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Guest Editors

We are delighted to bring to you this issue on the treatment of complex fractures. These
injuries continue to be problematic for the treating surgeon, and more importantly, for the
patient. Each of the articles is written by surgeons who truly are on the front lines, and
who deal with these complex fractures on a daily basis. In reading the articles, the passion
that each surgeon has for the particular injury hopefully is clear.
Patient expectations for improved outcomes following severe injuries have increased.
Although we, as an orthopedic community, have improved the treatment of such severe
injuries as complex tibial plateau fractures, we continue to be plagued by problems such as
wound infection, joint stiffness, and post-traumatic arthritis. Basic tenets for complex frac-
ture surgery have emerged in the past three decades. These include careful reduction
and rigid xation of the articular surface, appropriate rigid xation of the metaphyseal/
diaphyseal component of the fracture, preservation of the soft tissue environment around
the fracture, and early mobilization of the joint and patient.
Each of the treatment algorithms described in the following articles are logically derived
and follow the above principles. As new technologies and techniques emerge, we must
critically assess their efcacy, if possible, with multi-center, randomized clinical trials and
prospective functional outcome studies based-on active, planned follow-up. Only then will
we be certain that we are truly improving the lives of our patients.
Each of the authors has sacriced time away from clinical practice, research, and family
to present their expertise. We are indebted to them. We would also like to thank Ms. Deb
Dellapena and Ms. Ali Gavenda of W.B. Saunders, and Mrs. Jackie Manuel of the University
of Mississippi for organizing the entire project. Truly, without their efforts, this issue would
not be possible. We hope you nd it enjoyable.
Guest Editors
Division of Orthopedic Trauma
Department of Orthopedics and Rehabilitation
Vanderbilt University Medical Center
Nashville, Tennessee 37232

Department of Orthopaedic Surgery

University of Minnesota
UMHC # 492
420 Delaware Street, SE
Minneapolis, MN 55455

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

Peter Alexander Cole, MD

The rst investigator to publish on the outcomes of management. In addition, surgi-

topic of scapula fractures was Desault in cal approaches and xation techniques is de-
1805.7 Because of the rarity of this injury, the scribed for the most commonly encountered
literature is replete with small case series or fracture patterns. Lastly, rehabilitation of these
retrospective reports with poorly controlled patients is discussed.
variables. Fractures of the scapula account for
3% to 5% of all fractures about the shoulder
girdle5, 30, 49, 54 and make up less than 1% of all ANATOMY AND BIOMECHANICS
broken bones according to a Massachusetts
General Hospital review of 4,390 cases by The scapula is approximately a at and tri-
Wilson in 1938.57 It is likely that the injury is angular bone, with a thin translucent body,
rare because of the well-endowed muscular surrounded by borders that are well devel-
envelope in which it lies, the mobility of the oped because of their positions as muscu-
scapula on the thoracic cage, and surround- lar origins and insertions (Fig. 1). The scapula
ing musculoskeletal structures (proximal hu- spine divides the superior and inferior angles
merus, acromioclavicular joint, and clavicle), of the scapula, thus forming the supraspinatus
which usually yield rst. and infraspinatus fossae, which are origins for
These injuries typically occur in victims their respectively named muscles. Its concave
of high-energy trauma and therefore demon- anterior surface serves as a broad origin for the
strate a preponderance in young and middle- subscapularis muscle.
aged men who sustain direct force impact The spine of the scapula ends laterally as
to the posterosuperior and lateral forequar- the acromion, which arches over the humeral
ter. Because of the location and energy of head from which it is separated by the rota-
these forces, it is not surprising that associ- tor cuff and subacromial bursae. Along with
ated injuries occur in approximately 90% of the clavicle, it serves as origin for the deltoid
these patients.5, 29, 36 These associated injuries muscle. The trapezius also originates on the
frequently divert attention from appropriate acromion and spine anteriorly. The medial
diagnosis and treatment of the shoulder girdle border of the scapula is the site of attach-
because of their life-threatening nature. ment of the serratus anterior, which functions
The purpose of this review is severalfold. in scapula protraction, and rhomboid mus-
The reader should develop a better under- cles, the function of which is scapula retrac-
standing of the injured scapula in the con- tion. The levator scapulae muscle inserts on
text of a patient who is likely multiply in- the superior medial border and is specically
jured and direct a diagnostic workup that named for its function. The lateral border of
will elucidate operative and nonoperative in- the scapula sweeps up from the inferior an-
dications based on what is known regarding gle, forming a thick condensation of bone that

From the Department of Orthopedics, University of Minnesota, Regions Hospital, Saint Paul, Minnesota




Figure 1. Posterior image of a scapula depicting osseous landmarks. The well-developed

borders and processes of the scapula are also strategic opportunities for xation.

ends in the neck of the scapula. The lateral to the axial skeleton by the clavicle. Eigh-
border is the site of origin of the teres major teen muscular origins and insertions on the
and minor muscles, as well as the insertion scapula39 aid in its function to provide a stable
for the long head of the triceps on the neck, base from which glenohumeral mobility can
and part of latissimus dorsi at the inferior occur.55
angle. The coracoid process is a curved os- Motion of the humerus results from simulta-
seous projection off the anterior neck, which neous motion at the sternoclavicular, acromio-
is the origin for the coracoclavicular and clavicular, scapulothoracic, and glenohumeral
coracoacromial ligaments, and for the coraco- articulations. This concert of muscular forces
brachialis and short head of biceps muscles, as constrain the scapula body on the thorax at
well as the insertion for the pectoralis minor. approximately 35 , anteverted to the coronal
Just proximal to it on the superior margin is plane, and position the glenoid fulcrum so that
the scapula incisura, traversed by the trans- the rotator cuff can function as a dynamic sta-
verse scapular ligament, above which lies the bilizer of the proximal humerus.40 This force
suprascapular artery and below which runs vector of the rotator cuff, compressing the
the same nerve. humeral head against the glenoid, counter-
The pear-shaped glenoid fossa lies at the lat- acts the shear forces on the glenohumeral joint
eral angle, its margin covered by a brocar- imparted by the large deltoid muscle.51 These
tilaginous labrum, which is conuent above forces are formidable even during ordinary ac-
with the long head of the biceps tendon at the tivities; when the arm is held in 90 of abduc-
supraglenoid tubercle. This labrum enhances tion, the joint reactive force is 90% of body
the depth of the glenoid by 50%.26 The glenoid weight.46
fossa is approximately 39 mm in a superior
inferior direction and 29 mm in an anterior
posterior direction in its lower half, which is CLASSIFICATION
20% wider than the top half.27
The scapula is part of a suspensory mech- Because of the rarity of this injury, only a
anism, which attaches the upper extremity few classications are commonly recognized

for fractures of the scapula. Each of these Lesions to any two of these structures pro-
classications are based on radiographic nd- duce an unstable anatomic situation with loss
ings. The authors of these schemes have asso- of suspension for the appendicular skeleton.
ciated clinical outcomes with certain fracture It is likely that future series will be re-
variants; however, to date, no functional out- ported using the Orthopaedic Trauma Asso-
come study has been prospectively performed ciation (OTA) Classication System published
with a meaningful number of subjects to vali- in 1996 by the OTA Committee for Coding
date a classication system. and Classication.45 This alphanumeric sys-
The classications of Ada and Miller,1 as tem was developed out of the need for a sys-
well as that of Hardegger et al,22 are com- tematic classication of fractures to allow for
prehensive and anatomically dened. The for- standardization of research and communica-
mer is based on a retrospective experience of tion (Fig. 3). Although this scheme may be
116 scapulae, for which nomenclature was de- useful in this regard, it has not been validated
veloped for fractures of each scapula process clinically.
(acromion and coracoid), three types of neck
fractures, as well as the glenoid and body. The
Hardegger classication is similar but names EVALUATION
two types of glenoid and two types of neck
fractures. This classication is based on the History
experience of 37 operatively treated fractures.
Two recent classications were developed Knowledge of injury mechanism will assist
specically for intra-articular glenoid frac- in diagnosis. Low-energy injuries that may oc-
tures: (1) Ideberg28, 29 and (2) Mayo et al.35 The cur on the ball eld for example, may result
Ideberg classication is based on 100 glenoid from landing on the elbow or dislocating the
fractures reviewed over a 10-year period, and shoulder. Glenoid rim fractures are not un-
its merit lies largely in the epidemiologic con- common in this setting. High-energy injuries,
text in which it was written. Goss17 published on the other hand, can result from a massive
a variation on this scheme with more subdi- blow to the hemithorax or forequarter. These
visions for improved discussion of operative mechanisms result in scapula neck and body
management of these injuries. The scheme of fractures, sometimes with extension into the
Mayo et al is actually a reorganized version of glenoid. Direct blows to the superior shoulder
the Ideberg classication as well, but is based can result in comminuted scapula spine and
on the imaging and operative ndings of 27 displaced acromion fractures. A traction force
intra-articular glenoid fractures, the largest to the upper extremity may result in cora-
published surgical experience to date. The coid and acromion avulsion fractures, proxi-
intent of the latter authors was to correlate mal humerus fractures, severe neurovascular
a scheme with common patterns to direct lesions, and even scapulothoracic dissociation.
surgical decision making. In so doing, there
is emphasis on the associated scapula body
and process fractures with which glenoid Associated Injuries
fractures commonly occur. Specically, types 1
to 3 describe the location of the intra-articular Eighty to ninety-ve percent of patients
fractureanterior, superior, inferior respec- with scapula fractures have associated inju-
tively, whereas type 4 is associated with a ries,2, 21, 30, 36 thus underscoring the energy typ-
fractured body, and type 5 variants have as- ically imparted to these patients. These
sociated coracoid, acromion, or neck fractures patients had an average of 3.9 other major in-
(Fig. 2). This application may be the most juries in one study54 ; therefore, it is somewhat
useful for glenoid surgery. surprising that the associated mortality rate is
Combination lesions of the shoulder sus- only 10% to 15%, usually from pulmonary sep-
pensory complex are not uncommon in the sis or head injury.2, 54 Approximately 50% of
setting of scapula fractures. Goss17 has clas- patients sustain thoracic injuries; 15%, cranial;
sied double disruptions of this suspensory and 10%, spinal injuries.2, 17, 37, 54 Approxi-
complex and aided in the understanding of mately one half of all patients with scapula
the role of this bonesoft tissue ring made up fractures have other injuries to the ipsilat-
by the glenoid, coracoid, and acromion pro- eral extremity,2, 17, 29, 37 including vascular and
cesses, with the distal clavicle, coracoclavic- brachial plexus lesions in 13%.37, 54 Anterior
ular ligaments, and acromioclavicular joint. glenoid rim fractures are associated with

TYPE V Variants

Type II


Figure 2. A and B, This modication of the Ideberg classication by Mayo et al is useful for common
patterns of glenoid fractures. It emphasizes the associated fractures of the scapula body and pro-
cesses. (From CORR 347:124, 1998, with permission.)
Figure 3. This classication system for scapula fractures is part of the Fracture and Dislocation Com-
pendium developed by the Orthopaedic Trauma Association Committee for Coding and Classication.
The intent of its authors was to develop a consistent scheme that systematically integrates all long
bone fractures for the purpose of standardization of communication and research. (From Lippincott

Williams & Wilkins, JOT 10(suppl 1):8284, 1996; with permission.)


shoulder dislocations in two thirds of patients. deformity of neck and body fractures and
Although these fractures are also the most translatory displacement (Fig. 4C).
commonly associated with nerve lesions ac- The chest radiograph must be evaluated for
cording to Ideberg et al,29 another study found commonly associated abnormalities, such as
that 71% of brachial plexus and two thirds of clavicle and rib fractures and hemopneumoth-
arterial lesions occurred in patients with ma- oraces. Close inspection of the trauma chest
jor fractures of the scapula body. Heightened radiograph is often the tip-off for scapula frac-
awareness during physical examination is es- tures themselves. Other special x-rays may be
pecially crucial for these patients. helpful for further assessment of particular
scapula anatomy such as the West Point view
for anterior glenoid fractures,42 or the oblique
Physical Examination angled view for coracoid fractures.15 The two-
dimensional CT scan may be the best adjunc-
The physical examination should reect tive study for assessment of scapula spine and
an understanding of the commonly associ- process fractures, particularly the glenoid. Re-
ated injuries, particularly those that are life formatted three-dimensional imaging is par-
threatening. Shoulder girdle and their fre- ticularly helpful in understanding these frac-
quently associated neurovascular injuries ture variants because multiple fracture planes
demand an appropriate assessment of the and angular deformity become vivid (Fig. 4D
brachial plexus and distal perfusion. Although and E). After the fracture is well understood
the suprascapular and axillary nerve are at by a careful analysis of the plain radiographs
particular risk, it is sometimes impossible to and CT if necessary, the surgeon can consider
assess their end muscular function because treatment options.
of fracture displacement; however, axillary
nerve sensation should be documented. Abra-
sions over the scapula spine and acromion are TREATMENT
common; therefore, skin integrity should be
assessed for appropriate timing of surgery. Surgical Indications

The management of scapula fractures has

Radiographic Imaging historically been nonoperative, perhaps in
part because of the paucity of information
Radiographic imaging for assessment of regarding outcomes, combined with a relative
scapula fractures should begin with an antero- unfamiliarity in treating these injuries. Treat-
posterior (AP), axillary, and scapula Y view. ment has emphasized symptom relief and
The AP view should be tangential to the early motion to prevent long-term stiffness.
glenoid, and therefore the radiographic gantry After motion is restored in the rst four to
should project 35 off the perpendicular to 6 weeks, therapy is directed at rehabilitating
the body in a medial to lateral direction. In the rotator cuff and strengthening parascapu-
the normal shoulder, this will allow for vi- lar musculature. Because more than 90% of
sualization of the glenohumeral joint space. scapula fractures are minimally displaced,19
With angulated fractures of the scapula neck this noninvasive approach is effective for
and body, visualization of this joint space may most.2, 30, 34, 37, 49, 56, 58 No well-documented role
not be possible (Fig. 4A and B). Medialization for closed reduction techniques or effective
of the glenoid should be appreciated on this orthotic management exists.
view. On the axillary view, fractures of the However, a number of investigators have
glenoid, acromion, and coracoid can most of- accumulated data about injury characteristics
ten be elucidated. Furthermore, luxation of the that may portend a poor prognosis, shedding
humeral head will be demonstrated. It is often light on potential indications for surgery.
said that the patient with a broken humerus These recommendations fall more in line
or scapula has too much pain to abduct the with contemporary management principles
arm sufciently for the axillary view. For this for other periarticular fractures. Displaced
circumstance, the shoulder simply needs to be articular fractures of the glenoid, for exam-
abducted slightly and forward elevated. The ple, are the clearest indication for surgery. If
radiograph can then be taken by projecting humeral head subluxation, early arthrosis,
from just lateral to the hip toward the axilla.42 and a poor outcome are to be prevented, open
The scapula-Y radiograph reveals angular reduction internal xation (ORIF) should be

performed.5, 17, 18, 21, 22, 29, 35 Signicant articular relationship between the upper extremity and
displacement was dened as 5 mm in several axial skeleton, and providing a rm attach-
studies1, 17, 35 and 4 mm in another study.32 ment for the many soft tissues that enable
Mayo et al,35 in the largest operative series shoulder function.16
of intra-articular glenoid fractures, docu- Herscovici et al24 reported on ORIF of seven
mented 82% good or excellent results among clavicle fractures in patients with ipsilateral
27 patients evaluated clinically and radio- scapula neck fractures. In this series, all pa-
graphically at 43 months postoperatively. tients achieved excellent functional results
Fractures of the scapula neck should be with no deformity at 48.5-month follow-up.
treated operatively if displacement or angula- Two other patients in this series treated non-
tion renders functional imbalance to the paras- operatively had signicant shoulder drooping
capular musculature. Ada and Miller1 have and decreased range of motion. Others have
recommended ORIF if the glenoid is medially advocated internal xation of just the clavicle
displaced more than 9 mm or there is more as well for restoration of length and sufcient
than 40 of angular displacement.39 This rec- stability.22, 48 Leung et al33 treated 15 such
ommendation is based on a follow-up of 16 patients with internal xation of both the frac-
such patients treated nonoperatively, of whom tures and discovered good or excellent results
50% had pain, 40% had exertional weakness, in 14 patients 25 months after surgery.
and 20% had decreased motion at a minimum Ramos et al,48 on the other hand, reviewed
of 15 months follow-up. A group of eight pa- 16 patients with ipsilateral clavicle and scapu-
tients in this same study were treated oper- la neck fractures treated conservatively.
atively, and all achieved a painless range of Ninety-two percent had good or excellent
motion. Hardegger et al22 achieved 79% good results at 7.5-year follow-up. A signicant
or excellent results in a series of 37 patients shortcoming of the three former studies is
treated operatively, although only 5 cases were that none documented the degree of displace-
severely displaced or unstable scapula neck ment of the scapula neck fracture, and in the
fractures, and these were not analyzed sep- latter, the radiologic outcome was noted to
arately. Nordqvist and Petersson41 analyzed be good in all but one, suggesting minimal
68 patients with a mean 14-year follow-up and original displacement. In a recent retrospec-
found that 50% of patients with residual de- tive study by Edwards et al,10 the outcome of
formity have shoulder symptoms. Armstrong noninvasive treatment of ipsilateral clavicle
and Van Der Spuy2 noted that 6 of 11 pa- and scapula fractures was assessed at a mean
tients with displaced scapula neck fractures 28-months follow-up. Nineteen of 20 healed
had residual stiffness at 6 months. uneventfully, with excellent range of motion
Double disruption of the superior shoulder and function. This study did document the
suspensory complex (SSSC) is an entity that degree of displacement of the clavicle and
has gained distinct attention since Goss16 scapula fracture. Interestingly, this is a study
discussed its signicance in relation to scapula of mostly minimally displaced injuries; only
fractures. The signicance of this entity was 2 of 20 scapulas and 8 of 20 clavicles were
recognized much earlier, however, by a num- displaced more than 1 cm.
ber of investigators noting that the weight This authors recommended approach to
of the arm and the muscle forces acting on these double lesions is to restore integrity
the humerus result in a typical pattern of through ORIF of the clavicle or AC joint (if
displacement inferior and anteromedial.14, 22, 53 disrupted), unless the scapula fracture is sig-
The SSSC is a bonysoft tissue ring made nicantly displaced or angulated such that it
up by the glenoid, coracoid, and acromion would yield poor biomechanical function of
processes, as well as the distal clavicle, the the glenohumeral joint (Fig. 5). This author de-
acromioclavicular joint, and coracoclavicular pends on an opposite shoulder AP radiograph
ligaments. The superior strut is the middle and a CT scan to make such a determination.
clavicle, and the inferior strut is the lateral It is not uncommon to be mislead with an AP
scapula. Lesions to two of these structures of the injured shoulder because the glenoid
allow for signicant displacement at the may be signicantly displaced and angulated,
individual site and the entire SSSC itself. therefore making it impossible to get a view
Therefore, treatment recommendations have through the glenohumeral joint perpendicular
consisted of stabilizing one or both lesions to the normal plane of the scapula (seen in
to restore integrity to the SSSC, thereby pre- Fig. 4A). The author regards approximate op-
serving its function of maintaining a stable erative indications for extra-articular scapula
Text continued on page 12


Figure 4. A, AP shoulder radiograph of a 58-year-old man, whose car was struck by

an 18-wheeler truck. Appreciate the comminuted scapula neck and body, as well as
the distal clavicle fracture. Medialization of the glenoid is striking. B, This inverted AP
view of the opposite shoulder highlights the injured glenoid displacement, which is
appreciated by comparing the relationships of the glenoid neck to the lateral border.
C, The scapula-Y radiograph shows marked translatory displacement of the fractured
lateral border.
Illustration continued on opposite page


Figure 4 (Continued ). D, Axial CT scan cuts through the glenohumeral joint. Although one can deter-
mine an upper rib fracture and a suggestion of medialization of the glenoid, it is challenging to appreci-
ate the degree of medialization, extent of comminution, translation of the lateral border, and angular
relationship of the glenoid to the body. E, One three-dimensional (3D) reconstruction image of the
same scapula can assist greatly in understanding anatomic relationships. On this posterior view, per-
pendicular to the plane of the scapula, the extent of glenoid medialization noted is dramatic. The com-
minution of the body is better appreciated, as are the fracture planes exiting the medial and lateral bor-
ders and the scapula spine. Angular deformity is better appreciated in an image plane parallel to the



Figure 5. A, Anteroposterior shoulder radiograph of a righthanded architectural draftsman involved in

a car crash. He has a displaced, multifragmentary, scapula body fracture. Appreciate the medialization
of the glenoid over 2 cm, with resultant impingement at the lateral border spike. The clavicle fracture
represents a double disruption to the superior shoulder suspensory complex. B, Although the scapula-
Y radiograph shows minimal fracture angulation or translation of the body, medialization of the glenoid
represented the indication for surgery. The coracoid and acromion are noted to be intact on this view.
C, The 3D CT scan helps to identify areas of comminution, which borders will need xation, and what
reduction maneuvers will be necessary. Volume averaging required for these reconstructions often ob-
scures minimally displaced fractures such as the one entering the spine. D, The 3D CT scan parallel to
the plane of the scapula body aides in recognizing angular displacement and fractures of the spine.
Illustration continued on opposite page


Figure 5 (Continued ). E, Anteroposterior radiograph of the shoulder after xation. The comminuted
neck was stabilized with a 2.7 mm reconstruction and a 2.7 mm dynamic compression plate. A one-
third tubular plate was used for displaced body comminution using a spring plate concept. The scapula
spine and medial border were xed with a single 14-hole 2.7 mm reconstruction plate. Length has
been restored to the clavicle, which is then treated nonoperatively since suspension has been restored
to the injured appendicular skeleton. F, View 1 year after the injury shows the patients nearly symmet-
ric external rotation. He had sustained a highly comminuted fracture-dislocation of the ipsilateral ole-
cranon, but was back to work 6 months after the injury. G, View of patients forward elevation. He had
no pain or weakness, and almost no limitation of active shoulder motion. He did have a 15 exion con-
tracture of the elbow from injuries sustained to the olecranon.

fractures as being 100% translation of the lat- approach. This adjunct is very useful for ad-
eral border, or 25 of angular deformity of the dressing concomitant intra-articular glenoid
glenoid, or 1 cm of medialization. These crite- fractures.
ria are not absolute and must be placed in con- However, for most isolated intra-articular
text of the patients age, activity demands, and glenoid fractures, particularly the commonly
extremity dominance. Well-controlled studies encountered anterior rim fracture associated
are needed to validate this surgical algorithm with a glenohumeral dislocation, the del-
and further elucidate prognostic variables. topectoral approach is optimal (Fig. 8A). The
Other extra-articular fractures that re- deltopectoral sulcus is developed and the
quire ORIF include displaced fractures of the cephalic vein retracted laterally for exposure
spine, coracoid, and acromion. These frac- of the subscapularis muscle. The humerus is
tures carry a poor prognosis when treated rotated so that the subscapularis tendon can
nonoperatively.1, 20, 36, 39, 43, 44 be tenotomized near its origin, thus exposing
the capsule, which is incised and tagged for
closure (Fig. 8B). Retraction of the humeral
Operative Approaches head then allows for visualization, reduction,
and Techniques and xation of the glenoid fragments (Fig. 8C).
Implants for xation of neck and body frac-
Logical operative approaches should ef- tures have commonly included 3.5-mm dy-
fect exposure of the lesion, produce as little namic compression and reconstruction plates
structural damage as possible, and consider as well as one-third tubular plates. The au-
the restorative capacity of the repair process.3 thor has found that the lower-prole 2.7-mm
Most scapula fractures are best operated by reconstruction and dynamic compression
the posterior approach of Judet or the anterior plates are easy to contour, sufciently rigid,
deltopectoral approach. and offer more points of xation. At times,
The posterior approach through an exten- other minifragment plates may be useful for
sile Judet incision is the workhorse for scapula angulated intercalary body fragments. It is
neck and body fractures. It allows access to challenging at times to effect and hold the
each of the scapula borders and neck which reduction, particularly of the lateral border
yield the best bonestock for xation. The inci- and neck of the scapula. This reduction ma-
sion parallels the palpable scapula spine, be- neuver is particularly difcult in the highly
ginning at the acromion base and coursing to- medialized and angulated glenoid present-
ward the medial angle. A smooth turn is then ing beyond 1 week. In these circumstances,
taken down along the medial border toward it is helpful to place a 4-mm Schanz pin in
the inferior angle of the scapula (Fig. 6A). The the neck and another in the lateral border
author prefers to elevate the subcutaneous tis- away from the proposed plate position. These
sue above the muscular fascia and use only the pins serve as joysticks for each fragment and
intervals necessary for desired xation, thus may be used with a small external xator
protecting as much of the infraspinatus and for maintenance of reduction while applying
deltoid muscle origins as possible (Fig. 6B). the desired plate (see Fig. 7B). Glenoid frac-
The interval between the teres minor and in- tures usually are xed with minifragment
fraspinatus is most often developed for ac- or small-fragment lag screws (cannulated if
cess to the lateral border for best xation and desired), and in the setting of comminution,
restoration of the glenoid angle (Fig. 6C). In a minifragment buttress plate may be useful.
scapula fractures that involve displacement of Regardless of the choice of implants, the goal
the lateral and medial border as well as the of fracture xation must be stability that al-
spine, it may be necessary to expose the entire lows for early motion, which is the rst crucial
infraspinatus fossa by detaching the entire in- step in successful rehabilitation. A perfect
fraspinatus and posterior deltoid muscle ori- xation will end in failure if it is not followed
gin (Fig. 7A and B). by an effective plan of rehabilitation.
Other variations of the posterior approach
may include division of the infraspinatus
tendon6,50 ; however, this may prolong reha- REHABILITATION
bilitation. Osteotomizing the acromion has
been suggested to be useful in decreasing The plan of rehabilitation must take into
traction on the suprascapular nerve.8 A capsu- consideration the surgical approach, if used,
lotomy similar to that described by Kavanagh and the patients associated injuries. The
et al32 may be performed through a posterior goal in modern fracture surgery is to render


Figure 6. A, This patient is in the left lateral decubitus position leaning slightly forward. The line is
drawn for a posterior approach, using the scapula spine and medial border as the palpable landmarks.
It is preferred to incise slightly inferior to the spine and lateral to the medial border, and not to cut the
superior angle too sharp. B, The subcutaneous tissue is elevated as a ap directly above the fascia
of the deltoid, infraspinatus, and teres minor muscles. C, The interval between infraspinatus and teres
minor can be developed to expose the lateral border for reduction and xation. The lateral border was
restored with a 2.7 mm reconstruction plate, and angulated body fragments trapped and xed with a
one-quarter tubular plate and 2-mm T-plate. The inferior medial border is also exposed and xed with a
one quarter tubular plate through the same interval.


Figure 7. A, A posterior view (leftside medial) after a posterior approach to the scapula. In this
case, there were fractures exiting at seven different sites along the scapula perimeter, excluding the
glenoid; therefore, the infraspinatus was completely elevated from medial to lateral in one perios-
teocutaneous ap, also detaching its origin (with the deltoid) on the scapula spine superiorly. The
glenoid neck is out of view as it is displaced anterior and medial. This intraoperative photograph is
of the patient whose radiographs are depicted in Figure 4. B, The surgical tactic in this case was
to restore the relationship of the scapula spine and medial border rst. The rational here was to re-
construct the scapula body to provide a building block on which the glenoid neck could be placed.
The usual strategy is to begin by restoring the lateral border, but extensive comminution in this case
warranted a different sequence. Note the 20-hole 2.7 reconstruction plate used to restore the medial
angle relationship between the scapula spine and medial border. A single plate provides a stronger
construct then multiple plates with little screwhold and greater stress concentration on either side of
each fracture. Having xed the body, there is a small external xator with a pin in the neck, and one
lower at the lateral margin to resist deforming forces while restoring the lateral border with 2.7-mm


Figure 8. A, This patient who sustained a modied Ideberg Type II glenoid fracture as
shown in Figure 2 is in a beach chair position, and bony landmarks highlighted. The del-
topectoral incision runs from the coracoid toward the deltoid muscle insertion in the del-
topectoral groove. B, The incision was taken more cephalad for exposure of the coracoid
and supraglenoid region. The cephalic vein is retracted laterally with the deltoid (inferior re-
tractor), and the pectoralis major is retracted medially with the coracobrachialis. Sutures are
used to retract the subscapularis and capsule for exposure of the glenoid. There is a shantz
pin in the coracoid for manipulation of the superior fragment to which the articular surface is
attached. The superior glenoid articular surface is stepped off and translated signicantly in
relation to the inferior articular surface. C, Applied xation securing the glenoid reduction as
well as the fracture extension which runs inferior to the coracoid.

stability to the fracture. At the very least, sta- patients tend to resist exercises until the frac-
bility ought to mean that the bones can with- ture consolidates, and invariably they end up
stand physiologic motion. Motion is partic- with functional loss (Fig. 9).
ularly important in the shoulder that has a If the scapula fracture is treated nonopera-
propensity to become stiff with immobility. It tively, the patient should begin passive motion
can be argued that most patients with unxed immediately. It is helpful to begin with pendu-
and displaced scapula fractures are very un- lum exercises and increase the passive range
comfortable with attempts at motion. These under the guidance of a therapist within the


Figure 9. A, Anteroposterior radiograph of a shoulder demonstrating a malunion of the scapula body.

Appreciate signicant medialization of the glenoid by following the lateral border from the inferior an-
gle of the scapula to the large stepoff at the scapula neck. B, The scapula Y radiograph depicting the
gross angular deformity of the malunion. C, The patients radiographs are shown in Figures 8. Note
the signicant depression of the right forequarter, which mimics her psychological depression depicted
well by facial expression. D, Note patients maximum shoulder abduction. Despite months of physical
therapy, she complained of chronic aching shoulder pain and a sense of heaviness of her arm, as well
as weakness and fatigue.

rst few days. The patient should be taught sults in most cases of scapula fractures. Most
to use the uninvolved extremity, as well as scapula fractures, however, are minimally dis-
friends or family members, to assist with exer- placed. For scapula fractures that are intra-
cises. Initially, a sling may be used for comfort. articular, markedly displaced, or associated
Elbow and wrist active exercises are encour- with other injuries to the shoulder suspen-
aged in the immediate phase. Scapula frac- sory complex, excellent outcomes also can be
tures, because of a well-endowed blood sup- realized with operative intervention, assum-
ply, heal rapidly. Therefore, active range of ing a well-executed operation and plan of
motion can be started at 4 weeks and max- rehabilitation.
imized quickly. Resistive exercises are begun
by 8 weeks, and restrictions lifted (includ-
ing weight-bearing) as symptoms allow by
3 months. References
The deltoid approach requires division of
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Address reprint requests to

Peter Alexander Cole, MD
Department of Orthopedics and Rehabilitation
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216-4505

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00


Shawn W. ODriscoll, PhD, MD, Joaquin Sanchez-Sotelo, MD, PhD,
and Michael E. Torchia, MD

Among the most dreaded of injuries that the geometry of the distal humerus, and stable x-
orthopedic surgeon on call for trauma must ation of the fractured fragments to allow early
treat is what can be referred to simply as the and full rehabilitation.2, 4, 6, 810, 12 Although
smashed distal humerus. Resulting from high- these goals are now widely accepted by the or-
energy injuries, such as motor vehicle acci- thopedic community, they may be technically
dents and falls from a great height, these frac- difcult to achieve, especially in the presence
tures present special challenges to even the of bone loss, substantial comminution, or os-
most experienced elbow or trauma surgeon. teoporosis.12
Not only can there be extensive comminution When treatment of severe distal humerus
of both the joint surface and the supracondy- fractures fails, it does so either because of
lar metaphyseal region but also signicant nonunion at the supracondylar level or stiff-
bone loss may have occurred. To make mat- ness resulting from prolonged immobilization
ters much worse, these elbows usually present that has been used in an attempt to avoid fail-
with open wounds and sometimes soft tissue ure of inadequate xation.12 Either way, the
loss (Fig. 1). limiting factor is xation of the distal frag-
When faced with such a daunting task of ments to the shaft. Achieving the goals stated
treating this type of elbow, it is helpful to earlier and, therefore, successful treatment of
pause and consider the ultimate goals of treat- the smashed elbow require a departure from
ment, which include: traditional teaching, such as the misconcep-
1. Soft tissue healing without infection tion that plates must be applied in two per-
2. Restoration of diaphyseal bone stock pendicular planes, 90 to each other, as is
3. Union between the distal fragments and recommended by the Arbeitgemeinshaft fur
the shaft Osteosynthesefragn/Association for the Study
4. A stable and mobile articulation for Internal Fixation (AO/ASIF) group and
currently used by most surgeons.5, 9, 12, 14 Us-
When sufcient bone loss precludes a sta- ing existing techniques, different investigators
ble anatomic reduction, a nonanatomic recon- have reported unsatisfactory results in 20% to
struction that is stable and that achieves all 25% of the patients.2, 4, 6, 810
four of these goals is the preferable plan. In an effort to increase the yield of excel-
Restoration of painless and satisfactory lent and satisfactory results obtained after
elbow function after a fracture of the distal xation of distal humerus fractures and to
humerus requires anatomic reconstruction of reproducibly obtain stable xation in the
the articular surface, restitution of the overall presence of osteoporosis or comminution, the

From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota (SWO, MET); and the Shoulder and
Elbow Service, Hospital La Paz, University of Autonoma de Madrid, Spain ( JSS)



20 ODRISCOLL et al


Figure 1. A and B, A smashed distal humerus. These high-energy injuries usually occur from motor
vehicle accidents or falls from a great height. They are characterized by extensive intra-articular and
supracondylar comminution, and often bone loss. In this case, a 4-cm length of the lateral column is
missing. The lateral half of the trochlea is missing, while the medial half is in multiple pieces. Com-
minution sometimes extends well up into the diaphysis.

authors have developed and used for the 1. Soft tissue healing without infection
past 11 years an alternative philosophy and Principles
technique based on principles that maxi- Extensive debridement to minimize
mize xation in the distal fragments and risk for infection with open fractures.
compression at the supracondylar level. The Shorten the limb to relax soft tissues.
stability achieved has allowed the authors Technical objectives
to routinely commence an intensive rehabil- Leave clean surfaces on all soft tissues
itation program 36 hours postoperatively, and bones.
including full active motion with no external Cover essential structures (nerves, ten-
protection. dons, hardware).
This discussion expands on the general Obtain early closure (35 days).
principles of the authors current approach to Osteotomy of distal end of shaft to
these fractures, the specic technical details, permit 0.5 to 2.0 cm of supracondy-
the postoperative program, and the potential lar shortening, with maximal con-
complications. tact and interfragmentary compres-
sion between the distal fragments
and the shaft
PRINCIPLES AND 2. Restoration of diaphyseal bone stock
Obtain an anatomic reduction and sta-
Before discussing the details of surgical ble xation.
techniques, it is imperative that the treating Bone graft as necessary
surgeon understand the principles and tech- Technical objectives
nical objectives that, if followed and achieved Diaphyseal bone segments should be
respectively, will maximize the likelihood of reduced and xed with interfrag-
a successful outcome from treatment of these mentary compression.
severe fractures. At least one dynamic compression or
The principles by which the earlier-men- equivalent strength plate should ex-
tioned goals are achieved, and the technical tend an adequate length and num-
objectives at the time of surgery for achieving ber of screws (usually eight cortices)
them, are: proximal to the fracture.

Dual plating is not required for the dia- pared and draped in the usual fashion. The
physeal region. lateral position with the arm on a support
3. Union between the distal fragments and can be used, but hyperexion (which is neces-
the shaft sary with the triceps reecting anconeus pedi-
Principles cle [TRAP] approach) is easier in the supine
Maximize xation in the distal frag- position. A sterile tourniquet can be used for
ment. the initial ulnar nerve dissection, but the au-
All xation in distal fragments should thors prefer to avoid the use of the tourni-
contribute to stability between the quet. The ulnar nerve is routinely identied,
distal fragments and the shaft. isolated, and transposed subcutaneously. Ole-
Technical Objectives cranon osteotomy is the most commonly used
Concerning screws in the major distal and recommended approach, but the TRAP
fragments (articular segment): approach11 allows for wide exposure with-
Each screw should pass through a out the need for an olecranon osteotomy. This
plate. is especially important in older patients, in
Each screw should engage a frag- whom elbow replacement may be necessary.
ment on the opposite side that is The details of the TRAP exposure have been
also xed to a plate. described elsewhere.11 With this approach, the
As many screws as possible should intact proximal ulna and radial head can be
be placed in the distal fragments used as a template against which the distal
Each screw should be as long as humerus can be reconstructed. In addition, the
possible. potential complications associated with ole-
Each screw should engage as many cranon osteotomies are avoided,4, 15 and the in-
articular fragments as possible. nervation of the anconeus is preserved.11
Concerning the plates used for xation: The rst priority (goal 1) in managing open
Plates should be applied such injuries is to obtain soft tissue healing without
that compression is achieved at deep infection. With open wounds, the em-
the supracondylar level for both phasis is on extensive sharp debridement of all
columns. devitalized and potentially contaminated tis-
Plates used must be strong enough sues. Prevention of infection is of paramount
and stiff enough to resist break- importance even if the internal xation fails
ing or bending before union oc- because later reconstructive options may be
curs at the supracondylar level. limited if infection occurs. Lavage, regard-
4. A stable and mobile articulation less of the number of liters of saline used, is
Principles not nearly as effective as debridement with
Restore or recreate a stable hinge artic- a scalpel. With extensive soft tissue injuries
ulation for exionextension. and occasionally soft tissue loss, it is not al-
Technical objectives ways possible to cover the essential structures.
Preserve all ligaments and tendons at- The senior author (SOD) reasoned that, as
tached to the distal fragments. in limb replant surgery, shortening the limb
Obtain a stable congruous reduction would facilitate stable bony reduction (see
of either the trochlea, or the me- subsequent discussion) and relax the soft tis-
dial trochlea and capitellum; these sues, making coverage of the essential struc-
are the minimum requirements for a tures more achievable. Shortening of up to
functioning hinge articulation. 1 cm is of negligible consequence, and up to
Ensure that xation is adequate to per- 2 cm of shortening is well tolerated if needed.
mit immediate rehabilitation of the More extensive soft tissue defects that cannot
joint and limb starting within a few be covered by such shortening should be con-
days of surgery. sidered for free or pedicle ap coverage.
In the authors experience, it is preferable
to stabilize or x the fractures acutely, even in
the face of signicant soft tissue damage, loss,
SURGICAL TECHNIQUE or contamination. The wound is cleaner than
it will be a few days later after very thor-
Exposure ough surgical debridement. Soft tissue edema
will only increase in the days following injury,
The patient is placed in the supine posi- making both surgery and closure more dif-
tion and the affected upper extremity is pre- cult. Finally, the stability provided by fracture
22 ODRISCOLL et al

xation permits optimized position of the limb level, whereas the intra-articular fractures
for nursing, wound care, and edema control. typically unite. Based on current practice and
recommendations, this should not be surpris-
ing. Many of the fractures are dependent on
Bony Reconstruction
only two or three screws for stability at the
supracondylar level. The xation strategy
Diaphyseal Region
should concentrate on maximizing stability
For any fracture xation or delayed recon- between the distal fragments and the shaft of
struction, restoration of diaphyseal bone stock the humerus at the metaphyseal level. These
is required (goal 2). Diaphyseal bone segments principles are achieved by the successful
should be reduced and xed with interfrag- execution of the seven technical objectives
mentary compression. At least one dynamic listed earlier, each of which contributes to
compression or equivalent strength plate maximizing stability between the articular
should extend an adequate length and number segment and the shaft (see goal 3).
of screws (usually eight cortices) proximal to The practical application of these princi-
the fracture. Dual plating is not required for ples involves parallel plates that permit a to-
the diaphyseal region. tal of four to six long (4570 mm) screws to
be placed in the distal fragments, from one
Articular Surface side across the other (the plates are placed
with a slight offset, posteromedially and pos-
The articular surface of the distal humerus
terolaterally). The screws are placed at the
should be reconstructed anatomically unless
epiphyseal level interdigitate, which greatly
bone is missing. If bone is missing, two im-
increases the stability of the construct. The
portant principles should be taken into con-
plates must be contoured or precontoured to
sideration. First, the anterior aspect of the dis-
the normal geometry of the distal humerus
tal humerus is the critical part that needs to
to allow for screw placement at the appropri-
be xed to have a functional joint; reconstruc-
ate places and also not to be too prominent
tion of the posterior half is important but not
under the skin. One can contour a 3.5-mm
as crucial. Second, stability of the articulation
dynamic compression plate (DCP) or a pelvic
(goal 4) requires the medial trochlea and either
reconstruction plate (Synthes USA, Paoli,
the lateral half of the trochlea or the capitel-
PA) on the medial side and a DuPont plate
lum. Thus, the medial trochlea is essential to
(Howmedica, Rutherford, NJ) on the lateral
obtain a stable and well-aligned joint. Struc-
side. Currently, the authors use the Mayo
tural bone grafts, such as tricortical or bicorti-
Congruent Elbow Plates (Acumed, Portland,
cal grafts from the iliac crest, can be used to ll
OR), which are custom designed for the distal
defects in the joint surface.
humerus (see Figs. 47 and 10). They are pre-
The articular surface is xed provision-
contoured to the geometry of the distal humer-
ally with small smooth Kirschner wires. In
us and designed to permit placement of mul-
addition, or alternatively, very small (0.035,
tiple long screws (2.7 or 3.5 mm) in the distal
0.045) threaded Kirschner wires can be placed
fragments by clustering the distal screw holes.
in the subchondral bone and left in place
They have a dynamic compression prole in
for denitive xation after cutting them off.
the diaphyseal and metaphyseal regions, with
No screws are placed in the distal fragments
a continuously tapering articular region that
before applying the plates. Although this goes
is low prole. The undersurface of the dia-
against what has traditionally been taught by
physeal and metaphyseal regions is tubular in
the AO/ASIF group, the reason for this ap-
cross-section to greatly enhance sagittal plane
proach relates to the technical objective Every
stability and to permit provisional xation
screw in the distal fragments should pass
with a singe screw in the slotted hole.
through a plate. Doing so enhances xation
Interfragmentary compression is obtained
of the distal fragments, but, more important,
both between articular fragments and at the
it contributes to stability between the distal
metaphyseal level with large bone clamps that
fragments and the shaft (goal 3).
provide compression during the insertion of
the screws. This is done instead of using lag
Fixation of the Articular screws to provide maximum thread purchase
Segment to the Shaft for each screw. Additional compression at the
metaphyseal level results from slight under-
By far, most xation failures after a distal contouring of the plates and the use of dy-
humerus fracture occur at the supracondylar namic compression holes in the plates.

Provisional Assembly of the plates into the distal fragments. No screws are
Articular Surface placed in the distal fragments until the plates
are applied.
Once the fracture is exposed, the rst step
is the anatomic reconstruction of the articular Supracondylar Shortening
surface. The intact ulna and radial head can
be used as a template for the reconstruction In cases of supracondylar bone loss or
of the distal humerus. The articular fragments severe comminution that are interpreted to
are assembled paying attention to their rota- preclude anatomic reduction and stable xa-
tional alignment and are held in place provi- tion, supracondylar shortening osteotomy is a
sionally with smooth Kirschner wires (Fig. 2). viable option (Fig. 3). This is especially true
Fine-threaded wires (0.030 or 0.045) are used if structural bone grafting is contraindicated,
in cases with extensive comminution, cut off, particularly when associated with severe soft
and left in as denitive adjunct xation. The tissue injuries. The principles and details of
articular fragments are xed in the following the technique are described later.
Plate Placement and
1. Anterior trochlea and capitellum Provisional Reduction
2. Medial trochlea
3. Posterior fragments The next step is to contour plates to t the
distal humerus medially and laterally or to
As stated earlier, in cases with severe intra- chose medial and lateral precontoured plates
articular comminution, all efforts should be from the Mayo Congruent Elbow Plate Sys-
directed to reconstruct the anterior half of tem (Acumed, Portland, OR). This set also
the distal humerus articular surface and the provides for triple plating with both lateral
condyle and medial trochlea. It is necessary and posterolateral plates; however, in the au-
that all wires are placed at the subchondral thors experience with parallel plating, de-
level so as not to interfere with plate appli- scribed later, triple plating has never been nec-
cation nor with passage of screws from the essary thus far. At the medial side, a 3.5-mm

Figure 2. Provisional assembly of the articular surface. The articular frag-

ments, which tend to be rotated toward each other in the axial plane, are
reduced anatomically and provisionally held with 0.035 or 0.045 smooth
Kirchner wires. It is essential that they be placed close to the subchondral
level to avoid interference with later screw placement, and away from where
the plates will be placed on the lateral and medial columns. One or two large
(2-mm) pins are placed through the epicondyles where a hole in the plate will
be (see Fig. 4) and are later replaced by screws. One or two strategically
placed pins can be used to provisionally hold the distal fragments aligned
with the shaft.
24 ODRISCOLL et al

length of the plates is selected so that at least

three screws are placed on each side proximal
to the metaphyseal component of the fracture.
Ideally, the plates should end at different lev-
els to avoid the creation of a stress riser. The
Mayo Congruent Plates are designed to al-
ways stop at different levels regardless of how
they are combined. The plates are then pro-
visionally applied according to the following
steps (Fig. 4):
1. Two 2.0-mm smooth Steinmann pins
are introduced at the medial and lateral
epicondyles through holes in the plates
while they are held accurately against
the bone; the most commonly used holes
are the second laterally and the third
2. The appropriate reduction of the dis-
tal fragments to the humeral shaft at
Figure 3. Supracondylar shortening osteotomy. In cases
of supracondylar bone loss, and in some cases of severe the supracondylar level is conrmed. If
comminution, anatomic placement of the distal humerus supracondylar shortening is chosen over
with respect to the shaft would leave a large structural anatomic reduction at the metaphyseal
defect in one or other column, and only point contact level (see later section on metaphyseal
in the other. In such cases, a supracondylar shortening
osteotomy is a viable option when an anatomic recon-
region), the appropriate alignment is set
struction is thought not to be possible or structural bone and held.
grafting is undesirable, particularly when associated with 3. One cortical screw is inserted into the
severe soft tissue injuries. This involves reshaping the dis- slotted hole in each plate, but not fully
tal end of the shaft (solid lines, never the articular seg- tightened, to provide for provisional re-
ments) to enhance contact between the distal articular
segment and the shaft. Usually, only a small amount of duction of the distal fragments with re-
bone is resected off one side distally, and sometimes off spect to the shaft. The use of slotted holes
one side (for side-to-side apposition and compression). for these screws facilitates later adjust-
The limb is shortened through the fracture site to per- ments in plate positioning. The tubular
mit interfragmentary compression between the trochlea
and the distal shaft, between the capitellum and the distal
contour under the Mayo Clinic Congru-
shaft, and side to side on one or both sides. Once these ent Elbow Plates ensures alignment of the
surfaces have been compressed and xed with the plates, plate on the bone and greatly simplies
stability is strong enough to permit immediate motion and provisional reduction and xation.
rehabilitation. It is acceptable to translate the distal seg-
ment medially or laterally, and also slightly anteriorly, pro-
vided that rotational and valgus alignment are maintained. Articular and Distal Fixation
Once the plates are provisionally applied,
distal medial and lateral screws are introduced
pelvic reconstruction plate is used unless the to provide stable xation of the intra-articular
patient size or fracture comminution require fragments and rigid anchorage of the plates
the use of a stronger DCP. One-third tubular distally (Fig. 5).
plates are not strong enough. The medial plate
can be extended to the articular margin in 1. Two distal screws, one medial and one
very low or comminuted fractures and is con- lateral, are inserted. As stated earlier, the
toured to the shape of the medial epicondyle. screws should be as long as possible, pass
If a precontoured DuPont plate (Howmedica, through as many fragments as possible,
Rutherford, NJ) is used at the lateral side, and engage in the opposite column. Be-
it must be slightly uncontoured at the distal fore their application, a large bone clamp
end or placed more posteriorly to prevent im- is used to compress the intra-articular
pinging on, or cutting into, the common ex- fracture lines unless a gap is present
tensor tendon and lateral collateral ligament in the articular surface. This ensures in-
complex. Both plates should be slightly under- terfragmentary compression without the
contoured to provide additional compression need for lag screws. If a segmental de-
at the metaphyseal region when applied. The fect is present, iliac crest bone graft can

Figure 4. Plate placement and provisional reduction. A, Medial and lateral precontoured plates are
placed and held apposed to the distal humerus, while one smooth 2.0-mm Steinmann pin is in-
serted through hole No. 2 (numbered from distal to proximal) of each plate through the epicondyles
and across the distal fragments, to maintain provisional xation of the plates to the distal fragments.
B, A screw is placed in the slotted hole ( No. 5) of each plate, but not fully tightened, leaving some free-
dom for the plate to move proximally during compression later. Because the undersurface of each plate
is tubular in the metaphyseal and diaphyseal regions, the screw in the slotted hole only needs to be
tightened slightly to provide excellent provisional xation of the entire distal humerus.
26 ODRISCOLL et al

Figure 5. Articular and distal xation. Screws are inserted through hole No. 1 of the lat-
eral plate and across the distal articular fragments from lateral to medial and tightened. This
step is repeated on the medial side, using hole No. 3. In young patients, 3.5 cortical screws
are used (to prevent breakage) while long 2.7 screws are used in patients with osteoporotic
bone. The distal screws should be as long as possible, passing through as many fragments
as possible, and engaging the condyle or epicondyle of the opposite column.

be inserted but should be contoured to re- ternative reconstructive technique supracondy-

main below the level of the preexisting lar shortening. This technique is specially use-
articular cartilage so that it does not ar- ful in cases of combined soft-tissue and bone
ticulate with the ulnar cartilage or radial loss. Shortening by 1 cm or less creates no
head. apparent loss of function, and up to 2 cm
2. The 2.0-mm Steinmann pins can be re- of shortening can be tolerated without severe
placed with screws at this point, but the disturbance of elbow biomechanics.7 Maxi-
authors usually wait until the plates have mum stability and, therefore, minimum likeli-
been rigidly xed to the shaft to do so hood of nonunion at the supracondylar level
because it leaves more exibility in mak- are achieved by maximizing interfragmentary
ing ne adjustments to the supracondylar compression between the distal fragments and
reduction. the shaft (Fig. 6). The technical details for per-
forming the supracondylar shortening are de-
scribed below.
Metaphyseal Region: Supracondylar
1. A large tenaculum is used to apply
Compression and Proximal Plate Fixation
compression across the fracture at the
The metaphyseal region of the distal hu- supracondylar level of the lateral col-
merus can be xed in two ways. An anatomic umn (Fig. 6A). A screw then is inserted
reconstruction is desirable whenever possi- through the lateral plate proximally in
ble; however, adequate bony contact with in- compression mode to maintain the inter-
terfragmentary compression is necessary to fragmentary compression. Care should
ensure the stability of the construct and even- be taken not to change the varusvalgus
tually fracture union at this level. If meta- or rotational alignment of the articu-
physeal comminution or bone loss preclude lar surface when the bone clamps are
an anatomic reconstruction with satisfactory applied.
bony contact, the humerus can be shortened at 2. The same steps are followed on the oppo-
the metaphyseal fracture site provided that the site side (Fig. 6B). The amount of stability
overall alignment and geometry of the distal achieved after this step is nished is typi-
humerus are restored. The authors call this al- cally very gratifying already.

Figure 6. Supracondylar compression and proximal plate xation. A, Using a large tenaculum to pro-
vide interfragmentary compression across the fracture at the supracondylar level, the lateral column
is rst xed. A screw is placed in dynamic compression mode (inset ) in hole No. 4 of the lateral
plate. Tightening this further enhances interfragmentary compression at the supracondylar level (open
arrows) to the point of causing some distraction at the medial supracondylar ridge (solid arrows).
B, The medial column is then compressed in a similar manner using the large tenaculum and a screw
inserted in the medial plate in dynamic compression mode.
28 ODRISCOLL et al

3. The remaining diaphyseal screws are olecranon can be partially removed if it

then introduced providing additional impinges in extension-limiting motion.
compression as a result of the under- Recreating the olecranon fossa with a
contoured plates being pushed to gain burr can be performed if the fossa has
intimate contact with the underlying been obliterated because of supracondy-
bone. The two Steinmann pins then are lar shortening (Fig. 8).
replaced with distal screws that again 4. The nal intraoperative motion achieved
follow the principles mentioned earlier should be recorded as a baseline to moni-
regarding length and positioning. (Fig. 7) tor postoperative progress. One deep and
one subcutaneous drain are placed and
the type of approach used dictates the
Fixation of Remaining Intra-Articular closure. The skin should be closed with
Fragments and Motion Verication staples or interrupted sutures.
Once the overall architecture of the distal
humerus has been rigidly restored, any poste-
rior articular fragments remaining to be xed Supracondylar Shortening
are addressed, and intraoperative range of
motion is veried. Principles
1. Posterior articular fragments often re- In cases with supracondylar bone loss or ex-
quire denitive xation with either tensive comminution, it is not possible to per-
threaded metallic Kirschner wires or form an anatomic reconstruction and main-
ideally bioabsorbable pins. tain enough bone contact at the supracondylar
2. Any remaining provisional wires are level. A supracondylar shortening allows for
removed. restoration of bony contact and functional el-
3. The nal step before closure is to as- bow reconstruction provided that the follow-
sess the range of motion. The arc of mo- ing guidelines are followed.
tion should be smooth and free of im- 1. Shortening should be limited to no more
pingement of the coronoid or olecranon than 2 cm.
at their respective fossae, which would 2. The distal fragments can be translated
limit exion or extension. The tip of the laterally or medially with respect to the
center of the humeral canal to improve
bone contact at the metaphyseal level, but
the rotational and varusvalgus align-
ment of the distal articular surface should
be restored carefully.
3. The coronoid and olecranon fossae
should be recreated. A convenient meth-
od to provide room for the coronoid
and olecranon is to translate the epiphy-
seal segment anteriorly (taking care not
to ex it) and to sculpt the olecranon
fossa with a burr once the xation is
complete. The tip of the olecranon can
also be resected to allow extension to at
least 10 to 20 .

