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Over the years orthopaedic trauma has evolved to become an important subspecialty of orthopaedic surgery. An important component of the effective management of musculoskeletal injuries is the successful reconstruction of fractures. The art of surgery involves many steps, with ever-evolving techniques and implants.
Many textbooks are available for orthopaedic traumatologists. However, most of them are either handouts for scrub monkeys or advanced textbooks for experts. We have felt that the young orthopaedic surgeon on call is in need of an easy guide to help him or her set up a case until the attending surgeon is available. Moreover, standards for patient positioning are frequently absent and can be hard to understand unless they are well illustrated. Each chapter follows a comprehensive step-by-step approach which describes the hazards of surgery and gives technical tips in order to provide an overview of surgical procedures.
We do hope that this second edition has improved ontheirst, and that thebookwill continue tobeaworthy companion for the young surgeon on call.
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.
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.
This highly illustrated textbook is an essential guide for surgeons in training, providing step-by-step approaches to performing surgical procedures. Practical guidance is given on patient positioning, approach and reduction techniques, which implant to insert, protocols for postoperative mobilisation, possible complications, when the patient should be seen in the outpatient clinic, and whether the implant should be removed. This second edition has been extensively expanded and revised. Additional chapters address fractures of the scapula, fractures around the elbow, around the foot and minimal invasive plate osteosynthesis procedures. All of the other chapters have been expanded and revised to comprehensively cover the range of common trauma procedures performed by surgeons in training. Written by experts in orthopaedics and trauma, the book includes numerous intraoperative colour photographs to help readers visualise the techniques described. This will be an invaluable resource for all surgical trainees in orthopaedics, trauma, and general disciplines.
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.
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.
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.
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.