3 1. Primary survey: airway, breathing, circulation (ABCs) 2. Shock • Hemorrhagic shock classes I–IV (Table 3.1) • Compensated shock patients have relative hypoperfusion with preferential perfusion to heart and brain; may have normal heart rate/blood pressure and urine output but are at increased risk of systemic inflammatory response • Neurogenic a. Hypotension combined with bradycardia • Septic: etiology is a drop in systemic vascular resistance due to infection-driven inflammation a. Hypotension, tachycardia, fever 3. Resuscitation • Fluid bolus challenge of three to four times the estimated blood loss; if inadequate response, transfuse at plasma/platelets/packed red blood cells (PRBCs) ratio of 1:1:1 • Interleukin-6 (IL-6) associated with systemic inflammatory response after trauma/musculoskeletal injury and correlates with injury severity and outcome • End points: base deficit (normal –2 to 2), lactate (normal < 2.5), gastric intramucosal pH (normal > 7.3, indicates normal tissue oxygenation) are best predictors of resuscitation status, risk of death, and multisystem organ failure; time it takes to correct these parameters can predict survival • Base deficit is best predictor of resuscitation in the first 6 hours following insult • Hypothermia less than 95°F (35°C) is associated with increased mortality in trauma patients. 4. Trauma scoring systems • Injury Severity Score (ISS): calculated as the sum of the squares of the three highest Abbreviated Injury Scale (AIS) scores from the six body regions; score over 18 is considered polytrauma; mortality correlated with age and higher score • Revised Trauma Score: calculated from systolic blood pressure (SBP), respiratory rate (RR), and Glasgow Coma Scale (GCS) • Trauma and Injury Severity Score (TRISS): survival probability calculator, combining above scores and weighting by age (< 55 years greater survival, ≥ 55 years lower survival) and mechanism (lower survival for blunt trauma, higher for penetrating trauma) 5. Damage control orthopaedics (DCO) • Technique of external fixation of bony injuries in the polytrauma patient • Inflammatory surge 2–5 days after trauma in polytrauma patients; surgery in this window can lead to “second-hit” phenomenon, increase risk of acute respiratory distress syndrome (ARDS); if patient cannot be adequately resuscitated for definitive treatment in first 12–24 hours, DCO restricts surgery to life- and limb-saving procedures • Consider if: ISS > 40, ISS > 20 with thoracic trauma, multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs, hypothermia of less than 35°C, head injury • External fixation for acute stabilization of long bone fractures can decrease overall inflammatory burden and leads to less multisystem organ failure and ARDS than if patient is left untreated. • Head injury: not a contraindication for acute intramedullary nailing (IMN) of long bone fractures; no worsened GCS in patients with early nailing as long as there is no intraoperative hypotension or hypoxia 6. Compartment syndrome: • Remember the five P’s: pain out of proportion to injury, paresthesias, pallor, pain with passive stretch, pulselessness • Clinical diagnosis with use of objective measures to assist in diagnosis; permanent damage to muscle and nerve can occur after 6 hours • Mechanism: blunt extremity soft tissue injury, associated with fracture, particularly lower extremity (tibia) • Presentation: most reliable symptom is pain out of proportion to injury; most reliable sign is pain with passive stretch; external compression, vascular compromise. • Diagnosis: clinical diagnosis; needle compartment pressure monitoring can assist in diagnosis; objective measure of intracompartmental pressure, positive result if: a. Difference between diastolic blood pressure and compartment pressure (Delta P) < 30 mm Hg; corollary to perfusion pressure to tissue b. Absolute compartment pressure > 30 mm Hg • Pressure monitoring is used as an adjunct; compartment syndrome is a clinical diagnosis • Treatment: fasciotomy to decrease intracompartmental pressure to improve perfusion; delayed closure 7. Open fractures • AO/OTA open fracture classification: evaluates 5 areas for degree of injury a. Skin ◦ Edges that approximate ◦ Edges that do not appoximate ◦ Extensive degloving b. Muscle ◦ No appreciable muscle necrosis ◦ Transected or dead muscle unit with loss of function c. Arterial ◦ No major vessel disruption ◦ Vessel injury without ischemia ◦ Vessel injury with ischemia d. Contamination ◦ Minimal contamination ◦ Superficial contamination ◦ Embedded contamination in