Module 2 PDF

Research Article
Functional and Clinical Outcomes

of Nonsurgically Managed Tibial
Plateau Fractures
Abstract
Christian A. Pean, MD, MS Introduction: This study sought to assess and compare long-term
Adam Driesman, BA functional and clinical outcomes in patients with tibial plateau fractures
that are treated nonsurgically.
Anthony Christiano, MD
Methods: Over a period of 8 years, 305 consecutive tibial plateau
Sanjit R. Konda, MD fractures were treated by three surgeons at a single institution and
Roy Davidovitch, MD followed prospectively in an Institutional Review Board–approved
Kenneth A. Egol, MD study. Overall, 41 patients (13%) were treated nonsurgically and 37
were available for follow-up. Indications for nonsurgical management
were minimal fracture displacement or preclusion of surgery because
of comorbidities. A series of univariate retrospective analyses were
used to identify individual risk factors potentially predictive of Short
Musculoskeletal Functional Assessment scores.
From the Department of Orthopaedic Results: Thirty-seven patients were included with a mean follow-up of
Surgery, NYU Hospital for Joint
Diseases, New York, NY.
21 6 14.9 months. Overall, 59% of patients (n = 22) attained good to
excellent functional outcomes. In patients for whom surgery was
Correspondence to Dr. Egol: kenneth.
egol@nyumc.org.
precluded because of comorbidities, outcome scores were
significantly poorer (38.8 6 23.0 versus 12.7 6 14.2; P = 0.001).
Dr. Davidovitch or an immediate
family member serves as a paid Surgery precluded by a factor other than minimal fracture
consultant to Pacira and Stryker. displacement predicted poor outcome (P = 0.002).
Dr. Egol or an immediate family Discussion: Carefully selected patients with minimally displaced
member has received royalties from
Exactech; serves as a paid consultant tibial plateau fractures can expect good to excellent outcomes when
to Exactech and KCI; has received treated nonsurgically.
research or institutional support from
Level of Evidence: Level III, retrospective comparative study
OMeGA Medical Grants Association,
the Orthopaedic Research and
Education Foundation, and DePuy
T
Synthes; and serves as a board
member, owner, officer, or committee ibial plateau fractures are often ever, although most of these injuries
member of the Orthopaedic Trauma the result of various forces are treated surgically, nonsurgical
Association. None of the following across the knee secondary to high- management is considered for a
authors or any immediate family
member has received anything of
energy trauma and account for 1% of subset of patients with minimal
value from or has stock or stock fractures treated in the United fracture displacement (MFD) who
options held in a commercial company States.1 In a system devised by do not meet the criteria for surgical
or institution related directly or
Schatzker et al,2 the fractures are treatment. In addition, nonsurgical
indirectly to the subject of this article:
Dr. Pean, Mr. Driesman, classified into types I through III for management may be considered in
Dr. Christiano, and Dr. Konda. those involving the lateral plateau patients with multiple comorbidities
J Am Acad Orthop Surg 2017;25: and types IV through VI for those precluding surgery or for those who
375-380 involving the medial aspect or both have a delayed clinical presentation.
DOI: 10.5435/JAAOS-D-16-00217 sides of the plateau. Because tibial Although numerous studies have
plateau fractures present numerous detailed techniques and outcomes for
Copyright 2017 by the American
Academy of Orthopaedic Surgeons. challenges for restoration, surgical surgical fixation of tibial plateau frac-
fixation is often necessary.3-5 How- tures,1,4-9 minimal literature exists on
© American Academy Of Orthopaedic Surgeons 1

Knee Christian A. Pean, MD, MS, et al
Figure 1 and were medically stable to undergo

surgical intervention. Overall, 41
patients (13%) did not meet these
criteria and were treated non-
surgically. All patients were treated
similarly, with management consist-
ing of non–weight-bearing status for
a minimum of 10 weeks, placement
in a hinged brace with free knee
range of motion (ROM) encouraged
immediately following injury, and
participation in a prescribed physio-
therapy regimen. For patients with
posteromedial and posterolateral
fractures, radiographs were obtained
at 2, 4, and 6 weeks to ensure that no
interval displacement had occurred.
All injuries included were felt to be
nondisplaced and stable at the time
of injury for the ROM protocol used.
The overall cohort was followed
prospectively and seen at standard
follow-up intervals.
Analysis of data was conducted in
Lateral radiograph (A) and coronal CT scan (B) showing a posterolateral tibial
plateau fracture with minimal fracture displacement. Measurements of fracture retrospective fashion. Patients were
displacement or articular depression on coronal CT are also used to inform categorized into one of two cohorts
surgical decision making. based on the indication for non-
surgical care: (1) MFD defined as
,2 mm of articular depression or a
the functional and clinical outcomes three surgeons at a single institution
1-mm fracture gap and ,5 mm of
of nonsurgical management of these and followed prospectively in an
condylar widening, or (2) surgery
fractures and no consensus guidelines Institutional Review Board-approved
precluded (SP) by patient charac-
are available regarding nonsurgical study. For inclusion in the registry,
teristics, such as severe comorbid-
management of tibial plateau frac- patients were screened and identified
ities at the time of treatment,
tures. Because the focus in the litera- on presentation to the emergency
delayed presentation, or advanced
ture is now on recent advances in department or in the clinical office. arthritic change (Figure 1). Clinical
internal fixation techniques, most History and physical examination follow-up at 3, 6, and 12 months
studies detailing nonsurgical manage- findings were obtained for all and the latest visit included the
ment outcomes for patients with tibial patients, as well as advanced imaging, Short Musculoskeletal Functional
plateau fractures are out of date.2,3,10 including a CT scan, and standard Assessment (SMFA) question-
The purpose of this study is to describe radiographs, including AP, lateral, naire,12 clinical examination, and
the indications for nonsurgical man- and 10 caudal tilt plateau views of radiologic evaluation. Student
agement of tibial plateau fractures as the knee. Fractures were classified by t-tests for continuous variables and
well as the demographic characteris- the treating surgeon based on the chi-square tests for categorical var-
tics and clinical, radiographic, and system by Schatzker et al,2 as well as iables were used to assess differences
functional outcomes of a cohort of the Orthopaedic Trauma Association between the groups. Because the
patients with tibial plateau fractures classification.11 Surgical manage- Levene test was violated for com-
who were treated nonsurgically. ment was indicated if patients had parison of the two groups, contin-
.2 mm articular incongruence, open uous variables were subsequently
Methods fracture, condylar widening .5 mm, compared using the Mann-Whitney
.5 of varus-valgus instability on U test. Patient factors of sex, age
Over 8 years, 305 consecutive tibial physical examination, minimal or no .65 years, smoking history, body
plateau fractures were treated by preexisting osteoarthritis of the knee, mass index .30 kg/m2, and SP

Table 1 Table 2
Patient Demographics Fracture Classification of
Nonsurgical Patient Population
Demographics Average 6 SD SP MFD P Value
Fracture Type No. of Patients
Age 54.3 6 14.9 69.3 6 2.0 52.2 6 16.1 0.019
Female (%) 63 83 61 0.26 Schatzker
Follow-up (mo) 21 6 14.9 25.8 6 18.5 19.7 6 14.3 0.36 I 8
CCI 1.5 6 1.6 4.0 6 1.8 1.1 6 1.2 ,0.01 II 12
Mechanism III 4
HV (%) 30 17 32 0.39 IV 8
LV (%) 70 83 68 V 2
VI 3
CCI = Charlson Comorbidity Index, HV = high velocity, LV = low velocity, MFD = minimal fracture OTA
displacement, SD = standard deviation, SP = surgery precluded
412B1 13
412B2 9
412B3 10
group status were individually 59% of nonsurgically managed
412C1 2
compared to assess factors associ- patients (n = 22) in this study at-
ated with poor functional outcome tained good to excellent functional 412C2 1
defined as an SMFA score .15. outcomes as defined by a total 412C3 2
standard SMFA score of #15. OTA = Orthopaedic Trauma Association
Average knee ROM at the latest
Results follow-up for our nonsurgically
managed cohort was 123.0 6
SP group had a higher mean CCI
Thirty-seven patients (90% reten- 16.6. In the SP group, SMFA out-
score compared with those in the
tion) were available for follow-up at come scores were significantly
MFD group (4.0 6 1.8 versus 1.0 6
mean 21 6 14.9 months (range, 12 poorer than in the MFD group
1.2; P , 0.01).
to 63 months). The cohort was 63% (38.8 6 23.0 versus 13.2 6 14.4; P =
female, 54.3 6 14.9 years old, and 0.02). ROM in the SP group did not
had a mean age-adjusted Charlson vary significantly compared with the Discussion
Comorbidity Index (CCI) of 1.5 6 MFD group (115 6 23.3 versus
1.6. Patients in the SP group had a 125 6 15.1; P = 0.22). Univariate The indications for surgical man-
higher mean CCI score than those analyses revealed that the only factor agement of tibial plateau fractures
in the MFD group (4.0 6 1.8 versus associated with a poor SMFA out- have evolved over time. In a series of
1.1 6 1.2; P , 0.01). Overall, 30% come in nonsurgically managed 260 surgically and nonsurgically
of injuries were the result of a high- patients was having surgery pre- managed tibial plateau fractures by
velocity energy mechanism (Table 1). cluded either by comorbidities or Lansinger et al,13 the investigators
The fracture classifications of other mitigating factors (Table 3). concluded that all patients without
patients included in the study are Radiographic evidence of post- clinical impairment of stability of the
reported in Table 2. traumatic knee arthritis, first seen at extended knee joint, and irrespective
At the latest follow-up, median an average of 35 months, was present of radiologic appearance, can expect
total SMFA was 11.9 points (inter- in 5% of patients (n = 2). Mean satisfactory outcomes when treated
quartile range, 0.8 to 32.3) and the residual depression at final follow-up nonsurgically. However, qualifica-
median visual analog scale pain in the SP and MFD groups did tion of patient outcomes in their
score for all nonsurgically managed not significantly differ (2.4 mm 6 study was based on a limited ques-
patients was 2.0 (interquartile range, 3.5 mm versus 1.2 mm 6 2.0 mm; tionnaire that was less robust than
0 to 4.5). These outcomes were P = 0.31). To date, only one patient the SMFA implemented in our
comparable to patients whose frac- in the SP group had undergone total study. In addition, as more reliable
tures were surgically managed at our joint arthroplasty following the stable fixation methods have
center (SMFA: median, 12.0; inter- index injury. In this series, all frac- become available and more quality
quartile range, 3.0 to 30.0; visual tures treated surgically and non- biomechanical studies have been
analog scale: median, 2.5; inter- surgically went on to achieve conducted, tibial plateau fractures
quartile range, 0 to 5.0). Overall, radiographic union. Patients in the have increasingly been managed

