Indications

• Displaced (> 2 cm) fractures.

• Joint depression (usually > 3 cm).

• Open fractures.

• Fractures with neurovascular compromise.

• Fractures with concomitant compartment syndrome.

• Knee instability (valgus instability is an indication for surgery, but beware of the presence of pseudolaxity).

Preoperative planning

Clinical assessment

• In high-energy injuries, the patient should be initially evaluated and managed according to the ATLS protocol.

• The neurovascular status should be thoroughly evaluated and documented.

• Evaluate the leg compartments, for disproportionate pain in stretching, undue tension (compartment syndrome).

• Check for knee effusion (haemarthrosis).

• Evaluate the swelling of the proximal tibia. Repeat the examination at regular intervals.

• The stability of the knee is very difficult to assess preoperatively. Usually the knee is in valgus position.

Radiological assessment

• Anteroposterior, lateral and oblique views of the knee. Assess the degree of displacement and depression.

• The pure lateral tibial plateau fractures are classiied as Schatzker I (split), II (split–depression) or III (depression) (Fig. 13.1.1).

• A CT scan is the modality of choice for detecting occult fractures and for preoperative planning (Fig. 13.1.2). When a spanning external fixator is applied for sot tissue resuscitation or neurovascular repair, the CT scan follows the application of the ex-ix, which exerts ligamentotaxis and allows for better delineation of fracture lines and fragments.

• An MRI is not usually performed in pure lateral tibial plateau fractures.

Indications

• The indications for fixation of scapular fractures are not clearly defined. The literature is scant, outcome scores are variably used, and evidence-based choices are difficult. This is in large part due to the rarity of the injuries, as the scapula is well protected and supported by the rotator cuff muscles and other muscular attachments. Furthermore, these fractures most commonly occur in high-energy accidents and are therefore frequently associated with multiple injuries, particularly chest trauma, which may mitigate against intervention for a fracture that often gives few problems when managed non-operatively.

• There is some consensus that displaced fractures involving the glenoid fossa should be considered for fixation if they are associated with shoulder instability or if there is an articular step of 5 mm or more.

• The majority of fractures associated with instability are marginal fractures of the anteroinferior glenoid – bony Bankart lesions – which can be approached in the same way as soft tissue Bankart lesions, though usually fixation involves lag screws rather than soft tissue anchors. These injuries will not be considered further here.

• There is also consensus that combinations of injuries affecting the suspensory mechanism of the shoulder should be managed operatively, and one common pattern of these is a displaced fracture of the glenoid neck associated with a clavicle fracture (Fig. 2.1.1). However some argue that this ‘floating shoulder’ can be managed simply by plating the clavicle without addressing the glenoid neck. This remains one of the commoner indications for scapular surgery.

• Theoretically, medial displacement of the glenoid should defunction the rotator cuff, and it could be argued that these injuries should be treated to restore scapular width and cuff function. However, care should be taken to ensure that lateral displacement of the lateral column of the scapula, which is common, is not mistaken for medial displacement of the glenoid, which is rare.

Indications

• Displaced fractures of the ulnar shaft in adolescents/adults.

• Fractures of the ulnar shaft with fracture and dislocation of the proximal radius/radial head (Monteggia fractures).

• Fractures of both forearm bones.

Clinical assessment

• Define mechanism of injury: high or low-energy trauma, isolated or complex trauma, direct trauma, nightstick type of injury, axial compression, Monteggia fractures, or expression of combined forces.

• Exclude open wounds: assess extremity without the presence of any splint or dressing. If any, record location and size of the wound (clinical photograph should be taken), cover with moist dressing, immediately initiate broad-spectrum intravenous antibiotics and tetanus prophylaxis, follow local clinical pathway of open fractures.

• Initial and follow-up observations of the neurovascular status and signs of compartment syndrome.

• Adequate examination of the adjacent joints (elbow and wrist) for associated trauma or previous pathologies.

