Jeremy A. Hall

Distal humeral fractures in adults.

Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intra-articular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach.

Posterolateral rotatory instability of the elbow following radial head resection.

BACKGROUND Resection is a common procedure for the treatment of comminuted fractures of the radial head. While radial head resection is associated with a high success rate when performed for appropriate indications, a number of well-defined biomechanical complications have been reported following this procedure, including proximal migration of the radius, the development of valgus deformity, and recurrent elbow instability in the acute setting. However, posterolateral rotatory instability has not previously been recognized as a complication of radial head resection. While the absence of the radial head makes the diagnosis difficult, we have identified a series of patients with posterolateral rotatory instability following radial head resection. We believe that this instability is secondary to unrecognized lateral ulnar collateral ligament deficiency. METHODS Between November 1995 and September 2000, forty-two patients were evaluated because of elbow or forearm complaints following radial head resection. Seven patients (17%) were diagnosed with posterolateral rotatory instability on the basis of characteristic clinical and radiographic findings. RESULTS The study group included five men and two women with a mean age of forty-two years. All seven patients had had radial head excision for the treatment of a comminuted radial head fracture at a mean of forty-four months (range, four months to sixteen years) prior to referral. All seven patients had lateral elbow pain, a sense of instability and/or weakness, and a positive lateral pivot-shift test. Posterolateral rotatory instability secondary to lateral ulnar collateral ligament insufficiency was confirmed intraoperatively in the four patients who were managed surgically. CONCLUSIONS Clinicians should be aware that posterolateral rotatory instability may be a cause of unexplained elbow pain and instability following radial head resection. This diagnosis has implications for the prevention and treatment of this condition.

Open Reduction and Internal Fixation Compared with Circular Fixator Application for Bicondylar Tibial Plateau Fractures

BACKGROUND Standard open reduction and internal fixation techniques have been successful in restoring osseous alignment for bicondylar tibial plateau fractures; however, surgical morbidity, especially soft-tissue infection and wound necrosis, has been reported frequently. For this reason, several investigators have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach. To our knowledge, there has been no direct comparison of the two operative approaches. METHODS We performed a multicenter, prospective, randomized clinical trial in which standard open reduction and internal fixation with medial and lateral plates was compared with percutaneous and/or limited open fixation and application of a circular fixator for displaced bicondylar tibial plateau fractures (Schatzker types V and VI and Orthopaedic Trauma Association types C1, C2, and C3). Eighty-three fractures in eighty-two patients were randomized to operative treatment (forty-three fractures were randomized to circular external fixation and forty to open reduction and internal fixation). Follow-up consisted of obtaining a history, physical examination, and radiographs; completion of the Hospital for Special Surgery (HSS) knee score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) General Health Survey; and recording of complication and reoperation rates. RESULTS There were no significant differences between the groups in terms of demographic variables, mechanism of injury, or fracture severity and/or displacement. However, patients in the circular fixator group had less intraoperative blood loss than those in the open reduction and internal fixation group (213 mL and 544 mL, respectively; p = 0.006) and spent less time in the hospital (9.9 days and 23.4 days, respectively; p = 0.024). The quality of osseous reduction was similar in the groups. There was a trend for patients in the circular fixator group to have superior early outcome in terms of HSS scores at six months (p = 0.064) and the ability to return to preinjury activities at six months (p = 0.031) and twelve months (p = 0.024). These outcomes were not significantly different at two years. There was no difference in total arc of knee motion, and the WOMAC scores at two years after the injury were not significantly different between the groups with regard to the pain (p = 0.923), stiffness (p = 0.604), or function (p = 0.827) categories. The SF-36 scores at two years after the injury were significantly decreased compared with the controls for both groups (p = 0.001 for the circular fixator group and p = 0.014 for the open reduction and internal fixation group), although there was less impairment in the circular fixator group in the bodily pain category (a score of 46) compared with the open reduction and internal fixation group (a score of 35) (p = 0.041). Seven (18%) of the forty patients in the open reduction and internal fixation group had a deep infection. The number of unplanned repeat surgical interventions, and their severity, was greater in the open reduction and internal fixation group (thirty-seven procedures) compared with the circular fixator group (sixteen procedures) (p = 0.001). CONCLUSIONS Both techniques provide a satisfactory quality of fracture reduction. Because percutaneous reduction and application of a circular fixator results in a shorter hospital stay, a marginally faster return of function, and similar clinical outcomes and because the number and severity of complications is much higher with open reduction and internal fixation, we believe that circular external fixation is an attractive option for these difficult-to-treat fractures. Regardless of treatment method, patients with this injury have substantial residual limb-specific and general health deficits at two years of follow-up.

