Peter V.

Giannoudis
Editor

Fracture Reduction and

Fixation Techniques

Upper Extremities

123
Fracture Reduction and Fixation
Techniques
Peter V. Giannoudis
Editor

Fracture Reduction and

Fixation Techniques
Upper Extremities
Editor
Peter V. Giannoudis
School of Medicine
University of Leeds
Leeds
Yorkshire
United Kingdom

ISBN 978-3-319-68627-1    ISBN 978-3-319-68628-8 (eBook)

https://doi.org/10.1007/978-3-319-68628-8

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Preface

Fracture fixation techniques have continued to evolve since their introduction

in the 1950s by the AO Group in Switzerland. Advances made in metallurgy,
implant design, targeting devices, surgical instruments, radiology and func-
tional anatomy and the better understanding of fracture healing led to the
modern practising techniques. Preoperative planning became a routine step
of every fixation case. Moreover, it was recognised that optimal fracture
reduction prior to fixation is a key element facilitating bone repair and a sat-
isfactory anatomical and functional outcome. There is plenty of scientific evi-
dence available that suboptimal fracture reduction is often associated with
complications such as implant failure, impaired healing, malunion and early
onset of osteoarthritis, amongst others.
This highly illustrated textbook is written by a panel of experts in the
upper limb, who share tips and tricks that will aid in achieving an optimal
reduction and fixation of different fracture types whilst avoiding common
pitfalls.
Each technique is clearly demonstrated using a stepwise approach with
real-time intraoperative photographs, improving the understanding and
ensuring the production of an easy-to-read, memorable textbook.
Each chapter in this book includes an outline of useful techniques for
­fracture reduction. Its objective is to provide orthopaedic surgeons and espe-
cially those still in training with a quick reference to common reduction tech-
niques becoming an essential guide to their practice. The ultimate goal is to
improve the standards of care of our patients.

Leeds, UK Peter Giannoudis

v
Contents

Part I  General Considerations

1 Fracture Healing: Back to Basics and Latest Advances������������    3

Ippokratis Pountos and Peter V. Giannoudis
2 Instruments Used in Fracture Reduction������������������������������������   19
Ippokratis Pountos, K. Newman, and Peter V. Giannoudis
3 Direct and Indirect Reduction: Definitions, Indications,
and Tips and Tricks ����������������������������������������������������������������������   31
Stuart Aitken and Richard Buckley

Part II  Innovations in Fracture Reduction

4 Innovations in Fracture Reduction

Computer-Assisted Surgery����������������������������������������������������������   43
Rami Mosheiff and Amal Khoury
5 Inflatable Bone Tamp (Osteoplasty)
for Reduction of Intra-articular Fractures����������������������������������   51
Peter V. Giannoudis and Theodoros Tosounidis
6 Innovations in Fracture Reduction: Poller Screws ��������������������   59
Theodoros H. Tosounidis and Peter V. Giannoudis
7 Assessment of Reduction ��������������������������������������������������������������   69
David J. Hak
8 General Principles of Preoperative Planning������������������������������   77
Charalampos G. Zalavras

Part III  An Anatomical Based Approach: Upper Extremity

9 Acromioclavicular Joint Dislocation��������������������������������������������   89

Paul Cowling
10 Sternoclavicular Joint Dislocations����������������������������������������������   93
Harish Kapoor, Osman Riaz, and Adeel Aqil

vii
viii Contents

11 Clavicle Fracture����������������������������������������������������������������������������   97

Makoto Kobayashi and Takashi Matsushita
12 Scapula Fractures��������������������������������������������������������������������������  101
David Limb
13 Humeral Head Avulsion of Greater Tuberosity��������������������������  109
Mark Philipson
14 Fractures of Proximal Humerus Open Reduction
and Internal Fixation��������������������������������������������������������������������  113
Harish Kapoor, Adeel Aqil, and Osman Riaz
15 Humeral Shaft Fractures
(Transverse, Oblique, Butterfly, Bifocal) ������������������������������������  121
Anthony Howard, Theodoros Tosounidis,
and Peter V. Giannoudis
16 Distal Humerus Fracture��������������������������������������������������������������  133
Stefaan Nijs
17 Olecranon Fractures����������������������������������������������������������������������  143
Odysseas Paxinos, Theodoros H. Tosounidis,
and Peter V. Giannoudis
18 Coronoid Fractures������������������������������������������������������������������������  151
Mark Philipson
19 Radial Head and Neck Fracture ��������������������������������������������������  157
Austin Hill and David Ring
20 Monteggia Fracture and Monteggia-Like Lesion – Treatment
Strategies and Intraoperative Reduction Techniques����������������  163
Dorothee Gühring and Ulrich Stöckle
21 Forearm Fractures ������������������������������������������������������������������������  173
Katharina Sommer and Ingo Marzi
22 Galeazzi Fracture��������������������������������������������������������������������������  191
Theodoros H. Tosounidis and Paul J. Harwood
23 Distal Radius Fracture������������������������������������������������������������������  201
Georg Gradl
24 Distal Ulna Fractures��������������������������������������������������������������������  227
Tristan E. McMillan and Alan J. Johnstone
25 Scaphoid Fracture��������������������������������������������������������������������������  237
Anica Herlyn and Alice Wichelhaus
26 Perilunate Dislocation��������������������������������������������������������������������  247
Laurent Obert, Francois Loisel, and Daniel Lepage
Contents ix

27 Metacarpal Fractures��������������������������������������������������������������������  255

Sam Vollans
28 Bennett Fracture and Fracture of 
Trapeziometacarpal Joint of the Thumb ������������������������������������  261
Laurent Obert, Gauthier Menu, Daniel Lepage,
and Francois Loisel
29 Hand-Phalanx Fracture-­Dislocation (PIP Joint)������������������������  271
Laurent Obert, Margaux Delord, Gauthier Menu,
Damien Feuvrier, Isabelle Pluvy, and Francois Loisel

Index��������������������������������������������������������������������������������������������������������   277
 Part I
General Considerations
 Fracture Healing: Back to Basics
and Latest Advances 1
Ippokratis Pountos and Peter V. Giannoudis

The research on bone biology and healing over It prerequisites the coordinated interplay of
the last decades has been intense. The reason for ­multiple cell types with local and systemic cyto-
this high research output can be attributed to two kines, chemokines, and growth factors. This local
elements: firstly, the discovery of mesenchymal milieu is influenced and often regulated by the
stem cells (MSCs), a population of multipotent mechanical forces exerted locally. Bone healing
stem cells found to reside in bone marrow (and in can be divided into primary and secondary types
many other tissues within the body), which of healing.
opened new avenues in tissue engineering
approaches for bone regeneration, and secondly,
the discovery and commercialization of mole- Primary
cules that can upregulate bone repair mecha-
nisms. The aim of this chapter is to present the Primary bone healing occurs when there is a
key aspects of bone healing biology, factors that small fracture gap and absolutely no movement
can influence it adversely, and key strategies at the fracture site. The discovery of this type of
found to enhance the healing of fractures. healing occurred over a century ago with the
introduction of stable internal fixation [1]. It
was initially called “healing by primary inten-
Types of Bone Healing tion” and subsequently “soudure autogène,” but
following histopathologic studies, the terms
Bone healing is a well-orchestrated complex “direct” and “primary” bone healing were
process that results in the reconstitution of bone established [2]. Primary bone healing is the
continuity without the formation of scar ­tissue. same process as the normal bone remodeling.
Bone production and apposition to fill the frac-
ture gap occur by the osteoblasts, in the same
I. Pountos, M.B., M.D., E.E.C. way that the Howship lacunae are filled after
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK the action of “cutting cones.” It occurs in cases
where anatomic reduction and rigid internal
P.V. Giannoudis, M.D., F.R.C.S. (*)
Academic Department of Trauma and Orthopaedics, fixation are achieved or in incomplete stable
School of Medicine, University of Leeds, Leeds, UK cracks of the bone. Fragment end resorption
NIHR, Leeds, UK does not occur and no callus is formed. This
form of bone healing is less frequent. The
Musculoskeletal Biomedical Research Center, Chapel
Allerton Hospital, Leeds, UK majority of fractures heal through secondary
e-mail: pgiannoudi@aol.com bone healing.
© Springer International Publishing AG 2018 3
P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_1
4 I. Pountos and P.V. Giannoudis

Secondary Bone Healing first and possibly the most important determinant
of the healing outcome. Several animal studies
Secondary bone healing is the type of healing have shown that removing the fracture hematoma
that occurs in the absence of rigid fixation. It rep- leads to an arrest of the healing process. Equally,
resents an organized pattern of interlinked events when fracture hematoma is injected in ectopic
that aim to activate a number of different cell sites, osteogenesis follows.
types to prepare the fracture site for its consolida- During fracture hematoma formation, a num-
tion, to restore the vascularity, to produce a stable ber of changes of the local microenvironment
mechanical environment, and once successful to occur. The disruption of blood supply leads to a
conclude with the ossification of the area. It has significant drop of the oxygen availability. The
been previously proposed that this type of heal- low local oxygen saturation changes the genetic
ing occurs in three phases: the inflammatory, expression of osteoprogenitor cells, promoting
reparative, and remodeling phases. These gener- their proliferation, formation of extracellular
alized phases include a number of events, which matrix, and differentiation toward chondrocytes
are often overlapping. A more comprehensive [3, 4]. This environment also induces the release
description is that of the six stages of bone heal- of several inflammatory molecules, collagen, as
ing. Based on this descriptive system, healing well as angiogenic and osteogenic growth fac-
starts at the time of the injury with the formation tors. In addition to the hypoxia, the CO2 exuda-
of fracture hematoma, followed by the inflamma- tion from the dead and dying cells, the production
tory stage, which concludes with the formation of of lactic acid, and the conversion of blood sugars
granulation tissue. Then, the formation of the soft make the local microenvironment acidic. This
callus occurs that eventually calcifies and remod- acidic environment favors osteoclast resorptive
els (Figs. 1.1 and 1.2). activity, and the levels of calcium increase by ten-
fold compared to peripheral circulating levels.
Fracture Hematoma Phosphorous, alkaline phosphatase, lactic acid,
The formation of fracture hematoma represents a and beta and gamma globulins are also elevated
distinct stage of the bone healing process. It is the in fracture hematoma [5].

Fig. 1.1  The stages of Haematoma

secondary bone healing Granulation tissue
Activation of
coagulation cascade Active proliferation
Changes of local of osteoprogenitor
cells
environment Angiogenesis
Inflammatory cells
and molecules Extracellular matrix
released production
Inflammation
Recruitment and
activation of
inflammatory and
osteoprogenitor cells
Clearance of necrotic
tissues
Callus formation Remodeling
Soft and Hard Long process
Differentiation of (years)
MSCs according to Resorption of
the mechanical remaining cartilage
environment
Restoration of
Initial stabilization Haversian system
of fracture, then No scar formed
replaced by
calcified tissue
1  Fracture Healing: Back to Basics and Latest Advances 5

Hours 2d 7d 14d 21d 6w-years

Clot

Inflammation

MSC
proliferation

Angiogenesis

MSC
differentiation

Bone formation
and remodeling

Fig. 1.2  Evolution of fracture healing over time

Inflammatory Stage a­nti-inflammatory (IL-10) molecules are sig-

An adequate inflammatory phase is a pre- nificantly increased. Within the first week after
requisite for successful bone healing [6, 7]. the fracture, the fracture site develops an osteo-
The inflammatory stage is activated after the genic identity.
hematoma formation and serves mainly two
purposes. Firstly, it prepares the site for the Granulation Tissue
upcoming healing process and secondly elicits Once the inflammatory stage expires, the area of
pain that forces the individual to immobilize the the fracture site is organized forming the granula-
affected limb. A large number of cells invade tion tissue. The granulation tissue is a loose
the fracture site attracted by the numerous aggregate of cells (mainly mesenchymal, endo-
inflammatory molecules. Polymorphonuclear thelial, and immune cells) scattered inside an
leukocytes, lymphocytes, blood monocytes, extracellular matrix. Mesenchymal stem cells
and macrophages are present and release cyto- from the periosteum and adjacent tissues are seen
kines. They exert chemotactic effect, recruiting in the granulation tissue [12]. The fibrin deposits
further inflammatory and mesenchymal cells, are removed by macrophages and through the
and stimulate angiogenesis, enhancing extra- actions of fibrinolytic enzymes. There is a signifi-
cellular matrix synthesis. RUNX1 (runt-related cant mitogenic activity at the area, which is sup-
transcription factor 1) expression predominates ported by the formation of new small blood
which is important for the proliferation of the vessels.
hematopoietic stem cells and osteoprogeni-
tor cells [8]. TNF-α plays an important role in Soft Callus
the inflammatory stage, as it is significantly Soft callus is closely related to the formation of
upregulated. Absence of TNF-α delays fracture cartilage through endochondral ossification.
healing, while excessive amounts destroy the Endochondral ossification can be seen as an
bone [9, 10]. A number of cytokines are pres- attempt of the body to improve the stability at the
ent, but their exact role is still largely obscure. fracture site, allowing the ossification process to
Interleukin-17 (IL-17) has a dual effect enhanc- commence. The soft callus extends throughout
ing osteogenic output but also bone resorp- the fracture gap connecting the ends of the bone.
tion by the osteoclasts [11]. The levels of This process is similar to the bone growth
many inflammatory (IL-6, IL-8, IL-12) and observed in the growth plate. Chondrocytes start
6 I. Pountos and P.V. Giannoudis

preparing cartilage and extracellular matrix. The Remodeling

cellular density is significantly higher to that of The remodeling stage is the final stage of second-
healthy articular cartilage but its organization is ary bone healing that can last for many years. It
different [13]. In addition to chondrocytes, fibro- represents a gradual modification of the architec-
blasts start laying down stroma that helps and ture that ultimately reestablishes the typical
supports vascular ingrowth. It has been previ- osteon structure and the haversian system of the
ously shown that smoking adversely affects this bone [19]. This is done under the same mechani-
particular aspect of bone healing, i.e., vascular cal stresses involved in the normal remodeling of
ingrowth [14, 15]. the bone [20]. The end result resembles the pre-­
fracture state of the bone.
Hard Callus
Hard callus is synonymous to the formation
of woven bone. Depending on the stability of Factors Affecting Bone Healing
the fracture site, woven bone can be formed
immediately after the formation of granula- The last century was characterized by a revolu-
tion tissue through intramembranous ossifi- tion in our understanding of bone biology and
cation (stable fracture), or it can follow the fracture management. Among the pioneers are
endochondral ossification. During the intra- the members of the Arbeitsgemeinschaft für
membranous ossification, osteoprogenitor cells Osteosynthesefragen (AO) group who identified
differentiate directly to osteoblasts, without some of the key principles governing fracture
the formation of cartilage as an intermediate management, such as (1) accurate anatomical
step. In less stable fractures, the cartilage pre- reduction, (2) rigid internal fixation, (3) sound
viously formed by chondrocytes is replaced by atraumatic surgical technique, and (4) respect for
the bone. Irrespectively of the route followed, the soft tissue envelope. A number of factors
osteoblasts release vesicles that contain cal- have been found to interrupt the normal flow of
cium phosphate complexes into the matrix [16]. the bone healing process. These factors can be
They also release enzymes that degrade the pro- broadly divided in fracture or injury dependent
teoglycan-rich matrix and hydrolyze phosphate and patient dependent (Table 1.1).
esters to provide phosphate ions for precipita-
tion with calcium [17]. The transition from
cartilage formation to bone formation is not yet
Table 1.1  Factors affecting bone healing
fully elucidated. The simplest theory is based
on the property of cells of mesenchymal origin Local factors Systemic factors
to swap fates and become a different cell types. • Location • Age
•  Type of the fracture • Metabolic state and
It was previously shown that fully differenti- •  Fracture gap nutrition
ated osteoblasts with detectable alkaline phos- • Bone • Vitamins and mineral
phatase activity and elaboration of calcified loss—comminution deficiencies
extracellular matrix can redifferentiate to other • Degree of local •  Smoking, alcohol
trauma (injury and •  Systemic diseases
cell types like adipocytes and vice versa. This iatrogenic) –  Diabetes
phenomenon is termed genetic reprogramming •  Blood supply –  Vascular disease
or transdifferentiation. Another hypothesis sug- •  Method of fixation – Cancer—radiotherapy
gests that chondrocytes became engulfed in the • Level of fracture • Drug
stability •  Corticosteroids
newly formed matrix, stop producing cartilage, • Presence of •  NSAIDs
and eventually die [18]. Chondrocyte cell death infection, foreign •  Antibiotics
seems to occur at the border of the soft callus, material, debris, •  Anticoagulants
just within the newly produced matrix [18]. dead tissue •  Antineoplastic
1  Fracture Healing: Back to Basics and Latest Advances 7

Patient Dependent as well as the cellular flow to the fracture site.

Nutrient and systemically released molecule
Age and Gender availability can be compromised. Literature has
shown that in such situations, i.e., compromised
Patient’s gender does not increase the risk of peripheral blood supply, inhibition of the bone
delayed healing or non-union. Males, however, healing process can occur [30]. A circulatory
have an increased risk of complications with assessment should always be performed in
healing due to the higher incidence of high-­ patients that have sustained a fracture especially
energy fractures. those with vascular disease.
Children heal faster than adults and a non-­ Increased healing times and higher risk of
union is a rare occurrence [21, 22]. Children non-union have been demonstrated in patients
have a higher regeneration potential and thick with diabetes. Growth factors like the VEGF and
periosteum and form large subperiosteal hema- TGF-β were found to be reduced in diabetes, and
toma [21]. These factors contribute to the rapid insulin availability seems to be an important fac-
formation of callus (seen in children) [21, 22]. tor during bone healing [31]. The effective man-
In adults, animal and experimental models have agement of diabetes in these patients is critical to
shown that bone healing potential declines with minimize the potential complications [32].
age [23]. Some clinical studies have shown that Hypothyroidism has been found to inhibit
age is a negative predictor for healing in specific endochondral ossification and delay bone healing
fracture types like fractures of the clavicle and [33]. As undiagnosed hypothyroidism is quite
hip [24, 25]. However, whether this increased prevalent in the general population (approxi-
risk is related to the age per se or is related to mately 5%), screening in high-risk patients
the increased number of comorbidities seen in should be performed [34].
elderly is yet to be further elucidated [26]. Anemia is associated with significant defi-
ciencies in bone healing. This has been evident
in both clinical and animal studies [35]. These
Comorbidities findings have been attributed to the availability
of oxygen at the fracture site and the impair-
Malnutrition and metabolic deficiencies repre- ment of cellular functions like the production of
sent major risk factors for unsuccessful bone collagen [36].
healing. In addition to the general health state, Other comorbidities that have been associated
the patient’s body should be able to cope with with an impairment of bone healing include renal
the increased metabolic requirements [27]. disease, rheumatoid arthritis (possibly related to
Deficiencies in calcium, phosphorus, vitamins the use of steroids), and obesity [37].
C and D, albumin, and proteins were all shown
to affect bone healing and functional recovery
following a fracture [28, 29]. These parameters Drug Administration
should be checked and corrected in all high-risk
patients. The antineoplastic drugs have strong antiprolif-
Following a fracture, the local trauma and erative and cytotoxic properties. They inhibit
swelling impair the blood supply to the fracture angiogenesis and callus formation and result in
site. In patients with peripheral vascular disease, higher non-union rates [38]. Similarly, antiangio-
blood supply is already compromised resulting in genesis agents have a detrimental effect on frac-
a critical supply to the bone and soft tissue ture healing, and the final outcome resembles
­envelope. The oxygen transport can be reduced atrophic non-union [39].
8 I. Pountos and P.V. Giannoudis

Corticosteroid administration leads to osteo- doses were found to interfere with the early
blast apoptosis, osteocyte apoptosis, and i­ nhibition stages of bone healing in small animal models
of osteoblastogenesis. Patients on long-term ste- [47]. Other drugs like tobramycin, rifampicin,
roids are likely to suffer of low bone mass and and gentamicin were also found to downregulate
have a higher incidence of fractures [40]. During the functions of osteoblasts [48]. Combinations
bone healing the length of corticosteroid admin- of antibiotics could be detrimental in osteopro-
istration and dose are two critical parameters. genitor proliferation and differentiation, although
Prolonged administration and high doses seem the same antibiotics in isolation do not exhibit
to be detrimental for bone healing. Smaller doses significant effects. Often underestimated are the
can downregulate fracture healing as well; hence, kinetics of antibiotics loaded on cement which
the clinicians should decide on risks versus the can reach concentrations 1000-fold higher that
benefits basis [41]. In addition to corticosteroids, the systemically applied ones. Such high doses
disease-modifying drugs like methotrexate are were shown to have detrimental effects on bone
widely used for the treatment of chronic diseases. cells biology.
The available evidence is limited and mainly Anticoagulants are prescribed in the majority
related to methotrexate. Methotrexate seems to of hospitalized and non-weight-bearing patients
have a dose-dependant effect on experimental to prevent deep venous thrombosis. Studies that
studies with low doses being relatively safe [42]. evaluate their direct effect on human osteopro-
The clinical case series presenting bone healing genitor cells, quite uniformly, suggest that they
complications are related to higher doses similar reduce the proliferation and differentiation poten-
to the ones used in cancer treatment [43]. There tial of osteoprogenitor cells and several osteogenic
is limited evidence in regard to the remaining markers like BMP-2 and IGFs [49]. With regard
disease-­modifying drugs [42]. to the in vivo experimental studies, contradictory
Nonsteroidal anti-inflammatory drugs results exist; some studies suggest that anticoagu-
(NSAIDs) are effective medications for the man- lants can impair bone healing, while others con-
agement of acute musculoskeletal pain. They tradict these results [50]. At present there are no
block the cyclooxygenase activity and inhibit the clinical studies to address this in humans [53].
synthesis of prostaglandins, which are potent
mediators of pain and inflammation [20]. Their
analgesic effect in patients with fractures has Smoking and Alcohol
been graded equal to that of stronger opiates [20].
The numerous experimental studies available are Smoking has several adverse effects on the
inconclusive and present diverse and contradict- human skeleton. It decreases the proliferative
ing results [20]. With regard to the clinical stud- capacity of osteoblasts, reduces the overall bone
ies, there is sufficient evidence to suggest that mineral density, increases the rate of hip frac-
NSAIDs can inhibit bone healing and the forma- tures, and decreases its healing capacity [51].
tion of heterotopic bone [44, 45]. Non-union risk Currently several hypotheses exist for the mode
was shown to double or even triple among vari- of action of tobacco smoking on the skeleton;
ous studies [46]. In balance of evidence, it seems reduced blood supply, increase of oxygen inter-
judicious to avoid exposure to NSAIDs in patients mediates, interference with arteriole receptors,
with fractures. and inhibition of vitamins are all potential path-
Antibiotics play an important role in trauma ways [52]. The vast majority of orthopedic litera-
care and fracture management. They are most ture highlights the importance of ceasing smoking
frequently administered systemically but also with clinical studies uniformly showing that
applied locally, usually loaded onto the bone smoking delays bone healing, significantly
cement. Current literature is rather insufficient to increases the risk of non-union and, and at least
allow a clear statement on whether they inhibit doubles the risk of infection in patients undergo-
bone healing. Fluoroquinolones at therapeutic ing surgery [53].
1  Fracture Healing: Back to Basics and Latest Advances 9

Chronic alcohol consumption induces osteo- Fracture Dependent

penia and increases the risk of falls. Alcohol is
found to downregulate bone formation through a In addition to the patient-dependent factors,
dose-dependant adverse effect on the functions of local factors related to the injury are important.
osteoblasts. It is of great interest that Saville have Among them, the fracture personality, location,
shown that the bone density measured in the left extent of soft tissue damage, and fixation
iliac crest of alcoholics below 45 years of age method are critical elements for the bone heal-
was similar to that of nonalcoholic men and ing process.
women older than 70 years [54]. In addition,
alcohol inhibits the proliferation and differentia-
tion of MSCs as well as the production of ossified Fracture Personality and Location
bone matrix [55]. Clinical studies have shown
that alcoholism is associated with osteomalacia, The orientation of the fracture line and the
impaired fracture healing, and aseptic necrosis underlying bone are two factors that can influ-
(primarily necrosis of the femoral head) [55]. ence the bone healing process. The orientation of
In addition to smoking and alcohol consump- the fracture line influences the surface areas of
tion, the use of recreational drugs also impairs bony contact and can influence the healing. The
bone mineral density and bone healing capacity. differences in the repair process between undis-
The available literature is limited, but the available placed and displaced fractures are well docu-
studies clearly highlight an adverse effect [56]. mented. They involve retardation of the rate as
well as an increase in the amount of cartilage
formed and a decrease in the amount of primary
Genetic Predisposition bone formation between the fracture ends [60].
The location of the fracture can be also an impor-
A significant number of patients with an atrophic tant factor. Different healing rates are reported
non-union do not have any of the aforementioned between different bones. For instance, reported
risk factors. These patients are most often young, non-union rates ranged from up to 18% in tibial
active, fit and well, and without any conditions diaphysis but 1.7% in the femoral shaft after
that are known to interfere with bone healing. The reamed nailing [61].
theory of “genetic predisposition” to equation of The fracture gap can directly influence the
fracture non-union has been supported by a num- healing process. A gap of 2 mm or higher can
ber of authors. Animal studies have shown that a adversely affect the bone healing process [62].
downregulated expression of various bone mor- Claes et al. compared three different gap sizes:
phogenetic proteins, bone morphogenetic protein small, medium, and large [62]. Comparing the
inhibitors, fibroblast growth factor signaling path- small to the medium fracture gaps, a large callus
way, and insulin-derived growth factor can result was noted with lower fracture stiffness in the
in non-union [57]. In humans, an association group with medium fracture gap. The group with
between the CCG haplotype of PDGF-A, specific the large gap produced little callus and had low
variants of the TLR4 (mutated 1/W) and TGF-β stiffness. In addition to the amount of callus for-
(mutated homozygote T and heterozygote C/T), mation, the fracture gap influences the revascu-
and the occurrence of non-unions has been shown larization of the fracture site [63]. Other factors
[58]. In addition Dimitriou et al. showed that two that can influence the fracture healing process
specific polymorphisms of two inhibitors of the include the amount of bone loss, the fracture
BMP pathway, the noggin (the G/G genotype of comminution, and the presence of debris or
the rs1372857 SNP) and Smad6 (the T/T geno- necrotic tissue or other foreign materials [64].
type of the rs2053423 SNP), were associated with Finally, the presence of infection has devastating
a greater risk of fracture non-union [59]. outcomes on the overall healing process.
10 I. Pountos and P.V. Giannoudis

Soft Tissue Envelope  ixation Method and Mechanical

F
Stability
The degree of local trauma is crucial for fracture
healing. An intact soft tissue envelope will pre- The mechanical stability is closely related to the
vent the escape of fracture hematoma, provide fracture itself and the method used for fixation. It
osteoprogenitor cells, and contribute to the angio- has been previously shown that small interfrag-
genesis of the fracture site. It will also act as a mentary movement is beneficial to fracture heal-
barrier against pathogen invasion. The amount of ing but small interfragmentary movement is
trauma and the condition of the soft tissue enve- critical. Claes et al. have shown that the fate and
lope are related to the amount of callus that is output of osteogenic cells are related to the
formed. Moderate soft tissue trauma delays new mechanical environment [69]. In particular, intra-
bone formation but only in the early phase of membranous ossification found to occur with
fracture healing [65]. The latter occurs because small strain and small hydrostatic pressures,
the surrounding soft tissues are the primary sites while endochondral ossification occurred with
to support the bone healing by acting as an impor- higher hydrostatic pressures. Large strains were
tant vascular source to deliver oxygen, nutrients, found to lead to connective tissue formation. The
and osteoprogenitor cells to the fracture area. proliferation and transforming growth factor beta
Vascular damage accompanying skeletal injury production of osteoblasts were increased for
increases the rate of non-union by fourfold [66]. strains up to 5% but decreased for larger strains.
It requires muscle flap coverage that increases the In addition to the in vitro models, it has been
local bone blood flow and the rate of osteotomy shown that excessive macroscopic movement can
union compared to skin repair, thus supporting arrest the fracture healing process or result in the
the vascular role of muscle in bone regeneration refracture of the hard callus [70]. On the other
[67]. In addition to the blood flow, the surround- hand, the absence of any strains can result in the
ing soft tissue contributes in terms of osteogenic remodeling mechanisms to prevail over the mod-
growth factors, cytokines, and chemokines [67]. eling drifts, and the net result would be removal
Reverte et al. demonstrated that tibial fractures of callus with delayed or failed bone healing [70].
with associated soft tissue injury significantly The fracture fixation can significantly change
impaired fracture healing [68]. They showed that the biology of bone healing. Fractures treated
the rate of delayed union or non-­union in tibial with the AO principles of absolute stability heal
fractures with associated compartment syndrome through primary bone healing without the forma-
was 55%, in comparison to 17.8% in patients tion of callus. On the other hand, if the same frac-
with tibial fracture without associated compart- ture is fixed through the relative stability
ment syndrome [68]. principle, the fracture will heal with indirect bone
Iatrogenic damage to the bones’ soft tis- healing with callus formation (Fig. 1.3). In addi-
sue envelope is a parameter often overlooked. tion to the mode of healing, the type of fracture
The surgical approach used, the manipulation to fixation used can alter the outcome. It has been
reduce the fracture, and the preparation for the shown, for example, that humeral shaft fractures
application of the implant are all factors that can treated with an intramedullary device carry worse
lead to a vascular compromise of the fracture site. outcome in comparison to those treated with
Another factor often underestimate is the exces- ­plating [71]. Another example is the different
sive stripping of the periosteum during plating and union rates between reamed and unreamed femo-
the pressure of the plates on the on the periosteal ral nail with regard to the delayed union and non-
surfaces. A sound surgical technique and the use union rate [72]. Even minor adaptations of the
of low contact implants help to reduce the area of principles can alter the outcome. In a study by
contact. Today’s LC-DCP plates use a trapezoidal Krettek et al., for instance, 99 open tibial shaft
cross section, which varies along the length of the fractures were treated with external fixation,
plate, to reduce the impact on the periosteum. which was complemented with a lag screw [73].
1  Fracture Healing: Back to Basics and Latest Advances 11

The result was a significant reduction in fracture

consolidation. In a similar study, good union
rates were documented with external fixation
alone [74].

 pproaches to Enhance Bone

A
Healing

A number of different approaches have been

described to enhance the bone repair response
(Table 1.2). Moreover, the conceptual framework
of the diamond concept has been described to
assist the clinicians to appreciate the most impor-
tant components of fracture healing that must be
present for a successful outcome (Fig. 1.4) [75].

Bone Grafting

Autologous bone grafting from the iliac crest

contains all the required elements for bone heal-
ing [76]. It has osteoinductive, osteoconductive,
and osteogenic properties. It can be harvested
with a simple technique; it has low cost and no
risk of disease transmission or immunorejection.
On the other hand, autologous bone grafting is
associated with significant donor site morbidity,
Fig. 1.3  Anteroposterior right tibia radiograph 14 months often with persistent pain at the harvest site. It
after originally the fracture was fixed with an intramedul-
lary nail which was removed at 12 months following frac-
can be of limited volume, and the isolated graft,
ture union. The arrow demonstrates that union occurred unless tricortical, does not offer any structural
with indirect/secondary bone healing (callus formation) support [77].

Table 1.2 Potential Application of osteogenic materials Systemic enhancement

applications for the
upregulation of bone Autologous bone Parathyroid hormone
healing Autologous bone marrow Biphosphonates
Reamer-irrigation aspiration graft Anti-sclerostin antibodies
Combined grafts (Diamond concept) Anti-Dickkopf-related protein 1
antibodies

Local growth factor applications

Biophysical Stimulation
Bone morphogenetic proteins (BMPs)
Fibroblast growth factors (FGF)
Electromagnetic field stimulation
Vascular Endothelial growth factor Low-intensity pulsed ultrasound
(VEGF) stimulation
Platelet-derived growth factors (PDGF) Etracorporeal shock wave therapy
Molecules involved in Wnt pathway
12 I. Pountos and P.V. Giannoudis

a­spirates exist; however, difficulties regarding

Blood Osteogenic Growth the high volume of the injectable formulation and
Supply Cells Factors
Scaffo
the technical issues resulting in inconsistencies in
ity
d Stabil the number of MSCs and the volume of the bone
Fracture marrow require further research.
Healing

Application of Growth Factors

Bone morphogenetic proteins (BMPs) are mole-

cules involved in many functions of the body
Fig. 1.4  Diamond concept of fracture healing demon-
including development, repair, and regeneration.
strating the key players that must be present for a success- BMP-2 and BMP-7 have become commercially
ful bone repair response available for clinical applications including open
tibial fractures and lumbar spine fusion or under
a humanitarian device exception [80]. However,
In addition to the autologous grafting from the their off-label application has been diverse.
iliac crest, grafts obtained with the use of the BMP-2 and BMP-7 are potent osteoinductive
reamer-irrigator-aspirator (RIA) system molecules; both upregulate the osteogenic differ-
(Synthes®, Inc. West Chester, Philadelphia) have entiation and osteogenic output. Clinical results
gained popularity over the years. A larger volume of studies investigating the bone healing have
of graft material can be harvested, capable to fill been favorable [80, 81].
large bone defects. Unfortunately, RIA grafts Platelet-rich plasma (PRP) is an increased
contain no or little osteoprogenitor cells (most concentration of autologous platelets suspended
contained in the waste water) [78] and are associ- in a small amount of plasma after centrifugation.
ated with a number of complications. Significant The activation of platelets results in the release of
intraoperative blood loss with need for transfu- several molecules involved in the clotting cas-
sion as well as thinning of the cortex and iatro- cade but also growth factors stored in the platelet
genic fractures can occur [74]. A large number of α-granules. Such molecules include the platelet-­
bone graft materials are currently commercially derived growth factor (PDGF), insulin-like
available; none, however, is found to outperform growth factor (IGF), vascular endothelial growth
the autologous bone grafts. factor (VEGF), platelet-derived angiogenic fac-
tor (PDAF), and transforming growth factor beta
(TGF-β) [82]. This technique is relatively safe
Application of Cells and of low cost. The experimental studies have
been favorable; however, in a recent meta-­
Bone marrow aspirates contain MSCs, which analysis including 23 RCTs and 10 prospective
are renowned of their osteogenic and angiogenic studies, the authors questioned its overall effec-
properties. These cells have the capacity of self-­ tiveness in fracture healing [83].
regenerating and are able to produce some of the Platelet-derived growth factor is a potent pro-
key molecules involved in bone healing (BMPs, moter of osteogenic cell proliferation, differen-
VEGF, etc.). Several authors have shown that a tiation, and osteogenic output. It also regulates
simple bone marrow injection in the fracture or chemotaxis and angiogenesis at the fracture
non-union site can result in healing in approxi- site [84]. A prospective RCT including 434
mately 90% of cases [79]. Hernigou et al. found patients undergoing hindfoot or ankle arthrod-
that there was a significant correlation between esis has shown that PDGF with beta-tricalcium
the numbers of MSCs with the clinical outcome. (Augment® Bone Graft, Wright Medical)
Techniques to concentrate the bone marrow results in comparable fusion rates as autologous
1  Fracture Healing: Back to Basics and Latest Advances 13

grafting but with less side effects and less com- However, some uncertainty exists due to the
plaints of pain [85]. methodological limitations and the high between-­
study heterogeneity [91].
The low-intensity pulsed ultrasonography
Systemic Biological Factors (LIPUS) principle is based on the production of
its sound waves that generate micro-stresses at
Parathyroid hormone (PTH) is a naturally occur- the fracture site. The cells present at the fracture
ring hormone that is known to increase the bone site can be stimulated by these stresses and
density. Its effect seems to be directly related to increase their osteogenic output. LIPUS was
the osteogenic cell lineages and through interac- found to accelerate mineralization in vitro
tion with the Wnt pathway. Experimental and through the upregulation of the expression of
clinical results have been encouraging [86]. In osteocalcin, alkaline phosphatase, VEGF, and
elderly patients with pelvic fractures, PTH MMP-13 [92]. In vivo evidence also suggests
administration resulted in a faster time to union that LIPUS can accelerate all stages of the frac-
compared to controls [86, 87]. In a similar study, ture repair process (inflammation, soft callus for-
faster healing times were also noted in patients mation, hard callus formation). However, in a
suffering of distal radial fractures [88]. recent meta-analysis of the available evidence, it
Bisphosphonates are inhibitors of osteoclastic was suggested that LIPUS does not improve out-
activity. Experimental studies have shown how- comes and probably has no effect on radiographic
ever that they could also enhance fracture healing bone healing [93].
[89]. Despite the fact that the clinical studies are Extracorporeal shock wave therapy produces
very limited, some of the data presented seem a single high-amplitude sound wave that propa-
promising [90]. gates through the fracture site. These shock
waves stimulated cellular changes promoting
the production of several osteogenic growth
Physical Stimulation factors. Some evidence that extracorporeal
shock wave therapy is effective for hypertro-
Several devices nowadays are marketed as bone phic non-unions than atrophic non-unions
stimulators. They are appealing as they are non- exists, but most of the current knowledge is
invasive and with minimal complications. These based on level 4 evidence, and further studies
devices can be broadly divided into three catego- are needed to confirm whether any benefit
ries: electrical stimulators, low-intensity pulsed exists [94, 95].
ultrasonography, and extracorporeal shock wave
therapy. Conflict of Interest  No benefits in any form have been
Electrical stimulators are devices capable of received or will be received from a commercial party
related directly or indirectly to the subject of this chapter.
generating an electrical potential at the fracture
site. It was previously found that during fracture
compression an electronegative potential is cre-
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 Instruments Used in Fracture
Reduction 2
Ippokratis Pountos, K. Newman,
and Peter V. Giannoudis

Fracture reduction can be achieved by either In reality, not infrequently, combination of

direct or indirect means [1, 2]. Direct reduction both direct and indirect techniques is often per-
means that the forces and moments applied formed. Irrespectively of the reduction technique
when attempting to realign the bony fragments used, our current armamentarium in fracture
act at the vicinity of the fracture site, while, in reduction aids is ever expanding. The most com-
indirect reduction, the forces are applied distally monly used instruments are described below. In
to the fracture site [3]. Direct reduction is often general terms the instruments can be divided into
performed by direct visualization of the fracture external devices and internal devices.
site through surgical exposure. Utilising mini-
mally invasive approaches, fractures can also be
reduced percutaneously. External Devices
Indirect reduction involves forces along the
axis of the limb, which in turn can result in frac- In this category the most commonly used devices
ture realignment through the action of the sur- include fracture tables, bumps and bolsters, crutches,
rounding soft tissues (ligamentotaxis) [4, 5]. skeletal traction, PORD, F-tool, large distractor and
Indirect reduction can involve manual traction external fixator devices, amongst others.
with manipulation or can be combined with tools Fracture tables with the capacity for skeletal
like traction tables, distractors or external traction are widely used in fracture management
fixators. [6]. Fracture tables are radiolucent and designed
to achieve and maintain satisfactory reduction of
the fracture. The two most commonly used frac-
I. Pountos, M.B., M.D., E.E.C.
Academic Department of Trauma & Orthopaedics, ture tables are the traction table (Fig. 2.1) and the
School of Medicine, University of Leeds, Leeds, UK OSI table (Figs. 2.2 and 2.3).
K. Newman, F.R.C.S. Most often no further manipulation of the
St Peter’s Hospitals NHS Foundation Trust, fracture is required once the patient is posi-
Chertsey, Surrey, UK tioned. Patient positioning on the fracture table
P.V. Giannoudis, M.D., F.R.C.S. (*) is often critical. A thorough preoperative plan-
Academic Department of Trauma & Orthopaedics, ning with anticipation of potential difficulties
School of Medicine, University of Leeds, Leeds, UK
and easy access for fluoroscopic imaging is
NIHR, Leeds, UK
essential [6]. Nowadays, fracture tables are mod-
Musculoskeletal Biomedical Research Center,
ular, can adjust patient’s position with easiness
Chapel Allerton Hospital, Leeds, UK
e-mail: pgiannoudi@aol.com and can take numerous attachments to assist

© Springer International Publishing AG 2018 19

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_2
20 I. Pountos et al.

a b

Fig. 2.1 (a) Schematic representation of traction applied right femoral fracture. Traction has been applied on the
to right lower leg using a fracture table. (b) Patient placed right hand side to reduce the femoral fracture
in the supine position on a fracture table with an open

Fig. 2.2  A polytrauma patient

with a pelvic external fixator
(sustained vertical shear fracture)
is placed supine on an OSI table
where, with the appropriate
attachment device, traction is
applied through a right distal
femoral pin to reduce the right
hemipelvic disruption

Fig. 2.3  Patient has been

positioned prone on the
OSI table with skeletal traction
(distal femoral pin) applied on
the right distal femur to reduce
acetabulum fracture
2  Instruments Used in Fracture Reduction 21

fracture reduction (Fig. 2.4). Setting up the A number of adjuncts can be used during
patient can be labour intensive, which increases patient positioning on the operating table. Bumps
operative time, and performing multiple surger- and bolsters can change patient position, main-
ies in the same setting is often challenging [7, 8]. tain the correct orientation of the limb or assist in
Noteworthy, complications from patient posi- muscle relaxation during fracture reduction
tioning can occur and must be minimized. Such (Figs.  2.6 and 2.7) [11]. Alternatively, special
complications can range from skin necrosis, table attachments can be used, for example, the
nerve palsy and compartment syndrome to iatro- posterior reduction device, (PORD™), which
genic fractures [9]. can be used as a fulcrum to relax the gastrocne-
Coexisting injuries and body habitus often mius and soleus complexes in femoral or hip
preclude the use of the fracture table. In such cir- fracture fixation (Fig. 2.8) [11, 12].
cumstances the use of the standard radiolucent
table is required. Manual traction or the use of
skeletal traction (Fig. 2.5) devices can accom-
plish the same objective with no impact on the
final outcome [10]. However, an additional assis-
tant devoted to holding and maintaining traction
is required.

Fig. 2.6  Intraoperative picture showing a bump to con-

trol AP sag of knee

Fig. 2.4  Complementary reduction device attached on

the OSI table to assist the reduction of pelvic/acetabulum
fractures

Fig. 2.7  Bolsters to control rotation of leg

Fig. 2.5  Traction applied using a distal femoral pin

intraoperatively Fig. 2.8  Posterior reduction device (PORD)
22 I. Pountos et al.

Fig. 2.9  Use of a Schanz screw attached to a T-handed

chuck for fracture reduction in sagittal and coronal planes
for insertion of nails Fig. 2.10 (a) Femoral distractor. (b) Intraoperative pic-
ture of a patient in prone position demonstrating the appli-
cation of a femoral distractor to reduce a combined
Schanz screws can be inserted percutaneously acetabulum and proximal femoral fracture
and can be used as joysticks for manipulation and
reduction of the most displaced fracture segment forces are applied to the whole limb, the femoral
(Fig.  2.9). The T-handed chuck attached to a distractor applies forces directly to the bone.
Schanz pin can be a powerful combination in This makes the distractor readily adaptable in
manipulation and derotating large bony frag- coping with the awkward positioning problems.
ments. K-wires applied on the fracture fragments It also eliminates the risk of nerve injuries, for
can be used also as joysticks to achieve fracture example, peroneal nerve palsy or pudendal
reduction [13]. Further interfragmentary K-wires crush syndrome.
can be used as a temporary fixation method to The external fixator is a versatile device. Its
maintain intrafocal reduction. In large bone frag- use can range from the local damage control in
ments or when manipulation of the whole limb is cases of compromised soft tissue envelope to the
required, Schanz pins can be used. Kapandji definite management of fractures or bone trans-
technique involves the insertion of a K-wire port [15]. Not infrequently, the external fixator is
through the fracture gap [14]. Similar to the a valuable adjunct in fracture reduction and stabi-
reduction technique with the use of a Hohmann lization. With the use of the external fixator, the
retractor, manipulation of the distal fragment can indirect reduction of the bony fragments can be
occur. Definite stabilization is achieved by pass- accomplished under image intensification. Once
ing the K-wire through the distal cortex. reduced the position can be maintained while the
The femoral distractor is composed of a internal fixation plate is slipped under the soft tis-
threaded spindle carrying a fixed and a sliding sues. In some situations in which the internal fixa-
end piece (Fig. 2.10). Schanz screws are fixed tion does not provide adequate stability, the
through the end pieces, and the distractor is external fixator can be left in situ for a short period
positioned parallel to the axis of the bone. An of time, to provide additional support (Fig. 2.11).
excursion of about 27 cm is built into the device. The F-tool is a simple device composed of a bar
More excursion is possible, but angular malpo- on which different rods can be installed [16]. It
sition of the end of the device may occur. Once allows focused forces to be concentrated at the
the bony fragments are adequately reduced, the apex of the deformity. Once longitudinal traction is
position is maintained by the secure tightening applied to the limb, the F-tool can be used to cor-
of the connections. The distractor allows correc- rect deformity and angulation along one plane
tion of length, rotation and angulation. Also, (Fig. 2.12). The F-tool is not radiolucent and should
unlike to the skeletal traction where distraction only be used in simple fracture configurations.
2  Instruments Used in Fracture Reduction 23

a b

Fig. 2.11 (a) Application of an external fixator for a dis- allowing minimal invasive plating osteosynthesis of the
tal tibial fracture. (b) Maintaining the lateral component distal tibial fracture
of the external fixator, fracture reduction was possible

a b

Fig. 2.12 (a) F-tool prior to assemblage. (b) F-tool connected. (c) Fluoroscopic image showing use of the F-tool for
reduction of middle one third femoral shaft fracture
24 I. Pountos et al.

Internal Devices These forceps have curved serrated jaws

designed to have a firm purchase onto the bone
Common reduction tools found in the large and (Fig.  2.13b). In contrast to the pointy forceps,
small fracture sets include the following: these instruments have relatively larger contact
area with the bone, and the serrated teeth improve
(a) Weber forceps (point-to-point forceps) bone-forceps friction. This property, however,
comes to a cost, as they can create great perios-
These forceps have curved sharp pointy tips teal and superficial endosteal damage. They
(Fig.  2.13a). The pointy tips can be applied require greater soft tissue dissection around the
directly on bones’ surface or through drill holes bone to allow tip placement.
or on screws. They have minimal bone-forceps
contact and have minimal impact on the perios- (c) Bone-holding forceps (Verbrugge, ball spike)
teum. These forceps can be used to distract or
manipulate fractures when used in two pairs, and The Verbrugge style forceps are self-centring
when reduction is achieved, they can be used to forceps that aim to hold a plate onto the
secure fractures prior to definite fixation. The ­diaphyseal bone (Fig. 2.13c, d). They are com-
pointy tips have little interference with other prised of a curved serrated tip that comes in con-
hardware used for fixation like drills, plate and tact with the bone and a sort concave edge that
screws. The limitations of the pointy forceps can hold the plate. The hinge mechanism allows
include the easy slippage during fracture manipu- the advancement of the forceps tips relative to
lation and the potential cortex perforation espe- each other; the forceps centres itself between
cially in osteoporotic bone. the plate and the bone. It comes in various sizes
from 0 to 3. The use of the appropriate size in
(b) Toothed reduction forceps (crocodile for-
relation to the bone fragment is recommended.
ceps, lobster claw) A modified version of the forceps carrying a ball

a b c d e

Fig. 2.13 (a) Point-to-point forceps. (b) Toothed reduction forceps. (c, d) Bone-holding forceps. (e) The tensioner.
(f) Hohmann spike retractors
2  Instruments Used in Fracture Reduction 25

spike, intended to be placed in the hole of the wing f­ractures, introduction and turning of the
plate, is also available. retractor inside the bone, followed by a bending
force, can reduce the fractures. Often a small
(d) Tensioner area of impaction is created. Due to the fact that
the retractor is only inserted into the bone, no
The articulating tension device is a device that soft tissue damage/periosteal stripping is
can exert distraction or compression forces [17, created.
18] (Fig. 2.13e). It has a built-in strain gauge to
indicate the amount of tension applied. It is com- (f) Bone hook and spikes
posed of two legs: a rotatable hook that can fit
against plates and a foot that takes a 4.5 mm cor- Bone ball spikes are useful instruments that
tical screw. The standard model has a 40 mm can temporarily hold and maintain fixation of
total excursion. Once the tensioner is attached on fragments during fixation (Fig. 2.14a). They are
the bone with the screw, either it can exert a force long pointed instruments with a triangular or
on the plate to compress the fracture fragments quadrangular shape in cross-section and with a
or, in cases of highly comminuted fractures, it washer or sphere fixed in distal end. The shape of
can be used to distract and maintain the length of the ends prevents penetration of the end into the
the bone. bone during fixation.
Bone hooks are instruments designed to allow
(e) Hohmann spike retractors the surgeon to grasp, hold and manipulate bony
fragments in order to achieve proper alignment
The Hohmann retractor is often a valuable and anatomical reduction (Fig. 2.14b).
tool in fracture reduction (Fig. 2.13f). The small
tip Hohmann retractor can be inserted in the (g) Push-pull device
cortices of diaphyseal bone and used as a lever
and pusher to achieve reduction. In diaphyseal The push-pull reduction device is a simple
fractures, turning and bending of the retractor device that aims to temporarily compress a plate
inside the bone can disengage and reduce the to the bone. It acts by pushing the plate and pull-
fracture. In translated fractures like the iliac ing the bone at the same time. It is inserted under

Fig. 2.14 (a) Bone ball

spike. (b) Bone hook
26 I. Pountos et al.

power and requires turning the collet clockwise provide hold; balls prevent bony penetration of
to start compressing the plate. The device should thin cortex).
be inserted in a hole that will be subsequently
used for fixation; after removal of the device, a (b) Farabeuf and Jungbluth forceps
conventional screw can be inserted.
The Farabeuf forceps is an instrument that
can be either used directly on the bone or secured
I nstruments Found in  on screws through its cut-out jaws (Fig. 2.15b).
Specialized Sets The Jungbluth forceps on the other hand can be
only used in combination to screws. These for-
(a) Matta clamps ceps are designed to be used with 3.5 mm or
4.5 mm screws inserted at the opposite site of the
Joel Matta has initially designed two pairs of fracture line and away of the site of definite fixa-
clamps, which were subsequently modified in tion. They allow the application of considerable
different sizes and configurations (Fig. 2.15a). amount of reduction forces and fracture manipu-
The original clamps were designed with their lation in all three planes. They are capable of
handles angling away from critical soft tissues overcoming the distracting forces without
and out of the line of sight. Their tips were of the encumbering the plating site avoiding extensive
shape of a ball with sharp points (sharp points soft tissue striping.

a b c

Fig. 2.15 (a) Matta clamp. (b) Farabeuf forceps. (c) Bone spreader. (d) Periarticular clamp
2  Instruments Used in Fracture Reduction 27

(c) Mini-distractor and bone spreaders (laminar versatile allowing the surgeon to create an opti-
spreader) mal reduction tool according to the clinical needs.
These attachable arms include the percutaneous,
The mini-distractor belongs to the small frag- pelvic, bone hook-shaped and Hohmann-shaped
ment instrument set. It connects on 2.5 mm that can be used in applications in long bone,
Schanz screws or K-wires and has an overall articular and pelvic fracture types.
excursion of 4 cm. These pins should be inserted
in 90o angle to the bone in order to maintain the (f) Spiked disk
bony axis. Applications of the mini-distractor are
limited to smaller bones like fractures of the hand, This disk can attach to any ball-pointed instru-
feet, distal radius, olecranon and distal humerus. ment. It dispenses the forces applied to the for-
Bone spreaders permit the disimpaction of ceps over a greater area; hence, the risk of bone
bony fragments and facilitate the removal of soft penetration is reduced. The disk has points that
tissues trapped interfragmentarily (Fig. 2.15c). It prevent slippage and it allows the swivelling of
may also be used as a tension device placed off a the ball-tip. The spike disk needs to be placed on
plate and against a screw to create a distraction the bone prior to forceps attachment.
force.
A number of bone spreaders that use K-wires
are also available and can transmit forces along Implants Used as Reduction Tools
one axis of the bone. Most commonly they are
used to distract small joints in hand and feet but (a) Nails
occasionally can be used in fracture management
to distract or compress the fracture of small Fracture fixation with the use of an intramed-
bones. ullary device can reduce and stabilize a long bone
fracture. Once the guide pin has successfully
(d) Periarticular clamp passed to the distal fragment, the insertion of the
nail usually fully reduces the fracture. If coronal
The periarticular clamp has large bended arms or sagittal malalignment is noted, blocking
with ball-pointed ends (Fig. 2.15d). This clamp screws (Poller screws) can be placed on the con-
can be applied on previously surgically exposed cavity of the deformity [19–21]. These screws
bone or can be introduced percutaneously serve as pseudocortex guiding the nail in the
through stab incisions. It comes in different sizes, canal, realigning the bone and increasing the
and its most common applications are in distal overall construct stiffness. Alternatively, the long
femoral and proximal tibial fractures. In osteopo- reduction tool can be used to guide the guide pin
rotic bone, a spiked disk can be placed onto the to the centre of the canal (Fig. 2.16a). The posi-
tips to prevent bone penetration. A modification tioning of the proximal screws can either aim to
of the original design (Vosburg cannulated peri- fix or compress the fracture. Likewise, in cases
articular clamp) allows the passing of two pins where an intramedullary device is used for the
from its two ends. These pins can hold the frag- management of extracapsular hip fractures, com-
ments in place and allow more working space for pression of the fracture can be achieved through
the application of hardware. the axis of the hip screw by a compression attach-
ment (Fig. 2.16b).
(e) Collinear reduction clamp
(a) Plates
The collinear reduction clamp can be used to
achieve and maintain fracture reduction through The use of straight plates as antiglide and but-
minimally invasive techniques. The device can tress instruments is an elegant technique that can
accept a different attachment arm that makes it facilitate fracture reduction. These techniques
28 I. Pountos et al.

a b d

e
f

Fig. 2.16 (a) Long reduction tool. (b) Hip screw handle with compression wheel. (c, d) Plate-holding devices.
(e) Bone-holding forceps. (f) Blade plates of different sizes

aim to place the plate in an advantageous position comminuted metaphyseal fractures. The principle
that realigns the bone and could further aid in the of its application is the insertion of the blade of
axial loading of the fracture with the use of com- the plate in the most distal or proximal fragment,
pression screws. In some fracture configurations, reducing the alignment and splinting the commi-
the plate can be left in place as a blocking device nuted area by skipping the zone of the fracture.
preventing further displacement. The ‘spring This technique requires minimal soft tissue strip-
plate’ used in acetabular fractures and the ante- ping and does not disturb the fracture site.
rior buttressing plate in distal radial fractures are
distinctive examples. In addition to the standard (b) Wires and cables
straight plates, our armamentarium includes
many specialized plates like the cloverleaf-, ‘H’-, Cerclage with the use of wires and cables can
‘L’-, ‘T’- or ‘S’-shaped plates. These plates are produce interfragmentary compression aiming in
mostly intended to fix fracture of the epiphyseal the reduction of a fracture [22]. Cerclage is often
area of long bones. There are specific plate-­ the only fixation method or can be combined with
holding devices to facilitate maintenance of other devices more often K-wires, screws or
reduction (Fig. 2.16c, d). Bone-holding forceps Steinmann pins.
can also facilitate fracture reduction (Fig. 2.16e).
A condylar blade plate is an alternative hard- Conflict of Interest  No benefits in any form
ware that can be used as a reduction tool have been received or will be received from a
(Fig. 2.16f). Its use requires a detailed preopera- commercial party related directly or indirectly to
tive planning and is most commonly used for the subject of this chapter.
2  Instruments Used in Fracture Reduction 29

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Sanders R. Fractures of the proximal third of the tibial
Orthopedics. 2012;35:289–91.
shaft treated with intramedullary nails and blocking
11. Trompeter A, Newman K. Femoral shaft frac-

screws. J Orthop Trauma. 2001;15:264–70.
tures in adults. Orthopaedics and Trauma. 2013;27:
22. Mouhsine E, Garofalo R, Borens O, Blanc CH,

322–31.
Wettstein M, Leyvraz PF. Cable fixation and early
12. Hammer C, Afolayan J, Trompeter A, Elliott D. A
total hip arthroplasty in the treatment of acetabu-
novel approach to closed reduction of distal femur
lar fractures in elderly patients. J Arthroplast.
fractures. Ann R Coll Surg Engl. 2014;96:626–8.
2004;19:344–8.
 Direct and Indirect Reduction:
Definitions, Indications, 3
and Tips and Tricks

Stuart Aitken and Richard Buckley

Definitions Direct Reduction

Fracture reduction can be defined as the restora- Direct reduction is the act of achieving the above-­
tion of the correct anatomical position of fracture described objectives when the fracture site has been
fragments and is a reversal of the process of frac- exposed surgically (or traumatically) thus allowing
ture displacement which occurred at the time of the surgeon visual access to the fragments.
injury. It includes the elevation of impacted can- Inherently, it involves some disturbance to the skin,
cellous bone and articular fragments in fractures subcutaneous tissues, and vascular supply overlying
with intra-articular involvement. In extra-­ the fracture. This soft tissue envelope violation can
articular fractures, reduction includes the restora- be minimized by placing skin incisions away from
tion of limb length, alignment, and rotation so areas of superficial abrasion or contusion and keep-
that the joints above and below the fracture are ing deep dissection within muscle and fascial planes.
placed in the correct position. Fracture reduction Fracture visualization and subsequent direct reduc-
can be thought of as the recreation of the normal tion afford the surgeon a better chance of anatomical
three-dimensional spatial relationship of fracture restoration of the fracture but at the expense of con-
fragments relative to one another. In clinical ferring some degree of soft tissue stripping and devi-
practice, this process can be achieved by direct or talization of fracture fragments. The consequences
indirect means and often by a combination of of this devitalization vary according to the anatomi-
both techniques. cal site involved but include the adverse outcomes of
delayed union and nonunion (and potentially
implant failure), superficial wound dehiscence, and
deep infection of bone and/or adjacent joints.