muscle or bone e. Bone loss ◦ None ◦ Bone loss but with remaining contact between bone ends ◦ Segmental bone loss • Gustilo and Anderson classification: energy of mechanism is more important than wound size but is more difficult to quantify. Example: comminuted femoral shaft fracture is type III regardless of wound size. a. Type I: wound < 1 cm b. Type II: wound 1–10 cm c. Type IIIA: wound > 10 cm or significant comminution or periosteal stripping d. Type IIIB: requires flap coverage (best outcomes and lowest infection rate with early coverage; goal < 7 days) ◦ Coverage options in tibia fractures: ♦ Proximal third: gastrocnemius flap or free tissue transfer ♦ Middle third: soleus flap or free tissue transfer ♦ Distal third: fasciocutaneous or free tissue transfer ♦ Risk of infection in type IIIB open tibia coverage is related to timing of soft tissue coverage e. Type IIIC: associated vascular injury requiring repair, irrespective of wound size • Treatment: a. Debridement: removal of contaminants and devitalized tissue ◦ Best irrigation technique in open injuries: saline, low-flow gravity b. Antibiotics: time to first dose important predictor of infection ♦ First generation cephalosporin for types I and II, add aminoglycoside for type III, add penicillin for heavy contamination/farm wounds; tetanus prophylaxis for all • Limb salvage versus amputation: most important factor in success of limb salvage in open tibia fractures is extent of soft tissue injury, whereas amputation level is determined by soft tissue available for coverage • Lower Extremity Assessment Project (LEAP) study: compares amputation to limb salvage; most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain • Sickness Impact Profile (SIP) scores and rate of return to work not significantly different between groups at 2 years; self-efficacy (defined as one’s belief in one’s ability to succeed; part of the SIP) as well as social support thought to be two most important predictors in both groups 8. General fracture complications • Deep venous thrombosis (DVT): 5% develop pulmonary embolus • Fat embolus: can occur at time of fracture, reduction, or during intramedullary instrumentation; usually manifested in 48–72 hours of injury a. Presentation: hypoxia (Pao2 < 60 mmHg), tachycardia, petechial rash b. Treatment: supportive pulmonary care • Nonunion Fig. 3.1 Types of nonunion. (a) Hypertrophic (hoof-like appearance). (b) Oligotrophic. (c) Atrophic. a. Definitions ◦ Delayed union: fracture not completely healed in usual timeframe (varies with type and location) ◦ Nonunion: no radiographic evidence of healing over 3 months following expected union or lack of progression of healing or no healing by 6 months b. Classification (Fig. 3.1) ◦ Hypertrophic: adequate biology, inadequate stability ◦ Oligotrophic: adequate biology, fracture displaced (i.e., overdistracted during nailing) ◦ Atrophic: compromised biology (vascularity), adequate stability ◦ Infected c. Treatment ◦ Hypertrophic: improved stabilization (cast/brace vs operative) ◦ Oligotrophic: reduce displacement/interposition ◦ Atrophic: augment biology [bone graft, bone morphogenic protein (BMP), bone stimulation, vascularized graft] ♦ Bone graft materials (see Chapter 1) ◦ Infected: treatment of infection with or without removal of hardware acutely or in a delayed fashion after union • Segmental bone loss a. Treatment options: bone transport (Ilizarov, spatial frame), vascularized interposition graft (defect size > 10 cm), nonvascularized graft ◦ Masquelet technique: an option for large defects where bone cement is interposed in defect for 4–6 weeks while a biologically active pseudomembrane is induced, and then cement is removed and cancellous autograft placed at 4–6 weeks b. Growth factors shown to be at highest concentration in membrane around 4 weeks • Heterotopic ossification (common around acetabulum/elbow) a. Risk factors: extensive muscle damage, head injury b. Prophylaxis within 72 hours of surgery ◦ Indomethacin: 75 mg/day for 4–6 weeks ◦ Radiation: single 700 cGy (rad) dose • Infection/osteomyelitis a. Presentation: pain, fevers, draining wound, erythema, edema, inability to ambulate b. Diagnosis: elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP); on X-ray, lytic region is often seen surrounded by sclerotic bone; bone loss ◦ Sequestrum: necrotic bone that serves as a nidus for infection ◦ Involucrum: new bone around an area of necrotic bone ◦ CRP increases within 6 hours, peaks at 2–3 days, normalizes 5–21 days; ESR peaks on days 4–11, remains elevated longer (up to 90 days) in