Physeal consideratioms

 Introduction
 Always look to see if physis is open
 Unique principals in pediatric bone
o elasticity

 more elastic which leads to unique fracture patterns


buckle fractures
 greenstick fractures
 remodeling potential
 open physes (growth plates) can allow extensive bone
deformity remodeling potential
 occurs more rapidly in plane of joint motion
 sagittal plane in wrist, due to primarily
extension/flexion
 occurs more at the most active physes, due to most
growth and potential for remodeling
 most active physes in upper extremity


proximal humerus
 distal radius
 most active physes in lower extremity
 distal femur
 proximal tibia
 Same principles as adult bone
 intra-articular fractures must be reduced

Physeal Anatomy
Physeal Growth Plate
(letters on left correspond to histology in top right)

B. Reserve zone  Cells store lipids,  Gaucher's

glycogen, and  diastrophic dysplasia
proteoglycan  Kneist
aggregates for later  pseudoachondroplasia
growth and matrix
production
 Low oxygen tension

C. Proliferative  Proliferation of  Achondroplasia

zone chondrocytes with  Gigantism
longitudinal growth
 and stacking of  MHE
chondrocytes.
 Highest rate of
extracellular matrix
production
 Increased oxygen
tension in
surroundings inhibits
calcification

D.Hypertrophic  Zone of chondrocyte  SCFE (not renal)

zone maturation,chondrocyte  Rickets (provisional
hypertrophy, and chondrocyte calcification zone)
calcification.  Enchondromas
 Three phases occur in the  Mucopolysacharide
hypertrophic zone disease
o Maturation  Schmids
zone:preparation of  Fractures most
matrix for calcification, commonly occur
chondrocyte growth through hypertrophic
o Degenerative zone
zone: further
preparation of matrix
for calcification, further
chondrocyte growth in
size (5x)
o Provisional
calcification
zone:chondrocyte
death allows calcium
release, allowing
calcification of matrix
 Chondrocyte maturation
regulated by local growth
factors (parathyroid related
peptides, expression regulated
by Indian hedgehog gene)
 Type X collagen produced by
hypertrophic chondrocytes
important for mineralization

E. Primary  Vascular invasion and  Metaphyseal "corner

spongiosa resorption of transverse fracture" in child abuse
(metaphysis) septa.  Scurvy
 Osteoblasts align on
cartilage bars produced
by physeal expansion.
 Primary spongiosa
mineralized to form
 woven bone and then
remodels to become
secondary spongiosa
(below)

Secondary  Internal remodeling (removal of  Renal SCFE

spongiosa cartilage bars, replacement of fiber
(metaphysis) bone with lamellar bone)
 External remodeling
(funnelization)

Physis Periphery

Groove of  During the first year of life, the

Ranvier zone spreads over the adjacent
metaphysis to form a fibrous  Osteochondroma
circumferential ring bridging from
the epiphysis to the diaphysis.
 This ring increases the
mechanical strength of the
physis and is responsible for
appositional bone growths
o supplies chondrocytes to
periphery

Perichondrial fibrous ring  Dense fibrous tissue that

of La Croix is the primary limiting
membrane that anchors
and supports the physis
through peripheral
stability

 Perichondrial artery
o major source of nutrition to physis

Injury Classification

 Salter-Harris classification
o Type 1- physeal separation
o Type 2- fracture traverses physis and exits metaphysis


most common type
 Thurston Holland fragment
 Type 3- fracture traverses physis and exits epiphysis
  Type 4- fracture passes through epiphysis, physis,
metaphysis
 Thurston Holland fragment
 Type 5- crush injury to physis

Treatment

 Closed reduction vs. CRPP vs Open reduction

o depends on injury pattern
o intra-articular fractures must be reduced

Complications

 Growth arrests
o overview

 complete arrest leads to shortening

 see Leg Length Discrepancy

 partial arrest leads to angulation
 treatment
 bar resection with interposition
 indications

 < 50% physeal involvement

 > 2 years or 2cm growth remaining
 ipsilateral completion of arrest
 indications
 > 50% physeal involvement
 can combine with contralateral
epiphysiodesis and/or ipsilateral
lengthening

Evaluation, Resuscitation and DCO

Introduction

 Trauma is a major public health problem with high disability, death, and societal
cost
 Three peak times of death after trauma
o 50% within the first minutes of sustaining the injury
  caused by massive blood loss or neurologic injury
 30% within the first few days
 most commonly from shock, hypoxia, or neurologic
injury
 20% within days to weeks following injury
 multi system organ failure and infection are leading
causes
 Golden Hour
 period of time when life threating and limb threatening
injuries should be treated in order to decrease mortality
 estimated 60% of preventable deaths can occur during this
time ranging from minutes to hours
 Use of an airbag in a head-on collision significantly decreases the
rate of
 closed head injuries
 facial fractures
 thoracoabdominal injuries
 need for extraction

Evaluation
 Primary survey
 treat greatest threats to life first

 pelvic fractures can be a life threatening intervened on

by orthopedic surgeons
 brief history
 ABCDE's
 Airway


includes cervical spine control
 Breathing and ventilation
 Circulation
 includes hemorrhage control and resuscitation
(below)
 pregnant women should be placed in the left
lateral decubitus position to limit positional
hypotension
 Disability
 Exposure
 Secondary survey
 physical examination and updated history
 obtain indicated imaging studies
 Tertiary survey
  repeat physical examination and additional imaging as
indicated when mental status has stabilized
 formal tertiary survey decreases chances of missed
orthopedic inury

Hemorrhagic Shock Classification & Fluid Resuscitation

% Blood
Class HR BP Urine pH MS Treatment
Loss

< 15% > 30

I normal normal normal anxious Fluid
(<750ml) mL/hr

15% to 30% confused

> 100 20-30
II (750- normal normal irritable Fluid
bpm mL/hr
1500ml) combative

30% to 40%
> 120 5-15 lethargic Fluid &
III (1500- decreased decreased
bpm mL/hr irritable Blood
2000ml)

> 40% (life

> 140 lethargic Fluid &
IV threatening) decreased negligible decreased
bpm coma Blood
(>2000ml)

 Introduction
o average adult (70 kg male) has an estimated 4.7 - 5 L of
circulating blood
o average child (2-10 years old) has an estimated 75 - 80
ml/kg of circulating blood
 Methods of Resuscitation
o fluids


crystalloid isotonic solution
 blood options
 O negative blood (universal donor)
 Type specific blood
 Cross-matched blood
 transfuse in 1:1:1 ratio (red blood cells: platelets:
plasma)
 Indicators of adequate resuscitation
 urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
 serum lactate levels
 most sensitive indicator as to whether some circulatory
beds remain inadequately perfused (normal < 2.5
mmol/L)
  gastric mucosal ph
 base deficit
 normal -2 to +2
 Risk of transfusion
 risk of viral transmission following allogenic blood transfusion
 hepatitis B (HBV) has highest risk: 1 in 205,000
donations
 hepatitis C (HCV): 1 in 1.8 million donations
 human immunodeficiency virus (HIV): 1 in 1.9 million

Non-hemorrhagic shock
 Cardiogenic shock
o the heart is unable to generate sufficient cardiac output
 Neurogenic shock
o hypotension and relative bradycardia fromloss of
sympathetic tone following spinal cord inury
 Septic shock vs. hypovolemic shock
o the key variable to differentiate septic shock and
hemorrhagic shock is thatsystemic vascular resistance is
decreased with septic shock and increased with hypovolemic
shock

Hypovolemic
Septic Shock
Shock

Systemic Vascular
increased decreased
Resistance

Cardiac Output decreased increased

Pulmonary Capillary
decreased decreased
Wedge Pressure

Central Venous
decreased decreased
Pressure

Mixed Venous
decreased increased
Oxygen

Imaging
 Delay of fracture diagnosis is most commonly caused by failure to
image extremity
o image any extremity with pain, crepitus, ecchymosis,
deformity
 AP Chest
 o mediastinal widening
o pneumothorax
 Lateral C-spine
o must visualize C7 on T1
o not commonly utilized in lieu of increased sensitivity with
cervical spine CT
 AP Pelvis
o pelvic ring

 further CT imaging should be delayed until preliminary

pelvic stabilization has been accomplished
o acetabulum
o proximal femur
 CT Scan
o C-spine, chest, abdomen, pelvis
o often used in initial evaluation of trauma patient to rule out
life threatening injuries

Damage Control Orthopaedics (DCO)

