FRACTURES AND FIXATION
Featuring selections from the University of California, San Francisco, School of Medicine’s Orthopaedic Trauma
Course
Educational Objectives
| The goal of this program is to improve management of fractures. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Fix proximal humerus fractures.
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| 2. Determine which distal radius fractures require fixation.
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| 3. Repair periprosthetic fractures after total hip arthroplasty.
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| 4. Treat clavicle fractures.
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| 5. Manage elbow fracture dislocations.
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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 following has been
disclosed: Dr. McKee—Biotein (research support); Stryker (research support; consultant); Zimmer (consultant); Dr.
Rosenwasser—Stryker (consultant); Bionet (consultant). Dr. Meinberg and the planning committee reported nothing
to disclose.
Acknowledgments
Drs. McKee, Rosenwasser, and Meinberg were recorded at Orthopaedic Trauma Course, held May 1-3, 2008, in San
Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest
Foundation thanks the speakers and UCSF School of Medicine for their cooperation in the production of this program.
| PROXIMAL HUMERUS FRACTURES: IS THE FIXATION PROBLEM RESOLVE D?—Michael D. McKee,
MD, Professor, Division of Orthopaedics, Department of Surgery, University of Toronto, Faculty of Medicine, Toronto,
ON
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| Answer: “no, unfortunately”; lecture explains why
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| Problems: exposure difficult; osteoporotic bone; significant deformity; local anatomy unfavorable for complications;
consistent classification; lack of trials for guidance
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| Open reduction and internal fixation: nonunion; malunion; proximal hardware migration; impingement; avascular
necrosis; infection
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| Minimally invasive techniques: results less successful than advertised
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| Conventional fixation: indicated in young active patients; indications in elderly in doubt
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| First shot best shot: secondary reconstruction significantly less favorable than primary intervention
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| Locking plates: introduced to alleviate previous problems; angle-stable fixation—screws set relative to plate; prevents
toggle; improves fixation; prevents varus collapse with time
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| Clinical impact: early results promising; subsequent results in elderly less than desired; compared to standard fixation,
improvement only 19% (not enough to withstand fall or seizure in elderly); most papers show complications
(eg, hardware cut-out, loss of reduction) similar to previous methods; unique complication in osteoporosis—
solid fixation stays in place as osteoporotic humeral head collapses around it; late screw penetration rates ≤25%
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| Conclusions: select operative patients carefully; ensure selected patient has reasonable rehabilitation potential
(compliance essential); concentrate on principles such as reducing fracture while trying to repair; will be useful
adjunct; comparative studies needed
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| DISTAL RADIUS FRACTURES: WHICH ONES DO WE FIX ?—Melvin P. Rosenwasser, MD, Robert E. Carrou
Professor of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, and Chief, Orthopaedic
Hand and Trauma Service, Columbia University Medical Center, New York, NY
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| Approach to patients: depends on health, expectations, activity level, and whether patient can live with informed-
consent decisions about deformity
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| Fractures: closed reduction should be attempted in all; instability can be defined on x-rays; x-rays provide basis for
discussion with geriatric (>65 yr of age) patients (inform patients of presence [but also possible insignificance]
of malunion; patients can choose whether they can live with deformity); malunion main reason for malpractice
lawsuits in New York State
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| Patient satisfaction: depends on ability to make full fist, close hand, and supinate palm
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| External fixation: requires augmentation with some other device, eg, K-wire and/or metaphyseal bone support
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| Anatomy: radial length and distal radial joint congruence important; leaving wrist in 30° of dorsal tilt provides little
palmar flexion
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| Stability question: used Lafontaine’s criteria for stability; patients have osteoporosis and severe comminution; closed
reductions not maintained
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| Recommended parameters: ≤10° of dorsal tilt; ≤2 mm of shortening; not backed by evidence-based studies
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| Options: plaster; pins; plating; bone graft substitute needed with external fixation
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| Articular fractures: with carpal translation; closed reduction inadequate
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| Acceptable closed reduction: congruent joint; <4 mm of shortening; carpus aligned with radius; stable distal radius
articular joint
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| Dissenting voices: if patient cannot understand benefits of repositioning of fracture, “why bother?”; capability of
plating fractures vs necessity for plating (ie, “treat the patient, not the x-ray”)
