Fractures

Educational Objectives

The goal of this program is to improve the management of fractures of the chest and extremities. After hearing and as­similating this program, the clinician will be better able to:

1.   Discuss repair of proximal humerus fractures.

2.   Describe appropriate management techniques for flail chest injuries.

3.   Assess patients for metacarpal and phalangeal fractures.

4.   Differentiate between types and patterns of fractures to the distal radius.

5.   Explain aggressive interventions intended to provide superior functional outcomes after fractures to the distal radius.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Benson is on the Speakers’ Bureaus of Accumed and TriMed. Dr. Lee is a consultant for Biomet. Dr. Solberg and the planning com­mittee reported nothing to disclose. In his lecture, Dr. Solberg presents information related to off-label or investigational use of a therapy, product, or device.

Acknowledgments

Dr. Solberg was recorded at Orthopaedic Trauma Conference, held May 9, 2009, in Los Angeles, CA, and sponsored by Ce­dars-Sinai Medical Center, Department of Surgery, Division of Orthopaedics. Dr. Benson was recorded at 11th Annual Chi­cago Trauma Symposium, held July 30 to August 2, 2009, in Chicago, IL, and sponsored by Advocate Health Care. Dr. Lee was recorded at 97th Annual Meeting of the Clinical Orthopaedic Society, held September 10-12, 2009, in Point Clear, AL, and sponsored by the Clinical Orthopaedic Society. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Proximal Humerus Fractures

Brian Solberg, MD, Orthopaedic Surgery Management Specialist, Los Angeles, CA

Two-part fractures: mostly surgical neck fractures; multiple x-ray views or computed tomography (CT) required to differentiate impaction from displacement (affects prognosis); varus malalignment and varus malunion  —  frequently associated with poor outcomes; causes greater tuberosity of humerus to rub against acromion during movement of deltoid muscle; concomitant rotator cuff tear  —  in 5% to 10% of humerus fractures; assess preinjury function when considering surgical repair; magnetic resonance imaging (MRI) may be useful; multiple pins  —  potential problems with patient tolerance; requires insertion of pins from multiple angles; hold humeral head up; standard nonlock plates  —  assist in reduction, but provide no angular stability; commonly fail due to screw cutout and collapse; blade plates  —  decreasing availability; maintain angular stability; prone to splitting; poor results with osteoporotic fractures; intramedullary (IM) nail  —  does not damage soft tissue; requires hole placed in rotator cuff; difficult without intact greater tuberosity; less able to resist varus drift of humeral head and varus bending; locked implants  —compress plate bone while providing angular stability; tendency to fail by catastrophic cutout; resistant to varus drift of humeral head; mechanical superiority with osteoporotic bone; require relatively open approach; caveat  —  avoid malreducing fracture in varus (fails, even with locked plate)

Fractures with ³3 parts: greater tuberosity drifts upwards and posteriorly; humeral head tends to rotate internally and drift into varus; exacerbated by poor bone quality; hemiarthroplasty vs fixation  —  better outcomes with reduc­tion secured via plate; however, patients converted to hemiarthroplasty secondarily (after plate failure) have poor outcomes; poor bone quality plus 4-part fracture  —  hemiarthroplasty recommended; poor bone quality plus 3-part fracture  —  treatment varies based on surgeon’s skill; lock plates effective when reduction maintainable; initial ori­entation of humeral head strongly affects outcomes; speaker recommends attempting to repair valgus-impacted fractures (3- or 4-part); plates prone to failure when humeral head drifts into varus; complication rate 20% to 40%; hemiarthroplasty  —  studies show poor functional outcomes; open repair  —  study (average patient age 48 yr); found 72% of patients have satisfactory outcome, despite 36% rate of avascular necrosis (AVN); speaker’s recommendation  —surgical repair for valgus 3-part fractures; hemiarthroplasty for 4-part varus fractures with dis­placement; speaker’s surgical technique  —  patient in supine position; deltopectoral approach; secure screws within 5 mm of subchondral bone; attach sutures to free tuberosities before manipulating humeral head fragment; parts cinched together and pinned with multiple Kirschner wires; attaching plate before reduction of tuberosities and hu­meral head often leads to perforation or malreduction; axillary (anteroposterior [AP]) view and external rotation of humeral head allows accurate assessment of screw length; supine position may aid detection of screw perforation (occurs in superior-posterior portion of humeral head); axillary view allows assessment for retroversion; length of metaphyseal hinge important (<2 mm associated with necrosis of humeral head in 3- or 4-part fractures); >15° an­gle between humeral head and shaft in varus increases failure rate

