Milton L. Chip Routt

Percutaneous fixation of pelvic ring disruptions.

Percutaneous pelvic fixation is possible because intraoperative fluoroscopic imaging and other technologies have been refined. Anterior and posterior unstable pelvic ring disruptions are amenable to percutaneous fixation after closed manipulation or open reduction. Stable and safe fixation is achieved only after an accurate reduction. Anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation; however, percutaneously inserted medullary pubic ramus, transiliac, and iliosacral screws stabilize pelvic disruptions directly while diminishing operative blood loss and operative time. These percutaneous techniques do not decompress the pelvic hematoma allowing early definitive fixation without the risk of additional hemorrhage. Complications associated with open posterior pelvic surgical procedures are similarly avoided by using percutaneous techniques. A thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations are mandatory for percutaneous pelvic fixation to be effective.

Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure.

Over a four-year period, twenty-four patients who had a complex fracture of the acetabulum were treated by the same surgeon. The operation consisted of open reduction and internal fixation with combined anterior and posterior exposures during the same period of anesthesia. The cases of these patients were reviewed to ascertain whether access to both acetabular columns during the same procedure facilitates open reduction and internal fixation and to determine the indications for this combined procedure. As determined by intraoperative assessment and at follow-up examination four to thirty-two months postoperatively, anatomical reduction and rigid fixation were achieved in 88 per cent of the patients. No patient had an infection of the wound. All twenty-four patients had some degree of heterotopic ossification; as defined by Brooker et al., it was Class I in seven, Class II in thirteen, Class III in three, and Class IV in one. However, the heterotopic ossification limited motion of the hip enough to impair function in only two patients. We concluded that combined anterior and posterior exposures facilitate reduction and fixation and that these approaches should be used during the same period of anesthesia whenever anatomical reduction and rigid internal fixation cannot be achieved through a single exposure. Heterotopic ossification should be expected postoperatively, but it is rarely clinically important, at least in the short term.

Plate fixation of femoral shaft fractures in multiply injured children

A study was done of twelve patients (seven boys and five girls) who, because of multiple injuries or a head injury, had been managed with compression plating of a unilateral or bilateral femoral-shaft fracture at a level-I trauma center from 1986 through 1990. The patients had a total of fifteen fractures. The average age at the time of the injuries was eight years (range, five years to nine years and eleven months). There were nine closed fractures and six open fractures; three of the open fractures were Grade I; two, Grade II; and one, Grade IIIA, according to the criteria of Gustilo et al. Each patient had an average of three associated injuries. All fifteen fractures had healed clinically and radiographically at an average of eight weeks (range, six to twelve weeks) after the operation. There were no infections. Anatomical alignment was obtained in fourteen limbs. One fracture healed with 13 degrees of anterior angulation. The compression plates were removed at an average of ten months (range, three to twenty-four months) after the index operation. At the latest follow-up evaluation (average, twenty-six months; range, eleven to fifty-seven months), no patient had restriction of activities due to the femoral fracture. Scanograms revealed overgrowth of the injured femur averaging 0.9 centimeter (range, 0.3 to 1.4 centimeters) in seven patients who had an uninjured contralateral femur. We believe that plate fixation of the femur is a good treatment option for children who have a femoral shaft fracture and a major head injury or multiple injuries, or both.

Variations in sacral morphology and implications for iliosacral screw fixation.

Abstract Posterior pelvic percutaneous fixation following either closed or open reduction is a popular procedure. Knowledge of the posterior pelvic anatomy, its variations, and related imaging is critical to performing reproducibly safe surgery. The dysmorphic sacrum has several key characteristics. The upper portion of the sacrum is relatively colinear with the iliac crests on the outlet radiographic view. Other characteristics include the presence of mammillary bodies (ie, underdeveloped transverse processes) at the sacral mid‐alar area, anterior upper sacral foramina that are not circular, residual upper sacral disks, an acute alar slope oriented from cranial‐posterior‐central to caudal‐anterior‐lateral on the outlet and lateral views of the sacrum, a tongue‐in‐groove sacroiliac joint surface visualized on CT, and cortical indentation of the anterior ala on the inlet radiographic view. The surgeon must be knowledgeable about individual patient anatomy to ensure safe iliosacral screw placement.

Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review.

Although closed interlocking femoral nailing is generally considered to be a difficult but effective procedure, the true incidence of technical complications has not been well documented. Similarly, long-term and functional patient-oriented data are limited. We reviewed our experience with an interlocking nail system that was introduced in our institution in October 1987. One hundred and twenty-three patients were retrospectively reviewed with particular attention to technical complications (Group I). A second group of 144 patients with femoral shaft fractures were reviewed prospectively as a part of our Orthopaedic Trauma Outcome Database (Group IIA). In the earlier retrospective group, the technical complications in 123 cases included one distal screw fracture, one broken drill bit left (in situ), one “missed” locking distal screw, and three cases where comminution at the fracture site was increased. In the prospective group of 144 fractures, the technical complications included two “missed” distal locking screws, two broken screws, and one bent nail due to additional secondary trauma. In a third group of 56 patients (Group IIB) selected from Group IIA, an abbreviated functional assessment was performed at a minimum of 12 months postinjury. Of this group, 37% of the patients had pain that was described as related to barometric changes and was either constant or activity related; 39% had some limitation in ability to ambulate or stand. Nine percent had to obtain new employment or seek job modifications. Based on our data we conclude that closed intramedullary nailing can be done at a Level I Trauma Center with relatively few technical complications, but the functional outcomes are not as good as had been previously believed. A significant portion of patients with femoral shaft fractures treated with interlocking nails will have permanent functional loss.

