Forbidding Fractures

From the University of California, San Francisco, School of Medicine’s 5th Annual Orthopaedic Trauma Course

Educational Objectives

The goals of this program are to improve  surgical management of fractures involving the foot and ankle, pelvis, fe­mur, and clavicle, especially in the polytrauma patient. After hearing and assimilating this program, the clinician will be better able to:

1.   Outline the surgical approach for foot and ankle fractures and identify the indications for immediate surgery.

2.   Discuss the treatment of pelvic fractures, including the appropriate initial management of the unstable pelvis.

3.   Compare and contrast intramedullary nailing and plating in the treatment of distal-third femur fractures.

4.   Determine the optimal time for fracture fixation in the polytrauma patient.

5.   Summarize the treatment options for midshaft clavicular fractures.

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. Borrelli is a consultant for Wright Medical Technology. Dr. McKee is a consultant for Stryker and Zimmer. Drs. Trafton and Dick­son and the planning committee reported nothing to disclose.

Foot and Ankle Fractures

Peter G. Trafton, MD, Professor, Department of Orthopaedics, Division of Trauma, Warren Alpert Medical School of Brown University, Providence, RI

Background: soft tissue healing determines surgical management of severe foot and ankle injuries; predisposing factors  —  minimal subcutaneous tissue and muscle underlie thin soft tissues; fascia limits compartment expansion; vascular supply limited; feet involved in direct high-energy trauma; high risk for wound breakdown and infection following surgery through swollen, edematous tissue

History of pilon and calcaneal fractures: early attempts at open reduction internal fixation (ORIF) associated with major complications, including amputation; pilon fractures  —  staged surgery with initial external fixation (ex fix); repair fibula and articular surface; delay definitive internal fixation until swelling subsides; calcaneal fractures  —  delay ORIF until skin wrinkles when pinched

Management of fractures: some require urgent treatment; little quality evidence on how long to wait and how to manage fractures until definitive treatment occurs; study (Höiness; 2000) on malleolar fractures stated ORIF of ex­tensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis, and infection; inter­nal fixation required before or after period of critical soft tissue swelling; timing of surgery  —  immediate ORIF possible before onset of swelling; speaker cautions against early intervention; delay surgery (usually 4-6 days or longer) until definitive signs of tissue healing; indications for immediate surgery  —  1) vascular disruption or occlu­sion; 2) open fracture; 3) compartment syndrome; 4) bone deformity with stretching or tensioning of skin; goals of surgery  —  1) revascularize; 2) release swollen compartment; 3) reduce deformity; 4) remove dead and dirty mate­rial; know surgical risks; consider mechanism of injury; assess soft tissues for sensation, capillary refill, and hyper­mobility (degloving injury); assess skin for swelling, ecchymoses, wrinkling, blisters, and bony deformity; treatment before surgery  —  reduce fracture deformity with ex fix; elevate foot just above heart; little evidence for efficacy of soft tissue compression or vacuum-assisted closure (VAC) dressing; splint with ex fix; allow motion of free joints, especially toes

Pilon fractures: staged surgery; may wait >3 wk with initial ex fix; consider repair of fibula and articular surface; de­finitive ex fix if injury severe; choose optimal surgical approach

Malleolar fractures: often no need to wait; assess each individually; delay may compromise results, prolong hospi­talization, and increase costs; consider immediate surgery if soft tissues not extensively swollen

Talus fractures: early ORIF not supported by literature; correct significant deformity (ie, dislocation) urgently; delay definitive ORIF until soft tissues heal

Calcaneal fractures: immediate surgery for open fractures, compartment syndrome, and skin tension; otherwise de­lay surgery; however, ORIF harder >3 wk after injury; study (Gardner, et al; 2008) reported 21% incidence of pos­terior skin problems with tongue-type fractures; recommend immediate percutaneous reduction and pinning, with later definitive ORIF

Midfoot fractures: immediate repair of significant deformity with ex fix; watch for skin tension; delay definitive ORIF

