OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF MIDSHAFT FRACTURES OF THE METACARPALS

Indications

Screw and plate fixation is used to stabilize:

1. (a) Fractures of 2 or more metacarpal bones.

2. (b) Fractures irreducible by closed reduction.

3. (c) Open/comminuted fractures.

4. (d) Fractures with rotational mal-alignment.

5. (e) Angulation of more than 30?.

6. (f) Fractures if early mobilization is required.

Pre-operative planning

Clinical assessment

• Pain and swelling localized over the metacarpus.

• Assess and document neurovascular status of hand.

• Assess and document rotational alignment, axis and range of movement (ROM) of fingers.

Radiological assessment

• Anteroposterior, lateral, and oblique views (Fig. 6.6).

• A30° pronated lateral view for 2nd and 3rd metacarpal fractures and 30? supinated lateral view for 4th and 5th metacarpal fractures are helpful.

Anaesthesia

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

• At induction, administer prophylactic antibiotic as per local hospital protocol (e.g. 2nd generation cephalosporin).

Table and equipment

• Hand surgery instrumentation set.

• Hand small-fragment implant system.

• A radiolucent armtable.

• An upper armtourniquet.

• An image intensifier.

Table set up

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

• Image intensifier is fromthe front side of the armtable.

• Check for adequate visualization in 2 planes prior to draping.

Patient positioning

• Supine, supinated armextended on armtable.

OPEN REDUCTION AND INTERNAL FIXATION OF RADIAL HEAD FRACTURES

Indications

• Open reduction and internal fixation (ORIF) for radial head fractures is used to stabilize displaced radial head fractures (Mason Type II) (Table 4.1).

• Non-displaced fractures (Mason Type I) are managed with early motion. To facilitate immediate motion aspiration of the joint fluid (haematoma) is recommended. Comminutedanddisplaced fractures(Mason Type III and IV) are best treated with complete early excision.

Pre-operative planning

Clinical assessment

• Pain localized in the affected elbow.

• Obliterated contour of the skin in the intracondylar recess (‘soft spot’).

• Assess and document neurovascular status of the arm.

• Careful examination of ligament stability is mandatory.

Radiological assessment

• Anteroposterior (AP) radiograph, a lateral view and a radial head view of the affected elbow (Fig. 4.1). A CT scan is helpful to demonstrate the exact fracture geometry. In children or in unclear situations (e.g. previous injury) the contralateral side should be evaluated.

Operative treatment

Anaesthesia

• Regional and/or general anaesthesia.

• At induction, administer prophylactic antibiotics according to local hospital protocol (e.g. 3rd generation cephalosporin).

Table and equipment

• Small-fragment instrumentation set or Herbert screw set - ensure the availability of the complete set of small compression screws.

• Radiolucent armtable.

• Image intensifier. Check for adequate visualization in 2 planes prior to draping.

Table set up

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

• Image intensifier is fromthe front side of the armtable.

TENSION BAND WIRING OF OLECRANON FRACTURES

Indications

• Displaced transverse fractureof the olecranonwithdisruption of the extensor mechanism.

• The technique can be used with caution in oblique or fragmented fractures once issues related to these fracture patterns are addressed.

Pre-operative planning

Clinical assessment

• Mechanism of injury: forced extension usually following a fall. Beware of the high-energy fracture patterns that may suggest that the fracture is only a portion of the injury.

• Findings: pain, swelling and occasionally impressive ecchymosis over the elbow region. Beware of injury to the soft tissue envelope that may interfere or preclude surgical intervention.

• Findings: loss of active extension associated with displaced fractures. Beware of examination pitfall where passive gravity-assisted extension leads to the assumption of an intact extensor mechanism.

• Findings: check for ulnar nerve impairmentandensure the injury is in isolation.

Radiological assessment

• Anteroposterior and lateral radiographs of the elbow are the absolute minimum imaging requirement. Beware of more complex injuries that may need further imaging, most commonly in the formof a CT scan (Fig. 3.1).

Operative treatment

Anaesthesia

• Regional/general.

• Pre-operative administration of antibiotics (cephalosporin).