S. Aitken, M.B.Ch.B., M.D., F.R.C.S.Ed. Indirect Reduction

Department of Surgery, University of Calgary,
Calgary, AB, Canada
In contrast, indirect reduction is the act of achiev-
Department of Orthopaedics, MaineGeneral Medical
ing reduction with the fracture site unexposed
Center, Augusta, ME, United States
and the surrounding soft tissue envelope left
R. Buckley, M.D., F.R.C.S. (*)
intact. Fracture fragments are manipulated by
Department of Surgery, University of Calgary,
Calgary, AB, Canada applying corrective forces at a distance from the
e-mail: buckclin@ucalgary.ca fracture site which are resisted by tension in the

© Springer International Publishing AG 2018 31

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_3
32 S. Aitken and R. Buckley

intact soft tissues, taking advantage of the gen- normal length, alignment, and rotation of both
eral principle of ligamentotaxis. An anatomical bones is important to prevent limitation of fore-
reduction is often more difficult to achieve indi- arm rotation. This can be achieved via careful
rectly and requires an understanding of the frac- dissection through tissue planes and the limited
ture configuration and the deforming forces soft tissue elevation involved in a direct approach.
acting at the fracture site. However, reduction can Simple diaphyseal fractures of other long bones
be facilitated by the precise placement of reduc- such as the humerus or fibula can also be
tion clamps or other instruments through strategi- approached directly, without harmful violation
cally located ‘stab’ incisions, without necessarily of the soft tissue envelope (Fig. 3.2). Fractures of
imparting the same degree of soft tissue violation the tibial or femoral diaphyses can be reduced
involved in a direct approach. Notably, the sur- and treated this way, but the advent of intramed-
geon does not have the ability to visually inspect ullary fixation has changed the surgical manage-
the results of indirect reduction, relying instead ment of even the simplest fracture patterns
upon fluoroscopy or other forms of imaging to involving these bones. However, the surgical
judge whether bony anatomy has been restored. approach for direct reduction of more complex
or comminuted diaphyseal fractures of long
bones risks devitalization of segmental frag-
Indications ments and increases the risk of the adverse frac-
ture outcomes previously described. For these
The overarching aim of modern fracture surgery is reasons, an indirect reduction is often preferred.
to obtain an ‘acceptable’ reduction of the fracture
fragments, to maintain that reduction sufficiently
while allowing for early range of motion of the Indirect Reduction
injured part, and to achieve this with the least pos-
sible disturbance of the soft tissue envelope. In fractures of the diaphysis and metaphysis of
long bones, it is the soft tissue envelope that pro-
vides vascularity and viability to the underlying
Direct Reduction fragments. In most circumstances, a method of
reduction that preserves this soft tissue envelope
In most articular fractures, the aim of reduction is to but also allows for correction of angular and rota-
perfectly restore the joint surface, thereby providing tional deformity is preferable. When considering
a congruent articular surface and a stable joint indirect reduction for any fracture, the decision-­
which moves normally. Impacted osteochondral making process begins with obtaining an accurate
fragments are elevated and stabilized in a reduced history as to the amount of energy involved in the
position (Fig. 3.1). For these reasons, direct inspec- trauma, a detailed examination of the fracture pat-
tion of the joint surface via a direct reduction is usu- tern, and a close inspection of the soft tissues at
ally employed. Especially in the lower extremity, the fracture site. A simple spiral diaphyseal frac-
reduction of the disrupted joint surfaces and restora- ture without comminution, sustained from a low-
tion of the normal axial alignment of the limb will energy fall, with a healthy soft tissue envelope
reduce the risk of post-­ traumatic osteoarthrosis. might conceivably be stabilized surgically via an
Ideally, no residual joint displacement should be open direct reduction depending upon the surgical
accepted, although different joints with different strategy and choice of implant. In contrast, direct
loading conditions appear to have different toler- reduction would be contraindicated in a high-
ances. In general, there is much less malreduction energy meta-diaphyseal injury with marked bony
allowed for a constrained weight-bearing joint. comminution and extensively contused soft tis-
Direct reduction is occasionally used for sues due to the risks of further devitalization of
metaphyseal or diaphyseal fractures. One exam- already compromised tissues. In these high-
ple is that of a fracture involving the diaphyses energy trauma situations with threatened soft tis-
of the radius and ulna. Precise restoration of the sues, indirect techniques are preferred.
3  Direct and Indirect Reduction: Definitions, Indications, and Tips and Tricks 33

a b

c d

Fig. 3.1  The elevation and reduction of impacted articu- the depressed articular fragments on both views (c, d) and
lar osteochondral fragments. Anteroposterior (a) and lat- is then used to elevate the articular fragments back to their
eral (b) fluoroscopic images of a tibial plateau fracture are anatomic position (e)
shown. A bone tamp is introduced and positioned beneath
34 S. Aitken and R. Buckley

a b

d e

Fig. 3.2  Direct reduction of a fibula shaft fracture. The fibula. The butterfly fragment is reduced, held with pointed
tibial plateau fracture is associated with a shortened and reduction forceps (c), and secured with a lag screw (d),
comminuted fibula fracture (a). In order to restore the cor- thereby creating two main fragments. These are reduced
rect tibial height, the surgeon has chosen to perform an and fixed with a second lag screw (e). A neutralization
open approach (b) and direct anatomic reduction of the plate is then placed to protect the fixation construct (f)
3  Direct and Indirect Reduction: Definitions, Indications, and Tips and Tricks 35

With the use of modern fracture implants, ment will create some degree of fracture reduc-
indirect reduction techniques are often preferred tion, as the deforming forces are partially
for both low- and high-energy metaphyseal and overcome. Traction is most frequently applied
diaphyseal fracture situations. This highlights the indirectly (e.g. by using a traction fracture table,
emphasis currently placed on soft tissue envelope a universal distractor, or external fixation device
preservation in modern fracture surgery. or by suspending the limb and allowing gravity to
create traction), but this is only effective when
bone fragments are still connected to soft tissues.
Tips and  Tricks The direct application of traction to a fracture
overcomes this problem and involves the use of
Table 3.1 provides a list of commonly utilized instrumentation at the fracture site (e.g. standard
instruments and techniques for direct and indirect pointed reduction forceps applied with simulta-
fracture reduction. The subsequent text provides neous rotation of the handles creating distraction
further explanation regarding their application. Of between fragments, a retractor placed into the
note, some direct techniques may be considered fracture site and used as a lever, a Jungbluth pel-
indirect if applied through stab incisions (e.g. vic clamp or laminar spreader creating distrac-
Schanz screws, pointed reduction forceps) or if tion between two strategically placed cortical
introduced through incisions made at a distance screws, or the use of Schanz screws on either side
from the fracture site (e.g. pre-contoured plate). of the fracture as ‘joysticks’). In many circum-
stances, even after the successful application of
traction, there will be residual deformity in one
Longitudinal Correction (Traction) or more planes that must be addressed.

The deforming forces acting on the fracture and

preventing reduction result from the combined Angular Correction
effects of muscle spasm, ligament and fascial ten-
sion, and the effect of gravitational pull. Almost An imbalance of tension in the soft tissues (i.e.
universally, traction applied to the injured seg- muscles or fascia) on either side of a fracture or

Table 3.1  An example of the instrumentation and techniques used to obtain fracture reduction by direct and indirect
means [1–6]
Desired correction Direct reduction Indirect reduction
Longitudinal Pointed reduction forceps Traction on the fracture table
Bone lever in the fracture Universal distractor
Laminar spreader or Jungbluth External fixator
(between two screws) Gravity
Schanz screw joysticks
Universal AO compression/distraction device
Angular/translational Schanz screw joysticks Crutch under the apex
Ball spike pusher Sterile ‘bump’
Bone hook Radiolucent triangles
Dental pick F-tool
Periosteal elevator Externally applied mallets
Cerclage wire
Coaxial clamp
Pointed reduction forceps
Rotational/multiplanar Schanz screw joysticks Intramedullary reduction aid
Bone holding clamp Internal scaffold
External scaffold (Intramedullary nail)
(Temporary reduction plate)
(Pre-contoured plate)
36 S. Aitken and R. Buckley

a loss of bony integrity affecting one cortex but

not the other will cause an angular planar defor-
mity, with or without a rotational deformity,
depending on the deforming force vectors. The
effect of gravity on a fracture site can also pro-
duce angulation. The simplest corrective method
is to apply a force at the apex of the deformity.
Commonly utilized manoeuvers include place-
ment of a crutch under an apex posterior femo-
ral shaft fracture, placing a sterile ‘bump’ or
radiolucent triangle beneath a distal femoral
metaphyseal fracture, or using a Schanz pin
placed in the femoral neck to correct the apex
anterior deformity in a subtrochanteric fracture.

Translational Correction Fig. 3.3  Pointed reduction forceps, placed through stab
incisions at the fracture site, are being used to maintain and
hold the reduction of the tibial shaft fracture prior to passage
Any obliquity of fracture orientation will result in of the ball-tipped guide wire and intramedullary reaming
tensile forces at a fracture site being converted into
translational deformity. The pull of individual mus- Kirschner wires or Schanz pins) or by placing some
culotendinous units can also create translation type of forceps around the bone fragments prior to
dependent upon their site and direction of insertion. manipulation. With the use of intramedullary frac-
Correction of residual translation at a fracture site ture implants, a multiplanar reduction can be
is often difficult to achieve indirectly, but instru- achieved by using an intramedullary reduction aid
ments such as the ‘F-tool’ or externally applied (e.g. an undersized nail or a guide wire). However,
mallets can be used in some circumstances. More in contrast to the use of fracture joysticks, these
powerful and accurate correction can be achieved tools are unable to maintain a reduction prior to
by applying instruments at the fracture site via stab implantation of the definitive intramedullary device.
incisions (Fig. 3.3) or by utilizing a direct approach.
The ball spike pusher, the bone hook, the dental
pick, the periosteal elevator, or a cerclage wire can Fracture Implants as Reduction Aids
be used to push or pull bone fragments into a
reduced position. Depending on the obliquity of Ideally a fracture implant should contribute to
the fracture, the application of reduction forceps or the reduction as well as the stabilization of a
a coaxial clamp can be used to directly counteract fracture. Increasingly, modern fracture implants
the translational deforming force. are ‘pre-­contoured’ and anatomically ‘site-spe-
cific’. Their shape is designed to closely resem-
ble that of the injured segment to which they are
 otational and Multiplanar
R being applied. Perhaps the best example of this
Correction is the intramedullary nail. If attention has been
paid to its correct site of insertion, then passing
In most instances, residual deformity exists in mul- the pre-contoured device across the fracture site
tiple planes after traction has been applied to the will confer fracture reduction in the coronal and
injured segment. Obtaining control of the bone on sagittal planes. The nail acts as an internal scaf-
one or both sides of a fracture is one way of apply- fold. Alternatively, an external scaffold can be
ing the desired force vector to achieve fracture created but serves the same purpose of correct-
reduction. This can be achieved by applying one or ing angular and translational deformity
more ‘joystick’ devices through the bone (e.g. (Fig.  3.4). The use of pre-­contoured plates for
3  Direct and Indirect Reduction: Definitions, Indications, and Tips and Tricks 37

a b

c d

Fig. 3.4  Use of a reduction plate to maintain satisfactory lowing nail introduction (a, b). Via a direct approach, the
alignment of the tibial metaphysis during intramedullary fracture is reduced and held with two five-hole small frag-
nailing. Despite careful attention to the nail entry point ment plates. The eccentric placement of unicortical screws
and fracture reduction during reaming, the position of this prevents interference with the subsequent passage of the
proximal metaphyseal tibial fracture is unacceptable fol- nail (c, d)
38 S. Aitken and R. Buckley

stabilization of fractures of the proximal femur, sagittal alignment (Fig. 3.5). The concomitant
distal femur, or proximal tibia is a good example application of traction will restore length. It is
of the application of this scaffold principle. unusual for the application of pre-contoured
Provided the plate is applied correctly to the nails or plates to confer rotational fracture
metaphyseal segment and fixed securely, then reduction, and it is important to eliminate rota-
reduction of the diaphyseal fracture fragment to tional deformity prior to definitive fixation of
the plate (or vice versa) will restore coronal and the implant to the diaphysis.

a b

c d e f

Fig. 3.5  The use of a pre-contoured plate, correctly skin incision (b). Following anatomical reduction of the
applied to the proximal fracture segment, restoring coro- articular component, a pre-contoured plate is introduced
nal and sagittal alignment as the diaphyseal fracture frag- (c) and temporarily held proximally and distally with
ment is reduced to it. A tibial plateau fracture with Kirschner wires (d). A cortical screw, placed distal to the
extensive meta-diaphyseal comminution (a) is treated comminuted segment, pulls the diaphysis to the plate as it
using indirect reduction techniques through a proximal is tightened (e) thereby restoring limb alignment (f)
3  Direct and Indirect Reduction: Definitions, Indications, and Tips and Tricks 39

In summary, a variety of generic techniques Thieme; 2007. p. 165–88. Clin Orthop Relat Res.
2000 Jun;(375):7-14.
exist which can be used to restore the correct ana-
2. Perren SM. Trends in internal fixation potential,
tomical position of fracture fragments. Reduction limits and requirements. Injury. 1999;30(Suppl 2):
techniques may be applied directly or indirectly B2–4.
but must always take into consideration the vas- 3. Leunig M, Hertel R, Siebenrock KA, Ballmer FT,
Mast JW, Ganz R. The evolution of indirect reduction
cularity and viability of the affected bone frag-
techniques for the treatment of fractures. Clin Orthop
ments and surrounding soft tissues. The choice of Relat Res. 2000;375:7–14.
technique and its particular application will 4. Wenger R, Oehme F, Winkler J, Perren SM, Babst R,
depend largely upon the surgical strategy Beeres FJP. Absolute or relative stability in minimal
invasive plate osteosynthesis of simple distal meta
employed and the anatomical site affected.
or diaphyseal tibia fractures? Injury. 2017;48(6):
1217–23.
5. Huang HT, Huang PJ, Su JY, Lin SY. Indirect reduc-
Suggested Reading tion and bridge plating of supracondylar fractures of
the femur. Injury. 2003;34(2):135–40.
1. Gautier E, Pesantez RF. Surgical reduction. In: Ruedi 6. Krettek C, Müller M, Miclau T. Evolution of mini-
TP, Buckley RE, Moran CG, editors. AO Principles mally invasive plate osteosynthesis (MIPO) in the
of Fracture Management, vol. Volume 1. Stuttgart: femur. Injury. 2001;32(Suppl 3):SC14–23.
 Part II
Innovations in Fracture Reduction
 Innovations in Fracture Reduction
Computer-Assisted Surgery 4
Rami Mosheiff and Amal Khoury

Computer-Assisted Surgery of treatment of the orthopedic trauma patient,

in Trauma from preoperative planning to postoperative eval-
uation. The role of computerization in the treat-
Computer-Assisted Surgery (CAS) systems pro- ment of trauma patients is not only to enhance the
vide the surgeon with a precise, more complete, surgical options in the preplanning stage but also
and up-to-date view of the intraoperative situa- to shorten surgery, an advantage that could be
tion. By incorporating real-time tracking of the crucial for patient morbidity in a trauma setup.
location of instruments and anatomy, and their This integrates well with the current tendency
precise relation to preoperative and intraopera- toward minimal invasive surgery [3]. CAS tech-
tive images, the systems create a new modality nology brings important digitized information
akin to continuous imaging [1]. In this sense, into the operating room, enabling the accom-
CAS systems are like navigators based on global plishment of two main goals: minimal invasive
positioning systems (GPSs), currently found in surgery and maximal accuracy. Moreover, both
cars which help drivers find their way to a desired surgeon and patient enjoy a significant reduction
destination. During driving, the system shows the in the amount of radiation exposure usually
exact location of the car at all times on a comput- associated with orthopedic trauma surgery.
erized map and provides turn-by-turn directions Computerized navigation has made a break-
ahead of time. Today, a variety of image-free and through in expanding the use of CAS from the
image-based systems exist for planning and exe- preplanning to the postoperative stage, yet the
cuting a variety of orthopedic procedures, includ- crucial stage of fracture reduction is a dynamic
ing primary and revision total hip and total knee stage which makes the intraoperative integration
replacement, anterior cruciate ligament recon- of this new technology more difficult [4].
struction, spinal pedicle screw insertion, and
trauma. CAS has already become an integral part
of the orthopedic trauma surgery setup [2]. The Computer-Assisted Surgery
rapid development in the use of computers in this for Closed Reduction of Long
field provides many feasible options at all stages Bone Fractures

Open reduction of a long bone fracture can result

R. Mosheiff, M.D. (*) • A. Khoury, M.D.
in higher rates of infection and non-union. Several
Department of Orthopedic Surgery,
Hadassah Medical Center, Jerusalem, Israel techniques have been suggested to accomplish
e-mail: ramim@hadassah.org.il closed reduction, such as the use of a femoral dis-

© Springer International Publishing AG 2018 43

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_4
44 R. Mosheiff and A. Khoury

tractor, percutaneous Schanz screws to manipu- plays the tracked instrument only, but actually
late the fragments, and traction. These solutions represents the proximal fragment surrounding it.
rely exclusively on fluoroscopy, thus exposing This eliminates the need to fix a reference frame
both the patient and the surgeons to a significant to the proximal fragment. The actual fracture
amount of radiation [5]. reduction is then carried out by manipulating the
From the different computer-assisted surgery proximal fragment, using the tracked intramedul-
(CAS) systems, the main modality which has lary alignment device, and directing its virtual
been adapted to trauma surgery is fluoroscopy- image on the computer screen toward the medul-
based navigation. While this technology might be lary canal of the distal fragment. While navigat-
viewed by some as only improved fluoroscopy, it ing, the images seen on the computer screen
is undoubtedly this feature that has allowed during the reduction process are the virtual image
computer-based navigation systems to become a of the device and the distal fragment itself. The
pioneer in the process of CAS integration in the fracture is reduced when both images are aligned
orthopedic trauma operating room. The use of a on both previously taken AP and lateral views.
fluoroscopy-based computerized navigation sys- The procedure is entirely performed without the
tem can improve the nailing technique by locat- use of fluoroscopy.
ing the entry point of the nail, inserting locking
and Poller screws, and providing accurate nail
and screw measurements. These tasks then can Computer-Assisted Surgery
be performed with markedly reduced radiation to Control Length and Rotation
exposure. However, fracture reduction in vivo of Long Bone Fractures
has not been achieved by computerized naviga-
tion systems without difficulties, since it requires Femoral fracture nailing is considered to be a
simultaneous dynamic imaging of two separate highly successful procedure, with healing rates
anatomic sites, such as fracture fragments [6]. approaching 98–99%. However, the procedure is
The first innovative technique for closed not devoid of complications [8]. As more high-
reduction in intramedullary nailing utilizing a energy shaft fractures with excessive comminu-
fluoroscopy-based computerized navigation sys- tion and metaphyseal involvement are being
tem was published in 2005 [7]. A modular treated, malunions can occur, with malrotation
infrared-emitting active instrument tracker is deformity being the most common. The inci-
mounted on a cannulated intramedullary fracture- dence of clinically significant rotational defor-
aligning device which is inserted into the medul- mity (more than15°) is found in 10–22% of cases
lary canal of the proximal fragment, advanced to [9]. Several solutions and radiographic tech-
the fracture site, and will at a later stage be used niques aimed at reducing malrotation during
as a “joystick” for fracture reduction. A bone femoral shaft fixation have been proposed, such
tracker is inserted into the distal segment of the as the cortical step sign, the lesser trochanter pro-
fracture. Two fluoroscopic images (AP and lat- file, and radiographic comparisons of both
eral) of the distal fragment are taken and stored in extremities in the lateral view. However, despite
the computer. The fluoroscope is now removed the use of these techniques, there is no clear evi-
from the surgical field and will not be used dence that the incidence of femoral malrotation
throughout the reduction process. At the same has decreased.
time, the position sensor (infrared camera) is A significant breakthrough of fluoroscopy-
tracking the intramedullary fracture alignment based navigation in trauma surgery is the ability
device by locating the instrument tracker on it to simultaneously track more than one bone frag-
and the distal fragment using the bone tracker. ment during navigated fracture reduction surgery,
Since the intramedullary device is located inside enabling a real-time tracking and manipulation
the proximal fragment, its image represents both of the two main bone fragments. The fracture
the device and the proximal fragment as a single reduction navigation software includes both
unit. The image seen on the computer screen dis- single-bone tracking and the ability to follow in
4  Innovations in Fracture Reduction Computer-Assisted Surgery 45

real time two bone-attached trackers, one for each At the start of each surgical procedure after
bone fragment [10]. This software application anesthesia, a noninvasive optical tracker is placed
allows for performing femoral fracture fixation on the uninjured thigh. Four images of the intact
using fluoroscopy-based navigation with different femur are taken as follows: an anteroposterior
modules, including navigation of nail entry point, (AP), a lateral view of the proximal femur, an AP,
segmentation of the fracture fragments and virtual and a true lateral of the distal femur. The software
reduction without the use of live fluoroscopy, vir- automatically calculates the axial rotation angle
tual implant insertion, and nail locking. Most between the acquired proximal and distal femoral
importantly, it is possible to determine the length landmarks, as well as the femoral length. All
and rotation of the fixed bone by comparing it images and data are stored in a computerized
with the intact contralateral femur. By using database. After nail insertion and before nail
images obtained from both proximal and distal interlocking, trackers are placed in both proximal
ends of both the intact and the injured femurs, the and distal ends of the injured femur. The process
length and rotational profile of each bone can be of image acquisition and marking is similar to the
calculated. As a result, before nail locking, the one described above for the uninjured extremity.
fractured femur can be matched in length and The same four images are taken while tracking
rotation to the healthy limb (Fig. 4.1). with both a handheld fluoroscopic tracker (X-spot)

a b

c d

Fig. 4.1  A significant breakthrough is the ability to time two bone-attached trackers, one for each bone frag-
simultaneously track more than one bone fragment during ment. In vitro experiments in our lab (a and b) followed
navigated fracture reduction surgery. The fracture reduc- by real-time intramedullary nailing of a tibial fracture
tion navigation software has the ability to follow in real (c and d)
46 R. Mosheiff and A. Khoury

and bone trackers placed in the proximal and dis- the performance of a virtual operation of the
tal ends of the femur. The images are marked for injured skeleton. The purpose of this preopera-
the center of the femoral heads, the tip of the tive stage is to virtually perform all steps of the
greater trochanter, the posterior condyles, and the real surgical procedure. This method might
intercondylar line. At this point, the tracking cam- improve surgery in general, but could make a
era of the navigation system is recording the colossal advance in percutaneous surgery of this
length and rotation of the injured nailed extremity. area. The ability to exercise a virtual surgical pro-
The computer screen displayed the length in mil- cedure marking the safe zones allows for precise
limeters and rotation of both the intact and broken planning of fragment reduction, screw dimen-
femurs. After obtaining a satisfactory alignment, sions, and pathways and enables the pre-checking
interlocking screws are placed in both proximal of the percutaneous option as an alternative to the
and distal fracture ends. open approach. Moreover, since the information
is based on specific imaging of the fracture, it can
be used intraoperatively. The highly detailed
Computerized Virtual Fracture information that is acquired in the preoperative
Reduction Methods stage may be transferred to the execution stage
and thus direct the navigation accordingly.
The current standard of care starts with the acqui- Nowadays, all computerized preoperative plan-
sition of X-ray images and the evaluation of the ning softwares, available either experimentally or
fractures. Next, the surgery is planned to deter- in clinical use, are based on preoperative CT
mine the surgical approach, the bone fracture scans [11]:
reduction, and the type, number, and locations of
the fixation hardware. Surgeons can plan the 1. 3D imaging allowing for the performance of
fracture reduction and fixation with commercial the different stages of a virtual surgical proce-
software packages, based on 2D digital overlay dure, including segmentation, reduction, and
templates of the fixation hardware on the X-ray fixation [12]
images. In more complex cases, the planning is 2. 3D imaging in which the virtual reduction is
performed on CT scan 3D bone fragment models. based on a mirror image of the healthy side as
During surgery, the surgeon reproduces the pre- a template [13]
operative plan based on new fluoroscopic X-ray 3. 3D imaging allowing for the performance of
images. For simple fractures, this process yields finite element analysis, providing the neces-
adequate results in most cases. However, a higher sary information for choosing the most pre-
incidence of complications is reported for com- ferred biomechanical composition of fixation
plex fractures. [14]
Although 3D CT has considerably improved 4. Haptic computer-assisted patient-specific pre-
imaging, complete understanding of the fracture operative planning [15].
lines and fragments can, at times, still be difficult.
One of the most discussed difficulties is the
choice of a correct operative approach. Taking all Computerized Intra-articular
of this into account, it is obvious that strict preop- Fracture Fixation
erative planning is a crucial step especially in
percutaneous surgical treatment. It is not surpris- C-arm radiographs are commonly used for
ing that new technologies have been introduced intraoperative image guidance in surgical inter-
to help the surgeon plan the operative procedures ventions. Fluoroscopy is a cost-effective real-
more precisely. Computer programs that have time modality, although image quality can vary
been developed during recent years have enabled greatly depending on the target anatomy. Intra-
4  Innovations in Fracture Reduction Computer-Assisted Surgery 47

articular fracture fixation presents unique tech- increased field of view, higher spatial resolution,
nical difficulties. In many cases, the fracture is and soft tissue visibility. CBCT imaging provides
comminuted and has complex geometry that is exquisite visualization of articular details, subtle
difficult to evaluate on conventional CT slices fragment detection and localization, and confirma-
or fluoroscopic radiography images. For more tion of fracture reduction and implant placement.
than a decade, 3D intraoperative imaging CBCT imaging revealed areas of malalignment
was introduced, such as Siremobil Iso-C 3D and displaced fragments in intra-articular fracture
(Siemens Medical Solutions); it has been posi- reduction surgeries. CBCT facilitated fragment
tively investigated to improve intraoperative localization and improved anatomic reduction.
understanding for fracture reduction and tool CBCT image noise increased gradually with
placement. However, this tool has its limita- reduced dose; it has been proved in tibial plateau
tions: It can be used only once or twice during fracture reduction and fixation surgery [16].
surgery because of radiation exposure, and it Moreover, CBCT can provide intraoperative high-
has a static and limited field of view. Other resolution images with a large field of view. This
obstacles include tracking of small bone frag- quality of imaging enables surface matching algo-
ments and possible fragment motion during rithms to be utilized even with large areas of com-
fixation. Modifications of the isocentric C-arm minution. This was proved to be useful in judging
have recently been introduced, offering supe- precisely the femoral shaft rotation in femoral
rior image quality, increased field of view, fracture surgery using surface mapping algorithms
higher spatial resolution, and soft tissue visibil- [17].
ity, as well as the elimination of the need to In the former decade, challenges in improving
rotate around a fixed point (isocentricity). intraoperative quality have led to the combina-
In addition, newly developed patented soft- tion of robotic, floor-based 3D flat-panel CBCT
ware modules have recently been developed C-arm, known as Artis zeego (Siemens). In recent
which allow for intraoperative 3D assessment, years hybrid operating rooms were established
with decreased cost and less radiation, using con- over the world. In our setting we combined a 3D
ventional fluoroscope techniques. flat-panel C-arm (Artis zeego) with a navigation
system (Brainlab Curve, Brainlab). This unique
combination enables the surgeon to visualize an
 dvanced 3D Intraoperative
A entire pelvis in CT-like image quality with a sin-
Imaging for the Judgment gle 3D scan (figure). This way a surgeon is able
of Fracture Reduction to control fracture reduction and to alternate his
plan accordingly (Fig. 4.2). The Ulm group has
A relatively new technology in 3D intraoperative shown superior results in terms of precision in
imaging is offered by the application of flat-panel the placement of sacroiliac screws using the
detectors (developed for radiographic/fluoroscopic abovementioned modality [18].
imaging) to cone-beam CT. Cone-beam CT The use of the Artis zeego system allows for
(CBCT) provides volumetric image reconstruc- the validation of fracture reduction and intraoper-
tions from 2D projections acquired across a given ative hardware placement in different intra-
source-detector trajectory about the patient (e.g., a articular fracture surgeries. It is routinely used in
circular orbit). Cone-beam computed tomography our institution in Pilon, calcaneus, tibial plateau,
(CBCT) scans are sometimes available, so 2D-3D and some pelvic and acetabular fracture surgeries
registration is needed for intra-procedural guid- (figure). The need for a revision of fracture reduc-
ance. This technology is an important advance- tion is evaluated before final hardware placement.
ment over existing intraoperative imaging (e.g., If a further reduction is needed, the provisional
Iso-C 3D), offering superior image quality, fixation is removed, and the reduction is improved.
48 R. Mosheiff and A. Khoury

a b

Fig. 4.2  Advanced intraoperative 3D imaging assists in An intraoperative coronal reformat of a CT, acquired by
the judgment of the quality of the fracture reduction and the Artis zeego system, shows the status of the reduction
implant placement. A coronal reformat of a pelvic CT and fixation of the pelvis (b)
scan shows posterior pelvic non-union before surgery (a).

a b c d

Fig. 4.3  On the basis of combined CT scan and fluoro- the desired entry point and trajectory, as dictated by the
scopic data (a), the miniature robot (SpineAssist; Mazor surgeon’s preoperative plan (b and c). We use the same for
Surgical Technologies, Caesarea, Israel) aligns itself to the placement of sacroiliac screws (d)

Future Directions ence has been gained during this time, and
recently we use the same system with minor
One of the promising developments of computer- modifications for the placement of sacroiliac
assisted surgery is the robotic execution of the screws. This enables 3D environment naviga-
preoperative plans (Fig. 4.3). Today tool place- tion, based on the preoperative plan, for the
ment is well guided by different means of navi- placement of screws in narrow safe zones
gation, but not the fracture reduction. A decade [19, 20].
ago a new miniature robot (SpineAssist; Mazor This is an example of a computerized cou-
Surgical Technologies, Caesarea, Israel), which pling between preplanning and execution of fixa-
has been developed as a surgical assistant for tion. Direct computerized control of fracture
accurate percutaneous placement of pedicle reduction based on the digital preplanning
screws and translaminar facet screws, was intro- doesn’t exist yet. In the near future, we hope to be
duced. On the basis of combined CT scan and able to integrate this crucial stage of fracture care
fluoroscopic data, the robot aligns itself to the in the existing sequence of technologies of preop-
desired entry point and trajectory, as dictated by erative planning and intraoperative guided navi-
the surgeon’s preoperative plan. A vast experi- gation (Fig. 4.4).
4  Innovations in Fracture Reduction Computer-Assisted Surgery 49

7. Mosheiff R, Weil Y, Peleg E, et al. Computerised

navigation for closed reduction during femoral intra-
medullary nailing. Injury. 2005;36:866–70.
8. Tornetta P III, Ritz G, Kantor A. Femoral torsion after
interlocked nailing of unstable femoral fractures. J
Trauma. 1995;38:213–9.
9. Jaarsma RL, Pakvis DF, Verdonschot N, et al.
Rotational malalignment after intramedullary
nailing of femoral fractures. J Orthop Trauma.
2004;18:403–9.
10. Weil Y, Gardner MJ, Helfet DL, et al. Accuracy of
navigated femoral fracture reduction–a laboratory
study. Clin Orthop Rel Res. 2007;460:185–91.
11. Attias N, Lindsey RW, Starr AJ, Borer D, Bridges K,
Hipp JA. The use of a virtual three-dimensional model
to evaluate the intraosseous space available for percu-
taneous screw fixation of acetabular fractures. J Bone
Joint Surg Br. 2005;87(11):1520–3.
12. Cimerman M, Kristan A. Pre-operative plan-

ning in pelvic and acetabular surgery: the value of
advanced computerised planning modules. Injury.
2007;38(4):442–9.
13. Noser H, Heldstab T, Schmutz B, Kamer L. Typical
Accuracy and Quality Control of a Process for
Fig. 4.4  Integration of the reduction stage in the sequence Creating CT-Based Virtual Bone Models. J Digit
of technologies of preoperative planning and intraoperative Imaging. 2011;24(3):437–45.
guided navigation is desired. Part of our in vivo trials is 14. Varga E, Erdőhelyi B. Severe Pelvic Bleeding: The
based on table-skeletal pelvic fixation frame which secures Role of Primary Internal Fixation. Eur J Trauma
the normal side of the pelvis to the table and enables Emerg Surg. 2010;36(2):107–16.
maneuvering the other hemipelvis. This pelvic frame has 15. Kovler I, Joskowicz L, Weil Y, Khoury A, Kronman A,
increased our ability to obtain a closed reduction of the pel- Mosheiff R,·Liebergall M, Salavarrieta J. Haptic com-
vic ring and is coupled to the navigation system puter-assisted patient-specific preoperative planning
for orthopedic fractures surgery. Int J CARS. 2015:
10: 1535–1546.
References 16. Khoury A, Siewerdsen JH, Whyne CM, Daly MJ,
Kreder HJ, Moseley DJ, Jaffray DA. Intraoperative
1. Nolte L, Beutler T. Basic principles of CAOS. Injury. cone-beam CT for image-guided tibial plateau fracture
2004;35(suppl 1):6–16. reduction. Comput Aided Surg. 2007;12(4):195–207.
2. Liebergall M, Ben-David D, Weil Y, et al. Computerized 17. Khoury A, Whyne CM, Daly M, Moseley D, Bootsma
navigation for the internal fixation of femoral neck G, Skrinskas T, Siewerdsen J, Jaffray D. Intraoperative
fractures. J Bone Joint Surg Am. 2006;88A:1748–54. cone-beam CT for correction of periaxial malrotation
Reddix RN, Webb LX. Computed-assisted preoperative of the femoral shaft: a surface-matching approach.
planning in the surgical treatment of acetabular frac- Med Phys. 2007;34(4):1380–7.
tures. J Surg Orthop Adv. 2007;16:138–143. 18. Richter PH, Gebhard F, Dehner C, Scola A. Accuracy
3. Mosheiff R, Khoury A, Weil Y, et al. First generation of computer-assisted iliosacral screw placement using
of fluoroscopic navigation in percutaneous pelvic sur- a hybrid operating room. Injury. 2016;47(2):402–7.
gery. J Orthop Trauma. 2004;18:106–11. https://doi.org/10.1016/j.injury.2015.11.023. Epub 2015
4. Weil YA, Liebergall M, Mosheiff R, et al. Assessment Dec 12.
of two 3-D fluoroscopic systems for articular fracture 19. Lieberman IH, Togawa D, Kayanja MM, Reinhardt
reduction: a cadaver study. Int J Comput Assist Radiol MK, Friedlander A, Knoller N, Benzel EC. Bone-
Surg. 2011;6(5):685–92. mounted miniature robotic guidance for pedicle
5. Kahler DM. Virtual fluoroscopy: a tool for decreas- screw and translaminar facet screw placement:
ing radiation exposure during femoral intramedullary Part I-Technical development and a test case result.
nailing. Stud Health Technol Inform. 2001;81:225–8. Neurosurgery. 2006;59(3):641–50. discussion 641-50
6. Weil YA, Liebergall M, Mosheiff R, et al. Long bone 20. Stüer C, Ringel F, Stoffel M, Reinke A, Behr M,
fracture reduction using a fluoroscopy-based naviga- Meyer B. Robotic technology in spine surgery: cur-
tion system: a feasibility and accuracy study. Comput rent applications and future developments. Acta
Aided Surg. 2007;12:295–302. Neurochir Suppl. 2011;109:241–5. https://doi.org/
10.1007/978-3-211-99651-5_38.
 Inflatable Bone Tamp
(Osteoplasty) for Reduction of 5
Intra-articular Fractures

Peter V. Giannoudis and Theodoros Tosounidis

Introduction The Schatzker et al. classification of tibial

plateau fractures continues to be the most com-
Extra-vertebral balloon osteoplasty (the so- monly used classification for these injuries [5]
called inflatable bone tamp) has lately gained a (Fig. 5.1). For the type II and III fracture patterns,
lot of popularity being used as a tool for reduc- like any other intra-articular fracture, the goals of
tion of fractures. This technique has been applied treatment remain: anatomical fracture reduction,
successfully for reduction of depressed distal stable fixation and early range of motion.
radius, humeral head and calcaneal and tibia pla- Currently, the most commonly reduction tech-
teau fractures amongst others [1–4]. In this nique used involves a bone punch using a cortical
chapter the technique will be demonstrated for window that allows access to the depressed
the management of tibial plateau Schatzker type fragment.
II and III depressed intra-articular fractures. Recently however, borrowing from the success-
ful vertebral kyphoplasty technique, an inflatable
balloon acting as a tamp can reduce the depressed
 natomical Fracture Location:
A tibial plateau fracture. This technique gives the
Radiograph of Fracture Pattern advantage of reducing the bone window to a drill
hole while simultaneously increasing the area of
A tibial plateau fracture with intra-articular force transmission, resulting in easy and satisfac-
involvement occurs following an axial force tory fracture reduction and minimal trauma.
exerted from the femoral condyles against the
articular surface of the tibia.
Brief Preoperative Planning

P.V. Giannoudis, M.D., F.R.C.S. (*) Initial clinical examination of the affected extrem-
Academic Department of Trauma and Orthopaedics, ity is vital to assess the state of the soft tissues and
School of Medicine, University of Leeds, Leeds, UK
NIHR, Leeds, UK
the neurovascular status and to exclude the pres-
ence of compartment syndrome. In polytrauma
Musculoskeletal Biomedical Research Center,
Chapel Allerton Hospital, Leeds, UK
patients initial ATLS assessment is mandatory as
e-mail: pgiannoudi@aol.com well as secondary and tertiary s­ urveys to exclude
T. Tosounidis, M.D., Ph.D.
injuries to other anatomical locations. Radiological
Academic Department of Trauma and Orthopaedics, examination consists of AP and lateral knee
School of Medicine, University of Leeds, Leeds, UK (Fig.  5.2) and tibia radiographs. Acquisition of

© Springer International Publishing AG 2018 51

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_5
52 P.V. Giannoudis and T. Tosounidis

Type I Type II Type III Type IV Type V Type VI

Split Split-depression Central Split fracture, Bicondylar Dissociation of
depression medial plateau fracture, metaphysis and
diaphysis

Fig. 5.1  The Schatzker classification of tibial plateau fractures

a b

Fig. 5.2 (a) AP and (b) lateral radiograph of a right type II lateral tibial plateau fracture

computed tomography (CT) scan (Fig. 5.3) is cru- Patient Set-Up in Theatre

cial to appreciate in more detail the extent of
depression, comminution and the existence of In the operating room, the patient is placed in the
other fracture lines that may affect the placement supine position on a radiolucent table (Fig. 5.4).
of the metal work for achieving optimum The image intensifier is positioned to the
stability. opposite side of the surgeon who will be standing
5  Inflatable Bone Tamp (Osteoplasty) for Reduction of Intra-articular Fractures 53

a b

Fig. 5.3 (a, b) CT images of right lateral tibial plateau fracture

Fig. 5.4  Patient is

placed in the supine
position on a
radiolucent table

at the side of the injured limb. The opposite leg of flexion will facilitate relaxation of the gastroc-
can be flexed and supported with a leg-holding nemius muscle (Fig. 5.5).
attachment device to allow easy acquisition of
lateral knee radiographs (Fig. 5.5).
Reduction Instruments

Closed Reduction Manoeuvres Instrumentation that is required consists of Osteo

Introducer, precision drill, Kyphon inflation syringe,
Closed reduction is difficult to achieve in such inflatable balloon (IBT) of appropriate size, contrast
fractures. However, placing the knee in slight liquid, bone filler device, bone void filler, k-wires,
flexion over the triangle or a bolster to allow 15° reduction forceps, plates and screws (Fig. 5.6).
54 P.V. Giannoudis and T. Tosounidis

Fig. 5.5 Image
intensifier is positioned
to the opposite side of
the surgeon. The
uninjured leg is flexed
and supported with a
leg-holding attachment
device to allow easy
acquisition of lateral
radiographs. Note that
the injured leg is
supported with a bolster

Fig. 5.6 Kyphon
inflatable balloon set

made, and the trocar for the inflatable bone tamp

 urgical Approach: Identification
S is advanced from the medial to the lateral direc-
of the Area of Articular Depression tion, underneath the impaction area (Fig. 5.8).
To avoid subsidence of the inflatable balloon
This technique is used through a minimal inva- tamp away from the depressed fragment into the
sive approach. A thigh tourniquet is applied. cancellous metaphyseal bone, the authors have
Under fluoroscopic guidance, the tip of a k-wire recommended placing two or three rafting 2 mm
or a metal marker is placed on the medial aspect of k-wires just below the balloon. However, a spe-
the tibial plateau, approximately 2–3 mm below the cial cannula is currently available that prevents
depression, in the anteroposterior and lateral planes expansion of the balloon inferiorly, thus eliminat-
of the fluoroscopic acquisition images (Fig. 5.7). ing the need for inserting k-wires.
When the right level is identified, a small per- A carved incision is carried out posterior to
cutaneous skin incision on the medial side is the lateral joint line. A tunnel is created to elevate
5  Inflatable Bone Tamp (Osteoplasty) for Reduction of Intra-articular Fractures 55

a c

b d

Fig. 5.7 (a–d) Under fluoroscopic guidance, the tip of sion, in the anteroposterior and lateral planes of the fluo-
the metal marker is placed on the medial aspect of the roscopic acquisition images
tibial plateau, approximately 2–3 mm below the depres-

Fig. 5.9  Following a carved incision, a locking plate is

advanced and inserted over the lateral wall fragment

the proximal structures of the anterior compart-

ment of the leg. A plate to buttress the latter wall
Fig. 5.8  Following a small percutaneous skin incision on
the medial side, the trocar is advanced from the medial to and to prevent displacement of the lateral wall is
the lateral direction, underneath the impaction area inserted (Fig. 5.9).
56 P.V. Giannoudis and T. Tosounidis

Structure at risk during this step is in the to inspect the articular surface, a submeniscal
common peroneal nerve around the neck of the arthrotomy is made through the coronary liga-
fibula. If the surgeon feels that it is necessary ment to expose the lateral plateau fracture.

Reduction Manoeuvres

A large, pointed reduction clamp is applied in a

percutaneous fashion holding the plate and the
medial tibial plateau in order to prevent displace-
ment of the lateral split fracture fragment during
inflation of the balloon (Fig. 5.10).
The precision drill then is inserted through the
cannula to prepare the path for the ITB. After
removal of the precision drill, the IBT is inserted
in the cannula and is advanced under the area of
depression to allow a targetted expansion of the
balloon. The balloon is gradually inflated, and
Fig. 5.10  A large, pointed reduction clamp has been reduction is progressively achieved to anatomical
applied percutaneously in order to prevent displacement
of the lateral split fracture fragment during inflation of level by taking the necessary fluoroscopic acqui-
the balloon sition images (Fig. 5.11).

a b

c d

Fig. 5.11 (a–d) The IBT is inserted in the cannula and the balloon is gradually inflated and reduction is progressively
achieved to anatomical level by taking the necessary fluoroscopic acquisition images
5  Inflatable Bone Tamp (Osteoplasty) for Reduction of Intra-articular Fractures 57

When reduction is achieved and prior to the teau can be stabilised with 1–2 cannulated screws
deflation of the balloon, a k-wire is inserted from prior to the plate application for neutralisation of
the latter side in order to secure maintenance of the fixation.
the reduction (Fig. 5.12a). Post-operatively, the patient can initiate early
Following removal of the IBT, a bone filler range of motion of the affected knee joint.
device is inserted to facilitate delivery of the bone Mobilisation is toe-touch weight bearing for
substitute at the area where the void has been cre- 4 weeks followed by partial weight bearing for
ated. Prior to delivery of the bone substitute, the another 4 weeks, and then full weight bearing is
suction tip can be placed at the entry hole of the advised. Thromboprophylaxis is recommended
bone filler device to remove blood from the void for a period of 6 weeks.
(create a dry void area) for optimum interdigita-
tion of the cement filler (Fig. 5.12b, c). Following
filling of the void with the bone graft substitute Summary of Tips and Tricks: Pitfalls
(tricalcium phosphate), the bone filler device is
removed. • Accurate targeting of the depressed intra-­
Osteosynthesis then can be carried out by articular segment with the trocar is essential for
inserting the proximal and distal screws through subsequent optimum positioning of the ITB.
the selected plate (Fig. 5.12d, e). Occasionally, if • Attention must be paid not to overcompress
indicated, and following reduction of the the lateral condyle because this may lead
depressed articular segment, the lateral tibial pla- to entrapment of the depressed fragment

a b

c d e

Fig. 5.12 (a) After successful reduction and prior to (b, c) Delivery of bone substitute to fill the void for struc-
deflation of the balloon, a k-wire is inserted from the lat- tural support. (d, e) Definitive osteosynthesis with inser-
eral side in order to secure maintenance of the reduction. tion of proximal and distal screws through the plate
58 P.V. Giannoudis and T. Tosounidis

and the inability to achieve an anatomic References

articular congruence (so-called trapdoor
effect). 1. Sandmann GH, Siebenlist S, Imhoff FB, Ahrens P,
• When there is extensive articular surface col- Neumaier M, Freude T, Biberthaler P. Balloon-guided
lapse, consider the implantation of a second inflation osteoplasty in the treatment of Hill-Sachs
lesions of the humeral head: case report of a new tech-
ITB and the simultaneous inflation of both nique. Patient Saf Surg. 2016;10(1):4.
balloons. 2. Ollivier M, Turati M, Munier M, Lunebourg A,
• Follow the manufacturer’s instructions not Argenson JN, Parratte S. Balloon tibioplasty for
to go beyond the maximum recommended reduction of depressed tibial plateau fractures:
Preliminary radiographic and clinical results. Int
pressure for the balloon inflation in order to Orthop. 2016;40(9):1961–6.
minimise the risk of bursting of the 3. Broome B, Mauffrey C, Statton J, Voor M, Seligson
balloon. D. Inflation osteoplasty: in vitro evaluation of a new
• Adequate quantity of the bone substitute must technique for reducing depressed intra-articular frac-
tures of the tibial plateau and distal radius. J Orthop
be delivered within the void for reducing the Traumatol. 2012;13(2):89–95.
risk of secondary fracture collapse. 4. Hahnhaussen J, Hak DJ, Weckbach S, Heiney JP,
Stahel PF. Percutaneous inflation osteoplasty for indi-
Conflict of Interest  No benefits in any form rect reduction of depressed tibial plateau fractures.
Orthopedics. 2012;35(9):768–72.
have been received or will be received from a 5. Schatzker J, McBroom R, Bruce D. The tibial plateau
commercial party related directly or indirectly to fracture. The Toronto experience 1968-1975. Clin
the subject of this chapter. Orthop Relat Res. 1979;138:94–104.
 Innovations in Fracture Reduction:
Poller Screws 6
Theodoros H. Tosounidis and Peter V. Giannoudis

 ationale of the Clinical Use

R traction, percutaneous clamps), the reduction is
of Poller Screw difficult to be maintained until the secure proxi-
mal and distal interlocking screw application.
The use of “Poller” or “blocking” screws is a mini- Poller screws were initially recommended to be
mally invasive reduction technique used in intra- applied at the short segment on the concave side
medullary nailing of long bones. Its clinical use of the deformity. Other descriptions of the cor-
was first described in English literature by Krettek rect position include “place the screw were you
et al. in 1995 [1], and since then it has been widely don’t want the nail to go” or to the “deficient
accepted as a safe and efficient truly percutaneous cortex”. Nevertheless, these descriptions can be
technique. Their original indication, which was quite confusing and difficult to translate in the
the reduction and supplemental stabilisation of clinical setting especially for the less experi-
long bone metaphyseal fractures, has been recently enced surgeon.
expanded and is currently used in the management Various fine-tuning methods of the original
of nonunions and in intramedullary limb lengthen- technique have been described, with common
ing. The basic logic behind the use of Poller screws denominator being the meticulous preoperative
is to reduce the width of the medullary canal, block planning and the careful intraoperative technique.
the nail and increase the mechanical stiffness of We have found the method presented by Hannah
bone-implant construct [2, 3]. et al. [4] very useful and accurate, when only one
Poller screws are predominantly used in nail- Poller screw is used or in the case of the first
ing of metaphyseal fractures. In such cases the screw application when multiple Poller screws
short or flared segment is difficult to be aligned are used. This method is based on the fact that
to the long one, and even if this is achieved by most of the metaphyseal long bone fractures have
other means (unicortical plating, multiplanar an oblique configuration. Initially the long axes
of the short and long fragments are drawn. The
fracture line is then drawn. This divides the short
and long fragments in four quarters: two with an
T.H. Tosounidis, M.D., Ph.D. (*)
P.V. Giannoudis, M.D., F.A.C.S., F.R.C.S. acute angle facing the facture and two with an
Academic Department of Trauma and Orthopaedic obtuse angle facing the fracture. The Poller
Surgery, University of Leeds, Leeds, UK screws are placed in the acute angle close to the
NIHR Leeds Biomedical Research Unit, midline and close to the fracture line (Fig. 6.1
Chapel Allerton Hospital, Leeds, West Yorkshire, UK illustrates the use of Poller screws in a distal tib-
e-mail: ttosounidis@yahoo.com ial fracture).