noninfected cases; both are nonspecific markers of infection/inflammation c. Treatment: castile soap irrigation (nonsterile liquid soap additive) is as effective as bacitracin irrigation in terms of postoperative infection and fracture healing and entails fewer problems with wound healing 9. Gunshot wounds • High energy: hunting rifles, assault weapons, close-range shotguns—treated as open fractures • Low energy: handguns—treated as closed fractures, with antibiotics and wound care unless deformity and instability require surgery 10. Fracture biomechanics • Fracture pattern based on direction of energy load (Fig. 3.2) • Strain: change in fracture gap/overall length of fracture gap (delta L/L) • Absolute stability (strain < 2%): rigid fixation, compression plating, lag screw a. No motion at fracture site; leads to primary bone healing; no callus formation • Relative stability (strain 2–10%): intramedullary nailing, bridge plating a. Micromotion at fracture site; leads to secondary bone healing; callus formation • Fixation that leads to strain ranging from 11–20% leads to fibrous union • Fixation that leads to strain > 20% leads to nonunion and pseudoarthrosis 11. Fixation biomechanics (Fig. 3.3) • External fixation: the biggest influence on construct stiffness is pin diameter; other factors increasing stiffness: pin spread (“near-near-far-far”), bar to bone distance, bar number, out of plane pin; circular frames more stable than uniplanar frame, with wires tensioned at 90 degrees giving best angular and torsional stability • Lag screws a. Interfragmentary compression, absolute stability; neutralization plate to protect screw from torsion • Compression plating a. Pre-bend to convex shape to eliminate gap on opposite side of the fracture at the cortex Fig. 3.2 Fracture type is based on the direction of energy load. 1, a transverse fracture is created when bone fails in tension (patella fracture for example). 2, in compression, an axial load creates an oblique fracture 45 degrees to the axis. 3, because bone is stronger in compression than in tension, when a transverse (direct blow) or bending load is applied, bone first fails in tension, and then fails in compression; there is a butterfly fragment on the compression side of the fracture. 4, in a torsional or twisting energy load, a spiral fracture is created 45 degrees to the long axis Fig. 3.3 Fixation techniques. (a) Lag screw. Note the overdrilled near cortex and countersunk screw head. The angle of the screw bisects the angle between the lines normal to the bone surface and fracture plane. (b) Compression plate. A neutral screw (1) is placed first centrally, forming an axilla between the plate and the proximal fragment; a compression screw (2) is placed in the distal fragment in the distal aspect of the hole. (c) A bridge plate spanning the area of comminution. Fixation is performed away from the fracture to protect the biology. b. Screw order: neutral, compression, lag; strongest construct is lag screw through plate c. Absolute stability • Bridge plating a. Comminuted fractures, hypertrophic nonunion b. Relative stability c. Submuscular plating: respects fracture and soft tissue biology • Locked plating a. Fixed angle construct; absolute stability b. Short metaphyseal fractures, osteoporotic bone c. In hybrid plating of osteoporotic bone with both nonlocked and locked screws, biomechanically creating a stiffer construct requires placing at least three locked screws on each side of the fracture. If a locked screw is placed between the fracture and a nonlocked screw, the locked screw serves to protect the nonlocked screw (place a locked screw nearest to the fracture on each side). d. Locking plates do not provide buttress support when used in pure locking mode. • Intramedullary nails a. Relative stability b. Nail stiffness proportional to nail cross-sectional radius to the third power (r3) in bending and radius to the fourth power (r4) in torsion c. Radius of curvature: less than anatomic for improved interference fit ◦ Mismatch can induce fracture ◦ Larger radius of curvature risks breaching anterior cortex in femur fractures d. Nail with a larger radius of curvature is straighter than one with a smaller radius of curvature; therefore, it has less “bow” to it and it can breach the anterior cortex in a femur, for example. 