of nonunion. An anatomic
4. Evaluation reduction with stable internal fixation mini-
• Physical examination—A swollen elbow that mizes the likelihood of nonunion. The intra-
is tender to palpation over the lateral con- articular nature of the fracture and the limited
dyle but not tender to careful examination blood supply likely contribute to these com-
over the medial condyle. plications. It is imperative to closely monitor
• Imaging—The AP view of the involved elbow these fractures until definitive union occurs.
frequently demonstrates a subtle fracture The treatment of late-presenting fractures
line extending just proximal and parallel to remains controversial. Most recent studies
the physis of the capitellum. A lateral X-ray favor surgical treatment for these fractures.
demonstrates a classic subtle metaphyseal • Osteonecrosis—The blood supply to the lateral
fragment that is often missed in minimally condyle enters posteriorly through the mus-
displaced fragments. Oblique views of the culature and soft tissue from extra-articular
elbow, arthrograms, and ultrasound may be vessels. These must be meticulously pre-
helpful in identifying minimally displaced served during ORIF.
fractures. MRI has been utilized, but the need • Physeal arrest—Physeal arrests are rarely of
for sedation and the long scan times make clinical significance in this patient population.
this impractical. Recent advances in MDCT • Cubitus varus—This is the most common
technology allow for rapid scanning times complication occurring in up to 40% of pa-
(with radiation exposure that is comparable tients. It rarely necessitates clinical inter-
to a standard plain film series of the elbow) vention. Parents should understand that
to help identify minimally displaced fractures there will be a lateral prominence.
and those at risk for late displacement. It is • Lateral spur formation—Lateral spur forma-
not recommended for routine use, however. tion results from operative and nonopera-
5. Associated injuries—Associated injuries in- tive treatment of these fractures. It presents
clude elbow dislocation, fracture of the ulnar as an apparent cubitus varus. It does not af-
shaft, and fracture of the medial epicondyle. fect function.
6. Treatment—Treatment is based on the degree • Fishtail deformity—The etiology of fishtail
of displacement. Stable nondisplaced fractures deformity of the distal humerus is unknown
can be treated nonoperatively with long arm but likely results from either malunion,
casting for 4 to 5 weeks. Weekly follow-up with osteonecrosis, growth arrest, or some com-
serial X-ray evaluation needs to be undertaken bination of these.
to assess for displacement until radiographic E. Medial condyle fractures (see Figure 31-8)
healing occurs. Unstable minimally displaced 1. Incidence—Medial condyle fractures occur
fractures and displaced fractures require open most often in children ages 8 to 14 years.
reduction and internal fixation. Displaced frac- 2. Mechanism of injury—The mechanism of in-
tures include those that are displaced 2 mm or jury is the same as that for medial epicondyle
more. Open reduction is performed through fractures and can include a direct blow, valgus
an anterolateral approach because the blood
supply to the lateral humeral condyle arises
posteriorly through the soft tissues. Dissection
should not be carried out posteriorly to avoid
osteonecrosis of the fragment. An anterolateral
approach allows direct visualization of the lat-
eral metaphysis, the anterior metaphysis, and
the intra-articular surface. Each of these has to
be anatomically reduced prior to K-wire fixa-
tion. The role of closed reduction and percuta-
neous pin fixation remains controversial. CRPP
can be performed for minimally displaced frac- Type I Type II
tures or nondisplaced fractures if poor compli- FIGURE 31-8 Fracture patterns of medial humeral
ance with immobilization is anticipated. condyle fractures, as described by Milch.
stress, and a violent flexor-pronator muscle • Type A—Flexion injury

contraction. • Type B—Extension injury
3. Classification (a) Valgus pattern—Associated with radial
• Milch System—The Milch system is based neck fracture
on the location of the fracture line (see (b) Varus pattern—Associated with disloca-
Figure 31-8). tion of the radial head and posterior in-
(a) Type I—Type I is through the apex of the terosseus nerve injury
trochlea; it is the more common type. • Type C—Shear injury
(b) Type II—Type II is through the capi- 4. Associated injuries—Associated elbow frac-
tulotrochlear groove; it is the less com- tures occur in 20% to 50% of olecranon frac-
mon type. tures and include medial epicondyle, lateral
• Kilfoyle System—The Kilfoyle system is epicondyle and radial neck fracture.
based on the fracture location and degree of 5. Treatment principles—The most important
displacement. considerations in treatment include the degree
(a) Type I—Type I is a fracture through the of displacement (3 mm or lesser is considered
medial condyle metaphysis. minimal), whether intra- or extra-articular, and
(b) Type II—The fracture extends into the stability. Due to a thick periosteum, most olec-
medial condyle physis. ranon fractures remain minimally displaced and
(c) Type III—Rotation and displacement can be treated with cast immobilization for 3 to
occur. 4 weeks. Shear injuries (rare) are usually stable
4. Evaluation in flexion while flexion fractures occasionally
• Physical Examination—A displaced medial must be treated in extension. Displaced intra-
condyle fracture is intraarticular; unlike the articular fractures may require ORIF with a ten-
extraarticular medial epicondyle fracture, it sion band technique or resorbable pins.
produces a hemarthrosis. G. Nursemaid’s Elbow (“pulled elbow,” radial head
• Imaging—Before the ossification of the subluxation)
trochlea at age 9, this fracture may be dif- 1. Incidence—The peak incidence is 1 to 3 years;
ficult to diagnose; arthrography or magnetic this injury is rare after age 5 years. It is slightly
resonance imaging (MRI) may be useful. more common in girls and on the left side.
5. Treatment 2. Mechanism of injury—The injury occurs by
• Long Arm Cast—A long arm cast for 3 to 4 traction on the hand when the forearm is
weeks suffices for undisplaced fractures; as pronated and the elbow extended. In this
with lateral condyle fractures, x-ray studies position, the anterior aspect of the annular
should be performed every 5 to 7 days (to ligament subluxates over the radial head and
check for displacement) until evidence of interposes itself into the radial head-capitellar
healing is seen. articulation (see Fig. 31-9).
• CRPP—CRPP can be attempted for an undis- 3. Evaluation
placed or minimally displaced fracture, but • Physical examination—The child holds the
the alignment must be anatomic. arm at the side with the elbow in minimal
• ORIF—ORIF with K-wires or bioabsorbable flexion with the forearm pronated.
pins is necessary for displaced fractures. • Imaging—X-rays are not indicated with a his-
6. Complications—Complications include growth tory of traction on a pronated forearm. Ra-
disturbance, avascular necrosis, loss of mo- diographs appear normal with no evidence
tion, and elbow instability. of effusion.
F. Olecranon Fractures 4. Treatment—Reduction is achieved by simulta-
1. Incidence—Pediatric olecranon fractures are neous full flexion of the elbow and full supina-
uncommon and are associated with concomi- tion of the forearm. The child will protest but
tant elbow fractures in up to 50% of cases (most will return to normal uninhibited utilization of
commonly medial epicondyle fractures). the extremity within minutes.
2. Mechanism—Olecranon fractures result from 5. Differential diagnosis—Other injuries includ-
hyperextension, hyperflexion, shear or a di- ing septic elbow, radial neck fracture, or other
rect blow. fractures about the elbow may present in a
3. Classification—There is no universally ac- similar manner. Frequently, children present
cepted classification system for olecranon with a pseudoparalysis of the elbow that has
fractures in children. Wilkins has classified lasted for more than a day. They may have
these based on mechanism of injury. undergone prior attempts at reduction of a
Divergent dislocations are quite rare resulting in

displacement of the radius and ulna in opposite
directions.
3. Classification—Wilkins has classified pediatric
elbow dislocations based on the direction of
displacement with respect to the humerus.
Bare area
• Type I—The proximal radial ulnar joint
remains intact.
(a) Posterior
• Posteromedial
Lateral • Posterolateral
(b) Anterior
(c) Medial
(d) Lateral
• Type II—The proximal radial ulnar joint is
disrupted.
A B C (a) Divergent
FIGURE 31-9 A. Normal annular ligament of the elbow. • Anteroposterior
B. Nursemaid’s elbow with a tear in the distal part of the • Mediolateral (transverse)
annular ligament and a portion of the ligament trapped (b) Radioulnar translocation
within the radiocapitellar joint. C. Axial view of the tear in 4. Evaluation
the annular ligament. • Physical examination—The child presents
with a painful, swollen elbow held in flexion
nursemaid’s elbow. A repeat attempted reduc- and appears S-shaped. The antecubital fossa
tion is indicated with the appropriate history. appears markedly widened because of the
These children may not achieve immediate re- distal humerus.
lief and may benefit from 2 weeks of long arm • Imaging—Plain radiographs demonstrate
casting with the forearm in supination. radioulnar displacement with respect to the
6. Complications—Recurrence is the primary distal humerus. The congruency between
complication. Recurrence can be avoided in the capitellum and the radial head and neck
most instances with proper education of the is lost differentiating this injury from a trans-
family. Recurrent episodes should be treated physeal fracture in the very young. Special
the same as primary occurrences. Long arm attention needs to be paid to associated el-
cast immobilization may be necessary in some bow injuries including a medial epicondyle
instances. Some children suffer multiple refracture. The prereduction and postreduc-
currences secondary to a stretched annular tion position of the medial epicondyle must
ligament. Proper familial education combined be carefully scrutinized.
with bone growth will allow a proper bone– 5. Associated injuries—Elbow dislocations are
ligament relationship over time. frequently associated with fractures of the el-
H. Elbow Dislocation (see Fig. 31-5) bow particularly fractures of the medial epi-
1. Incidence—Elbow dislocations are an uncom- condyle. Proximal radius fractures, cornoid
mon occurrence in children. The peak inci- process fractures, olecranon fractures, bra-
dence for elbow dislocations is 13 years of age chial artery injury, median nerve injury, and
with dislocations occurring more frequently brachialis muscle injury can also be associ-
in boys than in girls. Elbow dislocations are ated with an elbow dislocation.
rare in young children. An apparent elbow 6. Treatment
dislocation in a young child should raise • Closed treatment—The acute posterior dis-
the possibility of a transphyseal fracture. location can usually be treated closed with-
2. Mechanism of injury—Elbow dislocations re- out the need of a general anesthetic. This
sult from a fall on the supinated, outstretched is accomplished by providing longitudinal
forearm with the elbow in full extension or mild traction with minimal hyperextension of the
flexion. The resultant hyperflexion and valgus elbow, supination of the forearm followed
strain on the elbow results in dislocation. The by flexion of the elbow. Care must be taken
resultant dislocation is usually posterior or pos- to avoid significant hyperextension in order
terolateral but less commonly anterior, medial, to avoid further injury to the median nerve
lateral, and divergent dislocations can occur. or brachial artery. This normally results in
a stable reduction that requires immobiliza- are much more common in children. Approxi-
tion in a long arm splint for approximately mately one half of all radial neck fractures are
2 weeks, followed by active and active as- associated with other elbow injuries. The peak
sisted range of motion. Anterior dislocations incidence for proximal radial fractures is 4 to
generally require a general anesthetic for 14 years of age.
reduction and are accomplished with lon- 2. Mechanisms of injury—Fractures of the radial
gitudinal traction on the flexed elbow with head and neck generally result either from a
posteriorly directed force applied to the fall onto an outstretched upper extremity with
forearm as the elbow is gradually extended. the elbow in extension with a resultant valgus
• Open treatment—Open treatment is pri- force applied or during the course of an elbow
marily indicated for an irreducible elbow dislocation. A radial neck fracture can also oc-
dislocation usually caused by a medial epi- cur in combination with a proximal ulnar frac-
condyle fracture fragment trapped within ture as a Monteggia variant.
the joint, an open elbow injury or a brachial 3. Classification (O’Brien’s) (see Fig. 31-10)
artery injury. • Type I—Angulation is less than 30°.
7. Complications • Type II—Angulation is 30° to 60°.
• Stiffness • Type III—Angulation is greater than 60°.
• Recurrent dislocation—Recurrent dislocation 4. Evaluation
is rare and difficult to treat. It is seen most • Physical examination—The child will pres-
commonly in late adolescence with posterior ent with discomfort over the lateral aspect
and posterior-lateral dislocations. The poste- of the elbow and will demonstrate pain and
rior capsule may fail to firmly reattach to the limited pronation and supination of the fore-
posterolateral aspect of the humerus owing arm. There will be tenderness to palpation
to a large amount of cartilage in this region. over the radial head especially with prona-
• Nerve injuries tion and supination.
(a) Ulnar nerve—The ulnar nerve can be • Imaging—AP and lateral X-rays of the elbow
trapped in the joint with a displaced me- may not demonstrate obvious injury. Fre-
dial epicondyle avulsion fragment. Open quently, multiple oblique views are needed
reduction and extraction of the medial when a high index of suspicion is present.
epicondyle and ulnar nerve normally re- Alternatively, MDCT can be utilized, as pre-
sults in complete recovery. viously described.
(b) Median nerve—Median nerve injuries 5. Associated injuries—Fractures of the proxi-
are less common than ulnar nerve in- mal ulna, medial epicondyle, lateral condyle,
juries due to elbow dislocations, but
have a poorer prognosis for recovery.
The nerve can be trapped between
the trochlea and olecranon during re- Type I Type II Type III
duction, can be trapped between the
medial epicondyle fracture and the
humerus, or can become displaced
behind the medial condylar ridge and
trapped between the distal humerus
and the olecranon as the joint reduces. 45°
Median nerve dysfunction following a
suspected elbow dislocation should
prompt a thorough evaluation for one
of these situations.
• Brachial artery injury—The brachial artery
is uncommonly injured as a result of a closed
elbow dislocation, but is more frequently in-
jured in open dislocations. Vascular repair
may be required.
I. Proximal Radius (Head and Neck) Fractures < 30° 30°- 60° > 60°
1. Incidence—Because of the cartilaginous FIGURE 31-10 Radial neck fractures in children (O’Brien’s
makeup of the radial head, radial neck fractures classification): Type I, Type II, and Type III fractures.
olecranon or rupture of the medial collateral rotational alignment of the forearm, the sur-
ligament can be seen with radial neck or head geon looks for the bicipital tuberosity to be
fractures. diagonally opposite the radial styloid and the
6. Treatment—The two primary determinants of coronoid to be anterior, diagonally opposite
treatment are angulation and displacement. the ulnar styloid, which is posterior.
Wilkins recommends early motion for angula- 3. Classification—There is no generally accepted
tion less than 30° and translation less than classification system for both bone forearm
5 mm, a closed reduction for angulation of fractures.
30° to 60° and ORIF for angulation more than • These fractures can be divided into three dis-
60° or translation more than 5 mm. Ogden tinct types for descriptive purposes.
considers angulation more than 10° to 15° in (a) Complete fractures—These fractures fre-
a child over 10 years of age as unacceptable quently demonstrate displacement and
because of the limited remodeling potential. are characterized by a complete frac-
Reduction may be achieved with closed manip- ture line through the cortex on all radio-
ulation, percutaneous K-wire manipulation, or graphic views.
intramedullary wire manipulation, or through (b) Greenstick fractures (Fig. 31-11)—These
open reduction. fractures are characterized by a fracture
7. Complications—Significant loss of motion oc- through only one visualized cortex on
curs in 30% to 50% of children with these in- each radiographic view. The contralateral
juries. In addition, premature physeal closure, cortex remains intact. These fractures
osteonecrosis, cubitus valgus, heterotopic have a tendency to displace over time.
ossification, radioulnar synostosis, and radial (c) Plastic deformation fractures—These
head overgrowth have all been described in fractures demonstrate no discernible
these fractures. fracture through either cortex on radio-
J. Coronoid Process Fractures graphic views but demonstrate angular
1. Incidence—Coronoid process fractures are deformity. These fractures are unique to
quite rare in children and are primarily asso- children. Either bone or both bones can
ciated with elbow dislocations. As such, they be plastically deformed.
are frequently accompanied by fractures of
the medial epicondyle, proximal radius, lateral
condyle, and proximal ulna.
2. Classification (Regan and Morrey’s)
• Type I—Involves the tip of the coronoid
process.
• Type II—Involves less than 50% of the coro-
noid process.
• Type III—Involves greater than 50% of the
coronoid process.
3. Treatment—These fractures are rarely displaced
and are almost always treated closed in children.
V. Injuries of the Radius and Ulna

A. Diaphyseal Forearm Fractures
1. Mechanisms of injury—Normally, the mecha-
B
nism of injury for a diaphyseal radius and ulna
fracture (bone forearm fracture) is a fall on an
outstretched upper extremity.
2. Evaluation
• Physical examination—The forearm demon-
strates a subtle or obvious deformation with
tenderness at the fracture site. Pronation and
supination are limited and cause pain. A
• Imaging—Orthogonal radiographs of the en- FIGURE 31-11 A. Greenstick fracture of a child’s forearm.
tire forearm including the wrist and elbow B. Torus fracture of a child’s distal radius. Arrows indicate
must be performed. To assess the proper the direction of forces that produce the injury.
• These fractures can also be described based • Nondisplaced fractures—Nondisplaced both

on their location within the bones. bone forearm fractures should be immo-
(a) Proximal 1/3 bilized in a long arm cast for 5 to 6 weeks
(b) Middle 1/3 depending upon patient age. Middle 1/3 and
(c) Distal 1/3 distal 1/3 fractures can frequently be con-
• These fractures can be described based on verted from a long arm cast to a short arm
their direction of displacement. cast at 4 weeks if adequate callus is present.
(a) Apex dorsal • Greenstick fractures—Greenstick fractures of
(b) Apex volar the forearm can have a surprisingly signifi-
(c) Apex radial cant amount of rotational deformity despite
(d) Apex ulnar appearing to have minimal angulation. Reduc-
4. Associated injuries—Associated injuries in- tion of these fractures prior to cast immobili-
clude elbow fractures, Monteggia fractures, zation is generally recommended. Reduction
and Galeazzi fractures. By this reason, it is im- is accomplished by the “rule of thumb.”
perative to visualize the elbow and wrist joints The rule of thumb refers to the maneuver
radiologically as part of the forearm evaluation. that must be undertaken to achieve adequate
5. Limits of acceptable reduction—Much literature fracture reduction. Fractures with apex dorsal
has been dedicated to what constitutes an accept- angulation have a pronation deformity and so
able reduction in a pediatric both bone forearm the thumb is moved toward the apex of the
fracture. Price presented guidelines that included fracture to create supination at the fracture
10° of angulation, 45° of malrotation, complete site in order to reduce the fracture. Similarly,
displacement, and loss of the radial bow to be rea- fractures with apex volar angulation have a
sonable limits for an acceptable reduction. The supination deformity and so the forearm must
remodeling potential for both bone forearm frac- be pronated (thumb moved in the direction of
tures in children younger than 10 years of age is the apex of the fracture) in order to correct
significant. Angular displacement remodels better the deformity and reduce the fracture. Once
than rotational displacement. Malunions follow- the reduction is complete, a long arm cast with
ing both bone forearm fractures in children are a good ulnar mold, a good interosseous mold
common. Nonetheless, the functional outcome and a good dorsal and volar mold is placed to
in these children is quite good. Radiologic mal- maintain the correction. Generally, plaster is
union, therefore, does not necessarily translate a better material to use in the acute fracture
into functional deficits. Although each patient and situation than fiberglass. Plaster allows better
fracture must be considered individually, Price’s molding than fiberglass and is more likely to
guidelines are quite reasonable and, frequently, hold the mold placed by the surgeon .
even more deformity can be accepted with the • Displaced fractures—Most displaced both
expectation of a good functional outcome. This bone forearm fractures in skeletally imma-
authors’ primary determinant of whether a reduc- ture children can be treated with closed re-
tion is satisfactory is based more on the external duction and casting. Reduction can generally
appearance of the arm than any other factor. be achieved with longitudinal traction, exag-
Specific attention should be paid to the amount geration of the deformity and correction of
of bowing of the ulna as this is a subcutaneous the angular and rotational malalignment. The
bone and seems to be the primary determinant of rule of thumb outlined above can be followed
whether a child or parent will be happy with the for postproduction immobilization. In other
cosmetic result of the forearm fracture treatment. words, fractures that were originally apex
6. Treatment—Proximal 1/3 both-bone forearm volar can be casted in slight pronation; those
fractures tend to have a less favorable out- that were originally apex dorsal can be casted
come than more distal fractures. This may be in slight supination. More importantly, close
due to the fact that it is more difficult to mold attention must be paid to the rotational align-
a cast in this region because of the large soft- ment of the distal fragment with respect to the
tissue covering. Special attention needs to be proximal fragment. These fractures are best
paid to maintaining a good border mold with a stabilized by lining up the bicipital tuberosity
good interosseous mold. All of these fractures opposite to the radial styloid thereby assur-
should be followed at weekly intervals for the ing proper rotational alignment. If there is any
first three weeks with AP and lateral X-rays to doubt, the forearm should be placed in the
assure that displacement does not occur. neutral position. These fractures all require
long arm immobilization initially with either 7. Complications

a well molded long arm cast, a sugar tong • Refracture—Refracture occurs in up to 5% of
splint, a univalved long arm cast or a bivalved greenstick fractures and open fractures.
long arm cast. As with all other forearm frac- • Loss of reduction—Diaphyseal both bone
tures, these need to be closely scrutinized at forearm fractures have a fairly high rate of
weekly intervals for the first three weeks to reduction loss in the weeks following initial
assure that displacement does not occur. reduction. Close scrutiny with weekly X-rays
• Plastic deformation—Recognition of plastic is required. While angular deformities can re-
deformation is important in avoiding loss of model, rotational deformities do not remodel.
pronation and supination. When plastic de- • Malunion—Frequently malunited forearm
formation occurs in one forearm bone in con- fractures do not result in functional defi-
junction with a displaced fracture in the other, cits for the patient. Corrective osteotomies
reduction of the plastic deformation must be should not be considered until the functional
performed prior to reduction of the displaced deficits are clearly identified. Ogden has sug-
fracture. Careful evaluation of the elbow joint gested that angulation of the radius affects
for displacement of the radial head must be forearm rotation more than angulation of the
performed when an isolated plastic deforma- ulna (Fig. 31-12).
tion of the proximal to mid ulna is encountered. • Cross union—Cross union is a relatively rare
• Indications for open treatment—The indica- complication of both bone forearm fractures
tions for operative treatment of pediatric but occurs more frequently following surgi-
radius and/or ulnar shaft fractures include cal intervention, repeat manipulations, and
an open fracture, an irreducible fracture, a high-energy injuries and in children with
fracture associated with a compartment syn- head injuries. The results of excision of the
drome or dysvascular extremity, inability to synostosis are reportedly not as good in chil-
maintain an acceptable reduction or entrap- dren as they are in adults.
ment of nerves or tendons within the fracture • Compartment syndrome—Compartment syn-
site. Skeletal fixation may be accomplished drome occurs less frequently in children than
utilizing plates and screws as in adults, intra- in adults. It is more common in open fractures
medullary fixation, or with external fixation. and can be the result of a constricting cast. A
External fixation is generally reserved for high index of suspicion must be maintained
forearm fractures associated with significant following reduction of a both bone forearm
soft-tissue injuries or burns. fracture.
FIGURE 31-12 Rotation of the radius

A A A on the ulna. Normally, the mechanical
triangle of rotation (ABC) has an axis
from the center of the radial head
(A) to the ulnar styloid (C). The
radial styloid (B) rotates around to
a pronated position (B'), subtending
D D a semicircular conical base. Angular
malunion introduces a frustrum (D)
into the normal cone of rotation,
thereby limiting the area (stippling)
of the cone base. In this example,
residual pronation of the distal radius,
caused by angular malunion, restricts
full supination.
C C
B B B B B
C
B
Normal Angular malunion
• Muscle or nerve entrapment—Muscles or They divide these fractures into five types.
peripheral nerves may become entrapped Letts’ Type A, B, and C fractures are similar
in the fracture site and can lead to residual to Bado Type I fractures.
functional deficits. (a) Type A fractures demonstrate anterior
B. Monteggia Fracture-Dislocation—A Monteggia dislocation of the radial head with apex
fracture-dislocation is a fracture of the ulnar shaft anterior plastic deformation of the ulna
associated with a dislocation of the radial head. (Bado I).
1. Incidence—These injuries have a peak inci- (b) Type B fractures demonstrate anterior
dence of occurrence between 7 and 10 years of dislocation of the radial head with a
age in children. greenstick fracture of the ulna (Bado I).
2. Classification (Fig. 31-13) (c) Type C fractures demonstrate ante-
• Bado has classified these fractures based on rior dislocation of the radial head with
the direction of the radial head dislocation. a complete fracture of the ulna (Bado I
The radial head always dislocates in the and IV).
direction of the apex of the ulnar fracture. (d) Type D–Type D fractures demonstrate
(a) Type I Monteggia fractures demonstrate posterior dislocation of the radial head
anterior dislocation of the radial head (Bado II).
(70% to 85%). (e) Type E—Type E fractures demonstrate
(b) Type II Monteggia fractures demon- lateral dislocation of the radial head
strate posterior dislocation of the radial (Bado III).
head (5%). 3. Monteggia fracture-dislocation variants—Vari-
(c) Type III Monteggia fractures demonstrate ants or equivalents of Monteggia fracture-dislo-
lateral dislocation of the radial head cation include an isolated anterior dislocation of
(15% to 25%). the radial head without an ulna fracture, fracture
(d) Type IV Monteggia fractures involve frac- of the ulna with fracture of the radial neck, a
tures of both the proximal radius and the fracture of both bones of the forearm with a frac-
ulna with anterior dislocation of the ra- ture of the radius proximal to the ulnar fracture
dial head (rare). and plastic deformation of the ulna with a radial
• Letts and coworkers have modified Bado’s head dislocation. These pediatric variants are ad-
classification for use in pediatric patients. dressed in Letts’ classification as outlined above.
Type I Type II
Type IV
Type III
FIGURE 31-13 Monteggia fracture-dislocations in children. Bado Type I, Type II, Type III, and Type IV fracture-
dislocations.
4. Mechanism of injury (Bado) maintained with the elbow in extension