Table 3 nonsurgical management of elderly

patients with numerous comorbid-
Patient Outcome by Fracture Type
ities and decreased functional status
Schatzker are documented in the literature on
Classification Type Average 6 SD SP (n = 6) MFD (n = 31) P Value
proximal humerus fractures, hip
SMFA I 10.40 — 10.4 (8) — fractures, and ankle fractures.23-25
II 21.33 43.33 (3) 14 (9) 0.018 As the patient population ages, it is
III 9.20 — 9.2 (4) — imperative to use clinical practice
IV 20.43 35.5 (2) 12.5 (6) 0.29 guidelines when evaluating the
V 21.50 — 21.50 (2) — optimal management of elderly
VI 27.33 32.1 (1) 25 (2) 0.88
patients needing orthopaedic treat-
ment. Su et al17 found that favorable
ROM (degrees) I 122.50 — 122.5 —
radiologic and clinical outcomes can
II 129.20 125.0 130.6 0.52
be achieved in surgically treated
III 126.00 — 126.0 —
tibial plateau fractures in patients
IV 121.43 110.0 126.0 0.41
aged .55 years. Similarly, in our
V 115.00 — 115.0 —
study, patient age .65 years was not
VI 110.00 100.0 115.0 0.67
found to be a considerable predictor
MFD = minimal fracture displacement, ROM = range of motion, SD = standard deviation, SMFA =
of poorer total SMFA score,
Short Musculoskeletal Functional Assessment, SP = surgery precluded although all patients with preexisting
arthritis or comorbidities precluding
surgeries were aged .55 years, thus
with surgical fixation.4,14-18 Despite for measuring patient outcomes indicating that this patient pop-
the expanding number of studies would have resulted in a 100% sat- ulation potentially requires more
describing outcomes for surgically isfactory outcome with regard to complex individual management.
managed tibial plateau fractures, ROM in our cohort. In long-term follow-up of tibial
guidelines are lacking for nonsurgical For nonsurgical management, the plateau fractures, reported rates of
management of these injuries. use of a cutoff of 2 mm of articular osteoarthritis have varied sub-
Our study evaluated the clinical depression or a 1-mm fracture gap stantially. In a study of 125 tibial
and functional outcomes of patients and condylar widening of ,5 mm plateau fractures, Manidakis et al26
with nonsurgically managed tibial was chosen based on findings in reported an osteoarthritis rate of
plateau fractures. Most appropri- previous studies that indicated 26.4% in their patient cohort. In a
ately selected patients achieved greater articular depression predicted study by Wasserstein et al,27 the
excellent functional outcomes as soft-tissue injuries as well as func- authors found that 7.3% of patients
indicated by SMFA scores. We tional outcome.13,19-21 Although underwent total knee arthroplasty
believe our protocol yielded superior previous studies have shown that (TKA) 10 years after surgical man-
clinical outcomes because we selected greater articular depression is pre- agement of tibial plateau fractures;
patients whose tibial plateau frac- dictive of soft-tissue injuries, Shepherd however, TKA rates have not been
tures were amenable to nonsurgical et al22 found that MRI detected 90% documented after nonsurgical man-
management and weight bearing was of soft-tissue injuries in a series of agement of tibial plateau fractures.
initiated at 10 weeks as tolerated. In a 20 tibial plateau fractures man- To date, only one patient in our
study by Segal et al,10 the authors aged nonsurgically. The incidence of study has undergone TKA for an
used .5 mm of initial depression or soft-tissue injury found using injury; therefore, the mean follow-up
displacement as an indication for advanced imaging was not recorded period prohibits conclusions to be
surgery in tibial plateau fractures. in our study, although the pro- made regarding the long-term prog-
This study also implemented early portion of patients achieving optimal nosis of patients undergoing non-
weight bearing as soon as an applied functional outcomes suggests that surgical management for tibial
cast had dried. The authors found some patients may be able to achieve plateau fractures. In a study of 131
that 76% of nonsurgically managed satisfactory results despite the pres- patients with tibial plateau fractures,
tibial plateau fractures had satisfac- ence of soft-tissue injury. Honkonen28 reported that signs of
tory outcomes, with 81% achieving Select patients were managed non- osteoarthritis in the compartment of
satisfactory ROM defined as 10 to surgically because of factors pre- the fractured tibial plateau devel-
90. Implementing these parameters cluding surgery (Table 4). Results of oped in 44% of patients at a mean

Table 4
Patient Characteristics for Surgery Precluded Cohort
Schatzker
Patient Reason Classification Knee SMFA Complication or
ID Age (yr) CCI Sex Contraindicated Type OTA ROM Score Revision Surgery
1SP 51 1 Male Delayed presentation, VI 412C2 100 32.07 None

preexisting arthritis
2SP 84 6 Female History of polio, IV 412B2 80 66.85 None
dependent functional
status
3SP 65 5 Female Delayed presentation, II 412B3 140 33.15 Chronic MCL
comorbid conditions insufficiency,
chronic pain, PTOA
4SP 63 4 Female Delayed presentation, II 412B3 120 62.5 None
sepsis preoperative,
comorbid conditions
5SP 74 5 Female Delayed presentation, IV 412B1 140 4.0 None
comorbid conditions
6SP 79 3 Female Delayed presentation, II 412B3 110 34.78 TKA at 10 mo after
comorbid conditions injury
CCI = Charlson Comorbidity Index, MCL = medial collateral ligament, OTA = Orthopaedic Trauma Association classification, PTOA = posttraumatic
osteoarthritis, ROM = range of motion, SMFA = Short Musculoskeletal Functional Assessment, SP = surgery precluded, TKA = total knee
arthroplasty
follow-up of 7.6 years (range, 3.3 to clusions drawn by these results. A cohort, some patients had suboptimal
13.4 years). This rate was higher in post hoc power analysis determined functional outcomes when surgery
patients who underwent removal of that to achieve 85% power for the was precluded because of medical co-
the meniscus during fracture surgery, observed differences in SMFA scores, morbidities, delayed presentation, or
with 74% demonstrating secondary a sample size of six patients in each preexisting arthritis. Still, it should be
degeneration. Among patients trea- group would be sufficient, making noted that only a small percentage
ted nonsurgically, 53% had signs of this study adequately powered. In later required surgical intervention.
joint space narrowing and 36% met addition, to date, this is the largest Based on these results, we recommend
the criteria for secondary degenera- prospective cohort of nonsurgically following the protocol detailed in this
tion. The relatively low 5% rate of managed tibial plateau fractures that study in patients who sustain a tibial
posttraumatic osteoarthritis in non- we are aware of that uses this pro- plateau fracture in which knee stabil-
surgically managed patients from tocol for nonsurgical therapy and ity is not compromised and whose
our study can likely be attributed to reporting in-depth functional out- MFD results may be managed non-
the shorter follow-up period.28 comes. In addition, univariate analy- surgically. Orthopaedic surgeons can
Long-term follow-up of .5 years ses of the overall cohort also offer use these findings in concert with their
would strengthen the findings of our significant merit and consideration. clinical judgment to guide patient
study and enable improved prog- Loss to follow-up was minimal; selection for surgery and to counsel
nostication for orthopaedic surgeons the follow-up rate of .80% should patients regarding their prognosis.
treating these injuries. serve to diminish any bias in our
This study has several limitations. comparisons.
This is a retrospective analysis of a Historically, most displaced tibial References
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small number of patients in this study results demonstrate that patients evidence are described in the table of
limits statistical significance in com- with minimally displaced fractures are contents. In this article, references
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AAOS Technology Overview
Locking Plates for Extremity