The rst step is to provisionally reduce the
articulation. At that point, one attempts to de-
termine how the existing contour of the dis-
Figure 7. The remainder of the screws are inserted, in- tal segment would best t against the shaft for
cluding the distal screws, which interdigitate for maximum maximum bone contact (see Fig. 3). The end of
xation in the distal articular fragments. If the plates are
slightly undercontoured, they can be compressed against
the shaft then is trimmed to match that con-
the metaphysis with a large bone clamp, giving further tour until maximum bony contact exists, while
supracondylar compression. the distal segment is positioned in proper

Figure 8. After shortening the distal humerus, the olecranon

fossa will be compromised. To preserve terminal extension,
the olecranon fossa can be recreated by burring out the same
shape from the distal end of the shaft. The tip of the olecranon
can be removed. The coronoid fossa and radial fossa are best
preserved by offsetting the distal segment anteriorly. It is tech-
nically easier to recreate a fossa posteriorly than anteriorly.

varusvalgus and rotational alignment. After keep the elbow in extension, and the upper
applying the rst two principles just men- extremity is kept elevated for 36 hours. After
tioned, the plates are applied medially and lat- that, the Robert-Jones dressing is removed; an
erally and the fractures xed. Bone graft can elastic, nonconstrictive sleeve is applied over
be placed under the plates in the triangular de- an absorbent dressing placed on the wound;
fects between the plate and bone, adjacent to and a program of continuous passive motion
where the shortening was performed. (CPM) is started with the goal being to ex
When a supracondylar shortening has been and extend the elbow as much as tolerated to
performed, the loss of the coronoid and radial avoid uid accumulation at the elbow region.
fossae need to be compensated for by ante- If the fracture unites with the normal
rior translation of the distal fragment, with- anatomic relationships restored and hetero-
out changing its position in other planes. In topic bone formation does not occur, the
addition, the olecranon fossa may need to ultimate range of motion will depend on
be sculpted with a burr removing bone only the avoidance of intra-articular adhesions
from the shaft, not from the distal fragments. and the characteristics the connective tissue
Whenever the burr is used, the eld should deposited in response to the traumatic and
be covered with sponges except for the region surgical insult. An intensive program of CPM
where bone needs to be removed, and irriga- is a reliable method to achieve a satisfactory
tion should be used thoroughly to avoid leav- range of motion. The CPM is used to avoid
ing bone dust in the wound that might facili- uid accumulation at the elbow. Experimental
tate heterotopic bone formation. and clinical data support the use of CPM for
this purpose.3 The uid that would tend to
Postoperative Treatment accumulate at the surgical site as part of the
inammatory response is literally squeezed
Immediately after closure the elbow is out of the elbow region by the high hydrostatic
placed in a bulky, noncompressive Robert- pressures generated when maximally exing
Jones dressing with an anterior plaster slab to and extending the elbow. The stability of the
30 ODRISCOLL et al

bony reconstruction allows such motion with- The CPM program is continued at home
out fear of failure of xation. The only factors for 3 to 4 weeks. The patient determines how
limiting full range of motion immediately much time he can spend out of the machine
after the operation are the amount of swelling, each day: if, by the time he or she goes back
the response of the overlying skin, and any to the CPM machine, the elbow is more dif-
problems with pain control. cult to move through its whole range, the time
The CPM program is labor intensive. The out of the CPM was too long. Most commonly,
CPM machine is adjusted so that the elbow is the CPM machine will be used for approxi-
higher than the shoulder. For the rst days, the mately 20 hours a day for the rst week, and
CPM is continued virtually 23.5 to 24.0 hours the number of hours spent in the CPM ma-
and the patient is allowed out of bed only chine is decreased progressively in the follow-
for bathroom privileges. During this time, the ing weeks. If, by the fourth week, motion is
patient works on progressively stretching the still substantially less than what was achieved
end ranges of exion and extension. Full ex- intraoperatively, formation of heterotopic os-
tension is normally easier to achieve because sication should be investigated and a pro-
the elbow was initially splinted in extension. gram of patient-adjusted static exion and
The patient lets the machine extend his or her extension splints used up to 3 to 4 months af-
elbow to the point at which the patient feels ter surgery.
tightness. The patient then backs the elbow
into exion a few degrees and keeps the el-
bow in that position for approximately 1 or RESULTS TO BE EXPECTED
2 minutes while the uid is being squeezed
from the tissues. After that couple of min- In the authors experience, the stability of
utes, the patient will tolerate further exten- the xation has been adequate to permit an
sion and continues working with several stops immediate intensive rehabilitation program
and starts until full extension is achieved. The consisting of active and passive motion, re-
same sequence is then repeated for exion. gardless of the severity of the fracture. A few
Once a full range of motion is achieved, the cases have had severe soft tissue injuries that
patient does not need to actively control the delayed the rehabilitation. By combining these
machine and can let the elbow be moved principles to obtain truly rigid xation and
through the whole range. On the second or commencing early aggressive rehabilitation,
third day, the patient can try to gain more excellent clinical results are possible (Fig. 9).
motion than the CPM machine will provide The main challenges relate to xation of the
by placing a folded towel alternatively under distal fragments to the shaft and being able to
the wrist to increase exion and under the contour strong plates to the complex anatomy
elbow to increase extension. As part of the of the distal humerus (especially considering
postoperative management, the patient is also that it has been fractured and cannot be used
encouraged to work on passive and active- easily as a templating surface). These tasks are
assisted pronation and supination exercises. made easier by the use of precontoured plates
Finally, thorough massage of the elbow by the that are specially designed for these fractures
patient or a relative will help with squeez- (Fig. 10).
ing the uid out of the elbow region and also
partially desensitize it to pain. Close atten-
tion should be paid to the neurovascular sta- POTENTIAL COMPLICATIONS
tus and the condition of the skin while the
patient is in the CPM machine. The patient The main complications that have been re-
should be encouraged to continuously read- ported after internal xation of distal humerus
just his or her position in the machine to avoid fractures are residual decreased range of mo-
radial nerve dysfunction secondary to contin- tion, xation failure with nonunion or malu-
uous pressure on the posterior aspect of the nion, nerve dysfunction, extensor mecha-
arm if it is held in a xed position for long pe- nism dysfunction, posttraumatic degenerative
riods of time. Some discoloration of the poste- changes, wound and skin problems, and avas-
rior skin is to be expected with elbow motion, cular necrosis.12, 4, 6, 810, 15
but if the integrity of the skin is in doubt, the As stated earlier, the neurovascular status
CPM should be stopped and the arm elevated and the condition of the skin should be fol-
in a Robert-Jones dressing until the status of lowed carefully during the postoperative pe-
the skin improves. riod. Anterior subcutaneous transposition of



Figure 9. Radiographic (A and B ) and clinical (C and D ) outcome 9 months after xing the smashed
distal humerus fracture shown in Figure 1 by applying the principles laid out in this article.

the ulnar nerve prevents many of the ulnar the misconception that plates must be applied
nerve complications.16 A radial neurapraxia in two perpendicular planes. Although that
may develop secondary to sustained pressure used to be true when very weak, 3.5, one-
on the dorsal aspect of the arm if the pa- third tubular plates were used, it most cer-
tient does not readjust his position while using tainly is not true when strong plates are used.
the CPM machine. Most skin problems can be The parallel, double-plate construct has been
avoided if motion is held and the elbow ele- shown to provide excellent stability even in
vated in extension as soon as the aspect of the the presence of supracondylar gaps.13 In fact,
skin is worrisome. Schemitsch et al13 showed that the combina-
The biggest impediment to successful ap- tion of a medial reconstruction and lateral
plication of this principle-based technique is DuPont plate in parallel planes was stronger
32 ODRISCOLL et al


Figure 10. A, A smashed elbow with extensive bone loss and comminution that was referred by a col-
league as unxable. In this case, as is frequently so, the olecranon and proximal ulna are also severely
fractured. B, The fractures are most conveniently and effectively xed using the Mayo Clinic Congruent
plates (Acumed, Portland, Oregon) that are specially designed for these fractures. They are precon-
toured to t each bone and fracture pattern. Unique design features permit provisional xation, greatly
enhanced xation in the articular fragments, increased sagittal plane stability, and ease of application.

than were two reconstruction plates placed release that can be performed 6 months to
in two planes 90 to each other, as is recom- 1 year after the initial surgery; at the time
mended by the AO/ASIF group and currently of capsular release, the hardware should be
used by most surgeons.5, 9, 12, 14 removed if the fracture is strongly healed.
With the internal xation technique de- Dysfunction of the extensor mechanism
scribed earlier, the authors have experienced may occur if the triceps tendon fails to heal to
only one case of xation failure. A 3.5 recon- the olecranon. Careful attention to reattach-
struction plate experienced fatigue fracture ment of the extensor mechanism at surgery
6 months after surgery in a patient with a should help prevent this complication. The
severe open injury treated by supracondylar reconstruction should be solid enough to
shortening and coverage with a local ap and allow passive elbow exion. Weakness does
skin graft. The lateral column had healed, ne- not seem to be a major problem with use of the
cessitating only rexation and bone grafting of TRAP approach for distal humerus fractures.
the medial column, which did result in union. Should discontinuity or subluxation of the
His nal range of motion was 20 to 120 . extensor mechanism occur, it can be surgically
Decreased range of motion may occur se- treated by primary repair or augmentation
condary to heterotopic ossication, intra- with an Achilles tendon allograft. Patients
articular adhesions, or capsular contracture. might experience a degree of triceps weak-
If motion does not respond to a program of ness following supracondylar shortening,
splinting, the patient may require a capsular but weakness is not uncommon following

these severe injuries. Thus, the authors have (CPM): Theory and principles of clinical application.
not been able to discern clinically any conse- J Rehabil Res Dev 37:179188, 2000
quences of the approach or treatment, separate 4. Henley MB, Bone LB, Parker B: Operative man-
agement of intra-articular fractures of the distal
from those of the injuries themselves. humerus. J Orthop Trauma 1:2435, 1987
Joint deterioration may be secondary to the 5. Helfet D, Hotchkiss R: Internal xation of the distal
cartilage damage sustained at the initial in- humerus: A biomechanical comparison of methods.
jury or the avascular necrosis secondary to J Orthop Trauma 4:260264, 1990
6. Holdsworth BJ, Mossad MM: Fractures of the adult
the devascularization of some articular frag- distal humerus: Elbow function after internal xation.
ments in severely comminuted injuries. The J Bone Joint Surg Br 72:362365, 1990
authors have had one case of osteonecrosis in a 7. Hughes RE, Schneeberger AG, An KH, et al: Reduc-
severely multifragmentary fracture. If the like- tion of triceps muscle force after shortening of the
lihood of this complication is to be minimized, distal humerus: A computational model. J Shoulder
Elbow Surg 6:444448, 1997
it is necessary to leave all soft tissues attached 8. John H, Rosso R, Neff U, et al: Operative treatment
to the distal fragments during surgery. of distal humeral fractures in the elderly. J Bone Joint
Finally, a question that is often asked re- Surg Br 76:793796, 1994
lates to blocking of motion caused by loss of 9. Jupiter JB, Neff U, Holzach P, et al: Intercondylar frac-
tures of the humerus. J Bone Joint Surg Am 67:226
the olecranon fossa. These injuries for which 239, 1985
supracondylar shortening is indicated are so 10. Letsch R, Schmit-Neuerburg KP, Sturmer KM, et al:
severe that even experienced surgeons would Intraarticular fractures of the distal humerus. Surgical
be pleased to reliably obtain healing of the treatment and results. Clin Orthop 241:238244, 1989
soft tissues and bones with a functional arc 11. ODriscoll SW: The triceps-reecting anconeus pedi-
cle (TRAP) approach for distal humeral fractures and
of motion (30 130 ). If motion is sufcient nonunions. Orthop Clin North Am 31:91101, 2000
to permit impingement, the hardware can be 12. Ring D, Jupiter JB: Fractures of the distal humerus.
removed and the bone recontoured at a later Orthop Clin North Am 31:103113, 2000
date. 13. Schemitsch EH, Tencer AF, Henley MB: Biomechani-
cal evaluation of methods of internal xation of the
distal humerus. J Orthop Trauma 8:468475, 1994
14. Self J, Viegas SF, Buford WL, et al: A comparison
of double-plate xation methods for complex distal
References humerus fractures. J Shoulder Elbow Surg 4:1016,
1. Ackerman G, Jupiter JB: Non-union of fractures of 15. Soderg
ard J, Sandelin J, Bostman
O: Postopera-
the distal end of the humerus. J Bone Joint Surg Am tive complications of distal humeral fractures. Acta
70:7583, 1998 Orthop Scand 63:8589, 1992
2. Gabel GT, Hanson G, Bennett JB, et al: Intraarticu- 16. Wang KC, Shih HN, Hsu KY, et al: Intercondylar frac-
lar fractures of the distal humerus in the adult. Clin tures of the distal humerus: Routine anterior subcuta-
Orthop 219:99108, 1987 neous transposition of the ulnar nerve in a posterior
3. Giori NJ, ODriscoll SW: Continuous passive motion operative approach. J Trauma 36:770773, 1994

Address reprint requests to

Shawn W. ODriscoll, MD, PhD
Medical Sciences Building, 369
Mayo Clinic
200 First Street SW
Rochester, MN 55905

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

Douglas P. Hanel, MD, Marci D. Jones, MD,
and Thomas E. Trumble, MD

Historically, fractures of the distal portion menopausal women with dual-energy x-ray
of the radius often were thought of as dislo- absorptiometry (DXA) within 2 weeks of
cations of the carpus. Hippocrates described fracture and found that half of the patients
4 directions of dislocation of the carpus; these had osteoporosis at the spine, hip, or radius.
descriptors were used until the eighteenth Patients younger than age 65 years had signif-
century. Pouteau, continuing the work of Petit, icantly lower bone mineral density (BMD) at
began to recognize these injuries as likely frac- the hip compared with age expected values.
tures most often taken for contusions, luxa- Similarly, Wigderowitz et at 43 measured BMD
tions incomplete, or for separation of the ra- by single-photon absorptiometry in 31 women
dius from the ulnar at their junction near the with Colles fracture and compared this with a
wrist. Colles, whose name is associated most control group of similarly aged women. They
often with fractures of the distal radius, pub- found that 25 of 31 women had BMD less than
lished a seminal article in 1814 describing in- 1 standard deviation below the control group
juries to the wrist as fractures and comment- and that in patients younger than age 66 years,
ing on treatment and outcome. This article BMD was signicantly lower than that in the
shifted the focus away from treatment of dis- control group. Currently the World Health
location and onto recognition and treatment of Organization advises that fracture of the distal
fracture.13 radius in a postmenopausal woman is an
Distal radius fractures account for 14% of indication for evaluation of BMD, and the Na-
all extremity injuries and 17% of all fractures tional Osteoporosis Foundation recommends
treated in the emergency department.19 Distal bone density testing for all postmenopausal
radius fractures occurring as a result of a high- women presenting with a fracture. Freed-
energy injury represent a subset of fractures, man et al15 reviewed a national insurance
often with resultant signicant injury and im- database to evaluate the rate of diagnosis or
pairment to the upper extremity. These frac- treatment for osteoporosis within 6 months
tures frequently have a high degree of com- of distal radius fracture in women older than
minution, instability, and associated soft tissue age 55. Of the 1162 patients included in the
injuries. study, the authors found that less than 3%
In older age groups, more women than underwent BMD evaluation, and less than
men have fractures of the distal radius, often 23% were treated with at least one medication
resulting from low-energy falls. The rela- for osteoporosis (estrogen, bisphosphonates,
tionship between distal radius fracture and or calcitonin). These studies underscore the
osteoporosis has been evaluated. Earnshaw importance of recognizing the association of
et al10 evaluated 106 of 149 consecutive post- distal radius fracture with osteoporosis, and

From the Department of Orthopaedics and Sports Medicine, Section of Hand and Microvascular Surgery, University
of Washington, Harborview Medical Center, Seattle, Washington (DPH, MDJ, TET); and Department of Orthopaedic
Surgery, University of Arizona, Tuscon, Arizona (MDJ)



36 HANEL et al

counseling patients appropriately to decrease

risk of future fracture.


The distal radius articular surface is angu-

lated 20 in the anteroposterior view and 5
to 11 in the lateral plane (Fig. 1). The dor-
sal cortex is thickened to form Listers tuber-
cle and the osseous prominences supporting
the radial wrist extensors in the second dor-
sal compartment. A central ridge divides the
articular surface into the scaphoid and lunate
facets (Fig. 2). A second articular surface ex-
ists in the sigmoid notch, where the radius ar-
ticulates with the ulna at the distal radioulnar
joint (DRUJ). These areas of bony thickening
direct the dissipation of energy delivered to Figure 2. Anteriorposterior radiograph. Bony ridge (aster-
the wrist and account for the frequently seen isks) divides the distal radius into a scaphoid fossa and lu-
nate fossa. Second articulation occurs between the radius
fractures occurring between the scaphoid and and ulna (double-lined circle).
lunate facets of the radius. The nature of the
applied load alters the exact fracture pattern
and may cause coronal or sagittal splits in the of the radius, inserting onto the radial sty-
lunate or scaphoid facets. loid. The remaining extrinsic wrist tendons in-
The soft tissue structures about the dis- sert more distally in the extremity. The extrin-
tal radius also may contribute to the fracture sic ligaments of the wrist, the scapholunate
pattern. The triangular broscartilage extends interosseous and lunotriquetral interosseous
from the rim of the sigmoid notch to the ul- ligaments, hold the scaphoid, lunate, and tri-
nar styloid. Fracture of the ulnar styloid, par- quetrum in place and form a smooth surface
ticularly at its base, may represent instability for articulation with the scaphoid and lunate
of the DRUJ. The brachioradialis tendon is the facets of the distal radius and the triangu-
only tendon to insert onto the distal portion lar brocartilage. Most distal radius fractures

Figure 1. Anteroposterior and lateral radiograph. Coronal ra-

dial inclination is 21 radial inclination. Saggital radial articu-
lar surface is tilted 5 to 11 palmarward palmar tilt.

result from compression forces during a fall. plete articular. Each of these is subdivided
The scaphoid and lunate may split apart as the into three subgroups based on fracture pat-
radius fractures. Likewise, distracting forces tern, degree of comminution, and associated
that result in avulsion fractures of the radial injuries. Kreder et al27 have shown that when
styloid may lead to the scaphoid being pulled intra-observer and interobserver variability is
apart from the lunate following the common taken into account, only the 3 main categories,
perilunate dislocation pattern. extra-articular, partial articular, and complete
articular, nd consistent agreement. The Uni-
versal Classication (Table 1) shows 4 main
groups of fractures, based on intra-articular
CLASSIFICATION extension, displacement, and metaphyseal
stability.8 This classication also proposes a
Myriad classication schemes exist for fra- treatment algorithm based on the classica-
ctures of the distal radius and ulna, varying tion. Fernandez and Jupiter14 propose a similar
on mechanism, fracture pattern, degree of classication that separates fractures into ve
comminution, or intra-articular extent. Tradi- main types based on mechanism: bending
tional fracture eponyms include Colles (extra- of the metaphysis, shearing of the articular
articular fractures with dorsal displacement surface, compression of the articular surface,
of the distal fragment), Bartons (either dorsal avulsion and radiocarpal fracture-dislocation,
or palmar marginal rim fracture with subluxa- and combined-complex open injury (Fig. 3).
tion of the carpus), Smiths (intra-articular or This system also gives guidelines for treat-
extra-articular fractures with palmar displace- ment based on fracture type and includes
ment of the distal fragment), Hutchinsons associated DRUJ pathology as stable, unstable,
or Chauffeurs (shear fracture of the radial or potentially unstable.
styloid often associated with scapholunate
dissociation), and others. The most useful clas-
sication system would be easy to understand
and reproduce. It would give useful informa- HISTORY AND
tion about mechanism of injury and treatment PHYSICAL EXAMINATION
and allow for meaningful comparison across
series of fractures to evaluate outcome. Al- Most patients with distal radius fractures
though some systems come close, none fulll initially are evaluated in the emergency
the desired goal. The AO classication is department. It is important that this initial
detailed, with three main categories of frac- examination include the history of the injury
ture: extra-articular, partial articular, and com- to assist in determining the degree of energy


Classication of Fracture Preference Treatment
I. Nonarticular, nondisplaced Cast/splint immobilization
II. Nonarticular, displaced Cast/splint immobilization
a. Reducible, stable Percutaneous pins
b. Reducible, unstable external xation
c. Irreducible Open reduction and internal xation external
III. Articular, nondisplaced Cast immobilization percutaneous pins
IV. Articular, displaced
a. Reducible, stable Closed reduction/percutaneous pins
b. Reducible, unstable Closed reduction external xation percutaneous
c. Irreducible Open reduction percutaneous pins internal
xation external xation
d. Complex Open reduction/external xation; plate xation
+ bone graft percutaneous pins

Included are volar shearing fractures, open fractures, fracture-dislocations and joint depression fractures.
Data from Cooney WP: Fractures of the distal radius: A modern treatment-based classication. Orthop Clin North Am 24:211216,
38 HANEL et al

Figure 3. Fernandez classication of the distal a-radius fractures. A, Bendinglow energy injury.
B, Shearingthese include volar, dorsal, and radial axial load resulting isolated articular fractures.
This is a volar shearing type. C, Compressionthe most common radius fracture. Direct axial load re-
sults in fractures about the distal radioulnar joint and the radiocarpal joint. D, Avulsion and radio-carpal
fracture dislocationthe radius portion of these injuries can appear to be quite simple (black arrows),
the associated perilunate fractures and dislocations (curved arrow, right panel).
Illustration continued on opposite page

involved. Evaluation for concomitant injuries nerves. In the emergency setting, Cooney et al9
is imperative. The carpus should be evaluated reviewed 565 cases and found persistent
for fractures or fracture-dislocations. Vascular neuropathy in 31%. If patients do not expe-
compromise occurs rarely, but neurologic rience improvement of sensibility after re-
lesions are relatively frequent. Objective mea- duction or if sensibility worsens over serial
sures of sensibility should be documented. examinations, one should measure carpal tun-
Monolament, vibratory, or 2-point discrimi- nel pressure and if elevated proceed directly
nation before and after reduction are essential. with an urgent carpal tunnel release. (The se-
Nerve decit most often involves the median nior author [DPH] believes that deteriorating
nerve but also can involve the ulnar or radial objective sensory ndings after distal radius

Figure 3 (Continued ). E, Combined-complex: Any of the aforementioned as-

sociated with open fractures. This injury resulted from the hand being caught
in a pulley system. (Modied from Fernandez D, Jupiter J: Fractures of the dis-
tal radius. A practical approach to management. New York, Springer, 1996;
with permission.)

manipulation is all that is necessary to warrant sured in degrees as the angle between a line
operative intervention. He combines fracture drawn parallel to the distal radius articular
stabilization with a carpal tunnel release.) surface and a line parallel to the radial shaft.
The ulnar variance, in millimeters, also is mea-
sured on the anteroposterior lm. The ulnar
RADIOGRAPHIC EVALUATION variance is the distance from a line drawn par-
allel to the ulnar head articular surface to a
Radiographic evaluation includes antero- line drawn tangential to the lunate facet of the
posterior, lateral, and oblique views; these distal radius perpendicular to the shaft of the
views show the extent and direction of the radius.28, 37
initial displacement. After closed reduction, Evaluation of the intra-articular extent of
radiographs should be repeated to identify the fracture is crucial. Knirk and Jupiter25
the residual deformity and the amount of found that 2.0 mm or greater of distal radial
comminution. Most measurements reference articular displacement can lead to posttrau-
the anteroposterior and lateral views; these are matic arthrosis. Trumble34 evaluated factors
described in the following section. The oblique affecting outcome in displaced intra-articular
view helps evaluate intra-articular step-off fractures and suggested that a substantial de-
and diastases.33 crease in patients functional results occurred
Measurement of the extra-articular align- with a postoperative gap of greater than
ment of the distal radius is necessary to deter- 1.0 mm, based on readings of postoperative
mine if fracture alignment is adequate. Palmar radiographs by 1 author at 1 point in time. The
inclination is measured on the lateral radio- ability to evaluate radiographs to this degree
graph in degrees, as the angle between a line of accuracy also has been examined. Kreder
drawn parallel to the distal radius articular et al28 reviewed 16 raters of various training
surface and a line parallel to the shaft of the and experience to determine the intraobserver
radius (see Fig. 1). A negative palmar inclina- and interobserver variability in the aforemen-
tion indicates that the distal radius articular tioned measurements of healed fractures on
surface is dorsally angulated. On the antero- standard radiographs. These authors found
posterior radiograph, ulnar inclination is mea- that extra-articular measurements, including
40 HANEL et al

ulnar variance and palmar inclination, have

a higher rater agreement, but that even ex-
perienced clinicians did not agree with them-
selves or others on intra-articular measure-
ments. Using their methods, it is expected
that two randomly chosen orthopedic clini-
cians measuring step and gap deformity will
differ by greater than 3 mm 10% of the time,
and repeated measurements by the same
clinician can be expected to differ by more
than 2 mm 10% of the time. Disagreement re-
garding 1-mm displacement occurs more often
than not.
In an attempt to evaluate better the frac-
ture pattern and components, plain or com- Figure 4. Articular step-off can be assessed with sagittal
puted tomography (CT) is useful to determine CT scans. This method is performed by matching a tem-
plate to the radius of curvature of the distal radius. Two
if surgery is recommended when the amount points are then made on the subchondral surface of the
of displacement is unclear or the fracture pat- fragments (a and b) to be measured, and a line is drawn
tern is difcult to visualize on plain radio- through the geometric center of the circle to the point
graphs. These scans are made in the sagittal on the more displaced fragment. A third point is made
intersecting the line and the arc of the circle (c). Step
and coronal planes, oriented along lines par- displacement is measured by determining the distance
allel to the shaft of the radius. CT scanning between point b and c. Diastases is measured by deter-
is highly recommended in die-punch fractures mining the distance between the two points on the arc of
(with central depression of the articular sur- the circle, a and c. (Modied from Cole RJ, Bindra RR,
face), volar rim fractures, and fractures involv- Evanoff BA, et al: Radiographic evaluation of osseous dis-
placement following intra-articular fractures of the distal
ing the scaphoid facet.40 radius: Reliability of plain radiography versus computed
Cole et al7 evaluated the reliability of CT tomography. Am J Hand Surg 22:792800, 1997; with
compared with plain radiography to deter- permission.)
mine better its utility for detecting small
displacements of articular fragments. They
looked for a reliable and reproducible method
for measurement of fracture displacement. TREATMENT
These authors had 5 independent blinded
observers evaluate plain radiographs and CT Background
scans of 19 acute intra-articular distal radius
fractures and determined that there was a Treatment of distal radius fractures is con-
poor correlation between plain lms and for troversial; there is no single denitive treat-
displacement of greater than 2 mm and that ment method that is considered the standard
30% of plain radiographs signicantly over- of care. Published clinical trials directly com-
estimated or underestimated displacement paring treatment regimens of indirect reduc-
compared with CT. Additionally, they found tion, external xation, and percutaneous pin-
the most reliable method of measurement ning with open reduction and internal xation
on CT was the arc method. This method is for intra-articular fractures are lacking. The re-
performed by matching a template to the sults of the currently published data are dif-
radius of curvature of the distal radius (Fig. 4). cult to compare. Most studies are retrospec-
Two points are made on the subchondral tive in nature and use various classications
surface of the fragments to be measured, and inconsistent outcome tools, especially in
and a line is drawn through the geometric regard to comminuted fractures with joint
center of the circle to the point on the more incongruity.
displaced fragment, and a third point is made Kreder et al26 presented results of a multi-
intersecting the line and the arc of the circle. center randomized, controlled trial of 147 pa-
Step displacement is measured by determin- tients younger than age 75 years with dis-
ing the distance between the point on the placed intra-articular distal radius fractures
arc of the circle and the displaced fragment; followed prospectively. Patients were ran-
diastass is measured by determining the domized into two groups. Group 1 was treated
distance between the 2 points on the arc of the with indirect reduction and percutaneous
circle. xation, with or without external xation.

Group 2 was treated with open reduction and Closed Reduction Versus
internal xation and bone graft as needed. Open Reduction
Surgical goals for both groups were the
same: Despite emphasis on invasive fracture man-
agement, some distal radius fractures can be
Ulnar inclination greater than 10 managed closed. Making the choice between
Palmar inclination greater than or equal closed and various open procedures can be as-
to 0 sisted by the universal classication (see Table 1)
Ulnar variance of 0 mm combined with the following 4 parameters8 :
Articular diastases and displacement of less
than 2 mm 1. Patient age. As the age of the popula-
A stable DRUJ tion increases, the viability and recreation
of individuals who by age alone would
If in the case of group 1 the goals could have been considered inactive in past gen-
not be met, patients were treated open and erations has changed markedly. The de-
placed in group 2. Evaluation 6 months after mands for an excellent repair of a dis-
treatment included general health status, tal radius fracture in 70-year-old skiers,
Jebson-Taylor hand function testing, grip snow boarders, golfers, and rowers are
and pinch strength, pain, return to work, and the same as those of 30-year-olds.
complications. Results at 6 months showed 2. Articular step-off. As noted earlier, artic-
that patients treated with indirect reduction ular displacement greater than 2 mm is
and percutaneous xation had signicantly signicant.28
better function than patients treated with open 3. Metaphyseal instability dened as:
reduction and internal xation. No signicant a. Fractures with volar obliquity, dis-
differences were seen in Jebson-Taylor scores, placed more than 2 mm (Fig. 5). These
grip and pinch strength, and range of motion. fractures require xation to push the
Further follow-up at 2 years revealed that the palmarly displaced fragment into
functional status had nearly equalized and its reduced position and to butters it
that pain scores were similar for the treatment while it is healing.11
groups at 6 months and 2 years. From these b. Die punch fractures, because even if the
data, it is evident that indirect reduction, ex- articular realignment is procured, the
ternal xation, and percutaneous xation are metaphyseal void would not support
appropriate if the radiographic parameters set the reduction.
by Kreder et al26 can be achieved. Similarly, if
the radiographic parameters cannot be met,
open reduction and internal xation should
be undertaken. Based on this study, the au-
thors use the radiographic parameters listed
previously as their treatment goals.
Kapoor et al23 achieved similar results
when 90 patients with closed intra-articular
fractures were treated randomly with closed
reduction and plaster immobilization, exter-
nal xation, or open reduction and internal
xation, with follow-up at an average of
4 years. Although it is difcult to determine
their randomization protocol, the treatment
groups showed no signicant differences
in age, sex, or fracture classication. Plaster
immobilization was inadequate in main-
taining reduction in most patients. External
xation improved functional scores (based
on residual deformity, subjective evaluation,
objective evaluation, and complications), and Figure 5. Volar shearing injuries can not be pulled into
position because they need to be pushed. This applies
open reduction and internal xation best cor- to the isolated volar shearing injuries (A) as well as the
rected palmar angulation and intra-articular volar ulnar corner (asterisk ) involved in compression type
step-off. fractures (B).
42 HANEL et al

c. Fractures with greater than 20 of dor- Closed Reduction

sal angulation or dorsal comminu-
tion greater than one third of the Whether a fracture can be treated open
anteroposterior diameter of the radial or closed is centered about the ndings at
shaft. Although potentially reducible, the time of closed reduction. Although most
the axis of rotation falls volar to the high-energy injuries require open reduction,
midaxis of the radial shaft, and the ex- invaluable information regarding metaphy-
trinsic forces acting on the distal frag- seal comminution, volar stability, and artic-
ment promote dorsal displacement. ular depression can be gleaned from closed
d. Any fracture that loses reduction reduction.
within weeks of initial treatment. Agee1 described an excellent method of re-
Although this may seem redundant, duction that takes advantage of ligamento-
it is included here to emphasize the taxis, provides detailed information regarding
point that the closed treatment of metaphyseal stability, and when used in the
distal radius fractures requires weekly setting of a stable fracture allows closed treat-
vigilance. By denition, progressive ment without placing undo pressure on the
displacement after reduction implies contents of the carpal tunnel. The reduction
failure to appreciate instability. is performed as follows. After adequate anal-
4. DRUJ stability. DRUJ stability is deter- gesia or anesthesia has been obtained, nger
mined after reconstruction of the radius. traps are placed on the index and long n-
Melone32 pointed out that reconstruction ger, and 1016 of longitudinal traction is ap-
of the sigmoid notch frequently leads to plied. Ten minutes is allowed to pass, then the
stabilization of the DRUJ and in so do- metacarpal-carpal complex is translated pal-
ing emphasizes that consideration of the marward, while the hand is pronated slightly
unstable ulnar joint always should be relative to the forearm. Wrist exion and forearm
preceded by reduction and xation of the pronation is avoided with this maneuver (Fig. 6). If
radius, specically the sigmoid notch. viewed with image intensication, one would

Figure 6. The reduction maneuver described by Agee. A, Longitudinal traction which restores length.
B, Palmar translation of the hand relative to the forearm, along with slight pronation of the hand rel-
ative to forearm restores volar tilt (and determines the extent of volar integrity). (Modied from Agee
JM: External xation. Technical advances based upon multiplanar ligamentotaxis. Orthop Clin North
Am 24:265274, 1993; with permission.)

note that length is restored with traction and

that palmar tilt and ulnar inclination are re-
stored with palmar translation and pronation
of the hand. If articular step-offs continue af-
ter reduction, percutaneous or open methods
would be required. If the distal radius fracture
fragments translate palmar to the radial shaft,
there is inadequate volar support, and buttress
plating is essential.

Closed Reduction and Splint

or Cast Alone

If the goals of reduction are met (see previ-

ous list) and there is no evidence of metaphy-
seal instability, cast or splint immobilization is
recommended. A long arm thumb spica splint
with the forearm in supination and the thumb
interphalangeal joint free is used for the rst
week and changed to a circular cast the second
and third weeks. The forearm is supinated to
overcome the pull of the brachioradialis, and a
thumb spica is worn to prevent irritation of the
radial sensory nerve by the leading edges of Figure 7. Closed treatment demands vigilance. This frac-
ture displaced 3 weeks after cast application.
cast that do not include the thumb. The wrist
is maintained in a neutral position through-
out treatment. A short arm cast is worn dur- Multiple external xators are available.
ing weeks 3 through 6. If closed reduction and They differ in variation of pin placement,
casting is the chosen treatment, weekly or at stiffness, ability to adjust after placement, and
least biweekly radiographs are imperative. Ra- cost. Frykman et al16 evaluated 13 external
diographs must be compared with the origi- xators for weight, cost, rigidity in different
nal postreduction radiographs. Changes in the planes, ability for controlled adjustment of
alignment may occur slowly, and what seems fracture reduction, ability to dynamize, and
to be a subtle difference compared with the ability to be placed radius to radius. These au-
previous weeks radiographs may be dramat- thors concluded that the selection of a specic
ically different from the postreduction lm device depends mostly on ease of application
(Fig. 7). and the surgeons familiarity with the device.
They suggested that dynamic xators, which
External Fixation allow early joint motion, would be benecial.
Studies suggest the opposite, however. Recur-
External xation overcomes the muscular rent dorsal angulation and nearly 20% fair or
pull of the forearm (i.e., it holds the fracture poor radiographic results were reported when
out to length) (Fig. 8). In the setting of signif- using dynamic wrist xators.20, 24, 38
icant metaphyseal comminution, a xator al- Augmentation of the external xator with
lows alignment of the articular surface with a radial styloid or dorsally placed Kirschner
the shaft of the radius without reliance on the wire xation is recommended in fractures in
support of the metaphysis. External xators which an articular reduction was obtained.
cannot reduce displaced intra-articular frac- Wolfe et al44, 45 and Weiland42 showed that ad-
tures. Indications for external xation include: ditional xation signicantly reduces move-
ment at the fracture site and increases the sta-
1. Longitudinal traction for extra-articular bility of extra-articular fractures.
fractures with an unstable metaphysis McQueen et al,30 reviewing their experience
2. An indirect reduction assistant during with radius-to-radius xation, found it to
open reduction and internal xation be a favorable adjunct to fracture manage-
3. An adjunct to percutaneous pin xation ment. Radius-to-radius xation is the one
4. Spanning open fractures method of external xation that can restore
44 HANEL et al

Figure 8. Radiographs of three commonly used xator congurations. A, Typical bridging external x-
ator with two pins in the second metacarpal and two pins in the radius shaft. B, Nonbridging xator
with distal pins in the subchondral bone. C, An internal splint introduced through separate forearm
and hand incision. The plate is passed along the second dorsal compartment. The implant used in
this case is a 2.4-mm Synthes (Synthes USA, PA) mandibular reconstruction plate. It was removed
10 weeks after placement.

and maintain palmar angulation. Although can be passed more easily through the second
McQueen et al30 suggested using this method dorsal compartment of the wrist. An example
for intra-articular fracture, the authors have is shown in Figure 8C.
limited their experience to extra-articular fra- Placement of the xation pins into the ra-
ctures with metaphyseal comminution as dius and metacarpals is done under anesthesia
shown in Figure 8B. with image intensication. The reduction
Another unique variation of external xa- described previously is performed, and the
tion is the percutaneous application of a xa- proximal pins are inserted. Multiple small
tion plate that spans the wrist from the radial incisions (1 to 2 cm) or one large incision (2.5
diaphysis to the second or third metacarpal. to 3 cm) is made along the radial border of the
A 3- to 5-cm incision is made proximal to forearm in the area of the planned pin place-
the outcropping muscles. The plate is intro- ment. Care must be taken to avoid the interval
duced deep to those muscles, passed through between the extensor carpi radialis longus and
the second dorsal compartment, and afxed brachioradialis. The radial sensory nerve runs
to the second metacarpal through a separate in this interval. Instead the interval between
incision. This xator-internal is removed 8 to the extensor carpi radialis longus and extensor
10 weeks later. Burke and Singer5 introduced carpi radialis brevis is identied. The extensor
the technique and have used it in more than carpi radialis longus is retracted palmarly, the
300 cases. The authors nd this technique to extensor carpi radialis brevis dorsally, and the
be particularly helpful in the management radial bone surface identied (Fig. 9). Under
of multiply-injured patients, in whom inter- direct vision, a drill guide is placed, and the
nal xation would not be otherwise neces- xator pins are passed through both cortices
sary and external xation adds a burden to using uoroscopic guidance. The distal pins
nursing care. Also, the rigidity of such a con- are placed similarly into the radial surface of
struct is far greater than any other external the index metacarpal; the rst pin is placed in
xator that allows weight bearing for bed- the proximal metadiaphyseal junction, and the
to-chair transfers or in conjunction with ambu- more distal pin is directed by the congura-
latory assist devices.3, 4 Burke and Singer5 used tion of the xator clamps. Terminal branches
3.5-mm Synthes dynamic compression plates. of the radial sensory nerve must be protected
The authors use 2.4-mm plates from the Syn- during distal pin placement.36 Whether or
thes mandibular reconstruction set. The holes not pins are predrilled depends on the tip
in this 2.4-mm plate accommodate a set screw conguration. Drill-tipped pins are becoming
interface such that the construct becomes a increasingly popular; those that are not should
xed angle device and the smaller plate size be predrilled.

Drill guide and fixator pin


Radius Brachioradialis

Ulna Radial nerve

Fixator pins between

Incision for fixator pin

Sensory branch
of radial nerve

External fixator




Figure 9. The interval for safe passage of external xator pins is be-
tween the extensor carpi radialis longus (ECRL) and extensor carpi ra-
dialis brevis (ECRB) tendons of the forearm. The insertion of distal pins
is along the lateral or dorsal lateral aspect of the second metacarpal.
(From Trumble TE, Culp R, Hanel DP, et al: J Bone Joint Surg 80A
4:596, 1998; with permission.)

Percutaneous Pin Fixation With or equate closed reduction is achieved under

Without Limited Dorsal Approach image intensication. Smooth Kirschner wires
0.045 inch (1.1 mm) or 0.062 inch (1.6 mm)
Various congurations of percutaneously are used. Clancey6 popularized the use of
placed pins have been advocated for the 2 pins passed through the radial styloid and
stabilization of distal radius fractures.35 Percu- 1 to 2 additional pins passed through the
taneous pinning has been used for displaced distal dorsal-ulnar corner of the radius be-
extra-articular fractures with or without tween the fourth and fth compartments.
dorsal comminution, early loss of reduction The planned site for placement of the wires
after closed manipulation, and comminuted is evaluated under uoroscopy, and a small
intra-articular fractures when adequate closed incision is made for pin insertion. Blunt dis-
reduction is able to be obtained but likely not section exposes the bone surface, and a tissue
maintained without addition support.19 guard protects the radial sensory nerve, while
Interfocal pinning, pins passed through the wires are drilled through the fracture
fracture fragments, is appropriate when ad- fragments (Fig. 10A).
46 HANEL et al

can be achieved through a limited dorsal ap-

proach and the need for an arthrotomy is cir-
cumvented. If there is an associated radial
styloid fracture, 0.062-inch (1.6-mm) pins are
drilled into the styloid and directed to but not
across the fracture line. One pin is directed
proximally to capture the radial shaft, and
the other pins are passed immediately sub-
chondral to the ulnar extent of the scaphoid
fossa. A small (< 3 cm) incision is made adja-
cent to Listers tubercle, and blunt dissection
identies the fracture fragments. Assisted by
image intensication, small elevators, dental
picks, and free-hand Kirschner wires are used
to reduce the die-punch fragment. The pre-
viously placed Kirschner wires also are used
as joysticks and are driven across the fracture
Figure 10. A, Interfocal pinning technique with wires site when proper alignment is procured. Addi-
passing through the reduced facture fragments into the tional Kirschner wires or small (2.0 to 2.7 mm)
metaphyseal bone. One or two pins support the radial sty- plates can be used to buttress the reduction. In
loid and one pin supports the dorsal ulnar corner. B, With
intrafocal pinning, the pins are introduced into the frac- most cases, the authors pack bone graft into
tures and used as levers to restore volar tilt and radial in- the metaphyseal defect left by the die-punch
clination. When the reduction is completed, the pins are fracture (Fig. 11).
driven into the far cortex. Pins that are to remain in place for less
than 6 weeks are left protruding from the skin.
Pins that are to be left in place longer than
Intrafocal pinning, promoted by Kapandji,22 6 weeks are buried. Pins that left out of the
places 0.062-inch (1.6 mm) Kirschner wires di- skin and external xation pins are treated sim-
rectly into the fracture site. One to 3 pins are ilarly. They are cleansed daily with dilute hy-
used to correct ulnar inclination and radial drogen peroxide, crusts are removed, and just
translation. The pins are passed through the enough dressings are applied to minimize the
fracture and along the radial cortex of the dis- motion about the pins. Ointments specically
tal radius, levered distally, then driven into the are avoided because they cannot seal a pin
opposite cortex in the anteroposterior and lat- tract and serve only to trap bacteria about the
eral planes. If more than 1 pin is used, they pin site. If pin sites become inamed a short
are placed between the rst and second com- course (5 to 7 days) of a broad-spectrum oral
partments, dorsal to the second compartment antibiotic is prescribed, and pin tract care is
and into Listers tubercle. Additional pins are reinforced. If the inammation continues and
placed dorsally to correct the palmar inclina- the pin is crucial to the fracture stabilization,
tion (Fig. 10B). Results of intrafocal pinning it is replaced through a distant incision. If the
alone are better in younger patients, likely ow- pin is not crucial, it simply is removed.
ing to better bone quality and the ability to
maintain reduction. Trumble et al41 reviewed
their experience with intrafocal pinning with
and without external xation in 61 patients, Operative Approaches to
23 of whom were older than age 55. The re- Distal Radius
sults suggested that intrafocal pinning alone
in older patients is functionally and radio- Three approaches, two volar and one dorsal,
graphically inferior to intrafocal pinning com- are used most frequently for exposure and x-
bined with external xation. In younger pa- ation of the distal radius. The approach chosen
tients, intrafocal pinning was not affected by is based on the conguration of the frac-
the use of external xators. ture and the planned placement of xation.
Percutaneous pin xation increasingly is Although most high-energy injuries are
combined with a small incision through which treated through a dorsal incision, the essen-
elevators or Kirschner wires are used as joy- tial rst step is to determine whether or not
sticks to manipulate fracture fragments. This palmar stability exists. As detailed in the
approach is particularly helpful in patients section on closed reduction and reiterated
with a die-punch fracture, in which elevation here, a uoroscopically assisted reduction is

and xation. If the palmar support is stable the

authors use a dorsal approach.

Radial and Ulnar Volar Approaches

The choice of a radial or ulnar volar ap-
proach is based on the fracture pattern and
the exposure necessary for reduction. A ra-
dial volar, or Henry, approach is used for frac-
tures involving the palmar radial surface or
for large, 1-piece shear fractures of the pal-
mar surface. Comminuted fracture patterns
that include a fracture of the volar ulnar sig-
moid notch necessitate a volar ulnar exposure.
This exposure, variously named as an extended
carpal tunnel incision or the universal approach,
allows direct line of sight for reduction and
placement of xation devices.20a
The volar radial approach is the most com-
monly used palmar approach and uses the in-
terval between the exor carpi radialis (FCR)
and the radial artery. An incision is made
just radial to the FCR tendon, and careful
dissection protects the radial artery, which
usually is retracted radially with the brachio-
radialis. The FCR and other exor tendons are
retracted ulnarly, and the pronator quadratus
Figure 11. A, Radiographs of a 34-year-old carpenter is elevated from the radial surface of the distal
2 weeks after injury. Longitudinal traction resulted only in radius (Fig. 12). This exposure can be extended
volar translation of the large volar portion of the lunate sul-
cus. B, Using an extended carpal tunnel approach, the distally by releasing the FCR from its attach-
volar fragment was manipulated under direct vision and ments to the trapezium. This release allows vi-
the reduction held with a 2.7-mm Synthes plate. The ra- sualization of the radial styloid and volar rim
dial styloid was pulled out to length and transxed with of the distal radius. The volar carpal branch
a k-wire. Dorsal metaphyseal comminution was pushed
against the now intact volar cortex and an external xa-
of the radial artery usually is encountered
tor was used to reinforce the reduction. C, The external and divided in the extended exposure. Frac-
xator and k-wire were removed 6 weeks after reduction. ture fragments are reduced and temporarily
These radiographs were obtained 6 months postopera- held with Kirschner wires. In cases in which
tively (From Hanel DP: Volar plate xation of distal ra- the radial styloid is a single large fragment
dius fractures. Atlas of Hand Clinics 2:124, 1997; with
permission.) and the remainder of the volar radius is in-
tact, the radial artery is mobilized toward the
FCR, and the brachioradialis insertion is di-
carried out on the anesthetized limb. Longi- vided. This dissection and reduction can be fa-
tudinal traction is applied, while the hand cilitated further with subperiosteal elevation
is translated palmarward against a stable of the rst dorsal compartment from the dis-
forearm. If the fracture translates beyond tal radius. Similar to the other volar fragments,
the palmar extent of the radius or the carpus the styloid is reduced and held with multi-
subluxates palmarly, palmar instability exists ple Kirschner wires. If the dorsal cortex of
(see Fig. 11A). Malunion is prevented with a the radius is intact, xation plates can be ap-
volar buttress support. Melone32 pointed out plied with the central portion of the plate el-
the volar fragments may include the ulnar evated 1 to 2 mm off of the underlying cor-
aspect of the sigmoid notch. The reduction tex. As the plate is afxed to the radius, it
of this crucial cornerstone of the distal radius acts as a spring pushing the fracture frag-
comes rst, and the remainder of the fracture ments together (Fig. 13). One should be cau-
fragments are built around it. To that end, tious with this technique; overenthusiastic ap-
if the previous reduction maneuver reveals plication leads to stenosis of the distal radius
palmar instability, the authors follow Melones articular surface. Failure to recognize dorsal
advice and proceed directly to volar reduction instability results in overreduction of the distal
48 HANEL et al

Figure 12. Standard anterior approach. A, The incision starts at the distal wrist crease, adjacent to the
exor carpi radialis and extends proximally to the junction of the mid and distal one-third of the fore-
arm. The interval between the exor carpi radialis and the artery is widened and the distal radius ex-
posed. B, Cross section at wrist level demonstrating the interval of dissection. (Modied from Hanel
DP: Volar plate xation of distal radius fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)

radius fracture, reversing the sagittal articu- ring nger. (The hypothenar crease is a read-
lar angle of the radius. Radial styloid fractures ily available landmark.) At the distal palmar
can be maintained with Kirschner wires or ap- crease, the incision travels ulnarly at 45 un-
plication of a recently developed xation plate til coming to within 5 mm of the radial bor-
that incorporates the Kirschner wires into an der of the exor carpi ulnaris. At this point,
antiglide construct (Fig. 14). the incision is aimed 90 radially toward the
The second volar approach uses the distal junction of the mid and distal one third of the
portion of an incision described for extensile radius diaphysis. In the distal extent of this in-
exposure of the median nerve, release of fore- cision, the palmar fascia and transverse carpal
arm compartmental syndromes, and manage- tunnel ligament are divided. Proximally the
ment of distal forearm fractures (Fig. 15). The forearm fascia is divided, and the interval be-
incision starts at the midpalm and is directed tween the ulnar neuromuscular bundle and
proximally in line with the radial aspect of the contents of the carpal tunnel is developed.

First screw Contact
placed here point

Figure 13. Spring plate applied with a 12 mm gap. The fragments are
pushed together as the screws are secured. An intact dorsal cortex is
essential. (Modied from Hanel DP: Volar plate xation of distal radius
fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)

Figure 14. A Trimed (Trimed, Inc.,CA) xation system incorpo-

rates K-wires used for initial xation into the antiglide plates.

Figure 15. Extensile exposure of the carpal tunnel and distal radius. A, The incision starts at the mid-
palm and crosses the wrist creases in an ulnar oblique direction. When the radial border of the exor
carpi ulnaris is encountered, the incision is directed radially. B, The contents of the carpal tunnel are
retracted radially. The ulnar neurovascular bundle is retracted ulnarly (a). In rare incidences, interval
(b) is developed, but it puts the palmar cutaneous branch of the ulnar at risk. (Modied from Hanel DP:
Volar plate xation of distal radius fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)
50 HANEL et al

The pronator quadratus is divided at its ori- ing the skin aps proximal to the wrist creases,
gin and lifted radialward off of the volar ra- protecting the palmar cutaneous branch of the
dius. As the radius is exposed, the contents median nerve and developing the interval be-
of the carpal tunnel fall forward and are re- tween the FCR and the radial artery as de-
tracted easily from the fracture site. This ex- scribed for the rst exposure.
posure allows direct visualization of the whole When the fracture fragments are assessed
of the distal radius, especially the sigmoid and the personality of the fracture determined,
notch; releases the carpal tunnel; and is di- reduction and provisional xation is carried
rected easily cephalad when forearm compart- out. The clinicians inclination may be to re-
ment releases are necessary. A problem with duce large radial styloid fracture fragments
this exposure is that the pronator quadratus rst, but this must be done with caution.
tends to be destroyed with the dissection and Malreduction of the radial styloid, however
frequently is discarded during the procedure. slight, makes the reduction of the volar ulnar
(One might consider this advantageous when corner difcult if not impossible. The volar ul-
removal of the pronator quadratus provides nar corner, should be reduced rst, and the
room for implants and compensates for soft distal radius should be built around this cru-
tissue swelling.) Whether the pronator teres is cial corner. Temporary xation is procured
preserved or not, care must be taken to pre- with Kirschner wires.31 Permanent xation is
serve the capsule of the DRUJ, especially the provided with a plate (2.0, 2.4, or 2.7 mm) con-
attachments to the volar ulnar fracture frag- toured to the volar surface. In the setting of
ments. Another problem with this approach is combined volar and dorsal comminution, the
exposing the radialmost aspect of the radial buttress plate must be contoured to take into
styloid. This problem can be overcome by ex- consideration the volar angulation of the dis-
tending the proximal limb of the incision to tal radius. If it is not, the distal radius is forced
the radial border of the forearm and mobiliz- into a reverse sagittal tilt malunion (Fig. 16B ).



Figure 16. A, This high-energy compression type facture is volarly and dorsally unstable.
B, The volar plate was contoured to the shape of the distal radius and can only serve as a
buttress. C, Dorsal exposure, bone graft and plates. D, Two years postrepair. Patient is pain-
free, distal radioulnar joint (DRUJ) is stable. There is loss of motion 20 of exion. Other wrist
and forearm motion is equal to the uninjured side.

In the most comminuted fractures, a second Neither volar approach allows visualization
dorsal incision may be necessary and the re- of the articular surface. The volar capsular
duction completed as described subsequently. ligaments are sacrosanct and should not be
Isolated volar shearing injuries deserve spe- violated in this exposure. Reduction is ob-
cial note. These inherently unstable fractures tained by cortical interdigitation of the meta-
come in three varieties: simple two-part frac- physeal portion of the fractures and observing
tures, three-part fractures that involve the the effect of the reduction with image inten-
radiocarpal and the radioulnar joint, and sication. If the reduction is questionable, the
fractures associated with metaphyseal com- fracture is visualized through a dorsal arthro-
minution. The volar radial approach is used tomy or by placing an arthroscope through
for the simple two-part fractures, whereas the space of Poirier volarly or the 34 portal
the volar ulnar approach is used for the more dorsally.
comminuted fractures. In two-part fractures,
the intact dorsal cortex can be used to advan-
Dorsal Approach
tage as previously shown in Figure 13. With
comminuted fractures, the amount of spring A longitudinal incision over the dorsum of
that is put into a plate should be tempered. the wrist just ulnar to Listers tubercle is made.
Overreduction leads to distal radius stenosis The extensor pollicis longus tendon is iden-
or reversal of normal volar tilt, both of which tied distally and followed to the third dor-
are associated with poor results.21 Reduction sal compartment over the wrist. This com-
of comminuted fractures starts at the crucial partment often is identiable by its distention
volar ulnar corner and builds from there. with hematoma because intra-articular frac-
Provisional Kirschner wire xation precedes ture splitting the scaphoid and lunate facets
plate application (Fig. 17). continues through the base of the third com-
partment, avoiding the thicker bone at Listers
tubercle. In most high-energy injuries, Listers
tubercle is a free-oating fragment with no ar-
ticular component. We usually remove it while
keeping capsular attachments intact. The third
and fourth dorsal compartments and dorsal
wrist ligaments are elevated sharply off of the
dorsal surface of the radius as a unit. This el-
evation obviates the need to repair the exten-
sor retinaculum at the time of closure, which
can be difcult because of swelling. If these
compartments are entered and not repaired,
A B the tendons bowstring with extension of the
wrist. The dissection stops at the ulnarmost
edge of the fourth compartment, preserving
the capsular attachment of the ulnar to the
dorsal sigmoid notch (Fig. 18).
Small elevators or probes are used to align
the articular fragments. The reduction is per-
formed under direct vision, conrmed by im-
age intensication. Similar to on the volar side,
C D the lunate fossa, including the sigmoid notch,
is reconstructed rst followed by scaphoid
Figure 17. A, The interdigitation of proximal fracture lines fossa and radial styloid. The reduction is sta-
(arrows) can be used as the template for reduction in bilized with Kirschner wires in the subchon-
most volar shearing fractures. The volar capsule should dral bone. Subcortical defects are supported
not be violated to procure reduction. B, The reduction
starts at the sigmoid notch and builds from there. C and
by bone graft and denitive xation often calls
D, Placement of the xation plate may require adjustment on the use of xation plates (see Fig. 16C, D).
of the provisional xation wires. Rather than changing the There are an increasing number of internal x-
position of a wire, as shown here, obstructing wire can be ation devices specially designed for the ra-
driven out the dorsum of the wrist, leaving just enough on dius or specic fractures of the radius. To date,
the volar surface of secure xation and not interfere with
plate placement. (Modied from Hanel DP: Volar plate x- none have proved to be superior to or a sub-
ation of distal radius fractures. Atlas of Hand Clinics 2:1 stitute for the surgeons ability to reduce the
24, 1997; with permission.) fracture. In this article, the implants used were
52 HANEL et al

Scaphoid Torn
Extensor digitorum articular scapholunate
comminus in surface ligament
compartment 4 of
extensor retineculum
Release EPL from
compartment 3


ECRL Distal radial Ulna


Figure 18. Dorsal exposure of the distal radius. A, Using a straight line incision oriented along the
base of the third metacarpal, Listers tubercle and the radial shaft, the dorsal retinaculum is exposed.
The third dorsal compartment is incised and the extensor pollicus longus is mobilized. B, The dorsal
joint capsule is incised radial to the fourth dorsal compartment. The capsule and the adjacent com-
partments are elevated as units off of the radius. The dissection stops ulnarly at the fth compartment
and radially at the rst compartment. The integrity of the scapholunate joint is determined in the distal
extent of the wound. Similarly, the capsule and second compartment are elevated. (From Trumble TE,
Culp R, Hanel DP, et al: J Bone Joint Surg 80A 4:596, 1998; with permission.)

designed to handle small fracture fragments with Kirschner wires supported with bone
not specic to the radius. They use 2-, 2.4-, and graft and stabilized further with dorsal plates
2.7-mm screws. (see Fig. 16). If the stability of the fracture con-
Closure is achieved by loosely suturing the struct is questionable, spanning xators are
edge of the fourth compartment capsule of the used. The xator can be a traditional exter-
wrist to the edge of the second or to what re- nal conguration or the internal xator champi-
mains of the third compartment. The extensor oned by Burke and Singer 5 (Fig. 19).
pollicis longus is left out of its sheath. This ten- Open fractures are addressed with aggres-
don does not bowstring owing to its oblique sive debridement, removal of all doubtfully
course across the wrist. viable tissue, and stabilization with either in-
ternal or external xation. Soft tissue cover-
age should be secured within 1 week of in-
High-Energy Injuries jury, and bone grafting is done when the soft
tissues have healed. In cases requiring skin
High-energy, complex intra-articular frac- grafts, we usually wait until the transferred
tures may require a dorsal and a volar ap- skin stops desquamating; this is usually 6 to
proach to achieve adequate reduction and 8 weeks after injury. In a closed high-energy
xation. As mentioned previously, it is rec- fracture, swelling often is extensive. In this
ommended that the volar rim undergo stabi- case, delaying the procedure several days until
lization rst, followed by a dorsal approach. the swelling has subsided is appropriate. The
Closure of the volar wound before making authors also decrease perioperative swelling
the dorsal incision helps tissue swelling and by limiting tourniquet time to that required
wound separation; however, delayed primary to isolate and protect crucial neurovascular
closure or split-thickness skin grafting may be structures and initial fracture reduction.
necessary to close the dorsal wound. Through High-energy injuries, especially those invol-
the dorsal exposure, intra-articular fractures ving shearing or avulsion of the radial styloid,
are reduced under direct visualization, xed frequently are associated with scapholunate

Figure 19. A, One of many fractures sustained by this patient included an intra-articular radius frac-
ture. B, Management included the reduction maneuver described in the text, percutaneous K-wire xa-
tion, and application of the internal splint. The plate was removed 10 weeks after injury. C and D, The
radiographic and clinical results 8 months after injury.

and other intercarpal injuries.18, 33 These If the DRUJ is stable in supination but not
should be treated with pin xation at the least pronation, treatment consists of splinting in
and repaired as part of any open procedure a long arm or Munster-type cast for 3 weeks
(Fig. 20). in supination, followed by 3 weeks of immo-
bilization in neutral pronosupination. If the
DRUJ is stable in pronation but not supina-
Treatment of the Distal Radioulnar tion, the authors reevaluate the reduction of
Joint and Associated Ulnar the volar-ulnar radius. If the reduction is satis-
Styloid Fractures factory, the ulnar head is reduced into the sig-
moid notch. With the forearm in mid prono-
Evaluating the stability of the DRUJ is supination, the reduction is maintained with
essential in the treatment of wrist fractures 20.062-inch (1.6-mm) Kirschner wires, placed
(Table 2). Although a sense of the degree of just below the articular surface of the ulnar
subluxation or dislocation can be obtained head. The authors do not recommend im-
from the initial injury radiographs, the deni- mobilizing the forearm in pronation because
tive assessment can be made only after of the difculty that patients have regaining
addressing the radius fracture. Frequently a supination postoperatively and because of the
grossly unstable DRUJ is secured with recon- increased deforming force of the brachioradi-
struction of the sigmoid notch. The stability of alis muscle on distal radius fractures when the
DRUJ is examined clinically and uoroscop- forearm is pronated.
ically in supination and pronation. A sense If the DRUJ is unstable throughout the
of the general stability of this joint can be range of motion, even with the sigmoid notch
obtained by examining the opposite uninjured reconstructed, treatment is based on 1 of
wrist preoperatively or intraoperatively. 3 radiographic ndings: no associated ulnar
54 HANEL et al

When an ulnar styloid fracture is associ-

ated with DRUJ instablity, it is likely that the
triangular cartilage complex is attached to
the styloid fragment. Fracture xation sta-
bilizes the DRUJ. Flexing the elbow 90 and
placing the forearm in maximal supination
reduces the fracture. If the fragment is large
enough, xation can be done percutaneously
with a 0.035-inch (0.89-mm) or 0.045-inch
(1.1-mm) Kirschner wire. If the closed reduc-
tion cannot be obtained, an incision is made
along the distal ulna immediately volar and
ulnar to the extensor carpi ulnaris tendon.
This exposure should be done while main-
taining elbow exion and forearm supination.
(Attempting to perform a reduction of ul-
nar styloid with the forearm in pronation,
outstretched on an arm table, proves to be
frustrating. The ulnar shaft and ulnar sty-
loid are misaligned by forearm pronation.)
Dissecting along the subcutaneous border
of the distal ulna exposes the fracture. Soft
tissue stripping stops when the fracture site is
encountered. Just distal to this point, the ulnar
Figure 20. This radial shearing injury had an associated styloid is palpated and reduced with a dental
scapholunate disruption. Treatment consisted of closed
reduction, screw xation of the radius, and open repair
pick. All soft tissue attachments are left on this
with K-wire stabilization of the intercarpal dissociation. fragment. Fixation of the fracture is secured
with Kirschner wires, cannulated screw, or
tension band wiring (Fig. 21A and B).
fractures, an associated ulnar styloid fracture, When DRUJ instability is associated with
or an associated ulnar neck fracture. When an ulnar neck fracture, the authors reduce
the ulnar head and styloid are not fractured, the fracture closed and introduce a 0.062-inch
two options can be exercised. First the ulnar (1.6-mm) wire in the ulnar styloid and pass
head can be reduced into the sigmoid, the fore- it down the medullary canal. Others have de-
arm placed in neutral pronosupination, and scribed using blade plates for these fractures
the reduction secured with Kirschner wires as (Fig. 21C and D).12
described previously. The second treatment
method is prompted by Geisslers nding17
Bone Graf t
that in these cases the triangular complex is
avulsed from the styloid and can be anchored Bone graft or bone graft substitutes fre-
back to the styloid through a limited incision quently are necessary in the treatment of dis-
or through arthroscopically assisted methods. tal radius fractures. Bone graft is used for


DRUJ Examination Recommended Treatment
Stable No treatment
Unstable in pronation/stable in supination Long arm cast in supination for 3 weeks,
neutral pronosupination for 3 weeks
Stable in pronation/unstable in supination Reduce and pin in neutral
Unstable in supination and pronation
No ulnar fracture Pin xation in neutral or supination
Ulnar styloid fracture Pin xation and/or tension band
Ulnar head fracture Transverse (blade) plate, intra-medullary
rod or pin xation

DRUJ = Distal radioulnar joint.


