OPEN REDUCTION AND INTERNAL FIXATION: PLATING PILON

Indications

• Fractures with > 2 mm articular incongruity.

• Fractures with significant displacement of the metaphysis.

• Reconstructable fractures (joint fragments that are large enough to hold small fragment screws).

• Compartment syndrome.

• Adequate soft tissue envelope.

Pre-operative planning

Clinical assessment

• Mechanism of injury (fall from a height, skiing injury, motor vehicle accident, forward fall with a trapped foot).

• Look for associated injuries.

• Thoroughly assess the soft tissue condition.

• Look for the presence of an open injury.

• Assess the neurovascular status of the extremity.

• Look for early signs or symptoms of compartment syndrome.

• Review patient's past medical history and recognize the presence of existing medical conditions (diabetes, osteoporosis, vascular disease) that can modify the plan of treatment).

• Displaced or dislocated fractures must be reduced immediately.

Radiological assessment

• Standard high-quality anteroposterior (AP), lateral, 45° external rotation and mortise views of the ankle.

• CT scan: provides information regarding the fracture pattern, the number and location of the cortical fragments, the extent of articular comminution and the amount of articular displacement (Fig. 12.35a,b,c).

Timing of surgery

• Open fractures are treated on an emergency basis.

• Generally it is determined by the condition of the soft tissues.

• Simple fractures or fractures with minimal soft tissue injury can be definitively stabilized in 6–8 hours.

• For other types of fractures a 6–12 day delay is preferable.

• The use a joint bridging external fixator with elevation of the limb in the meantime is mandatory.

TENSION BAND WIRING

Implants for patellar fractures have to resist high-tensile stress. Tension band wiring transforms distraction forces of the extensor mechanism to compression forces. The wires provide anchorage for the tension band wire and neutralize the rotational forces.

Indications

• Transverse and multifragmental patellar fractures. In case of multifragmental fractures, often a combination of tension band wiring and cortical screws, lag screws, K-wires or cerclage wires is necessary.

• A pair of lag screws can exert high-compression forces to transverse fractures.

Pre-operative planning

Clinical assessment

• Pain, swelling, deformity, haemarthrosis, loss of function.

• Palpate gap between the fragments. Rule out an injury of the quadriceps and patellar tendon.

• Soft tissue injuries like abrasions arecommonandmay require debridement or delayed operation, in order to reduce the risk of infection.

• Assess neurovascular status of the leg.

Radiological assessment

• Analyse fracture geometryby standardanteroposterior (AP) and lateral X-rays, and a tangential patellar view (Fig. 11.1).

• Differentiate between fractures and growth abnormalities (e.g. a bipartite patella is typically found on the proximal lateral quadrant of the patella, usually with sclerotic edges of the fragment in contrast to fractures).

• Rule out an abnormal patellar position caused by isolatedquadriceps or patellartendonruptures.TheInsall index calculates the ratio of greatest patellar lengthand the distance between the distal patellar pole and the tibial tuberosity. Normal ratio = 1; a ratio < 1 suggests a patellar tendon rupture. If in doubt, compare with the lateral view of the contralateral side. Ultrasound reveals the tendon rupture site and haematoma.

KIRSCHNER WIRE FIXATION OF BASAL FRACTURES OF THE FIRST METACARPAL

Indications

Fractures of the base of the first metacarpal tend to dislocate owing to forces from the tendons (e.g. abductor pollicis longus (APL) tendon in Bennett's fracture). Therefore operative treatment is necessary if stable retention cannot be achieved by casting. Closed reduction and internal K-wire fixation can be performed for:

1. (a) Fractures with small fragments.

2. (b) Fractures with good alignment after closed reduction but no stable retention without fracture fixation, in the absence of large impression defects.

Pre-operative planning

Clinical assessment

• Pain and swelling localized to carpometacarpal joint I.

• Assess and document neurovascular status of thumb.

Radiological assessment

• Standard anteroposterior (AP) and lateral radiographs of the trapezium (Kapandji) obtained by placing the hand for a true lateral view, with abduction of the thumb and directing the imaging beam centred over the trapeziometacarpal joint.