Fractures
Abstract
Jeffrey Anglen, MD Thirty-three peer-reviewed studies met the inclusion criteria for the
Richard F. Kyle, MD Overview. Criteria were framed by three key questions regarding
indications for the use of locking plates, their effectiveness in
John Lawrence Marsh, MD
comparison with traditional nonlocking plates, and their cost-
Walter W. Virkus, MD effectiveness. The studies were divided into seven applications:
William C. Watters III, MD distal radius, proximal humerus, distal femur, periprosthetic femur,
Michael Warren Keith, MD tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or
C), and distal tibia. Patient enrollment criteria were recorded to
Charles M. Turkelson, PhD
determine indications for use of locking plates, but the published
Janet L. Wies, MPH studies do not consistently report the same enrollment criteria.
Kevin M. Boyer Regarding effectiveness, there were no statistically significant
differences between locking plates and nonlocking plates for
The Technology Overview was patient-oriented outcomes, adverse events, or complications. The
prepared by an AAOS physician
task force using systematic review literature search did not identify any peer-reviewed studies that
methodology and summarizes the address the cost-effectiveness or cost-utility of locking plates.
findings of studies published as of
April 1, 2008, on locking plates for
extremity fractures. As a summary,
this document does not make
recommendations for or against the
use of locking plates for extremity
I nternal fixation plates function as
splints for a fractured long bone and
perform a variety of specific mechan-
quentially.1,2 This feature may be of
particular advantage in osteoporotic
bone with thinner cortices; in this sit-
fractures. It should not be construed
as an official position of the ical functions, including compression, uation, nonlocking screws cannot
American Academy of Orthopaedic buttressing, bridging, and neutralization generate as much plate-to-bone com-
Surgeons. Readers are encouraged
(ie, protection). Both locking and non- pression, so the frictional forces re-
to consider the information
presented in this document and locking plates can be used to perform sisting motion are less. In addition,
reach their own conclusions about any of these functions. Nonlocking the fixed-angle nature of the plate-
locking plates for extremity fractures. plates stabilize bone fragments against and-screw fixation resists cantilever
The Technology Overview was
deforming forces by the use of friction bending stresses and reduces the risk
adopted by the Board of Directors of
the American Academy of Ortho- between the plate and bone, generated of angular deformity in metaphyseal
paedic Surgeons on December 6, by screws that compress the two sur- fractures that are comminuted, miss-
2008. faces together. Locking plates stabilize ing bone, or otherwise mechanically
The American Academy of bone fragments by means of the attach- unable to share load. It has been pro-
Orthopaedic Surgeons has ment of the screw to the plate in a rigid, posed that the reduced plate-to-bone
developed and is providing the
Technology Overview as an
fixed-angle coupling, usually accom- compression afforded by locking
educational tool. Patient care and plished with threads in the screw head, plates serves to protect the viability
treatment should always be based plate hole, or both. This locking of of the bone by maintaining mi-
on a clinician’s independent medical screw to plate makes the fixation con- crovascular circulation within the
judgment given the individual
patient’s clinical circumstances.
struct more resistant to failure from se- cortex and its investing tissues.3 The
quential screw loosening and pullout. clinical importance of this theoretic
J Am Acad Orthop Surg 2009;17:
465-472
Because all the screws in a single bone advantage, however, is unproven.
fragment are locked to the plate at fixed Both traditional (nonlocking) and
angles, they must fail (ie, pull out) as a locking plates can be inserted through
Academy of Orthopaedic Surgeons.
unit rather than individually and se- less invasive surgical techniques, also

Knee Jeffrey Anglen, MD, et al
known as percutaneous, submuscular, bone) are not dependent on minimally Articles were included only when
or minimal incision plating. The intro- invasive surgical techniques. Locking they met our a priori criteria. A level
duction of locking plate technology has plates can be put in through traditional of evidence was assigned to each ar-
temporally coincided with the develop- exposures. ticle included in this Technology
ment of these less invasive surgical tech- Overview.
niques, but it is important that the two
concepts be kept separate. Newer Findings of Published
surgical techniques that involve smaller Studies Included Articles
incisions, less soft-tissue dissection, less
periosteal stripping, and use of intraop- We used systematic processes to lo- Our searches identified 452 cita-
erative imaging or navigation are cate published studies relevant to this tions. Of these, 33 met all inclusion
believed by many to improve healing topic. These processes began with criteria and were used to address the
rates and reduce complications, but the framing of three key questions questions below. Four of the studies
they are not dependent on the use of (see below). We next developed arti- compared the outcomes of patients
locking plate implants. Similarly, the cle inclusion criteria (Appendix I, receiving locking plates and patients
theoretic biomechanical advantages of available online at www.aaos.org/ receiving nonlocking plates. One ad-
locking plates (eg, reduced screw pull- technologyoverviews) and then con- ditional study compared the out-
out in osteopenic bone, reduction of ducted systematic literature searches comes of patients receiving locking
cantilever bending, reduction of angu- (Appendix II, available online at plates and patients receiving in-
lar deformity in deficient metaphyseal www.aaos.org/technologyoverviews). tramedullary nailing (for the pur-
Dr. Anglen is Professor and Chairman, Department of Orthopaedic Surgery, Indiana University Medical Center, Indianapolis, IN.
Dr. Kyle is Chair, Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, MN. Dr. Marsh is Professor,
Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA. Dr. Virkus is Orthopaedic
Surgeon, Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, Chicago, IL.
Dr. Watters is Orthopaedic Surgeon, Bone and Joint Clinic of Houston, Houston, TX. Dr. Keith is Professor, Orthopaedics and
Biomedical Engineering, and Chief, Hand Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
Dr. Turkelson is Director, Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL.
Ms. Wies is Manager, Clinical Practice Guidelines Unit, Department of Research and Scientific Affairs, American Academy of
Orthopaedic Surgeons. Mr. Boyer is Research Analyst, Guidelines, Department of Research and Scientific Affairs, American Academy
of Orthopaedic Surgeons.
Dr. Anglen or a member of his immediate family serves as a board member, owner, officer, or committee member of American Board
of Orthopaedic Surgery, American College of Surgeons, and Orthopaedic Trauma Association; is affiliated with the publications
Journal of the American Academy of Orthopaedic Surgeons and Journal of Orthopaedic Trauma; has received royalties from Biomet;
serves as a paid consultant to or is an employee of Stryker; has received research or institutional support from Stryker and Wyeth;
and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related
funding (such as paid travel) from the Journal of the American Academy of Orthopaedic Surgeons. Dr. Kyle or a member of his
immediate family serves as a board member, owner, officer, or committee member of Twin Cities Orthopaedic Education Association,
Minneapolis Medical Research Foundation, Midwest Orthopaedic Research Foundation, Hennepin Faculty Associates, and Millennium
Medical Technologies; is affiliated with the publication Journal of Shoulder and Elbow Surgery; has received royalties from DePuy,
Encore Medical, Smith & Nephew, and Zimmer; and has received research or institutional support from DePuy. Dr. Marsh or a
member of his immediate family serves as a board member, owner, officer, or committee member of Orthopaedic Trauma
Association; has received royalties from Biomet; has received research or institutional support from Smith & Nephew; and has
received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding
(such as paid travel) from Oxford University Press and Smith & Nephew. Dr. Virkus or a member of his immediate family serves as a
paid consultant to or is an employee of Stryker; has received research or institutional support from Stryker; has stock or stock options
held in Stryker; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other
non–research-related funding (such as paid travel) from Stryker. Dr. Watters or a member of his immediate family serves as a board
member, owner, officer, or committee member of Bone and Joint Decade, USA, North American Spine Society, Intrinsic Therapeutics,
Work Loss Data Institute, and American Board of Spine Surgery; is affiliated with the publication The Spine Journal; serves as a paid
consultant to or is an employee of Blackstone Medical, Medtronic Sofamor Danek, Stryker, Intrinsic Therapeutics, and McKessen
Health Care Solutions; and has stock or stock options held in Intrinsic Therapeutics. Ms. Wies or a member of her immediate family
has stock or stock options held in Shering Plough. None of the following authors or a member of their immediate families has
received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of
this article: Dr. Keith, Dr. Turkelson, and Mr. Boyer.
Evidence tables displaying the raw data and information extracted for the Technology Overview are available in a supplemental
document available on the AAOS Website, www.aaos.org/technologyoverviews.