 Definition/History
o definitive treatment delayed until physiology has improved
o popularized in 2000
o replaced the 1980s philosophy of Early Total Care (ETC), the concept of
fixing long bone fractures as soon as possible because patients were "too
sick not to operate"

 ETC led to exacerbation of the "second-hit" in a subset of patients

with hemodynamic instability, head, and/or chest injuries
 Involves staging definitive management to avoid adding trauma to patient during
vulnerable period
o the decision to operate and surgical timing on multiple injured trauma
patients remains controversial
o intra-operative hypotension increases mortality rate in patients with head
injury
 Parameters that help decide who should be treated with DCO
o ISS >40 (without thoracic trauma)
o ISS >20 with thoracic trauma
o GCS of 8 or below
o multiple injuries with severe pelvic/abdominal trauma and hemorrhagic
shock
o bilateral femoral fractures
o pulmonary contusion noted on radiographs
o hypothermia <35 degrees C
o head injury with AIS of 3 or greater
o IL-6 values above 500pg/dL
 Optimal time of surgery
o patient are at increased risk of ARDS and multisystem failure during acute
inflammatory window (period from 2 to 5 days characterized by a surge in
inflammatory markers)
  therefore only potentially life-threatening injuries should be treated
in this period including

 unstable pelvic fracture

 compartment syndrome
 fractures with vascular injuries
 unreduced dislocations
 traumatic amputations
 unstable spine fractures
 cauda equina syndrome
 open fractures
 Stabilization followed by staged definitive management
o to minimize trauma, initial stabilization should be performed and followed
by staged definitive management
 includes initial pelvic volume reduction via sheet, pelvic packing,
skeletal traction, binder, or external fixation
 if hemodynamically stable

1. proceed with further imaging including CT chest,

abdomen, pelvis
2. if not hemodynamically stable
1. consider exploratory laparotomy and/or pelvic
angiography and embolization
2. definitive treatment delayed for
1. 7-10 days for pelvic fractures
2. within 3 weeks for femur fractures (conversion from exfix to IMN)
3. 7-10 days for tibia fractures (conversion from external fixation to
IMN)

Early Appropriate Care

1. Definition/History
1. identifies major trauma patients and definitively treats the most time-critical orthopaedi
inflammatory response, guided by laboratory parameters of adequate resuscitation
2. popularized in 2013
2. Parameters
1. lactate of < 4.0 mmol/L
2. pH ≥ 7.25
3. base excess ≥ -5.5 mmol/L
3. Optimal time of surgery
1. goal is to definitively treat spine, pelvis, femur, and acetabulum fractures within 36 hour
4. Outcomes
1. decreased delay to surgery
2. decreased complication rates
3. increased hospital revenues
4. main reason for delay to treatment with imp

Open Fractures Management

Introduction
 Open fracture definition
o a fracture with direct communication to the external
environment
o historically described as a "compound" fracture
o a soft tissue wound in proximity to a fracture should be treated as an open
fracture until proven otherwise
 Often associated with additional injuries
 Orthopaedic urgency
o in the absence of life-threatening injuries, there is no clinical advantage to
performing surgery within 6 hours of injury versus 6-24 hours

Classification
 Gustilo Classification
 Tscherne Classification

Antibiotic Management
 Gustilo Type I and II
 1st generation cephalosporin
 clindamycin or vancomycin can also be used if allergies exist
 Gustilo Type III
 1st generation cephalosporin + aminoglycoside
 Farm injuries, heavy contamination, or possible bowel
contamination
 add high dose penicillin for anaerobic coverage
(clostridium)
 Special considerations
 fresh water wounds


fluoroquinolones or 3rd or 4th generation
cephalosporin
 saltwater wounds
 doxycycline + ceftazidime or a fluoroquinolone
 Duration
 initiate as soon as possible
 studies show increased infection rate when antibiotics
are delayed for more than 3 hours from time of injury
 continue for 24 hours after initial injury if wound is able to be
closed primarily
 continue for 24 hours after final closure if wound is not
closed during initial surgical debridement (72 hours for Type
III wounds)

Tetatnus
  Initiate in emergency room or trauma bay
 Two forms of prophylaxis
 toxoid dose 0.5 mL, regardless of age
 immune globulin dosing

 <5-years-old receive 75 U
 5-10-years-old receive 125 U
 >10-years-old receive 250 U
o toxoid and immunoglobulin should be given intramuscularly
with two different syringes in two different locations
 Guidelines for tetanus prophylaxis depend on 3 factors
o complete or incomplete vaccination history (3 doses)
o date of most recent vaccination
o severity of wound

Emergency Room Management

 Fracture management begins after initial trauma survey and
resuscitation is complete: airway, breathing, circulation, disability,
and exposure (ABCDE)
 Antibiotics
 initiate early IV antibiotics and update tetanus prophylaxis as
indicated
 low-energy gunshot wounds should be treated with a single
dose of a 1st generation cephalosporin in the ED
 Control bleeding
 direct pressure will control active bleeding
 do not blindly clamp or place tourniquets on damaged
extremities
 Assessment
 soft-tissue damage
 neurovascular exam

 if concern for vascular insult, ankle brachial index (ABI)

should be obtained

normal ratio is >0.9

 vascular surgery consult and angiogram is
warranted if ABI <0.9
o consider saline load test if concern for traumatic arthrotomy
 Dressing
o remove gross debris from wound, do not remove any bone
fragments
o place sterile saline-soaked dressing on wound
 o little evidence to support aggressive irrigation or irrigation
with antiseptic solution in the ED, as this can push debris
further into wound
 Stabilize
o splint, brace, or traction for temporary stabilization
 decreases pain, minimizes soft tissue trauma, and
prevents disruption of clots

Operating Room Management

 Aggressive debridement and irrigation
o thorough debridement is critical to prevention of deep
infection; remove foreign bodies
o expose fracture by recreating mechanism of injury, extend
wound proximally and distally in line with extremity
o low pressure irrigation is preferred over high pressure pulse
lavage
o saline shown to be most effective irrigating agent

 on average, 3L of saline are used for each successive

Gustilo type

 Type I: 3L
 Type II: 6L
 Type III: 9L
o bony fragments without soft tissue attachments should be
removed
 Fracture stabilization
o internal fixation, external fixation, or intramedullary nail as
indicated
 avoid placement of pins in proximity to planned
definitive incisions
 Staged debridement and irrigation
o perform every 24 to 48 hours as needed
 Early soft tissue coverage or wound closure is ideal
o timing of flap coverage for open tibial fractures remains
controversial, <5 days is desired
o increased risk of infection beyond 7 days
o can proceed with bone grafting after wound is clean and
closed
o negative-pressure wound therapy may be utilized during
debridement until definitive coverage can be achieved
 Can place antibiotic bead-pouch in open dirty wounds
o beads made by mixing methylmethacrylate with heat-stable
antibiotic powder
  Reconstruction options for bone loss

o Masquelet technique
o distraction osteogenesis
o vascularized bone flap/transfer

Complications
5. Infection
6. Neurovascular injury
7. Compartment syndrome
1. can still occur in the setting of open fractures

Gustilo Classification
Abridged version
 Type I
o wound ≤1 cm, minimal contamination or muscle damage
 Type II
o wound 1-10 cm, moderate soft tissue injury
 Type IIIA
o wound usually >10 cm, high energy, extensive soft-tissue
damage, contaminated
o adequate tissue for flap coverage
o farm injuries are automatically at least Gustillo IIIA
 Type IIIB
o extensive periosteal stripping, wound requires soft tissue
coverage (rotational or free flap)
 Type IIIC
o vascular injury requiring vascular repair,regardless of degree
of soft tissue injury
 Most accurate way to grade open fratures is by intra-operative
examination

Complete version

Gustilo Type I II IIIA IIIB IIIC

Images

Energy Low Moderate High High High

Wound Size ≤ 1 cm 1-10 cm usually >10 cm usually >10 cm usually > 10 cm

Soft Tissue
Minimal Moderate Extensive Extensive Extensive
Damage

Contaminatio Moderate
Clean Extensive Extensive Extensive
n contamination

Simple fx Severe Severe Severe

Fracture pattern with Moderate comminution or comminution or comminution
Pattern minimal comminution segmental segmental or segmental
comminution fractures fractures fractures

Periosteal
No No Yes Yes Yes
Stripping

Requires free
Typically
Local Local tissue flap or
Skin Coverage Local coverage requires flap
coverage coverage rotational flap
coverage
coverage

Exposed
fracture with
Neurovascular
Normal Normal Normal Normal arterial
Injury
damage that
requires repair

