2.4 Preoperative planning

10.1055/b-0038-160820

2.4 Preoperative planning

Matthew Porteous

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1 Introduction

Planning is the first step in the operative management of any fracture and should not be regarded as an optional extra. This is well understood by many trauma specialists but some wrongly perceive planning as time-consuming and of little benefit. Those who formally plan the management of their fractures can confirm the truth of the maxim that “failing to plan is planning to fail”. It is the surgeon′s responsibility to ensure that planning is carried out. This chapter discusses the key steps in formulating a successful surgical plan.

2 Why plan?

Planning is an important surgical discipline that encourages the surgeon to focus on the fracture pattern, fixation technique, and surgical approach. The surgeon can mentally rehearse the operation, equipment and instruments can be ordered, operating room personnel (ORP) can be briefed and problems can be anticipated and either avoided or solved by developing an alternative plan to deal with difficulties should they arise during surgery ( Fig 2.4-1 ).

**Fig 2.4-1** Planning is an important surgical discipline. Failing to plan is planning to fail.

Problems that can arise when planning is inadequate include:

Lack of suitable scrub ORP familiar with equipment to be used
Inappropriate anesthetic or block given to patient
Correct operating table in use elsewhere
Instruments not available (used earlier and not resterilized)
Implants not available
Image intensifier booked for another operating room
Lack of suitable assistant
Incision in wrong place
Excessive dissection and soft-tissue stripping to obtain reduction
Inability to reduce or maintain fracture reduction while the definitive implant applied
Long wait while unanticipated additional implants or instruments are located
Position of one screw prevents placement of others from a different direction
Implant positioned in wrong place
Unanticipated complications arise
Surgery takes longer
Improper wound closure
Inappropiate postoperative program

Failure to plan can cause uncertainty about whether a fixation technique is intended to provide absolute or relative stability. This may lead to the failure of the application of the appropriate principles with eventual implant failure and/or fracture nonunion.

3 Assessment

As much information must be obtained about a fracture as is necessary to treat it. Radiology is the mainstay of diagnosis and clear views of the fracture in two planes with correct position showing the joint above and below are mandatory. The use of an image intensifier immediately before surgery, with its inferior image resolution and narrow field of view, is a poor substitute for good quality x-rays. Once the patient is anesthetized, x-rays taken with traction of the limb can be helpful for planning. Good quality x-rays are only useful if they are examined carefully. Fractures tend to follow patterns, which can give a false sense of security. Without a minute inspection of the x-rays, subtle variations that can have significant implications for the operation can easily be missed.

Plain films, even supplemented by oblique views, may be inadequate and when there is uncertainty computed tomography (CT) (supplemented when available by 3-D reconstructions) are required to enable the surgeon to build up the 2-D and 3-D image of the fracture pattern that is required for good planning. This is particularly important in fractures around joints, which generally require accurate anatomical reduction. The 2-D CT is more important than 3-D for evaluating articular fractures as it demonstrates the fracture in the transverse, sagittal, and coronal planes while the 3-D shows only the outer surface and overview of the fracture pattern.

If there is more than one reasonable method for fixing the fracture, all possibilities can be tried out on paper before a decision is made about the method of fixation, the approach, and the equipment required. In some situations the surgeon needs more than one plan; when the first plan is not possible then the second plan is applied. This process allows the surgeon to practice the steps of the operation on paper and rehearse it in their mind. This way mistakes can be left in the wastepaper bin and not in the patient.

With details of the fixation established, the ORP can check the availability of instruments and implants, and other departments, such as radiology, can be notified of the need for their services. During the operation, the ORP and anesthetic teams can follow the steps of surgery from the plan; operations that have been planned tend to have fewer problems and take less time. The type of anesthesia is important in some type of surgery. General anesthesia is required in procedures that need more muscle relaxation such as pelvic and acetabular surgery, while most upper limb operations need only regional or selective nerve block.

Planning allows a detailed analysis of the options and gives a much better evaluation of the risks and benefits of surgery and complications, which can be discussed with the patient to allow informed consent. Inclusion of the preoperative plan and tactics in the medical records clearly reflects the thought and planning put into the operation. It indicates a professional approach and is likely to make any litigation easier to defend.

4 How to plan

For descriptive purposes the planning process is divided into four sequential stages. The first three stages—reconstruction, decision making, and fixation—lead to a detailed drawing and rehearsal of the proposed fixation. The final stage, the surgical tactic, is a sequential list of steps to be taken in the operating room to achieve the planned fixation.

In reality, these stages tend to develop in parallel in the mind of the surgeon. However, the more complex the problem, the more formal the planning process should be.

The steps laid out here form the basis of all surgical planning techniques. Variations and shortcuts are possible and digital radiography is promoting the development of specialized planning software that avoids the need for pens and tracing paper. The principles, however, remain the same.

Material required:

X-rays of the fracture: It is important to be able to see the joint above and below the fracture. If the fragments appear to be grossly displaced or rotated (which can be a problem in complex elbow fractures), the perspective can be improved by taking traction x-rays once the patient is anesthetized.
X-ray of the uninjured side: This x-ray is flipped over to produce a mirror image, which is used as the template onto which the fracture is reduced. Both x-rays need to be of the same known magnification.
Sets of templates of implants: These need to be in a magnification identical to that of the x-rays. Most commercial templates have a magnification of 115%. If necessary, they can be enlarged or reduced on a photocopier.
Tracing paper.
Color pens: Making and understanding the drawing is easier if different colors are used for the outline of the bones, fracture lines, and implants, although this is not essential.

4.1 Reconstruction

This involves identifying and reassembling the fracture fragments, much like doing a jigsaw puzzle:

Step 1—Tracing the intact bone: place a piece of tracing paper over the normal x-ray and trace the outline of the intact bone (this is best done over a light box). If there is significant bone overlap (such as in a lateral view of the forearm), the overlapped bones can be traced separately side by side ( Fig 2.4-2 ).
Step 2—Tracing the fracture: put a separate piece of tracing paper over the fracture x-ray and trace around the fracture fragments. Where fragments overlap they can be drawn separately and slightly apart from each other, as their relative position to each other is not important ( Fig 2.4-3 ).
Step 3—Restoration: place the tracing of the intact bone over the tracing of the fractured bone. By moving the outlines of the intact bone over the fracture pieces it is possible to mark out, on the tracing of the intact bone, where the fracture fragments would fit once the fracture has been fully reduced ( Fig 2.4-4 ).

**Fig 2.4-2** Tracing of the intact bone. Note that the radius and ulna have been drawn separately on the lateral view.

**Fig 2.4-3** Tracing of the outline of the fracture fragments. All overlapping fragments have been separated.

**Fig 2.4-4** Restoration: The intact tracing (Fig 2.4-2) is placed over the fracture tracing (Fig 2.4-3) and the fractures drawn onto the intact bone.

The product of the reconstructive phase is a tracing of an intact bone with the reduced fracture fragments marked out on it. In complex fractures it is advisable to copy the reconstruction, as often more than one attempt at fixation planning is required ( Fig/Animation 2.4-5 ). In simple fractures it is often possible to reassemble the fragments on tracing paper without requiring a tracing of the intact bone as a guide, like fitting together the bits of a jigsaw without being able to see the original picture before starting.