Figure 21. Fixation of the distal radioulnar joint. A, Two 0.062 inch
(1.6 mm) k-wires transx the distal ulna to the radius. The pins pur-
posely avoid the articular surface of the sigmoid notch. B, Tension
band xation. C, A K-wire or Stienman pin passes through the ulnar
styloid down the medullary. The pin is cut off at the level of the sty-
loid. D, This xed angled blade plate is an alternative to treatment of
unstable transverse ulnar meta-diaphyseal fractures.

fractures with signicant metaphyseal com- hematomas developed; these were not iden-
minution for added support of the articular tied by site. Minor complications included
surface during healing and to ll a bony void 5 supercial infections, 20 supercial seromas,
left by the comminuted fragments. Autoge- and 16 minor hematomas.2
nous bone graft is considered the standard There are multiple allograft preparations
because it has osteoinductive and osteocon- and synthetic graft substitutes. Ladd and
ductive properties, is readily available, has Pliam29 published a detailed review of the
structural support, and becomes incorporated use of bone graft substitutes in distal radius
into the fracture site. There is signicant mor- fractures. Early reports suggest that bone graft
bidity associated with this procedure, how- substitutes are useful alternatives to auto-
ever, especially with the use of iliac crest graft. graft and offset the morbidity and possible
Morbidity is associated with increased opera- complications of its use. Most studies are not
tive time, blood loss, postoperative pain, and comparative, do not use standardized out-
increased hospital stay. Arrington et al2 re- come measures, and often are supported by
viewed 414 bone grafting procedures over a the commercial developers of the bone graft
10-year period; the numbers of anterior and substitutes. This area of biotechnology is bur-
posterior procedures were not specied. They geoning, and further objective, comparative,
found an incidence of 5.8% major compli- longer term studies are necessary to assist the
cations (those requiring a major change in surgeon in decision making.
treatment or a return to the operating room) Allograft, or banked human bone, is the
and 10% minor complications. Major compli- authors treatment of choice in distal radius
cations related to anterior iliac crest bone graft fractures. Allograft has the advantage of de-
harvesting included 2 donor defect hernia- creasing the morbidity and operative time
tions of small bowel, 3 cases of meralgia pares- associated with autograft harvesting. Allo-
thetica with no noted association to the surgi- graft bone partially retains the properties
cal incision site, and 2 cases of pelvic iliac wing of autograft, including structural support,
fracture. Seven deep infections and 4 deep osteoconductivity, and osteoinductivity. The
56 HANEL et al

extent to which a graft carries these properties 10. Earnshaw SA, Cawte SA, Worley A, et al: Colles
is modulated by its preparation method, with fracture of the wrist as an indicator of under-
frozen bone maintaining greater strength than lying osteoporosis in postmenopausal women: A
prospective study of bone mineral density and bone
either freeze-dried or irradiated bone.29 Allo- turnover rate. Osteoporos Int 8:5360, 1998
graft has the theoretical possibility of disease 11. Ellis J: Smiths and Bartons fractures: A method of
transmission. treatment. J Bone Joint Surg Br 47:724727, 1965
12. Faierman E, Jupiter JB: The management of acute
Postoperative Care fractures involving the distal radio-ulnar joint and
distal ulna. Hand Clin 14:213229, 1998
After surgery, the injured extremity is 13. Fernandez D, Jupiter J: Fractures of the Distal
placed into a bulky dressing, including a short Radius: A Practical Approach to Management.
New York, Springer, 1996
or long arm thumb spica splint. Complete 14. Fernandez DL, Jupiter JB: Fractures of the Distal Ra-
digit range of motion is encouraged immedi- dius. New York, Springer, 1995
ately, and the 6-pack exercises of Palmer34 are 15. Freedman KB, Kaplan FS, Bilker WB, et al: Treat-
begun on postoperative day 1. The exercises ment of osteoporosis: Are physicians missing an
opportunity? J Bone Joint Surg Am 82:10631070,
include active range of motion for metacar- 2000
pophalangeal, proximal interphalangeal, and 16. Frykman GK, Peckham RH, Willard K, et al: Exter-
distal interphalangeal joint through a series nal xators for treatment of unstable wrist fractures:
of congurations of the hand (arrow, spread A biomechanical, design feature, and cost compari-
table-top, st, claw, in-and-out, and thumb- son. Hand Clin 9:555565, 1993
17. Geissler WB: Arthroscopically assisted reduction of
to-tip). If the DRUJ is stable, supination is intra-articular fractures of the distal radius. Hand
emphasized, noting that pronation returns Clin 11:1929, 1995
with little effort. After 2 to 3 weeks, stable 18. Geissler WB, Freeland AE, Savoie FH, et al: In-
fractures are placed in removable thermo- tracarpal soft-tissue lesions associated with an intra-
plastic short arm splints, and gentle wrist articular fracture of the distal end of the radius.
J Bone Joint Surg Am 78:357365, 1996
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until edema resolves. Resistive exercises begin Academy of Orthopaedic Surgeons Monograph Se-
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have been used for patients who fail to achieve 20. Goslings JC, Broekhuizen AH, Boxma H, et al:
Three-dimensional dynamic external xation of dis-
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lar fractures of the distal radius. Clin Orthop 202: 40. Trumble TE, Culp RW, Hanel DP, et al: Intra-
103111, 1986 articular fractures of the distal aspect of the radius.
32. Melone CP: Distal radius fractures: Patterns of artic- Instr Course Lect 48:465480, 1999
ular fragmentation. Orthop Clin North Am 24:239 41. Trumble TE, Wagner W, Hanel DP, et al: Intrafocal
253, 1993 (Kapandji) pinning of distal radius fractures with
33. Mudgal C, Hastings H: Scapho-lunate diastasis and without external xation. J Hand Surg Am
in fractures of the distal radius: Pathomechanics 23:381394, 1998
and treatment options. J Hand Surg Br 18:725729, 42. Weiland AJ: External xation, not ORIF, as the treat-
1993 ment of choice for fractures of the distal radius.
34. Palmer AK: Fractures of the distal radius. In Green J Orthop Trauma 13:570572, 1999
DP (ed): Operative Hand Surgery. New York, 43. Wigderowitz CA, Rowley DI, Mole PA, et al: Bone
Churchill Livingstone, 1993, pp 929972 mineral density of the radius in patients with Colles
35. Rayhack JM: The history and evolution of percuta- fracture. J Bone Joint Surg Br 82:8789, 2000
neous pinning of displaced distal radius fractures. 44. Wolfe SW, Austin G, Lorenze M, et al: Biomechan-
Orthop Clin North Am 24:287300, 1993 ical comparison of different wrist external xators
36. Seitz WH Jr, Putnam MD, Dick HM: Limited open with and without K-wire augmentation. J Hand
surgical approach for external xation of distal ra- Surg Am 24:516524, 1999
dius fractures. J Hand Surg Am 15:288293, 1990 45. Wolfe SW, Swigart CR, Grauer J, et al: Augmented
37. Shea K, Fernandez DL, Jupiter JB, et al: Corrective external xation of distal radius fractures: A biome-
osteotomy for malunited, volarly displaced fractures chanical analysis. J Hand Surg Am 23:127134, 1998

Address reprint requests to

Douglas P. Hanel, MD
Box 359798
Harborview Medical Center
325 Ninth Avenue
Seattle, WA 981042499

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

M. L. Chip Routt, Jr, MD, Sean E. Nork, MD, and William J. Mills, MD

High-energy pelvic ring disruptions re- disruption pattern reects the traumatic load
sult from signicant traumatic events and application. For this reason, pelvic ring in-
are associated with a variety of primary or- juries were classied based on plain pelvic ra-
gan system injuries. Severe pelvic ring in- diographs according to the direction of the
stability causes life-threatening hemorrhage force producing the injury by Pennal et al.38
and must be treated rapidly and efciently. They described anteroposterior compression,
For these patients, initial diagnostic evalua- lateral compression, and vertical shear pat-
tions and resuscitations proceed simultane- terns. Other authors have elaborated on this
ously. A multispecialty team of experienced simple pelvic fracture classication scheme in
personnel facilitates successful management. attempts to describe the associated injuries
Acute resuscitation of the patient must include better.7
a mechanism to decrease pelvic instability, Patients with high-energy traumatic events
which, in turn, diminishes pelvic bleeding, sustain pelvic ring disruptions along with
provides patient comfort, and expedites the associated primary organ system injuries,
ongoing evaluation. Numerous techniques including chest and abdominal, urogenital,
are available to treat acute pelvic traumatic craniocerebral, and other skeletal injuries. In
instability. numerous clinical reports, a variety of meth-
ods have been used to reect these associated
injuries.17, 42, 57 For these reasons, an effective
INJURY AND MECHANISM pelvic fracture classication system should
include the precise locations of pelvic ring
Unstable pelvic ring disruptions result from injuries, their displacement patterns, and their
high-energy traumatic events. Motor vehicle associated injuries.
accidents, including automobile, motorcycle,
and automobile and pedestrian accidents, ac-
count for most pelvic ring disruptions. In a se- EVALUATION AND RESUSCITATION
ries of 68 patients with unstable pelvic frac-
tures treated operatively at a level 1 trauma The initial evaluation and resuscitation of
center, Routt et al42 reported 74% were due the injured patient begin at the accident scene
to vehicular trauma. Other common injury and continue in the hospital with airway
mechanisms include falls from a signicant control, predictable ventilation, and adequate
height or crush injuries by a heavy object circulation. Large-diameter intravenous cathe-
or animal. Except in unusual instances of ters are inserted, and volume resuscitation
complex injury mechanisms, the pelvic ring is initiated by the paramedics. The patients

From the Department of Orthopedic Surgery, Harborview Medical Center, Seattle, Washington



60 ROUTT et al

core temperature is optimized by covering is aspirated with routine suction equipment

the patient with warm blankets, using heat at the scene. Both techniques allow abdom-
lamps, and providing warmed intravenous inal and lower extremity access. These are
uids. In patients with high-energy pelvic only temporary stabilization methods because
injuries, pelvic ring mechanical instability is of skin pressure concerns. Regardless of the
identied by a single examination of the pelvis chosen technique, pelvic overcompression is
at the accident scene or in the emergency avoided (Fig. 2).
department. Gentle manual compression over The peripheral neurologic examination is
both iliac crests bilaterally causes pain and documented in alert patients. A digital rectal
reveals pelvic ring instability. Bony crepitus examination assesses the prostate gland loca-
may be noted. Pelvic and associated lower ex- tion and the rectal mucosal surface and tests
tremity deformities, such as malrotation, iliac for gross and occult blood. A bimanual vagi-
crest asymmetry, and subcutaneous palpable nal examination is performed in female pa-
bone, indicate potential pelvic injury. Open tients. Speculum vaginal evaluations are de-
pelvic wounds, typically located along the ferred until initial pelvic stability is achieved,
iliac crest or perineal areas, should be cleansed allowing safe placement of the patient in the
quickly and dressed aseptically while manual lithotomy position. Lower extremity deformi-
pressure controls related bleeding. ties are realigned carefully, then splinted.
The injured pelvis is immobilized at the ac- Scrotal swelling or ecchymoses and the
cident scene before patient transport using a presence of urethral meatal bleeding are de-
variety of simple techniques. A vacuum bean- layed signs of a urethral disruption and are
bag, a large circumferential sheet, or military noted in male patients. Similarly the inability
antishock trousers (MAST) are recommended to urinate or insert a urinary catheter easily
to stabilize the pelvis temporarily.31 Circum- are signs of urethral disruption. In a retro-
ferential pelvic sheeting is the least expensive spective review of 405 male patients with
and most readily available option. The folded pelvic fractures treated at a level 1 trauma
sheet is wrapped snugly around the pelvis and center, Lowe et al29 identied a 5% incidence
either clamped or knotted anteriorly.44 The of urethral injuries, especially in patients
sheet can be positioned around the hips if ab- with displaced pubic ramus fractures and
dominal access is needed (Fig. 1). A vacuum sacroiliac joint disruptions. They found that
beanbag can be positioned beneath the patient physical signs suggesting a urethral injury
and wrapped around each ank. The beanbag were absent in 57% of the patients and were


Figure 1. A, This 19-year-old female patient was injured in a high speed motorcycle accident.
Her physical examination conrmed an unstable pelvis along with a right labial traumatic lacer-
ation. The open labial wound drained blood and urine. Her plain pelvic radiograph before sheet
application demonstrates the disrupted symphysis pubis, ramus fractures, and posterior pelvic in-
juries. B, The subsequent radiograph reveals the pelvic reduction accomplished by the circumferential
pelvic sheet.

images in 3-mm increments. Other helpful

imaging studies include pelvic angiography,
cystography, retrograde urethrography, and
two-dimensional or three-dimensional pelvic
CT. The angiographic image intensier can
be used to visualize and quantify the pelvic
instability sites during a careful manual ex-
amination under uoroscopy.35 Using these
diagnostic tools, the orthopedic surgeon
gathers an improved understanding of the
High-energy pelvic ring disruptions occur
in predictable locations. The symphysis pu-
bis yields through ligaments. Superior pubic
ramus fractures occur in the parasymphyseal
region, midramus, or adjacent to the acetabu-
Figure 2. The pelvic sheet worsened the pelvic defor- lum. Frequently the anterior aspect of the ac-
mity in this patient with a right sided transforamenal sacral
fracture, risking neurologic injury. etabulum is involved in so-called pubic root
fractures. These are low anterior column ac-
etabular fractures occurring as a component of
related directly to the time interval since a pelvic ring disruption. Combination injuries
injury. Lowe et al29 recommended that male occur in the anterior pelvic ring. Segmental
patients with the combination of pubic ramus pubic ramus fractures and pubic ramus frac-
fractures and a sacroiliac joint disruption un- tures with associated symphyseal disruptions
dergo retrograde urethrograms before urethral are common in high-energy pelvic injuries.
instrumentation. The prompt recognition and Iliac fractures are divided into 3 types. Two of
appropriate management of these injuries the 3 types spare the sacroiliac joint. Periph-
may have a signicant impact on subsequent eral iliac fractures are conned to the iliac crest
morbidity. area and may be comminuted and associated
with open iliac wounds. Other iliac fractures
extend from the iliac crest into the greater sci-
RADIOLOGY AND COMMON atic notch, sparing the sacroiliac joint. These
ZONES OF INJURY iliac fractures may be associated with gluteal
vascular injuries.56 The third iliac fracture type
At hospital presentation, a screening antero- extends from the iliac crest into the anterior
posterior pelvic radiograph usually reveals sacroiliac joint, the so-called crescent fracture-
the pelvic ring injury. After high-energy trau- dislocation. The posterior iliac fracture com-
matic events, signicant pelvic instability may ponent remains attached to the dorsal sacrum
be present, but the radiograph may show only and is the stable portion in these injuries
minor displacements. When indicated, the ra- (Fig. 3).5
diographic evaluation is performed without Sacroiliac joint dislocations are variable.
removing the circumferential sheet or vac- They may present as incomplete anterior
uum beanbag. In certain instances, the pelvic articular disruptions or complete ligamentous
radiograph obtained with the circumferen- injuries with signicant displacement. Poste-
tial pelvic sheet or wrap in place underesti- rior iliac and dorsal sacral avulsion fractures
mates the extent of pelvic displacement and are noted infrequently in association with
instability.10 complete sacroiliac joint disruptions. Anterior
Pelvic inlet and outlet plain radiographs sacral impaction fractures are noted in asso-
identify the major pelvic ring disruptions ciation with certain sacroiliac joint injuries.
and their associated displacements.38 Lat- Sacral fractures were classied according to
eral sacral plain radiographs are obtained Denis et al13 as alar, transforaminal, or in-
in patients with sacral fractures. Most pa- volving the central or vertebral portion of the
tients with pelvic ring disruptions undergo sacrum. In high-energy trauma, lumbosacral
abdominal computed tomography (CT) scans, nerve root injuries can occur when the sacral
which can be reformated to provide valuable fracture involves the nerve root pathway or
pelvic osseous and soft tissue details. Osseous central vertebral body and with signicant
pelvic CT scans consist of sequential axial hemipelvic displacements.
62 ROUTT et al

Figure 3. A, This 18-year-old female patient was ejected from an

automobile during a high-speed rollover accident that caused other
occupant deaths at the accident scene. Her pelvis was unstable to
examination, and she had sustained hypotension, despite adequate
volume resuscitation. Her plain pelvic radiograph reveals left-sided
comminuted pubic ramus fractures and an iliac crescent fracture-
sacroiliac dislocation injury. B, The abdominal CT scan axial image
further delineates the posterior pelvic injury pattern.

EARLY TREATMENT surgery, neurosurgery, interventional radiol-

ogy, pulmonology, and others. The combined
Pelvic xation controls instability, decreases expertise facilitates the evaluation and man-
bleeding, diminishes pain, and allows pa- agement of these difcult patients. Early
tient mobilization. Pelvic stability should be coordinated treatment decisions have a sig-
achieved as soon as possible after injury and nicant impact on patient survivability and
evaluation. For patients with ongoing hem- eventual function. Controversy arises in these
orrhage, pelvic stabilization is a vital portion patients when emergent treatments are pri-
of the resuscitation. Early pelvic xation has oritized. Open communication and physician
been shown to improve patient outcomes.27, 57 availability are mandatory to maximize ef-
Optimal treatment is coordinated using a cient and effective care. The general surgeon
multidisciplinary team and should consist of leader should be experienced to coordinate
a general surgeon leader along with numer- the patients care wisely. The team members
ous subspecialty consultants. Because of the always must anticipate the impact of their
complexity of such patients, the usual consul- treatment plans. Aggressive tactics, such as
tants include experts in urology, orthopedic acute open reduction and internal xation,

should be reasonable and are reserved for rare for certain unstable fracture patterns. Pelvic
patients in whom routine efforts fail. Ideally, malreduction progresses to malunion, which
early treatment should be denitive treatment. causes chronic pain and gait disturbances.
Pelvic external xation frames have been Pelvic malreduction should be corrected
advocated for these patients, especially in situ- before malunion.54 Nepola et al33 evaluated
ations of ongoing venous bleeding.21 Similar to 33 patients with unstable and displaced pelvic
the circumferential sheet, anterior pelvic exter- fractures, however, and found no correlation
nal frames are designed to stabilize the pelvis, between patient outcomes and residual pelvic
allow clot formation, and diminish the po- displacements.
tential volume of the pelvis. Usually the pins Pelvic antishock clamps are posterior pelvic
are inserted into the iliac crest and connected external xation devices. These antishock
anteriorly using a variety of constructs. Closed clamps are applied percutaneously to stabilize
reduction of the pelvic deformity and uo- the posterior pelvic ring in an attempt to limit
roscopic imaging facilitate improved pelvic pelvic expansion and bleeding. The antishock
external xation.59 Certain fracture patterns, clamp pivots around posterior pelvic xa-
specically comminuted iliac fractures, pro- tion pins and allows access to the abdomen
hibit placement of routine external xation or perineum.14 Application of the clamp is
iliac pins. In these instances, anterior inferior difcult in patients with severe posterior
iliac pin sites often are useful. These pins also pelvic deformity or obesity. Certain posterior
are inserted after closed reduction and using pelvic ring fracture patterns, such as iliac
uoroscopy (Fig. 4). Poorly applied anterior crescent fractures, limit the use of this device.
pelvic external xation frames obstruct ab- Overcompression is avoided in patients with
dominal access and hip exion. Abdominal ac- transforaminal sacral fractures. The anti-
cess is important for exploratory laparotomy, shock clamp and the anterior external xation
serial abdominal examinations, and ileus frame can be applied after a closed pelvic
accommodation. Patient mobilization from re- reduction is achieved temporarily using the
cumbency is affected by a frame that obstructs circumferential sheet. Similarly, these external
hip exion. Anterior pelvic external xation is xation devices can be inserted while the
mechanically inferior compared with internal patient is in the angiography suite using the
xation techniques. Failure to maintain an uoroscope to assess pelvic closed reduction,
accurate pelvic reduction is common when direct pin placement, and avoid application
anterior pelvic external xation is used alone errors.


Figure 4. A, This 42-year-old woman was crushed by a tractor-trailer truck. She had a comminuted
iliac crest fracture and severely comminuted fractures and dislocations of the posterior pelvic ring. B,
On the day of injury, an anterior external xation device was applied using anterior inferior iliac pin
locations because of the iliac crest comminution bilaterally. Closed manipulative pelvic reduction was
achieved and secured using the anterior simple frame construct along with percutaneously inserted
bilateral iliosacral screws.
64 ROUTT et al

Intraoperative uoroscopic pelvic imaging the perineum. Open pelvic wounds result
advances and improved implant designs have from bone fragment laceration or penetrating
led to the use of percutaneous pelvic xa- trauma. Certain open pelvic wounds may not
tion in the acute setting for anterior and pos- be obvious initially. Traumatic lacerations in
terior pelvic ring injuries. Iliosacral screws the gluteal cleft, buttock fold, vaginal vault,
are inserted percutaneously through the but- and other locations are identied only with
tock, from the lateral ilium, and spanning the careful and complete physical examinations
sacroiliac joint or sacral injury stabilize cer- based on a high index of suspicion. Ballistic in-
tain posterior pelvic injury patterns. Iliosacral juries also occur. Digital exploration of pelvic
screws are advocated only when closed ma- open wounds determines their limits, rectal or
nipulative reduction of the posterior pelvic vaginal involvement, level of contamination,
ring is successful, the surgeon understands the and fracture relationship. The open pelvic
upper sacral morphology and its uoroscopic wound should be cleansed thoroughly and
imaging, and accurate posterior pelvic uo- debrided of necrotic tissue. Bleeding is con-
roscopy is possible (Fig. 5).17, 42, 45, 46 Keating trolled initially with tamponade and fracture
et al20 noted unacceptable xation failure rates stability. Devitalized bone fragments facilitate
when iliosacral screws were combined with accurate reconstruction of the fracture but
anterior pelvic external xation devices. In should not remain in the wound. All foreign
their series, 38 unstable pelvic fractures were material should be removed completely from
treated using iliosacral screw xation. They the wound. Shotgun wadding may be difcult
identied increased malunion rates in patients to identify using plain pelvic radiographs but
treated without stable anterior pelvic internal is noted on pelvic CT scan.23
xation. They found iliosacral screw xation is Open wound management using serial
a useful method of xation for unstable pelvis debridement is necessary in high-energy open
injuries when augmented by rigid anterior x- pelvic wounds. Open perineal wounds involv-
ation. A variety of iliosacral screw complica- ing the rectum require sphincter repair and
tions have been described.2, 49, 55 open wound management. Several studies
Similarly, unstable superior pubic ramus have conrmed that fecal diversion is reserved
fractures are stabilized acutely using uoro- for patients with rectal involvement by the
scopically directed, percutaneously inserted open perineal wound. Pell et al37 found that
medullary screws (Fig. 6). Routt et al48 used colostomy may not be necessary in all patients
these ramus screws in combination with pos- with open pelvic fracture. They noted that
terior iliosacral screw xation in 26 patients their protocols for fecal diversion based on
with unstable pelvic ring injuries. One screw open wound location were safe and decreased
was misplaced superior to the pubic ramus resource usage and subsequent morbidity
and noted only on the postoperative CT scan. related to colostomy closure. Woods et al62
Another patient experienced symptomatic noted infections in 27% of patients who un-
screw disengagement that required reoper- derwent fecal diversion compared with 29%
ation. All of the fractures healed, and there in patients who did not. In their study, only
were no infections. Blood loss was minimal for mechanical instability was determined by
these percutaneous procedures. Routt et al48 stepwise logistic regression to be associated
noted that the technique provided anterior signicantly with pelvic infection. This associ-
pelvic stability without the need for extensile ation was not altered by fecal diversion status.
surgical exposures. Woods et al62 concluded that diversion of the
fecal stream to protect open pelvic fractures
was not associated with a lower incidence
ASSOCIATED INJURIES of abdominopelvic infectious complications.
They postulated that fecal diversion may offer
Open Wounds protection to select patients with extensive
perineal soft tissue injury or posterior pelvic
Open pelvic fractures are among the most wounds.
devastating injuries in orthopedic trauma. In a series of patients with pelvic fractures,
Open wounds are common in association with Brenneman et al6 found a 4% incidence of
high-energy pelvic ring disruptions and have open pelvic injuries. Most occurred in younger
been associated with high mortality rates. male patients injured in motorcycle accidents.
Traumatic pelvic lacerations are noted most These patients had signicant transfusion
frequently adjacent to the iliac crest and in requirements. Deep infections resulted in



Figure 5. A, This patient sustained symphyseal and right-sided sacroiliac joint dislocations. He was
hemodynamically unstable and had pelvic angiographic embolizations. This intraoperative uoroscopic
image demonstrates complete right-sided sacroiliac joint disruption, despite anatomic reduction and
plate xation of the symphysis pubis acutely. A guide pin has been inserted across the SI joint using
uoroscopic guidance. The embolic coil is seen (arrow). B, The iliosacral lag screw is positioned to
compress the SI joint disruption. C and D, As the screw is tightened, the SI joint surfaces are reduced
and secured. E, A second fully threaded iliosacral screw has been inserted to secure the xation.
66 ROUTT et al


Figure 6. A, This patient had an extraperitoneal bladder disruption and pelvic ring injuries. The intraop-
erative uoroscopic image demonstrates minimally displaced pubic ramus fractures that were believed
to be stable based on their radiographic appearance. B, Gentle bilateral iliac crest manual compres-
sion revealed pelvic instability. The pubic ramus instabilities and displacements are shown. Her blad-
der was repaired, and the superior pubic ramus fracture was stabilized with a retrograde medullary

patients not treated with fecal diversion. compromise skin vascularity, resulting in
Based on outcome evaluations, surviving pa- eschar formation. The ank, proximal lateral
tients with open pelvic fractures noted chronic thigh, and lumbodorsal region are common
pain and residual disabilities in physical locations. Treatment options include open
functioning and physical roles. debridement with closure over suction drains,
Open wounds occur in association with open packing after debridement, or obser-
iliac fractures. Switzer et al56 reported that vation. Hak et al18 reviewed 24 patients with
comminuted iliac fractures occur in 2 distinct closed internal degloving injury and pelvic
patterns and are associated with numerous area trauma. Three patients developed deep
local injuries that complicate management. To bone infections. They recommended early
avoid infections, these authors recommended debridement of the injured soft tissues prefer-
early open reduction and stable internal x- ably at the time of fracture xation. They also
ation of the iliac fracture without primary recommended open wound management.
closure of the traumatic open wound. Open Kottmeier et al24 recommended early recog-
wound management with subsequent wound nition of degloving injuries. They advocated
irrigation and debridement may be followed aggressive early debridement and closure
with delayed wound closure as indicated. over suction drains to optimize outcome and
Pelvic internal xation can be used in patients avoid catastrophic complication.
with open pelvic fractures when there is not
gross contamination of the fracture region.
In situations of environmental or fecal con- Genitourinary Injury
tamination of the fracture site, external pelvic
xation is preferred. Patients with high-energy pelvic ring dis-
ruptions have associated urologic injuries.
Bladder disruptions are divided into intraperi-
Closed Degloving Injury toneal or extraperitoneal types. Urethral inju-
ries in male patients occur in association with
Closed internal degloving is a signicant unstable pubic ramus fractures. Urethral inju-
soft tissue condition associated with high- ries and associated vaginal lacerations occur
enegy pelvic injury in which the subcutaneous less frequently in females.
tissue is separated traumatically from the Lowe et al29 found that the likelihood for
underlying fascia. A large potential space the presence of physical signs of genitourinary
containing hematoma and necrotic fat results. disruptions is related directly to the interval
The closed internal degloving injury may since injury. They concluded that men with the

combination of ramus fractures and sacroil- root. Zone II fracture frequently was associ-
iac disruption should undergo retrograde ure- ated with sciatica but rarely with bladder dys-
thrograms before urethral instrumentation. In function. Zone III fractures frequently were as-
their series, physical signs were unreliable in- sociated with saddle anesthesia and loss of
dicators for urethral injuries, especially soon sphincter function.
after the injury. Patients with combined geni- In a retrospective study of 44 patients with
tourinary system injuries and unstable pelvic sacral fractures, Gibbons et al15 conrmed the
ring disruptions are treated optimally using a ndings of Denis et al.13 Fractures through the
team approach. The combined expertise is not ala sacralis only (zone I, 25 patients) or in-
only helpful initially when managing these volving the neural pathway but not the cen-
difcult patients but also later as problems tral canal (zone II, 7 patients) were less likely
develop. In one clinical series, 23 patients to cause nerve injury (24% and 29%). Frac-
with unstable pelvic fractures and associated tures involving the central sacrum (zone III,
bladder or urethral disruptions or both were 12 patients) were more likely to cause neuro-
treated surgically with open reduction and in- logic injury (58%). In their patients, neurologic
ternal xation of the anterior pelvic ring in- decits in zone I and II injuries usually were
juries at the same anesthesia and using the unilateral lumbar and sacral radiculopathies,
same surgical exposure as the urethral realign- whereas zone III decits usually were bilateral
ments or bladder repairs or both. There was and severe. Bowel or bladder incontinence or
1 deep wound infection (4.3%) that presented both were present in 6 of the 12 patients with
6 weeks after injury. It was concluded that zone III injuries. The nerve decits generally
a low infection rate can be expected despite improved with time, and Gibbons et al15 ad-
the use of internal xation, early urethral vocated operative reduction and internal x-
indirect realignments avoid more difcult de- ation particularly in patients with unilateral
layed open repairs, early direct bladder repairs root symptoms.
are performed easily at the time of anterior Frequently, patients with transforaminal
pelvic open reduction and internal xation, sacral fractures have associated nerve root
and suprapubic tubes are not necessary to di- decit and obvious bone debris within the
vert the urine adequately when large-diameter sacral neural tunnel. In these patients, the
urethral catheters are used in these patients.47 nerve root decompression is performed at
Other authors reported good results when the same procedure as open reduction and
combined urologic and pelvic ring disrup- internal xation of the fracture. Foraminal
tions were treated surgically using a team debridements are recommended for patients
approach.63 in whom the anticipated reduction maneuver
would cause nerve root injury because of the
bone debris within the sacral neural tunnel.

Neurologic Injury

High-energy pelvic ring disruptions are as- Occult Orthopedic Injuries

sociated with neurologic injuries, particularly
to the lumbosacral plexus.36 Sacral fractures, Delay in diagnosis of musculoskeletal injury
often undiagnosed and untreated, frequently in polytraumatized patients, especially those
result in neurologic symptoms and decits to with high-energy pelvic ring disruptions, may
the lower extremities and urinary, rectal, and lead to functional or cosmetic disability. Born
sexual dysfunctions.26 These same neurologic et al4 noted an incidence of 4% occult fracture
problems often remain the major chronic se- in such patients with numerous injuries. Delay
quelae after the more obvious pelvic ring dis- in recognition ranged from 1 to 91 days. They
ruption has healed. Denis et al13 reviewed recommended secondary clinical and appro-
236 consecutive patients with sacral fractures. priate radiographic skeletal surveillance in
They classied sacral fractures based on their polytraumatized patients. Special attention on
location as alar (zone I), involving the nerve physical examination is directed to the hands
root pathway (zone II), and involving the cen- and feet, shoulder, spine, and areas beneath
tral portion of the sacrum (zone III). Neuro- bandages and intravenous catheters. Repeti-
logic injuries correlated with the area of sacral tive daily musculoskeletal evaluations should
fracture. Zone I fracture occasionally was asso- diminish the incidence and diagnostic delay of
ciated with partial damage to the fth lumbar occult orthopedic injuries.
68 ROUTT et al

DEFINITIVE TREATMENT improved, allowing accurate visualization of

the posterior pelvis. Percutaneous iliosacral
Denitive treatment consists of accurate screw xation has been advocated for sacral
pelvic ring reduction, stable and safe xation, fractures, sacroiliac disruptions, certain iliac
and appropriate management of associated fracturesacroiliac dislocations, and combined
injuries. In certain patients, the initial xation posterior pelvic injuries. An accurate closed
is the denitive xation. Early management reduction, excellent intraoperative imaging,
decisions have a dramatic impact on eventual and a thorough understanding of the tech-
treatment and outcome. Examples of poor nique are necessary for this xation to be
decisions in the acute phase of treatment in- successful.8, 43, 45 Some authors advocate nerve
clude anterior pelvic external xation applied monitoring during iliosacral screw insertion.60
inappropriately resulting in pelvic instability, Several clinical series noted the complica-
malreduction, and contaminated zones of tions associated with iliosacral screws.20, 49
future surgical exposures (e.g., placement of Percutaneous xation techniques have been
suprapubic catheters or colostomy sites within recommended for unstable pubic ramus
the area of future pelvic surgical exposures fractures.48
for reduction and xation). The orthope- Open reduction of a high-energy pelvic ring
dic surgeon must consider the pelvic injury disruption is selected when other less invasive
zones, their displacements, the local soft tissue techniques are not possible. For the anterior
condition, and the overall patient condition pelvic ring, a Pfannenstiel exposure and its ex-
when planning early and denitive pelvic tensions allow open reduction of symphysis
stabilization. pubis injuries and pubic ramus fractures.9, 19
Denitive treatment of pelvic ring insta- After reduction, the injury is stabilized
bility begins with accurate reduction of the denitively using plate xation. Pelvic re-
displacements. In the acute clinical situation, construction plates are adjusted to t the
closed reduction is possible because the asso- individual pelvic anatomy.25 For symphyseal
ciated fracture hematoma is not organized and disruptions, Webb et al61 advocated plate
accommodates manipulative reduction. Spica xation using a 2-hole implant. This exible
casting and circumferential pelvic wrapping implant may show early xation failure in
have been shown to provide accurate pelvic high-energy, unstable pelvic ring disruptions.
closed reduction in certain injury patterns.12, 44 Because of this possibility, many surgeons
Closed reduction also is accomplished us- use anterior pelvic implants with more than
ing pelvic external xation pins inserted at 1 screw securing each component of the injury
the iliac crest or anterior inferior iliac spine. (Fig. 7). In these patients, posterior pelvic xa-
The pins are used as pelvic manipulators man- tion improves overall pelvic stability clinically
ually or by connecting them using an ex- and in laboratory evaluations.20, 52
ternal xation system. Certain external xa- Iliac fractures and the sacroiliac joint can
tion systems have threaded connecting bars be exposed using an iliac surgical approach.53
that can be positioned to provide satisfactory Pelvic reconstruction plates and lag screws
closed reduction.3 Distal femoral skeletal trac- are used to stabilize these injuries.25, 50, 56 The
tion also aids closed pelvic reduction in many posterior pelvic surgical exposure is recom-
situations. mended for sacral fractures and posterior iliac
For most high-energy pelvic ring disrup- fracturesacroiliac disruptions.30 Kellam et al22
tions, the pelvic external xator alone rarely reported signicant wound complications af-
provides sufcient stability to be used deni- ter open reduction of the posterior pelvis.
tively. The external pelvic frame can be used, Moed and Karges32 described various tech-
however, to support internal xation in these niques for posterior pelvic surgical exposure,
unstable situations. In their series, Lindahl reduction, and xation. Surgical implants ap-
et al28 found that pelvic external xation may plied between the posterior iliac crests for sta-
be useful in the acute phase of resuscitation, bility after open reduction include sacral bars,
but it is of limited value in the denitive treat- tension band plates, and screws.1
ment of an unstable type C injury and even in Iliosacral screws are inserted using uoro-
type B open-book injuries.28 scopic guidance after open reduction as af-
Denitive posterior pelvic xation de- ter closed reduction. Iliosacral screws can be
pends on the injury. Percutaneous iliosacral used in combination with other implants pos-
screw xation has become popular as in- teriorly (Fig. 8). Other techniques are emerg-
traoperative uoroscopic techniques have ing for posterior pelvic xation. Schildhauer


Figure 7. A, This man was crushed by heavy logs sustaining complete symphyseal and left-sided
sacral injuries. The postoperative radiograph demonstrates the reductions. B and C, Fixation failure
was noted several weeks after surgery.

et al51 described lumbopelvic xation of suf- reported that associated injuries continued
cient stability to permit early weight bearing. to be a major source of disability in these
Local plate osteosynthesis after open reduc- patients. Other authors have identied
tion has been evaluated and recommended for similar clinical results. In a large series of
sacral fractures.39 patients with unstable pelvic ring fractures,
Pohlemann et al40 found that open reduction
and internal xation provided the best stabil-
OUTCOMES AND COMPLICATIONS ity of xation and the best late clinical results.
Their follow-up included a detailed clinical
Outcome after pelvic ring disruption has and radiologic examination, an evaluation
been investigated by numerous authors. Tor- of the patients general social status, and a
netta and Matta58 described 46 patients with detailed neurologic and urologic screening.
48 operatively xed unstable posterior pelvic They noted that anatomic reduction and union
ring disruptions observed for an average of do not guarantee an acceptable result.
44 months after surgery. Two thirds of the Gruen et al16 evaluated 48 patients of 54
patients returned to their original jobs, and treated operatively for an unstable pelvic
16% changed jobs because of an associated ring injury. All 48 had osseous union and
injury. Of the patients, 63% had no pain or an anatomic alignment of the pelvis. They
pain only on strenuous activity and ambulated measured disability at a minimum of 1 year
without limitation; however, 35% had signif- after injury using the Sickness Impact Pro-
icant neurologic injuries that compromised le (SIP). Of the patients, 37 (77%) had mild
the nal study result. Tornetta and Matta58 disability (SIP, < 10); 11 (23%) had moderate
70 ROUTT et al


Figure 8. A, This patient was injured in an automobile accident. She had a symphysis pubis disruption,
bilateral incomplete pubic ramus fractures, right-sided sacral fracture, and left incomplete sacroiliac
joint injury. B and C, Open reduction with neurodiagnostic monitoring was selected for her transfora-
menal displaced sacral alar fracture. Because of her upper sacral dysmorphism, the iliosacral screw
was inserted into the second sacral vertebral segment using uoroscopic imaging. A posterior tension
band plate supported the xation. The symphyseal open reduction was secured with sutures.

disability (SIP, > 10). Of the patients who were 2 years. The average Injury Severity Score of
employed before injury, 76% were employed; the eligible adult patients was 17.5. There was
62% had returned to full-time work, and 14% a 14% impairment in physical outcome score
had returned with job modication. Oliver and a 5.5% impairment in mental outcome
et al34 similarly followed 55 multiply-injured score compared with the normal population.
patients with operatively treated unstable Residual vertical displacement related to
pelvic fractures. Their patients were evalu- poor outcome in patients with pelvic injuries
ated for patient-oriented outcome measures. according to some studies.54 Nepola et al33
Forty-six adult patients were eligible to com- studied 33 patients with vertical shear (Tile C)
plete the Short-Form Health Survey (SF-36) fractures and residual displacements. Out-
medical outcome score and completed it by comes were quantied using SF-36 and
postal questionnaire at a mean follow-up to the Iowa Pelvic Score (IPS). They found no

correlation between IPS or SF-36 scales and 12. Cotler HB, LaMont JG, Hansen ST Jr: Immediate
residual pelvic vertical displacement, suggest- spica casting for pelvic fractures. J Orthop Trauma
ing other factors reponsible for poor outcomes 2:222228, 1988
13. Denis F, Davis S, Comfort T: Sacral fractures: An im-
after unstable pelvic fracture. In a clinical portant problem: Retrospective analysis of 236 cases.
study, Poole et al41 stressed the impact of asso- Clin Orthop 227:6781, 1988
ciated injuries on the clinical outcome of pelvic 14. Ganz R, Krushell RJ, Jakob RP, et al: The antishock
fracture patients. pelvic clamp. Clin Orthop 267:7178, 1991
15. Gibbons KJ, Soloniuk DS, Razack N: Neurological
Pelvic ring disruptions cause unique prob- injury and patterns of sacral fractures. J Neurosurg
lems for female patients. Copeland et al11 72:889893, 1990
found that pelvic trauma negatively affected 16. Gruen GS, Leit ME, Gruen RJ, et al: Functional out-
genitourinary and reproductive function in come of patients with unstable pelvic ring fractures
female patients. They identied an increased stabilized with open reduction and internal xation.
J Trauma 39:838845, 1995
rate of cesarean section in women after pelvic 17. Gruen GS, Leit ME, Gruen RJ, et al: The acute
trauma, which they postulated to be multifac- management of hemodynamically unstable multiple
torial in origin. trauma patients with pelvic ring fractures. J Trauma
36:706713, 1994
18. Hak DJ, Olson SA, Matta JM: Diagnosis and man-
SUMMARY agement of closed internal degloving injuries associ-
ated with pelvic and acetabular fractures: The Morel-
Successful treatment of high-energy pelvic Lavallee lesion. J Trauma 42:10461051, 1997
19. Hirvensalo E, Lindahl J, Bostman O: A new approach
ring disruptions relies on early intervention, to the internal xation of unstable pelvic fractures.
accurate reduction, stable xation, and a low Clin Orthop 297:2832, 1993
rate of associated injuries and complications. 20. Keating JF, Werier J, Blachut P, et al: Early xa-
tion of the vertically unstable pelvis: The role of
iliosacral screw xation of the posterior lesion.
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46. Routt ML Jr, Simonian PT, Ballmer F: A ratio- plate xation for traumatic symphysis pubis diasta-
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Address reprint requests to

M. L. Chip Routt, Jr, MD
Department of Orthopaedic Surgery, Box 359798
Harborview Medical Center
325 Ninth Avenue
Seattle, WA 98104

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

Review and Case Studies

Philip J. Kregor, MD, and David Templeman, MD

The management of acetabular fractures The goal of open reduction and internal
has improved considerably since the 1970s. xation of an acetabular fracture is a per-
Letournel2730 elucidated the interpretation of fect reduction, dened as 0 to 1 mm of
plain radiographs of the pelvis, presented a displacement on all 3 acetabular views.30, 35
classication system for acetabular fractures, Letournel and Judet 30 and Matta35 have
and developed operative approaches and tac- shown that clinical outcome correlates di-
tics for their surgical management. Letournel30 rectly with the quality of the reduction.
also documented the outcome of 569 surgi- In Mattas series,35 a perfect reduction was
cally managed acute acetabular fractures. associated with an overall good or excel-
From his work, several principles for the lent clinical result in 83% of cases. With
management of acetabular fractures have been an imperfect reduction (2 to 3 mm of dis-
established, as follows: placement on any acetabular view), an

overall good or excellent clinical result
A thorough understanding of normal was obtained in only 68% of cases. This
pelvic anatomy and plain radiographs is number drops further to 50% (9 of 18 hips)
necessary to understand fracture patterns. when the reduction is poor (> 3 mm of dis-
An understanding of the Letournel classi- placement on any acetabular view).
cation aids the surgeon in understanding The ability to preserve the native hip joint
the individual fracture pattern, in plan- with appropriate management is quite
ning the surgical approach, and in un- good, although 16% of patients in the
derstanding surgical reduction techniques series by Matta35 had a poor clinical result,
for a given fracture. (For example, an un- and 6% had a total hip arthroplasty per-
derstanding of the common displacement formed at an average follow-up of 6 years.
and rotational deformity of a transverse
fracture gives the surgeon an appreciation Impaction loading of articular cartilage has
for reduction strategies for the operative been shown experimentally to result in al-
management of a particular fracture.) tered chondrocyte metabolism and histologic

From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt University Med-
ical Center, Nashville, Tennessee (PJK); and Department of Orthopaedic Surgery, Hennepin County Medical Center,
Minneapolis, Minnesota (DT)




evidence of structural damage.5, 14, 46, 58 Trau- later treatment of the acetabular fracture, it is
matic injury to the articular surface or bone important to develop treatment strategies that
of the femoral head has been shown by achieve the best result for both injuries. Impor-
Letournel and Judet30 and Matta35 to be signi- tant factors include placement of incisions that
cantly predictive of a worse clinical prognosis. allow optimal treatment of both injuries, tim-
Age at the time of injury is predictive of a ing of surgery, and consideration of whether
worse clinical prognosis, but only in that it the injury should be treated in 1 or 2 surgeries.
is more difcult to achieve an anatomic re- Certain requirements should be met before
duction in patients who are older than age open reduction and internal xation of acetab-
40 years.35 Patients younger than age 40 years ular fractures, including the following:
have an overall 81% chance of a good or ex-
cellent result, whereas patients older than 1. A stable, well-resuscitated patient who
age 40 have a 68% chance of a good or ex- has had other life-threatening and limb-
cellent result.35 The quality of the reduction threatening injuries addressed
able to be achieved in the rst 3 weeks after 2. Appropriate radiologic work-up of
injury also has been shown to be better than the injury (anteroposterior, Judet, and
that achieved in delayed cases, or in surgical inlet/outlet radiographs and computed
revisions.23, 30, 37 There are several factors that tomography scan)
Letournel and Judet30 and Matta35 have shown 3. Adequate personnel and facilities
do not inuence clinical outcome, including: Specic injuries (e.g., a femoral neck frac-
The type of fracture pattern ture in a young adult) require that the as-
The initial displacement of the fracture sociated injury be treated in an emergent
The timing of the reduction of an associated fashion.17, 24, 56, 57 In such cases, the intervention
posterior hip dislocation should be performed in such a way not to
The presence of intra-articular fragments or interfere with future surgeries. In other cases,
acetabular impaction such as unstable hip dislocation associated
with a posterior wall fracture, there should
Several associated fractures and injuries af- be a sense of urgency to perform an open re-
fect the management or outcome of acetab- duction and internal xation of the acetabular
ular fractures. Although several of these as- fracture with an open reduction of the femoral
sociated injuries are discussed by Letournel30 head dislocation. This procedure should not
and others, specic protocols have not been be performed, however, if the above-listed
developed because of the uncommon occur- preoperative criteria are not met. If the treat-
rence of specic injury combinations. This ar- ing orthopedic surgeon does not perform
ticle reviews the literature available on such xation of acetabular fractures routinely, he or
injuries and discusses the surgical manage- she should not proceed simply because of the
ment of these injuries through multiple case hip dislocation. An urgent referral to a trauma
examples. It is not possible to present signif- center should be considered.
icant data on the clinical outcome of these It is important to have a good understand-
injuries using current reduction and xation ing of the surgical approaches performed for
schemes. The combinations of injuries to be acetabular fractures. As dened by Letournel
discussed include an acetabular fracture with and others,30, 35, 36, 49 three approaches are used
an associated: routinely for the operative management of ac-
etabular fractures:
Hip dislocation
Femoral head fracture 1. Kocher-Langenbeck approach. The Kocher-
Femoral head impaction Langenbeck approach is used in posteri-
Femoral neck fracture or wall fractures, posterior column frac-
Proximal femur fracture tures, posterior column and posterior
Femoral shaft fracture wall fractures, most transverse fractures
with posterior wall fractures, most trans-
The purpose of this article is to develop verse fractures with predominantly pos-
treatment strategies for the acetabular fracture terior displacement, and some T-type
surgeon and for the orthopedic surgeon, who fractures.
will treat the associated injury denitively, 2. Ilioinguinal approach. The ilioinguinal ap-
then refer the patient for denitive treatment proach was developed by Letournel and
of the acetabular fracture. Because the initial Judet30 and is used in cases of anterior
management of associated injuries affects the wall fractures, anterior column fractures,

some transverse fractures (with predom- result could entail a slight limp, 25% loss
inantly anterior displacement), anterior of joint motion, and radiographic evidence
column and posterior hemitransverse of joint space narrowing and spur formation.
fractures, and most fractures of both Satisfactory outcomes were seen in 42% of pa-
columns. tients who underwent an open reduction after
3. Extended iliofemoral approach. The exten- a closed reduction and in 63% of patients un-
ded iliofemoral approach was developed dergoing a primary open reduction. Epstein15
by Letournel and Judet30 to give exten- noted that no attempt was made to reduce or
sive exposure to the outer aspect of the x the fracture into the oor of the acetabu-
innominate bone and to provide simul- lum. At the time, routine xation of acetabu-
taneous visualization and control of the lar fractures, other than isolated posterior wall
anterior and posterior columns. It is used fractures, was not being performed. The ac-
predominantly in cases of transtectal etabular fractures with an associated posterior
transverse fractures, transtectal trans- hip dislocation had a poor clinical outcome.
verse fractures with posterior wall frac- Epstein15 commented, The extent of the in-
tures, certain T-type fractures, fractures jury in Type IV fracturedislocations makes a
of both columns (especially with high poor result almost certain because of the de-
greater sciatic notch involvement), and gree of disruption of the acetabulum. Later,
delayed (> 3 weeks) reconstructive cases. in 1985, Epstein et al16 recommended primary
open reduction for all fracture-dislocations of
Certain associated injuries are discussed
the hip to remove loose fragments from the
subsequently with case examples.
hip joint, to restore stability to the joint by
open reduction and internal xation of any
large fragments of the acetabulum, and to as-
sure accurate reduction of the dislocation.
The presence of a posterior hip dislocation
or an extended period of time before reduc-
In hip dislocations not associated with an
tion does not correlate signicantly with a
acetabular fracture, the timing of reduction
worse clinical outcome.30, 35 In Mattas series35
has been shown to correlate with clinical out-
of 262 displaced acetabular fractures, 83 hips
come. An increased length of time before re-
(32%) had a posterior dislocation of the
duction of a hip dislocation (without an acetab-
femoral head, whereas 140 hips (68%) did not.
ular fracture) is associated with an increased
A good or excellent outcome was seen in 71%
incidence of avascular necrosis.15, 19, 21 In 1951,
of the hips that had a posterior dislocation and
Thompson and Epstein59 classied posterior
78% of the hips that did not have a posterior
hip dislocations into 5 types:
dislocation. These outomes are in contrast to
Type Iposterior hip dislocation without a pure hip dislocation, in which an increased
an associated fracture or a small fracture length of time before reduction of a simple hip
of the posterior wall dislocation (without acetabular fracture) has
Type IIposterior hip dislocation with a been associated with an increased incidence
large single fracture of the posterior wall of avascular necrosis.15, 19, 21 The reason for
Type IIIposterior hip dislocation with the difference between the effect of timing of
a comminuted fracture of the posterior reduction between a simple hip dislocation
wall, with or without a major fragment and hip dislocation with acetabular fracture is
Type IVposterior hip dislocation with an unclear. It may be that other factors (e.g., qual-
acetabular fracture, including the associ- ity of reduction) affect the clinical outcome
ated posterior wall more signicantly.
Type Vposterior hip dislocation with a It is prudent to reduce a posterior hip dis-
fracture of the femoral head location as soon as possible, however.30, 35 This
reduction should be done under conscious se-
In 1974, Epstein15 reported on the clini- dation in the emergency department. A small
cal outcome of 242 patients with a posterior percentage of hip dislocations cannot be re-
hip dislocation associated with a fracture of duced (Fig. 1). Possible reasons include:
the acetabulum or the femoral head or both.
Attempts at closed reductions of these injuries Inadequate muscle paralysis
were unsuccessful. Only 12% of patients un- Reduction of the femoral head being pre-
dergoing a closed reduction as denitive treat- vented by the hip capsule or short exter-
ment had a satisfactory result. A satisfactory nal rotators of the hip




Figure 1. A 17-year-old female patient who was involved in a motor vehicle collision and sustained an
isolated transtectal transverse with posterior wall acetabular fracture associated with a posterior hip
dislocation. A, Injury AP radiographs of the pelvis. Arrow indicates the posterior wall in the hip joint.
B, An attempt at closed reduction was not successful. Although the femoral head is more inferior, it
is not sitting well within the hip socket. C, CT scan at the level of the joint demonstrates the poste-
rior wall fragment inside the hip joint, preventing reduction of the femoral head. D, The patient was
taken to the operating room in the rst 8 hours after injury. A prone Kocher-Langenbeck approach was
performed. Intraoperatively, the femoral head was found to be button-holed between the obturator in-
ternus tendon and the capsule/piriformis. The piriformis was released 1 cm from its insertion or the
posterior border of the greater trochanter, and the hip joint was distracted. The posterior wall fragment
was then ipped out of the hip joint, with care taken to maintain its soft tissue/capsular attachments.
E, Intraoperative view of the hip joint while distracted. The posterior wall fragment, now removed
from the hip joint, is labeled. An arrow indicates transverse acetabular fracture line. The transverse
fracture involves the weight-bearing bone (transtectal transverse fracture line). Reduction and xation
was carried out. F, AP radiograph 6 months postinjury.

An interposed fragment of the posterior

wall in the acetabulum
A femoral fracture, which makes control of
the proximal femur difcult
With a femoral fracture, attempted reduc-
tion under general anesthesia may be per-
formed and may be aided by a Schantz pin
in the proximal femoral region (at the level
of the lesser trochanter) to aid the reduction
of the hip dislocation. If a closed reduction is
not possible in the operating room, a decision
should be made by the treating surgeon to pro-
ceed with an open reduction and internal xa-
tion of the acetabular fracture or proceed with
a referral.
In another scenario, the reduction may be
possible but is not stable. The cause most com-
monly is a large posterior wall fracture or a su-
perior posterior wall fragment or both. In such
cases, abduction or skeletal traction or both of
the limb may be of benet. In most cases, how-
ever, urgent stabilization of the posterior wall
fragment is warranted. Repeated attempts at
closed reductions may damage the articular
surface further because there is often a large
exposed raw cancellous bone surface at the in- Figure 2. Pipkin classication for femoral head fractures.
tact ilium, which may injure the cartilage on (From Swiontkowski MF: Hip dislocations and femoral
the femoral head further. head fractures. In Hansen ST, Jr, Swiontkowski MF [eds]:
Traditionally the use of skeletal traction for Orthopaedic Trauma Protocols. New York, Raven Press,
acetabular fractures is limited.30, 35 Certain sit- 1993; with permission.)
uations may be aided by its use, however, such
as an acetabular fracture with:
Large intra-articular fragments, which may Pipkin IVfemoral head fracture associated
cause damage to the femoral head with an acetabular fracture
Unstable hip dislocations, which may be
stabilized by skeletal traction with the leg Brumback et al7 classied femoral head frac-
in abduction tures further (Table 1). This classication is
A transverse pattern with signicant medi- more complete in that it differentiates be-
alization of the femoral head, in which the tween anterior and posterior dislocations of
femoral head may be in contact with the the femoral head. The Pipkin IV category is the
fracture surface on the intact ilium (see subject of this subsection.
Fig. 8) Epstein et al16 reported in 1985 on 55
Thompson/Epstein type V injuries (poste-
rior fracture-dislocation of the hip associated
FEMORAL HEAD FRACTURE with a fracture of the femoral head). Poor
WITH ASSOCIATED results were obtained with closed reduction
ACETABULAR FRACTURE or with open reduction after an attempt at
closed reduction. Although Epstein et al16
Pipkin42 classied femoral head fractures recommended open reduction for the injury,
into 4 categories (Fig. 2): only 47% of the patients overall had a good
Pipkin Ifemoral head fracture with frac- result. Signicant complications were noted,
ture plane below the fovea with 11 cases of traumatic arthritis, 11 cases
Pipkin IIfemoral head fracture with frac- of avascular necrosis, and 3 cases of hip in-
ture plane above the fovea fection. Epstein et al16 concluded, Traumatic
Pipkin IIIfemoral head fracture associated dislocation of the hip is a very serious injury;
with a femoral neck fracture Type V dislocations give a low percentage of


Type I A posterior hip dislocation with a femoral head fracture involving the inferomedial nonweight-bearing
portion of the femoral head
IA With minimal or no fracture of the acetabular rim and a stable hip joint after reduction
IB With signicant acetabular fracture and hip joint instability
Type II A posterior hip dislocation with a femoral head fracture involving the superomedial weight-bearing portion
of the femoral head
IIA With minimal or no fracture of the acetabular rim and a stable hip joint after reduction
IIB With signicant acetabular fracture and hip joint instability
Type III A dislocation of the hip from an unspecied direction with an associated femoral neck fracture
IIIA Without fracture of the femoral head
IIIB With fracture of the femoral head
Type IV An anterior dislocation of the hip with fracture of the femoral head
IVA Indentation type, with a depression in the superolateral weight-bearing surface of the femoral head
IVB Transchondral type, with an osteocartilaginous shear fracture on the weight-bearing surface of the femoral
Type V A central fracture-dislocation of the hip with fracture of the femoral head

Modied from Swiontkowski MF: Hip dislocations and femoral head fractures. In Hansen Jr ST, Swiontkowski MF (eds):
Orthopaedic Trauma Protocols. New York, Raven Press, 1993; with permission.

good results, regardless of the method or type of normal anatomy, with ultimate normal
of treatment. hip function. Although the effects of the ini-
In general, the acetabular fracture and tial impact on the articular cartilage of the
femoral head fracture are treated at the same femoral head cannot be undone, mechanical
operative intervention. No signicant data are symptoms of the hip joint can be avoided by
available in the literature for this relatively normal restoration of the femoral head and
rare injury utilizing modern reduction tech- acetabular fracture. An inferiorly displaced
niques. In reviewing results from femoral femoral head fracture can decrease normal
head fractures alone, Swiontkowski et al55 hip function, especially in exion and internal
recommended open reduction and internal rotation (Fig. 3). Options available for this
xation for Pipkin I and II fractures with injury include the following:
greater than 1 mm of displacement. They
reported on 43 femoral head fractures in Debridement of the femoral head frag-
41 patients. Of 43 patients, 26 were managed ment and joint, with open reduction and
operatively. There were 24 patients available internal xation of the posterior wall frac-
for minimal 2-year follow-up. Of patients, ture through a Kocher-Langenbeck ap-
12 were treated with a posterior surgical ap- proach. This approach may be reasonable
proach, and 12 were treated with an anterior if the femoral head fragment itself is in-
surgical approach (Smith-Peterson approach). frafoveal and relatively small.
Swiontkowski et al55 commented that the Open reduction and internal xation
anterior approach allowed for better visu- of the femoral head through a Smith-
alization of the femoral head fracture and Peterson approach, followed by nonop-
was not associated with cases of avascular erative treatment of the posterior wall
necrosis. An increased incidence of hetero- fracture. After xation of the femoral head
topic ossication was seen with the anterior fracture, an examination under anesthe-
approach, perhaps attributable to dissection of sia may reveal no instability of the hip.
the tensor fascia lata muscle off the iliac crest. Tornetta60 described the stress view for
Moed and Smith39 showed the benet of using this purpose. If no instability is noted,
the Judet views to assess the displacement of especially in the setting of a low posterior
the femoral head fracture because the fracture wall fracture, nonoperative management
plane is in the frontal plane and may not be of the posterior wall fracture may be
diagnosed on a routine anteroposterior pelvic warranted.
radiograph. Open reduction and internal xation
The most common presentation for this of the femoral head during posterior
injury is that of a posterior wall fracture, surgical dislocation, followed by open
posterior hip dislocation, and associated reduction and internal xation of the
femoral head fracture. The goal of the treat- posterior wall fracture, all through a
ment of such an injury should be restoration Kocher-Langenbeck approach. Given the


Figure 3. A 22-year-old woman sustained an inferior posterior wall fracture, posterior hip disloca-
tion, and an infrafoveal femoral head fracture. She was treated nonoperatively. She was referred at
7 months postoperatively as she had signicant groin pain with running. In addition, she had pain
with exion and internal rotation of the hip. A, AP radiograph at 7 months post-trauma. The arrow
indicates the healed inferiorly displaced femoral head fragment. B, The obturator oblique view
demonstrates best the inferior displacement of the femoral head fragment. C, Coronal plane CT re-
construction demonstrates the inferiorly displaced femoral head fragment. With exion and internal
rotation, this would cause impingement and groin pain. D, Intraoperative nding at the time of surgi-
cal dislocation of the hip. The inferiorly displaced femoral head fragment is seen. The patient under-
went a femoral head debridement and varus/exion intertrochanteric osteotomy.

typical frontal plane nature of the fracture, posterior wall fracture is addressed and
anterior-to-posterior lag screws are de- adequate reduction of the femoral head is
sired. This approach does not provide not possible, a sequential Smith-Peterson
optimal exposure for reduction and approach is possible, as described next.
xation of the femoral head fragment. Open reduction and internal xation
Visualization of the femoral head fracture of the posterior wall fracture through a
is possible with maximal exion, inter- Kocher-Langenbeck approach followed
nal rotation, and adduction of the hip. If by sequential open reduction and internal
the femoral head fragment is above the xation of the femoral head through a
fovea, however, the attached ligamentum Smith-Peterson approach (Fig. 5). These
teres prevents reduction of the femoral sequential approaches give appropriate
head fracture. This approach should be visualization of the femoral head fracture
reserved for relatively small infrafoveal and the posterior wall fracture. The
fragments that the surgeon wishes to strategy is especially helpful in the set-
internally x or debride (Fig. 4). If the ting of a femoral head fracture that is



Figure 4. A 38-year-old man sustained a posterior wall fracture, posterior hip dislocation, and in-
frafoveal femoral head fracture. A closed reduction was performed in the emergency room. A, Injury
AP radiograph after reduction of posterior hip dislocation. Note the nonconcentric reduction. B, CT
scan demonstrating the posterior wall fracture. C, CT scan in the hip joint demonstrating the femoral
head fracture. D, CT scan slightly more caudad demonstrating the inferior displacement of the femoral
head fragment. E, The patient underwent open reduction internal xation all by way of a Kocher-
Langenbeck approach with surgical dislocation of the femoral head. AP radiograph at 5 years post-
trauma. The patient has a totally normal hip.