 1st generation  1st generation cephalosporin for

cephalosporin (e. gram positive coverage.
g. cefazolin)  Aminoglycoside (such as
for 24 hours after gentamicin) for gram negative
closure coverage in type III injuries
 the
cephalosporin/aminoglycosi
de should be continued
for 24-72 hoursafter the last
Antibiotics
debridement procedure
 Penicillin should be added if
concern for anaerobic organism
(farm injury)

aminoglycoside
1st

the

penicillin
  Flouroquinolones (e.g. ciprofloxacin)
 should be used for fresh water wounds or salt water wounds
Antibiotics
 can be used if allergic to cephalosporins or clindamycin
(other
consideration  Doxycycline and 3rd or 4th-generation
s) cephalosporin(e.g. ceftazidime)
 can be used for salt water wounds

Antibiotic Indications for Open Fractures

 Gustillo Grade I and II
 1st generation cephalosporin
 Gustillo Grade III
 1st generation cephalosporin + aminoglycoside

 traditionally recommended, but there is controversy

about this regimen
 With farm injury / bowel contamination
o 1st generation cephalosporin + aminoglycoside + PCN
o add PCN for clostridia
 Duration
o initiate as soon as possible
 increased infection rate when antibiotics are delayed >
3 hours from time of injury
o continue for 24-72 hours after I&D
 Tetanus booster if not up to date (no booster in last 5 years)

Fracture Healing
Introduction
 Fracture healing involves a complex and sequential set of events
to restore injured bone to pre-fracture condition
o stem cells are crucial to the fracture repair process
o the periosteum and endosteum are the two major
sources
 Fracture stability dictates the type of healing that will occur
o the mechanical stability governs the mechanical strain
o when the strain is below 2%, primary bone healing will occur
o when the strain is between 2% and 10%, secondary bone
healing will occur
 Modes of bone healing
o primary bone healing (strain is < 2%)
o intramembranous healing
o occurs via Haversian remodeling
o occurs with absolute stability constructs
 o secondary bone healing (strain is between 2%-10%)
o involves responses in the periosteum and external soft
tissues.
o enchondral healing
o occurs with non-rigid fixation, as fracture
braces, external fixation, bridge plating,
intramedullary nailing, etc.
o bone healing may occur as a combination of the above two
process depending on the stability throughout the construct

Type of Fracture Healing with Treatment Technique

Cast treatment Secondary: enchondral ossification

External fixation Secondary: enchondral ossification

IM nailing Secondary: enchondral ossification

Compression plate Primary: Haversian remodeling

Secondary Bone Healing

Stages of Fracture Healing

Inflammation  Hematoma forms and provides source of hemopoieitic cells

capable of secreting growth factors.
 Macrophages, neutrophils and platelets release several
cytokines
o this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6,
10,12
o they may be detected as early as 24 hours post
injury
o lack of TNF-Alpha (ie. HIV) results in delay of both
enchondral/intramembranous ossification
 Fibroblasts and mesenchymal cells migrate to fracture site
and granulation tissue forms around fracture ends
o during fracture healing granulation tissue tolerates
the greatest strain before failure
 Osteoblasts and fibroblasts proliferate
o inhibition of COX-2 (ie NSAIDs) causes repression
of runx-2/osterix, which are critical for differentiation
of osteoblastic cells

Repair  Primary callus forms within two weeks. If the bone ends are
not touching, then bridging soft callus forms.
o the mechanical environment drives differentiation of
either osteoblastic (stable enviroment) or
chondryocytic (unstable environment) lineages of
cells
  Enchondral ossification converts soft callus to hard callus
(woven bone). Medullary callus also supplements the
bridging soft callus
o cytokines drive chondocytic differentiation.
o cartilage production provides provisional
stabilization
 Type II collagen (cartilage) is produced early in fracture
healing and then followed by type I collagen (bone)
expression
 Amount of callus is inversely proportional to extent of
immobilization
o primary cortical healing occurs with rigid
immobilization (ie. compression plating)
o enchondral healing with periosteal bridging occurs
with closed treatment

Remodeling  Begins in middle of repair phase and continues long after

clinical union
o chondrocytes undergo terminal differentiation
o complex interplay of signaling pathways
including, indian hedgehog (Ihh), parathyroid
hormone related peptide (PTHrP), FGF and
BMP
o these molecules are also involved in terminal
differentiation of the appendicular skeleton
o type X collagen types is expressed by hypertrophic
chondrocytes as the extraarticular matrix undergoes
calcification
o proteases degrade the extracellular matrix
o cartilaginous calcification takes place at the junction
between the maturing chondrocytes and newly
forming bone
o multiple factors are expressed as bone is
formed including BMPs, TGF-Betas, IGFs,
osteocalcin, collagen I, V and XI
o subsequently, chondrocytes become apoptotic and
VEGF production leads to new vessel invasion
o newly formed bone (woven bone) is remodeling via
organized osteoblastic/osteoclastic activity
 Shaped through
o Wolff's law: bone remodels in response to
mechanical stress
o piezoelectic charges : bone remodels is response to
electric charges: compression side is electronegative
and stimulates osteoblast formation, tension side is
electropostive and simulates osteoclasts

Variables that Influence Fracture Healing

 Internal variables
o blood supply (most important)
o initially the blood flow decreases with vascular
disruption
o after few hours to days, the blood flow increases
 o this peaks at 2 weeks and normalizes at 3-5
months
o un-reamed nails maintain the endosteal blood supply
o reaming compromises of the inner 50-80% of the
cortex
o looser fitting nails allow more quick reperfusion
of the endosteal blood supply versus canal filling
nails
o head injury may increase osteogenic response
o mechanical factors
o bony soft tissue attachments
o mechanical stability/strain
o location of injury
o degree of bone loss
o pattern (segmental or fractures with butterfly
fragments)
o increased risk of nonunion likely secondary to
compromise of the blood supply to the
intercalary segement
 External variables
o Low Intensity Pulsed Ultrasound (LIPUS)
o exact mechanism for enhancement of fracture healing
is not clear
o alteration of protein expression
o elevation of vascularity
o development of mechanical strain gradient
o accelerates fracture healing and increases mechanical
strength of callus (including torque and stiffness)
o the beneficial ultrasound signal is 30 mW/cm2
pulsed-wave
o healing rates for delayed unions/nonunions has been
reported to be close to 80%
o bone stimulators
o four main delivery modes of electrical stimulation
o direct current
o decrease osteoclast activity and increase
osteoblast activity by reducing oxygen
concentration and increasing local tissue
pH
o capacitively coupled electrical fields (alternating
current, AC)
o affect synthesis of cAMP, collagen and
calcification of carilage
o pulsed electromagnetic fields
o cause calcification of fibrocartilage
o combined magnetic fields
 o they lead to elevated concentrations of TGF-Beta and
BMP
o COX-2
o promotes fracture healing by causing mesenchymal
stem cells to differentiate into osteoblasts
o radiation (high dose)
o long term changes within the remodeling systems
o cellularity is diminished
 Patient factors
o diet
o nutritional deficiencies
o vitamin D and calcium
o as high as 84% of patients with nonunion were
found to have metabolic issues
o greater than 66% of these patients had
vitamin D deficiencies
o in a rat fracture model
o protein malnourishment decreases fracture
callus strength
o amino acid supplementation increases muscle
protein content and fracture callus mineralization
o gastric bypass patients
o calcium absorption is affected because of
duodenal bypass with Roux-en-Y procedure
o leads to decreased Ca/Vit D levels,
hyperparathyroidism (secondary) &
increased Ca resportion from bone
o treat these patients with Ca/Vit D
supplementation
o gastric banding does not lead to these
abnormalities because the duodenum is not
bypassed
o diabetes mellitus
o affects the repair and remodeling of bone
o decreased cellularity of the fracture callus
o delayed enchondral ossification
o diminished strength of the fracture callus
o fracture healing takes 1.6 times longer in diabetic
patients versus non-diabetic patients
o nicotine
o decreases rate of fracture healing
o inhibits growth of new blood vessels as bone is
remodeled
o increase risk of nonunion (increases risk of
pseudoarthrosis in spine fusion by 500%)
o decreased strength of fracture callus
 o smokers can take ~70% longer to heal open tibial shaft
fractures versus non-smokers
o HIV
o higher prevalence of fragility fractures with associated
delayed healing
o contributing factors
o anti-retroviral medication
o poor intraosseous circulation
o TNF-Alpha deficiency
o poor nutritional intake
o medications affecting healing
o bisphosphonates are recognized as a cause of
osteoporotic fractures with long term usage
o recent studies demonstrated longer healing
times for surgically treated wrist fractures in
patients on bisphosphonates
o long term usage may be associated with atypical
subtrochanteric/femoral shaft fractures
o systemic corticosteroids
o studies have shown a 6.5% higher rate of
intertrochanteric fracture non unions
o NSAIDs
o prolonged healing time becaue of COX enzyme
inhbition
o quinolones
o toxic to chondrocytes and diminishes fracture
repair