© Springer International Publishing AG 2018 59

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_6
60 T.H. Tosounidis and P.V. Giannoudis

For the application for multiple screws, we ies using the surgeon’s fingers (thumbs and
consider the method recently described by indexes) as reduction tools. In the so-called
Muthusamy et al. [5] very effective. According “reverse rule of thumb” technique, the subse-
to this, the deformity is reduced by simultane- quent blocking screws are inserted on the side of
ously pushing the apex and the peripheries of the nail opposite to where the thumbs and the
the deformity towards the midline. This can be fingers are placed on the bone. Figure 6.2 illus-
conceptualised by applying a pushing moment trates the application of Poller screws with this
to the apex and bending moment to the peripher- technique.

a b c d

Proximal Tibia Proximal Tibia

Distal Tibia Distal Tibia

e f g
Proximal Proximal Tibia
Tibia
Acute

Acute

Distal Tibia Distal Tibia

Fig. 6.1  The use of Poller screws in intramedullary nail- ment. (i, j) The ball-tipped guide wire and the reamer are
ing of a distal tibia. (a, b) Schematic and anteroposterior inserted. (k) The nail is inserted. Note that the deformity
radiograph of a right distal tibia fracture. (c, d) The frac- is corrected when the nail is touching the Poller screws
ture line and the lines of the long axes of the short and and is directed towards the opposite side. (l) Final intra-
long fragments are drawn. (e, f) The fracture line on each operative anteroposterior and lateral fluoroscopic views
segment and the corresponding long axis produce two showing the central position of the nail. (m)
angles, one acute and one obtuse. (g, h) The first Poller Anteroposterior and lateral radiographs showing the
screw is inserted to the acute angle area of the short seg- healed fracture 5 months post-operatively
6  Innovations in Fracture Reduction: Poller Screws 61

Fig. 6.1 (continued)
62 T.H. Tosounidis and P.V. Giannoudis

Fig. 6.1 (continued)
6  Innovations in Fracture Reduction: Poller Screws 63

Fig. 6.1 (continued)
64 T.H. Tosounidis and P.V. Giannoudis

a b c

Proximal Tibia Proximal Tibia

Distal Tibia Distal Tibia

d e f
Proximal Tibia

Distal Tibia

g h
Proximal Tibia

Distal Tibia

Fig. 6.2  Demonstration of the use of the “reverse rule of shows the position of the screws opposite to thumbs and
thumb” technique in a distal tibia fracture. (a, b) indexes. (f, g, h, i, j, k) In this case Poller screws were
Schematic and plain radiographs showing the fracture placed only at the distal short fragment. Initially the most
with apex lateral angulation (varus deformity). (c, d) In proximal to the fracture, distal Poller screw was applied.
order to correct the deformity, the apex has to be pushed This was not enough to correct the deformity, and subse-
medially, whilst the ends of the deformity have to be dis- quently an additional distal screw was applied to the
placed laterally. The Poller screws are inserted opposite to opposite distal cortex on the same (i.e. short) fragment.
the side of the application of correcting force, i.e. opposite (l, m) Final intraoperative and immediate post-operative
to the apex of the deformity and to the same of the apex radiographs showing the final reduction and position of
side at the periphery. (e) The “reverse rule of thumb” the nail in relation to the Poller screws
6  Innovations in Fracture Reduction: Poller Screws 65

i j

k l

Fig. 6.2 (continued)
66 T.H. Tosounidis and P.V. Giannoudis

Tips and  Tricks The above depends on the fracture configura-

tion and the diameter of the nails used.
Technical points that deserve special consider- Application of the Poller screw very close to
ation include the following: the fracture line can result in propagation of
the fracture; on the other hand, application
• Poller screws can be used either before or after very close to the midline can potentially block
the nail insertion. When they are used after the the screw insertion. Figure 6.3 illustrates the
nail insertion, only minor corrections can be application of “ineffective Poller screws”.
performed. The critical point is that Poller • Other “Poller devices” that can be used
screw insertion must be performed before the include K-wires and Steinmann pins. K-wires
application of the proximal and distal inter- have a minimal footprint and offer versatility
locking screws. in their applications allowing for “trial place-
• The exact distance of Poller screws from the ment”. The Steinmann pin can also be used
midline and from the fracture line is not well as a joystick for fracture manipulation and
defined with suggestions being from 1 to 3 cm reduction [6].
[6, 7] away from the fracture line and as close • The use of cannulated screws should be per-
to midline as safe as it could be (6–7 mm) [6]. formed with caution since they can deform

a b

Fig. 6.3  The application of ineffective Poller screws to sagittal plane is not abutting on the nail, and thus it exerts
the distal femur. (a) Anteroposterior and lateral radio- no effect in reduction and stabilisation of the fracture. The
graphs showing a comminuted distal femoral fracture. (b) remaining translation of the proximal fragment in relation
Intraoperative fluoroscopic views showing the application to the distal is apparent. (c) Post-operative radiographs
of two Poller screws, one anterior to posterior and one showing that distal femur in malreduced position (varus
lateral to medial. It is obvious that the Poller screw at the malreduction)
6  Innovations in Fracture Reduction: Poller Screws 67

intra- or post-operatively making their removal ommend additional CT imaging of the joint
problematic. adjacent to the short fragment so that the use of
• Reaming of the canal adjacent to the Poller the Poller screw can carefully be planned and
screw should be done with great caution or avoid any propagation of fracture lines and fur-
even avoided. ther comminution of the fragment. Apparently,
• A second Poller screw can be used on the the intra-articular component should be
opposite site of the short fragment. This tech- addressed prior to the metaphyseal fracture.
nique can be used in short oblique or very dis-
tal metaphyseal fractures. By placing a second
Poller screw on the opposite site of the short References
fragment and closest to the articular surface, a
“goalpost” for insertion of the nail is created. 1. Krettek C, Schandelmaier P, Tscherne H. Nonreamed
interlocking nailing of closed tibial fractures with
• Poller screws can be used in either sagittal or severe soft tissue injury. Clin Orthop Relat Res.
frontal planes. They can also be used in both of 1995;315:34–47.
these planes simultaneously. Their position 2. Krettek C, Miclau T, Schandelmaier P, et al. The
depends on the displacement/deformity, and mechanical effect of blocking screws (“Poller
screws”) in stabilizing tibia fractures with short
they should be positioned perpendicular to this proximal or distal fragments after insertion of small-­
plane. This means that if the displacement diameter intramedullary nails. J Orthop Trauma.
exists on the frontal plane (varus/valgus), the 1999;13:550–3.
Poller screws should be inserted on the sagittal 3. Krettek C, Stephan C, Schandelmaier P, et al. The
use of Poller screws as blocking screws in stabilising
plane (anterior to posterior). Similarly, if the tibial fractures treated with small diameter intramed-
displacement exists on the sagittal plane (pro- ullary nails. J Bone Joint Surg Br. 1999;81:963–8.
curvatum or recurvatum), then the Poller screw 4. Hannah A, Aboelmagd T, Yip G, et al. A novel tech-
should be inserted on the frontal/coronal plane. nique for accurate Poller (blocking) screw placement.
Injury. 2014;45:1011–4.
• Poller screws can be left in place in order to 5. Muthusamy S, Rozbruch SR, Fragomen AT. The use
augment the stability of the construct. This is of blocking screws with internal lengthening nail
particularly helpful in very distal fractures and reverse rule of thumb for blocking screws in
where the insertion of three interlocking limb lengthening and deformity correction surgery.
Strategies Trauma Limb Reconstr. 2016;11:199–205.
screws to the distal fragment is not always fea- 6. Shahulhameed A, Roberts CS, Ojike NI. Technique
sible. The principle of implant stability aug- for precise placement of poller screws with intramed-
mentation with Poller screws is used in the ullary nailing of metaphyseal fractures of the femur
management of nonunions [8]. and the tibia. Injury. 2011;42:136–9.
7. Seyhan M, Cakmak S, Donmez F, et al. Blocking
• When a Poller screw is overcorrecting the defor- screws for the treatment of distal femur fractures.
mity, disengagement of the screw from the far Orthopedics. 2013;36:e936–41.
cortex makes it less “efficient” and allows nail 8. Eom TW, Kim JJ, Oh HK, et al. Challenge to treat
to correct to a more central position [9]. hypertrophic nonunion of the femoral shaft: the Poller
screw augmentation technique. Eur J Orthop Surg
• Metaphyseal long bone fractures and especially Traumatol. 2016;26:559–63.
those involving the distal tibia often have an 9. Guthrie HC, Bellringer SF, Nicol S. Fine-tuning of
additional intra-articular component not always blocking screws in long bone nailing. Ann R Coll
visible on plain radiographs. We strongly rec- Surg Engl. 2015;97:240–1.
 Assessment of Reduction
7
David J. Hak

Using a direct reduction method, the fracture site Palpation

is visualized greatly increasing the likelihood of
an anatomic reduction in simple fracture patterns. Palpation of the fracture reduction can be per-
In contrast, the fracture site is commonly not formed either with your finger or an instrument
visualized during indirect reductions, and the sur- such as a Freer elevator. It allows assessment of
geon relies on various methods to ensure restora- areas that may not be seen with direct vision, but
tion of accurate length, alignment, and rotation. soft tissues may not allow full access to the entire
The benefits of indirect reduction methods area of reduction, and the ability to assess the
include decreased soft tissue dissection and less degree of step-off or malrotation may be limited.
stripping of periosteal blood supply, with the goal
of improving fracture healing and decreasing soft
tissue wound complications. Because indirect Intraoperative Fluoroscopy
reduction methods are being increasingly used,
methods to assess fracture reduction have become Intraoperative fluoroscopy is used to assess frac-
vitally important. ture reduction and implant position during mini-
mally invasive procedures. Limitations of
fluoroscopy include a limited field of view, diffi-
Direct Vision culty in obtaining certain views, and degradation
of image quality in obese patients. The ability to
Direct visual inspection of the fracture reduction manipulate the fluoroscopic angles allows the
can easily assess the accuracy of the reduction surgeon to find and save the best-looking image,
but often requires significant soft tissue expo- which may not always reflect accuracy of the
sure. Usually only one side of the reduction can reduction. In addition, fluoroscopy exposes the
be visually inspected, and it is important to note operative team to radiation and requires the use
that while the visualized cortex may be well of protective equipment that may increase sur-
aligned, there can occasionally be a cortical gap geon fatigue.
along the far cortex that cannot be directly The accuracy of fluoroscopic assessment of
visualized. articular reduction may be limited. Investigators
studied a simulated intra-articular lateral tibial
plateau fracture cadaveric model. Anterior-­
D.J. Hak, M.D., M.B.A., F.A.C.S.
Denver Health Medical Center, University of
posterior (AP), lateral, and joint line fluoro-
Colorado School of Medicine, Aurora, CO, USA scopic views were obtained of each specimen
e-mail: david.hak@dhha.org with anatomic reduction, 2 mm of articular dis-
© Springer International Publishing AG 2018 69
P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_7
70 D.J. Hak

placement, and 5 mm of articular displacements. Fig. 7.1 An electrocautery cord

can be used as a radiopaque
Assessment of whether the articular surface was
“plumb” line. Center one end of the
reduced was performed by eight orthopedic cord over the femoral head and the
traumatologists. For 5 mm of displacement, other end over the ankle joint, and
using both the AP and lateral views yielded the then pull taut to represent the
mechanical axis. The varus/valgus
highest accuracy for detecting reduction at 90%
alignment of the limb can be
(95% confidence interval, 83–94%), but for the assessed by the position that the
other conditions, agreement was poor to moder- “plumb” line crosses the knee joint
ate, and accuracy ranged from 37 to 83%. The
authors concluded that applying these findings
clinically suggests that direct visualization of
the articular surface may be necessary to ensure
malreduction less than 5 mm [1].
Intraoperative fluoroscopy can be used to
assess lower extremity alignment by using an
electrocautery cord as a radiopaque “plumb”
line. Center one end of the cord over the femoral
head and the other over the ankle joint to repre-
sent the mechanical axis. Pull the cord taut and
assess the location where the cord crosses the
knee joint (Fig. 7.1). Compare this with the pre-
operative plans or with the contralateral leg
mechanical axis. The average normal mechani-
cal axis crosses the knee 10 mm medial to the
center of the knee joint (normal range 3–17 mm)
[2, 3].

Intraoperative Plain Radiographs

While the quality of fluoroscopic imaging has

increased with improved technology, the resolu- Arthroscopic Assessment
tion of plain radiographs is still superior. Plain
radiographs were found to be superior to fluo- Arthroscopic assessment of articular reduction
roscopy in the assessment of articular gap, step- has primarily been promoted for fractures of the
off, and displacement in a cadaveric model of distal radius and tibial plateau. Its use in fracture
closed reduction and percutaneous pinning of reduction and assessment has been described in
simulated Bennett’s fractures [4]. Another ben- almost every joint in which arthroscopic assess-
efit of plain radiographs is the ability to image a ment is feasible including the hip, shoulder,
larger field of view, which can be advantageous ankle, and other smaller joints. It provides the
in assessing angular alignment such as in a tibial benefit of direct visualization of the articular sur-
osteotomy [5]. Disadvantages of intraoperative face. It can also identify additional soft tissue
plain radiographs are that it is time-consuming injuries. The disadvantages include the need for
and may represent a sterility concern. While a additional equipment and potential risks of fluid
fluoroscopic machine is typically covered with a extravasation [6].
sterile drape, such precautions are not typically A retrospective case-matched study compared 15
followed with a standard the portable radio- comminuted intra-articular distal radius fractures
graph unit. treated with arthroscopically assisted reduction with
7  Assessment of Reduction 71

15 that were treated with fluoroscopic-assisted reduc- 3D Fluoroscopy

tion. Investigators reported that those who underwent
arthroscopically assisted reduction had significantly
Several 3D intraoperative imaging systems that
improved supination, wrist extension, and wrist flex-
use CT technology are available for verifying
ion. The authors concluded that arthroscopically anatomic relationships. They can also be used in
assisted reduction permits a more thorough inspection
conjunction with intraoperative navigation.
of the ulnar-sided components of the injury [7]. Three-dimensional (3D) fluoroscopic imaging
Investigators performed arthroscopic assess- uses a mobile C-arm unit that is modified to pro-
ment of 17 consecutive tibial plateau fractures vide a motorized rotational movement and com-
following reduction under fluoroscopic visualiza- bined with a computer workstation. These allow
tion. Persistent fracture depression (≥2 mm) was real-time intraoperative assessment and correc-
seen on arthroscopic assessment in 10 of the tion of reduction and implant position. The use of
cases necessitating intraoperative correction. The 3D fluoroscopy provides increased understand-
authors concluded that arthroscopic assessment ing of fracture patterns and implant position dur-
significantly improved visualization of articular ing fracture surgery.
displacement, particularly in the posterolateral The ARCADIS Orbic 3D devices (Siemens,
central region of the tibial plateau [8]. In contrast,
Malvern, Pennsylvania, USA) are a high-end
a study that compared ten consecutive unicondy- C-arm with an isocentric design and 190° orbital
lar tibial plateau fractures treated by arthroscopi-movement that provide 3D functionality. In con-
cally assisted control of reduction were compared trast to the standard C-arm used in two-­
with 23 consecutive unicondylar tibial plateau dimensional fluoroscopy, the C-arm rotates
fractures treated by fluoroscopic control. The around an isocentric point such that the distance
investigators in this study concluded that they between the X-ray tube and targeted region
were not able to demonstrate any significant ben- remains constant. The device acquires a series of
efit from arthroscopy compared with fluoroscopic approximately 100 fluoroscopic two-dimensional
reduction [9]. images at equidistant angles, which are then
reconstructed into a three-dimensional image at a
volume of 120 mm. The images have comparable
Computed Tomography resolution and similar clinical value compared
with standard CT images [15].
Fracture reduction and fixation using computed The O-arm imaging system (Medtronic,
tomography was initially popularized in the early Louisville, Colorado, USA) provides surgeons
1990s for placement of iliosacral screws [10, 11]. with real-time, 3D images, as well as multiplane,
The major advantage of computed tomography-­ 2D, and fluoroscopic imaging. The unique design
guided sacral fixation is direct visualization of allows a 360° orbital movement. It can be used
the course of the guidewire and screw placement, with navigation for image-guided surgery. While
avoiding significant complications from mis- it is used primarily for navigated spinal and neu-
placed implants. Because of limitations of access rosurgery, it can also be used to assess fracture
during the procedure, typically only percutane- reduction [16]. Both 2D and 3D volumetric imag-
ous procedures can be performed in real time. ing can be obtained within seconds, yielding
Computed tomography has been shown supe- high-quality imaging comparable to fixed CT
rior to conventional radiographs in detecting systems.
articular steps and gaps following open reduction Investigators reported that three-dimensional
and internal fixation of fractures of the distal fluoroscopy exhibited higher precision in reduc-
radius and the acetabulum [12–14]. Because tion assessment in a cadaveric tibial plateau frac-
these CT findings are only discovered following ture model compared to standard fluoroscopy
the procedure, additional surgery may be required [17]. Intraoperative 3D imaging has been studied
if the findings indicate revision is indicated. in fractures of the distal radius, scaphoid, calca-
72 D.J. Hak

neus, pelvis, and acetabulum [18–22]. The use of length radiographic cassette is moved for the
this advanced intraoperative imaging may pro- three exposures.
vide improved articular reduction and optimal CT scanogram can also be obtained to mea-
implant position [23]. sure leg lengths. CT scout images of the joints are
obtained, and measurements are obtained with
the CT cursor. Measurements from the CT scano-
Leg Length Measurement gram are more consistently reproducible, and it
requires lower radiation doses than conventional
Leg length discrepancy can occur when treating imaging techniques. Typically the leg lengths are
comminuted fractures. The contralateral leg, if measured using an anterior-posterior (AP) scout
uninjured, can serve as a guide for restoration of view of the bilateral femurs and tibias. Assessment
normal length. Leg lengths should be clinically of leg lengths on the lateral scout view is espe-
assessed at the conclusion of any operation cially useful for patients with flexion contractures
involving a comminuted femur or tibia. To mea- of the knee, in whom measurements on standard
sure leg lengths in the supine position, the torso anterior-posterior views may be underestimated
and pelvis should be aligned straight, and the [26].
patients’ feet brought together until their ankles
touch. Knee or hip flexion deformities can affect
this measurement. Another method to assess leg Rotational Assessment
length is measure the distance from anterior
superior iliac spine to the medial malleolus with Assessment of rotational alignment is very chal-
a tape measure. Additional quantification of leg lenging during indirect reductions. Malrotation
length inequality can be obtained with a CT abnormalities have been reported following intra-
scanogram. medullary nailing of both femoral and tibial frac-
In a study of 91 comminuted femoral shaft tures. Twenty-eight percent (21 of 76) of patients
fractures treated with intramedullary nailing, that had undergone IM femoral nailing on a frac-
investigators found a mean leg length discrep- ture table had a rotational deformity of 15° or
ancy of 0.58 cm in 98% of the patients, but only greater as assessed by postoperative CT scans.
six (7%) patients had a leg length discrepancy Twelve of these were external rotation deformi-
greater than 1.25 cm [24]. ties, and nine were internal rotation deformities
Various radiographic methods are also avail- [27]. Malrotation greater than 10° was found in
able for assessment of leg lengths. There is gen- 22% of tibial fractures treated with intramedul-
eral consensus that radiographic methods are lary nailing [28].
more accurate and reliable than clinical examina- Krettek popularized several useful techniques
tion for assessment of leg length discrepancy that can be used to judge the proper rotation of
[25]. femoral shaft fractures during either IM nailing
For the orthoroentgenogram radiographic or minimally invasive plate fixation [29]. These
technique, the patient lies supine next to a cali- techniques include assessment of cortical
brated ruler. Three distinct exposures centered ­thickness, internal and external cortical diame-
over the hip, knee, and ankle are obtained using a ters, and profile of the lesser trochanter.
long cassette that accommodates all three images. Comparison of the cortical thickness may be
It was developed to minimize measurement error used to evaluate rotational alignment of simple
secondary to magnification. The scanogram transverse and short oblique fractures. In the
radiographic technique also utilizes three distinct absence of comminution or eccentric reaming,
exposures centered over the hip, knee, and ankle the cortical thickness of the proximal fragment
in order to minimize magnification error. The should match the cortical thickness of the distal
patient lies supine next to a calibrated ruler, and fragment (Fig. 7.2). Comparison of the outer cor-
unlike the orthoroentgenogram, the standard tical diameter may be used to evaluate rotational
7  Assessment of Reduction 73

a b rotation. However, if the cortical diameters are

equal, it may not necessarily indicate malreduc-
tion, since if the femoral shaft cross section is
round at the level of the fracture, the diameters
will be equal even with marked rotational
malalignment.
The most accurate fluoroscopic method for
assessing the accuracy of rotation during IM femo-
ral nailing is assessment of the profile of the lesser
trochanter, with comparison to the uninjured side.
Since the lesser trochanter is a posteromedial struc-
ture, its profile changes depending on the rotation
of the proximal femoral segment. Since there is
some variation from patient to patient, the profile of
Fig. 7.2  Evaluation of cortical thickness at the fracture the lesser trochanter on the uninjured side should
site to assess accuracy of rotational reduction. The cortical
thickness of the proximal fragment is equivalent to the be obtained and saved. Begin by first obtaining a
distal fragment, suggesting correct rotational alignment true AP knee image. With the uninjured leg held
(a). The cortical thickness of the proximal fragment is not stationary, move the fluoroscope to the hip, and
equivalent to the distal fragment indicating that the rota- save an image of the lesser trochanter profile.
tional alignment is off (b)
The fluoroscopic process is repeated on the
injured side. Again a true AP image of the knee is
a obtained. The fluoroscope is moved to the hip
and an image obtained. If the profile of the lesser
trochanter matches that seen on the uninjured
side, then the rotational alignment is correct
(Fig. 7.4). If the profile of the lesser trochanter is
smaller than the uninjured side, it indicates that
the proximal segment is internally rotated com-
pared to the AP image of the knee (an external
b
rotational deformity of the distal segment). If the
profile of the lesser trochanter is larger than the
uninjured side, it indicates that the proximal seg-
ment is externally rotated compared to the AP
image of the knee (an internal rotational defor-
mity of the distal segment).
Jeanmart et al. have described a technique for
evaluating femoral malrotation using limited CT
cuts through the proximal and distal femur [30].
Fig. 7.3  Evaluation of cortical diameter at the fracture site
to assess accuracy of rotational reduction. The cortical
A line is drawn along the posterior border of the
diameters of the proximal fragment are equivalent to the femoral condyles and another line drawn through
distal fragment suggesting correct rotational alignment if the femoral neck. The angle between these two
the fracture is at a level where the femoral cross section is lines is measured, and any difference between the
oval rather than round (a). The cortical diameters of the
proximal fragment are not equivalent to the distal fragment
injured and uninjured sides is compared
indicating that the rotational alignment is not correct (b) (Fig.  7.5). A decrease in angle of the fractured
side indicates increased external rotation of the
alignment because at many levels the femur is distal fragment, while an increase of this angle
oval in shape, rather than round (Fig. 7.3). If the indicates an increased internal rotation of the dis-
cortical diameters are different, it suggests mal- tal femoral fragment.
74 D.J. Hak

Fig. 7.4 Assessment of a b c d
the lesser trochanter profile.
Assessment of the lesser tro-
chanter profile on
the uninjured side with the
leg in neutral rotation
(AP image of the knee) (a).
Matching profile of the lesser
trochanter on the injured side
indicates correct rotation (b).
A smaller profile of the lesser
trochanter indicates
that the proximal segment is
internally rotated (an
external rotational deformity
of the distal segment) (c).
A larger profile of the
lesser trochanter indicates
that the proximal segment is
externally rotated compared
to the AP image of the
knee (an internal rotational
deformity of the distal seg-
ment) (d)

+10-15° for
mortise view

90°

0°

Fig. 7.6  Fluoroscopic technique to evaluate tibial rota-

tion. First, a true lateral of the knee is obtained by super-
imposing the medial and lateral femoral condyles. With
the leg held stable, the fluoroscopic unit is rotated 90°,
Fig. 7.5  Computerized tomographic evaluation of femo- which provides a true AP view. If the tibial fracture is
ral malrotation. Right-angle lines are drawn from the axis accurately reduced, rotation of an additional 10–15°
of the femoral neck and from the posterior border of the should provide an accurate mortise view of the ankle
femoral condyles. The angle of the intersection of these
lines is measured as shown. Rotational malalignment is
determined by differences between the fractured and
uninjured side. A decrease in angle of the fractured side
Tibial torsion can be assessed by measuring
indicates increased external rotation of the distal frag- the rotational difference between a true AP of
ment, while an increase in angle indicates increased inter- the knee and a true mortise view of the ankle
nal rotation of the distal femoral fragment. The angle on (Fig.  7.6). A true lateral of the knee can be
the uninjured side measures 30°, while the malrotated
fractured side measures only 3°, indicating a 27° external
obtained by superimposing the medial and lat-
rotation deformity eral femoral condyles. With the leg held stationary,
7  Assessment of Reduction 75

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fractures and sacroiliac joint disruptions. Radiology.
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12. Cole RJ, Bindra RR, Evanoff BA, Gilula LA,

accurate mortise view [31]. A more precise Yamaguchi K, Gelberman RH. Radiographic evalua-
degree of rotation can be obtained by imaging tion of osseous displacement following intra-articular
the uninjured extremity to determine the fractures of the distal radius: reliability of plain radi-
ography versus computed tomography. J Hand Surg
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nailing of femoral fractures. J Orthop Trauma. adults. Acta Orthop Scand. 1988;59(4):441–2.
2004;18:403–9.
 General Principles of Preoperative
Planning 8
Charalampos G. Zalavras

Definition meaning accountant or responsible for count-

ing) is the detailed organization and imple-
Planning is the process of thinking about and orga- mentation of a complex operation.
nizing the activities required to achieve a desired
goal. It involves the creation and maintenance of a Similarly, in fracture surgery, preoperative
plan, which is defined by the American Heritage planning involves the careful evaluation of vari-
Dictionary of the English Language as “a system- ous variables (fracture characteristics, extremity
atic arrangement of elements or important parts,” condition, patient status) in order to define the
“a proposed or intended course of action,” and “an current problem, determine the goal of manage-
orderly or step-by-step conception or proposal for ment, and develop and implement an individual-
accomplishing an objective” [1]. ized management plan that will optimize outcome
Planning consists of the following key for a patient with a fracture.
components:

1. Analysis of the current situation, definition of I mportance of Preoperative

the problem at hand, and determination of the
Planning
desired goal.
2. Evaluation of potential solutions and determi-
Preoperative planning is very important for sev-
nation of the optimal course of action in order
eral reasons [2, 3]. Most importantly, preopera-
to achieve the goal (tactic). Tactic (from the
tive planning improves patient outcomes. Without
ancient Greek “τακτική” meaning “art of
careful analysis in a systematic fashion of the
arrangement”) is a conceptual action aiming
specific characteristics of the fracture, the extrem-
at the achievement of a goal.
ity, and the patient and without detailed evalua-
3. Implementation of the plan (logistics).

tion of all available treatment options, the best
Logistics (from the ancient Greek “λόγος”
treatment plan may be overlooked, and the final
meaning reason or speech; “λογιστικός”
outcome may be compromised. For example, a
fracture pattern that is relatively uncommon may
C.G. Zalavras, M.D., Ph.D., F.A.C.S. not be readily recognized, and the fixation
Department of Orthopaedics, Keck School of
method selected may not be the optimal one,
Medicine, University of Southern California,
Los Angeles, CA, USA thereby leading to failure. Such failure could
e-mail: zalavras@usc.edu have been prevented by careful planning.

© Springer International Publishing AG 2018 77

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_8
78 C.G. Zalavras

Preoperative planning optimizes efficiency understand how important this is. A study by
and operative performance of the surgeon. The Wade et al. reported that 94% of consultants and
mental exercise of developing a plan and rehears- 100% of residents considered preoperative plan-
ing each step of the procedure will prepare the ning important in orthopedic trauma; however,
surgeon and will lead to less time thinking and only half routinely planned fracture surgery [5].
debating between options during the procedure. Time constraints may be a potential explanation.
As a result, unnecessary delays on the part of the However, time invested in planning and prepara-
surgeon will be minimized, and he/she will be tion is time well spent. As Abraham Lincoln
free to dedicate his/her mental resources to the exclaimed “Give me six hours to chop down a tree
task at hand without having to think about the and I will spend the first four sharpening the axe.”
next step for the first time. The procedure will
flow better, and any stress will be minimized.
Potential problems can be anticipated, and in  ethodology of Preoperative
M
addition to the surgical tactic, alternative plans Planning
can be developed in advance in case intraopera-
tive difficulties arise. A well-defined plan will Preoperative planning involves the careful evalu-
also improve communication between members ation of various variables in order to develop and
of the operative team. implement an individualized management plan
Attention to the logistics will ensure that that will optimize outcome for a patient with a
implementation of the plan is not compromised fracture. More specifically, preoperative planning
because of a preventable lack of resources. For consists of the following elements:
example, some of the necessary implants and
equipment may not be readily available and may 1. Analysis of the current situation, definition of
have to be requested in advance. the problem, and determination of the desired
Finally, the process of preoperative planning goal
is of unique educational value for the surgeon
him/herself and for the residents and medical stu- Preoperative planning starts with the analysis
dents participating in the care of the patient. The of fracture characteristics, extremity condition,
careful assessment of each specific fracture and patient status. Based on this analysis, the sur-
patient and the detailed analysis of potential geon needs to define the current problem and
treatment options stimulate critical thinking and determine what the goal of treatment should be.
improved decision-making ability of everyone In an ideal situation, the goal should be union of
involved. the fracture without any complications and resto-
Antoine de Saint-Exupéry’s statement that a ration of preexisting function of the extremity
goal without a plan is just a wish and Benjamin and the patient. However, this goal may not
Franklin’s warning that by failing to prepare you always be attainable.
are preparing to fail, both apply to fracture sur- The treating surgeon needs to obtain as much
gery as well. Prior to an operation, the time that a information as possible from a detailed history and
surgeon devotes to a careful preoperative plan is clinical exam, from assessment of relevant imaging
of critical importance and often determines the studies, and from review of all available records in
success or failure of the procedure [4]. The author case of a preexisting injury or surgery, for example,
of the current chapter believes that the decision-­ in case of a new peri-implant fracture at the end of
making process and the preoperative plan are a the plate used to fix a previous fracture.
component of patient’s care that is as, or even Fracture characteristics need to be carefully
more, important than technical execution of the evaluated. In addition to the anatomic location of
procedure. the fracture (specific bone) and the diaphyseal,
Unfortunately preoperative planning is not metaphyseal, or intra-articular location of the
routinely practiced, although almost all surgeons fracture, the surgeon needs to determine the exact
8  General Principles of Preoperative Planning 79

fracture pattern and the presence of associated the order of vascular repair versus fracture fixa-
fractures, since this will have implications for tion and for provisional versus definitive fixation.
selection of the optimal fixation method. Good-­ Decisions on the management of an associated
quality orthogonal radiographs should be peripheral nerve injury need to be incorporated in
obtained and scrutinized. Further imaging stud- the overall a management plan, for example, tim-
ies, such as computed tomography (CT) scan, CT ing of repair and primary repair versus nerve
scan with 3-D reconstructions, or magnetic reso- grafting. Functional deficits due to existing con-
nance imaging (MRI), may assist the surgeon ditions, such as adjacent joint stiffness, previous
understand the exact fracture pattern and/or injuries, or neurologic problems, may compro-
detect presence of an associated fracture with mise the final outcome and may not allow resto-
important implications for management, for ration of function following healing of the
example, a femoral neck fracture associated with fracture.
a diaphyseal femoral fracture. Associated injuries need to be carefully con-
The presence of osteoporosis, for example, in sidered. For example, respiratory compromise
elderly patients, may compromise stability of the may necessitate a damage control approach with
fixation construct, and this needs to be consid- provisional external fixation of a femoral fracture
ered when selecting fixation implants, for exam- instead of intramedullary nailing to avoid further
ple, by using locking implants when plate fixation insult to the lungs. A spine injury may preclude
would be the preferred fixation method. lateral positioning of a patient and may necessi-
Previous trauma and/or surgery in the involved tate intramedullary nailing in a supine position
bone may create unique challenges for fixation of for fixation of a femoral fracture. An associated
a fracture. A deformity may be present and the injury, such as an ipsilateral fracture of the patella
medullary canal may be obliterated, which will or tibia, may make retrograde intramedullary
make intramedullary nailing difficult to perform. nailing preferable to the antegrade technique.
Implants may be present at the location of the The health status of the patient is an important
fracture (such as in peri-implant fractures at the factor that affects the healing potential as well as
end of an existing plate or in periprosthetic frac- the surgical risk. Patient’s condition needs to be
tures associated with an arthroplasty), which will optimized before surgery and specific measures
necessitate a decision and plan for maintaining or taken postoperatively to minimize complications
removing the existing implants and for selecting and improve outcome.
implants for fixation of the new fracture. The
existing implants should be identified by careful 2. Evaluation of potential solutions and deter-
evaluation of radiographs and by obtaining previ- mination of the optimal course of action
ous medical records. (tactic)
The soft tissue envelope should be carefully
assessed. Small punctate wounds indicating an Starting with the goal in mind, which should
open fracture may be overlooked. Intraarticular be union of the fracture without any complica-
fractures, such as tibial plateau or pilon fractures, tions and restoration of preexisting function, the
are usually associated with a considerable amount surgeon then evaluates different courses of action
of soft tissue swelling and development of frac- to achieve this goal and various potential solu-
ture blisters. Resolution of the swelling will help tions to the current problem.
reduce soft tissue complications and timing of The surgeon assesses the potential advantages
surgery needs to be adjusted accordingly. and disadvantages, risks and benefits, and feasibil-
The neurovascular and functional status of the ity for each course of action. The surgeon needs to
extremity should be taken into account. Presence evaluate whether a specific fracture would benefit
of an associated vascular injury compromising from absolute or relative stability, which surgical
perfusion of the extremity requires not only techniques and approaches may achieve that, and
emergent intervention but also a specific plan for how stability can be optimized, while at the same
80 C.G. Zalavras

time minimizing soft tissue damage. Often more Operative Considerations

than one courses of action may be reasonable with and Surgical Tactic
unique advantages and disadvantages. These need
to be discussed with the patient, and he/she should Assuming that surgical management is indicated,
participate in the decision-making. the first decision involves the optimal timing of
The optimal course of action is decided upon, surgery. A fracture with an associated vascular
and all its individual components are determined, injury requires emergent management, whereas
thereby developing the surgical tactic, which is a an intra-articular fracture with soft tissue swell-
step-by-step guide to the procedure. Preoperative ing may require a delay of 2 weeks or more until
and postoperative considerations are also the swelling resolves.
included in the plan. An associated decision involves the provi-
During the mental exercise of planning, it is also sional versus definitive fixation of the fracture.
important that the surgeon develops alternative An associated vascular injury may require expe-
plans to accommodate possible intraoperative find- dient provisional fixation with an external fixator
ings or a change in the patient’s condition. Having a prior to vascular repair. Presence of soft tissue
plan A and a plan B (or even a plan C) beforehand swelling over an intra-articular fracture may
will optimize the flow of the procedure (Fig. 8.1). require provisional fixation with a joint-spanning
external fixator, followed by definitive fixation
when the swelling has resolved. When provi-
Preoperative Considerations sional fixation is employed, it is useful to think
about the definitive fixation and avoid compro-
If emergent management of the fracture is not mising it in any way. For example, external fix-
necessary, the patient’s condition needs to be ator pins should be preferably inserted outside of
evaluated and optimized before surgery in con- the area that would be occupied by a plate for
sultation with appropriate specialties and with definitive fixation of the fracture. The operative
the anesthesiologist, for example, by correcting setup details and the steps of the surgical proce-
coagulopathies or electrolyte imbalances. The dure (tactic) are then decided upon.
type of anesthesia and need for advanced intraop- The operative setup includes preparation of the
erative monitoring or blood products are dis- operative room and preparation of the patient. The
cussed and decided upon in advance. operative room setup includes having the

Fig. 8.1  A 55-year-old female patient sustained a disloca- of the radial head fracture. If fixation of the radial head is
tion of the left elbow after a fall. Anteroposterior and lat- the chosen course of action (plan A), the surgeon should be
eral radiographs of the elbow demonstrate associated prepared to proceed with the alternative plan of replace-
fracture of the radial head and fracture of the coronoid pro- ment (plan B) in case stable fixation of the radial head frac-
cess constituting the terrible triad injury (a, b). The largest ture cannot be achieved. In addition, the surgeon should be
part of the radial head appears to be intact, and the treating prepared to address residual instability of the elbow after
surgeon may plan to fix this radial head fracture to help fixation or replacement of the radial head (plan C). Options
restore stability of the elbow joint. Careful evaluation of include fixation of the coronoid process fracture, repair of
the CT scan coronal cuts demonstrates that in that addition the lateral collateral ligament, repair of the medial collat-
to the displaced fragment of the radial head, there is impac- eral ligament, application of a hinged external fixator, or
tion of the remainder of the radial head (c). This impaction combinations of the above. Preoperative planning allows
is also evident in the sagittal cuts (d). Understanding the the surgeon to be prepared and have the necessary equip-
complexity of the fracture pattern warns the surgeon about ment for different courses of action according to the spe-
the difficulty of achieving stable fixation of the radial head cific demands of each procedure. In this patient the author
fracture and allows the surgeon to plan accordingly. Radial elected to proceed directly with radial head replacement,
head replacement implants and trays should be available in which successfully restored stability of the elbow as seen
terrible triads of the elbow in order to be able to proceed in intraoperative fluoroscopic view (e). The lateral collat-
with radial head replacement if needed. Depending on eral ligament was also repaired (f), but fixation of the coro-
fracture characteristics, the surgeon may elect to proceed noid fracture or any additional interventions was not
directly with radial head replacement or to attempt fixation deemed necessary
8  General Principles of Preoperative Planning 81

a b

e f
82 C.G. Zalavras

a­ ppropriate fracture or radiolucent table if needed implant, as well as on the insertion and position-
and having a fluoroscopy machine available and ing of the implant.
optimally positioned relative to the table. The For example, when considering intramedullary
patient setup includes positioning on the table, nailing of the femur, the surgeon has the options of
padding of prominences, deciding on use of a tour- antegrade versus retrograde insertion. Antegrade
niquet, and preparation/disinfection of the surgical insertion options include cephalomedullary versus
site. It is important to remember the potential need standard nail and piriformis versus trochanteric
to harvest bone, vein, or nerve grafts and have the entry point. Once the type of nail is selected, the
appropriate sites prepared and draped. dimensions (length and diameter) need to be esti-
The main steps of the surgical procedure mated based on imaging studies. Images of the
(tactic) include the surgical approach, reduction uninjured extremity may be helpful in determining
of the fracture, and fixation of the fracture. length and rotation in comminuted fractures.
Supplemental procedures, such as bone grafting, When considering plate fixation, the surgeon
may be needed. The decisions are made working needs to determine the need for anatomic plate ver-
backwards, i.e., once the surgeon decides on the sus a standard plate, the dimensions of the plate
optimal fixation technique, and then he/she (thickness, width, and length), the type of the plate
decides on the reduction technique, on the (non-locking versus locking versus combination of
approach, and on patient positioning. options), the insertion technique (minimally inva-
The surgical approach and the pertinent sive insertion versus full surgical approach), the
anatomy need to be reviewed preoperatively, location of the plate on the bone, the number of
especially if the surgeon does not have consider- screws needed on each side of the fracture, the order
able expertise with the approach. The surgeon of screw insertion, and whether a specific screw
should be aware of the neurovascular structures should be locking or non-­locking. The surgeon also
at risk and has a specific plan to ensure that the may consider insertion of lag screw(s) outside or
risk is minimized, either by maintaining a safe through the plate based on the fracture pattern.
distance from these structures or by identifying When considering external fixation, the sur-
them so that they can be visualized and protected geon needs to decide on a half-pin unilateral
throughout the case. For example, once the sur- frame versus a fine-wire frame, on the size and
geon has decided to fix a diaphyseal humeral the exact insertion location of the half-pins or
fracture with an anterolateral plate using an wires, and the details of frame construction.
anterolateral approach to the humerus, it is neces- Especially with plate fixation, planning has
sary to dissect and protect the radial nerve before been traditionally done with the process of tem-
reduction and fixation of the fracture. plating. Templating involves hand-tracing the
Fracture reduction is an important part of final reduction and fracture fixation construct on
the surgical tactic. The surgeon may consider paper based on hard copies of radiographs of the
direct open reduction techniques, for example, injured and contralateral intact bone utilizing a
using a reduction forceps; indirect reduction view box, tracing paper, pencils, and templates of
techniques, for example, using a fracture table or the implants [3, 4, 6].
a universal distractor device; or combinations of Templating helps the surgeon determine the
direct and indirect techniques. Provisional stabi- required type and dimensions of the implant. This
lization with Kirschner wires may be needed. becomes very important when the characteristics
Selection of the fixation implant is a critical of the bone and the fracture necessitate an implant
element of preoperative planning. It is not enough that is not readily available and has to be called in,
to determine whether fixation will be optimally such as a very long plate to span an extensive area
accomplished with intramedullary nailing, plate of comminution or an ­intramedullary nail of very
and screw fixation, or external fixation. Selection small or large diameter to accommodate the
of implant involves consideration of several patient’s anatomy, (Fig. 8.2). Templating makes
details on the specific type and dimensions of an the surgeon mentally rehearse each step of the
8  General Principles of Preoperative Planning 83

a b

d
c

Fig. 8.2  An 18-year-old female patient was involved in a reconstruction nail was only available as a trochanteric
motor vehicle accident and sustained a right subtrochan- entry implant, in contrast to the larger diameter implants
teric femur fracture (a). Careful evaluation of the preop- that were available as both trochanteric and piriformis
erative radiographs generates concerns about the proximal entry implants. Postoperative anteroposterior and lateral
extension of the fracture and the integrity of the femoral radiographs are seen in panels e and f. Preoperative plan-
neck. A CT scan did not demonstrate a femoral neck frac- ning helped the surgeon avoid several pitfalls, such as (a)
ture or extension of the fracture to the piriformis fossa (b, underestimating the complexity of the fracture and not
c). A cephalomedullary nail was selected as implant of using a cephalomedullary nail, (b) not recognizing the
choice for fixation of this fracture. Preoperative planning need for a smaller diameter implant and not having the
and measurement of the canal diameter showed that the optimal implant available during the case, and (c) estab-
isthmus was less than 8 mm (d). The smallest diameter of lishing a piriformis entry point only to recognize after-
the cephalomedullary nail readily available at the sur- wards that a trochanteric implant had to be used. Avoiding
geon’s institution was 10 mm, and the narrow canal such pitfalls helps optimize patient care and improve out-
alerted the surgeon to potential difficulties of extensive comes. In this patient uneventful healing of the fracture
reaming of the canal to insert a 10 mm nail. An adolescent took place as demonstrated in the anteroposterior radio-
reconstruction nail of 8.5 mm diameter was called in and graph at 2.5 months postoperatively (g)
was ready to be used in this patient. Of note, this 8.5 mm
84 C.G. Zalavras

f desired end result was achieved, thereby achieving

quality control.
The expanding use of digital radiographs and
CT scans offers the possibility for novel digital
preoperative planning techniques. Software pro-
grams using digital imaging studies allow 3-D
reconstruction of fractures and malunions and
preoperative planning of the surgical reduction
and fixation, which may be enhanced by creation
of real-size prototypes [6–11].
The surgical tactic also includes the need of sup-
plemental procedures, such as harvesting of autog-
enous bone grafting or using allograft or bone
g substitutes, possible insertion of a drain, wound clo-
sure, and any form of splint or immobilization.

Postoperative Considerations

Postoperative considerations include the dis-

charge of the patient (same-day surgery) versus
admission or even need for an intensive care unit
bed, need for thromboembolic prophylaxis, need
for nutritional supplementation, plan for any
weight bearing or activity restrictions, plan for
physical and occupational therapy, and plan for
follow-up. The need for any other interventions
such as improved control of diabetes mellitus,
cessation of smoking, and therapy for osteoporo-
sis, needs to be considered as well.

3. Implementation (logistics)

As part of preoperative planning, the surgeon

should make sure that all steps of the plan (surgi-
cal tactic) can be implemented smoothly without
obstacles pertaining to resources, such as space,
personnel, and implants/equipment/products.
Important elements of the logistics include
ensuring the appropriate consultations for opti-
mization of patient condition before surgery, the
Fig. 8.2 (continued) availability of an operative room with the required
table and fluoroscopy support, and the availabil-
fixation and helps her/him prepare in advance. ity of assistance. An experienced assistant may
Templating also allows for a direct comparison of be very valuable in complex cases, and his/her
the postoperative radiographs with the ­preoperative availability should be confirmed beforehand.
plan. The surgeon can evaluate whether the preop- Availability of all necessary or potentially
erative plan was successfully followed and the useful implants, equipment, and products (e.g.,
8  General Principles of Preoperative Planning 85

blood products, allograft bone, bone graft substi- experience of everybody involved in the planning
tutes, or other biologic products) is critical and process. Preoperative planning starts with analy-
needs to be confirmed in advance. During the sis of fracture, extremity, and patient characteris-
development of the surgical tactic, the surgeon tics in order to understand the current problem
becomes aware of the specific type and size of and determine the management goals. Potential
implants that will be needed and the necessary solutions are evaluated, the optimal course of
instruments, but this is not enough, and potential action is decided upon, and a step-by-step indi-
problems may occur: (a) the specific type of vidualized management plan is developed and
implants may not be readily available at the sur- implemented. Traditional planning has involved
geon’s facility and may have to be ordered, deliv- hand-tracing the final reduction and fracture fixa-
ered, and sterilized; (b) the specific type of tion construct on paper based on hard copies of
implants may be available at the surgeon’s facil- radiographs. Modern digital imaging studies
ity, but a patient may need a specific size that is offer the possibility for digital preoperative plan-
not in stock, for example, a very long plate or an ning techniques based on software.
intramedullary nail of very small or large diame-
ter or length; and (c) the necessary implants and
instruments may be available at the surgeon’s References
facility, but another surgeon may be planning to
simultaneously use them in a different room. 1. https://www.ahdictionary.com/word/search.
html?q=plan. Assessed 15 May 2017.
These problems can compromise the outcome of 2. Graves ML. The value of preoperative planning. J
the procedure but are all preventable, and Orthop Trauma. 2013;27(Suppl 1):S30–4.
­attention to logistics will facilitate smooth execu- 3. Hak DJ, Rose J, Stahel PF. Preoperative planning in
tion of the surgical plan. orthopedic trauma: benefits and contemporary uses.
Orthopedics. 2010;33(8):581–4.
Clear communication and coordination with 4. Ruedi TP, Buckley RE, Moran CG. AO principles of frac-
the operating room personnel well in advance ture management. Switzerland: AO Publishing; 2007.
are essential. In complex cases it is helpful to 5. Wade RH, Kevu J, Doyle J. Pre-operative planning in
differentiate between the implants and equip- orthopaedics: a study of surgeons’ opinions. Injury.
1998;29(10):785–6.
ment that will definitely be required (and should 6. Atesok K, Galos D, Jazrawi LM, Egol
be opened and ready for use during the proce- KA. Preoperative planning in orthopaedic surgery.
dure) and the implants and equipment that Current practice and evolving applications. Bull Hosp
should be stand-by in case they are needed. For Jt Dis (2013). 2015;73(4):257–68.
7. Citak M, Gardner MJ, Kendoff D, Tarte S, Krettek C,
example, if a preexisting plate needs to be Nolte LP, Hüfner T. Virtual 3D planning of acetabular
removed prior to fixation of a new fracture, the fracture reduction. J Orthop Res. 2008;26(4):547–52.
surgeon should anticipate potential problems 8. Pilson HT, Reddix RN Jr, Mutty CE, Webb LX. The
with removal of the implant, such as stripped or long lost art of preoperative planning–resurrected?
Orthopedics. 2008;31(12):1–3.
broken screws, and a broken screw removal set 9. Suero EM, Hüfner T, Stübig T, Krettek C, Citak M. Use
should be readily available to be opened in case of a virtual 3D software for planning of tibial plateau
such problems occur. fracture reconstruction. Injury. 2010;41(6):589–91.
10. Wang H, Wang F, Newman S, Lin Y, Chen X, Xu L,
Wang Q. Application of an innovative computerized
virtual planning system in acetabular fracture surgery:
Summary a feasibility study. Injury. 2016;47(8):1698–701.
11. Fürnstahl P, Vlachopoulos L, Schweizer A, Fucentese
In fracture surgery, preoperative planning is a SF, Koch PP. Complex osteotomies of tibial plateau
malunions using computer-assisted planning and
critical component of management as optimizes patient-specific surgical guides. J Orthop Trauma.
the patient outcome, the efficiency and operative 2015;29(8):e270–6.
performance of the surgeon, and the educational
 Part III
An Anatomical Based Approach:
Upper Extremity
 Acromioclavicular Joint
Dislocation 9
Paul Cowling

 natomical Fracture Location:

A
Radiograph of Fracture Pattern

Radiological views required to diagnose ACJ dis-

locations include standard anteroposterior shoul-
der views (Fig. 9.1), as well as axial views to
determine any anteroposterior dislocation. A
Zanca view can also be performed (a 15° cephalic
view) to determine subtle superior subluxations.
Stress views are also available where the patient
is asked to hold a weight in the adducted injured
arm, and comparison views are required with and
without the weight, but this is often painful so Fig. 9.1  AP radiograph of right shoulder demonstrating
rarely used. ACJ injuries are most commonly type V ACJ dislocation
described using the Rockwood classification sys-
tem. In general, types I and II will make a good
recovery with conservative management includ- Brief Preoperative Planning
ing physiotherapy. Types III–VI, where the cora-
coclavicular (CC) ligaments are torn, may require Classically, a ‘Weaver-Dunn’ procedure and its
surgical intervention, though the timing of any modifications have been used, where the cora-
intervention remains controversial. Generally, a coacromial (CA) ligament is transferred to the
detailed discussion with the patient is required, distal clavicle to recreate the torn CC liga-
including risks and benefits of surgery, their own ments. More recently, surgeons favour internal
expectations (including sports and any overhead fixation methods between the distal clavicle
manual work) and likely outcomes of both con- and coracoid. These often include a combina-
servative and operative management. tion of suture or other material as a ‘substitute’
for the CC ligament and metalwork to provide
P. Cowling, M.B.B.S., M.Sc., F.R.C.S. (Orth) the fixation into the clavicle and/or coracoid.
Leeds General Infirmary University Hospital, Skilled arthroscopic surgeons have also
Leeds, UK become proficient at performing ACJ fixation
e-mail: paulcowling@nhs.net
arthroscopically.

© Springer International Publishing AG 2018 89

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_9
90 P. Cowling

Patient Setup in Theatre traction on the clavicle. Higher grades of ACJ

dislocation are more difficult to reduce closed, as
Though a standard beach-chair position can be the trapezius muscle and/or deltotrapezial fascia
used as for most upper limb procedures, this may be interposed between the distal clavicle and
author prefers to elevate the head end of the table acromion.
by only 30°, so the weight of the arm doesn’t fur-
ther exacerbate the deformity of the injury, to aid
reduction. The head end of the table is also posi- Reduction Instruments
tioned away from the anaesthetic machine, either
90° or 180° from normal table positioning, to Describe and show picture of exclusive instru-
allow for easy access to the shoulder area. A ments to be used for the specific procedure
radiolucent table is required (ideally a specific
shoulder table to allow access to the shoulder • A basic shoulder set including small and large
from all angles) and the head supported in a head soft tissue retractors should be available
ring or other head-supporting device. Skin prepa- (Fig. 9.3).
ration covers the whole forequarter from sternum • If ‘hooking’ suture or other material under the
to the medial border of scapula, with a U-drape coracoid to provide fixation, a passing device
used to shut off the forequarter. The arm is draped is required.
free, using a stockinette to cover up to the level of • The manufacturer’s trays for the particular fixa-
the proximal humerus, to allow it to be manoeu- tion device used are selected and checked to
vred to aid reduction. The surgeon would then ensure all components required are present.
stand at the side of the arm and assistant at the
head end (Fig. 9.2). The image intensifier can
then be brought in easily, usually from the head Surgical Approach
end with the screens across the patient.
A number of approaches have been described,
but a vertical sabre incision over the ACJ usu-
Closed Reduction Manoeuvres ally allows all the access required to the distal
clavicle and coracoid and is cosmetically satis-
Generally, reduction of a type III ACJ dislocation factory for patients. Once the skin is incised, the
requires pushing the humerus proximally towards distal clavicle and ACJ are exposed by mobiliz-
the acromion, with a small amount of counter ing the overlying deltoid muscle. In higher
grades of ACJ injury, trapezius may also require
clearing from the distal clavicle. The coracoid is
found inferior to the distal clavicle and should

Fig. 9.2  Patient positioning at 30° head end elevation, Fig. 9.3  Basic shoulder tray including retractors and
draping of the upper extremity, with operating surgeon on curved suture passers if need to pass suture/material
the right, assistant at the head end on the left of the image around the coracoid
9  Acromioclavicular Joint Dislocation 91

be easily ­ palpated throughout the operation.