Figure 5. A 17-year-old male patient sustained a posterior hip dislocation, posterior wall fracture, and
femoral head fracture. A, Injury AP radiograph of the hip. B, CT scan demonstrating posterior wall frac-
ture. C, CT scan demonstrating inferiorly displaced femoral head fracture. D, The patient underwent
open reduction internal xation of his posterior wall fracture using a Kocher-Langenbeck approach, fol-
lowed by xation of his femoral head fracture by way of a Smith-Peterson approach. AP radiograph of
the hip at 1 year post-trauma.

suprafoveal, in which the ligamentum its superolateral quadrant . . . produced at the

teres would be expected to remain intact time of trauma by localized contact between
to the femoral head fragment. In this case, the head and an intact part of the innominate
any attempt at visualization and xation bone (Fig. 8). Delee et al13 noted an indentation
of the femoral head fracture through sur- fracture in 9 of 15 anterior dislocations of the
gical dislocation of the femoral head (with hip and noted the poor clinical outcome in its
or without a trochanteric ip osteotomy presence.
described subsequently) would require Matta35 noted injury to the cartilage or bone
division of the ligamentum teres and of the femoral head in 19% of operatively
possible compromise of the femoral head treated acetabular fractures. He noted its sig-
fragment vascularity. nicance in the clinical outcome of the pa-
The trochanteric ip osteotomy, as de- tients. In patients with damage to the femoral
scribed by Siebenrock et al52 for treatment head, a good or excellent result was seen in
of acetabular fractures (Fig. 6). The ap- 60% of cases, with a mean dAubigne-Postel
proach permits dislocation of the femoral clinical score of 14 out of a possible 18 points.
head through capsulotomy, while main- In contrast, a good or excellent clinical out-
taining the femoral head blood supply. A come was seen in 80% of patients with-
capsulotomy can be performed around out femoral head damage, with a mean
the perimeter of the labrum, allowing for dAubigne-Postel clinical score of 16. Matta35
complete visualization of the femoral head commented, Finally, the most clearly predic-
and surgical dislocation of the femoral tive initial factor was injury to the cartilage
head with hip exion, external rota- or bone, or both, of the femoral head; this
tion, and adduction. The approach is fact was signicantly predictive of a worse
performed through a traditional Kocher- prognosis.
Langenbeck incision, with the patient in Femoral head damage has been evaluated
the lateral position. After identifying the by magnetic resonance imaging in 37 patients
obturator internus and piriformis tendon, with acetabular fractures.43 As expected,
a longitudinal trochanteric osteotomy of computed tomography scans were seen to
approximately 1.5 cm thick is created, be superior to magnetic resonance imaging
with the distal end attached to the vastus in detecting intra-articular fragments. Of
lateralis and the proximal end attached the fractures, 27% were associated with a
to the gluteus medius and minimus (also fracture of the femoral head, and in 24 of
called the digastric or two-belly approach). 37 cases, a subchondral contusion was seen.
The hip joint may be debrided, the femoral As was pointed out, the clinical impact of
head fracture is reduced and internally these subchondral contusions is unknown, but it
xed, and any transverse fracture is re- may account for a poor outcome, even in the
duced under direct visualization with setting of an anatomic reduction.
the hip dislocated. After the hip is re- A macroscopic injury to the femoral head
duced, any posterior wall component is most commonly occurs in two fracture
addressed. The femoral head fracture is patterns:
internally xed with anterior-to-posterior
1. The impaction can occur in the setting of
cortical lag screws or variable pitch screws
a transverse acetabular fracture, in which
(e.g., Herbert screws) (Fig. 7).
the inferior ischiopubic fragment is dis-
placed medially and the femoral head is
impacted onto the intact ilium (Fig. 8).
2. The impaction can occur in the setting
FEMORAL HEAD INJURY of a posterior wall fracture, or extended
WITH ASSOCIATED posterior wall fracture (which extends
ACETABULAR FRACTURE superior and anterior). In this case, the
femoral head impacts on the outer aspect
Femoral head injury with associated acetab- of the intact ilium and may impact on
ular fracture is distinguished from Pipkin frac- cancellous bone.
ture in that it is not a true frontal plane fracture
of the femoral head, but rather can be thought A reliable method for surgical reconstruc-
of as an impaction or divot in the femoral head. tion for impaction of the femoral head has not
Letournel and Judet30 described 20 cases of a been described. In the young patient, one may
localized subsidence of the femoral head in consider an intertrochanteric osteotomy to

Figure 6. The trochanteric ip osteotomy as described by Siebenrock et al. A, The hip capsule is ex-
posed after the trochanteric osteotomy. B, A capsulotomy permits surgical dislocation of the hip, with
exion, external rotation, and adduction of the hip. (From Siebenrock KA, Gautier E, Ziran BH, et al:
Trochanteric ip osteotomy for cranial extension and muscle protection in acetabular fracture xation
using a Kocher-Langenbeck approach. J Orthop Trauma 12:387381, 1998; with permission.)



Figure 7. A 48-year-old woman was involved in a motor vehicle collision and sustained a left sacroiliac
joint injury, left pubic root fracture, symphysis disruption, left posterior wall fracture, left posterior hip
dislocation, and left femoral head fracture. A, Injury AP radiograph of the pelvis. Closed reduction of
the hip was not possible. B, CT scan demonstrating the superior-posterior dislocation of the femoral
head. C, CT scan demonstrating the femoral head fragment in the hip joint. D, Intraoperative view of
the hip joint following trochanteric ip osteotomy. The femoral head fragment was seen to be rotated
180 and was detached from the ligamentum teres.
Illustration continued on opposite page


Figure 7 (Continued ). E, The fragment underwent reduction and internal xation. Posterior to ante-
rior lag screws were used because patient positioning prevented the placement of normal anterior to
posterior screws. F, Postoperative obturator oblique radiographs. G, AP radiograph at 10 months post-
trauma. The patient has moderate pain secondary to signicant joint space narrowing.



Figure 8. A 52-year-old man was involved in a motor vehicle collision and sustained a left transverse
acetabular fracture, right T-type acetabular fracture, and left fracture-dislocation of his shoulder. The
patient was referred 4 weeks post-trauma. A, AP radiograph. Note the signicant medialization of the
femoral head. B, The patient was taken to the operating room for a closed reduction of his hip. Note
the triangular divot in the superolateral aspect of the femoral head (arrow). C, The patient under-
went open reduction internal xation of his right acetabular fracture at 4.5 weeks using a Kocher-
Langenbeck approach in the prone position. AP radiograph at 6 weeks postoperative. Residual
anterior column displacement is seen. The left hip was treated nonoperatively. D, Iliac oblique view at
6 weeks postoperative. E, Obturator oblique view at 6 weeks postoperative.

derotate the lesion out of the weight-bearing dome, which has been well described.22, 33 In
surface of the hip joint.34 This method can the elderly patient, the goal is an anatomic
be likened to an intertrochanteric osteotomy restoration of the hip joint. If the clinical im-
for avascular necrosis, in which the compro- pact of the femoral head injury results in a
mised portion of the head is rotated out of the signicant posttraumatic arthritis, however, a
major weight-bearing area of the acetabular total hip arthroplasty is a good clinical option.

FEMORAL NECK FRACTURE 1. Emergent timing of operative interven-

ACETABULAR FRACTURE 2. Open visualization of the fracture and
capsulotomy to release intracapsular
Several review articles on the treatment tamponade, all through a Watson-Jones
of femoral neck fractures have been writ- approach
ten.24, 32, 56 It is helpful to consider the two 3. Rigid xation of the fracture through
fractures as separate entities and to provide three cancellous lag screws
the optimal treatment for each of the injuries.
One should consider the physiologic age of the The femoral neck in a young adult should
patient. In patients younger than age 65 years be treated in an emergent fashion. In this
with a displaced femoral neck fracture, the situation, it would be an unusual circum-
operative management is considered an ortho- stance to treat the associated acetabular frac-
pedic emergency.17, 57 Historical reports on the ture at the same operative intervention. This
treatment of femoral neck fracture have had situation mandates the planning of two surgi-
relatively disastrous results, with a reported cal incisions. The Watson-Jones approach is a
rate of 86% poor results.44 Swiontkowski et al57 curvilinear incision centered over the anterior
and Gerber et al17 have reported on the op- aspect of the greater trochanter (Fig. 9).54 The
erative treatment of femoral neck fractures muscular interval is between the tensor fascia
in young adults, with a 0% to 17% rate of lata and gluteus medius muscles. With proper
nonunion and 10% to 20% rate of avascular planning, the Watson-Jones approach can be
necrosis. The improved outcome probably is placed slightly anterior and not compromise
related to the tenets emphasized in both series: the Kocher-Langenbeck approach. In the

Figure 9. Watson-Jones approach for xation of a femoral neck fracture
in a young adult. A, The patient is positioned with the leg free or on a
fracture table. The interval between the tensor fascia lata and gluteus
medius muscle is developed. B, The vastus lateralls muscle belly is el-
evated off the interochamteric ridge of the proximal femur. The hip cap-
sule is exposed. C, A T capsulotomy is performed, exposing the femoral
neck fracture. (From Swiontkowski MP: Hip dislocations and femoral
head fractures. In Hansen ST, Jr, Swiontkowski MF [eds]: Orthopaedic
Trauma Protocols. New York, Raven Press, 1993; with permission.)

setting of an associated femoral neck fracture is important when faced with an elderly pa-
with an acetabular fracture, one rst should tient with a combined femoral neck fracture
address the femoral neck fracture through a and acetabular fracture. One must consider
Watson-Jones approach (Fig. 10). Then the the physiologic status of the patient, fracture
acetabular fracture can be addressed through pattern, and ability to reconstruct the acetab-
a separate approach. Alternatively the inferior ular fracture. Often a reasonable approach in
limb of the Watson-Jones approach can be the setting of signicant trauma may be open
incorporated into the Kocher-Langenbeck reduction and internal xation of the acetabu-
approach. lar fracture with a Girdlestone procedure, with
The combination of a displaced femoral delayed total hip arthroplasty.
neck fracture associated with an acetabular
fracture in an elderly adult (> 65 years old) PROXIMAL FEMORAL FRACTURE
is rare. Treatment of the displaced femoral WITH ASSOCIATED
neck fracture in the elderly adult is contro- ACETABULAR FRACTURE
versial. Lu-Yao et al32 performed a compre-
hensive meta-analysis of displaced femoral Proximal femur fractures associated with
neck fractures in adults older than age 65 acetabular fractures can be divided into in-
and concluded that there was an increased tertrochanteric hip fractures and subtrochan-
chance of need for reoperation if the frac- teric femur fractures. Optimal treatment of
ture was treated with internal xation versus both injuries should be undertaken, with-
prosthetic replacement. In most cases, optimal out compromising the treatment of either.
treatment of the displaced isolated femoral In general, the acetabular fracture is treated
neck fracture in an elderly adult is hemiarthro- through the optimal approach. If the Kocher-
plasty. Outcomes of operatively treated ac- Langenbeck or extended iliofemoral approach
etabular fractures in elderly adults are reason- is chosen, the fracture can be addressed
ably favorable.18 Results from immediate total through the same surgical approach. If an
hip arthroplasty for acetabular fractures are ilioinguinal approach is used, a separate
not favorable.38 Individualization of treatment approach can be made for the proximal femur.


Figure 10. This 18-year-old male patient sustained a left transverse acetabular fracture, left basilar
femoral neck fracture, and a left midshaft femur fracture. A, AP radiograph of left proximal femur.
B, AP radiograph of the pelvis. The patient had a right parasymphyseal injury.
Illustration continued on opposite page


Figure 10 (Continued ). C, On the night of his injury, he underwent open reduction internal xation of
his left femoral neck by way of a Watson-Jones approach. A capsulotomy was performed. A submus-
cular plating of the femur fracture was performed, with the plate introduced through the Watson-Jones
approach. D, AP radiograph after xation of the femoral neck and shaft. E, Open reduction internal
xation of his left acetabular fracture by way of an ilioinguinal approach on hospital day 3. This AP
radiograph at 3 months demonstrates slight adduction of the lower ischiopubic fragment.

The gold standard treatment for the in- 1. Is the piriformis fossa involved?
tertrochanteric femur fracture is the dynamic 2. Does the fracture extend proximal to or
hip screw.1, 12, 20, 25, 26, 45 Baumgartner et al2, 3 involve the lesser trochanter?
showed that appropriate placement of the hip
Based on the answers to these two ques-
screw is crucial in ensuring a good surgical
tions, one can divide the fracture into the fol-
outcome (Fig. 11).
lowing classication groups:
Russell and Taylor50 presented a useful clas-
sication scheme for subtrochanteric femur Type IAfracture extension with no degree
fractures. One must ask the following two of comminution below the level of the
questions regarding the morphology of the lesser trochanter with no extension into
subtrochanteric femur fracture: the piriformis fossa



Figure 11. A 64-year-old woman who was involved in a motor vehicle collision. She sustained a left
pilon fracture, left tibial plateau fracture, left pertrochanteric hip fracture, and left transverse with pos-
terior wall acetabular fracture. She underwent xation of her acetabular fracture, followed by xation of
her pertrochanteric hip fracture. Both were performed in the prone position with a Kocher-Langenbeck
approach. A, Injury AP radiograph of hip. B, AP radiograph of pelvis at 1 year. She is fully ambulatory
without aids and has minimal pain. C, Iliac oblique view at 1 year. D, Obturator oblique view at 1 year.

Type IBfracture extension involving the Relative instability or deformity of the

lesser trochanter with no extension into proximal end of the femur secondary to
the piriformis fossa the acetabular fracture (e.g., both column
Type IIAfracture extension into the piri- acetabular fracture)
formis fossa, but not involving the lesser Concern regarding ultimate surgical ap-
trochanter proaches for treatment of the acetabular
Type IIBfracture involving the piriformis fracture (e.g., a large devitalization of the
fossa and lesser trochanter abductor musculature may make a fu-
ture Kocher-Langenbeck approach prob-
Options available for treatment of sub- lematic)
trochanteric fracture include antegrade in- Irreducible or unstable posterior disloca-
tramedullary nailing, cephalomedullary in- tion of the femoral head
tramedullary nailing, a 95 angled blade plate, Concern regarding articular damage to the
and a 95 condylar screw.50 Special situations femoral head or acetabulum or both dur-
arise regarding the positioning of the pa- ing intramedullary nailing
tient. Depending on the approach necessary Possible concern regarding avascular
for treatment of the acetabular fracture, the necrosis. Avascular necrosis after ante-
patients position may be prone, lateral, or grade femoral nailing in adults is not a
supine. In each of these positions, xation of known entity. Theoretically, however,
the proximal femur fracture may be accom- antegrade femoral nailing could compro-
plished in the same position. It does present mise the blood supply of the femoral head
unusual surgical situations, however, such in the setting of an acetabular fracture.
as placement of an implant for the proximal (The normal blood supply to the femoral
femur in the prone position. head may be compromised by the initial
Another consideration is the timing of trauma.)
treatment of the two injuries. In contrast to Possible abductor weakness after ante-
the situation of the femoral neck fracture in grade femoral nailing4
the young adult, the proximal femur fracture
does not need to be internally xed in an For these reasons, alternative methods of
urgent or emergent fashion. The surgeon has dealing with the combination of a femoral
two options: shaft fracture and acetabular fracture often are
used. These include the following:
1. Fixation of the proximal femur fracture
followed by future xation for the acetab- Sequential open reduction and internal xa-
ular fracture tion of the acetabulum followed by ante-
2. Fixation of the proximal femur fracture at grade intramedullary nailing of the femur
the same operative intervention with ei- (same anesthesia)
ther separate or identical incisions Sequential open reduction and internal x-
ation of the acetabulum followed by plat-
ing of the femoral shaft (same anesthesia)
(Fig. 12)
FEMORAL SHAFT FRACTURE Retrograde nailing of the femoral shaft frac-
WITH ASSOCIATED ture followed by later open reduction
ACETABULAR FRACTURE and internal xation of the acetabulum
(Fig. 13)
A relatively infrequent and challenging situ-
ation is that of the femoral shaft fracture with Retrograde femoral nailing in the setting of
an acetabular fracture. The gold standard for an ipsilateral acetabular fracture has the ad-
treatment of a femoral shaft fracture is an an- vantages of intramedullary nailing, sparing of
tegrade reamed intramedullary nail.811, 63 It the abductor musculature, and avoidance of
is associated with a 98% to 99% union rate incisions in the region of future acetabular sur-
and low chance of infection (1% to 2%), even gical approaches. It has been associated with a
when used in open fractures.811, 63 In the set- slightly higher nonunion rate when compared
ting of an associated acetabular fracture, ini- with antegrade intramedullary nailing.40, 41, 61
tial antegrade intramedullary nailing before A report has noted, however, no difference in
acetabular fracture xation may be problem- union between antegrade and retrograde in-
atic. Its use may be limited because of the tramedullary nailing.47 The long-term effects
following: of intra-articular nail placement are unknown.



Figure 12. A 34-year-old man who was involved in a motor vehicle collision. He sustained a left pos-
terior hip dislocation, left posterior wall fracture, and left proximal one third femoral shaft fracture.
A, Injury AP radiograph of the pelvis. The arrow marks the posterior wall fracture. B, Injury AP
radiograph of the proximal femur. Closed reduction of the hip dislocation was not possible. The pa-
tient was taken expediently to the operating room for open reduction internal xation of his left acetab-
ular fracture and left femur fracture. This was accomplished in the prone position by way of a Kocher-
Langenbeck approach. C, Postoperative radiograph. D, AP radiograph of pelvis at 5 years postinjury.
The patient has a normal hip.
Illustration continued on opposite page

Figure 12 (Continued ). E, Healing of the femur fracture was uneventful.


Figure 13. A 28-year-old woman who sustained a right transverse/posterior wall acetabular fracture,
right proximal one third femur fracture, right tibial shaft fracture, and right calcaneus fracture. At the
outside institution, retrograde nailing of the femur and intramedullary nailing of the tibia was per-
formed. A, AP radiograph of the proximal femur following retrograde intramedullary nailing. B, AP ra-
diograph of pelvis following open reduction internal xation of her right acetabular fracture.

Plating of the femoral shaft is a viable op- 10. Brumback RJ, Reilly JP, Poka A, et al: Intramedullary
tion. Although historically associated with nailing of femoral shaft fractures: I. Decision-making
a higher rate of infection and need for bone errors with interlocking xation. J Bone Joint Surg
Am 70:14411452, 1988
grafting,6, 31, 48, 51, 53 new submuscular techni- 11. Brumback RJ, Uwagie-Ero S, Lakatos RP, et al:
ques reliably lead to union.62 The plate may Intramedullary nailing of femoral shaft fractures:
be introduced through the inferior limb of the Part II. Fracture-healing with static interlocking xa-
Kocher-Langenbeck incision. tion. J Bone Joint Surg Am 70:14531462, 1988
12. Clawson DK: Trochanteric fractures treated by the
sliding screw plate xation method. J Trauma 4:753,
SUMMARY 13. DeLee JC, Evans JA, Thomas J: Anterior dislocation of
the hip and associated femoral-head fractures. J Bone
Joint Surg Am 62:960964, 1980
The initial and denitive management of ac- 14. Donahue JM, Buss D, Oegema TR, et al: The effects of
etabular fractures can be complicated by a va- indirect blunt trauma on adult canine articular carti-
riety of associated injuries. As with all injuries, lage. J Bone Joint Surg Am 65:948957, 1983
a careful analysis of the patient and the injury 15. Epstein HC: Posterior fracture-dislocation of the hip:
Long term follow-up. J Bone Joint Surg Am 56:1103,
pattern is paramount. The orthopedic surgeon 1974
must recognize associated injuries in the prox- 16. Epstein HC, Wiss DA, Cozen L, et al: Posterior frac-
imity of the acetabular fracture because they ture dislocation of the hip with fractures of the
have an impact on the timing, surgical ap- femoral head. Clin Orthop 8:917, 1985
proaches, and outcome from the acetabular 17. Gerber C, Strehle J, Ganz R: The treatment of frac-
tures of the femoral neck. Clin Orthop 64:7786, 1993
fracture. A plan must be formulated that opti- 18. Helfet DL, Borrelli J, DiPasquale T, et al: Stabilization
mally treats both injuries, either in a sequential of acetabular fractures in elderly patients. J Bone Joint
or a simultaneous manner. Surg Am 74:753765, 1992
19. Herndon JH, Aufranc OE: Avascular necrosis of the
femoral head in the adult: A review of its incidence
in a variety of conditions. Clin Orthop 86:4362,
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J Orthop Trauma 15:161169, 2001 Orthop Clin North Am 11:633648, 1980

Address reprint requests to

Philip J. Kregor, MD
Division of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Nashville, TN 37232

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00


Andrew H. Schmidt, MD, and Marc F. Swiontkowski, MD

Femoral neck fractures remain a vexing tures would triple.27 As a consequence, proxi-
clinical problem for orthopedic surgeons. mal femur fractures are a signicant cause of
Attempting to salvage the femoral neck often morbidity and mortality in all age groups, es-
leads to healing complications, while the more pecially in the elderly.
predictable operation (prosthetic replacement) At the present time, more than 250,000
is associated with poorer function and has hip fractures occur in the United States each
signicant complications of its own. Added year, with associated health care costs of
to this dilemma is the high mortality rate of $8.7 billion.66 Extensive debate continues over
patients in the age group that most often sus- the cost-effectiveness of various medical and
tains these fractures. The orthopedic literature surgical therapies, including the treatment
is replete with case studies and retrospective of fractures of the hip. Using the concept
comparative trials on the treatment of femoral of quality-adjusted life years, Parker et al64
neck fractures, but the quality of evidence determined that operative treatment was
that we have to guide us is poor. Lu-Yao cost-effective for displaced intracapsular and
et al51 attempted to perform a meta-analysis all extracapsular fractures of the hip. The
of the outcome of displaced femoral neck proper care of hip fractures is important not
fractures. Nonunion was twice as common only for the continued health and vitality of
as osteonecrosis (33% and 16%, respectively). our population but also for the health of our
Although reoperation was more common economy.
after internal xation than after prosthetic Femoral neck fractures occur most com-
replacement, the investigators were not able to monly in the elderly patient after a seem-
draw any statistically valid conclusions about ingly minor fall or twisting injury and are
the factors that affect the outcome of femoral more common among women.66 Numerous
neck fractures. factors are related to the high incidence of
hip fractures in the elderly population, in-
cluding osteoporosis, malnutrition, decreased
EPIDEMIOLOGY physical activity, impaired vision, neurologic
disease, poor balance, altered reexes, and
The incidence of femoral neck fracture is muscle atrophy. Chronically ill elderly pa-
increasing dramatically as the mean age of tients have an increased risk for infection and
the population increases.68 The number of hip other systemic complications after fracture de-
fractures in the United States doubled from spite appropriate medical and surgical man-
the mid-1960s to the 1980s. It has been pre- agement. Osteoporosis remains the most im-
dicted that by 2050, the number of hip frac- portant contributing factor to hip fractures,

From the Department of Orthopaedic Surgery, University of Minnesota (AHS, MFS) and Hennepin County Medical
Center (AHS), Minneapolis, Minnesota




and its incidence has been well documented

with respect to age-, race-, and sex-matched
controls.48, 50, 56, 75, 79 The absolute rate of hip
fracture is highest for white women, followed
by white men, black women, and black men.38
These differences in incidence are thought to
reect the difference in bone density, which
is greater in blacks than in whites. Alffram1
reported that patients with intertrochanteric
fractures are slightly older and have higher
morbidity and mortality rates than do those
with femoral neck fractures.
Femoral neck fractures also occur in the
young but less frequently. In the young, these
fractures are usually the result of high-energy
trauma and often are associated with other in-
juries. In the young, hip fractures are more
common in males, who are also more prone to


Most of the vascular supply to the femoral Figure 1. A healed femoral neck fracture, showing ideal
head originates from the medial and lateral screw placement in the center of the femoral head,
at the convergence of the tension and compression
femoral circumex arteries, which form an trabeculae.
extracapsular ring around the femoral neck.
Ascending cervical branches pass the femoral
neck proximally and enter the capsule at these patterns has made its use unreliable44
its insertion. Fractures of the femoral neck (Fig. 2).
may disrupt the vascularity of the femoral The two major forces acting on the hip joint
head18, 69, 70 ; however, displaced fractures of the are abductor muscles and body weight, as
femoral head can occur without disruption of dened by the joint reaction force. In men, the
the medial femoral circumex or lateral epi- normal joint reaction forces can be as much
physeal systems.22 Therefore, urgent anatomic as four- to sevenfold body weight, and in
reduction and internal xation of displaced women, 2.5- to fourfold body weight.60 Stair
femoral neck fractures is advocated to restore climbing causes maximum hip forces of up
blood ow in vessels that may be kinked by to sevenfold body weight.25 The use of a bed-
the displaced fragments. Rarely, collateral pan produces forces on the hip equivalent to
circulation can maintain the viability of the walking with the use of external supports.60
femoral head when the primary vessels are Nordin and Frankel60 showed with instru-
disrupted.70 mented nailplate implants that only one
The bony anatomy of the upper end of fourth of the total load is borne by the xation
the femur is extremely important because it device if bone fragments are allowed to im-
determines where internal xation devices pact. Implants designed for fracture xation
should be implanted for maximum purchase must withstand extremely high loads and
in the femoral head (Fig. 1). With increasing bending moments. Fortunately, many stud-
age, the cortex of the femoral neck thins and ies have shown that full weight-bearing is
cancellous trabeculae are resorbed, signi- not detrimental if stable internal xation is
cantly weakening the proximal femur.71 This achieved.45 This is important because mobi-
increases the risk for fracture with loading and lization of the patient is important to avoid
makes internal xation more prone to failure. systemic complications. Even after fracture
Study of the trabecular pattern allows sur- union, the risks for osteonecrosis and arthrosis
geons to estimate the degree of osteoporosis remain. If these late complications ensue,
and the likelihood of successful internal xa- the patient is subject to further costs and the
tion, although the subjectivity of evaluating hazards of secondary intervention.


Figure 2. A failed attempt to repair a femoral neck fracture with screws. Careful study of the preop-
erative radiograph (A) shows that there are no bone trabeculae within the femoral neck causing the
screw xation to fail (B).

CLASSIFICATION surgeon the best estimate of the severity and

the comminution of the fracture. Rotational
The Garden classication of femoral neck moments are a signicant part of the normal
fractures remains in wide use.29, 32, 67 The Gar- loading of the hip, and resistance to rotation
den classication is based on the amount of is an important factor in fracture stability.
fracture displacement evident on anteroposte- Posterior comminution increases the potential
rior (AP) radiography of the hip, although sur- for rotational and varus instability (Fig. 3).
geons must be aware that signicant displace- Rotational malignment is present when the
ment may be apparent on lateral radiography major compressive trabeculae in the femoral
and not seen on AP radiography. The grades head do not accurately align themselves
correlate with the prognosis for healing and despite overall good alignment of cortical
the rates of avascular necrosis or nonunion. shells.
Garden I and II fractures are nondisplaced.
Garden III and IV fractures are displaced
and have a worse prognosis for healing and TREATMENT
osteonecrosis. Recently, it has been shown
that the inter- and intraobserver reliability of The treatment of femoral neck fracture de-
the Garden classication is poor 86 ; however, pends primarily on the age and activity of the
agreement was improved when fractures patient, the severity of fracture displacement,
were grouped into either undisplaced (stage I the age of the fracture, and the degree of
and II) or displaced (stage III and IV) classes.86 osteoporosis present. Elderly patients with
An alternative way to classify femoral neck medical comorbidities should have their
fractures is based on the angle of the fracture condition optimized.43 The optimum timing
line with the horizontal plane.63 More vertical of internal xation of femoral neck fractures
fractures have higher shear forces across the remains controversial.65 It has been suggested
femoral neck and may have a greater potential that the incidences of avascular necrosis and
for hardware failure; however, recent retro- nonunion are decreased by xation within
spective reviews have failed to conrm that 6 hours after injury 53 ; however, some studies
the fracture angle is of any value for predicting have not shown an increase in the rate of os-
the risk for xation failure.63 teonecrosis or nonunion with delayed xation
In addition to displacement, the rotation of of up to 1 week. Because of the biological
the femoral head must be evaluated to give the advantages, the authors perform stabilization

Figure 3. Posterior comminution of the femoral neck, with posterior an-

gulation, impaction, and malrotation.

of the fracture as soon as the patient has been avascular necrosis and nonunion in 14%. In
evaluated medically and is stable. contrast, the use of hip compression screws led
For undisplaced fractures, in situ xation is to 50% avascular necrosis and 40% nonunions.
advisable because the risk for displacement Malreduction with varus angulation resulted
with nonoperative treatment is as high as in 60% avascular necrosis and 40% nonunion.
20%.26 Displaced femoral neck fractures are Ten degrees or more of anterior or posterior
treated according to the age and functional angulation also led to increased complications.
demands of the patient. Patients with these Muscle pedicle grafting was of no benet
fractures are at high risk for avascular necro- in preventing either avascular necrosis or
sis and nonunion, averaging 30% and 15%, nonunion and was associated with a 13%
respectively.33, 51, 67, 82 In healthy, active patients, infection rate. Swiontkowski et al82 reported
the treatment of choice is reduction and in- avascular necrosis in 19% and no nonunions in
ternal xation. An anatomic reduction must a smaller series of young patients with femoral
be obtained for a good result. Femoral neck neck fractures treated with multiple screws.
fractures reduced anatomically are best xed Inactive or chronically ill patients may be
with three pins or screws.83 A closed reduction considered for primary prosthetic replace-
may sufce, but the capsule should be opened ment to avoid the complications from loss of
to decompress the hemarthrosis that may xation or osteonecrosis. A prosthetic replace-
impair head perfusion. If a satisfactory closed ment also may be desired in a patient with hip
reduction is not achieved, an open reduction is arthritis in conjunction with a femoral neck
indicated. One should avoid repeated at- fracture.
tempts at performing closed reduction ma-
neuvers because repeated manipulations
may cause additional trauma and potential CLOSED REDUCTION OF FEMORAL
vascular insult. The most important factor NECK FRACTURES
leading to success in the treatment of the
young patient with a femoral neck fracture Closed reduction of the femoral neck is per-
is immediate anatomic reduction with stable formed with the patient under general anes-
internal xation. In the series from the Ortho- thesia using image intensication. In general,
pedic Trauma Hospital Association,46 multiple a simple combination of traction in extension
screws seemed to be the best choice for xa- and gentle internal rotation is all that is nec-
tion, with complications that include 13% with essary. Alternatively, Leadbetters maneuver

may be performed and involves reducing the

femoral neck in exion. First, the hip is exed
90 and the thigh is rotated internally. With
traction applied in line with the femur and
while internal rotation is maintained, the limb
is then circumducted into an abducted posi-
tion and then brought into extension. If closed
reduction is successfully achieved, one may
proceed with internal xation. Release of the
capsule should be performed at the same time
to decompress the joint and relieve possible
intra-articular tamponade.78, 84



Placement of multiple screws across the A

fractured femoral neck is the treatment of
choice and may be performed following either
closed or open reduction using a standard lat-
eral approach or a more limited percutaneous
technique. Many types of screws are available,
including solid or cannulated screws made
from either stainless steel or titanium.
Good results are to be expected following
xation of nondisplaced femoral neck frac-
tures. The outcome after xation of displaced
fractures is less predictable, and the manage-
ment of displaced fractures is more controver-
sial. Swiontkowski and Hansen80 reported on
the results of percutaneous pinning of femoral
neck fractures in 32 medically debilitated pa- B
tients. Technical complications occurred only
in the group with displaced fractures, none of Figure 4. A and B, Correct screw placement, with the
whom regained functional ambulation. In con- screws against the inferior and posterior cortices, and
trast, 92% of the patients with nondisplaced or within 5 mm of subchondral bone in the center of the
impacted fractures were ambulatory at 2-year femoral head.
To minimize complications, pins or screws
should be placed within the central two thirds Bout et al14 achieved union in 35 of 40 dis-
of the femoral head.59 The authors aim for cen- placed femoral neck fractures. Four of the ve
tral screw placement, with the tip of the screw failures were associated with clear faults in
no closer than 5 mm to subchondral bone. The the operative technique.14 Imperfect fracture
authors recommend that one inferior screw reductions may prevent reestablishment of the
should be placed along the medial femoral blood supply to the femoral head and decrease
neck, with two more proximal screws placed the amount of bony apposition at the fracture,
in a triangular conguration both anteriorly causing poor mechanical stability after xa-
and posteriorly in the femoral neck (Fig. 4). tion. Garden31 showed that valgus reduction
Placing the screws adjacent to the cortex of of more than 20 is associated with higher
the femoral neck may improve stability.13 The rates of avascular necrosis. Any amount of
inferior screw must exit the lateral femoral varus deformity after reduction is associated
cortex at or above the lesser trochanter. The with increased rates of avascular necrosis
authors have seen subsequent subtrochanteric and nonunion.46 AP angulation of more than
fracture at the distal screw when it is placed 10 should not be accepted, particularly in
distal to the lesser trochanter. Using the osteoporotic bone, because of the potential for
three-point principle, with screws placed further displacement. On lateral radiography,
adjacent to the inferior and posterior cortices, surgeons should pay particular attention to

the degree of posterior comminution. Both avascular necrosis; however, the relative mer-
Garden and Banks have shown that fractures its of attempting xation versus performing
with marked posterior comminution have a arthroplasty are controversial. In one study
high incidence of nonunion.8, 30, 32 In a study of more than 500 femoral neck fractures
using cadaveric femora with simulated pos- treated with internal xation, 79% of the pa-
terior comminution, fractures xed with four tients retained their femoral head and 67%
screws were signicantly stronger than were required only one operation.57 The incidence
those repaired with three screws.42 In cadaver of reoperation was actually lower among
bone, the use of a calciumphosphate cement the patients over age 70 years than among
dramatically improved the load to failure of younger patients. Other studies have found
femoral neck fractures xed by three 7-mm arthroplasty to be associated with lower com-
cannulated screws.74 plication rates than internal xation.39 Gerber
If closed reduction within acceptable lim- et al33 found that local complications pre-
its cannot be obtained, the surgeon should dominated after internal xation, whereas
proceed to open reduction, which affords systemic complications were more common
surgeons several advantages. First, it decom- after hemiarthroplasty. Bogoch et al12 reported
presses the hip. Second, it is the best way that internal xation of displaced femoral neck
to ensure appropriate rotational alignment fractures in patients with rheumatoid arthritis
of the femoral head. Finally, drilling of the failed in 64%, whereas primary total hip re-
femoral head may allow surgeons to assess placement was successful in 95%. Carpenter
the viability of the femoral head.34 Open et al17 found that the reoperation rate follow-
reduction may be performed by extending the ing internal xation was much higher (28%)
lateral incision and using the interval between than that following either unipolar (5%) or
the tensor fascia lata and gluteus medius bipolar (3%) arthroplasty. In general, it is best
(Watson-Jones approach) or by an anterior to salvage the femoral head whenever pos-
approach. In the latter case, a separate incision sible. The use of a study implant that main-
may be necessary for screw placement. If the tains a valgus neck-shaft angle, controls
patient is a candidate for arthroplasty and the potential rotation, and allows for controlled
surgeon is unwilling or unable to perform an compression of the fracture; it provides the
adequate open reduction, the treatment plan best results with minimal complications. In
for reduction and xation may be abandoned older and less active patients with displaced
and the surgeon may proceed with prosthetic femoral neck fractures, hemiarthroplasty
replacement. seems to be the optimum management. Bray
et al15 performed a prospective, random-
ized comparison of bipolar hemiarthroplasty
SLIDING HIP SCREWS to internal xation. Fewer complications
and better function at 2-year follow-up
Many experts advocate the use of a slid- were found in the hemiarthroplasty-treated
ing hip screw for the xation of basicervical group.
fractures (Fig. 5).10 In a biomechanical study, Options for prosthetic replacement include
a sliding hip screw with or without a derota- unipolar hemiarthroplasty, bipolar hemiar-
tion screw was stronger than three cannulated throplasty, and total hip arthroplasty. Ce-
screws in axial loading10 ; however, a clinical mented or uncemented devices may be used.
study found that the union rate of displaced Early unipolar devices were found to have
femoral neck fractures was higher after xa- frequent complications, including disabling
tion with four cancellous screws than with a pain and acetabular erosion.41 Bipolar hemi-
sliding screw plate.52 Sliding hip screws pro- arthroplasty was developed in hopes of less-
vide improved xation of vertically oriented ening this complication, but clinical reports
fractures,4 and these devices should be consid- suggest that measurable acetabular erosion
ered in the treatment of such fractures. still occurs.11, 47 Nevertheless, clinical studies
comparing unipolar with bipolar prostheses
suggest better results with the latter devices.61
PROSTHETIC REPLACEMENT Other potential complications include stem
loosening, dislocation, femoral shaft perfora-
Prosthetic replacement of the displaced tion, periprosthetic fracture, and infection.
femoral neck fracture is advocated by some Total hip replacement provides the best re-
because of the high rates of nonunion and sults of any form of prosthetic replacement



Figure 5. A and B, A basicervical fracture treated with a sliding hip screw and single derotation screw
(C and D).

for displaced femoral neck fracture; however, undergoing surgery for fractures.35 This in-
several investigators have found that disloca- creased movement is thought to be a pre-
tion after hip arthroplasty for fracture is more disposing factor for dislocation in patients
common than after operations for arthritis.35, 86 managed with hip arthroplasty for femoral
In 50 patients equally divided between frac- neck fractures. Total hip arthroplasty after
tures and arthritics, the hip range of mo- a displaced femoral neck fracture should be
tion was signicantly greater among those reserved for patients with preexisting arthritis

or for very high-demand patients in whom in- (see Fig. 2). Technical problems that may lead
ternal xation is not possible or has failed. to failure include poor screw position, place-
ment of screws with threads that cross the
fracture site, and imperfect fracture reduction.
COMPLICATIONS Failure of internal xation of a femoral neck
fracture with either multiple pins of a sliding
Loss of Fixation hip screw is most dependent on bone quality
and screw placement.24, 87 Swiontkowski et al83
Implants that are used for internal xation found no benet to using more than three pins
of the proximal femur can fail because of the and that bone density is a useful predictor of
large bending loads that are present in the the success of xation.
proximal femur and the poor bone quality that The treatment of failed osteosynthesis of
is usually associated with fracture. Many dis- the femoral neck depends on the timing and
placed fractures are unstable and have poste- mode of failure and the patients general
rior and medial comminution with loss of a condition and activity level. Repeat xation
stable medial buttress. The implant may cut may be considered in younger or more active
out of the superior femoral neck as the frac- patients if the bone stock is adequate. Often,
ture settles into varus displacement; break at a valgus osteotomy with blade plate xation
the site of the fracture; or, in the case of a side- is necessary to restore the correct mechanical
plate device, pull out from the femoral shaft axis of the femoral neck (Fig. 6). Conversion



Figure 6. A femoral neck nonunion (A), conrmed by CT scan (B). Union was achieved after valgus
osteotomy and blade plate xation (C and D). (Courtesy of David Templeman, MD, Minneapolis, MN.)

to an arthroplasty is needed if osteonecrosis The variability in the incidence of nonunion

ensues or because of poor bone quality. Long- in different series of cases may be explained
stem devices should be used to ensure that by differences in patients, fracture type and
the tip of the stem is distal to the screw holes by the investigators method of reduction and
in the lateral femoral cortex (Fig. 7). Franzen xation technique.62 Madsen et al52 found that
et al28 found that the results of total hip arthro- the union rate of displaced femoral neck frac-
plasty for failed xation of femoral neck tures was higher after xation with four can-
fractures was age dependent. Patients aged cellous screws (84%) than with a sliding screw
more than 70 years who underwent primary plate (64%). Nonunion is associated with
hip replacement after fracture had a vefold pin migration.54 Furthermore, nonunion and
risk for prosthetic failure compared with age- pin migration occurred only in the displaced
matched patients undergoing hip replacement fracture patterns. Valgus reduction seemed to
for osteoarthritis. protect against pin migration.54 Hammer 37 re-
viewed 141 patients following osteosynthesis
of a femoral neck fracture with 6.5-mm AO
Nonunion screws. The rate of nonunion was correlated
with the Garden classication and was 1% for
Delayed or nonunion of a femoral neck Garden I fractures and over 25% in Garden III
fracture often is manifested by continued pain and IV fractures. Irrespective of the Garden
with weight-bearing beyond 3 months af- classication, a vertical fracture orientation
ter xation. Nonunion of femoral neck frac- resulted in a 40% rate of nonunion.37 Parker 62
tures has a reported incidence from 2% to 22% found that the best predictor of nonunion
and generally becomes apparent within was patient age and preoperative fracture
1 year.2, 7, 8, 19 The risk for nonunion is greater displacement.
with displaced fractures and has been reported Nonunion may be accompanied by avascu-
to be as high as 30% in some series.21, 62, 66, 72 lar necrosis. If nonunion occurs, the surgeon

Figure 7. A total hip performed for a failed proximal femur fracture treated with a sliding
hip screw. Two screw holes are present in the femoral shaft below the tip of the prosthe-
sis (A). A displaced periprosthetic fracture occurred within 2 weeks after surgery (B).

should use MR imaging to evaluate vascular at considerable risk of lacuation or kinking af-
supply to the femoral head before continuing ter femoral neck fracture; it runs in the su-
with treatment options. Fixation of the femoral perior capsule, which frequently is disrupted
neck with titanium screws aids in accuracy by such fractures, especially when displaced.
of MR imaging interpretation by minimizing Most clinically relevant avascular necrosis fol-
scatter of the image that occurs with the use of lows displaced intracapsular fractures.
stainless steel screws. MR imaging has largely Most studies report osteonecrosis rates in
supplanted scintigraphy in the evaluation of displaced femoral neck fractures of 10% to
femoral head viability. 20%.33, 51, 82 Differences may be explained by
Options for the treatment of nonunion in- the fracture type and by the investigators
clude repeat internal xation, bone or muscle- method of reduction and xation. Stromqvist
pedicle grafting, valgus osteotomy, and hip et al76, 77 examined the use of scintigraphy to
arthroplasty. In active patients, nonunion is assess the viability of the femoral head after
treated with a valgus osteotomy and repeat femoral neck fracture. Decreased radionuclide
xation. Marti et al55 reported a series of uptake within the rst 2 weeks of injury is 91%
50 patients aged less than 70 years who under- predictive of healing complications.77 Further-
went valgus osteotomy for ununited femoral more, decreased uptake is found in some frac-
neck fractures. Six cases required reoperation tures preoperatively; these patients invariably
because of technical complications. Seven hips experience healing complications.76 In other
underwent later replacement: three hips for patients, decient uptake is seen only postop-
persistent nonunion, three hips for severe os- eratively, indicating that perioperative factors
teonecrosis, and one hip for hardware break- (e.g., intra-articular tamponade, traction, of re-
age. The remaining 43 fractures had 7 years duction maneuvers, also inuence the devel-
average follow-up. Although avascular necro- opment of osteonecrosis. Patients with normal
sis was evident in 22, only 3 patients had uptake 2 weeks after injury are unlikely to de-
symptoms sufently severe to require arthro- velop osteonecrosis.77
plasty. In a series of 17 patients, union was The risk for avascular necrosis is propor-
achieved in all but one after osteotomy.6 Five tionate to the degree of displacement and the
patients required an additional operation. Al- time to reduction. Operation within 6 hours of
though the operation is difcult, this study injury leads to improved union rates and a de-
recommends osteotomy in younger, active pa- creased incidence of femoral head collapse.53
tients with nonunion of the femoral neck.6, 55 Late-onset avascular necrosis is manifested
Only smaller series have reported on the by bone sclerosis, subchondral collapse and,
use of a posterior muscle pedicle graft and eventually, secondary degenerative changes
bone graft as an adjunct to internal xation of the hip. In the early stages of symptoms,
of a femoral neck nonunion.5 The success of radiographic ndings are normal. MR imag-
this treatment is difcult to assess because ing provides the most sensitive and specic
the series report a limited experience. Most means of identifying avascular necrosis in
nonunions have drifted into some varus an- the early stages, when treatment may be ben-
gulation, and a valgus osteotomy and xation ecial; however, MR imaging performed at
are essential to apply compression loads at the time of injury is unable to predict which
the fracture site and promote healing. There- intracapsular fractures will develop clinical
fore, the best option is an intertrochanteric os- avascular necrosis.3, 73 Furthermore, treat-
teotomy with realignment of the proximal fe- ment should not be based on the results of
mur into valgus if salvage of the femoral head MR imaging alone; the severity of clinical
is warranted. symptoms, the degree of femoral head col-
In some instances, such as if severe os- lapse, and the amount of degenerative change
teonecrosis is present or in elderly community on radiographs are more important clinical
ambulators, nonunion may be treated best by factors.
total hip replacement. Unfortunately, no com- Surgeons can minimize the risk for os-
parative studies are available to aid clinicians teonecrosis in several ways. Urgent reduction
in decision making for this complex problem. and xation may be the most important. Sev-
eral investigators have shown that intracap-
sular fractures of the proximal femur result in
Avascular Necrosis markedly elevated intracapsular pressures se-
condary to hematoma formation.24, 40, 78 Using
The lateral epiphyseal artery supplies most laser Doppler owmetry, Swiontkowski, et al84
of the femoral head circulation. This vessel is showed signicant diminution of femoral

head blood ow with elevated intracapsu- propriate. Although arthrodesis is more dif-
lar pressures in an animal model. Crawfurd cult because of the avascular bone, it may
et al24 used ultrasonography to show capsu- be considered for younger patients with
lar distension following both nondisplaced more severe involvement that precludes
and displaced femoral neck fractures and osteotomy. For the management of severe
documented elevated intracapsular pressures osteonecrosis in the older patients, total hip
associated with joint hemarthrosis. Some dis- arthroplasty is recommended. Whether ce-
placed fractures showed evidence of capsular mented or uncemented implants are better
disruption with extracapsular hematoma; is unknown; surgeons should select what-
this subgroup of hips had low pressures ever technique and implant they are most
consistent with decompression of the hip. familiar with. Hemiarthroplasty is performed
Capsulotomy is recommended to relieve the in elderly patients with minimal functional
intracapsular hematoma and restore blood demands.
ow.24, 84 Stromqvist et al78 showed that the
intracapsular pressure is highest with the leg
internally rotated and lowest in a position FEMORAL NECK FRACTURES
of mild exion and external rotation. These IN CHILDREN
workers also demonstrated, that following
hip aspiration, intracapsular pressures de- Children rarely sustain fractures near the
creased to zero, and scintigraphic uptake hip; when they occur, they are often the result
increased in most hips, consistent with im- of high-energy trauma. Multiple injuries are
proved blood ow. Although the need for present in half of these cases, and these pa-
capsulotomy in femoral neck fracture remains tients traditionally are considered to have a
controversial, it is so simple to perform that poor prognosis. Potential complications in-
it should be recommended. Another benet clude osteonecrosis, nonunion, coxa vara, and
of capsulotomy is that it allows for direct premature physeal closure with trochanteric
visualization of the femoral head and its ca- overgrowth and leg-length inequality.16
pacity to bleed. Gill et al34 drilled a 2-mm hole Twenty percent of cases are associated with
into the femoral head fragment at surgery; ipsilateral femoral shaft fractures. Complica-
none of 56 patients with bleeding from the tion rates are proportional to the initial degree
drill hole developed avascular necrosis at of displacement,16 and studies that have fol-
2 years of follow-up or more. In contrast, all lowed up patients into adulthood have shown
8 patients without bleeding developed avas- that the initial results deteriorate signicantly
cular necrosis. Intraoperative drilling may be with time.49
the best method to assess the risk for avascular Delbet20, 58 has classied these fractures into
necrosis, although longer-term follow-up is four types: type I, transepiphyseal; type II,
needed. transcervical; type III, cervicotrochanteric; and
The treatment of avascular necrosis re- type IV, intertrochanteric. Proximal femur
mains controversial. Often, osteonecrosis does fractures involving the growth plate (type I)
not involve the entire femoral head. In many are reported to result in avascular necrosis and
cases, collapse of the head does not occur. premature physeal closure in 80% to 100% of
If the patient is asymptomatic, no further patients.16 Early hip decompression in type I
treatment is indicated. If collapse of the os- injuries does not affect the incidence of avas-
teonecrotic fragment has occurred and the cular necrosis, suggesting that the vessels are
patient is symptomatic, then surgical treat- disrupted.58 Nevertheless, the best results of
ment may be indicated. The degree of involve- treatment overall have been with immediate
ment on imaging studies does not necessarily decompression of the joint by capsulotomy
correlate with the severity of symptoms. and rigid internal xation.20, 58 Despite the
In general, young, active patients are more lack of documented efcacy, decompression
disabled by avascular necrosis than are seden- of type I fractures still should be attempted.
tary patients. Treatment options are based on Early hip decompression seems to decrease
age, activity level, and severity of symptoms the risk for avascular necrosis in type II and III
and include core decompression, proximal fractures and should be performed in all such
femoral osteotomy, arthrodesis, and prosthetic cases.20, 58, 81 In one series, hip capsulotomy re-
replacement. Core decompression may be duced the rate of avascular necrosis in type II
performed in painful lesions that have not col- and III fractures from 41% to 8%.58 Cheng and
lapsed. In younger patients or those with Tang 20 had no cases of avascular necrosis in
well-circumscribed lesions, osteotomy is ap- a series of 14 patients with a mean follow-up

of almost 5 years. These investigators per- compromise the reduction and xation of
formed hip aspiration, closed reduction, and the femoral neck and may lead to complica-
internal xation within 24 hours of injury. tions. Poor results have been reported with
By using an aggressive operative approach the reconstruction nail, with complications
with early open reduction, capsulotomy, and in as many as 75% of cases in one series.88
compression screw xation, Swiontkowski Another option is antegrade nailing of the
and Winquist 81 reported good results in shaft, with supplemental screw xation of
eight patients with 2-year follow-up. One the neck. In this circumstance, two addi-
patient had a type I (transepiphyseal) fracture tional lag screws are placed anterior to the
in their series; this patient developed radio- nail. As mentioned earlier, it is of paramount
graphic evidence of partial avascular necrosis importance to avoid displacing the femoral
of the femoral head but was asymptomatic neck fracture when this technique is used.
at the 2-year follow-up examination. Imme- An acceptable alternative is routine stabiliza-
diate anatomic reduction and screw xation tion and xation of the femoral neck fracture
are recommended for all children with frac- with multiple screws, followed by plating
tures of the proximal femur, except for there or retrograde nailing of the femoral shaft
with undisplaced basilar neck fractures or (Fig. 8).
fractures in the intertrochanteric region (type Avascular necrosis seems to be less common
IV), which may be treated by spica casting.81 in cases of ipsilateral neck and shaft fractures
As in fractures in adults, hip decompression than of isolated neck fractures.9 Occasionally,
should be performed in all femoral neck the femoral neck fracture is not identied un-
fractures in children.81 til after, or may occur during, intramedullary
nailing of a diaphyseal fracture. This also
calls for emergent reduction and stabilization
of the femoral neck, and multiple cancellous
COMBINED FRACTURES OF THE lag screws generally can be placed around
FEMORAL NECK AND SHAFT the proximal femoral nail. Higher rates of os-
teonecrosis and nonunion should be expected
Ipsilateral fractures of the femoral neck in these situations.88
and shaft are uncommon and challenging
injuries that typically occur in multitrauma
patients. Often, the femoral neck fracture is THE FUTURE TREATMENT OF
not recognized at the time that the shaft frac- FEMORAL NECK FRACTURES
ture is treated.88 In a review of the literature,
Bennett et al9 reported that the incidence of Future advances in the surgical manage-
delayed diagnosis was 31%. The associated ment of femoral neck fractures depend on
femoral shaft fracture often is comminuted or an improvement in the methods of orthope-
open and usually occurs in the proximal to dic research and advances in the management
middle third of the femur.88 In contrast, the of osteoporosis. Certainly, as physicians learn
femoral neck fracture usually is minimally of the results of well-designed randomized
displaced and is typically extracapsular, which prospective trials, treatment will become ev-
may contribute to the difculty in diagnosis. idence based rather than anecdotal. In addi-
The injury of primary importance in this tion, it is likely that physicians will have bet-
fracture complex is the femoral neck fracture. ter methods to manage one of the biggest
Most surgeons recommend immediate re- problems in the xation of femoral neck frac-
duction and stabilization of the femoral neck tures, namely, poor bone quality. The med-
fracture with compression screws, followed ical management of osteoporosis is improv-
by subsequent stabilization of the femoral ing, and the incidence of osteoporosis will be
shaft fracture.88 In unstable multitrauma pa- less in the future. In addition, fracture com-
tients, a delay in xation of several days to minution likely will be managed by augment-
weeks should not preclude xation because ing the bone with some sort of injectable
the complication rate does not seem to be bone graft substitute. Specically, augmenta-
increased.88 tion with calciumphosphate cement has been
One possible choice for xation is a second- shown to improve signicantly the strength
generation interlocking nail, which may be and stiffness of xation in cadaveric bone
used to stabilize both the femoral neck and xed with screws.36, 74 Clinical pilot studies of
shaft fractures; however, this technique may this technique are in progress.36


Figure 8. An ipsilateral femoral neck and shaft fracture. The radiograph clearly shows both frac-
tures (A). The patient underwent closed reduction and screw xation of the femoral neck, followed
by retrograde nailing of the femoral shaft (B and C).