Gunshot Wounds
Introduction
 Epidemiology
o Gun shot wounds represent the second-leading cause of death for
youth in United States.
 Pathoanatomy
o wounding capability of a bullet directly related to its kinetic
energy
o damage caused by

 passage of missile
 secondary shock wave
 cavitation
  exponential increase in injury with increasing velocity and
efficient energy transfer
 fractures may be caused even without direct impact
 Associated conditions
 lead intoxication (plumbism)
 may be caused by intra-articular missile
 systemic effects include

neurotoxicity
 anemia
 emesis
 abdominal colic
 GSW to hip and acetabulum are most commonly associated
with bowel perforation > vascular injury > urogenital injuries

Classification
 Low velocity
 muzzle velocity <350 meters per second or < 2,000 feet per
second
 most handguns except for magnums
 wounds comparable to Gustillo-Anderson Type I or II
 Intermediate velocity
 muzzle velocity 350-500 meters per second
 shotgun blasts

 highly variable depending on distance from target

 can reflect wounding potential of high velocity firearms
from close range (less than 21 feet) or multiple low
velocity weapons
 wound contamination/infection with close range
injuries due to shotgun wadding
 wounding potential depends on 3 factors

 shot pattern
 load (size of individual pellet)
 distance from target
 High velocity
o muzzle velocity >600 meters per second or >2,000 feet per
second
o military (assault) and hunting rifles
o wounds comparable to Gustillo-Anderson Type III regardless
of size
o high risk of infection
  secondary to wide zone of injury and devitalized tissue

Presentation
 Symptoms
 pain, deformity
 Physical exam
 perform careful neurovascular exam
 clinical suspicion for compartment syndrome

 secondary to increased muscle edema from higher

velocity wounds
o examine and document all associated wounds
 massive bone and soft tissue injuries occur even with
low velocity weapons

Evaluation
 Radiographs
o obtain to identify bone involvement and/or fracture pattern
 CT scan
o identify potential intra-articular missile
o detect hollow viscus injury that may communicate with
fracture

 high index of suspicion for pelvis or spine fractures

given increased risk of associated bowel injury

Treatment General
 Nonoperative
o local wound care

 indications

 low velocity GSW with no bone involvement and

clean wound edges
o local wound care, tetanus +/- short course of oral
antibiotics
 indications
 low-velocity injury with no bone involvement
or non-operative fractures
 technique
 primary closure contraindicated
 antibiotic use controversial but currently
recommended if wound appears contaminated
  Operative
o treatment of other non-orthopedic injuries
 for trans-abdominal trajectories, laparotomy takes
precedence over arthrotomy
o ORIF/external fixation
 indications
 unstable/operative fracture pattern in low-
velocity gunshot injury
 technique
 treatment dictated by fracture characteristics
similar to closed fracture without gunshot wound
 stabilize extremity with associated vascular or
nerve injuries
 stabilize soft tissues in high velocity/high energy
gunshot injuries

 grossly contaminated/devitalized wounds managed with

aggressive debridement per open fracture protocol

 arthrotomy
 indications
 intra-articular missile
 may lead to local inflammation, arthritis and lead
intoxication (plumbism)
 transabdominal GSW

GSW to Hand/Foot

 Nonoperative
o antibiotics
o indications
o gross contamination
o joint penetration
o extent of contamination unclear
 Operative
o surgical debridement +/- ORIF/external fixation
o indications
o articular involvement
o unstable fractures
o presentation 8 or more hours after injury
o tendon involvement
o superficial fragments in the palm or sole

GSW to Femur
 Operative
o intramedullary nailing
o indications
 o diaphyseal femur fracture secondary to low-
velocity gunshot wound
o superficial wound debridement and immediate
reamed nailing
o similar union and infection rates to closed
injuries
o external fixation
o indications
o high-velocity gunshot wounds or close range
shotgun blasts
o stabilize soft tissues and debride aggressively
o associated vascular injury
o temporize extremity until amenable to
intramedullary nailing

GSW to Spine
 Nonoperative
o broad spectrum IV antibiotics for 7-14 days
o indications
o gunshot wounds to the spine with associated
perforated viscus
o bullets which pass through the alimentary canal
and cause spinal cord injuries do not require
surgical removal of the bullet
 Operative
o surgical decompression and bullet fragment removal
o indications
o when a neurologic deficit is present that correlates with
radiographic findings of neurologic compression
o a retained bullet fragment within the spinal canal
in patients with incomplete motor deficits is a
relative indication for surgical excision of the
fragment

Amputations
Introduction
 Amputations may be indicated in the following
o trauma
o infection
o tumor
o vascular disease
o congenital anomalies
 Prognosis
 o outcomes are improved with involvement of psychological
counseling for coping mechanisms
o amputation vs. reconstruction
o LEAP study
o impact on decision to amputate limb
o severe soft tissue injury
o highest impact on decision-making
process
o absence of plantar sensation
o 2nd highest impact on surgeon's
decision making process
o not an absolute contraindicationto
reconstruction
o plantar sensation can recover by
long-term follow-up
o outcome measure
o SIP (sickness impact profile) and return to
work not significantly different between
amputation and reconstruction at 2 years
in limb-threatening injuries
o most important factor to determine patient-
reported outcome is the ability to return to
work

Metabolic Demand
 Metabolic cost of walking
o increases with more proximal amputations
o perform amputations at lowest possible level to
preserve function
o exception
o Syme amputation is more efficient than midfoot
amputation
o inversely proportional to length of remaining limb
 Ranking of metabolic demand (% represents amount of increase
compared to baseline)
o Syme - 15%
o transtibial
o traumatic - 25% average
o short BKA - 40%
o long BKA - 10%
o vascular - 40%
o transfemoral
o traumatic - 68%
o vascular - 100%
o thru-knee amputation
 o varies based on patient habitus but is somewhere
between transtibial and transfemoral
o most proximal amputation level available in children to
maintain walking speeds without increased energy
expenditure compared to normal children
o bilateral amputations
o BKA + BKA - 40%
o AKA + BKA - 118%
o AKA + AKA - >200%

Wound Healing
 Dependent on
o vascular supply
o nutritional status
o immune status
 Improved with
o albumin > 3.0 g/dL
o ischemic index > .5
o measurement of doppler pressure at level being tested
compared to brachial systolic pressure
o transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm
Hg)
o toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
o ankle-brachial index (ABI) > 0.45
o total lymphocyte count (TLC) > 1500/mm3
 Hyperbaric oxygen therapy
o contraindications include
o chemo or radiation therapy
o pressure-sensitive implanted medical device
(automatic implantable cardiac defibrillator,
pacemaker, dorsal column stimulator, insulin pump)
o undrained pneumothorax

Upper Extremity Amputation

 Indications
o irreparable loss of blood supply
o severe soft tissue compromise
o malignant tumors
o smoldering infection
o congenital anomalies
 Levels of amputation
o wrist disarticulation versus transradial amputation
o wrist disarticulation advantages
o improved pronation and supination
o recommended in children for preservation of
distal radial and ulnar physes
 o longer lever arm
o transradial advantages
o more aesthetically pleasing
o easier to fit prosthesis
o transhumeral versus elbow disarticulation
o elbow disarticulation advantages
o indicated in children to prevent bony overgrowth
seen in transhumeral amputations
 Techniques
o transcarpal
o transect finger flexor/extensor tendons
o anchor wrist flexor/extensor tendons to carpus
o wrist disarticulation
o preserve radial styloid flare to improve prosthetic
suspension
o transradial amputation
o middle third of forearm amputation maintains length
and is ideal
o transhumeral amputation
o maintain as much length as possible
o shoulder disarticulation
o retain humeral head to maintain shoulder contour

Transfemoral Amputation
 Maintain as much length as possible
o however, ideal cut is 12 cm above knee joint to allow for
prosthetic fitting
 Technique
o 5-10 degrees of adduction is ideal for improved prosthesis
function
o adductor myodesis
o improves clinical outcomes
o creates dynamic muscle balance
o provides soft tissue envelope that enhances prosthetic
fitting

