FOCUS ON FRACTURES
| PERIPROSTHETIC FEMUR FRACTURES AND LOCKED PLATING: DOES IT CHANGE THE OUTCOME?—
Matthew L. Jimenez, MD, Clinical Assistant Professor, Division of Orthopedic Surgery, Rosalind Franklin University
of Medicine and Science, and Chief of Orthopedic Trauma, Illinois Bone and Joint Institute, Lutheran General
Hospital, Chicago, IL
|
| Predisposing risk factors: older population has more falls, more fractures; osteoporosis; arthroplasty acts as stress
riser (fracture at or around arthroplasty; cortical defect from original surgery, or arthroplasty migrating from femur)
|
| Beals and Tower classification: assess stability of implant; if implant unstable, revise implant; assess stability of
fracture, and fix if fracture unstable; type I—fracture (often stable) in proximal area; often does not require surgery;
type II—starts in proximal segment; metadiaphyseal region spirals downward, does not exit anywhere where
component is not; type IIIA—tip of prosthesis; community and household ambulator; heals with cables superiorly
and cables and screws distally; can sneak screws behind prosthesis; type IIIB—starts at tip of prosthesis and spirals
upward; type IIIC—tip of revision prosthesis; type IV—well away from any component
|
| Lock-plate fixation: alternating locked unicortical screw with cable proximally and bicortical screws distally;
treatment goals—length, rotation, and alignment; restore function by mobilizing patient; speaker against using
(historically) retrograde femoral nails for periprosthetic fractures above total knee; can (historically) use above total
knee blade plates for short metaphyseal segments; condylar screw (dynamic condylar screw [DCS]); lock
plates—offer more stability, particularly with porotic bone; if lock plate construct fails, it fails at fracture site
through plate or stress between screw and plate at bone; increasing diameter of bicortical lock screws makes them
36% stronger than conventional plating; conventional plating not unreasonable if bone good; good plate-bone compression
and stable friction fit; in osteoporotic bone, a bicortical locked fixation with bigger screw nearly 100%
stronger than conventional fixation; in femur, use locking 4.5-mm broad plate; comes in curved variety; for locked
plate, alternate screw, cable, screw, cable; unicortical locked screws; available in shorter variety for thin cortex;
multiple fixed-angle devices in short metaphyseal segment (in porotic segment) useful for fracture above total knee
|
| Total hip: example of type IIIB injury with revision prosthesis placed; sustained fracture; strutted with locked-plate
construct that united; example of steroid-dependent patient 80 yr of age with rheumatoid arthritis and diabetes,
smoker—requiring third surgery; use very long plate, locks fixation, alternating unicortical locked cable and screw
cable; stay out of zone of injury; use unicortical locked screws proximally and locked bicortical screws distally,
locked-plate construct; when in doubt, go longer with plate and spread forces out; think of internal-external fixator;
screws close to fracture site, but stay out of zone of injury; example of type IV injury with very porotic patient—
lateral, can revise prosthesis with posterior approach; curved 4.5-mm broad plate allows good positioning of screws;
alternate screw, cable, screw proximally; use long plates and stay out of zone of injury; bridge it; go well down femur
3 to 4 bicortical screws distally; curved plate stays on bone; unstable prosthesis and unstable fracture—must
revise prosthesis; long bone stem to get distal fixation; porous ingrowth; prosthesis length at least 2 diameters below
stress riser; in this case, last stress riser at cement plug
|
| Above total knee: speaker prefers stainless steel lock-plate vs Less Invasive Stabilization System (LISS) plate;
screw has drill tip on it that strips out proximal thread hole; LISS has higher failure and pull-off rates; retrograde
nail converted to locking condylar plate —nonunion that went on to unite; changing mechanics of fracture (particularly
hypertrophic nonunion) facilitates union; long zones of injury between total hip and total knee—long locking
condylar plate above total knee; curved plate now available; speaker does not recommend titanium (brittle;
shorter ductal face upon loading); take-home message—lock plates provide added stability in porotic bone
|
| HUMERAL SHAFT FRACTURES: LESSONS FROM A SURGEON WHO BECAME THE PATIENT —Sean E.