• Type I—There are three theories: and the forearm in neutral position in a
(a) A fall on an outstretched upper extremity cast.
with the hand planted and the forearm (c) Type III—Longitudinal traction is placed
pronated results in increased pronation on the forearm with the elbow in exten-
resulting in a fracture of the ulna and sub- sion and direct pressure is placed over the
sequent anterior dislocation of the radial apex of the radial head and ulna fracture.
head. The reduction is best maintained with the
(b) A direct blow to the ulna posteriorly re- elbow at 90° and the forearm in supination.
sults in an ulna fracture and anterior dis- 8. Complications—There is a high association of
location of the radial head. ipsilateral extremity fractures in patients with
(c) A fall on an outstretched upper extrem- Bado II Monteggia fracture-dislocations. The po-
ity with resultant hyperextension and tential for redislocation of the radial head is high.
forceful contracture of the biceps, which Therefore, close weekly radiographic follow-up
dislocates the radial head anteriorly with is required to assure that no redisplacement oc-
subsequent fracture of the ulna. curs in patients treated with closed reduction.
• Type II—A fall on a flexed elbow. C. Distal Radius and Ulna Fractures
• Type III—Most likely results from a varus 1. Incidence—Distal radius and ulnar fractures
force applied to a hyperextended elbow. are extremely common injuries in children.
• Type IV—Unknown mechanism. These injuries occur throughout childhood but
5. Evaluation are more likely to occur in adolescents than in
• Physical examination—Children with Monteg- younger children.
gia fracture-dislocations present with deformity 2. Mechanism of injury—These fractures are nor-
of the elbow and forearm. There is pain and lim- mally caused by a fall on an outstretched hand.
itation on active and passive forearm rotation. If the wrist is in extension, the patient will most
The dislocated radial head may be palpable as likely sustain a volarly angulated fracture. If the
a lump in the position of its dislocation. wrist is in flexion, the patient will most likely
• Imaging—True AP and lateral X-rays of the el- sustain a dorsally angulated fracture.
bow are critical in the diagnosis of Monteggia 3. Classification—These fractures include buckle (to-
fracture-dislocation. The radial head-capitel- rus) fractures (see Fig. 31-11), growth plate frac-
lar alignment must be closely scrutinized by tures (usually Salter-Harris I or II), metaphyseal
drawing a line down the long axis of the radius fractures, or greenstick fractures.
and assuring that it passes through the center 4. Evaluation
of the capitellum on each radiographic view, • Physical examination—In displaced or angu-
regardless of the amount of elbow flexion (see lated fractures there may be a visible “dinner
Fig. 31-3). It is easy to miss a subtle radial head fork” deformity. There is discomfort with pal-
dislocation. pation and range of motion of the wrist.
6. Differential diagnosis—Congenital dislocation • Radiographic evaluation—High-quality AP
of the radial head is almost always posterior views and lateral X-rays of the distal radius
and bilateral. The radial head is usually en- must be obtained. As with other forearm
larged and elliptical in shape. fractures, visualization of the elbow is also
7. Treatment desirable although not absolutely required if
• Closed reduction the physical examination is indicative of an
(a) Type I—Reduce the ulna fracture with isolated distal injury.
longitudinal traction and three-point 5. Treatment—Treatment decisions are based on
force centered on the apex. The radial the amount of angulation deemed acceptable
head can then be reduced with direct for a given patient. Because the motion of the
pressure. The reduction is best main- wrist is usually in the same plane as the dis-
tained with elbow flexion to 120° and placement, significant remodeling can occur
neutral forearm positioning in a cast. even in individuals nearing skeletal maturity.
(b) Type II—Reduce the ulna fracture with Bayonet apposition is quite acceptable as it
longitudinal traction and three-point usually remodels. In patients 10 years old or
force centered on the apex. The ra- younger, up to 40° of sagittal plane angula-
dial head can then be reduced with tion and 20° of coronal plane angulation can
direct pressure. The reduction is best be accepted. Because distal radius fractures
remodel at rates of up to 10° per year, 10° of with repeated reduction attempts. Repeat
angulation can be accepted in patients felt to closed reductions after 10 to 14 days for
be within one year of skeletal maturity. As with progressive malalignment requires forceful
other forearm fractures, it may be wise to remanipulation and has an increased risk of
duce clinically apparent angular deformities so growth arrest. Distal physeal fractures of the
that less frequent reassurance to the parents ulna are uncommon but have a fairly high in-
need to be undertaken during remodelling. cidence of growth arrest.
• Torus (buckle) fractures—Recent studies • Indications for operative intervention——
suggest that these fractures can be treated Indications for surgery in distal radius and
symptomatically in a removable wrist splint. ulna fractures include open fractures, failure
Most surgeons still prefer to treat these in a to obtain an acceptable closed reduction,
short arm cast for three weeks. After three compartment syndrome, acute carpal tunnel
weeks, the immobilization is removed and no syndrome that does not improve with closed
further X-rays are required. reduction, ipsilateral upper extremity frac-
• Nondisplaced fractures—Nondisplaced com- ture and recurrent displacement after initial
plete fractures can be treated in a short arm closed reduction. When loss of reduction is
cast for 5 weeks. If there is pain with pronation appreciated 1 week after initial closed reduc-
and supination at initial presentation, a long tion despite a well-molded cast, repeat closed
arm cast is advisable for the initial 2 to 3 weeks. reduction in the operating room can be con-
• Greenstick fractures—The periosteum is dis- templated. In this situation, percutaneous pin
rupted on the convex side of the fracture and fixation should be considered to avoid further
the bone is deformed on the concave side mak- or repeat displacement necessitating a return
ing progression of angulation likely. Angulation trip to the operating room. In children ap-
can result in a permanent rotational deformity proximately 10 years of age with a distal both-
so reduction of these fractures, normally with bone fracture in which the ulna is a greenstick
completion of the fracture on the concave fracture and the radius is displaced, dorsally
side, is recommended. A well-molded long arm translated, and shortened, the radius is often
cast should be applied for 5 to 6 weeks. buttonholed by the periosteum and cannot
• Distal metaphyseal fractures—Distal me- be reduced. In these fractures, it is frequently
taphyseal fractures of the forearm rarely oc- necessary to make a small dorsal incision and
cur in a single bone. Generally, the radius reduce the fragment manually.
demonstrates a complete fracture with either 6. Complications—Complications are uncommon
a complete fracture of the ulna, an ulnar sty- but include growth arrest, median nerve palsy,
loid fracture, plastic deformation of the ulna, refracture and malunion.
or a greenstick fracture of the ulna. These D. Galeazzi Fracture—A Galeazzi fracture is a com-
fractures are treated with closed reduction bination of a radial shaft fracture and a disloca-
of the radius. The ulna fracture usually does tion of the distal radioulnar joint. A pediatric
not require separate attention. Careful mold- variant is a distal radial physeal or metaphyseal
ing of the cast is required in order to maintain fracture with a concomitant distal ulnar physeal
the reduction. Hyperflexion of the wrist in the fracture.
cast can precipitate an acute carpal tunnel 1. Incidence—This injury is much less common in
syndrome and should be avoided. These frac- children than in adults.
tures are generally healed within 4 to 5 weeks. 2. Mechanism of injury—A fall on an outstretched
• Distal physeal fractures—Distal physeal frac- hand is the usual cause of this fracture.
tures of the radius are common. These can 3. Classification
be treated similar to displaced metaphyseal • Type A—The direction of the fracture line is
fractures and rapid healing can be expected. oblique, from proximal to distal-lateral. This
Only one attempt at closed reduction under fracture is unstable and usually requires
conscious sedation should be made in the ORIF.
emergency room. If the reduction is unsuc- • Type B—The direction of the fracture line is
cessful, subsequent reduction should be from proximal to distal-medial and is more
done under general anesthetic in the operat- transverse.
ing room with full muscular relaxation. This 4. Evaluation—Standard AP and lateral views of
avoids secondary trauma to the growth plate the wrist should be obtained. If the injury is
not visualized on plain films, a CT scan may be to stabilize the fracture. The examiner must
required. look for evidence of “fight bites” that may
5. Treatment—Reducing the radial fracture usu- indicate contact with the mouth or teeth of
ally restores the distal radioulnar joint. ORIF is another individual. Appropriate prophylactic
rarely required but should be undertaken when antibiotic therapy should be employed in this
closed reduction fails. situation.
B. Fracture of the Thumb Metacarpal
VI. Carpal Fractures 1. Classification
A. Scaphoid Fractures—In the skeletally immature • Type A is a metaphyseal fracture that is
patient, scaphoid fractures are usually avulsion usually impacted.
injuries of the distal pole. They present with • Type B is a Salter-Harris II fracture that is
snuff box tenderness. They frequently result angulated medially.
from a fall on an outstretched hand. They can • Type C is a Salter-Harris II fracture that is
be treated with a thumb spica cast for 4 to 8 angulated laterally.
weeks. Midwaist scaphoid fractures in children • Type D is a Salter-Harris IV fracture that is
can result in avascular necrosis or nonunion. If a true Bennett’s fracture-dislocation.
a scaphoid fracture is suspected but not evident 2. Treatment
on plain X-rays, a CT scan should be obtained. • Type A—Closed reduction and thumb spica
B. Other Carpal Injuries—Other carpal injuries are casting.
uncommon in children. Treatment guidelines for • Type B and C—Closed reduction and
adults for equivalent injuries in children should thumb spica casting for most. Occasion-
be followed. ally, percutaneous pinning is required.
• Type D—This is an intra-articular fracture
VII. Metacarpal and Phalangeal Fractures—Metacarpal that requires ORIF for anatomic reduction
and phalangeal fractures are common after rela- of the joint surface.
tively minor trauma. They frequently involve the C. Proximal Phalanx Fractures
physis but rarely cause growth disturbance. They 1. Mechanism of injury—This fracture usually
heal rapidly. The intact periosteal hinge aids in re- results from either a fall or from being struck
duction. The method of treatment for these frac- by an object.
tures is similar in adults and children. Injuries that 2. Classification—Most are usually Salter-Har-
are common in children and unique to children are ris II fractures of the base of the proximal
described here. phalanx but shaft fractures are also seen.
A. Boxer’s Fracture (Fifth Metacarpal Fracture) 3. Evaluation
1. Incidence—Boxer’s fractures occur in pre- • Physical examination—When the small fin-
adolescents and adolescents possessing ger is involved there may be excessive ab-
enough strength to generate the force needed duction present (“extra octave” fracture).
to break this bone. Otherwise pain with palpation and swelling
2. Mechanism of injury—The mechanism of in- as well as some deformity may be evident.
jury is a direct blow with a clenched fist strik- • Imaging—Good AP, lateral and oblique
ing a hard object. X-rays should be obtained because these
3. Treatment—Usually, an ulnar gutter splint fractures are frequently seen on only one
or cast for 4 to 6 weeks is sufficient for heal- view.
ing. Reduction and fixation are generally not 4. Treatment
needed because up to 70° of angulation re- • Nondisplaced fractures—The finger with the
models and causes no loss of function. The fracture can be buddy taped to the adjacent
only residual deformity is a less prominent finger for 3 to 4 weeks until healing occurs.
knuckle on the involved digit. Rotational ma- • Displaced or angulated fractures—The frac-
lalignment must be corrected, as it will not ture should be reduced by placing a pencil
remodel. If needed, reduction can be accom- in the web space of the apex of the displace-
plished by dorsally directed pressure on the ment. This provides an effective means of
distal fragment while the metacarpophalan- reducing the proximal metaphyseal fracture.
geal and proximal interphalangeal joints are It can then be placed either in a short arm
in flexion. Redisplacement can occur and ulnar gutter cast or in a radial gutter cast
so percutaneous pinning is often employed (depending on the digit involved) for 3 to 4
weeks until the fracture is healed. After cast SUGGESTED READINGS

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CHAPTER 32
Pediatric Spinal and Pelvic Injuries

Scott Rosenfeld
I. Pediatric Spinal Injuries these cartilaginous regions, producing distinct

A. Epidemiology—Spinal injuries are less common in pediatric spinal fracture patterns such as ver-
children than in adults. Patients who are younger tebral endplate injuries. These fractures may
than 15 years old account for less than 10% of pa- produce only subtle radiographic findings such
tients who sustain spinal cord injuries. The most as disc space widening.
common causes of spinal injury in children are 3. The pediatric spinal column—The pediatric spi-
motor-vehicle collisions, falls, and sporting inju- nal column is more elastic than the spinal cord
ries. A very young child with a spinal injury should due to underdeveloped paraspinal musculature
be evaluated for nonaccidental trauma. Multilevel and ligaments. The spinal column can tolerate
spinal injuries are common in children. 2 inches of stretch, whereas the spinal cord
B. Differences between Children and Adults with can only tolerate approximately 0.25 inches of
Spine Trauma—Children are not just small adults. stretch. This puts the pediatric spine at risk
There are physiologic and anatomic differences for spinal cord injury without radiographic
that predispose them to different types of injuries abnormality (SCIWORA).
and require different methods for management. 4. Long-term management—Long-term manage-
1. Head size—The pediatric patient’s head is dis- ment of pediatric spinal injury differs from that
proportionately larger than that of the adult. of adults. The pediatric patient is more likely
This raises the fulcrum of motion into a more to recover from neurologic injury due to the
cephalic position (C2 – C3 in children vs. C5 – greater plasticity of the neural elements. In
C6 in adults) which increases the incidence of pediatric spine fractures, physeal injury may
upper cervical spine injuries in children. The result in the development of spinal deformity.
upper cervical facets in children are also more Alternatively, growth may allow for remodeling
horizontal, allowing for greater upper cervical of mild deformities.
motion. During evaluation on a back board, C. Imitators of Pediatric Spine Injuries
these properties force the cervical spine into 1. Pseudosubluxation (Fig. 32-1)—Pseudosublux-
greater flexion, which can make radiographic ation is a normal physiologic variant in the pedi-
interpretation difficult and may manifest as atric cervical spine secondary to the relatively
pseudosubluxation. To accommodate for this a large head size and horizontal upper cervical
pediatric patient should be evaluated on a pe- facets.On radiographs, it manifests as an-
diatric back board with an occipital cutout. Al- terior translation of the cephalic vertebral
ternatively, a standard back board can be used body relative to the caudad body and is most
with supports under the shoulders. common at C2 – C3. There may be up to 4 mm
2. Spine anatomy—The pediatric spine may have and 3 mm of pseudosubluxation at C2 – C3
open physes and developing ossification cen- and C3 – C4, respectively. It is most com-
ters. This can make evaluation difficult for a monly seen in children younger than 8 years
physician unaccustomed to viewing pediatric being evaluated with a supine lateral cervical
spine radiographs. For instance, the odontoid radiograph taken on a standard back board
synchondrosis may be mistaken for a fracture. without shoulder supports or an occipital cut
Furthermore, fractures may occur through out. The diagnosis is made (true subluxation is
510
C H A P T E R 3 2 | P E D I A T R I C S P I N A L A N D P E L V I C I N J U R I E S 511
D. Workup for Pediatric Spine Injury

1. Clinical examination—Since spinal fractures
are often the result of a significant trauma,
workup should begin with assessment of the
patient: Airway, Breathing, and Circulation. The
patient should be transported and assessed on
a pediatric back board with an occipital cut out
or a standard back board with shoulder sup-
ports to accommodate for the relatively large
head size. The Primary Survey should include
a visual survey and palpation of the head,
neck, back, and pelvis. The abdomen should be
evaluated for a lap belt sign, which should in-
crease suspicion for an injury of the spine and
viscera. A complete neurologic exam should be
performed.
2. Radiographic examination—Patients involved in
high-energy trauma should have lateral C-spine,
AP pelvis, and AP chest radiographs. Dedicated
AP and lateral radiographs should be obtained
of any location with tenderness, swelling, or ec-
chymosis. Any patient with an identified spine
fracture should have AP and lateral radiographs
of the entire spine as noncontiguous multilevel
injuries are common. Twenty-four percent of
pediatric cervical spine injuries have a sec-
FIGURE 32-1 Pseudosubluxation of C2 on C3. ond spine injury . CT scan and MRI may be
Hypermobility is common in children younger than
used for increased bony and soft-tissue detail.
8 years. Specific measurement of the movement of the
MRI may be used to clear a C-spine in a nonco-
vertebral bodies is unreliable, whereas the relationship
with the posterior elements is more consistent. In flexion, operative patient.
the posterior arch of C2 lies in a relatively straight line E. Radiographic Evaluation Specific to the Pediatric
with C1 and C3. Note the relative horizontal nature of the Spine
facet joints, which allows greater mobility. (Reprinted 1. Cervical spine—Powers ratio is used to evalu-
with permission from Capen DA, Haye W. Comprehensive ate the atlanto-occipital junction and should be
Management of Spine Trauma. St Louis, MO: Mosby; 1998.) between 0.7 and 1.0. Normal atlantodental in-
terval may be up to 4.5 mm. At the level of C1,
one-third should be taken up by the odontoid,
ruled out) using the posterior spinolaminar line one-third by the spinal cord, and one-third by
(Swischuk’s line) on the lateral radiograph. This space available for the cord. Pseudosubluxation
line connects the posterior arches of C1 and C3 up to 4 mm at C2 – C3 is physiologic. Subtle disc
and should come within 2 mm of C2. height changes may be signs of fracture through
2. Ossification of the odontoid process—Different vertebral endplates.
stages of ossification of the odontoid process F. Developmental Anatomy (Figs. 32-2 and 32-3)—
can mimic injuries to this structure. The apical Knowledge of the unique ossification patterns of
ossification center can mimic an avulsion frac- the pediatric spine is necessary for proper evalua-
ture. The synchondrosis fuses by age 6, but is tion of an injury.
still visible until age 12 and this may make diag- 1. Atlas (C1)
nosis difficult. Persistence of the synchondrosis • Ossification centers—The atlas has three pri-
at the base of the odontoid can mimic fracture. mary ossification centers. The right and left
Incomplete ossification of the odontoid process neural arches are ossified at birth, and the
can mimic atlantoaxial instability. body ossifies at 1 year.
3. Imitators of compression fractures after minor • Fusion—The atlas body and neural arch syn-
trauma—Eosinophilic granuloma, Mucopoly- chondroses fuses at 7 years. The spinous
saccharidoses, Gaucher’s disease, Osteogenesis process (neural arch) synchondrosis fuses at
imperfecta, Tuberculosis, tumor. 3 years.
A B C
Body Body
Dens
Neural arch
Neural arch Body
Neural arch Dens
Body Body
Neural arch Neural arch
Body
FIGURE 32-2 Ossification centers. A, C1. B, C2. C, Typical of C3-L5.
of the odontoid appears at 3 years. The infe-

rior epiphyseal ring ossifies at puberty.
• Fusion—The synchondrosis between the
body and the odontoid fuses by 6 years. The
fusion line is often visible until age 12. The
neural arches fuse to the body by 6 years,
and the spinous processes fuse by 3 years.
The secondary ossification center at the tip
of the odontoid fuses by 25 years, as does the
inferior epiphyseal ring ossification center.
3. C3 – C7
• Ossification centers—Five ossification cen-
ters are all present at birth. These are the
body, two neural arches, and two transverse
processes.
• Fusion—The transverse processes fuse to the
FIGURE 32-3 Morphologic development of the second body by age 6. The body and neural arches
cervical vertebra at 3 months. The odontoid ossification fuse by age 6. The spinous processes fuse by
centers have coalesced. The neurocentral synchondroses age 3. Bifid spinous processes appear at pu-
separate the centrum from the posterolateral elements.
berty and fuse by age 25. The superior and
(Reprinted with permission from Ogden JA. In: Ogden JA,
ed. Skeletal Injury in the Child. 2nd ed. Philadelphia, PA:
inferior epiphyseal rings fuse by age 25.
WB Saunders; 1990.) 4. Thoracic and lumbar spine—Adult characteris-
tics and size are present by age 10 with a similar
radiographic examination except for the open
2. Axis (C2) epiphyses.
• Ossification centers—The axis has four pri- • Overview—The thoracic and lumbar spine
mary ossification centers at birth. The two ossify and fuse in a similar manner.
odontoid ossification centers fuse in the mid- • Lumbar Ossification Centers—Additional os-
line by the seventh fetal month. The body and sification centers are present in the lumbar
the two neural arches are ossified at birth. spine for the mammary processes. They ap-
The secondary ossification center at the tip pear during puberty and fuse by age 25.
G. Immobilization Techniques—During initial evalua- while older children have lower cervical inju-
tion, the patient should be immobilized on either a ries. Clinical findings such as facial lacerations and
pediatric back board or a standard back board with contusion, and palpable posterior cervical defects
shoulder supports. Traction should not be used. may be clues to cervical spinal injury.
1. Rigid immobilization collars—A rigid collar with 1. Atlanto-occipital dislocation (Fig. 32-4)
access to the oropharynx and neck should be • Incidence—Atlantooccipital dislocation ac-
used. Rigid collars allow up to 17° of flexion, 19° counted for one-third of deaths from trau-
of extension, 4° of rotation, and 6° of lateral mo- matic cervical spine injuries in one series. It
tion. Motion can be decreased to 3° in each direc- is frequently associated with severe spinal
tion by supplementing with sandbags and tape. cord and brainstem injury causing respira-
2. Halo-vest immobilization—Halo-vest immobi- tory arrest. The atlantooccipital joint is a
lization may be used in patients as young as condylar joint that in the pediatric popula-
1 year of age. The thickness of the pediatric tion is almost horizontal and provides little
skull is variable and therefore pin penetration bony stability. Injury mechanism is usually a
is a potential complication. CT scan of the skull sudden deceleration causing hyperextension
should be considered to estimate skull thick- of the occipitocervical junction.
ness at potential pin sites. eight to twelve pins • Evaluation—The Powers ratio can be mea-
should be placed with torques of only 2 to 4 in- sured on the lateral cervical spine radiograph.
lb. Halo-vest restricts 75% of C1 – C2 motion. Ratio greater than 1.0 indicates anterior dis-
H. SCIWORA—SCIWORA is more common in children location and a ratio less than 0.7 indicates
than in adults because of the increased elasticity of posterior dislocation.
the vertebral column, shallow facet joints, poorly • Treatment—Associated injuries often in-
defined uncinate process, and more proximal ful- clude severe head, thoracic, and visceral
crum of cervical motion. The term was coined injuries. Initial cervical stabilization should
before MRI was available, and despite having no
radiographic abnormality, most will have an MRI
abnormality. Approximately 20% to 30% of children
with spinal cord injury have SCIWORA. There are
two peak incidences:
1. Age 8 to 10 years—Most commonly a proxi-
mal injury at the cervicothoracic junction.
Neurologic injuries in this group are usually
permanent.
2. Adolescents—Most commonly a mid-thoracic
injury that may be associated with a visceral
injury. Neurologic injuries in this group have a
better prognosis for neurologic recovery.
SCIWORA often has delayed onset of neurologic
deficit, which may take up to 4 days to manifest.
Spine precautions should be maintained until insta-
bility is ruled out. Recurrence of neurologic deficit
has been reported but it is unclear whether bracing
prevents recurrence. Outcome is correlated with
MRI findings and severity of neurologic deficit on
presentation.
I. Cervical Spine Injuries—Cervical spine fractures
account for approximately 1% of pediatric frac-
tures. The incidence is estimated to be 7.41 in
FIGURE 32-4 Atlantooccipital dislocation (large arrow).
100,000 per year. There is a 16% mortality rate
This 3-year-old child was struck by a car. Note the
associated with cervical spine fractures. Sixty
hypopharyngeal soft-tissue swelling, the dislocation of the
percent of these injuries occur in boys and 27% oc- atlantooccipital joint, and the additional injury at C2 – C3
cur during sporting activities. Other mechanisms (small arrow). This patient died. (Courtesy Dr. Tim Tyler.
of injury include motor-vehicle collisions, falls, Reprinted with permission from Sullivan JA. In: Green
and nonaccidental trauma. Children under age NE, Swiontkowski ME, eds. Skeletal Trauma in Children.
8 most commonly have upper cervical injuries 2nd ed. Vol 3. Philadelphia, PA: WB Saunders; 1998.)
be obtained with a halo vest. Traction is con- J. Fractures and Dislocations of the Thoracolumbar
traindicated. Definitive treatment requires Spine (Figs. 32-5 and 32-6)
occiput—C2 fusion. 1. Overview—The estimated incidence of thora-
2. C1 – C2 fractures columbar injuries in children is 1/17,000,000.
• C1 and C2 ring fractures—Isolated fracture of Common mechanisms of injury include mo-
the ring of C1 or C2 are rare and are usually tor-vehicle collision, falls, sports injuries, and
caused by axial loading similar to a Jefferson nonaccidental trauma. Associated injuries are
fracture in an adult. Open mouth odontoid common and may overshadow the spine in-
views will allow visualization of lateral mass jury. Most thoracolumbar injuries are around
alignment. Neurologic injury is rare because the thoracolumbar junction and are related to
the space available for the cord is preserved. a seat-belt injury. The mechanism of injury de-
Treatment is with immobilization in either termines the fracture pattern.
a cervical collar or halo-vest. Distraction 2. Compression fractures—Compression fractures
should be avoided. are usually low-energy flexion injuries causing
• Traumatic atlantoaxial instability—Acute failure of the anterior vertebral body oftentimes
rupture of the transverse ligament causing C1 at multiple levels. The superior endplate most
– C2 instability occurs in fewer than 10% of commonly fails and the posterior cortex and lig-
pediatric cervical spine injuries. The normal amentous complex remain intact. Compression
atlantodental interval is 3 mm in adults and of greater than 50% should be closely evaluated
4.5 mm in children; greater than 4.5 mm sug- for posterior ligamentous injury. Neurologic in-
gests instability, and reduction in extension jury is rare and these injuries can be managed
with immobilization in a Minerva cast, halo- with activity restriction, physical therapy, and
vest, or cervical orthosis for 8 to 12 weeks is thoracolumbar orthoses.
recommended. 3. Burst fractures—Burst fractures are rare in the
• Odontoid fractures—Odontoid fractures pediatric population. These fractures have a
represent up to 75% of cervical spine in- low incidence of neurologic injury, and stable
juries in children. In younger children, the injuries can be managed with thoracolumbar
fracture usually occurs through the synchon-
drosis at the base of the odontoid. Neurologic
injury is rare. Most displacement occurs ante-
riorly and should be reduced with extension
to obtain at least 50% apposition. Odontoid
fractures generally heal uneventfully with
6 to 8 weeks of immobilization in a Minerva
cast or halo-vest. Flexion-extension radio-
graphs should be obtained after bony union
to assess stability.
3. C3 – C7 fractures and dislocations—Subaxial
cervical spine injuries are more common in pa-
tients over 8 years of age. Injury types include
fracture-dislocations, burst fractures, simple
compression fractures, facet dislocations,
endplate fractures, and posterior ligamentous
injuries. Associated head injuries are com-
mon. Treatment should include realigning the
spinal canal and immobilization with a halo-
vest. Decompression by laminectomy has little
role in treatment. Facet dislocations require
reduction and halo-vest immobilization. Facet
fracture-dislocations are more unstable and
FIGURE 32-5 Fatal thoracic end-plate injury (arrow).
more likely to require posterior instrumenta- Note that the hemorrhage in the spinal cord extends
tion and fusion. Endplate fractures are often several levels above and below the fracture. (Reprinted
associated with neurologic injury and are very with permission from Ogden JA. In: Ogden JA, ed.
unstable but will heal well with appropriate Skeletal Injury in the Child. 2nd ed. Philadelphia, PA: WB
immobilization. Saunders; 1990.)
Management in the multi-injured patient should