Through-Knee-Amputation
 Indications
o ambulatory patients who cannot have a transtibial
amputation
o non-ambulatory patients
 Technique
o suture patellar tendon to cruciate ligaments in notch
o use gastrocnemius muscles for padding at end of amputation
 Outcomes (based on LEAP data)
o slower self-selected walking speeds than BKA
 o similar amounts of pain compared to AKA and BKA
o worse performance on the Sickness Impact Profile (SIP)
than BKA and AKA
o physicians were less satisfied with the clinical, cosmetic, and
functional recovery
o require more dependence with patient transfers than BKA

Below-Knee-Amputation (BKA)
 Long posterior flap
o 12-15 cm below knee joint is ideal
o ensures adequate lever arm
o need approximately 8-12 cm from ground to fit most modern
high-impact prostheses
o osteomyoplastic transtibial amputation (Ertl) technique
o create a strut from the tibia to fibula from a piece of
fibula or osteoperiosteal flap
o "dog ears"
o left in place to preserve blood supply to the flap
 Modified Ertl
o designed to enhance prosthetic end-bearing
o technique
o the original Ertl amputation required a corticoperiosteal
flap bridge
o the modified Ertl uses a fibular strut graft
o requires longer operative and touniquet times
than standard BKA transtibial amputation
o fibula is fixed in place with cortical screws,
fiberwire suture with end buttons, or heavy
nonabsorbable sutures.

Ankle/Foot Amputation
 Syme amputation (ankle disarticulation)
o patent tibialis posterior artery is required
o more energy efficient than midfoot even though it is more
proximal
o stable heel pad is most important factor
o used successfully to treat forefoot gangrene in diabetics
 Pirogoff amputation (hindfoot amputation)
o removal of the forefoot and talus followed by calcaneotibial
arthrodesis
o calcaneus is osteotomized and rotated 50-90 degrees to
keep posterior aspect of calcaneus distal
o allows patient to mobilize independently without use of
prosthetic
 Chopart amputation (hindfoot amputation)
 o a partial foot amputation through the talonavicular and
calcaneocuboid joints
o primary complication is equinus deformity
o avoid by lengthening of the Achilles tendon
and transfer of the tibialis anterior to the talar neck
 Lisfranc amputation
o equinovarus deformity is common
o caused by unopposed pull of tibialis posterior and
gastroc/soleus
o prevent by maintaining insertion of peroneus brevis
 Transmetatarsal amputation
o more appealing to patients who refuse transtibial
amputations
o almost all require achilles lengthening to prevent equinus
 Great toe amputations
o preserve 1cm at base of proximal phalanx
o preserves insertion of plantar fascia, sesamoids, and
flexor hallucis brevis
o reduces amount of weight transfer to remaining toes
o lessens risk of ulceration

Complications
 Wound healing
 Postamputation Neuroma
o treatment
o targeted muscle reinnervation
o a method of guiding neuronal regeneration to prevent or
treat post-amputation neuroma pain and improve patient
use of myoelectric prostheses
 Phantom limb pain
o mirror therapy is a noninvasive treatment modality
 Bone overgrowth
o most common complication with pediatric amputations
o treatment
o prevent by performing disarticulation or using
epihphyseal cap to cover medullary canal

Fractures of the Upper limb

Clavicle shaft fracture
Introduction
 Epidemiology
o incidence
o 75-80% of all clavicle fractures will occur in the middle
third segment
o demographics
 omost often seen in young, active patients
 Pathophysiology
o mechanism
o fall on an outstretched arm or direct trauma to lateral
aspect of shoulder
o pathoanatomy
o displaced fractures
o medial fragment: sternocleidomastoid muscle
pulls the medial fragmentposterosuperiorly
o lateral fragment: pectoralis and weight of arm
pull the lateral fragmentinferomedially
o open fractures usually the result of the medial
fragment "buttonhole" through platysma
 Associated injuries
o are rare but may include:
o ipsilateral scapular fracture
o scapulothoracic dissociation
o should be considered with significantly
displaced/widened fracture fragments
o rib fracture
o pneumothorax
o neurovascular injury
 Pediatric Clavicle fractures
o fracture patterns include
o medial clavicle physeal injury
o distal clavicle physeal injury

Relevant Anatomy

 Acromioclavicular Joint Anatomy

 AC joint stability
o static stabilizers
o acromioclavicular ligament
o provides anterior/posterior stability
o has superior, inferior, anterior, and posterior components
o superior ligament is strongest, followed by posterior
o coracoclavicular ligaments (trapezoid and conoid)
o provides superior/inferior stability
o trapezoid ligament inserts 3 cmfrom end of clavicle
o conoid ligament inserts 4.5 cm from end of clavicle
in the posterior border
o conoid ligament is strongest
o capsule
o dynamic stabilizers
o deltoid and trapezius

Classification

Neer Classification - Middle third clavicle fracture

Nondisplaced  Less than 100%
displacement Nonoperative

Displaced  Greater than 100%

displacement
Operative
 Nonunion rate of 4.5%

AO Classification - Middle third clavicle fracture

Type A=Simple  A1 = spiral

 A2 = oblique
Nonoperative or Operative
 A3 = transverse

Type B=Wege  A1 = spiral wedge

 A2 = bending wedge
Nonoperative or Operative
 A3 = fragmented wedge

Type C=Complex  A1 = complex spiral

 A2 = segmental
Operative
 A3 = irregular

Presentation

 Symptoms
o anterior shoulder pain
 Physical exam
o deformity
o perform careful neurovascular exam
o tenting of skin (impending open fracture)

Imaging
 Radiographs
o views
o sitting/standing upright, standard AP view of bilateral
shoulders
o additional views
o 15° cephalic tilt (ZANCA view) determine
superior/inferior displacement
o may consider having the patient hold 5 to 10 lbs
weight in affected hand
 CT
o views
o coronal, saggital, axial
o 3D reconstruction views
o findings
o may help evaluate displacement, shortening,
comminution, articular extension, and nonunion
 o vascular injury

Treatment
 Nonoperative
o sling immobilization with gentle ROM exercises at 2-4
weeks and strengthening at 6-10 weeks
o indications
o minimally displaced Group I (middle third)
o shortening and displacement <2cm
o no neurologic deficit
o no significant displacement to the superior
shoulder suspensory complex (<10mm
displacement)
o outcomes
o nonunion (1-5%)
o risk factors for nonunion
o comminution
o 100% displacement & shortening
(>2 cm)
o advanced age and female gender
o poorer cosmesis
o decreased shoulder strength and endurance
o seen with displaced midshaft clavicle
fracture healed with > 2 cm of shortening
 Operative
o open reduction internal fixation
o indications
o absolute
o open fxs
o displaced fracture with skin tenting
o subclavian artery or vein injury
o floating shoulder (clavicle and scapula
neck fx)
o symptomatic nonunion
o symptomatic malunion
o relative and controversial indications
o displaced Group I (middle third) with >2cm
shortening
o bilateral, displaced clavicle fractures
o brachial plexus injury (questionable b/c
66% have spontaneous return)
o closed head injury
o seizure disorder
o polytrauma patient
o outcomes
o advantages of ORIF
 o improved results with ORIF for clavicle
fractures with >2cm shortening and 100%
displacement
o improved functional outcome / less pain
with overhead activity
o faster time to union
o decreased symptomatic malunion rate
o improved cosmetic satisfaction
o improved overall shoulder satisfaction
o increased shoulder strength and
endurance
o disadvantages of ORIF
o increased risk of need for future
procedures
o implant removal
o debridement for infection