Nork, MD, Associate Professor, University of Washington School of Medicine, Seattle
|
| Goals: healing and reasonable alignment; treatment should be nonoperative, especially in isolated humeral shaft
fracture; closed treatment yields union in majority of patients; coaptation splint for short period, followed by functional
brace; some evidence of healing by 12 wk; functional brace produces hydrostatic mechanism; should heal
predictably in majority of patients
|
| Operative indications: some open fractures can be washed and carefully treated with functional brace; floating elbow
injuries; vascular injuries; polytrauma primary indication; articular extension; brachial plexopathy
|
| Treatment: plates; nails (from top and bottom); flexible nails; unlocked nails; external fixation may be useful in
mangled upper extremity; nails—useful in pathologic fractures and long segmental fractures; use somewhat limited;
no advantage over plates; causes shoulder problems; nerves are issue; avoid nail prominence; newer nails
avoid cuff; or expose and incise rotator cuff, place nail down, then repair cuff; avoid distraction of humerus; consider
nerve function
|
| Plates: gold standard; extensile exposures; pick plate that fits humerus; do not need 4.5-mm broad plate; use 4.5-mm
narrow plate in majority of patients; direct compression or reduction techniques; bridging techniques; anatomic reduction;
correct rotation; protection of radial nerve advantage; union rates predictable with good technique; 7-hole 3.5-
mm low-contact dynamic compression (LCDC) bad technique (does not work for humerus); plate length important;
use at least 9- to 10-hole 4.5 mm long exposure
|
| Anterolateral and posterior triceps-sparing exposures: once proximal to deltoid, think about approach from
front; can do anterolateral exposure and plate directly; along distal two thirds, can do posterior triceps-sparing exposure
and place implant; always examine radial nerve; anterolateral exposure—can expose “stem to stern”; more
difficult to apply plate laterally as you get distal to humerus; not necessary to perform posterior triceps split approach;
Gerwin and Hotchkiss posterior triceps-sparing approach—elevate triceps off lateral intermuscular septum
to completely visualize humerus; place plate beneath nerve; protect radial nerve; apply plate from axillary nerve
proximally into olecranon fossa; lateral paratricepital plus medial paratricepital exposure—to treat more difficult
injuries
|
| Nails and plates: complication rate significantly higher with nails; huge increase in secondary surgical procedures;
plates gold standard
|
| Nerve palsies: radial nerve out in closed fracture—will probably come back; look at and monitor nerve; radial
nerve out in open fracture—high percentage of interposed or lacerated nerves; explore nerve; theoretic nerve deficit
after closed reduction—inadequate exam before reduction; nerve recovery rate same; can plate humerus in any
location
|
| FEMORAL SHAFT FRACTURES: CURRENT CONCEPTS —Cory A. Collinge, MD, Medical Director, Orthopedic
Trauma, Harris Methodist Hospital, Fort Worth, TX
|
| Rod: mechanically perfect device; almost immediate weight bearing, compared to plates or external fixators
|
| Femoral nailing: standard of care; union predictable; occasionally need to remove locking screw or revise nail;
good union rate; antegrade nailing gold standard; used to treat peritrochanteric and ipsilateral neck and shaft fractures;
procedure difficult in—big patients, anatomic variations, far proximal or distal fractures, femoral shaft fractures
combined with necks
|
| Nail placement: piriformis fossa entry point in line with femoral shaft; straight nail with distal locking options; other
proximal option is greater trochanteric entry (not in line with femoral shaft); requires bent nail; entry point tip of
greater trochanter at anterior one-third junction; recon screws go into head, right down axis of neck and head; distally,
retrograde nail goes into intercondylar notch at end of Blumensaat’s line; entry portals critical to good nail insertion
|
| Differences between antegrade and retrograde nailing: healing rates and time same; knee pain controversial
on studies; symptoms same; more hip pain after antegrade nail, but some pain also after retrograde nails; location of
fracture determines nail placement; use antegrade nail in proximal fractures; use retrograde nail in far distal segment;
provides better alignment; be familiar with both techniques
|
| Entry point (piriformis fossa vs trochanter) controversial: use piriformis fossa for entry; if using straight
nail, should not go through greater trochanter (causes medial fracture); implant does not match anatomy; study by
Ritchie compared nails specifically designed for piriformis fossa and trochanteric entry; identical healing rates; operating
room and fluoroscopy time longer using piriformis fossa entry; subclinical damage to abductors using piriformis
entry; no difference in gait using different entry points; trochanteric entry point acceptable; safe; dedicated
trochanter nails match proximal femur anatomy; more data needed
|
| Ipsilateral neck and shaft: 5% of patients with femoral shaft fractures also have femoral neck fractures (missed
up to 40% of time; displace over time); missed neck fractures are disastrous; obtain dedicated preoperative hip radiographs;
look at previously taken computed tomography (CT) image
|
| SALVAGE OF FAILED HIP FRACTURES —George J. Haidukewych, MD, Orthopedic Traumatologist, Tampa General
Hospital and Florida Orthopedic Institute, Tampa, FL
|
| Minimize failures: outcome depends on fracture displacement (ie, femoral neck or inner trochanter), age, success
of reduction, fracture pattern, and timing; choose correct operation; failure rate 30% to 40% for displaced femoral
neck fractures in old patients; failure rate for internal fixation higher than for arthroplasty; outcome of cemented
hemiarthroplasty in older patients (>65 yr of age) with 10-yr survivorship (free of revision) 94%; in young patients,