poses of this Overview, only the out- level II study comparing the out- patients with acute, traumatic frac-
comes of the locking plate patients in comes of patients receiving locking tures of varying degrees or severity
this study were considered). The re- plates and patients receiving in- and typically did not enroll patients
maining 28 studies were case series tramedullary nailing was included.27 with fractures that were not amena-
and reported outcomes only for pa- For the purposes of this Overview, ble to adequate reduction and/or fix-
tients receiving locking plates. only the outcomes of the patients re- ation. In studies with age criteria, no
The studies were divided into seven ceiving locking plates were consid- studies enrolled patients under the
applications: distal radius, proximal ered from this study (as level IV age of 18 years or not of skeletal ma-
humerus, distal femur, periprosthetic data). An additional seven level IV turity. In addition, studies enrolled
femur, tibial plateau (AO/OTA type case series studies were included.28-34 patients with minimal comorbidities
C only), proximal tibia (AO/OTA One level IV case series study32 re-
in their medical histories.
type A or C), and distal tibia. There ports outcomes for a subgroup of pa-
were no studies addressing the appli- tients from a previously published
cation of locking plates for extremity study31 that is included in this Over- Question 2: Are locking
fractures in patients with osteoporo- view. For the more recent publica- plates more effective than
sis that met all of the inclusion crite- tion, only the unique, relevant out- traditional plates?
ria. Several published studies discuss comes are reported in this Overview.
osteoporosis in their study popula- All relevant outcomes are reported To address this question, we re-
tions; however, none of these studies for the previous, original study. corded the outcomes of studies that
adequately reports quantitative data, Periprosthetic femur fractures are compared locking plates with non-
for the outcomes of interest to this addressed by four level IV case series locking plates. Four studies investi-
Overview, in patients with os- studies.35-38 gated the differences between pa-
teoporosis. Our inclusion criteria Fractures of the tibial plateau (AO/ tients receiving locking plates and
specified that surrogate outcome OTA type C only) are addressed by a patients receiving nonlocking plates.
measures, such as fracture union, single level II RCT39 comparing the These four studies addressed the ap-
would be included in this Overview outcomes of patients receiving lock- plication of locking plates in distal
only in the absence of patient- ing plates via a single incision and radius,4,5 proximal humerus,17 or tib-
oriented outcome measures. All stud- patients receiving nonlocking plates ial plateau39 fractures (AO/OTA type
ies included in this Overview present via a double incision. Two additional C only). There were no statistically
patient-oriented outcome measures. level IV case series studies were in- significant differences between lock-
Therefore, surrogate outcomes are cluded, as well.40,41 ing plates and nonlocking plates for
not presented. Proximal tibia fractures (AO/OTA patient-oriented outcomes, adverse
type A or C) are addressed by five events, or complications (Figure 1,
level IV case series studies.42-46 A sin- available online at www.aaos.org/
Levels of Evidence gle level IV case series study47 was technologyoverviews).
excluded because it was updated by We recorded patient-oriented out-
For distal radius fractures, two level comes, adverse events, and complica-
a more recent article43 that is in-
II randomized controlled trials tions from case series studies that
cluded in this Overview.
(RCTs) were included.4,5 An addi- met our inclusion criteria. Conclu-
tional level II comparative study,6 Distal tibia fractures are addressed by
a single level IV case series study.48 sions from case series studies are dif-
which did not compare outcomes be- ficult to interpret because they lack
tween patients receiving locking the context that a control group pro-
plates and patients receiving non- Question 1: What are the vides. Further, it is difficult to use
locking plates, was excluded, along
indications for locking normative values to interpret the re-
with three level III comparative
plates? sults of such studies because case se-
studies7-9 and seven level IV case series often enroll highly selected pa-
ries studies.10-16 To address this question, we re- tients to whom such values may not
Proximal humerus fractures were corded the patient enrollment criteria apply. Making comparisons between
addressed with a single level III com- of the included studies. The pub- studies is difficult because of the
parative study17 and nine level IV lished studies do not consistently re- wide variety of patient-oriented out-
case series studies.18-26 port the same enrollment criteria. In come measures and duration to
For distal femur fractures, one general, published studies enrolled follow-up used to evaluate patients

Table 1
Patient-oriented Outcome Measures From Case Series Studies*
Duration of
Outcome Measure Application Follow-up (mo) Study (Year)
American Orthopaedic Foot and Distal tibia 19 Bahari et al48 (2007)

Ankle Society (AOFAS) score
Blood loss Proximal humerus N/A Laflamme et al23 (2008)

N/A Koukakis et al22 (2006)
Distal femur N/A Kregor et al29 (2004)
Periprosthetic femur N/A Fulkerson et al37 (2007)
Constant-Murley score Proximal humerus 1.5 Fankhauser et al19 (2005)

3 Fankhauser et al19 (2005)
3 Hepp et al21 (2008)
3-6 Koukakis et al22 (2006)
6 Hepp et al21 (2008)
11 Moonot et al24 (2007)
12 Hepp et al21 (2008)
12 Laflamme et al23 (2008)
Final follow-up Laflamme et al23 (2008)
NR Sharafeldin et al26 (2008)
Disabilities of the Arm, Shoulder, Proximal humerus 12 Laflamme et al23 (2008)

and Hand (DASH) score Laflamme et al23 (2008)
Final follow-up
NR Sharafeldin et al26 (2008)
QuickDASH score Proximal humerus 12 Owsley and Gorczyca25

(2008)
d’Aubigne and Postel score Periprosthetic femur NR Buttaro et al35 (2007)
Functional score Proximal tibia 3 yr Boldin et al42 (2006)
Hospitalized (days) Proximal humerus N/A Sharafeldin et al26 (2008)

Distal femur N/A Fankhauser et al28 (2004)
Periprosthetic femur N/A Erhardt et al36 (2008)
Hospital for Special Surgery Proximal tibia 3 yr Boldin et al42 (2006)

(HSS) score Syed et al33 (2004)
Distal femur Final follow-up
Knee Society score Distal femur 20 Fankhauser et al28 (2004)

Proximal tibia 3 yr Boldin et al42 (2006)
Lysholm score Distal femur 3 Markmiller et al27 (2004)

12 Markmiller et al27 (2004)
N/A = not applicable, NR = not reported

* This table demonstrates the wide variety of patient-oriented outcome measures that have been used in case series studies of patients
receiving locking plates for extremity fractures. Few studies used the same outcome measure at similar duration of follow-up. No statistical
hypothesis testing was performed by the study authors to assess the effectiveness of locking plates for any outcome of interest to this
Technology Overview.

Table 1 (continued)
Patient-oriented Outcome Measures From Case Series Studies*
Duration of
Outcome Measure Application Follow-up (mo) Study (Year)
Surgical time (minutes) Proximal humerus N/A Koukakis et al22 (2006)

N/A Laflamme et al23 (2008)
Distal femur N/A Kregor et al29 (2004)
N/A Markmiller et al27 (2004)
N/A Schütz et al31 (2001)
Periprosthetic femur N/A Buttaro et al35 (2007)
Erhardt et al36 (2008)
Fulkerson et al37 (2007)
Proximal tibia N/A Schütz et al45 (2003)
Tibial plateau N/A Gosling et al40 (2005)
Oxford Knee score Distal femur 23 Wong et al34 (2005)
Pain Distal femur 10 wk Ricci et al44 (2004)

12 Markmiller et al27 (2004)
23 Wong et al34 (2005)
Return to previous activity level Periprosthetic femur Final follow-up Erhardt et al36 (2008)
Final follow-up Ricci et al38 (2006)
Medical Outcomes Study 36- Proximal humerus NR Sharafeldin et al26 (2008)

Item Short Form (SF-36) score Tibial plateau 6 Stannard et al41 (2004)
12 Stannard et al41 (2004)
Distal tibia 19 Bahari et al48 (2007)
Distal femur 30 Ricci et al44 (2004)
Short Musculoskeletal Function Proximal humerus 12 Owsley and Gorczyca25

Assessment (SMFA) (2008)
Subjective contentment Periprosthetic femur Final follow-up Erhardt et al36 (2008)
Weight bearing—full (wk) Distal femur N/A Fankhauser et al28 (2004)

N/A Kregor et al29 (2004)
Periprosthetic femur N/A Ricci et al38 (2006)
N/A = not applicable, NR = not reported