• Computed tomography helps to define the degree of comminution within a fracture, as well as suspected impaction of the articular surface.

Operative treatment

Anaesthesia

• Brachial plexus block, intravenous regional anaesthesia or general anaesthesia.

• Prophylactic antibiotic according to the local hospital protocol (e.g. 2nd generation cephalosporin).

Table and equipment

• Hand surgery instrumentation set, K-wires: 1.2mm.

• Radiolucent armtable.

• Upper armtourniquet.

• Image intensifier.

Table set up

• The instrumentation is set up on the side of the operation.

• Image intensifier is from the front side of the arm table.

Patient positioning

• Supine, supinated armextended on armtable.

Fracture reduction

• Gentle axial traction and pressure on the displaced fragment usually reduces displaced fractures.

• Open anatomical reduction is indicated if closed reduction fails and/or stable reduction cannot be achieved.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF MIDSHAFT FRACTURES

Indications

1. (a) Open fractures.

2. (b) Painful non-union.

3. (c) Associated injury to the brachial plexus and/or subclavian artery.

4. (d) Floating shoulder.

5. (e) Bilateral fractures.

6. (f) Multiple-injured patient.

7. (g) Soft tissue interposition between the fragments.

8. (h) Impending skin necrosis or penetration from a prominent fragment.

Pre-operative planning

Clinical assessment

• Mechanism of injury: motor vehicle accident, sports injury, fall on outstretched hand, direct trauma.

• Deformity, ecchymosis, swelling, tenderness, crepitation.

• Look for pneumothorax or haemothorax, especially in presence of associated injuries.

• Assess and document vascular status of the upper arm and any difference in peripheral pulses between the injured and contralateral extremity.

• Assess neurological status (usually brachial plexus injury presents as an upper roots traction injury).

Radiological assessment

• Anteroposterior view of the clavicle, including sternoclavicular and acromioclavicular joints (Fig. 1.1).

• Oblique views.

• Lordotic view (usually after surgery for ORIF evaluation).

Operative treatment

Anaesthesia

• General anaesthesia at induction.

• Administration of prophylactic antibiotics as per local hospital protocol (usually second generation of cephalosporin is administered).

Table and equipment

• AO small fragment (3.5 mm) set.

• Ensure availability of the pre-planned plate length. A 3.5 DCP plate or a reconstruction plate can be used (Fig. 1.2a,b).

• Standard osteosynthesis set as per local hospital protocol.

Table set up

• The instrumentation is set up on the side of the operation.

• Image intensifier is from the ipsilateral side.

• Position the table diagonally across the operating room so that the operating area lies in the clean air field.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR DISTAL ULNAR FRACTURES

Indications

• Displaced isolated fractures of the distal ulna.

• Fractures of the distal ulna associated with distal radius fractures.

Pre-operative assessment

Clinical assessment

• High-energy fractures, often with an open wound over the ulnar fracture.

• Ensure the injury is in isolation and the arm remains neurovascularly intact.

• Specifically test for ulnar nerve impairment.

Radiological assessment

• Ensure adequate views are available.

• In complex fractures of the distal radius (Fig. 3.20) a CT scan may be helpful to delineate the injury and assist in reconstruction.

• Displaced fractures must be reduced with simple means to avoid complications but also to facilitate further imaging.

• Problems are often encountered related to the amount of fragmentationandthe quality of thebonein thehead of the ulna.

Operative treatment

Anaesthesia

• General anaesthetic is preferred. In acute injuries the use of regional blocks is discouraged as it may mask underlying pressure phenomena or compartment syndrome.

Operative equipment

• Use the mini-fragment set with 2.7mmscrews for fractures proximal to the distal radio-ulnar joint.Use a tension band for the most distal fractures.

• In associated fractures of the distal radius with shortening, the small external fixator is also used as a reduction aid.

Set up and positioning

• Hand table at 45°.

• Imager intensifier.

• Rolled up towel.

• Surgeon on the head side of the table (Fig. 3.21).

• Prescrub the limb.

• Antibiotic prophylaxis and tourniquet if there are no contraindications.

• Prepare the armto the elbow as occasionally it may be necessary to obtain a graft from the olecranon.