Techniques
 Sling Immobilization
o technique
o sling or figure-of-eight (prospective studies have not
shown difference between sling and figure-of-eight
braces)
o after 2-4 weeks begin gentle range of motion exercises
o strengthening exercises begin at 6-10 weeks
o no attempt at reduction should be made
 Closed Reduction, Intramedullary Fixation
o equipment options
o cannulated screw
o specialized screw systems (e.g, Dual Trak)
o titanium elastic nail
o Hagle pin
o approach
o beach chair or supine
o posterolateral incision
o contraindications
o substantial comminution
o segmental fractures
o advantages
o smaller incision
o less soft-tissue disruption
o less prominent hardware
o avoids the supraclavicular cutaneous nerves
commonly injured with plating
o disadvantages
o higher complication rate including hardware migration
o biomechanically inferior to plating
  Open Reduction, Plate and Screw Fixation
o equipment
o most common
o limited contact precontroured, dynamic
compression plate
o k-wires for preliminary fixation
o others
o 3.5mm reconstruction plate
o locking plates
o approach
o beach chair or supine
o direct superior vs anterior incision
o biomechanics
o superior vs anteroinferior plating
o higher load to failure (superior plating >
anterointerior plating)
o plate strength with inferior bone
comminunion (anteroinferior plating > superior
plating)
o lower risk of neurovascular injury (anteroinferior plating
> superior plating)
o lower removal of deltoid attachment(superior plating >
anterointerior plating)
o outcomes
o time to union
o operative (16.4 weeks) vs. non-operative (28.4
weeks)
 Postoperative Rehabilitation
o early
o sling for 7-10 days followed by active motion
o late
o strengthening at ~ 6 weeks when pain free motion and
radiographic evidence of union
o full activity including sports at ~ 3 month

Complications
 Nonoperative treatment
o nonunion (1-5%)
o risk factors
o fracture comminution (e.g, Z deformity)
o fracture displacement
o female
o advancing age
o smoker
o treatment of nonunion
o if asymptomatic, no treatment necessary
 o if symptomatic, ORIF with plate and bone graft
(particularly atrophic nonunion)
o malunion
o definition
o shortening >3cm, angulation >30 degrees, translation >1cm
o complaints
o increased fatigue with overhead activities
o thoracic outlet syndrome
o dissatisfaction with appearance
o difficulty with shoulder straps, backpacks and the like
o treatment
o clavicle osteotomy with bone grafting, if symptomatic
 Operative treatment
o hardware prominence
o ~30% of patient request plate removal
o superior plates associated with increased irritation
o neurovascular injury (3%)
o superior plates associated with increased risk of subclavian artery
or vein penetration
o subclavian thrombosis
o nonunion (1-5%)
o infection (~4.8%)
o risk factors
o illicit drug use
o diabetes
o previous shoulder surgery
o mechanical failure (~1.4%)
o pneumothorax
o adhesive capsulitis
o 4% in surgical group develop adhesive capsulitis requiring surgical
intervention

Distal third clavicle fracture

Introduction

 Epidemiology
o incidence
o 10-15% of clavicle fracture occur in the distal third
segment
o demographics
o more commonly in older or osteoportic patients
o less common in pediatric patients
 Pathophysiology
o mechanism
o similar mechanism to mid-shaft clavicle fractures
o usually occur after a direct, compressive force
applied to the shoulder after a fall or trauma
o pathoanatomy
 ofracture displacement corresponds to
o fracture location (e.g, extra-articular vs. articular)
o fracture pattern (e.g, simple vs. comminuted)
o integrity of the coracoclavicular ligments
o conoid [medial] and trapzoid [lateral]
provide primary resistence to superior
displacement of the lateral clavicle
o age (e.g, pediatric patients usually have an intact
periosteal sleeve)
 Associated injuries
o are rare but include
o floating shoulder
o scapulothoracic dissociation
o should be considered with significantly displaced
or widened fractures
o rib fracture
o pneumothorax
o neurovascular injury

Relevant Anatomy

 AC joint stability consist of

o static stabilizing factors
o acromioclavicular ligament
o function
o provides anterior + posterior translation stability
o components
o superior
o inferior
o anterior
o posterior
o clinical significance
o superior and posterior ligaments are most important
o coracoclavicular ligaments (trapezoid and conoid)
o function
o provides superior + inferior translation stability
o components
o trapezoid ligament (lateral)
o inserts 3 cm from end of clavicle
o conoid ligament (medial)
o inserts 4.5 cm from end of clavicle
o clinical significance
o conoid ligament is strongest
o capsule
o dynamic stabilizing factors
o deltoid and trapezius act as additional stabilizers

Classification

 Two most common classification systems

o Neer Classification
 Neer Classification of Lateral third Clavicle Fractures (10-
15%)
Type  Fracture is LATERAL to coracoclavicular
1 ligaments
 Conoid and/or trapezoid ligament
remain INTACT Nonoperative
 Minimal displacement
 STABLE

Type IIA  Fracture occurs MEDIALto coracoclavicular

ligaments
 Conoid and trapezoid ligment
remain INTACT
 Significant medial clavicle displacement Operative
 UNSTABLE
o Up to 56% nonunion rate with
nonoperative management

Type IIB  Two fracture patterns

o (1) Fracture occurs
either BETWEEN the coracoclavicular
ligaments
o Conoid ligament TORN
o Trapezoid ligament INTACT
o (2) Fracture
occurs LATERAL to coracoclavicular
Operative
ligaments
o Conoid ligmanet TORN
o Trapezoid ligament TORN
 Signficant medial clavicle dispalcement
 UNSTABLE
o Up to 30-45% nonunion rate with
nonoperative management

Type III  INTRA-ARTICULAR fracture extending into

AC joint
 Conoid and trapezoid ligaments
remainINTACT
 Minimal displacement Nonoperative x
 STABLE injury
o Patients may develop posttraumatic
AC arthritis

Type IV  PHYSEAL fracture that occurs in the

skeletally immature
 Conoid and trapezoid ligaments
remainINTACT
 Displacement of lateral clavicle occurs
Nonoperative
superiorly through a tear in the thick
periosteum
o Clavicle pulls out of periosteal sleeve
 STABLE
 Type V  COMMINUTED fracture pattern
 Conoid and trapezoid ligaments
remainINTACT
Operative
 Significant medial clavicle displacement
 Usually UNSTABLE

 AO Classification

AO Classification
Type  Undisplaced fracture, CC ligaments intact
A o A1 = extraarticular
Nonop
o A2 = intraarticular

TypeB  Displaced fracture, CC ligaments intact

o A1 = extraarticular Nonop
o A2 = comminuted Operat

Type C  Displaced fracture, CC ligaments disrupted

o A1 = extraarticular
Operat
o A2 = intraarticular

Presentation

 Symptoms
o tip of shoulder pain
 Physical exam
o AC joint deformity
o tenting of skin (impending open fracture)
o perform careful neurovascular exam

Imaging

 Radiographs
o views
o sitting/standing upright, standard AP view of bilateral
shoulders
o additional views
o 15° cephalic tilt (ZANCA view) determine
superior/inferior displacement
o may consider having the patient hold 5 to 10 lbs
weight in affected hand
 CT
o views
 o coronal, saggital, axial
o 3D reconstruction views
o findings
o may help evaluate displacement, shortening,
comminution, articular extension, and nonunion

Treatment

 Nonoperative
o sling immobilization with gentle ROM exercises at 2-4
weeks and strengthening at 6-10 weeks
o indications
o stable fractures (Neer Type I, III, IV)
o pediatric distal clavicle fractures (skeletally
immature)
o outcomes
o nonunion (1-5%)
o risk factors for nonunion
o Neer group II (up to 56%)
o disrupted CC ligaments
o advanced age and female gender
o poor cosmesis
 Operative
o open reduction internal fixation
o indications
o absolute
o open, or impending open, fractures
o subclavian artery or vein injury
o floating shoulder (e.g., distal clavicle and
scapula neck fx with >10mm of
displacement)
o symptomatic nonunion
o relative
o unstable fracture patterns (Type IIA, Type
IIB, Type V)
o brachial plexus injury (questionable b/c
66% have spontaneous return)
o closed head injury
o seizure disorder
o polytrauma patient
o outcomes
o advantages of ORIF
o higher union rates
o faster time to union
o improved functional outcome / less
pain with overhead activity
 o decreased symptomatic malunion
rate
o improved cosmetic satisfaction
o disadvantages of ORIF
o increased risk of need for future
procedures (e.g, removal of hook
plate)
o symptomatic hardware
o infection