include early surgical stabilization with long
posterior instrumentation.
K. Complications of Pediatric Spinal Injuries
1. Spinal cord injury—Spinal cord injury is less
common in young children than in older chil-
dren and adults. The overall incidence of spi-
nal cord injury increases 10-fold over age 14.
In patients with a spinal injury, children have
a higher incidence of spinal cord injury than
adults. There is a higher incidence of complete
neurologic injury in children than in adults.
Death from spinal cord injury occurs more com-
monly in young children than in older children
and adults.
FIGURE 32-6 Posterior epiphyseal injury (arrow) (limbus
2. Posttraumatic spinal deformity—The pediatric
fracture) that may mimic a herniated nucleus pulposus. spine has a great propensity for remodeling af-
ter injury. Children less than 10 years old with
less than 30° of wedging will typically remodel.
orthoses. Anterior vertebral growth may re- Increasing deformity in the skeletally mature
model residual kyphosis. If the injury is un- patient is unlikely to remodel. In addition, fac-
stable (posterior element injury) or if there is tors such as inadequate immobilization, unrec-
neurologic injury, posterior spinal instrumenta- ognized posterior ligamentous injury, physeal
tion and fusion is recommended. injury, crankshaft phenomenon, inadequate
4. Limbus fractures (see Fig. 32-6)—Limbus frac- length of fusion, and spinal cord injury can all
tures are posterior vertebral epiphyseal frac- contribute to the development of posttraumatic
tures, which most commonly occur in the spinal deformity. The prevalence of spinal defor-
lumbar spine. These injuries may be mistaken mity approaches 100% in children who sustain
for a herniated nucleus pulposus and if symp- a spinal cord injury prior to the age of 10 years.
toms are recalcitrant may be treated with exci- L. Summary (Table 32-1)—The incidence of spinal in-
sion of the fragment. juries in children is less than that in adults. How-
5. Flexion-distraction injuries (lap-belt injuries)— ever, children with spinal injuries are more likely
Originally coined by Chance, these injuries oc- to have complete neurologic defects. Noncontigu-
cur in the restrained child in a motor-vehicle ous multilevel spinal injuries are common in
collision. Three-point harness restrains are not children, and the identification of one fracture
protective from this injury pattern. Patients should prompt a physical and radiographic
may have a characteristic abdominal lap belt evaluation of the entire spine. Children have dis-
abrasion and a palpable posterior defect. Asso- proportionately larger heads and should be evalu-
ciated injuries are common and include small ated on a back board with either an occipital cut out
bowel perforation, jejunal transection, and aor- or shoulder supports. Most pediatric spine injuries
tic dissection. Paraplegia may be present in up may be managed with immobilization. Proper halo
to 30% of these injuries. The spine injury may be vest use in children includes the use of multiple (8
bony, soft tissue, or mixed. CT scan with sagittal to 12) pins placed at lower insertional torque. SCI-
reconstruction is helpful to detect transverse WORA is common in children and will usually show
fractures. Pure bony injuries may be treated changes on MRI. Lap belt injuries are often asso-
with immobilization. Increasing posterior soft- ciated with severe abdominal injuries and general
tissue injury results in poor long-term stability surgeons should be involved early. Traction should
and progressive kyphosis, warranting posterior be avoided in the treatment of most pediatric spi-
spinal fusion and instrumentation. Patients with nal injuries.
multiple injuries should be surgically stabilized
as soon as possible. II. Pediatric Pelvic Injuries
6. Fracture-dislocations—Thoracolumbar fracture- A. Overview—Pelvic fractures comprise only 1% to
dislocations are high-energy injuries with a high 2% of all pediatric fractures. They are most com-
incidence of neurologic injury and concomitant monly associated with high-energy mechanisms
life-threatening thoracic and abdominal injuries. such as motor–pedestrian collision, motor-vehicle
TA B L E 3 2 - 1
Injuries of the Pediatric Spine for Children 8 Years and Under
Injury Unique Findings Treatment Most Common Complication
Atlantooccipital dislocation Intercondylar distance of Immobilization and Neurologic compromise
over 5 mm arthrodesis
Atlas fracture Rare incidence Immobilization —
C2 ring fracture — Immobilization —
C1–C2 fractures Epiphysiolysis of the Immobilization —
odontoid
C3–C7 fractures Distraction injury Immobilization Spontaneous fusion
(common)
Thoracic and lumbar Apophyseal injuries and Treatment is dictated by Neurologic compromise
fractures multiple level fractures pathology
collision, and falls. Less commonly pelvic injuries cartilage, which fuses at age 15 to 18 years.
can be sustained in sporting activities. The most The ischium and pubis meet at the inferior pu-
important consideration in the evaluation and bic rami and fuse at age 6 to 7 years.
treatment of a pediatric pelvic fracture is recogni- 2. Secondary ossification centers—There are
tion of possible associated life-threatening injuries. several secondary ossification centers: iliac
The immature pelvic bone has a lower modulus of crest, ischial apophysis, anterior inferior iliac
elasticity and the sacroiliac joint and pubic sym- spine, pubic tubercle, angle of the pubis, is-
physis have increased elasticity, which allows the chial spine, and lateral wing of the sacrum. The
pelvis to absorb much greater energy before failure. iliac crest ossification center appears at age 12
Therefore, a pediatric pelvic fracture is evidence of to 14 and fuses at 16 to 18 years. The ischial
a very-high-energy mechanism and should increase apophysis appears at age 16 and fuses at age
suspicion of other injuries. In all, 58% to 87% of pe- 19. The anterior inferior iliac spine appears at
diatric pelvic fractures are associated with injuries age 14 and fuses at age 16.
to other systems such as genitourinary, neurologic, 3. Acetabular secondary ossification centers—
abdominal, and cardiopulmonary. One series found Acetabular secondary ossification centers are
the pelvic fracture to be the pediatric orthopaedic the os acetabuli, the acetabular epiphysis, and
injury with the greatest number of associated in- the secondary center of the ischium.
juries (5.2 concomitant injuries). The mortality C. Workup
rate for pediatric patients with pelvic fractures is 1. Clinical examination—Because pelvic fractures
2% to 14% and is most commonly from associated are often the result of a significant trauma,
head injuries. Hemorrhage from the pelvic fracture workup should begin with assessment of patient
accounts for a very small percentage of deaths. airway, breathing, and circulation. This should
Outcomes are generally associated with the con- be followed by a systems-based evaluation to
comitant injuries and once these are addressed, identify injuries to the head, chest, abdomen,
pediatric pelvic fractures usually require minimal genitourinary tract, and appendicular skeleton.
treatment and have a good prognosis. Ecchymosis and crepitus over the iliac crest, pu-
B. Pelvic Ossification Centers—Appreciation of the bis, and sacrum as well as hematuria or rectal or
location and ages of appearance of pelvic ossifi- vaginal bleeding may be signs of a pelvic fracture.
cation centers helps to better understand pedi- 2. Radiographic examination—Patients involved
atric pelvic fracture patterns. Apophyseal and in high-energy trauma or with clinical signs
physeal cartilage are weaker than ligamentous suspicious of a pelvic injury should have an
attachments and are more likely to fracture. This AP pelvis X-ray. Once the patient is stabilized
creates different injury patterns in the pediatric and life-threatening injuries are treated, Judet
pelvis than in the adult pelvis. view, inlet and outlet views, and a CT scan
1. Primary ossification centers—There are three may be considered. Radiographic evidence of
primary ossification centers: ilium, ischium, a pelvic fracture should increase the treating
and pubis. They are joined at the triradiate team’s suspicion of associated injury.
D. Classification of Pediatric Pelvic Fractures—Pe- G. Fractures of the Pubis or Ischium (Fig. 32-8)—Pu-

diatric pelvic fractures may be classified by con- bic rami fractures are caused by high-velocity
comitant injuries, fracture severity, prognosis, or trauma and may have significant associated
skeletal maturity. injuries. Death occurred in 2% of cases in one
1. Quinby and Rang classification addresses prog- series. These fractures represent approximately
nosis based on soft-tissue injury. It includes un- 38% of pediatric pelvic fractures and are most
complicated fractures, fractures with visceral commonly caused by motor-vehicle collisions
injuries requiring surgical exploration, and or motor-vehicle–pedestrian collisions. Unlike
fractures with immediate massive hemorrhage. adults, isolated pubic and ischium fractures are
2. Torode and Zieg classification is based on se- seen in pediatric patients secondary to the in-
verity and stability of fracture. creased elasticity of the immature pelvis. They
• Avulsion fracture are mechanically stable because the pelvic ring
• Iliac wing fracture is not broken and treatment involves bedrest and
• Simple ring fracture progressive weightbearing.
• Ring disruption—Producing an unstable H. Iliac Wing Fractures (Duverney Fracture)—Iliac
segment wing fractures represent approximately 16% of pe-
3. Silber and Flynn classification is based on skel- diatric pelvic fractures. It may occur as an isolated
etal maturity, and it predicts ability of the frac- fracture (46%) or in combination with other frac-
ture to remodel without operative intervention. tures of the pelvis. The most common etiology is
• Immature—Open triradiate cartilage direct lateral compression from a vehicular pedes-
• Mature—Closed triradiate cartilate trian collision (88%). Associated injuries are com-
E. Treatment of Pediatric Pelvic Fractures—Life- mon and should be sought out. Death occurred in
threatening injuries are the primary focus. The 4% of cases in one series. Displacement is usually
pelvic fracture itself is of low priority in the criti- mild, and reduction is not necessary as the frac-
cal care of the child with multiple traumas and tures usually unite without sequelae. Treatment
may be addressed after the patient is stabilized. consists of bedrest and progressive weightbearing.
If the patient is hemodynamically unstable and I. Sacral Fractures—Sacral fractures represent ap-
other sources of bleeding have been ruled out, proximately 6% of pediatric pelvic fractures.
a pelvic binder, sling, or external fixator may be They may be isolated or may occur in combina-
used to stabilize the pelvis and decrease pelvic tion with anterior pelvic fractures. CT scan can
volume. This may be followed by arteriogram be used to evaluate for sacroiliac subluxation or
and embolization. Hemodynamic instability due dislocation. Associated sacral nerve injuries that
to the pediatric pelvic fracture is much less com- result in bowel or bladder dysfunction are rare.
mon than in adults. Definitive management of the Treatment consists of progressive weightbearing.
pelvic fracture itself is often different from that J. Coccygeal Fractures—Coccygeal fractures usu-
in adults secondary to the remodeling capacity ally result from direct falls on the buttocks.
of the immature pelvis. In general, most pediat- Associated injuries are rare. Manipulation is
ric pelvic injuries are treated with protected and unnecessary, and long-term sequelae are rare.
progressive weightbearing. However, some stud- Treatment consists of progressive weightbearing.
ies have suggested specific guidelines for reduc- K. Single Breaks of the Pelvic Ring—In the skeletally
tion such as (a) articular or triradiate cartilage immature patient, the mobility of the sacroiliac
displacement of greater than 2 mm, (b) pelvic ring joint and pubic symphysis and the increased elas-
disruptions causing more than 2 cm leg length ticity of bone allow for a single break in the pelvic
discrepancy, and (c) fractures with more than 1.1 ring to occur. Single breaks in the pelvic ring can
cm of pelvic asymmetry. occur as two ipsilateral pubic rami fractures, or
F. Avulsion Fractures (Fig. 32-7)—Avulsion fractures fracture or subluxation near the symphysis pubis
are usually of the secondary ossification centers or near the sacroiliac joint. Given the ability of
and occur with low-energy mechanisms such as the immature pelvis to withstand large forces, the
forceful concentric or eccentric contractions of presence of these injuries suggests considerable
the attached muscles. The ischium (38%), anterior trauma and the likely presence of associated life-
superior iliac spine (32%), and anterior inferior il- threatening injuries.
iac spine (18%) are the most common sites. Treat- 1. Ipsilateral pubic rami fractures—Ipsilateral
ment involves rest and protected weightbearing. pubic rami fractures represent 8% to 16% of
Results are not improved with open reduction and pediatric pelvic fractures. These fractures are
internal fixation. usually mechanically stable, but often have
FIGURE 32-7 Avulsion
fracture patterns (arrows) of
Anterior superior
the iliac and ischial regions.
iliac spine These fractures occur where
secondary ossification centers
normally develop.
Anterior inferior
iliac spine
Ischium
reduction with traction, external, or internal

fixation. Stable fractures may be treated with
progressive weightbearing.
3. Sacroiliac joint fracture or subluxation—Sacro-
iliac joint fracture or subluxation rarely occurs
as an isolated injury. It is usually associated
with an anterior pelvic fracture or dislocation,
which may result in mechanical instability.
Apparent sacroiliac joint subluxation may be
proven by CT scan to actually be a fracture
through subchondral physeal cartilage. Iso-
lated, stable fractures or subluxations should
be treated with progressive weightbearing.
Rami Unstable fractures may require reduction with
internal fixation or a spica cast.
L. Double Breaks of the Pelvic Ring—Double breaks
of the pelvic ring are due to high-velocity trauma.
FIGURE 32-8 Stable fracture of the ischiopubic rami. They are differentiated from single breaks because
of their instability. There is a very high incidence
major life-threatening associated injuries such of associated soft-tissue injury and visceral injury.
as head, genitourinary, abdominal, and cardio- 1. Bilateral fractures of the inferior and superior
vascular injury. The most common mechanism pubic rami (Straddle fractures)—Straddle frac-
of injury is motor-vehicle–pedestrian. Treat- tures are vertical inferior and superior pubic
ment of the fractures consists of progressive rami fractures on both sides of the pubic sym-
weightbearing. physis. Alternatively, it may be a unilateral in-
2. Pubic symphysis fracture or subluxation— ferior and superior pubic rami fracture with a
Fractures near or subluxation of the pubic dislocated pubic symphysis. Both fracture pat-
symphysis represents approximately 3% of pe- terns render an unstable floating anterior seg-
diatric pelvic injuries. This injury often occurs ment. These injuries are usually caused by a
in combination with a posterior pelvic ring in- fall while straddling an object or a lateral com-
jury. Genitourinary injuries must be ruled out. pression force and are commonly associated
More than 1 cm difference on lateral compres- with bladder or urethral disruption. Fractures
sion X-rays may indicate subluxation of the will heal with conservative treatment and re-
symphysis pubis. One report suggests that di- modeling usually corrects displacement. Pelvic
astasis greater than 2.5 cm or rotation greater sling is contraindicated as it may increase dis-
than 15° implies instability and the need for placement of the floating fragment. Treatment
includes bedrest in the semi-Fowler position fragments may lacerate viscera or the arterial
followed by progressive weightbearing. tree. Initial treatment should focus on associ-
2. Malgaigne fractures (Fig. 32-9)—Malgaigne frac- ated injuries and control of pelvic hemorrhage
tures include all fractures of the posterior arch with external fixation and embolization if nec-
in combination with fractures or dislocations essary. Mechanical instability of the pelvic
of the anterior arch. These fractures represent fracture may be addressed with internal or
approximately 17% of all pediatric pelvic frac- external fixation after the patient is stabilized.
tures. Most are the result of motor-vehicle–pe- M. Acetabular Fractures—Pediatric acetabular
destrian collisions. These unstable fractures fractures are less common than in adults, repre-
are associated with retroperitoneal and intra- senting approximately 9% of pediatric pelvic frac-
peritoneal hemorrhage as well as associated tures. Mechanism is similar to that in adults as
injuries. Hemodynamic instability may require the force is transmitted through the femoral head
a pelvic sling or external fixation to stabilize to the acetabulum causing fracture and disloca-
the fracture and decrease pelvic volume. Ini- tion. High-energy mechanisms often have major
tial treatment of the fracture depends on the associated injuries.
amount of displacement and may require trac- 1. Small fragment acetabular fractures associated
tion if there is vertical instability or leg length with hip dislocation—Small fragment acetabu-
discrepancy. Definitive treatment is usually lar fractures are seen in conjunction with hip
nonsurgical in skeletally immature patients. dislocations. The majority of pediatric hip dis-
Unstable fractures that have failed nonsurgi- locations are posterior and may be associated
cal management and fractures in skeletally with posterior wall acetabular fractures and
mature patients often require open reduction anterior capsulolabral avulsions. The goal of
and internal fixation as is often used in adults. treatment is to obtain congruent reduction and
Increasing pelvic asymmetry and leg length prevent recurrent dislocation. CT scan should
discrepancy after fracture union has been as- be performed after reduction of the dislocation
sociated with poorer long-term outcomes. to ensure congruency. When a fracture frag-
3. Pelvic crushing and open injuries—Crush in- ment is incarcerated in the reduction causing
juries cause marked distortion of the pelvis incongruency, arthrotomy, and open reduction
and can be associated with massive hemor- is indicated. Open reduction is often performed
rhage. One series of crushed open pelvis inju- from the direction of the dislocation. Postopera-
ries reported a mortality rate of 20%. Mobile tive care includes protected weightbearing and
hip dislocation precautions for 6 to 8 weeks.
2. Undisplaced stable linear acetabular frac-
True sacroiliac joint tures—Stable linear acetabular fractures are
Sacroiliac separation caused by pelvic compression injuries and of-
ten occur in association with pelvic fractures.
These fractures may be treated nonoperatively
with protected weightbearing.
3. Triradiate cartilage fractures (Fig. 32-10)—
Triradiate cartilage fractures may result in
growth disturbance leading to acetabular dys-
plasia. Patients younger than age 10 at the time
of injury have more remaining growth and are
therefore more likely to develop dysplasia. Tri-
radiate cartilage injuries occur as Salter-Harris
Types I, II, or V fractures. Types I and II frac-
tures have a favorable prognosis for normal ac-
Shift
etabular growth. Crushing Type V injuries have
a poor prognosis and often develop a medial
osseous bridge, which may result in an acetab-
Symphysis ular growth deformity. Open reduction should
FIGURE 32-9 Unstable Malgaigne fracture of the be considered with triradiate cartilage dis-
immature pelvis. The true sacroiliac joint is intact but placement of greater than 2 mm. Nondisplaced
a chondroosseous separation occurs on the iliac side, injuries are treated with protected weightbear-
mimicking a sacroiliac disruption radiographically. ing and early range of motion.
FIGURE 32-10 Triradiate cartilage

growth arrest leading to a shallow
acetabulum. Dark arrows indicate
growth, and white arrows indicate
acetabular size.
4. Linear fractures with hip joint instability—Lin- osteonecrosis, loss of reduction, arthrosis, and
ear fractures with hip instability may cause ar- sciatic nerve injury. Leg length discrepancy after
ticular incongruity or injury to the triradiate fracture union has been associated with low-back
cartilage. Early management includes restoring pain. Triradiate cartilage injury can result in ac-
acetabular congruity and hip stability. Open re- etabular dysplasia. Open reduction of fractures
duction should be performed for displacement may result in heterotopic bone formation.
greater than 2 mm. Late sequelae may include O. Summary (Table 32-2)—Given the ability of the
instability, arthrosis, and acetabular dysplasia. pediatric pelvis to absorb tremendous energy
5. Central fracture-dislocation of the hip—Central before failure, the presence of a fracture sug-
fracture-dislocation of the hip may cause severe gests that the patient has sustained a violent
articular injury and may grossly disrupt the high-energy injury and should alert the treat-
triradiate cartilage. These injuries may be as- ing physician to the possibility of associated
sociated with severe life-threatening soft-tissue life-threatening injuries. Such injuries should
and visceral injuries. Central fractures often be identified and treated primarily. Once the pa-
have poor outcomes, regardless of treatment tient is stabilized, most pediatric pelvic fractures
modality. Displacement of articular or physeal require minimal treatment. The immature pelvis
surfaces greater than 2 mm should be reduced has significant remodeling capacity and treat-
by either closed or open reduction. Open re- ment decisions should be based on patient age
duction is often associated with heterotopic as well as fracture or pelvic stability. Stable in-
bone formation. Long-term sequelae include juries such as avulsion fractures, single-ring dis-
osteonecrosis, acetabular dysplasia, leg length ruptions, and nondisplaced acetabular fractures
discrepancy, arthrosis, and sciatic nerve injury. may be managed with protected weightbearing.
N. Complications of Pelvic Fractures—General com- Unstable and widely displaced fractures may re-
plications of pelvic fractures include sacroiliac quire open or closed reduction with or without
and pubic symphyseal pain, nonunion, malunion, fixation.
TA B L E 3 2 - 2
Injuries of the Pediatric Pelvis
Fracture Type Associated Injuries Treatment Comments
Avulsion Secondary — Rest and crutches Callus or avulsed
ossification apophysis is
center injuries rarely symptom-
atic
Pubis or ischium Stable high-velocity Significant Bedrest and —
fracture progressive
weightbearing
Iliac wing (Duverney) — Common Bedrest and progressive —
weightbearing
(Continue)
TA B L E 3 2 - 2
Injuries of the Pediatric Pelvis (continued)
Fracture Type Associated Injuries Treatment Comments
Sacrum — Possibly combined Bedrest There are no
with an anterior reports of
fracture (double associated nerve
break) injuries
Coccyx — No associated No manipulation Impairment is not
injuries prolonged
Single breaks of the Ipsilateral pubic Common Bedrest —
pelvic ring rami fracture
Fracture near the Common Bucks traction, Lateral compression
symphysis pubis pelvic sling, or cast X-ray films are
immobilization diagnostic of
subluxation
Fracture near the Common Avoidance of further An associated
sacroiliac joint displacement anterior pelvic
fracture should be
sought
Double breaks of the Straddle fracture Bladder or urethral Bedrest in the This is the most
pelvic ring disruption semi-Fowler dangerous type
position, avoidance of pediatric pelvic
of lateral fracture
compression
Malgaigne fracture Common Bedrest, traction, —
ORIF or external
fixation
Multiple pelvic Visceral lacerations, Acute injury with Survival is rare
crushing injuries arterial tears external fixation
Acetabulum Small-fragment Hip dislocation Open reduction if the —
fracture joint is incongruous
Undisplaced stable Possible involvement Bedrest Acetabular dysplasia
linear fracture of the triradiate may occur
cartilage
Linear fracture Possible involvement Restoration of Acetabular dysplasia
with hip joint of the triradiate acetabular congruity may occur
instability cartilage
Central fracture- Involvement of Open reduction Most patients do
dislocation the triradiate if reduction is poorly
cartilage unacceptable after
closed treatment
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Kellum E, Creek A, Dawkins R, et al. Age-related patterns of Smith W, Shurnas P, Morgan S, et al. Clinical outcomes of un-
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INDEX
A Allergic reaction to transfusion, 10–11 Anterior approach, 235, 255

