To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
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.
Knee instability (valgus instability is an indication for surgery, but beware of the presence of pseudolaxity).
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.
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 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.
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.
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).
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.
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.
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.
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).
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.
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.
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.
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.
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.