first obtain anatomic reduction, then accurately place implant; speaker uses Harding approach to obtain anatomic
reduction; cortical support concept important; keep screws in periphery; screws do not perform well on vertical
femoral neck injuries; internal fixation with screws resulted in failure rate twice that of fixed-angle device; fracture
pattern important; joint reactive force 159°; vertical load on femoral neck; vertical fracture behaves like intratrochanteric
fracture; does not tolerate compression; shears; eventually will need revision operation
|
| Young patient with failed internal fixation of femoral neck: preserve native femoral head, even with patches
of avascular necrosis (AVN); fully collapsed head requires arthroplasty; Powell’s valgus-producing intertrochanteric
osteotomy procedure of choice for nonunion femoral neck injuries in young patient with round femoral head; principle
to convert shear into compressive forces; goal 20° to 30° of horizontality
|
| Femoral neck fractures in older patients: arthroplasty best choice for internal fixation failure; total hip and
hemipelvis can be effective; beware of osteopenia; osteonecrosis can occur; consider using cement; hybrids might
not achieve press fit on acetabular side
|
| Intratrochanteric fractures: choose correct implant from fracture pattern; avoid varus; reduce and put screw in
middle of head; rare to see well done internal fixation fail; use revision open reduction internal fixation (ORIF) for
failure in young patient—target inferior femoral head using fixed-angle device; blade plate useful for salvage around
hip; can restore neck shaft axis to 130°; union rate 90%; arthroplasty best choice for intertrochlear failure in older
patients—inadequate proximal bone stock; total hip or bipolar replacement “dealers choice”; if socket good, bipolar
has distinct advantages from stability standpoint; less surgery; total hip more predictable for pain relief; have calcium
carbonate-replacing long stems available; bypass stress risers; get down to 2 diaphyseal widths of standard; have bearings
available; might need to deal with trochanter; dislocate hip once before taking hardware out; modular stems help
to fine tune height of femoral reconstruction; use center of femoral head tip of trochanter as guide to rotation; avoiding
failure mostly under surgeon’s control
|
Educational Objectives
| The purpose of this program is to provide the listener with information on the nature and management of fractures.
After hearing and assimilating this program, the clinician will be better able to:
|
 | 1. Review the causes of femoral fractures.
|
| 2. Discuss strategies to correct femoral fractures.
|
| 3. Summarize the Beals and Tower classification.
|
| 4. Describe nonoperative and operative treatments for humeral shaft fractures.
|
| 5. Discuss the rationale for nail placement in hip fractures.
|
Suggested Reading
Chapman C et al: Classification of intertrochanteric fractures with computed tomography: a study of intraobserver
and interobserver variability and prognostic value. Am J Orthop 32:443, 2003; Duwelius P et al: A prospective,
modernized treatment protocol for periprosthetic femur fractures. Orthop Clin North Am 35:485, 2004; Edwards T
et al: Stripping torque as a predictor of successful internal fracture fixation. ANZ J Surg 75:1096, 2005; Frigg R et
al: The development of the distal femur Less Invasive Stabilization System (LISS). Injury 32:SC24, 2001; Fulkerson
E et al: Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical
comparison of locked plating and conventional cable plates. J Orthop Trauma 20:89, 2006; Gardner M et
al: Helical plating of the proximal humerus. Injury 36:1197, 2005; Gerwin, M et al: Alternative operative exposures
of the posterior aspect of the humeral diaphysis. with reference to the radial nerve. J Bone Joint Surg 78-
A:1690, 1996; Haidukewych G & Berry D: Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg
13:101, 2005; Little C et al: Osteonecrosis in retrieved femoral heads after failed resurfacing arthroplasty of the
hip. J Bone Joint Surg Br 87:320, 2005; Mani U et al: Biomechanical comparison of flexible stainless steel and titanium
nails with external fixation using a femur fracture model. J Pediatr Orthop 26:182, 2006; Martinez, A et
al: Treatment of humeral shaft nonunions: nailing versus plating. Arch Orthop Trauma Surg 124:92, 2004; Matta J
et al: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res
441:115, 2005; McDonough E & Crosby L: Periprosthetic fractures of the humerus. Am J Orthop 34:586, 2005;
Menezes D et al: Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop
Relat Res 439:221, 2005; Ricci W et al: Trochanteric nail insertion for the treatment of femoral shaft fractures.
J Orthop Trauma 19:511, 2005; Shao Y et al: Radial nerve palsy associated with fractures of the shaft of the humerus:
a systematic review. J Bone Joint Surg Br 87:1647, 2005; Tower S & Beales R: Fractures of the femur after
hip replacement: the Oregon experience. Orthop Clin North Am 30:235, 1999; Weber T et al: The role of fibular
fixation in combined fractures of the tibia and fibula: a biomechanical investigation. J Orthop Trauma 11:206, 1997;
Wedin R & Bauer H: Surgical treatment of skeletal metastatic lesions of the proximal femur: endoprosthesis or
reconstruction nail? J Bone Joint Surg Br 87:1653, 2005; Wu C: Treatment of femoral shaft aseptic nonunion associated
with plating failure: emphasis on the situation of screw breakage. J Trauma 51:710, 2001
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue
Dr. Haidukewych has disclosed that he is a consultant for Zimmer and Depuy.
Drs. Jimenez, Nork, Collinge and Haidukewych addressed the 7th Annual Trauma Symposium, held August 11-14,
2005, in Chicago, IL. The Audio-Digest Foundation thanks Matthew J. Jimenez, Course Chair, and all the speakers
for their cooperation in the production of this program.
|