1. Shoulder • Sternoclavicular (SC) dislocation a. Presentation: localized SC joint pain and swelling; in posterior dislocations can present with tachypnea, dysphagia, and stridor b. Associated injuries: compression of thoracic structures in 30% of posterior dislocations c. Imaging: X-ray demonstrates 40-degree cephalic tilt to evaluate direction of dislocation (serendipity view); axial CT typically required to identify vessel or tracheal compression ◦ Cephalic tilt of X-rays from medial to lateral: 40 degrees for SC (serendipity), 30 degrees for clavicle, and 10 degrees for acromioclavicular (AC) (Zanca view) d. Pathology: clavicle either anteriorly or posteriorly dislocated on sternum e. Treatment ◦ Conservative: anterior dislocations, though can attempt closed reduction; chronic dislocations (> 3 weeks old) and in ligamentously lax ◦ Surgical: posterior dislocations, closed or open reduction in operating room (OR) with thoracic surgeon available • Clavicle fractures a. Mechanism: fall onto upper extremity or direct injury to shoulder b. Associated injuries: rib fractures, rarely brachial plexus injury ◦ Open clavicle fractures are high-energy injuries and are associated with closed head injury, pulmonary injuries, or spine fractures. c. Imaging: AP and 30-degree cephalad oblique X-rays d. Classification by location: medial, middle (most common), distal third e. Treatment (middle clavicle fractures) ◦ Conservative: equivalent healing in sling versus figure-of-eight brace, higher incidence of contralateral nerve compression with figure-of-eight brace; closed treatment of displaced midshaft fracture leads to decreased (20%) strength and endurance, with higher nonunion rate ◦ Surgical: open fractures, vascular injury, skin compromise due to fracture displacement, 100% displaced middle third with comminution or > 2 cm shortening f. Outcomes: fixation of displaced clavicle fractures leads to decreased nonunion/malunion and has better functional outcomes up to 1 year compared with conservative treatment. Fig. 3.4 Distal clavicle fractures. (a) Type I: fracture between coracoclavicular (CC) and acromioclavicular (AC) ligaments, nondisplaced. (b) Type IIA: fracture proximal to CC ligaments, displaced. (c) Type IIB, fracture between conoid and trapezoid ligaments with torn conoid, displaced. (d) Type III, fracture extends into AC joint. g. Distal third clavicle fractures (Fig. 3.4) ◦ Type I: nondisplaced; between coracoclavicular (CC) and AC ligaments ◦ Type IIA: displaced; conoid and trapezoid attached to distal fragment; high rate of nonunion ◦ Type IIB: displaced; conoid torn, trapezoid attached to distal fragment; high rate of nonunion ◦ Type III: fracture extends into AC joint ◦ Treatment: indications similar to middle clavicle fractures; open, displaced, or extending into AC joint ◦ Outcomes: fixation leads to decreased nonunion/delayed union rates; however, nonunion may be clinically asymptomatic without effects on function. • Acromioclavicular (AC) dislocations a. Classified by displacement magnitude and direction, determined by involvement of CC and AC ligaments b. Types I-VI (Fig. 3.5) c. Imaging: X-ray, Zanca view (10 degrees cephalad, 50% penetrance) d. Treatment: ◦ Types I, II, and III AC dislocations treated conservatively ◦ Types I and II: sling ◦ Type III: sling is treatment of choice; some have suggested surgery in athletes and laborers (Weaver-Dunn) ◦ Types IV to VI: surgery • Scapula fractures a. Mechanism: high energy; fall from height, motor vehicle accident, motorcycle crash b. Associated injuries: polytrauma; head injury, hemo/pneumothorax, rib/sternum fracture, brachial plexus injury c. Imaging: anteroposterior (AP) chest X-ray, AP/lateral shoulder X-rays, computed tomography (CT), Stryker notch view (coracoid) d. Zdravkovic and Damholt anatomic fracture classification: ◦ Type I: body ◦ Type II: coracoid and acromion ◦ Type III: scapular neck and glenoid e. Treatment ◦ Nonoperative: isolated scapular body fracture and minimally displaced glenoid neck fractures; sling and early range of motion (ROM) Fig. 3.5 Acromioclavicular (AC) ligament complex injuries, type I to VI. Type I: AC sprain. Type II: AC tear, CC sprain. Type III: AC/CC tear, less than 100% superior displacement. Type IV: clavicle posterior, sometimes buttonholes trapezius. Type V: Clavicle displaced more than 100% superiorly. Type VI: Clavicle inferior, caught under conjoined tendon. Mnemonic: Four out the Trap Door (trapezius), High Five, Deep Six. ◦ Operative indications: humeral head instability, glenoid rim fracture involving > 25% articular surface, glenoid fossa fracture with > 3–5 mm displacement, significant anterior/medial displacement of glenoid neck (> 1 cm) or angulation > 40 degrees; some suggest injury to both scapula and clavicle (double disruption