Systematic review of the treatment of periprosthetic distal femur fractures.

Objectives: To systematically review and compare nonoperative and operative treatments for the management of periprosthetic distal femur fractures adjacent to total knee arthroplasties. Specific operative interventions compared included locked plating, retrograde intramedullary nailing (RIMN), and conventional (nonlocked) plating. Where possible, data were pooled to arrive at summary estimates of treatment effect [odds ratios (ORs) with associated 95% confidence intervals (CIs)]. Methods: A comprehensive database search (via Pubmed, Medline, Cochrane Database, and the Orthopaedic Trauma Association database) was completed, yielding 44 eligible studies with a total of 719 fractures for analysis. Pertinent outcomes including malunion, nonunion, and the need for secondary surgical procedures were compared statistically. Results: Both locked plating and RIMN demonstrated significant advantages over nonoperative treatment. Some advantages were also observed when locked plating and RIMN were compared with conventional (nonlocked) plates. Comparison of locked plating and RIMN showed no significant differences with regard to nonunion rates (OR = 0.39, 95% CI = 0.13–1.15; P = 0.09) or rate of secondary surgical procedures (OR = 0.65, 95% CI = 0.31–1.35; P = 0.25). However, RIMN demonstrated a significantly higher malunion rate when compared with locked plating (OR = 2.37, 95% CI = 1.17–4.81; P = 0.02). Conclusions: Locked plating and RIMN offer significant advantages over nonoperative treatment and conventional (nonlocked) plating techniques in the management of periprosthetic femur fractures above total knee arthroplasties. Locked plating demonstrated a trend toward increased nonunion rates when compared with RIMN. Malunion was significantly higher with RIMN compared with locked plating.

Total Hip Arthroplasty After Acetabular Fracture Is Associated With Lower Survivorship and More Complications.

BackgroundDespite modern fracture management techniques allowing for near anatomic reduction of acetabular fractures, there continues to be a risk of posttraumatic arthritis and need for total hip arthroplasty (THA). Few well-controlled studies have compared THA after acetabular fractures with THAs performed for other indications in terms of survivorship or complications, and none, to our knowledge, present 10-year survivorship data in this setting.Questions/purposes(1) How does the 10-year survival of THA compare between those patients who underwent THA after an acetabular fracture and those who underwent THA for primary arthritis or avascular necrosis (AVN)? (2) Is there an increased risk of serious complications like infection, dislocation, and aseptic loosening as well as heterotopic ossification associated with a THA performed after a previous acetabular fracture?MethodsThis retrospective case-control study compared findings of patients who underwent THA after acetabular fracture versus a matched cohort of patients who had received a primary THA for primary osteoarthritis or AVN. Between 1987 and 2011, we performed 95 THAs after acetabular fracture; of those, 74 (78%) met inclusion criteria and had documented followup beyond 2 years in our institutional registry. We selected 74 matched patients based on an algorithm that matched patients based on preoperative diagnosis, date of operation, age, gender, and type of prosthesis. During this time, we performed approximately 8000 THAs that were potentially available for matching based on complete followup beyond 2 years. We compared cases and control subjects using the Kaplan-Meier survivorship estimator as well as a comparison of the proportions in each group that developed major complications (including infection, dislocation, loosening, and heterotopic ossification) based a retrospective chart review.ResultsThe 10-year survivorship after THA was lower in patients with a previous acetabular fracture than in the matched cohort (70%, 95% confidence interval [CI], 64%–78%, versus 90%, 95% CI, 86–95%; p < 0.001). There was no difference in the 10-year survival rate for those patients whose acetabular fracture was initially treated conservatively and those treated by open reduction and internal fixation. Patients with previous acetabular fracture had a higher likelihood of developing infection (7% [five of 74] versus 0% [zero of 74]; odds ratio [OR], 11.79; p = 0.028), dislocation (11% [eight of 74] versus 3% [two of 74]; OR, 4.36; p = 0.048), or heterotopic ossification (43% [32 of 74] versus 16% [12 of 74]; OR, 3.93; p < 0.001).ConclusionsIn this case-control study, patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary osteoarthritis or AVN. Given these findings, management of these complex cases should be in highly specialized units where the expertise of arthroplasty and trauma reconstruction is available.Level of EvidenceLevel III, therapeutic study.