Abbreviated Injury Score (AIS), 8, 9 Allis and Bigelow techniques, hip posterior pelvic ring fixation and, 220
Abdomen dislocations and, 251–252 thoracolumbar spine fractures and, 448
injuries evaluation of, 213 Allografts, 29, 182, 450 Anterior C1-C2 fusion, 432
trauma, 6–7 Alternating current (AC), fracture healing Anterior cervical surgery, 431–432,
Abdominal viscera, injuries to, 460 and, 28 435–436
Abrasive wear mechanisms, biomaterials Aluminum oxide, bone grafts and, 29 Anterior column fractures, acetabulum
and, 61 American Spinal Injury Association fractures and, 231, 241–242
Absorptiometry, 31 (ASIA), 390, 443 Anterior compression screw fixation, 432
AC; see Alternating current AMPLE, 3 Anterior cord syndrome, 395
Acetabular fractures, 519–520 Amputation, 21 Anterior cranio-cervical membranes, 419
hip dislocations and, 248 in children, 484 Anterior cruciate ligament (ACL)
Acetabular labrum injuries, 249 hand injuries and, 380–381 tears, 474
Acetabular secondary ossification thumb, 380–381 Anterior decompression of C1 or C2, 432
centers, 516 tibial shaft fractures and, 151 Anterior deltopectoral approach, scapula
Acetabulum fractures, 224–242, 519–520 Anderson and D’Alonzo classification, of fractures and, 264
bony anatomy, 224, 225, 226, 227, 228 odontoid fractures, 408, 409 Anterior fusions, cervical spine trauma
classification of, 225–232 Anderson and Montesano classification, and, 432
complications of, 242 of occipital condyle fractures, 407 Anterior glenohumeral dislocations, 275
treatment of, 232–242 Anemia, sickle cell, 32 Anterior implant biomechanics, cervical
Achilles tendon rupture, 183–184 Anesthesia spine trauma and, 432
Acquired resistance, 9 cervical spine trauma and, 430–431 Anterior interosseous nerve (AIN),
Acromioclavicular (AC) joint injuries, of face, Dejerine pattern of, 393–394 493, 495
267–269, 488–489 femoral neck fractures and, 68 Anterior longitudinal ligament, subaxial
Acromion fractures, 264 Aneurysm, false, hand injuries and, 378 cervical spine and, 407
Active motion, elbow dislocations Angiographic embolization, pelvic Anterior neck exposures, cervical spine
and, 306 fractures and, 219 trauma and, 435–436
Acute central disc herniation, 396 Angular deformity, 52 Anterior neck fusion, cervical spine
Acute hematogenous osteomyelitis, 32 distal femoral metaphysis and epiphysis trauma and, 436
Acute injection, hand injuries and, 379 fractures and, 472 Anterior plate fixation, cervical spine
Acute osteomyelitis, 32 femoral shaft fractures and, 471 trauma and, 432
Acute phase, of soft-tissue injuries measurement of, 45–46 Anterior process calcaneus fractures, 198
associated with fractures, 21–22 shaft of tibia and fibula fractures Anterior pubic symphysis plating, pelvic
Acute respiratory distress syndrome and, 478 fractures and, 219–220
(ARDS), 81, 460 Angular femoral malunion, 86 Anterior roof arc (ARA), acetabulum
Acute spinal cord injury, Angular malalignment, femoral shaft and fractures and, 227, 228
methylprednisolone therapy for, 399 subtrochanteric region fractures Anterior talofibular ligament (ATFL), 175,
Acute tubular necrosis, 7 and, 85 176, 181
Adhesive wear mechanisms, biomaterials Angulation, tibial shaft fractures Anterior tibial artery, talus fractures and
and, 61 and, 147 dislocations and, 187
Adson test, 290 Anisotropic properties Anterior wall fractures, acetabulum
Adults biomaterials and, 60 fractures and, 229, 231, 241–242
acute hematogenous osteomyelitis of bone, 61 Anteroinferior tibiofibular ligament
and, 32 Ankle (AITFL), thickening of, inversion
hip fractures in, 66 bony injuries of, 175–180 ankle injury and, 177, 182
tachycardia in, 3 fracture-dislocations of, 184 Anterolateral approach, talar neck
Advanced trauma life support (ATLS), fractures of, 480–481 fractures and, 191
2–3, 17, 146, 213, 420, 441 injuries of, 175–184 Anteromedial approach, talar neck
Aggressive debridement, 206 instability, chronic lateral, foot and fractures and, 191
Airway ankle injuries and, 182 Anteroposterior (AP) femoral anatomic
in primary survey, 2–3 soft-tissue injuries of, 180–183 axis, 40
resuscitation and, 3 Ankle impingement, anterior, calcaneal Anteroposterior radiograph, of
supracondylar femoral region fractures fractures and, 197 pelvis, 245
and, 88 Ankle mortise, restoration of, 179 Anteroposterior tibial anatomic axis, 40
Alar ligaments, 406, 419, 424 Ankle spasms, lateral, 198 Anteroposterior view, of pelvis, 213
Algorithm Ankle sprains, 180–182 Antibiotic beads, 9–10
for hip dislocation, 250 Ankylosing conditions, cervical spine Antibiotic-impregnated
for isolated proximal humerus trauma and, 434 polymethylmethacrylate (PMMA)
fractures, 275 Ankylosing spondylitis, 436–437 beads, 152–153
Alignment, tibial shaft fractures and, 147 Antegrade piriformis starting point, Antibiotic-resistant bacteria, 9–10
Allen and Ferguson classification, of femoral shaft and subtrochanteric Antibiotics, 9–10
injuries involving lower cervical region fractures and, 83 action of, 11
spine, 410 Anterior ankle impingement, calcaneal indications and side effects, 10
Allen’s test, 378 fractures and, 197 lawnmower injuries and, 206
523
524 INDEX
Antibiotics—Continued Articular margin fractures, 331 Basilar neck fractures, 74

open fractures and, 20–21 Articular multifragmentary fractures, 165 Beck’s triad, 6
in children, 461 Articular surface, displacement of, tibial Bending loads, biomechanics and, 56
tendon sheath infections and, 384 plateau fractures and, 139 Berndt and Harty classification, of
tibial shaft fractures and, 152–153 Articulation between distal radius and osteochondral lesions of talus, 193
AO classification ulna, 323 Biceps brachii transection, soft-tissue
of thoracolumbar spine fractures, 445 ASIA/IMSOP impairment scale, spinal injuries of shoulder and, 285
of tibial plateau fractures, 136 cord injury and, 390–391 Biceps tendon, dislocation of, 284
AO principles of fracture care, 25 Atasoy flap, fingertip injuries and, 381 Bicycle spoke injuries, 479
AO/ASIF classification ATFL; see Anterior talofibular ligament Bilateral injuries, 81
of cervical spine trauma, 428 Atlanto-Dens interval (ADI), 408, 421, 422 Bimalleolar fractures, 176–178
of malleolar fractures, 175, 178 Atlanto-occipital dislocation (AOD), 407, Bimanual compression, pelvic fractures
of thoracolumbar spine fractures, 445 425, 513–514 and, 213
of tibial plafond fractures, 164–165 Atlanto-occipital injuries, 434 Biocora, 29
of wrist fractures, 326, 328 Atlantoaxial instability, 426 Biologics, of tibial shaft fractures, 153
AOD; see Atlanto-occipital dislocation Atlantoaxial joint, 407 Biomaterials, 58–63
AO/ORIF classification, of tibial plafond Atlantoaxial rotatory subluxation, 408 biomechanics and, 54–63
fractures, 173 Atlas bone as, 61–63
Aortic disruption, 6 fractures, 407–408 Biomechanics, 54–58
AP view; see Rotational anteroposterior injuries involving, 407–409 and biomaterials, 54–63
view malunion of, 436 cervical spine trauma and, 431–434
Apatite crystals, 29 nonunion of, 436 distal radius fractures and, 323
Ape-hand deformity, 320, 321 pediatric spinal injuries and, 511–512 fractures and, 462
Apical ligament, 419 Atrophic nonunion, fractures and, 32, 158 patellar dislocation and, 124
odontoid process and, 406 Autograft, 29, 450 patellar tendon rupture and, 120
Arachnoid matter, 388 Autoimmune diseases, cervical spine scapula fractures and, 262
Arachnoiditis, chronic posttraumatic trauma and, 428 solving basic problems of, 54–55
syndromes and, 396 Autonomic recovery, spinal cord injury Bite injuries, 15, 16
Arbeitsgemeinschaft für and, 401–403 Blackburne and Peele index, patellar
Osteosynthesefragen; see AO entries Avascular necrosis (AVN), 35 dislocation and, 128, 129
Arc, electrical injuries and, 8 of carpal bones, 337–338 Bladder
Arterial injuries hip dislocations and, 255, 256, 260 pelvic fractures and, 212
hip dislocations and, 249 hip fractures in children and, 468 spinal cord injury and, 401–402
wrist fractures and, 327 proximal humerus fractures and, 276 Blatt capsulodesis, 342
Arteriography scaphoid fractures and, 336 Bleeding, intertrochanteric fractures
hand injuries and, 378 Aviator’s astragalus, 188–191 and, 74
knee dislocations and, 100 Avulsion Blocking screws, 155
proximal humerus fractures and, fractures, 24, 517 Blood administration, pelvic fractures
273–274 minimally displaced, of cuboid, 200 and, 218
Arthritis proximal fifth metatarsal fractures Blood pressure, pediatric trauma and, 459
hip dislocations and, 255 and, 204 Blood supply
degenerative, 260 of intercondylar eminence, 136 to femoral head, hip dislocations and,
knee dislocation and, 110 knee dislocation and, 101, 104 253–254
posttraumatic, 242, 260; see also Axial compression, thoracolumbar spine of scaphoid, 333
Posttraumatic arthritis fractures and, 438 spinal cord and, 388–389
pre-existing knee, 92 Axial disruption patterns, 339, 345 talus fractures and dislocations and, 187
septic, 384 Axial loading, 55–56, 428 Blood transfusion; see Transfusion
Arthrodesis burst fractures and, 413 Blumensaat’s line, patellar dislocation
ankle fractures and, 180 tibial plafond fractures and, 162, 163 and, 128
proximal humerus fractures and, 276 Axillary nerve, acute dislocations of Blunt abdominal injuries, 7
Arthrofibrosis, acute dislocations of shoulder and, 278, 283 Blunt cardiac injury, 6
shoulder and, 283 Axis BMP; see Bone morphogenetic protein
Arthrography, 347 injuries involving, 407–409 Body fractures of calcaneus, 199
Arthroplasty pediatric spinal injuries and, 512 Bone
failed, femoral neck fractures and, 71 ring fractures of, 436 allograft, 30
volar plate, fracture-dislocation of PIP traumatic spondylolisthesis of, 408–409 as biomaterial, 61–63
joint and, 358 Axonal sprouting, nerve regeneration density, measurement of, 31
Arthroscopy and, 376 fracture healing and, 26–28
acute dislocations of shoulder and, 280 Axonotmesis, 376 fractures and, 462
distal radius fractures and, 332 growth factors of, 27
DRUJ injuries and, 347 infection, 32–35
surgery, delayed, knee dislocation B injuries, 23–35
and, 109 Bacteria, antibiotic-resistant, 9–10 of ankle, 175–180
tibial plateau fractures and, 139–140 Bado classification hip dislocations and, 248
Arthrosis forearm injuries and, 318 scan, 242
patellar, 117 of Monteggia fracture-dislocation, 504 cervical spine trauma and, 424
posttraumatic; see Posttraumatic Ballistics, penetrating injuries of spine fractures and, 30–31
arthrosis and, 414 reflex sympathetic dystrophy and, 385
subtalar, calcaneal fractures and, 197 Ballottement, carpal dislocations and, 342 types of, 24
Arthrotomy, 141 Bankart lesions, 278 Bone grafts, 28–30
Articular capsules, 419 Bankart reconstruction, acute both-bone forearm fractures and, 318
Articular fractures, complex, 331–332 dislocations of shoulder and, 283 cervical spine trauma and, 431
Articular impression fractures, 276 Barton’s fracture, 324 distal radius fractures and, 330
INDEX 525
scaphoid fractures and, 334–335 Calcaneofibular ligament (CFL), injuries stabilization of, in children, 459
tibial plateau fractures and, 140 and ankle and, 175, 181 stenosis, spondylotic, 428–429
Bone loss Calcaneus subaxial, 406–407
fracture with, 23–24 anterior process fractures of, 198 upper; see Upper cervical spine
open fractures and, in children, 461 body fractures of, 199 Cervical spine trauma, 418–437
Bone matrix gelatin, 30 tuberosity fractures of, 198 anatomic considerations in, 431–434
Bone morphogenetic protein (BMP), 27, Calcium carbonate, 29 associated injuries, 428–429
29, 30 Calcium phosphate, 29, 241 biomechanical considerations in,
Bone plates, 58 Calcium sulfate, 29 431–434
Bone screws, 58 Callus, bridging, fracture repair and, 26 complications of, 434–435
Both-bone forearm fractures, 316–318 Cancellous bone grafts, 28 treatment of, 435–436
Both-column fractures, acetabulum Cannulation, hand injuries and, 378 deformities, 436
fractures and, 231, 242 Capitate fractures, 337 evaluation of, 420–424
Boundary layer lubrication mechanisms, Capitellum fractures, 302 injury classification, 424–428
biomaterials and, 60 Capsular ligaments, SC joint injuries and, malunion, 436
Boutonnière deformity, 373, 374–375, 386 269 nonunion, 436
Bowel function, spinal cord injury and, Capsule, hip dislocations and, 254 operative techniques in, 431–434
401–402 Capsulodesis, Blatt, carpal dislocations special circumstances, 436–437
Boxer’s fracture, 363, 507 and, 342 treatment of, 429–431
Brace Capsulotomy, 68, 258, 260, 283 Cervicomedullary syndrome, 393
cervicothoracic, cervical spine trauma Cardiac tamponade, 6 Cervicothoracic braces, cervical spine
and, 429 Cardiogenic shock, 4 trauma and, 429
functional, foot and ankle injuries Carpal bones Cervicothoracic injuries, 434
and, 181 avascular necrosis (AVN) of, 337–338 Cervicothoracic orthoses (CTO), 446
skeletal, femoral shaft and fractures of, 332–338 CFL; see Calcaneofibular ligament
subtrochanteric region fractures Carpal dislocations and instability, 336, Chance fractures, 413, 445
and, 82 338–345 Chauffeur’s fracture, 324, 326
Brachial artery injury, dislocation of Carpal fractures, 337, 507 Chemical burns, 8, 383
elbow and, 500 Carpal instability adaptive (CIA), 340 Chest, flail, 6
Brachial plexus injuries, 285–288 Carpal instability complex (CIC), 340 Child abuse
Brackish water/shellfish exposure, 16 Carpal instability dissociation (CID), 339 fractures and, 461
Brain injury, 5–6 Carpal instability nondissociative (CIND), multiple injuries and, 458
Breathing 339–340 pediatric trauma and, 461
primary survey and, 2–3 Carpal ligament injury wrist fractures shaft of tibia and fibula fractures and,
resuscitation and, 3 and, 327 479
supracondylar femoral region fractures Carpometacarpal (CMC) joint, dislocation Children; see pediatric entries
and, 88 of, 360–362 Chronic lateral ankle stability, foot and
Brewerton X-ray view, metacarpal Carpometacarpal joint, 360–362 ankle injuries and, 182
fractures and, 363 Carpus, vulnerable zone of, 337 Chronic multifocal osteomyelitis, 34
Bridging, fractures and, 25, 26 Carrying of objects at arm’s length, Chronic osteomyelitis, 32–34
Broström procedure, modified, foot and biomechanics and, 55 Chronic posttraumatic syndromes,
ankle injuries and, 182 Cast 396–397
Brown-Séquard syndrome, 395, 416 fractures and, 24 Chronic sclerosing osteomyelitis, 34
Brumback et al’s classification, of hip plaster, distal radius fractures and, 330 CIA; see Carpal instability adaptive
dislocations, 247, 256 thumb radial collateral ligament injury CIC; see Carpal instability complex
Bucholz classification, of pelvic and, 359 CID; see Carpal instability dissociation
fractures, 214 Cauda equina syndrome, 396, 440 CIND; see Carpal instability
Bucket-handle metaphyseal Cavitation, penetrating injuries of spine nondissociative
fractures, 479 and, 414 Circular external fixators, fractures and,
Buckle fractures, 506 CD4 cells, HIV infection and, 12 58
Bullets in spinal canal, 416 Cell body, nerve regeneration and, 375 Circulation
Bunnell-type repair of patellar tendon Cellulitis, 14 primary survey and, 2–3
rupture, 120 Central cord syndrome, 394–395, 411 resuscitation and, 3
Burns, 7, 382–383 Central fracture-dislocation of hip, 520 supracondylar femoral region fractures
Burst fractures, 410, 413, 514–515 Central nervous system, foot and ankle and, 88
thoracolumbar spine fractures and, injuries and, 207 Clamp
452–454 Central slip injuries, 357 pelvic fractures and, 219
vertebral, 439 Central slip rupture, 374–375 posterior column fractures and, 241
Butterfly fragment Centroid, biomechanics and, 56 Clavicle
fracture with, 24 Ceramics anatomy, 265
transverse fracture with, 63 corrosion of, 61 congenital pseudoarthrosis of, 487
molecular structure of, 60 fractures of, 265–267
Cerebrospinal fluid-cutaneous fistulas, functions of, 265
C gunshot wounds to spine and, 416 injuries of, 487
C-clamps, pelvic fractures and, 219 Cervical laminectomy, 431 Claw toes, 206
C1-C2 subluxation, 408 Cervical spine Clawhand deformity, 320
C1 ring fracture, 425–426 complications of, 434–435 Cleidocranial dysostosis, 487
C1 to C2 fractures, 514 injuries of, 407–411, 513–514 Closed diaphyseal fractures, 478
C2 ring fracture, 426–427 severity score, 428 Closed fractures, 20
C3 to C7 fractures and dislocations, loss of alignment of, 435 in children, 460
512, 514 lower; see Lower cervical spine tibial plafond fractures and, 162, 165
Calcaneal fractures, 194–198, 482–483 protection of, airway with, 2 Closed internal degloving injuries, pelvic
Calcaneocuboid subluxation, 200 proximal humerus fractures and, 272 fractures and, 221
526 INDEX
Closed nerve injuries, 377 cervical spine trauma and, 423 Croutons, 30
Closed reduction and percutaneous clavicle fractures and, 265 Crown of death, acetabulum fractures
pinning (CRPP) technique DRUJ injuries and, 347 and, 239
lateral condyle fractures and, 497 elbow dislocations and, 305 Cruciate ligament, 419
supracondylar fractures and, 493–494 fractures and, 31 knee dislocation and, 104
Closed reduction, hip dislocations and, of hip, 237 Cruciate paralysis of Bell, 394
250–251 hip dislocations and, 245, 246 Crush injuries of foot, 208
Clostridium tetani, tetanus and, 11 patellar dislocation and, 128 Crystalloid solution, pelvic fractures
CMC joint; see Carpometacarpal joint pediatric trauma and, 459 and, 218
Coccygeal fractures, 517 pelvic fractures and, 213 CT; see Computed tomography
Codvilla tendon-lengthening technique, 124 proximal humerus fractures and, 273 Cubitus varus
Cold flow, biomaterials and, 60 scapula fractures and, 262 lateral condyle fractures and, 497
Cold injuries, 8 sternoclavicular (SC) joint injuries and, supracondylar fractures and, 495
Collagraft Bone Graft Matrix, 29 270, 271 Cuboid
Collars, neck, cervical spine trauma thoracolumbar spine fractures and, injuries of, 200
and, 429 443–444 minimally displaced avulsion fractures
Collateral ligaments, 353 tibial plafond fractures and, 162 of, 200
and capsule tibial plateau fractures and, 136 Cuneiform fractures, 200
knee dislocation, 104 wrist fractures and, 326 Cutaneous neuromas, calcaneal fractures
repair, tibial plateau fractures and, 136 Concussion, 4, 5 and, 198
sprains Conduction, electrical injuries and, 8
ligamentous injuries of knee, 474–475 Congenital pseudoarthrosis
of PIP joint, 356–357 of clavicle, 487 D
Colles’ fracture, 324, 325 of tibia, 479 Dall approach, hip dislocations and, 254
Columnar, intra-articular fractures, 301 Congruence angle of Merchant, patellar Dameron and Rockwood classification, of
Comminution, 23, 165 dislocation and, 127–128 injuries of acromioclavicular joint, 488
Common iliac artery, pelvic fractures Congruency, hip dislocations and, 253 Dancer’s fractures, 205
and, 211 Construct failure, 452 Danis-Weber classification, of malleolar
Commotio cordis, 6 Contaminated fractures, of tibial shaft fractures, 175, 178
Compartment pressure, tibial shaft fractures, 152 DBM; see Demineralized bone matrix
fractures and, 144 Contiguous compression fractures, 452 DC; see Direct current
Compartment syndrome, 14, 206 Contusion Deafferentation pain, chronic
and ankle, 206 crush injuries of foot and, 208 posttraumatic syndromes and,
diaphyseal forearm fractures and, 503 intracerebral, 5–6 396–397
femoral shaft and, 471 pulmonary, 6 Debridement, 21–22
forearm injuries and, 319 quadriceps, 132–133 aggressive, 206
injuries of foot, 484 Conus medullaris syndrome, 388, 395–396 of open fractures, 96
knee dislocation and, 100 Coracoacromial (CC) ligament, 268, 284 timing of, 13
shaft of tibia and fibula fractures fixation of, 269 Decompression, spinal, 446–449
and, 478 Coracoid fractures, 264 Deep venous thrombosis (DVT), 13
supracondylar Corner metaphyseal fractures, child acetabulum fractures and, 242
femoral region fractures and, 88 abuse and, 479 pelvic fractures and, 221
fractures and, 495 Corona mortis Deformities
tibial acetabulum fractures and, 239 accurate, 37
plateau fractures and, 135 pelvic fractures and, 212 angular, 45–46; see also Angular
shaft fractures and, 144, 147, 151, 156 Coronary ligament, tibial plateau deformity
tubercle fractures and, 126, 477 fractures and, 140 AP plane angular, 46–48
wrist fractures and, 327 Coronoid fractures, 301, 303, 308–309 ape-hand, 321
Complex articular fractures, 331 Coronoid process fractures, 501 boutonnière, 373, 374–375, 386
Complex dislocations, lesser toe Corralline hydroxyapatite, 29 cervical spine trauma and, 436
dislocations and, 205 Corrosion, biomaterials and, 61 clawhand, 320
Complex fractures, acetabulum fractures Corrosive wear mechanisms, biomaterials correction truisms, 51–53
and, 231 and, 61 fishtail, lateral condyle fractures
Complex regional pain syndrome Cortical bone grafts, 28 and, 497
(Formerly RSD) Cortical ring sign, 341 fractures and, 24
distal radius fractures and, 332 Costoclavicular ligament, 269 gunstock, supracondylar fractures
foot and ankle injuries and, 206–207 Cotyloid fossa, 257 and, 495
Composites Coumadin; see Warfarin horizontal plane angular, 49
graft, fingertip injuries and, 381 Coxa vara, 468 humpback, scaphoid fractures and,
material, bone and, 61 Cracking, stress corrosion and, 61 334, 335
molecular structure of, 60 Craig classification, clavicle fractures intrinsic-minus, 320, 385
Compression fractures, 412–413, 452, 514 and, 265, 266 intrinsic-plus, 385
contiguous, 452 Cranial displacement, pelvic fractures lateral plane angular, 48–49
imitators of, 511 and, 222 lower extremity, consequences of, 37
interfragmentary, fractures and, 25 Cranial tong traction, cervical spine lumbrical-plus, 386
Compression plates, femoral shaft trauma and, 430 mallet, 374
fractures and, 471 Creep, biomaterials and, 60 malrotation, 74
Compressive extension, 411, 428 Crevice corrosion, biomaterials and, 61 oblique frontal sagittal, 24
Compressive flexion injuries, 410, 428 Cross finger flap, fingertip injuries and, orientation of, 50–51
Compressive injuries of foot, 208 381–382 pelvic fractures and, 222
Computed tomography (CT) Cross-sectional area, biomechanics and, 55 rotational; see Rotational deformity
acetabulum fractures and, 225 Cross union, diaphyseal forearm fractures skeletal, 37
calcaneal fractures and, 195 and, 503 swan-neck, 356, 374, 386
INDEX 527
tibial shaft fractures and, 143, 158 of long head of biceps tendon, 284 Duran’s program, 370
translation, 24 metatarsophalangeal joint, 205 DVT; see Deep venous thrombosis
measurement of, 49 patellar, 126–132, 475–476 Dynamic compression plates, humeral
wrist-drop, 320 peroneal tendon, 182–183 shaft fractures and, 295
Degenerative arthritis, 37, 336, 374 posterior glenohumeral, 275 Dynamic instability, carpal, 340–341
hip dislocations and, 260 SC joint injuries and, 269 Dysostosis, cleidocranial, 487
Degloving of shoulder, 276–283
closed internal, pelvic fractures of shoulder girdle, 262–271
and, 222 subtalar, 193 E
crush injuries of foot and, 208 talus, 187–194 Elastic modulus, 58–59
Dejerine pattern of anesthesia of face, of thoracolumbar spine, 438–454 Elasticity
393–394 toe, 205 linear, 55
Delayed arthroscopic surgery, knee total talar, 194 modulus of, orthopaedic materials and,
dislocation and, 109 of wrist, 323–350 61–63
Delayed union Displaced femoral neck fractures, 68–70 Elastohydrodynamic lubrication
fractures and, 32 Distal clavicle, excision of, 269 mechanisms, biomaterials and, 61
proximal fifth metatarsal fractures Distal femoral metaphysis, fractures of, Elbow
and, 204 471–472 dislocations of, 300–311, 499–500
shaft of tibia and fibula fractures Distal femur, 41 fractures of, 300–311
and, 478 lateral approach to, 94–95 injuries of
talar neck fractures and, 190 Distal humerus fractures, 300–302 in children, 490–500
Delbet classification, of hip fractures in Distal injuries, brachial plexus injuries complications of, 310–311
children, 467, 468 and, 288 nursemaid’s, 499, 498–499
DeLee classification, of transphyseal Distal interphalangeal (DIP) joint injuries, unhappy triad of, 309
fractures, 491, 492 353–356 Elbow joint, 305
Deltoid ligament sprains, foot and ankle Distal metaphyseal fractures, 478, 506 Elderly patients, hip fractures in, 66–76
injuries and, 181 Distal phalanx Electric stimulation, scaphoid fractures
Deltopectoral approach, anterior, scapula amputation and, 380 and, 336
fractures and, 264 fractures of, 508 Electrical burns, 382–383
Demineralized bone matrix (DBM), Distal physeal fractures, 506 Electrical injuries, 8
29, 330 Distal radioulnar joint (DRUJ), 323 Electricity, fracture healing and, 28
Denis classification injuries of, 345–350 Electrodiagnostic studies, brachial plexus
of sacral fractures, 222 posttraumatic contracture of, 350 injuries and, 288
of spine, 411 Distal radius Elmslie-Trillat procedure, patellar
of thoracolumbar spine fractures, articulation between ulna and, 323 dislocation and, 131
444–445 fractures of, 323–332, 348, 505–506 Embolism, pulmonary, 13–14, 221
Depression-type fractures, tibial plateau Distal third fractures, 267 Embolization, angiographic, pelvic
fractures and, 140 Distraction osteogenesis, 30 fractures and, 219
Dermatomes, spinal cord and, 390 Distractive extension Endoneurium, 375
Diabetes, ankle fractures and, 180 cervical spine trauma and, 428 Endosteal circulation, disruption of, tibial
Diagnostic peritoneal lavage (DPL), 7, 213 injuries, 411 shaft fractures and, 149–150
Diaphragmatic injuries, 6 Distractive flexion Endurance limit, biomaterials and, 60
Diaphyseal extension, tibial plafond cervical spine trauma and, 427 Environment, exposure and, 3
fractures and, 165 injuries, 410–411 Epidural hematoma, 5
Diaphyseal forearm fractures, 501–504 Doppler scan Epidural space, 388
Diaphyseal fractures, closed, 478 hand injuries and, 378 Epineurium, 375
Diarthrodial joint, 269 supracondylar femoral region fractures Epiphysiodesis, contralateral limb, in
Die-punch fracture, 324–325 and, 88 children, 464–465
Diffuse brain injury, 5 Dorsal dislocation Epiphysis
Digastric trochanteric osteotomy, 258–259 of metacarpophalangeal (MCP) joint, 360 distal femoral, fractures of, 471–472
Dilatant fluids, 60 of proximal interphalangeal (PIP) fractures and, 462
Direct current (DC), fracture healing joint, 357 Equilibrium, biomechanics and, 54
and, 28 Dorsal instability patterns, carpal Erysipelas, 14
Disability, neurologic status and, 2–3 dislocations and instability and, Essex-Lopresti classification
Discoid meniscus, meniscal injuries 339–341 of calcaneal fractures, 194–195
and, 473 Dorsal intercalated segmental instability of radial head fractures, 309
DISI; see Dorsal intercalated segmental (DISI), 336, 339 Examination under anesthesia (EUA),
instability Dorsal ligaments, distal radius fractures knee dislocation and, 106
Dislocations and, 323, 325 Exposure and environment, 3
ankle, 187 Dorsal lip fractures, 198 Extended iliofemoral approach,
anterior glenohumeral, 275 Dorsal lunate dislocation, 343 acetabulum fractures and, 234,
atlanto-occipital, 407, 513–514 Dorsal muscle, forearm injuries and, 315 239–240
carpal, 338–345 Dorsal perilunate dislocation, 343, 344 Extension
of carpometacarpal joint, 360–362 Dorsalis pedis artery, talus fractures and injuries, supracondylar fractures
complex, lesser toe dislocations dislocations and, 187 and, 492
and, 205 DPL; see Diagnostic peritoneal lavage thoracolumbar spine fractures and, 441
of elbow, 300–311, 499–500 Drugs, for spinal cord injury, 399–400 Extension contracture of knee, distal
glenohumeral, 276–283, 489 DRUJ; see Distal radioulnar joint femoral metaphysis and epiphysis
hallux interphalangeal, 205 Dual-energy X-ray absorptiometry fractures and, 472
hip; see Hip dislocations (DEXA), bone density and, 31 Extension splinting, 96
interphalangeal joint, 205 Dual-photon absorptiometry bone density Extensor carpi ulnaris (ECU)
involving talus, 193–194 and, 31 interposition of, 318
knee, 98–114, 248 Ductility biomaterials and, 60 tendon dislocation of, 350
528 INDEX
Extensor mechanism injuries of knee, Femoral metaphysis, distal, fractures of, Flexion-rotation, thoracolumbar spine
116–134 471–472 fractures and, 440
patellar dislocation, 126–132 Femoral nail removal, femoral shaft and Flexor digitorum profundus (FDP)
patellar fracture, 116–119 subtrochanteric region fractures rupture, 370–371
patellar tendon rupture, 119–120 and, 85 Flexor tendons
quadriceps contusion, 132–133 Femoral neck adhesions of, 370
quadriceps tendon rupture, 120–124 fractures of, 66–72, 82 bowstringing of, 367
Extensor tendons displaced, 68–70 healing of, 368
injuries of, 371–375 femoral shaft fractures and, 71 injuries of, 367–371
lacerations of, 372–374 hip dislocations and, 248 laceration of, 368–370
rupture of, 374–375 nondisplaced, 68 rehabilitation protocol for, 369–370
External epineurium, 375 pathologic fractures of, 72 rupture of, 370
External fixation and shaft injuries, ipsilateral, 80 Floating elbow injury, forearm injuries
distal radius fractures and, 330–331 stress fractures of, 71 and, 318–319
femoral shaft fractures and, 470–471 Femoral shaft Floating knee
subtrochanteric region fractures, 82, 84 fractures of, 71, 77–86, 112, 248, 470–471 injuries, femoral shaft fractures and,
of forearm fractures, 317 and neck injuries, ipsilateral, 80 80, 471
fractures and, 24, 58 Femoral-sided fractures, 112 tibial shaft fractures and, 159
humeral shaft fractures and, 296 Femur Fluid replacement
hybrid, tibial plafond fractures and, 173 anatomic axes of, 40 burns and, 8
nonunion after, tibial shaft fractures anatomy of, 77 hemorrhagic shock and, 3–4
and, 158 axes of, 39–40 intravenous; see Intravenous fluids
pelvic fractures and, 219 divisions of, 77 pediatric trauma and, 459
supracondylar femoral region fractures fractures of, 4, 462 Fluid resuscitation, 3
and, 89 Fernandez classification, of ulnar-sided Fluoroscopy, tibial plateau fractures
tibial plafond fractures and, 172–173 lesions, 348 and, 139
tibial shaft fractures and, 147–148, Fibers, lamination of, 390 Foley catheter, pelvic fractures and, 212
153–156 Fibial tubercle avulsion fractures, Foot
Extra-articular fractures classification of, 125 crush injuries of, 207–208
calcaneal fractures and, 198 Fibula, tibial plafond fractures and, injuries of, 187–208, 481–484
of olecranon, 306 165–166 puncture wounds of, 16, 208, 484
Extraosseous blood supply, talus Fibular comminution, ankle fractures Football-related injuries, 397
fractures and dislocations and, 187 and, 180 Forces, biomechanics and, 54
Extraperitoneal rupture, pelvic fractures Fibular diaphysis, fractures of, 479 Forearm injuries, 314–321
and, 212 Fibular fractures, 177 anatomy of, 314–316, 317
Extremity examination, pediatric trauma Fielding and Magliato classification, of complications of, 319–321
and, 459 subtrochanteric fractures, 78 physical evaluation of, 316
Extrinsic tightness, traumatic injuries Filum terminale, 388 radiographic evaluation of, 316
and, 385–386 Finger specific injury patterns of, 316–319
mallet, 353–355 treatment of, 316–319
metacarpophalangeal (MCP) collateral Forefoot injuries, 203–206
F ligament injury, 360 45-degree oblique views, acetabulum
Face, Dejerine pattern of anesthesia of, rotational deformity of, 364 fractures and, 224
393–394 Fingertip injuries, 381–382 Fourth-degree burn, 7
Failed arthroplasty, femoral neck First-degree burn, 7 Fovea, 346, 347
fractures and, 71 Fishtail deformity, lateral condyle Fovea centralis, 257
Failure point, biomaterials and, 60 fractures and, 497 Fracture-dislocation
False aneurysm, hand injuries and, 378 Fixation ankle, 187
False pelvis, 210 external; see External fixation of carpometacarpal joint, 360–362
Fasciitis, necrotizing, 14 failure of, femoral neck fractures and, 71 central, of hip, 520
Fasciotomies, prophylactic, humeral shaft hybrid, tibial shaft fractures and, 153 of knee, 110–112
fractures and, 298 internal; see Internal fixation Monteggia, 318, 504–505
Fat emboli syndrome (FES), femoral shaft tibial plateau fractures and, 140 proximal humerus fractures and, 276
and subtrochanteric region fractures Flail chest, 6 of proximal interphalangeal (PIP)
and, 84 Flaps joint, 358
Fat embolism coverage, tibial shaft fractures and, tarsometatarsal, 200–203
femoral shaft and subtrochanteric 151–152 thoracolumbar spine fractures and, 454
region fractures and, 80 fingertip injuries and, 381–382 transradial styloid perilunate, 343
pediatric trauma and, 460 free, open fractures and, in children, 461 transscaphoid perilunate, 343
Fat-pad sign, elbow fracture and, 309, 491 Fleck sign, tarsometatarsal fracture- transtriquetral perilunate, 345
Fatigue, biomaterials and, 60 dislocations and, 202 Fracture healing
Febrile reaction to transfusion, 11 Flexible intramedullary nails biochemistry of, 27
Felon infection, 384 femoral shaft fractures and, 82, 471 bone formation and, 26–28
Female urethra, pelvic fractures and, 212 humeral shaft fractures and, 296 Fractures, 20–35
Femoral anatomic axis, lateral, 40 Flexion of acetabulum; see Acetabulum
Femoral distractor, tibial plateau injuries, supracondylar fractures and, 495 fractures
fractures and, 140 thoracolumbar spine fractures and, acromion, 264
Femoral fractures, 4, 462 438–439 of ankle, 480–481
Femoral head Flexion-distraction, 413, 440–441, 453–454 articular margin, 330
blood supply to, hip dislocations and, injuries, 515 atlas, 407–408
253–254 Flexion-extension radiographs avulsion; see Avulsion fractures
fractures of, 244–260 lateral, 423 Barton’s, 325
prosthetic replacement of, 69 pediatric spinal injuries and, 514 at base of thumb metacarpal, 365–367
INDEX 529
basilar neck, 74 incomplete, 23 pubic symphysis, 518