• Exclude occult injuries of the rest of the extremity, especially of the carpus and/or hand. Note history of previous trauma or surgery of the extremity.

Indications

Sliding compression hip screw devices are used to stabilize:

• Stable intertrochanteric hip fractures (Fig. 10.1.1).

• Rotationally unstable, comminuted and vertical (Pauwels type 3) intracapsular fractures of neck of femur.

Preoperative planning

Clinical assessment

• Pain localized in the affected hip side – radiation of pain to the knee.

• Limb is shortened and externally rotated.

• Assess and document the neurovascular status of the leg.

• In young patients careful examination for other injuries must be made, as these fractures are a result of high-energy trauma.

• A complete medical examination in elderly patients.

Radiological assessment

• Anteroposterior radiograph and a lateral view of the afected hip to demonstrate the fracture geometry.

• Anteroposterior radiograph of the pelvis to estimate the contralateral ‘normal’ neck-shat angle.

Preoperative consent

• Obtain informed consent from the patient, including but not limited to risks, beneits, alternatives, complications and potential outcome.

Operative treatment

• The World Health Organization (WHO) Surgical Safety Checklist should be used in the operating room.

Indications

• Posterior wall fractures.

• Posterior column fractures.

• Posterior column and wall fractures.

• Transverse fractures.

• Transverse posterior wall and T-shaped fractures.

Indications for emergency acetabular fracture fixation

• Recurrent hip dislocation after reduction despite traction, progressive sciatic nerve deficit after closed reduction, irreducible hip dislocation, associated vascular injury requiring repair, open fractures.

Indications for acetabular fixation

• Incongruent hip joint due to incarcerated fracture fragments (Fig. 9.1.1).

• Ipsilateral femoral neck fractures.

• Marginal impaction of the posterior wall.

• Be aware that the roof-angle measurement criteria used as indications for fracture fixation in acetabulum fractures do not apply in the setting of pure posterior wall fractures.

• Involvement of more than half of the posterior wall as defined on the CT scan ater comparison with the contralateral side.

• When less than half of the posterior wall surface is involved, testing of the stability of the hip is recommended to deine unstable hips that merit surgical ixation.

Preoperative planning

Clinical assessment

• Examination of the injured limb is essential, including the sot tissue envelope. Be aware of the Morel–Lavallée degloving injury of the posterior sot tissue envelope, which has a high rate of Staphylococcus epidermidis colonization with subsequent increased risk for infection.

• In cases of high-energy trauma, examination for other potential associated injuries should be performed carefully.

• The ATLS evaluation protocol should be followed.

Indications

The distal ulna acts as the fulcrum for the distal radius during forearm rotation and is therefore vital for positioning the hand. Injuries in this region potentially destabilize the distal radioulnar joint (DRUJ) and are frequently seen in association with distal radial fractures. Indications for surgical intervention in such injuries include:

• Open injuries.

• Unstable fractures, particularly where the radius is also fractured.

• Displaced articular injuries involving the DRUJ or the ulnocarpal joint.

• Fractures with associated DRUJ instability.

The last of these are probably the most difficult to assess. DRUJ instability is a common cause of pain and limited range of motion following distal forearm injury. The triangular fibrocartilage complex (TFCC) is a primary stabilizer of the DRUJ, inserting within a fovea at the base of the ulnar styloid. Styloid tip fractures are seldom associated with instability and probably represent capsular avulsions rather than ligamentous injuries. In this situation other causes of instability should be sought, including malreduction of a radial fracture and ligamentous injury. Anatomic reduction of radial fractures frequently restores anatomic relationships at the DRUJ, re-tensioning the remaining ligaments and restoring stability even in the presence of ulnar styloid base fractures. Evidence suggests that fixation of ulnar styloid base fractures is only indicated where DRUJ instability persists following anatomic reduction and stabilization of radial injuries (Fig. 4.9.1).