ORTHOPAEDIC TRAUMA
From the University of California, San Francisco, School of Medicine’s 2nd Annual San Francisco Orthopaedic Trauma
Course
Educational Objectives
| The goal of this program is to improve the management of orthopaedic trauma. After hearing and assimilating this program,
the surgeon will be better able to:
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 | 1. Treat proximal humerus fractures.
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| 2. Manage complex carpal injuries.
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| 3. Evaluate and treat elderly trauma patients.
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| 4. Repair calcaneus fractures.
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| 5. Provide proper diagnosis and treatment for pediatric ankle fractures.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
The speakers were recorded at the 2nd Annual San Francisco Orthopaedic Trauma Course, sponsored April 19-21,
2008, by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks the
speakers and the UCSF School of Medicine for their cooperation in the production of this program.
| PROXIMAL HUMERUS FRACTURES —Peter G. Trafton, MD, Professor, Department of Orthopaedic Surgery, Brown
University Warren G. Alpert School of Medicine, Providence, RI
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| Overview: probably third most common fracture, 5% to 10% of all; older patients—osteoporotic; increasing frequency;
younger patients—high-energy fractures; bone better for fixation
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| Osteoporosis: confers 2 to 5 times increased risk for another low-energy fracture soon after first; typically in younger
men; diagnose and treat fragile bone—liability issue
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| Outcome: functional impairment in ≤50% of patients, depending on displacement, comminution, age, and (possibly) treatment
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| Diagnosis: hampered by interobserver variation, evaluation of displacement, and ability to identify parts; assessment—
x-rays in ≥2 planes; check for nerve injuries
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| AO/ATO classification: type A—extra-articular unifocal; type B—extra-articular bifocal; type C—articular
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| Fracture frequency: >50% of fractures—displaced greater tuberosity, varus-impacted proximal humerus, surgical
neck fracture; completely displaced; surgical neck fracture; valgus 3-part impacted fractures; <10% of fractures—3-
or 4-part fractures
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| Avascular necrosis (AVN): vascularity anterior as well as posterior (through soft tissues); risk factors —long posteromedial
metaphyseal extension; torn medial hinge; anatomic neck fracture; if all 3 present, incidence ≈97%; increases chance of
AVN—4-part fractures treated with percutaneous fixation or open reduction and internal fixation (ORIF); favorable
outcome—75% after satisfactory fixation and anatomic healing
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| Surgery: for displacement >45° or >1 cm; for greater tuberosity, >5 mm; fixation results—major difficulties; in Mayo
Clinic study, fixation (51% early complications; 26% reoperation) and replacement (high early complication; less
reoperation)
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| Nonoperative treatment: minimal displacement—type A fracture, >50%; type B, 40%; type C, ≈15%; results—85%
good to excellent; treatment options—sling and swath; hand exercise; wait for consolidation; begin early passive
motion; resistance exercises after bone healing
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| Recommendations
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| Displaced greater tuberosity: minimal—observe; >5 mm—fixation with pins or screws; heavy suture through insertion
of rotator cuff tendon; possible cuff tear
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| Varus-impacted surgical neck fracture: nonoperative; angulation may increase; 80% excellent to good at 1 yr
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| Translated surgical neck fracture: nonoperative
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| Valgus-impacted 3- or 4-part fracture: less displacement—nonoperative; more displacement—ORIF; bone graft
helpful
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| Nonimpacted 3-part fracture: head perfusion likely; fixation challenging
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| Displaced 4-part fracture: 29% good to excellent with nonoperative care; ORIF possible, but risk for avascular necrosis;
replacement limited to elderly, fracture-dislocation, and unfixable fracture; locking plate may be useful
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| Locking plate: requires good exposure; anchor with traction sutures; fluoroscopy key
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| Hemiarthroplasty: consider in 4-part fracture-dislocation, elderly with comminution and osteoporosis, head-splitting