Pelvic Fractures

Kyle F. Dickson, MD, MBA, Professor and Chair, Department of Orthopaedic Surgery, University of Texas Medical School, Houston, and Memorial Herman Hospital, Texas Medical Center, Houston

Initial evaluation: goals  —  assess and treat open pelvic fractures, pelvic hemorrhage, and associated injuries; apply mechanical devices to stabilize pelvis; transfuse 1:1; perform rectal and vaginal examinations; transrectal ap­proach to hip joint; aggressive debridement critical; team approach; direct general surgeon to perform transverse colostomy to provide room around pelvis; infection in about one-third of patients

Urologic injuries: common; retrograde urethrography indicated; avoid if patient hemodynamically unstable be­cause dye interferes with embolization procedure; repair intra- and extra-peritoneal bladder ruptures; Foley cath­eter preferred; delay repair of urethral injuries to decrease chance for impotence

Neurologic injuries: occur between L2 and S4, depending on location and amount of displacement of pelvic frac­ture; L5 and S1 most common; Denis (1988) reported 57% chance of neurologic injury with sacral fracture me­dial to foramen; perform careful neurologic examination; worsening neurologic status may require decompression; recovery may take £3 yr

Management: stabilize pelvic hemorrhage; (Burgess; 1990) only 1% of pelvic injuries associated with extensive bleeding; consider force vectors, especially anteroposterior (AP) compression (largest blood loss); most blood loss originates from bone; arterial bleeding also occurs; angiography indicated if hemodynamic instability persists after pelvic stabilization; speaker checks pelvic stability at anterior superior iliac spine (ASIS); displacement on x-ray suggests instability; binder placed over greater trochanter stabilizes pelvis; can switch out for ex fix (anterior or posterior); ex fix  —  use of posterior ex fix limited in some fractures and overcompresses comminuted sacrum; used for resuscitation, not definitive treatment; understand deformity in pelvis; stabilize pelvis by reducing posterior complex instead of squeezing together anteriorly; (Dickson; 2009) 70% of hemodynamically unstable patients treated at outside hospitals for unstable pelvic fractures demonstrated worsening of posterior results; stabilization with percutaneous fixation (eg, Louisiana Fat Boy) possible; preventing complications  —  understand deformity; understand stability of fixation; do not accept poorly-performed reductions; pelvic packing  —  rare; perform in pa­tients going for exploratory laparotomy; pack retroperitoneal space to tamponade venous plexus

Distal-Third Femur Fractures: Nailing vs. Plating

Joseph Borrelli Jr, MD, Professor and Chair, Department of Orthopaedic Surgery, University of Texas South­western Medical School, Dallas

Background: represent 5% to 7% of all femur fractures (one-third of all femur fractures if hip fractures excluded); bimodal distribution  —  1) 18 to 45-yr-old with high-energy, comminuted, open fracture associated with other inju­ries; 2) elderly patient with low-energy fracture from fall; complicated by osteopenia or osteoporosis and comminu­tion; occasionally associated with total joint replacement above or below injury; imaging  —  computed tomography (CT) indicated with intra-articular fracture; helps with surgical decision making; arteriography useful if arterial in­jury suspected; AO/OTA fracture classification  —  type A extra-articular; type B unicondylar; type C bicondylar; treatment goals  —restore articular congruity; restore length, alignment, and rotation; provide stable fixation to as­sist fracture healing and allow patient and limb mobilization; treatment options  —  ORIF with plates and screws, in­tramedullary (IM) nails, and ex fix; choice depends on 1) fracture location and personality; 2) patient’s demands and expectations; 3) expertise of surgeon

