Indications

• Large/displaced fractures of the femoral head. Typically occurs in conjunction with hip dislocation.

• Operative treatment is offered in the majority of these fractures (those managed non-operatively are typically intrafoveal fractures – Pipkin 1, non-displaced fractures with congruent and stable joint without any interposed fragments).

• Excision of the fragments is appropriate when they are small and their fixation is deemed questionable intraoperatively.

• Those fractures classified as Pipkin IV (associated with acetabular fracture) are typically approached using the surgical approach during the ORIF of the acetabular fracture, as part of the same procedure (usually via a Kocher–Langenbeck posterior approach combined with a trochanteric osteotomy and surgical dislocation of the femoral head).

Clinical assessment

• Usually a result of high-energy trauma, so thorough assessment of the patient according to ATLS principles should precede any focus given to the femoral head injury itself.

• History related to the mechanism of injury, including the time that has elapsed since the accident.

• Dislocation of the hip joint is usually present at initial assessment unless spontaneous reduction has occurred. Closed hip reduction is usually attempted, and is successful in about 80% of the cases.

• Neurovascular assessment of the extremity should be performed and recorded before and after any intervention.

Indications

• Displaced intra-articular fractures with > 2 mm gap or step.

• Fractures with significant displacement of the metaphysis.

• Reconstructable fractures (joint fragments that are large enough to hold small-fragment screws). In cases where ORIF is not feasible an ankle fusion is an alternative option.

• Compartment syndrome.

Preoperative 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 existence of 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, lateral, 45 degrees external rotation and mortise views of the ankle (Fig. 13.6.1).

• The standard initial anteroposterior radiograph is very useful for the understanding of the mechanism of injury and the type of the deinitive surgical ixation to be implemented.

• CT scan (two- and three-dimensional): provides information regarding the fracture pattern, the number and location of the cortical fragments, the extent of articular comminution, the amount of articular displacement and the further planning of the surgical technique. The CT scan should be performed after the application of the ex-fix (Fig. 13.6.2).

Indications

• Unstable, displaced, irreducible extra-articular fractures (A3).

• Unstable, partial (B1, B2, B3) or complete (C2, C3) intra-articular fractures. The volarly displaced partial articular fracture (Barton's fracture) is a classic indication.

• Surgical fixation of distal radius fractures is recommended when post-reduction radiographs reveal more than 3 mm of radial shortening, 10 degrees of dorsal angulation and 2 mm of an intra-articular step or gap.

• Fractures requiring bone grafting, malunion and non-union procedures.

Preoperative planning

Clinical assessment

• Obtain a detailed history of the patient, including age, hand dominance, occupation and level of activity.

• Mechanism of injury: grading from low- to high-velocity trauma. Fall on outstretched hand (FOOSH) is the most common mechanism.

• Evaluate neurovascular status of the hand.

• Assess soft tissue damage.

• Typically deformity, swelling and tenderness are present.

• Check for associated ligamentous lesions and fractures of carpal bones.

Radiological assessment

• High-quality anteroposterior and lateral radiographs (Fig. 5.5.1).

• Oblique ilms (45 degrees, pronated and supinated).

• Assess degree of fragment displacement, quality of bone, whether the fracture is intra-articular or extra-articular, direction of displacement, metaphyseal comminution.

• The Fernandez classiication of distal radius injuries is particularly helpful because it takes into account the mechanism of injury (bending, shearing, compression, avulsion and combined mechanisms), estimates the stability of the injury, predicts the presence of associated injuries and guides treatment.

• CT scan is useful when the diagnosis is not clear in plain radiographs or when a more complex fracture pattern is present and consequently a more complex management plan needs to be formulated.

Indications

Halo devices are used in a variety of trauma settings, including:

• Reduction of cervical spine facet subluxations and dislocations (usually via axial traction applied through the halo).

• Stabilization of non-displaced cervical spine fractures.

• Post-reduction stabilization of cervical spine fractures, subluxations and dislocations.

• Temporary stabilization of a cervical spine injury, prior to definitive surgical treatment, or to facilitate safe transfer of the patient to a specialist spinal centre.

If the patient is physically able to mobilize, the halo can be attached to a ‘vest’. The vest may be a custom-made plaster or fibreglass orthosis, or one of the readily available ‘off-the-shelf’ devices. Several orthopaedic implant manufacturers market combinations of haloes and vest orthoses, in a range of sizes. The most useful halo and vest devices contain no ferrous components and are therefore MRI-compatible, permitting scanning of the patient after application.

Preoperative planning

• Most halo and halo–vest systems are available as pre-packed kits containing all of the necessary implants and tools for halo application and subsequent attachment of the halo to a detachable vest. A careful check of the manufacturer’s kit inventory against the kit components and instruments should be done in every case; do not assume that even a pre-packed kit will be complete! If the halo is to be used for ambulatory cervical spine stabilization a suitably sized orthosis (vest) is selected. Standard antiseptic skin preparation solutions should be available. If not supplied in the halo kit, a small pointed scalpel will also be needed.

• Measure head circumference using a tape measure and select the smallest possible halo size (Fig. 16.1.1).

• The halo selected should permit an air gap of approximately 10 mm between the inner aspect of the halo and the largest circumference of the skull, measured as shown in Fig. 16.1.2.

Indications

• Unstable pelvic fractures: AP-II, AP-III, LC-II, LC-III, vertical shear fractures and fractures with combined mechanism of injury according to the Young–Burgess classification. LC-I pelvic fractures with a complete sacral fracture or proven unstable after manipulation under anaesthesia.

• The anterior external fixation of the pelvis might be used as a part of the resuscitation process for the above injuries, or it can be used as the definitive fixation device to restore the normal biomechanics of the pelvic ring.

• When the anterior external fixator is used in the context of the damage control orthopaedics concept to temporarily stabilize the patient's haemodynamic condition, it can be exchanged to an internal fixation, depending on fracture configuration and the physiologic status of the patient. This usually takes place after the fourth or fifth day from the time of the injury.

Clinical assessment

• Check and document the neurovascular status of the lower extremities.

• Check the condition of soft tissues around the pelvis. Document any abrasion, ecchymosis/haematoma and degloving injuries. This might have an implication for the postoperative course of the patient.

• Pay special attention to inspection of the perineum area. Any open wound or indirect signs of injury of the urogenital system should be identified. Check the urethral meatus for blood, and in men perform a rectal digital examination to evaluate the position of the prostate.

• Check for pelvic asymmetry and leg-length discrepancy. When the latter is present it denotes either an ipsilateral fracture of the lower extremity or an ipsilateral vertical shear injury of the pelvis.

Indications

• Management of acute closed and open (types I, II, IIIa and IIIb according to Gustilo classification) tibial shaft fractures.

• Failed non-operative treatment of tibial shaft fractures.

• Late management of open tibial fractures or when the definitive care is implemented after the damage control orthopaedics concept in a polytraumatized patient, i.e. conversion of an external fixator to an intramedullary nail.

Clinical assessment

• History of the mechanism of injury. May be high-energy injury associated with considerable soft tissue damage.

• History of increasing disproportionate pain suggests compartment syndrome. Early detection and appropriate documentation of this condition is especially important, since intramedullary nailing of closed tibial fractures has been associated with increased incidence of compartment syndrome.

• Assess and document the neurovascular status of the leg.

• Complete physical examination.

• Careful examination for open wound (20–25% of patients). Obtain a photograph of the injured leg at presentation and keep it in the patient's records for future reference (medical and medicolegal issues). Assess the need for early involvement of a plastic surgeon in the management (act according to local protocols, and clearly document the management plan).