Introduction

Distal femur fractures are complex injuries. Their aetiology includes high-energy traumas in young patients, often combined with polytrauma or combined fractures (e.g. dashboard injury), and low-energy traumas usually in elderly patients associated with reduced bone quality.

Clinical assessment

• Check for pain, swelling, deformity, shortening and intra-articular effusion.

• Assess the neurovascular status of the leg and soft tissue damage of closed fractures.

• In case of diminished or absent pulse the ankle-brachial indices as well as a Doppler should be done early. In doubt, in case of side-to-side difference, or if a value of less than 0.9 occurs, an arteriogram is indicated.

• Open fractures: do not open dressings placed on the scene out of the operating room. Information about local wound findings requires a clear medical handover.

• Assess local injury severity with the Abbreviated Injury Scale (AIS) and the total severity of injuries with the Injury Severity Score (ISS).

• Check for previous surgery, especially total hip arthroplasty (THA) and total knee arthroplasty (TKA).

• Be aware of typically associated injuries: calcaneus, proximal tibia fracture, patella fracture, ligament ruptures of the knee (posterior cruciate ligament), femoral neck fracture, femoral head fracture, acetabulum fracture.

Introduction

Implants for patellar fractures have to resist high tensile stress. Tension band wiring transforms distraction forces of the extensor mechanism into compression forces. The wires provide anchorage of 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, Kirschner wires (K-wires) or cerclage wires is necessary.

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

Preoperative 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 such as abrasions are common and may require debridement or delayed operation, in order to reduce the risk of infection.

• Assess the neurovascular status of the leg.

Radiological assessment

• Analyse fracture geometry by standard anteroposterior and lateral x-rays, and tangential patellar view (Fig. 12.1.1).

• Diferentiate between fractures and growth abnormalities (e.g. 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 abnormal patella position by isolated quadriceps or patellar tendon ruptures. The Insall index calculates the ratio of greatest patella length to the distance between distal patellar pole and tibial tuberosity. Normal ratio = 1, ratio < 1 suggests patellar tendon rupture. If in doubt, compare with the lateral view of the contralateral side. Ultrasound reveals tendon rupture site and haematoma.

Indications

• The various existing classifications are inadequate to guide the treatment of these common injuries.

• Fractures with talar displacement.

• Almost all bimalleolar fractures.

Preoperative planning

Clinical assessment

• The mechanism of injury most commonly points to indirect rotational, translational and axial forces applied to the ankle joint.

• Soft tissue swelling, ecchymosis, tenderness.

• Look for associated osseous and/or soft tissue injuries.

• Assess the neurovascular integrity of the extremity.

• Obtain a careful patient history.

• Evaluate age, osteoporosis and systemic conditions.

• Smoking and diabetes are well known to adversely affect the operative management of ankle fractures.

Radiological assessment

• High-quality anteroposterior and lateral radiographs (Fig. 14.1.1a, b).

• Mortise view: AP in 20 degrees of internal rotation.

• CT scan: for evaluation of posterior malleolus. A CT scan is useful in abduction injuries when an injury to the talar dome is suspected.

• Assess degree of fragment displacement, quality of bone.

Timing of surgery

• In cases of an ankle subluxation, reduction is necessary in the emergency department (Fig. 14.1.1c, d).

• Dictated by the sot tissue condition.

• Before the development of sot tissue swelling or blisters.

• Delayed ORIF when sot tissue injury resolves. In these cases think about soft tissue resuscitation by means of a spanning external ixator to the ankle prior to the internal ixation.

Indications

• Non-displaced fractures of neck of femur (Garden grade I, II).

• Displaced fractures of the femoral neck in a physiologically/biologically young patient after adequate reduction has been obtained.

Preoperative planning

Clinical assessment

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

• The 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 femoral neck fractures are the result of high-energy trauma.

• Perform a complete medical examination in elderly patients.

Radiological assessment

• Anteroposterior and lateral radiographic views of the afected hip (Fig. 10.3.1).

• Anteroposterior radiograph of the pelvis.

• Evaluate head retroversion and posterior comminution.

• Assess the primary, secondary compression lines and the tension trabeculae on radiographs (Singh).

• Assess the ‘verticality’ of the fracture using the Pauwels classiication.

• An MRI or a CT is indicated when physical history and/or signs are suggestive of a fracture and this is not clear on the plain radiographs.

Indications

• Non-displaced and minimally displaced radial head fractures can be treated with a sling or splint followed by early motion exercises of the elbow to prevent stiffness.

• Partial (Mason type II) fractures of the radial head are amenable to operative fixation.

• Fractures involving the entire radial head (Mason type III or IV) are best treated with excision and eventually prosthetic replacement.

Clinical assessment

• Tenderness over the radial head.

• Assess and document neurovascular status.

• Careful examination of ligament stability, including the wrist and forearm, is mandatory to rule out elbow dislocations and Essex-Lopresti lesions.

Radiological assessment

• Plain radiographs taken in orthogonal planes with the addition of oblique views (Fig. 5.1.1).

• CT is helpful to assess the exact fracture geometry. In children or in unclear situations (e.g. previous injury), the contralateral side should be evaluated.

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.

Introduction

The practicalities of surgical management of proximal humeral fractures are common to the various injuries treated. A generic description of the investigations required and the 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 – anteroposterior 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 any tuberosity attachments remaining. A humeral head fragment with an attached tuberosity is much less likely to suffer avascular necrosis than one with no remaining tuberosity attachments. 3D CT is particularly useful for assessing glenoid fossa fractures.