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| Speaker’s conclusions: some of dorsal tilt correctable; all such cases deserve closed reduction; not possible to
maintain first closed reduction; inform patient malunion inevitable; latest literature shows, in extra-articular cases,
relative risk for poor outcome with malunion diminished in older patients (ie, some of worst looking x-rays had
good outcomes); speaker asserts intra-articular fractures with diastasis or carpal translation should be fixed in older
population, using augmented external fixation
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| PERIPROSTHETIC FRACTURES: TOTAL HIP ARTHROPLASTY —Eric G. Meinberg, MD, Clinical Assistant
Professor of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill
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| Predictions: currently ≈300,000 joint replacements per year; 3.5 million total joint replacements per year expected
by year 2035 (673% increase), and ≈600,000 total hip replacements/yr (174% increase); periprosthetic fractures
now occur in ≈1% to 3% of primary joint replacements and in ≤6% of revisions; risk expected to grow due to more
joint replacements in younger patients, worsening comorbidities (eg, obesity, diabetes), and longer patient lifespans
(ie, longer survivorship of joints)
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| Associated problems: 11% mortality at 1 yr after fixation; presence of femoral implants limits fixation options;
poor bone quality
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| Advantages: options increasing; walking periarticular implants; cable plates; cables and allografts; revision surgery
also option in older patients
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| Postoperative implications: early weight-bearing often possible and necessary; immediate range of motion attainable;
rate of union 80% to 100%
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| Vancouver classification: type A—greater or lesser trochanter; type B1—near tip of well-fixed stem; type B2—
around loose stem; type B3—around femur with smooth-bore bone stock around proximal femur; type C—well
below, in well-fixed stem
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| Nonoperative management: nondisplaced fractures, eg, splits in lesser trochanter; missed but managed perioperatively
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| Operative management usually required: high rate of complications—25% to ≤50% nonunion rate; 50% to
100% revision rate; high rate of malunion; stiffness in joint; complications from prolonged immobilization
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| Goals of surgery: regain alignment; attempt to restore length; restore function to preinjury level; obtain union
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| Type A fractures: intra- or perioperative; due to poor bone stock, excessive bone resection, or aggressive handling
of femur; treatment—stabilization plates; abduction (bracing); lesser trochanter (cerclage cable for nondisplaced
split; collared stem); choice of stem—collared cemented or diaphyseal-fitted press-fit
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| Type B1 fractures: at or near tip of stem; relatively rare; treatment—longer stem revision (fully beaded press-fit
or cemented); ≈2 cortical diameters past fracture; open reduction and internal fixation (ORIF) with retention of
stem; use longest plates possible; cerclage proximally; unicortical screws available
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| Type B2 fractures: common; femoral component loose; treatment—careful preoperative planning; ORIF; revise
loose stem; acetabular revision possible
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| Operative technique: plate with or without allograft; work through fracture; pull out cement from distal tip of fracture;
tap out implant (retrograde direction); rebuild femur around provisional stem; use flat-top table and C-arm;
insert stem; vary length of implants to avoid stress risers
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| Type B3 fractures: extraordinarily difficult; occur around stem with significant proximal bone loss; treatment—
revision with cortical strut and plate; proximal femoral allograft
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| Type C fractures: occur distal to stem; treatment—ORIF with locking plate (retaining stem); bicortical screws
safe through cement mantle
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| CLAVICLE FRACTURE S—Dr. McKee
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| Characteristics: completely displaced fractures of midshaft of clavicle represent minority of clavicle fractures; occur
in otherwise healthy individuals; pattern—distal fragment driven inferiorly; translated medially; vertical piece
creates Z pattern; distal piece rotated anteriorly
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| Reasons to repair (ie, plate): nonunion rate not 1% (as speaker was taught), but actually 15% to 20%; some
malunions symptomatic; immediate fixation slightly superior to late reconstruction; ORIF provides early return to
activities
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| Study finding: Hill and Crosby (1999) evaluated 60 to 70 consecutive patients; patient-based assessment found
≈33% of patients thought outcome poor; nonunion rate 15%; degree of deformity associated with degree of nonunion
and symptomatic malunion
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| Meta-analysis by speaker: included 2000 fractures and 8 to 10 papers; nonunion rate 15.1% with nonoperative
treatment; nonunion rate corresponds to degree of displacement or comminution
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| Clinical experience: patients with significant radiographic nonunion complained of easy fatigability of shoulder,
difficulty with overhead work because of thoracic outlet syndrome, and malpositioning of scapula; osteotomy restores
acceptable function
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| Does delay matter? recent publication by speaker looked at delayed vs early reconstruction; involved 15 patients