injuries, and anatomic neck fractures; technical concerns—version; height; tuberosities sutured to prosthesis
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| FRACTURE-DISLOCATIONS OF THE ELBOW— Milan Sen, MD, Assistant Professor, Department of Orthopaedic
Surgery, University of California, San Francisco, School of Medicine, and Director, Upper Extremity Surgery, San Francisco
General Hospital
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| Mechanism of injury: fall on outstretched hand; usually posterolateral instability; also varus posteromedial; injury
progresses from lateral to medial (lateral ulnocolateral ligament; anterior capsule; medial collateral ligament
[MCL]); dislocation without disruption of medial structures possible
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| Structures involved: both collateral ligaments; variable amount of muscle origin (with increasing instability); radial
head; coronoid; olecranon; associated injuries—≤20% neuropraxias (assess intraosseous nerve)
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| Classification (simple dislocations): based on displacement relative to humerus; posterior—posterolateral; posteromedial;
lateral; medial; anterior—rare
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| Fracture-dislocation: dislocation of elbow with intra-articular fracture; difficult to classify various possibilities
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| Dislocation vs disruption: disruption—elbow joint preserved, with lateral collateral ligament disrupted (medial
may not be disrupted); dislocation—medial and lateral collateral ligaments disrupted
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| Dislocation injuries: posterior dislocation with radial head fracture; terrible triad—posterior dislocation; radial head
fracture; coronoid fracture
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| Disruption injuries: olecranon fracture-dislocation (anterior or posterior); varus posteromedial rotational instability
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| Posterior dislocation of elbow: possibly nonoperative; usually operative to avoid secondary procedures
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| Terrible triad: very unstable; unstable ulnotrochlear notch; collateral disruption; Toronto protocol—repair coronoid;
repair or replace radial head; repair lateral collateral ligament; sometimes repair MCL; external fixator if needed;
good results reported
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| Coronoid fractures: screw fixation if large enough fragment; modular hand plate for smaller fragment; for very small
fragment, sutures through olecranon and anterior capsule
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| Varus posteromedial rotational injuries: easily missed; appear benign on x-ray; stress view reveals lateral collateral ligament
(LCL) disruption; involve anteromedial facet with MCL attached; elbow unstable; attach medial facet
fragment—Acumed plate
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| Olecranon fracture-dislocation: anterior (trans-olecranon)—ligaments often spared; posterior (Monteggia variant)—
LCL often disrupted; treatment—anterior (results good; treat as bony injury); posterior (results unsatisfactory)
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| THE ELDERLY TRAUMA PATIENT— Paul Tornetta III, MD, Professor and Vice Chair, Department of Orthopaedic
Surgery, Boston University School of Medicine, and Director, Orthopaedic Trauma, Boston Medical Center, Boston, MA
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| Introduction: by 2040, 20% of population >65 yr of age; elderly more active (driving; walking; recreation), leading to
more trauma, as opposed to slip-and-fall injuries
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| Osteoporosis: compared to men, more distal extremity injuries in women (forearm; wrist; tibia; foot; ankle);
pretreatment—strengthening bones important
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| Special considerations: comorbidities; medications; mobility score; diminished cardiac and pulmonary reserve; findings
in patients >60 yr of age—lower cardiac index; lower oxygen delivery and consumption (remained low >24 hr;
levels correlated with mortality)
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| Thromboembolic disease: thromboembolic events in 11% of 203 rehabilitation patients treated with low molecular
weight heparin; add mechanical prophylaxis
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| Cardiac morbidity: with injury severity score (ISS) >15, study found 28% morbidity, 36% 2-yr mortality, and 60%
2-yr complication rate; increased with age
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| Trauma patient mortality: 3 times higher than any other group; 28% of traumatic deaths in 12% of population; elderly
more likely to succumb later; ISS correlates with mortality