bimalleolar, 176–178 infratectal, 231 of pubis, 517
body, of calcaneus, 199 of intercondylar eminence, 472–473 radial head, 309–310, 348–349
bone and, 63 of intertrochanteric region, 66–76 of radial shaft, 348–349
with bone loss, 23 intra-articular; see Intra-articular radial styloid, 331
boxer’s, 364, 507 fractures reverse obliquity, 74
buckle, 506 of ischium, 517 ring, of axis, 436
burst, 410, 413, 452–454, 514–515 isolated greater trochanteric, 75 sacral, 222, 517
with butterfly fragment, 24 isolated lesser trochanteric, 75 sacroiliac joint, 518
C1 ring, 425–426 Jefferson, 407–408 Salter-Harris III, 508
C1 to C2, 514 Jones, 204–205, 483 Salter-Harris distal tibial, 480–481
C2 ring, 426–427 juxtatectal, 231 Salter-Harris physeal, 488
C3 to C7, 514 knee dislocation and, 101–103 scaphoid, 332–336, 507
calcaneal, 194–198, 482–483 lateral condyle, 496–497 scapular, 263, 487
of capitate, 337 lateral epicondyle, 301 segmental, 23
capitellar, 302 lateral plateau, 135 Shepherd’s, 192
capitellum, 301, 303 limbus, 515 of shoulder girdle, 262–271
carpal, 332–338, 507 linear, with hip joint instability, 520 simple, 90–91
cervical spine, 513–514 long bone, 3, 462 skull, 5
chance, 413 of lunate, 337–338 sleeve, 116–117, 475
chauffeur’s, 324, 326 lunate load, 326 Smith’s, 325
in children, 461–462 Malgaigne, 519 soft-tissue, 20–22
of clavicle, 265–267 management of, 24–25 spiral, 23, 63
closed, 20 medial epicondyle, 301, 495–496 straddle, 518–519
closed diaphyseal, 478 medial plateau, 135 stress; see Stress fractures
coccygeal, 517 fragment, 141 supracondylar, 301, 462, 492–495
Colles’, 324, 325 medial third, 265 of supracondylar femoral region; see
columnar, intraarticular, 301 metacarpal, 363–365, 366, 507–508 Supracondylar femoral region
complete, 501 metaphyseal, 141 fractures
complex articular, 330 diaphyseal junction, 204–205 T-shaped, acetabulum fractures and,
compression, 412–413, 514 metatarsal, 203–204, 483 231, 241
coracoid, 264 middle third, 266–267 talus, 187–194, 481–482
coronoid, 301, 303, 308–309, 501 Milch, 496–497 thoracolumbar, 413, 438–454, 514–515
cuneiform, 200 minimally displaced impacted, pelvic thumb metacarpal, 507
dancer’s, 205 fractures and, 222 of tibia, of shaft, 477–479
diaphyseal forearm, 501–504 Monteggia, 301, 303 of tibial plafond; see Tibial plafond
die-punch, 326 multiple injuries and, in children, 458 fractures
of distal femoral metaphysis and navicular, 198–199 of tibial plateau; see Tibial plateau
epiphysis, 471–472 of necessity, 318 fractures
distal humerus, 300–302 and neck, 301, 303 tibial-sided, 110–112
distal metaphyseal, 506 nightstick, 316 tibial tubercle, 124–126, 476–477
distal phalanx, 508 nonoperative treatment of, 24 tillaux, 481
distal physeal, 506 nutcracker, 200 torsion and, 57–58
distal radius, 323–332, 348, 505–506 oblique, 23, 63 torus, 506
distal third, 267 occipital condyle, 407, 424–425 transphyseal, 490–493
dorsal lip, 199 odontoid; see Odontoid fractures transtectal, 231
of elbow, 300–311 olecranon, 301, 306–307, 498 transverse; see Transverse fractures
femoral, 4, 462 tip, 301 of trapezium, 337
of femoral head, 244–260 open; see Open fractures of trapezoid, 337
of femoral neck; see Femoral neck, operative treatment of, 24–25 trimalleolar, 178
fractures of osteochondral, 128–129, 482 triplane, 481
of femoral shaft, 71, 77–86, 248, 470–471 patellar, 116–119, 248, 475 of triquetrum, 337
femoral-sided, 112 pathologic; see Pathologic fractures triradiate cartilage, 519
fibial tubercle avulsion, 125 patterns of, 23, 63 tuberosity; see Tuberosity fractures
of fibula, of shaft, 477–479 pelvic, 4, 210–222, 515–521 ulnar, 347–348, 505–506
fibular, 177 periprosthetic, 92 ulnar shaft, 316
of fibular diaphysis, 479 periprosthetic; see Periprosthetic ulnar styloid, treatment of, 332
of fifth metacarpal, 507 fractures vertebral burst, 439
flexion, supracondylar fractures phalangeal, 205, 483–484, 507–508 of wrist, 323–350
and, 495 physeal, 462, 463, 465 Fragments, tibial plateau fractures
Galeazzi, 318, 506–507 in children, 366–367 and, 140
glenoid fossa, 264 pilon, 178 Free flaps, open fractures and, in
glenoid neck, 264 plastic deformation, 501 children, 461
greenstick, 501, 502, 506 posterior process, 192 Free tissue transfer
gunshot, 17 of proximal fifth metatarsal, 204–205 foot and ankle injuries and, 182
of hamate, 337 proximal humerus, 272–276, 489 sites for, 22
of hand, 362–367 proximal metaphyseal, 477–478 Freeze-dried bone graft, 30
hangman’s, 408, 426–427 proximal phalanx, 507–508 Fresh bone graft, 30
hip; see Hip fractures proximal radius, 500–501 Fresh frozen bone graft, 30
Holstein-Lewis, 294 proximal tibial epiphysis, 477 Fretting wear mechanisms, biomaterials
of humeral shaft, 293–398, 489–490 proximal tibial shaft, 155–156 and, 60
iliac wing, 517 proximal ulna, 307–309 Friction, biomaterials and, 60
impacted, 24 pubic rami, 220, 517–518 Frostbite, 8
530 INDEX
Frykman classification, of fractures of Growth, physeal injury and, 463 Hemodialysis, acute hematogenous
wrist, 325, 326 Growth plate, 464 osteomyelitis and, 32
Fulkerson procedure, patellar dislocation Gull sign, acetabulum fractures and, 229 Hemolytic reaction to transfusion, 11
and, 131, 132 Gunshot fractures, 17 Hemorrhage
Full-thickness skin graft, fingertip injuries Gunshot wounds, to spine, 415 control of, 2
and, 381 Gunstock deformity, supracondylar pelvic fractures and, 218
Functional bracing fractures and, 495 shock, 3–4
foot and ankle injuries and, 181 Gustilo classification Hemothorax, 6
humeral shaft fractures and, 294 of femoral shaft fractures, 79 Henry approach, forearm injuries and, 316
of open fractures, 20–21 Hepatitis A, 12
of tibial shaft fractures, 152 Hepatitis B, 12
G Hepatitis C, 12
Galeazzi fractures, 318, 506–507 Herbert classification, of scaphoid
Galleazzi procedure, patellar dislocation H fractures, 333
and, 131 Hallux interphalangeal dislocations, 205 Heterotopic bone formation, acetabulum
Gallie and Brooks techniques, cervical Halo treatment fractures and, 242
spine trauma and, 433 cervical spine trauma and, 430, 435 Heterotopic ossification (HO), 16, 35
Gallium scan, 31 pediatric spinal injuries and, 513 elbow injuries and, 311
Galvanic corrosion, biomaterials and, 61 Hamate, fractures of, 337 femoral shaft and subtrochanteric
Gamekeeper’s thumb, 359 Hand region fractures and, 85
Gangrene, gas, 14 burns and, 382–383 hip dislocations and, 256, 260
Garden’s classification, of femoral neck fingertip and nailbed injuries, 381–382 High-energy injuries
fractures, 67 fractures of, 362–367 pelvic fractures and, 213, 218
Gartland’s classification supracondylar high-pressure injection injuries, 383 thoracolumbar spine fractures and, 452
fractures, 492 infections, 383–384 tibial plafond fractures and, 166, 172
Gas gangrene, 14 injuries, 353–386 High-pressure injection injuries, 383
Gastrointestinal complications of late effects of traumatic injuries, High velocity, 17
trauma, 7 385–386 Hip, anatomy of, 237, 253–255, 257
Gate theory, foot and ankle injuries nerve injuries of, 375–377 Hip dislocations, 244–256
and, 207 phalangeal, 362–363 acetabular fractures and, 520
GCS; see Glasgow coma scale reflex sympathetic dystrophy, 384–385 algorithm for treatment of, 250
Gender, pediatric trauma and, 461 regional pain syndrome, 384–385 anatomy and, 253–255, 257
Generalized Hooke’s law, 58 soft-tissue injuries of, 367–371 associated injuries and, 248–249
Genitourinary injuries, 7 Hangman’s fracture, 408, 426–427 classification of, 246–248
Genu recurvatum, tibial tubercle Hardinge approach complications of, 255–256
fracture, 126 acetabulum fractures and, 236 evaluation of, 244–246
Geometric properties of objects, hip dislocations and, 254 and femoral head fractures, 244–260
biomechanics and, 55 Hardware failure, pelvic fractures and, 221 recurrent, 255
Gertzbein classification, of thoracolumbar Harris lines, 422 surgical techniques for, 253–255
fractures, 412–413 Hauser procedure, patellar dislocation treatment of, 250–253
Glasgow coma scale (GCS), 2, 459 and, 130–131 Hip fractures, 66–76
Glenohumeral joint Hawkins and Canale classification, of talar in children, 467–470
acute dislocations of, 276–283 neck fractures, 189 devices for, 58
dislocations of, 275, 276–283, 489 Hawkins sign in younger patients, 66
injuries of, 489–490 ankle fractures and, 482 Hip joint, 253
instability of, 277, 278 talar neck fractures and, 190 malreduction, 260
soft-tissue injuries of, 272–291 Head injuries, 4–6, 81, 459–460 Hip replacement, total, 69–70
Glenohumeral ligaments, 281–282 Head size, pediatric spinal injuries and, Hip screw, 58
Glenoid fossa fractures, 264 510 intramedullary, 74
Glenoid labrum, acute dislocations of Head-splitting fractures, proximal sliding, 72–73
shoulder and, 281, 282 humerus fractures and, 276 HIV infection, 12
Glenoid neck fractures, 264 Healing HO; see Heterotopic ossification
Glenoid rim fractures, 277, 278 fractures and, 462 Hobbs view, sternoclavicular (SC) joint
Gradual return to activity, foot and ankle tibial shaft fractures and, 147, 153 injuries and, 270
injuries and, 181 Heel pad pain, calcaneal fractures and, 198 Hockey-related injuries, 397
Grafton, 29 Heel pain, 484 Hoffa fragments, 89
Grafts Hemarthrosis, tibial plateau fractures Holdsworth classification, thoracolumbar
bone; see Bone grafts and, 135 spine fractures and, 444
fingertip injuries and, 381 Hematogenous osteomyelitis, acute, 32 Holstein-Lewis fracture, 294
Graphic method, 50, 51 Hematoma Home intravenous therapy, 10
Greater arc injuries, carpal dislocations epidural, 5 Hooke’s law, generalized, 58
and, 343–345 extension of, into soft-tissues, tibial Horizontal plane angular deformity,
Greater arc patterns, carpal dislocations plateau fractures and, 135 measurement of, 49
and instability and, 339 intracerebral, 5 Hormones, fracture healing and, 28
Greater trochanteric fractures, retropharyngeal, cervical spine trauma Horner’s syndrome, brachial plexus
isolated, 75 and, 436 injuries and, 287
Greenstick fractures, 501, 502, 506 subdural, 5 Hughston procedure, patellar dislocation
Group A streptococcus, necrotizing subungual, nailbed injuries and, 382 and, 131
fasciitis and, 14 Hemipelvis, posteriorly displaced, 219, Human bite wound, 373, 384
Growth arrest 220 Humeral shaft
ankle fractures and, 481 Hemisection syndrome, 395 anterolateral approach to, 297
hip fractures in children and, 468–469 Hemitransverse fractures, posterior, complications of, 297–298
Growth cone, nerve regeneration and, 376 acetabulum fractures and, 231, 241 fractures of, 293–298, 489–490
INDEX 531
posterior approach to, 296–297 Implant devices, 58 Intercondylar eminence

