Fixation of Traumatic Fractures

Educational Objectives

The goal of this program is to improve the operative and nonoperative treatment of traumatic fractures. After hearing and assimilating this program, the clinician will be better able to:

1.   List the indications for surgical repair of clavicular and scapular fractures.

2.   Identify tibial shaft fractures that can be managed nonoperatively.

3.   Cite recent data on the possible benefits of reaming and the use of bone morphogenic proteins (BMPs) in the treat­ment of tibial fractures.

4.   Describe the surgical options for fixation of distal radius fractures.

5.   Evaluate and provide immediate management for the patient with a suspected pelvic ring fracture.

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. Moon is a consultant for Stryker Corporation and Zimmer. Dr. Merk  has received institutional support from Stryker Corporation and Synthes, and is a reviewer for the Journal of Bone and Joint Surgery, the Journal of Trauma, the Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research.

Acknowledgements

Dr. Moon 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. Merk spoke at the 11th Annual Chicago Trauma Symposium, held July 30 to August 2, 2009 in Chicago, IL, and sponsored by Advocate Health Care. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Surgical Indications for Scapular and Clavicular Fractures

Charles N. Moon, MD, Associate Director, Orthopaedic and Trauma Services, Cedars-Sinai Orthopaedic Cen­ter, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA

Indications for surgical repair of clavicle fractures: traditional  —  painful nonunion; open or impending open frac­ture; floating shoulder; neurovascular compromise; polytrauma (controversial); newer  —  chest wall injuries; dis­placement; soft  —  patient who needs to get upper extremity mobile as soon as possible; pain control; prevention of deformity; Canadian Orthopedic Trauma Society study  —  surgical indications also included shortening of >2 cm with displacement in midshaft and obvious clinical deformities; polytrauma considered definite indication (not a disputed is­sue); study found that many clavicular fractures treated nonoperatively and do well, but select cohort of patients get worse with nonsurgical management

Options for fracture fixation: nails; pins; plates (superior or anteroinferior); biomechanical data suggest locked plates may offer some advantage in managing these fractures (better tortional and bending resistance achieved using superior pre­countered plate and adding a locked screw)

Correction of nonunion: requires accurate measurements to evaluate length (posteroanterior [PA] chest x-ray most accurate way to judge length); local bone graft sufficient if patient not missing bone (if missing bone, patient requires intercalary graft)

Indications for surgical repair of scapular fractures: displaced intra-articular fractures (Bankart lesions; unstable glenoid frac­tures); severe displacement of glenoid neck; floating shoulder; chest wall injuries; displacement of scapular body (debatable)

Data from scapular fracture studies: analysis of »113 cases  —authors concluded that significantly displaced spine and neck fractures lead to significant disability (however, hard to define what constitutes significantly displaced fracture); sys­tematic review of literature  —  showed repair of displaced glenoid and neck fractures produces definite benefit; insuffi­cient data regarding body fractures (but feeling is there may be group of patients who will benefit from surgical repair)

Tibial Shaft Fractures: Current Concepts

Bradley R. Merk, MD, Associate Professor of Orthopaedic Surgery, Director of Orthopaedic Trauma, Feinberg School of Medicine, Northwestern University, Chicago, IL

Tibial shaft fractures: spectrum of injury (ranging from low-energy injury in elderly patients with osteopenic bone to younger patients with good bone condition who have more significant bony and soft-tissue injuries; can have fractures at either end of bone); tibia most commonly fractured long bone and most commonly seen open fracture; prone to complications

Physical examination: assess soft tissues; examine leg; be aware of compartment syndrome and neurovascular injury

Nonoperative treatment: if initial x-ray shows less than 5 to 10° of angulation and less than 1 to 2 mm of shortening, fib­ula broken, and position can be maintained, fracture can be managed with closed treatment (typically involves long-leg cast with early transition to patellar tendon–bearing cast or orthosis and early institution of weight-bearing); studies have reported high union rates and reasonably good alignment with closed treatment