Remembering the musculocutaneous nerve
enters the medial border of the conjoint tendon
2.5–8 cm distal to the coracoid provides expo-
sure of the coracoid down to its base. The pecto-
ralis minor (medially) and CA ligament
(laterally) usually need not be divided. Some Fig. 9.4  AP radiograph of final fixation demonstrating
surgeons take the decision to excise up to 1 cm ACJ fixation using two drill holes through clavicle and
suture passed under coracoid
of the lateral end of the clavicle, especially in
chronic cases, to ease reduction and prevent
impingement, though there is no evidence to
support preserving or resecting. Summary of Tips, Tricks and Pitfalls

• As reduction is usually assessed under direct

Open Reduction Manoeuvres vision, as well as on image intensifier, it is
imperative to ensure both superior displace-
Reduction generally requires upward elevation ment and anteroposterior reduction are
of the humerus towards the acromion, with achieved.
downward pressure on the distal clavicle. Once • To avoid fracture of the coracoid during the
full surgical exposure is achieved, a reduction fixation, any sutures passed inferior to the
of the ACJ can be performed using pointed coracoid should do so at the ‘elbow’ of this
reduction forceps, with one arm placed inferior bony structure, deep to the conjoint tendon.
to the lateral coracoid and one arm superior to • Likewise, if the fixation device used requires a
the distal clavicle. Care should be taken to drill hole through the coracoid, this must be
ensure, as well as correcting the superior dis- placed centrally on the horizontal part of the
placement, anteroposterior reduction is also coracoid: any offset medially or laterally will
achieved. Anteroposterior image intensifier eccentrically load this bone.
views can now be taken to assess reduction, • The placement of the clavicle part of the fixa-
and a Zanca view can often be achieved. tion device, either via drill hole or placement
on the superior clavicle, is also important in
the success of the fixation: generally, this is at
Implant Insertion a point directly superior to the centre of the
coracoid, as placement too medial or lateral
The fixation device of choice can then be may lead to eccentric loading and failure.
implanted. If this involved hooking suture or
other material around the coracoid, this is usually
performed from medial to lateral keeping the Further Reading
passing device on the undersurface bone of the
coracoid at all times, to prevent nerve injury. If Modi CS, Beazley J, Lawrence TM, Veillette
CJH. Controversies relating to the management of
this involves placing drill holes through the cora- acromioclavicular joint dislocations. Bone Joint J.
coid, great care should be placed upon exposing 2013;95-B:1595–602.
the superior aspect of the coracoid to ensure the Rockwood CA, Williams GR, Young
drill passes centrally on the horizontal limb of the DC. Acromioclavicular injuries. In: Rockwood
CA, Green DP, Bucholz RW, Heckman JD, editors.
coracoid. Again, anteroposterior image intensi- Fractures in adults, vol. I. 4th ed. Philadelphia, PA:
fier views can now be taken to assess reduction Lippincott-Raven; 1996. p. 1341–413.
before the device selected is tightened and locked Weaver JK, Dunn HK. Treatment of acromioclavicular
into place, and a Zanka view can often be injuries, especially complete acromioclavicular sepa-
rations. J Bone Joint Surg Am. 1972;54-A:1187.
achieved (Fig. 9.4).
 Sternoclavicular Joint Dislocations
10
Harish Kapoor, Osman Riaz, and Adeel Aqil

Anatomical Fracture Location contralateral clavicle. Computed tomography

(CT), gold standard for investigation, axial views
Anteroposterior (AP) view including both sterno- to determine position of medial end of clavicle in
clavicular joints (Fig. 10.1). Difficult to visualise relation to mediastinal structures and associated
on AP therefore recommend serendipity views injuries (Fig. 10.3). Posterior dislocation can
(Fig.  10.2), beam at 40 degree cephalic tilt. present as an acute emergency with acute com-
Anterior dislocation (much commoner)— pression of mediastinal structures. Medial end
affected clavicle above contralateral clavicle. clavicle last to fuse at 23–25 years and poten-
Posterior dislocation—affected clavicle below tially growth plate injuries may occur.

Fig. 10.1  AP radiograph showing inferior

displacement of right medial end of clavicle
(arrow); this suggests posterior dislocation

H. Kapoor, M.B.B.S., M.S.(Orth), D.N.B. (*)

Consultant Trauma and Orthopaedics,
Leeds General Infirmary, Leeds, UK
e-mail: harish.kapoor@nhs.net
O. Riaz, M.B.B.S., M.R.C.S. • A. Aqil, M.B.B.S.,
M.R.C.S.
Department of Trauma and Orthopaedic Surgery,
Leeds General Infirmary, Leeds, UK

© Springer International Publishing AG 2018 93

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_10
94 H. Kapoor et al.

Would advise crossmatch of four units of packed

red cells. Equipment—AO small fragment
(3.5 mm) set, have FiberWire or Ethibond suture
available. Would recommend sternotomy set to be
available in the operating room.

Patient Setup in Theatre

Table setup—instrumentation is set up on the side

of the operation. Image intensifier is from the con-
tralateral side. Position table diagonally across the
Fig. 10.2 Serendipity radiograph demonstrating right
posterior dislocation (arrow) operating room so that the operating area lies in
the clean air field. Place patient supine with arm at
edge of the radiolucent table (OSI or equivalent)
with side support (Fig. 10.4). Both surgeon and
assistant will stand on the injured side.

 losed Reduction Manoeuvres

C
(Anterior Dislocation)

Abduct and extend arm while applying axial trac-

tion, and simultaneously apply direct posterior
pressure over medial clavicle. Manipulate medial
Fig. 10.3  Axial CT demonstrating posterior dislocation clavicle with towel clip or fingers. Figure of eight
of right clavicle and its relationship to the structures in the bandage with sling post reduction for 6 weeks.
mediastinum (arrow)

Pre-op Planning Surgical Approach

Clinical assessment—usually high-energy injury Skin preparation is carried out using usual antisep-
(RTC, contact sports), deformity is present with tic solution. Prepare the whole chest and both
ecchymosis, swelling, tenderness and crepitation.
Anterior dislocation—palpable bump present, pos-
terior dislocation can be associated with dyspnoea,
dysphagia, tachypnoea and stridor which are worse
on lying supine. Important to assess for pneumo-
thorax or haemothorax. Assess and document vas-
cular status of the upper arms and any difference in
peripheral pulses between the injured and contra-
lateral side. Assess neurological status to determine
any injury to brachial plexus. Cardiothoracic/tho-
racic surgeon consult should be undertaken before
any surgical intervention and should be on standby
during procedure ideally. Anaesthesia—general
anaesthetic at induction, administration of prophy- Fig. 10.4  Position of patient, supine with arm support on
lactic antibiotics as per local hospital protocol. a radiolucent table
10  Sternoclavicular Joint Dislocations 95

Fig. 10.7  Excise the articular disc to create space for

reduction
Fig. 10.5  Draping of patient allows access to perform
sternotomy. Ensure curved incision of the clavicle is per-
form which is shown in this figure

Fig. 10.8  Using a 2.5 mm drill, create a tunnel of the

medial end of the clavicle around 2 cm lateral from SCJ

Fig. 10.6  Dissect down to the periosteum

cially if old injury. If so, careful dissection is
required with cardiothoracic team standby. Apply
clavicle; clean up the anterior aspect of neck and to towel clip or serrated clamp to the end of the
the lateral deltoid region. Use a sternotomy drape clavicle, and gently reduce the medial end onto
(like a DHS drape) to allow access to the mediasti- the manubrium of the sternum. Gentle lifting of
nal structures should it become necessary. Make manubrium with a langenback can increase the
an incision over the medial end of the clavicle, view behind it to help deliver the clavicle. Use a
which curves inferiorly of the affected side 2.5 mm drill to create a tunnel of the medial end
(Fig.  10.5). Using the cutting diathermy, bring of the clavicle around 2 cm lateral from SCJ
down the incision through the skin to the perios- (Fig. 10.8). Create another tunnel in the articular
teum. Perform a subperiosteal dissection of the surface of the sternum with a blunt malleable
sternoclavicular joint (Fig. 10.6). Excise the fibro- retractor posteriorly for protection. Create mini-
cartilage articular disc to expose the SCJ; this mum two loops for stability. Pass FiberWire or
helps with reduction as it creates space (Fig. 10.7). Ethibond suture through the tunnels in a figure of
eight configuration. While holding the joint
reduced, tie the suture ensuring adequate reduc-
Open Reduction Manoeuvres tion is maintained (Fig. 10.9). Assess dynamic
stability by abducting, flexing and extending the
Ensure the medial end of the clavicle is not teth- arm at the shoulder joint. Obtain AP and seren-
ered to the structures of the mediastinum espe- dipity views on the image intensifier to confirm
96 H. Kapoor et al.

• Do not compromise on the incision as poste-

rior dislocations can be difficult to visualise.
• Try closed reduction manoeuvres first which
may be successful.
• Excise the articular disc of the SCJ to help cre-
ate access to reduce posteriorly displaced
clavicle.
• FibeWire is recommended as it provides good
strength and hold. Other strong non-­absorbable
sutures like Ethibond/Ticron can be used.
• Repair of the posterior capsule/periosteal
sleeve after delivering medial clavicle helps in
preventing the medial end of clavicle falling
Fig. 10.9  FibeWire passed through drill tunnels and tied
off maintaining reduction
into the dead space created.
• Always obtain intraoperatively serendipity
views to confirm reduction and a CT
reduction. Continue with wound closure using postoperatively.
1/0, 2/0 vicryl and 3/0 S/C to skin. Immobilise • Keep immobilised for 6 weeks and restriction
arm with a polysling. Protect arm for 6 weeks. of abduction and flexion beyond 90° and to
avoid contact sports up to 4–6 months. Some
swelling is likely to persist long term over the
Summary of Tips and Tricks medial end of clavicle.
• Avoid metalwork due to the potential high risk
• Always obtain preoperative CT scan with 3D of migration and implant failure and subse-
reconstructions. quently potentially disastrous consequences.
• Most anterior sternoclavicular subluxations • I do not use grafts in my primary fixations, but
can be treated closed/nonoperatively with a tendon grafts including the sternomastoid fas-
small percentage needing intervention and cia have been described in literature through
reconstruction for symptoms of instability. intraosseous tunnels instead of non-­absorbable
• With posterior SCJ dislocations—have the sutures.
cardiothoracic team on standby with presence • Supplement additional suture/anchor fixation
of sternotomy kit in the operating theatre if in the first rib for additional fixation as
proceeding to open reduction in case of a necessary.
vascular emergency.
 Clavicle Fracture
11
Makoto Kobayashi and Takashi Matsushita

Fractures of the clavicle usually present in young displacement (Fig. 11.1). CT can assist in a
males constituting approximately 2–4% of all detailed evaluation of the fracture pattern.
fractures in adults [1]. The most common loca-
tion of fractures is the midshaft area followed by
the lateral and medial part. For many years, clav- Preoperative Planning
icle fractures have been managed nonoperatively,
irrespective of the type of fracture. However, Assess fracture pattern and degree of comminu-
lately, new evidence has emerged indicating high tion. In this case it is appreciated that the interme-
incidence of nonunion with nonoperative treat- diate fragments are small and would be difficult to
ment and a reduced functional capacity in up to reduce them anatomically without disturbing their
40% of patients [2]. Consequently more interest blood supply. As the contact area between the
has been shown in operative interventions tech- main fragments was noted to be small, intramed-
niques. The Neer's and AO are the most com- ullary wire fixation would not have been the ideal
monly used fracture classifications. method to prevent shortening of the clavicle.

Anatomical Fracture Location

A direct fall on the shoulder is the most common

mechanism of injury. Clinical examination
should assess the neurovascular status of the
affected extremity. Anteroposterior and 15°
cephalic tilt (ZANCA view) will allow determi-
nation of fracture pattern and superior/inferior

M. Kobayashi
Department of Orthopaedic Surgery, Teikyo
University School of Medicine, Tokyo, Japan
T. Matsushita (*)
Department of Traumatology, Fukushima Medical Fig. 11.1  Radiographs of a 48-year-old male with mid-
University, Fukushima, Japan shaft clavicle comminuted fracture. Top: cephalic view.
e-mail: takashi@matsushita.net Bottom: caudal view

© Springer International Publishing AG 2018 97

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_11
98 M. Kobayashi and T. Matsushita

Consequently, it was decided to apply MIPO: Open Reduction Maneuver

minimally invasive plate osteosynthesis technique
with an anatomically shaped locking plate [3]. The main fragments are controlled directly with
small pointed forceps. Thereafter, these frag-
ments were temporarily fixed with an intramed-
 atient Setup in the Operating
P ullary Kirschner wire (1.8–2.0 mm), (Fig. 11.3).
Theater The “blunt” end of the K-wire is cut obliquely to
make it a “double-tipped spear.” One end of the
The patient is placed in the supine position on a K-wire is inserted into the medial fragment from
radiolucent table. The arm does not need to be the fracture end and is advanced through the bone
included in the operative field. A bolster can be fragment and out through the skin over the medial
placed under the spine to reduce the existing end of the medial fragment. Then the opposite
shortening of the clavicle. Image intensifier is end of the wire is pushed back into the lateral
positioned cephalad to the patient allowing acqui- fragment from the fracture end. This “switchback
sition of cephalic and caudal tilt views insertion” is time saving. The alignment of the
intraoperatively. main fragments is checked with the image inten-
sifier on two different views.

Surgical Approach
Implant Insertion (Figs. 11.4 and 11.5)
The entire shape of the clavicle is marked on the
skin (Fig. 11.2). It is enough to fix only the two An anatomically shaped locking plate is conve-
main fragments with a plate using two small inci- nient for MIPO [4]. The plate should be long
sions. Two 4 cm incisions are made, one on each, enough so that three bicortical screws can be
of the medial and lateral sides of the clavicle.
Dedicated anatomical plates are available with
either locking or non-locking screw options.
Reduction instruments include K-wires, small
pointed reduction forceps. The main fragments
are manipulated and reduced directly with small
pointed reduction forceps.

Fig. 11.3  K-wire insertion to the medial fragment. A

“double-tipped spear” K-wire is inserted through the
Fig. 11.2  Skin incision marking on the left clavicle. A medial fragment from the fracture end. The main frag-
acromion, F fracture site, N suprasternal notch ments are manipulated directly with small pointed forceps
11  Clavicle Fracture 99

Fig. 11.4  Temporary K-wire fixation and plating. The

“double-tipped spear” K-wire exits through the skin near
the suprasternal notch. Then, the wire is pushed back such
that opposite end goes into the lateral fragment in a Fig. 11.6  Postoperative roentgenograms
“switchback” manner. An anatomically shaped locking
plate is placed on the bone so that three consecutive screw
holes are correctly over each fragment. A acromion, N each fragment (Fig. 11.5). Using 1, 2/0 vicryl and
suprasternal notch 3/0 s/c sutures, the wound is stitched.
Postoperative radiographs are obtained prior to
discharge (Fig. 11.6).
Postoperatively, a sling is worn for 1 week
for comfort and to facilitate wound healing.
Daily activities of living are not restricted, but
manual labor is not allowed before callus for-
mation is seen on the roentgenograms
(Fig. 11.7).

Summary of Tips, Tricks, and Pitfalls

• “Switchback insertion” of K-wires is time

saving as it maintains reduction.
Fig. 11.5  Completion of plating. A acromion, N supra- • It is important to confirm by fluoroscopy that
sternal notch
the plate is appropriately positioned on the
bone prior to screw insertion.
inserted into each main fragment. In this case, an • Three bicortical screws on each fragment are
eight-hole locking plate is chosen. The plate is mandatory for optimum stability.
inserted subcutaneously, and each main fragment • Make sure that the length of the screws is not
is temporarily fixed using the plate with two long enough to cause irritation/damage of
1.8 mm Kirschner wires (Fig. 11.4). The position the neurovascular structures underneath the
of the plate on the bone is confirmed with the clavicle [5].
image intensifier. It is important to make sure that • Take caution not to devitalize the bone
three consecutive screw holes are located on each fragments.
fragment to optimize fracture stability. Then, • Prevent iatrogenic damage to supraclavicular
three bicortical locking screws are inserted into nerve endings [5].
100 M. Kobayashi and T. Matsushita

Fig. 11.7  8 weeks

postoperative
roentgenograms
demonstrating fracture
union

Operative treatment of dislocated midshaft clavicu-

References lar fractures: plate or intramedullary nail fixation? A
randomized controlled trial. J Bone Joint Surg Am.
1. Postacchini F, Gumina S, De Santis P, Albo 2015;97:613–9.
F. Epidemiology of clavicle fractures. J Shoulder Elb 4. VanBeek C, Boselli KJ, Cadet ER, Ahmad CS, Levine
Surg. 2002;11(5):452–6. WN. Precontoured plating of clavicle fractures:
2. Xu J, Xu L, Xu W, et al. Operative versus nonoperative decreased hardware-related complications? Clin
treatment in the management of midshaft clavicular Orthop Relat Res. 2011;469:3337–43.
fractures: a meta-analysis of randomized controlled 5. Wijdicks FJ, Van der Meijden OA, Millett PJ,
trials. J Shoulder Elb Surg. 2014;23:173–81. Verleisdonk EJ, Houwert RM. Systematic review of
3. van der Meijden OA, Houwert RM, Hulsmans M, the complications of plate fixation of clavicle frac-
Wijdicks FJ, Dijkgraaf MG, Meylaerts SA, et al. tures. Arch Orthop Trauma Surg. 2012;132:617–25.
 Scapula Fractures
12
David Limb

 natomical Fracture Location:

A tion—fractures of the blade and posteroinferior
Radiograph of Fracture Pattern scapula often being approached from behind,
whilst superior and anterior/anteroinferior frac-
Fractures of the body of the scapula are usually tures are usually approached from the front. The
high-energy injuries resulting from a directly latter include anteroinferior fractures of the gle-
applied force. Fractures of the spine of the scap- noid rim associated with shoulder dislocation.
ula and blade are therefore often associated with These may also occur with much lower energy
chest trauma and possibly abdominal and head injuries on the sports field, for example, and
injury. Fractures of the acromion result from a many are amenable to arthroscopic management
force applied to the point of the shoulder, and, if but will not be considered further in this chapter,
downwardly directed, the brachial plexus is vul- which will deal with open approaches for high-­
nerable. High-energy forces directed to the front energy trauma. Given the significant differences
of the shoulder can tear the acromioclavicular between anterior and posterior approaches, both
joint apart and, in extreme cases, produce a will be considered. Occasionally complex frac-
scapulothoracic dissociation with vascular injury. ture patterns dictate a combined approach, whilst
If the force is transmitted to the scapula through not uncommonly, fractures of the glenoid neck
the upper limb, then fractures of the glenoid fossa are associated with displaced clavicle fractures
can occur, with or without glenohumeral disloca- (the commonest variety of floating shoulder), and
tion. Of course, any combination of these injuries a decision has to be taken about whether to fix the
can occur depending on the energy delivered to clavicle and, if so, whether to reposition the
the shoulder girdle and its vectors. patient or carry out both procedures in one
The surgical management of scapular frac- position.
tures is most often indicated for displaced inju-
ries including the glenoid fossa (Fig. 12.1), as
this is assumed to have great potential for future Preoperative Planning
impact on shoulder function. However, the
approach differs significantly with fracture loca- The management of scapula fractures is not life-­
saving in its own right and occurs in a planned
fashion. The indications are not clear-cut but are
D. Limb often taken to include fractures of the glenoid that
Leeds Teaching Hospitals Trust, Chapel Allerton are associated with fixed subluxation or disloca-
Hospital, Leeds LS7 4SA, UK tion of the humeral head, often involving 5 mm or
e-mail: david.limb@nhs.net

© Springer International Publishing AG 2018 101

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_12
102 D. Limb

Fig. 12.1  An AP view of the scapula showing a fracture

involving the glenoid neck and articular surface with
medial displacement of the coracoid and glenoid frag-
ments coupled with rotation
Fig. 12.2  3D reconstruction of CT data can be very use-
ful in preoperative planning—in this case the data for the
more of displacement at the articular surface. humeral head has been subtracted, allowing easier visuali-
Very comminuted fractures may be impossible to sation of the glenoid fracture
fix but often demonstrate secondary congruence,
with the many fragments aligning on the humeral form callus and heal—reduction of scapula blade
head and healing there to form a socket against fractures in particular can be difficult by 2 weeks
which articulation can occur. The trauma CT is after trauma and impossible by 3 weeks.
useful in identifying the fracture, any associated In general terms, fractures approached anteri-
joint subluxation or dislocation, any acromiocla- orly are fractures involving a large segment of the
vicular or clavicle injury and indeed any other glenoid fossa, usually superior or anteroinferior,
chest wall or thoracic trauma that might affect the and are fixed with lag screws after direct or
timing of intervention. arthroscopic observation of satisfactory reduc-
If the trauma CT has sufficient data, 3D recon- tion of the joint surface. Those approached from
struction is extremely useful for planning behind are displaced structural elements of the
approaches and fixation (Fig. 12.2). If not, then a scapula, particularly the lateral column (often
specific shoulder CT can be obtained once the including part of the glenoid fossa, usually its
patient is well enough. Plain radiographs are still interior half), spine and acromion, and are usu-
useful for assessing the fracture, but these have to ally fixed with plates and screws.
be centred on the injury—anteroposterior (AP),
axial and scapula lateral views. Remember that
the scapula faces forwards by approximately 30°, Patient Setup in Theatre
so an AP chest or direct AP including the shoul-
der images the scapula turned towards the film For anterior approaches, the patient is set up in
and is less useful. the beach chair position (Fig. 12.3). A gel pad or
Finally, timing is important—the patient has sandbag medial to the scapula and lateral to the
to be physiologically fit enough for surgery, and spine helps push the scapula forwards. The arm is
the fixation of scapula fractures is often delayed draped free and supported on a Mayo stand. The
beyond the immediate period after trauma. surgeon stands facing the shoulder, in the angle
However, the scapula is encased in a highly vas- between the table and the Mayo stand. From this
cular muscle envelope, and fractures quickly approach, direct reduction and lag screw fixation
12  Scapula Fractures 103

Fig. 12.3  The beach

chair position is suitable
for anterior approaches
and allows easy
intraoperative screening
using the image
intensifier

are often performed, and this can be facilitated by

image intensifier (II) use. The II is brought in
from behind the shoulder and raised to the top of
its travel; then the ‘C’ arm is rotated over the
shoulder—in this way the surgeon can operate
without hindrance whilst using screening.
For posterior approaches, the patient is set up
in a lateral position on a sandbag or between pel-
vic supports. Again, the affected arm is draped
free and this time is rested on a Mayo table on the
opposite site of the table to the surgeon (Fig. 12.4).
The Mayo can be raised to abduct the arm and
thus relax deltoid, facilitating exposure of the
posterior glenoid.

Closed Reduction Manoeuvres

Closed reduction manoeuvres have limited roles

in the fixation of scapula fractures. However, the
shoulder can be unstable and may need to be Fig. 12.4  The lateral position allows posterior approaches
reduced to reduce fracture fragments. to the scapula. The arm is draped free so can be manipu-
lated to allow indirect reduction of articular fragments
Manipulation of the arm also indirectly moves with intact joint capsule attached
fragments of the glenoid that are attached to the
humerus through the joint capsule, though this is
more helpful once the shoulder is open. However, and rotation of the humerus, all of which can be
draping the arm free as described above allows used to help reduction at different steps in the
traction, elevation, abduction, flexion, extension operative procedure.
104 D. Limb

Reduction Instruments Surgical Approach

By far the most useful aids to reduction are varia- From the front, the deltopectoral approach is the
tions on the joystick—stout K-wires or long, workhorse and does not interfere with any future
small fragment screws that are inserted into frag- surgery that might be needed for consequences of
ments and used to manipulate them into place. the shoulder injury. The incision can be a full del-
For large fragments of the joint surface, espe- topectoral exposure, or more limited. For exam-
cially from anterior approaches, the wires can be ple, a low deltopectoral approach allows a
used from a cannulated screw set to allow defini- subscapularis split to give access to a single
tive fixation over the wires. If a large superior anteroinferior fragment that can be fixed with
glenoid fragment is contiguous with the coracoid small fragment or cannulated screws. A higher
process, which is easily visible through the delto- limited deltopectoral approach allows the rotator
pectoral approach if tackling a fracture from the interval to be opened and the glenoid surface to be
front, then a bone clamp can be used to grasp the inspected—through this approach the coracoid
coracoid and manipulate the superior glenoid can also be grasped and used to manipulate the
into place. Bone clamps from the small fragment superior glenoid, to which it is often still attached.
set (pointed and crocodile) are also valuable in The coracoid can also be fixed itself through this
reducing fractures from a posterior approach approach if involved in the injury pattern.
(Fig. 12.5). However, the blade of the scapula is From the back a Judet approach gives excel-
very thin, and the borders, which are strong lent visualisation of the whole of the scapula
enough for the application of clamps, are also the spine and the blade below it, elevating infraspina-
only areas suitable for the application of plates. tus to expose medial and lateral columns.
Therefore, after pulling a fragment into a position However, the thickness of the medial and lateral
of reduction, temporary K-wires might be possi- columns is such that even in stout individuals,
ble around the glenoid fossa, but elsewhere wires screws of 14 mm or even less are all that can be
and screws used as joysticks have to be removed inserted.
before a plate can be applied. It is sometimes use- The Judet approach is, however, quite an injury
ful to have a drill and strong suture available to in itself, and many fractures for which fixation is
create a pair of holes through which suture can be indicated affect principally the lateral column, gle-
passed simply to use to hold and manipulate frag- noid neck and glenoid, and for these a more lim-
ments once they have been brought into reason- ited direct posterior approach can be used. The
able alignment by a joystick or bone clamp incision is placed from the joint line posteriorly
technique. and passes down the line of the lateral column of

Fig. 12.5  Bone clamps,

K-wires, pliers and a
selection of retractors
and screws can be used
as reduction aids
12  Scapula Fractures 105

the scapula (Fig. 12.6). The skin is very thick here

and the fat layer quite fibrous and attached to the
muscle fascia quite firmly. After separating the fat
from muscle layers, the inferior edge of deltoid is
identified and lifted towards the head, being
relaxed by arm abduction, allowing the identifica-
tion of infraspinatus and teres minor (Fig. 12.7).
There is an internervous plane between the latter,
which is exploited. It can be difficult to see but is
usually easy to palpate as infraspinatus is sitting
on the scapula blade, but teres is arising from the
lateral column and running just off the lateral bor-
der as it passes up to the humeral head. Quite often Fig. 12.7  The inferior edge of deltoid is identified, and
the interval is easy to locate, as a displaced lateral below this infraspinatus and teres minor run side by side
but are often separated by the injury. The interval can be
column takes teres with it and leaves behind infra-
developed and held open with a self-retaining retractor
spinatus, tearing open the interval so that the frac-
ture is immediately encountered. Once identified
the interval is opened inferiorly, to the flat of the Open Reduction Manoeuvres
inferior angle of the scapula, and superiorly to the
transition into rotator cuff tendons—a split devel- An anteroinferior glenoid fragment, approached
oped here through the capsule opens the joint, but from the front, is best controlled initially by a
remember that the glenoid is facing forwards by ‘K’-wire inserted about 5 mm from the joint mar-
about 30°, so the view of the joint surface is quite gin, and the wire is then driven through, parallel
limited, though it may be palpated (it can also be to the glenoid surface, until it reaches the fracture
inspected by inserting an arthroscope from the surface. The wire is then used as a joystick to
front, whilst carrying out the open procedure from manipulate the fragment into position before
the back). By elevating infraspinatus medially by driving it across to the posterior cortex of the gle-
about one centimetre, the whole lateral column is noid. This can be done under direct vision if a
exposed, as well as the inferior half of the posterior deltopectoral approach has been used, but this is
glenoid, to the level of the spinoglenoid notch. also exactly the same principle as is used for
arthroscopic fixation of a large bony Bankart
lesion. If there is room, a screw or second wire is
passed through the fragment separately before
replacing the wire with a screw. Alternatively, a
cannulated screw can be inserted over the wire.
Although 3.5 mm small fragment screws are per-
fectly adequate for holding such fragments, the
guidewire for a 3.5 mm cannulated screw is very
thin and flexible. When using an arthroscopic
approach in particular, therefore, a larger screw
diameter of at least 4.5 mm is chosen so that a
thicker, stiffer K wire can be used, which is a bet-
ter joystick for reducing the bone fragment before
driving the wire across the fracture site.
Superior fragments attached to the coracoid can
Fig. 12.6  A posterior approach starting over the posterior
joint line and passing vertically down allows access to the
be manipulated by grasping the coracoid
lateral column through an internervous plane with mini- (Fig. 12.8), otherwise a long screw is inserted into
mal muscle stripping the superior fragment from the anterior rim and
106 D. Limb

Fig. 12.8  If superior glenoid fragments remain attached

to the base of the coracoid, the latter can be grasped and
used to reduce the articular surface

used as a joystick to manipulate the fragment into

place— a thin lever may also be used through the
fracture site to help coax the superior fragment into
place. Fixation then depends on the orientation of
the fracture line. Oblique fractures may be amena-
ble to lag screw fixation from the front, angling
across the fracture line but being careful not to
cause shear whilst compressing and lose reduction.
Transverse fractures can be stabilised by passing a
percutaneous wire under image intensifier control
from superiorly (Fig. 12.9), behind the distal clavi-
cle (a Nevassier portal in arthroscopic terms) to
pass through supraspinatus muscle belly into the
glenoid. Once happy with the position, a cannu- Fig. 12.9  The scapula seen from above—the coracoid
lated screw can be used over the wire to compress can be gripped with a crocodile reduction clamp and be
used to reduce attached superior glenoid fragments—a
the fracture, after which the wire is removed. screw can be inserted from superior to inferior (entry
Posterior fragments can be reduced under point indicated by circle), whilst the reduction is main-
direct vision, but the lateral column and glenoid tained by grasping the coracoid
often disappear into muscle tissue anteriorly
making safe grasping and manipulation a chal- get good compression, though attempts should
lenge. The posterior glenoid is usually visible, still be made to appropriately place screws in
and there is sufficient room to insert a long screw compression plates to achieve this. As noted
(say a 50 m screw inserted only 10 mm into the above, if the lateral column tends to fall back into
bone, leaving a good length to use as a handle to the wound once any holding device is removed, it
manipulate the glenoid). This can then be used to can be useful to pass a ‘2’ or ‘5’ braided polyester
lift and rotate the lateral column gently back into suture through drill holes adjacent to the required
place, holding it with a crocodile clamp if suffi- plate position or around the lateral column itself
cient is exposed or a second joystick screw if not so that the bone can be held up against the plate
(Fig. 12.10). Fortunately, the scapula is so vascu- by traction on the sutures as fixation proceeds.
lar that healing still occurs even if one does not
12  Scapula Fractures 107

certainly be entering the glenohumeral joint. Take

account of the scapular plane when inserting
screws in glenoid fragments, and if necessary visu-
alise either by posterior arthrotomy to allow direct
vision or palpation, or insert an arthroscope from
the front of the joint. Use the image intensifier to
ensure satisfactory reduction without intra-articu-
lar penetration, and check by rotating the free arm
and ensuring a smooth, full range of movement.

Fig. 12.10  The lateral column can be controlled and Summary: Tips, Tricks and Pitfalls
reduced by inserting long screws into the column either
side of the fracture line and grasping these with pliers or
reduction clamps to effect a reduction under direct vision • Scapula fractures are high-energy injuries and
are usually fixed as a planned procedure,
though rapid healing makes reduction very dif-
Implant Insertion ficult much beyond 2 weeks after injury. CT
and 3D reconstruction are useful preoperative
When inserting cannulated screws over wires planning tools. Superior and anteroinferior dis-
anteriorly, always try to insert a second wire placed glenoid fossa fragments are approached
before drilling for the screw—the act of drilling most usually from an anterior approach, whilst
abolishes any friction between the fragment and other scapula fractures and glenoid fractures
the wire and allows it to slide up the wire. involving the interior and posterior glenoid are
Insertion of the screw can still push the fragment usually approached from posterior.
back down into the same place, but care has to be • Views of the joint surface are relatively good
taken not to allow any rotation of the fragment in from anterior approaches but more difficult
this case, or joint incongruency will result. from posterior as the glenoid faces approxi-
When inserting plates from a posterior approach mately 30° forwards from the coronal plane. An
(Fig.  12.11), remember that the glenoid articular arthroscope can be used as an adjunct for joint
surface is tilted forwards—a screw passing for- visualisation, whilst some anterior fractures can
wards in the sagittal plane of the patient will almost be fixed entirely by an arthroscopic approach.
• Approaches that use internervous planes and
involve minimal muscle stripping allow rapid
healing and rehabilitation after surgery.
However, access is more difficult, and reduc-
tion can be tricky—inserting long screws a
short distance into the posteroinferior glenoid
and lateral column is a useful trick as these
screws can then be grasped with instruments
and used to reduce fracture fragments.
• Aim to create a congruent glenoid that is sup-
ported on the scapular blade and in particular the
lateral column of the scapula (Fig. 12.12), which
fortunately is the strongest segment of bone for
the attachment of plates. Aim to allow immedi-
ate mobilisation—the long-term complication
Fig. 12.11  The lateral column has been plated, being
contoured away from the articular surface. A separate lag that is almost inevitable to a degree is stiffness,
screw is compressing two large glenoid fragments and immobilisation will make this worse.
108 D. Limb

2013;10(4):188–92.
Mighell MA, Hatzidakis AM, Otto RJ, Watson JT, Cottrell
BJ, Cusick MC, Pappou IP. Complex trauma to the
shoulder girdle, including the proximal humerus, the
clavicle, and the scapula: current concepts in diagnosis
and treatment. Instr Course Lect. 2015;64:121–37.
Pizanis A, Tosounidis G, Braun C, Pohlemann T, Wirbel
RJ. The posterior two-portal approach for reconstruc-
tion of scapula fractures: results of 39 patients. Injury.
2013;44(11):1630–5.
Schroder LK, Gauger EM, Gilbertson JA, Cole
PA. Functional outcomes after operative management
of extra-articular glenoid neck and scapular body frac-
tures. J Bone Joint Surg Am. 2016;98(19):1623–30.
Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole
PA. Treatment of scapular fractures: Systematic
review of 520 fractures in 22 case series. J Orthop
Fig. 12.12  Aim for a congruent glenoid supported by a Trauma. 2006;20-3:230–3.
stable lateral column—comminution of the blade of the
scapula itself rarely needs any intervention or stabilisation

Further Reading
Bartoníček J, Tuček M, Frič V, Obruba P. Fractures of
the scapular neck: diagnosis, classifications and treat-
ment. Int Orthop. 2014;38(10):2163–73.
Lewis S, Argintar E, Jahn R, Zusmanovich M, Itamura
J, Rick Hatch GF. Intra-articular scapular frac-
tures: outcomes after internal fixation. J Orthop.
 Humeral Head Avulsion
of Greater Tuberosity 13
Mark Philipson

I ndications for Surgery Closed Reduction Manoeuvres

and Preoperative Planning
There is no role for closed reduction except to
Surgical management of displaced isolated frac- relocate the humerus in cases of glenohumeral
tures involving the greater tuberosity is not con- dislocation (Fig. 13.1).
troversial. I will offer surgical fixation to all fit
patients with an isolated greater tuberosity frac-
ture displaced more than 5 mm. Surgical Approach
I approach these as I would an open cuff repair
not as an osteosynthesis procedure. My experi- I utilise a coronal incision, extending from the
ence is that simple screw fixation often fails even ACJ to 3–4 cm distal to the acromion (Fig. 13.2).
when the bone quality appears to be good. My I take the coracoacromial ligament off the acro-
objective is to repair the rotator cuff with the mion. I perform an acromioplasty using a saw or
tuberosity fragment restored to the fracture bed. osteotome if the acromion is hooked. I find the
tendinous raphe at the anterolateral corner of the

Patient Setup in Theatre

The patient is sat up in the beach chair position.

The arm is draped free and rests on a Mayo stand,
typically in an abducted position to reduce the
tension in deltoid. The surgeon stands facing the
shoulder. While others may do, I do not routinely
utilise an image intensifier.

M. Philipson Fig. 13.1  An X-ray image of an isolated greater tubero­

Leeds General Infirmary, Leeds, UK sity fracture associated with anterior dislocation of the
e-mail: mark.philipson@nhs.net ­glenohumeral joint

© Springer International Publishing AG 2018 109

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_13
110 M. Philipson

Implant Insertion

I utilise two anchors designed for labral repair

in the hard cortical bone at the posterior edge of
the bicipital groove. An effective repair can be
achieved using transosseous sutures through
drill holes in the metaphysis; however I find
that access for the drill holes and suture passing
is challenging through my preferred superolat-
eral approach. Each anchor is double loaded
with abrasion-resistant suture material.
Utilising the four available sutures, I place four
simple horizontal mattress sutures spread out
evenly from front to back in the injured cuff.
Before tensioning and tying these sutures, I
place a stitch to secure the most anterolateral
portion of the free edge of supraspinatus to
rotator interval tissue at the most posterolateral
portion of subscapularis. In other words, I
secure the cuff over the top of the bicipital
groove. This is to help achieve anatomic ten-
sion in the cuff when the four mattress sutures
Fig. 13.2  The skin incision for a superolateral deltoid-­
splitting approach
are tied using a sliding locking knot (Figs. 13.3
and 13.4). It is easy to inadvertently over-ten-
sion the cuff in a fresh injury.
acromion and split deltoid at this point for a dis-
tance of approximately 4 cm. The humerus can
be rotated to facilitate access. Post-op Instructions

In cases involving a fresh injury with minimal

Open Reduction Manoeuvres tension in the cuff and the anchors are in good
bone, then this is a very secure repair, and I am
An assistant elevates the acromion utilising a
large Langenbeck retractor. The surgeon applies
traction to the humerus to open the subacromial
space and retrieves the retracted posterosuperior
cuff tendon and tuberosity fragment(s) with for-
ceps. A stay suture is placed in supraspinatus.
In cases of locked anterior dislocation associ-
ated with a greater tuberosity fracture, I still uti-
lise the same superolateral approach described
above. This gives excellent access to the empty
glenoid so that any debris can be removed from
the joint and facilitating direct digital manipula-
tion of the humeral head. If relocation remains
difficult, then a bone hook can be used on the
strong bone of the proximal humeral shaft to Fig. 13.3  A large isolated greater tuberosity fracture has
manipulate the humerus in to joint. been repaired using two double-loaded anchors
13  Humeral Head Avulsion of Greater Tuberosity 111

happy for the patient to commence active-assisted

exercises immediately. The patient wears a sim-
ple sling for 4–6 weeks.

Tips, Tricks and Pitfalls

• Always try and repair these earlier rather than

later. At 2 weeks the reduction is easy. At
6 weeks it is challenging because of retraction
of the cuff. Beyond 6 weeks it can be impos-
sible even with extensive releases.
• Avoid using screw fixation alone. Think of it
as a cuff repair.
• The use of double-loaded anchors rather than
transosseous sutures facilitates a smaller
superolateral exposure.
• Avoid over-tensioning the cuff.

Fig. 13.4  A post-op X-ray image of the same case (the

anchors are radiolucent)
 Fractures of Proximal Humerus
Open Reduction and Internal 14
Fixation

Harish Kapoor, Adeel Aqil, and Osman Riaz

Initial Assessment plasty solution can be very difficult. Patients can

potentially retain better function if they retain their
It is crucial that all proximal humerus fractures are own humeral heads and in the presence of intact
assessed with an anteroposterior (AP) Fig. 14.1 and rotator cuff muscles.
axial view (Figs. 14.2 and 14.3) X-rays. Axial views Open reduction in the presence of severely com-
in most cases can be obtained; however in some minuted fractures is more challenging as the head,
instances where pain restricts shoulder movement, a both tuberosities and the shaft are separated from
modified angled axial view should be undertaken to one another. However, an arthroplasty solution in
ensure a dislocation is not missed. A scapular lateral the form of a hemiarthroplasty or total or reverse
view may also be useful. In complex injuries, com- shoulder arthroplasty may be indicated when the
puted tomography (CT) may assist in diagnosis and fracture is deemed unreconstructable especially in
surgical planning. CT scans can help to determine an older population group. Internal fixation is pref-
whether the humeral head is intact and to assess the erable in younger group as far as possible in three-
position and comminution of the tuberosities or even four-part fractures.
(Fig. 14.4). Clinically always assess for neurovascular status
The decision as to whether to treat three- or four- especially in reference to axillary nerve and brachial
part fractures by internal fixation or with an arthro- plexus.

H. Kapoor, M.B.B.S., M.S.(Orth), D.N.B. (*)

Consultant Trauma and Orthopaedics,
Leeds General Infirmary, Leeds, UK
e-mail: harish.kapoor@nhs.net
A. Aqil, M.B.B.S., M.R.C.S. • O. Riaz, M.B.B.S.,
M.R.C.S.
Department of Trauma and Orthopaedic Surgery, Fig. 14.1  AP radiograph of a right proximal humeral
Leeds General Infirmary, Leeds, UK fracture

© Springer International Publishing AG 2018 113

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_14
114 H. Kapoor et al.

Fig. 14.2 Modified axial view of a right proximal

humeral fracture

Fig. 14.4  Preoperative CT scan

Therefore, a definitive airway that is well secured is

our preference, as the head and face are usually well
covered from the sight of the anaesthetist. I do not
like laryngeal masks especially in a semi-reclining
beach chair position due to the tendency to
dislodge.
Prophylactic antibiotics should be administered,
as per institutional guidelines.
A general set for the surgical approach, includ-
ing suitable retractors (a West and Norfolk and
Norwich self-retaining retractor), are adequate, but
specially designed shoulder retractors can improve
Fig. 14.3 Modified axial view of a right proximal the exposure.
humeral fracture Plates of different lengths should be available
with the set including the jig for correct aiming of
the locking screws. Small fragment set, K-wires and
 reoperative Planning
P Ethibond sutures should also be available.
and Anaesthesia Considerations

A general anaesthesia with or without an intra-­ Patient Setup in Theatre

scalene block is commonly used. Blocks are very
useful in providing effective post-operative analge- Given the methodical staged process of patient
sia; however they introduce additional risks includ- setup and surgical exposure for clarity, these steps
ing pneumothorax or phrenic nerve injury paralysis. are given in list and bullet point format.
An experienced anaesthetist in upper limb surgery
is extremely helpful. • Shoulder table attachments are available which
Due to proximity of the surgical site to the air- convert normal operating table to p­ ermit patient
way, anaesthetic tubes should be secured and posi- positioning into a beach chair position (Fig
tioned, so they are not unnecessarily close to avoid 14.5).
displacement or getting in the way of the surgeon.
14  Fractures of Proximal Humerus Open Reduction and Internal Fixation 115

Fig. 14.5  Simulated patient positioning (model)—see reversed arm support

• The patient should be sat up at the hips into a • A U-drape is used to shut off, and a separate
beach chair position. The torso is normally 40 impervious stocking is rolled up the arm to
degrees from the horizontal, but if access of the above the level of the elbow. This leaves the
shoulder is needed from the back or front, then draped arm free for manipulation.
an upright position is more appropriate. Spine • Both ends of the C-arm are covered with sterile
and the head need to be supported, but at the drapes (Fig. 14.6).
same time, access to the whole shoulder needs to
be maintained.
• Patient feet are tilted up to avoid patient sliding  losed Reduction Techniques
C
down. Knees are flexed with a pillow behind and Manoeuvres
them.
• Table needs to be radiolucent as it can interfere Reduction can be achieved by external manoeuvres
with the C-arm when using the image with traction, adduction and internal rotation of the
intensifier. arm. Displacement of the distal fragment is usually
• Proximal humerus surgery requires the surgeon medially and anteriorly, and pushing laterally and
to be in the axilla of the patient on the affected posteriorly helps in lining up the most common dis-
side. The assistant or the C-arm can be posi- placement. To complete the reduction, a bone lever
tioned above the patient’s shoulder. can be introduced via a small incision to correct
• It is preferable the head of the table to be away varus/valgus angulation by pushing on the supero-
from the anaesthetic machine which should be at lateral portion of the head. If needed, a hook instru-
the foot end. Extension tubing will be required ment can be introduced into the subacromial space
for this. and used to complete the reduction of the greater
• The scrub nurse can work from behind of the tuberosity by pulling the tuberosity forwards and
surgeon as along the instruments are within the downwards. Three- or four-part fracture disloca-
laminar flow. tions may be impacted or non-impacted. In impacted
• Skin preparation is carried out using usual anti- fractures, cautious reduction via external manoeu-
septic solutions. vres in the operating room under anaesthetic and
• Prepare up to the midline of the chest to the image intensifier can be attempted. There is a risk of
medial border of the scapula. Clean up to the disimpaction, an event consistently followed by
root of the neck and down level of the nipple. AVN in four-­ part fractures. The lifting of the
The arm is prepared down to the wrist. impacted head should be gentle in open procedures.
116 H. Kapoor et al.

Fig. 14.6  Theatre setup

Overall though, these closed reduction manoeuvres pierce your glove, endangering you and the patient.
are useful if one was to use minimally invasive fixa- Therefore, we only recommend using your finger as
tion using intramedullary nails, for example. They a last resort. K-wires are extremely useful as levers
are less important when aiming to internally fix the and for transfixing fragments once reduced.
fracture as reduction is more easily achieved fol- However, stout wires should be used to prevent
lowing open surgical exposure. If using an intra- bending and to avoid deviating from the intended
medullary nail and with a fracture where the head is trajectory when being inserted. We favour mini-
in varus malposition, part of the reduction can be mum 2 mm wires as a general rule. Other general
achieved by slightly medialising the entry point of instruments such as Trethowan bone levers should
the nail. Note, however, that this will not correct be available to free up fragments to allow easier
gross varus malposition. One should only use this to manipulation. Strong sutures should also be avail-
correct mild varus malreductions and take care not able to grab the superior cuff and subscapularis ten-
to encroach too much on to the articular surface. My dons. Once attached they can be used to pull the
preference is to use locking proximal humeral tuberosities down and tied to the plate or each other.
plates; rarely, I use an IM nail in a low metaphyseal Occasionally a 5 mm bone anchor can be used to
neck fracture or a pathological fracture. I am aware pull both lesser and greater tuberosities and associ-
that humeral nailing is used for complex two, three ated tendons down to the required positions, thus
and even four part fractures with similar results in acting as a reduction and fixation tool. I prefer to use
some centres to good affect. transosseous sutures to recreate the shape of the
head with the tuberosities reattached before applica-
tion of plate in three- or four-part fractures.
Reduction Instruments

Tools useful in fracture reduction: your finger, Surgical Approach

pointed reduction clamps, bone hook, blunt bone
retractors and large Bristow-like elevator. The deltopectoral approach is the workhorse
Intraoperative X-rays can then give further visual approach to the shoulder in fracture fixation. It
feedback as to what your finger has been trying to allows adequate exposure to the joint and allows
achieve. Care must be taken when using your finger. easier access to head fragments which may have
However, fracture fragments are sharp and can been left behind when anterior fracture dislocations
14  Fractures of Proximal Humerus Open Reduction and Internal Fixation 117

of the shoulder have occurred. In deltopectoral Open Reduction Manoeuvres

approach, incision extends from the clavicle across
the lateral edge of the coracoid process and down to It is important that the reduction process does not
the arm in the groove between anterior edge of the further compromise the blood supply to the humeral
deltoid muscle and the biceps muscle. Length of head. Detachment of cuff tendons and capsule is not
incision is depending on the extent of exposure advised; image intensifier should be used to check
required (Fig. 14.7). The deltoid and pectoralis reduction (Fig. 14.10 (a,b)). Any fracture involving
major muscle are separated, retracting the cephalic the tuberosities heavy no. 5 Ethibond suture should
vein either laterally or medially depending on avail- be placed, to bring the supraspinatus and infraspina-
able anatomy (Fig. 14.8 (a,b,c)). Fascia is exposed tus onto the greater tuberosity and subscapularis
deep in the deltopectoral interval. It is opened verti- onto the lesser tuberosity. Traction can be applied to
cally, adjacent to the lateral border of the conjoint bring these fragments down to the humeral head.
tendon. Using your finger, sweep under the conjoint Varus angulation—the head is separated from the
tendon to ensure axillary nerve is not in close prox- shaft and pulled into varus by the superior rotator
imity. Then insert self-retaining retractors. The cuff m­ uscles that are still attached. If only the lesser
proximal humerus is now visible, which the rotator tuberosity is attached to the head, then the head is
cuff tendon surrounds (Fig. 14.9). I use the direct pulled in medial rotation by the subscapularis ten-
lateral approach with deltoid split in fresh/relatively don. Impacted fractures—overlap exists between
new up to 7–10 days old displaced two-part frac- the medial part of the head and shaft. The lateral
tures in suitable patients where the plate is used as a periosteum is normally intact. The stability pro-
reduction tool with putting a non-­locking first screw vided by the intact lateral periosteum allows medial
in the shaft after positioning the plate at the right hinge reduction via external manoeuvres involving
height depending on implant design. abduction and traction of the shoulder. A Bristow or
a similar instrument can be introduced between the
tuberosities and elevating the supero-lateral edge of
the head upwards. The medial periosteum acts as a
hinge that prevents medial translation of the head.

Fig. 14.7  Deltopectoral marked incision for the surgical exposure

118 H. Kapoor et al.

a b

Fig. 14.8 (a–c) The deltoid and pectoralis major muscle are separated, retracting the cephalic vein either laterally or
medially depending on available anatomy

in this. The first step consists in aligning the head on

the shaft. With the arm in traction, an instrument
such as a blunt elevator is introduced at the medial
edge of the anatomic neck to reduce the medial
hinge. Medial rotation of the head can be corrected
by looping a suture around the bone tendon junction
of the subscapularis then pulling it in the medial to
lateral direction. Valgus angulation—lateral impac-
tion of the head on the shaft. The fractured tuberosi-
ties remain aligned with the head and shaft, and the
lateral periosteum connecting the four fragments is
intact. The medial hinge should be assessed; it may
or may not be intact. Fracture-dislocation—percu-
taneous pinning using K-wires of the head can help
aid with reduction prior to opening the shoulder
joint. Reduction of the head and tuberosities can be
determined with the arm held in neutral rotation.
When acceptable reduction is attained, it can be
held using tension band sutures which can be passed
through the locking plate.

Fig. 14.9  Exposure of proximal humerus Implant Position

Non-­impacted fractures—the head is completely The plate is then attached to the shaft using slotted
separated from the shaft and the lateral periosteum hole for adjustment of height (Fig. 14.11 (a,b)).
is torn. Reduction is considerably more challenging The locking plate should sit on/below the cuff
14  Fractures of Proximal Humerus Open Reduction and Internal Fixation 119

a b

Fig. 14.10 (a) Intraoperative picture and (b) image intensifier view demonstrating reduction of fracture using K-wires

a b

Fig. 14.11 (a) Intraoperative image and (b) fluoroscopic view demonstrating application of the plate on the humeral
shaft

insertion on the greater tuberosity; any higher will fracture can then be stabilised by the placement of
cause impingement. Plate can be fixed onto the locking screws/pegs through the head and tuber-
shaft using K-wires through the small holes on the osities. Try to catch the greater tuberosity under
plate. The anterior edge of the plate should be the plate if possible depending on the fracture pat-
about half a cm behind the posterior lip of bicipital tern and implant design. Check AP and axial views
groove to avoid impinging the biceps tendon. The on the image intensifier to see if reduction is main-
120 H. Kapoor et al.

a b

Fig. 14.12 (a) Lateral and (b) anteroposterior image intensifier views of the proximal humerus showing definite fixa-
tion of the fracture

tained on dynamic testing. Ensure the implant is • Use non-absorbable sutures like Ethibond
well centred on AP and lateral views (Fig. 14.12 sutures to bring down the tuberosities and reat-
(a,b)). Minimal eight cortices are necessary dis- tach to the screw holes in plates.
tally with proximal head pegs/screws as per • Ensure good reduction with adequate release
implant design (prefer six minimum pegs if possi- and mobilisation and control of tuberosities in
ble). I prefer locked pegs, but additional threaded complex three- or four-part fractures recreating
screws can be used in young strong bone or large humeral head before plate application.
head fragments for additional compression. • Restore Gothic arch akin to the Shenton’s line in
the pelvis.
• Medial calcar contract/restoration key. Calcar
Summary of Tips, Tricks and Pitfalls screw and pegs important to prevent secondary
collapse.
• Ensure proper positioning of the patient ensuring • Locking plates always as majority in osteopo-
no interference in the surgical field from anaes- rotic bone in elderly patients.
thetic equipment. • High risk of screw penetration intraoperatively.
• Positioning of the C-arm with a good radiogra- Screen in all positions including live imaging to
pher will make the operation easier, before drap- avoid screw penetration after nearly every screw
ing test the position of the C-arm. insertion proximally.
• Avoid detaching capsular and rotator cuff mus- • Balance between good subchondral fix and too
cles as it further compromises blood supply and far insertion of pegs/head screws. Safe distance
preserve blood supply to head fragment with between 5 and 8 mm.
minimal dissection for reduction as necessary.
 Humeral Shaft Fractures
(Transverse, Oblique, Butterfly, 15
Bifocal)

Anthony Howard, Theodoros Tosounidis,
and Peter V. Giannoudis

Anatomical Fracture Location fractures. Butterfly fractures are classified B1–3

and bifocal fractures C1–3 dependent on their
The humeral shaft commences inferior to the sur- configuration.
gical neck, having a cylindrical cross section,
which flatters in the coronal plane towards the
condyles distally. Brief Preoperative Planning
Mid-shaft humerus fractures (Fig. 15.1 (a,b))
make up 3–5% of all fractures, with a bimodal Anatomic reduction and stable fixation are the
age distribution, occurring through high-energy goals of surgical management, although many of
trauma in the young and lower-energy mecha- these fractures can be managed nonoperatively
nism in the elderly patients [1, 2]. (Figs. 15.2 (a,b) and 15.3 (a,b,c)). Indications for
The majority of these types of fractures can be surgery include failure of nonoperative manage-
managed nonoperatively [3]. It has been estab- ment, open fractures, neurovascular injury, high-
lished that good function is retained where there energy injury, ipsilateral radial/ulna fixation,
is less than 3 cm shortening, <20 in the sagittal impending pathological fractures, bilateral
plane and <30° varus/valgus angulation [4]. humeral fractures, fractures of the humeral shaft
The prevalence of radial nerve palsy after that are associated with displaced intra-articular
fractures of the humeral shaft is in the region of fracture extension, obesity and polytrauma.
12%, particularly in transverse and spiral frac- In comminuted fractures, a CT scan is advis-
tures; thus closer observation of the radial nerve able to assist in preoperative planning. In intra-
is essential [1]. It is imperative that in any surgi- medullary fixation, canal size, nail length and
cal fixation, the nerve is identified and protected. diameter can all be estimated from radiographs
Fractures are classified according to the AO of the uninjured humerus.
classification system. Type A1 fractures are mid-­ If there is severe comminution at the fracture
shaft spiral fractures, type A2 fractures are site, lack of soft tissue coverage or gross swell-
oblique fractures, and type A3 are transverse ing, an external fixation may be required as a
temporizing measure; 4–5 mm pin should be
employed (Figs. 15.4 and 15.5).