Flail Chest Injuries

Dr. Solberg

Injury location: advent of automobile airbags decreased incidence of anterior flail chest dramatically; side-impact automobile collisions remain major cause; posterior rib fractures  —associated with side-impact collisions; con­comitant clavicle fractures and closed-head injuries common; midaxillary fractures and anterior compression  —  cardiac and pulmonary contusions common; patients intubated in intensive care unit (ICU) for long periods and cannot tolerate prolonged procedures on chest wall; posterolateral flail chest  —  fractures in posterior paramidline segments; cardiac contusions less common; typically presents with pain, difficulty inspiring, and flourishing pul­monary contusion (leads to fatigue and intubation); patients receive greatest benefits from repair

Repair: IM nail  —  inserted posteriorly (creates difficulty in patients unable to assume prone position); plating  —  clamp onto ribs; associated with extended thoracotomy; indications for repair  —  severe overriding rib fracture; pleural volume decreased by >30% (associated with long-term pulmonary dysfunction and poorer outcomes); diffi­culty weaning from ventilation (often exacerbated by high-dose narcotics); operative stabilization of multiple rib fractures with pulmonary contusion  —  several studies found decreases in length of ICU stay, total intubation time, visual analogue scale, and severity of pulmonary contusion; posterolateral injuries with multiple fractures and overriding segments  —  implosion of chest wall places significant pressure on lung; surgical freeing of ribs required to restore lung function; patient placed in prone position with arm adducted (moves scapula off rib cage); superfi­cial dissection from above trapezius muscle toward midline; repair of medial-based fractures  —  release latissimus, trapezius, and rhomboids off midline; entirety of erector spinae (internervous plane) may be released and moved over as sleeve; release off medial board of scapula more common; scapulothoracic bursa lies 1 layer down (ex­tremely robust tissue; typically inflamed); individual incising of ribs necessary; apply clamps and pull to align ribs; hoop stress of tension on ribs maintains reduction; finalize with plate; critical assessment of reduction via x-ray rec­ommended; plate clavicle for rib segment injuries in which entire forequarter imploded (improves shoulder func­tion); higher nonunion rates without clavicle repair

Metacarpal and Phalangeal Fractures:
Latest Techniques

Leon S. Benson, MD, Professor of Clinical Orthopaedic Surgery, University of Chicago, Pritzker School of Medicine, Chicago, IL

Metacarpal fractures: boxer’s fracture  —  common; consider infection if wound open; speaker does not recommend surgical management; low morbidity rates despite high risk for deformity; surgery often results in binding of exten­sor tendons to metacarpal head; carpal-metacarpal (CMC) fracture dislocations  —  often missed in emergency de­partment (ED); typically involves multiple metacarpals; significant morbidity if untreated; treated with pinning or open reduction (recommended for delayed presentation); need lateral image to reveal full extent of injury; metacar­pal shaft fractures  —  appear benign on x-ray, but patient’s hand typically exhibits significant rotational issues (have patient flex fingers during assessment of rotation); previous fractures in other fingers with resulting malrotation may make assessment of rotation difficult; oblique or spiral fracture patterns  —  most common type; speaker rec­ommends plating as simplest method for achieving early motion (rigid fixation permits movement in 5-7 days); more aggressive approaches considered with multiple metacarpal fractures; after reduction, check rotational align­ment with fingers in flexion; avoid opening metacarpophalangeal (MCP) joint capsule (causes stiffness); Bennett’s fracture  —  common metacarpal base fracture; extra-articular version common in teenagers; articular malalignment primary indication for surgery (patients often compensate for angular deformities); CT recommended when articu­lar involvement unclear; surgical repair involves twisting thumb into pronation (corkscrew effect creates reduction); closed pinning reduction most common; open reductions typically performed via volar incision at base of thumb on palmar side; open approach suitable with fracture fragments large enough to capture screws or plates; primary goal joint reduction; multiple metacarpal fractures  —  rotational alignment difficult because adjacent metacarpals broken (use patient’s other hand as reference); adjacent metacarpal shaft fractures create regional instability (use multiple screws); IM nails avoid complications due to extensor tendon adhesions, but require second procedure for removal within 6 to 12 wk