Quantification of the Upper and Second Sacral Segment Safe Zones in Normal and Dysmorphic Sacra

Objectives: To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology. Design: Retrospective cohort. Setting: University Level I trauma center. Patients/Participants: Fifty patients with pelvic computed tomography scans. Intervention: All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane. Main Outcome Measurements: In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared. Results: Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30° versus 21° in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm2 versus 109 mm2, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra. Conclusions: Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.

Retrograde nailing of femoral shaft fractures

OBJECTIVE The purpose of the study was to define the outcome following retrograde nailing of the femoral shaft. DESIGN Retrospective clinical study. MATERIALS AND METHODS Seventeen retrograde intramedullary nailings of the femur were performed in 16 patients for management of complex orthopedic trauma. Thirteen patients were followed for an average of 22.8 months (range from 9 to 72 months). The indications for retrograde nailing were an ipsilateral femoral neck and shaft fracture in eight cases, knee disarticulation or long above knee amputation associated with a femoral shaft fracture in five cases, traumatic arthrotomy of the knee ipsilateral to a shaft fracture in two cases, one case of a shaft fracture ipsilateral to an acetabular fracture that required an extensile exposure, and one case of a femoral nonunion with a knee contracture. In fourteen of the seventeen cases the femur fracture was open including two grade III C injuries. MEASUREMENTS AND MAIN RESULTS Two patients died in the early postoperative period due to the severity of the initial trauma and one patient was lost to follow-up. The results were generally poor and postoperative complications were common. There were five nonunions in the group, one which required revision to an above knee amputation for an infected nonunion following a grade III open femur fracture. The average range of motion of the knee was 3 degrees to 110 degrees, and two patients had an extensor lag of 5 degrees or more. Six patients underwent removal of hardware through a second arthrotomy with no significant loss of knee function related to the second procedure. CONCLUSIONS The authors concluded that the high complication rate and poor results were related to the severity of the initial injury. An intercondylar starting can be used in properly selected cases with minimal effect on knee function.

Anterior versus posterior provisional fixation in the unstable pelvis: A biomechanical comparison

Pelvic ring injuries with associated hemorrhage often require provisional fixation to achieve tamponade. Biomechanics information regarding these provisional fixators is unknown. Six fresh-frozen cadaveric pelvic specimens were physiologically loaded, first intact and then after each of the following modifications: disrupted-unilateral superior and inferior rami osteotomies, ipsilateral anterior and posterior sacroiliac joint, and sacrospinous and sacrotuberous ligament disruption; disrupted and with placement of a Ganz pelvic resuscitation clamp; and disrupted and with placement of a simple anterior 2-bar external fixator. This injury resulted in significant motion at the disrupted rami and the injured sacroiliac joint, compared with the intact pelvic specimen. Motions at the superior ramus and injured sacroiliac joints were significantly (p < 0.05) greater than the intact specimen, with both the external fixator and the Ganz clamp. Motions at the superior ramus and injured sacroiliac joints were not significantly (p < 0.05) different when comparing the Ganz clamp to the external fixator. However, the anterior external fixator decreased motion to a greater degree at the disrupted rami, whereas the Ganz clamp decreased motion to a greater degree at the disrupted sacroiliac joint.

Osseous fixation pathways in pelvic and acetabular fracture surgery: osteology, radiology, and clinical applications.

P and acetabular fractures are severe musculoskeletal injuries. High-energy traumatic events such as automobile crashes continue to cause significant injuries, whereas refinements in the initial evaluation and resuscitation of trauma patients have led to increased patient survivability. With increasing longevity, a growing geriatric population is also vulnerable to lower energy pelvic fractures. The complex fracture patterns and associated injuries of the high-energy trauma patient, the poor bone quality and associated medical comorbidities of the elderly trauma patient, combined with the challenging pelvic osteology and soft tissue anatomy make the treatment of these injuries daunting for the orthopedic surgeon. Patients with operatively treated pelvic fractures have previously experienced significant morbidity, often in the form of hemorrhage or wound healing complications. The desire to avoid the morbidity of open surgery and technical and conceptual advances in obtaining and interpreting intraoperative images have driven the development of minimally invasive fixation. Percutaneous techniques have been established as biomechanically sound, safe, and effective in treating patients with a variety of pelvic ring injuries. Open reduction and stable internal fixation with a focus on anatomic restoration of the articular surface remains the gold standard in acetabular fracture care, although percutaneous treatment, either as a supplement to formal open reduction and stable internal fixation or as a stand-alone procedure with select indications has also been reported. Regardless of technique or surgical approach, safe and effective fracture fixation mandates a thorough understanding of the osteology and radiographic anatomy of the pelvis. We have come to conceptualize the opportunities for fixation about the pelvis and acetabulum as pelvic osseous fixation pathways (OFPs). These geometrically complex ‘‘bone tubes’’ are simply corticated bony cylinders of different dimensions and orientations that accommodate intraosseous implants (Fig. 1). Commonly, screws are used to fill the available OFP and thereby stabilize pelvic and acetabular fractures either percutaneously or after a formal open approach. The screw numbers, locations, diameters, and lengths selected are completely dependent on the individual patient’s osteology, assuming that an accurate fracture reduction has been achieved. The goals of this article are to review the osteology of these pathways, to provide a detailed description of the associated radiographic anatomy and requisite fluoroscopic views, and to summarize their clinical applications (Table 1).

Fracture-dislocation of the shoulder in a child : case report

This is a case of an 11-year old girl with a delayed diagnosis of a shoulder fracture-dislocation. Shoulder dislocations are rare, and proximal humerus fractures are uncommon. A fracture-dislocation in a child is, to our knowledge, as yet unrepresented in the English-language literature. The childs injury resolved without recurrence.