A. Howard • T. Tosounidis • P.V. Giannoudis (*)

Academic Department of Trauma and Orthopaedic
Surgery, University of Leeds, Leeds, UK
e-mail: pgiannoudi@aol.com

© Springer International Publishing AG 2018 121

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_15
122 A. Howard et al.

a b

Fig. 15.1 (a) AP radiograph. (b) Lateral radiograph of right mid-shaft humeral fracture

a b

Fig. 15.2 (a) AP radiograph. (b) Lateral radiograph of a right mid-shaft humeral fracture treated with nonoperatively
with a functional brace demonstrating healing 6 weeks after injury
15  Humeral Shaft Fractures (Transverse, Oblique, Butterfly, Bifocal) 123

a b c

Fig. 15.3 (a) AP view of spiral left humeral fracture with comminution; (b) AP radiograph showing fracture position
treated nonoperatively with a brace; (c) lateral view 6 weeks after injury showing fracture healing

Patient Setup in Theatre Closed Reduction Manoeuvres

Predominately the procedures will be under- These are indicated when nonoperative manage-
taken under general anaesthesia, although ment has been decided as the method of treat-
regional blocks afford early mobilization and ment. Closed techniques available include
pain relief. Given the high incidence of radial traction, hanging arm cast, Velpeau dressing
nerve palsy and the potential for compartment (polysling) (Fig. 15.8) and functional brace
syndrome, regional blocks, which mask both of amongst others. Usually, the initial application of
these symptoms, have to be approached with a hanging cast is replaced after 3 weeks with a
caution. functional brace. Nonoperative treatment is more
The selection of fixation method and surgical effective when the patient remains upright (stand-
approach will dictate the patient position in the- ing or sitting) allowing the exerted gravitational
atre. The beach chair or supine position can be force to assist in fracture reduction.
used for antegrade nailing/anterior approach For many of the nonoperative treatments (e.g.
(Fig. 15.6). Whereas for retrograde nailing/poste- functional bracing, hanging arm casts, polysling)
rior approach, the patient is placed in a prone in order to work most effectively, the patient
position with the arm placed onto an arm board should remain upright, either standing or sitting,
or lateral decubitus position (Fig. 15.7). and should avoid leaning on the elbow for sup-
A c-arm image intensifier will need adequate port. This allows gravitational force to assist in
access to the relevant positions, and a radiotrans- fracture reduction. Range of motion exercises of
lucent arm board/table will be required. the shoulder, elbow, wrist or fingers should com-
124 A. Howard et al.

mence as soon as these can be tolerated. Serial

radiographic imaging is essential to ensure that
satisfactory reduction can be maintained. Where
this is proven difficult, then operative intervention
is indicated.
Intramedullary fixation of humeral shaft frac-
tures may be advantageous in osteoporosis and
impending pathological fractures. The antegrade
intramedullary nail is recommended for this type
of fracture, although this has the disadvantage of
damaging the rotator cuff [5]. The patient is
placed in the beach chair or supine position with
the head off the table, elevated at 40°. The surface
anatomy is identified and marked. The incision
for the nail insertion is the anterolateral corner of
the acromion centred over the top of the greater
tuberosity, which is extended distally no greater
than 5 cm to avoid damaging the axillary nerve.
Under an image intensifier, the entry point
(medial to the top of the greater tuberosity/lateral
to the articular margin/5 mm posterior to the
bicipital groove) is identified using a K-wire. The
entry point and intramedullary canal are devel-
oped in a manner appropriate to the design of nail
being deployed (Fig. 15.9 (a,b)) [6, 7].
Retrograde intramedullary nail insertion
requires a distal triceps-splitting approach. An
entry point, 1 cm wide and 2 cm long, is made
2.5 cm proximal to the olecranon fossa. The nail
can be locked proximally, either lateromedially
(placing the axillary nerve at risk) or anteroposte-
Fig. 15.4  Segmental left mid-shaft humeral fracture ini-
tially managed with an external fixator riorly (placing the biceps tendon at risk).
For both antegrade and retrograde intramedul-
lary nailing procedures, no residual fracture gap
must be left after fixation as this will increase the
risk of fracture non-union. Finally, if difficulty is
noted during passage of the nail either antegrade
or retrograde, thought should be given to creating
an incision to safeguard that the radial nerve is
not entrapped in the fracture site.

Reduction Instruments

Fig. 15.5  Open right humeral shaft fracture following For the humerus, reduction tools that can be
industrial accident stabilized with external fixator. used are as follows: small Hohmann retractors,
Forearm and hand fasciotomies were performed due to
compartment syndrome small periosteal elevators, Howarth elevator,
15  Humeral Shaft Fractures (Transverse, Oblique, Butterfly, Bifocal) 125

Fig. 15.6  The beach chair patient position

Fig. 15.7  The lateral

decubitus patient
position

pointed reduction clamps, blunt/serrated bone

holding forceps/clamps (small “crocodile” Surgical Approach
clamps), articulated tension device and K-wires
to joystick. The anterior lateral approach is used for proximal
If severely comminuted or minimally invasive and mid-shaft fractures, whereas for more distal
plate osteosynthesis is being adopted, then the shaft fractures, the posterior approach is pre-
use of an external fixation is required to reduce ferred, exploiting the flat posterior surface of the
the risk of malalignment or mal-union [8]. distal humerus for plate placement [9].
126 A. Howard et al.

The anterior lateral approach is a distal exten- of brachialis, and the lateral antebrachial cutane-
sion of the deltopectoral approach, coursing ous nerve located in the distal aspect of the inci-
along the lateral aspect of the biceps and splits sion (Fig. 15.10) [10].
the brachialis muscle. It is critical to identify the The posterior approach with triceps splitting
radial nerve, which is located in the lateral aspect and radial nerve mobilization enables visualiza-
tion of 76% of the humerus [11]. A large incision
is made over the midline of the posterior arm
extending to the olecranon fossa. Initially a plane
is developed between the long and lateral heads
of triceps brachii, until the deeper medial head
comes into view. The medial head is then incised
allowing dissection onto the humeral shaft
(Fig. 15.11 (a,b,c)). The radial nerve crosses the
posterior aspect of the humerus, where it is, on
­average, 20.7 (±1.2) cm proximal to the medial
epicondyle and 14.2 (±0.6) cm proximal to the
lateral condyle.

Open Reduction Manoeuvres

The fracture location relative to the deltoid and

pectoralis major insertions will influence how the
fracture is reduced, if the fracture is in between:

Fig. 15.8  Polysling immobilization device for nonopera- 1. Rotator cuff and pectoralis major, the humeral
tively treated humeral shaft fractures head will abduct and internally rotate.

a b

Fig. 15.9 (a) Humeral nail is inserted into the intramedullary canal of the humerus; (b) whilst closed fracture reduction
is maintained, the nail is advanced to the distal fragment
15  Humeral Shaft Fractures (Transverse, Oblique, Butterfly, Bifocal) 127

If there is a high degree of comminution, an

external fixation may be deployed. Proximally,
the pins should be inserted along the anterior
margin of the deltoid insertion from anterolateral
direction, Fig. 15.13 [13]. The distal pins are
applied to the posterior surface of the humerus
inferior to the radial groove.

Open Reduction and Fixation

The fracture fragments are released from the sur-

rounding soft tissue to enable inspection of frac-
ture site and to achieve a good reduction. Both
ends of the fractures are held in crocodile clamps
to allow rotation of the two ends into the
­appropriate orientation to achieve reduction. The
rotation to achieve this reduction is often the reverse
of the deforming forces that caused the fracture or
muscle forces acting on the now fractured humerus,
Fig. 15.14 (a,b,c,d).
It is critical that a good reduction is achieved
and maintained; in spiral or oblique fractures,
this reduction and compression can be achieved
by using a lag screw. If the humeral fracture is
transverse or an oblique angle of less than 30°,
then the reduction and compression can be
achieved by using a DCP plate in compression
Fig. 15.10  Anterolateral approach used to expose left
mode. As a minimum six cortices of fixation
humeral fracture (white arrow). Blue arrow illustrates proximal and distal to the fracture site should be
radial nerve achieved, Fig. 15.15 (a,b). Care needs to be taken
to ensure the plate does not impinge on the shoul-
2. Pectoralis major and deltoid insertion, the dis- der joint [14]. Further, it is also important to pay
tal fragment will shift laterally and the proxi- attention to the working length created by the
mal segment will adduct. construct. If early mobilization is desired or there
3. Distal to the deltoid insertion the proximal may be poor patient compliance anticipated, then
segment will adduct [12]. the placement of a secondary plate at 90°, in the
transverse plane, is advisable.
Understanding and counteracting the respec- In highly comminuted fracture, distraction
tive deforming forces caused by the muscles act- needs to be applied to achieve restoration of length
ing on the fractured humerus will enable an easier and a long plate employed in a bridging mode con-
and better reduction. figuration. With the appropriate expertise, a mini-
The reduction needs to be maintained until the mally invasive percutaneous osteosynthesis
plate fixation is secured (Fig. 15.12); for spiral or technique can be used in these circumstances, hav-
butterfly fractures, this can be achieved with a lag ing the advantage of reducing biological disrup-
compression screw. The alternative is to use a tion and soft tissue dissection. In a recent network
small plate or cerclage wires around the defini- meta-analysis found comparative to plates, intra-
tive plate to maintain the reduction. medullary nails are more advantageous [14].
128 A. Howard et al.

a b c

Fig. 15.11 (a) A large incision is made over the midline view. Note mobilization of radial nerve with artery clip
of the posterior arm extending to the olecranon fossa. (b) forceps (white arrow points to radial nerve; blue arrow
A plane is developed between the long and lateral heads of points to medial head of triceps). (c) Image illustrates iso-
triceps brachii, until the deeper medial head comes into lation of radial nerve

During the procedure, if feasible, the nerve

needs to be identified and protected, with careful
movement of the arm during fixation to avoid iat-
rogenic injury.

Summary of Tips and Tricks-Pitfalls

• If the fracture is managed in a brace, this will

need to be tightened periodically over the ini-
tial 2 weeks to account for the reduction in
swelling.
• Pendulum exercises should be encouraged
regardless of the type of management to pro-
mote shoulder joint flexibility.
• The humerus needs to be treated as a full load-­
bearing structure, in terms of the fixation
decision-making.
• During the posterior approach, identify and
Fig. 15.12  Using the anterolateral approach, the humeral
isolate the radial nerve to avoid iatrogenic
fracture has been reduced with reduction forceps with the nerve damage. Ensure that the nerve can sit
plate to use for fixation place in position to continue with freely over the plate (Fig. 15.16).
fixation whilst maintaining reduction
15  Humeral Shaft Fractures (Transverse, Oblique, Butterfly, Bifocal) 129

Fig. 15.13  An open humeral fracture that was treated with

a rectus abdominal free flap and an external fixator

a b c d

Fig. 15.14 (a) Using a posterior approach, the distal 1/3 line. (c) A lag screw is inserted into the split distal frag-
shaft of the humeral fracture has been exposed. White ment to convert it to one piece. (d) Following insertion of
arrow demonstrates the two-­part split of the distal frag- lag screw, distal fragment moves as one unit (white
ment. Blue arrow illustrates fracture line. (b) Split of dis- arrow). It can now be connected to the proximal fragment.
tal fragment has been reduced with a reduction forceps Blue arrow represents the fracture line
and a K-wire (white arrow). Blue arrow is the fracture
130 A. Howard et al.

Fig. 15.15 (a) AP and (b) lateral a b

radiographs of a mid-shaft humeral
fracture stabilized with a plate using a
posterior approach. Note that there are
four screws supporting each fragment

• Ensure that the image intensifier is rotated

during surgical fixation rather than the arm,
reducing the risk of iatrogenic injury.
• Compression plating is the preferred method of
fixation compared to intramedullary nailing.

References
1. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis
PV. Radial nerve palsy associated with fractures
of the shaft of the humerus. J Bone Joint Surg Br.
2005;87-B(12):1647–52.
2. Humeral Shaft Fractures. https://www.orthobullets.
com/trauma/1016/humeral-shaft-fractures.
3. Walker MPB, Badman B, Brooks J, Van Gelderen
J, Mighell M. Humeral shaft fractures: a review. J
Shoulder Elb Surg. 2011;20(5):833–44.
4. Klenerman L. Fractures of the shaft of the humerus. J
Bone Joint Surg Br. 1966;48(1):105–11.
5. Bencic I, Cengic T, Prenc J, Bulatovic N, Matejcic
Fig. 15.16 Humeral fracture stabilized with plating A. Humeral nail: comparison of the antegrade and
using posterior approach. Note the radial never sitting retrograde application. Acta Clin Croat. 2016;55(1):
freely above the plate 110–6.
15  Humeral Shaft Fractures (Transverse, Oblique, Butterfly, Bifocal) 131

6. Euler SA, Petri M, Venderley MB, Dornan GJ, 10. Carroll EA, Schweppe M, Langfitt M, Miller AN,
Schmoelz W, Turnbull TL, Plecko M, Kralinger FS, Halvorson JJ. Management of humeral shaft fractures.
Millett PJ. Biomechanical evaluation of straight ante- J Am Acad Orthop Surg. 2012;20(7):423–33.
grade nailing in proximal humeral fractures: the ratio- 11. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative
nale of the “proximal anchoring point”. Int Orthop. operative exposures of the posterior aspect of the
2017;41(9):1715–21. humeral diaphysis with reference to the radial nerve. J
7. Langer P, Born C. Intramedullary fixation of humeral Bone Joint Surg Am. 1996;78(11):1690–5.
shaft fractures. In: Wiesel S, editor. Operative tech- 12. Higgs D. Humeral shaft fractures - principles of man-
niques in orthopaedic surgery. London: Lippincott agement. In: Bentley G, editor. European ­ surgical
Williams & Wilkins; 2011. orthopaedics and traumatology. Berlin: Springer;
8. Lee H-J, C-W O, J-K O, Apivatthakakul T, Kim J-W, 2014.
Yoon J-P, Lee D-J, Jung J-W. Minimally invasive plate 13. Crenshaw A. Fractures of shoulder, arm and fore-
osteosynthesis for humeral shaft fracture: a reproduc- arm. In: Canale ST, Beaty JH, Campbell WC, editors.
ible technique with the assistance of an external fix- Campbell’s operative orthopaedics, vol. 3. London:
ator. Arch Orthop Trauma Surg. 2013;133(5):649–57. Mowby; 2003.
9. Garberina M, Getz C. Plate fixation of humeral shaft 14. Zhao JG, Wang J, Meng XH, Zeng XT, Kan

fractures. In: Wiesel S, editors. Operative techniques SL. Surgical interventions to treat humerus shaft frac-
in orthopaedic surgery. London:Lippincott Williams tures: a network meta-analysis of randomized con-
& Wilkins. trolled trials. PLoS One. 2017;12(3):e0173634.
 Distal Humerus Fracture
16
Stefaan Nijs

Anatomical Fracture Location

Distal humerus fractures are fractures of the dis-

tal metaphysis of the humerus with or without
involvement of the articular surface.
The distal metaphysis of the humerus can be
considered as a triangle, consisting of a radial
and an ulnar column, between which the joint
block is positioned (Fig. 16.1). The joint block
consists of the hemispheric capitellum humeri on
the radial side and the spool-shaped trochlea on
the ulnar side.
In the frontal plane, the axis of the trochlea
makes an angle of 94°–98°, relative to the
humeral diaphyseal axis (Fig. 16.2). Therefore,
the forearm is not in line with the arm. The angle
between both is what we call the ‘carrying angle’.
The axis of rotation, a line drawn between the
centre of the capitellum and the centre of the
trochlear sulcus, exits medially just anterior and
inferior to the medial epicondyle. It has the same
angulation as the axis of the trochlea.
In the sagittal plane, the medial (ulnar) col-
umn angulates 10°–20° to the longitudinal axis of

S. Nijs
Department Trauma Surgery, UZ Leuven,
Leuven, Belgium
Department Development and Regeneration, KU Fig. 16.1  AP view of the distal humerus, showing the
Leuven, Leuven, Belgium radial column (dark red), the ulnar column (orange) and
e-mail: stefaan.nijs@uzleuven.be the interposed articular block (yellow)

© Springer International Publishing AG 2018 133

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_16
134 S. Nijs

Fig. 16.3  Medial view of the distal humerus. The medial

column (orange) makes a 10° angulation to the longitudi-
nal humerus axis (red), positioning the trochlea slightly in
front of the humeral shaft

Brief Preoperative Planning

Fig. 16.2  AP view of the distal humerus. There is a 94°–
Anatomic reduction and stable fixation are the
98° angle between the longitudinal axis of the humerus
(red) and the trochlear axis (orange) goals of surgical management of distal humerus
fractures. For the articular component, absolute
stability is the aim for stability; for the metaphy-
the humerus (Fig. 16.3). The lateral column seal components, relative stability is the goal.
(radial) angulates 30°–40° to the longitudinal This mandates for open reduction and internal
axis of the humerus (Fig. 16.4). fixation. Indirect and minimal reduction and fixa-
In physiological circumstances, about 60% of tion techniques yield suboptimal result and
the forearm load is transmitted to the humerus should be avoided. Standard open reduction and
through the radio-capitellar joint. This load trans- internal fixation techniques with meticulous soft
mission however is influenced by the relative tissue handling should be employed.
position of both forearm bones in elbow flexion In order to evaluate the fracture and to ade-
and/or elbow extension. quately plan, CT scan with 3D reconstruction is
Fractures are classified according to the AO preferred (Fig. 16.5). Preoperative planning should
classification system. A-type fractures are extra-­ take into account the comminution of the articular
articular fractures. B-type fractures are partial-­ surface and of both columns. Furthermore, CT is
articular, mono-column fractures. C-type extremely useful to determine the presence of cap-
fractures are articular, bi-column fractures. itellar shear fractures (Fig. 16.6).
16  Distal Humerus Fracture 135

Anatomically preshaped plates are available

for the fixation of the humerus with 3.5 mm
screws in the metadiaphyseal part and 2.7 mm
screws in the articular area. One should be able to
choose between cortical and angular stable screw
options (preferably variable angle angular stabil-
ity). For metaphyseal and/or articular fractures, a
double plating system, i.e. a medial plate com-
bined to a posterolateral or lateral plate, is pre-
ferred. In AO B-type fractures, a mono-plate
fixation in combination to a lag screw can be
used.
Traditionally (AO philosophy) distal humerus
fractures have been instrumented by a medial and a
posterolateral plate (90° construct). This has been
challenged by O’Driscoll, proposing a fixation by
medial and lateral plates (180° construct) [1]. No
clinical study could prove a benefit of one construct
over the other [2]. Biomechanically 180° constructs
are more stiff under axial loading [3], but both con-
structs show loads to failure well above clinical
loads [4]. Based upon these observations, we devel-
oped a treatment strategy as in Algorithm 16.1.
For extra-articular fractures at the metadiaphyseal
Fig. 16.4  Lateral view of the distal humerus. The lateral
column makes a 30° angulation to the humeral axis.
transition or with diaphyseal extension, a single pos-
Therefore, the capitellum is positioned in front of the terolateral 3.5 mm angular stable plate can be used.
humeral diaphysis

Fig. 16.5  3D CT shows the extension of articular com- Fig. 16.6  Axial CT scan image showing the coronal
minution and fragment displacement shear fragment (arrow)
136 S. Nijs

Distal humerus fracture

Capitellum coronal
shear fragment

Comminuted column

Weight bearing
extremity

90° construct 180° construct

Algorithm 16.1  Plate-positioning algorithm

To fix small articular fragments, headless com- for early mobilization. Attention should be given
pression screws and/or resorbable pins can be used. not to mask a compartment syndrome and/or
For temporary fixation, 1.6 mm and 2 mm neural (ulnar nerve) injury.
K-wires can be used. The patient is positioned prone or in lateral
Fixation of an eventual olecranon osteotomy decubitus on a standard table, and the affected
would require 2 mm K-wires and metal wire arm is placed on a radiolucent side table. One
(1.25 mm) or anatomical preshaped plates. should check prior to draping that free flexion of
the elbow, well over 90°, is possible so that visu-
alization of the anterior compartment of the
Patient Set-up in Theatre elbow (capitellum and anterior half of the troch-
lea) is guaranteed. The table is placed in such a
General anaesthesia is preferred as the procedure way that unobstructed intraoperative imaging can
can be of longer duration. A regional block can be performed. This usually requires rotation of
be used to reduce postoperative pain and allow the table 90° so that the affected extremity is
16  Distal Humerus Fracture 137

Surgical Approach

A straight posterior incision over the distal

humerus, aiming at the posterior crest of the ulna,
is made. This incision curves around the tip of the
olecranon, avoiding excessive pressure at the
wound after closure (Fig. 16.8). The skin and
subcuticular tissue are taken down as one to the
level of the fascia overlying the triceps, creating
two big skin flaps (Fig. 16.9).
We start creating a lateral window. The triceps
Fig. 16.7  The patient is positioned prone on a standard muscle is mobilized off the humerus at its lateral
table, and the affected arm is placed on a radiolucent side edge (Fig. 16.10). If needed, this approach can be
table extended proximal up to the level of the deltoid
insertion (Fig. 16.11). Along the lateral border of
the triceps, we can identify the posterior ante-
placed at the centre of the operating theatre brachial cutaneous nerve. Following this nerve
(Fig.  16.7). A tourniquet is placed, and the proximally will guide us to the radial nerve. In
affected extremity is prepped and draped follow- cases of fractures with proximal extension
ing the administration of intravenous antibiotics. towards the diaphysis, identifying and protecting
Some people prefer not to use a tourniquet the radial nerve while reflecting it medially are a
because they fear the procedural time exceeds must requirement (Fig. 16.12).
that of allowed tourniquet use. However, this
causes more blood loss, and because of the
blurred visualization, caused by excessive bleed-
ing, surgical time increases. The image intensi-
fier is brought from the top of the patient.

Closed Reduction Manoeuvres

Closed reduction manoeuvres are not used for

distal humerus fractures. In cases with extreme
soft tissue situations (swelling, bruising), a tem-
porary external fixator can be used until subsid- Fig. 16.8  Straight posterior incision, making a curve
around the olecranon tip
ence of the swelling. In those circumstances, a
fixation in extension allows for easier and more
stable fixation, than a 90° fixation.

Reduction Instruments

For the humerus, reduction tools that can be used

are the following: small Hohmann retractors,
small periosteal elevators, Howarth elevator,
pointed reduction clamps, blunt/serrated bone
holding forceps/clamps (small ‘crocodile’
Fig. 16.9  The incision is taken down to the triceps fascia,
clamps), articulated tension device, K-wires to creating big skin-subcutaneous flaps medially and
joystick and temporarily fixing fragments. laterally
138 S. Nijs

To visualize the distal part of the radial col-

umn and the posterior surface, the approach can
be extended in the interval between the anconeus
and extensor carpi ulnaris muscle (Kocher’s
interval) (Fig. 16.13).
For more distal and intra-articular fractures, a
second window is created. The ulnar nerve is dis-
sected on the medial side (Fig. 16.14). It is impor-
tant to leave the nerve together with its
vascularization and a layer of soft tissue around
it, to cover later implants, avoiding direct contact
Fig. 16.10  After creating a lateral window, releasing the between the implant and the nerve (Fig. 16.15).
triceps of the lateral septum, extending distally in Kocher’s
interval (between anconeus and extensor carpi ulnaris),
the lateral column can be visualized

Fig. 16.13 The radial incision can be extended in

Kocher’s interval (yellow line). When an osteotomy
becomes necessary, the anconeus can be mobilized of its
Fig. 16.11  Proximal extension of the release to the level ulnar insertion, reflecting the anconeus together with the
of the deltoid insertion. The posterior antebrachial cutane- triceps, respecting its innervation that comes of a radial
ous nerve can be recognized and guide us to the radial nerve branch, going through the triceps
nerve

Fig. 16.12  Reflecting the entire triceps laterally visual- Fig. 16.14  Medially the ulnar nerve should be mobilized
izes the humeral diaphysis and the radial nerve. Implants from above the arcade of Struthers to the level of the deep
need to be positioned underneath the nerve. A thin layer of flexor-pronator aponeurosis, opening the cubital retinacu-
soft tissue should be positioned between the nerve and the lum and Osborne’s ligament and identifying the first
implant to avoid adherence motor branch to the flexor carpi ulnaris
16  Distal Humerus Fracture 139

Fig. 16.15  A thin layer of soft tissue, containing among Fig. 16.16  After mobilization of the medial triceps, a
others the nerve blood supply, should be left together with second medial window can be created that allows visual-
the nerve. This makes it possible to reposition this layer ization of the medial column
between the nerve and the implant, avoiding adhesion. It
is important to preserve the nerve vascularization, as post-
­op ischemia is an important cause of neuritis

The nerve should be mobilized from above the

arcade of Struthers to the level of the deep flexor-­
pronator aponeurosis, opening the cubital reti-
naculum and Osborne’s ligament and identifying
the first motor branch to the flexor carpi ulnaris.
In cases where anterior transposition of the nerve
is performed, a piece of the medial intermuscular
septum should be resected, avoiding kinking of
the nerve over the septum after transposition. Fig. 16.17  In complex articular fractures, a Chevron
After mobilization of the nerve, a window to the osteotomy is performed. The apex lays at the bare area of
humerus can be created, medial to the nerve, the olecranon fossa, between the coronoid and the olecra-
non process
mobilizing the triceps of the humerus (Fig. 16.16).
Both windows will be sufficient to treat extra-­
articular and simple intra-articular fractures. In
cases of extensive intra-articular comminution Open Reduction Manoeuvres
however, more visualization of the articular sur-
face is necessary. Many approaches have been The fracture is identified, and it is debrided from
described; however, the approach giving the most soft tissue debris and hematoma (Fig. 16.18).
extensile visualization of the joint surface is the In most cases, the fracture of one of both col-
olecranon osteotomy. A chevron osteotomy, apex umns is simple. If this is the case, this column is
distal, is performed (Fig. 16.17). We release the reduced first. It is held in its reduced position
anconeus first of its ulnar insertion, leaving it in using K-wires and reduction clamps (Fig. 16.19).
continuity to the triceps, and reflect it, together In case of articular fracture, the articular surface
with the triceps proximally. This TRAP approach is reconstructed next. Perfect anatomical reduc-
avoids denervation, and subsequent atrophy, of tion is aimed for. In case of simple articular frac-
the anconeus. The anconeus is an active stabiliz- ture, a large reduction clamp is used across the
ing muscle to the elbow (posterior stability radial fracture to put it under compression. In commi-
head). The osteotomy is performed with its apex nuted cases, this should be avoided, as overcom-
at the level of the bare area, between the olecra- pression could result in loss of articular width
non and the coronoid processes [5]. and therefore in joint incongruency. Again, the
140 S. Nijs

Fig. 16.18  After osteotomy we visualize the fracture. Fig. 16.20  The articular surface is reconstructed
Fracture haematoma is rinsed and removed

plate can be used. In these cases, only the lateral

window of the approach should be used. Fracture
fixation can be either using absolute stability in
simple fractures or bridging in complex fractures
(Fig. 16.12).

Open Reduction and Fixation

After temporary fixation with K-wires and

clamps, fluoroscopic control is performed to con-
firm reconstruction of the alignment, both in AP
Fig. 16.19  The column(s) are repositioned and tempo-
and lateral direction (Figs. 16.21 and 16.22).
rarily hold by K-wires and reduction clamps
We use Algorithm 16.1 to determine plate
positioning. First, we look for the presence of a
reduction is held with multiple small K-wires coronal shear fracture of the capitellum. If pres-
(Fig. 16.20). Finally the second column is recon- ent, postero-anterior screws, going through a
structed. If this fracture is simple, it should plate, should be used to fix this fracture to the
reduce perfectly. In case of comminution, the column. Therefore, the radial-sided plate should
joint block should be aligned, reconstructing be positioned posteriorly. If there is no coronal
both the frontal and sagittal angulation of the shear, we look for the presence of column com-
joint surface relative to the longitudinal axis of minution. If absent there is no proven advantage
the humerus. of either construct. The choice is then depending
In cases with severe comminution of both col- on the surgeon’s preference. A 180° construct,
umns, one should reconstruct the articular block however, involves a more extensive soft tissue
first and then align it to the frontal and sagittal release at the lateral side of the elbow, with a
longitudinal axis of the humerus. In cases of theoretical risk of devascularisation and iatro-
severe comminution, some shortening of the col- genic ligament injury (lateral collateral ligament
umns can be accepted to reconstruct bone con- complex, with the lateral ulnar collateral liga-
tact, if the axes are respected and the olecranon ment being most at risk). For these reasons, my
fossa remains of adequate volume to accept the personal preference goes to a 90° construct. If
olecranon tip. there is a/are comminuted columns, angular sta-
In cases of metadiaphyseal fractures, without ble bridging is preferred. Under physiologic
articular involvement, a single posterolateral loads, both 90° and 180° constructs accept loads
16  Distal Humerus Fracture 141

In cases of articular fracture, again a distinc-

tion between simple and complex fracture pat-
terns guides fixation principles. In simple
fractures, anatomical reduction and absolute sta-
ble fixation (compression by interfragmentary
lag screws) are the golden standards. In commi-
nuted fractures, using lag screws however bears a
risk of overcompression and subsequent narrow-
ing of the articular surface, resulting in incongru-
ence of the humeroulnar and/or humeroradial
joint. In comminuted fractures, a three-­
dimensional scaffold of interdigitating 2.7 mm
screws is used to support the fragments in their
reduced position. Each screw should engage as
many fragments as possible and certainly a frag-
ment on the opposite side to increase stability
Fig. 16.21  The axes of the distal humerus after recon-
(Fig. 16.23).
struction and temporary fixation are evaluated under fluo- The ulnar nerve is not transposed anteriorly
roscopic control routinely. We leave it in its natural position, but
put a thin layer of soft tissue between the plate
and the nerve (Fig. 16.15).
If an olecranon osteotomy has been per-
formed, this needs to be stabilized after fixation
of the distal humerus fracture. The most often
used technique of osteosynthesis for olecranon
osteotomies is the K-wire and cerclage fixation.
This has a high complication rate, especially in
osteoporotic bone. We prefer an angular stable
plate to fix the osteotomy. This is positioned next

Fig. 16.22  The axes of the distal humerus after recon-

struction and temporary fixation are evaluated under fluo-
roscopic control

well above these. In axial loading (weight bear-

ing of the upper extremity), biomechanical stud-
ies have shown the superiority of a 180° construct.
Thus, for patients in need of crutches or a walker
(because of pre-existing conditions or concomi-
tant injuries to the lower extremities), a 180° con-
struct is preferred. Fig. 16.23  Osteosynthesis of the distal humerus
142 S. Nijs

• Both 90° and 180° plate positions have their

specific advantages and indications.
• Simple fractures can be treated using a dual
window approach; complex fractures should
be treated by olecranon osteotomy.
• In distal fractures, the ulnar nerve should be
identified and in fractures with proximal
extension the radial nerve. Try to protect the
nerves by positioning a thin layer of soft tis-
sues between the nerve and the implant.
• Fix an eventual osteotomy by plate and screw
Fig. 16.24  Osteosynthesis of the olecranon osteotomy. fixation, especially in osteoporotic bone.
In osteoporotic bone, we prefer an angular stable plate
fixation

to the olecranon tip, by sliding it through a triceps References

tendon split (Fig. 16.24). A lag screw is used
through the plate to obtain compression of the 1. O’Driscoll SW, Sanchez-Sotelo J, Torchia
ME. Management of the smashed distal humerus.
osteotomy. Orthop Clin North Am. 2002;33(1):19–33, vii
2. Shin SJ, Sohn HS, Do NH. A clinical comparison
of two different double plating methods for intraar-
Summary of Tips and Tricks-Pitfalls ticular distal humerus fractures. J Shoulder Elb Surg.
2010;19(1):2–9.
3. Stoffel K, Cunneen S, Morgan R, Nicholls R,
• Obtain good quality intraoperative fluoro- Stachowiak G. Comparative stability of perpendicu-
scopic views. lar versus parallel double-locking plating systems in
• Aim for anatomic reduction of the humerus. osteoporotic comminuted distal humerus fractures. J
Orthop Res. 2008;26(6):778–84.
Comminuted articular surfaces should be sup- 4. Penzkofer R, Hungerer S, Wipf F, von Oldenburg
ported by angular, stable, interdigitating G, Augat P. Anatomical plate configuration affects
2.7 mm screws. Comminuted columns should mechanical performance in distal humerus fractures.
be fixed by angular stable bridging plates. Clin Biomech (Bristol, Avon). 2010;25(10):972–8.
5. O’Driscoll SW. The triceps-reflecting anconeus
Simple fractures, both articular and metaphy- pedicle (TRAP) approach for distal humeral frac-
seal, should be fixed by interfragmentary tures and nonunions. Orthop Clin North Am.
compression. 2000;31(1):91–101.
 Olecranon Fractures
17
Odysseas Paxinos, Theodoros H. Tosounidis,
and Peter V. Giannoudis

 natomical Fracture Location:

A has a fatty cover and is devoid of cartilage. It
Radiograph of Fracture Pattern articulates with the trochlea groove of the distal
humerus that is also extensively covered by carti-
Olecranon fractures are common (about 10% of lage (320°). Stability of the elbow is mainly
all upper extremity fractures) [1] and are one of depended on the articular congruity with little
the first fractures to be treated by junior surgeons, additional support offered by the ligaments [1].
given the straightforward approach. However, Resection of more of 60% of olecranon [3] and
loss of elbow extension and posttraumatic arthri- more of 40% of the coronoid [4] has been shown
tis are common sequels [2], and good preopera- to destabilize the joint. Despite good congruency,
tive planning and proper surgical technique are the joint is not a rigid hinge one since there is
necessary to avoid perioperative complications some toggling of the axis of rotation (around
and long-term morbidity. 3–4°) due to the obliquity of the trochlear groove
The ulnohumeral joint—in which the olecra- and the sigmoid notch. Although not a load-­
non forms part of the concave side—allows for bearing joint, as much as three times the body
the flexion/extension movement of the elbow weight may be transmitted across the elbow when
while being highly stable. The sigmoid notch is a lifting heavy weights. Noteworthy, restoration of
saddle-shaped articular surface made of the olec- joint congruency following a fracture is essential
ranon proximally and the coronoid distally. The to avoid arthritis. Posttraumatic stiffness of the
sigmoid notch is almost completely covered with elbow is not rare, and the residual range of motion
cartilage (180°) except for the mid-portion that centres around 80° of flexion given that the cap-
sule at this position has maximum expansion.
Normal flexion-extension range of motion for the
O. Paxinos, M.D., F.A.C.S
elbow is 0°–150°. For daily activities a range of
251 Hellenic Air Force Hospital, Athens, Greece
30°–130° is considered necessary with flexion
T.H. Tosounidis
deficits being more restricting [1].
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK The most commonly used classification of olec-
ranon fractures is the Mayo that is based on the
P.V. Giannoudis, M.D., F.R.C.S (*)
Academic Department of Trauma and Orthopaedics, presence of displacement, instability and commi-
School of Medicine, University of Leeds, Leeds, UK nution. Type I is a stable joint with a minimally
NIHR, Leeds, Musculoskeletal Biomedical Research displaced fracture (less than 2 mm of gap between
Center, Chapel Allerton Hospital, Leeds, UK the fracture fragments), Type II is a stable joint
e-mail: pgiannoudi@aol.com with a displaced fracture, and Type III fractures

© Springer International Publishing AG 2018 143

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_17
144 O. Paxinos et al.

can be removed without loss of elbow function or

stability [5]. Coronoid fractures in the presence of
olecranon fractures should always be considered
for fixation especially if the fragment is displaced
and larger than simple tip fractures [4]. Since
reduction and fixation of the coronoid will be per-
formed through the fracture line, one needs to plan
in advance the definitive fixation of the coronoid
before reducing the olecranon fracture [1].

Patient Setup in Theatre

Olecranon fracture surgery can be accomplished

Fig. 17.1  A Type IIB olecranon fracture with concomi-
tant coronoid fracture Type III in almost any surgical table. All possible patient
positions (supine, lateral and even prone) have
been described, but depending on surgeon prefer-
have associated instability of the joint. The Types II ence and the availability of an assistant, the most
and III are further subdivided into subgroups A and commonly used positions are the supine and lat-
B based on the presence of comminution. Coronoid eral decubitus. Both offer very good visualization
fractures are also classified in three types according of the fracture. Positioning the patient supine
to the Regan-Morrey system. Based on the site of with the elbow flexed and the arm sited on the
the fracture line visible in a lateral X-ray, Type I are chest provides good visibility but requires an
tip fractures, Type II fractures with fragment less assistant from the other side. Although preferred
than 50% and Type III with a fragment more than in polytrauma patients, it may interfere with
50% of the coronoid process (Fig. 17.1) [1]. anaesthesia or chest expansion. In lateral decubi-
tus the forearm hangs freely in front of the patient
with the extremity resting over an arm support,
Brief Preoperative Planning negating the need for an assistant (Fig. 17.2).

It is necessary to define the type of fracture before

surgery, since joint stability and fixation device
effectiveness depend on fragment size and commi-
nution. Fixation techniques include tension band
wiring (TBW), conventional or locking plating sys-
tems, intramedullary nails and screws. Choice of
implant should take into consideration the biome-
chanics of the fracture and of the fixation device.
TBW and plates provide similar stability in simple
fractures, while plates have been shown to be bio-
mechanically more stable in comminuted fracture
patterns. Bone graft may be needed to restore the
geometry of the joint, and this should be taken into
consideration when positioning and preparing the
patient. When the olecranon fragment is very small
and fixation is difficult (especially in elderly
patients), one can plan for fragment resection and Fig. 17.2  Lateral decubitus position for elbow fracture
triceps reattachment since up to 60% of olecranon fixation
17  Olecranon Fractures 145

Good AP and lateral fluoroscopic images are

necessary to ensure anatomical fracture reduction
and proper implant placement. The position of
the image intensifier will depend on the position-
ing of the patient [1].

Closed Reduction Manoeuvres

Since the fracture is an intra-articular one, closed

reduction should be only reserved for cases with
significant soft tissue injury and for elderly
patients [6]. In these cases, extending the elbow
while pushing the olecranon tip with the thumb
will reduce the fragment over the trochlea.
Percutaneous K-wires may then hold the frag-
ment in position supplemented by an external fix-
ator until the soft tissues recover. In elderly
patients the elbow may be immobilized in a splint
until protected range of motion exercises begin.

Reduction Instruments

A hand surgery set and a small fracture fixation

set will be sufficient to deal with most olecranon
Fig. 17.3  Intraoperative inspection of the fracture line
fractures. The surgeon will need K-wires in vari- and joint surfaces
ous sizes (usually 0.045 and 0.062 in.) as well as
surgical wire 20G. Pointed reduction clamps are
very useful and should be available in various Depending on the preoperative planning and the
sizes. Small-sized periosteal elevators will assist intraoperative picture, the surgeon may decide to
in mobilizing the impacted fragments, and proceed medially and decompress the ulnar
0.045 in. K-wires will provide provisional fixa- nerve. This can be easily identified proximally
tion. Vascular loops should be readily available in and followed distally. The nerve may be mobi-
case the surgeon decides to explore and decom- lized temporarily to allow reduction manoeuvres
press the ulnar nerve. and implant positioning, but anterior nerve trans-
port is not advisable. Final inspection of the frac-
ture site will allow the surgeon to confirm that the
Surgical Approach preoperative plan developed and the fixation
technique chosen are appropriate for the fracture
Most surgeons prefer a straight midline incision pattern being stabilized [1].
either curving laterally over the olecranon or cen-
tred slightly medial to the middle line. Full-­
thickness flaps should be elevated until the Open Reduction Manoeuvres
olecranon is encountered and the fracture haema-
toma evacuated. The joint should be washed out The fracture is intra-articular and should always
to remove any bony or cartilaginous fragments be anatomically reduced. This may be very easy
and the trochlea inspected for defects (Fig. 17.3). to achieve in simple fracture patterns where
146 O. Paxinos et al.

Implant Insertion

 ype I and Type IIA Olecranon

T
Fractures

In simple Type I and Type IIA olecranon fractures,

one can use either tension band fixation with
K-wires or plate and screws with equal stability
and fusion rates. There is very little evidence to
determine the best treatment for these fractures
with confidence [7]. After fracture reduction and
provisional fixation with pointed clamps, two par-
allel 0.045 in. Kirschner wires are inserted from the
olecranon tip and directed to the anterior ulnar cor-
tex distal to the coronoid [8]. However, fixation to
the anterior cortex instead of intramedullary inser-
tion has been shown to increase complications [2]
(Fig. 17.5). After fluoroscopic confirmation of the
position, the wires are withdrawn for 1 cm, and
then a 20G or 22G surgical wire is looped around
then and fixed in a figure of eight passing through
2.5 mm drill holes in the triangular-shaped part of
the proximal dorsal ulna cortex. Alternatively, the
K-wires can be inserted intramedullary towards the
ulna styloid in a longer distance [8]. In order to
Fig. 17.4  Provisional fracture reduction with two pointed avoid prominent hardware problems, it is better to
clamps
pass the figure-of-eight wire as close to the

d­orsal cortical apposition of the fragments

restores joint congruity. In this case reduction can
be provisionally held with either pointed reduc-
tion clamps or K-wires (Fig. 17.4). In complex
fractures, one may have to use indirect reduction
techniques utilizing the trochlea as a template to
restore the sigmoid notch anatomy and then pro-
visionally hold the fragments with K-wires. In
cases with severe comminution, it may be easier
to visualize through the major fracture line and in
a stepwise manner reduce the smaller fragments
and turn a multi-fragmentary fracture into a sim-
ple one. When there is a concomitant coronoid
fracture that should be addressed first and held in
place with guide wires, subsequently the coro-
noid fracture can be stabilized with the most Fig. 17.5  Lateral fluoroscopic view of Type IIA olecra-
non fracture treated with a tension band construct with
appropriate method of fixation. two K-wires and figure-of-eight wire loop
17  Olecranon Fractures 147

Fig. 17.6  AP intraoperative view of Type IIA olecranon

fracture treated with tension band. Passing the figure-of-­
eight wire as close to the bone will decrease hardware
problems
Fig. 17.7  Intraoperative picture of Type IIA olecranon
fracture treated with tension band with two tightening
o­ lecranon tip underneath the triceps tendon as pos- knots
sible (Fig. 17.6). Making two tightening twists
instead of one seem to improve stability. The two fracture (Type II or III), it should be reduced and
K-wires are then cut and bent and impacted into the fixed first with either simple partially threaded
olecranon deep under the triceps tendon (Fig. 17.7). 4.0 mm lag screws or pullout wire [1]. A cannu-
Instead of K-wires, intramedullary screws with or lated 3.5 screw will be easier to insert over the
without figure-of-eight wire have been used with guide wire used to provisionally fix the coronoid
variable success. Although biomechanically infe- fragment. The screw can be inserted either
rior to K-wire tension band, they can be useful as through the fracture line and buried in the bone or
low profile implants in non-comminuted fractures from the dorsal ulna cortex taking care not to
with good bone quality [8]. interfere with the plate. After fixation of the coro-
noid, any other fragment is anatomically reduced
using the trochlea as template before the major
 ype IIB and Type III Olecranon
T fracture line is closed and provisionally held in
Fractures place. There are several plates marketed specifi-
cally for elbow fractures, although one can still
Types IIB and III are better treated with plate use inexpensive 3.5 steel plates provided she/he
fixation. If there is a concomitant large coronoid respects the principles of fixation. The plate can
148 O. Paxinos et al.

construct. Tension band with K-wires is only

appropriate for stable Type I or IIA fractures.
In elderly persons with comminution, one
may consider conservative treatment or exci-
sion and reattachment of the triceps to the
ulna.
• Reduction is essential before applying any
fixation. In comminuted fractures the coro-
noid is reduced first and then all other frag-
ments in a stepwise fashion before closing the
main fracture line.
• When using K-wires through the anterior cor-
tex, one should avoid over-penetration since
Fig. 17.8  Lateral X-ray of Type IIIB olecranon fracture
neurovascular injury may occur. The correct
treated with locking plate. The lag screw is directed to the length is estimated with the image intensifier,
coronoid fracture, while the two diagonal screws to the and the wires are pulled back 1 cm to cut and
anterior cortex increase rigidity of the fixation bend in over to avoid prominence into the
anterior forearm when impacted in place.
be positioned either dorsal or lateral since there is Alternatively, one may use long K-wire pass-
no biomechanical difference [9]. When using ing intramedullary into the ulna. Passing the
non-locking screws, it is important to bend the figure-of-eight wire under the triceps mass
end of the plate over the olecranon tip as to allow will reduce the chance of prominent implant
for the insertion of one screw towards the coro- irritation and the need for wire removal.
noid. This configuration significantly improves • Plate fixation should be used whenever there
the stability of the construct (Fig. 17.8). In is comminution. In osteoporotic bones, lock-
osteopenic bones, one may choose locking plates ing plates may be used. After fixation, in the
for better purchase. When using locking plates, lateral fluoroscopic view, the plate may be
one should make sure the fragments are perfectly seen sitting away from the tip some millime-
reduced since the plate will not provide interfrag- tres despite having taking measures such as
mentary compression. Hybrid plates may allow splitting the triceps insertion to improve appo-
for both compression and locking screw inser- sition. This image should not raise concerns.
tion—however one needs to be familiar with the
principles of absolute and relative stability to Conflict of Interest  No benefits in any form have been
avoid implant failure and/or inadequate fracture received or will be received from a commercial party
related directly or indirectly to the subject of this
reduction. Fluoroscopic imaging is important to chapter.
avoid joint penetration. In elderly patients with
severe comminution, one may opt either to treat
conservatively or to excise the fragments and
attach the triceps directly to the bone. Good References
results can be expected if the olecranon excised is
less than 60% [10]. 1. Morrey BF, Sanchez-Sotelo J. The elbow and its dis-
orders. 4th ed. Bone 2010:13-42.
2. Schneider MM, Nowak TE, Bastian L, et al. Tension
band wiring in olecranon fractures: the myth of tech-
Summary of Tips and Tricks-Pitfalls nical simplicity and osteosynthetical perfection. Int
Orthop. 2014;38(4):847–55. https://doi.org/10.1007/
s00264-013-2208-7.
• The surgeon needs to respect the principles of 3. Ferreira LM, Bell TH, Johnson JA, King GJW. The
intra-articular fracture fixation and aim for effect of triceps repair techniques following olec-
absolute stability in the articular part of the ranon excision on elbow stability and extension
17  Olecranon Fractures 149

strength: an in vitro biomechanical study. J Orthop ing fractures of the olecranon in adults. Cochrane
Trauma. 2011;25:420–4. https://doi.org/10.1097/ Database Syst Rev. 2014;11:CD010144. https://doi.
BOT.0b013e3181fadd55. org/10.1002/14651858.CD010144.pub2.
4. Doornberg JN, Ring D. Coronoid fracture patterns. 8. Huang T-W, C-C W, Fan K-F, Tseng I-C, Lee
J Hand Surg Am. 2006;31(1):45–52. https://doi. P-C, Chou Y-C. Tension band wiring for olecra-
org/10.1016/j.jhsa.2005.08.014. non fractures: relative stability of kirschner wires
5. Ikeda M, Fukushima Y, Kobayashi Y, Oka Y.  in various configurations. J Trauma Inj Infect Crit
Comminuted fractures of the olecranon. Management Care. 2010;68(1):173–6. https://doi.org/10.1097/
by bone graft from the iliac crest and multiple tension-­ TA.0b013e3181ad554c.
band wiring. J Bone Jt Surg Br. 2001;83(6):805–8. 9. King GJ, Lammens PN, Milne a D, Roth JH, J a
https://doi.org/10.1302/0301-620X.83B6.11829. J. Plate fixation of comminuted olecranon fractures:
6. Powell AJ, Farhan-Alanie OM, Bryceland JK, Nunn an in vitro biomechanical study. J Shoulder Elb
T. The treatment of olecranon fractures in adults. Surg. 1996;5(6):437–41. https://doi.org/10.1016/
Musculoskelet Surg. 2017;101(1):1–9. https://doi. S1058-2746(96)80015-2.
org/10.1007/s12306-016-0449-5. 10. Iannuzzi N, Dahners L. Excision and advancement in
7. Matar HE, Ali AA, Buckley S, Garlick NI, the treatment of comminuted olecranon fractures. J
Atkinson HD. Surgical interventions for treat- Orthop Trauma. 2009;23(3):226–8.
 Coronoid Fractures
18
Mark Philipson

Avulsion Fractures of the Coronoid A CT scan can be useful to confirm the pres-

ence of a coronoid avulsion and to assess an asso-
I ndications for Surgery ciated radial head fracture.
and Preoperative Planning

Small avulsion fractures of the tip of the coronoid Patient Set-Up in Theatre
are often found in association with elbow dislo-
cations (Fig. 18.1). The avulsion fracture occurs The patient is positioned supine with the arm on
as part of an injury to the anterior capsular attach- an armboard. I utilise a tourniquet. The surgeon
ments to the coronoid. Most can be successfully sits on the cephalad side of the arm board. A
managed nonoperatively. When a coronoid avul- C-arm can be positioned under the armboard.
sion exists together with an unstable radial head
fracture and a medial collateral ligament rupture,
then repairing the anterior capsule will confer
additional stability to the elbow. In my practice,
if I am reconstructing or replacing a radial head
fracture and there is an associated avulsion of the
tip of the coronoid, I will repair the anterior cap-
sular avulsion injury. The additional stability
gives me confidence to mobilise the elbow early.

M. Philipson Fig. 18.1  An elbow dislocation with avulsion of the tip

Leeds General Infirmary, Leeds, UK of the coronoid and a comminuted fracture of the radial
e-mail: mrphilipson@hotmail.com head

© Springer International Publishing AG 2018 151

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_18
152 M. Philipson

Fig. 18.2  The skin incision for an anterolateral approach

to the elbow

Closed Reduction Manoeuvres

The ulnohumeral joint should be reduced with

axial traction and flexion prior to making a skin
incision.