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Subtrochanteric femoral fractures de- tachments lead to strong deforming forces that
serve special consideration when discussing can make fracture reduction difcult.
femoral fractures because of the difculties in
their management and reported signicant
rates of complications with their surgical treat- ANATOMY AND BIOMECHANICS
ment.9, 42, 46, 49, 50, 56, 57 The subtrochanteric area
has been dened in various ways, but most The greater trochanter is a large bony emi-
commonly this term has been used to de- nence at the proximal femur that provides an
scribe the area between the inferior border insertion site for the tendons of the gluteus
of the lesser trochanter and the isthmus of medius and gluteus minimus that function as
the femoral shaft or the inferior border of strong hip abductors. The piriformis, gemellus
the lesser trochanter to the junction of the superior and gemellus inferior, and obtura-
proximal and middle one third of the femur. tor internus tendons also insert in this area
The lower border of the subtrochanteric area and function as external rotators of the hip.
is not well dened, but generally the area 5 cm The lesser trochanter is a bony eminence
below the level of the lesser trochanter is in- posteromedially on which the iliopsoas ten-
cluded. Subtrochanteric fractures are fractures don attaches. The insertion and action of these
in which the major portion of the fracture muscles is important in understanding the
involves this area. These fractures may have stresses and reaction forces in this area and
proximal trochanteric extension, which is the typical deformity that results with sub-
important in choosing between treatment trochanteric femoral fractures as a result of the
options. deforming forces of these muscles acting on
The difculties encountered in the treatment the individual fragments. Classically the prox-
of subtrochanteric fractures are related to the imal fragment assumes a position of exion,
anatomic and biomechanical features unique abduction, and external rotation.21 The gluteus
to this area. Anatomically the subtrochanteric medius and gluteus minimus account for
area consists of mostly cortical bone, which the position of abduction. The iliopsoas ac-
often is comminuted and tends to heal more counts for the position of exion and the
slowly than metaphyseal bone. Just proxi- external rotation results from the forces of
mal, the canal widens in the intertrochanteric the short external rotators and the iliopsoas.
area, which leads to less optimal xation with This deformity complicates attempts at closed
intramedullary devices because of the wide reduction. The angle formed by the axis of
canal and short segment proximally. Biome- the femoral neck and femoral shaft is 127
chanically the subtrochanteric area is an area to 130 . If this angle is decreased, as would
of high stress concentration, and the muscle at- occur with a varus reduction of a fracture,

From the Carolinas Medical Center; and the Miller Orthopaedic Clinic, Charlotte, North Carolina



114 SIMS

the distance between the head and shaft is region. There tends to be a bimodal distri-
increased, which increases the moment arm bution of the fractures. Fractures occurring
and the bending forces across the fracture and in younger patients result from high-energy
may produce varus collapse. Joint reaction trauma and often have signicant comminu-
forces at the hip result from the compressive tion. These most commonly result from motor
forces of the bodys weight and most impor- vehicle accidents or falls from a height. Pene-
tantly the forces generated by the muscles trating trauma secondary to gunshot wounds
that cross the hip. Forces on the hip and prox- is another common mechanism of fractures in
imal femur have been analyzed by numerous young patients in most series. Older patients
investigators.19, 20, 30, 43, 44, 52 Koch30 showed that often present with low-energy subtrochanteric
forces greater than 1200 lb per square inch fractures. These usually have less comminu-
of force could be generated by a 200-lb man. tion, and long spiral fractures in this popu-
Major compressive stresses in the femur are lation are common. Older patients also may
greatest in the medial cortex 1 to 3 inches present with pathologic fractures or impend-
below the lesser trochanter and exceed 1200 lb ing pathologic fractures, but these are note
per square inch. This is the most highly discussed in this article. The relative percent-
stressed region in the body. Tensile stresses ages of these fracture patterns depend on the
of approximately 25% less occur at the lateral type of center from which the patient popu-
cortex slightly more proximal. These high lation is obtained. Trauma centers tend to see
compressive forces medially explain the high higher percentages of high-energy and pene-
instance of implant failure and complications trating fractures in younger patients, whereas
seen historically in these fractures when the other centers may see a higher percentage of
medial buttress could not be restored because low-energy fractures in older patients.
of comminution. If the posterior and medial
cortex is intact or reduced anatomically with
bone-to-bone contact, internal xation devices CLASSIFICATION
act as a tension band on the lateral femoral
cortex. If this medial buttress is not intact Many classication systems for subtro-
or cannot be reestablished, the internal xa- chanteric fractures have been proposed. Some
tion devices are subjected mainly to bending of the more frequently mentioned are re-
stresses, and the loads are concentrated in viewed. Boyd and Grifn8 divided all tro-
this high stress area.19 This concentration may chanteric fractures into 4 groups. Type I and
result in implant failure or loss of xation. II are intertrochanteric fractures, type III are
Intramedullary nails have a biomechanical subtrochanteric fractures, and type IV are sub-
advantage over plates in this situation. Their trochanteric fractures with intertrochanteric
intramedullary position reduces the moment extension. An analysis of the specic subtro-
arm on the nail by reducing the distance over chanteric fracture patterns was not done. The
which the bending forces act compared with a classication of Fielding et al19 was specically
plate on the lateral cortex. Others have shown for subtrochanteric fractures and included
the signicant forces at the hip and proximal three types based solely on the location of the
femur.19, 20, 30, 43, 44, 52 Forces about the hip have primary fracture line. Type I are fractures at
been measured using mathematical models,43 the level of the lesser trochanter, type II are
cadaver systems that attempt to simulate fractures within 1 inch of the lesser trochanter,
normal hip forces,52 and insertion of pressure and type III are fractures 1 to 2 inches be-
measuring instrumented implants.44 It seems low the lesser trochanter. This classication
that pressures from normal gait may reach 5 to does not take into account fracture com-
7 times body weight or higher, and signicant minution, which is important in assessing
pressures approaching this can occur with fracture stability and planning treatment.
supine straight-leg raising or getting on and Fracture patterns, such as spiral fractures,
off a bedpan.20 may be difcult to classify with this system.
Seinsheimer49 devised a classication system
for subtrochanteric fractures based on the
INCIDENCE AND MECHANISM number of major fragments and the location
OF INJURY and shape of the fracture lines. Implant fail-
ures and nonunions occurred in his series
Of the fractures of the proximal femur, 7% with a higher incidence in the type IIIA and IV
to 34% primarily involve the subtrochanteric fractures. These are the fracture patterns with

medial comminution, and their higher inci- present. In type IIB fractures, there is exten-
dence pointed to the importance of the medial sion into the greater trochanter area with sig-
buttress. Waddell56 devised a system that clas- nicant comminution of the medial femoral
sied fractures based on their fracture pattern. cortex and loss of continuity of the lesser
In this scheme, type I fractures included the trochanter; this likewise has important impli-
transverse and short oblique fractures; type II, cations for treatment.
the long oblique or spiral fractures; and type
III, the comminuted fractures.
Delee16 proposed the concept of stable and PATIENT ASSESSMENT
unstable fractures in place of a specic classi-
cation system.55 Stable subtrochanteric frac- As with all injuries, an adequate history and
tures were dened as those in which it is physical examination of the patient is essen-
possible to reestablish bone-to-bone contact tial. In patients with low-energy trauma, the
of the medial and posterior femoral cortex history and physical examination should con-
anatomically. sider the possibility of a pathologic fracture
In the comprehensive classication of frac- secondary to neoplasm or metabolic bone dis-
tures, subtrochanteric fractures are classied ease. Patients involved in high-energy trauma
as diaphyseal fractures and appear under the should proceed through a trauma system
classication for the diaphyseal segment. The and ATLS guidelines to evaluate for other in-
dividing line between the subtrochanteric and juries. Neurologic and vascular examination
trochanteric area is a horizontal transverse line of the extremities should be documented, es-
at the inferior border of the lesser trochanter. pecially in patients with penetrating trauma.
This classication often is believed to be too Assessment of the surrounding local soft tis-
cumbersome to use in routinely describing sues is important when planning surgery. Ra-
fractures but is important for research and diographic evaluation should include antero-
data collection. Additionally, if one spends posterior and cross-table lateral radiographs
some time becoming familiar with this system, centered on the hip and anteroposterior and
it can be used in routine fracture and treatment lateral radiographs of the entire femur to rule
analysis. out other fractures in the femur more distal
The Russell-Taylor classication has proved and to assess adequately the subtrochanteric
to be useful because it has implications re- fracture. It is important to assess the most
garding the appropriate treatment and appro- proximal extent of the fracture and to detect
priate choice of implants with the implants any trochanteric extension of the fracture. It is
that currently are used most commonly. This important to note if the fracture involves the
classication divides subtrochanteric fractures area of the piriformis fossa. Manual traction
into two major groups. Type I fractures are on the extremity while the radiographs are
fractures that do not have extension into the being taken may aid in more accurate visu-
piriformis fossa. These fractures can be treated alization of the proximal fragment. Placing a
with intramedullary xation. In type IA frac- bump beneath the hip to roll the patient, as
tures, comminution and fracture lines extend one would do to obtain an obturator oblique
from below the level of the lesser trochanter view of the pelvis, may give a better antero-
only. In type IB fractures, fracture lines and posterior and lateral radiograph if the proxi-
comminution do involve the area of the lesser mal fragment does have signicant external
trochanter. The importance of this distinction rotation. Occasionally, radiographs of the op-
is that in type IA fractures, it may be suitable posite hip may be of benet in preoperative
for standard interlocking nailing, whereas the planning. Leg length may be difcult to deter-
type IB fractures would be more suitable for mine in patients with severe comminution. In
cephalomedullary nails if an intramedullary these patients, preoperative measurement of
nail is chosen. Type II fractures extend prox- the opposite leg using a radiopaque ruler can
imally into the greater trochanter and do in- be helpful. Measures from the femoral head or
volve the piriformis fossa. This distinction is greater trochanter to the end of a condyle or
important because it may lead one to con- physeal scar can be determined and matched
sider this a contraindication to intramedullary on the operative side. This measurement of
nailing. Type IIA fractures extend from the the intact leg also can be made on the com-
lesser trochanter to the isthmus with exten- puted tomography scan with the use of a cal-
sion into the piriformis fossa, but signicant ibrated cursor on the scout lm of the femur.
comminution of the lesser trochanter is not This measurement may be useful if the patient
116 SIMS

is in the computed tomography scanner pre- ture xation of diaphyseal fractures. These
operatively for other reasons. principles must be considered carefully be-
cause fractures in this area are unforgiving of
anything other than the most thoughtful, well-
TREATMENT planned surgery that is executed carefully and
Treatment Options The rst principle is careful preoperative
planning for the surgery. After thoughtful
Nonoperative treatment of subtrochanteric assessment of the radiographs and fracture
femoral fractures requires prolonged immobi- pattern, the reduction technique and implant
lization and is associated with high morbidity should be selected. The surgeon needs to be
and mortality rates for the patient and high sure that the equipment needed will be avail-
rates of local complications related to frac- able. Also, the surgeon needs to decide if he or
ture healing (nonunions, delayed unions, she has the expertise and support available to
and malunions).1, 8, 27, 28, 55, 56 For these reasons, treat the fracture properly; if not, the surgeon
nonoperative treatment of subtrochanteric should transfer the patient to an appropriate
femoral fractures has little or no role in the facility. There is evidence to support that early
denitive treatment. xation of femoral fractures decreases patient
Internal xation of these fractures has morbidity; however, short delays to assemble
evolved through a long list of implants. Many the appropriate operative team may avoid in-
of the early reports have high incidences of traoperative delays.
loss of xation and implant failure. Improved The second principle is to accomplish the
manufacturing abilities, a better understand- goals of fracture xation for fractures in this
ing of the local stresses, and application of area, including to restore length, to restore
improved engineering principles have led axial rotation, to restore angular alignment,
to stronger implants with greater fatigue and to obtain union. The surgeon must plan
life for use in these fractures. Additionally, the reduction technique and choose the ap-
preservation of soft tissue attachments and propriate implant to obtain stable xation,
blood supply in the fracture zone has yielded while preserving the vitality of the bone.
a better biologic response with these fractures Anatomic reduction of each fracture surface is
and more rapid healing. The results have not crucial, and it should not be the absolute
been fewer complications in the operative goal of surgery in the diaphysis, especially
treatment of these fractures if the principals if the tradeoff for anatomicity is the devi-
of fracture xation are understood and adher- talization of the fracture zone. The surgeon
ence to these principles is not compromised. must remember that living bone will heal. If
Implants commonly used currently include in- there is question of the preservation of living
tramedullary devices and xed angled plates. bone in the fracture zone in these fractures,
Intramedullary devices currently suitable for autogenous bone graft should be considered.
these fractures include locked intramedullary The third principle is the postoperative care,
nails and a variety of cephalomedullary nails which is as important as the operative treat-
that allow for xation into the femoral head ment. The postoperative rehabilitation needs
and neck proximally and distally locking with to be individualized for patient factors, the
screws. Fixed angle plates currently suitable fracture pattern, and the operative result. The
for treatment of these fractures including the ultimate goal is the best possible functional
95 condylar blade plate, the 95 dynamic outcome.
condylar screw, and compression hip screws
(dynamic hip screws [DHS]). Reports of use
of the Medhoff plate have appeared also that Intramedullary Fixation
may allow a sliding at the plate junction and
along the plate.33 Intramedullary xation offers mechani-
cal, technical, and biologic advantages over
other forms of xation. Statically locked in-
Principles of Treatment tramedullary nails are probably the most
commonly used implant in the treatment of
Operative treatment of these fractures must subtrochanteric femoral fractures and consid-
adhere carefully to the basic principles of frac- ered by many as the implant of choice. For

fractures that are completely below the level track record. They provide relative stability to
of the lesser trochanter, a standard statically the fracture and have high union rates with a
locked intramedullary nail has been used with low incidence of nonunion, hardware failure,
good results. For fractures that extend into or loss of alignment. The cephalomedullary
the lesser trochanter but do not involve the nails have a biomechanical advantage over
greater trochanter at the area of the piriformis plates. Nails because of their intramedullary
fossa, a cephalomedullary, statically locked position have a shorter distance to the tip
intramedullary nail may be employed with ex- of the portion of the implant in the femoral
pectations of good results. Cephalomedullary head than do the plate systems that are on
nails have been shown to provide improved the lateral border of the bone. The shorter the
stability for proximal fractures so that in this distance over which the bending forces act, the
situation in which there is some question lower the moment is on the implant. This is
of the proximal extent of the fracture or in especially important in fractures in which the
situations in which increased stability may be medial buttress cannot be restored. In some
thought to be important, one should lean in fracture patterns, early weight bearing may
the direction of using the cephalomedullary be allowed with intramedullary xation. The
nails over standard locked nails.41 These situa- biologic advantage of intramedullary nails
tions may include fractures at the level of the also is well known. These devices allow for
lesser trochanter with severe comminution or indirect reduction without exposure of the
patients with concerns of poor bone quality. fracture. This maintenance of the vitality of the
Intramedullary nails are not recommended bone in the area of the fracture usually leads
generally for subtrochanteric fractures that to rapid healing with abundant callus. It is
involve the greater trochanter and the area postulated that reamings may spill into the
of the piriformis fossa. In these situations, fracture site and may function as bone graft
the nail may be inserted through the frac- material. The relative importance of these
ture and lead to further displacement of the reamings is unclear. Reaming itself does have
intertrochanteric component of the fracture. some impact on blood ow to this area, which
Intramedullary hip screw devices have been may stimulate periosteal reaction and healing.
used for some intertrochanteric fractures and Technically, intramedullary nails offer
subtrochanteric fractures. These devices are advantages and disadvantages. Most ortho-
inserted through a greater trochanteric inser- pedic surgeons are familiar with techniques
tion site and may extend the indications for for intramedullary nailing of femoral frac-
intramedullary xation to the fractures that in- tures. Also, the surgery can be accomplished
volve the piriformis fossa. Their use has led to through small incisions with some amounts of
acceptable union rates with decreased blood external blood loss.
loss and short operative times.4, 5, 7, 14, 31, 35, 45, 54 These fractures do offer a technical chal-
Concerns with these devices are their large lenge to obtain a good reduction and restore
diameter proximally, which may require axial rotational and angular alignment and re-
reaming at the trochanter to 17 or 18 mm. store length (Fig. 1). These fractures usually
The long-term importance of removing this are abducted because of the pull of the hip ab-
amount of bone from the proximal femur in a ductors on the greater trochanter. This posi-
young patient is unknown and should be con- tion may cause difculty in nding the appro-
sidered cautiously when considering the use priate starting point and being able to pass a
of these implants in young patients. Also, this reamer in the appropriate direction down the
amount of reaming at the greater trochanter intramedullary canal. The greater trochanter
may have an effect on the abductor insertion. tends to be in the way with a proximal frag-
The biomechanical advantages of in- ment abducted, and the guidewire and ream-
tramedullary nails in these types of fractures ers tend to go from a more lateral starting
have been alluded to earlier and are generally point than ideal and pass medial toward the
well known. For fractures below the lesser medial cortex. Additionally, the pull of the
trochanter, which basically are diaphyseal iliopsoas on the proximal fragment leads to
fractures, intramedullary nails have a proven exion. This exion should be corrected while
reaming to prevent completely reaming away
the posterior cortex of the short proximal frag-
References 2, 1012, 22, 25, 26, 28, 34, 37, 47, 53, and ment. The alignment of the fracture may re-
59. quire a small incision to allow a pushing
118 SIMS

Figure 1. A, AP radiograph of proximal femur in a 60-year-old patient involved in a motor vehicle acci-
dent with a subtrochanteric femur fracture with involvement of the area of the lesser trochanter without
extension into the piriformis fossa. B and C, Postoperative AP and lateral radiographs after insertion
of a sliding intramedullary hip screw (Gamma nail, Howmedica, Rutherford). This shows a typical
maintenance of malalignment commonly seen after intramedullary nailing of these subtrochanteric
femur fractures with the proximal fragments remaining in some varus angulation, with signicant per-
sistent exion of the proximal fragment leading to an apex anterior deformity.

tool to be used to push the proximal frag- Rotational alignment also must be assessed
ment toward adduction and extension, while carefully because the proximal fragment may
manipulating the leg to help maneuver the be externally rotated; this should be compared
distal fragment (Fig. 2). Occasionally, placing with the opposite extremity and conrmed to
a clamp at the fracture may be required. Good be symmetric with the opposite leg clinically
anteroposterior and lateral radiographs are and radiographically before leaving the op-
essential, and the alignment must be assessed erating room. In comminuted fractures, leg
carefully during each stage of the surgery. length may be determined by measurement

Figure 2. A, The preoperative AP radiograph of a subtrochanteric femur fracture

with extension into the area of the lesser trochanter in a young patient with high-
energy trauma. B, Intraoperative C-arm view after making a 5-cm incision cen-
tered over the area of the fracture. An elevator is then placed anteriorly and lat-
erally on the distal portion of the proximal fragment to push this fragment into
anatomic alignment. This was done by pushing posteriorly to resolve the exion
of the proximal fragment and pushing in the medical direction to solve the abduc-
tion deformity forces. This is maintained in alignment throughout the procedure by
an assistant while a guide-wire and reamers, and subsequently the intramedullary
nail, are passed across the fracture site. C and D, AP and lateral radiographs of
this fracture at approximately 2 months postoperatively, with good alignment and
callus formation.
120 SIMS

of the opposite leg and choosing a nail length 2 reasons. First, any sliding of the compression
based on this measurement. Leg lengths screw in the plate results in medial transla-
should be checked clinically before leaving tion with subtrochanteric fractures, in contrast
the operating room and adjusted if needed. to intertrochanteric fractures, in which it leads
Residual apex anterior angulation with exion only to impaction of the fracture fragments
of the proximal fragment often is seen after in- without change in their position. Second, with
tramedullary xation of subtrochanteric fem- only the compression screw through the bar-
oral fractures. This angulation may be recog- rel of the proximal fragment, sagittal plane de-
nized more easily in the long spiral fractures formities may be difcult to avoid. Although
typically associated with low-energy trauma the compression screw is keyed into the bar-
of older patients because the length of the rel of the plate, the head may spin on the
fracture magnies the offset seen. The ef- screw, and exion of the proximal fragment
fects of this angulation on the functional and may occur. If the fracture pattern allows ad-
long-term outcome of patients are not clear. ditional screws through the plate to be placed
in the proximal fragment, it helps resist this
type of reduction; however, it also may pre-
Sliding Hip Screws vent the sliding hip screw to slide as it is de-
signed. Finally, the implant does not lend it-
Sliding hip screw devices have been em- self to axial loading with a tensioning device,
ployed with good success in the treatment which has been reported to be important.29
of subtrochanteric femoral fractures.6, 36, 42, 56, 58 There have been reports of poor results with
Union rates of 95% and average healing times loss of reduction and loss of xation with these
of 2.5 months have been reported. These im- devices leading to unacceptable rates of re-
plants do offer some advantages. They are vision surgery.23 This implant was designed
strong implants with low rates of fatigue fail- for treatment of intertrochanteric fractures and
ures. They are familiar implants to most ortho- should be used cautiously in rare instances
pedists because of their common use and in- only for treatment of subtrochanteric femoral
tertrochanteric fractures, which may decrease fractures.
some of the technical difculties. Cutout of the
implants can be avoided with proper place-
ment of the compression screw in the center of 95 Fixed Angle Devices
the femoral head and the design allowing slid-
ing of the screw on the plate. Best results with The 95 condylar blade plate and the 95
this type of device have stressed the impor- condylar screw devices are discussed together
tance of restoring the medial buttress, if neces- in this section. These implants have unique
sary with bone grafting. characteristics, which should be considered,
These implants do have some disadvan- but both function as a 95 xed angle device
tages and limitations. As stated earlier, intact when placed. The angled blade plates are a
medial buttress is important with these im- xed angle 1-piece device rst developed by
plants. To obtain an intact buttress may re- the AO group in 1959. The 95 condylar blade
quire stripping of bone fragments medially plate was released later in the 1970s and still
and placement of lag screws. Bone graft is nec- is useful in the treatment of subtrochanteric
essary in these situations to avoid nonunion fractures.3, 21, 38, 47, 49, 5557 The 1-piece design cre-
with subsequent fatigue of the plate. In frac- ates the disadvantage of increased difculty
ture patterns that are complex and multifrag- with insertion. The plate has to be inserted in
mentary, especially over a segmental area, the appropriate location in the head at the cor-
these implants are not appropriate because rect angle. Additionally, the blade must be in-
they telescope until the threads of the com- serted so that the plate portion of the condylar
pression screw reach the barrel of the plate. blade plate lines up with the axis of the shaft
This situation prevents further sliding, which at the end of the procedure. Good radiographs
may make head penetration more likely; this and careful attention to detail are required be-
also results in an excessive medialization of cause the blade is inserted with the fragments
the shaft of the femur. Maintenance of normal still in a displaced position, and the implant
anatomic relationship of the proximal head is used to accomplish the reduction. Malalign-
and neck fragments to the femoral shaft is ments are not easily adjustable after the blade
often not maintained in these fragments for has been placed.

The technical difculties led to the later situations. This technique of indirect reduction
development of the dynamic condylar screw, with a 95 xed angle implant and tensioning
which was designed primarily for the distal of the system has led to improved results
femur but also proved useful in the treatment reported as 100% union rate and 4.2 months
of subtrochanteric femoral fractures. This time to healing without bone grafting.29
implant, the dynamic condylar screw, has in- This is a very exact technique and requires
creased thickness, which makes it more preoperative planning and careful surgical
resistant to fatigue fracture than the 95 condy- technique to duplicate these excellent results
lar blade plate, and allows for easier adjust- (Figs. 4 and 5).
ment in the alignment in the sagittal plane
after the screw is placed. It does require more
bone to be removed for its placement, how-
ever, which may complicate further surgery SUMMARY
should a nonunion or other complication
occur. Subtrochanteric femoral fractures can be
These 95 xed angled implants were rec- complex fractures for treatment with high
ommended for use as a lateral tension band complication rates historically. Multiple im-
system requiring reconstruction of the me- plants have been used with varying rates of
dial buttress and additional bone grafting. success. The Russell-Taylor classication is
Nonunion rates were reported in 10% to 18% useful in planning the type of internal xation
of patients, and these nonunions often were best suited for the fracture with the implants
explained as being secondary to not recon- that currently are used most commonly. For
structing the medial cortex, and their use was fractures located below the level of the lesser
urged to be restricted only to cases in which trochanter, standard locked intramedullary
the medial cortex could be restored. This rec- nails can be used effectively. For fractures that
ommended plate technique requires visualiza- extend into the lesser trochanter but do not
tion of the fracture line, necessitating suf- involve the piriformis fossa, the options of a
cient medial dissection to verify the quality cephalomedullary nail versus a 95 xed angle
of the reduction and the stabilization of frac- device have yielded the best results. The ad-
ture fragments. More recently, the importance vantages and disadvantages of these 2 systems
of maintaining the blood supply and vitality have been discussed. If one chooses a 95 xed
of all fragments by avoidance of medial dis- angle device, careful adherence to indirect
section has been emphasized. Medial dissec- reduction techniques with preservation of the
tion is avoided by determining the entry site of blood supply to the fracture zone should be
the blade by a preoperative plan using a radio- employed. Implant device of choice should
graph of the opposite hip. Image intensica- be based on careful review of the fracture
tion may be used to conrm proper placement pattern and the surgeons experience with
of the implant. No dissection of the fracture fractures in this region. The 95 condylar blade
area and no attempts at reduction are made up plates still serve an important role for fractures
to this point. The shaft of the plate is applied in this area because they greatly facilitate a
to the main distal fragment with a clamp dis- return of an anatomic reduction and good
tal to the fracture zone with care to avoid maintenance of this reduction until fracture
stripping any soft tissues in the fracture zone healing if careful indirect reduction techniques
(Fig. 3). are employed. Good results also can be ob-
The femoral distractor occasionally may be tained with cephalomedullary implants. For
of assistance to gain length. Axial loading by fractures that do have proximal trochanteric
use of a tensioning device increases stability of extension into the area of the piriformis fossa
this system and allows the bone to share some or greater trochanter, sliding nail screw de-
of the load with the plate. These plates may vices may have some usefulness in the future;
be slid submuscularly from proximal to distal however, outcomes are not well documented
without removing any muscle from the femur at this time. Otherwise, fractures in this area
in the fracture zone. The bone can be exposed are suited best to the use of an appropriate
only at the entry point proximally and distally 95 xed angle device. The DHS implant in
at the area of the screws insertion. It is possi- the authors opinion has limited usefulness
ble to accomplish this surgery with only small and is not employed for the treatment of
skin incisions proximally and distally in some subtrochanteric femoral fractures.
Figure 3. A, The preoperative radiograph in a young patient involved in a high-energy trauma with a
segmental area of multifragmentary fracture extending from the area of the lesser trochanter to the
area of the isthmus. B and C, AP and lateral postoperative radiographs after insertion of a 95 DCS
device. This operation was performed through a small proximal incision and a small distal incision with-
out any skin incision or any exposure over the area of the fracture. The entry port was established
proximally and the plate was then slid submuscularly to assure indirect reduction techniques and no
damage to the vitality of the fracture zone. No attempt to restore the medial buttress and no bone graft-
ing was performed. D and E, Radiographs obtained 10 weeks postoperatively with abundant callus
formation already present. At this time, the patient is full weightbearing without pain. F and G, The -
nal radiographs obtained at 5 months postoperatively with complete healing of the fracture treated with
122 this 95 device and indirect reduction technique with submuscular plating.

Figure 4. A, The preoperative radiograph a young patient involved in a high-energy trauma with an
area of segmental multifragmentary fracture involving the lesser trochanter, as well as with extension
proximally into the piriformis fossa and greater trochanter. B and C, The AP and lateral postopera-
tive radiographs of this fracture treated with a 95 condylar blade plate. This was done without taking
the muscle down off of the area of the fracture zone and using the 95 condylar blade plate to estab-
lish the reduction after the blade had been placed in the proximal fragment. No attempt to reconsti-
tute the medial buttress was made and no bone grafting was performed. D and E, The AP and lateral
radiograph obtained at 10 weeks postoperatively with abundant callus formation. The patient began
full weightbearing at this point and did go on to uneventful union with excellent radiographic and func-
tional outcome, again demonstrating the ability of this area to heal with careful indirect reduction tech-
niques avoiding damage to the vascularity of the fracture zone.
124 SIMS

Figure 5. A and B, AP and lateral preoperative radiographs in a young patient with this sub-
trochanteric femur fracture that extends into the area of the lesser trochanter, but does not extend
proximal to this. This demonstrates the typical picture seen of abduction, external rotation, and ex-
ion of the proximal fragment due to strong muscle forces that pull on it and can lead to difculties with
closed reductions. C and D, The postoperative AP and lateral radiographs obtained at 45 months
postoperatively. Reconstitution of alignment with healing with abundant callus in this fracture was
treated with an indirect reduction technique using the 95 condylar blade plate to accomplish the re-
duction after it had been xed to the proximal fragment in the appropriate position.

References the long Gamma nail. J Orthop Trauma 14:324328,

5. Bellabarba C, Herscovici D Jr, Ricci WM: Percuta-
1. Allis OH: Fracture in the upper third of the femur ex- neous treatment of peritrochanteric fractures using
clusive of the neck. Med News 59:585589, 1891 the Gamma nail. Clin Orthop 375:3042, 2000
2. Aronoff PM, Davis PM Jr, Wickstrom JK: Intra- 6. Berman AT, Metzger PC, Bosacco SJ, et al: Treatment
medullary nail xation treatment of subtrochanteric of the subtrochanteric fracture with the compression
fractures of the femur. J Trauma 11:637650, 1971 hip nail: A review of 138 consecutive cases [abstr].
3. Asher MA, Tipper JW, Rockwood CA, et al: Compres- Orthop Trans 3:225256, 1979
sion xation of subtrochanteric fractures. Clin Orthop 7. Bess RJ, Jolly SA: Comparison of compression
117:202208, 1976 hip screw and gamma nail for treatment of per-
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26. Hey-Groves EW: Ununited fractures, with special ref- ment of subtrochanteric fractures of the femur using
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ing. Br J Surg 203:247, 19181919 Academy of Orthopaedic Surgeons Annual Meeting,
27. Hibbs RA: The management of the tendency of the Atlanta, GA, February 49, 1988
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49. Seinsheimer F: Subtrochanteric fractures of the femur. problems in subtrochanteric fractures of the femur.
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51. Tencer AF, Johnson KD, Johnston DWC, et al: A 57. Whatley JR, Garland DE, Whitecloud T, et al: Sub-
biomechanical comparison of various methods of sta- trochanteric fractures of the femur: Treatment with
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J Orthop Res 2:297305, 1984 1978
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54. Van Doorn R, Stapert JW: The long gamma nail in the tramedullary nailing of femoral fractures. J Bone Joint
treatment of 329 subtrochanteric fractures with major Surg Am 66:529539, 1986

Address reprint requests to

Stephen H. Sims, MD
Miller Orthopaedic Clinic
1001 Blythe Boulevard, #200
Charlotte, NC 28203
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

George V. Russell, Jr, MD, Philip J. Kregor, MD,
Christopher A. Jarrett, MD, and Michael Zlowodzki, MD

Since the advent and popularization of in- with an open femoral shaft fracture is eval-
tramedullary nailing, the treatment of femoral uation and stabilization of life-threatening
shaft fractures has become a good, safe, and injuries. After resuscitation and medical stabi-
reproducible procedure for the successful lization, one must consider surgical stabiliza-
management of femoral shaft fractures. Many tion of the femoral shaft fracture.
orthopaedic surgeons have been trained well Historically, open femoral shaft fractures
in the nailing of femoral shaft fractures and were treated with operative debridement and
commonly treat these injuries; however, many skeletal traction. As management of femoral
femoral shaft fractures are complicated by shaft fractures has evolved, several investiga-
associated fractures, extensive comminution, tors have demonstrated benecial effects to
extensive contamination, arterial injury, and patient management with early stabilization
compartment syndrome. Other problematic of femur fractures. Early retrospective stud-
situations include existing nonunion with ies evaluating the efcacy of early fracture
broken hardware, deformed nails with acute stabilization of multitrauma patients found
injury, and associated femoral shaft and that the incidence of acute respiratory distress
femoral neck fractures. The management of syndrome and other complications associated
these complex femur fractures is not common with prolonged recumbency were consider-
and demands special techniques to obtain a ably decreased.27, 58 Also, the mortality rate
successful outcome. The techniques to suc- was decreased in multiply injured patients
cessfully treat several types of complicated who underwent early fracture stabilization.27
femoral shaft fractures are discussed herein. Bone et al,8 in a prospective study compar-
ing early versus delayed xation of femur
fractures, found the incidence of pulmonary
OPEN FRACTURES complications, hospital stay, and intensive
care unit stay were all decreased in patients
Considerable energy is required to create who underwent early stabilization of femur
a femoral shaft fracture, and even greater fractures.
energy is required to create an open femoral As early stabilization of open femoral shaft
shaft fracture. Open femoral shaft fractures fractures became widely accepted, various
usually result from motor vehicle accidents techniques and implants evolved to stabilize
and often are associated with other injuries these fractures. Early management included
and fractures. The rst priority in a patient ORIF using plates,45, 60 open intramedullary

From the Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi (GVR,
PJK, MZ); and the Department of Orthopaedic Surgery, University of South Alabama Medical Center, Mobile,
Alabama (CAJ)



128 RUSSELL et al

nailing with cerclage wires,38, 71 and external fracture and not in the 16 patients with open
xation.1, 30, 49 These techniques have been fractures. Moed et al,48 using unreamed ret-
largely abandoned because of a considerable rograde femoral nails, did not have any in-
complication prole and the success of closed fections or septic knees in their series, which
intramedullary nailing in the treatment of included 11 open fractures, but one third of
open femoral shaft fractures. the patients required dynamization to achieve
Closed intramedullary nailing has become union.
the standard of care for both closed and Management of types 1 and 2 open femoral
open femoral shaft fractures. Chapman15 re- shaft fractures should consist of urgent irri-
ported no infections and good functional gation and debridement followed by closed,
results after delayed (1014 days after in- reamed, antegrade femoral nailing; however,
jury) closed intramedullary nailing of open management of type 3 open fractures can
femur fractures, but this technique negated be controversial. For type 3A open fractures,
the benets of early patient mobilization. good results have been demonstrated with
Brumback et al11 had no infections in patients closed, reamed femoral nailing and can be
with type 1 or 2 open femoral shaft fractures safely recommended. A consensus statement
stabilized in either early or delayed fashion is difcult to make regarding management of
with closed, reamed intramedullary nailing. type 3B open fractures or those open frac-
Winquist et al74 reporting on 520 femoral tures associated with massive contamination.
nailings, of which 86 were type 1 or 2 open The difculty lies in part because previous
fractures, found a 2% infection rate. Lhowe literature does not typically distinguish be-
and Hansen42 found a 5% infection rate in their tween type 3A and type 3B open fractures and
series of 67 patients who underwent imme- also because of the relative paucity of these
diate closed reamed nailing for open femoral types of injuries. Most patients with type 3B
shaft fractures. open femoral shaft fractures can be managed
Treatment of type 3 open femoral shaft safely with urgent irrigation and debridement
fractures with reamed intramedullary nailing followed by closed, reamed intramedullary
has demonstrated good results with accept- nailing. If, however, extensive contamination
able infection rates. OBrien et al50 found ve is encountered, a provisional spanning exter-
supercial and three deep infections among nal xator may be applied until the open
63 open femoral shaft fractures treated with wound is clean enough to allow for antegrade
early closed nailing. Lhowe and Hansen42 nailing.
found no infections among eight patients with Retrograde femoral nailing is not routinely
type 3 open fractures. Similarly, Wolinsky performed for open fractures at the authors
et al80 reported no infections among 15 pa- institution; however, reamed retrograde nail-
tients with type 3 open fractures treated with ing techniques have been used safely in types
intramedullary nailing. Brumback et al11 re- 1 and 2 open femoral shaft fractures in patients
ported no infections among patients with type with associated ipsilateral acetabular, patel-
3A open fractures, but 3 of 27 patients with lar, and tibial shaft fractures (Fig. 1). Similar
type 3B open fractures developed infections. patients with type 3 open fractures also have
Some have advocated the use of unreamed been managed with retrograde nailing tech-
nails in the treatment of open femoral shaft niques, but concerns about knee joint contami-
fractures to decrease infectious complications; nation have limited the use of retrograde nails
however, the complication prole is similar in these patients. Recently, the senior author
to that of reamed nails, and the use of un- (GVR) stabilized open femoral shaft fractures
reamed nails requires more secondary surgical with plates, emphasizing indirect fracture re-
procedures.19 duction techniques with good results seen at
Retrograde nailing has gained popularity early follow-up.
for the stabilization of femoral shaft fractures,
but the role of retrograde femoral nails has not
been clearly established with open fractures. SEGMENTAL FEMORAL
Fear of knee joint contamination and subse- SHAFT FRACTURES
quent septic knee arthrosis has deterred some
from its use in open fractures. Ostrum et al,52 Segmental femoral shaft fractures occur in
using reamed retrograde nails, recommended approximately 5% of femoral shaft fractures.76
against their use in patients with type 3 open Segmental fractures of the femur result from
fractures despite the fact that the only sep- high-energy injuries and are usually accom-
tic knee occurred in a patient with a closed panied by massive soft tissue damage.76, 82

for fractures that are proximal to the lesser

trochanter but do not involve the piriformis
fossa. Fractures with proximal extension to
the piriformis fossa are best treated with a
xed-angle device. Retrograde nails are also
an option if the proximal fragment is long
enough to ensure adequate stabilization with
the proximal locking bolts.
Patients with segmental femoral shaft frac-
tures are best treated on a fracture table using
traction to reestablish proper length, rotation,
and alignment. A full-length radiograph of the
contralateral femur is benecial in establishing
proper length and alignment. Proper rotation
may be difcult to determine but can be as-
sisted by clinical examination of the contralat-
eral thigh or if this is not possible radiographic
analysis is possible using intraoperative uo-
roscopic imaging.70
The starting hole is crucial, and care must
be taken to ensure that it is within the piri-
formis fossa and aligned with the long axis
of the proximal femur in the AP and lateral
uoroscopic images. Cephalomedullary nails
require a slightly anterior starting hole to
allow for passage of screws or spiral blade
through the femoral neck into the femoral
head. A helpful technique, if the fracture
Figure 1. This 17-year-old female patient sustained bi- pattern allows, is to reduce the segmental
lateral transforaminal sacral fractures, bilateral acetabular component to the proximal fragment and then
fractures, right closed femoral shaft fracture, left Gustilo pass the guidewire in the center of each frag-
Type II open femoral shaft fracture, and left patella frac- ment using uoroscopic imaging. Reaming is
ture, as a result of a motor vehicle crash. Her femoral
shaft fractures were stabilized the day of the injury in a
then undertaken to the appropriate diameter.
single operative anesthetic, allowing for concomitant left After reaming proximally, the distal fracture
patellar fracture xation without jeopardizing planned op- is then reduced and the guidewire is passed
erative exposures for the acetabular fractures. into the distal fracture fragment. Reaming
then is performed in the distal fragment to the
same diameter as was done proximally. For
The resultant fracture can be characterized fractures with a large comminuted segmental
by the position of the segmental component fracture, the guidewire is passed through
as a purely diaphyseal intercalary segment, the proximal and distal intact femur and
a subtrochanteric-diaphyseal component, a reaming is undertaken bypassing the com-
diaphyseal-supracondylar segment, or a vari- minuted injury zone, with care to maintain
ation thereof. Also, the intercalary fracture reduction.
fragment can be a simple intercalary fragment, Obtaining and maintaining reduction is
a fragment with multiple fracture planes, or a often difcult without an intact diaphysis to
comminuted intercalary fragment. use as a template for reduction. Also, multi-
Although technically difcult, intramedul- ple fracture lines often are difcult to align
lary nailing has been recommended by sev- with closed manipulative means. Reduction
eral investigators and has demonstrated devices commonly are required to obtain
good results.2, 67, 75, 76 When electing intramed- and maintain reductions. Mallets and spiked
ullary nailing, care must be taken for proper pushers, found on the pelvic reduction tray,
nail selection. Standard interlocking in- are useful to push fragments into position.
tramedullary nails may be used successfully Various hooks are also useful if fragments
for fractures that are distal to the lesser require a pull to obtain reduction. Unicortical
trochanter; however, this may require leaving diaphyseal or bicortical metaphyseal Schanz
the nail proud to ensure proximal xa- pins are frequently benecial in aligning
tion. Cephalomedullary nails are required intercalary fractures and the distal metaphysis
130 RUSSELL et al

during guidewire placement, reaming, and only small incisions are required and soft
nail placement. tissue stripping is minimized.
Passage of the nail requires vigilance to Fixed-angle devices are recommended for
maintain an appropriate reduction. Without fractures that enter into piriformis fossa and
an intact diaphysis to capture the nail, the usually require long surgical exposures for
nail tends to translate medially. This can be plate placement; however, a dynamic condy-
particularly problematic in patients with large lar screw and side plate can be placed using a
buttocks in whom there is difculty in ad- percutaneous technique.61 A standard 4.5-mm
ducting the proximal nail and jig against the broad low contact dynamic compression
soft tissues, which exacerbates distal medial (LCDC) plate is also an option if adequate
nail translation. Occasionally, it may be nec- screw purchase can be obtained proximal and
essary to guide the nail into the distal meta- distal to the fracture. A careful preoperative
physis with a percutaneously placed hook. plan is required before surgery. Reduction
With introduction of the nail into the distal techniques are typical for many other fractures
femoral metaphysis, alignment must be mon- in which plates are applied with an emphasis
itored because the nail will have a tendency on minimizing soft tissue stripping. Using
for eccentric placement leading to fracture techniques to decrease soft tissue stripping
malalignment. Reduction must be reexamined and other techniques to promote healing with
after the nail is seated, and locking screw callus formation, good results can obtained
positions must be ensured both proximally plating segmental femoral shaft fractures.46
and distally. Based on the fracture pattern,
it may be necessary to place a slightly long FEMORAL SHAFT FRACTURES IN
nail proud to ensure adequate locking bolt COMBINATION WITH IPSILATERAL
Plating of segmental femoral shaft fractures
is also an option, particularly when associ- An ipsilateral fracture of the femoral neck
ated with peritrochanteric fractures. Plating of is a signicant nding in patients with a
segmental femur fractures has been associated femoral shaft fracture, occurring in 2% to
with periosteal stripping, increased blood loss, 6% of femoral shaft fractures.6, 69, 74, 83, 84 Most
and increased operating room time.76 Despite of these double fractures result from high-
these reported disadvantages, plating has the energy trauma,16, 26, 34, 55, 79 with motor vehicle
advantages of direct visualization to assist accidents, motorcycle accidents, and falls from
with fracture reduction and also management signicant heights being the most common
of very proximal and very distal fractures causes.79 Frequently, the femoral neck frac-
are frequently easier with plating techniques. ture is not initially diagnosed; several series
Periosteal stripping can be minimized with in- have shown that as many as 33% of associ-
direct reduction techniques despite an open ated femoral neck fractures were not initially
surgical wound. Bridge plating of commin- diagnosed.6, 68, 69
uted fracture zones also minimizes periosteal Most commonly, the femoral neck fracture
stripping and allows for healing by callus is a minimally displaced vertical fracture.40
formation. Daffner et al,21 in explaining the high percent-
Patients may be placed on a radiolucent age of initially missed femoral neck fractures,
table or a fracture table. If a radiolucent noted that these fractures tend not to displace
table without traction is used, a femoral during the initial evaluation period. Often, an
distractor is recommended to maintain the external rotation deformity of the proximal
appropriate femoral length. A fracture table femoral fragment is present secondary to the
is recommended for fractures with extensive femoral shaft fracture, and the femoral neck
comminution or when proximal fracture ex- is not well visualized in this position. Several
tension is into the peritrochanteric region. investigators have noted that the most accu-
Traction is benecial to attain and maintain rate visualization of the femoral neck occurs
proper length, rotation, and alignment during with 15 of internal rotation.39, 69 A commin-
reduction and plating. The surgical exposure uted midshaft femoral fracture secondary to
is based on the fracture pattern. If a long surgi- axial loading should alert the treating physi-
cal exposure is required, periosteal stripping cian to the possibility of an associated femoral
should be minimized laterally and medial neck fracture.55
soft tissue stripping should be avoided. If a As part of the Advanced Trauma Life
submuscular plating technique is performed, Support protocol, all traumatized patients

undergo AP pelvic radiography on presen- Geissler et al24 also treated six patients with
tation to the emergency department. Gill screw xation of the femoral neck and com-
et al26 recommend, in addition to the initial pression plate xation of the femoral shaft
AP pelvic radiography, specic hip radiogra- with uncomplicated union of both fracture
phy to better detect associated femoral neck types.
fractures. Hughes et al36 recommend a femoral Antegrade intramedullary nailing followed
neck CT scanning in obtunded multitrauma by screw xation of the neck is also a widely
patients with high-energy femoral shaft frac- used treatment option. Wu and Shih83 treated
tures but further state that pelvic CT scans 22 patients with this protocol without any
taken for other purposes also can be useful to osteonecrosis or nonunions noted at 26-month
detect a neck fracture. Several investigators follow-up. Benett et al6 also managed
report that the femoral neck can fracture after 19 patients with a similar protocol, and no
the antegrade insertion of a nail for femoral patient demonstrated either nonunion or os-
shaft fracture treatment.17, 31, 66 Therefore, the teonecrosis at 12-month follow-up. Their re-
authors recommend intraoperative radio- sults regarding osteonecrosis are not convinc-
graphy of the femoral neck in 15 internal ing, however, because of limited follow-up
rotation after insertion of the femoral nail. and the fact that osteonecrosis may not
Ipsilateral femoral neck and femoral shaft develop for more than 3 years after injury, par-
fractures typically occur in multitrauma ticularly in young patients.68, 69 Despite the
patients. Therefore, treatment options should popularity of this management sequence,
highlight decreased operative time, decreased several difculties must be noted, including
blood loss, and decreased technical difculty. difculty achieving stable xation of the
Also, xation of either fracture potentially femoral neck, technical difculty of placing
compromises xation of the other fracture, but screws anterior to the femoral nail, potential
the ultimate goal of any treatment plan should compromise of the femoral head blood supply,
be anatomic reduction of the neck fracture and malunion and nonunion.78
stable xation of the femoral neck and shaft Another treatment option is the use of a
fractures.6, 14, 68, 69, 79 cephalomedullary femoral nail. These nails
Treatment options are ORIF of the femoral allow for the placement of either screws or a
neck and antegrade nailing of shaft fracture, spiral blade device across the femoral neck
ORIF of the femoral neck and retrograde nail- fracture into the femoral head. The same dis-
ing of femoral shaft, a cephalomedullary nail advantages as with the standard antegrade in-
(e.g., Russell-Taylor reconstruction femoral tramedullary nail regarding the blood supply
nail) or ORIF of the femoral neck and plating to the femoral head and xation of the femoral
of the femoral shaft fracture (Fig. 2). neck fracture also apply to this nail. Randelli
Several investigators recommend immedi- et al56 treated 27 ipsilateral femoral neck and
ate internal xation of the femoral neck frac- shaft fractures with the Russell-Taylor re-
ture followed by femoral shaft stabilization construction nail. The femoral neck fractures
given the potentially devastating complica- healed at an average of 3.7 months, and
tions of the femoral neck fracture, especially femoral shaft fractures healed within an av-
in young patients (e.g., avascular necrosis, erage of 4.8 months. Complications included
nonunion, and malunion).14, 25, 55, 69 Other in- one case of avascular necrosis of the femoral
vestigators believe, however, that a delay of head, and varus malunion of a femoral neck
days to weeks does not seem to increase the fracture. Several other series showed similar
complication rate.6, 83 results with a limited complication prole;
Swiontkowski et al69 reported a series of however, instances of nonunion and malu-
15 patients treated with urgent ORIF of the nion of the femoral neck were noted in each
femoral neck fracture with multiple cancel- series.6, 9, 51, 79
lous screws. The associated femoral shaft Although each management protocol has
fractures were treated either with closed demonstrated successful results, each has as-
retrograde intramedullary nailing; dynamic sociated difculties particular to the service of
compression plating; and, in a single case of xation and the implant selection. No method
a very distal femoral shaft fracture, a blade has been established as the gold standard.
plate. All of the fractures united 4 months The choice of treatment hinges on many pa-
postoperatively, and of the nine patients tient, surgeon, and implant variables, and the
followed up for at least 3 years, two devel- choice of treatment must be framed within this
oped aseptic necrosis of the femoral head. context.
132 RUSSELL et al

Figure 2. A 22-year-old woman was involved in a motor vehicle crash and sustained a ruptured
spleen necessitating a laparotomy. She was hemodynamically unstable. Her orthopaedic injuries in-
cluded bilateral sacroiliac joint disruptions, symphysis pubis disruption, and a right femoral neck frac-
ture. A, Injury AP radiograph. B, AP radiograph of right proximal femur. C, The patient underwent
open reduction-internal xation of the right femoral neck through a Watson-Jones approach. Sub-
muscular plating of the right femur was then performed, introducing the plate proximally through
the Watson-Jones incision. Because of her signicant instability, external xation and percutaneous
iliosacral screws were chosen for denitive xation of her pelvis. AP radiograph of the right femur post-
operatively. D, AP radiograph at 1 year. The patient had a mild Trendelenburg limp, but was otherwise
asymptomatic. E, Uneventful healing of the femur at 1 year.

FEMORAL SHAFT injury are rare (1%).41 Because of the low

FRACTURES ASSOCIATED incidence of associated arterial injury with
WITH VASCULAR INJURY femoral shaft fractures, detection of these
injuries can be delayed.4 Several types of ar-
Vascular injuries associated with femoral terial injuries have been described, including
shaft fractures not resulting from a penetrating complete laceration, thrombosis, intramural

hematoma, spasm, stretch injury, and intimal ow, such as intimal tears and small pseudoa-
tears.20 Associated vascular injuries most neurysms. Also, API results may be inaccurate
commonly associated with femur fractures in patients in hypovolemic shock, and attain-
result from tethering injuries of the supercial ing pressure measurements may not be practi-
femoral artery (SFA) at the adductor hiatus cal in some multitrauma patients.37
in combination with distal femoral shaft and
supracondylar fractures32 (Fig. 3). Lacerations
of a branch of the profunda femoris artery
have been reported and usually manifest
themselves as a thigh hematoma; however,
unlike SFA injuries, the risk for limb gangrene
Compartment syndrome of the thigh is a
is not present.12 Unless a patient presents
rare nding after an isolated femoral shaft
with obvious signs of vascular compromise,
fracture. Schwartz et al64 found only 21 cases
the evaluation of vascular injury associated
of thigh compartment syndrome in 17 patients
with femoral shaft fractures must begin with
after reviewing more than 6000 patient admis-
a high index of suspicion. Intimal tears and
sions over a 4.5-year period. Ten of the cases
intramural hematomata may present with
of thigh compartment syndrome were found
palpable pulses and have contributed to de-
to be associated with either open or closed
layed diagnoses of vascular injuries associated
femur fractures. Compartment syndrome of
with femoral shaft fractures.4 Also, collateral
the thigh is seen more often in multitrauma
ow may account for palpable pulses in the
patients who often present with risk factors
face of an SFA injury.12 Patients with an open
for the development of thigh compartment
injury and signs of vascular compromise
syndrome, such as systemic hypotension, co-
should be taken immediately to the operating
agulopathy, vascular injury, prolonged limb
room for intraoperative angiography and
compression, and the use of military antishock
emergent revascularization. In other patients,
the pulse should be palpated and, if unsuc-
Diagnosis of thigh compartment syndrome
cessful, Doppler signals should be sought. For
demands a high index of suspicion, particu-
patients with diminished pulses, biplanar, se-
larly in unresponsive patients. Patients who
quential angiography is the gold standard for
are responsive typically complain of severe
detecting subtle vascular injuries20 ; however,
pain in the thigh, which may be difcult to
widespread use of angiography, so-called
distinguish from fracture-related pain. The
exclusion angiography, has been called into
presence of a tense thigh should prompt
question because of its invasive nature and its
compartment pressure measurement of the
tendency to document many injuries that are
three thigh compartments. The threshold
benign and warrant only observation, such as
for decompression is debatable, but many
investigators recommend fasciotomy for in-
The use of a Doppler arterial pressure in-
tracompartmental pressures between 30 and
dex (systolic arterial pressure in the injured ex-
45 mm Hg.10, 47, 64, 73
tremity divided by the arterial pressure in an
Treatment of a patient with recognized
uninvolved arm) has proven efcacy in the as-
thigh compartment syndrome in association
sessment of potential vascular injuries in the
with a femur fracture is emergent, three-
extremities. Johansen et al37 found that an ar-
compartment fasciotomy followed by femoral
terial pressure index (API) of less than 0.9 was
fracture stabilization. The patient should be
95% sensitive and 97% specic in detecting
returned to the operating room every 48 hours
major arterial injury. The investigators estab-
for irrigation and debridement until the
lished a protocol in which patients with an
wound is clean, at which time wound closure
API of less than 0.9 underwent arteriography,
can be performed.
and patients with an API of 0.9 or more were
followed up with serial API measurements.
Using this protocol, the investigators avoided FEMORAL SHAFT FRACTURE
many unnecessary angiograms without jeop- ASSOCIATED WITH
ardizing limb viability.37 Despite its success, IMPLANT FAILURE
the use of APIs to detect arterial injury has
several limitations, such as an inability to de- Secondary fractures of the femoral shaft as-
tect lesions of the profunda femoris artery and sociated with implant failure can be classied
an inability to detect lesions that do not reduce broadly as (1) implant failure associated with
134 RUSSELL et al

Figure 3. A 23-year-old man was involved in a motorcycle crash and sustained a head injury,
right distal radius fracture, right distal femoral shaft fracture, and profunda femoris artery injury.
The patient developed elevated compartment pressures in his thigh. He had a previous right fe-
mur fracture, which had been treated with an intramedullary nail. The nail had since been removed.
A, Injury AP radiograph of the pelvis. The femoral neck fracture is indicated by the arrow. B, Distal fe-
mur fracture at the site of the old femur fracture. C, Arteriogram indicating complete cut off of the pro-
funda femoral artery at the level of the fracture. D, The patient was taken to the emergency room for
fasciotomy of the thigh, expedient plating of the femur, vascular repair, four compartment fasciotomy of
the lower leg, and open reduction-internal xation of the right femoral neck by way of a Watson-Jones
approach. Intraoperative photo of the right lower extremity is shown. The plating of the femur was done
through the thigh fasciotomy incision. E, AP radiograph of the plated femur. F, AP radiograph of the
right hip/proximal femur. The patient had skin grafts over his fasciotomy sites. He went on to an un-
eventful healing.

acute injury or (2) more commonly, presenta- the plate, followed by intramedullary nailing
tion of implant failure secondary to nonunion. with expected good results57 ; however, dif-
Management of patients with secondary frac- culties may arise when plates have been over-
tures in association with hardware failure grown by periosteal bone formation and the
shares many similarities regardless of whether medullary cavity has been overgrown with
it results from a nonunion or an acute injury; endosteal callus. In these circumstances, it is
however, patients who present with nonunion frequently necessary to remove the bone that
must be evaluated for a nascent infection. Pre- has overgrown the plate before plate removal.
operatively, a white blood count, erythrocyte Because of intramedullary callus, a plate may
sedimentation rate, and a C-reactive protein be the implant of choice to restabilize the frac-
should be examined. Several intraoperative ture. It is helpful to identify the vendor of the
Gram stains and cultures also should be ex- previous plate if possible to secure the proper
amined in patients with nonunions. Despite tools for plate extraction. Occasionally, a sec-
the presence of an infection, management ond plate may be placed around the original
principles dictate for fracture stability to cure plate to obtain fracture stabilization without
the infection. With this in mind, the princi- removal of the original plate.
ples of secondary fracture management and Removal of broken intramedullary nails
implant failure are discussed here and the also is facilitated by identication of the im-
specic of infected nonunions are discussed in planted nail. Many nail manufacturers have
a subsequent section. designed extraction devices to retrieve their
Most implant failures associated with specic nails. If the vendor cannot be identi-
femoral shaft fractures occur after femoral ed, then a Snap-On set (Snap-On-Tools, Med-
plating. Secondary fractures after ORIF after ical Products, Kenosha, WI) is recommended.
plating of femoral shaft fractures have been Usually the proximal segment of the nail
reported in as many as 13% of cases.43, 45, 57, 60 is removed easily with an extraction bolt
Soft tissue stripping required for fracture and a slap-hammer following removal of
reduction and plate application plate can proximal interlocking screws. The proximal
lead to increased healing time, resulting in intramedullary canal should then be reamed
hardware fatigue, and secondary fracture. 2 mm more than the diameter of the broken
Also, the eccentric position of the plate on the nail while reduction at the fracture site is
femoral shaft increases the bending stresses on maintained.23 The distal interlocking screws
the plate, which may contribute to hardware are removed next in preparation for extraction
failure. of the distal nail segment. If the nail has a large
The incidence of implant failure associ- inner diameter, hooks can be passed through
ated with a prior intramedullary nail is very the nail and anchored at the end of the nail or
low and has been recorded infrequently.5, 12 through an interlocking screw hole, and the
Bucholtz et al13 noted in their series that nail is removed.
the presence of fracture extension in close Extraction of femoral nails with a small
proximity to the distal interlocking screws inner diameter requires different techniques
was a risk factor for nail breakage secondary for removal from the intramedullary canal.
to increased stresses on the nail that were The proximal fragment usually can be re-
greater than the fatigue endurance of the nail. moved as previously described using an ex-
Patient-associated factors contributing to early traction bolt and a slap hammer. The proximal
implant failure include fracture comminution, intramedullary canal should be over-reamed
bone loss, severe open fractures, and patient 2 mm more than the diameter of the nail. After
noncompliance. Technical factors associated this, a ball-tip guidewire is inserted through
with early nail failure are scoring the nail with the distal nail fragment through the end of
an interlocking screw, improper nail inser- the nail. A second, straight guidewire then is
tion site, small diameter nail insertion, and inserted through the distal fragment through
under-reaming of the femoral canal.23 Several the nail. At this point, the ball-tip guidewire
mechanical factors, which have been largely is grasped with a T-handle chuck. Using a
corrected, associated with early nail failure in- mallet against the T-handle chuck, the ball-tip
clude fabrication defects, proximal nail welds, guidewire is backed out until it incarcerates
anterior slots, large interlocking screw holes, against the straight guidewire. With repeated
and thin nail wall diameter.5, 12, 23, 72 taps with the mallet, the distal nail fragment
Treatment of femoral shaft fractures with is removed (Fig. 4). Long pituitary rongeurs
retained plates usually requires removal of or cement-removal rongeurs also can prove
136 RUSSELL et al

Figure 4. A 23-year-old man was referred for a right femoral nonunion 18 months after intramedullar
nailing for a femoral shaft fracture. He was 18 months after his original treatment. There was no sus-
picion of infection. A, AP radiograph demonstrating a right femoral nonunion and broken nail (arrow)
approximately 2 cm proximal to the nonunion site. B, Lateral radiograph. C, The proximal aspect of the
nail was removed and reamed 2 mm larger than the nail. The inside of the nail was then cleaned of soft
tissue with a long trocar guide wire. D, A replica of the exact broken nail is placed on the back table.
The correct combination of smooth and bulb-tipped guide rods are chosen in order to wedge the guide
wires in the end of the nail. The bulb-tipped guide wire is placed down the canal, followed by the
smooth-tipped wire to wedge the two wires in the end of the distal aspect of the broken intramedullary
nail. E, The nail is then back-slapped out of the distal femur by use of a handle connected to the guide
Illustration continued on opposite page

Figure 4 (Continued ). F, Close-up of the two guide wires in the extracted bro-
ken nail. G, The patient underwent exchange intramedullary nailing with iliac crest
bone grafting. The nail placed was 3 mm larger in diameter. Rapid healing ensued.
AP radiograph at 3rd month. H, Lateral radiograph at 3 months. (The authors ac-
knowledge the teaching of Robert Winquist, MD regarding this technique. The bro-
ken Nail Guide Wire set is commercially available through Zimmer [Warsaw, IN].)

helpful in removing nails with small inner di- open procedure is performed by transecting
ameters and closed-section nails. Should these the nail, straightening the limb, and then treat-
measures fail, then a corticotomy may be per- ing the injury as a broken nail as described
formed to facilitate nail extraction. Another earlier.
technique that may be used as a last resort is
to prepare the distal femur as if implanting
a retrograde nail and removing the nail with FEMORAL SHAFT FRACTURES
cement-removal rongeurs through the knee. RESULTING FROM
Retrieval of bent nails usually requires GUNSHOT WOUNDS
straightening of the nail, followed by nail
removal. The patient should be taken to the Injuries sustained as a result of gunshot
operating room, and, with the patient under wounds are generally divided into two groups
general anesthesia, attempts should be made based on the kinetic energy (KE = 1/2 mv2 )
to straighten the nail using a femoral wrench of the projectile. Low-energy injuries usu-
(Fig. 5). Should this prove unsuccessful, an ally occur secondary to handgun shots in
138 RUSSELL et al

Figure 5. A 23-year-old woman was involved in a motor vehicle crash and sustained a right femoral
neck fracture and a left femoral shaft fracture in the area of a previous fracture. She was 18 months
following a right acetabular fracture and left femoral neck/shaft fracture. She had undergone recon-
struction nailing of the left neck/shaft fracture combination. Attempts at completely bending the nail
back to a straight position were not successful. A, AP radiograph of the femur. B, A femoral neck frac-
ture nonunion was evident when the proximal screws were removed from the nail. C, The nail be-
ing removed. Note that the angulation of the nail is proximal to the fracture angulation. D, A new in-
tramedullary nail 2 mm larger in diameter was placed. Screws were placed anterior and posterior to
the nail. E, Uneventful healing ensued of both fractures. AP radiograph at 6 months.

which the velocity of the projectile is less Femoral shaft fractures resulting from
than 1000 ft/s. High-energy injuries usually low-energy gunshot wounds can be thought
result from ries in which projectile velocity of as type 1 open fractures. After a normal
is greater than 2000 ft/s or from close-range neurovascular examination has been ensured,
shotguns in which the mass of the projectile the fracture can be addressed. Treatment of the
factors signicantly to increase the kinetic open wound does not require a formal irriga-
energy imparted to the tissues.22, 65 tion and debridement, and good results have

been reported with minimal, local wound results, especially for the low-energy frac-
care.7, 35, 62, 81 Early closed reamed nailing has tures. Several investigators have reported
become the treatment of choice for these infection rates comparable to those of closed
injuries, with infection rates comparable to fractures treated with closed intramedullary
reamed intramedullary nailing for closed nailing.11, 15, 42, 74 Type 3 open femoral shaft
fractures.7, 81 Antibiotic use usually consists fractures treated with intramedullary nails
of a rst-generation cephalosporin that is have demonstrated infection rates of 0% to
continued for 48 hours postoperatively.7, 81 6.5%,3, 11, 15, 42 but it was the type 3B fractures
Management of high-energy gunshot that led to infection in the series that distin-
wounds resulting in femoral shaft fractures guished between the type 3 injuries.11
is more difcult because of the associated Detection of infection associated with a
severe soft tissue trauma caused by crushing femoral shaft fracture may be difcult if obvi-
from the projectile, formation of shock waves, ous signs, such as persistent wound drainage,
and cavitation.28, 33, 63 These injuries should be erythema, and cellulitis are not present. Any
approached as any type 3B open fracture with nonunion should be thought of as infected un-
the realization that extensive and multiple til proven otherwise. Plain radiographs should
debridement will likely be required. Stabi- be evaluated for nonunion, periosteal reaction,
lization of these fractures should follow the sequestrum, and involucrum. Tomograms and
guidelines established for the treatment of CT also can be helpful in the search for a se-
type 3B open fractures, with an emphasis on questrum. Laboratory examinations also may
immediate closed nailing.11, 50 be helpful in the diagnosis of infection. An
Management of close-range shotgun in- elevated white blood cell count, erythrocyte
juries parallels that of other high-energy sedimentation rate, and a C-reactive protein
gunshot wounds, with one notable exception: are indirect indicators of an infectious process
wadding is a common added contaminant65 and can be used to assist in the evaluation of a
of the open wound. Wadding usually consists suspected infection.
of paperboard, felt, or plastic. Felt is partic- A general guideline for the management
ularly irritable to the body and can incite an of infections is to classify them as either
intense inammatory response.65 Multiple supercial or deep. Supercial infections
debridement often is required to achieve a often are detected early and are commonly
clean wound, at which time the wound can wound infections, which usually respond to
be closed in a delayed primary fashion. Re- debridement, irrigation, and a short course
current wound drainage is not uncommon of intravenous or oral antibiotics. Deep in-
and may ultimately require open treatment of fections frequently present remotely after
the wound. A rst-generation cephalosporin treatment and often involve the bone (Fig. 6).
and aminoglycoside antibiotics should be The primary goal in treating established
administered until the wound is sealed if infections after femoral shaft fractures is
closed primarily. If the wound is managed in achievement of fracture union assisted by sur-
an open fashion, intravenous antibiotics are gical debridement and antibiotics to suppress
not required if the patient does not manifest the infection.44, 53
symptoms of septicemia. Oral antibiotics Initial management of a patient with an in-
may assist in maintaining a clean wound as it fection after a femoral shaft fracture is assess-
granulates. ment of fracture stability. For patients who
demonstrate fracture stability, the nail should
be retained and the patient should be placed
INFECTED FEMORAL on culture-specic intravenous or oral antibi-
SHAFT FRACTURES otics to suppress the infection while the frac-
ture heals.29, 44, 54 Patients who demonstrate in-
The incidence of infection after a closed stability at the fracture site should undergo a
intramedullary nailing for a closed femoral reamed exchange nailing supplemented with
shaft fracture has been reported to occur in culture-specic antibiotics to suppress the in-
1% or less of cases.18, 59, 74, 77, 80 If an open nail- fection while the fracture healing occurs.
ing is performed for a closed femur fracture, After fracture union, further attempts to
however, then the incidence of infection in- cure the infection, if it is still present, should
creases to 2% to 9%.38, 71 The management of be made. Patients without evidence of infec-
open femoral shaft fractures with closed in- tion after fracture union do not require further
tramedullary nailing has demonstrated good treatment, and the nail may be retained.29, 44, 54
140 RUSSELL et al

Figure 6. A 32-year-old man was referred with an acute Pseudomonas aeruginosa

infection of the left proximal femur after intramedullary nailing. The patient underwent
irrigation and debridement and placement of antibiotic beads. Intravenous aminoglyco-
side coverage was administered for 6 weeks. A, AP radiograph at 6 weeks postinjury.
B, The patient underwent repeat irrigation and debridement and exchange reamed
nailing at 10 weeks to remove the previous infected nail. Uneventful healing ensued.
AP radiograph at 5 months. C, AP radiograph at 5 months. D, Lateral radiograph at
5 months.