Operative treatment: indications include fractures initially displaced and unstable; compartment syndrome; floating knee; open fractures; treatment of choice intramedullary nail (IMN) stabilization; open reduction internal fixation (ORIF) with plates good option for patient with small IM canals or juxta-articular fracture; external fixation typically used more for damage control; in grade IIIC injury, provides quick stability to allow for vascular repair

IMN stabilization: advantages  —  minimally invasive insertion; allows for early total care; load-sharing, stable fixation; in mid-diaphyseal fractures, implant aids reduction; technical points  —  reduction must be maintained during reaming pro­cess, implant insertion, and locking; recommended start point is medial border of lateral eminence on anteroposterior (AP) view, or very proximal and parallel to anterior cortex on lateral view; approach can be medial or lateral to tendon, transtendon, or above tendon with suprapatellar start point; use of femoral distractor during nailing helpful for indirect re­duction (must put pins in parallel to joints at both pin sites); use of percutaneous clamps also helpful

Blocking screws: typically used in fractures at upper or lower end in area of nail-bone mismatch; screw prevents nail from drifting from desired position; always inserted in concavity of deformity

Ancillary plate fixation: can be used to facilitate nailing; generally used in management of open injuries; can use unicorti­cal screws to maintain reduction during nailing procedure, then remove plate when through

IMN for proximal meta-diaphyseal fractures: literature has reported high rates of malunion and nonunion; however, in re­cent study, use of ancillary techniques (femoral distractor, unicortical plates, percutaneous clamps, Shanz pins) achieved ac­ceptable alignment in »92% of patients and »100% union of proximal fractures (group reported similar results with distal fractures)

Reaming vs unreamed IM nailing: literature suggests reaming associated with higher healing rates and fewer secondary procedures; seems to be safe in open fractures; Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures (SPRINT) trial  —  multicenter trial; involved >1300 tibial fractures treated with reamed vs unreamed IMN stabilization; 1-yr follow up; studyfound possible benefit from reaming in patients with closed fractures (greatest differ­ence lower rate of auto-dynamization, ie, screw breakage); does not appear to be any benefit from reaming in patients with open fractures

Bone morphogenic proteins (BMPs) and open tibial fractures: BMP-2 Evaluation in Surgery for Tibial Trauma (BESST) Trial  —  involved »450 open tibial fractures treated with IMN, with or without BMP-2; results showed faster healing rates, fewer infections in grade III injuries, and fewer secondary procedures; subgroup analysis of 2 previous prospective trials re­ported »90% decrease in need for bone grafting, »66% decrease in need for secondary procedures, and significant decrease in infection rates; BMPs also useful in acute phase and reconstructive phase of segmental bone defects

Soft tissue management: vacuum-assisted closure (VAC) used widely; studies have shown it is useful tool; however, some cautionary literature suggests that in severe injuries (eg, grade IIIB open-tibia fractures), reliance on VAC can lead to higher infection rate

Fractures of the Distal Radius:
Spectrum of Treatment and Patients

Dr. Moon

Fractures of distal radius: common; many treatment options; called by many names; intercarpal ligamentous injuries more common than has been appreciated; triangular fibrocartilage complex (TFCC) a major problem in managing these fractures because it is a ring (difficult to break distal radius significantly without injuring other side of ring); no easy treatment for ul­nar-sided wrist pain and TFCC injuries; mode of injury is falls; several different classification systems; most patients older and have low-energy falls; younger patients tend to have higher-energy injuries, and intra-articular injuries more common

Associated injuries/complications: median nerve injuries fairly common and often not recognized; other complications  —difficult, unstable, or lost reduction (can occur from pushing closed treatment too far); distal radial ulnar joint sublux­ation; acute carpal tunnel syndrome; tendon injuries and associated carpal injury; late complications  —  malunion; pain; dysfunction; rupture of extensor tendon

Initial management: ideally, every patient should have closed reduction and sugar-tong splinting; loss of reduction can occur after median nerve injury (second most common complication of closed treatment); if reduction lost, not useful to repeat closed treatment (unless patient not a surgical candidate under any circumstances); malunion defined as dorsal angulation at 30°