Techniques

 Sling Immobilization
o technique
o sling or figure-of-eight (prospective studies have not
shown difference between sling and figure-of-eight
braces)
o after 2-3 weeks begin gentle range of motion exercises
o strengthening exercises begin at 6-8 weeks
o no attempt at reduction should be made
 Open Reduction Internal Fixation
o technique
o limited contact dynamic compression plate
o position
o beach chair or supine
o approach
o superior approach to AC joint
o temporary fixation with k wires
o equipment
o locking plates
o precontoured anatomic plates
o fixation
o need larger distal fragment for multiple
locking screws
o >3 or 4 bicortical screws into medial
fragment to reduce the risk of screw pull
out
o hook plate
o position
o beach chair or supine
o approach
o superior approach to AC joint
o temporary fixation with k wires
o equipment
o hook plates vary in hook depth and number
of holes
 o proper hook depth ensures the AC joint is
not over- or under-reduced
o fixation
o hook plates are generally used when there is
insufficent bone in the distal fragment for
conventional clavicle plate fixation
o the hook should be placed posterior to AC
joint and positioned as far lateral as
possible to avoid hook escape
o >3 or 4 bicortical screws should be placed
into the proximal (medial) fragment to
reduce the risk of screw pull out
o Other types of fixation
o AC joint spanning fixation
o usually used as an alternative to hook
plates
o tension band wire
o intramedullary screw
o coracoclavicular ligament reconstruction
o postoperative rehabilitation
o early
o sling for 7-10 days followed by active motion
o late
o strengthening at ~ 6 weeks when pain free
motion and radiographic evidence of union
o full activity including sports at ~ 3 month
o hardware removal considered usually after 3
months

Complications

 Nonoperative treatment
o nonunion (1-5%)
o risks
o comminution
o Z deformity
o female
o older
o smoker
o distal clavicle higher risk than middle third
o treatment of nonunion
o if asymptomatic, no treatment necessary
o if symptomatic, ORIF with plate and bone graft
(particularly atrophic nonunion)
 Operative treatment
o hardware prominence
o ~30% of patient request plate removal
 o superior plates associated with increased irritation
o hardware removal
o mostly with hook plates
o neurovascular injury (3%)
o superior plates associated with increased risk of
subclavian artery or vein penetration
o subclavian thrombosis
o nonunion (1-5%)
o infection (~4.8%)
o mechanical failure (~1.4%)
o pneumothorax
o adhesive capsulitis
o 4% in surgical group develop adhesive capsulitis
requiring surgical intervention

Scapula Fracture
Introduction
 Uncommon fracture pattern associated with high energy trauma
o 2-5% associated mortality rate
o usually pulmonary or head injury
o associated with Increased Injury Severity Scores
 Epidemiology
o incidence
o less than 1% of all fractures
o location
o 50% involve body and spine
 Associated injuries (in 80-90%)
o orthopaedic
o rib fractures (52%)
o ipsilateral clavicle fracture (25%)
o spine fracture (29%)
o brachial plexus injury (5%)
o 75% of brachial plexus injuries resolve
o medical
o pulmonary injury
o pneumothorax (32%)
o pulmonary contusion (41%)
o head injury (34%)
o vascular injury (11%)

Classification
 Classification is based on the location of the fracture and includes
o coracoid fractures
 o acromial fractures
o glenoid fractures
o scapular neck fractures
o look for associated AC joint separation or clavicle fracture
o known as "floating shoulder"
o scapular body fractures
o described based on anatomic location
o scapulothoracic dissociation

Coracoid Fracture Classification

Type I Fracture occurs proximal to the coracoclavicular ligament

Type II Fracture occurs towards the tip of the coracoid

Acromial Fracture Classification

Type I Nondisplaced or minimally displaced

Type II Displaced but does not compromise the subacromial space

Type III Displaced and compromises the subacromial space

Ideberg Classification of Glenoid Fracture

Type Ia Anterior rim fracture

Type Ib Posterior rim fracture

Type II Fracture line through glenoid fossa exiting scapula laterally

Type III Fracture line through glenoid fossa exiting scapula superiorly

Type IV Fracture line through glenoid fossa exiting scapula medially

Type Va Combination of types II and IV

Type Vb Combination of types III and IV

Type Vc Combination of types II, III, and IV

Type VI Severe comminution

Imaging

 Radiographs
o recommended views
o true AP, scapular Y and axillary lateral view
 CT
o intra-articular fracture
o significant displacement
 o three-dimensional reconstruction useful

Treatment
 Nonoperative
o sling for 2 weeks, followed by early motion
o indications
o indicated for vast majority of scapula fractures
o 90% are minimally displaced and acceptably
aligned
o outcomes
o union at 6 weeks
o can expect no functional deficits
 Operative
o open reduction internal fixation
o indications
o glenohumeral instability
o > 25% glenoid involvement with
subluxation of humerus
o > 5mm of glenoid articular surface step off
or major gap
o excessive medialization of glenoid
o displaced scapula neck fx
o with > 40 degrees angulation or 1 cm
translation
o open fracture
o loss of rotator cuff function
o coracoid fx with > 1cm of displacement
o outcomes
o 70% good to excellent results with operative
treatment

Surgical Technqiues
 Open Reduction Internal Fixation of Scapula
o approach
o based on fracture location
o Judet approach is most common
o utilizes internervous plane between infraspinatus
(suprascapular nerve) and teres minor (axillary
nerve)

Proximal Humerus fracture

Introduction
  Epidemiology
o incidence
o 4-6% of all fractures
o third most common non-vertebral fracture pattern seen
in the elderly (>65 years old)
o demographics
o 2:1 female to male ratio
o increasing age associated with more complex fracture
types
 Pathophysiology
o mechanism
o low-energy falls
o elderly with osteoporotic bone
o high-energy trauma
o young individuals
o concomitant soft tissue and neurovascular
injuries
o pathoanatomy
o pectoralis major displaces shaft anteriorly and medially
o supraspinatus, infraspinatus, and teres minor externally
rotate greater tuberosity
o subscapularis interally rotates articular segment or
lesser tuberosity
o vascularity of articular segment is more likely to be preserved
if ≥ 8mm of calcaris attached to articular segment
o 3 most accurate predictors of humeral head ischemia are
o <8 mm of calcar length attached to articular segment
o disrupted medial hinge
o basic fracture pattern
o predictors of humeral head ischemia do not necessarily
predict subsequent avascular necrosis
 Associated conditions
o nerve injury
o axillary nerve injury most common
o arterial injury
o uncommon (incidence 5-6%), higher likelihood in older
patients
o most often occur at level of surgical neck or with
subcoracoid dislocation of the head

Anatomy

 Osteology
o anatomic neck
o represents the old epiphyseal plate
o surgical neck
o represents the weakened area below head
o more often involved in fractures than anatomic neck
o average neck-shaft angle is 135 degrees
  Vascular anatomy
o anterior humeral circumflex artery
o large number of anastamoses with other vessels in the
proximal humerus
o branches
o anterolateral ascending branch
o is a branch of the anterior humeral
circumflex artery
o arcuate artery
o is the terminal branch and main supply to
greater tuberosity
o posterior humeral circumflex artery
o recent studies suggest it is the main blood supply to
humeral head

Classification

 AO/OTA
o organizes fractures into 3 main groups and additional
subgroups based on
o fracture location
o status of the surgical neck
o presence/absence of dislocation
 Neer classification
o based on anatomic relationship of 4 segments
o greater tuberosity
o lesser tuberosity
o articular surface
o shaft
o considered a separate part if
o displacement of > 1 cm
o 45° angulation

Neer Classification
Minimally
Two Part Three Part Four Part Articular Segme
Displaced

Anatomical Neck

Surgical Neck

Greater Tuberosity

Lesser Tuberosity

Fracture-Dislocation

Head Split
Evaluation

 Symptoms
o pain and swelling
o decreased motion
 Physical exam
o inspection
o extensive ecchymosis of chest, arm, and forearm
o neurovascular exam
o axillary nerve injury most common
o determine function of deltoid muscle (axillary n.)
o arterial injury may be masked by extensive collateral
circulation preserving distal pulses
o examine for concomitant chest wall injuries

Imaging

 Radiographs
o recommended views
o complete trauma series
o true AP (Grashey)
o scapular Y
o axillary
o additional views
o apical oblique
o Velpeau
o West Point axillary
o findings
o combined cortical thickness (medial + lateral
thickness >4 mm)
o studies suggest correlation with increased
lateral plate pullout strength
o pseudosubluxation (inferior humeral head
subluxation) caused by blood in the capsule and
muscular atony
 CT scan
o indications
o preoperative planning
o humeral head or greater tuberosity position uncertain
o intra-articular comminution
 MRI
o indications
o rarely indicated
o useful to identify associated rotator cuff injury