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of the femur secondary to low velocity gunshot of the femoral neck and shaft. J Orthop Trauma
wounds. J Trauma 21:160162, 1981 6:159166, 1992
63. Rybeck B, Janzon B: Absorption of missile energy in 79. Wolinsky PR, Johnson KD: Ipsilateral femoral neck
soft tissue. Acta Chir Scand 142:201207, 1976 and shaft fractures. Clin Orthop 318:8190, 1995
64. Schwartz JT, Brumback RJ, Lakatos R, et al: Acute 80. Wolinsky PR, McCarty E, Shyr Y, et al: Reamed
compartment syndrome of the thigh: A spectrum of intramedullary nailing of the femur: 551 cases.
injury. J Bone Joint Surg Am 71:392400, 1989 J Trauma 46:392399, 1999
65. Shepard GH: High-energy, low-velocity close range 81. Wright DG, Levin JS, Esterhai JL, et al: Immedi-
shotgun wounds. J Trauma 20:10651067, 1980 ate internal xation of low-velocity gunshot-related
66. Simonian PT, Chapman JR, Selznick HS, et al: Ia- femoral fractures. J Trauma 35:678681, 1993
trogenic fractures of the femoral neck during closed 82. Wu C, Chen W: Healing of 56 segmental femoral
nailing of the femoral shaft. J Bone Joint Surg Br shaft fractures after locked nailing. Acta Orthop
76:293296, 1994 Scand 68:494500, 1997
67. Sojbjerg J, Eiskjaer S, Moller-Larsen F: Locked nailing 83. Wu CC, Shih CH: Ipsilateral femoral neck and shaft
of comminuted and unstable fractures of the femur. fractures: Retrospective study of 33 cases. Acta Or-
J Bone Joint Surg Br 72:2325, 1990 thop Scand 62:346351, 1991
68. Swiontkowski MF: Ipsilateral femoral shaft and hip 84. Zettas JP, Zettas P: Ipsilateral fractures of the femoral
fractures. Orthop Clin North Am 18:7384, 1987 neck and shaft. Clin Orthop 160:6373, 1981

Address reprint requests to

George V. Russell, Jr, MD
Department of Orthopaedic Surgery
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216

TREATMENT OF COMPLEX FRACTURES 00305898/01 $15.00 + .00

Andrew H. Schmidt, MD, and Richard F. Kyle, MD

Periprosthetic fractures of the femur repre- the need for a tight press t. Reported rates vary
sent a heterogeneous and challenging prob- from 4.1% to 27.8% after uncemented hip re-
lem for the orthopedist. The incidence of these placement, compared with less than 3% when
fractures is dramatically increasing, as there cemented stems are used.18 Schwartz et al18
are more and more patients with aging to- reviewed 1318 consecutive arthroplasties per-
tal joint replacements.13 The fractures may oc- formed with the Anatomic Medullary Locking
cur as the result of a traumatic event but stem (DePuy, Warsaw, IN) and found an inci-
more often are the result of minor trauma dence of 3%. The fractures occurred in the prox-
spontaneous fracture, and they are frequently imal femur or at the tip of the stem and most
associated with preexisting sometimes ne- were incomplete. Only one-half were recog-
glected problems with the associated joint nized at the time they occurred. The occurrence
replacement.2 of fracture did not affect the ultimate success
of the arthroplasty.18 In contrast, in another re-
port of 40 intraoperative fractures that occurred
FRACTURES AROUND THE during uncemented stem insertion, all but two
FEMORAL COMPONENT OF A were recognized at the time of occurrence.10
TOTAL HIP ARTHROPLASTY However, in three patients, the fracture was felt
to have contributed to the eventual loosening
Epidemiology of the prosthesis.10

The incidence of periprosthetic femur frac-

ture following total hip arthroplasty varies by Biologic and Mechanical
more than 10-fold, depending on the clinical Considerations
situation.18 The exact incidence is difcult to
determine because of the problems with long- Periprosthetic fractures are generally associ-
term follow-up. The incidence is much higher ated with stress risers in the bone, frequently
after revision surgery than primary hip re- osteolytic lesions or areas of cortical perfora-
placement and is similarly increased when un- tion (Fig. 1). In addition, the tip of an implant
cemented stems are used.18 functions as a stress riser. The combination of
Intraoperative fractures of the femur dur- an osteolytic lesion located at the tip or just
ing total hip replacement are more common distal to a femoral stem should be considered
when uncemented stems are used because of an impending pathologic fracture in the same

From the Department of Orthopaedic Surgery, University of Minnesota; and Hennepin County Medical Center,
Minneapolis, Minnesota




Figure 1. A and B, An early postoperative femoral shaft fracture that occurred at

the site of a preexisting stress riser in the femur, namely, empty screw holes from
a previous sliding hip screw.

manner that a metastatic lesion in the sub- loosening but may occur with osteolysis or os-
trochanteric region would be. teopenia.
When the surgeon is evaluating a peripros-
thetic fracture, specic mechanical factors that
are unique to each case must be identied and Classication
considered. This includes limb alignment, bone
density, fracture location, fracture pattern, the In general, the goals of fracture classication
location of any bone defects, and the presence are to suggest treatment, estimate prognosis,
of any implants. Fractures that occur within and indicate likely complications. Factors to
the proximal region are often longitudinal consider when evaluating a periprosthetic fe-
splits that occur intraoperatively. These may mur fracture include such things as the age and
be divided into stable and unstable patterns. health of the patient, the location and pattern
Longitudinal splits above the lesser trochanter of the fracture, and the stability of xation of
are considered stable, provided a collared pros- the prosthesis. Other factors, such as a history
thesis is used. A proximal femoral split should of tobacco use, chronic medical illness, and im-
be considered unstable if it extends below the munosuppression, may play an important role
lesser trochanter, as it may threaten the stabil- in perioperative decision making. Local factors
ity of the implant. Fractures in the middle third that inuence prognosis and treatment include
of the femur are typically associated with pros- a history of previous irradiation, osteoporosis,
thetic loosening or osteolysis. Those that oc- osteolysis, the type of implant (i.e., press t
cur between the lesser trochanter and the pros- versus cemented, short versus long stem, or
thetic tip may be stable if the stem stays within more than one implant), a history of previous
the distal canal. Fractures within the distal re- fracture, and the presence of any other stress
gion are less often associated with prosthetic risers in the bone. The surgeon can consider

these items as they affect either the biologic different examiners.3 The Vancouver classi-
or mechanical aspects of the fracture and its cation is based on the fracture location, the
consequences. quality of xation of the stem, and the qual-
Factors affecting treatment of periprosthetic ity of the bone. It was developed with the goal
femoral fractures include: that treatment decisions would naturally fol-
Patient characteristics low from correct classication of the fracture.
General factors The Vancouver classication divides peripros-
Age thetic femoral fractures into three main types
Health based on the location of the fracture. These are
Tobacco use further subdivided based on bone stock or bone
Immunosuppression quality (Table 1).
Local factors Beals and Tower1 proposed another classi-
Previous irradiation cation, which is worth discussing because
Osteoporosis it identies a few other clinically important
Osteolysis fracture subtypes. These authors added a
History of previous fracture fourth broad category: the proximal metaphy-
Presence of other stress risers seal/diaphyseal fracture, which occurs around
Fracture characteristics the stem but does not involve the stem tip
Location which and was seen only in patients with un-
Pattern cemented implants (12% of their series). These
Implant characteristics authors further note that this fracture was of-
Stability ten unstable and usually required revision of
Well xed the prosthesis.1 Additionally, a subcategory
Loose of supracondylar fracture was identieda
Type of implant distal femur fracture occurring below a long
Press-t versus cemented femoral stem. Nonoperative management with
Short versus long stem traction and cast braces was often chosen for
More than one implant these fractures because of the difculty in
achieving any type of xation about the long
At least 11 different classications have been femoral stem. Nonetheless, successful union of
suggested for periprosthetic femoral fractures these fractures was obtained.
with hip prostheses.1, 2, 5, 9, 11, 12, 1416, 18, 21 All of the
classications separate fractures into different
groups by fracture location. Other factors, such METHODS OF TREATMENT
as the time of fracture (intraoperative or post-
operative), status of the implant (loose or sta- The primary considerations in deciding on
ble), and type of implant (cemented or unce- a rationale treatment plan for a periprosthetic
mented), are considered differently by various femur fracture are whether to treat the frac-
authors. ture operatively or not, and if an operative ap-
The Vancouver classication proposed by proach is warranted, whether to proceed with
Duncan and Masri9 is becoming the standard fracture repair or revision arthroplasty. There
system for assessing and reporting peripros- is no single approach that is applicable to all
thetic femur fractures (Table 1). It is the only cases. In general, displaced fractures should
classication that has been rigorously evalu- be stabilized. Similarly, loose stems should be
ated, and its reliability and validity are ac- replaced with long stems extending well be-
ceptable with consistent agreement among yond the fracture. In the following sections,


Type Proportion Location Subtype
A 4% Trochanteric A(G): Greater trochanter
A(L): Lesser trochanter
B 87% About the stem tip B(1): Prosthesis stable (18%)
B(2): Prosthesis loose (45%)
B(3): Bone stock inadequate (37%)
C 9% Well below the stem tip

From Duncan CP, Masri BA: Fractures of the after hip placement. Instr Course Lect 44:293304, 1995; with permission.

individual treatment options will be discussed, and unnecessary periosteal stripping should
and then each clinical situation is reviewed in be avoided. Because of its poor biomechanic
order to summarize the appropriate options for strength, cerclage xation is rarely appropriate
that specic fracture. as the sole form of xation. The exception to
this would be the management of a longitu-
Nonoperative Treatment dinal crack in the proximal femur that occurs
during stem insertion.10 Usually, cerclage xa-
Nonoperative treatment is appropriate in the tion is combined with plate or intramedullary
case of a stable fracture about a well-xed xation.
implant. Examples of this would be nondis-
placed trochanteric fractures or longitudinal
cracks in the femoral neck that are recog- Plating
nized postoperatively (Fig. 2). Displaced frac-
tures are rarely treated nonoperatively because Traditional internal xation with plates is
of the morbidity associated with immobiliza- generally performed for diaphyseal fractures
tion of the elderly patient and the problem of that occur about well-xed implants. In order
malunion. to achieve success with plating of peripros-
thetic femoral fractures, the surgeon should en-
sure that the prosthesis is well xed and that the
Cerclage Fixation
limb and prosthesis are in correct alignment.
Tadross et al20 reported a series of nine patients
Cerclage xation with monolament wire or
that were treated with the Dall-Miles plate. Six
braided cable may be considered for the man-
of the nine cases had unsatisfactory results be-
agement of spiral or long oblique fractures as
cause of varus malunion or nonunion. In all
well as for the xation of plate or cortical strut
six cases, the femoral stem had been initially
grafts. Specialized instruments for passing the
inserted in a varus position. In the three cases
wire or cable about the femur are necessary,
that were successfully treated, the components
were in neutral alignment.20 Thus, varus align-
ment of the stem may be a contraindication
for plate xation. In contrast, Serocki et al19 re-
ported the results of 10 patients treated with
compression plating, achieving a minimum of
eight cortices of xation on each side of the frac-
ture. The patients were immediately mobilized
(touch-down weight bearing), and nine of the
10 fractures united in an average of 5 months.19
It is often necessary (and probably desirable)
for the plate to overlap the intramedullary im-
plant. Fixation of the plate over the femoral
stem is problematic. Often, cerclage xation is
used for the portion of the plate that spans
the stem. Specialized plates with wire mounts
are available. Small fragment screws can of-
ten be angled and directed either anterior or
posterior to the implant (Fig. 3). Alternatively,
unicortical screws can be used.19 Dennis et al7
compared ve options for plate xation about
femoral stems: plate with cable only, plate with
proximal cable and distal bicortical screws,
plate with proximal unicortical screws and dis-
tal bicortical screws, plate with proximal ca-
ble plus unicortical screws and distal bicortical
screws, and two allograft struts xed with ca-
bles. The specimens were tested in axial com-
Figure 2. A nondisplaced greater trochanter fracture found
pression, lateral bending, and torsion. The two
after this patient fell several months after undergoing total constructs that contained proximal unicortical
hip replacement. screws (either alone or combined with cerclage

healing may be incomplete and the grafts may

be prone to stress fracture or loosening. Finally,
cortical strut grafts can be a potential source of
The results of cortical strut grafting are fa-
vorable. Wong and Gross22 reviewed 52 corti-
cal strut grafts used in revision hip arthroplasty
with 5-year follow-up.22 Four of the grafts (8%)
failed either because of resorption or nonunion;
there were no graft fractures.

Revision Arthroplasty

Long-stem revision arthroplasty is the pro-

cedure of choice for most periprosthetic frac-
tures associated with loose prostheses. Use of
an uncemented stem with distal xation, sup-
plemented with cortical strut grafting, is the
standard approach to these fractures (Fig. 5).
Occasionally, a long cemented stem may be ap-
propriate in the case of an elderly patient with
poor bone stock, but the surgeon must be care-
ful to avoid placing methylmethacrylate within
the fracture site.

Figure 3. An example of screw xation about a femoral

stem. Screws are angled anterior and posterior to the stem,
providing optimal xation.

wires) were signicantly more stable than the

other constructs.7

Cortical Strut Grafts

Allograft cortical struts are generally frozen

and irradiated. They are usually segments of
cortical bone from the tibia, bula, or humerus.
Cortical strut allografts have an established
role in the treatment of periprosthetic fractures
of the femoral shaft. Cortical struts may be used
in several ways. First, strut grafts may be used
to augment the junction between host bone and
a structural allograft. Second, the cortical struts
may be used to augment xation with a stan-
dard metal plate (Fig. 4). Last, cortical struts
may be used alone as a biologic bone plate. In
general, such struts are xed to the femoral di-
aphysis with cerclage wires or cables. Potential
advantages of cortical strut grafts relate to the
possibility that they will heal to the host bone
and remodel over time, thereby restoring bone
Figure 4. Intraoperative view of a spiral femoral shaft
stock for the future. Potential disadvantages of periprosthetic fracture treated with a lateral plate and aug-
cortical struts include the prolonged time that mented by an anterior cortical strut allograft. Note the cer-
graft incorporation takes as well as the fact that clage bandsbicortical screws were used in addition.

Figure 5. A periprosthetic femoral fracture treated by revision total hip replacement. A, The initial radio-
graph shows a loose, cemented stem with osteolysis and a displaced spiral fracture. B, The fracture was
treated by revision to a long porous-coated stem with cortical strut grafting. C, A follow-up radiograph
taken 3 years later shows a stable femoral stem and healing of the fracture.

Whole structural allografts may be indicated performed, the surgeon must be careful of not
in cases with severe, circumferential bone loss. leaving a small area of bone between the tip
The existing prosthesis is removed through a of the femoral stem and the retrograde nail.
longitudinal or sliding trochanteric osteotomy, This represents a severe stress riser and may
and the host bone is maintained for xa- doom the patient to suffer another peripros-
tion around the allograft. A long-stemmed thetic fracture between the two implants
femoral component with a narrow proximal (Fig. 6).
dimension is cemented into the graft, and
the stem is press t into host bone. A step-
cut is helpful in maintaining rotation. Corti- TYPES OF FEMUR FRACTURES
cal allograft struts are generally placed around ASSOCIATED WITH TOTAL HIP
the osteotomy site and the tip of the long ARTHROPLASTY
stem for additional support. Using this tech-
nique, Wong and Gross22 report that 13 of Intraoperative Fractures
15 cases were successful with average 5-year
follow-up. Intraoperative fractures must be recognized
in order for them to be treated appropriately.
Cerclage wires sufce to stabilize longitudinal
Intramedullary Nails fractures of the proximal femur.10, 18 Perfora-
tions about the tip of the stem may be man-
Retrograde intramedullary nailing may be aged with cortical strut grafting and use of a
performed for distal femoral fractures be- long-stem implant that achieves distal xation
low a proximal femoral prosthesis. If this is and bypasses the defect by several centimeters.

treatment.1, 14 Fractures occurring about stable,

well-aligned stems should be repaired with
plates. Proximally, a combination of unicorti-
cal or bicortical screws and cerclage wires is
used. Distally, bicortical screws are used. If the
distal aspect of the plate extends to the supra-
condylar region, it has been found that a xed
angle blade plate or dynamic condylar screw
has the best xation (see Fig. 3).

Fractures Distal to Femoral Stems

Fractures that occur below a femoral stem

can be treated essentially without regard to the
implant, as long as the stem does not exhibit
loosening. Either nonoperative or internal x-
ation may be appropriate, depending on the
health and activity level of the patient. If in-
ternal xation is chosen, plating is generally
preferred, usually with a long dynamic condy-
lar screw or blade plate with a long side plate.
A preferred method is to overlap the stem, so
as not to leave an unprotected region of femur
that may serve as the location for a potential
future periprosthetic fracture.
Figure 6. A fracture occurring between a hip hemiarthro-
plasty and a short retrograde femoral nail.
Rarely, open reduction and plate xation will
be necessary for displaced fractures of the dis- Supracondylar fractures of the femur may
tal femur. occur about total knee components and are
similarly difcult to manage. Distal femoral
osteolysis, osteoporosis, or the presence of a
Trochanteric Fractures
supracondylar notch are risk factors for supra-
condylar fracture and are frequently present.
Fractures of the greater trochanter may
be undisplaced or displaced. Undisplaced
fractures are treated nonoperatively (see Fig. 2).
Displaced fractures should be treated with ten- Classication
sion band wiring as long as the health of the
patient and the local skin condition is favor- Several classications have been proposed
able. Intertrochanteric fractures are rare but are for femoral fractures after total knee replace-
generally stable as long as the implant is stable ment.4, 8, 17 As is the case for fractures about to-
and in good position, and they can be treated tal hip replacement, many common themes are
nonoperatively.14 Intertrochanteric fractures evident in the different classication schemes.
that occur around loose implants should be Fractures are generally grouped according to
treated by long-stem revision arthroplasty. the degree of displacement and comminution
and the stability of the prosthesis. The schema
of Rorabeck17 has proven useful. Supracondy-
Diaphyseal Fractures lar fractures are divided into three types. Type I
fractures are undisplaced and adjacent to a sta-
Femoral shaft fractures are treated accord- ble prosthesis. Type II fractures are displaced
ing to the status of the implant and the but with a prosthesis intact. Type III fractures
bone stock. Traction treatment appears to are those that are associated with a prosthesis
have inferior results compared with operative that is loose or failing.

Methods of Treatment

It has been found that displaced distal

femoral fractures that occur adjacent to a total
knee replacement can be managed according
to the same principles as fractures about total
hip implants. When the prosthesis is stable, in-
ternal xation is readily performed with either
a retrograde nail or xed-angle plate. When
the implant is loose, revision of the femoral
component to a long-stem implant may be

Nonoperative Treatment
Although operative methods are frequently
chosen for the treatment of displaced supra-
condylar femoral fractures, it remains contro-
versial whether outcomes are in fact better after
operative treatment compared with nonoper-
ative management.4 Chen et al4 performed a
literature review of 12 articles (195 fractures)
and found no differences in the proportion of
successful results between operative (69%) and
nonoperative (67%) treatment groups.
Nondisplaced fractures can be successfully
treated nonoperatively4 ; however, the rate of
malunion is high, and in one study, 50% of the Figure 7. A supracondylar fracture in a patient who under-
went total knee replacement and sustained a previously
patients had increased pain or decreased am- plated femoral shaft fracture at the tip of an ipsilateral total
bulatory status following nonoperative man- hip replacement, which had healed in varus malalignment.
agement compared with 13% of those who re- The fracture was treated by revision to a long-stem dynamic
ceived operations.6 condylar screw. The side plate of the condylar screw was
bent to accommodate the existing varus deformity of the
distal femoral shaft.
Open Reduction and Internal Fixation
Internal xation is recommended whenever
the implant is considered to be stable. The are wide enough (Fig. 8). A preferred method
choice of device depends on the pattern and is to nail over the plate xation if the fracture
location of the fracture and the bone quality. is comminuted, extends into the diaphysis, or
Plating is preferred when the bone quality is if the bone quality is poor.
adequate. In most cases, it is possible to insert a
dynamic condylar screw or blade plate into the
femoral condyle between the anges of the im- FRACTURES BETWEEN IMPLANTS
plant (Fig. 7). Polymethylmethacrylate can be
inserted into screw tracks to improve xation. Fractures that occur between implants, such
as between ipsilateral total knee and hip re-
Intramedullary Nails placements or between a joint prosthesis and a
fracture implant at the other end of the femur,
Standard antegrade intramedullary nailing are especially challenging to treat. In the case of
can be performed in the patient with a femoral a previous fracture, it is important to determine
shaft fracture above a total knee replacement whether the fracture has healed and whether
as long as adequate bone stock for distal inter- the implant needs to be removed. If the fracture
locking is present. Retrograde intramedullary is united, the preexisting plate may sometimes
nailing may be performed in some cases of be exchanged for a longer implant. In cases of
supracondylar femur fracture about total knee ipsilateral hip and knee prostheses, treatment
replacement (Fig. 8). Retrograde nailing is pos- depends on whether either implant is loose. In
sible if the dimensions of the intercondylar box the case of stable implants, plating is the only

Figure 8. A and B, A supracondylar femur fracture above a total knee replacement. C and
D, The fracture was treated with a retrograde nail. This technique typically produces some
extension of the fracture because of the necessity to avoid the intercondylar box of the femoral
prosthesis, resulting in a nonanatomic posterior starting point.

option for these cases as both ends of the fe- fractures after hip replacement. J Arthroplasty 15:59
mur are occupied by existing implants. If the 62, 2000
prosthesis is loose, whether it is a hip or a knee, 4. Chen F, Mont MA, Bachner RS: Management of ipsi-
lateral supracondylar femur fractures following total
a long-stem revision may be considered. Corti- knee arthroplasty. J Arthroplasty 9:521526, 1994
cal strut grafting in conjunction with plating is 5. Cooke PH, Newman JH: Fractures of the femur in re-
recommended. Fixed angle devices obtain the lation to cemented hip prostheses. J Bone Joint Surg
best purchase in the distal femur. 70:386389, 1988
6. Culp RW, Schmidt RG, Hanks G, et al: Supracondylar
fracture of the femur following prosthetic knee arthro-
PREVENTION OF PERIPROSTHETIC plasty. Clin Orthop 222:212222, 1987
7. Dennis MG, Simon JA, Kummer FJ, et al: Fixation of
FEMORAL FRACTURES periprosthetic femoral shaft fractures occurring at the
tip of the stem: A biomechanical study of 5 techniques.
There are a number of things that orthope- J Arthroplasty 15:523528, 2000
dists can do to lessen the risk for peripros- 8. DiGioia AM, Rubash HE: Periprosthetic fractures of
the femur after total knee arthroplasty: A literature re-
thetic fracture. By denition, intraoperative view and treatment algorithm. Clin Orthop 271:135
fractures are often associated with errors in 142, 1991
surgical planning or technique. Wide surgical 9. Duncan CP, Masri BA: Fractures of the after hip re-
exposure is necessary to avoid placing exces- placement. Instr Course Lect 44:293304, 1995
sive force, especially torque, on the femur. De- 10. Fitzgerald RH Jr, Brindley GW, Kavanagh BF: The
uncemented total hip arthroplasty: Intraoperative
cient bone must be identied prior to surgery femoral fractures. Clin Orthop 235:6166, 1988
and efforts made to avoid further bone dam- 11. Gonzalez MH, Barmada R, Fabiano D, et al: Femoral
age. Implant removal must be done carefully. shaft fracture after hip arthroplasty: A system for clas-
Extended trochanteric osteotomy may be per- sication and treatment. J S Orthop Assoc 8:240248,
formed to better expose the medullary canal 12. Johansson JE, McBroom R, Barrington TW, et al: Frac-
and facilitate cement or prosthesis removal. Vi- ture of the ipsilateral femur in patients with to-
sualization of the femur is further facilitated tal hip replacement. J Bone Joint Surg 63:14351442,
by the use of headlamps or handheld, battery- 1981
powered lights and suction instruments. Intra- 13. Lewallen DG, Berry DJ: Periprosthetic fracture of the
femur after total hip arthroplasty: Treatment and re-
operative uoroscopy can be considered when sults to date. Inst Course Lect 7:243249, 1998
instrumentation of the distal femoral shaft is 14. Mont MA, Maar DC: Fractures of the ipsilateral fe-
performed to lessen the chance of unrecog- mur after hip arthroplasty: A statistical analysis of out-
nized cortical perforation. come based on 487 patients. J Arthroplasty 9:511519,
Postoperative fractures are best avoided 15. Morrey BF, Kavanaugh BF: Complications with revi-
by performing timely revision surgery. The sion of the femoral component of total hip arthroplasty:
biomechanic consequences of endosteal de- Comparison between cemented and uncemented tech-
fects can be signicant, especially when they niques. J Arthroplasty 7:7179, 1992
are located at the tip of an intramedullary stem. 16. Roffman M, Mendes DG: Fracture of the femur after
total hip arthroplasty. Orthopedics 12:10671070, 1989
Proximal osteolytic lesions may be observed if 17. Rorabeck CH, Taylor JW: Periprosthetic fractures of
asymptomatic, but lesions within 2 cm of the the femur complicating total knee arthroplasty. Orthop
stem tip should be considered an indication for Clin North Am 30:265277, 1999
revision surgery or strut grafting even if they 18. Schwartz JT Jr, Mayer JG, Engh CA: Femoral fracture
during non-cemented total hip arthroplasty. J Bone
are asymptomatic. Joint Surg 71:11351142, 1989
19. Serocki JH, Chandler RW, Dorr LD: Treatment of frac-
tures about hip prostheses with compression plating.
References J Arthroplasty 7:129135, 1992
20. Tadross TSF, Nanu AM, Buchanan MJ, et al: Dall-Miles
1. Beals RK, Tower SS: Periprosthetic fractures of the plating for periprosthetic B1 fractures of the femur.
femur: An analysis of 93 fractures. Clin Orthop 327: J Arthroplasty 15:4751, 2000
238246, 1996 21. Whittaker RP, Sotos LN, Ralston EL: Fractures of the
2. Bethea JS III, DeAndrade JR, Fleming LL, et al: femur about femoral endoprostheses. J Trauma 14:675
Proximal femoral fractures following total hip arthro- 694, 1974
plasty. Clin Orthop 170:95106, 1982 22. Wong P, Gross AE: The use of structural allografts for
3. Brady OH, Garbuz DS, Masri BA, et al: The reliability treating periprosthetic fractures of the hip and knee.
and validity of the Vancouver Classication of femoral Tech Orthop 14:102106, 1999

Address reprint requests to

Andrew H. Schmidt, MD
701 Park Avenue
Minneapolis, MN 55415
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00


Management by Articular Exposure and
Submuscular Fixation

Philip J. Kregor, MD

The treatment of distal femur fractures re- Standard implants used for other supra-
mains a signicant surgical challenge. Sig- condylar femur fractures (e.g., condylar
nicant advances in patient outcome have blade plate and retrograde nails) may
been achieved with internal xation com- jeopardize the articular surface reduction
pared with historical controls of nonoperative and xation.
treatment.3234 A variety of implants and Especially in the setting of a short distal
standard surgical approaches are helpful for segment, varus collapse or loss of xation
xation of most supracondylar femur frac- of the distal femoral block can occur.
tures. The A.O./O.T.A. Classication is help-
ful in determining the surgical treatment for This article reviews the past experience with
the fracture (Fig. 1). treatment of supracondylar femur fractures, in
For A.O./O.T.A. Classication A-type (non- particular the C3 distal femur fracture. The
articular supracondylar femur fractures) and pertinent anatomy and injury patterns seen
C1/C2 (supracondylar femur fractures with with the C3 fracture are discussed. Finally,
simple articular splits), a variety of implants the technique of visualization, reduction, and
have proved efcacy: xation of the articular surface by a lateral
parapatellar approach, followed by submus-
95 dynamic condylar screw30 cular xation of the metaphyseal/diaphyseal
95 condylar blade plate2, 3, 29, 3234, 36 component of the fracture, as developed by
Retrograde supracondylar nail5, 810, 12, 35 Krettek et al, will be discussed.19, 22
Antegrade intramedullary nail23
The C3 distal femur fracture remains a dif- CLINICAL RESULTS IN THE
cult surgical challenge, however, because of TREATMENT OF DISTAL
several factors: FEMUR FRACTURES
Adequate exposure of articular surface, es-
pecially of the medial femoral condyle, is In nonoperative treatment of distal femur
challenging, without large surgical expo- fractures with or without signicant articular
sure or tibial tubercle osteotomy. involvement, problems included malunion,

From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt University
Medical Center, Nashville, Tennessee




Figure 1. The A.O./O.T.A. Classication divides supracondylar femur frac-

tures into type A (extra-articular), type B (partial articular), and type C (ar-
ticular involvement). Type C1 and C2 distal femur fractures have simple ar-
ticular injury. The type C3 fracture has complex articular involvement. This
articular injury may be comprised of Hoffa frontal plane and multiplane
articular fractures. (From Hansen ST, Swiontkowski MF (eds): Orthopaedic
Trauma Protocols. Raven Press, New York, 1993, p 296; with permission.)

nonunion, and joint stiffness. Early compar- No category of fracture at this level seemed
ison of distal femoral fracture treatments well suited for internal xation, and sufcient
favored nonoperative versus operative xation to eliminate the need for external
methods.27, 39 In 1967, Neer et al,27 in dis- support or to shorten convalescent was rarely
cussing supracondylar femur fractures, stated, attained. They evaluated 110 patients with

fractures in the distal 3 inches of the femur xation may be quite poor. The functional
treated between 1942 and 1966. Of these, expectations for treatment of a supracondylar
71 patients were treated with traction and femur fracture were relatively low, however.
subsequent casting, 36 patients were treated For example, to obtain a satisfactory Neer
with internal xation, and three required score of 72, one could have pain with fatigue,
primary amputation for peripheral vascular have restricted function (requiring going up-
disease. Sixty-seven fractures were suitable stairs side ways), have motion of 100 , do reg-
for result analysis. In fractures treated with ular work with handicap, and have 5 of angu-
internal xation, 52% were deemed satisfac- lation or 0.5 cm of shortening.
tory, whereas with closed treatment, 90% were With the advent of rigid internal xation of
satisfactory. distal femur fractures, the surgeons were able
Stewart et al,39 in 1966, reported on the treat- to obtain earlier and more aggressive knee
ment of 215 supracondylar femur fractures. Of motion. Several complications occurred, how-
142 fractures treated by closed methods, 67% ever, including nonunion, need for bone graft-
were rated good or excellent, whereas 54% ing, malunion, failure of hardware, infection,
treated by ORIF were rated as good or excel- and loss of motion (Fig. 2). Wenzl et al,40 in
lent. Ten of 69 patients treated operatively de- 1970, published the rst results of blade plate
veloped a delayed union, and an additional xation of supracondylar femur fractures, re-
10 developed a nonunion. Stewarts conclu- porting 73.5% good or excellent results in
sions regarding internal xation were: The 112 patients treated with rigid xation and
additional trauma of surgery and the prox- early full, unsupported, unrestricted early mo-
imity of metallic implants to the joint predis- tion. Olerud,28 in 1972, reported on 16 cases
pose to excessive reaction and subsequent ad- of supracondylar femur fractures treated with
hesions. Even though one obtains an excellent blade plate xation using a large, Y-shaped in-
roentgenographic result with solid union, nal cision with osteotomy of the tibial tubercle.

Figure 2. This 63-year-old man was referred after undergoing open re-
duction internal xation of a right AO/OTA Classication C2 injury and a
left C3 injury. At 3 months postoperatively, the right distal femur had un-
dergone irrigation and debridement, and placement of antibiotic beads
for infection with methicillin-resistant Staphylococcus aureus. The left
C3 injury was treated with a condylar buttress plate and had shortened
and displaced into varus collapse, (arrow). Postoperative immobilization
resulted in stiff knees with a exion arc of 10 bilaterally.

Bone grafting was used in 6 of 16 fractures, was used liberally. Bone grafting rates docu-
and using this extensile approach, ve ma- mented in the treatment of supracondylar fe-
jor complications were seen, including os- mur fractures ranged between 23% and 87%.26
teomyelitis, loss of xation, septic arthritis, The relatively slow rate of healing of supra-
and postoperative infection. In addition, 5 of condylar femur fractures and other fractures,
16 patients had a range of motion of less than as well as the rather extensive need for bone
90 of exion. In 1974, Schatzker32 reported grafting, led to the clinical need for improved
on the results of rigid xation versus nonop- soft tissue handling around fractures.
erative methods. Seventy-ve percent of pa- Mast et al25 popularized the concept of in-
tients had good or excellent results with rigid direct reduction of fractures, which relies on:
xation, whereas 32% of patients had similar
Maintenance of the soft tissue attach-
results with nonoperative methods. In 1979,
however, Schatzker did point out the possible ments and vascularity to the cortical bone
failure of internal xation.34 Forty-nine frac- fragments
Anatomic restoration of the articular sur-
tures in 47 patients were described, with the
fractures occurring in the distal 15 cm of the fe- face in the traditional sense
Restoration of the appropriate length, ro-
mur. He noted common errors, including inac-
curate reduction, failure to achieve interfrag- tation, and alignment of the metaphyseal
mental compression with lag screws, medial diaphyseal region of the fracture, without
protrusion of the blade plate, and the blade preoccupation with complete anatomic
plate being introduced too proximal from the restoration of this region
knee joint. In 18 cases, poor results were seen:
The goal of anatomic restoration of the ar-
two malunions affecting joint congruity, six
ticular surface, avoidance of soft tissue devi-
delayed unions, two nonunions, seven blade
talization, and xation to allow for early mo-
plate loosenings, three broken plates, two me-
bilization can be accomplished by traditional
dial protrusions of the plate, one refracture,
articular reconstruction, followed by:
one fracture above the plate, and two in-
fections. Siliski et al36 reported on 52 supra- Plating with an emphasis on preserva-
condylar intercondylar fractures of the femur tion of the muscular attachments to the
which were treated in Graz, Austria, between diaphyseal and metaphyseal area of the
1968 and 1983. There were 13 C1, 26 C2, and femur
13 C3 fractures. Twenty of 52 fractures had Retrograde intramedullary nail xation
open wounds, and 10 were associated with a External xation
patella fracture. Fixation used included 42 95
angle condylar blade plates, 7 condylar but- In 1996, Bolhofner et al3 reported on the
tress plates, 2 T-plates, and one straight plate. treatment of 57 cases of supracondylar fe-
Cancellous bone grafting was used in 19 of mur fractures treated with biological reduc-
the 52 fractures. Average time to healing was tion techniques, stating, the xed angle of the
13.6 weeks. Seven fractures healed in 4 to 8 blade and the known relationship of the blade
of varusvalgus malalignment and three frac- and the plate to the normal distal femoral
tures healed in 5 to 10 of recurvatum. Short- anatomy allows for exploitation of the plate,
ening of 1 to 3 cm occurred in 15 patients. both as a reduction tool and a xation im-
The average eventual arc of motion of the knee plant simultaneously. They reported on the
averaged 107 , with the average knee motion treatment of a total of 57 cases: eight cases of
being 113 for C1 fractures and 99 for C3 AO/OTA Classication A2 fractures, 14 cases
fractures. Overall, C1 fractures resulted in a of A3 fractures, 10 cases of C1, 16 cases of
good or excellent outcome in 92% of cases, C2, and 9 cases of C3 fractures. No type IIIB
whereas C2 and C3 fractures resulted in 77% or IIC open fractures were included because
excellent or good results as based on the rat- it was believed that the biology was signif-
ing system of Neer et al. Three major infec- icantly disrupted about the fracture in these
tions were seen, resulting in two amputations open injuries. Twenty-nine condylar buttress
and one need for arthrodesis. Thus, as seen in plates and 28 95 angle blade plates were
the series by Schatzker and Siliski et al, while used. Nineteen of the fractures were open.
anatomic reduction and rigid xation did offer No bone grafting or dual plating of frac-
improvement in function, it did not guarantee tures was used. At 1-year follow-up, the re-
uniform satisfactory results.33, 34, 36 sults were 40% excellent and 44% good, with
In the early experience with rigid xation of 16% of the cases resulting in unsatisfactory
supracondylar femur fractures, bone grafting outcomes. The time to radiographic union

and full weight-bearing was 10.7 weeks. Two than 90 of motion. Five of these patients un-
delayed unions occurred. No nonunions de- derwent Judet quadricepsplasty. Varusvalgus
veloped. Ostrum and Geel29 have reported deformities were reported if greater than 10 .
on a similar series, in which maintenance Deformities seen were one case of 12 of val-
of the soft tissue around the metaphyseal gus deformity, two cases of procurvatum de-
diaphyseal component of the fracture was as- formity, and six cases of recurvatum defor-
sociated with early consolidation of the frac- mity. Three cases of infectious complications
ture, a low need for bone grafting, and paucity and two cases of refracture were seen. The in-
of infection and soft tissue problems. vestigators noted that high-energy soft tissue
injury (e.g., extensor mechanism disruption)
or articular surface bone loss had a large im-
CLINICAL RESULTS IN pact on the clinical outcome of the patient.
TREATMENT OF THE C3 The use of the condylar buttress plate in
DISTAL FEMUR FRACTURE the setting of the C3 distal femur fracture
has been particularly challenging. Numerous
By denition, a C3 distal femur fracture has investigators have commented on the rela-
a complex articular injury with or without a tive instability of the distal femoral block
Hoffa (frontal plane) fracture. Treatment op- with its use and varus collapse (caused by
tions for internal xation of C3 distal femur screw toggling).1, 3, 16, 3134, 37 A variety of strate-
fractures include: gies have been attempted to counteract this.
Sanders et al31 reported on double plating and
Condylar Buttress Plate, with or without bone grafting in nine C3 distal femur fractures
medial plating3, 15, 16, 31 with a decient medial cortical buttress. All
Retrograde Intramedullary Nail4, 5 fractures healed, with ve good and four fair
External xation11, 24 results; however, no patient achieved greater
than 100 of exion. Three patients had less
The use of a 95 condylar buttress blade than 90 of exion, and six had between 90
plate or dynamic condylar screw is not recom- and 100 of exion. In addition, four patients
mended for these injuries30, 3234 because of two had an extensor lag of 5 . Simonian et al37
factors: showed that a screw could improve the biome-
1. If a Hoffa or frontal plane split is chanical stability against varus collapse diago-
present in the medial or lateral femoral nally placed from proximal aspect of the plate
condyle, introduction of the blade plate or into the medial femoral condyle. In addition,
condylar screw would jeopardize xation distal screws, which lock in to the side of the
of this fracture. plate, and locked double plating also greatly
2. Often, the distal femoral block is rel- improve biomechanical stability13, 17 ; however,
atively short and therefore does not probably the most proven method to mini-
allow for placement of the xation de- mize varus collapse and loss of xation is an
vice. (For introduction of the dynamic emphasis on soft tissue preservation, rather
condylar screw, 4 cm of distal femur is than mechanical stability.3, 29 Bolhofner et al3
recommended.) reported on nine C3 injuries, eight of which
were treated with a condylar buttress plate.
Articular reconstruction followed by exter- Although open fracture types IIIB and IIIC in-
nal xation of the C3 distal femur fracture juries were excluded from his study, seven of
also has been described, both with half-pin ex- nine of the injuries healed with good or excel-
ternal xation and tensioned-wire xation.11, 24 lent results. Two poor results were seen.
Marsh et al24 described three C3 distal femur
fractures treated with limited internal xation
of the articular surface, followed by half-pin ANATOMY
external xation. Hutson and Zych11 reported
on the use of articular reconstruction followed The distal femoral articular surface is at an
by distal femoral tensioned-wire external x- angle of 7 to 8 of valgus to the long axis of
ation for 16 C3 distal femur fractures. Tradi- the femur in males, and 8 to 9 of valgus in
tional internal xation of the articular surface females. The lateral cortex of the distal femur
was carried out using a lateral approach; in slopes approximately 10 to 15 , and the me-
four cases, this tibial tubercle osteotomy was dial cortex slopes approximately 25 (Fig. 3).
used. The average time in the external x- The anterior cruciate ligament occupies the in-
ator was 24 weeks. Eight patients had less tercondylar notch. A line drawn across the

anterior aspect of the lateral femoral condyle

and medical femoral condyle slopes by ap-
proximately 10 to 15 .


A C3 distal femur fracture is characterized

from other supracondylar and intercondylar
femur fractures by its complex involvement of
the articular surface. The articular surface may
be involved with:
An intercondylar split with an intercalary
articular segment (thus, differentiating it
Figure 3. End-on view of the distal femur. The lateral cor- from a C1 or C2 injury)
tex of the distal femur slopes 10 to 15 , and the medial
cortex slopes 20 to 25 . A line drawn across the ante- Medial or lateral condylar frontal plane
rior aspect of the femoral condyles slopes medially 10 to fractures (Hoffa fractures; Fig. 4)
15 . These relationships are important in placement of Separate intercondylar notch fragments
internal xation in the distal femur. (From Hansen ST, (Fig. 5)
Swiontkowski MF (eds): Orthopaedic Trauma Protocol.
Raven Press, New York, 1993, p 295; with permission.)
Multiplane complex articular surface in-
volvement (Fig. 5)

Traction, anteroposterior, lateral, and obli-

que radiographs help to delineate the distal

Figure 4. A 39-year-old woman sustained a type IIIa open right C3 distal femur. A, Injury AP traction
radiograph. B, Injury lateral radiograph. The lateral radiograph should always be inspected for a frontal
plane Hoffa fracture (arrow). C, Sagittal plane CT reconstruction of the distal femur with Hoffa fracture,
Illustration continued on opposite page

Figure 4 (Continued ). D, Intraoperative view of the distal femoral articular injury. The distal femur was
exposed by way of a lateral peripatellar approach. The arrows indicate the two-level Hoffa plane frac-
ture in the lateral femoral condyle. E, Intraoperative view of the articular reduction after clamp applica-
tion. Depth gauges are in the various anterior to posterior directions for screw placement for xation
of the frontal plane fractures. The patella is everted. F, The articular reduction after screw placement.
G, Fixation by way of submuscular xation utilizing the LISS xator (described in text). (Courtesy of
Peter A. Cole, MD, Minneapolis, Minnesota)

extent of the fracture, better clarifying articu- sessing these patients for other injuries, the
lar involvement, and allow one to perform the treating surgeon must ask the following perti-
preoperative plan. If these lms are not ob- nent questions:
tained, it is relatively easy to underestimate
the articular injury. 1. What is the status of the soft tissue en-
velope around the distal femur; are there
any open wounds?
2. Is there any vascular injury in the lower
AND PLANNING 3. Is there any sign of impending compart-
ment syndrome?
A careful history and physical examination
are mandatory for patients with high-energy One must recognize that concomitant with
C3 distal femur fractures. In addition to as- the high energy needed to cause a signicant

Figure 5. A 39-year-old woman sustained a closed C3 distal femur fracture. A, Traction AP radiograph.
B, Traction lateral radiograph demonstrates frontal plane fracture in articular surface, (arrow). C, Axial
CT scan demonstrating multiplane articular involvement. D, Frontal CT scan demonstrating separate
osteochondral fragment in intercondylar notch (arrow).
Illustration continued on opposite page

Figure 5 (Continued ). E, Intraoperative view of articular injury as viewed from a lateral peripatellar ap-
proach. F, Intraoperative uoroscopic AP view of articular surface reduction. G, Articular surface re-
duction. Multiple 3.5 mm lag screws were used for xation of the articular surface. A variable pitch
screw was used for xation of the intercondylar notch fragment. H, AP radiograph at 24 months. Sig-
nicant medial callus develops with maintenance of the soft tissue envelope around the metaphyseal
region of the fracture (arrow). I, Lateral radiograph of the distal femur at 24 months postoperatively.

articular injury is the potential for other high- thrombosis is not described in the literature,
energy effects on the distal femur or injured surveillance for it is warranted.
lower extremity.
Radiographic assessment, at a minimum,
must consist of good quality anteroposterior, THE TARPO TECHNIQUE
lateral, and oblique radiographs centered at
the knee. Traction radiographs are helpful in The transarticular percutaneous osteosyn-
aiding visualization of the articular surface thesis (TARPO) technique was rst described
and in assessing potential closed reduction by Krettek et al19, 22 in 1996 (Fig. 6). It sought to
of the metaphysealdiaphyseal components of address at least two problems common in the
the fracture. The oblique radiographs are often treatment of C3 distal femur fractures:
helpful in assessing the articular involvement;
1. Difculty with complete articular surface
often, the patella obscures the intercondylar
visualization (and, therefore, reduction
fracture. The Hoffa or frontal plane fracture
and xation)
is best seen on lateral radiography. Axial CT
2. Devitalization of the metaphysis by large
scans with sagittal and frontal plane recon-
surgical incisions, with the resultant
structions are helpful to conrm interpreta- problems of infection, need for bone
tion of plain radiographs and in more closely grafting, and potential nonunion
delineating articular involvement. In particu-
lar, it is helpful to map out the articular in- Although the entire articular surface and
volvement in multiplane fractures and to ver- lateral cortex of the femur can be exposed by
ify the presence or absence of intercondylar one surgical approach (the swashbuckler
notch fragments. approach), it does create a large surgical
The Ankle-Brachial Index or Ankle-Ankle exposure.38 The TARPO technique involves
Index is helpful as a screening tool for pos- a lateral peripatellar approach much like a
sible arterial injury.14 If additional study is medial peripatellar approach used for a total
warranted, arteriography may be performed. knee arthroplasty.19, 22 This approach allows
Signicant displacement of the fracture may for complete visualization of the entirety of the
potentially cause a venous intimal injury. distal femur, without signicant devitalization
Although an association with deep venous of the metaphyseal area of the fracture. As

Figure 6. The TARPO (Trans-articular Percutaneous Osteosynthesis) technique as described by

Krettek, et al.19, 22 (Courtesy of Christian Krettek, MD, Hannover, Germany). A and B, Approach for
lateral peripatellar approach. C, With subluxation or eversion of the patella, appropriate exposure
of the articular surface is obtained, without signicant metaphyseal diaphyseal soft tissue stripping.
D, A plate can then be slid in a submuscular manner after articular reconstruction.

such, it is helpful when addressing multi-

plane fractures, separate intercondylar notch
fragments, and Hoffa fragments, especially
when on the medial femoral condyle. Eversion
of the patella can be performed to expose the
distal femoral condyle.
The articular surface can then undergo re-
duction provisional xation, followed by def-
inite xation. Traditionally, screw xation is
accomplished by 6.5-mm, partially threaded
lag screws. The author has found it helpful to
use small fragment (3.5- or 2.7-mm) cortical
screws placed in true lag mode. Their use
grew out of similar use of such screws in the
proximal tibia, popularized by Benirschke.
Although each fracture conguration is
intrinsically different, certain screws remain
very helpful for xation of complex mul-
tiplane articular fragments. In particular,
several specic strategies are helpful:
1. 3.5-mm cortical lag screws can be placed
from lateral to medial about the periph-
Figure 7. Typical Hoffa plane fracture in femoral condyle.
ery of the lateral femoral condyle to Its orientation is in the frontal plane and can be xed
secure the lateral condylar block to the with cortical lag screws placed from the anterior to pos-
medial condylar block (see Figs. 4 and 5). terior direction. The starting position for the screws is
2. Separate minifragment lag screws or just proximal to the articular surface. (From Hansen ST,
variable pitch lag screws can be used Swiontkowski MF (eds): Orthopaedic Trauma Protocols.
Raven Press, New York, 1993, p 300; with permission.)
to address small separate intercondy-
lar notch fragments (see Figs. 4 and 5); Appropriate length, axis, and rotational
although these small fragments are usu-
ally not important from a structural or Stable, but not necessarily rigid xation
articular surface standpoint, they may
connecting the distal femoral block to the
be attached to bers of the anterior cru-
proximal femur
ciate ligament. In such a case, a suture Avoidance of metaphysealdiaphyseal
rendered repair of the anterior cruciate
soft tissue stripping
ligament through drill holes in the lateral
femoral cortex may be warranted.
3. Anterior-to-posterior 3.5-mm lag screws The advantages of submuscular xation
can then be placed to address Hoffa of distal femur fractures have been well
frontal plane fractures in the femoral shown, both in the experimental and clinical
condyle (Fig. 7). The starting point for setting.6, 7, 1922 Naturally, the surgeon may
these screws is just cephalad to the ar- envision that a plate placed in a submuscular
ticular surface of the femoral condyle. In manner would disrupt a signicant soft tissue
placing the screws in this manner, there or vascular disruption. Such is not the case
is a corridor of bone left for placement because there is a potential space beneath the
of future screws that will afx the distal vastus lateralis muscle belly that allows for
femoral block to the plate and proximal the passage of the plate beneath the muscle.
femur. Farouk et al6, 7 compared the vascular distur-
4. Similar screws to the Hoffa screws can be bance to the femoral perforating and nutrient
placed on the diagonal from one femoral arteries of the distal femur using silicone dye
condyle to the other. These screws then injection in matched pairs of 10 fresh cadav-
lock in one condyle with the other, ers. Comparing conventional plating versus
which can be helpful in the setting of a submuscular plating, better periosteal and
short distal segment. medullary perfusion was seen in 70% of the
cases with submuscular plating. The use of
After the articular surface is reduced and in- dynamic condylar screw in a submuscular
ternally xed, the goals are: manner has proven efcacy20 (Fig. 8). Articular

Figure 8. A 67-year-old women sustained a nonarticular supracondylar femur fracture. The use of a
dynamic condylar screw in a submuscular manner is demonstrated. A, Injury AP traction radiograph.
Note long proximal extension. B, Many options are available for treatment of this fracture. In this case,
the intraoperative view demonstrates placement of the dynamic condylar screw through a small lateral
incision. Note the supracondylar bump posterior to the supracondylar region to counteract the hyper-
extension deformity of the distal femur.
Illustration continued on opposite page

Figure 8 (Continued ). C, Intraoperative uoroscopic view demonstrating placement of the dynamic

condylar screw parallel to the joint surface. D, Postoperative AP radiograph. Appropriate alignment
was performed utilizing manual traction. The side plate for the dynamic condylar screw was placed in
a submuscular manner, and the proximal screws were placed in a percutaneous manner. E, Postoper-
ative lateral radiograph.

reconstruction by a lateral peripatellar ap- Less Invasive Stabilization System

proach, followed by submuscular plate xa- for Distal Femur Fractures
tion, was reported by Krettek et al19 in eight
cases of C2 and C3 distal femur fractures. The Less Invasive Stabilization System
Average time to healing was 12 weeks, with (LISS; Synthes, USA) was introduced recently.
no infections seen; however, the investiga- Mathys Corporation in Switzerland and the
tors did note two varusvalgus deformities of A.O. Development Institute in Switzerland
more than 5 , two leg length discrepancies of were responsible for its development (Fig. 9).
more than 10 mm, and two rotational defor- Its characteristics include:
mities of 15 . These ndings point out that, 1. Multiple, xed angled screws which lock
although submuscular plating leads to rapid into the distal end of the xator
consolidation of the fracture, obtaining correct 2. An insertion handle that allows for sub-
alignment and rotation may be difcult using muscular sliding of the xator and for
closed reduction. placement of percutaneous, self-drilling,
After the articular surface is addressed, the unicortal screws for xation of the dia-
surgeon can then carry out xation of the physeal component of the fractures
supracondylar component of the fracture us-
ing either a biological plating technique or The LISS system should be viewed as a
a submuscular technique. Although a care- new surgical technique and not as an implant.
fully performed soft tissuesparing lateral ap- The major characteristics of the LISS technique
proach to the proximal femoral shaft may entail:
be connected to the lateral peripatellar ap-
Direct visualization and classic ORIF of
proach, this does make a rather large incision.
Without the lateral peripatellar approach, one the articular fracture surface
Closed manipulation of the metaphyseal
may not be able to obtain the visualization
of the articular surface. Thus, the usefulness diaphyseal component of the fracture, us-
of the TARPO technique lies in its ability to ing reduction aids
expose well the articular surface and to pre-
The characteristics of the technique and
serve the soft tissues around the metaphyseal
implant, when viewed together, allow for both
diaphyseal component of the fracture.
submuscular xation of the supracondylar
component of the fracture and placement of
multiple xed-angle locked screws in the dis-
IMPLANT OPTIONS tal femoral fragment. The ability to maintain
the soft tissue envelope around the frac-
Ideally, the plate implant for the distal fe- ture can be attributed to the LISS technique,
mur should have angular stability in the dis- while the improved distal femoral condyle
tal screws to help avoid varus collapse. The purchase corresponds to the multiple distal
clinical problem of varus collapse is being ad- xed-angle locked screws.
dressed by several new plate designs, all of
them having the common denominator of dis-
tal xed-angled locked screws. This idea is at- THE LISS IS AN
tributed to Jeff Mast, MD, who originated the INTERNAL FIXATOR
idea of Schuli
(Synthes, USA) devices, which
lock a cortical screw into a compression plate. Given the biomechanics of the LISS system
A locking condylar buttress plate (Synthes, as just discussed, it is most helpful to consider
USA) has been introduced and features screws the LISS system as an internal xator rather
that lock into the distal aspect of the plate. than as a plate. The characteristics of the LISS
In such a C3 fracture, the locking condylar parallel that of an external xator in several
buttress plate may be passed in a submuscu- ways:
lar manner and percutaneous proximal screws
placed. Alternatively, a separate proximal in- The LISS screws have self-drilling,
cision can be used for the attachment of the self-tapping, and cutting utes similar
proximal end of the plate to the proximal fe- to several current Schanz pin designs used
mur after closed reduction of the metaphysis. in external xators. Just as self-drilling
Undoubtedly, other similar plate systems will external xation pins will push away the
be introduced in the next years. bone when inserted, so too do the LISS


Figure 9. The less invasive stabilization system (LISS [Synthes, USA]) has been developed to allow
for submuscular xation of supracondylar-intercondylar femur fractures. All screws lock into the plate,
making it an internal external xator, rather than a plate. A, The LISS has an outrigger device that al-
lows for percutaneous placement of the proximal screws. Screws are self-drilling, self-tapping, and are
drilled in under saline cooling provided by an irrigation system. B, The screws are 5.0 mm in diameter
and are self-drilling and self-tapping. The proximal cortical screws are 26 mm in length, and the dis-
tal screws are 55, 65, 75, and 85 mm in length. C, The screws lock into the LISS xator, as the screw
heads are threaded that screw into the xator.

screws tend to push away the bone during Often, rotational control of one condyle
screw insertion with a power drill. is aided by a Schanz screw placed into the
The xation will maintain, but not obtain, medial femoral condyle. Large tenaculum
fracture reduction. Using conventional clamps (Weber clamps) or pelvic reduction
plating techniques, xation of a reduced clamps in conjunction with Kirschner wire
fracture with an improperly contoured xation can be used for provisional xation of
plate will result in loss of fracture reduc- the articular splits. Dental picks can be helpful
tion. Conversely, a properly contoured for manipulation of small fragments.
plate can aid in fracture reduction be-
cause the screws will approximate the
bone to the plate. The exact opposite is Metaphysis and Diaphysis
the case with the LISS system. Acting as
an internal xator, the fracture reduc- Closed reduction of the metaphyseal
tion must be achieved before the LISS is diaphyseal component of the fracture is often
internally xed, just as one would ob- possible, as known from intramedullary nail
tain an appropriate femoral diaphyseal xation of distal femur fractures. In general,
reduction before placing on an external a multifragmentary metaphyseal fracture is
xator. One cannot rely on the xator to easier to reduce than is the spiral metaphyseal
help afford the reduction. This in sharp fracture. In one series of 66 supracondylar
distinction to the use of the 95 angle femur fractures treated with attempted closed
condylar blade plate, in which the estab- reductions, in two cases, a closed reduction
lishment of proper placement of the blade was not possible.18 Both cases consisted of
plate in the distal femoral region will a simple spiral fracture of the metaphyseal
ensure appropriate axial and sagittal plane region. Closed reduction of the metaphysis is
alignment. aided by:
The articular surface is addressed with Early intervention
direct visualization and traditional ORIF.
This may be liked to treatment of a prox- Complete clinical paralysis
Manual traction
imal tibial plateau fracture with articular
involvement. Although the metaphyseal Supracondylar bumps
diaphyseal component of the fracture may
be addressed with external xation, the The supracondylar bumps are made of
joint surface is addressed with classic joint rolled operating room towels of various num-
surface visualization, reduction, and lag bers and are placed posterior to the supra-
screw xation. condylar region. These bumps are placed to
Longer constructs than with conventional counteract the normal hyperextension defor-
plating techniques are used. As longer x- mity of the distal femur seen secondary to the
ator placement (i.e., 13-hole versus 9-hole) pull of the gastrocnemius. In addition to these
is not associated with longer surgical inci- modalities, the use of the femoral distractor or
sions, longer xators tend to be used. external xator may be helpful to gain length.
Additional case examples are demonstrated in
Figures 10 and 11.