posterolateral approach, 297, 298 IMSOP; see International Medical Society fractures of, 472–473
radiographic evaluation and, 294 of Paraplegia repair of avulsions of, tibial plateau
treatment of, 294–297 Incomplete fractures, 23 fractures and, 136
Humerus, injuries of, 489–490 Incomplete spinal cord syndromes, Interfragmentary compression, fractures
Humpback deformity, scaphoid fractures 393–396 and, 25
and, 334, 335 Incongruency, acetabulum fractures Intergranular corrosion, biomaterials
Hybrid fixation and, 224 and, 61
tibial plafond fractures and, 173 Indirect reduction Interlocking, femoral shaft and
tibial shaft fractures and, 153 of fractures, 25 subtrochanteric region fractures
Hydrodynamic lubrication mechanisms, thoracolumbar spine fractures and, 448 and, 84
biomaterials and, 60 Indium scan, fractures and, 31 Interlocking screws, tibial shaft fractures
Hydrostatic lubrication mechanisms, Inertia, moment of, 54 and, 155
biomaterials and, 60 Infected nonunion, tibial shaft fractures Internal epineurium, 375
Hydroxyapatite, 29 and, 157–158 Internal fixation
Hypertrophic nonunion, fractures and, 32 Infection femoral neck fractures and, 69
Hypertrophic zone, 463 bone, 32–35 fractures and, 25
Hyperventilation, head injuries and, 6 calcaneal fractures and, 197 tibial plateau fractures and, 140
Hypothermia, 12, 218 deep, tibial shaft fractures and, 156–157 Internal iliac artery, pelvic fractures
Hypovolemic shock, resuscitation of forearm injuries and, 319 and, 211
patients in, 218–219 fractures and, 32 Internal pudendal artery, pelvic fractures
gunshot wounds to spine and, 416 and, 211
of hand, 383–384 “Internal–external fixator” technique,
I hip dislocations and, 256 humeral shaft fractures and, 295
Iatrogenic nerve palsy, acetabulum HIV, 12 International Medical Society of
fractures and, 242 nonunion of fractures and, 32 Paraplegia (IMSOP), 390
IGF-II; see Insulin-like growth factor II palmar space, 384 International Standards for Neurological
Ignition, electrical injuries and, 8 patellar fractures and, 118 and Functional Classification of
Iliac wing fractures, 220–221, 517 pin tract, cervical spine trauma Spinal Cord Injury, 390
Iliofemoral approach, extended, and, 435 Interosseous membrane, forearm injuries
acetabulum fractures and, 234, puncture wounds of, 208 and, 314
239–240 talar neck fractures and, 190 Interosseous nerve, 321
Ilioinguinal approach, acetabulum tendon sheath, 384 Interphalangeal joint
fractures and, 233–234, 238–239 tibial plateau fracture and, 141 dislocations of, 205
Iliolumbar ligaments, pelvic fractures wound, acetabulum fractures and, 242 hallux, 205
and, 210 Inferior facets, subaxial cervical spine metatarsophalangeal and, 484
Iliopectineal fascia, acetabulum fractures and, 406 Interpore 200, 29
and, 239 Inferior glenohumeral ligament complex, Interpore 500, 29
Iliopectineal line, pelvic fractures and, 210 acute dislocations of shoulder Interposition of extensor carpi
Iliosacral screws, pelvic fractures and, 220 and, 282 ulnaris, 318
Iliotibial band, tibial plateau fractures Inferior gluteal artery, pelvic fractures Interpositional bone grafting, scaphoid
and, 140 and, 211 fractures and, 334
Ilizarov external fixation, 141, 165, 172 Inferolateral half, talus fractures and Interspinous wire fixation, cervical spine
IM nailing; see Intramedullary nailing dislocations and, 187 trauma and, 432–433
Imaging Inflammation, fracture repair and, 26 Intertrochanteric region fractures,
diaphyseal forearm and, 501 Inflammatory mediators, 12–13 66–76
dislocation of elbow and, 499 Infraclavicular peripheral nerve injuries, Intra-articular fractures, 301
DRUJ injuries and, 346–347 brachial plexus injuries and, 287 of calcaneal, 195–198
fractures and, 30–31 Infratectal fractures, 231 of olecranon, 306
humerus injuries and, 489 Inhalation injury, 7 phalangeal fractures and, 205
medial epicondyle fractures and, 495–496 Initial resuscitation, multiple injuries and, Intraarticular pressure, negative,
Monteggia fracture-dislocation and, 505 in children, 459 acute dislocations of shoulder
nursemaid’s elbow and, 498 Injection injuries, 8 and, 281
patellar dislocation and, 127–128 acute, hand injuries and, 379 Intracerebral contusion, 5–6
patellar fracture and, 117 high-pressure, 383 Intracerebral hematoma, 5–6
patellar tendon rupture and, 120 Injury severity Intracranial pressure, 6
pediatric trauma and, 459 cervical spine trauma and, 434 Intramedullary (IM) devices, 58
proximal phalanx fractures and, 507–508 pediatric trauma and, 459 Intramedullary fixation, of forearm
proximal radius fractures and, 500–501 Injury Severity Score (ISS), 9, 35, 459 fractures, 316–318, 317
quadriceps tendon rupture and, 124 Inlay bone grafting, scaphoid fractures Intramedullary hip screw,
scapula fractures and, 262 and, 334 intertrochanteric fractures and, 74
supracondylar fractures and, 492–493 Insall-Salvati index lines, patellar Intramedullary nailing
tibial plafond fractures and, 162 dislocation and, 128 breakage of, femoral shaft and
transphyseal fractures and, 491 Inspection, tibial plateau fractures subtrochanteric region fractures
Immersion solution, 10 and, 135 and, 83
Immobilization Instability femoral shaft and subtrochanteric
patellar dislocation and, 129 carpal, 336, 338–345 region fractures and, 82, 83–84
pediatric spinal injuries and, 513 glenohumeral, 277 flexible, femoral shaft fractures and, 471
tibial shaft fractures and, 146–147 late, knee dislocation and, 110 humeral shaft fractures and, 295–296
Impacted fractures, 24 mechanical, 444 locked, femoral shaft fractures and, 470
Implant complications, femoral shaft and Insulin-like growth factor II (IGF-II), 27 stiffness of, femoral shaft and
subtrochanteric region fractures Interclavicular ligament, SC joint injuries subtrochanteric region fractures
and, 85 and, 269 and, 83
532 INDEX
Intramedullary nailing—Continued Kellam and Waddell classification system, Lateral flexion injuries, 411, 428
supracondylar femoral region fractures of tibial plafond fractures, 163, 166 Lateral impingement, calcaneal fractures
and, 92 “Keystone effect,” tarsometatarsal joint and, 197–198
tibial shaft fractures and, 149–151, and, 200, 201 Lateral malleolar fractures, isolated,
154–156 Kienböck’s disease, 337, 338 175–176, 179
nonunion after, 158 stages of, 338 Lateral malleolus, 176, 180
Intramedullary nailing, nonunion after, 158 Kinematics Lateral patellofemoral angle, patellar
Intraoperative fluoroscopy, 97 biomechanics and, 54 dislocation and, 128
Intraosseous blood supply, talus fractures carpal dislocations and instability Lateral plane angular deformity,
and dislocations and, 187 and, 339 measurement of, 48–49
Intraperitoneal rupture, pelvic fractures Kirschner wires, 117, 355, 362, 371 Lateral plateau fractures, 135
and, 212 olecranon fractures and, 306 Lateral retinacular release, patellar
Intrarticular, supracondylar femoral Kleinert’s program, 370 dislocation and, 130
region fractures and, 89 Knee Lateral sacral view, pelvic fractures
Intravenous access, pediatric trauma arthritis, pre-existing, 92 and, 213
and, 459 extension contracture of, 472 Lateral spur formation, 497
Intravenous drug abusers, acute extensor mechanism injuries of; see Lateral talar process fractures, 482
hematogenous osteomyelitis and, 32 Extensor mechanism injuries of knee Latissimus dorsi tendon, soft-tissue
Intravenous fluids, head injuries and, 6 floating; see Floating knee injuries of shoulder and, 284
Intrinsic-minus deformity, 320, 385 jumper’s knee, 119 Lauge-Hansen classification, of malleolar
Intrinsic-plus deformity, 385 lateral approach to, 94–95 fractures, 175, 178
Intrinsic resistance, 9 ligamentous injuries of, 473–475 Lawnmower injuries, 206, 484
Inversion ankle injury, thickening of physical examination of, 101 Lead poisoning, bullets in spinal canal
AITFL and, 182 traumatic ligamentous injuries of, and, 415
Involucrum, 32 98–114 Leddy and Packer classification, of FDP,
Ipsilateral femoral neck and shaft Knee dislocations (KDs), 98–112, 248 370–371
fractures of, 71 Knee ligamentous and meniscal Left-sided Smith-Robinson approach,
injuries of, 80 injuries, 80 cervical spine trauma and, 431
Ipsilateral fracture, tibial shaft fractures Knee pain Leg length discrepancy
and, 146 tibial plateau fractures and, 135 distal femoral metaphysis and epiphysis
Ischemia, hand injuries and, 379 tibial shaft fractures and, 157 fractures and, 472
Ischemic limbs, 17 Knee stiffness, 85, 120, 126 femoral shaft fractures and, 471
Ischium, fractures of, 517 Knee trauma, 98–114 pelvic fractures and, 222
Isolated greater trochanteric fractures, 75 Kocher-Langenbeck approach shaft of tibia and fibula fractures
Isolated lesser trochanter fractures, 75 acetabulum fractures and, 233, 237–238 and, 479
Isolated malleolar fractures, 175–176, 179 hip dislocations and, 254, 258 Lesser arc injuries, carpal dislocations
Isotropic properties, biomaterials and, 60 Kutler flap, fingertip injuries and, 381 and, 339, 342–343
Kyphosis, cervical spine trauma and, 423 Lesser toe dislocations, 205
Lesser trochanteric fractures, isolated, 75
J Letournel subdivided transverse
J; see Polar moment of inertia L fractures, 231
Jefferson fracture, 407–408, 425–426 L5 nerve root, pelvic fractures and, Levine classification, of traumatic
Jewett (hyperextension appliances), 211, 220 spondylolisthesis, 426–427
446, 452 Labrum, hip dislocations and, 254 Lift-off test, acute dislocations of
Johner and Wruh’s classification system, Lachman test, stabilized, knee dislocation shoulder and, 279
for tibial shaft fractures, 144, 145 and, 105, 106 Ligament injuries, 21
Joint capsule, 94–95, 238, 283, 463 Lag screws Ligament sectioning studies, 218
hip dislocations and, 249 patellar fractures and, 118 Ligamentotaxis, 25
Joint injuries tibial plateau fractures and, 137 tibial plafond fractures and, 173
acromioclavicular (AC), 267, 268, tibial shaft fractures and, 153 tibial plateau fractures and, 140
488–489 Lamination of fibers, spinal cord and, 390 Ligamentous injuries
of hand, 353–386 Laminectomy, cervical, 431 of knee, 98–114, 473–475
midtarsal, 200 Laminin, nerve regeneration and, 376 tibial plateau fractures and, 135
sternoclavicular, 269 Lap-belt injuries, 515 vertebral, 136, 406–416
Joint motion, loss of, tibial plateau Laryngeal nerve, recurrent injury of, Ligamentum teres injuries, hip
fracture and, 141 cervical spine trauma and, 436 dislocations and, 249
Joint orientation, 40–43 Late instability, knee dislocation and, 110 Limb injury severity scores, 16
Joint position, knee dislocation and, Lateral ankle spasms, 198 Limb loss, knee dislocation and,
98–99 Lateral ankle stability, chronic, foot and 100, 110
Joint visualization, tibial plateau fractures ankle injuries and, 182 Limb-threatening injuries, 16
and, 140 Lateral collateral ligamentous complex, Limbus fractures, 515
Jones fractures, 204–205, 483 ankle injuries and, 175 Limited contact dynamic compression
Judet approach, posterior, scapula Lateral compression plate (LCDC), 316
fractures and, 264 pelvic fractures and, 222 Linear elasticity, biomechanics and, 55
Jumper’s knee, 119 thoracolumbar spine fractures and, 440 Linear fractures with hip joint
Jungbluth pelvic reduction clamp, 219, Lateral condyle fractures, 492, 496–497 instability, 520
220 Lateral epicondyle fractures, 301 Lisfranc’s fracture-dislocation, 200–203
Juxtatectal fractures, 231 Lateral femoral circumflex artery, hip Lisfranc’s ligament, 200, 201
dislocations and, 255 Load transmission, hip dislocations
Lateral femoral condyle, osteochondral and, 249
K fracture of, 128–129 Loading, axial; see Axial loading
Kanavel’s sign, 384 Lateral flexion-extension radiographs, Locked intramedullary nail, femoral shaft
KDs; see Knee dislocations cervical spine trauma and, 423 fractures and, 470
INDEX 533
Locked plating, humeral shaft fractures patellar dislocation and, 128 Medial malleolus, 176, 180
and, 295 pediatric trauma and, 459 Medial nerve injury, wrist fractures
Locking plates, forearm injuries and, 316 proximal humerus fractures and, 273 and, 327
Long bone fracture, 3, 462 thoracolumbar spine fractures and, 444 Medial patellofemoral ligament (MPFL)
Long head of biceps tendon, dislocation tibial plateau fractures and, 136 repair, patellar dislocation and,
of, 284 wrist fractures and, 327 126, 130
Long thoracic nerve palsy, 288–289 Malalignment Medial plateau fractures, 135
Lordosis, physiologic, cervical spine rotational, 147 Medial plateau fragment, 141
trauma and, 423 tibial shaft fractures and, 157 Medial restraints of patella, 126
Loss Male urethra, pelvic fractures and, 212 Medial roof arc (MRA), acetabulum
of fixation, patellar fractures and, 119 Malgaigne fractures, 519 fractures and, 224, 226
of motion, supracondylar femoral region Malleolar fractures, foot and ankle Medial talar process fractures, 482
fractures and, 96 injuries and, 175–178 Medial third fractures, 265
of range of motion, patellar fractures Mallet deformity, 374 Median nerve
and, 119 Mallet finger, 353–355 dislocation of elbow and, 500
Low-energy injuries Malreduction forearm injuries and, 315
pelvic fractures, 212 tibial shaft fractures and, 157 humeral shaft fractures and, 293
thoracolumbar spine fractures and, 452 of ulna fracture, 308 injuries of, 320, 321
tibial plafond fractures and, 166 Malrotation deformities, intertrochanteric Median sacral artery, pelvic fractures
Low velocity fractures and, 74 and, 211
gunshot fractures and, 17 Malunion Mediastinum, widened, 6
injuries of spine and, 414 angular femoral, 86 Medical antishock trousers (MAST), 218
knee dislocations and, 100, 107 ankle fractures and, 180, 481 Medical Research Council (MRC) scale,
Lower cervical spine, 418–419 cervical spine trauma and, 436 spinal cord injury and, 391
cervical spine trauma and, 436 diaphyseal forearm fractures and, 503 Medullary callus, fracture repair and, 26
injuries involving, 409–411, 427–428 distal radius fractures and, 332 Melone’s classification, of wrist fractures,
malunion and, 436 fractures and, 32 326, 327
radiographic reference line, 422–423 humeral shaft fractures and, 297–298 Meningeal layers of spinal cord, 388
soft-tissue structures of, 420 metacarpal shaft fractures and, 365 Meniscal injuries, 135, 473
stability of, 427 pelvic fractures and, 222 Meniscal tears, 136
Lower extremity compartment phalangeal fractures and, 363 Meniscal tissue, loss of, tibial plateau
syndrome, 218 proximal humerus fractures and, 276 fracture and, 141
Lower extremity deformity rotational, 471 Meniscus, knee dislocation and, 103
consequences of, 37 scaphoid fractures and, 336 Mental status changes, cervical spine
mechanical axis of, 37–39 supracondylar femoral region fractures trauma and, 434–435
Lower extremity injuries, pediatric; see and, 96–97 Metacarpal base fractures, 365
Pediatric lower extremity injuries talar neck fractures and, 190 Metacarpal fractures, 363–365, 366,
Lubrication mechanisms, biomaterials tibial plateau fractures and, 141 507–508
and, 60 tibial shaft fractures and, 158, 159 Metacarpal head, 354
Ludloff approach, acetabulum fractures Mangled Extremity Severity Score fractures of, 363
and, 236 (MESS), 16 Metacarpal neck fractures, 363–364
Lumbar spine, 411 Mangling, crush injuries of foot and, 208 Metacarpal shaft fractures, 364–365, 366
pediatric spinal injuries and, 512 Manual leg traction, pelvic fractures Metacarpophalangeal (MCP) joint, 353,
supporting ligaments of, 411 and, 213 354, 358–362
Lumbar vertebra, 388, 411 Marti technique, quadriceps tendon Metals
Lumbosacral ligaments, pelvic fractures repair and, 124 corrosion of, 61
and, 210 Martin classification, of tibial plafond molecular structure of, 60
Lumbosacral trunk, pelvic fractures fractures, 165 Metaphyseal avulsion fractures, 479
and, 210 Mason classification, of radial head Metaphyseal complex fractures, 164
Lumbrical-plus deformity, 386 fractures, 303, 309 Metaphyseal diaphyseal junction
Lunate Massive hemothorax, 6 fractures, 204–205
AVN of, 338 MAST; see Medical antishock trousers Metaphyseal diaphyseal separation, 136
dislocation, 343 Mayo classification, of scapula fractures, Metaphyseal fractures, 141, 479
fractures of, 337–338 262–263 distal, 478
vascularity pattern, 338 McAfee classification, thoracolumbar Metaphyseal simple fractures, 164
Lunate load fracture, 324–325 spine fractures and, 445 Metaphyseal wedge fractures, 164
Lunotriquetral dissociation, 342 MCL; see Medical collateral ligament Metatarsal fractures, 483
Lyophilized bone graft, 30 McLaughlin wire, 120 Metatarsal head fractures, 204
MCP joint; see Metacarpophalangeal joint Metatarsal neck fractures, 203–204
Mechanical instability, thoracolumbar Metatarsal shaft fractures, 203–204
M spine fractures and, 444 Metatarsophalangeal joint dislocations,
Mackinnon’s classification, 376 Medial antebrachial cutaneous nerve, 377 205, 484
Magnetic resonance imaging (MRI) Medial clavicular epiphysis, SC joint Methylprednisolone
acute dislocations of shoulder and, 279, injuries and, 269 cervical spine trauma and, 430
280 Medial collateral ligament (MCL), 98, 126, spinal cord injury and, 399
cervical spine trauma and, 423–424 135, 176, 300, 474 therapy for acute spinal cord injury, 399
DRUJ injuries and, 346–347 Medial epicondyle fractures, 301, 496–497 Microcystic myelomalacia, chronic
femoral neck fracture and, 67 Medial femoral circumflex artery posttraumatic syndromes and, 396
forearm injuries and, 316 (MFCA), 248 Microfractures, knee dislocation and, 103
fractures and, 31 ascending branch of, 237 Mid palmar space, 384
of hip, 237 Medial malleolar fractures, isolated, 176 Midcarpal instability, 340, 345
hip dislocations and, 245–246 Medial malleolar fragments, ankle Middle phalanx, amputation and, 380
knee dislocation and, 106 fractures and, 180 Middle third fractures, 266–267
534 INDEX
Midfoot, injuries of, 198–203 Myers and McKeever classification, Neurotmesis, 376
Midsubstance ligamentous tears, 21 of intercondylar eminence Neurovascular examination
Midsubstance tears of cruciates, 104 fractures, 473 hip dislocations and, 245
Midtarsal joint injuries, 200 Myotomes, spinal cord and, 390, 391 proximal humerus fractures and, 272
Milch fractures, 496 tibial plafond fractures and, 162
Mineral component, bone and, 63 Neurovascular injuries
Minimally displaced avulsion fractures of N distal femoral metaphysis and epiphysis
cuboid, 200 Nail matrix, loss of, 382 fractures and, 472
Minimally displaced impacted fractures, Nailbed injuries, 382 elbow injuries and, 310
pelvic fractures and, 222 Nailbed lacerations, 382 femoral shaft fractures and, 471
Minimally invasive plate osteosynthesis Nailing tibial shaft fractures and, 146
(MIPO), 91 intramedullary; see Intramedullary Neurovascular insult, clavicle and, 267
lateral exposure, 95 nailing Newtonian fluids, biomaterials and, 60
tibial shaft fractures, 149 unreamed, tibial shaft fractures and, 155 Newton’s laws, biomechanics and, 54
Missed C-spine injuries, 434 Narrow pulse pressure, 3 Nightstick fractures, 316
Missiles, secondary, penetrating injuries NASCIS; see National Acute Spinal Cord Node of Ranvier, nerve regeneration
of spine and, 414 Injury Study and, 376
Miyakawa technique of patellectomy, 119 National Acute Spinal Cord Injury Study Non-newtonian fluids, biomaterials and, 60
Moberg flap, fingertip injuries and, 381 (NASCIS), 399–400 Nondisplaced articular fractures,
Mobilization, early, pelvic fractures Navicular fractures, 198–199, 483 calcaneal fractures and, 195–196
and, 221 Neck collars, cervical spine trauma Nondisplaced femoral neck fractures, 68
Modified Broström procedure, foot and and, 429 Nonhemorrhagic shock, 4
ankle injuries and, 182 Necrosis Nonunion
Modified tension band wiring, patellar avascular; see Avascular necrosis cervical spine trauma and, 436
fractures and, 117, 118 skin, talar neck fractures and, 190 clavicle fractures and, 267
Modulus Necrotizing fasciitis, 14 distal radius fractures and, 332
bone and, 63 Negative intra-articular pressure, acute after external fixation, tibial shaft
of elasticity, 55, 61 dislocations of shoulder and, 281 fractures and, 158
Molecular structure, biomaterials and, 60 Negative pressure wound therapy femoral neck fractures and, 70
Moment(s) (NPWT), 92, 152 femoral shaft and subtrochanteric
biomechanics and, 54 Nerve(s) region fractures and, 85
of inertia, 57 forearm injuries and, 315 forearm injuries and, 319
Monteggia fracture-dislocation, 318, humeral shaft fractures and, 293 fractures and, 32
504–505 injuries, 17 hip dislocations and, 260
Monteggia injury, 301, 303, 307–308 closed, 377 hip fractures in children and, 469
Morel-Lavallee lesions, acetabulum dislocation of elbow and, 500 humeral shaft fractures and, 298
fractures and, 242 femoral shaft and subtrochanteric infected, tibial shaft fractures and,
Mortality, femoral neck fractures and, 71 region fractures and, 80 157–158
Motor pathways, spinal cord and, 390 forearm injuries and, 319, 320, 321 intertrochanteric fractures and, 74
MRA; see Medial roof arc of hand, 375–377 after intramedullary nailing, tibial shaft
MRC scale; see Medical Research Council pelvic fractures and, 221 fractures and, 158
scale supracondylar fractures and, 493 lateral condyle fractures and, 497
MRI; see Magnetic resonance imaging regeneration, 375–376 metatarsal fractures and, 204
Muenster cast, forearm injuries and, 318 Nerve graft, nerve repair and, 377 patellar fractures and, 119
Multidetector CT (MDCT) scan Nerve palsy pelvic fractures and, 222
medial epicondyle fractures and, 497 iatrogenic, acetabulum fractures proximal fifth metatarsal fractures
supracondylar fractures and, 493 and, 242 and, 204
Multifocal osteomyelitis, chronic, 34 long thoracic, 288–289 proximal humerus fractures and, 276
Multifragmentary depression, tibial Neural structures, pelvic fractures and, scaphoid fractures and, 334–336
plafond fractures and, 165 210–211 shaft of tibia and fibula fractures
Multiple injuries Neurapraxia, 376 and, 478
child with, 458–461 Neurofibromatosis, congenital supracondylar femoral region fractures
femoral shaft and subtrochanteric pseudarthrosis of tibia and, 479 and, 96
region fractures and, 81 Neurogenic shock, 4, 391–393 talar neck fractures and, 190
tibial shaft fractures and, 147 Neurologic compromise, pediatric spinal tibial plateau fractures and, 141
Muscle injuries and, 516 tibial shaft fractures and, 157–158
diaphyseal forearm fractures and, 504 Neurologic deterioration, cervical spine Nuclear medicine, fractures and, 30–31
forearm injuries and, 314–315 trauma and, 434–435 Nursemaid’s elbow, 499, 498–499
injuries, hip dislocations and, 249 Neurologic examination, head injuries Nutcracker fractures, 200
weakness, femoral shaft and and, 6 Nutrition, 9
subtrochanteric region fractures Neurologic impairment, femoral neck flexor tendon injuries and, 368
and, 84–85 fractures and, 71 hip dislocations and, 255
Muscle transfer, AC joint injuries Neurologic injuries pediatric trauma and, 460
and, 269 knee dislocation and, 100, 110
Musculature, humeral shaft fractures proximal humerus fractures and, 276
and, 293 supracondylar femoral region fractures O
Musculocutaneous nerve, 276 and, 88 Oblique fractures, 23, 63
humeral shaft fractures and, 293 supracondylar fractures and, 493 Oblique frontal sagittal deformities, 24
Musculoskeletal function, cervical spine Neurologic status, thoracolumbar spine Oblique plane deformity, 50–51
trauma and, 435 fractures and, 453 O’Brien’s classification, of proximal
Musculoskeletal traumatic injuries, 16–17 Neuroma-in-continuity, 376, 377 radius fractures, 500
Myelomalacia, microcystic, chronic Neuromas, cutaneous, calcaneal fractures Obturator artery, pelvic fractures and,
posttraumatic syndromes and, 396 and, 198 211, 212
INDEX 535
Occipital condyle fractures, 407, 424 of subtrochanteric fractures, 78 Paraplegia, 401