The radiographic quantification of scapular malalignment after malunion of displaced clavicular shaft fractures

BACKGROUND Malunion after displaced fractures of the clavicle can result in varying degrees of scapular malalignment and potentially scapular winging. The purpose of our study was to quantify the scapular malalignment in patients with midshaft clavicle malunions showing scapular winging. METHODS Eighteen patients with symptomatic midshaft clavicle malunions showing scapular winging were identified and underwent standardized computed tomography scanning of the thorax. Specific bony landmarks on the clavicle and scapula were digitized, allowing generation of 3-dimensional points. These points were acquired bilaterally so that relative translations comparing the malunited side with the contralateral side could be obtained. Statistical analysis using a paired t test was performed. RESULTS The mean time from fracture to examination was 42.9 months. There were 15 men and 3 women with a mean age of 41.6 years. The mean clavicular shortening was 21.1 mm (P = .0000004). The acromion of the affected scapula on average translated 24.3 mm. The components of this translation were medial, 11.9 mm (P = .00008); inferior, 20.7 mm (P = .0009); and anterior, 4.6 mm (P = .02). Posterior bony landmarks on the scapula including the superior and inferior angles of the scapula translated a total of 9.9 mm and 5.9 mm, respectively. CONCLUSION This is the first study to document the degree of scapular malalignment in patients with symptomatic clavicle malunions showing scapular winging. The acromion closely follows the distal clavicular fragment and translates medially, inferiorly, and anteriorly. The translations of the superior and inferior angles of the scapula are quite variable in magnitude and direction, and on average, these angles translate substantially less than the acromion.

Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial.

Objectives: The aim of this study was to compare early weightbearing and range of motion (ROM) to nonweightbearing and immobilization in a cast after surgical fixation of unstable ankle fractures. Design: Multicentre randomized controlled trial. Setting: Two-level one trauma centers. Patients: One hundred ten patients who underwent open reduction and internal fixation of an unstable ankle fracture were recruited and randomized. Intervention: One of 2 rehabilitation protocols: (1) Early weightbearing (weightbearing and ROM at 2 weeks, Early WB) or (2) Late weightbearing (nonweightbearing and cast immobilization for 6 weeks, Late WB). Main Outcome Measurements: The primary outcome measure was time to return to work (RTW). Secondary outcome measures included: ankle ROM, SF-36 heath outcome scores, Olerud/Molander ankle function score, and rates of complications. Results: There was no difference in RTW. At 6 weeks postoperatively, patients in the Early WB group had significantly improved ankle ROM (41 vs. 29, P < 0.0001); Olerud/Molander ankle function scores (45 vs. 32, P = 0.0007), and SF-36 scores on both the physical (51 vs. 42, P = 0.008) and mental (66 vs. 54, P = 0.0008) components. There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the Late WB group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%, P = 0.005). Conclusions: Given the convenience for the patient, early improved functional outcome, and the lack of an increased complication rate, we recommend early postoperative weightbearing and ROM in patients with surgically treated ankle fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Total Elbow Arthroplasty for Intra-articular Fractures of the Distal Humerus

Summary: Although open reduction and internal fixation is the treatment of choice for most intra‐articular distal humeral fractures, this technique can be challenging in certain patients. Severe osteopenia, intra‐articular fracture comminution, and preexisting degeneration are conditions of the elbow that can complicate attempts at fixation in the elderly patient. Total elbow arthroplasty (TEA) as a treatment method for such fractures has several theoretical advantages, and some recent evidence indicates it may be an ideal solution for some patients. Technical simplicity, decreased operative time, lower complication rate, and easier, quicker rehabilitation are all features that make TEA an attractive option. The authors discuss the indications, contraindications, and technique of semiconstrained total elbow arthroplasty for intraarticular fractures of the distal humerus in the elderly patient.

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-irrigator-aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures

Objectives: We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures. Design: Prospective randomized clinical trial. Setting: Multi-centered trial, level I trauma centers. Patients/Participants: All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group. Intervention: Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli. Main Outcome Measure: Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative. Results: There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2). Conclusions: This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Conditions of the Hip and Pelvis

This chapter will focus on the assessment and management of fractures and dislocations around the hip and pelvis secondary to traumatic injuries sustained in the young and active population during athletic activities. Traumatic soft tissue injuries, such as labral tears, are covered in other chapters in this book. Fractures and dislocations around the hip and pelvis in young patients are most commonly seen secondary to high energy trauma, such as motor vehicle accidents (MVAs) or falls from a significant height. However, they are occasionally seen secondary to high energy athletic activities such as cycling [1], motor cross, horseback riding, alpine skiing or snowboarding [2, 3], mountain climbing [4], hockey [5], rugby [6], and American football [7]. As such, these injuries will occasionally be seen by physicians and allied health specialists covering sporting activities, and it is important to have an understanding of these injuries and their emergent management.