Surgical Approach

A straight oblique incision is made starting just

proximal to the lateral epicondyle and extending
distally towards Lister’s tubercle on the dorsum
of the wrist for a distance of 5–10 cm (Fig. 18.2).
Fig. 18.3  An anterolateral approach has been used to
This anterolateral approach is also known as a access the coronoid tip. Note that the lateral epicondyle is
Kaplan interval approach. Invariably the lateral denuded of all soft tissue attachments. This is the typical
collateral ligament together with the extensor ori- finding in cases of elbow dislocation
gin is avulsed from the lateral epicondyle. The
forearm fascia is incised in line with the skin adequate access to the coronoid can be achieved
incision commencing just anterior to the lateral with progressive release of brachioradialis and
epicondyle. The surgeon will encounter a the anterior capsule from the humerus in a lateral
haematoma-­filled wound cavity where the lateral to medial direction (Fig. 18.3). Obviously, it is
collateral ligaments and extensor origin have important to minimise the release of anterior cap-
been avulsed and the radiocapitellar joint is at the sule from the humerus; otherwise, any benefit
base of this wound. Reconstruction of a stable from repairing the anterior capsule to the coro-
proximal radius by fixation or prosthetic replace- noid is nullified.
ment is essential. Fixation of the radial head is
preferable to replacement if the surgeon is confi-
dent that union can be achieved. Prosthetic Open Reduction Manoeuvres
replacement has the advantage of giving a pre-
dictable stable reconstruction. It also makes The challenge in this procedure is achieving ade-
access to the coronoid much easier if the radial quate exposure of the coronoid without excessive
head is excised. Even with an intact radial head, release of anterior capsule from the humerus. Flex
18  Coronoid Fractures 153

the elbow and place a single ring-handled spike

with the tip over the medial aspect of the proximal
ulna. This spike then retracts the brachioradialis,
anterior capsule and brachialis medially. The
anterior capsule and brachioradialis should then
be released sequentially until adequate exposure
of the fracture bed of the coronoid is achieved. An
anchor double loaded with number 2 abrasion-
resistant suture material is then implanted in the
centre of the coronoid fracture bed. Both 5-mm
threaded cuff anchors and 2.9-­mm labral anchors
can be used for this purpose. The torn anterior
capsule is now located together with the avulsion
fragment. The bony fragment can be trimmed or
excised altogether with a pair of rongeurs. For
each loop of suture, one limb is passed though the
anterior capsule with several bites in the manner Fig. 18.4  The radial head has been replaced, and metal-
of a modified Mason-Allen suture; the other limb lic anchors have been used to repair the coronoid avulsion
is passed with a single bite of capsule. The limb and lateral collateral ligament injury
with a single bite will be used as a post when knot
tying in order to pull the capsule down on to the
coronoid. It is important to keep the suture bites  ractures Through the Base
F
near to the torn edge of the capsule to avoid over- of Coronoid
tightening. The sutures should be left loose and
untied (with some means of easily identifying I ndications for Surgery
which limbs are the posts) until reconstruction of and Preoperative Planning
the proximal radius is complete.
As the sutures are tied with a sliding locking Fractures involving more than just the tip of the
knot, the anterior capsule and avulsion fragment coronoid are uncommon. Frequently they are part
are reduced onto the coronoid (Fig. 18.4). of a complex unstable elbow injury. Fixation is
necessary if there is clinical or radiographic evi-
dence of instability (Fig. 18.5).
Post-op Instructions A CT scan is very useful for understanding the
morphology of the fracture and planning fixation.
The aim is to achieve a repair that facilities This is especially true when there is an associated
immediate active movement. The patient wears a complex fracture of the olecranon.
collar and cuff sling for comfort. Patient and
physiotherapist are advised to avoid pushing
extension past 30° in the first 6 weeks. Patient Set-Up in Theatre

Tips, Tricks and Pitfalls The patient is positioned supine with the arm on
• A well-placed ring-handled spike with the an armboard. An arm tourniquet is used. The sur-
elbow flexed gives better exposure of the coro- geon sits on the caudal side of the armboard. A
noid than multiple retractors. C-arm can be positioned under the armboard. In
• Don’t tie the sutures in the anterior capsule until many cases simultaneous fixation of the olecra-
reconstruction of the proximal radius is complete. non will be necessary. In these cases the olecra-
• Avoid overtightening the capsule as this will non is fixed with the patient supine with the arm
increase the risk of stiffness. bent over a cushion on the patient’s chest. The
154 M. Philipson

Fig. 18.6  The skin incision for a medial approach to the

coronoid

Fig. 18.5  An elbow dislocation with a fracture through In cases of high-energy trauma, there may be
the base of the coronoid. This is a grossly unstable injury an obvious defect in the muscular envelope over
(Figure courtesy of Mr. S Vollans, Leeds Teaching the medial aspect of the proximal ulna. The sur-
hospitals) geon should be flexible and utilise such a defect
for the exposure of the coronoid. Otherwise I
arm can then be moved down on to an armboard approach the coronoid via the floor of the ulnar
for the coronoid fixation. All image intensifier nerve between the two heads of flexor carpi ulna-
images can be obtained with the arm swung out- ris (FCU). The ulnar nerve is mobilised and
wards on to the armboard. transposed anteriorly so as to avoid any kinks or
tension on the nerve. The two heads of FCU are
then separated to expose the proximal ulna.
Closed Reduction Manoeuvres

The ulnohumeral joint should be reduced with Open Reduction Manoeuvres

axial traction and flexion prior to making a skin
incision. A traction suture in the anterior capsule is used to
aid reduction of the coronoid fragment. Limited
access does not normally allow application of
Surgical Approach reduction forceps.
I recommend the use of a pre-contoured lock-
For isolated fractures of the coronoid, the inci- ing plate specifically designed for the coronoid
sion starts 5 cm proximal to the medial epicon- with an anterior paddle which sits over the
dyle then passes in line with the ulnar nerve just ­coronoid fragment to act as a buttress and resist
behind the medial epicondyle and extends anterior displacement. I utilise the Biomet ALP
5–10 cm distal to the medial epicondyle plate (Fig. 18.7).
(Fig. 18.6). If exposure of the olecranon is also
required then I utilise a single midline posterior
incision curved medially around the olecranon. Postoperative Instructions
In cases where access to the radiocapitellar
joint is required but not the olecranon, I will The aim is to achieve a reconstruction that facili-
utilise separate anterolateral and posteromedial tates immediate active elbow movement once the
incisions. skin wound has settled. The patient is provided
18  Coronoid Fractures 155

Further Reading
Chan K, Faber KJ, King GJ, Athwal GS. Selected antero-
medial coronoid fractures can be treated nonopera-
tively. J Shoulder Elb Surg. 2016;25(8):1251–7.
Han SH, Yoon HK, Rhee SY, Lee JK. Anterior approach for
fixation of isolated type III coronoid process fracture.
Eur J Orthop Surg Traumatol. 2013;23(4):395–405.
Hartzler RU, Llusa-Perez M, Steinmann SP, Morrey
BF, Sanchez-Sotelo J. Transverse coronoid fracture:
when does it have to be fixed? Clin Orthop Relat Res.
2014;472(7):2068–74.
Ring D, Horst TA. Coronoid Fractures. J Orthop Trauma.
2015;29(10):437–40.
Rhyou IH, Lee JH, Kim KC, Ahn KB, Moon SC,
Kim HJ, Lee JH. What injury mechanism and pat-
terns of ligament status are associated with isolated
coronoid,isolated radial head, and combined frac-
tures? Clin Orthop Relat Res. 2017;475(9):2308–15.
Wang P, Zhuang Y, Li Z, Wei W, Fu Y, Wei X, Zhang
Fig. 18.7  The base of coronoid fracture has been fixed K. Lasso plate - an original implant for fixation of type
with a pre-contoured plate and a cannulated screw (Figure I and II Regan-Morrey coronoid fractures. Orthop
courtesy of Mr. S Vollans, Leeds Teaching hospitals) Traumatol Surg Res. 2017;103(3):447–51.
Yoon RS, Tyagi V, Cantlon MB, Riesgo AM, Liporace
FA. Complex coronoid and proximal ulna frac-
tures are we getting better at fixing these? Injury.
with a collar and cuff sling for comfort. Patient 2016;47(10):2053–9.
and physiotherapist are advised to avoid pushing
extension past 30° in the first 6 weeks.

Tips, Tricks and Pitfalls

• Utilise a pre-contoured plate designed for the
coronoid.
• Avoid the temptation to fix the coronoid with
screws alone.
• Any associated radial head fracture must be
securely reconstructed.
 Radial Head and Neck Fracture
19
Austin Hill and David Ring

Fracture Location and Pattern setting, if the radial head fracture does not hinder
forearm rotation or cause crepitation, it may not
Fractures of the radial head not associated with benefit from specific treatment. And if it does,
other ligament injuries or fractures are typically resection without replacement is an option.
stable (intact periosteum, impacted, not mobile) For unstable fractures, it can be useful to
and usually involve the anterolateral aspect of the obtain a computed tomography scan, make 3D
radial head or the neck of radius [1]. reconstructions, and subtract the distal humerus
Fractures associated with other ligament inju- to get a good look at the fracture [6]. It is intuitive
ries (e.g. elbow dislocation or interosseous liga- to think that partial articular fractures will have
ment of the forearm) or fractures (e.g. fracture of fewer fragments, but a recent study suggests that
the proximal ulna) are usually displaced and there are more and small fragments, making them
unstable and may involve the entire head of the more difficult to repair than a fracture of the
radius [1]. Unstable fractures may have limited entire head of the radius (Fig. 19.1) [7]. A CT
periosteal connections. For unstable fracture, the scan can also be used for radial neck fractures to
overall injury pattern helps determine what to do
with the radial head [2]. For instance, in the set-
ting of elbow dislocation with fractures of the
radial head and coronoid (the terrible triad
lesion), restoration of radiocapitellar contact is so
important that tenuous or incomplete repair of a
radial head fracture is risky and surgeons should
have a low threshold to resect the radial head and
insert a prosthesis [3, 4]. In contrast, many extra-­
articular posterior Monteggia injuries have a sta-
ble ulnohumeral joint, making preservation of
radiocapitellar contact less important [5]. In this

A. Hill, M.D. • D. Ring, M.D., Ph.D. (*) Fig. 19.1  A 3D CT scan with the distal humerus sub-
Department of Surgery and Perioperative Care, Dell tracted shows a partial articular fracture of the radial head
Medical School—The University of Texas at Austin, as part of a terrible triad pattern injury. The radial head is
Austin, TX, USA fragmented, with numerous small fragments. This radial
e-mail: david.ring@austin.utexas.edu head should be replaced with a prosthesis

© Springer International Publishing AG 2018 157

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_19
158 A. Hill and D. Ring

get a sense of how impacted/angulated it is and

the potential bone defect that might exist after the
fracture is reduced.

Brief Preoperative Planning

When the surgeon understands the injury pattern

and has radiographs and 3D-CT with the distal
humerus subtracted, there are very few surprises
at surgery [2].
For impacted partial articular fractures of the Fig. 19.2  The patient lies supine with the arm supported
articular surface and impacted radial neck frac- on a hand table. A sterile tourniquet provides good access
tures, it can be useful to have a broad (1 cm or to and mobility of the arm. A lateral skin incision is an
option. A posterior skin incision could also be used
greater) bone tamp; the tamp can be used to
realign the fracture without disrupting any bent
but intact metaphyseal bone or intact periosteum. tourniquet makes it easier to access the elbow and
The surgeon should be prepared for a substantial manipulate the arm. When the fracture of the radial
defect and consider obtaining autogenous cancel- head is associated with a fracture of the olecranon
lous bone graft from the proximal ulna, distal or proximal ulna, a lateral decubitus position with
radius, or iliac crest or a graft alternative. For the arm supported on a bolster is preferred.
most of these fractures, a few small screws are
sufficient for fixation. Countersunk screws with a
head are fine for the nonarticular part of the head. Closed Reduction Manoeuvres
Headless screws are used for the unusual fracture
that involves a part of the radial head that articu- There is no point in attempting closed reduction
lates with the lesser sigmoid notch of the ulna in of a radial head fracture.
the proximal radioulnar joint [8].
For unstable fractures, small Kirschner wires
and bone clamps can assist with reduction. Some Surgical Approach
unstable fractures with no bone defect can be
treated with screws alone. Even fractures of the The skin incision can be lateral or posterior
radial neck or whole-head articular fractures can be depending on associated injuries and surgeon and
fixed with screws alone if there is no metaphyseal patient preferences. The preferred muscle inter-
bone defect—a few long screws cross obliquely val to expose a fracture of the radial head is
from the articular margin across the fracture to the between the extensor carpi radialis brevis and
radial neck distal to the fracture [9]. If there is a extensor digitorum communis (eponym Kaplan)
bone defect, a plate and screws are needed. or slightly posterior. It is not possible to distin-
For unstable, fragmented fractures, the sur- guish the interval. Rather the common extensor
geon should be prepared to replace the radial muscle mass is split at the 50:50 anterior poste-
head with a prosthesis or craft a spacer prosthesis rior division of the capitellum. This can be done
out of methyl methacrylate bone cement [10]. by feel or by elevating the origin of the extensor
carpi radialis brevis from the supracondylar ridge
and looking into the joint as the split is extended
Patient Set-Up in Theatre distally [11]. The annular ligament is split in this
interval. The supinator muscle is separated using
For most radial head fractures, the patient lies blunt dissection with small scissors and elevated
supine on a standard operating table with the arm distally using a blunt elevator keeping the perios-
supported on a hand table (Fig. 19.2). A sterile teum in place if possible.
19  Radial Head and Neck Fracture 159

This anterior exposure may not provide access wires. It can also be helpful to use a dental pick
to some posterior displaced, unstable articular to align and hold fragments along with a small
fragments. In that case the anconeus can be split pointed tenaculum forceps (Fig. 19.4). The wires
to retrieve this fragment and bring it to the ante- can then be used to help place and position the
rior part of the elbow. fragment while another wire is drilled across to
hole the fragment in place. Once all the frag-
ments are aligned, the decision is made whether
Open Reduction Manoeuvres or not to apply bone graft or bone graft substi-
tute. Screws or a plate and screws are then
If the fracture does not move and there is intact applied.
periosteum, it is considered impacted. It is helpful If at any point there are missing, deformed, or
to try to maintain as much of the inherent stability small fragments that are important to the stability
of this type of fracture as possible. A tip for doing of the elbow, the radial head is resected and a
this is to place a bone tamp on the nonarticular part prosthesis inserted.
of the radial head or neck and use a small mallet
with as little force as needed and gradually push
the fracture back into position with many small Implant Insertion
blows (Fig. 19.3 (a,b)). Done well and with a little
luck, the fracture will be repositioned and main- The screws or plate should be applied within a 90
tain some inherent stability. degree arc centred directly lateral with the fore-
For unstable fractures, it can help to skewer arm in neutral rotation. There is a little more room
the fragments with small (0.8–1.1 mm) Kirschner anterior than posterior for the implants [12].

a b

Fig. 19.3  A stable isolated partial articular fracture of the radial head. (a) A bone tamp is used to realign the fracture.
(b) Stability and periosteal attachments are maintained
160 A. Hill and D. Ring

tial experience with open reduction and inter-

nal fixation of the radial head.
• The pitfalls are to fix a fracture tenuously and
have it collapse, place implants on the articu-
lar surface of the proximal radioulnar joint or
too long and into the joint, or to harm the pos-
terior interosseous nerve. It is wise to avoid
placing a retractor over the anterior part of the
radial neck to avoid injuring the posterior
interosseous nerve.

References
1. Duckworth AD, McQueen MM, Ring D. Fractures of
the radial head. Bone Joint J. 2013;95-B(2):151–9.
https://doi.org/10.1302/0301-620X.95B2.29877.
Review. PubMed PMID:23365021
2. Doornberg JN, Guitton TG, Ring D. Science of
Variation Group.. Diagnosis of elbow fracture pat-
terns on radiographs: interobserver reliability
and diagnostic accuracy. Clin Orthop Relat Res.
Fig. 19.4  A dental pick, Kirschner wires, and tenaculum 2013;471(4):1373–8. https://doi.org/10.1007/s11999-
clamps can help reduce complex fractures of the entire 012-2742-4. Epub 2012 Dec 18. PubMed PMID:
head of the radius 23247817; PubMed Central PMCID: PMC3586040
3. Pugh DM, Wild LM, Schemitsch EH, King GJ,
McKee MD. Standard surgical protocol to treat elbow
dislocations with radial head and coronoid fractures.
Summary of Tips, Tricks, and Pitfalls J Bone Joint Surg Am. 2004;86-A(6):1122–30.
PubMed PMID: 15173283
• Most stable, isolated fractures do not benefit 4. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation
of the elbow with fractures of the radial head and cor-
from fixation. It should be the unusual sub- onoid. J Bone Joint Surg Am. 2002;84-A(4):547–51.
stantially impacted fracture that is considered PubMed PMID: 11940613
for surgery [1]. 5. O'Driscoll SW, Jupiter JB, Cohen MS, Ring D,
• Most unstable, displaced fractures are part of an McKee MD. Difficult elbow fractures: pearls and
pitfalls. Instr Course Lect. 2003;52:113–34. Review.
unstable elbow or forearm injury, are frag- PubMed PMID: 12690844
mented, create small fragments and metaphyseal 6. Guitton TG, Ring D, Science of Variation Group.
impaction, and are difficult to fix. A radial head Interobserver reliability of radial head fracture classi-
prosthesis might be a better option here [13]. fication: two-dimensional compared with three-dimen-
sional CT. J Bone Joint Surg Am. 2011;93(21):2015–21.
• Anticipate avulsion of the lateral collateral https://doi.org/10.2106/JBJS.J.00711. PubMed PMID:
ligament from the lateral epicondyle with an 22048097
elbow fracture dislocation. It will make expo- 7. Guitton TG, van der Werf HJ, Ring D. Quantitative
sure much easier. Use drill holes through the three-dimensional computed tomography mea-
surement of radial head fractures. J Shoulder Elb
lateral epicondyle or suture anchors to reat- Surg. 2010;19(7):973–7. https://doi.org/10.1016/j.
tach the lateral collateral ligament complex. jse.2010.03.013. Epub 2010 Jun 20. PubMed
• Consequently, it is difficult to become familiar PMID:20566295
with these reduction techniques. Based on 8. van Leeuwen DH, Guitton TG, Lambers K, Ring
D. Quantitative measurement of radial head fracture
preoperative evaluation, if you think it may be location. J Shoulder Elb Surg. 2012;21(8):1013–7.
possible to repair the fracture, consider doing https://doi.org/10.1016/j.jse.2011.08.056. Epub 2011
the surgery with a colleague that has substan- Nov 9. PubMed PMID: 22071412
19  Radial Head and Neck Fracture 161

9. Smith AM, Morrey BF, Steinmann SP. Low profile 11. Hotchkiss RN. Displaced fractures of the radial head:
fixation of radial head and neck fractures: surgi- internal fixation or excision? J Am Acad Orthop Surg.
cal technique and clinical experience. J Orthop 1997;5(1):1–10. PubMed PMID: 10797202
Trauma. 2007;21(10):718–24. PubMed PMID: 12. Smith GR, Hotchkiss RN. Radial head and neck frac-
17986889 tures: anatomic guidelines for proper placement of
10. Clembosky G, Boretto JG. Open reduction and
internal fixation. J Shoulder Elb Surg. 1996;5(2 Pt
internal fixation versus prosthetic replacement for 1):113–7. PubMed PMID: 8742874
complex fractures of the radial head. J Hand Surg 13. Ring D, Quintero J, Jupiter JB. Open reduction and
Am. 2009;34(6):1120–3. https://doi.org/10.1016/j. internal fixation of fractures of the radial head. J Bone
jhsa.2008.12.031. Epub 2009 May 28. PubMed Joint Surg Am. 2002;84-A(10):1811–5. PubMed
PMID: 19481361 PMID: 12377912
 Monteggia Fracture
and Monteggia-Like 20
Lesion – Treatment Strategies
and Intraoperative Reduction
Techniques

Dorothee Gühring and Ulrich Stöckle

Anatomy components in relation to one another. In addition

to conventional diagnostic X-rays, computed
Fractures of the proximal ulna in combination tomography is to be regarded as standard for sub-
with a dislocation of the proximal radioulnar stantiated preoperative planning (Fig. 20.2).
joint (PRUJ) and the radiohumeral joint (disloca- Since a Monteggia injury is a dislocation frac-
tion of the head of the radial bone) are named ture, a timely and anatomical reconstruction of
“Monteggia fractures” after the individual who the ulna fracture should be aimed for. Often,
first described such fractures, Giovanni Monteggia injuries are fractures with significant
Monteggia [1]. The dislocation mechanism that closed or open soft tissue damage which requires
takes place in the context of a Monteggia injury emergency intervention. If open reconstruction is
often results in a concomitant fracture of the neck not possible due to the severity of soft tissue
or head of the radial bone and/or a fracture of the injury, the elbow joint should be temporarily sta-
coronoid process. These complex injuries are bilized using an external fixation device
summarized by the term “Monteggia-like lesion” (Fig. 20.3).
(Fig. 20.1).

Preoperative Planning

Conventional diagnostic X-rays of the elbow in

two planes provide an overview of the extent of
injury and serve the purpose of evaluating the joint

D. Gühring
Klinik im Kronprinzenbau, Reutlingen, Germany
U. Stöckle (*)
Trauma and Reconstructive Surgery, BG Unfallklinik, Fig. 20.1  Monteggia-like lesion. Fracture of the proxi-
Tübingen, Germany mal ulna in combination with a fracture of the radial head
e-mail: ustoeckle@bgu-tuebingen.de and the coronoid process

© Springer International Publishing AG 2018 163

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_20
164 D. Gühring and U. Stöckle

General Considerations

Monteggia Lesion

In Monteggia fracture dislocations, anatomical

reduction with correct length and stable fixation
of the ulna are mandatory, in order to ensure sta-
ble relocation of the radial head. Once operative
fixation of the ulna has been completed, the sur-
geon must ensure the stability of the reduced
radial head, preferably under image intensifica-
tion. Anatomic reduction and fixation of the ulna
is achieved first, through a standard posterior
approach.
Check the position of the radial head, which
reduces spontaneously in most of these cases
(>90%). The surgeon must determine the posi-
tion of forearm rotation in which the radial head
is most stable. This is very often in full supina-
tion after the radial head has dislocated anterolat-
erally. The stable rotational position of the
forearm is that which will be used when postop-
erative splintage is applied.
If the radial head does not reduce correctly or
if it dislocates on forearm movement (pronation/
Fig. 20.2  Computed tomography of the Monteggia-like supination and flexion/extension), this may be
lesion. Three dimensional imaging due to either malreduction of the ulnar shaft or
there may be interposed soft tissue. If ulnar
reduction is confirmed and radial head disloca-
tion persists, access the radial head via a short
lateral approach or an extension into a Speed and
Boyd approach (<10%).
In cases of persisting radial head instability
after anatomical fixation of the ulna, interposed
annular ligament or the torn joint capsule is usu-
ally the cause and should be extracted from the
joint and sutured.

Monteggia-Like Lesion

C3 fractures, with extensive comminution of cor-

onoid and radial head. are characteristic of poste-
rior olecranon fracture dislocation. Lateral
collateral ligaments are typically disrupted.
Restoration of elbow stability requires repair of
the proximal ulna; radial head ORIF, or replace-
ment; and lateral collateral ligament repair. A
coronoid fragment, if present, may be reduced
Fig. 20.3  External fixation device and fixed through the olecranon fracture and/or a
20  Monteggia Fracture and Monteggia-Like Lesion 165

medial extension of the usual posterior approach. the forearm to support the elbow in extension
Radial fracture repair or replacement follows. when necessary. A tourniquet at the proximal arm
Then the remainder of the proximal ulna must be is optional.
reduced and fixed in correct length. While it may
be possible to reduce the multifragmentary ulna
fracture anatomically, occasionally length can be Posterior Approach
determined better from the radius, after fixation
or replacement. Stability of the elbow must be A number of fracture patterns of the proximal
confirmed at the conclusion of reduction and fix- forearm can be addressed using this approach
ation. If instability remains, supplementary exter- (Fig. 20.5). The more complex the fracture con-
nal fixation may be necessary. figuration, the more extensile the approach needs
to be.
The ulna is a subcutaneous bone. Start the
Patient Set-Up in Theater incision a few centimeters proximal to the tip of
the olecranon, as needed for access to the injured
Prone Position area. Curve slightly radially around the tip of the
olecranon, and go distally for a few centimeters,
The patient lies prone with the arm on a radiolu- as needed to provide access to the injured area
cent support, or on a padded post (Fig. 20.4). (Fig. 20.6).
Either of them gives maximum freedom to Elevation of the lateral flap provides access to
approach the elbow. The forearm should be in a the lateral structures of the elbow. In the proximal
position so that it can be flexed beyond 100 portion, dissect and elevate the subcutaneous tis-
degrees. A small padded table can be placed under sue. Over the olecranon, remove the olecranon

Fig. 20.4  Prone position with the arm on a padded post Fig. 20.5  Skin incision of the posterior approach
166 D. Gühring and U. Stöckle

Fig. 20.6  Posterior approach after skin incision Fig. 20.7  Ulnar nerve

bursa and incise the triceps aponeurosis exposing subcutaneous tissues laterally exposing the sep-
the bone. Behind the medial humeral epicondyle, tum between the anconeus and the extensor carpi
identify and protect the ulnar nerve (Fig. 20.7). ulnaris muscle.
Detach the flexor carpi ulnaris muscle on the
medial side and the anconeus muscle on the lat-
eral side as far as necessary to expose the involved ORIF
articular surfaces and for an anatomical reduction
and stable fixation. Some coronoid fractures can Radial Head
be addressed through the proximal ulna fracture
or the lateral extension of this approach, particu- Radial fracture repair or replacement usually fol-
larly with the elbow dislocated, and/or with dis- lows reduction and fixation of the coronoid pro-
placement of a proximal radius fracture. The cess. Exposure of both fractures is a good initial
decision to detach the anconeus muscle from the step (Fig. 20.9).
ulna depends on the necessity to address a frac- The radial head is completely covered with
ture of the radial head, or neck, or a fracture of articular cartilage. The implant is applied to the
the proximal ulna involving the sigmoid notch radial head in a location that causes the least
(Fig. 20.8). compromise of full pronation and supination.
In a combined, simple proximal ulnar and Release the annular ligament as necessary to see
radial fracture, it may not be necessary to detach the radius. Expose the fracture with minimal soft
the anconeus. The proximal radial fracture may tissue dissection off the bone. Remove hematoma
be approached by dissecting and elevating the and irrigate. Directly reduce the joint fragments
20  Monteggia Fracture and Monteggia-Like Lesion 167

Fig. 20.8  Detach of the anconeus muscle Fig. 20.9  Exposure of the radial head

with the help of small pointed reduction forceps reduction and absolutely stable fixation of the
and provisionally fix them with two K-wires major articular surface fragments, particularly
(Fig. 20.10). the coronoid process. Compression will deform
If joint depression is encountered, the the articular surface, so it no longer fits the troch-
depressed joint fragment is elevated, and the lea. In this situation, the fracture must be bridged
underlying defect may be bone grafted with bone without compression to preserve size and shape
from the lateral humeral condyle. of the olecranon fossa. Small interfragmentary
Insert two horizontal lag screws (1.5 or screws or K-wires may improve stability.
2.0 mm) into the proximal fragment (Fig. 20.11).
Control reduction with direct visualization of
articular surface, and confirm with C-arm fluo- Bridge Plating
roscopy (Fig. 20.12). Repair the annular ligament
using non-absorbable sutures. A bridge plate is analogous to locked intramedul-
lary nail fixation of a comminuted shaft fracture.
In multifragmentary fractures of the olecranon,
Proximal Ulna anatomical reconstruction of the articular surface
itself is the primary goal. Intermediate, nonartic-
Absolute stability is desirable for articular frac- ular fragments do not need to be reduced anatom-
tures. However, this may not be possible in mul- ically. Cancellous bone graft can be used to
tifragmentary fractures of the proximal ulna. support the articular fragments and fill defects.
Every effort should still be directed at anatomical Directly manipulate only the articular fragments.
168 D. Gühring and U. Stöckle

Fig. 20.10  Reduction of the joint fragments with forceps Fig. 20.11  2.0 mm lag screws
and K-wire

Excessive manipulation of intermediate frag-

ments risks disturbing their blood supply. If the
soft tissue attachments are preserved, and the
fragments are relatively well aligned, healing is
predictable. Alignment of the main fragments
can usually be achieved indirectly utilizing trac-
tion and soft tissue tension. Mechanical stability,
provided by the bridging plate, is adequate for
indirect healing (callus formation). Correct
length of the ulna is the key for the treatment of
Monteggia-like lesions.
Through the posterior incision, release the
joint capsule medially and laterally at the fracture
site. With direct visualization, manipulate and
anatomically reduce the articular fragments. Use
the distal humerus as a template for reduction. Fig. 20.12  C-arm fluoroscopic control of the radial head
Provisionally fix the fragments with 1.0 mm
K-wires (Fig. 20.13). hold the reduction with one or two K-wires.
Reduce the proximal part of the olecranon Insert all K-wires in a position where they do not
with pointed reduction forceps, and temporarily interfere with the planned plate and screws.
20  Monteggia Fracture and Monteggia-Like Lesion 169

Fig. 20.13  Provisionally reduction with K-wires and Fig. 20.14  Preshaped olecranon LCP with locking head
forceps screws

Control reduction with direct visualization of the bone plate contact, split the triceps attachment
sigmoid notch and the posterior cortex of the before positioning the plate (Fig. 20.15).
olecranon, and confirm with C-arm fluoroscopic. Anchor the plate with three screws to the prox-
imal olecranon. Make sure that the screws do not
protrude into the joint. Whenever possible, insert
Implant Choice the screws bicortically, aiming the drill to the lat-
eral or to the medial cortex. Insert three bicortical
A 3.5 dynamic compression plate (DCP), recon- screws in the distal fragment and in a divergent
struction plate, limited contact dynamic com- pattern. Make sure to maintain contour and size of
pression plate (LC-DCP), or locking plate (LCP) the olecranon’s articulation (Fig. 20.16).
can be used. The reconstruction plate is the least Reduction of a large coronoid component of
durable and should be used cautiously as a multifragmentary proximal ulna fractures can
bridged plate. Choose the length of the plate so often be done through the fracture site. Provisional
that at least three screws can be inserted in the or definitive fixation can be placed at that time, but
most proximal fragment and three in the diaphy- sometimes it helps to use a screw through a poste-
sis. If the fracture is very proximal or in osteopo- rior plate for its fixation, as shown here. Insert this
rotic bone, a preshaped olecranon LCP with as a lag screw, as perpendicularly as possible to the
locking head screws is preferred to allow best fracture plane at the base of the coronoid. Smaller
possible fixation (Fig. 20.14). To achieve close diameter screws may be better (Fig. 20.17).
170 D. Gühring and U. Stöckle

Fig. 20.15  Triceps split Fig. 20.17  Reduction of the coronoid process with a lag
screw through the plate

Control reduction with direct visualization of

the sigmoid notch and the posterior cortex of the
olecranon, and confirm with C-arm fluoroscopic
control (Fig. 20.18).

Aftercare

Finally, after fixing both radius and ulna, assess

the range of motion in pronation, supination,
flexion, and extension. Fixation should be stable,
and crepitus or restricted motion should be absent
(Fig.  20.19). Radiocapitellar and ulnohumeral
joints should remain located through a full range
of motion. Postoperative treatment with a
­removable splint in supination for three weeks is
then recommended to allow controlled mobiliza-
Fig. 20.16 C-arm fluoroscopic control of the plate
installed tion of the elbow. Also X-rays are taken in two
planes after six and twelve weeks (Fig. 20.20).
20  Monteggia Fracture and Monteggia-Like Lesion 171

Fig. 20.18 C-arm
fluoroscopic control of
the coronoid process

Fig. 20.19  Close contact casting in operation theater

Fig. 20.20  Postoperative X-ray

of the elbow in two planes
172 D. Gühring and U. Stöckle

Reference Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp

NP. Monteggia fractures in adults: long-term results
and prognostic factors. J Bone Joint Surg Br. 2007;
1. Monteggia GB. Instituzioni chirurgiche. Milano:
89(3):354–60.
Maspero; 1814.
Ring D. Monteggia fractures. Orthop Clin North Am. 2013;
44(1):59–66.
Wong JC, Getz CL, Abboud JA. Adult monteggia and
Further Reading olecranon fracture dislocations of the elbow. Hand
Clin. 2015;31(4):565–80.
Guitton TG, Ring D, Kloen P. Long-term evaluation of sur-
gically treated anterior monteggia fractures in skeletally
mature patients. J Hand Surg Am. 2009;34(9):1618–24.
 Forearm Fractures
21
Katharina Sommer and Ingo Marzi

 natomical Fracture Location:

A these joints is essential for correct reduction
Radiograph of Fracture Pattern (Figs. 21.1 and 21.2).
The forearm is a two-bone structure that is sta-
Usually fractures of the forearm are associated bilized by the interosseous membrane. This
with high-energy loads. Both bones ulna and membrane is a complex structure that allows
radius can be involved. In a case of dislocation of smooth forearm rotation [4]. It is also important
one of the two bones, the other bone should be for load transfer between the radius and ulna
suspected to be fractured as well, though this from the distal to the proximal portion. The force
might not be visible on the radiograph. As conse- distribution at the elbow is 43% ulnar and 57%
quence, the adjacent joints, elbow, and wrist need radial, whereas at the wrist the radius bears 80%
to be visualized by X-ray in these cases [1]. and the ulna only 20% of the load [5]. It consists
Important for later rotational function is the of membranous portions, which are soft and thin,
anatomical reconstruction of both the radius and different stronger bands. The most homoge-
and the ulna [2, 3]. Failure in restoration of the nous and robust structure of these bands is the
physiological bowing of the radius with an axis central band. Its fibers are orientated at an angle
deviation that measures more than 5° will of 21° to the longitudinal axis of the ulna. It origi-
result in loss of forearm rotation and grip nates from the proximal third of the radius and
strength. The best picture to understand the inserts at the distal third of the ulna. Accessory
forearm is to look at it like a joint. Therefore, bands are highly variable in number, thickness,
every fracture needs an evaluation of the distal and location. Their fibers display the same orien-
and proximal radioulnar joint. First of all, tation as those of the central band. Posttraumatic
knowledge of the anatomical variations of fibrosis of the interosseous membrane may result
in restricted forearm rotation [6] (Fig. 21.2).
Most commonly, fracture pattern of the
forearm is grouped by the AO classification. It
K. Sommer • I. Marzi (*) divides the diaphyseal fractures into three main
Department of Trauma, Hand and Reconstructive types. The simple fractures are classified A, the
Surgery, Goethe University of Frankfurt,
Frankfurt, Germany wedge fractures B, and the complex fractures C. 
e-mail: marzi@trauma.uni-frankfurt.de It also distinguishes whether the radius, the ulna,

© Springer International Publishing AG 2018 173

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_21
174 K. Sommer and I. Marzi

a b

Fig. 21.1 (a) Normal appearance of the “forearm joint,” (b) correct projection of the radius head to the capitellum at
the elbow, (c) alignment of the bones of the forearm in pronation, supination, and neutral position

or both bones are broken. The knowledge about tion of the radius as the interosseous membrane is
the muscle forces of the forearm is helpful to torn. Though the injury occurs seldom, it should
understand direction of dislocation of the fracture be considered in radial head fractures with pain in
(Fig. 21.3). the ulnar-sided wrist, DRUJ instability, or loss of
A particular injury to the forearm is the Essex-­ forearm rotation [8]. Radiographs typically show
Lopresti lesion that comprises a fracture of the a significant positive ulnar variance for more than
radial head with a dislocation of the distal radio- 7 mm. MR imaging may allow the visualization
ulnar joint [7]. This is the result of an approxima- of this rare injury in these cases.
21  Forearm Fractures 175

a b

Fig. 21.2 (a) Normal relation of the radial (8–18 mm) the distal radioulnar joint in the frontal plane, (d) interos-
and ulnar (−4 − +4 mm) length, (b) normal variation of seous membrane
the sigmoid notch, (c) normal variation of the position of
176 K. Sommer and I. Marzi

Fig. 21.3 (a) AO
fracture classification of a
forearm fractures, (b)
fracture dislocation

Brief Preoperative Planning mally displaced or stable reduced ulna fractures

that do not involve the distal or proximal radio-
Fractures of the diaphyseal forearm in adults usu- ulnar joint and can be treated by cast immobi-
ally require surgical treatment to restore normal lization (AO Classification A1.2 fractures) [9].
biomechanics. There are only rare cases of mini- Casting may also be considered in patients with a
21  Forearm Fractures 177

Fig. 21.4  Closed reduction by hanging traction and circular casting

s­ ignificant disease limiting surgery in severe soft up to 20° can be tolerated [11]. A long arm cast
tissue damage resulting in compromised func- as described above achieves the immobilization.
tional outcome. After 2–5 days wedging of the circular cast can
For casting, both wrist and elbow joint have to be performed to improve fracture positioning.
be immobilized with the elbow in 90° flexed This has to be done thoroughly in a very well-­
position. It should end proximal to the palmar adapted cast, but the effects of wedging are criti-
flexor crease and spare the thumb to allow full cally discussed. In all other children, elastic
range of motion of all fingers. Right after trauma stable intramedullary nailing is the primary
the cast should be split to avoid compartment choice of treatment [12] (Fig. 21.5).
syndrome due to progressive swelling. It can be Most of the times, fractures of the diaphyseal
closed after swelling has subsided (Fig. 21.4). forearm are unstable and need surgical treat-
In children, fractures with an angle less than ment. Furthermore, conservatively treated frac-
10° can be treated conservatively by casting [10]. tures tend to fail bone healing, and angulation
Only in very young children, even a dislocation results in an impairment of rotation or joint
178 K. Sommer and I. Marzi

Fig. 21.5  Reduction by

wedging of the circular
cast

incongruence. If possible, plate osteosynthesis tralization plate. If in transverse fractures a lag

should be favored in most of the cases. screw is not possible, the plate can be used as a
Intramedullary rigid nailing lacks rotational sta- compression plate. These two options are only
bility, thus resulting in nonunion of the bone as possible in simple fractures as complex and
well as synostosis and has not been established in compound fractures may not be compressed. In
adults [6, 13]. However, if such a method is cho- these cases, a bridging of the fracture site leav-
sen, a sugar tongue splint or a similar brace can ing the partially vascularized fragments
add stability and improve healing allowing elbow untouched should be done. Preoperatively,
and wrist movement at the same time. Hybrid length of the needed implant should be deter-
treatment with plating of the radius and intra- mined with the aid of the radiograph. At least
medullary elastic nailing of the ulna can be con- three bicortical screws are needed in each of the
sidered but is not a standard procedure. In case of main fragments. The advantage of the LCP
absent other options, external fixation is possible, implant is that it can be used as both an internal
but usually results are not satisfactory, and it has fixator as well as for compression of the frag-
the risk for radial nerve injury. ments. As plating of the forearm needs an open
Plate osteosynthesis of the radius and ulna access to the bone, open reduction is used most
may be performed as compression osteosynthe- of the times in adults. Nevertheless, a biological
sis or as indirect bridging in the sense of a bio- osteosynthesis that preserves blood supply to
logical osteosynthesis. Most commonly used is the fracture side should be sought (Fig. 21.6).
a LCP (Locking Compression Plate). In case of In case of severe soft tissue injury, loss of
an oblique fracture, a lag screw should be bone, and infection, an external fixator is an alter-
inserted either through the plate or indepen- native for plate osteosynthesis. Defect after infec-
dently. By doing so the plate is used as a neu- tion or bone loss due to the trauma can be bridged
21  Forearm Fractures 179

Fig. 21.7  Bridging of a radial defect with a cement

spacer

Image Surgeon
intensifier
b Nurse

Assistant

Fig. 21.8  Patient setup in operation theater

view. For optimal intraoperative positioning of

the arm, it is favorable to drape up to the mid part
of the upper arm. The surgeon sits on a stool that
can be adjusted in height either on the radial or
the ulnar side of the forearm depending on the
fracture. The assistant is positioned on the oppo-
site side of the arm. The image intensifier is
Fig. 21.6 (a) LCP for radius and ulna, (b) intramedullary
placed on the distal side opposite of the surgeon.
nails In cases of intramedullary nailing, a counter
device at the elbow might be helpful for distrac-
tion (Figs. 21.9 and 21.10).
using bone cement and later replaced by bone
grafting, thus applying the Masquelet technique
(Fig. 21.7) [14]. Closed Reduction Maneuvers

For closed reduction, the arm can be suspended

Patient Setup in Theater in Chinese finger traps in a supine position with
the elbow bent 90°. If conservative treatment is
For surgery, the patient is placed in a supine posi- sought, the cast can be molded into the groove
tion with the fractured arm on a hand table. between the radius and ulna to help separate the
Alternatively, the arm may be placed across the two bones.
torso of the patient or in an overhead arm gutter. In the operation theater, manual longitudinal
If using a Henry approach, the arm is put in traction and rotation often suffice for fracture
supine position (Fig. 21.8). A non-sterile pneu- reduction. When performing intramedullary nail-
matic tourniquet is applied to the forearm above ing, it is advisable first to push both the ulnar and
the elbow to improve intraoperative reduction of the radial nail right up to the side of the fracture.
bleeding and enhancement of intraoperative Then reduction is performed by traction and
180 K. Sommer and I. Marzi

r­otation, and both nails are moved beyond the flexion helps in reduction (Fig. 21.12). In certain
fracture in an alternating way (Figs. 21.10 and cases, the reduction of the second forearm bone
21.11). Traction can also be exerted horizontally might be very difficult, if one side is fixed.
during surgery by a special traction table with a
hypomochlion put in the 90° flexed elbow
(Fig. 21.9). If the fracture is more distal, hyperex-
tension of the distal fragment in traction before

Fig. 21.9  Traction table for the forearm for intramedul- Fig. 21.10  Insertion point for intramedullary nails on the
lary nailing [15] radius and the ulna

a b c

Fig. 21.11  Intramedullary nailing of a complete forearm fracture in a child (a) before surgery, (b) after surgery, and (c)
after bone consolidation
21  Forearm Fractures 181

Reduction Instruments pointed or a blunt reduction forceps is usually

used to maintain fracture reduction (Fig. 21.13).
Open reduction can be helped by placing reduc- In forearm fractures the plate itself is very helpful
tion forceps on each main fragment. Beyond that, for fracture reduction. Especially in commuted
a small bone lever can be used to set the frag- fractures, new anatomic plates address the form
ments in place. Another way for reduction in of the radial bone very well. Thus, the plates can
oblique fractures is to place a reduction forceps temporarily be fixed with reduction clamps after
in the area of the fracture and twist it, thereby achieving anatomic reduction.
lengthening and compressing the fracture. A

Surgical Approach

If both bones need to be taken care of, a separate

approach to the radius as well as to the ulna is
chosen as a single approach increases the risk for
synostosis. The interval between the two skin
incisions should at least be 5 cm in order to avoid
skin necrosis.
Unreduced
Hyporoxtond Realign Reduced Overview of the different approaches can be
and distract fragments
seen at Table 21.1.
Fig. 21.12  Closed reduction technique with hyperexten-
sion and traction before reduction by flexion

a b

Fig. 21.13 (a) Pointed

and blunt reduction
forceps, (b) pointed and
blunt bone lever
182 K. Sommer and I. Marzi

Table 21.1  Summary of approaches to the forearm

Lateral to Intramedullary Medial to
Approach Henry Thompson the ulna nailing Kocher Boyd Kaplan elbow
Access to Radius Radius Ulna – Lateral Lateral Capitulum Processus
(volar side) (dorsolateral capsule, ulna humeri, coronoideus,
side) lateral ligaments radial medial
ligaments, head capsule and
distal ligaments
humerus,
proximal
radius
Structures Deep and Dorsal Dorsal Superficial Motoric Ulna nerve
at risk superficial interosseous branch of radial nerve branch of
branch of nerve ulna radial
the radial nerve nerve
nerve

Anterior Approach (Henry) Posterolateral Approach (Thompson)

For this approach the forearm is laid out in full The skin incision for the dorsal approach is a
supination. The surgeon sits on the ulnar side of straight line between the lateral epicondyle and
the arm. The incision runs proximally from the the Lister’s tubercle. The arm is lightly pronated.
biceps tendon distally to the radial styloid pro- The deep dissection lies between the extensor
cess. The fascia is opened between the interval of digitorum communis muscle and the radial fore-
the brachioradialis muscle that is mobilized to arm extensors (especially the extensor carpi radi-
the radial side. The flexor carpi radialis muscle is alis brevis). The underlying abductor pollicis
retracted ulnar. The lateral recurrent branches of longus and extensor pollicis brevis muscles are
the radial artery are to be ligated. The superficial partially freed and retracted radially. For distal
branch of the radial nerve needs to be carefully exposure, these two muscles can be detached
dissected to avoid accidental injury. Then the proximally. For proximal exposure, the distal
supinator muscle needs to be freed from the peri- third of the supinator muscle can be stripped
osteum to be retracted to the radial side. For fur- from the radius. The proximal part of the muscle
ther distal dissection, the underlying pronator may not be touched as the dorsal interosseous
teres muscle is gently to be stripped from the nerve lies within (Fig. 21.15).
bone radially to expose the radial shaft. Care
must be taken not to completely strip off the
flexor pollicis longus muscle. Lateral Approach to the Ulna
If dissection is in the distal part of the forearm,
care has to be taken not to injure the deep (m. The forearm is fully pronated. The surgeon sits
supinator) and superficial (m. brachioradialis) on the lateral side of the arm. The skin incision
branch of the radial nerve by lever traction. In the runs the whole way 1 cm dorsally to the edge of
proximal part, the lateral cutaneous nerve of the the ulna. The fascia is separated between the
forearm is to be preserved. However, the radial extensor carpi ulnaris muscle that is carefully
bone at the palmar side between the radial tuber- pushed from ulna and the flexor carpi ulnaris
osity is flat and therefore provides a good orienta- muscle. The dorsal branch of the ulna nerve is to
tion for reduction – especially to avoid malrotation be gently dissected at the very distal part of the
(Fig. 21.14). ulna (Fig. 21.16).
21  Forearm Fractures 183

a
b c

Fig. 21.14  Henry approach. (a) Skin incision, (b) intraoperative photograph, (c) anatomical picture

a b c

Fig. 21.15  Thomson approach. (a) Skin incision, (b+c) anatomical picture showing the abductor pollicis longus and
extensor pollicis brevis crossing the radius

Approach for Intramedullary Nailing either on the distal radial side or on the dorsal side
in the area of the Lister’s tubercle. If the radial inci-
For intramedullary nailing a small incision is made sion is used, care has to be taken not to injure the
at the dorso-radial side of the ulna about 3 cm distal superficial radial nerve. Thus, after skin incision,
to the ulna apophysis. The incision for the radius is preparation is performed with blunt instruments.
184 K. Sommer and I. Marzi

a b c

Fig. 21.16  Lateral approach to the ulna. (a) Skin incision, (b) intraoperative photograph, (c) anatomical picture

a
This technique is usually only used in children Anconeus muscle
when elastic stable intramedullary nailing is Supinator muscle
performed.

Lateral Approach to the Elbow (Kocher)

The typical Kocher approach is chosen for the treat-

ment of injuries of the lateral capsule and ligaments
as well as the distal humerus and the proximal Radial head
radius. The dorsolateral portion of the joint capsule
can be reached through the gap between the anco- b
neus and extensor carpi ulnaris muscle in order to
stabilize the ligament for example (Fig. 21.17).

Lateral Approach to the Elbow (Boyd)

In case of injuries to the lateral ulna ligaments, the

approach needs to be modified to exhibit the more
dorsally localized ligaments that originate lower to
the lateral epicondyle and distend to the olecranon.
For this purpose, the anconeus muscle and the distal
part of the triceps muscle are mobilized dorsally.
Finally, the extensor muscles as well as the extensor Fig. 21.17 (a) Skin incision and dissection for Boyd’s
carpi ulnaris muscle are dissected to the ventral side approach, (b) anatomical view of dissection plane for (1)
and lifted up (Fig. 21.17). Boyd, (2) Kocher, and (3) Kaplan
21  Forearm Fractures 185

Anterolateral Approach (Kaplan) c­ orrect alignment and rotation of the forearm.

Then osteosynthesis of the other bone is per-
This approach gives access to the capitulum formed. Sometimes fixation of the first bone
humeri as well as the radial head. The entrance is hinders reposition of the other. Thus loosening
between the extensor carpi ulnaris and the exten- of the first osteosynthesis might be needed in
sor digitorum muscles. For this approach, it is order to a­ natomically reduce the other bone. If
generally important to take care of the deep fracture pattern is similar in both bones, the
motoric branch of the radial nerve (Fig. 21.17). ulna usually is taken care of first before osteo-
synthesis of the radius because the ulna is less
curved and anatomical reduction is easier to
Medial Approach achieve.