• Prescrub and drying of the limb.

• Tourniquet application, if there are no contraindications. Ensure the tourniquet does not interfere with the operative field and that no preparation solution leaks underneath. Inflate the tourniquet once the limb has been elevated for approximately 3 minutes.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR BIMALLEOLAR ANKLE FRACTURES

Indications

• None of the existing classifications is adequate alone to dictate the treatment strategy.

• Fractures with talar displacement.

• Almost all bimalleolar fractures.

Pre-operative planning

Clinical assessment

• Mechanism of injury: direct or, more commonly, by indirect rotational, translational and axial forces.

• Soft tissue swelling, ecchymosis, tenderness.

• Look for associated injuries.

• Assess neurovascular integrity of the extremity.

• Obtain a careful patient history.

• Evaluate age, osteoporosis and systemic conditions.

Radiological assessment

• High-quality anteroposterior (AP) and lateral radiographs (Fig. 13.1a,b).

• Mortise view: AP in 20° internal rotation.

• CT scan: for evaluation of posterior malleolus.

• Assess: degree of fragment displacement, quality of bone.

Timing of surgery

• Dictated by the soft tissue condition.

• Before the development of soft tissue swelling or blisters.

• Delayed ORIF when soft tissue injury resolves.

Operative treatment

Anaesthesia

• Spinal or general anaesthesia.

• Prophylactic antibiotics as per local hospital protocol.

• Application of a pneumatic tourniquet to the upper thigh.

Table and equipment

• AO small fragment set.

• 3.5 mm cortical and 4.0 cancellous screws.

• Standard osteosynthesis set as per local hospital protocol.

• A radiolucent table.

• An image intensifier and a competent radiographer.

Table set up

• The instrumentation set is at the foot end of the table.

• Image intensifier is from the contralateral side.

CANNULATED SCREW FIXATION

Indications

• Undisplaced fractures of neck of femur (Garden Grade I, II).

• Displaced fractures in patients with adequate bone density and no severe chronic illness (rheumatoid arthritis, renal failure).

• Active individuals up to mid 70s.

Pre-operative planning

Clinical assessment

• Groin pain localized in the affected hip site – radiation of pain to the knee.

• Limb is shortened and externally rotated.

• Assess and document neurovascular status of the leg.

• In young patients carefulexaminationforotherinjuries must be made, as they are a result of high-energy trauma.

• A complete medical examination in elderly patients.

Radiological assessment

• Anteroposterior radiograph and a lateral view of the affected hip (Fig. 9.16a,b).

• Evaluate head retroversion and posterior comminution.

• Assess primary and secondary compression and tension trabeculae on radiographs.

• CT or bone scans when physical signs are lacking.

Timing of surgery

• The outcome is improved if the surgery is performed within 8 hours.

• For young patients it is a true orthopaedic emergency.

Operative treatment

Anaesthesia

• Regional (spinal/epidural)and/orgeneral anaesthesia.

• At induction, administer prophylactic antibiotic as per local hospital protocol.

Table and equipment

• Use a 7.0 or 7.3 cannulated screw set – ensure the availability of the complete set of implants.

• A radiolucent table or a fracture table with the appropriate traction devices.

• An image intensifier.

INTRAMEDULLARY FIXATION FOR SUBTROCHANTERIC FRACTURES USING A PROXIMAL FEMORAL NAIL (PFN)

Indications

• Low and extended subtrochanteric fractures.

• Ipsilateral femoral neck and shaft fractures.

• Unstable inter-trochanteric fractures.

• Failed plate fixation of subtrochanteric fractures.

• Pathological fractures.

Pre-operative planning

Clinical assessment

• Obtain a thorough patient's history (mechanism of injury, past medical records).

• Mechanism of injury: as a result of low-energy trauma in patients with osteoporotic bones (watch for underlying pathology).

• High-energy trauma: motor vehicle accidents, falls from a height, gunshot injuries.

• In polytrauma patients the Advanced Trauma Life support (ATLS) protocol must be followed.

• Look for associated injuries, especially in polytrauma patients.