Phalangeal fractures: repair involves complicated work with small aspects of anatomy; pins predominant; signifi­cant issues with stiffness in adjacent joints; check for multiple fractures in same digit; mallet fractures  —  common; surgical repair not recommended (unless joint dislocated); size of fracture fragment irrelevant; significant joint sub­luxation only indication for surgery; splint care critical; skin care should focus on preventing irritation and main­taining motion in proximal interphalangeal (PIP) joint; improper attention to PIP joint causes stiffness (lowers patient satisfaction more than mallet extension lag); elderly patients, those with repeat injuries, and those present­ing >6 wk after fracture typically experience poorer outcomes; distal phalangeal shaft fractures  —  residual shaft angulation creates significant discomfort; pinning simple; phalangeal neck fractures  —  often missed in ED; com­mon in children 2 to 10 yr of age; often result in lost joint flexion; closed reduction with pinning possible if diagno­sis made £10 days after injury; lateral image recommended before repair; retrocondylar fossa reconstruction treats abnormal flexing caused by malunion; proximal phalangeal shaft fractures  —oblique patterns often successfully repaired with 2 screws or pins; closed reduction with percutaneous pinning recommended (if possible); mini-screw application possible, but typically requires open approach; phalangeal base fractures  —often exhibit palmar angu­lation; surgery not recommended (early motion and stretching often achieve superior results); warn patients about possible permanent mild loss of extension; PIP articular fractures  —  surgical repair for unicondylar or bicondylar fractures; PIP fracture dislocations  —  identify early and distinguish from stable volar plate avulsion fractures; sub­luxation of dorsal PIP fractures typically causes permanent impairment (aggressive operative care required)

Pediatric considerations: long-term growth arrest rare; Seymour’s lesion  —  injuries in which fingers crushed; com­mon up to age 5 yr; combined physeal injury, nail bed laceration, and open fracture; germinal matrix of nail must be removed from fracture site before pinning in reduced position; extra octave fracture  —  Salter-Harris II fracture at base of proximal phalanx of small finger; causes deviation of finger toward ulna; usually simple to reduce in office without anesthetic; use ulnar gutter splint and buddy taping

Current Management of Distal Radius Fractures

Donald H. Lee, MD, Professor, Department of Orthopaedics and Rehabilitation, Vanderbilt University, School of Medicine, Hand and Upper Extremity Center, Nashville, TN

External fixation: indicated for fractures with dorsal displacement; insufficient evidence of improved functional out­comes; less redisplacement and improved anatomic results; low complication rates; studies failed to determine ideal technique; rehabilitation  —  insufficient evidence to establish effectiveness of physical therapy; goals of treatment  —  restore radial inclination, volar tilt, radial length, and distal radioulnar joint; reduce intra-articular step-off to <2 mm; minimally displaced intra-articular fractures  —  check for associated scapholunate and perilu­nate dislocation and scaphoid fractures; intra-articular fractures with impaction or axial load  —  3 patterns, ie, ra­diostyloid, dorsolunate, or volar lunate fracture; obtain AP and 20° lateral-oblique views (to visualize articular surface) pre- and post-operatively; increasing use of 2-dimensional CT to view radiocarpal extension in gap; 3-di­mensional CT helpful in determining degree of articular comminution and number of fragments; nondisplaced fractures  —  CT required to confirm nondisplacement; treated with immobilization and follow-up imaging at 1 to 2 wk; discontinue splint and start activity at 4 to 6 wk; warn patients of risk for late extensor pollicis longus (EPL) rupture; displaced fractures  —  closed reduction and hematoma block or intravenous sedation; mobilization and fol­low-up at 1-wk intervals; adequate postreduction imaging recommended; in patients with reasonable stability, range of motion (ROM) exercises begin at 6 wk; at 6 mo, maximal motion and strength achieved, but subjective im­provement reported at £1 yr; operative intervention or re-reduction considered with inadequate or lost reduction at 0 to 3 wk