of superior shoulder suspensory complex) ◦ Treatment: fixation through posterior approach through interval between infraspinatus and teres minor; Judet approach elevates entire infraspinatus for sub-infraspinatus approach (Fig. 3.6) f. Complications: suprascapular nerve and artery, and circumflex scapular artery at risk during posterior approach • Scapulothoracic dissociation: lateral displacement of > 1 cm of scapula on AP chest X-ray compared with spinous process (can also use axial CT scan) a. High frequency of brachial plexus and vascular injury (subclavian) b. 10% mortality, 90% neurologic injury c. Management contingent on success of vascular repair d. Forequarter amputation in severe cases 2. Proximal humerus fracture • Mechanism: direct fall on upper extremity • Imaging: trauma shoulder series (X-rays: AP, axillary lateral, and scapular Y) • Neer classification (Fig. 3.7) a. One- to four-part fractures; separate parts defined by displacement—45- degree angulation or 1 cm displacement (5 mm for greater tuberosity) b. Parts: head, shaft, greater and lesser tuberosities • Treatment a. One-part fracture: none of the parts is displaced ◦ Treatment: sling and early ROM ◦ Age predicts outcome in conservative management of displaced fractures b. Two-part fracture: one part displaced ◦ Treatment: percutaneous pinning or open reduction and internal fixation (ORIF) c. Three-part fracture; two parts displaced ◦ Treatment: ORIF (young) or hemiarthroplasty or reverse total shoulder arthroplasty (elderly); good results with low avascular necrosis (AVN) rates in ORIF of valgus impacted fractures d. Four-part with or without head splitting fracture: three parts displaced ◦ Treatment: ORIF (young) or hemiarthroplasty or reverse total shoulder arthroplasty (elderly) ◦ In hemiarthroplasty, pectoralis major tendon insertion is the best landmark to assess prosthesis height and version; superior aspect of tendon is 5.6 cm distal to top of humeral head • Complications: a. Most common complication following ORIF is screw penetration of articular surface (15–30%) • Hemiarthroplasty or reverse total shoulder arthroplasty (elderly) is salvage procedure of choice; total shoulder arthroplasty (TSA) if glenoid damaged ◦ Decreased cut-out rate with use of inferomedial calcar screw b. Humeral head AVN ◦ Predictors of AVN: four-part fractures with disrupted medial hinge, angular displacement (> 45 degrees), tuberosity displacement > 10 mm, glenohumeral dislocation, head-split components ◦ Having 8 mm of the posterior medial calcar attached to the articular segment is a good prog nostic indicator for head vascularity (via posterior humeral circumflex artery). Fig. 3.6 The posterior muscles of the shoulder joint and arm. Muscles of the right shoulder and right arm from the posterior view after removal of the deltoid and forearm muscles. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.) c. Complications: axillary nerve, musculocutaneous nerve, cephalic vein at risk; axillary nerve at higher risk during anterolateral approach to the shoulder versus deltopectoral (usually emerges anteriorly 5 cm distal to lateral aspect of acromion) 3. Glenohumeral dislocation (also see Chapter 7) • Mechanism: direct/indirect trauma, seizures/electrocution (posterior dislocations) a. Anterior dislocation associated with rotator cuff tears in patients of ages > 40 years, and labral tears in patients of ages < 20 years • Posterior dislocations present with the inability to externally rotate the shoulder. • Imaging: shoulder trauma series (axillary lateral most revealing) • Treatment a. Conservative: closed reduction; sling, early ROM b. Surgical: irreducible dislocation; labral/capsular procedures for multiple dislocations, refractory instability (capsular shift in multidirectional instability), young overhead athlete Fig. 3.7 Four parts of proximal humerus in the Neer classification: A, head; B, greater tuberosity; C, lesser tuberosity; D, shaft. 