Surgical treatment: pinning  —  recommended for noncomminuted extra-articular 2–part fractures; put in couple of radial styloid pins and one ulnar column pin; cast patient until callus forms, then pull pins; do not try to pin comminuted fractures; special care should be taken to avoid nerves when pinning; external fixation  —in United States, most physicians use bridging external fixture from metacarpals to radial shaft; augment with pins so fixture can be removed early to prevent reflex sympathetic dystrophy (RSD) and stiffness; ORIF  —  classically used for volar shear (Barton’s) and comminuted fractures; can be done with either fragment-specific (Medoff) or volar locked plates; locked plating  —  popular new approach; pretty much any fracture of distal radius can be addressed with this technique; metaphyseal reduction  —  try to use indirect means

Fixing the fracture: Kirschner (K) wire usually applied temporarily; with volar plating, tilt-neutral reduction more likely than re­storing volar tilt; be wary of long screws, particularly in shaft; typically do not need any locked fixation in shaft; all plates fit dif­ferently, be familiar with how implant supposed to look and fit

Dorsal plating: sometimes out of vogue in orthopedics, but can be useful (major benefit is that physician can arthrotomize dorsal wrist capsule and look at distal radius articular surface directly, and not cause carpal ligament instability); offers huge advantage over volar approach in select fractures; complications include tendon rupture

Combined dorsal/volar plating: Harvard group study reported good reduction, compression, and alignment, with no cases of avascular segments or nonunion, despite having implanted large amount of metal in joints (distal radius extremely tol­erant of stripping)

Fragment-specific fixation: allows physician to break distal radius down into different parts and to address them sepa­rately; good but not perfect procedure (efficacy »82%; literature has reported “some interesting complications”)

Open fractures: typically small, ulnar-sided open injuries; if concerned, get fracture reduced, “ballpark” it, and put on ex­ternal fixture; let fracture heal and confirm not infected, then radial side can be addressed

Bone grafting: in the past, when treated with external fixation and pinning, all patients received bone graft; now, with ad­vent of volar locked plate, bone grafting less common

Extensor pollicis longus (EPL) rupture: still occurs (watch for it); needs to be addressed early

Distal radioulnar joint: probably bane of treating fractures of distal radius; in most cases, ulnar-sided wrist pain resolves in »6 mo

Fractures of the Pelvic Ring:
Evaluation, Immediate and Definite Management

Dr. Moon

Pelvic ring fractures:2 types (high-energy injuries and insufficiency fractures, which are much more common); tradition­ally managed nonoperatively; do not require urgent treatment, but can be painful for long period of time

High-energy injuries: motor vehicle accidents, auto vs pedestrian crush injuries; these injuries life-threatening and inter­vention can be life-saving; acute care principles  —  standard advanced trauma life support (ATLS) principles; if not treat­ing injury definitively, do not do anything that could potentially compromise future surgical approach around hip and pelvis; question of when to do embolization or external fixation still debated (physician should do what he or she can get done at his or her institution in timely manner; no longer necessary to perform external fixation in emergency depart­ment) 

Acute fixation: if patient scheduled for exploratory laparotomy, not difficult to extend incision and place plate; with pa­tients who are critically ill, sometimes better to “ballpark” injury and get it stabilized rather than fix it perfectly (can al­ways come back and fix it later)

Importance of vaginal examination in detecting open fractures in female patients: open fractures and vaginal injuries, such as impingement and canal intrusion, often missed because of  physician’s reluctance to do thorough vaginal exami­nation (fortunately, open fractures relatively rare); thorough rectal and vaginal examinations required for all cases of high-energy pelvic trauma

Indications for surgical treatment: unstable pelvic injuries; pubic diastasis; displaced posterior ring injuries; vertical displacement; walk symphysis; overly compacted lateral compression injuries; vaginal wall impingement; if pelvis can be felt moving on physical examination, not stable, regardless of what appears on x-ray; with lateral compression injuries, important to look at hip rotation of intact side vs rotation of affected side (easy to fix early, but difficult once fracture healed in internally rotated position); vaginal wall impingement must be addressed early

Pain control: controversial; some patients with stable injuries, who are otherwise hard to mobilize, helped by placement of percu­taneous screws, while others continue to have debilitating pain; fine line between doing things that help patient get up and mo­bilize early vs potentially unnecessary procedures