The medial approach is needed for the treatment of

the distal medial humerus, the coronoid process, Manual Traction
and the medial structures of the capsule and liga-
ments. It is most important in this approach to Usually rotation and alignment of the bones
mobilize the ulnar nerve sufficiently. In the distal can be achieved by traction and rotation of the
part of the upper arm, the intermuscular septum is forearm. The reduction result can be main-
identified and excised if need. Afterward, the pro- tained either by applying a reduction forceps
nator muscle and part of the flexor communis on the fracture side or by fixing the plate as a
muscles are separated, and the muscles to the dis- template with two clamps on the bone in com-
tal side are split. Now the capsule and the brachia- minuted fractures. A small bench or a roll can
lis muscle are visible. Incision of the capsule assist in reposition as a hypomochlion
enables the view into the medial joint, especially (Fig. 21.19a).
the coronoid process. Detachment of the distal part
of the triceps muscle from the distal medial col-
umn of the humerus allows display of the medial Temporal External Fixation
complex of the capsule and ligaments (Fig. 21.18).
In case that reduction cannot be achieved or
maintained directly, an external fixator can be
Open Reduction Maneuvers applied to temporarily fix length and rotation.
Care has to be taken that the pins do not inter-
In case of a whole forearm fracture, the bone fere with the positioning of the plate
with the simpler fracture should be approached (Fig. 21.19b).
first and fixed preliminary as this helps in
Epicondylus M. triceps

Trochlea

a b
humeri
N. ulnaris

coronoideus

N. ulnaris
Processus
medialis

Epicondylus
M. pronator

Glenkkapsel

medialis

Fig. 21.18  Medial approach to the elbow. (a) Anatomical view for (1) Hotchkiss, (2) approach between the two heads
of the flexor carpi ulnaris muscle, (b) deep dissection for Hotchkiss approach “over the top”
186 K. Sommer and I. Marzi

Fig. 21.19 (a) Fracture

reduction by plate a
fixation as a template,
(b) temporal external
fixation, (c) plate
distraction

Plate Distraction proximal and distal main fragment. In case of

revision surgery, even four bicortical screws
For this technique, the plate is fixed to one of the might be needed. Only in simple fractures, two
main fragments, firstly with two bicortical screws bicortical screws may be possible to reduce soft
in the desired position. Secondly, a screw is tissue damage.
applied distant to the plate on the other main If possible, e.g., in oblique fractures, a lag
fragment. The plate is held loosely in place with screw is to be inserted separately or through a
blunt reduction forceps still allowing a sliding plate hole. It is also possible in wedge fractures to
motion along the shaft of the bone. A laminar fix the wedge fragment to one of the main frag-
spreader is put between the separate screw and ments by lag screw fixation.
the plate. By opening distraction is achieved up On the ulna the plate should be positioned
to the desired length. Lastly, the plate is fixed to dorsally underneath the extensor carpi radialis
the other main fragment (Fig. 21.19c). muscle if possible. The position under the flexor
carpi radialis muscle and the interval in between
is also feasible if dorsal positioning is
Implant Insertion impractical.
On the radius the plate can be positioned volar or
If available, a 3.5 mm LC-DCP is the implant of dorsal as required by fracture pattern. As the Henry
choice in adults. If needed, the plate can be bent approach ensures extensile exposure, a volar posi-
with bending irons or pliers. Correct bending of tion is usually chosen in complex fractures.
the plate supports the reconstruction of the curved In multilevel fractures, correct alignment can be
form of the radius in the middle of the shaft helped by treating each fracture individually. Thus,
where it bents away from the ulna double plating on one bone is a good option for cor-
(Figs. 21.20–21.22). rect reduction. For this, plates need to be placed in
The size of the implant should be chosen so an overlapping fashion to avoid stress fractures in
that there are at least three bicortical screws in the the plane between the two plates (Fig. 21.23).
21  Forearm Fractures 187

a b

Fig. 21.20  Fracture treatment of the radial shaft by plate osteosynthesis. (a) Before operative care, (b) after osteosyn-
thesis by plate

a b c

Fig. 21.21  Fracture treatment of the radial shaft by plate bone with primary bone healing on the radius and second-
osteosynthesis. (a) Before operative care, (b) after osteo- ary bone healing of the ulna; notice the callus formation
synthesis by double plate, (c) after consolidation of the

For correct implant positioning and verifica- After successful osteosynthesis, the DRUJ
tion of correct alignment of the bones, exact should be assessed for possible instability ruling
radiographs AP and laterally are essential. out an Essex-Lopresti injury. Furthermore, rota-
Correct alignment can also be judged by thick- tion should be checked to verify that full range of
ness of the bone cortex. In case of inhomoge- motion is possible that is achieved by anatomical
neous thickness or steps in caliber, an incorrect reduction. In addition, the rotation in the DRUJ
reduction is likely (Fig. 21.24). has to be checked as well.
188 K. Sommer and I. Marzi

a b

Fig. 21.22 (a) Temporary reduction of the complete sis is carried out in an interval; notice ulna plating is
forearm fracture by external fixation in case of severe tis- performed on the volar side due to sever tissue damage
sue damage, (b) definitive treatment by plate osteosynthe-

a b c

Fig. 21.23  Treatment of a multilevel fracture of the ulna, (a) radiograph before surgery, (b) after temporary external
fixation, (c) definitive treatment with two plates

After ORIF treatment early rehabilitation with after surgery. Thus, a splint or orthosis is
free range of motion without weight bearing required for aftercare. Passive and active flex-
should be the aim. In case of a healing fracture in ion and extension of the elbow should be per-
the radiograph, pain depending full weight bear- formed out of the cast during this time. After 4
ing should be performed after 6 weeks [16]. weeks, the patient can start with gentle forearm
In Essex-Lopresti injury, rotation of the rotation that can be extended to passive exer-
forearm should be avoided for the first 4 weeks cises after 6 weeks. Weight bearing can be
21  Forearm Fractures 189

a b

Fig. 21.24  Intraoperative assessment of (a) plate position and fracture reduction, (b) evaluation of correct alignment
in the distal radioulnar joint

Fig. 21.25  Splint for immobilization of the distal radioulnar joint

i­nitiated 8 weeks after surgery progressing as children intramedullary nails are usually removed
tolerated (Fig. 21.25). after 4–6 month. In younger children, removal
In children, ESIN (elastic stable intramedul- might be performed earlier due to faster growth.
lary nailing) is be performed retrograde in the
radius and antegrade in the ulna [17]. The ulna is
addressed by a small incision dorso-ulnar in the Summary of Tips and Tricks-Pitfalls
metaphyseal area of the ulna, and the prebent
elastic nail is inserted antegrade. The approach to • If both bones are fractured, the simpler frac-
the radius is in the distal radial metaphysis, but ture should be approached first and anatomi-
there, the superficial branch of the radial nerve cally fixed.
should be seen and protected. The nail is inserted • Correct reduction and implant position have to
retrograde up to the proximal radial neck under be checked at the end of the surgery by image
X-ray observation. Diameter of the elastic nails is intensifier including elbow and wrist joints [18].
2 or 2.5 mm in general. Other approaches such • The forearm needs to be tested for complete
as radius from dorsal or ulna from distal are not rotational ability with the elbow bent at 90° as
recommended due to higher complication rates. well as instability of the DRUJ.
Implants in adults can be removed after • After surgery be careful to watch for signs of
18 months with secure bone consolidation. In compartment syndrome [19].
190 K. Sommer and I. Marzi

References 10. Laurer H, Sander A, Wutzler S, Walcher F, Marzi

I. Therapy principles of distal fractures of the forearm
in childhood. Chirurg. 2009;80:1042–52.
1. Pandey S, Pandey A. Chapter-27 fracture of forearm
11. Högström H, Nllsson BE, Wlllner S. Correction with
bones (Radius and Ulna). Fundamentals of orthope-
growth following diaphyseal forearm fracture. Acta
dics & trauma. 1st ed. Bengaluru: Jaypee Brothers
Orthop Scand. 2009;47:299–303.
Medical Publishers (P) Ltd; 2015. p. 479–88.
12. Lascombes P, Prevot J, Ligier JN, Metaizeau JP,

2. Yasutomi T, Nakatsuchi Y, Koike H, Uchiyama
Poncelet T. Elastic Stable Intramedullary Nailing
S. Mechanism of limitation of pronation/supi-
in Forearm Shaft Fractures in Children: 85 Cases. J
nation of the forearm in geometric models of
Pediatr Orthop. 1990;10:167.
deformities of the forearm bones. Clin Biomech.
13. Dhariwal Q, Inamdar P, Arora P, Shyam A. Stacked
2002;17:456–63.
flexible nailing for radius ulna fractures: revival of a
3. LaStayo PC, Lee MJ. The forearm complex: anatomy,
lost technique. J Orthop Case Rep. 2017;7:106–8.
biomechanics and clinical considerations. J Hand
14. Masquelet AC, Fitoussi F, Begue T. Reconstruction of
Ther. 2006;19:137–44.
the long bones by the induced membrane and spongy
4. Skahen JR, Palmer AK, Werner FW, Fortino MD. The
autograft. Ann Chir Plast Esthet. 2000;45:346–53.
interosseous membrane of the forearm: anatomy and
15. Yaligod V. Forearm fracture table for closed nailing of
function. J Hand Surg Am. 1997;22:981–5.
fractures of shafts of forearm bones in adults. J Evol
5. Shaaban H, Giakas G, Bolton M, Williams R, Wicks
Med Dent Sci. 2013;2:7347–56.
P, Scheker LR, et al. The load-bearing characteristics
16. Matsuura Y, Rokkaku T, Suzuki T, Thoreson AR,
of the forearm: pattern of axial and bending force
An K-N, Kuniyoshi K. Evaluation of bone atrophy
transmitted through ulna and radius. J Hand Surg Br.
after treatment of forearm fracture using nonlinear
2006;31:274–9.
finite element analysis: a comparative study of lock-
6. Bauer G, Arand M, Mutschler W. Post-traumatic
ing plates and conventional plates. J Hand Surg Am.
radioulnar synostosis after forearm fracture
2017;42:659.e1–9.
osteosynthesis. Arch Orthop Trauma Surg.
17. Weinberg A-M, Castellani C, Amerstorfer F. Elastic
1991;110(3):142–5.
stable intramedullary nailing (ESIN) of forearm frac-
7. Sabo MT, Watts AC. Longitudinal instability of the
tures. Orthop Traumatol. 2008;20:285–96.
forearm: anatomy, biomechanics, and treatment con-
18. Damle A. Chapter-15 bow fracture of forearm. Tips
siderations. Shoulder Elbow, vol. 4. London: SAGE
& tricks in orthopedic surgery. 1st ed. Bengaluru:
Publications; 2012. p. 119–26.
Jaypee Brothers Medical Publishers (P) Ltd; 2015.
8. Green JB, Zelouf DS. Forearm instability. J Hand
p. 108–12.
Surg Am. 2009;34:953–61.
19. Royle SG. Compartment syndrome following forearm
9. Fisher H. Splint for fracture of the forearm. Lancet.
fracture in children. Injury. 1990;21:73–6.
1883;122:722.
 Galeazzi Fracture
22
Theodoros H. Tosounidis and Paul J. Harwood

 natomical Fracture Location:

A The above translates into the characteristic
Radiograph of Fracture Pattern radiographic appearance of the Galeazzi fracture,
i.e. a short oblique distal third ulnar fracture and
Galeazzi fracture or otherwise known as “frac- a subluxation/dislocation of the DRUJ. Most of
ture of necessity” is a fracture of the distal the times, the latter is obvious on the anteroposte-
radius with disruption of the distal radioulnar rior and true lateral radiographs of the wrist, but
joint (DRUJ). It is called fracture of necessity when this is not the case, indirect radiographic
because in adults its management necessitates signs of DRUJ injury include the fracture of the
the surgical treatment with anatomic reduction ulnar styloid and the shortening of the radius
and stable fixation of both the radial fracture more than 5 mm. A contralateral wrist radiograph
and the DRUJ. It is well established that non- for comparison is always helpful in equivocal
surgical management of this highly unstable cases [5].
fracture results in malunions with significant
functional deficit and unsatisfactory results
[1]. The fracture of the radius that involves the Brief Preoperative Planning
distal third of the bone is the result of the axial
loading of the forearm in either supination or Anatomic reduction and stable fixation are the
rotation. A short oblique fracture with apex goals of surgical management of Galeazzi frac-
anterior (volar) [2] (Fig. 22.1a, b) or apex pos- ture. This mandates for open reduction and inter-
terior (dorsal) [3] (Fig. 22.2a, b) angulation of nal fixation. Indirect and minimally reduction and
the radius occurs, respectively. The torsional fixation techniques yield suboptimal result and
mechanism of the injury results to concomitant should be avoided. Standard open reduction
disruption of the DRUJ and injury to its pri- and internal fixation techniques with meticulous
mary stabiliser (triangular fibrocartilage com- soft tissue handling should be employed.
plex—TFCC) [4]. Preoperative planning should take into account
the reduction and fixation of the radius as well as the
potential reduction and fixation of the DRUJ.
Fixation of radius: 3.5 mm and dynamic com-
T.H. Tosounidis (*) • P.J. Harwood
pression plates with 3.5 mm cortical screws
Academic Department of Trauma and Orthopaedic
Surgery, University of Leeds, Leeds, UK (Fig. 22.2a). 2.7 mm and 3.5 mm cortical screws.
e-mail: ttosounidis@yahoo.com DRUJ fixation: 1.6 mm k-wires.

© Springer International Publishing AG 2018 191

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_22
192 T.H. Tosounidis and P.J. Harwood

Fig. 22.1  AP and

a b
lateral radiographs
demonstrating an apex
anterior (a, b) Galeazzi
fracture

Fixation of the ulnar styloid and or TFCC: Reduction Instruments

1 mm cerclage wires and 1 mm k-wires, cannu-
lated mini fragment screws. For the radius, reduction tools that can be used
are the following: small Hohmann retractors,
small periosteal elevators, Howarth elevator,
Patient Setup in Theatre pointed reduction clamps, blunt/serrated bone
holding forceps/clamps (small “crocodile”
General anaesthesia is preferred over regional clamps) and articulated tension device.
due to potential masking of postoperative com- DRUJ reduction is performed manually.
partment syndrome when the latter is used. For the reduction of the ulnar styloid, a pointed
The patient is positioned supine on a standard reduction clamp or a stay suture (e.g. No 1 Vicryl)
table, and the affected arm is placed on a radiolu- is needed.
cent hand table. The table is placed in such a way
that unobstructed intraoperative imaging can be
performed. This usually requires rotation of the Surgical Approach
table 45° or 90° so that the affected extremity is
placed at the centre of the operating theatre. A The volar approach to the radius is the workhorse
tourniquet is placed, and the affected extremity is for the surgical treatment of Galeazzi fractures.
prepped and draped following the administration This can either be a flexor carpi radialis (FCR)
of intravenous antibiotics. The image intensifier sheath or the classic Henry’s approach. The latter
is brought from the top or the side of the patient. is used when the radial fracture is more proximal.
For the FCR approach, the volar sheath of the
FCR tendon is identified after the skin incision
Closed Reduction Manoeuvres which is centred over the short oblique radial
fracture and measures 10–12 cm (Figs. 22.3 and
Closed reduction manoeuvres are not used for 22.4). Then the FCR tendon is retracted ulnarly
Galeazzi fractures. (Fig.  22.5). The dorsal (deep) sheath of the
22  Galeazzi Fracture 193

Fig. 22.2  AP and

a b
lateral radiographs
demonstrating an apex
posterior (a, b) Galeazzi
fracture

investing fascia is identified and incised of the Galeazzi fractures. The former has been
(Fig. 22.6). The flexor pollicis longus tendon is associated with soft tissue complications (irrita-
identified and retracted ulnarly (Fig. 22.7). This tion/attrition of tendon with risk of postoperative
manoeuvre protects the median nerve. The frac- rupture), whilst the latter is technically more
ture of the radius is then visible (Fig. 22.8). challenging since it requires mobilisation of the
The dorsal and direct radial approaches to the brachioradialis tendon and the sensory branch of
radius are not indicated for the surgical fixation the radial nerve.
194 T.H. Tosounidis and P.J. Harwood

Fig. 22.3  Marking of the incision centred over the radius Fig. 22.6  The dorsal (deep) sheath of the investing fascia
fracture in line with the FCR is identified and incised

Fig. 22.4  The FCR tendon is identified, and the investing Fig. 22.7  The flexor pollicis longus tendon is identified
sheath is dissected and retracted ulnarly

Fig. 22.5  The FCR tendon is retracted ulnarly Fig. 22.8  Identification of the radius fracture. Note its
short oblique configuration
Open Reduction Manoeuvres
with pointed reduction forceps, and debridement
The fracture is identified, and it is debrided from is performed using a small curette (Fig. 22.9).
soft tissue debris and hematoma. A dental pick is Minimal dissection of the periosteum (especially
an instrument quite useful for manipulation of in areas of infolded periosteum) is performed
fracture fragments whilst minimising the soft tis- along the edges of the fracture. The fracture frag-
sue damage. The facture can also be manipulated ments are exposed sufficiently enough without
22  Galeazzi Fracture 195

times, a 3.5 mm lag screw is sufficient, but in

short oblique fractures, a 2.7 mm lag screw is
sometimes useful in achieving the compression
without propagation of the fracture ends
(Fig. 22.11a–c). At that stage intraoperative fluo-
roscopic confirmation is obtained with particular
attention paid at the DRUJ. Good quality true AP
and lateral wrist views are obtained.
A neutralisation plate is then applied taking
into account the natural bent of the radius which
has “two concavities”, one facing volarly and one
Fig. 22.9  The facture is manipulated with pointed reduc- facing ulnarly (Figs. 22.12, 22.13 and 22.14).
tion forceps, and debridement is performed using a small Bending the plate on the sagittal plane allows for
curette proper sitting of the plate on the bone. An 8 hole
3.5 mm DCP is usually sufficient to support a
stripping the periosteum and violating the sur- short oblique fracture, but occasionally a longer
rounding soft tissue envelope. plate is necessary. Three bicortical screws proxi-
mally and three screws distally are needed for
adequate fixation. In the vast majority of cases,
Open Reduction and Fixation the use of locking plates is neither needed nor
advocated. Fluoroscopic confirmation is again
The fracture fragments are mobilised using obtained.
small serrated reduction clamps (Fig. 22.10). When lagging of the fracture is not pos-
The fracture is then provisionally stabilised with sible due to the configuration of the fragment
a pointed or serrated clamp. Galeazzi fractures ­(transverse, short oblique <30°), then the DCP
have usually short oblique configuration, and a plate should be applied in compression mode
Howarth’s elevator or a small Hohmann retrac- after provisional stabilisation of the fracture.
tor can be used to lever the fracture with intra- In short oblique fractures, this can be done by
focal manipulation. Combinations of initially fixing the plate in one of the bone frag-
longitudinal traction along with twisting of the ments in such a way that an obtuse angle (axilla)
fragments represent useful manoeuvres in frac- between the plate and the bone can be created.
ture reduction. The surgeon should keep in mind This is followed by re-apposition of the other
that the fracture was produced by a torsional fragment and e­ccentrically loading the screws
moment to the bone, and reversing the mecha- and thus compressing the gap providing a­ bsolute
nism of injury helps reducing the fracture. Pure
traction or pure rotation of the fracture frag-
ments is not enough for reduction.
At that stage the fracture is inspected, and the
plan for anatomic reduction is confirmed. This
means that the preoperative radiographs and the
intraoperative fracture configuration are corre-
lated, and the plan for anatomic reduction and
fixation either with a lag screw and neutralisation
plate or with plate used as a reduction tool is con-
firmed. When a lag screw is utilised, the correct
entry point and the trajectory of the screw are of
paramount importance. In order to achieve the
above, the three-dimensional configuration of the Fig. 22.10  Small serrated clamps are used to manipulate
fracture has to be taken into account. Most of the and reduce the fracture fragments
196 T.H. Tosounidis and P.J. Harwood

a b

Fig. 22.11  Intraoperative picture (a) and fluoroscopic images (b, c) showing the lag screw fixation of the radius

Fig. 22.12  Picture showing the bent applied to a straight Fig. 22.13  Plate holed with clamps in the reduced radius
DCP plate in order to accommodate the volar concavity of
the radius
the ­reduction using serrated clamps is needed in
this situation.
stability. In transverse fractures, the plate is After the fixation of the radius, the DRUJ is
fixed to one fragment, and then the other frag- checked and classified as reduced/stable,
ment is reduced onto the plate. Maintenance of reduced/unstable or irreducible [5] (Fig. 22.15).
22  Galeazzi Fracture 197

a b

c d

Fig. 22.14  Lateral (a, c) and AP (b, d) intraoperative pictures and fluoroscopic images showing the lag screw and the
neutralisation plate

a b

Fig. 22.15  Lateral (a) and AP (b) fluoroscopic images showing a reduced DRUJ
198 T.H. Tosounidis and P.J. Harwood

Reduction and stability are tested both clini- is prohibited by the interposition of the exten-
cally and fluoroscopically. Intraoperative true sor carpi ulnaris tendon or small fracture frag-
AP and lateral fluoroscopic views are obtained ments. After the reduction via a dorsal
without excessive forcing the wrist. If undue approach to the wrist, the joint is again tested
force is applied, the DRUJ can be potentially for stability, and the aforementioned steps are
reduced even with existing soft tissue interpo- performed.
sition. After its reduction, the stability of the
DRUJ is tested, and in supination and prona-
tion, instability is defined when gross transla- Summary of Tips and Tricks-Pitfalls
tion of the ulna in relation to the sigmoid notch
is observed. • Obtain good quality intraoperative fluoro-
scopic views.
• If reduced/stable status is observed, then no • Aim for anatomic reduction of the radius that
further intervention is required. facilitates anatomic reduction of the DRUJ. This
• If the DRUJ is in reduced/unstable state, then can be achieved either by a lagging screw and
the TFCC should be explored and repaired. neutralisation plate (Fig. 22.16a, b) or by a
This is performed through a dorsal approach compression plate (Fig. 22.16c, d).
to the DRUJ. The TFCC is usually avulsed • Open reduction necessitates manoeuvring of
from its ulnar attachment and is repaired with both fracture fragments.
anchor and bone sutures through drill holes. • Use small serrated reduction forceps/clamps
In these situations, transfixation of the ulna to without causing soft tissue and periosteal
the radius is advocated using two stripping.
1.6 mm k-wires, which are driven from the • Reduction of the radius is achieved by combi-
ulnar border of the distal ulna to the radial nation of traction and rotation.
border of the radius. The k-wires should be • Test the reduction and stability of the DRUJ
parallel to each other, should not be placed to after fixation of the ulna.
the DRUJ (the most distal one should be • Irreducible DRUJ necessitates open reduction
placed just proximal to DRUJ) and should be via a posterior approach
left protruding to the medial border of the • Reduced but not stable DRUJ should be man-
ulna and the lateral border of the radius (mak- aged with fixation of the TFCC and transfix-
ing easier their later retrieval). In the case that ation k-wires. Make k-wires tetracortical to
the DRUJ is stable only in supination and not facilitate their retrieval in case they break.
in pronation, consideration could be given to • Reduced and stable DRUJ does not require
the immobilisation of the arm initially in long any further surgical intervention. Protective
arm cast and later in a brace for 4–6 weeks splint and early forearm range of motion are
without application of transfixation k-wires. advocated.
If there is an ulnar styloid fracture, this is • After fixation of the reduced/unstable and
reduced and fixed with cannulated screws or irreducible DRUJ conditions, the arm should
more commonly with k-wires using a tension be immobilised in an above-the-elbow cast
band technique. with the forearm in supination from 4 to
• If the DRUJ is irreducible, then exploration of 6 weeks. The transfixation k-wires should be
the joint is required. Commonly the reduction kept in place for the same period of time.
22  Galeazzi Fracture 199

a b

Fig. 22.16  Postoperative radiographs showing the fixation of a Galeazzi fracture with a lag screw and neutralisation
plate (a, b) and a DCP applied in a compression mode (c, d)
200 T.H. Tosounidis and P.J. Harwood

c d

Fig. 22.16 (continued)

3. Shiboi R, Kobayashi M, Watanabe Y, et al. Elbow dis-

References location combined with ipsilateral Galeazzi fracture.
J Orthop Sci. 2005;10:540–2.
1. Mikic ZD. Galeazzi fracture-dislocations. J Bone 4. Tsai PC, Paksima N. The distal radioulnar joint. Bull
Joint Surg Am. 1975;57:1071–80. NYU Hosp Jt Dis. 2009;67:90–6.
2. Rose-Innes AP. Anterior dislocation of the ulna at the 5. Atesok KI, Jupiter JB, Weiss AP. Galeazzi fracture. J
inferior radio-ulnar joint. Case report, with a discus- Am Acad Orthop Surg. 2011;19:623–33.
sion of the anatomy of rotation of the forearm. J Bone
Joint Surg Br. 1960;42-B:515–21.
 Distal Radius Fracture
23
Georg Gradl

Anatomical Fracture Location Smith fractures (1847). Intra-articular fractures

with displacement of the radiocarpal joint were
Fractures of the distal forearm have an incidence detailed by Barton as early as 1838 with a dorsal
of 37 out of 10,000 females and 9 out of 100,000 articular fragment (Barton fracture) or a palmar
males and are among the most frequent fractures articular fragment (reversed Barton). One wide-
of the adult population above the age of 35 years spread fracture classification is the AO/ASIF
[1]. Above the age of 85 years, the incidence fur- classification according to Maurice E. Müller
ther increases in females to 120 out of 10,000 et al. [4]. The principle of the AO classification is
citizens [1, 2]. The age has an influence on the the discrimination between extra- and intra-­
accident pattern; in younger adults below the age articular fracture extensions (Fig. 23.1a, b). A
of 39 years, high-energy trauma is more frequent, meticulous analysis of these fracture patterns on
leading to a higher percentage of additional car- plain X-rays and CT scans is a prerequisite for
pal ligamentous injuries. This has an impact on proper preoperative planning and selection for
both operative strategy and implant selection [3]. implants as well as surgical approach. The fol-
lowing treatment algorithm will be based on this
classification. Further classification systems are
Fracture Classification and Analysis the Frykman classification, which additionally
includes fractures of the styloid process
Extra-articular fractures of the distal radius about (Fig. 23.1c), the Melone classification with four
2 cm proximal to the joint surface and dorsal dis- main fragments (shaft, radius styloid, dorsal
placement are called Colles fractures according medial joint fragment, palmar medial joint frag-
to the historical description of Abraham Colles or ment) and the very detailed Fernandez classifica-
according to Pouteau who detailed this fracture tion which takes into account the patient’s age,
type as early as 1783. Fractures with palmar dis- type of accident, stability, displacement and
placement are called reversed Colles fractures or nature of fragment.
Extra-articular fractures are the most frequent
G. Gradl, M.D. fracture pattern (43–46%), dominated by simple
Clinic for Trauma, Orthopedic Surgery, Hand- and fractures with a lack of dorsal comminution (A2,
Reconstructive Surgery, Spine Surgery, Munich
27%), followed by unstable fractures with multi-
Municipal Hospital Group, Clinic Harlaching,
Munich, Germany ple dorsal metaphyseal fragments (A3, 16%).
e-mail: Georg.Gradl@klinikum-muenchen.de Partial articular involvement renders one part of

© Springer International Publishing AG 2018 201

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_23
202 G. Gradl

Fig. 23.1 (a, b, c) The a

AO classification
discriminates between
extra- and intra-articular
fracture extension

AO A2 AO A3

Fernandez 1 Fernandez 2

AO B1 AO B2 AO B3

Fig. 23.1 (continued)
23  Distal Radius Fracture 203

AO C2 AO C3

Fernandez 3 Fernandez 4

Fig. 23.1 (continued)
204 G. Gradl

the articular surface stable connected to the shaft proper reduction and maintenance of reduction.
fragment and is classified as B in the AO/ASIF This means easy operation technique and reduc-
classification system. B1 fractures are fractures tion aids; rigid implants, designed to match with
in the sagittal plane (5%) and B2 in the frontal the anatomic curvature of the distal radius; inter-
plane (palmar aspect, reversed Barton, 5%; B3, locking and stable fixation options for fractures
Barton, 6%). Complete intra-articular fractures involving the joint; and certain fracture fragments
account for 41–54% of fractures, whereas simple like the dorso-ulnar fragment. Accessibility to
articular involvement in combination with simple displaced fragments that need to be reduced and
metaphyseal fracture is less frequent (C1, 13%) fixed remains an unsolved problem of closed fix-
than simple intra-articular fractures with dorsal ation techniques.
comminution (C2, 22%) and multiple intra-­ Angular stable plate fixation from a volar
articular fractures (C3, 7%) [3, 5]. Reduced bone approach has gained significant attention over the
quality promotes extra-articular fractures and has last years. The flexor carpi radialis (FCR)
a major influence on fracture incidence, fracture approach allows for limited soft tissue dissection;
geometry and treatment strategy. On the other however, it remains an open technique which in
hand, multiple intra-articular fractures more most cases leads to dissection of the pronator
often develop after high-velocity trauma [6]. quadratus muscle [10]. Fragment displacement to
The perioperative accurate analysis of fracture the dorsal aspect of the wrist does not simplify
geometry and joint angles is of paramount impor- open reduction from palmar which formed the
tance for the choice of therapy strategy, surgical ground for many different reduction techniques
approach and choice of implants. Plain X-rays of that mostly use indirect efforts to restore palmar
the wrist in two planes recommend the lower arm inclination.
lifted 25° from the horizontal line in the lateral
view [7, 8]. CT scans help in terms of evaluation
of articular fragments and step-offs. Certain ana- AO A2 and C1 Fractures
tomical landmarks need to be defined. Ulnar vari-
ance is ideally measured in the middle of the These fractures lack a dorsal fracture fragmenta-
palmar and dorsal radial joint surface [9] and tion. Closed reduction and maintenance of reduc-
shows a mean value of −0.9 mm with a wide tion using a plaster cast may be completely
range (−4.2 to 2.3 mm), thus rendering compari- sufficient due to the fact that fracture edges are
son to the uninjured arm necessary in uncertain not comminuted and may be firmly adjusted.
cases [7]. Palmar inclination or volar tilt presents Additional Kirschner wire fixation may be help-
with a mean value of 10° ranging from 5° to 12°, ful. Figure 23.2 shows the typical distraction
slowly decreasing with age [9]. device of the wrist, where local anaesthesia in the
fracture gap helps to lower pain during the reduc-
tion manoeuvre. Reduction is performed by
Operative Techniques ­gentle dorsal pressure. Figure 23.3a shows an
intraoperative approach where the surgeon dis-
Among the broad variety of treatment options for tracts the wrist with ulnar abduction and palmar
distal radius fractures, there are three most fre- bending. This helps to restore the radial length
quent treatment categories: closed reduction and and palmar inclination and thus serves as one
immobilisation in a cast, percutaneous fixation standard reduction procedure. Percutaneous
with Kirschner wires/external fixation and open K-wire insertion is performed over the tip of the
reduction and internal fixation. While each has radial styloid (Figs. 23.3b and 23.4). Rotational
merits and disadvantages, there is no consensus stability is achieved by using two pins that should
regarding which is the best option. not cross at the site of the fracture because this
The distal radius demands for certain prereq- would significantly reduce anti-rotation fixation
uisites in implant technology in order to achieve stability. In case of an undisplaced articular
23  Distal Radius Fracture 205

f­ racture line, additional pins may be placed paral-

lel to the joint surface. In some cases, however,
reduction in a closed manner may not be achieved
even in simple fractures, mainly if the palmar
cortical edge of the distal fragment fails to fit to
the shaft fragment. In these cases, or other cases
of difficult restoration of the palmar inclination, a
Kapandji wire, inserted from the dorsal aspect of
the wrist, through the fracture gap may be helpful
(Figs. 23.5 and 23.6).
The Kapandji technique employs a K-wire not
smaller than 1.8 mm which is inserted percutane-
ously from a dorsal approach into the fracture
gap and forwarded until the palmar cortex. This
is done while bending the K-wire in direction to
the dorsum of the hand (Fig. 23.5). Thus, the dis-
tal fragment is pushed into the anatomical palmar
inclination. Gentle hammer hits may secure the
pin in the palmar cortical bone. Alternatively, the
K-wire may be forwarded through the palmar
cortex machine driven. Special care must be
taken in order not to injure the cutaneous branch
of the radial nerve, which is at risk during percu-
taneous pinning through the radial styloid. One
pin is, mostly, safe; however, in case of multiple
pinning, a limited open approach and careful dis-
section of the nerve may help to circumvent nerve
lesion (Fig. 23.5).
Wrist immobilisation in a palmar splint with
Fig. 23.2 Typical distraction device of the wrist is 20° of dorsal wrist angulation is recommended,
demonstrated in cases of nonoperative treatment as well as
K-wire pinning. A dorsally placed plaster cast

a b

Fig. 23.3 (a) Shows an intraoperative approach where the surgeon distracts the wrist with ulnar abduction and palmar
bending. (b) Percutaneous K-wire insertion is performed over the tip of the radial styloid
206 G. Gradl

Fig. 23.4  Preoperatively and postoperatively AP and lateral left wrist radiographs showing stabilisation of the fracture
with K-wiring

a c e

b f

Fig. 23.5 (a) Fluoroscopic AP image of right distal tal radius fracture demonstrating insertion of Kapandji
radius fracture demonstrating insertion of K-wire through wire. (e) Fluoroscopic AP image of right distal radius
the tip of the radial styloid. (b) Fluoroscopic lateral image fracture demonstrating insertion of K-wire through the tip
of right distal radius fracture demonstrating insertion of of the radial styloid across to the opposite cortex. (f)
K-wire through the tip of the radial styloid. (c) Fluoroscopic lateral image of right distal radius fracture
Demonstration of dorsal incision for access for Kapandji demonstrating insertion of K-wire through the tip of the
wire insertion. (d) Fluoroscopic lateral image of right dis- radial styloid with restoration of volar inclination
23  Distal Radius Fracture 207

Fig. 23.6  Preoperatively and postoperatively AP and lateral right wrist radiographs showing stabilisation of the intra-­
articular fracture with K-wiring

with slight dorsal angulation may help to main- buttressing [14]. Restoration of anatomy seems
tain reduction. to be more demanding in IM nailing, and some
Even after multiple K-wire pinning in rare studies demonstrate less palmar inclination than
cases of unstable fractures (Fig. 23.6), an addi- in plating procedures [12].
tional dorsal or palmar splint is recommended. Figure 23.7 demonstrates a technique that
Implant removal of K-wires takes place 6 weeks helps palmar restoration in IM nailing. Most
after surgery with local anaesthesia if required. radial nails are inserted through an approach
between the first and second tendon sheet, ren-
dering direct fragment reduction difficult. Thus,
Extra-articular AO A3 Fractures joystick techniques are used or more favourable
than the Kapandji technique, where the dorsal
Extra-articular fractures with dorsal comminu- K-wire is inserted in the fracture gab close to the
tion may not qualify for nonoperative treatment lunate fossa. A more radial K-wire interferes with
due to the fact that they tend to lose initial reduc- the nail. Straight nails without curvature in the
tion within the first 2 weeks before initiation of anterior-posterior plane tend to direct the distal
consolidation. However, this may be tolerated in fragment in a neutral position without the ana-
geriatric patients. In this chapter open and semio- tomical palmar inclination of 10°. A temporal
pen techniques will be described in order to Kapandji wire may help to circumvent this prob-
restore anatomy in comminuted extra-articular lem, until the nail is inserted and locked.
fractures. Both palmar locking plate fixation and There are multiple possibilities to facilitate
intramedullary nailing are techniques that pro- reduction in palmar plating procedures. One
vide sufficient stability in order to allow for func- major drawback of palmar plating is that most
tional after treatment. fractures (Colles) present with dorsal displace-
Although intramedullary (IM) nailing has not ment. A palmar approach may thus not be able to
become widely spread, biomechanical studies reduce the distal fragment directly like a buttress-
revealed superiority over plates in terms of fixa- ing procedure that works from a dorsal approach
tion stability [11]. Furthermore, there is a large in these cases. Having this in mind, all indirect
amount of clinical evidence that extra-articular reduction manoeuvres may be used intraopera-
fractures with dorsal displacement are safely tively during the palmar approach. I recommend
treated with IM nailing [12, 13]. Smith fractures, the flexor carpi radialis (FCR) approach radial of
however, may not qualify since they need palmar the FCR tendon (Fig. 23.8). After closed ­reduction
208 G. Gradl

Fig. 23.7  Demonstration of technique facilitating palmar restoration during IM nailing in a right distal radius extra-­
articular fracture

Fig. 23.8  Having used the FCR approach to get access to the distal radius fracture, different intraoperative reduction
techniques are demonstrated
23  Distal Radius Fracture 209

a K-wire is placed percutaneously through the of the palmar inclination, the anatomically pre-
radial styloid in order to maintain the reduced curved plate itself may help to achieve better
fragment in position. Fracture reduction may be anatomy.
facilitated by placing a joystick into the distal Figures 23.8, 23.9 and 23.10 demonstrate
fragment or using the Kapandji method. In case two different reduction techniques. One simple
of a not ideal reduction, mainly failed restoration technique of reduction through the precurved

Fig. 23.9  Having used the FCR approach to get access to the distal radius fracture, different intraoperative reduction
techniques are demonstrated

Fig. 23.10  Having used the FCR approach to get access to the distal radius fracture, different intraoperative reduction
techniques are demonstrated
210 G. Gradl

plate is the placement of any type of surgical technique restores the palmar inclination,
instrument underneath the long aspect of the although the primary attempt of closed reduction
plate in order to lift it up, prior to insertion of was less successful.
the distal screws. The distal screws (alterna-
tively only K-wires—see Fig. 23.8) are firmly
anchored in both the plate (stiff angle) and the I ntra-articular AO B1–3 Fractures
fragment. In this manner the plate carries the and C2–3 Fractures
distal fragment and reduces the fragment in a
pronounced radial inclination as soon as the The abovementioned techniques that help reduc-
long aspect of the plate is approximated to the tion and maintenance of reduction are well suit-
radial shaft (Fig. 23.8). There are, however, able for intra-articular fractures, given that the
some obstacles. Since the long aspect of the articular fragment is attached to the joint capsule
plate is lifted upwards from the radial shaft, the and not separated. This serves as a prerequisite
surgeon loses control of the exact plate position- for indirect reduction applying distraction and
ing. The distal fixation of the plate may not flexion or using precurved plates. In general, the
match to the radial shaft followed by malposi- full arsenal of reduction techniques, a meticulous
tioning of the plate. Furthermore, the surgeon analysis of fracture geometry and available
has only limited control of the amount of reduc- implants are necessary to manage these fractures.
tion. The more he lifts the plate, the more radial Palmar or dorsal shearing fractures (Barton and
inclination he gets. There is an imminent risk of reversed Barton fractures) have no IM nailing
overaction followed by exaggerated radial incli- indication since the nail could well further dis-
nation angles. This needs to be avoided, since it place the fracture on its way through the small
goes along with severe restriction of wrist intramedullary canal [14]. These fractures need
motion during dorsal extension. exact preoperative planning; CT scan can be
However, there is another technique that fol- helpful and is highly recommended. Thus, the
lows the same rules but circumvents the afore- surgeon is capable to choose the adequate opera-
mentioned shortcomings. Figures 23.9 and 23.10 tive approach either from dorsal or palmar aspect
show the technique, where a spacer of different of the wrist.
sizes is mounted underneath the plate. The first Figure 23.11 demonstrates a dorsal shearing
step is the FCR approach to the distal radius. injury, involving the dorso-ulnar fragment. Open
After indirect reduction and K-wire placement reduction and maintenance of reduction were
through the radial styloid, the surgeon may detect achieved by employing a dorsal buttress plate.
a less favourable palmar inclination, however, Figure 23.12a shows a palmar shearing frac-
sufficient reconstruction of radial length. In this ture (reversed Barton) with luxation of the wrist
case, the surgeon may place the plate prior to the joint. These fractures most often follow a high-­
distal fragment fixation—like the standard proce- energy trauma like in this case of a road traffic
dure in palmar plating—on the radial shaft. The accident and present with a high percentage of
surgeon chooses the size of the spacer in depen- soft tissue injuries. Palmar shearing fractures
dence upon the previously achieved reduction. may well be reduced through a palmar approach
Less palmar inclination means bigger spacer. and a buttress plate, where there is no need for
Direct control of plate fixation to the radial shaft angular stability. The ulnar styloid which may be
securely circumvents malpositioning. The plate neglected in most cases of radius fractures was
is securely anchored to the radial shaft with a lon- addressed using a suture anchor due to complete
ger screw, since the spacer lifts the plate up. After rupture of the TFC complex (Fig. 23.12b).
insertion of the distal screws in the T-shaped Articular step-offs and separated fragments
plate, the spacer is removed and the curved plate may be reduced by direct manipulation, using a
further reduces the distal fragment. Figure 23.10 rasp or other instruments, or indirectly with the
demonstrates how highly effective the spacer aid of K-wire joysticks (Fig. 23.13). A separated
23  Distal Radius Fracture 211

Fig. 23.11  Demonstration of a dorsal shearing injury, involving the dorso-ulnar fragment. Open reduction and main-
tenance of reduction were achieved by employing a dorsal buttress plate

radial styloid may be partly detached from the steep angle in order to facilitate manipulation of
brachioradialis muscle in order to facilitate the styloid fragment. The angle may be lowered
reduction. If a K-wire is used, the diameter during the insertion, and the K-wire may
should not be less than 1.6 mm and inserted in a securely be anchored in the ulnar fragment or
212 G. Gradl

Fig. 23.12 (a) Demonstrates a palmar shearing fracture tress plate was used for stabilisation. The ulnar styloid
(reversed Barton) with dislocation of the wrist joint. (b) fracture was addressed using a suture anchor due to com-
Fracture was approached via a palmar approach. A but- plete rupture of the TFC complex
23  Distal Radius Fracture 213

Fig. 23.13 Intraoperative picture and fluoroscopic using a rasp and a K-wire as a joystick, which was then
images demonstrating a case with articular step-off. The advanced to maintain reduction
separated fragment was reduced by direct manipulation,

even in the ulnar head, when used temporarily block need not be removed (Fig. 23.15). Double
[13]. The creation of a stable articular block is plating without separation or removal of the
highly recommended. Lister tubercle and the use of an extensor reti-
Figure 23.14 gives an example of a fracture naculum flap help to avoid extensor tendon dys-
with multiple articular involvement and a sepa- function/injuries.
rated radial styloid. In this case the palmar In case of severe joint depression and
approach was chosen even though a dorsal metaphyseal comminution (AO C3 fractures),
approach might have given the chance of direct especially in reversed Barton fractures with
fragment manipulation. Three different reduction additional dorsal wedge, the combination of
tools are used in this case simultaneously. palmar and dorsal plating is one standard pro-
Through a small dorsal extra incision, a rasp cedure. However, this is highly invasive and
passed guided through the metaphyseal fracture may go along with soft tissue problems and
line in order to lift the dorsal articular surface prolonged healing time.
(Fig. 23.14a). A K-wire joystick helped to reduce One possible technique, especially in the
and fix the separated styloid fragment. No special elderly, is the combination of external fixation
care was taken for reconstruction of the palmar and palmar plating. Distraction and slight ulnar
inclination. A malreduction of 0° was initially as well as palmar deviation help to reduce the
tolerated, which helped to restore the joint sur- articular surface without direct manipulation of
face (Fig. 23.14b). The palmar plate was then small fragments. Figure 23.16 shows a case of a
inserted carrying a spacer. The spacer removal C3 fracture (Fig. 23.16a), where the external fix-
and reduction of the palmar inclination by the ation alone gains radial length; however, it fails
curved plate finalised the reduction manoeuvre to reduce the frontal articular line (Fig. 23.16b).
(Fig. 23.14c). Additional palmar plating serves (a) as a buttress
Radius fractures with dorsal comminution in function of the palmar fragment and (b) helps to
combination with articular fragments of the dor- create a firm block with the dorsal articular part
sal rim, however, qualify nicely for open reduc- using both angular stable and compression
tion buttress plating. K-wires that fix the articular screws (Fig. 23.16c).
214 G. Gradl

Fig. 23.14 (a, b, c) Images demonstrate a distal radius lift the dorsal articular surface. A K-wire joystick helped
fracture with multiple articular involvements and a sepa- to reduce and fix the separated styloid fragment. The pal-
rated radial styloid fragment. The palmar approach was mar plate was then inserted carrying a spacer. The spacer
chosen. Through a small dorsal extra incision, a rasp removal and reduction of the palmar inclination by the
passed through the metaphyseal fracture line in order to curved plate finalised the reduction manoeuvre
23  Distal Radius Fracture 215

Fig. 23.15  Distal radius fracture with dorsal comminu- do not need to be removed. Double plating without sepa-
tion in combination with articular fragmentation of the ration or removal of the Lister tubercle and the use of an
dorsal rim. Open reduction and stabilisation with buttress extensor retinaculum flap help to avoid extensor tendon
plating were carried out. The K-wires used for reduction dysfunction/injuries

Fig. 23.16 (a, b, c) In this case (type C3 fracture), a Additional palmar plating serves as a buttress function of
combination of external fixation and palmar plating is the palmar fragment and also helps to create a firm block
demonstrated. External fixation alone gains radial length; with the dorsal articular part using both angular stable and
however, it fails to reduce the frontal articular line. compression screws
216 G. Gradl

Fig. 23.16 (continued)

 xternal Fixation for A3 and C1–3

E One major obstacle is the problem of wrist
Fractures overdistraction and long-term immobilisation.
There are in principal two possibilities to mount
External fixation has lost clinical relevance; how- an external fixation. One is wrist spanning and the
ever, it may be highly effective for indirect reduc- other one non-spanning. The so-called radio-radial
tion and maintenance of reduction in both external fixator is motion preserving and suitable for
extra-articular and intra-articular fractures. both extra- and intra-articular fractures [15–18].
23  Distal Radius Fracture 217

Figure 23.17a–c demonstrate the technique of

first wrist spanning assembly, fracture reduc­ a 1
tion employing distraction, ligamentotaxis and
K-wire fixation of the distal fragment.
The examples of Fig. 23.18a, b show (a) the
assembly using a standard small fixator and (b) a
precurved bar compatible with a Ilizarov hybrid
technique that accommodates several pins/K-­wires
that are forwarded in the distal fragment. The pins
range in diameter from 1.6 to 2.0 mm. Up to six
threaded or unthreaded pins may be placed in the
distal fragment from different angles and may
cross the fracture line. Figure 23.19a presents
highly comminuted fractures, extending into the
joint which was treated by a wrist non-spanning
external fixator. The pins were first securely b 2
anchored in the distal fragment and then connected
to the external fixator bars in order to achieve
reduction employing direct fragment movement.
Additional pins were inserted without connection
to the external fixator as shown in Fig. 23.19b, c. Connection to ex fix
Implant removal may be prolonged until 98 weeks
post-surgery in order to safely ensure fracture con-
solidation (Fig. 23.19d).

Tips, Tricks and Pitfalls

• Palmar locking plating has indeed advanced to

one standard technique in the treatment of dis-
tal radius fractures. However, there remain
certain obstacles and pitfalls. c 3
• Restoration of palmar inclination and mainte-
nance of reduction during the healing period
remain an issue [10]. Angular stable screws
tend to cut through comminuted fragments of
the dorsal rim and thus promote secondary
loss of reduction. Length measurement fail-
ures with concomitant screw overlength may
lead to extensor tendon affection. Another dis-
advantage of palmar plating remains the
placement of a plate on top of the bone. Even
though current plate designs address some-
how ideally the distal radius bony geometry,
still it appears that plates and prominent
screws lead to discomfort in the wrist region.
Different plate designs either refer to the Fig. 23.17 (a, b, c) Figures demonstrate the technique of
watershed line or the palmar rim. The later are wrist spanning assembly, fracture reduction employing
distraction, ligamentotaxis and K-wire fixation of the dis-
located more distally. It is of paramount
tal fragment
218 G. Gradl

Fig. 23.18 (a) Demonstration of the assembly using a ment. Up to six threaded or unthreaded pins may be
standard small fixator. (b) A precurved bar compatible placed in the distal fragment from different angles and
with an Ilizarov hybrid technique that accommodates sev- may cross the fracture line
eral pins/K-wires that are forwarded in the distal frag-
23  Distal Radius Fracture 219

Fig. 23.19 (a) A highly comminuted fracture extending fragment movement. (b, c) Additional pins were inserted
into the joint which was treated by a wrist non-spanning without connection to the external fixator. (d) Implant
external fixator. The pins were first securely anchored in removal was prolonged until 9 weeks post-surgery in
the distal fragment and then connected to the external fix- order to safely ensure fracture consolidation
ator bars in order to achieve reduction employing direct
220 G. Gradl

Fig. 23.19 (continued)

importance to place these plates in the right Furthermore, preoperative and intraoperative
position. Plates may not be located ideally and analysis of soft tissue injuries, mainly ruptures
stiff angle screws may thus penetrate the joint. of the scapholunate ligaments, needs to be
23  Distal Radius Fracture 221

performed, no matter which fixation tech- screw design may help to circumvent this
nique is used. problem as well as intraoperative X-ray con-
• Figure 23.20 demonstrates a typical case of trol of correct plate position. However, a mul-
palmar plate fixation of an extra-articular tidirectional screw provides the risk of
comminuted fracture with concomitant weak surgeon-based mistakes. Figure 23.21b dem-
bone stock. During the healing period, the onstrates an angular stable screw that diverges
angular stable screws were not able to pre- extremely in order to fix the radioulnar frag-
serve palmar inclination and cut through. ment. Post-surgery CT scan revealed malposi-
Until now it is not clear as to whether a second tion of the screw into the radioulnar joint. If
“line of defence” using the second row of there is any doubt on post-surgery X-rays, CT
screws may help to address the problem of scans are recommended to securely rule out
secondary loss of palmar inclination of dor- any intra-articular screw placement.
sally displaced comminuted fractures. Dorsal • One further surgeon-based mistake is false
buttress plate fixation is an additional way to measurement of the screw length. This is of
securely provide fixation stability in cases of importance both in the distal and the proximal
weak bone stock and imminent dorsal fragment. Screw overlength may cause severe
re-displacement. tendon affections as well as tendon ruptures.
• The problem of correct plate and screw posi- Figure  23.22 demonstrates screw overlength
tion is shown in Fig. 23.21a. The plate is after palmar plate fixation. During implant
placed too far proximal, and angular stable removal, contrast material was injected in the
screws were placed through the joint surface. bony canal and exposes the tendon sheet as a
Plates with a multidirectional angular stable sign of tendon irritation.

Fig. 23.20 (a, b, c)
Preoperative and
postoperative radiographs
demonstrating a typical
case of palmar plate
fixation of an extra-
articular comminuted
fracture with concomitant
weak bone stock. During
the healing period, the
angular stable screws
were not able to preserve
palmar inclination and cut
through
222 G. Gradl

Fig. 23.20 (continued)
23  Distal Radius Fracture 223

Fig. 23.21 (a) This case demonstrates that the plate is stable screw diverging extremely in order to fix the radioul-
placed too far proximal and angular stable screws were nar fragment is demonstrated. Post-surgery CT scan
placed through the joint surface. (b) In this case an angular revealed malposition of the screw into the radioulnar joint

Fig. 23.22  Demonstration of screw overlength after palmar plate fixation. During implant removal, contrast material
was injected in the bony canal and exposes the tendon sheet as a sign of tendon irritation
224 G. Gradl

Fig. 23.23  Demonstration of a case associated with scapholunate interosseous ligament (SLD) damage which was
fixed surgically with open ligament repair and temporary K-wire fixation together with an IM nailing procedure

• Soft tissue injuries are frequent mainly in 2. Thompson PW, Taylor J, Dawson A. The annual inci-
dence and seasonal variation of fractures of the distal
intra-articular distal radius fractures and need
radius in men and women over 25 years in Dorset,
to be meticulously analysed in the periopera- UK. Injury. 2004;35:462–6.
tive setting [19]. Ruptures of the scapholunate 3. Pechlaner S, Gabl M, Lutz M, Krappinger D,
interosseous ligament (SLD) are most fre- Leixnering M, Krulis B, Ulmer H, Rudisch A,
Arbeitsgruppe A. Distal radius fractures—aetiology,
quent and go along with severe degenerative
treatment and outcome. Handchir Mikrochir Plast
changes of the wrist if neglected. However, Chir. 2007;39:19–28.
plane radiographs are moderately reliable and 4. Müller ME, Nazarian S, Koch P, Schatzker J. The
are better at ruling out than ruling in SLD. In comprehensive classification of fractures of long
bones. New York: Springer; 1990. p. 106–15.
patients at risk with suspicious results on plain
5. Cuenca J, Martínez AA, Herrera A, Domingo J. The
X-rays, further evaluation using CT scans or incidence of distal forearm fractures in Zaragoza
at least dynamic C-arm evaluation during sur- (Spain). Chir Main. 2003;22:211–5.
gery is necessary [17]. In case of acute injury, 6. Vogt MT, Cauley JA, Tomaino MM, Stone K, Williams
JR, Herndon JH. Distal radius fractures in older
primary fixation is recommended. Immediate
women: a 10-years follow-up study of descriptive
treatment is capable to restore hand function characteristics and risk factors. The study of osteopo-
in the same way as if there was no carpal rotic fractures. J Am Geriatr Soc. 2002;50:97–103.
injury [20]. Figure 23.23 presents a SLD 7. Hollevoet N, Van Maele G, Van Seymortier P,
Verdonk R. Comparison of palmar tilt, radial inclina-
which was fixed surgically with open ligament
tion and ulnar variance in left and right wrists. J Hand
repair and temporary K-wire fixation together Surg Br. 2000;25:431–3.
with an IM nailing procedure. 8. Lundy DW, Quisling SG, Lourie GM, Feiner CM,
Lins RE. Tilted lateral radiographs in the evaluation
of intra-articular distal radius fractures. J Hand Surg
[Am]. 1999;24:249–56.
References 9. Medoff RJ. Essential radiographic evaluation for dis-
tal radius fractures. Hand Clin. 2005;21:279–88.
1. O'Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, 10. Arora R, Lutz M, Hennerbichler A, Krappinger

Reid DM, Rowe R, Woolf AD, Wallace WA, Colles D, Espen D, Gabl M. Complications following
UK. Fracture Study Group. Incidence of distal fore- internal fixation of unstable distal radius fracture
arm fracture in British men and women. Osteoporos with a palmar locking-plate. J Orthop Trauma.
Int. 2001;12:555–8. 2007;21:316–22.
23  Distal Radius Fracture 225

11. Burkhart KJ, Nowak TE, Gradl G, Klitscher D,

fixation technique using multiplanar k-wires. J Hand
Mehling I, Mehler D, Mueller LP, Rommens Surg [Am]. 2005;30(5):960–8.
PM. Intramedullary nailing vs. palmar locked plating 17. Gradl G, Gradl G, Wendt M, Mittlmeier T, Kundt G,
for unstable dorsally comminuted distal radius frac- Jupiter JB. Non-bridging external fixation employing
tures: a biomechanical study. Clin Biomech (Bristol, multiplanar K-wires versus volar locked plating for
Avon). 2010;25(8):771–5. https://doi.org/10.1016/j. dorsally displaced fractures of the distal radius. Arch
clinbiomech.2010.06.004. Epub 7 Jul 2010 Orthop Trauma Surg. 2013;133(5):595–602. https://
12. Gradl G, Falk S, Mittlmeier T, Wendt M, Mielsch doi.org/10.1007/s00402-013-1698-5 . Epub 2013
N, Gradl G. Fixation of intra-articular fractures of Feb 19.
the distal radius using intramedullary nailing: a ran- 18. Gradl G, Mielsch N, Wendt M, Falk S, Mittlmeier
domized trial versus palmar locking plates. Injury. T, Gierer P, Gradl G. Intramedullary nail versus
2016;47(Suppl 7):S25–30. https://doi.org/10.1016/ volar plate fixation of extra-articular distal radius
S0020-1383(16)30850-6. fractures. Two year results of a prospective random-
13. Falk SS, Mittlmeier T, Gradl G. Results of geriat- ized trial. Injury. 2014;45(Suppl 1):S3–8. https://doi.
ric distal radius fractures treated by intramedullary org/10.1016/j.injury.2013.10.045. Epub 4 Nov 2013
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org/10.1016/S0020-1383(16)30851-8. Prommersberger KJ, Ring D. Science of Variation
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versus volar angular stable plating for the fixation of Prommersberger KJ. The functional outcome of acute
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of the distal radius treated with a nonbridging external Jun 2013
 Distal Ulna Fractures
24
Tristan E. McMillan and Alan J. Johnstone

Introduction and Fracture Patterns of the ulna shaft coinciding with the proximal
border of the pronator quadratus (PQ) muscle [2].
Isolated fractures of the distal ulna are relatively Fractures proximal to the insertion of the DOB
rare and usually result from a direct force or should be considered as ulnar shaft fractures.
crush injury. However, ulna fractures do occur Thereafter, we have classified distal ulna frac-
more commonly in association with fractures of tures anatomically into styloid tip, styloid base,
the distal radius, with up to 65% of fractures of ulnar head and ulnar metaphysis (neck)/distal
the distal radius having associated distal ulna diaphysis, as shown in Fig. 24.1. This has simi-
fractures [1]. Fractures of the distal ulna can be larities to the Comprehensive Classification of
overlooked; however, due to the distal ulna’s Fractures, where distal ulna fractures associated
direct interaction with the bony anatomy of the with distal radius fractures have been classified
distal radius and complex soft tissue attachments using a Q modifier; Q1 designates a fracture of
of the interosseous membrane (IOM), distal the ulnar styloid, whilst Q2 and Q3 are fractures
radioulnar joint (DRUJ) itself, ulnocarpal liga- of the ulnar neck, Q4 and Q5 are fractures involv-
ments and the triangular fibrocartilage complex ing the ulnar head and Q6 is a fracture of the dis-
(TFCC), a mistreated injury can have significant tal ulnar shaft [3]. Our reasoning for this
long-term consequences on wrist function sub-classification is the distinct significance of
through persistent symptoms or reduced each of these anatomical regions and their influ-
function. ence on fracture patterns and their subsequent
We have defined fractures of the distal ulna as management:
those that occur distal to the IOM. The most dis-
tal fibres of the IOM, named the distal oblique –– Styloid tip, avulsion through its attachment to
bundle (DOB), originate from the distal one sixth the ulnar collateral ligament
–– Styloid base, avulsion or involvement of the
TFCC
T.E. McMillan, M.B.Ch.B., M.R.C.S. –– Ulnar head, intra-articular nature and associ-
Trauma and Orthopaedics, Aberdeen Royal Infirmary, ated disruption to the DRUJ
Aberdeen, Scotland, UK
–– Metaphysis/distal diaphysis, classical radial
A.J. Johnstone, F.R.C.S. (*) displacement of the proximal fragment due to
Trauma and Orthopedic Surgery, Aberdeen Royal
Infirmary, Aberdeen, Scotland, UK
the action of PQ and IOM, as shown in
e-mail: alanjjohnstone@me.com Fig. 24.2

© Springer International Publishing AG 2018 227

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_24
228 T.E. McMillan and A.J. Johnstone

Styloid Tip

Styloid Base

Ulnar Head

Metaphysis &
Distal Diaphysis

Fig. 24.1  Diagram illustrating the anatomical classifica-

tion of fractures of the distal ulna

 ecision to Treat and Preoperative

D
Planning
Fig. 24.2  Radiograph showing a neck fracture of the dis-
tal ulna, with classic medial displacement of the proximal
Frequently the most difficult decision that is fragment due to the action of the pronator quadratus and
associated with distal ulna fractures is whether to interosseous membrane
treat operatively or nonoperatively.
Absolute indications for surgical management
include: –– Any distal ulna fracture with associated DRUJ
instability
–– Open fractures –– Unstable fractures of the ulna in association
–– Neurovascular compromise usually affecting with unstable fractures of the distal radius,
the ulnar nerve whereby reduction and stabilisation of the
ulna facilitate the treatment of the distal radius
Relative indications for surgical management fracture
include:
As a minimum, good-quality anteroposterior
–– Displaced metaphysis/distal diaphysis, partic- and lateral preoperative radiographs of the distal
ularly those with significant shortening radius and DRUJ are required to evaluate the
–– Displaced head fractures with intra-articular wrist for co-existing injury keeping in mind that
extension Essex-Lopresti-type injuries may need more
24  Distal Ulna Fractures 229

Fig. 24.3  Case of a young gentleman with a large base of sented 3 months later with wrist pain and loss of pronation
styloid fracture and DRUJ dislocation, treated out with and supination, at which point a CT confirmed DRUJ dis-
our unit with prolonged cast immobilisation. He repre- location and fracture non-union

detailed radiographs to assess the whole of the a tension band construct. We have also managed
forearm including the wrist and elbow. A wid- to treat these fractures successfully with single
ened distal radioulnar space on the anteroposte- mini-fragment screws, so as to avoid the need for
rior radiographs should raise suspicion of a DRUJ removal of hardware, but have found this tech-
injury, and a true lateral of the wrist should be nique to be labour intensive and of no long-term
obtained to assess for dislocation or subluxation clinical advantage to the patient.
of the DRUJ. We advocate that cases with DRUJ Overall we advocate that the majority of sty-
instability, especially those that can be visualised loid tip fractures should be treated conservatively,
on true lateral radiographs of the wrist, should be although patients should be educated about the
treated operatively in most cases to prevent incidence of ulnar-sided wrist pain and the poten-
chronic instability or dislocation. This is high- tial for a slower recovery of grip strength and
lighted in Fig. 24.3. wrist flexion, although these should improve
In those patients where the extent of the asso- within 12 months of injury [7].
ciated DRUJ bony injury or soft tissue injury is
unclear, computed tomography (CT) or magnetic
resonance imaging (MRI) can aid clinical deci- Patient Set-Up in Theatre
sion making and surgical planning.
Although a large percentage of ulnar styloid Patient set-up is similar to that used for fixation
fractures will go on to non-union, surgical fixa- of the distal radius. The patient is supine, and the
tion of these injuries remains controversial with arm is draped free so that the forearm can be
some studies demonstrating no effect upon clini- supinated or pronated on a radiolucent arm table,
cal outcome, providing any associated distal or, through flexing the elbow, the arm can be held
radius fracture is suitably reduced and stabilised in mid-pronation whilst the hand is held verti-
[4, 5]. On the other hand, Dar et al. advocate that cally. Following positioning, the operating table
a more vigorous approach to treating these inju- is then rotated by 90 degrees, as seen in Fig. 24.4,
ries is adopted to reduce weakness and ulnar-­ to provide more room for the operating surgeon
sided wrist pain [6]. Due to the potential and to facilitate easier positioning and use of the
disruption to the stabilising ligaments of the dis- image intensifier intraoperatively.
tal ulna and TFCC, and subsequent effect upon Although not always required, if the surgeon
the stability of the DRUJ, we advocate fixation of envisages the need for a bloodless operative field,
large base fractures with >2 mm of displacement, a tourniquet is applied to the upper arm and the
using a percutaneous Kirschner wire (K-wire) or patient is prepped and draped to a suitable level,
230 T.E. McMillan and A.J. Johnstone

proximal to the elbow. We are increasingly seeing The surgeon positions themselves at the cau-
the use of extremity drapes with an incorporated dal aspect of the hand table for the management
elastic aperture, and whilst we appreciate their of any associated distal radius fracture, then
benefit in ease of use and effective isolation, there moving to the cranial aspect with the forearm
is a concern with regard to the potential venous pronated to address the distal ulna fracture. The
tourniquet effect of the elastic aperture. We there- reverse is true depending upon the arm being
fore choose to use two large adhesive drapes as operated upon and of course the hand dominance
shown in Fig. 24.5. of the surgeon.