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| Orthopaedic management: study based on 4 centers fairly aggressive in getting patients to operating room; 62% to
97% stabilized within 24 hr; associated head injury most common cause of delay; mortality lower with early operation;
taking into account delays due to cause, speaker concludes safe to operate early (“as long as you can get everything
else corrected”); complications predictive of mortality—ISS correlated with systemic complications (acute
respiratory distress syndrome [ARDS]; pneumonia; sepsis; gastrointestinal); fluid requirements correlated with myocardial
infarction (MI); need for surgery or transfusion correlated with sepsis; with ISS <18, mortality 4%, rising to
37% with higher ISS; conclusion—early stabilization not unsafe; treat elderly as regular trauma patients
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| Octogenarians: patients ≥80 yr of age; 41% of elderly trauma; dementia, congestive heart failure (CHF), hematologic
disorders much more common; ISS correlated with mortality
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| Importance of trauma centers: in octogenarians, direct admission to trauma center with ISS 21 to 45 correlated
with 56% survival, compared to 8% for community institutions; Florida study of 7000 patients found significant
preventable mortality in nontrauma centers compared to trauma centers (difference based on superior management
of comorbidities)
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| Reduction in mortality: 78 yr of age added to criteria for trauma-center activation for patients demonstrating hypotension,
tachycardia, or unresponsiveness to pain; 9-yr results in patients with ISS >15—mortality reduced from 54% to
34%; with ISS <20—from 68% to 47%; lower rate of permanent disability
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| Recommendations: damage-control orthopaedics to avoid secondary complications; early aggressive monitoring;
avoid complications; early (safe) bony stabilization; triage adjustments based on age
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| CALCANEUS FRACTURES —Sean E. Nork, MD, Associate Professor, Department of Orthopaedics and Sports Medicine,
University of Washington School of Medicine, and Harborview Medical Center, Seattle
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| Fracture pattern types: joint depression type; tongue type; first, identify type based on plane x-rays and computed
tomography (CT); require different reduction maneuvers
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| Sorting out fragments: based on CT (axial images most useful); classification based on remaining medial constant
fragment; medial sustentacular fragment (strongest bone), separated from anterior-process fragment (fracture lines often
extend into it); tuberosity fragment; superolateral facet (or lateral portion of posterior facet in joint depression type
fracture); assess other foot—utilize contralateral, lateral, and axial CT views as guidance for reconstructing height and
length
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| Plane x-rays: assess rotation of posterior facet; axial view for height loss and tuberosity width, potential impingement
or dislocation; anteroposterior (AP) and oblique views of foot for extension of fracture line and calcaneocuboid joint
involvement
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| Operative fixation: lateral position; cut-out pillows facilitate surgery; extensile-lateral approach (straight incision; can
be curved anterodistally; need to visualize entire anterior process, out to calcaneocuboid joint; avoid sural nerve; indirect
reduction of tuberosity to medial constant fragment; remaining articular reduction direct and visual; complicating
factors—anterior process comminution; small medial constant fragment; fragmented posterior facet; surgical goals
restore height and calcaneal length; articular reduction
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| Order of reduction: from front and medial, to back and lateral; smaller fracture lines into anterior process; change rotation
between medial constant fragment and anterior process; tuberosity to medial constant fragment; return posterior
facet
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| Bone grafting: useful for placement of lateral wall in final reduction
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| Implant selection: trend smaller implants; combination of multiple small plates; specialized plates available; span
calcaneus from anterior process to tuberosity (engages articular portion in fixation); for tongue-type fracture, screw or
plate extension to engage posterior tuberosity
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| Closure: sutures to close periosteum over calcaneus; avoid any tension on skin to prevent necrosis; skin contracts with
delay from time of injury to fixation
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| PEDIATRIC ANKLE FRACTURES —Stephen J. Pinney, MD, Associate Clinical Professor, Department of Orthopaedic