4. Humeral shaft fracture • Treatment a. Conservative: accept 20-degree angulation in AP plane, 30-degree varus/valgus angulation, 3-cm shortening; treat in fracture brace or coaptation splint b. Surgical: open fractures, floating elbow, polytrauma, segmental fracture, articular extension, short transverse pattern in active individual (relative) ◦ ORIF: lower reoperation rate, no rotator cuff injury/shoulder impingement pain, allows immediate postoperative weight bearing ◦ Intramedullary nailing (IMN): for segmental or pathologic fracture, polytrauma patient ◦ No difference between ORIF and IMN in terms of infection, nonunion, or radial nerve issues • Complications: a. IMN distal interlocking screws: radial nerve injury with lateral to medial screw, musculocutaneous nerve injury with AP screw; shoulder pain b. Radial nerve palsy: most common with distal third spiral fracture (Holstein-Lewis lesions), 92% resolve with observation; following closed fracture or ORIF, wait 3 months before ordering electromyogram (EMG); exploration indicated for open fractures (transection more common) or after workup after 3 months of deficit; consider tendon transfers for the wrist and fingers if no improvement c. Atrophic nonunion: bone graft/compression plate 5. Distal humerus fracture • Single-column fractures (lateral or medial condyle) a. Conservative: immobilization in supination or pronation for nondisplaced fractures b. Surgical: ORIF for displaced fractures c. Complications: loss of motion (most common), cubitus valgus/varus, ulnar nerve injury d. Radial nerve crosses posterior to anterior roughly 10 cm proximal to radiocapitellar joint and at risk in this area; therefore, the region within 7.5 cm of the radiocapitellar joint is considered the “safe zone” for posterior approach to distal humerus Fig. 3.8 Jupiter classification of distal humerus fractures. • Two-column fractures a. Jupiter classification: describes common patterns of comminution (Fig. 3.8) b. Treatment: bicolumn plate fixation versus total elbow arthroplasty (TEA) for age > 65 years ◦ Low demand and elderly patients with comminuted distal humerus fracture, consider TEA, especially in setting of osteoporosis, steroid use, or rheumatoid arthritis (RA) c. Complications: ◦ Stiffness most common (treat with static progressive splinting), loss of strength, arthritis, ulnar nerve injury (transpose if in direct contact with metal hardware) 6. Olecranon fracture • Classification: by fracture orientation and comminution • Treatment a. Conservative: 1–2 mm displacement or with greater displacement in elderly/infirm patient; immobilization and early ROM b. Surgical ◦ Tension band: simple transverse fractures without comminution; anteriorly prominent Kirschner wires (K-wires) decreases forearm rotation, associated with anterior interosseous nerve (AIN) injury ◦ Plating: fractures involving coronoid, oblique, comminuted, or associated with dislocation ◦ Excision/triceps advancement for low demand, elderly patients (stability possible in up to 50–70% posterior articular surface excision if anterior structures intact) • Complications: symptomatic hardware 7. Coronoid fracture • Classification: types I-III (Fig. 3.9) a. Suggestive of elbow instability; shear injury of distal humerus against coronoid • Associated injuries a. Posteromedial rotatory instability; coronoid anteromedial facet fracture with lateral collateral ligament (LCL) injury from posteromedial rotation; secondary to varus force and leads to varus instability if not addressed b. Posterolateral rotatory instability; coronoid fracture with LCL injury and radial head fracture; leads to instability with supination and valgus stress if not addressed c. Terrible triad (see 9. Elbow dislocation, below) • Operative indications: must address in setting of elbow instability, or must address associated injuries until elbow stable • Treatment: suture lasso technique using suture to fix coronoid through bone tunnels through olecranon, ORIF • Complications: elbow instability, late degenerative change 8. Radial head fracture • Classification: Mason types I-IV (Fig. 3.10) • Associated injuries a. Essex-Lopresti injury-radial head fracture with disruption of the interosseous membrane; must examine wrist in setting of radial head fracture to rule it out; treatment with radial head resection leads to shortening of the radius, and distal radioulnar joint (DRUJ) injury/chronic wrist pain b. Posterolateral rotatory instability (see 7. Coronoid fracture, above) c. Terrible triad (see 9. Elbow dislocation, below) Fig. 3.9 Coronoid fracture classification. I: Tip of coronoid. II: Less than 50% of coronoid height. III: Greater than 50% of coronoid. Useful landmark: on a lateral film, the coronoid and olecranon are roughly the same height. Fig. 3.10 Mason classification of radial head fractures. Type I: Nondisplaced. Type II: Some displacement, articular involvement. Type III: Comminution involves entire head. Type IV: Associated dislocation. • Treatment: a. Type I- early ROM ◦ Minimally displaced fractures without block to motion should undergo immediate elbow range of motion as tolerated. b. Type II: early ROM unless mechanical block, in