Timing of surgery: patient typically should be stable; avoid second procedure in ill patient in acute inflammatory phase; ensure adequate fluid resuscitation; remember that closed reduction of pelvis hard to perform after several days

Surgery: as rule, do back first (except when hemipelvis completely intact); important to reduce posterior ring, because if it heals malreduced, patient develops posterior pelvic/low back pain for which there is no good recourse (speaker feels open reduction of pelvis can be done posteriorly with “fairly benign” complications)

Closed reduction: if done on fracture table with perineal post, beware possibility of pelvis rotating around post (commer­cially available frame helps pin down intact pelvis); speaker prefers drill-tip guide wires rather than threaded (better aim­ing and control); prone position better than supine (easier to place iliosacral screws)

Anterior ring fixation: many options; if doing distraction external fixation for lateral compression fractures, only need fixture on for »4 wk; Pfannenstiel incision typically not used in orthopedics; any fixation that controls length and rotation should use plates with minimum of 4 holes (2-hole constructs fail at higher rate); low incidence of failure has been reported for 4-hole and 6-hole constructs (essentially due to screw breakage); external fixation easiest way to fix lateral compression injury

Postoperative care: touch-down weight-bearing on injured side (weight-bearing tolerated at »2 mo with insufficiency frac­tures; if displacement occurs when patient walking on affected side, not insufficiency fracture and probably requires addi­tional treatment); postoperative complications include infection, fixation failure (usually malreduction) 

Neurologic injuries: »40% of young men with significantly displaced posterior ring injuries have erectile dysfunction and other sexual function problems; must warn patients about this, and refer for treatment when necessary

Malunion: corrective surgery difficult; known that posterior ring problematic in terms of achieving union; some have ar­gued anterior ring problematic as well

Suggested Reading

Beardi J et al: Operative treatment of tibial shaft fractures: a comparison of different methods of primary stabilisation. Arch Orthop Trauma Surg 128(7):709, 2008; Gofton W, Liew A: Distal radius fractures: nonoperative and percutaneous pinning treatment op­tions. Hand Clin 26(1):43, 2010; Hoenig M et al: Extra-articular distal tibia fractures: a mechanical evaluation of 4 different treat­ment methods. J Orthop Trauma 24(1):30, 2010; Ilyas AM, Jupiter JB: Distal radius fractures--classification of treatment and indications for surgery. Hand Clin 26(1):37, 2010; Judd D et al: Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop 38(7):341, 2009; Kloen P et al: Anteroinferior plating of midshaft clavicle nonunions and fractures. Oper Orthop Traumatol 21(2):170, 2009; Lantry JM et al: Operative treatment of scapular fractures: a systematic review. Injury 39(3):271, 2008; Lapner PC et al: Scapula fractures. Orthop Clin North Am 39(4):459, 2008; Melvin JS et al: Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg 18(1):10, 2010; Melvin JS et al: Open Tibial Shaft Fractures: II. Definitive Management and Limb Salvage. J Am Acad Orthop Surg 18(2):108, 2010; Metze M et al: Male sexual dys­function after pelvic fracture. J Trauma 63(2):394, 2007;  Moon CN, Merkle PF: A level one trauma center's experience with the posterior approach to the pelvis. Orthopedics 25(2):159, 2002; No authors listed: Canadian Orthopaedic Trauma Society. Nonoper­ative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 89(1):1, 2007; Orbay JL et al: The extended flexor carpi radialis approach: a new perspective for the distal ra­dius fracture. Tech Hand Up Extrem Surg 5(4):204, 2001; Papakostidis C et al: Pelvic ring disruptions: treatment modalities and analysis of outcomes. Int Orthop 33(2):329, 2009; Payandeh JB, McKee MD: External fixation of distal radius fractures. Hand Clin 26(1):55, 20210; Schweitzer D et al: Closed reduction and iliosacral percutaneous fixation of unstable pelvic ring fractures. Injury 39(8):869, 2008; Vora AM et al: Extracapsular placement of distal tibial transfixation wires. J Bone Joint Surg Am 86-A(5):988, 2004.