with malunion or nonunion ≈60 mo after injury; matched group underwent operative repair at mean of 2 wk after injury;
opposite arm used as control; findings—muscle recovery much better in early fixation group; significant problem
with muscle strength in delayed fixation group; Constant score 5 to 7 points higher (statistically significant) in
early group
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| Randomized clinical trial: speaker’s study compared sling treatment to plate fixation; 111 patients completed
study (49 in nonoperative group; more of these patients lost to follow-up); multicenter trial; findings—early
marked improvement in Constant store for operative group (patients felt better, used less medication, and returned
to work and sports quicker) and statistically significant improvement up to 1-yr follow-up; patient-oriented disabilities
of arm, shoulder, and hand (DASH) score dramatically better in operative group; nonoperative group—9 of
49 patients had symptomatic malunion; 7 nonunions (≈15%, as expected); complication—irritation around
straight plate; contoured plates fit better; unpublished study—confirmed results
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| Conclusion: ORIF decreases nonunion rate from 15% to ≤2%, and symptomatic malunion rate from 20% to ≤2%;
early fixation ≈5% to 10% better than delayed reconstruction (patients informed of this statistic); ORIF cosmetically
equal or superior to nonoperative care
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| ELBOW FRACTURE DISLOCATIONS —Dr. McKee
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| Basis of elbow stability: 50% soft tissue constraints; 50% bony congruity; 95% of elbow instability posterior; supporting
bony structures in front most important
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| Bony constraints: coronoid process of ulna; radial head; restore proper position to obtain stability; radial head becomes
more important if primary constraints lost
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| Soft tissue structures: collateral ligaments
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| Medial collateral ligament: sports-related throwing injuries received most attention in past; often injured in elbow
fracture dislocations (however, not predominant soft tissue structure in elbow as previously thought)
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| Lateral ulnar collateral ligament: refers to thickening of lateral capsule; most important soft tissue structure for stability;
runs from lateral epicondyle to tubercle of supinator crest; almost always injured in trauma; resists varus
and rotation stress
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| Simple dislocations: closed reduction; concentric and stable; early motion
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| Fracture (complex) dislocations: nonconcentric and nonstable; eg, radial head or coronoid fracture; most require
operative treatment (elderly or infirm patients possible exceptions)
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| Concentricity and stability: goal of surgery that joint moves and functions well, without pain; concentricity—line
bisecting radial lead lines up with capitellum in every x-ray view; ulnohumeral joint appears concentric;
stability—elbow stays in joint through functional range of motion (30°-130°)
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| Simple dislocations: most do not require surgery (based on clinical experience); trial found no advantage to surgery;
exception—some reductions nonconcentric; promptly redislocate or resubluxate
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| Terrible triad: dislocation, with fracture of coronoid and radial heads; results of conventional treatment—in type
3 coronoid fractures, incidence of good results ≈20%; poor results in 8 of 11 patients; poor results in 7 of 11 patients
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| Speaker’s technique: fix coronoid if large enough or repair anterior capsule; fix or replace radial head (metal; modular
[enables adjustments for proper dimensions]); repair lateral-collateral ligament or common extensor origin;
if necessary, repair medial side; if all else fails—hinged fixator
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Suggested Reading
Altamimi SA et al: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.
Surgical technique. J Bone Joint Surg Am 90 Suppl 2:1, 2008; Bhandari M et al: Four part fractures of the
proximal humerus. J Orthop Trauma 18:126, 2004; Cook RE et al: Risk factors for periprosthetic fractures of the
hip: a survivorship analysis. Clin Orthop Relat Res 466:1652, 2008; Epub 2008 May 10.Herrera M et al: Treatment
of unstable distal radius fractures with cancellous allograft and external fixation. J Hand Surg [Am] 24:1269,
1999; Hill JM et al: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone
Joint Surg Br 79:537, 1997; Kim RY et al: Internal fixation of distal radius fractures. Am J Orthop 36:2, 2007; Kumar
V et al: Less invasive stabilization system for the management of periprosthetic femoral fractures around hip
arthroplasty. J Arthroplasty 23:446, 2008; McKee MD et al: Deficits following nonoperative treatment of displaced
midshaft clavicular fractures. J Bone Joint Surg Am 88:35, 2006; McKee MD et al: Midshaft malunions of
the clavicle. J Bone Joint Surg Am 85-A:790, 2003; McKee MD et al: Midshaft malunions of the clavicle. Surgical
technique. J Bone Joint Surg Am 86, 2004; McKee MD et al: The pathoanatomy of lateral ligamentous disruption
in complex elbow instability. J Shoulder Elbow Surg 12:391, 2003; Potter JM et al: Does delay matter? The restoration
of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed
reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg 16:514, 2007; Ring D et
al: The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal
humerus. J Shoulder Elbow Surg 10:501, 2001; Zdero R et al: Biomechanical evaluation of periprosthetic femoral
fracture fixation. J Bone Joint Surg Am 90:1068, 2008.
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