Closed reduction with percutaneous pinning: indicated for isolated styloid fractures or extra-articular metaphyseal fracture with minimal comminution; intrafocal pinning or extrafocal pinning through styloid or dorsal ulnar aspect of radius into proximal metaphysis; requires supplemental casting; pins removed in office at 6 wk

External fixation: bridging or nonbridging; indicated in displaced fractures with intra-articular comminution; re­quires supplementation with percutaneous pinning or limited internal fixation (open incisions for pin placement); external fixation removed at 6 wk; advantages  —  less invasive; provides good stability; neutralizes forming forces (especially in comminuted extra-articular fractures); relatively simple and fast procedure; disadvantages  —bridging external fixators may prevent wrist motion; overdistraction of wrist may promote stiffness (eg, extrinsic tightness of digits, carpal tunnel syndrome); possible pin tract infections; arthroscopic-assisted reduction  —  helps evaluate and manipulate articular surfaces; requires additional time

Volar buttress plating: supports volar marginal fractures; used in volar lip-type fractures; requires screw fixation of metaphysis; dorsal buttress plate  —  resists dorsal displacement; allows buttressing of dorsal articular fragments and limited visualization of articular surface (allows simultaneous evaluation for intercarpal ligament injuries); associ­ated with tendon irritation and/or rupture; requires eventual plate removal; volar fixed-angle lock plates  —  precontoured; threading guides for distal holes in transverse portion of plate (allows restoration or support of artic­ular surface); threads used to match normal tilt and inclination of distal radial articular surface; advantages  —  avoids zone of dorsal comminution and leaves blood supply intact; fewer soft tissue complications, but some stud­ies found tendon irritation and rupture associated with excessively long screws; provides flexor tendon protection; pronator quadratus may be repaired over plate; volar lock plates  —  resist subchondral displacement; may allow lim­ited purchase of dorsal cortical fragments; achieves stable fixation; allows earlier ROM; heavily dependent on fluo­roscopy; distal peg placement ideally within 2 mm of subchondral bone; requires cortical screw purchase in diaphyseal bone; plates vary in configuration; fragment-specific fixation  —  system of small internal fixation devices to address specific components of distal radius; utilizes smaller incisions (typically 2-3); maintains stable reduc­tion; user-dependent

Suggested Reading

Atroshi I et al: Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures. Acta Orthopae­dica 77:445, 2006; Bastian J, Hertel H: Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: Out­comes in a consecutive case series. Journal of Shoulder and Elbow Surgery 18:216, 2009; Bastos R et al: Flail chest and pulmonary contusion. Seminars in Thoracic and Cardiovascular Surgery. 20:39, 2008; Helzel I et al: Evaluation of intra­medullary rib splints for less-invasive stabilisation of rib fractures. Injury 40:1104, 2009; Kapoor H: Displaced intra-artic­ular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury 31:75, 2000; Kurzen P et al: Complications after plate fixation of phalangeal frac­tures. The Journal of Trauma: Injury, Infection, and Critical Care 60:841, 2006; Mayberry JC et al: Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. Journal of Trauma 66:875, 2009; Mici ID et al: Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures. Jour­nal of Orthopaedic Science 14:596, 2009; Orbay JL et al: The treatment of unstable metacarpal and phalangeal shaft frac­tures with flexible nonlocking and locking intramedullary nails. Hand Clinics 22:279, 2006; Rozental T, Blazar P: Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. The Journal of Hand Surgery 31:359, 2005; Simic P et al: Treatment of distal radius fractures with a low-profile dorsal plating system: an outcomes assessment. The Journal of Hand Surgery 31:382, 2006; Solberg BD et al: Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. Journal of Orthopaedic Trauma 23:113, 2009; Solberg BD et al: Surgical treatment of three and four-part proximal humeral fractures. The Journal of Bone and Joint Surgery (American) 91:1689, 2009; Solberg BD et al: Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. The Journal of Trauma: Injury, Infection, and Critical Care 67:8, 2009; Westbrook AP et al: The clinical significance of malunion of fractures of the neck and shaft of the little finger metacarpal. The Journal of Hand Surgery: British and European Volume 33:732, 2008; Wong TC et al: Comparison between percuta­neous transverse fixation and intramedullary K-wires in treating closed fractures of the metacarpal neck of the little finger. The Journal of Hand Surgery: British and European Volume 31:61, 2006.