Surgery, and Chief, Foot and Ankle Service, University of California, San Francisco, School of Medicine
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| Anatomy: ankle highly constrained hinged joint (lever effect places 2-3 times body weight through joint); distal tibial
physis; distal fibula physis; accessory ossicles; ligaments—may be stronger than physis; medial deltoid; anterior
talofibular; calcaneofibular; anterior tibiofibular
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| Treatment principles: make diagnosis (understand anatomy; have high index of suspicion); adequate fracture reduction;
monitor and counsel for growth plate disturbances
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| Fracture types: early childhood—metaphyseal; middle childhood —physeal; transitional—Tillaux
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| Physeal fractures: open physis; growth plate weaker than ligaments; history—acute injury; significant pain; mechanism
(dictates fracture pattern, eg, abduction); physical examination—swelling; weight-bearing difficult; x-rays—look
for metaphyseal fracture; stress x-ray may reveal injury; treatment—reduce and cast; immobilize for 6 wk; educate
parents; monitor for growth plate disturbances
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| Tillaux fractures: anatomy—distal tibial physis closure (from posteromedial to anterolateral; girls median age ≈12 yr;
boys median age ≈14 yr); external rotation injury (intra-articular; anterior tibiofibular ligament avulses off open area of physis;
assessment—high index of suspicion in adolescents and after recent growth spurt; rotational injury; pain; weight-bearing
difficult; swelling; pronounced tenderness in anterolateral ankle; plane x-rays—may be difficult to see; lateral view
helpful; CT imaging—use to rule out suspected injury; assess gap size and step-off incongruity; nonoperative treatment—
undisplaced or minimally displaced (<2-mm gap) with no step-off; for 2- to 5-mm gap with no step-off, attempt closed reduction
(may require surgery); immobilize in cast ≈6 wk; operative treatment—displaced fractures; obtain anatomic reduction
with adequate fixation; may require screws across growth plate
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| Triplane fractures: transitional fracture of distal tibia; involve physis; intra-articular involvement; rotational injuries;
classification (medial or lateral); subclassification based on number of fragments; imaging—x-rays; CT imaging may
be required; treatment—ORIF; anatomic reduction of articular surface; reduction and fixation more important than
growth plate (almost closed)
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Suggested Reading
Buckley R: Calcaneal fractures: to fix or not to fix: nonoperative approach. J Orthop Trauma 19:357, 2005; Buckley
RE et al: Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 12:172, 2004; Court-Brown CM et
al: Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg
Br 84:504, 2002; Court-Brown CM et al: The translated two-part fracture of the proximal humerus. Epidemiology
and outcome in the older patient. J Bone Joint Surg Br 83:799, 2001; Csizy M et al: Displaced intra-articular calcaneal
fractures: variables predicting late subtalar fusion. J Orthop Trauma 17:106, 2003; Doornberg JN et al: Coronoid
fracture patterns. J Hand Surg [Am] 31:45, 2006; Epstein CD et al: Oxygen transport and organ dysfunction in the
older trauma patient. Heart Lung 31:315, 2002; Gallagher SF et al: The role of cardiac morbidity in short- and long-
term mortality in injured older patients who survive initial resuscitation. Am J Surg 185:131, 2003; Horn BD et al: Radiologic
evaluation of juvenile tillaux fractures of the distal tibia. J Pediatr Orthop 21:162, 2001; Kaya A et al: Open
reduction and internal fixation in displaced juvenile Tillaux fractures. Injury 38:201, 2007; Kingwell S et al: The association
between subtalar joint motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures.
Foot Ankle Int 25:666, 2004; Longino D et al: Bone graft in the operative treatment of displaced intraarticular
calcaneal fractures: is it helpful? J Orthop Trauma 15:280, 2001; Loucks C et al: Bohler's angle: correlation with outcome
in displaced intra-articular calcaneal fractures. J Orthop Trauma 13:554, 1999; Meldon SW et al: Trauma in the
very elderly: a community-based study of outcomes at trauma and nontrauma centers. J Trauma 52:79, 2002; Perdue
PW et al: Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of
delayed death. J Trauma 45:805, 1998; Pugh DM et al: The "terrible triad" of the elbow. Tech Hand Up Extrem Surg
6:21, 2002; Ring D et al: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint
Surg Am 84-A:547, 2002; Sugimoto K et al: Geriatric trauma patients at a suburban level-I trauma center in Japan.
Prehosp Disaster Med 14:186, 1999; Wijgman AJ et al: Open reduction and internal fixation of three and four-part
fractures of the proximal part of the humerus. J Bone Joint Surg Am 84-A:1919, 2002.
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