* This table demonstrates the wide variety of patient-oriented outcome measures that have been used in case series studies of patients
receiving locking plates for extremity fractures. Few studies used the same outcome measure at similar duration of follow-up. No statistical
hypothesis testing was performed by the study authors to assess the effectiveness of locking plates for any outcome of interest to this
Technology Overview.
receiving locking plates in extremity months).19,21-24 In three studies re- mean surgical times of 53 and 75
fractures (Table 1). porting the mean Constant-Murley minutes.22,23
Patient-oriented outcome measures score at 12 months, the scores range Adverse events and complications
from case series studies using locking from 74.6 to 79.19,21,23 Two studies in patients receiving locking plates
plates for proximal humerus frac- reporting mean Disabilities of the for proximal humerus fractures are
tures are reported in the included Arm, Shoulder, and Hand (DASH) or reported in the included studies, as
studies. In summary, five studies re- QuickDASH scores indicated low well. In summary, eight studies re-
port Constant-Murley scores at vari- levels of disability 12 months post- ported failure of hardware in 0% to
ous durations to follow-up (1.5 to 12 operatively.23,25 Two studies reported 4% of patients,17-19,21,23-26 eight stud-

ies reported osteonecrosis in 0% to reported in the included studies, as 13% of patients.42-44 Two studies re-
7% of patients,17-19,21-25 four studies well. In summary, three studies reported revision rates in 13% and
reported nerve palsy or paresthesia ported failure of hardware in 0% to 15% of patients.43,45
in 0% to 7% of patients,19,21,23,24 and 21% of patients,35,36,38 and three
six studies reported subacromial im- studies reported revision rates of
pingement in 0% to 14% of pa- 14% to 29%.35-37 Question 3: Are locking
tients.17,19,21,22,24,25 Six studies reported Patient-oriented outcome measures plates cost effective?
implant removal in 1% to 8% of from case series studies using locking
patients,17,19,21-23,25 and four studies plates for tibial plateau fractures Our literature searches did not
reported infections in 2% to 5% of (AO/OTA type C only) are reported identify any peer-reviewed cost-
patients.18,19,22,24 Eight studies re- in the included studies. One study re- effectiveness or cost-utility studies
ported revision rates of 6% to ported a mean Medical Outcomes that directly addressed this question.
16%.17-21,23-25 Study 36-Item Short Form physical
Patient-oriented outcome measures subscale score of 29 at 6 months and
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Review Article
Timing of Fracture Fixation in

Multitrauma Patients: The Role of
Early Total Care and Damage
Control Surgery
Abstract
Hans-Christoph Pape, MD The optimal timing of surgical stabilization of fractures in the
Paul Tornetta III, MD multitrauma patient is controversial. There are advantages to early
definitive surgery for most patients. Early temporary fixation using
Ivan Tarkin, MD
external fixators, followed by definitive fixation (ie, the damage
Christopher Tzioupis, MD control approach), may increase the chance for survival in a subset
Vani Sabeson, MD of patients with severe multisystem injuries. Improved
Steven A. Olson, MD understanding of the pathophysiology of trauma has led to a
greater ability to identify patients who would benefit from damage
control surgery. A patient is classified as physiologically stable,
unstable, borderline, or in extremis. The stable patient can undergo
fracture surgery as necessary. An unstable patient should be
resuscitated and adequately stabilized before receiving definitive
orthopaedic care. The decision whether to perform initial temporary
Dr. Pape is W. Pauwels Professor or definitive fixation in the borderline patient is individualized based
and Chairman of Orthopaedic/
Trauma Surgery, University of
on the clinical condition. In patients presenting in extremis, life-
Aachen, Aachen, Germany, and saving measures are pivotal, followed by a damage control
Adjunct Professor, Division of approach to their injuries.
Orthopaedic Traumatology,
University of Pittsburgh Medical
Center, Pittsburgh, PA. Dr. Tornetta
T
is Chief, Trauma Surgery, Boston he timing of definitive fixation control approach. Recent clinical
Medical Center, Boston, MA.
Dr. Tarkin is Chief, Trauma Service, of major extremity fractures in data have yielded recommendations
and Assistant Professor, University the multitrauma patient has been the for optimal musculoskeletal care of
of Pittsburgh Medical Center. subject of debate for the past four the multitrauma patient. Historically,
Dr. Tzioupis is Research Fellow,
decades. Recommendations for early several eras can be differentiated.
University of Pittsburgh Medical
Center. Dr. Sabeson is Resident, total care versus a damage control
Division of Orthopaedic Surgery, approach are based on the physiol-
Duke University School of Medicine,
ogy of these critically ill patients, Rationale for Delayed
Durham, NC. Dr. Olson is Chief,
with the benefits of early fracture Fixation: The 1960s
Division of Orthopaedic Surgery,
Duke University School of Medicine. stabilization balanced against the po- In the 1960s, immediate stabilization
Reprint requests: Dr. Pape, tential side effects of excessive surgi- of long-bone fracture in the patient
Department of Orthopaedic Surgery, cal burden. Advances in orthopaedic with multiple traumatic injuries was
University of Aachen Medical trauma surgery, along with pivotal
Center, 30 Pauwels Street, 52074
associated with an unacceptably high
Aachen, Germany. improvements in anesthesia and criti- mortality rate. The major concern of
cal care medicine, have increasingly surgeons treating multitrauma pa-
J Am Acad Orthop Surg 2009;17:
541-549 enabled orthopaedic surgeons to per- tients was the development of fat
form definitive operations on initial embolism syndrome and associated
Academy of Orthopaedic Surgeons. presentation. However, a subset of pulmonary dysfunction.1 Fat and in-
patients may benefit from a damage tramedullary contents liberated from

Knee Hans-Christoph Pape, MD, et al
the fracture were linked to pulmo- longer intensive care unit (ICU) stay, forts and others culminated in a
nary failure. Perioperative cardiovas- including more episodes of leukocy- change in orthopaedic practice. In
cular and pulmonary support was tosis and fever. light of the convincing results of
not well established, leading to mor- Frequently, musculoskeletal out- Bone et al,9 patients with femur frac-
tality rates of up to 50%.2 As a re- comes are compromised when fracture spent less time in traction and
sult, long-bone fractures were ini- ture surgery is delayed. Prolonged were stabilized more rapidly. Time
tially treated with splints, casts, or immobilization prevents initiation of in traction decreased from an aver-
traction until the systemic effects of comprehensive physiotherapy. Major age of 9 days to 2 days.10 However,
fat embolism syndrome resolved. De- joints cannot be exercised, which “early fracture fixation” was loosely
finitive surgical stabilization was of- sometimes leads to profound stiff- defined and could be interpreted as
ten delayed for 10 to 14 days until ness. Disuse muscle atrophy hampers several days after hospital admission.
the pulmonary, cardiovascular, and recovery in the long term.4-7
Along with a better understanding
neurologic systems and the coagula-
of pathophysiology after trauma,
tion profile had stabilized.3
Rationale for Early major improvements were made in
In 1967, Küntscher4 provided three
Fixation: The 1980s the general physiologic support of
recommendations for intramedullary
severely injured patients. Border10
stabilization of major fractures:
A radical shift in the treatment para- emphasized that optimizing nutri-
(1) “Do not nail as long as symp-
digm of the multitrauma patient with tion was correlated with decreased
toms of fat embolization are
major long-bone fracture occurred in mechanical ventilation requirements
present.” (2) “Take special precau-
the 1980s as a result of outcome and prolonged recumbency. Ventila-
tions for patients with multiple frac-
studies that focused on the timing of tion strategies improved and allowed
tures and extensive injuries to soft
orthopaedic fixation and the devel- orthopaedic surgery to be performed
tissues.” (3) “Do not nail immedi-
opment of acute respiratory distress earlier than previously.
ately, but wait a few days.”
syndrome (ARDS). Femur fracture in The principle of early fixation sur-
the multiply injured patient became gery sometimes was interpreted too
Negative Effects of the focus of and the study model for literally, however, resulting in an
Delayed Fixation intensive clinical research. Better out- overly aggressive treatment protocol
comes were achieved in the multi- in the multitrauma patient. Ortho-
Delayed fixation of major fractures trauma patient when intramedullary paedic operations for both major (ie,
is fraught with local and systemic nailing of femur fracture was per- immobilizing) and minor musculo-
implications. Without adequate fixa- formed within the first few days after skeletal injuries were being per-
tion, the patient cannot be mobilized admission.2,6-8 formed within 24 hours of admis-
and is often forced into supine re- Bone et al9 performed the first pro- sion, a practice that appeared to be
cumbency for prolonged periods. spective study that revealed the po- associated with an increased compli-
This can result in dysfunction of tential benefits of early fracture fixa- cation rate.11,12 The beneficial effects
multiple organ systems, leading to a tion. One hundred seventy-eight of fracture fixation were often ne-
variety of disorders, including pneu- patients with acute femoral fracture gated by the harm inflicted to the
monia, decubitus ulcers, vascular were randomized to receive early fix- overall physiology of the patient as a
abnormalities, psychological distur- ation or traction. Within the original result of lengthy operations associ-
bance, and gastrointestinal stasis, study population, 83 presented with ated with substantial blood loss.13
which is associated with a high risk multiple injuries. The cohort of pa- The lessons learned from this overly
of aspiration. Seibel et al5 were the tients treated with traction and late aggressive, comprehensive approach
first to describe an association be- femoral fixation had the highest inci- to managing orthopaedic injuries led
tween delayed stabilization and a dence of ARDS. These research ef- to further consideration of the timing
Dr. Tornetta or a member of his immediate family has received royalties from, has received research or institutional support from, and
serves as a paid consultant to or is an employee of Smith & Nephew, and has stock or stock options held in ExploraMed. Dr. Olson
or a member of his immediate family serves as a board member, owner, officer, or committee member of the Southeastern Fracture
Consortium Foundation, serves as a paid consultant to or is an employee of Synthes, and has received research or institutional
support from Synthes. None of the following authors or a member of their immediate families has received anything of value from or
holds stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pape, Dr. Tarkin,
Dr. Tzioupis, and Dr. Sabeson.