IM nails: advantages  —  load-sharing; use small incisions; preserve maximum vascularity to fracture fragments; min­imal blood loss with retrograde insertion; allow early weight-bearing; familiar technique; speaker uses full-length nails to enter subtrochanteric area with retrograde technique; disadvantages  —  loose fit; mismatch between medul­lary canal and nail prevented with polar screws; insert screw where cortex missing; leave screws in place; ante­grade technique  —  disrupts abductors; stimulates heterotopic ossification; risks disruption of femoral neck if too anterior or medial; retrograde technique  —  risk knee sepsis; nail removal requires arthrotomy; start nail at junction of subchondral notch where it meets Blumensaat’s line in mid portion of distal fragment; reduce fracture, ream, in­sert and lock nail; study of 80 patients found quicker operating room (OR) times, less blood loss, and similar knee stiffness and nonunion rates with nails and plates

ORIF with plates and screws: distal femoral locking plates  —increasingly utilized; anatomically reduce distal por­tion  to fracture fragments, then percutaneously fix to shaft; advantages  —more stable than IM nail; early healing; can perform entirely percutaneously with small incisions around knee

Timing of Fracture Fixation and Polytrauma Fractures

Dr. Dickson

Background: known factors  —  1) benefits of resuscitation; majority benefit from definitive long-term bone stabiliza­tion; 2) systemic effects of IM nailing; 3) systemic inflammatory response from trauma; unknown factors  —  1) ability to predict complications from IM nailing; 2) optimal timing of fracture repair; 3) when to use ex fix; 4) ef­fect of head injury on polytrauma patients

Example: patient in motor vehicle accident (MVA) with bilateral femur fractures, open tibia, unstable pelvis, rib fractures, and lacerations to spleen and liver; management  —Morshed (2009) showed delay >12 hr for femoral shaft stabilization decreased mortality by 50%; decreased mortality evident in many time ranges, but not between 24 hr and 48 hr; identified low mortality rate for bilateral femur fracture patients, compared to literature, but no significant effect on outcome from femur fracture; age, pedestrian accident, and Injury Severity Score (ISS) cor­related with mortality; lethal triad  —  hemorrhage, coagulopathy, and inflammatory problems; 30% of trauma pa­tients arrive with coagulopathy; associated with increased mortality; replace blood and clotting factors (1:1)

Resuscitation: heart and brain protected, even with inadequate perfusion of other organs; extremities at risk; look for compartment syndrome and dysvascular limbs; address major dislocations; manage wounds; indications for amputation  —more than 6 to 8 hr of warm ischemia, transection of tibial nerve, and crush injury

Fracture fixation: retrospective data suggest early fixation beneficial; study (Bone; 1989) showed severely injured patients benefit most; lungs benefit from fewer emboli, which reduces pain and improves breathing; surgical approach  — IM nail or ex fix; Pape (1993) showed higher rates of acute respiratory distress syndrome (ARDS) and mortality with early IM nailing; however, most patients still benefit from early definitive stabilization; complications  —  identify those patients likely to have systemic effects from IM nailing; systemic inflammatory response protects against infection, removes damaged tissue, and initiates repair; however, can lead to organ in­jury; proinflammatory response increased by IM nailing; Pape (2003) observed increased levels of interleukin (IL)-6 with IM nailing, but not with ex fx; no difference in clinical outcome; prevent “second hit” causing ARDS and multiorgan failure; delay surgery for unstable patients; place ex fix in intensive care unit (ICU); damage con­trol philosophy  —  stay out of trouble; restore normal physiology; wait to restore normal anatomy

External fixation: stabilize orthopedic injuries while physiology improves; avoid second hit; stabilize fractures to prevent emboli; benefits  —  Pape (2002) showed significant reduction in systemic complications; no increase in local complications

Resuscitation: indications for delaying surgery  —  hemoglobin <8 g/dL, base deficit >5 mEq/L, temperature <33ºC, and increased international normalized ratio (INR); perform ex fix instead; timing of surgery  —  German study showed significant increase in mortality if OR time >6 hr; surgery best within 24 to 48 hr, worst between 2 and 5 days; once positive fluid balance occurs (day 5 or 6), patient can tolerate longer surgery

Effect of head injury: keep cerebral perfusion pressure  >70 mm Hg; no evidence timing or type of fracture fixation predicts outcome; assume full neurologic recovery