Treatment
 Nonoperative
o sling immobilization followed by progressive rehab
o indications
o most proximal humerus fractures can be treated
nonoperatively including
o minimally displaced surgical and anatomic
neck fractures
o greater tuberosity fracture displaced <
5mm
o fractures in patients who are not surgical
candidates
o additional variables to consider
o age
o fracture type
o fracture displacement
o bone quality
o dominance
o general medical condition
o concurrent injuries
o technique
o start early range of motion within 14 days
 Operative
o CRPP (closed reduction percutaneous pinning)
o indications
o 2-part surgical neck fractures
o 3-part and valgus-impacted 4-part fractures in
patients with good bone quality, minimal
metaphyseal comminution, and intact medial
calcar
o outcomes
o considerably higher complication rate compared
to ORIF, HA, and RSA
o ORIF
o indications
o greater tuberosity displaced > 5mm
o 2-,3-, and 4-part fractures in younger patients
o head-splitting fractures in younger patients
o outcomes
o complication rate higher compared with ORIF
o medial support necessary for fractures with
posteromedial comminution
o calcar screw placement critical to decrease varus
collapse of head
o intramedullary nailing
o indications
o surgical neck fractures or 3-part greater
tuberosity fractures in
 o younger patients
o combined proximal humerus and humeral shaft
fractures
o outcomes
o biomechanically inferior with torsional stress
compared to plates
o favorable rates of fracture healing and ROM
compared to ORIF
o arthroplasty
o indications
o hemiarthroplasty
o controversial when considering
hemiarthroplasty versus RSA
o younger patients (40-65) with complex
fractures or head-splitting components
likely to have complications with ORIF
o recommended use of convertible stems to
permit easier conversion to RSA if
necessary in future
o reverse total shoulder
o low-demand elderly individuals with non-
reconstructible tuberosities and poor bone
stock
o low-demand patients with fracture
dislocation
o outcomes
o improved results if
o accurate tuberosity reduction
o restoration of humeral height and version
o poor results with
o tuberosity nonunion or malunion
o retroversion of humeral component > 40°

Treatment by Fracture Type

Two-Part Fracture

Surgical Neck • Most common fx Nonoperative

pattern • Closed reduction often
• Deforming forces: possible
1) pectoralis pulls • Sling
shaft anterior and Operative
medial 2) head and • indications controversial
attached tuberosities • technique
stay neutral - CRPP
- Plate fixation
- IM device
Greater tuberosity • Often missed Nonoperative
• Deforming forces: GT • indicated for GT displaced <
 pulled superior and
posterior by SS, IS, and
TM
• Can only accept
minimal displacement
(<5mm) or else it will
block ER and ABD
Lesser tuberosity • Assume posterior
dislocation until proven
otherwise
Anatomic neck • Rare
Three-Part Fracture
Surgical neck and GT • Subscap will internally
rotate articular segment
• Often associated with
longitudinal RCT
Surgical neck and LT • Unopposed pull of
posterior cuff
musculature leads
articular surface to point
anterior
• Often associated with
longitudinal RCT
5 mm
Operative
• indicated for
GT displacement > 5 mm
- isolated screw fixation only in
young with good bone stock
- nonabsorbable suture
technique for osteoporotic
bone (avoid hardware due to
impingement)
- tension band wiring
Nonoperative
• Minimally or non-displaced
Operative
• ORIF if large fragment
• excision with RCR if small
Nonoperative
• Minimally or non-displaced
Operative
• ORIF in young
• ORIF v. hemiarthroplasty v.
reverse total shoulder
arthroplasty in elderly
Nonoperative if:
• Minimally displaced (GT<5
mm; articular segment <1 cm
and <45 degrees)
• Poor surgical candidate
Operative:
• Young patient
- percutaneous pinning (good
results, protect axillary nerve)
- IM fixation (violates cuff)
- locking plate (poor results
with high rate of AVN,
impingement, infection, and
malunion)
• Elderly patient
- hemiarthroplasty with RCR or
tuberosity repair vs. reverse
total shoulder arthroplasty
•Trend towards nonoperative
management given high
complications with ORIF
• Young patient
- percutaneous pinning (good
results, protect axillary nerve)
- IM fixation (violates cuff)
- locking plate (poor results
with high rate of AVN,
 impingement, infection, and
malunion)
• Elderly patient
- hemiarthroplasty with RCR or
tuberosity repair vs. reverse
total shoulder arthroplasty
Four-Part Fracture

Valgus impactedfracture • Radiographically will • Low rate of AVN if

see alignment between posteromedial component
medial shaft and head intact thus preserving
segments intraosseous blood supply
• Surgical technique
1. raise articular surface and
fill defects
2. repair tuberosities
4-part with head- • Characterized by high • Young patient
splitting fracture risk of AVN (21-75%) - ORIF vs. hemiarthroplasty
• Deforming forces: (hemiarthroplasty favored for
nonreconstructible articular
1) shaft pulled medially surface, severe head split,
by pectoralis extruded anatomic neck
fracture)

• Elderly patient
- hemiarthroplasty v. reverse
total shoulder arthroplasty
Techniques

 CRPP (closed reduction percutaneous pinning)

o approach
o percutaneous
o technique
o use threaded pins but do not cross cartilage
o externally rotate shoulder during pin placement
o engage cortex 2 cm inferior to inferior border of
humeral head
o complications
o with lateral pins
o risk of injury to axillary nerve
o with anterior pins
o risk of injury to biceps tendon, musculocutaneous
n., cephalic vein
o possible pin migration
 ORIF
o approach
o anterior (deltopectoral)
o lateral (deltoid-splitting)
o increased risk of axillary nerve injury
o technique
 o heavy nonabsorbable sutures
o (figure-of-8 technique) should be used for
isolated greater tuberosity fx reduction and
fixation (avoid hardware due to impingement)
o isolated screw
o may be used for greater tuberosity fx reduction
and fixation in young patients with good bone
stock
o locking plate
o screw cut-out (up to 14%) is the most common
complication following fixation of 3- and 4- part
proximal humeral fractures and fractures treated
with locking plates
o more elastic than blade plate making it a better
option in osteoporotic bone
o place plate lateral to the bicipital groove and
pectoralis major tendon to avoid injury to the
ascending branch of anterior humeral circumflex
artery
o placement of an inferomedial calcar screw(s) can
prevent post-operative varus collapse, especially
in osteoporotic bone
 Intramedullary nailing
o approach
o superior deltoid-splitting approach
o technique
o lock nail with trauma or pathologic fractures
o complications
o rod migration in older patients with osteoporotic bone is
a concern
o shoulder pain from violating rotator cuff
o nerve injury with interlocking screw placement
 Hemiarthroplasty
o approach
o anterior (deltopectoral)
o technique for fractures
o cerclage wire or suture passed through hole in
prosthesis and tuberosities improves fracture stability
o place greater tuberosity 10 mm below articular surface
of humeral head (HTD = head to tuberosity distance)
o impairment in ER kinematics and 8-fold increase
in torque with nonanatomic placement of
tuberosities
o height of the prosthesis best determined off the
superior edge of the pectoralis major tendon (5.6 cm
between top of humeral head and superior edge of
tendon)
 post-operative passive external rotation places the
o
most stress on the lesser tuberosity fragment
 Reverse shoulder arthroplasty
o approach
o anterior (deltopectoral)
o technique for fractures
o ensure adequate glenoid bone stock
o ensure functioning deltoid muscle
o repair of tuberosities recommended despite ability of
RSA design to compensate for non-functioning
tubersosities/rotator cuff

Rehabilitation

 Important part of management

 Best results with guided protocols (3-phase programs)
o early passive ROM
o active ROM and progressive resistance
o advanced stretching and strengthening program
 Prolonged immobilization leads to stiffness

Complications

 Screw cut-out
o most common complication after locked plating fixation (up to
14%)
 Avascular necrosis
o risk factors
o risk factors for humeral head ischemia are not the
same for developing subsequent avascular necrosis
o better tolerated than in lower extremity
o no relationship to type of fixation (plate or cerclage wires)
 Nerve injury
o axillary nerve injury most common (up to 58% with studies
using EMG)
o increased risk with lateral (deltoid-splitting) approach
o axillary nerve is usually found ~7cm distal to the tip of
the acromion
o suprascapular nerve (up to 48%)
 Malunion
o usually varus apex-anterior or malunion of GT
o results inferior if converting from varus malunited fracture to
TSA
o use reverse TSA instead
 Nonunion
o usually with surgical neck and tuberosity fx
 o treatment of chronic nonunion/malunion in the elderly should
include arthroplasty
o lesser tuberosity nonunion leads to weakness with lift-off
testing
o greater tuberosity nonunion leads to lack of active shoulder
elevation
o greatest risk factors for non-union are age and smoking
 Rotator cuff injuries and dysfunction
 Missed posterior dislocation (especially in cases with lesser
tuberosity fractures)
 Adhesive capsulitis
 Posttraumatic arthritis
 Infection