of fracture fixation in the multi- major sources of hemorrhage rather locking of the original implant after
trauma patient. than performing immediate, lengthy, resuscitation and stabilization.
definitive repair of the visceral or- Scalea et al12 used a DCO approach
gans. As part of the damage control on 43 critically ill patients with femo-
Role of the Immune philosophy, immediate life-saving ral fracture who underwent initial ex-
System interventions directed at stopping
ternal fixation followed by conversion
bleeding are applied, after which re-
Trauma causes sustained changes in to an intramedullary nail. They re-
suscitation and further stabilization
the immune response. A hyperin- are performed in the ICU. Only after ported minimal orthopaedic complica-
flammatory early phase may be fol- the overall physiology has improved tions and optimal survival rates. Indi-
lowed by a hypoinflammatory phase, is definitive intervention performed. cations for DCO in this study included
which often precedes the onset of or- This change in trauma practice re- head injury (46%) and hemodynamic
gan failure. The magnitude of the in- sulted in improved survival rates.17 instability (65%). Taeger et al7 re-
flammatory response depends on the Soon orthopaedic trauma surgeons ported a prospective cohort of pa-
used a similar temporizing approach tients treated according to DCO cri-
degree of trauma, and it can be influ-
for major fractures in multitrauma teria and described similar beneficial
enced by treatment. Surgery also in-
patients. Initial surgery was done effects. Pape et al20 reported a lower
cites an inflammatory response.14
with the goal of achieving rapid skel- incidence of pulmonary complica-
In a normal host, there is usually
etal stabilization of major ortho- tions in borderline patients with
no clinically significant consequence
paedic injuries to stop the cycle of femoral fractures (ie, those with in-
to the inflammatory response. How-
ongoing musculoskeletal injury and creased risk of systemic complica-
ever, in the multitrauma patient, ex-
to control hemorrhage. This ap- tions) treated with external fixation
posure to prolonged surgery with
proach was termed damage control initially. The largest study popula-
considerable blood loss and hypo-
orthopaedics (DCO).12 tion was examined by Morshed
thermia causes an exaggerated in-
The external fixator is the primary et al,21 who reviewed 3,069 patients
flammatory response.11,15 In these pa-
tool associated with DCO. This ap- with multisystem trauma. The data
tients, the beneficial effects of early pliance can be used in extremity frac- were housed in the National Trauma
definitive fracture stabilization may tures and in select pelvic fractures Data Bank. Definitive stabilization
not outweigh the associated risk of (Figure 1). A fixator can be applied done within 12 hours was associated
immune-related side effects, such as rapidly and with minimal blood loss. with a higher mortality rate than was
ARDS and multiple organ failure.12 Compared with a splint, access to delayed management. The authors
The surgical impact can act as a sec- the soft tissues is relatively easy, al- concluded that delaying repair of
ond hit (ie, second inflammatory in- lowing for wound management and
femoral shaft fracture beyond 12
sult after the initial trauma) when monitoring of compartment pres-
hours in the multisystem trauma
the timing and the duration are unfa- sure.18 In contrast to skeletal trac-
patient reduces mortality by approx-
vorable. Waiting several days before tion, treatment with initial external
imately 50%. Patients with life-
performing surgery in multitrauma fixation improves patient mobility,
threatening abdominal injury bene-
patients eradicates the danger of this which is beneficial for many aspects
fited most from delayed treatment.
detrimental immunologic response.16 of management, including pulmo-
nary toilet.11 Such fixation also facili-
tates nursing care. In some cases, es- Patient Assessment
Damage Control Surgery pecially those involving severe head
trauma, external fixation can serve The initial patient assessment usually
The term damage control was origi-
as a definitive treatment strategy un- is performed using standard scoring
nally used by the United States Navy
til fracture union. systems such as the Injury Severity
to describe tactics necessary to keep
afloat compromised vessels at sea. Damage control nailing has been Score or the New Injury Severity
General trauma surgeons came to advocated as an alternative to the Score. For life-threatening condi-
apply this term to a management spanning external fixator. In this ap- tions, which frequently are the result
strategy that involves reducing the proach, an unlocked retrograde nail of penetrating trauma, the triad of
impact of the initial operation and is used with limited or no reaming19 death (ie, blood loss, coagulopathy,
improving survival of critically ill pa- (Figure 2). For this treatment, the pa- loss of temperature) approach has
tients. Damage control in general tient is typically returned to the oper- been used. However, in patients with
trauma surgery includes packing the ating room for exchange nailing or blunt trauma, it is important to ac-

Figure 1 Figure 2
Intraoperative photograph
demonstrating the use of an
unreamed, unlocked retrograde
intramedullary nail for rapid
stabilization of a femur fracture in a
multitrauma patient (ie, damage
control nailing).
Table 1
Clinical Parameters to Describe
Multitrauma Patients in
Borderline Condition
ISS >40
Multiple injuries (ISS >20) in associa-
Postoperative photograph demonstrating the use of spanning external tion with thoracic trauma (AIS >2)
fixators for temporary fracture stabilization in a multitrauma patient with Multiple injuries in association with se-
extremity fractures. vere abdominal or pelvic injury and
hemorrhagic shock at presentation
(systolic blood pressure <90 mm Hg)
count for soft-tissue injury, as well. tion are listed in Table 1. Three of the Bilateral femoral fractures
Parameters to assess adequate oxy- four criteria delineated in Table 2 Radiographic evidence of pulmonary
genation are useful for determining (shock, coagulation, temperature <35°C contusion
the clinical status of the patient. [95°F], soft-tissue injuries) should be Hypothermia (temperature <35°C
A patient can be classified as stable present to qualify a patient for a spe- [95°F])
(grade I, cleared for surgery), border- cific category.22 The current level of Additional moderate or severe head
line (grade II, uncertain condition with evidence is insufficient to definitively injuries (AIS ≥3)
episodes of cardiovascular instability stratify patients; thus, the proposed
AIS = Abbreviated Injury Score,
and hypoxemia), unstable (grade III, combination of these parameters is ISS = Injury Severity Score
cardiovascular instability [systolic blood only suggestive. Nevertheless, most
pressure <90 mm Hg]), or in extremis of these components are scores that
(grade IV, acutely life-threatening inju- have been routinely applied and are sponsive to therapy with >10 blood
ries). Although several parameters are widely accepted. units per 6 hours, and requirement
considered in classifying patients, clear For screening purposes, the follow- for vasopressors.20 Inflammatory pa-
numerical cutoffs have not been estab- ing threshold levels have been used: rameters have also been described to
lished; thus, judgment and experience pulmonary dysfunction (Pao2/Fio2 have predictive power for the devel-
are required. The parameters used to <250 mm Hg), platelet count opment of complications. However,
identify a patient in borderline condi- <95,000/mm3, hypotension unre- routine screening for inflammatory

Table 2
Criteria Used to Determine the Clinical Condition of Multitrauma Patients and Refer to Treatment Guidelines*
Patient Status
Criterion Parameter Stable Borderline Unstable In Extremis
Shock Blood pressure ≥100 80-100 <90 ≤70