Occipitoatlantoaxial complex, 406, 407 of tibial plafond fractures, 164–165 pediatric spine injuries and, 515
Occipitocervical dissociation (AOD), 425 Orthoses, 446 Paratenon-covered tendon injuries, 21
Occipitocervical fusion, cervical spine Orthotropic properties, biomaterials Paronychia, 383
trauma and, 433–434 and, 60 Partial patellectomy, patellar fractures
Occiput, injuries involving, 407–409 Os vesalianum, 483 and, 118
Occult ligament injuries, 434 Osgood-Schlatter disease, tibial tubercle Passivation, corrosion and, 61
Occult orthopaedic injuries, 16 fractures and, 476 Patella
Odontoid fractures, 408, 426, 434, 436 Osmotic pump, 10 dislocation of, 126–132, 475–476
malunion of, 436 Osseous factors, acute dislocations of fractures of, 116–119, 248, 475
nonunion of, 436 shoulder and, 281 medial restraints of, 126
pediatric spinal injuries and, 514 Ossification Patella alta, tibial tubercle fracture, 126
Odontoid process centers, pediatric pelvic injuries Patellar tendon rupture, 119–120
cervical spine and, 406, 408 and, 516 Patellectomy
ossification of, 511 heterotopic, elbow injuries and, 311 partial, patellar fractures and, 103
Ogden classification, 125 of odontoid process, 511 patellar dislocation and, 132
Older patient, tibial plateau fractures Osteitis pubis, pelvic fractures and, 222 total, patellar fractures and, 118
in, 135 Osteoarticular allografts, 28–29 Patellofemoral arthrosis, 117
Olecranon fractures, 301, 306–307, 498 Osteochondral allografts, 28–29 Patellofemoral ligaments, 116
Olecranon osteotomy, 301, 302 Osteochondral defects of talus, 192–193 Patellofemoral sulcus angle, 127
Olecranon tip fractures, 301 Osteochondral fractures, 128–129, 482 Pathologic fractures, 23
Open book injuries, pelvic fractures and, Osteoconductive effect, 330 of femoral neck, 72
218, 221 Osteoconductive matrix, bone grafts of femur, 86
Open capsulotomy, 68 and, 28, 29 hip fractures in children and, 469
Open fractures, 20–21 Osteogenesis, distraction, 30 tibial shaft fractures and, 159
antibiotic prophylaxis for, 20–21 Osteogenic cells, bone grafts and, 28 Pauwel’s classification, of femoral neck
in children, 460–461 Osteoinductive factors, bone grafts fractures, 67–68
of femoral shaft and subtrochanteric and, 28 PDGF; see Platelet-derived growth factor
region, 79 Osteology, humeral shaft fractures PE; see Pulmonary embolism
management, 13 and, 293 Pectoralis major tendon, tears of, 284
pediatric trauma and, 459 Osteomyelitis, 32 Pediatric lower extremity injuries,
pelvic fractures and, 218 acute hematogenous, 32 467–484
phalangeal fractures and, 205 chronic multifocal, 34 foot injuries, 481–484
proper debridement of, 96 chronic sclerosing, 32–34 fractures
shaft of tibia and fibula fractures humeral shaft fractures and, 297 of ankle, 480–481
and, 478 tibial shaft fractures and, 157 of distal femoral metaphysis and
of supracondylar femoral region and, 92 with unusual organisms, 34 epiphysis, 471–472
tibial plafond fractures and, 162, 166 Osteonecrosis, 31 of femoral shaft, 470–471
tibial shaft fractures and, 144, 147 femoral neck fractures and, 70–71 of hip, 467–470
wrist fractures and, 327 lateral condyle fractures and, 497 of intercondylar eminence, 472–473
Open physes, femoral shaft and subtalar dislocations and, 192 of patella, 475
subtrochanteric region fractures talar neck fractures and, 190–191 of proximal tibial epiphysis, 477
and, 81 tibial tubercle fracture, 126 of shaft of tibia and fibula, 477–479
Open pneumothorax, 6 Osteopenia, 75 of tibial tubercle, 476–477
Open reduction Osteoporotic fibulae, ankle fractures ligamentous injuries of knee, 473–475
distal radius fractures and, 329 and, 180 meniscal injuries, 473
hip dislocations and, 253 OsteoSet, 29 patellar dislocation, 475–476
and plate osteosynthesis, 294–295 Osteosynthesis, plate, humeral shaft traumatic amputations, 484
supracondylar fractures and, 494 fractures and, 294–295 Pediatric pelvic injuries, 515–521
tibial plateau fractures and, 140 Osteotomy, 51, 71, 131, 132, 158, 259 Pediatric physeal fractures, 366–367
Open reduction with internal fixation (ORIF) OTA classification; see Orthopaedic Pediatric spinal injuries, 510–515
bimalleolar fractures and, 176 trauma association classification Pediatric trauma, 458–465
calcaneal fractures and, 197 Ovadia and Beals classification, of tibial fractures, 461–463
distal radius fractures and, 331 plafond fractures, 163–164 multiple injuries, 458–461
fracture-dislocation of PIP joint and, 358 Overgrowth, humeral shaft fractures physeal injury, 463–465
lateral condyle fractures and, 497 and, 490 Pediatric upper extremity injuries,
scapula fractures and, 263 487–507
tibial plafond fractures and, 166, 173 carpal fractures, 507
tibial shaft fractures and, 148–149, P injuries
153–154 Paget’s disease, 72 of acromioclavicular joint, 488–489
ORIF; see Open reduction with internal Pain of clavicle, 487
fixation chronic, gunshot wounds to spine of elbow region, 490–500
Orthogonal imaging, scapula fractures and, 416 of glenohumeral joint, 489–490
and, 262 deafferentation, chronic posttraumatic of humerus, 489–490
Orthopaedic implants, 58 syndromes and, 396–397 of radius, 501–507
Orthopaedic management in children, heel, 484 of sternoclavicular joint, 488
460–461 hip dislocations and, 256 of ulna, 501–507
Orthopaedic materials, mechanical knee, tibial plateau fractures and, 135 metacarpal fractures, 507–508
properties of, 61–63 Palmar space infections, 384 phalangeal fractures, 507–508
Orthopaedic trauma association (OTA) Palpation scapular fractures, 487
classification hip dislocations and, 245 Pedicles
cervical spine trauma and, 428 tibial plateau fractures and, 135 screw augmentation, 451
of femoral shaft fractures, 78 tibial shaft fractures and, 143 subaxial cervical spine and, 406
536 INDEX
Pelvic binder, 218 Physes, open, femoral shaft and Positive rim sign, acute dislocations of
Pelvic brim, orientation of, 219 subtrochanteric region fractures shoulder and, 277
Pelvic C-clamps, 219 and, 81 Posterior atlantoaxial fusion, cervical
Pelvic crushing and open injuries, 520 Physical therapy, RSD and, 207 spine trauma and, 433
Pelvic fractures, 4, 210–222 Physiologic lordosis, cervical spine Posterior cervical fusion, cervical spine
Pelvic injuries trauma and, 423 trauma and, 432
classification of, 213–215 Physis, fractures and, 462, 463 Posterior cervical segmental fixation,
pediatric, 515–521 Pia mater, 388 cervical spine trauma and, 433
Pelvic ossification centers, pediatric, 516 Piezoelectric effect, fracture healing Posterior cervical surgery, cervical spine
Pelvic ring and, 28 trauma and, 432–434, 436
double breaks of, 518–519 Pilon fractures, 178, 358 Posterior column fractures, acetabulum
injuries, 9, 210–222 Pin tract infections, cervical spine trauma fractures and, 227–229, 231, 241
pelvic fractures, 210–222 and, 435 Posterior cruciate ligament (PCL) tears,
single breaks of, 517–518 Pincer fracture, 438 ligamentous injuries of knee and, 474
Pelvic veins, pelvic fractures and, 212 Pins, distal radius fractures and, 330 Posterior distal femoral angle (PDFA),
Pelvis Pipkin’s classification of posterior hip 43, 44
anteroposterior view of, 213 dislocations associated with femoral Posterior glenohumeral dislocation, 275
false, 210 head fractures, 256–257 Posterior hemitransverse fractures,
inlet view of, 213 treatment for, 257–258 231, 241
instability, 214 Pitting, biomaterials and, 61 Posterior interosseous nerve (PIN),
outlet view of, 213 Plain films 308, 315
stable, 214 hip dislocations and, 245 Posterior Judet approach, scapula
true, 210 patellar dislocation and, 127–128 fractures and, 264
PEMF; see Pulsed electromagnetic Plain X-ray, clavicle fractures and, 265 Posterior ligamentous complex,
fields Plantar sensation, 16–17 thoracolumbar spine fractures and,
Penetrating abdominal injuries, 7 Plaster cast, distal radius fractures 443, 453
Penetrating injuries, cervical spine and, 330 Posterior longitudinal ligament, subaxial
trauma and, 414–416 Plastic deformation fractures, cervical spine and, 407
Penetrating trauma, cervical spine trauma 501, 503 Posterior occipito-cervical membrane, 419
and, 428 Plate fixation, supracondylar femoral Posterior pelvic ring fixation, 220
Percutaneous pin fixation, distal radius region fractures and, 89 Posterior process fractures, 192
fractures and, 330 Plate osteosynthesis, humeral shaft Posterior proximal tibial angle (PPTA),
Perilunate dissociation, 343 fractures and, 294–295 43, 44
Perineal skin, pelvic fractures and, 213 Plate removal, refracture after, forearm Posterior roof arc (PRA), acetabulum
Perineurium, 375 injuries and, 320–321 fractures and, 227
Periosteum, fractures and, 462, 505 Plate stabilization, femoral shaft and Posterior SI (sacroiliac) ligaments,
Peripheral bars, resection of, pediatric subtrochanteric region fractures sectioning of, pelvic fractures
trauma and, 465 and, 82 and, 218
Peripheral nervous system, foot and Plateau fractures Posterior tibial artery, talus fractures and
ankle injuries and, 207 with associated shaft fracture, 139 dislocations and, 187
Periprosthetic fractures, 92 tibial; see Tibial plateau fractures Posterior transiliac plate, pelvic fractures
of femur, 86 Platelet-derived growth factor (PDGF), 27 and, 220
tibial shaft fractures and, 158–159 Plates Posterior wall fractures, acetabulum
Peritoneal lavage, diagnostic, pelvic bone, 58 fractures and, 227, 229, 241
fractures and, 213 compression, femoral shaft fractures Posteriorly displaced hemipelvis, pelvic
Peritoneal packing, 219 and, 471 fractures and, 219, 220
Peritoneum, pelvic fractures and, 212 femoral shaft and subtrochanteric Posterolateral approach, talar neck
Permanent cavitation, penetrating region fractures and, 83, 84 fractures and, 191
injuries of spine and, 414 submuscular bridge, femoral shaft Posttraumatic arthritis
Peroneal artery, talus fractures and fractures and, 471 acetabulum fractures and, 242
dislocations and, 187 PMMA; see Polymethylmethacrylate ankle fractures and, 180
Peroneal distribution, hip dislocations PMMA beads; see Antibiotic-impregnated DRUJ injuries and, 349
and, 245 polymethylmethacrylate beads hip dislocations and, 260
Peroneal nerve Pneumothorax talar neck fractures and, 190
injury, femoral shaft and open, 6 Posttraumatic arthrosis, patellar fractures
subtrochanteric region fractures simple, 6 and, 119
and, 84 tension, 4, 6 Posttraumatic contracture, of DRUJ, 350
knee dislocation and, 100, 110 Poisoning, lead, bullets in spinal canal Posttraumatic spinal deformity, 515
Peroneal neuropathy, tibial plateau and, 415 Posttraumatic stiffness, elbow injuries
fracture and, 141 Poisson’s ratio (v), 59–60 and, 311
Peroneal “sacrificing” procedures, foot Polar moment of inertia (J), 57 Posttraumatic stress disorder (PTSD), 16
and ankle injuries and, 182 Poller screws, 155, 156 Posttraumatic syndromes, chronic,
Peroneal tendon dislocations, Pollicization of thumb, 381 396–397
182–183 Polymers Power’s ratio, 422
Perthes-Bankart lesion, 280 corrosion of, 61 Prevertebral soft-tissue swelling, 422
Phalangeal fractures, 205, 362–363, molecular structure of, 60 Primary survey, 2–3, 6
483–484, 507–508 Polymethylmethacrylate (PMMA), 9–10 Progressive perilunar disruption, carpal
Phalanx, amputation and, 380 Polytraumatized patient, orthopaedic dislocations and instability and, 339
Physeal arrest, 463–465 management in, 12–13 Proliferative zone, 463
lateral condyle fractures and, 497 Popliteal artery Prophylactic fasciotomies, humeral shaft
Physeal fractures, 462, 463–465 knee dislocation and, 100 fractures and, 298
in children, 366–367 proximal tibial epiphysis fractures Proprioception, hand injuries and, 380
Salter-Harris, 488 and, 477 Prostatic hypertrophy, 7
INDEX 537
Prosthetic replacement, intertrochanteric Quadriplegia, 401 Radiographic signs of pelvic instability,

fractures and, 74 Quantitative CT, bone density and, 31 pelvic fractures and, 218
Proximal and distal fractures, 155–156 Radiolucent table, supracondylar femoral
Proximal humerus fractures, 272–276, 489 region fractures and, 92
Proximal interphalangeal (PIP) joint R Radionuclide bone imaging
collateral ligament sprain of, 356–357 Rabies, 11–12 DRUJ injuries and, 347
dorsal dislocation of, 357 Radial artery, forearm injuries and, 315 wrist fractures and, 327
fracture-dislocation of, 358 Radial head Radius
injuries of, 356–358 excision of, 309 bone, forearm injuries and, 314
volar dislocation of, 358 fractures of, 301, 303, 309–310, 348–349 distal; see Distal radius
volar plate injury of, 357 subluxation of, 498–499 injuries of, 501–507
Proximal metaphyseal fractures, 477–478 Radial nerve Rang classification, of pediatric pelvic
Proximal phalanx forearm injuries and, 315 fractures, 517
amputation and, 380 humeral shaft fractures and, 293, Range of motion
fractures of, 507–508 298, 490 loss of, patellar fractures and, 119
Proximal radius fractures, 500 injuries, 320 tendon sheath infections and, 384
Proximal tibia-fibular joint dislocations, 479 Radial shaft fractures wrist, distal radius fractures and, 323
Proximal tibial epiphysis, fractures of, 477 DRUJ injury and, 348–349 Ray resection, amputation and, 380
Proximal tibial physeal closure, shaft forearm injuries and, 316 Reaming
of tibia and fibula fractures and, Radial styloid fractures, 331 femoral shaft and subtrochanteric
478–479 Radiation, effect of, on bone, 28 region fractures and, 84
Proximal tibiofibular dislocations of knee, Radiocapitellar relationships, 491 humeral shaft fractures and, 296
113–114 Radiographic evaluation tibial shaft fractures and, 149–151,
Proximal “tube” realignment of patella, AC joint injuries and, 269 154–155
patellar dislocation and, 130 acetabulum fractures and, 224 Reconstructive phase of soft-tissue
Proximal ulna fractures, 307–309 acute dislocations of shoulder and, 277 injuries associated with fractures, 21
Pseudoarthrosis of calcaneal fractures, 195 Rectal examination, pelvic fractures
of clavicle, congenital, 487 cervical spine trauma and, 421–424 and, 213
congenital, of tibia, 479 clavicle fractures and, 265, 266 Reduction
Pseudomonas aeruginosa, puncture distal radius fractures, 324 elbow dislocations and, 305
wounds of foot and, 16 and ulnar fractures, 505 fracture, via manipulation, 24
Pseudoparalysis, of upper extremity, 487 of dorsal dislocation open; see Open reduction
Pseudosubluxation, pediatric spinal of DIP joint, 355 tibial shaft fractures and, 146
injuries and, 510–511 of PIP joint, 357 Reflex sympathetic dystrophy (RSD),
Pubic rami fractures, 220, 517–518 DRUJ injuries and, 346–347 384–385
Pubic symphysis femoral neck and intertrochanteric distal radius fractures and, 332
fracture or subluxation of, 518 region fractures and, 66–67 Refracture
pelvic fractures and, 210 of femoral shaft, 78 femoral shaft and subtrochanteric
sectioning of, pelvic fractures and, 218 of finger MCP collateral ligament injury, region fractures and, 85
Pubis, fractures of, 517 360 greenstick fractures and, 503
Pudendal nerve injury, femoral shaft and foot and ankle injuries and, 181, 188, after plate removal, forearm injuries
subtrochanteric region fractures 192, 193 and, 320–321
and, 84 forearm injuries and, 316 Regan and Morrey classification, of
“Pulled elbow”, 498–499 fracture-dislocation of PIP joint and, 357 coronoid process fractures, 501
Pulmonary contusion, 6 fractures at base of thumb metacarpal Regional pain syndrome, 384–385
Pulmonary dysfunction, femoral shaft and, 365 Rehabilitation
and subtrochanteric region fractures high-pressure injection injuries and, 383 distal radius fractures and, 332
and, 84 hip dislocations and, 245–246 femoral head fracture and, 258
Pulmonary embolism (PE), 13–14, 222 humeral shaft fractures and, 294 nerve repair and, 377
Pulsating irrigation, 21 knee dislocation and, 106 patellar dislocation and, 129
Pulse pressure, narrow, 3 metatarsal neck and shaft fractures Rehabilitative phase, of soft-tissue
Pulsed electromagnetic fields (PEMFs), 28 and, 203 injuries associated with fractures, 21
Pulses pediatric spinal injuries and, 511 Remodeling, fracture repair and,
supracondylar femoral region fractures pediatric trauma and, 459 27, 463
and, 88 penetrating injuries of spine and, 415 Renal problems, chronic, femoral neck
tibial plateau fractures and, 135 proximal humerus fractures and, fractures and, 72
tibial shaft fractures and, 143 272–273 Replantation
Puncture wounds of foot, 16, 208, 484 reflex sympathetic dystrophy and, 385 hand injuries and, 379
Pure depression fractures, tibial plateau SC joint injuries and, 270 of thumb, 380
fractures and, 139 scaphoid fractures and, 334, 335 Reserve zone, 463, 464
Pure split fractures, tibial plafond scapulothoracic dissociation and, Resilience, biomaterials and, 60
fractures and, 165 264–265 Rest, ice, compression, and elevation
tarsometatarsal fracture-dislocation (RICE), foot and ankle injuries
and, 202 and, 181
Q thumb radial collateral ligament injury Resuscitation, 3
Quadrangular space and, 359 fluid, 3
brachial plexus injuries and, 287 thumb ulnar collateral ligament injury initial, multiple injuries and, in
syndrome, 289–290 and, 359 children, 459
Quadriceps active test, ligamentous tibial plafond fractures and, 162 Retrograde starting point, femoral shaft
injuries of knee and, 474 tibial plateau fractures and, 136 and subtrochanteric region fractures
Quadriceps contusion, 132–133 tibial shaft fractures and, 144 and, 83–84
Quadriceps tendon rupture, 120–124 volar dislocation of PIP joint and, 357 Retrograde urethrogram, pelvic fractures
Quadriga effect, flexor tendons and, 370 wrist fractures and, 326–327 and, 212
538 INDEX
Retrograde urethrography, pediatric Sacrospinous ligaments, pelvic fractures Second-degree burn, 7

trauma and, 459 and, 210, 218 Secondary missiles, penetrating injuries
Retropharyngeal hematoma, cervical Sacrotuberous ligaments, pelvic fractures of spine and, 414
spine trauma and, 436 and, 210, 218 Secondary survey, 3
Revascularization, hand injuries and, 379 Safe zone, radial head fractures and, 310 Seddon’s classification, 376
Reverse obliquity fractures, 74 Sagittal angulation, 24 Segmental fractures, 23
Rheumatoid arthritis, 302 Salter fractures, 491 Seizure disorders, acute dislocations of
RICE; see Rest, ice, compression, and Salter-Harris III fractures, 508 shoulder and, 277
elevation Salter-Harris classification, 472 Sensation, hand injuries and, 380
Rigid immobilization collars, pediatric of physeal fractures, 465, 488 Sensibility, hand injuries and, 380
spinal injuries and, 513 of physeal injuries of hand, 366–367 Sensory pathways, spinal cord and, 389–390
Rigid intramedullary nail fixation, Salter-Harris distal fibular fractures, 481 Septic arthritis, 384
humeral shaft fractures and, 295–296 Salter-Harris distal tibial fractures, Septic shock, 4
Rigid neck collars, cervical spine trauma 480–481 Sequelae, 206, 467
and, 429 Salvage procedures, scaphoid fractures Sequestra, 32
Ring avulsion injuries, hand injuries and, 335 Serendipity view
and, 379 Salvage versus amputation, 16 clavicle fractures and, 265
Ring fixators, tibial shaft fractures Sanders classification, of calcaneal sternoclavicular joint injuries and,
and, 148 fractures, 195 270, 488
Ring fractures of axis Saupe’s classification, of accessory Sever’s disease, foot pain and, in
malunion and, 436 ossification centers of patella, 117 children, 484
nonunion and, 436 SC joint injuries, 269–271 Sexual function, spinal cord injury
Rogers’ rule, cervical spine trauma Scalars versus vectors, 54 and, 402
and, 429 Scaphocapitate syndrome, 344–345 Shear
Roof arc measurements, acetabulum Scaphoid crush injuries of foot and, 208
fractures and, 224–225, 226, 227 AVN of, 337 hip dislocations and, 255
Root avulsions, brachial plexus injuries blood supply of, 333 Shear forces, tibial plafond fractures
and, 288 fractures of, 332–338, 507 and, 162
Rotation, fractures and, 24 Scapholunate advanced collapse (SLAC), Shear injuries, thoracolumbar spine
Rotational anteroposterior (AP) view, 336, 339, 342 fractures and, 454
proximal humerus fractures and, 273 Scapholunate dissociation, carpal Shear stress, biomechanics and, 54
Rotational deformity dislocations and, 342 Shear-thickening, biomaterials and, 60
of fingers, 364 Scapholunate instability, 340 Shear-thinning, biomaterials and, 60
shaft of tibia and fibula fractures Scapular fractures, 263, 487 Sheathed tendon injuries, 21
and, 478 Scapular winging, long thoracic nerve Shepherd’s fractures, 192
Rotational forces, tibial plafond fractures palsy and, 289 Shock, 3–4
and, 162 Scapulothoracic dissociation, 264–265 cardiogenic, 4
Rotational malalignment Schatzker classification, tibial plateau hemorrhagic, 3–4
femoral shaft and subtrochanteric fractures and, 136, 137 hypovolemic, pelvic fractures and, 218
region fractures and, 85 Schatzker fractures, tibial plateau neurogenic, 4, 392
tibial shaft fractures and, 147 fractures and, 140 nonhemorrhagic, 4
Rotational malunion, femoral shaft Schwann cell, nerve regeneration pelvic fractures and, 218
fractures and, 471 and, 376 septic, 4
Rotator cuff, acute dislocations of SCI; see Spinal cord injury spinal, 391–393
shoulder and, 282–283 Sciatic nerve Shortening orientation of tuberosity, 195
Rotator cuff tear injuries, hip dislocations and, 245, 249, Shortening, tibial shaft fractures and, 147
acute dislocations of shoulder and, 253, 255, 256 Shotgun injuries, penetrating injuries of
278–279 palsy, hip dislocations and, 260 spine and, 414
soft-tissue injuries of shoulder and, pelvic fractures and, 210 Shoulder
283–284 SCIWORA; see Spinal cord injury without dislocations of, 276–283
Roux-Goldthwait procedure, patellar radiographic abnormalities elevation, 262
dislocation and, 130 Sclerosing osteomyelitis, chronic, 34 proximal humerus fractures and, 272
Row theory, carpal dislocations and Screw-barrel disengagement, soft-tissue injuries of, 283–285
instability and, 338 intertrochanteric fractures and, 74 Shoulder girdle, fractures and
RSD; see Reflex sympathetic Screws dislocations of, 262–271
dystrophy blocking, 155 Shuck test, 342
Rüedi and Allgöwer classification, of tibial bone, 58 SI joint; see Sacroiliac joint
plafond fractures, 163, 166 iliosacral, pelvic fractures and, 220 Sickle cell anemia, 32
Rule of nines, 8 interlocking, tibial shaft fractures Silastic replacement, radial head fractures
Rule of Spence, 422 and, 155 and, 310
Russe classification, of scaphoid intramedullary hip, intertrochanteric Silicate-based bone grafts, 29
fractures, 333 fractures and, 74 Simple fractures, 90–91
Russell-Taylor classification, of lag; see Lag screws Simple pneumothorax, 6
subtrochanteric fractures, 78, 79 locked, for humeral shaft fractures, 295 Single-column fractures of elbow, 300–301
poller, 155, 156 Single cruciate ligament-intact knee
sliding hip, intertrochanteric fractures dislocation, 99
S and, 72–73 Single-photon absorptiometry, 31
Sacral fractures, 222, 517 transarticular, cervical spine trauma Sitting imbalance, pelvic fractures and, 222
Sacroiliac (SI) joint, 518 and, 433 Skeletal deformity, 37
pelvic fractures and, 210 Scuderi technique, quadriceps tendon Skeletal immaturity, and open physes, 81
subluxation or fracture of, 518 rupture and, 124, 125 Skeletal injuries
Sacroiliac ligaments, posterior, pelvic Seat belt injuries, 413, 440–441 muscle, 21
fractures and, 218 Seat belt sign, 413 tibial plafond fractures and, 165
INDEX 539
Skeletal traction, 218 Spinal cord injury without radiographic Stiffness