which case ORIF indicated c. Type III: ORIF or replacement; if > 3 fragments, replacement has better short-term outcomes than fixation (long-term outcomes still unknown) d. Type IV: ORIF or radial head replacement; head resection contraindicated, as dislocation implies marked ligamentous injury e. 25% of the radial head, defined as the 90-degree arc between the radial styloid and Lister’s tubercle, does not articulate with the ulna and is the “safe zone” for placement of fixation f. Kocher approach (anconeus/extensor carpi ulnaris [ECU]) to radial head: forearm held in pronation to protect posterior interosseous nerve (PIN) • Complications: stiffness, PIN injury (pronate to move nerve out of field), shortening (in excisions with Essex-Lopresti injury) 9. Elbow dislocation (Fig. 3.11) • Classification: by direction (posterolateral, posterior, anterior, medial, lateral, divergent) and presence/absence of fracture (complex versus simple) • Pathology: a. Primary stabilizers: joint articulation, lateral ulnar collateral ligament (LUCL), anterior band of medial collateral ligament (MCL) b. Secondary stabilizers: radial head, capsule, mobile wad and surrounding musculature c. Pattern of ligament failure from lateral to medial; only LUCL failure required for dislocation • Treatment a. Conservative: simple dislocation; brief immobilization (1–2 weeks), then ROM b. Surgical: complex; address fracture with ORIF Fig. 3.11 (a) The capsule and ligaments of the right elbow joint in extension. Anterior view with the ventral portions of the capsule removed. (b) The capsule and ligaments of the right elbow joint in 90 degrees flexion. Medial view. (c) The capsule and ligaments of the right elbow joint in 90 degrees flexion. Lateral view. (From Schuenke M, Schulte E. General Anatomy and the Musculoskeletal System: Thieme Atlas of Anatomy. New York: Thieme; 2005. Illustration by Karl Wesker.) c. Terrible triad: elbow dislocation, coronoid fracture (tip), radial head fracture ◦ Mechanism: valgus and supination force ◦ Treatment: surgical management with coronoid fixation, radial head replacement or fixation, and LUCL repair to humeral origin ♦ If elbow is unstable after above repairs, then must repair MCL ♦ If unstable after medial ligamentous repair, requires hinged external fixator to ensure elbow stability ♦ LUCL avulsion from humerus is most common mode of failure • Complications a. Stiffness (most common); posttraumatic arthritis b. Heterotopic ossification (HO): can resect after maturation; use prophylactic radiation in head-injured patients; Indocin may have some effect in prevention c. Neurovascular injury: brachial artery, ulnar/median nerve 10. Forearm fracture • Monteggia: proximal ulna fracture with radial head dislocation a. Classification: Bado (Fig. 3.12) b. Treatment: ORIF of ulna; radial head reduces when ulna fixed anatomically; if radiocapitellar joint nonconcentric, usually due to annular ligament interposition requiring open reduction of radial head c. Complications ◦ PIN injury: most resolve; observe ◦ Bado type II Monteggia fracture (posterior) has a higher nonunion rate and poorer outcomes compared with other Monteggia fractures. • Radius and ulna fracture ◦ Restoration of radial bow important for pronation/supination a. Treatment: ORIF with compression plating b. Complications: stiffness, loss of rotation (related to restoration of radial bow), nonunion, synostosis (higher with single incision approach), PIN injury ◦ Refracture risk after plate removal (12–18 months); highest with diaphyseal location of initial fracture; other risks are removal before 12 months, high initial comminution/displacement, and immediate full weight bearing • Ulna fracture (nightstick) a. Classification: stable if < 25–50% displacement, < 10- to 15-degree angulation; otherwise considered unstable b. Treatment ◦ Stable: reduce and cast ◦ Unstable: ORIF • Radial shaft fracture with DRUJ instability (Galeazzi) a. Treatment: ORIF fracture, assess DRUJ; if unstable, pin DRUJ in position of concentric reduction (usually supination) ◦ If irreducible, assess for muscle interposition (usually ECU); the closer the radius fracture is to DRUJ, the more likely it is unstable. Fig. 3.12 Bado classification of Monteggia fractures. Classified by direction of ulnar angulation/radial head dislocation. I: Anterior. II: Posterior. III: Lateral. IV: Associated proximal radius fracture. (Medial not possible as the ulna blocks the radial head.)
Trauma
I. General Trauma Principles
II. Upper Extremity
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