• The extremity is shortened, the thigh is swollen and there is a prominence of the proximal fragment.

• Neurologic and vascular injuries are uncommon; however, neurovascular assessment is mandatory.

• Although rare, be alert for signs of compartment syndrome.

Radiological assessment

• High-quality anteroposterior (AP) and lateral radiographs of the femur including the knee, the femoral neck and head (Fig. 10.1a,b).

• Anteroposterior radiograph of the pelvis.

• Look for extension of the fracture into the greater trochanter and piriformis fossa.

• Contralateral radiographs of the unaffected femur are useful in assessing the width of the medullary canal, the shaft-neck angle and for the determination of the nail's length.

Operative treatment

Anaesthesia

• Spinal or general anaesthesia.

• Prophylactic antibiotic as per local hospital protocol.

Table and equipment

• PFN set (Fig. 10.2).

• Standard osteosynthesis set as per local hospital protocol.

• An image intensifier.

GENERAL CONSIDERATIONS

The practicalities of surgical management of proximal humeral fractures are common to the various injuries treated. A generic description of the investigations required and practical set-up of the operating room will therefore be presented before discussing specific injuries.

Radiological assessment

• It is essential that all shoulder fractures be assessed with a minimum of two shoulder views – the anteroposterior (AP) and axial views.

• A scapular lateral completes the trauma series but is not always essential.

• The axial view can be obtained successfully in most cases – in the rare instances where the patient will not permit sufficient movement of the injured limb away from the side, angled views (modified axial) should be obtained. Never miss a dislocation (too many are missed, and most of these have not had an axial view taken).

• In complex cases a CT scan might assist, particularly in assessing whether the humeral head is intact and has anytuberosityattachmentsremaining.Ahumeralhead fragmentwithanattached tuberosity ismuchless likely to suffer avascular necrosis thanonewithnoremaining tuberosity attachments. Three-dimensional CT is particularly useful for assessing glenoid fossa fractures.

Anaesthesia

• General anaesthesia or scalene blocks can be used. Even if general anaesthesia is selected, a scalene block can add useful analgesia.

• The risk of phrenic nerve palsy and pneumothorax should be considered if a scalene block is to be used, particularly if there is already chest trauma (which not infrequently accompanies shoulder trauma).

• Great care has to be taken to avoid interference with anaesthetic tubes and pipes by the surgeon or assistant in general anaesthetic cases.

OPEN REDUCTION AND INTERNAL SCREW FIXATION FOR TALAR NECK FRACTURES

Indications

• Open reduction and internal screw fixation (ORIF) is used to stabilize a displaced talar neck fracture (Fig. 14.1).

Pre-operative planning

Clinical assessment

• Swelling, neurovascular status, stability.

• Be aware of compartment syndrome (see below). If suspicion for compartment syndrome exists, pressure measurement should be performed (for example with the IntracompartmentalPermanentPressureMonitoring System, StrykerTM Corporation, Santa Clara, CA, USA). Fasciotomy is indicated, if there is a difference of less than 30mmHg between diastolic blood pressure and compartment pressure.

• Be aware of associated fractures in the adjacent foot and ankle (Fig. 14.1a,b).

Radiological assessment

Three standard views:

• Mortise view of the ankle (20° internal rotation).

• True lateral ankle view.

• Anteroposterior (AP) view of the talar neck and head (15° internal foot rotation, 15° caudo-cranial X-ray angle); Canale view.

• CT Scan.

Classification

• Talar neck fractures are classifed according toHawkins, and Canale and Kelly (who added Type IV, Fig. 14.2).

Operative treatment

Anaesthesia

• Regional (spinal/epidural/popliteal) or general anaesthesia.

• Prophylactic antibiotics as per local hospital protocol (e.g. 3rd generation cephalosporin).

Table and equipment

1. 3.5 mm standard cortical and cancellous screws, steel or titanium alloy.

2. Standard osteosynthesis set as per local hospital protocol.

3. A radiolucent table.

4. An image intensifier and a competent radiographer.

Table set up

• The instrumentation set is at the foot end of the table.

• Image intensifier is from the contralateral side.