and bracing, 82 abnormalities (SCIWORA), 437, 513 knee dislocation and, 110
cervical spine trauma and, 429–430 Spinal decompression, 446–449 posttraumatic, elbow injuries and, 311
fracture-dislocation of PIP joint and, 358 Spinal dura, 388 structural, 56
pelvic fractures and, 221 Spinal instability, 411 supracondylar fractures and, 495
Ski-pole thumb, 359 Spinal instrumentation, cervical spine Stimson technique, hip dislocations
Skin grafts trauma and, 431 and, 252
fingertip injuries and, 381 Spinal nerve, 286 Stoppa approach, modified, 239
lawnmower injuries and, 206 Spinal reconstruction and Straddle fractures, 518–519, 521
Skin injuries, 7–9 instrumentation, 449–451 Strain, linear elasticity and, 55
Skin necrosis, talar neck fractures and, 190 Spinal shock, 442–443 Streaming potentials, fracture healing
Skin slough, tibial plateau fracture and, 141 spinal cord injury and, 391–393 and, 28
SLAC; see Scapholunate advanced Spinal stability, thoracolumbar spine Strength, bone and, 63
collapse fractures and, 444 Streptococcal toxic shock syndrome, 15
Sleeve fracture, 117, 475 Spine Stress
Sliding hip screw, intertrochanteric anatomy, pediatric, 510 biomechanics and, 54
fractures and, 72–73 cervical spine trauma and, 434 corrosion, biomaterials and, 61
Slipped capital femoral epiphysis, hip gunshot wounds to, 415 linear elasticity and, 55
fractures in children and, 470 involvement, 17 Stress fractures, 24, 71
Smith-Petersen approach penetrating injuries of, 414–416 calcaneal fractures and, 199
acetabulurn fractures and, 235 spear-tackler’s, 429 femoral neck, 71
hip dislocations and, 255, 258, 259 stab wounds to, 416 femoral shaft fractures and, 471
Smith-Robinson approach, cervical spine Spinolaminar line (SLL), 422 foot and ankle injuries and, 192
trauma and, 431 Spiral fractures, 23, 63 hip fractures in children and, 469–470
Smith’s fracture, 324 Splint, distal radius fractures and, 330 shaft of tibia and fibula fractures
Snaking, cervical spine trauma and, 430 Splintage, fractures and, 25 and, 479
Snowboarder’s fracture, 192 Split-depression fractures Stress-generated potentials, fracture
Snuffbox tenderness, scaphoid fractures tibial plafond fractures and, 165 healing and, 28
and, 333 tibial plateau fractures and, 139, 140 Stress relaxation, biomaterials and, 60
Soft callus, fracture repair and, 26 Split fractures, tibial plateau fractures Stress-strain curves, biomaterials and,
Soft neck collars, cervical spine trauma and, 139 58, 60
and, 429 Split-thickness skin excision, crush Stricture, pelvic fractures and, 212
Soft-tissue constraints, pelvic fractures injuries of foot and, 208 Structural adaptation, bone and, 63
and, 222 Split-thickness skin graft, fingertip Structural stiffness, 56
Soft-tissue envelope, knee dislocation injuries and, 381 Stryker view, scapula fractures and, 262
and, 103 Spondylitis, ankylosing, 436–437 Subacute osteomyelitis, 34
knee dislocation and, 103 Spondylolisthesis, traumatic, of axis, Subarachnoid space, 388
tibial shaft fractures and, 145 408–409 Subaxial cervical spine, 406–407
Soft-tissue injuries, 20–22 Spondylotic cervical spine stenosis, Subaxial cervical spine injury
of ankle, 180–183 428–429 classification system (SLIC), 428
ankle fractures and, 180 Sports-related spinal cord injury, 397 Subdural hematoma, 5
calcaneal fractures and, 195 Sprains Sublaminar books and clamps, cervical
of glenohumeral joint, 272–291 ankle, 180–182 spine trauma and, 434
of hand, 367–371 deltoid ligament, injuries of foot and Subluxation
hip dislocations and, 248–249 ankle and, 181 calcaneocuboid, 200
supracondylar femoral region fractures ligamentous injuries of knee and, 474–475 cervical spine trauma and, 423
and, 88 SC joint injuries and, 270 posterior, acute dislocations of shoulder
tibial plafond fractures and, 162, 165, syndesmosis, injuries of foot and ankle and, 277
166, 173 and, 181 SC joint injuries and, 270
wrist fractures and, 327 Spur sign, acetabulum fractures and, 231 Submuscular bridge plates, femoral shaft
Somatic motor recovery, spinal cord Stab wounds to spine, gunshot wounds to fractures and, 471
injury and, 401 spine and, 416 Subtalar arthrosis, calcaneal fractures
Space of Poirier, carpal dislocations and Stability, hip dislocations and, 252–253 and, 197
instability and, 338 Stabilization Subtalar injuries, 183, 192
Spear-tackler’s spine, 429 distal radius fractures and, 330–332 Subtrochanteric femur fracture, 71
Spica casting, femoral shaft fractures tibial plateau fractures and, 141 Subtrochanteric fracture stabilization, 82
and, 470 Stabilized Lachman test, knee dislocation Subtrochanteric region, fractures of,
Spinal column, pediatric, 510 and, 105 77–86
Spinal cord, anatomy of, 388–390 Stair-climbing, biomechanics and, 55 Subungual hematoma, nailbed injuries
Spinal cord injury (SCI), 388–403 Stance, biomechanics and, 55 and, 382
chronic posttraumatic syndromes, Staphylococcal toxic shock syndrome, 14 Sucking chest wound, 6
396–397 Staphylococcus aureus, 14 Sunderland’s classification, 376
classification of, 390–393 Staphylococcus epidermidis, 15 Superficial circumflex iliac artery, hip
drugs for, 400 Static equilibrium, 54 dislocations and, 255
early treatment for, 397–400 Static instability, carpal, 341 Superficial palmar arch, 377
epidemiology of, 387–388 Statically locking all fractures, 84 Superior articular facet, 406–407, 411
incomplete spinal cord syndromes, Statics, biomechanics and, 54 Superior facets, subaxial cervical spine
393–396 Stellate ganglion, reflex sympathetic and, 406
pediatric, 510–515 dystrophy and, 385 Superior glenoid labrum, tears of, 284, 285
recovery, 401–403 Stener’s lesion, 359 Superior gluteal artery, pelvic fractures
sports-related, 396–397 Sternoclavicular joint, injuries of, 488 and, 211
timing of surgical intervention for, Stewart and Milford classification, hip Superior labrum anterior and posterior
400–401 dislocations and, 247 (SLAP) lesions, 281
540 INDEX
Superior rectal artery, pelvic fractures Temporary cavitation, penetrating Thrombosis; see also Deep venous
and, 211 injuries of spine and, 414 thrombosis (DVT)
Superior vesical artery, pelvic fractures Tenderness, snuffbox, scaphoid fractures ulnar artery, injuries of hand and, 379
and, 211 and, 333 Thumb
Superomedial half, talus fractures Tendinous healing, 21 amputation, 380–381
and dislocations and, 187 Tendinous injuries, knee dislocation flexor tendon of, 369
Supraclavicular peripheral nerve injury, and, 103 pollicization of, 381
287 Tendon injuries, 21, 327 Thumb metacarpal, fracture of,
Supracondylar femoral region fractures, Tendon lacerations, foot injuries and, 484 365–367, 507
88–97 Tendon problems, distal radius fractures Thumb radial collateral ligament injury,
classification of, 89 and, 332 359–360
evaluation of, 88–89 Tendon sheath infections, 384 Thumb ulnar collateral ligament injury,
initial management, 89 Tensile failure, acute dislocations of 358–359
perioperative plan, 92–96 shoulder and, 279 Tibia
preventing complications, 96–97 Tension band wiring, modified, patellar axes of, 39–40
treatment of, 89–92 fractures and, 117, 118 congenital pseudarthrosis of, 479
Supracondylar fractures, 301, 492–495 Tension, biomechanics and, 56 tibial plafond fractures and, 165
Supracondylar humerus fractures, 462 Tension pneumothorax, 4, 6 Tibia-fibular joint dislocations,
Suprafoveal fractures, 258 Tetanus, 11 proximal, 479
Supraorbital nerve, injury of, cervical TFC; see Triangular fibrocartilage Tibial anatomic axis, lateral, 40
spine trauma and, 435 TFCC; see Triangular fibrocartilage complex Tibial epiphysis, proximal, fractures
Sural nerve, 183, 377 TGF-; see Transforming growth of, 477
Surgical sympathectomy, RSD and, 207 factor-beta Tibial plafond fractures, 162–173
Surgical wound infections, 15–16 Thenar flap, fingertip injuries and, 382 anatomic considerations and, 165
Survey Thenar space, 384 associated injuries, 165
primary, 2–3, 6 Thenar wasting, forearm injuries and, classification of, 162–165
secondary, 3 320, 321 complications of, 173
Swan-neck deformity, 356, 374, 386 Thermal injuries, 7–8, 382 evaluation of, 162
Sympathectomy Thigh compartmental syndrome, femoral surgical techniques for, 165
reflex sympathetic dystrophy and, 385 shaft and subtrochanteric region treatment of, 147–171, 165
surgical, RSD and, 207 fractures and, 84 Tibial plateau fractures, 135–141
Symptomatic hardware, 119, 363 Third-body wear anatomic considerations of, 139–141
Syndesmosis sprains, foot and ankle biomaterials and, 61 associated injuries and, 136
injuries and, 181 hip dislocations and, 255 classification of, 136
Syndesmotic fixation, ankle fractures Third-degree burn, 7 complications of, 141
and, 180 Thixotropic fluids, 60 treatment for, 141
Syndesmotic ligament injuries, 176, 177 Thomas’ classification, of Smith’s evaluation of, 135–136
Synostosis, forearm injuries and, fractures, 325 surgical techniques for, 139–141
319–320 Thomboembolism, pelvic fractures treatment of, 139
Synthetic bone grafts, 29 and, 221 Tibial shaft fractures, 89, 143–159
Syringomyelia, chronic posttraumatic Thompson and Epstein’s classification, anatomy and, 153–156
syndromes and, 396 hip dislocations and, 247 associated injuries and, 145–146
Thompson approach, forearm injuries classification of, 144–145
and, 316 complications of, 157
T Thoracic cord, 388 treatment for, 157
T-shaped fractures, acetabulum fractures Thoracic injuries, pediatric trauma and, deformities and, 158
and, 225, 231, 241 460 evaluation of, 143–144
T4 lymphocytes, HIV infection and, 12 Thoracic nerve palsy, 288–289 nonunion and, 157–158
Tachdjian-Dias classification, of pediatric Thoracic outlet syndrome, 290 surgical techniques for, 165
ankle fractures, 480 Thoracic spine, 411 treatment of, 146–153
Tachycardia, 3 pediatric spinal injuries and, 512 Tibial-sided fractures, 110–112
Tachypnea, pulmonary embolism and, 13 supporting ligaments of, 411 Tibial tubercle fractures, 124–126,
Talar body, fractures of, 187, 191–192 Thoracic trauma, 6 476–477
Talar dislocation, total, 194 Thoracolumbar injury classification and Tibiofibular dislocations, proximal, of
Talar head, talus fractures and severity score (TLICS), 445–446 knee, 113–114
dislocations and, 187–188 Thoracolumbar spine, 411–414 Tile classification of pelvic fractures, 213,
Talar neck fractures, 188–191 fractures and dislocations of, 438–454, 214, 215
Talar process fractures, 192 514–515 Tillaux fractures, 481
Talus Gertzbein classification of, 413 Timing definitive procedures, 12
fractures, 187–194, 481–482 injury classification of, 444–446 Timing of debridement, 13
osteochondral defects of, 192 injuries of, 411–414, 452–454 Tissue graft, free, injuries of foot and
TAM; see Total active motion mechanisms of injury, 438–441 ankle and, 182
Tarsal canal, artery of, talus fractures and spinal stability and, 444 Toddler’s fractures, shaft of tibia and
dislocations and, 187 techniques of spinal decompression, fibula fractures and, 479
Tarsal sinus, artery of, talus fractures and 448–449 Toe injuries, 205
dislocations and, 187 treatment of, 452–454 Toe-to-thumb transfer, 381
Tarsometatarsal (Lisfranc’s) fracture- Thoracolumbosacral orthosis (TLSO), Toes, claw, 206
dislocations, 200–203 446, 452 Tomography, SC joint injuries and, 270
Tarsometatarsal joint, 200 Thoracotomy, massive hemothorax and, 6 Tooth sign, quadriceps tendon rupture
injuries of, 483 Three-point fixation casting technique, 24 and, 124
Technetium 99m-phosphate bone scan, 30 Thromboembolism Torode and Zieg classification, of
Technetium-labeled WBC scan, 31 femoral neck fractures and, 71 pediatric pelvic fractures, 517
Tectorial membrane, 406, 419 hip dislocations and, 256 Torques, biomechanics and, 54
INDEX 541
Torsion, biomechanics and, 57 musculoskeletal, 16–17 Ultrasonography, pediatric trauma

Torsional load, biomechanics and, 57 orthopaedic, 16 and, 459
Torus fractures, 506 pediatric; see Pediatric trauma Ultrasound
Total active motion (TAM), 370 penetrating, cervical spine injuries and, fracture healing and, 28
Total contact casting, ankle fractures 414–416, 428 pelvic fractures and, 213
and, 180 proximal humerus fractures and, 272, 273 Uncinate processes, subaxial cervical
Total elbow arthroplasty (TEA), 302 shock, 3–4 spine and, 407
Total hip replacement, 69–70 skin injuries, 7–9 Uncovertebral joints of Luschka, 407
Total patellectomy, patellar fractures soft-tissue injuries, 7–9 Unhappy triad of elbow, 309
and, 118 thoracic, 6 Uniform corrosion, biomaterials and, 61
Total talar dislocation, 194 Traumatic amputations, 21 Unilateral external fixation, tibial plafond
Toughness, biomaterials and, 60 in children, 484 fractures and, 172
Toxic shock syndrome, 14 Traumatic atlantoaxial instability, Union, delayed; see Delayed union
Traction pediatric spinal injuries and, 514 Unreamed nailing, tibial shaft fractures
femoral shaft and subtrochanteric Traumatic ligamentous injuries of knee, and, 155
region fractures and, 82 98–114 Unstable bony injuries, cervical spine
fractures and, 24 Traumatic spondylolisthesis of axis, trauma and, 429
pelvic fractures and, 221 408–409 Upper cervical spine, 418, 421, 424–427
skeletal, 429–430 Triangular fibrocartilage (TFC), 323 ligaments of, 419
supracondylar femoral region fractures Triangular fibrocartilage complex (TFCC), radiographic reference line, 422
and, 89 323, 325, 347 Upper extremity injuries, pediatric;
supracondylar fractures and, 494–495 injuries of, 349 see Pediatric upper extremity
Traction-delayed spica, femoral shaft wrist fractures and, 327 injuries
fractures and, 470 Triangular interval, brachial plexus Urethra, pelvic fractures and, 212
Transarticular screws, cervical spine injuries and, 287 Urethrogram, retrograde, pelvic fractures
trauma and, 433 Tribologic properties, biomaterials and, 60 and, 212
Transfer wear mechanisms, biomaterials Tricortical iliac crest autograft, cervical Urethrography, retrograde, pediatric
and, 61 spine trauma and, 431–432 trauma and, 459
Transforming growth factor-beta Trigonometric method, 50 Urinary output, pelvic fractures and, 219
(TGF-), 27 Trimalleolar fractures, 178 Urinary tract infection (UTI), 7
Transfusion reactions, 10–11 Triplane fractures, 481 UTI; see Urinary tract infection
Transiliac plate, posterior, pelvic Triquetrum, fractures of, 337
fractures and, 220 Triradiate cartilage fractures, 519
Translation, measurement of, 49 Trochanteric slide, hip dislocations V
Translational deformities, 24 and, 254 v; see Poisson’s ratio
Translational displacement, 427 True pelvis, 210 V-Y advancement, fingertip injuries
Translational injuries, 413–414 Tscherne method, grading of fractures and, 381
Transmembrane potentials, fracture by, 20 Vacant glenoid sign, acute dislocations of
healing and, 28 Tuberosity fractures shoulder and, 277
Transolecranon fracture-dislocation of acute dislocations of shoulder and, 279 Vaginal examination, pelvic fractures
elbow, 307 of calcaneus, 198–199 and, 213
Transphyseal fractures, 490–493 shortening and widening of, 195 Valgus deformity after proximal tibia
Transradial styloid perilunate fracture- Turf toe injuries, 205, 206 fracture in children, 478
dislocation, 343 Turn-up test, patellar dislocation and, 130 Valgus instability, tibial plateau fractures
Transscaphoid perilunate fracture- Two-column fractures of elbow, 301–302 and, 139
dislocation, 343 Valgus pattern, olecranon fractures
Transtectal fractures, 231 and, 498
Transtriquetral perilunate fracture- U Valgus stress view, tibial plateau fractures
dislocation, 345 Ulna and, 136
Transverse and posterior wall fractures, approach to, forearm injuries and, 316 Varus displacement of proximal
acetabulum fractures and, 231 articulation between distal radius fragment, 74
Transverse atlantal ligament (TAL), 419 and, 323 Varus instability, tibial plateau fractures
Transverse foramina, 407 fractures of and, 139
Transverse fractures, 23, 63 DRUJ injury and, 347–348 Varus malunion, talar neck fractures
acetabulum fractures and, 231, 241 malreduction of, 308 and, 190
with butterfly fragments, 63 injuries of, 501–507 Varus pattern, olecranon fractures
Transverse ligament, odontoid process Ulnar artery and, 498
and, 406 forearm injuries and, 315–316 Varus stress view, tibial plateau fractures
Transverse sacral fractures, 222 thrombosis of, injuries of hand and, 379 and, 136
Transverse wall fractures, acetabulum Ulnar collateral ligament, stress testing Vascular evaluation, supracondylar
fractures and, 241 of, 359 femoral region fractures and, 88
Trapezium, fractures of, 337 Ulnar fractures, 505–506 Vascular injuries, 80–81
Trapezoid, fractures of, 337 Ulnar nerve acute dislocations of shoulder and, 278
Trauma, 2–17 elbow dislocation and, 500 hip dislocations and, 248
abdominal, 6–7 forearm injuries and, 315 humeral shaft fractures and, 298
advanced trauma life support, 2–3 humeral shaft fractures and, 293 knee dislocation and, 100, 110
cervical spine; see Cervical spine injury to, 320 superficial palmar arch and, 377
trauma Ulnar neuropathy, 310 supracondylar fractures and,
complications of, 13–16 Ulnar shaft fractures, 316 493, 495
head injuries, 4–6 Ulnar styloid fractures, treatment of, 332 tibial shaft fractures and, 147, 157
knee, 98–114 Ulnocarpal abutment, DRUJ injuries tibial-sided fractures and, 111
multiple injuries and, in children, and, 349 vascular tendon injuries, 21
458–459 Ulnocarpal joint, 346 Vascularized bone grafts, 29
542 INDEX
Vasculature Volar intercalated segmental instability Wilkins classification

humeral shaft fractures and, 293 (VISI), carpal dislocations and of elbow dislocations, 499
pelvic fractures and, 211–212 instability and, 339 olecranon fractures and, 498
Vectors Volar ligaments, distal radius fractures “Windshield wiper” effect, 92
resolution of, into components, 54 and, 323, 324 Winquist-Hansen classification, of femoral
scalars versus, 54 Volar lunate dislocation, 343, 344 shaft fractures, 78–79
Velocity, knee dislocation and, 99 Volar muscle, forearm injuries and, Wolff’s law, fracture repair and, 27
Venography, 13, 273–274 314–315 Wound-healing, tibial shaft fractures and,
Venous thromboembolic disease, 13 Volar perilunate dislocation, 343 157
Ventilation, primary survey and, 2 Volar plate arthroplasty, fracture- Wounding capacity, penetrating injuries
Vertebra, lumbar, 411 dislocation of PIP joint and, 358 of spine and, 414
Vertebral artery injuries, cervical spine Volar plate injury of PIP joint, 357 Wounds
trauma and, 429 Volar tilt, wrist fractures and, 324 acetabulum infections and, 242
Vertebral bony and ligamentous injuries, closure of, 22
406–416 Wright hyperabduction test, 290
Vertebral burst fracture, 439 W Wrist
Vertical compression Wackenheim’s line, 422 dislocations of, 323–350
cervical spine trauma and, 427 Wallerian degeneration, 375 fractures of, 323–350
injuries of, 410 Warfarin (Coumadin), 13, 71 range of motion of, 323
Viscoelasticity, biomaterials and, 60 Watson-Jones approach Wrist-drop deformity, radial nerve injury
Viscosity, biomaterials and, 60 acetabulurn fractures and, 235 and, 320, 321
VISI; see Volar intercalated segmental hip dislocations and, 254
instability Watson-Jones classification, 125
VMO advancement, patellar dislocation Watson test, carpal dislocations and, 342 Y
and, 130 Wear mechanisms, biomaterials and, 61 Yield point, biomaterials and, 60
Volar advancement, fingertip injuries Weber tenaculum, pelvic fractures and, Yield region, biomaterials and, 60
and, 381 219, 220 Young and Burgess classification, of
Volar dislocation of PIP joint, 358 Weeping lubrication mechanisms, pelvic fractures, 213, 215, 216
Volar instability patterns, carpal biomaterials and, 61 Young patients, tibial plateau fractures
dislocations and instability Widened mediastinum, 6 in, 135
and, 339 Widening orientation of tuberosity, 195 Young’s modulus (E), 55, 59

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Review

Copyright © 2013 by Lippincott Williams and Wilkins

351 West Camden Street

530 Walnut Street

Library of Congress Cataloging-in-Publication Data

Review of orthopaedic trauma / [edited by] Mark R. Brinker. —- Second Edition.

Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott

Robert Victor Cantu, MD

James B. Bennett, MD Luke S. Choi, MD

John T. Gorczyca, MD Byron Hobby, MD

Frank A. Gottschalk, MD Joseph R. Hsu, MD

Thomas L. Mehlhoff, MD Steven A. Olson, MD

Jerry S. Sher, MD Michael W. Wolfe, MD

General Principles of Trauma

• Mild brain injury (GCS, 14 to 15)—Patients

1. Blunt abdominal injuries (b) Ultrasound

(c) Calculation of burned body area—In-

• Streptococcal—Involves toxins from Group 7. Surgical wound infections—Most commonly

Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary Lange RH, Bach AW, Hansen ST Jr, et al. Open tibial fractures

I. Fracture Description caused by a farm injury are special catego-

This should be performed every 24 to

Medial FIGURE 2-2 Topical atlas of the most commonly

B. Bone Comminuted fractures generally result from

FIGURE 2-3 Condition of the bone in fractures.

Comminuted Pathologic Incomplete Segmental Fracture with

Butterfly Stress Avulsion Impacted

the scene of the injury (a high-energy open • Angulation—Describes the direction (frontal,

III. The Biology of Bone Formation and Fracture Healing later replaced, via the process of enchondral

5. Growth hormone–insulin-like growth factor I- • Pulsed electromagnetic fields (PEMF)—

immunogenic (cartilage is vulnerable to in- and osseointegration. These materi-

D. Graft Preparation—Allograft bone can be pre- C. Biology

• Third phase (delayed, 4 hours)—This C. Computed Tomography (CT)—It continues to

VII. Complications of Fractures reflect the organisms present deep within

D. Standardized radiographic imaging technique to

FIGURE 3-1 Mechanical axis of the lower extremity,

FIGURE 3-3 Bilateral weight-bearing 51-in AP alignment

FIGURE 3-5 The mechanical axis of a long bone is

2. The AP mechanical axis of the tibia is a straight

FIGURE 3-7 AP Anatomic axis of the femur. (Reprinted

a series of mid-diaphyseal points will not define

FIGURE 3-10 The longitudinal axis of the femoral

FIGURE 3-13 The distal tibial joint orientation line and

cortices at the proximal tibial joint orienta-

FIGURE 3-14 The lateral view distal femoral joint

FIGURE 3-16 The lateral view distal tibial joint

XI. Measurement of Horizontal Plane Angular Deformity Translation = 20 mm

XIII. Measurement of Orientation of Deformity: Oblique by drawing two perpendicular lines.

Anterior Lateral (pr)

3. Both 1 and 2 Compensatory No Aggravating

3. An angular deformity or a translation defor- Paley D, Tetsworth K. Mechanical axis deviation of the lower

Biomechanics and Biomaterials

BIOMECHANICS 2. The rate of change of momentum is proportional

FIGURE 4-2 When load is applied parallel to the face of

FIGURE 4-3 A patellar ligament is

is called tensile axial loading. The ligament • Bending loads produce stresses in a mate-

Neutral axis (mn)

mc FIGURE 4-4 Under the influence of bending

Materials testing machine

Support Plastic region

Area under curve = work done

• Mineral component—This varies throughout SUGGESTED READINGS

Fractures of the Femoral Neck

of the proximal femur. This view can help diag-