Articular Surface
Reduction strategies for the articular surface
are aided by a well-thought-out preoperative The C3 distal femur fracture remains a prob-
plan, aided by a thorough understanding of lematic one because of severe articular injury,
the injury. Early intervention minimizes the signicant soft tissue disruption, bone loss,
need for debridement of the cancellous bone and fracture patterns that compromise xa-
surfaces. The accuracy of the reduction in a tion quality. Optimal visualization of the ar-
multiplane fracture is usually aided by com- ticular surface, followed by soft tissue preser-
plete provisional xation of all fractures to as- vation around the metaphyseal component of
sure anatomic reduction. A common malre- the fracture, is advantageous. This may be ac-
duction is to have rotational mismatch of one complished by a lateral peripatellar approach,
femoral condyle or the other. followed by submuscular xation.
(Text continued on page 174)


Figure 10. A 42-year-old man sustained a left Type IIIA open distal femur fracture and a right Lisfrancs
fracture-dislocation of the foot. A, Traction AP radiograph of the distal femur. B, Lateral radiograph. The
arrow points out the Hoffa frontal plane fracture (arrow). C, Close-up lateral of distal femur. The ar-
row indicates the Hoffa plane fracture. D, Initial operative view of left femur. The patient sustained a
prepatellar traumatic laceration, which was repaired. The arrow indicates the traumatic injury after irri-
gation and debridement of the open fracture wound. This wound was extended distally to give appro-
priate visualization of articular surface. Anterior to posterior lag screws were placed to address both
the medial and lateral Hoffa fractures. Submuscular xation was then placed utilizing LISS xation.
The proximal incision is to ensure the xator is in the appropriate position on the proximal femur.
Illustration continued on following page


Figure 10 (Continued ). E, Postoperative AP radiograph. F, Postoperative lateral radiograph. Note the

anterior to posterior direction of the lag screws to address the Hoffa plane fracture. G, AP radiograph
at 6 weeks. H, Lateral radiograph at 6 weeks. I, AP radiograph at 9 months. The patient had full range
of motion (0130 of exion). J, Close-up of distal femur at nine months post-trauma. K, Lateral radio-
graph at nine months. Complete consolidation is seen.
Illustration continued on opposite page


Figure 10 See legand on oppsite page.




Figure 11. An 18-year-old woman sustained an isolated closed left C3 distal femur fracture in a mo-
torcycle accident. A, Injury AP traction radiograph. B, Injury lateral traction radiograph. A multiplane
articular fracture is seen. The patella is seen to divide the articular surface (arrow). C, Axial CT scan
demonstrates patella driven into midsubstance of lateral femoral condyle (arrow). D, Intraoperative
view of articular injury, as seen by way of the lateral peripatellar approach. E, Provisional xation of
the articular surface.
Illustration continued on opposite page

Figure 11 (Continued ). F, Lateral view of articular reconstruction. Note short segment of distal femur
(arrow). G, Intraoperative view of distal femoral block with LISS xator in place. The 3.5-mm corti-
cal lag screws are placed around the periphery of the condyle (arrow). Note preservation of the soft
tissues around the metaphyseal region. H, Three months postoperative AP radiograph. The patient re-
gained only 90 of exion despite immediate range of motion. She had signicant extensor mechanism
injury. I, Postoperative lateral at 3 months.

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Address reprint requests to

Philip J. Kregor, MD
Division of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Vanderbilt University Medical Center
Nashville, Tennessee 37232

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00


William J. Mills, MD, and Sean E. Nork, MD

Proximal tibial articular fractures are caused This article discusses the surgical stabiliza-
by a variety of mechanisms and are character- tion of these fractures with plate and screw
ized by numerous distinct fracture patterns. constructs. The features of high-energy com-
Surgical treatment for other than minimally plex tibial plateau fractures identied by
displaced or nondisplaced fractures is rec- Watson45 include signicant articular depres-
ommended to restore joint congruity and sion, condylar displacement, metadiaphyseal
limb alignment and to allow early, stable knee fracture extension, and open wounds or exten-
motion.1, 4, 20, 37 Potential complications vary sive closed degloving injuries of the proximal
with the degree of energy absorbed during tibia (Fig. 1). Although soft tissue injuries may
the injury and include soft tissue compro- make open reduction and internal xation
mise requiring coverage procedures, lower (ORIF) difcult, in many instances it has cer-
extremity compartmental syndrome, peroneal tain advantages over external xation and
nerve injury, vascular injury, and eventual frequently can be accomplished safely in the
knee arthrosis.15 Associated injuries include setting of high-energy blunt trauma to the
ipsilateral femoral and tibial diaphyseal proximal tibia. The goals of both treatment
fractures, cruciate and collateral ligament methods include anatomic reconstruction of
injuries, and meniscal tears.3 Each of these the proximal tibial articular surfaces, restora-
injuries affects early surgical treatment and tion of the limb axis, spanning metaphyseal
long-term outcomes. A heightened awareness comminution if present, and minimization of
of these potential injuries and complications further morbidity to an already traumatized
has altered the approach to complex proximal soft tissue envelope. These goals can be ac-
tibial articular fractures. Internal and exter- complished in the proximal tibia with plate
nal xation design advances have changed and screw constructs if one uses appropriate
several of the techniques of fracture xation. and limited incisions when necessary, longer
Similarly a greater appreciation of soft tissue bridging plate constructs in comminuted
injuries about the proximal tibia has changed fractures, and xed angled implants or me-
treatment protocols to limit potential surgical dial external xation supplementation when
morbidity. isolated conventional plates are insufcient.
Another article in this issue describes sur- The concept of spanning areas of severe frac-
gical treatment of high-energy tibial plateau ture comminution evolved in the 1990s as
fractures using limited periarticular inter- proponents of indirect fracture reduction and
nal xation combined with external xation. biologic internal xation reported increased

From the Department of Orthopedic Surgery, University of Washington, Harborview Medical Center, Seattle,





Figure 1. A and B, This 56-year-old woman sustained a severe injury to her left proxi-
mal tibia after a fall from height. Note the signicant articular depression and distal ex-
tension. The soft tissue injury delayed denitive operative treatment for 3 weeks.

rates of fracture healing with decreased infec- of certain complex plateau fractures, they
tion rates.23 Delaying denitive treatment until noted clinical ligamentous laxity in 7 patients,
optimal soft tissue conditions exist also min- posttraumatic osteoarthritis in 5 patients,
imizes complications. Temporary knee span- and septic arthritis requiring surgical treat-
ning external xation is a useful adjunct in ment in 2 patients. These authors also con-
injuries with soft tissue compromise. ceded an average residual joint displacement
Potential advantages of ORIF over some of 2 mm.
external xation techniques include the ability The optimal treatment for high-energy tibial
to recognize and repair associated menis- plateau fractures frequently is not limited to
cal and collateral ligament injuries, greater purely internal or external xation but com-
visualization of the articular surface for monly combines elements of both. Authors
restoration of joint congruence, and avoid- who advocate predominantly tensioned ne
ance of prolonged external xation half-pins wire or hybrid external xation for high-
and wires. These pins and wires can lead to energy plateau fractures do so with the caveat
some of the complications they are designed that restoration of the articular surface with
to avoid, including cellulitis, osteomyelitis, limited internal xation should be performed
and septic arthritis. Marsh et al27 reviewed before spanning the metaphysis with external
their experience with external xation and xation.11, 12, 43, 45 Similarly, ORIF of high-
limited internal xation of complex Schatzker energy plateau fractures can be combined with
type IV, V, and VI tibial plateau fractures in temporary knee spanning external xation
20 patients. In only 2 knees was an arthro- or supplemental medial external xation to
tomy performed for direct visualization of neutralize deforming forces when signicant
the articular reduction. Meniscal or collateral cortical comminution is present.45
ligament pathology was not addressed in any Published series describing internal and ex-
patient. Although Marsh et al27 concluded that ternal xation as treatment of high-energy
this was a satisfactory technique for treatment plateau fractures have reported high rates

of soft tissue and infectious complica- by Houben et al,16 who found that patients
tions.17, 26, 30, 47 For this reason, the common older than age 60 with surgically treated tibial
theme in management of these complicated plateau fractures had less functional loss than
injuries is respect for the soft tissue envelope. younger patients treated with ORIF.
The authors approach to operative treat-
ment of most closed high-energy plateau
fractures typically is coupled with temporary CLASSIFICATION
knee spanning external xation (Fig. 2) and
delayed treatment when needed to allow Any discussion of fracture treatment bene-
soft tissue recovery. It also is helpful to use ts from a useful classication system. Tibial
2 plate constructs placed through 2 incisions, plateau fractures have been classied by many
to avoid anterior midline approaches, to use authors.14, 21, 3032, 39, 41 Although each has its
medial external xation or xed angled plates advantages and disadvantages, the Schatzker
on occasion to avoid a medial surgical ap- classication currently is accepted most
proach, and to perform soft tissue coverage widely and is employed here. In tibial plateau
procedures to treat local injuries. fractures, as in any lower extremity periartic-
ular fracture, the articular cartilage damage at
the time of injury signicantly affects patient
NONOPERATIVE TREATMENT outcome. No current classication incorpo-
rates the degree of cartilage injury. Although
This article focuses specically on the oper- cartilage injury can be inferred by the degree
ative treatment of tibial plateau fractures us- of fracture displacement and the presumed en-
ing ORIF techniques. There is a role for non- ergy absorption in these fractures, there is no
operative treatment of certain tibial plateau direct correlation between fracture type and
fractures in selected patients. The indications prognosis. Injuries to the local soft tissues, in-
for closed treatment include nondisplaced or cluding the menisci, collateral ligaments, and
minimally displaced (< 3 mm of articular in- adjacent neurovascular structures, are com-
congruity) fractures; peripheral (submeniscal) mon. Although these injuries are not a part
plateau fractures; and fractures in elderly, low- of standard classication schemes, they have
demand, or osteoporotic patients. The concept a signicant impact on patient outcomes.3
of mandating closed treatment solely on the Finally, signicant intraobserver and inter-
basis of age has been challenged, however, observer variability has been documented

Figure 2. A temporary knee spanning external xator is useful for main-

taining the length and alignment of the limb while the soft tissue swelling
resolves. Care should be taken to place the pins proximal to the knee
joint capsule at the femur and distal to the proposed operative incisions
at the tibia.

when the Schatzker classication has been CT scans with coronal and sagittal reforma-
employed.9 tions are helpful for (1) enhancing the under-
standing of the fracture pattern, (2) showing
more precisely locations and degrees of artic-
RADIOGRAPHIC ASSESSMENT ular depression and incongruity, and (3) plan-
ning optimal screw and plate placement. The
Standard preoperative radiographic evalu- axial and coronal images frequently identify
ation includes plain radiographs and com- the intact region of the plateau from which
puted tomography (CT) scans. The most help- a stable construct can be built or into which
ful plain radiographs include anteroposterior, screws will achieve optimal purchase.
lateral, and plateau views. The plateau view is CT scans with three-dimensional recon-
obtained by tilting the radiographic beam ap- structions have been recommended for eval-
proximately 10 caudad, to parallel the prox- uation, classication, and surgical planning
imal tibial articular surface. The anteroposte- in tibial plateau fractures.24, 46 Others have
rior and plateau views help dene the extent suggested the superiority of magnetic reso-
of medial and lateral plateau involvement. nance imaging for evaluating plateau fractures
The plateau and lateral views give an in- because of its superior soft tissue evaluation.7, 8
dication of the degree of comminution and These images are especially helpful in delin-
joint depression. The lateral view is particu- eating meniscal tears. In most cases, a careful
larly helpful in assessing posterior displace- assessment of plain radiographs and standard
ment of one (usually the medial) or both tibial two-dimensional CT reformations provides
condyles (Fig. 3) and may show associated tib- sufcient information to allow the generation
ial tubercle avulsions or nondisplaced tubercle of a proper surgical plan.
fractures. Preoperative two-dimensional axial


Type I Through III Fractures

The major emphasis of this article is a de-

tailed discussion of the open treatment of
more complex tibial plateau injuries, such as
type IV, V, and VI fractures, with the great-
est emphasis on type V and VI fractures.
A general discussion is presented, however,
of all fracture types (I through VI), includ-
ing fractures with associated ligamentous and
meniscal injuries and fractures associated with
vascular injuries.
Type I through III fractures involve the lat-
eral tibial plateau. These tend to be lower en-
ergy, axial loading injuries and usually are
closed. The type I fracture originally was de-
scribed as a pure cleavage (split) fracture;
the type II fracture, a cleavage (split) com-
bined with lateral articular depression; and
the type III fracture, a pure articular surface
Lateral plateau fractures can be approached
surgically in a variety of ways. Many authors
advocate arthroscopically assisted treatment
of unicondylar (generally lateral) plateau
fractures.6, 28, 33 One advantage of arthroscopy
Figure 3. The lateral injury radiograph demonstrates pos-
terior displacement of the proximal tibial articular injury. In
is the ability to identify associated meniscal
this case, the posteromedial fragment is separated from and ligamentous injuries. Scheerlinck et al42
an additional depressed central medial fragment. noted that 15 of 28 patients (54%) with tibial

plateau fractures had meniscal tears or cruci- terns. In the past, large fragment implants
ate ligament injuries or both. These authors commonly were used to treat type I through
reported no signicant complications with the III fractures.40 More recently, authors have
arthroscopic technique and good-to-excellent supported the clinical and biomechanical
results in 91% of patients at a mean follow-up efcacy of small-fragment, low-prole im-
of 5 years. All but one of their patients with plants, such as T-plates with a subchondral raft
long-term follow-up had a unicondylar frac- of 3.5-mm screws (Fig. 5) for these lateral
ture. Published comparison studies of open fractures.13 New low-prole precontoured
or uoroscopically assisted percutaneous plate designs have been introduced to simplify
procedures versus arthroscopically assisted lateral plate application, and most include
procedures are rare and have yet to show an perforations in the plate to increase the ease of
advantage of one approach.25 the submeniscal arthrotomy repair.
A common surgical approach for ORIF of
type I, II, and III lateral plateau fractures can
be employed. This incision also is used for ap- Type IV Fractures
proaching lateral plateau fractures occurring
as a component of type V and VI fractures. Type IV fractures of the medial plateau can
It is a standard anterolateral incision begin- be considered a transitional injury between
ning 1 to 2 cm lateral to the patella, extend- the type I through III fractures and type V and
ing distally over Gerdys tubercle and 1 cm VI fractures. Although they generally occur as
lateral to the crest of the tibia (Fig. 4). The a result of high-energy trauma in all but the el-
deep dissection reects the iliotibial band from derly, osteopenic patient,40 the fracture pattern
Gerdys tubercle and extends distally to in- tends to be a relatively simple split resulting
cise the anterior compartment fascia, leaving a in an intact wedge of medial plateau (Fig. 6).
narrow cuff attached to the tibial crest for po- Although central depression or eminence frac-
tential repair at the time of closure. The an- tures may occur, marked comminution rarely
terior compartment musculature is elevated is encountered. Typically the medial plateau
carefully from the proximal lateral tibia, ex- portion of the fracture remains in continuity
posing lateral plateau fracture lines and the with the distal femur, whereas the associated
lateral knee capsule. A transverse submenis- lateral tibia and bula translate laterally and
cal arthrotomy is made, leaving a small cuff shorten. Although fracture xation schemes
of coronary ligament attached to the proximal generally can be limited to unilateral medial
tibia for later arthrotomy closure. Many mod- neutralization plating, one must be aware of
ications of this approach exist and have their potential soft tissue injuries. Signicant lateral
advantages. One key to successful fracture re- translation of the lateral plateau and the intact
duction is application of a lateral femoral dis- tibial shaft may occur, resulting in lateral col-
tractor; this virtually always enhances articu- lateral ligament and capsular disruption. Most
lar surface visualization. A headlamp worn by authors suggest repairing the lateral collateral
the primary surgeon also is a valuable tool. ligament acutely in this setting.3, 40 The per-
Detachment of the anterior horn of the lat- oneal nerve and popliteal artery also are at
eral meniscus has been advocated by some risk in this fracture pattern. Ankle-arm indices
to improve visualization of the lateral plateau should be measured in all patients with high-
fracture34, 35 but is generally unnecessary. The energy plateau fractures and patients with
surgeon should consider the need for bone gross residual displacement in the emergency
graft in most plateau fractures. Patients rou- department. This simple technique is a use-
tinely should be consented for iliac crest au- ful screening tool for occult and gross arte-
tograft and allogeneic cancellous bone graft. rial injury.19 A value of less than 0.90 after
Careful evaluation of the preoperative radio- traction and closed reduction of the fracture
graphs and CT scan helps determine the po- should prompt vascular surgical consultation
tential role for bone graft or graft substitutes. and probable surgical intervention.
Although most type II or III fractures are not
likely to require more than 10 to 15 cm3 of
supporting graft, high-energy bicondylar frac- Type V and VI Fractures
tures often require larger volumes.
Newer plate designs have simplied the The treatment of high-energy Schatzker
treatment of lateral plateau fracture pat- type IV, V, and VI fractures can be divided


Figure 4. A, The anterolateral approach to the proximal tibial articular surface. An important
feature of this approach includes preservation of the tibial capsular attachments before per-
forming a submeniscal arthrotomy to allow for later closure (Courtesy of Kate Sweeney).
B, A femoral distractor allows for improved visualization of the lateral plateau articular

Figure 5. A raft of screws may be placed closer to the subchondral bone.

This allows for effective compression of the lateral plateau combined with
support of the articular reduction. (Courtesy of Kate Sweeney).

into 2 categories: (1) treatment of the soft sis. Although emergent operative treatment
tissue injury and (2) treatment of the skele- of these open injuries, including debridement
tal injury. The treatment of both must occur and stabilization (ORIF), is recommended by
concurrently. some,2 the placement of surgical incisions or
extensions of traumatic wounds must be con-
sidered carefully. Frequently, rotational ap
Treatment of the Soft Tissue Injury coverage or free tissue transfer is required in
this setting.
When high-energy plateau injuries are
closed, signicant contusion and degloving of
the periarticular tissues can occur, rendering Reduction of the Articular Surface and
early surgical incisions harmful to the in- Maintenance of Axial Alignment
tegrity of the soft tissue envelope. The authors Anatomic or near-anatomic restoration of
routinely treat closed, comminuted bicondylar the articular surface remains a goal of the trau-
plateau fractures with temporary knee span- matologist, as does restoration of the sagit-
ning external xation with a mild distraction tal and coronal alignment of the proximal
force across the knee to improve the resting tibia.5, 29, 36 Anatomic reduction of the meta-
position of fracture fragments by available lig- physis is not necessary and may increase
amentotaxis (Fig. 7). This approach minimizes surgical morbidity. The goal of xation is
the embarrassment to the soft tissue envelope to span severe comminution with bridging
from displaced fragments and helps restore plates, avoiding unnecessary dissection, while
the sagittal and coronal alignment to allow for providing alignment and adequate stability,
soft tissue recovery during the 2 to 3 weeks allowing early range of motion.
before ORIF. When applying the frame, care
should be taken to keep the distal femoral
Shanz pin proximal to the suprapatellar pouch Management of Open Bicondylar
and the proximal of the tibial pins distal to the High-Energy Fractures of the
expected extent of eventual plate application. Tibial Plateau
A tibial Shanz pin placed too proximally in the
eventual surgical zone risks deep infection at A treatment protocol for the acute de-
the time of ORIF. bridement and stabilization of open type V
Schatzker type V and VI fractures may be and VI fractures has been proposed by
open injuries with marked soft tissue contu- Benirschke et al.2 These authors emphasized
sion, frank soft tissue loss, or tissue necro- early stable articular surface restoration and



Figure 6. A and B, This 48-year-old man sustained multiple injuries after a high-speed motor vehi-
cle crash. The articular injury consisted of separation of the entire medial plateau with rotation into
varus and exion. C, CT scan axial view. D, Coronal reformation. E and F, Fixation was accomplished
through a posteromedial approach with placement of the plate to resist inferior translation and exion
of the articular fragment.



Figure 7. A and B, AP and lateral radiographs of a typical bicondylar tibial plateau fracture with metadi-
aphyseal separation in a 72-year-old woman involved in a high speed motor vehicle crash. The antero-
posterior view demonstrates the condylar widening and signicant shortening. The lateral view clearly
shows the coronal fracture line of the medial tibial plateau. C and D, After application of a temporary
knee spanning anterior external xator, length is re-established, and the condylar width is improved
through ligamentotaxis. The soft tissue injury improved over a period of 3 weeks, allowing operative
xation through two incisions. E and F, Follow-up radiographs at 6 months demonstrate maintenance
of the articular reduction, limb axis, and condylar width.

joint coverage. Their protocol included deni- spanning external xation, and delayed or
tive internal xation at the time of initial staged ORIF. Figure 8 Shows the steps in
debridement. Bone grafting of metaphyseal management of such a high-grade open type
defects created after elevation and restoration VI plateau fracture.
of the articular surface is performed at the
time of delayed primary closure, skin graft, or
ap coverage. Surgical incisions for fracture Dual Plating
exposure and soft tissue debridement are
designed to limit the creation of large aps, Although newer xed angle plate and screw
and standardized incisions are not prede- designs, such as the less invasive stabilization
termined. Fixation schemes are planned to system (see later) may obviate the need for
yield maximal bony stability, while limiting dual plating of many bicondylar plateau frac-
further soft tissue stripping or further wound tures, this is evolving technology not available
compromise. By following this protocol, the to all surgeons and not applicable to all frac-
authors were able to accomplish immediate tures. Medial and lateral plate application re-
rigid internal xation without deep infec- mains a common treatment for high-energy,
tion in 14 patients with type II and III open complex, bicondylar tibial plateau fractures at
bicondylar tibial plateau fractures. This treat- the authors institution.
ment protocol continues to be employed with Many authors have reported remarkably
minor modications for open high-energy high complication rates with dual plating of
plateau fractures. Alternatively, these open high-energy tibial plateau fractures. In most
fractures may be treated with debridement, such reports, wide stripping of the proximal
antibiotic bead placement as necessary, knee tibia is reported and implicated in the rates of


Figure 8. This-27-year old woman sustained this high-energy Type IIIB open proximal tibial frac-
ture with associated articular involvement, bone loss, and contamination. Initial management con-
sisted of debridement,
application of a spanning external xator, and placement of antibiotic im-
pregnated beads. A, Soft tissue coverage consisted of a latssimus free ap at 72 hours followed
by eventual frame removal and ORIF. Delayed antibiotic bead removal and bone grafting of the
large defect was performed at 4 weeks. B, Three-month follow-up radiographs.

infection seen. Moore et al30 reported a 23% achieved with minimal soft tissue disruption.
infection rate with dual plating of bicondy- Two plates frequently are necessary to stabi-
lar fractures but used an anterior Mercedes lize some bicondylar fractures optimally, espe-
incision to approach the injury. Young and cially those with posteromedial displacement
Barrack47 reported an 87.5% deep infection of the medial plateau fracture.
rate and 100% complication rate with dual
plating for comminuted or bicondylar plateau
fractures. Although not specically describ- Combined Anterolateral and
ing their surgical approach, they do describe Posteromedial Plate Application
devascularization of the proximal tibia with (Dual Plating Technique)
the approach, and postoperative radiographs
suggest the plates were applied through a The patient is positioned supine when
single midline incision. Veri et al44 reported using a dual plate construct is anticipated.
a matched cohort series comparing internal Generally, the medial column is approached
xation with ring xator methods for high- rst, although occasionally one can work
grade tibial plateau fractures. These authors through medial and lateral incisions to op-
found 44% of the fractures treated with open timize the metaphyseal reduction. If so, the
methods had an infection requiring intra- lateral approach is that described for type I
venous antibiotics or operative debridement through III fractures. In these high-energy
or both compared with 12% in the ring xator fractures with signicant metaphyseal com-
group. Mallik et al26 described an 80% deep minution, one should consider using larger
infection rate in a few patients with bicondylar (4.5 mm) metaphyseal spanning plates for
plateau fractures treated with ORIF but also the lateral column to compensate for the
described large amounts of soft-tissue strip- absence of cortical support. No thigh or
ping and the use of dual plates. To minimize buttock bumps are placed initially to allow
the rate of deep infection in these high-energy improved access to the posteromedial border
bicondylar fractures, many authors have of the tibia. Delayed placement of a lateral
recommended minimally invasive, limited bump under the buttock enhances the lateral
incision reduction techniques for joint surface approach.
restoration combined with standard, hybrid or The medial incision is made approximately
ne-wire xation and spanning of the metadi- 1 cm posterior to the posteromedial border
aphyseal fracture.11, 12, 27, 38, 43 This is a common of the tibia metaphysis (Fig. 10). The saphe-
and efcient means of treatment of types V nous vein and nerve are retracted anteriorly.
and VI fractures. It is as technique and sur- Deep dissection proceeds to the pes anseri-
geon dependent as ORIF, however, and in the nus, which is mobilized proximally and dis-
authors experience frequently suboptimally tally but not detached. The underlying me-
performed. Satisfactory reduction of commin- dial collateral ligament is protected, the fascia
uted articular surfaces with limited incision overlying the medial head of the gastrocne-
techniques or indirect reduction maneuvers mius incised longitudinally, and the postero-
may be difcult and can result in malreduc- medial margin of the tibial metaphysis visual-
tion. Incorrect placement of intra-articular ized. Subperiosteal dissection is limited to the
half-pins or ne wires can lead to compli- fracture margins and the region of anticipated
cations of septic arthritis17 and prolonged plate application. Disruption of anteromedial
external xation pin or wire placement to soft tissues is avoided. This deep exposure
osteomyelitis (Fig. 9). Anatomic studies have through a more anterior skin incision has been
improved understanding of safe extracapsular described but with detachment and retrac-
wire placement.10, 18 tion of the pes tendons.30 In general, mobiliza-
Dual plating through a midline extensile tion of the proximal and distal border of the
incision carries a relatively high risk of soft pes tendons allows adequate retraction and
tissue complications and deep infection as a fracture visualization and reduction. Two pat-
result of medial and lateral soft tissue strip- terns of medial plateau injury are recognized:
ping. It is intuitive, especially in the patient (1) The entire medial plateau may separate as
with direct anterior force application and re- a single condylar segment (Fig. 11); (2) more
sulting fracture with anterior open wounds, commonly the medial plateau injury consists
closed degloving, or signicant contusion, that of separation and rotation of a posterome-
straight anterior surgical incisions should be dial fragment (Fig. 12). After provisional frac-
avoided. If used, dual plate application can be ture reduction and stabilization, a plate can be
Text continued on page 194



Figure 9. A, This 38-year-old man sustained a closed Type VI tibial plateau fracture in a motor ve-
hicle accident. Initial treatment consisted of a limited approach to the lateral plateau articular injury
with percutaneous large fragment subchondral screw stabilization. B, The meta-diaphyseal separa-
tion was narrowly spanned with a hybrid external xator. C, The patient eventually developed septic
arthritis, requiring multiple joint debridements
and proximal tibial osteomyelitis with a draining sinus.
Antibiotic beads were placed after an extensive debridement
of the proximal tibia. Gastrocnemius
rotational myoplasty was used to cover the antibiotic beads and the associated soft tissue defect.
D, The healed proximal tibia following large volume cancellous bone grafting. While his infection is
controlled, he has a signicant varus malunion of the articular surface and proximal tibia.

Figure 10. The posteromedial approach to the tibial

plateau and proximal tibia. The incision is posterior to the
palpable border of the tibia. The gastrocnemius fascia is
dissected off the posteromedial tibia and retracted pos-
teriorly. The pes anserinus tendons are retracted anteri-
orly (arrow ) for reduction and plate xation. The soft tis-
sue attachments at the anteromedial tibial surface are left


Figure 11. Radiographs demonstrating the medial plateau component of a bicondylar injury (A).
Note the complete separation of the medial plateau with posterior displacement of the articu-
lar segment (B). The axial (C) and coronal (D) CT scans demonstrate the medial injury and the
intercondylar split. The medial plateau is stabilized with a posterior antiglide plate and transxa-
tion from the lateral implant (E and F ).
Illustration continued on opposite page


Figure 11 (Continued ).


Figure 12. In this patient, the medial plateau injury (A) consists of an additional coronal split that is
best visualized on the lateral view (B). The CT scan (C and D) further denes the medial plateau artic-
ular separation, which is best visualized in the sagittal reformation (D). Fixation can be accomplished
with an antiglide plate and lag screws placed from anterior to posterior (E and F ).
Illustration continued on opposite page


Figure 12. (Continued ).


applied to the posteromedial aspect of the tages include (1) submuscular, extra-periosteal
tibia. This can be a difcult plate to contour if plate application through relatively small in-
one chooses the rigidity of a 3.5 dynamic cisions; (2) percutaneous screw placements
compression (DC) or limited contact dynamic through a guide, limiting additional expo-
compression (LCDC) plate. A one third or one sure; and (3) the xed angled nature of the
fourth tubular plate can be an effective but- plate, potentially obviating the need for me-
tress and much easier to contour. This dual dial xation (Fig. 14). Plate lengths are avail-
plate scheme allows for a wide anterior skin able to span the metadiaphysis. Limitations
bridge if the described lateral incision and are the need for adequate exposure allow-
posteromedial incision are used (Fig. 13). Im- ing articular reduction and the inability of
proper plate placement limits the effective- the plate to reduce or buttress posteromedial
ness of the 2-plate construct. Effective control displacement.
of posteromedial displacement requires poste-
rior plate application. When soft tissue con-
cerns limit additional surgical dissection, a
unilateral medial half-pin external xator may
be used as an alternative to medial plate appli-
Recovering range of motion is a challenge
cation. This xator can be used to avoid varus
in the multiply-injured patient who (1) can-
malalignment and generally is removed 8 to
not participate actively in rehabilitation and
12 weeks postoperatively when consolidation
(2) may have soft tissue injuries precluding
of the metaphyseal fracture is evident.
immediate range of motion. Knee exion con-
An alternative to external xation and ORIF
tracture is a commonly reported problem.22
has been introduced for high-energy bicondy-
Recognizing the potential disability of chronic
lar tibial plateau fractures. The less invasive
exion contracture, the authors place patients
skeletal stabilization system provides precon-
in a hinged knee brace locked in extension
toured plates with a locking screw-plate inter-
postoperatively. A padded bump under the
face providing a xed angled implant. Advan-
heel is used in the hospital bed and at home
after discharge to maximize knee extension.
Motion is held until surgical and traumatic
wounds are dry. Continuous passive motion
begins when wounds are dry; the goal is
full extension and 90 of exion within 5 to
7 days. If other injuries allow, the patient
is mobilized with a hinged brace locked in
extension for 6 weeks. Nonweight-bearing
precautions generally continue for 12 weeks.
Active exion and passive extension is en-
couraged for 6 weeks, then active knee ex-
tension is begun. Active knee extension is de-
layed if ORIF of a tibial tubercle avulsion was


High-energy bicondylar tibial plateau frac-

tures are a treatment challenge for the ortho-
pedic traumatologist. Although alternative
methods for treating these injuries have
yielded satisfactory results, ORIF remains a
safe technique if performed correctly (Fig. 15).
Although the soft tissues often present the
Figure 13. Intraoperative clinical image of the incisions
for xation of a bicondylar tibial plateau fracture. Note the
greatest treatment challenge, stabilization and
skin bridge, which is left intact over the anteromedial tibial reconstruction of the osseous anatomy is
surface (arrow ). possible.



Figure 14. A and B, High-energy open tibial plateau fracture in a 32-year-old man after
a high-speed motor vehicle crash. Note the signicant metaphyseal and diaphyseal in-
volvement. C and D, Stabilization consisted of reduction of the articular surface and bio-
logic plating of the tibia with a xed-angled device.



Figure 15. A and B, This bicondylar tibial plateau fracture is characterized by condylar widening,
shortening, severe lateral comminution, and a displaced coronal fracture of the medial plateau. Initial
management consisted of spanning external xation followed by operative stabilization of the medial
plateau (10 days) and the lateral plateau (22 days). Lateral and medial meniscus tears were identi-
ed and repaired. C and D, The patient was allowed to bear weight at 12 weeks, and healing occurred

ACKNOWLEDGMENTS vascular tests reliably exclude occult arterial trauma

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Carlo Bellabarba, MD, and Stephen Benirschke, MD for generative arthritis of the knee secondary to fracture
their contributions to this article. malunion. Clin Orthop 234:159169, 1988
21. Khan RM, Khan SH, Ahmad AJ, et al: Tibial plateau
fractures: A new classication scheme. Clin Orthop
375:231242, 2000
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Address reprint requests to

William J. Mills, MD
Department of Orthopedic Surgery
Harborview Medical Center
Box 359798
325 Ninth Avenue
Seattle, WA 98104

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00


Clinical and Biomechanical Correlation

J. Tracy Watson, MD, Steve Ripple, MD, Susan J. Hoshaw, PhD,

and David Fyhrie, PhD

INDICATIONS diametaphyseal comminution and signi-

cant extension into the shaft region are best
For most tibial plateau fractures, especially treated with this technique. Those complex
those caused by a low-energy mechanism fracture patterns with additional soft tissue
of injury, contemporary internal xation compromise (e.g., associated compartment
techniques using cannulated screws; low- syndrome), open fractures with soft tissue
prole, precontoured, periarticular plates; loss, and fractures in association with the mul-
and arthroscopic-assisted reduction, with or tiply injured patient are relative indications for
without limited incisional approaches have this technique.
demonstrated excellent clinical outcomes with The specic denition of hybrid xation is
few severe complications; however, for those quite ambiguous. The term hybrid xation de-
fractures that are a result of a higher-energy notes no single or universally accepted treat-
mechanism, typically the Schatzker type 5 ment strategy or device. As commonly ap-
and type 6 injury patterns, these fractures plied, the method uses an external xator to
have been associated with a high incidence provide a ligamentotaxis reduction force and
of severe complications when treated with maintains this reduction as a neutralization
traditional internal xation techniques. The device. Percutaneous or limited open incisions
concept of hybrid external xation has may be used to reduce displaced metaphyseal
gained wide approval as the severity of the and articular fragments in conjunction with
soft tissue injury has increased, and many lag screws or small plates.4, 6, 15, 16, 21
of the factors that preclude even a limited Periarticular small diameter tensioned wires
exposure and plating are present. are used to achieve articular stabilization and
Other indications for this methodology are then connected to a proximal ring at the
include those fractures with signicant meta- level of the proximal tibia. The proximal peri-
physeal and subchondral comminution with articular ring then is attached to the shaft be-
resultant periarticular fragmentation that low the distal extent of the fracture using a va-
would preclude routine plate and screw sta- riety of Schanz pin orientations. Despite the
bilization. Plateau fractures that present with variety of hybrid frames available, specic

From the Division of Orthopaedic Traumatology, Department of Orthopedic Surgery, Wayne State University School
of Medicine ( JTW); the Detroit Receiving Hospital, Detroit Medical Center ( JTW); Phoenix Orthopaedic Consul-
tants, Glendale, Arizona (SR); Dow Corning Corporation, Midland, Michigan (SJH); and the Section of Biomechanics,
Breech Research Laboratory, Henry Ford Hospital Musculo Skeletal Research Laboratory, Detroit, Michigan (DF)



200 WATSON et al

biomechanical principles must be adhered to. designed to reproduce the normal working
It is currently accepted that dual plating pro- and biomechanical characteristics of normal
vides the gold standard of fracture stabiliza- bone) were cut using templates to produce a
tion for the treatment of complex tibial plateau Schatzki 6 injury (Fig. 1).
fractures. Many investigators have described The simulated fracture was then stabilized
various xation methodologies for the man- using one of the following hybrid wire cong-
agement of Schatzker type 5 and 6 fracture urations or plating strategies.
patterns as well as those fracture patterns that A. Two counteropposed olive wires, each
may present with solitary intra-articular frac-
tensioned to 90 kg and attached to a
ture lines in association with diametaphyseal
proximal xation ring. Each wire was
comminution and shaft dissociation. Fixation positioned centrally in the midportion
strategies have included medial and lateral
of each condylar fragment to act in a
buttress plating for Schatzker 5 injuries, and
lag fashion and provide intercondylar
lateral dynamic compession (DC) plating with compression.
medial buttress plating for Schatzki 6 injuries.
B. Two counteropposed olive wires placed
In an effort to avoid the soft tissue compli-
as previously described and a solitary
cations that can result from the extensile expo-
6.5-mm cancellous lag screw was in-
sures required to facilitate these xation strate- serted from the lateral condyle into the
gies, the use of small tensioned wire hybrid medial fragment in an effort to pro-
xators has become an accepted treatment vide intracondylar compression. (This is
option. The use of these devices has become the conguration commonly shown by
quite liberal despite the fact that little, if any, many hybrid manufacturers in product
biomechanical data are available to support information brochures.)
the use of these small wire techniques. C. Four counteropposed olive wires with
a 6.5-mm cancellous intracondylar lag
FRACTURE MODEL screw. The additional olive wires are
placed inferiorly on each condylar frag-
A biomechanical model of a complex proxi- ment near its apex to function in an
mal plateau fracture was developed to evalu- antiglide fashion. Each hybrid congu-
ate the stability of various tensioned wire con- ration used two rings, with distal ring
gurations and compare them to the currently xation composed of three 5-mm Schanz
accepted gold standard of dual plating.19 pins oriented 60 to each other. The rings
Composite material tibial bone models are connected with four threaded rods to
(Sawbones, Pacic Research, Vaston, WA; provide 360 stability of the rings (Fig. 2).

Figure 1. A template was used to produce consistent condylar frac-

ture lines using a thin saw blade. A Schatzker Type VI pattern was
fashioned in the testing bones.

Figure 2. A two-ring frame was mounted onto the testing bone using
four connecting rods to connect the distal and proximal rings. The dis-
tal ring was attached to the shaft using three schantz pins, all placed
out of plane to each other to increase the pin spread, and thus, shaft

This ring conguration was selected to

alleviate the cantilever loading effects
that can occur with solitary monolateral
bar to ring hybrid adaptations.
D. The contemporary low-prole internal
xation strategy used a lateral 4.5-mm
buttress plate and a medial 3.5-mm
DC plate (Fig. 3).

Mechanical Testing

For each repaired tibial model, both fracture

lines were instrumented using two linear mo-
tion potentiometers, and the entire construct
was mounted on an Instron 8501 machine (In-
stron, Cantron) (Figs. 4 and 5). Each model
was then cyclically loaded to 300 N at stan-
dard loading rates to simulate a normal gait
pattern. Stressstrain curves were measured
from both condylar potentiometers to evalu-
ate stability of the individual condyles and
from the MTS actuator to evaluate the stabil-
ity of the entire construct. Five bone models
were tested for each condylar xation method-
ology, and each model underwent three test-
ing sequences, for a total of 15 tests per bone Figure 3. Dual-plating conguration using a 4.5-mm lat-
eral buttress plate and a medial 3.5-mm DC plate. Note
model. With 75 mechanical tests per xation that each condylar fracture line has been instrumented
technique, multiple data points were sufcient with a linear motion potentiometer to determine the de-
to achieve statistical signicance. gree of condylar displacements that occur with loading.
202 WATSON et al

Figure 4. Two counter-opposed olive wire xation with the potentiome-

ters mounted on both of the condylar fragments.

Figure 5. Test setup demonstrating the xation construct mount-

ed on the Instron machine.

Results pression slightly but did not signicantly en-

hance the overall stability of the construct and
Actuator data revealed the most stable should not be used instead of additional wire
construct to be the hybrid frame with four xation elements.19
counteropposing olive wires and cannulated
screw. The dual plating construct was next
in rigidity (Fig. 6). The potentiometer results Frame Conguration
demonstrated that the highest displacements
occurred at the medial condylar fragment, Using the previous data, proximal articular
regardless of the xation methodology. Sta- xation must consist of at least three tensioned
tistical analysis of each construct for condylar wires. Contrary to what many manufactures
stability revealed signicant superiority of the illustrate in their sales brochures, if an inad-
four wires plus screw conguration (C) with equate number of wires are used (only two
respect to two wires only (A), and to two wires) and they are placed with a minimal di-
wires plus cannulated screw (B). Dual plating vergent angle of less than 60 , the proximal
(D) was shown to be similar in preventing periarticular segment will have a tendency to
condylar displacement to four wires plus translate along the mediolateral axis as if a
screw (C), with no signicant differences solitary wire or axle were present.3, 7, 8
between the two (Table 1). Clinical and mechanical studies have shown
These data support the use of multiple the inadequacies of a two-wire-only construct;
tensioned wires to stabilize complex plateau therefore, at least three or more out-of-plane
fractures that incorporate a bicondylar frac- wires are recommended to avoid this transla-
ture pattern. Fixation with four counterop- tional effect.3, 7, 8, 13, 1618, 20
posed olive wires is comparable to the stability Full ring stabilization is preferable to mono-
achieved with dual plating congurations. lateral shaft stabilization because of the can-
The commonly shown xation with only tilever loading that is accentuated when a
two wires is inadequate, and the addition of proximal ring is attached to a solitary dia-
cannulated screws increased condylar com- physeal bar (Fig. 7). This frame conguration









2 Wires 2 Wires + screw 4 Wires + screw 2 Plates

Figure 6. Load versus displacement, illustrating the relative instability of the two-wire con-
gurations. The actuator data trendlines show that the four-wire and two-plate constructs
are similar in the stability that they afford. Open bar = lateral condyle, shaded bar = medial
condyle. P = 0.0001.
204 WATSON et al


Medial Condyle Lateral Condyle
(potentiometer (potentiometer
Fixation Construct Test Count displacement [mean] m/N) displacement [mean] m/N)
A (2 wires) 75 53.462 33.656
B (2 wires + screw) 75 46.998 15.834
C (4 wires + screw) 75 6.601 1.926
D (2 plates) 75 5.362 4.192

Two wires were compared with all other methodologies. This revealed no signicant improvement to 2 wires + screw (P = 0.6988);
however, superior stability was seen when comparing 4 wires to 2 wires (P < 0.0001), and 2 plates to 2 wires, (P < 0.0001). (ANOVA
and Fishers PLSD.) (Signicance achieved with P = 0.005.)

functions similar to a diving board, produc- Clinical Applications

ing tremendous loads at the metadiaphyseal
junction with associated development of non- The advantages of using a circular, ten-
or malunions at this location. Thus, if mono- sioned small wire, external xator in these
lateral adaptations are to be used, it is situations are numerous.29, 1113, 1618, 21 The ar-
recommended that at least three divergent ticular wires are placed percutaneously with
connecting bars be used to attach the intact minimal additional devitalization of the bone
distal diaphyseal segment to the periarticular and its periosteal and endosteal blood sup-
ring. The bars should be oriented to achieve plies. Small tensioned wires allow for the
270 of bar to ring attachment to alleviate this capture of very small metaphyseal and sub-
problem of cantilever loading. The additional chondral fragments. Therefore, this type of
disadvantage of this monolateral type of xation is especially useful in comminuted pe-
construct is the inability to easily dynamize riarticular injuries. For Schatzker 5 and 6 frac-
this xator. In addition, if adjustments for tures, olive wires can compress the condy-
alignment or dynamic gradual compression lar fracture lines, much as lag screws are
or lengthening is required, this frame cong- used.
uration is generally unsatisfactory for these A mechanically stable and adjustable hybrid
complex maneuvers and thus should not be ring xator can span across a fracture gap in
used for these situations. cases of comminution or minimal bone loss,

Figure 7. A complex open plateau fracture treated with a circular hybrid. Note the
multiple proximal wires, as well as the full circular connections between proximal and
distal xation. The large areas between connection rods allow for ease of secondary
procedures. In this case, multiple debridements and the use of an antibiotic bead
pouch facilitated early ap closure.

similar to an internal neutralization plate. with calcaneal pin or distal tibial pin traction.
Compression can be directed across the site Alternatively, femoral distractors or tempo-
of bone loss or fracture gap that occurs in rary spanning external xators can be used
type 6 injuries when comminution is found to obtain preliminary ligamentotaxis and
at the diaphysealmetaphyseal region. The reduction. Additional closed reduction of the
xator can be used to compress fracture gaps condylar components is achieved by the use
to achieve bone-on-bone contact without of large, percutaneously placed reduction for-
additional bone grafting. Patient performing ceps. Percutaneous Kirschner wires also can
self-adjustments of the frame can continually function as joysticks and aid in the manipula-
modify the maintenance of the mechanical tion of these large condylar fragments. After
axis. Rotational and translational deformi- reduction of the condyles, olive wires (1.8-mm
ties also can be corrected as consolidation Kirschner wires with a 4-mm bead located
progresses. In addition, small tensioned wire eccentrically on the wire) are used to achieve
xators allow for early partial weight-bearing interfragmentary compression of the condylar
and range of motion of the knee. At the time articular surface. If necessary, limited incisions
of early consolidation, the frame should allow are used to elevate depressed fragments and
for dynamization to decrease pinbone inter- bone graft defects through submetaphyseal
face stress and facilitate fracture consolidation. cortical windows.
During the treatment of these complex Careful preoperative planning using CT
injuries, secondary procedures are often re- scan data is of tremendous value. The ability
quired (e.g., to achieve soft tissue coverage to maintain the condylar reduction depends
or to perform delayed bone grafting). These on the presence of compressive forces on
circular frames can be modied easily by tem- either side of the fracture lines; this is accom-
porarily removing any obstructing connecting plished by placing counteropposed olive wires
bars, performing the additional procedure, through the fragments coming from opposite
and then replacing the struts. The authors sides of the major condylar fracture line. One
have found it problematic to drape the xator can also substitute cannulated screws for olive
out of the operative eld and additionally wires if the metaphyseal fragments are large
maintain this usually small area as sterile enough and not extensively comminuted.
throughout an entire procedure. It has been Placement and direction of periarticu-
shown that, following a standardized protocol lar olive wires and cannulated screws is
of precleansing the ex-x frame, followed by performed with the aid of uoroscopy, fol-
alcohol wash, sequential povidoneiodine lowing the surgical plan as determined by
prep, paint, and spray, with air drying fol- the preoperative CT scan (Fig. 8). Three or
lowed by draping the extremity and xator four olive wires are usually required for sta-
directly into the operative eld, one can bilization of the condylar and metaphyseal
safely perform the additional surgery without fragments. These wires should be applied in
the increased risk for postoperative wound such a way that they cross perpendicular to
infection.15, 16, 18 the major fracture lines, much as one would
place a lag screw. This is done to achieve
maximal condylar compression. If this wire
SURGICAL TECHNIQUE FOR HYBRID orientation cannot be placed to achieve inter-
FIXATION OF PLATEAU FRACTURES fragmentary compression because of anatomic
constraints (i.e., front-to-back transxion
The technique of hybrid application relies wires), cannulated screws will accomplish this
heavily of the principles of ligamentotaxis to without the risk for neurovascular compro-
achieve a metaphyseal reduction. These tech- mise. Great care should be taken to avoid the
niques usually will not reduce the impacted proximal tibial capsular reection. Olive wires
articular surfaces. Simply pulling on it is not should not transx this region so as to avoid
indicated in cases in which large areas of artic- secondary seeding of the joint with resulting
ular depression and comminution are present. joint sepsis. To avoid articular penetration, the
These areas must be addressed through lim- wires should be placed at least 14 mm from the
ited incisions using uoroscopic or arthro- subchondral line of the joint.14
scopic guidance to reestablish congruent artic- Following articular reduction, a preassem-
ular surfaces. bled frame consisting of three or four appro-
The application of a circular or hybrid priately sized rings is placed around the limb.
external xator may involve positioning of The proximal ring is temporarily placed at the
the patient on a fracture or radiolucent table level of the bular head, and the wires are
206 WATSON et al

Figure 8. A, Proximal plateau fracture with overlap of fracture fragments and inability to determine the
fracture pattern. B, A traction lm that demonstrates an excellent reduction, as well as the ability to de-
termine the fracture pattern. Early distraction is a crucial portion of this treatment option. C, A traction
CT scan of this fracture reveals near anatomic reduction of the condyles, which will allow a percuta-
neous stabilization to be performed using a stable wire and ring pattern.

attached and tensioned to the proximal ring. As this technique has developed, many in-
The distal aspect of the frame is attached to vestigators have found it necessary to use
the bone using 5-mm half-pins or, in some additional small plates for xation of heav-
cases of extensive shaft comminution, transx- ily comminuted metaphyseal fragments (cor-
ion wires. The proximal and distal rings are tical substitution) or for those fracture pat-
connected to each other with fully adjustable tern that preclude small wire xation because
components to allow for the appropriate cor- of anatomic constraints and wire corridors
rection and alignment of the overall mechani- that orient wires in a front-to-back orienta-
cal axis (see Fig. 7). tion4, 16 (Fig. 9).

Figure 9. A, Complex proximal plateau fracture with dissociation of the tibial tubercle fragment, as
well as severe impaction of the articular surface requiring a limited open approach. B, Intraoperative
ouroscopy view demonstrating anterior hook plate used to achieve xation of the tubercle fragment.
Bone graft substitute was placed through a cannula to provide support for the reduced articular sur-
faces. C and D, AP and lateral views demonstrating the hybrid xation construct consisting of a three-
ring frame using four proximal wires with additional cannulated screw augmentation.
Illustration continued on following page
208 WATSON et al


Figure 9 (Continued ). E and F, Two year follow-up radiographs showed the preservation of the lateral
joint surfaces and the overall preservation of the mechanical axis.