(mm Hg)
Blood units given 0-2 2-8 5-15 >15
in a 2-hr period
Lactate levels Normal range ≈2.5 >2.5 Severe acidosis
(mg/dL) according to local
laboratory
Base deficit level Normal range No data No data >6-8
(mmol/L) according to local
laboratory
ATLS classifica- I (no shock) II-III (slight shock) III-IV (severe shock) IV (severe shock)
tion
Coagulation Platelet count >110,000/mm3 90,000-110,000/mm3 <70,000-90,000/mm3 <70,000/mm3
Factor II and V 90-100 70-89 50-70 <50
(%)
Fibrinogen (g/L) >1 ≈1 <1 Disseminated intra-
vascular coagulation
D-dimer (µg/mL) Normal range Abnormal Abnormal Disseminated intra-
according to local vascular coagulation
laboratory
Temperature °C (°F) <33 (<91.4) 33-35 (91.4-95.0) 30-32 (86.0-89.6) ≤30 (≤86.0)
Soft-tissue Lung function 350-400 300-350 200-300 <200

injuries (Pao2/Fio2
[mm Hg])
Chest trauma 1 or 2 (ie, abrasion) ≥2 (ie, 2-3 rib ≥3 (ie, serial rib ≥3 (ie, unstable chest)
scores (AIS) fractures) fractures >3)
Chest trauma 0 (concussion) I-II (slight thoracic II-III (moderate) IV (severe)
score (thoracic trauma)
trauma severity
score)
Abdominal trauma ≤II (none) ≤III (slight) III (moderate) ≥III (severe)
(Moore classifi-
cation)
Pelvic trauma (AO A (none) B or C (slight) C (moderate) C (crush, rollover,
classification) abdominal)
External AIS I-II (eg, abrasion) AIS II-III (eg, multiple AIS III-IV (eg, <30% Crush injury (>30%
tears >20 cm) burn) burn)
* Three of the four criteria must be met to classify for a certain grade. Note that the condition can change according to resuscitation or
additional hemorrhage.
AIS = Abbreviated Injury Score, ATLS = Advanced Trauma Life Support
markers is not available at many the limb, as well as to limit the time therapy plays an integral role in the
trauma centers.23 in the operating room to ≤2 hours.22 management of orthopaedic wounds.
Within this surgical window, open An initial guillotine amputation may
fractures should be débrided and sta- be lifesaving for the patient who is in
Surgical Priorities
bilized with an external fixator. A extremis because of an extremity
The first surgical priority is to save splint may be sufficient for upper ex- fracture or who has an open fracture
the patient’s life and, when feasible, tremity injuries. Negative pressure with vascular injury. It is not possi-

Figure 3
Algorithm for management of femur fracture in borderline and unstable multitrauma patients. CHI = creatinine height
index, ICU = intensive care unit, IM = intramedullary, ISS = Injury Severity Score
ble to indicate specific criteria for ev- of fluids (should not exceed 3 L, or 5 hours following injury.26 Intraopera-
ery situation because each decision units of blood), and absence of sig- tive hypotension is an important risk
must take into account a number of nificant coagulopathy. Provided that factor for secondary brain injury.27
variables. However, some general the patient maintains these levels, the The primary goals of management of
recommendations can be made. surgeon may address the next major traumatic brain injury are mainte-
fracture; otherwise, a temporizing nance of adequate cerebral perfusion
In the patient in extremis, hemor-
approach should be selected.24 In the and avoidance of secondary insults.28
rhage control is paramount, followed
stable patient, all fractures can be de- Treatment of the multitrauma pa-
by stabilization of vital parameters in
finitively stabilized within the first tient with head injury requires a mul-
the ICU. Major fractures are considered
day. An algorithm for treatment of tidisciplinary approach that includes
to be a secondary priority. In the unsta-
borderline and unstable patients is the neurosurgical team, with treat-
ble patient, major lower extremity frac-
presented in Figure 3. ment tailored to the evolving status
tures should be stabilized with a tem-
porary method, such as external of the patient. The degree of cerebral
fixation. In the borderline patient who Head Injury swelling, imminent herniation, and
responds to resuscitation, definitive pro- Following significant head injury, increase in bleeding must be closely
cedures (eg, intramedullary nailing) can the brain loses the capacity for auto- monitored.
be performed but within an upper sur- regulation of blood flow in zones of Clinical studies have provided con-
gical time limit of <2 hours. The patient contusion. Furthermore, glucose uti- flicting results. In one study that
with several lower extremity fractures lization increases, adding to a flow- compared multitrauma patients who
should be continuously reassessed, with metabolism mismatch. Consequently, had closed head injury and femur
particular attention paid to the the injured brain is highly susceptible fracture with multitrauma patients
following parameters: lung function to ischemic injury.25 who had head injury but no femur
(Pao2/Fio2 should not drop below The individual with head trauma is fracture, McKee et al29 reported no
250 mm Hg), temperature (should at greatest risk for decreased cerebral significant difference in mortality, no
not be <32°C [89.6°F]), requirement blood flow during the first 12 to 24 difference in length of stay, and no

difference in neurologic outcome ac- action that affects the pulmonary en- complicated by the fracture and not
cording to the timing of stabilization. dothelium, similar to the response to timing of fixation.
However, in a study by Townsend described for general blood loss.33 van Os et al39 found no statistical
et al,30 patients with a Glasgow The progressive nature of a pulmo- difference in the incidence of ARDS
Coma Scale value of <9 on admis- nary contusion can cause problems in patients treated with early versus
sion who were operated on within 2 and is frequently underestimated.34 late fixation and concluded that se-
hours had an eightfold increased risk Early diagnostic studies may not vere thoracic trauma is not a con-
of hypotension. Thirty-six of 43 pa- adequately reveal the extent of the traindication for early osteosyn-
tients with poor neurologic out- evolving lung injury. Even when thesis. Bone et al40 compared three
comes had cerebral perfusion pres- blood gas parameters are within nor- groups of chest-injured patients:
mal limits and the chest radiograph
sures <70 mm Hg within the first 24 those whose femoral fracture was
is normal, pulmonary contusion may
hours. Jaicks et al31 reported that treated with a nail, those whose frac-
occur as a result of the immune re-
fracture fixation in the presence of ture was treated with a plate, and
sponse, resulting in an increased risk
severe head injury has negative ef- those without a femur fracture. The
of ARDS.35,36
fects; however, the authors did not authors concluded that the chest in-
Patient evaluation should be fo-
include in their analysis patients who jury, not the method of femoral frac-
cused on the following clinical crite-
died before discharge. These conflict- ria: presence of a lung contusion on ture fixation, was responsible for
ing results are noteworthy and may the initial chest radiograph or CT ARDS.
be attributable to different inclusion scan, worsening oxygenation (re- Pryor and Reilly41 noted that inclu-
criteria in these respective studies. quirement of increased Fio2 >40% or sion criteria may be responsible for
In the multitrauma patient with Pao2/Fio2 <250 mm Hg), and in- the conflicting results in the litera-
head injury, acceptable thresholds creased airway pressures (eg, >25 to ture. Most publications have relied
for operating room time, blood loss, 30 cm H2O). Pulmonary function on the Abbreviated Injury Scale for
and temperature loss must be deter- can change within hours after the in- assessment,42 but use of a more so-
mined on an individual basis. In jury, and repeat blood gas analyses phisticated scoring system may be
equivocal cases, monitoring of the should be obtained. appropriate to precisely grade pul-
intracranial pressure is prudent. Dur- The timing of fracture management monary injury. Because all authors
ing fracture fixation, the goals of in patients with thoracic injuries re- agree that severe chest trauma repre-
management should include mainte- mains controversial, with conflicting sents a risk factor for ARDS, ruling
nance of adequate cerebral perfusion studies and recommendations. Fakhry out severe lung contusions by early
and avoidance of secondary insults. et al37 examined a statewide database CT scan is advisable; the decision re-
and discovered a 4.6% mortality rate garding how to proceed should be
Chest Injury in patients with severe chest injuries made on an individualized basis us-
Chest injury in the multitrauma pa- who underwent surgery on day 1, ing a multidisciplinary approach.
tient typically consists of either chest compared with a 0% mortality rate
wall fracture or lung contusion, or in patients who were definitively sta- Pelvic Ring Injury
both. In the patient with isolated rib bilized >1 day after admission to the Pelvic fracture is an indicator of
fractures, the act of breathing is hospital. The authors concluded that high-energy trauma. The systemic ef-
painful, causing hypoxemia that can “the presence of severe chest injury fects of severe pelvic injuries are de-
be addressed with either local pain may be an indication to delay the termined by the degree of hemor-
blocks or artificial ventilation. femoral repair for 24 to 48 hours un- rhage and soft-tissue injury. Unlike
Lung contusion is of utmost con- til these injuries have been stabi- other injuries, autotamponade does
cern because it is closely associated lized.” In a study by Pelias et al,38 not occur, and retroperitoneal bleed-
with ARDS.32 In the patient with the comparison between early and ing may mimic intra-abdominal in-
lung contusion, the disturbance of late fixation of long-bone fractures jury. Soft-tissue disruption can cause
oxygenation can increase despite ad- revealed no appreciable difference more severe side effects in pelvic
equate efforts at mechanical ventila- in pulmonary complications (early fracture than in extremity fracture
tion, because of the formation of operation, 27.6%; late operation, because, in the former, a higher de-
pulmonary edema. This pulmonary 29.4%). The authors concluded that gree of kinetic energy is required
edema is mediated by inflammatory the incidence of ARDS in these pa- to cause substantial displacement.
cells, causing a local immunologic re- tients is attributable to chest trauma Open injuries are common. Gas-

trointestinal contamination is partic- 4. Küntscher G: Practice of Intramedullary