Clavicular Fractures

Michael D. McKee, MD, Associate Professor, Department of Orthopaedic Surgery, University of Toronto Fac­ulty of Medicine, and St. Michael’s Hospital, Toronto, ON

Background: most treated nonoperatively; displaced fractures  —obvious deformity; 15% to 20% nonunion rate at 1 yr; 15% to 20% symptomatic malunion rate with significant residual strength deficits; studies support ORIF over nonoperative treatment in selected patients

Nonoperative treatment: no clear advantage to any technique; (Hill; 1997) one-third of patients reported poor out­come; 15% nonunion rate; greater deformity correlated with greater patient dissatisfaction; Robinson (2004) showed 21% nonunion rate at 1 yr for displaced, comminuted mid-shaft fractures; clavicular malunion  —  common; heals shortened (mean shortening 3 cm) and crooked; orthopedic symptoms include easy fatigability with overhead work or heavy lifting; neurologic symptoms include thoracic outlet syndrome; functional and cosmetic issues from shoulder asymmetry; objective strength deficits in maximal effort and endurance in involved shoulder

Operative treatment: Canadian Orthopaedic Trauma Society (2007) randomized clinical trial compared operative (ie, plate fixation) vs nonoperative (ie, sling) treatment; predominantly young men; 111 of 132 patients followed >1 yr; Constant score (surgeon-oriented) improved dramatically in operative group but tapers to 10- to 12-point differ­ence at 1 yr; disabilities of arm, shoulder, and hand (DASH) score (patient-oriented) remained 10 points lower in operative group at 1 yr; complications  —  in nonoperative group (n=50), 7 nonunions and 9 symptomatic mal­unions; in operative group (n=62), 5 local (straight) plate irritations, 1 early hardware failure, and 1 nonunion; conclusion  —  selected group of young healthy patients benefit from operative fixation

Acknowledgments

Drs. Trafton, Dickson, Borrelli, and McKee were recorded at the University of California, San Francisco, School of Medi­cine’s 5th Annual Orthopaedic Trauma Course, held April 22-24, 2010, in San Francisco, CA. The Audio-Digest Founda­tion thanks the speakers, and University of California, San Francisco, School of Medicine for their cooperation in the production of this program.

Suggested Reading

Bone LB et al: Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am, 1989 Mar;71(3):336-40; Burgess AR et al: Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma, 1990 Jul;30(7):848-56; 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, 2007 Jan;89(1):1-10; Denis F et al: Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res, 1988 Feb;227:67-81; Dickson KF, Matta JM: Skeletal deformity after anterior external fixation of the pelvis. J Orthop Trauma, 2009 May-Jun;23(5):327-32; Gardner MJ et al: Secondary soft tissue compromise in tongue-type calcaneus frac­tures. J Orthop Trauma, 2008 Aug;22(7):439-45; Henderson CE et al: Stabilization of distal femur fractures with intramedul­lary nails and locking plates: differences in callus formation. Iowa Orthop J, 2010;30:61-8; Hill JM et al: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br, 1997 Jul;79(4):537-9; Höiness P, Strömsöe K: The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures. Ann Chir Gynaecol, 2000;89(1):6-9; Langford J, Burgess A: Nailing of proximal and distal fractures of the femur: limitations and techniques. J Orthop Trauma, 2009 May-Jun;23(5 Suppl):S22-5; Morshed S et al: Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am, 2009 Jan;91(1):3-13; Pape HC et al: Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma, 2002 Sep;53(3):452-61; Pape HC et al: Impact of intramedullary instrumentation ver­sus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma, 2003 Jul;55(1):7-13; Pape HC et al: Influences of different methods of intramedullary femoral nail­ing on lung function in patients with multiple trauma. J Trauma, 1993 Nov;35(5):709-16; Robinson CM et al: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am, 2004 Jul;86-A(7):1359-65; Robinson CM et al: The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures. J Bone Joint Surg Br, 2001 Sep;83(7):963-73; White TO et al: The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study. J Orthop Trauma, 2010 Dec;24(12):757-63.