In some instances, with acute fractures, the ened (frame dynamization) so that the pin
tibial tubercle is fractured as a separate frag- bone stresses are decreased and the weight-
ment in conjunction with posterior cortical bearing forces are transmitted by the bone
comminution. Because of the anatomic con- instead of the external xator.
straints and inherent dangers of placing front- Before frame removal, the authors allow pa-
to-back transxion wires, the stabilization of tients unrestricted activity for approximately
this tubercle fragment is accomplished with an 10 days after frame dynamization in the hope
anterior hook plate (Fig. 9), allowing for rigid of preventing late deformity. If a patient has
xation of the tubercle fragment with distally an increase in pain or subtle changes are
directed screws, which are able to purchase visualized on radiography after the frame
intact posterior cortex at a site distal to the tu- is dynamized, it can be assumed that frac-
bercle fragment.16 ture healing is incomplete. If so, the frame
Serial radiographs should be observed for is retightened to allow forfurther consolida-
any deviation of the mechanical axis while tion before its removal, and bone grafting is
in the external xator. If needed, adjustments considered.
may be made gradually to realign the extrem-
ity and to add compression to small areas
of bony comminution. This maneuver allows SUMMARY
one to gain bone on bone contact and thus
a more stable fracture conguration. As frac- The biomechanical data support the use of
ture consolidation progresses, these frames do tensioned wire xation to stabilize complex
allow full, unrestricted weight-bearing. After fractures of the proximal tibia. The authors
consolidation is complete, the connections be- have shown that the stability of a four-wire
tween the proximal and distal rings are loos- construct is comparable to the gold standard

of dual plating internal xation techniques. 8. Kummer FJ: Biomechanics of the Ilizarov external
Using these techniques many recent investi- xator. Clin Orthop 280:1115, 1992
gators have demonstrated improved clinical 9. Mallik AR, Coval DJ, Whitelaw GP: Internal versus
external xation of bicondylar tibial plateau fractures.
results, with average knee scores (Knee Soci- Orthop Rev 21:14331436, 1992
ety Rating System) for most patients ranging 10. Marsh JL, Smith ST, Do TT: External xation and lim-
from 85 to 90. More important is that these ited internal xation for complex fractures of the tib-
studies continue to show decreases in the rates ial plateau. J Bone Joint Surg Am 77:661673, 1995
11. Mikulak SA, Gold SM, Zinar DM: Small wire external
of major wound complications or residual os- xation of high energy tibial plateau fractures. Clin
teomyelitis; these decreases had occurred with Orthop 356:230238, 1998
traditional ORIF techniques despite the fact 12. Murphy CP, DAmbrosia R, Dabezies ET: The small
that approximately one third of cases in these pin circular xator for proximal tibial fractures
series were open injuries.1, 10, 15, 20, 21 With these with soft tissue compromise. Orthopedics 14:273280,
data available, small wire hybrid xation po- 13. Paley D: Biomechanics of the Ilizarov external xa-
sitioned in a stable frame conguration is an tor. In Bianchi-Miocchi A, Aronson J (eds): Operative
additional tool that should be considered for Principles of Ilizarov. Baltimore, Williams & Wilkins,
complex proximal tibial injury. 1991
14. Reid JS, Vanslyke M, Moulton MJR, et al: Safe place-
ment of proximal tibial transxation wires with re-
spect to intracapsular penetration. In Orthopaedic
References Transactions. Presented at the 10th Annual Meeting
of the Orthopaedic Trauma Association. Tampa, 1995
1. Blake R, Watson JT, Morandi M, et al: Treatment 15. Watson JT: High energy fractures of the tibial plateau.
of complex tibial plateau fractures with the Ilizarov Orthop Clin North Am 25:728752, 1994
external xator. J Orthop Trauma 7:167168, 1993 16. Watson JT, Coufal C: Treatment of complex lat-
2. Catagni M: Fractures of the leg (tibia). In Maioccki eral plateau fractures using Ilizarov techniques. Clin
AB, Aronson J (eds): Operative Principles of Ilizarov. Orthop 353:97106, 1998
Baltimore, Williams & Wilkins, 1991, pp 91124 17. Watson JT: Tibial pilon fractures. Techniques Orthop
3. Calhoun JH, Li F, Ledbetter BR, et al: Biomechanics of 11:150159, 1996
the Ilizarov xator for fracture xation. Clin Orthop 18. Watson JT, Moed BR, Karges DE, et al: Pilon fractures:
280:1523, 1992 Treatment protocol based on severity of soft-tissue
4. Dendrinos GK, Kontos S, Katsenis D, et al: Treatment injury. Clin Orthop 375:7890, 2000
of high-energy tibial plateau fractures by the Ilizarov 19. Watson JT, Fhyrie D, Ripple S, et al: Biomechani-
circular xator. J Bone Joint Surg Br 78:710717, 1996 cal analysis of tibial plateau fracture xation using
5. Frankel VH, Green SA, Paley D, et al: Sympo- tensioned wire constructs [abstract]. In Program and
sium: Current applications for the Ilizarov technique. Abstracts of the 6th Annual Meeting of the Associa-
Contemp Orthop 28:5171, 1994 tion for the Study and Application of the Methods of
6. Gaudinez RF, Mallik AR, Szporn M: Hybrid external Ilizarov (ASAMI-NA). Atlanta, 1996, p 25
xation of comminuted tibial plateau fractures. Clin 20. Weiner LS, Kelley M, Yang E, et al: The use of com-
Orthop 328:203210, 1996 bination internal xation and hybrid external xation
7. Ilizarov GA: The treatment of fractures: Theoretical in severe proximal tibia fractures. J Orthop Trauma
considerations, experimental studies and clinical ap- 9:244250, 1995
plication of the apparatus. In Ilizarov GA, Green SA 21. Zecher SB, Danziger MB, Segal D, et al: Treat-
(eds): Transosseous Osteosynthesis: Theoretical and ment of high-energy proximal tibial fractures using
Clinical Aspects of the Regeneration and Growth of the Monticelli-Spinelli external xator: A preliminary
Tissue. Berlin, Springer-Verlag, 1992, pp 369452 report. Am J Orthop 25:4954, 1996

Address reprint requests to

J. Tracy Watson, MD
University Health Center 7-C
Department of Orthopaedic Surgery
4201 St. Antoine Boulevard
Detroit, MI 48201

TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

Bruce French, MD, and Paul Tornetta, III, MD

Skeletal xation of tibia fractures resulting tion, prophylactic antibiotics, and skeletal
from high-energy trauma has undergone a stabilization.19 Scheduled, repeat debride-
number of fundamental changes over the past ments, interim obliteration of dead space with
few decades. These changes are because, in antibiotic-laden methylmethacrylate beads,
part, of a better understanding of the intimate early, tension-free vascularized soft tissue
association between the disruption of the soft coverage, and prophylactic bone grafting have
tissue envelope of the tibia and the osseous in- also decreased complications and improved
jury, increased implant choices, and the devel- results in patients with open fractures. Modi-
opment of protocol-driven studies to evaluate cation of the external xation frame constructs
treatment options. Current xation principles based on sound biomechanical testing has
of open fractures are based on Gustilo and made their application more uniform (hence,
Andersons classication scheme, originally reproducible) and user friendly, while decreas-
published in 1976 and modied in 1984.42, 43 ing complication rates. Frame dynamization
Soft tissue injuries found in association with also has been recently introduced as a means
closed tibia fractures, as classied by Tscherne to diminish healing times. The emergence of
and Gotzen, have also been shown to have interlocking tibia nails, inserted with either
clinical and therapeutic signicance.78 These reamed or unreamed technique, has stimu-
soft tissue classication schemes represented lated debate as to the optimal treatment of
a major step forward in the treatment of tibia these fractures. Recent emphasis on more care-
fractures, and they facilitated a description ful study design has helped to better delineate
of the injury, which was then used to guide indications for one mode of xation versus an-
treatment protocols and evaluate outcomes. other, although many questions still remain to
Results of the treatment of tibia fractures be answered. The following is a review of the
before these schemes must be viewed with current treatment principles, with particular
skepticism as increasingly poor prognosis is attention to skeletal xation of high-energy
associated with higher grades of soft tissue tibia fractures in the multi-trauma patient.
disruption. The development of aggressive
and emergent protocol-driven management
of soft tissue injuries in association with tibia ENERGY ABSORPTION AND SOFT
fractures has markedly improved outcomes, TISSUE INJURY
regardless of the xation method. In open
fractures, these principles involve emergent Soft tissue and osseous injury associated
debridement of contaminated, nonviable with trauma to the leg is dependent on the
soft tissues and bone, pulse lavage irriga- energy absorbed by the limb at the time of

From Orthopaedic Trauma and Reconstructive Surgery, Columbus, Ohio (BF); and the Department of Orthopaedic
Surgery, Boston Medical Center, Boston, Massachusetts




impact. The amount of energy transferred to in prolonged union times and increased risk
the limb during, for example, a bumper injury for skin necrosis after cast immobilization, as
is directly proportional to the mass of the ve- compared with animals with a tibia fracture
hicle and the squared value of the velocity. Al- without additional crush injury. Clinical series
though a fall from the curb may result in the involving closed and open treatment of tibia
transfer of 100 ft/lb of energy, a high velocity fractures have documented increased compli-
gun shot results in the transfer of 2000 ft/lb, cation rates and prolonged union times asso-
and a typical bumper injury at 20 miles per ciated with high-energy injuries.51, 55, 79 Gaston
hour in the transfer of 100,000 ft/lb.24 This en- et al39 found the Tscherne grade to be a signif-
ergy transfer is responsible not only for os- icant predictor of time to union and functional
seous disruption but also soft tissue damage, outcome after intramedullary nailing.
such as periosteal stripping, muscle crush, Open fracture classication generally is
closed degloving, and loss of skin intergrity. by the scheme initially published in 1976 by
As the energy absorbed by the limb increases, Gustilo and Anderson42 and later modied in
the fracture pattern and associated soft tis- 1984 by Gustilo et al43 (Table 2). This classica-
sue damage also increases. Unlike the frac- tion has gained widespread support because
ture, which is visualized by radiographs, the it has prognostic signicance. Regardless of
amount of soft tissue damage is harder to treatment, modality, increased complication
dene. rates and prolonged union times are associ-
Oestern and Tscherne78 have proposed a ated with the high-grade open fractures. In
classication of soft tissue injury in association one series of open fractures treated with plate
with closed fractures (Table 1). Closed type 0 xation, the infection rate was 5.4% for low-
and 1 injuries imply a low energy mechanism energy fractures compared with nearly 50%
of injury with intact soft tissues and simple for high-grade open injuries.25 Of particular
fracture patterns. Grade 2 and 3 closed injuries concern is the open fracture with inadequate
imply a great deal of energy absorption by soft tissue coverage (type 3B) or signicant
the limb with signicant osseous and soft tis- vascular injury (type 3C). Brumback and
sue disruption. Treatment of these injuries re- Jones18 surveyed orthopedic surgeons to
quires urgent care to prevent long-term ad- assess the interobserver reliability associated
verse sequelae. The successful treatment of with this classication system. Even among
these higher-grade injuries is more difcult. In orthopedic surgeons experienced in the treat-
an animal study, Edwards34 demonstrated that ment of these injuries the interobserver agree-
the addition of a crush injury to the soft tissues ment was only 60%.
in association with a tibia fracture resulted

Grade 0 Soft tissue damage absent or negligible;
fracture is the result of indirect forces and
has a simple conguration Cast immobilization, particularly with early
Grade 1 Supercial abrasion or contusion caused by conversion to a functional brace orthotic or
fragment pressure from within; fracture cast, is the mainstay of treatment of lower-
conguration more severe
Grade 2 Deep contaminated abrasion associated with energy tibia fractures with minimal (Tscherne
localized skin or muscle contusion from 0 or 1) soft tissue disruption, provided re-
direct trauma; impending compartment duction of the osseous deformity is accept-
syndrome included in this category; able. Fractures resulting from more violent
generally direct violence has produced the
energy transfer generally have more signi-
Grade 3 Skin is extensively contused or crushed; cant osseous and soft tissue disruption, mak-
muscle damage may be severe; other ing closed reduction difcult to obtain and
criteria for this category are subcutaneous maintain.1 Hooper et al,51 in a randomized-
avulsions, decompensated compartment prospective study comparing casting with in-
syndrome, and rupture of a major blood
vessel; fracture conguration is severely tramedullary nailing in displaced closed and
comminuted type 1 open tibia fractures, reported a sig-
nicant decrease in malunion rates and time
From Oestern HJ, Tscherne H: Pathophysiology and clas- to union after nailing compared with casting.
sication of soft tissue injuries associated with fractures. In
Tscherne H, Gotzen L (eds): Fractures with Soft Tissue Injuries. Conversion from casting to nailing was re-
Berlin, Springer-Verlag, 1984, pp 19; with permission. quired in 20% of the cases secondary to loss


Grade 1 Skin opening of 1 cm or less; most like
an inside out mechanism; minimal Plate xation has fallen into disfavor for
muscle contusion; simple transverse the treatment of these injuries. Traditional
or short oblique fracture pattern plating techniques require extensive soft
Grade 2 Skin laceration greater than 1 cm, with
extensive soft tissue damage, aps or
tissue dissection, further devitalizing soft
avulsion; minimal to moderate tissue and bone. Bach and Hansen,6 in a
crushing component; simple prospective-randomized study comparing
transverse or short oblique fracture external xation with open reduction and plat-
pattern with minimal comminution ing of type 2 and 3 open fractures, reported
Grade 3 Extensive soft tissue damage including
muscle skin and neurovascular infections in 35% after plating versus 19% after
structures; often a high-velocity external xation. Osteomyelitis developed in
injury with severe crushing 13% of patients with plated tibias compared
component with 3% of patients with external xation
3A Extensive soft tissue laceration (10 cm),
adequate bone coverage; includes
patients. Burwell20 reported a nonunion rate
segmental fractures and gunshot of 27% and a deep infection rate of 14% in a
wounds subset of patients with severe tibia fractures
3B Extensive soft tissue injury with who underwent open reduction and plating.
periosteal stripping and bone Ruedi et al86 reported a complication rate of
exposure; typically associated with
massive contamination; inadequate 30% after open reduction and plating of open
soft tissue coverage requires ap tibia fractures compared with less than 1% in
advancement or free ap closed fractures. Johner and Wruhs55 also saw
3C Vascular injury requiring repair complication rates increase from 13% to 32%
From Gustilo RB, Mendoza RM, Williams DN: Problems in the
after plating of open tibia fractures compared
management of type III (severe) open fractures: A new classi- with closed. At this time, open reduction and
cation of type III open fractures. J Trauma 24:742746, 1984; with internal xation of high-energy tibia fractures
with a standard plating techniques is not
of reduction. Puno et al79 also reported in- Percutaneous plating, featuring small inci-
creased rates of malunion and failure to main- sions, limited periosteal stripping and indirect
tain reduction with casting compared with reduction techniques, is a biologic benecial
intramedullary nailing of displaced closed- alternative to traditional plating techniques.
and low-grade open fractures. Sarmiento88 has Collinge et al27 reported on a small series of
written extensively on the effectiveness of patients with high-energy open and closed
functional bracing of tibia fractures. This treat- tibia fractures with metaphyseal extension
ment method is associated with high union thought not to be amenable to intramedullary
rates and minimal morbidity, provided adher- nailing. Although technically challenging,
ence to proper indications. This method of acceptable reduction and stable xation was
treatment is acceptable for reduced transverse achieved in all the patients. Deep infection
fractures and axially unstable fractures with occurred in only one patient. This technique,
less than 12 mm of initial shortening with ac- though promising, particularly in periarticular
ceptable angular and rotational reduction. An fractures, has yet to be evaluated in large
intact ipsilateral bula predisposes the frac- study cohorts or in a randomized prospective
tured tibia to fall into varus and is therefore fashion.
a relative contraindication to functional brac-
ing. Furthermore, closed treatment does not
allow for ongoing soft tissue evaluation and External Fixation
treatment, an essential component of the suc-
cessful management of high-energy injuries. Based on high complication rates seen
Union times become prolonged as the injury with available treatment modalities, exter-
severity increases with a subsequent increased nal xation emerged as the treatment of
immobilization time and resultant limb dys- choice for high-energy closed and open tibia
function, including muscle atrophy and joint fractures (Fig. 1). Based on biomechanical
stiffness. For these reasons, functional bracing studies, bulky external xation frames and
is thought to be a poor choice of skeletal stabi- transxion pins have largely been supplanted
lization for tibia fractures resulting from high- with anteriorly-applied, unilateral-uniplanar
energy mechanisms. constructs. These frames are easy and safe


Figure 1. A and B, Radiographs of a Tscherne 3 injury in an 18-year-old female pedestrian. C and

D, The canal size measured only 6 mm, and the patient was treated with standard anterior external

to apply, allow sufcient access for wound fractures required greater than 1 year to unite.
care and secondary procedures, and provide The deep infection rate was 21% in the rst
sufcient mechanical xation for patient half of the study and only 9% in the second.
mobilization and bone healing.8 The further This decreased rate was attributed to more
benet of cyclical motion (dynamization) in aggressive soft tissue debridement and early
fracture healing has also been demonstrated soft tissue coverage. Prolonged union times
recently by a number of authors in test sub- have been demonstrated when comparing
jects as well as clinical series.61, 62, 69 Results external xation in type 3A compared with
of external xation of open fractures using type 3B open fractures, with a difference of
current open fracture protocols and simple nearly 4 months.31 Table 3 demonstrates union
frame constructs have yielded acceptable times and deep infection rates in a recent
union and complication rates. Marsh et al 69 re- series of open fractures treated with external
ported a 98% union rate in 101 open fractures xation. In general, union times range from
treated with acute application of a dynamic, 6 to 9 months with deep infection rates in the
unilateral-uniplanar external xation frame. range of 5% to 20%.31, 35, 69, 75, 104
Union occurred at an average of 25 weeks. The External xation, for all its advantages,
deep wound infection rate was 6%, and the is associated with a relatively high rate of
malunion rate was low (95% of the fractures hardware complications, which ultimately
united with less than 10 malalignment). A limit the durability of the frame construct.
union rate of 93% with a deep infection rate Pin tract infectious complications, resulting
of 15% was reported by Edwards et al35 in in recalcitrant infection or loosening, are the
a series of 176 type 3 open fractures treated most common cause for failure of the external
with external xation. Of note, 33% of the xation device. Limiting cortical necrosis


Open Unions, Deep Bone Pin Tract
Study # Fractures, n Grade wk Infection, % Graft, % Infection, %
Edwards35 202 3 36 15 28 29
Marsh69 101 2,3 25 6 NA 29
Melendez75 38 2,3 23 3 58 17
Court-Brown31 51 3 37 18 70 35
Behrens8 26 2,3 26 0 45 25

during half pin insertion and meticulous soft when prophylactic bone grafting at 10 weeks
tissue care are essential to prolong the life span was compared with bone grafting for delayed
of the half pins. Pins should be placed after union at 20 weeks. Comparing prophylactic
predrilling to diminish the amount of necro- with delayed bone grafting in a cohort of
sis and posterior cortical injury. Regardless, patients with type 3B open fractures, Trabulsy
most half pins loosen between 3 to 6 months et al103 also reported a statistically signicant
after their application. The incidence of pin decreased time to union of 9 weeks. The re-
tract complications increases as the time in ported rate for prophylactic bone grafting
the external xation device increases. Table 3 after external xation of open fractures ranges
demonstrates rates of pin tract infectious com- from 20% to 50%. More recently, a number of
plications. The prolonged union times seen in authors have reported successful prophylactic
the higher-grade open fractures push the lim- bone grafting of type 3B open fractures under
its of frame durability. A number of strategies a mature ap.49, 57, 81 Interim obliteration of
are employed to decrease the time spent in the dead space under the ap with antibiotic-
the external xation frame, thereby decreasing impregnated, methylmethacrylate beads is
the rate of pin tract infections. Early frame recommended. This simplies the procedure
removal with cast application, once the soft and also has shown to decrease deep infection
tissues have healed, has not met with uni- rates.49, 57
formly successful results. Loss of reduction Dynamization of the external xation frame
has been the primary problem associated with has a benecial effect on union rates. Dy-
removal of the external xation frame prior namization, an imprecise term, is generally
to union, with reported rates ranging from brought about by some modication of the
10% to 30%.8, 25, 31 Most authors recommend external xation frame that allows for some
continuation of the external xation device axial motion and loading at the fracture site.
until clinical and radiographic union. In one Kenwright and Goodship,61 in a sheep fracture
study, refracture after frame removal did not model, demonstrated a signicantly increased
occur if the instrumented bending stiffness at rate of callus formation and mineralization
the fracture site was above 15 Nm/deg. These as stability of the external xation frame was
authors conclude that a bending stiffness decreased by increasing the offset between
greater than or equal to 15 Nm/deg is me- the frame and the bone. Motion of 0.5 mm
chanically equivalent to clinical union.62 Early was more benecial than 2 mm of motion.
prophylactic bone grafting at 6 to 8 weeks is In a randomized-prospective study compar-
a well-accepted mode to increase the rate of ing dynamic external xation (1 mm) versus
union and to diminish the time in the frame. static external xation, Kenwright et al62
Bone grafting is generally performed through demonstrated more rapid achievement of
a posterolateral approach, creating a synosto- clinical and radiographic union. Marsh et al69
sis between the bula and the tibia. Although demonstrated no loss of reduction with good
the bone defect is typically located antero- union rates in a large group of patients treated
medially, the posterolateral approach has a with a commercially-available, spring-loaded
number of advantages over anteromedial dynamic external xation frame and early
graftingavoidance of compromised antero- weight bearing. Aro et al5 demonstrated that
medial soft tissues, placement of the graft in a frame dynamization does not alter xation
well vascularized area for rapid graft incorpo- rigidity in either torsion or bending. In their
ration, and ability to place a large amount of animal osteotomy model, these authors found
graft. Blick et al13 demonstrated a statistically increased callus formation and decreased
signicant (12 weeks) decrease in union times times to union with dynamized versus static

frames. Early frame dynamization is a safe xation frame for an average of 17 days.
and effective method to positively alter the Reamed nailing was undertaken at an av-
local mechanical environment at the fracture erage of 9 days after removal of the frame
site and, thereby, produce improved union (26 days from the injury) when the pin tracts
times compared with a rigid frame construct. had healed. Union was achieved in 92% of the
Precise control of the amount of axial motion is patients with a deep infection rate of 5%. Inter-
provided by commercially available frames or estingly, the two patients with a history of pin-
can be achieved by decreasing the stiffness of tract infections did not develop deep infection
the external xation frame. after the nailing procedure. In a prospective-
The nal solution to prevention of exter- randomized study of sequential nailing or
nal xation failure is conversion of the exter- casting after 4 weeks of primary external x-
nal xation to an intramedullary nail. Early, ation of open fractures, patients undergoing
anecdotal reports concerning conversion ex- nailing demonstrated increased union rates
ternal xation to a reamed intramedullary nail and decreased malunion rates.4 The deep in-
featured high secondary infection rates. In a fection rate after nailing was 6% (one pa-
series of 47 nonunions, treated initially by a tient). Cole et al,26 with the use of temporary
variety of methods followed by reamed in- spanning femoral-calcaneal external xation
tramedullary nailing, the deep infection rate or splinting and early conversion to a reamed
was 13%.108 Even with a prolonged period nail after soft tissue coverage in a cohort of
of casting between frame removal and nail- 46 open fractures, reported a 98% union rate
ing, 85% of these infections occurred after ini- with only one deep infection (2%). Of the
tial treatment with external xation. Maurer70 46 patients, 25 underwent primary external
reported a deep infection rate of 25% when xation followed by either reamed nailing
reamed intramedullary nailing followed exter- (metaphyseal fractures) or nonreamed nailing
nal xation. Pin-tract infection was found to (diaphyseal fractures). Henry 48 presented the
be a signicant predictor of deep infection, results of a prospective protocol for conver-
with 71% of the patients with a previous pin- sion of external xation to a reamed nail. A
tract infection developing deep infection af- group of patients with short-term xation and
ter reamed intramedullary nailing. Other au- no history of pin-tract infections underwent si-
thors have reported this association between multaneous frame removal and nailing. A sec-
previous pin-tract infections and deep infec- ond group of patients with prolonged frame
tion after intramedullary nailing for delayed xation (average of 146 days) and a history
or nonunion.72 Fischer reported a 47% deep in- of pin-tract infections underwent a sequen-
fection rate in type 3B open fractures treated tial protocol involving frame removal, irriga-
with delayed reamed nailing after initial ex- tion and debridement of the pin tracts, and
ternal xation.38 Risk of deep infection was reaming of the canal with placement of antibi-
associated with a history of pin-tract infec- otic impregnated beads. Nailing was accom-
tions, current pin-tract infections, or persistent plished when the pin tracts had healed and
wound drainage. Open fractures with a his- the canal cultures were negative. The infection
tory of supercial wound infection also were rate was 0% with an 84% union rate. Sequen-
found to have high rates of deep infection with tial, reamed intramedullary nailing after tem-
a delayed nailing procedure. As a reconstruc- porary external xation and wound stabiliza-
tive procedure, reamed intramedullary nailing tion appears to be a safe procedure. Exchange
after primary external xation has not been a nailing should be performed within 14 days
successful procedure. This technique is partic- of injury, when possible, if the soft tissues
ularly contraindicated in the presence of active allow.
infection of the bone, wound or pin, ring or
halo sequestrum, poor soft tissue coverage, or
open half-pin tracts. Intramedullary Nailing
Sequential conversion of an external xa-
tion device to a reamed intramedullary nail Kuntscher and Maatz66 introduced inser-
relatively early in the treatment course, gen- tion of a locked intramedullary nail after
erally after initial soft tissue stabilization, has reaming of the tibia in the 1940s, during the
received better results. Blachut11 reviewed a same time femoral nailing was being in-
sequential nailing protocol in 39 patients with troduced. Unlike the femur, however, the
open fractures. Patients were in the external tibia was thought to be ill suited for reamed

nailing secondary to its relatively precarious has led to routine use of reamed nailing for
blood supply. Alternatively, small diameter, displaced closed and type 1 open fractures,
nonlocked intramedullary devices, partic- particularly after failed closed reduction or in
ularly those of Lotte and Ender, were more unstable patterns.
commonly used in order to protect the blood
supply of the tibia. Based on the success of
reamed intramedullary nailing of the femur POTENTIAL IATROGENIC
and dissatisfaction with the stability provided COMPLICATIONS OF
by these small diameter, unlocked tibial in- INTRAMEDULLARY NAILING
tramedullary devices, reamed intramedullary
nailing of unstable tibia fractures became Elevation of Compartment Pressures
more popular. Puno et al79 reviewed 200 dis-
placed closed- and low-energy tibial fractures Use of the reamed intramedullary nail in
treated with either casting or a reamed locked the high-energy closed- and open-fracture,
intramedullary nail. Intramedullary nailing however, continues to raise a number of is-
resulted in a union rate of 98%, infection sues surrounding potential iatrogenic com-
rate of 3.3% with no malunions compared plications. Of particular concern is the de-
with 90%, 1.4% and 4.3%, respectively, for velopment of compartment syndrome as a
the casted cohort. The casting group had a result of the nailing procedure. Another con-
13% failure rate, treated with conversion to cern surrounds damage to the blood supply
an intramedullary nail. Bone and Johnson,15 of the cortical bone as a result of the ream-
also in 1986, reported on a diverse group of ing procedure and the potential effects this
tibia fractures treated with intramedullary would have on union and infection rates.
nailing. Although the union rate was 98% These concerns have lead to a recent surge
for the acute fractures, the infection rate in in clinical and laboratory studies about the
type 2 and 3 open fractures was 25%, com- reaming process as well as the development of
pared with 2.9% in the closed or type 1 open a locked unreamed intramedullary device for
fractures. Wiss and Stetson109 reported on the treatment of these injuries. Compartment
a cohort of 134 patients with high-energy, syndrome has a well-recognized associa-
unstable tibia fractures treated with acute tion with high-energy tibia fractures. As the
reamed nailing. The union rate was high in amount of energy absorbed by the extremity
open and closed fractures, with an overall increases, so does the possibility of an associ-
deep infection rate of 9%. The infection rate, ated compartment syndrome. Compartment
however, was ve times higher in the open syndrome incidence after major trauma to the
fractures, compared with the closed fractures. tibia, regardless of the soft tissue injury, varies
These early studies suggested that reamed between 0% to 48% (Fig. 2).13, 19, 110 Several au-
nailing is a safe and effective mode for the thors have anecdotally reported an apparent
treatment of lower-grade open fractures. association between delayed development of
However increased infection rates made this a compartment syndrome and acute, reamed
technique less effective for the management of intramedullary nailing.71, 98 As early as 1971,
the high-energy open fracture. Studies specif- Hamza et al45 reported ve neuromuscular
ically limiting reamed intramedullary nailing complications after reamed nailing of 50 acute
to closed- and lower-grade open fractures tibia fractures. By description, these com-
have validated these early conclusions. Court- plications can be inferred to have been the
Brown et al28 reported on 125 acute, displaced result of untreated elevated compartment
closed and type 1 open fractures after reamed pressures. Koval et al64 found nearly one third
nailing. The union rate was 98% at an aver- of the patients treated with delayed reamed
age of 17 weeks. The deep infection rate was nailing of the tibia using a fracture table and
1.6% with a malunion rate of 2.4%. The most 90/90 traction had some neurologic decit
common complication was anterior knee pain, postoperatively. Primary neural injury or in-
occurring in 40% of the patients. This similar jury from the traction post could be partially
problem has been noted in other studies.60 responsible. The cause of these decits, how-
A 98% union rate and 3% infection rate was ever, was likely multifactorialbleeding into
reported by Williams et al107 in another large the compartments, reaming of the canal with
group of closed fractures treated with acute expulsion of intramedullary contents into
reamed nailing. Success of this procedure the closed compartments, vascular congestion


Figure 2. A 38-year-old man with a Tscherne 3 closed fracture and compartment syndrome that was
treated with emergent fasciotomy through a lateral approach and unreamed intramedullary nail (A). AP
(B ), and lateral (C ) radiographs. The patient developed excellent callus by 12 weeks (D ).
Illustration continued on opposite page

secondary to the traction post, and soft tissue than 40 mm Hg were recorded in almost half
swelling. The factors, together, may have the patients. Of the 56 patients in the study,
resulted in increased pressure in the compart- none developed clinical sequelae of a missed
ment and resultant neurologic compromise. compartment syndrome.
McQueen et al74 conducted a prospective A number of factors associated with the
study of compartment pressures associated nailing process may be responsible for these
with reamed nailing of acute tibia fractures. increased pressures. Moed and Strom74 found
These authors found signicant pressure that the reaming procedure itself raised com-
increases during the surgical procedure, partment pressures in an animal fracture
particularly during traction and reaming, model. Similarly, Wozasek et al111 reported
which were frequently greater than 30 mm that intramedullary pressure increases by a
Hg. After nail insertion and during the ensu- factor of 10 during reaming. This pressuriza-
ing 24 to 36 hours these pressures decreased tion causes extrusion of blood and marrow
to acceptable levels. Tornetta and French101 products through the fracture site into the
found similar but much shorter lived pressure compartments. The use of 90/90 positioning
increases during unreamed intramedullary with a posterior distal femoral/popliteal post
nailing without the use of a fracture table. can cause vascular congestion by impeding
Pressures peaked during the nailing pro- venous outow and may impede arterial in-
cedure (reduction and nail insertion) but ow, decreasing the perfusion pressure of the
returned to baseline at the termination of limb. Possibly the most important factor is the
the procedure. Transient pressures greater use of traction. Shakespeare and Henderson93


Figure 2 (Continued ). At 1 year, the patient had excellent function

with complete restoration of bony continuity and functioning of the
lower extremity (EG ).

demonstrated an increase in posterior com- transient elevations of compartment pressures

partment pressure of 5.7% per kilogram of in the lower extremity. In a patient at high risk
weight applied during calcaneal traction. for developing a compartment syndrome,
Finally, tourniquet use decreases perfusion to effort should be made to avoid factors that
the limb and promotes vascular congestion; may potentiate this problem, including: 90/90
therefore, it has also been implicated in this positioning, continuous traction, tourniquets,
problem. and reaming. A number of these factors may
Ultimately, it can be conclude that the intra- be avoided by not using the fracture table
medullary nailing process, whether reamed or for the nailing procedure. In a recent study
unreamed, can be expected to lead to at least prospectively comparing patients nailed with

and without use of the fracture table, the was found to be greater in the unreamed nail
fracture table cohort demonstrated a signif- group at 2 and 6 weeks after the nailing pro-
icant increase in set-up time and decreased cedure but not at 12 weeks, as compared with
ability of the surgeon to perform concomi- the reamed group. Comparison of loose tting
tant procedures.73 The time for the nailing and tight tting unreamed nails suggests that
procedure, number of assistants, and overall the amount of cortical perfusion decit is pro-
reduction quality were similar in the two portional to the amount of cortical contact be-
groups, suggesting that the use of a fracture tween the nail and the endosteum.54 Nutrient
table is not necessary in the multitrauma artery blood ow is nearly completely oblit-
patient and may increase the complexity of erated after standard intramedullary nailing,
the patients care. The possibility of a delayed whether reamed or unreamed. However, at
compartment syndrome, developing after 2 weeks it was found to return to baseline af-
nailing of the tibia, must be appreciated by ter unreamed nailing and only to 25% of base-
the operating surgeon. Frequent postoperative line after reamed nailing.17 Perhaps somewhat
pressure monitoring may be required in the paradoxically, reamed nailing was found to re-
obtunded or uncooperative patient. sult in increased muscle perfusion surround-
ing the fracture at the conclusion of the ream-
ing process, and unreamed nailing lead to a
Disturbance of Cortical decrease in muscle perfusion.52 Although the
Bone Circulation perfusion of the muscles surrounding the frac-
ture site had returned to baseline at 11 weeks
The effect of reaming and nailing on the after unreamed nailing, there was still found
blood ow to the lower extremity, particu- to be a statistically signicant increase in the
larly the cortex of the tibia, has been the muscle perfusion in the reamed group. In an-
subject of many studies. Rinelander80 has de- other closed fracture model, the amount of
ned the three basic components of the arte- callus formed after reamed and unreamed
rial blood supply to the long bones: nutrient nailing was similar; however, the porosity of
artery, metaphyseal arteries, and periosteal ar- the fracture callus was greater in the reamed
teries. In the normal long bone, blood ow group, suggesting a more active and advanced
is centrifugal, from the medullary cavity to bone repair process.92 Thus, the nailing pro-
the periosteum. Periosteal arteries supply the cess does signicantly interfere with the blood
outer 30% of the cortex, and medullary arter- ow to the diaphysis of long bones. This dis-
ies supply full thickness of the cortex. All ve- ruption is dependent on the amount of contact
nous drainage is to the periosteal surface. Dur- between the endosteal surface and the nail as
ing fracture repair, surrounding soft tissues well as the amount of reaming.53 This process
provide a new vascular component to the area is reversible with a more rapid return of cor-
of bone repair, termed the extraosseous blood tical and nutrient artery blood ow after un-
supply. This blood supply can effectively re- reamed than reamed nailing. Finally, there is a
verse the normal centrifugal blood ow. Early paradoxical increase in muscle perfusion sur-
animal studies concerning reaming of the fe- rounding the fracture site, even above base-
mur have demonstrated complete obliteration line, after reamed nailing that is not present
of the medullary blood supply, rendering the after unreamed nailing, which produces a de-
inner 70% of the cortex ischemic.63 Blood sup- crease in muscle perfusion.
ply to the callus was found to come predom-
inantly from the extraosseous blood supply.
The concern, then, was that intramedullary Thermal Injury to Cortical Bone
reaming, combined with periosteal stripping
and soft tissue loss, as seen with high-grade Further injury to the tibia and soft tissues
open tibia fractures, would render the cortex during the reaming process is created by heat
of the tibia avascular, resulting in increased in- generation. Case reports of thermal necrosis
fections and delayed healing. Unreamed nail- involving bone and soft tissue after ream-
ing has also been shown to have a signi- ing of long bone fractures can be found.68, 77
cant negative effect on the medullary blood Henry et al50 demonstrated mean intrame-
supply, rendering approximately 30% of the dullary temperatures of 52 C and mean ex-
inner cortex avascular, compared with 70% af- tramedullary temperatures of 46 C with ream-
ter reamed nailing of closed fractures in an ex- ing of cadaveric tibia.50 Increased heat was
perimental setting.91 Cortical bone perfusion generated with increased reamer diameter.

Osteocyte necrosis is seen with temperatures tion of the devascularized cortical segment
of 50 C.9 Eriksson et al36 found delayed osteo- was primarily the result of peripheral osteo-
cyte death after elevation of bone temperature clastic resorption and vascular inltration not
to 47 C for 1 minute. In an elegant theoretical via medullary arterial revascularization. Skin
model, Baumgart7 concluded that the essential coverage alone of the avascular segment re-
factor in temperature increases with reaming sulted in minimal callus formation of low
is friction between the reamer and the bone. porosity. Muscle coverage of the defect re-
This heat generation is directly proportional to sulted in a threefold increase in the amount
the rotational speed of the reamer, the reaming of callus formed and sixfold increase in the
time, and the axial force applied during the cortical porosity of the callus compared with
reaming procedure. Temperature increases are the skin coverage group. Increased porosity is
inversely proportional to the reamer diameter. thought to be the result of increased osteoclas-
Reaming without advancing can rapidly ele- tic activity. In the bone repair process, osteo-
vate temperatures. With blunt reamers, even clastic activity precedes osteoblastic activity.
under optimal conditions, a reaming time of A small amount of endosteal callus was ob-
30 seconds produces local temperature in- served. Muscle has a higher resting blood ow
creases of at least 6 to 8 C above body temper- than either skin or bone. In a follow-up study,
ature. Under unfavorable circumstances (e.g., Richards et al82 demonstrated that muscle ap
high reamer speeds, high axial forces, high coverage resulted in a statistically signicant
friction), temperature increases to 80 C may be increase in the early strength of union com-
seen in as little as 30 seconds. Sharp reamers pared with skin coverage. Likewise, 12 weeks
are the most important prerequisite for limi- after the osteotomy the maximum bending
tation of heat generation. Reamer size should load was signicantly greater in the muscle
be increased in 0.5 mm increments rather than coverage group. The energy absorbed to fail-
1 mm increments in order to decrease fric- ure at 12 weeks was three times greater when
tion. Reamers should be cleaned during the the defect was covered by muscle than by skin.
reaming process to prevent clogging and con- Interestingly, two animals in the skin cover-
gealing of the cutting utes. Reaming time age group were dropped from the study sec-
should be minimized and never should be in ondary to deep infections. None of the animals
one spot without advancing. Axial forced ap- in the muscle coverage group had infections.
plied during the reaming process should be Muscular aps have been shown to have a
minimized. Additionally, tourniquet use in- greater resistance to bacterial inoculation than
hibits convective heat transfer from the bone random pattern aps.23 It appears that dis-
to the soft tissue by limiting blood ow to ruption of the medullary and periosteal blood
the limb and is contraindicated. Each succes- supply results in a fracture repair process ini-
sive larger reamer causes expansion of the tiated by the soft tissue envelope. The qual-
devascularized zone of bone on either side of ity of the soft tissue envelope, in terms of
the fracture, not only because of vascular in- blood supply, profoundly affects the healing
sult, but also by heat generation. In extreme process.
cases this heat generation may cause necro- This concept of early, well-vascularized soft
sis of the bone, periosteum, and skin, limit- tissue coverage of avascular tibial segments
ing the regenerative ability of the adjacent soft of the tibia has been shown to have clinical
tissues. merit. In a series of high-energy tibia fractures
with soft tissue loss, Byrd et al21 demonstrated
increased rates of complications in fractures
SOFT TISSUE COVERAGE after delayed coverage compared with early
coverage. Osteomyelitis was ve times more
In experimental canine studies, the type prevalent, and nonunion was three times
of soft tissue coverage has a profound ef- more prevalent in the delayed compared
fect in the healing response of an avascu- with the acute coverage group. Similarly,
lar bone segment. Richards et al83, 84 created Caudle and Stern22 also found signicant
a 2 cm avascular zone of tibia, disrupting increases in nonunion and infection in a group
the medullary and periosteal blood supply. of patients with type 3B open fractures who
The segment was then internally xed with a either had late ap coverage or whose wounds
laterally applied plate. Medially, the avascu- were allowed to close by secondary intention
lar bone was covered with either skin alone compared with patients with acute ap cover-
or a rotational muscle ap. Vascular penetra- age. Flap coverage within 2 weeks of a type 3B

fracture was shown to result in decreased bone grafting of osseous defects. The animal
infection rates, hospital stay, and number of laboratory studies concerning reamed or un-
secondary procedures compared with ap reamed nailing have not lead to as denitive
coverage accomplished after 2 weeks.43 conclusions. One school of thought is that
Soft tissue coverage prior to osseous recon- unreamed nailing produces less damage to
struction has been advocated by a number of the cortex and more rapid regeneration of the
authors. Fisher et al38 demonstrated that early medullary blood supply. Therefore, this nail
ap coverage followed by delayed, prophy- should be used in high-energy open fractures
lactic bone grafting after wound maturation with an already compromised blood supply
lead to a signicant (9 weeks) decrease in time to prevent infection and promote healing.
to union than acute bone grafting before soft The other school of thought is that calus
tissue stabilization. Trabulsy et al103 evaluated formation after disruption of the medullary
early ap coverage within 7 days, prophylactic and periosteal blood supply depends on ex-
bone grafting at 8 to 12 weeks, and early skele- traosseuos blood supply derived from the
tal stabilization (nonrandom external xation surrounding soft tissues. Medullary callus
or unreamed nail) in 45 type 3B fractures. Only formation is not pronounced, even with plate
6% of the patients developed infection, with xation. Theoretically, then, early soft tissue
4% developing chronic osteomyelitis. Union coverage combined with the reaming process
was achieved in 98% of the fractures at an av- (which appears to stimulate muscular blood
erage of 55 weeks. Prophylactic bone graft- ow) may stimulate more rapid bone union
ing at 8 to 12 weeks was found to decrease and increased bacterial clearance. Infectious
the time to union by 9 weeks compared with complications are not a product of the ream-
bone grafting at 12 weeks or greater (aver- ing process but secondary to inadequate
age 8 months) for delayed union. No dif- debridement and soft tissue coverage.
ferences were seen in union rates compar-
ing external xation to unreamed nailing. Fix
and ap techniques, which feature soft tis- UNREAMED TIBIAL NAILING
sue coverage concurrent with the rst or sec-
ond debridement, have also been advocated. Unreamed locked intramedullary nailing
Sinclair et al94 reported on 17 patients with has been evaluated in a number of clinical
type 3B open tibia fractures, who underwent studies, particularly involving high-energy
free ap coverage of within 72 hours of their tibia fractures, to better evaluate the effect
injury. No ap failures occurred. There was of not reaming the canal. In a group of mul-
one deep infection. Cole et al26 reported on titrauma patients undergoing unreamed
the extensive use of local fasciocutaneous aps nailing, the overall union rate was 93%.3 The
for wound coverage with the initial debride- closed fracture union rate was 100%, and 86%
ment of patients with open tibia fractures. In- of the open fractures went on to timely union.
tramedullary nailing was accomplished on a There were no infections in the closed frac-
delayed basis. No ap failures or deep in- tures and one infection (6%) in the open group.
fections were reported. Gopal et al40 reported In another group of polytrauma patients with
on 57 patients with type 3B open tibia frac- mixed open and closed fractures, even with
tures. Nearly 50% of these patients had acute 40% of the patients undergoing early inter-
ap coverage with the initial debridement. vention procedures to promote union, Riemer
The ap failure rate was 3.6%. The deep in- et al85 reported a 35% delayed/nonunion
fection rate was 9%, with three of ve infec- rate. Comparison of closed and type 1 and
tions occurring when ap coverage was de- 2 open fractures with grade 3 open fractures
layed greater than 1 week. These studies stress revealed that there were similar times to union
the importance of the initial debridement fol- and reoperation rates. Fractures with less
lowed by early, well-vascularized soft tissue comminution (Winquist 1 or 2) healed at an
coverage and by prophylactic bone grafting average of 29 weeks with a 24% reoperation
when the soft tissue envelope has matured, re- rate, and fractures with more comminution
gardless of the method of xation. (Winquist 3 or 4) required an average of
Based on these studies, the standard treat- 35 weeks to unite with a 53% reoperation rate.
ment of tibia fractures with soft tissue and Static locking of the nail was found to be a
bone loss involves early, vascular soft tis- signicant predictor of reoperation and lead
sue coverage and delayed, prophylactic to statistically signicant increases in union

times, even when adjusting for Winquist erably higher rate of secondary reamed intra-
classication. Only two infections were re- medullary nailing in the unreamed group to
ported in this cohort, which included 29 type 3 promote union. Based on these prospective-
open fractures. randomized studies there appears to be
Studies specically addressing unreamed little justication for the routine use of the
nailing of closed, high-energy tibia fractures unreamed nailing technique in closed tibia
have demonstrated its clinical efcacy. Gre- fractures undergoing operative stabilization,
gory and Sanders41 prospectively evaluated regardless of the soft tissue injury. The un-
the use of unreamed nailing in Winquist 3 and reamed technique appears to lead to longer
4 fractures as the result of high-energy trauma. time to union, increased need for secondary
Only 87% of the fractures healed within procedures, and increased rates of hardware
26 weeks, and 5% and 8% of the fractures were failure. These studies, however, were per-
classied as having delayed or nonunion, formed using nails with small cross-locking
respectively. Acute infectious complications bolts by surgeons with extensive experience in
did not occur. Krettek et al65 reported on un- the reamed technique using the fracture table
reamed nailing in patients with acute fractures and not with unreamed nailing. The technical
classied as having severe soft tissue injury. A aspects of the nailing, including the presence
100% union rate, at a mean time of 44 weeks, of a fracture gap, was not examined. Infection
was achieved. Almost 25% of the patients, rates in closed fractures after nailing do not
however, required a secondary procedure seem to be appreciably altered by the presence
to achieve union. Both studies reported that or absence of reaming.
approximately 15% of the cross-locking bolts Evaluation of unreamed nailing of open
failed. Both authors concluded that unreamed tibia fractures has been undertaken by a
nailing provides safe and effective tibia sta- number of authors (Table 4).14, 16, 87, 95, 96, 102, 105
bilization in the acute multitrauma patient. Generally, the union rates are high, how-
Union times, hardware failure rates, and sec- ever, the time to union is prolonged. In a
ondary procedures, however, appear to be prospective study with follow up on 143 open
increased compared with previous studies of fractures, Tornetta and McConnell102 found
reamed nailing. only 53% of the fractures to have united at
Prospective-randomized studies comparing 6 months. Ultimately, the vast majority of
reamed with unreamed nailing of closed tibia the fractures united without the need for
fractures conrm what was suggested in these secondary procedures. Overall, 25 proce-
studies. In one study, Blachut et al12 found dures were performed in 16 fractures (11%)
the reoperation rate to achieve union was to achieve union. The deep infection rate was
twofold greater after unreamed compared 2.8%. Evaluation of these studies concerning
with reamed nailing. There was a trend to- unreamed nailing of open tibia fractures leads
wards increased rates of nonunion of the to a number of conclusions. Prolonged union
tibia affter unreamed (11%) compared with times can be expected, particularly as the
the reamed (4%) nailing. Court-Brown et al32 grade of the fracture is more severe. Secondary
found a statistically signicant increase in time procedures to achieve union are frequently
to union after unreamed (22 weeks) compared necessary. Aggressive early debridement
with reamed (15 weeks) nailing with no dif- and soft tissue coverage combined with un-
ference in infection rates. There was a consid- reamed nailing produces low rates of deep


Open Union at Deep Secondary Hardware
Study Fractures, n Grade 6 mo, % Infection, % Procedures, % Failure, %
Bonatus14 72 IIII 68 4 30 <1
Bone16 29 IIIIA 51 7 50 0
Sanders87 46 IIII 66 13 24 20
Singer95 43 IIII 98 12 47 41
Tornetta102 143 IIII 53 2.8 11 <1
Whittle105 50 IIII 46 8 36 10
Stegemann96 41 IIIIA 2 37 7.3

infection. High rates of hardware failure are to obtain union were much more prevalent,
seen compared with reamed nailing but only if with 50% of the patients requiring bone graft
small diameter locking screws are used. Most procedures. Keating et al59 assessed results in
cases of hardware failure were associated 110 open fractures treated with acute, reamed
with delayed union and frequently did not nailing. Average union times and number of
lead to a loss of reduction. Many authors delayed unions progressed steadily with in-
have referred to this late cross-locking bolt creasing severity of fracture grade. Overall,
failure as self-dynamizationa potentially the infection rate was 5%, with 11% of the
benecial complication. Fractures at the meta- type 3B fractures having a deep infection. The
physeal/diaphyseal junction, particularly in most common complication was anterior knee
the setting of a delayed union, are more prone pain, occurring in 57% of the patients. The au-
to nail breakage.106 Use of a titanium alloy nail thors attributed their success to aggressive
and attempts to achieve cortical contact are soft tissue and bone debridement followed by
benecial in prevention of hardware failure. early soft tissue coverage. Henry49 found the
Tornetta and McConnell102 reported a screw addition of interim dead space management
failure rate of only 0.3% and no nail failures with antibiotic impregnated methylmethacry-
in the largest reported series of open fractures late beads prior to soft tissue coverage to
treated with unreamed nailing. They attribute signicantly decrease infection rates from 16%
this to the use of a nail with larger locking to 4% in a large series of patients undergo-
screws for all sizes from 8 mm and up. It ing reamed nailing of open tibia fractures.
clearly has been demonstrated that interlock- Robinson et al81 reported on the use of reamed
ing screw and nail failure is independent of nailing in 30 acute type 3B open fractures
placement technique (reamed or unreamed) associated with signicant bone loss. All but
and related to union and the mechanical one fracture united at an average of 53 weeks.
strength of the implant. The deep infection rate was 20%; however,
85% (5/6) of the infections developed in pa-
tients who initially had split thickness skin
REAMED TIBIAL NAILING graft coverage of the soft tissue defect. Serial
irrigation and debridement combined with
Alternatively, reamed nailing has also ap coverage resulted in stabilization of the
been investigated for use in open fractures, infection and osseous union in 85% of the
although more sparingly than unreamed infections. Poor soft tissue management, not
nailing (Table 5). In a prospective study in- the reaming process, was thought to be re-
volving reamed nailing of 41 acute type 2 sponsible for the high infection rate. Keating
and 3 open fractures, Court-Brown30 reported et al56 recently presented results of a group of
good results in the type 2 and 3A fractures but 55 patients with 57 type 3B open fractures who
increased complication rates in the type 3B underwent acute reamed intramedullary nail-
fractures. Type 2 and 3A fractures united at ing. These authors reported a 17.5% infection
an average of 24 and 27 weeks, respectively, rate. Of these infections, 40% were considered
with only one deep infection (3.5%). Ap- supercial and resolved with local irrigation
proximately one fth of the type 2 and 3A and debridement with retention of the hard-
fractures required a secondary procedure to ware. The mean time to union was 43 weeks
obtain union. Conversely, the infection rate with 26% of the fractures requiring bone graft
in type 3B fractures was 23% with an average and 23% revision nailing. The average nail
union time of 50 weeks. Secondary procedures diameter was 11 mm.


Union Deep Infection


Court-Brown30 41 24 27 50 7 23
Keating59 110 29 32 34 39 10 11
Keating57 53 28 31 30 4 8
Robinson81 30 53 20
Keating56 57 43 17.5

COMPARISON STUDIES OF TIBIAL open fractures was unable to generate enough

FRACTURE FIXATION data to denitively support one method of x-
ation over the other.33 There was found to be
Prospective, randomized studies of skele- reduced time to union (4 weeks) and a re-
tal xation methods in open fractures are rel- duced need for intravenous antibiotics follow-
atively lacking. External xation compared ing unreamed nailing compared with external
with unreamed nailing of open fractures in xation. Union rates were similar in the two
a prospective-randomized fashion has been groups. Although there was a trend toward
published in only two reports.46, 100 Tornetta decreased rates of malunion and supercial
et al,100 in a cohort of 29 patients with type 3B sepsis after nailing, the numbers did not reach
open fractures, found a similar time to union, statistical signicance.
ankle and knee range of motion, and the Studies comparing reamed to unreamed
number of secondary procedures needed to be nailing of open fractures of the tibia are also
similar in the two groups. Prophylactic bone lacking.2, 37, 58 In a prospective-randomized
grafting was performed in approximately two study comparing these two techniques in
out of three of the patients, regardless of the closed and open fractures, excluding type
mode of xation. Deep infection rates were 3B injuries, reamed nailing of closed frac-
also similar one in each group), however, 21% tures was found to yield higher union rates
of the patients with external xation had pin- at 4 months but not at 6 or 12 months.37 Un-
tract infection problems. The second study, by reamed nailings of closed fractures resulted
Henley et al46 included 174 type 2 and type 3A in a signicant increase in cross locking screw
and B open fractures. Again, no signicant dif- failure and a trend towards increased rate of
ferences were noted in the time to union or secondary procedures performed in order to
deep infection rates. These parameters were achieve union. Reamed nailing of the open
more closely associated with the grade of open fractures was not found to lead to more rapid
fracture, rather than the mode of xation. Loss union or increased infection rates. Keating
of alignment and hardware infection com- et al58 reported on 94 open fractures treated
plications were signicantly increased in the in a prospective-randomized fashion with a
external xation group, with a signicant in- reamed or unreamed nail. With regards to the
crease in the rate of secondary procedures per- technical aspects of the operative procedure
formed per fracture in the external xation and the rate of early complications, there were
group. Nonrandomized studies mirror these no signicant differences between the two
results (Table 6).47, 89, 90 Schendelmaier et al89 re- groups. No signicant differences were found
ported decreased time to full weight bearing, in the time to union or rates of nonunion
better function, and decreased need for sec- and infection between the two groups; how-
ondary procedures after unreamed nailing in ever, the unreamed group healed faster for
a nonrandomized comparison with external types 1 through 3A, and there were twice as
xation. Signicant decreases in the need for many infections in the reamed group. The
secondary procedures after unreamed nailing limited number of patients in each subgroup
compared with external xation has been re- of open fractures decreased the power of
ported in a number of studies. A meta-analysis the study to detect meaningful differences.
of recent literature concerning the use of un- Functional outcomes were also similar. The
reamed nailing or external xation of type 3B only signicant difference reported in the


Nail External Fixation
Bone Bone
Study # Grade Union, wk Deep Infection, % Graft % Union, wk Infection, % Graft, %
Tornetta100 29 3B 23 6.6 60 28 7 70
Henley46 174 II 46 13 14 50 21 36
Schandelmaier90 179 closed & 26 3 23 26 2 30
Schandelmaier89 32 3B 31 5 18 37 10 53

Prospective randomized.

study was the rate of screw failure, occurring jury. Hemodynamic instability and elevated
in 29% of the unreamed compared with 9% compartment pressures or impending com-
in the reamed cohort. Although certainly an partment syndrome may be indications for
important study, the limited number of frac- an alternative mode of treatment, at least
tures limited the ability of the study to detect initially. In the setting of a hemodynamically
subtle differences in outcome and complica- unstable patient, an external xation device
tions. A meta-analysis of reamed compared can be more rapidly applied. In the setting
with unreamed nailing of lower extremity of elevated compartment pressures, reaming
long bone fractures was unable to demon- may potentiate the problem. An unreamed
strate signicant differences in the rates of nail or external xation device may be more
malunion, infection, pulmonary embolus, or appropriate in this situation.44 Unreamed
compartment syndrome based on the method nailing as the rst choice in the treatment of
of xation.10 Within the tibia fracture subset, this injury has shown to lead to increased rates
the authors reported a pooled nonunion rate of delayed/nonunion and hardware failure if
of 14% after unreamed nailing. As expected, a small diameter interlocking bolts are used.
signicant increased risk of screw failure was Skeletal stabilization of open fractures of the
associated with unreamed nailing with small tibia, despite numerous studies, has no one
diameter cross-locking bolts. Published stud- optimal solution. External xation emerged
ies prospectively comparing reamed nailing to as the gold standard for treatment of these
external xation in high-grade open fractures injuries. More recently, the unreamed, locked
are currently lacking in the literature. tibial nail seems to have largely supplanted
this device, particularly at trauma centers
treating large numbers of these injuries.
SUMMARY Although union and deep infection rates ap-
pear to be similar, unreamed nailing avoids
Optimal skeletal stabilization of high- the Achilles heel of the external xation
energy tibia fractures, particularly with an devicethe half pin/bone interface. Failure
open wound, remains controversial. Optimal of the half pin, either through aseptic or septic
treatment of the injured limb, however, is loosening, invariably limits the duration of
far less controversial. As a rst step, acute, the external xation device. Problems associ-
aggressive debridement of the soft and os- ated with delayed reconstruction of the mal-
seous tissues combined with high pressure or nonunited tibia after failed external xa-
pulsatile lavage is essential. Repeat, sched- tion have been outlined earlier. Conversely,
uled debridements followed by early, well reamed exchange intramedullary nailing after
vascularized coverage of soft tissue defects initial stabilization with a reamed or un-
decreases complication rates, regardless of reamed nail has shown to be an extremely
the skeletal stabilization method chosen. The effective method to bring about union of the
importance of these steps to the outcome of tibia with low complication rates (Table 7).29, 97
the injury is of paramount importance. Devi- The ease of reconstructive procedures after
ation from this protocol will invariably raise unreamed nailing compared with that with
complication rates despite adequate skeletal external xation has largely been responsible
stabilization. When reviewing large series of for the decrease in routine use of the external
open tibia fractures reported from trauma xation device in open tibia fractures. The
centers, the skill, judgement, experience of the external xation device, however, remains an
orthopedic traumatologist, and the quality of important tool in the armamentarium of the
the support services involved in the patients orthopedic surgeon. The intramedullary nail
care can not be underestimated in terms of limits secondary debridement, particularly of
the potential positive aspect on the outcome. the canal and soft tissues opposite the open
These intangible factors, which certainly have wound. Thus, in extremely contaminated
signicant impact on outcomes, must be taken fractures, or in injuries with questionable soft
into consideration in the decision of the treat- tissue viability, an external xation device
ment of these injuries because little margin for offers stabilization without compromising fu-
error. ture debridements. Again, the hemodynami-
Reamed intramedullary nailing is the cally unstable patient benets from rapid
treatment of choice for the vast majority of frame placement, rather than nailing, which
high-energy unstable closed tibia diaphysis typically requires more time. Instances of
fractures, regardless of the soft tissue in- compromised or questionable limb viability

Time to Exchange
Study N Type Nail, wk Union, % Infection, %
Templeman97 28 Closed/open 24 93 11
Riemer85 12 Closed/open 24 100 0
Gregory41 4 Closed > 26 100 0
Bonatus14 4 Open > 24 100 0
Sanders87 5 Open > 24 91 0
Singer95 11 Open NA 91 0
Tornetta102 12 Open NA 100 0

or function, such as prolonged warm ischemia of the larger diameter nail exceeds the risk of
with a major vascular disruption or tibial minimal reaming. On the other hand, sequen-
nerve disruption, may be better initially man- tial increases in reamer diameter result in in-
aged with rapid frame application. More cremental damage to the vascular supply of
denitive reconstruction or amputation can the cortex and in increased potential for cor-
then be evaluated in a more controlled setting. tical necrosis. In a patient with an open tibia
Finally, intramedullary nailing, particularly fracture and with a large intramedullary tibia
small diameter nailing, can be a demanding diameter, the risks of reaming to place a large
procedure. The widened proximal and distal diameter tibia nail (e.g., 11 mm or greater di-
aspects of the tibia do not allow for intimate ameter) probably outweigh the benets and
contact between the nail and the endosteum. should be avoided. Thus, the decision to place
Reduction, therefore, can be challenging. High an intramedullary nail with or without ream-
rates of malunion have been reported after ing should be dependent on the size of the pa-
nailing of proximal fractures.67 A number of tients intramedullary canal and the severity of
techniques have been described to success- the soft tissue damage. Rather than represent-
fully nail proximal tibia fractures.99 These ing a true dichotomy (to ream or not to ream),
variations include: variation of the portal the real issue should center on achieving an
placement, nailing with the knee extended, optimal environment for fracture healing by
use of poller or blocking screws, and appli- obtaining adequate stabilization with mini-
cation of an anterior unicortical push plate. mal damage to the soft and osseous tissues.
Successful use of an intramedullary nail, par- As experience and available data increase ad-
ticularly a small diameter nail in the extremes vocates of reamed and unreamed techniques
of the tibia, requires a thorough knowl- have converged. Reamed nailing is now per-
edge of the techniques in order to prevent formed after minimal increases in the inner
malreduction. canal size and unreamed nailing is performed
Reamed intramedullary nailing of lower- with implants large enough to have good me-
grade open fractures has been successful. Use chanical characteristics. At this point, the size
of this technique in high-grade open frac- of unreamed and reamed nailing differs by
tures has been reported by some authors, but only 1 mm to 1.5 mm. Finally, complete and
concern still exists surrounding the vascular expeditious irrigation and debridement com-
and cortical damage incurred by the reaming bined with early well-vascularized soft tissue
process and resultant risk of deep infection. coverage of traumatic defects is of paramount
The debate of reamed or unreamed nailing of importance in the successful treatment of open
open tibia fractures has not come to a con- tibia fractures, regardless of the mode of skele-
clusion. Ultimately, the goal should be to ob- tal xation.
tain adequate skeletal stabilization while min-
imizing the iatrogenic damage to the blood
supply and cortex. Transition from an 8 mm References
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Address reprint requests to

Bruce French, MD
Orthopaedic Trauma and Reconstructive Surgery
340 East Town Street, Suite 10200
Columbus, OH 43215
TREATMENT OF COMPLEX FRACTURES 00305898/01 $15.00 + .00

Assessment and Treatment

Joseph Borrelli, Jr, MD, and Erik Ellis, MD

Complex intra-articular fractures of the tibial guidelines for the treatment of intra-articular
plafond (pilon fractures) have been studied for distal tibia fractures.29 These recommendations
some time.8 Because of the severity of some of included ORIF of the bula, anatomical re-
these fractures, several previous investigators duction and internal xation of the articular
have referred to them as explosion fractures fragments, iliac crest bone graft placed within
of the distal tibia.17, 32 The most challenging of the metaphysis to support the articular reduc-
these fractures are those that result from high- tion, and medial tibial buttress plating of the
energy trauma, including falls, motor vehicle distal tibia to stabilize the tibia and prevent
crashes, and industrial accidents. Pilon frac- varus deformity. Successful treatment of these
tures resulting from high-energy trauma typ- injuries was expected when these recommen-
ically have multiple metaphyseal fragments dations were followed particularly in cases
and displaced articular fragments associated where the pilon fracture was the result of low-
with signicant soft tissue injury. Another sub- energy trauma.17, 21, 29, 30, 31 Unfortunately, simi-
set of these fractures is the result of low-energy lar results were not realized when these same
trauma. These fractures are characterized by a principles were applied to high-energy frac-
spiral fracture of the metaphysis of the tibia tures with signicant soft tissue injury.22, 27, 34 As
and minimal or no displacement of the articu- a result of this early experience, in particular
lar surface. the high complication rate associated with op-
Treatment of pilon fractures has evolved erative treatment of the injuries, the need for
over the last 100 years. Because of the limited the development of more effective treatment
implants available and poor outcomes associ- regimens became obvious.
ated with surgical intervention in the past, con- A review of the literature shows that for the
servative means of treatment was commonly best outcome operative treatment of these in-
advocated.16 In an effort to improve patient juries should be tailored to the fracture pat-
outcomes while decreasing the amount of time tern (i.e., personality of the fracture), degree
in a cast, Leach et al18 advocated open reduc- of soft tissue injury, patients demands and ex-
tion and internal xation (ORIF) of the bula pectations, and the surgeons experience and
and nonoperative management of the tibia. training. Currently, surgeons have a variety of
Rouff et al32 subsequently advocated ORIF of surgical options and implants in their arma-
the bula and limited internal xation of mentarium for the treatment of these injuries.
the tibial fragments. In the late 1950s and These options include external xation, exter-
early 1960s, the Arbeitsgemeinschaft fur Oste- nal xation with limited internal xation, and
osynthesefragen/Orthopaedic Trauma Associ- traditional ORIF. Newer techniques and im-
ation (AO/OTA) group developed general plants are on the horizon and include newly

From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri




designed plates, which can be placed along to the medial malleolus and along the medial
the medial tibia through small incisions with surface of the tibia to reach the knee. The lesser
percutaneously placed screws. Regardless of saphenous vein and nerve and the sural nerve
which technique is used, the goals of opera- pass posterior to the lateral malleolus and prox-
tive intervention include the preservation of imally to the center of the posterior aspect of
soft tissue attachments to the fracture frag- the leg between the medial and lateral heads
ments, anatomical reduction of the articular of the gastrocnemius muscle. Disruption of the
fragments, and realignment of the limb. This veins at the time of injury or surgery can cause
review assesses these complex injuries, the var- subsequent venous stasis changes of the skin,
ious treatment options, and their outcomes. chronic swelling, and potential ulceration.