ularly worrisome because of the sub- Summary Nailing. Springfield, IL, Charles Thomas,
1967, pp 36-51.
stantially increased risk of infection
The patient with multiple traumatic in- 5. Seibel R, LaDuca J, Hassett JM, et al:
and late sepsis.43 Blunt multiple trauma (ISS 36), femur
juries may be classified as stable, bor-
Evaluation of the patient with pel- traction, and the pulmonary failure-
derline, unstable, or in extremis. Early septic state. Ann Surg 1985;202:283-
vic fracture is similar to that for any 295.
definitive fracture fixation is recom-
patient with an injury associated
mended for the stable multitrauma pa- 6. Goris RJ, Gimbrère JS, van Niekerk JL,
with sustained hemorrhage. Timing Schoots FJ, Booy LH: Early
tient and in the borderline or unstable osteosynthesis and prophylactic
of pelvic fixation is based on hemo-
patient who responds well to resusci- mechanical ventilation in the
dynamic status and the presence of multitrauma patient. J Trauma 1982;22:
tation. However, in the patient who pre- 895-903.
associated abdominal injuries. The
sents with severe hemorrhagic shock or
decision to attempt definitive fixa- 7. Taeger G, Ruchholtz S, Waydhas C,
any other life-threatening condition, Lewan U, Schmidt B, Nast-Kolb D:
tion within 24 to 48 hours appears
prolonged surgical procedures should Damage control orthopedics in patients
to be dependent on the pelvic ring with multiple injuries is effective, time
be avoided, and staged fracture fixation saving, and safe. J Trauma 2005;59:409-
fracture pattern.44 Fixation can be at-
should be done. The damage control 416.
tempted in stable and borderline pa-
approach, which uses external fixation 8. Johnson KD, Cadambi A, Seibert GB:
tients. In unstable patients, the use of Incidence of adult respiratory distress
as a primary tool, may be applied in
sheets wrapped about the pelvis or a syndrome in patients with multiple
such cases. For the patient who presents musculoskeletal injuries: Effect of early
pelvic binder, optimally placed at the operative stabilization of fractures.
as borderline or in poorer condition, a
level of the greater trochanters, al- J Trauma 1985;25:375-384.
multidisciplinary approach is required
lows for rapid circumferential splint- 9. Bone LB, Johnson KD, Weigelt J,
to determine the best timing of muscu- Scheinberg R: Early versus delayed
ing of the pelvic ring.45
loskeletal care. stabilization of femoral fractures: A
There is a paucity of literature on the prospective randomized study. J Bone
Joint Surg Am 1989;71:336-340.
optimal timing of definitive pelvic sta-
bilization. Favorable patterns may be References 10. Border JR: Death from severe trauma:
Open fractures to multiple organ
treated with percutaneous fixation dysfunction syndrome. J Trauma 1995;
when certain criteria are met: a closed Evidence-based Medicine: Levels of ev- 39:12-22.
reduction is possible, the injury pattern idence are described in the table of con- 11. Giannoudis PV, Abbott C, Stone M,
is amenable to screw fixation alone, and tents. In this article, references 9, 14, Bellamy MC, Smith RM: Fatal systemic
inflammatory response syndrome
the surgeon and operating team are and 18 are level I studies. References following early bilateral femoral nailing.
available and experienced.46 In ex- 7, 8, 30, 33, and 34 are level II stud- Intensive Care Med 1998;24:641-642.
treme cases of exsanguination result- ies. References 2, 3, 5, 6, 13, 15, 17, 12. Scalea TM, Boswell SA, Scott JD,
ing from pelvic ring injury, direct 21, 25-29, 35, and 36 are level III Mitchell KA, Kramer ME, Pollak AN:
External fixation as a bridge to
packing of the true pelvic space has studies. References 1, 4, 10, 12, 16, intramedullary nailing for patients with
been described.47 However, this tech- 20, 22-24, 31, 32, 37-39, 44, and 45 multiple injuries and with femur
are level IV studies. References 40-43 fractures: Damage control orthopedics.
nique must be performed with ad- J Trauma 2000;48:613-621.
junctive pelvic ring stabilization, are level V expert opinion.
13. Pape HC, van Griensven M, Rice J, et al:
which may include a binder, external Citation numbers printed in bold Major secondary surgery in blunt trauma
fixation, or internal fixation. type indicate references published patients and perioperative cytokine
liberation: Determination of the clinical
Currently it is recommended that within the past 5 years. relevance of biochemical markers.
the surgeon identify the source of J Trauma 2001;50:989-1000.
1. Tscherne H, Schreyer H, Magerl F:
pelvic hemorrhage and stop bleeding Pulmonary and cardiac x-ray findings in 14. Pape HC, Schmidt RE, Rice J, et al:
emergently, then stabilize the pelvic traumatic fat embolism [German]. Biochemical changes after trauma and
Fortschr Geb Rontgenstr Nuklearmed skeletal surgery of the lower extremity:
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2. Beck JP, Collins JA: Theoretical and
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damaged artery may be treated by embolism syndrome. Instr Course Lect Extending the horizons of “damage
1973;22:38-87. control” in unstable trauma patients
coil embolization instead. The local
beyond the abdomen and gastrointestinal
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nique for stabilizing the pelvic ring. Br 1964;46:28-31. et al: Impact of intramedullary

instrumentation versus damage control ischaemia: Implications for therapy. Br J statewide population-based analysis of
for femoral fractures on Anaesth 1985;57:120-130. 2805 adult patients in a rural state.
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27. Chesnut RM, Marshall LF, Klauber MR,
Prospective randomized analysis by the
et al: The role of secondary brain injury 38. Pelias ME, Townsend MC, Flancbaum L:
EPOFF Study Group. J Trauma 2003;55:
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Research Article

Functional and Clinical Outcomes

© American Academy Of Orthopaedic Surgeons 1

Figure 1 and were medically stable to undergo

© American Academy Of Orthopaedic Surgeons 2

© American Academy Of Orthopaedic Surgeons 3

Table 3 nonsurgical management of elderly

© American Academy Of Orthopaedic Surgeons 4

1SP 51 1 Male Delayed presentation, VI 412C2 100 32.07 None

© American Academy Of Orthopaedic Surgeons 5

© American Academy Of Orthopaedic Surgeons 6

Locking Plates for Extremity

© American Academy Of Orthopaedic Surgeons 7

© American Academy Of Orthopaedic Surgeons 8

© American Academy Of Orthopaedic Surgeons 9

American Orthopaedic Foot and Distal tibia 19 Bahari et al48 (2007)

Blood loss Proximal humerus N/A Laflamme et al23 (2008)

Constant-Murley score Proximal humerus 1.5 Fankhauser et al19 (2005)

Disabilities of the Arm, Shoulder, Proximal humerus 12 Laflamme et al23 (2008)

QuickDASH score Proximal humerus 12 Owsley and Gorczyca25

d’Aubigne and Postel score Periprosthetic femur NR Buttaro et al35 (2007)

Functional score Proximal tibia 3 yr Boldin et al42 (2006)

Hospitalized (days) Proximal humerus N/A Sharafeldin et al26 (2008)

Hospital for Special Surgery Proximal tibia 3 yr Boldin et al42 (2006)

Knee Society score Distal femur 20 Fankhauser et al28 (2004)

Lysholm score Distal femur 3 Markmiller et al27 (2004)

N/A = not applicable, NR = not reported

© American Academy Of Orthopaedic Surgeons 10

Surgical time (minutes) Proximal humerus N/A Koukakis et al22 (2006)

Oxford Knee score Distal femur 23 Wong et al34 (2005)

Pain Distal femur 10 wk Ricci et al44 (2004)

Medical Outcomes Study 36- Proximal humerus NR Sharafeldin et al26 (2008)

Short Musculoskeletal Function Proximal humerus 12 Owsley and Gorczyca25

Subjective contentment Periprosthetic femur Final follow-up Erhardt et al36 (2008)

Weight bearing—full (wk) Distal femur N/A Fankhauser et al28 (2004)

N/A = not applicable, NR = not reported

© American Academy Of Orthopaedic Surgeons 11

© American Academy Of Orthopaedic Surgeons 12

© American Academy Of Orthopaedic Surgeons 13

© American Academy Of Orthopaedic Surgeons 14

Timing of Fracture Fixation in

© American Academy Of Orthopaedic Surgeons 15

© American Academy Of Orthopaedic Surgeons 16

© American Academy Of Orthopaedic Surgeons 17

© American Academy Of Orthopaedic Surgeons 18

Criterion Parameter Stable Borderline Unstable In Extremis

Shock Blood pressure ≥100 80-100 <90 ≤70

Soft-tissue Lung function 350-400 300-350 200-300 <200

© American Academy Of Orthopaedic Surgeons 19

© American Academy Of Orthopaedic Surgeons 20

© American Academy Of Orthopaedic Surgeons 21

trointestinal contamination is partic- 4. Küntscher G: Practice of Intramedullary

© American Academy Of Orthopaedic Surgeons 22

© American Academy Of Orthopaedic Surgeons 23

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