Fig. 24.4  Operative table set-up with radiolucent arm table attached and table rotated 90° to ease the placement and
use of intraoperative fluoroscopy

Fig. 24.5  Draping technique, utilising two large adhesive drapes to isolate and drape the limb, whilst still allowing free
movement of the limb and, importantly, avoiding the potential tourniquet effect of elasticated extremity drapes
24  Distal Ulna Fractures 231

Closed Reduction Manoeuvres

Due to the relatively subcutaneous nature of the

distal ulna, reduction can sometimes be achieved
with closed manipulation. Importantly, restora-
tion of alignment is significantly aided by first
restoring the length and alignment of any associ-
ated distal radius fracture. The radius fracture
must therefore be addressed first, with assess-
ment of the alignment and stability of the ulna Fig. 24.6  The longitudinal incision along the subcutane-
fracture once this has been achieved. ous border of the ulna, volar to the dorsal prominence
Closed reduction of an ulnar styloid fracture is
technically difficult due to its small size and to the
deforming forces through the attachment of the
ulnar collateral ligament, dorsal carpal ligament and
TFCC. Therefore, where it is considered necessary
to achieve accurate reduction of these fractures, they
usually require an open or ‘mini-open’ approach.

Surgical Approach
Fig. 24.7 Cadaveric dissection showing the dorsal
For most distal ulna fractures, a longitudinal inci- branch of the ulnar nerve crossing the subcutaneous bor-
der of the distal ulna, from palmar to dorsal
sion is made along the subcutaneous border of
the ulna (Fig. 24.6). The intended inter-nervous
plane lies between the extensor carpi ulnaris the tendons of extensor and flexor carpi ulnaris
(posterior interosseous nerve) and flexor carpi using sharp dissection, both tendons are retracted
ulnaris (ulnar nerve). Careful superficial dissec- dorsally and volarly, respectively, using a self-­
tion to allow identification and protection of the retainer or two small Hohmann retractors.
dorsal branch of the ulnar nerve as it passes from Subperiosteal dissection, shown in Fig. 24.8, pro-
volar to dorsal is essential. Cadaveric research on vides suitable exposure to facilitate fixation of
the course of the dorsal branch of the ulnar nerve fractures of the ulna neck/distal diaphysis and
has shown that the nerve passes dorsal to the simple fractures of the ulnar head. If, however,
flexor carpi ulnaris and pierces the deep fascia the ulnar head fracture is comminuted, direct
where it becomes subcutaneous on the ulnar visualisation of the articular surface may be
aspect of the forearm approximately 5 cm proxi- required. Although limited, this can occasionally
mal to the pisiform [8]. It crosses from palmar to be achieved through the same incision, by devel-
volar at that distal aspect of the ulna as shown in oping the plane between the fifth and sixth exten-
Fig. 24.7. There is variation in the exact point at sor compartments. Subsequent radial retraction
which it crosses the subcutaneous border of the of extensor digiti minimi then allows direct visu-
ulna making it vulnerable to iatrogenic injury. alisation of the dorsal aspect of the ulnar head
Although Puna and Poon demonstrated that the and the articular surface.
dorsal branch of the ulnar nerve crosses on aver- Whilst this allows some degree of exposure to
age 0.2 cm proximal to the tip of the ulnar styloid the DRUJ, if a more extensive exposure is needed,
[9], this range varied from 2.5 cm proximal to a separate volar or dorsal approach is indicated.
2.5 cm distal to the tip of the styloid. The authors favour a dorsal approach particularly
To achieve suitable exposure of the distal ulna, when there is an ulnar head fracture with signifi-
after defining and establishing the plane between cant intra-articular comminution, or if DRUJ
232 T.E. McMillan and A.J. Johnstone

Fig. 24.8  Cadaveric subperiosteal dissection to expose the ulna. The incision and dissection can be extended distally
to expose the styloid

reconstruction is indicated since the dorsal liga- Open Reduction Manoeuvres

ments usually require to be repaired. This is per-
formed through a longitudinal incision in line The main aim is to restore length, rotation and
with the fifth extensor compartment. After exten- natural bone alignment. With open reduction,
sor digiti minimi is retracted radially, the joint is head, neck and distal diaphyseal fractures can be
approached through the floor of the fifth com- reduced using a combination of gentle traction and
partment. Bain et al. describe incising the reti- direct manipulation using bone reduction forceps.
naculum and capsule as one, creating an Fractures of the styloid can be reduced using
ulnar-based thick capsular-retinacular flap that pointy reduction forceps. An alternative, and
allows suitable exposure of the joint and a stable arguably more effective, method for these frag-
repair at the end [10]. ments is the placement of a K-wire into the distal
24  Distal Ulna Fractures 233

styloid fragment whilst using a drill sleeve to the shaft to correct alignment. We recommend
control the fragment and to protect the adjacent that this is achieved by placing a toothed reduc-
soft tissues. The wire is then used to ‘joystick’ the tion clamp on the proximal fragment before
fragment back to its anatomical position, before applying a force ulnarwards, perpendicular to the
finally securing it by advancing the wire. shaft, as shown in Fig. 24.9. By applying only the
As previously mentioned, fractures of the dis- tips of the forceps to the shaft, it is usually pos-
tal metaphysis/diaphysis tend to result in radial sible to slide a suitable plate through the gap
displacement of the proximal fragment, thereby between the jaws in the forceps, to lie in an opti-
requiring reduction by applying an ulnar force to mal position on the distal ulna.

Fig. 24.9  A toothed reduction clamp is applied to the proximal fragment with force applied in the direction shown (ulnar-
wards). This is opposed by direct pressure with the surgeon’s thumb over the ulna head, thereby enabling reduction
234 T.E. McMillan and A.J. Johnstone

Implant Insertion ited screw options, it was difficult to achieve

more than one or two screw fixation within the
When deciding whether to fix an associated sty- distal fragment resulting in poor fracture stabil-
loid base fracture, it is essential to assess the sta- ity that was prone to mechanical failure. This
bility of the DRUJ clinically and radiologically has led to the evolution and increased use of
intraoperatively. Clinically this can be achieved low-profile (Fig. 24.12), anatomical locking
with flexion of the elbow to 90°, placing the fore-
arm in neutral rotation whilst the surgeon
attempts to translate the distal ulna in dorsal,
volar and ulnar directions. If there is any doubt
about the clinical findings, the same process
should be repeated using fluoroscopy to ‘visual-
ise’ the stability of the DRUJ.
Whilst K-wires have a role in styloid frac-
tures, their role in fractures of the ulna head or
neck should be limited to simple, non-­
comminuted fractures. Where possible they
should be avoided in those with osteoporotic
bone due to the poor hold and increased risk of
loosening and/or loss of reduction. An example
of this is seen in Fig. 24.10.
Open reduction and internal fixation on the
other hand have the potential benefit of secure
fixation and early mobilisation. Due the thin
soft tissue envelope and the shape of the distal
ulna, traditional standard plates were not well
suited for fixation of fractures of the distal ulna. Fig. 24.11  Intraoperative image highlighting the bulky
Through their bulk and prominence under the nature of the more traditional non-locking plates used for
the fixation of distal ulna fractures. This was acceptable in
skin (Fig. 24.11), many required to be removed this case due to the proximity of the fracture and a greater
after fracture union. Moreover, with their lim- than normal soft tissue envelope

Fig. 24.10  Radiographs of a distal diaphysis/metaphyseal fracture reduced closed and fixed with two percutaneous
K-wires and subsequent loss of reduction
24  Distal Ulna Fractures 235

Fig. 24.12  Postoperative and intraoperative radiographs selected to highlight the importance of careful anatomical
of two different low-profile plates used to treat fractures placement of the plates to reduce their prominence
of the distal ulna. These particular images have been

plates. These plates lend themselves much bet- Summary of Tips, Tricks and Pitfalls
ter to fixation of fractures of the ulna head, neck
and distal diaphysis. Even with extremely distal The key to treating ulnar fractures is to assess their
fractures, the modern anatomical plates permit importance to overall wrist alignment, fracture sta-
the insertion of several tightly packed angled bility and long-term function. Although it may not
screws through the distal part of the plate be immediately apparent, understanding the asso-
improving overall fragment hold. Also, through ciated soft tissue disruption that accompanies
the introduction of locking screw technology, these fractures is paramount to treating and obtain-
fixed-angle stability has enhanced the pull-out ing an optimal result. Overall, surgical exposure of
strength of the screws, especially where the the distal ulna is not challenging provided the dor-
screws inserted into each fracture fragment are sal branch of the ulnar nerve is identified and care-
inserted in different planes. fully protected throughout the procedure. However,
236 T.E. McMillan and A.J. Johnstone

there is little doubt that the small size of the distal 3. Müller ME, Koch P, Nazarian S, Schatzker J. The
comprehensive classification of fractures of long
ulnar fragment, especially since fracture commi-
bones. Berlin, Heidelberg: Springer; 1990.
nution is common, provides the real challenge to 4. Kim JK, Koh Y-D, Do N-H. Should an ulnar sty-
obtaining stable fracture fixation and correct frac- loid fracture be fixed following volar plate fixa-
ture alignment. Modern low-profile locking plate tion of a distal radial fracture? J Bone Jt Surg Am.
2010;92(1):1–6.
technology has revolutionised the treatment of
5. Sawada H, Shinohara T, Natsume T, Hirata
these fractures when compared to traditional plate H. Clinical effects of internal fixation for ulnar
designs, except for ulnar styloid tip and ulnar sty- styloid fractures associated with distal radius frac-
loid base fractures, where K-wire fixation remains tures: a matched case-control study. J Orthop Sci.
2016;21(6):745–8.
a good method for treating these injuries.
6. Dar I, Wani I, Mumtaz U, Jan M. Effect of ulnar sty-
loid fracture on functional outcome of Colle’s frac-
Acknowledgements We would like to thank the tures: a comparative analysis of two groups. Int Surg
Department of Anatomy and the Department of Medical J. 2015;2(4):556–9.
Illustrations at the University of Aberdeen for their assis- 7. Daneshvar P, Chan R, Macdermid J, Grewal R. The
tance and expertise in the preparation of this chapter. effects of ulnar styloid fractures on patients sus-
taining distal radius fractures. J Hand Surg [Am].
2014;39(10):1915–20.
8. Botte MJ, Cohen MS, Lavernia CJ, von Schroeder
References HP, Gellman H, Zinberg EM. The dorsal branch of
the ulnar nerve: an anatomic study. J Hand Surg [Am].
1. Sammer DM, Shah HM, Shauver MJ, Chung KC. The 1990;15(4):603–7.
effect of ulnar styloid fractures on patient-rated out- 9. Puna R, Poon P. The anatomy of the dorsal cutane-
comes after volar locking plating of distal radius frac- ous branch of the ulnar nerve. J Hand Surg Eur Vol.
tures. J Hand Surg [Am]. 2009;34(9):1595–602. 2010;35(7):583–5.
2. Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa 10. Bain GI, Pourgiezis N, Roth JH. Surgical approaches
H, Moritomo H. Interosseous membrane of the fore- to the distal radioulnar joint. Tech Hand Up Extrem
arm: an anatomical study of ligament attachment Surg. 2007;11(1):51–6.
locations. J Hand Surg [Am]. 2009;34(3):415–22.
 Scaphoid Fracture
25
Anica Herlyn and Alice Wichelhaus

Anatomical Fracture Location The precarious blood supply to the scaphoid is

largely retrograde through the dorsal and volar
The scaphoid bone connects both carpal rows, branches of the radial artery. Seventy to eighty
synchronizes the motions of the carpal bones, percent of the proximal scaphoid is supplied via
and serves as an intercalated anchor. The scaph- the dorsal ridge, whilst the volar branch supplies
oid is situated at a 45° plane to the horizontal and the remaining 20–30% via the scaphoid tubercle
longitudinal axes of the carpus that leads to spe- [3, 4]. Unfortunately, 60% of scaphoid fractures
cific fracture patterns with typical trauma mecha- affect the modestly supplied scaphoid waist; 15%
nisms such as a fall on the dorsiflexed wrist. involve the scarcely supplied proximal and
Consequently, the scaphoid proximal pole densely supplied distal third; and 10% involve
remains fixated between the distal radius and the tuberculum ossis scaphoidei. Scaphoid frac-
radioscaphocapitate ligament. The mobile distal tures are at risk of delayed union and nonunion
pole has a less protected position, with an increas- because of its peculiar blood supply and the fact
ing degree of dorsiflexion and a dorsally directed that more than two-thirds is covered by articular
acting force vector [1]. During impact, when cartilage [5].
radial adduction is combined with dorsiflexion, To identify fractures that are appropriate for
distal scaphoid fractures are caused by palmar operative treatment, the Herbert and Fisher clas-
positioning of the scaphoid. A combination of sification [6] is most commonly used in British
ulnar adduction and dorsiflexion with dorsal and American literature. Type A fractures involv-
scaphoid inclination leads to distal scaphoid frac- ing non-dislocated fractures of the tuberosity
tures [2]. Proximal pole fractures result from ini- (A1) or scaphoid waist (A2) are stable and asso-
tial subluxation of the scaphoid prior to forced ciated with superior union rates. Type B fractures
supination. including the oblique distal one-third (B1), prox-
imal fractures (B3), waist fractures with displace-
ment (B2) or fracture dislocations (B4), and
A. Herlyn (*) • A. Wichelhaus
comminuted fractures (B5) are defined as poten-
Dept. of Trauma, Hand and Reconstructive Surgery,
University of Rostock, Medical Center, tially unstable and most likely require operative
Rostock, Germany treatment (Fig. 25.1). Type C and D fractures cor-
e-mail: anica.herlyn@med.uni-rostock.de respond to delayed union and nonunion [7].

© Springer International Publishing AG 2018 237

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_25
238 A. Herlyn and A. Wichelhaus

a b c

d e

Fig. 25.1 (a–e) Radiographs in anteroposterior (a), lateral (b) views and CT scans (c, d, e) of a type B scaphoid frac-
ture pattern according to Herbert and Fisher [6]

Brief Preoperative Planning The commonly used implants are cannulated

titan double-threaded (tip and head) compression
For scaphoid fractures with any pathologic angu- screws, self-tapping, and self-drilling.
lation, displacement (type B), or carpal malalign- The implant is characterized by two threaded
ment, arthroscopic-assisted or open reduction screw parts that are both broader than the
and fixation are recommended if any concerns unthreaded screw shank. To allow compression
exist regarding fracture stability. Some authors of the fracture gap, the thread pitch of the screw
recommend minimally invasive arthroscopic-­ head is smaller than the tip, allowing for an axial
assisted reduction and percutaneous fixation; force vector. With both threads anchored in the
however, current literature has not demonstrated bone, compression is applied to the fracture gap
the mid- or long-term benefits, as compared with to help further tighten the screw.
open reduction and internal fixation, which we A broad variety of cannulated screws can be
believe is the current standard treatment and purchased in different threads, pitches, and sizes.
facilitates reduction considerably. Moreover, larger screws have demonstrated lower
25  Scaphoid Fracture 239

rates of implant failure [8–10]. However, no study and Ring [12] placed the image intensifier in a
has demonstrated significant differences in out- vertical position and fixed the wrist in extension
comes with different screw characteristics, except with the carpus vertical to the beam using
for commonly used cannulated screws that allow towels.
for improved central screw positioning, as com-
pared with the original Herbert screw [11].
Closed Reduction Manoeuvres

Patient Set-Up in Theatre Only a few fractures can be reduced solely using
extension and radial deviation. A roll of cotton
A radiolucent ‘hand’ table is commonly used. cloth may help gain reduction; however, a surgi-
Few authors have described the positioning cal assistant has to ensure maximum extension
directly at the image intensifier collector [12]. throughout the whole procedure (Fig. 25.3). The
Patients are placed in a supine position with complex scaphoid shape and carpal anatomy
their shoulder abducted and their forearm supi- make intraoperative image intensification
nated for a volar approach or pronated for a dor- extremely challenging. Arthroscopic visualiza-
sal approach. The wrist is extended dorsally for a tion may aid reduction for experienced surgeons.
volar approach or flexed for a dorsal approach
using a roll of cotton cloth.
Figure 25.2 shows patient positioning with the Reduction Instruments
main surgeon sitting on the radial side, a surgical
assistant on the opposite side, and a surgical nurse No specific reduction instruments are required;
and an image intensifier in extension of the all necessary instruments are within a standard
patient’s arm. The image intensifier is placed so it hand operation set:
maintains a dorsal and volar course with respect to
the beam projection during the whole operation. –– K wire(s) (1.2–1.5 mm) used as a joystick for
For arthroscopic techniques, the wrist may be reduction
placed in a traction tower to facilitate arthros- –– K wire (0.8–0.9 mm) used as a guidewire for
copy. As described by Slade and Jaskwhich [13], screw insertion
a mini C-arm may be placed laterally. Duckworth –– Elevator

S SA

Fig. 25.2  Intraoperative positioning of a

patient on a hand table for a volar
approach with the surgeon sitting at the
patient’s radial site (S), the surgical
assistance sitting at the ulnar site (SA).
The operating assistant (OA) and image
intensifier (II) are positioned in extension II OA
of the patients arm
240 A. Herlyn and A. Wichelhaus

Fig. 25.3  A closed reduction manoeuvre

with maximum extension and radial
deviation using a towel roll. Incision for
an open volar approach is marked

Surgical Approach  pen Volar Approach for Scaphoid

O
Waist Fractures
 pen Dorsal Approach for Proximal
O
Pole Scaphoid Fractures Waist fractures and dislocated or unstable
(oblique) distal third scaphoid fractures are com-
Proximal pole scaphoid fractures are believed to monly treated using a volar open or minimally
be unstable because of rotational forces from the invasive approach. An advantage of the palmar
scapholunate ligament. This issue coupled with a approach is a lower risk of injury to the vascular
high risk of nonunion and the peculiar blood supply [14].
­supply leads to a common approach involving a A 4- to 5-cm slightly bowed incision is per-
small, open dorsal incision that offers the surgeon formed starting distal to the distal scaphoid pole
the advantage of being able to visually check that crosses the transverse wrist wrinkle along the
fracture alignment. An open approach enables flexor carpi radialis tendon. The tendons sheath is
optimal implant positioning and application of opened, and the flexor carpi radialis tendon is
two K wires that function as joysticks and can be retracted in an ulnar direction (Fig. 25.4a). Care
applied to each fragment to facilitate reduction. should be taken if the superficial radial artery is a
For the open dorsal approach, a 3- to 4-cm hindrance and necessitates distal retraction or
radiocarpal incision is created that is centred ligation. After visualization of the wrist joint cap-
oblique relative to and above the extensor pollicis sule, an incision is created longitudinal to the
longus tendon. The third compartment is opened, scaphoid to visualize the fracture line (Fig. 25.4b).
and the extensor pollicis longus tendon is Fracture hematomas usually dissipate after inci-
retracted radially. The second compartment and sion of the capsule. To spare as much of the
dorsal wrist joint capsule that is close to the dor- crossing radioscaphocapitate ligament as possi-
sal radiotriquetral ligament is incised, and the ble, the incision should be started at the distal
proximal pole is exposed. Maximum dorsiflexion pole and proceed proximally until the fracture is
of the wrist is important for optimal viewing of adequately visualized.
the fracture site. Potential disadvantages are higher rates of
Care should be exercised during incision scaphotrapezial osteoarthrosis over the years that
because of the dorsal ridge vessels. anyhow remain mostly asymptomatic [15].
25  Scaphoid Fracture 241

Fig. 25.4 (a, b) Intraoperative exposure

a
of an open volar approach for a scaphoid
waist fracture. The flexor carpi radialis
tendon sheath is opened, and the tendon
is retracted in an ulnar direction to
visualize the wrist joint capsule (a).
Incision of the wrist joint capsule is
created longitudinal to the scaphoid in
order to visualize the fracture (b)

 ercutaneous or Minimally
P wire. If a minimally invasive dorsal approach
Invasive Arthroscopic-Assisted with a small open incision is used, there is an
Approach for (Stable) Scaphoid Waist increased risk of lesions to the posterior interos-
Fractures seous nerve, extensor indicis proprius tendon, or
extensor digitorum tendon [17].
Percutaneous or minimally invasive arthroscopic-­ For a stark arthroscopic approach, a midcarpal
assisted techniques have the advantage of sparing portal (3/4 or 4/5) allows for the best.
the volar carpale capsule and tendons and, there-
fore, may allow for less postoperative immobili-
zation because of improved stability [16]. Open Reduction Manoeuvres
Visualization of the scaphotrapezial joint
space with fluoroscopy is followed by the cre- Most scaphoid fractures require direct reduction
ation of a 1-cm-maximum percutaneous stab manoeuvres that are facilitated by the use of K
incision in a volar-radial course above the sca- wires (preferably 1.2–1.5 mm) drilled into each
photrapezial joint and the insertion of a guide- fragment that serve as joysticks:
242 A. Herlyn and A. Wichelhaus

Fig. 25.5  Reduction manoeuvre using a

K wire as a joystick

In case of a volar approach, the wrist is posi- With unstable fractures, a second guidewire
tioned in maximum extension to allow for opti- may be used to control rotation if the fragment is
mal visualization of the fracture. Ulnar deviation unstable during both the drilling and screw inser-
may aid the reduction, as well as a dorsally posi- tion phases.
tioned towel roll beneath the wrist. For the joy- For comminuted fractures, bone grafting has
stick technique, a K wire is inserted into each to be considered to facilitate reduction and stimu-
fragment at an angle to the pole, gripping the late union.
maximum possible diameter to increase For a stark arthroscopic approach, fracture
strength. Slight off-centre positioning of the reduction is performed using a manoeuvre of
joysticks to the longitudinal axis of the frag- extension and radial deviation, followed by volar
ments is important to spare the fracture line and percutaneous guidewire stabilization [12, 16].
to allow correct guidance and positioning of the
wire that corresponds with the central axis of
the scaphoid. If the approach allows for use of Implant Insertion
only one K wire, the distal fragment displays the
more important one covering the dislocated Any of these approaches, along with reduction,
fragment (Fig. 25.5). To prevent a respective is followed by guidewire insertion. Its posi-
fragment from evading an elevator may be tioning is of uppermost importance to the suc-
placed below the proximal pole. Using the K cess of the operation. It helps to keep in mind
wires as a joystick, rotation and positioning of that the scaphoid is positioned at a 45° plane to
both fragments can be controlled until the guide- the horizontal and longitudinal axes of the
wire is positioned. wrist.
For dorsal and arthroscopic approaches (ver- For a volar approach, the ideal insertion point for
sus percutaneous), an analogous proceeding may the guidewire is distal through the scaphoid tuber-
be performed. cle, allowing for central wire placement in the prox-
For slightly displaced or comminuted frac- imal scaphoid pole, which is often slightly radial to
tures, the guidewire itself may be used as a joy- the tuberculum. Under the image intensifier in the
stick if it is drilled into the first fragment to be anteroposterior, lateral, and oblique supinated/pro-
retained for reduction manoeuvres and to be nated views, the guidewire is drilled longitudinally
advancement crossing past the fracture line. along the long axis of the scaphoid to the proximal
25  Scaphoid Fracture 243

a a <2-mm screw in case of any doubt. With a per-

cutaneous approach, measurements using a
sleeve measure may be difficult because of the
surrounding soft tissues; therefore, preoperative
estimation of length using CT scans or a second
K wire of the same length to approximate the
difference is recommended. Some authors have
indicated that they drilled the wire further into
the trapezoid bone to fix it [18]. This injurs
crossing cartilage, so the authors do not recom-
b
mend this method.
In case no self-drilling screw is available, pre-
drilling can be performed with the guidewire in
place. Drilling should be stopped if any resis-
tance is encountered as the guidewire may bend
and be at risk of breakage. A bent wire can usu-
ally be drilled further until the straight part of the
wire is encountered. After drilling, a cannulated
screw is carefully inserted under visualization via
Fig. 25.6 (a, b) Intraoperative image intensifier views image intensifier to avoid loss of reduction sec-
after bicortical guidewire insertion (a) and fracture fixa- ondary to rotational forces or fragment distrac-
tion using a cannulated self-drilling double-threaded com- tion. Whilst inserting the screw, palpable
pression screw (b) compression of the fracture gap and tight anchor-
ing of the implant are noted (Fig. 25.6b).
pole using a guide sleeve. A virtual line parallel to Following wire extraction and final image inten-
the adducted thump may serve as an auxiliary line. sifier viewing, anteroposterior, lateral, and oblique
The K wire should be placed bicortical without supinated/pronated views should enable approxi-
injuring the proximal cartilage (Fig. 25.6a). If the mation of central screw positioning without joint
positioning is inadequate, a second K wire may be penetration in either scaphotrapezial or radiocarpal
used that is positioned parallel to the first one in a aspects. Non-penetrating subchondral screw posi-
more optimal position. In some cases, the trapezial tioning should be obtained under direct view if an
bone interferes with wire positioning, leading to open approach is performed. Postoperative and fol-
suboptimal wire positioning that is too volar or hori- low-up radiographs are shown in Fig. 25.7.
zontal and necessitates repositioning under fluoro-
scopic control. Therefore, in rare cases, it is
necessary to insert the wire through the trapezium Summary of Tips, Tricks, and Pitfalls
that does not seem to increase morbidity [18].
During image intensifier control, it is important to • The use of self-tapping and self-drilling
keep the wrist at maximum flexion to prevent wire screws reduces the risk of loss of fracture
bending. Therefore, the anteroposterior view is only reduction during fixation.
possible with the forearm in a vertical position. • An open approach facilitates reduction con-
After correct guidewire positioning and fluo- siderably because of direct visualization of the
roscopic guidance, control of reduction length fracture.
measurement is ensued. The screw length is • During the whole procedure, secure maximum
usually 22–26 mm. To prevent screw promi- extension is necessitated for a palmar
nences at any end that would necessitate implant approach, or maximum flexion is necessitated
removal at a later time, it is recommended to use for a dorsal approach.
244 A. Herlyn and A. Wichelhaus

a b

c d

Fig. 25.7 (a–d) Postoperative (a, b) and follow-up radiographs 8 weeks after surgery (c, d) following open reduction
and screw fixation using an open volar approach
25  Scaphoid Fracture 245

References 10. Oduwole KO, Cichy B, Dillon JP, et al. Acutrak ver-
sus Herbert screw fixation for scaphoid non-union and
delayed union. J Orthop Surg. 2012;20(1):61–5.
1. Schmitt R, Lanz U. Bildgebende Diagnostik der
11. Trumble TE, Clarke T, Kreder HJ. Non-union of the
Hand. Stuttgart, Germany: Thieme; 2013.
scaphoid. Treatment with cannulated screws com-
2. Taleisnik J. Fractures of the carpal bones. In: Green
pared with treatment with Herbert screws. J Bone
DP, editor. Operative hand surgery, vol. 2. New York:
Joint Surg Am. 1996;78(12):1829–37.
Churchill Livingstone; 1988. p. 813–40.
12. Duckworth AD, Ring D. Carpus fractures and disloca-
3. Reigstad O, Grimsgaard C, Thorkildsen R, et al.
tions. In: Court-Brown CM, Heckmann JD, McQueen
Scaphoid non-unions, where do they come from? The
MM, et al., editors. Rockwood and Green’s fractures
epidemiology and initial presentation of 270 scaphoid
in adults, vol. 1. Philadelphia: Wolters Kluwer; 2015.
non-unions. Hand Surg. 2012;17(3):331–5. https://
p. 1019–25.
doi.org/10.1142/S0218810412500268.
13. Slade JFIII, Jaskwhich D. Percutaneous fixation of
4. Slutsky DJ, Slade JFIII. The scaphoid. Stuttgart:
scaphoid fractures. Hand Clin. 2001;17(4):553–74.
Thieme; 2010.
14. Dias JJ, Singh HP. Displaced fracture of the waist of
5. Duckworth AD, Ring D. Carpus fractures and disloca-
the scaphoid. J Bone Joint Surg Br. 2011;93(11):1433–
tions. In: Court-Brown CM, Heckmann JD, McQueen
9. https://doi.org/10.1302/0301-620X.93B11.26934.
MM, et al., editors. Rockwood and Green’s fractures
15. Vinnars B, Pietreanu M, Bodestedt A, et al.

in adults, vol. 1. Philadelphia: Wolters Kluwer; 2015.
Nonoperative compared with operative treatment of
p. 1008–9.
acute scaphoid fractures. A randomized clinical trial.
6. Herbert TJ, Fisher WE. Management of the fractured
J Bone Joint Surg Am. 2008;90(6):1176–85. https://
scaphoid using a new bone screw. J Bone Joint Surg
doi.org/10.2106/JBJS.G.00673.
Br. 1984;66(1):114–23.
16.
Sauerbier M, Schaedel-Hoepfner M, Mehling
7. Duckworth AD, Ring D. Carpus fractures and disloca-
IM. Die Behandlung der frischen Skaphoidfraktur.
tions. In: Court-Brown CM, Heckmann JD, McQueen
Handchirurgie Scan. 2013;2(4):313–33. https://doi.
MM, et al., editors. Rockwood and Green’s fractures
org/10.1055/s0033-1359021.
in adults, vol. 1. Philadelphia: Wolters Kluwer; 2015.
17. Adamany DC, Mikola EA, Fraser BJ. Percutaneous
p. 1010–7.
fixation of the scaphoid through a dorsal approach: an
8. Sugathan HK, Kilpatrick M, Joyce TJ, et al. A bio-
anatomic study. J Hand Surg [Am]. 2008;33(3):327–
mechanical study on variation of compressive force
31. https://doi.org/10.1016/j.jhsa.2007.12.006.
along the Acutrak 2 screw. Injury. 2012;43(2):205–8.
18. Geurts G, van Riet R, Meermans G, et al. Incidence
https://doi.org/10.1016/j.injury.2011.07.011.
of scaphotrapezial arthritis following volar percuta-
9. Beadel GP, Ferreira L, Johnson JA, et al.
neous fixation of nondisplaced scaphoid waist frac-
Interfragmentary compression across a simulated
tures using a transtrapezial approach. J Hand Surg
scaphoid fracture—analysis of 3 screws. J Hand Surg
[Am]. 2011;36(11):1753–8. https://doi.org/10.1016/j.
[Am]. 2004;29(2):273–8.
jhsa.2011.08.031.
 Perilunate Dislocation
26
Laurent Obert, Francois Loisel, and Daniel Lepage

Anatomical Fracture Location poor, with slight cracking noises upon examina-
tion of the wrist that has only slightly increased
Perilunate dislocation of the carpus is defined as in volume. There is nonetheless an important
loss of contact between the capitate and the sign: it is difficult to extend the fingers. The diag-
lunate; it accounts for 5–10% of all carpal inju- nosis can be made based on AP X-rays (the lunate
ries. These dislocations follow multiple trauma in has a pyramid-like aspect, the Gilula lines are
10% of cases and always result from high-energy disturbed) and lateral X-rays (the lunate has lost
injuries, when the wrist is more or less locked in its normal ratios with the radius and the capitate,
hyperextension (motorcycle handlebars) or it is dislocated forward or backward from the
resulting from falls from a height. The distal row radius) (Fig. 26.2). In one quarter of cases, poste-
of the carpus is very solidly attached to the meta- rior perilunate dislocation is not detected because
carpals, and the proximal row is blocked between of a lack of diagnostic rigor and/or a poorly inter-
the radius and the distal row; the lesions therefore preted or absent lateral X-ray. However, in the
occur in the proximal row (Fig. 26.1). context of a patient that needs to be resuscitated,
an AP X-ray alone can be misleading and the
absence of a lateral image can lead to misjudging
Brief Preoperative Planning the lesions. The capitate is displaced backward
from the radius, and the lunate can remain under
Oedema and thickening of the wrist are different the radius (stages I and II) (Fig. 26.3) or be dislo-
from what is observed in fractures of the distal cated forward (stage III). Two-thirds of the peri-
radius. If the patient is conscious, there is pain on lunate dislocations are dorsal and associated with
both sides of the wrist, sometimes with paresthe- scaphoid fractures (Fig. 26.4); in this case, the
sia of the median nerve, but the clinical picture is trauma forces were applied to the scaphoid rather
than to the scapholunate ligament. In two-thirds
of cases, there is another associated fracture
caused by the severity of the injuring forces:
L. Obert, M.D. (*) • F. Loisel, M.D. lesions in the antebrachial area (distal radioulnar
D. Lepage, M.D., Ph.D. dislocation, Galeazzi fracture) or in the elbow, as
Orthopedic, Traumatology, and Hand Surgery Unit,
University Hospital CHRU Besancon, Medical well as intracarpal lesions with osteochondral
School, University of Bourgogne - Franche Comte, fractures of the top of the capitate, the tip of the
Research Unit: Nano Medicine, Besancon, France styloid, and avulsions of the anterior pole of the
e-mail: laurentobert@yahoo.fr; triquetrum.
lobert@chu-­besancon.fr

© Springer International Publishing AG 2018 247

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_26
248 L. Obert et al.

Fig. 26.1  Perilunate dislocation is a spectrum of injuries secondary to high-energy trauma at wrist level, in exten-
sion at radiocarpal level but with a flexion at finger level. Palmar capsule is a weak zone

Fig. 26.2  An example of perilunate dislocation with styloid fracture which contains the radio carpal ligaments. In this
case the fixation of the styloid and the reinsertion of radio carpal ligaments both allow to stabilize the radiocarpal joint

Patient Set-Up in Theatre Closed Reduction Manoeuvres

Standard table is used, patient in supine position, The injury must be reduced as soon as possible
surgeon on the side of the patient’s head (depend- under general anaesthesia in the operating room,
ing on the dominant hand of the surgeon), and with 5–7 kg of traction, possibly using a digital
image intensifier coming from lateral side posi- traction system. With the wrist flexed, the thumb
tioning, under tourniquet (250 mmHg) (Fig. 26.5). pushes forward on the lunate, whereas the index
26  Perilunate Dislocation 249

Fig. 26.3  Perilunate stage 1 (left) and stage 2 (right) dislocation

Fig. 26.4  Perilunate dislocation with

scaphoid fracture
250 L. Obert et al.

Fig. 26.5  Patient in supine position, tourniquet, and C arm are mandatory

exerts a posterior counterpressure. The lunate is Posterior approach is longitudinal on the skin.
reduced gently with the thumb and the wrist is A retinaculum flap radially based allows an
moved in dorsiflexion. This manoeuvre should be access to different extensor compartments.
easy, but traction is long (10–15 min). Surgical Arthrotomy can be performed in different ways
stabilization is ideally performed at the same (Fig. 26.6): we prefer the Herzberg “Z” approach
time or in the following days, depending on the (Fig. 26.7) in case of breaches in dorsal capsule
patient’s condition, but can be delayed in the fol- and extrinsic ligaments or detachment of capsule
lowing days. Even if 40% of perilunate disloca- and ligaments from the distal rim of radius in
tions remain reduced, surgical stabilization is case of intact capsule (Fig. 26.8). The posterior
imperative in all cases. interosseous nerve is resected due to the opening
of the capsule.

Surgical Approach
Open Reduction Manoeuvres
Volar and dorsal approaches each have advan-
tages and drawbacks. Herzberg reports that a After appropriate exposure of the dorsal carpus,
combined volar and dorsal approach improves the carpal bones are identified clinically as well
exposure, but increases the possibility of postop- as with fluoroscopy. Any free osteochondral
erative fibrosis and stiffness. Dorsal approach debris are removed. After ligamentous injury
allows a perfect view on the first row which has scaphoid tends to go into palmar flexion, whereas
to be reduced and fixed. Even if median nerve has triquetrum extends. The first phase consists of
to be released, it does not justify to perform a pal- reducing the lunate, which can be very unstable,
mar approach. in pushing it between the radius and the capitate.
26  Perilunate Dislocation 251

Fig. 26.6  Incision of capsule and extrinsic ligaments can be done following the direction of extrinsic dorsal ligaments
(Z incision) or with a detachement of the capsule from the distal rim of the dorsal radius

If reduction is not easily possible, 1.4-mm joint are each immobilized by K wires. Those K
Kirschner wires can be used as “joysticks” to wires will be put in place, checked, and left in
manipulate each bone. After reduction, lunate place for 2–3 months and reconstruction of liga-
has to cover the entire head of the capitate. ments done (Fig. 26.11). Radiolunate arthrodesis
Anchors are inserted into bones of first row K wire can be removed or left in place for
(Fig.  26.9). The proper lateral position of the 2 months. In cases where associated scaphoid
lunate under the radius and above the capitate fracture is present, first placing osteosynthesis of
bone must be verified under fluoroscopy, and this the scaphoid makes it possible to proceed to
reduction is maintained in introducing 1.4-mm scapholunate pinning if the scapholunate liga-
Kirschner wires to immobilize radio lunate joint ment is intact. Postoperative immobilization is
(Fig. 26.10). Then, reduction of bone of the first done for 2 months.
row is done; the scapholunate and lunotriquetral
252 L. Obert et al.

Fig. 26.7  Herzberg “Z” approach and view on the first row

Fig. 26.8  Detachment of the capsule allow a “sur mesure” reinsertion by anchors more or less distally on the dorsal
rim of distal radius

Summary of Tips, Tricks, and Pitfalls • Closed reduction can only be maintained for a
short period with cast immobilization.
• Advanced imaging is not necessary for diag- • The optimal timing of definitive surgery for a
nosis of perilunate dislocations among experts, manipulatively reducible dislocation is within
but 2-D and 3-D CT might be helpful in evalu- a week after injury.
ating of complexity. • The surgical approach should be based on the
• Manipulative reduction is mostly unsuccess- surgeon’s preference and individualized for
ful if not performed within the first few days. the patient.
26  Perilunate Dislocation 253

Fig. 26.9  Reduction of the bones of the first row is facilitated using Kirschner wire as “joysticks”

Fig. 26.10  A temporary fixation of the radio lunate joint allows to reduce anatomically the lunate

• The results of treatment with temporary • There is no evidence to determine the best
screws and temporary K wires are methods for reduction (open or closed), liga-
comparable. ment repair or reattachment, or immobiliza-
• The most important factors predicting impair- tion. Percutaneous reduction and fixation
ment and disability are delay in treatment, without direct ligament repair is appealing,
open injury, and osteochondral fracture of the but the little data published on this technique
capitate head. suggest that it is inferior to open techniques.
• Clinical outcomes are often substantially bet- Arthroscopy has to demonstrate now the ben-
ter than radiographic outcomes. efit but probably will become.
254 L. Obert et al.

Fig. 26.11  Ligament reconstruction is not always possible, but suture anchor is a support for ligament healing

Kremer T, Riedel K. Perilunate disclocations. In: Garcia

Further Reading Elias M, Mathoulin C, editors. Articular injury of the
wrist FESSH instructional course Book. Stuttgart,
Herzberg G. Perilunate and axial carpal dislocations Germany: Thieme; 2014. p. 52–60.
and fracture-dislocations. J Hand Surg [Am]. Obert L, Loisel F, Jardin E, Gasse N, Lepage D. High-­
2008;33:1659–68. energy injuries of the wrist. Orthop Traumatol Surg
Buijze GA, Doornberg JN, Ring D. Perilunate disclo- Res. 2016;102:S81–93.
cations. In: Bhandari M, editor. Evidence-based
orthopedics. Hoboken, NJ: Wiley-Blackwell; 2012.
p. 437–42.
 Metacarpal Fractures
27
Sam Vollans

Anatomical Fracture Location stable within traditional casts or splints and can
be managed definitively in this way. If unstable
The annual incidence of metacarpal fractures has however, then it must be stabilised through per-
been reported to be 16.1 per 10,000 people [1]. cutaneous or internal fixation to aid bone heal-
Non-union is a rare complication of the nonop- ing and allow early range of movement. If the
erative management of metacarpal fractures. It is fracture cannot be reduced closed, it requires
however encountered more commonly following open reduction and fixation. The specific indi-
poor reduction and fixation of fractures. In addi- cations for fixation of all types of metacarpal
tion, malunion, though often found in fractures fracture are outside the remit of this chapter,
treated nonoperatively, is most commonly asymp- but the above basic principles will serve as a
tomatic. Some patients, however, have significant general guide.
functional problems following malunion [2, 3]. Below, we give examples of different metacar-
The challenge, therefore, is to identify which pal fractures requiring surgical reduction and
metacarpal fractures require fixation to prevent fixation (shaft, head and base). We discuss the
symptomatic malunion and, in doing so, respect different techniques employed and the instru-
the biology and mechanisms of bone healing to mentation required.
prevent non-union.
Two factors will aid decision-making, dis-
placement and stability. If a metacarpal fracture Metacarpal Shaft Fracture
is displaced, then one needs to ask whether this
displacement will cause unacceptable defor-  natomical Fracture Pattern
A
mity, unacceptable function or post traumatic The AP radiograph of the right hand shows a
arthritis. If the answer is yes, the fracture must mid-shaft ring finger short oblique metacarpal
be reduced whether by closed or open tech- fracture with a small degree of comminution
niques. If reducible closed, the fracture may be (Fig. 27.1). The radiographs reveal shortening of
the metacarpal with loss of the normal length
progression of the metacarpal heads. This degree
S. Vollans, F.R.C.S. (Orth) of shortening may lead to extensor lag and so is a
Consultant Upper Limb Surgery, Department of
relative indication for fixation. The length of the
Trauma and Orthopaedics, Leeds General Infirmary,
Leeds, UK main fracture appears less than two times the
e-mail: s.vollans@me.com diameter of the bone, so fixation with a plate is

© Springer International Publishing AG 2018 255

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_27
256 S. Vollans

Theatre Setup
The vast majority of hand fractures requiring sur-
gery can be treated as ambulatory day case
patients, awake and with an appropriate regional
block. The patient is positioned supine with an
arm table. The surgeon is sat at the head end
(since the dorsum of the hand naturally falls that
way) with the mini c-arm or image intensifier
brought in from the axilla when required. The
assistant or scrub nurse can position themselves
beside the surgeon with ease.

Surgical Approach

Metacarpal fractures are fixed via a dorsal

approach. If a single metacarpal is to be fixed, an
incision directly over the bone is utilised. If mul-
tiple metacarpals are to be fixed, a single incision
between a pair of metacarpals can be used to
access two bones.
The clinical photograph shows the incision
directly over the ring finger metacarpal. The expo-
sure continues to the side of the extensor tendon
Fig. 27.1  AP radiograph* of the right hand showing a dividing and tagging the juncturae tendinum as in
mid-shaft ring finger short oblique metacarpal fracture
(*Radiograph and clinical photographs courtesy of Mr. B this case, which will be repaired at the end (Fig. 27.2).
Thé, Consultant Hand Surgeon, Amphia Ziekenhuis, If the fracture is a long spiral pattern, one must
Breda, Netherlands) at least expose each end of the fracture site to
ensure correct reduction of both length and
indicated, with or without a lag screw. If the frac- rotation (Figure 27.3 shows the short oblique frac-
ture length was longer (2–3 times the diameter of
the bone or more), then fixation with two or three
lag screws without a plate should be adequate to
allow early mobilisation.

Pre-op Planning
The key to a successful clinical outcome is pre-
venting post-op stiffness. For that reason, direct
reduction and stability leading to primary bone
healing without callous is what is required. Lag
screw fixation is the gold standard for interfrag-
mentary compression in the hand, with compres-
sion plating only reserved for transverse fractures
and very short oblique fractures. In the case we
present, we would attempt a lag screw between
the two major fragments and neutralise the frac- Fig. 27.2  Incision directly over the ring finger metacar-
ture with a plate, aiming for two screws on each pal (exposure continues to the side of the extensor tendon
side of the fracture (four cortices). dividing and tagging the juncturae tendinum)
27  Metacarpal Fractures 257

Fig. 27.3  Short oblique fracture has been exposed and

cleared of haematoma to enable direct reduction Fig. 27.4  Reduction of metacarpal fracture using one
techniques mini-fragment pointed reduction forceps

ture has been exposed and cleared of haematoma

to enable direct reduction techniques).

Reduction Manoeuvres
and Instruments

If planning to plate a metacarpal fracture as in

this case, open reduction is usually required. This
is because the hand is often quite swollen and the
surround structures prevent insertion of a plate
through smaller (minimally invasive) incisions.
The reduction is most commonly achieved by
Fig. 27.5 Stabilisation of the fracture with a mini-­
applying traction and then using one (for short fragment plate
oblique fractures) or two (for long spiral frac-
tures) mini-fragment pointed reduction forceps,
as seen in this case to hold the reduction out to Two bicortical screws are inserted to each side
length (Fig. 27.4). of the fracture in non-locking mode if the bone is
of good quality as in this case. The final radio-
graphs are seen in Fig. 27.6. The ulnar side of the
Implant Insertion hand will be protected for a week until the wound
heals and then fully mobilised without restriction
With the fracture now reduced, a 2 mm drill is thereafter to prevent stiffness.
used to drill perpendicular to the fracture site
through near and far cortices prior to over-­drilling
the near cortex with a 2.7 mm drill. This allows a Metacarpal Head Fractures
2.7 mm lag screw to compress the fracture which
should now hold the fracture reduced and allow In complex metacarpal head fractures, the prin-
release of the bone reduction clamp. Finally, a ciple is to trap smaller fragments between the
mini-fragment plate is placed after having been bigger fragments rather than try and hold every
pre-bent to match the convexity of the dorsum of fragment with instrumentation. Through an
the metacarpal, Fig. 27.5. extensor tendon split, small elevators, dental
258 S. Vollans

Fig. 27.6  AP and

oblique radiographs of
right-hand ring
metacarpal
demonstrating open
reduction internal
fixation (lag screw and
mini-fragment plate)

Fig. 27.7 Preoperative
and postoperative
radiograph*
demonstrating little
finger metacarpal head
fracture and its
subsequent fixation with
1.5 mm threaded screws
(*Radiographs courtesy
of Mr. D Dewar,
Consultant Hand
Surgeon, Leeds General
Infirmary, Leeds, UK)

picks and 1–1.25 mm K-wire joysticks are used This is to allow healing of the intermetacarpal
to position fragments prior to fixing them with ligaments which provides stability. In these cases
1.5 mm fully threaded screws (Fig. 27.7). closed reduction is almost always successful with
longitudinal traction and pressure directed pal-
marwards to the CMCJ base. The little finger
Metacarpal Base Fractures CMCJ is held in joint via a percutaneous K-wire
through the metacarpal base driven into the
Comminuted fractures at the base of the metacar- hamate. The ring finger fracture is additionally
pals, especially in the ring and little finger, are stabilised by transfixing the metacarpal shafts of
frequently associated with dislocations as can be the little and ring finger. This acts as an internal
seen in Fig. 27.8. In these cases restoration of the ex-fix construct to offload the comminuted frac-
alignment of the carpometacarpal joint (CMCJ) ture at the base of the ring finger, providing rela-
and the length of the metacarpal is the priority. tive stability (Fig. 27.8).
27  Metacarpal Fractures 259

Fig. 27.8  Preoperative and postoperative radiograph* the metacarpal base driven into the hamate, while the ring
demonstrating a comminuted fracture at the base of the finger fracture is additionally stabilised by transfixing the
right ring and little finger metacarpals associated with dis- metacarpal shafts of the little and ring finger (*Radiographs
location. Following closed reduction, the little finger courtesy of Mr. D Dewar, Consultant Hand Surgeon,
CMCJ is held in joint via a percutaneous K-wire through Leeds General Infirmary, Leeds, UK)

Summary of Tips, Tricks and Pitfalls tex). In these cases the bone, whether lagged
or not, will deform at the fracture site to con-
• Since non-union is a feared complication of form to the plate rather than the plate con-
open reduction with internal fixation, the biol- forming to the bone. This will result in either
ogy of bone healing must be respected. Fixing the volar or dorsal aspect of the fracture being
the fracture anatomically, with a sound con- held in distraction and risking non-union.
struct as well as interfragmentary compression • Fourthly, plates must be pre-bent to match the
will more than likely lead to a good result. contour of the bone exactly prior to applying
There are a number of tips and tricks to get this them to the fixation construct.
right. • Finally, stress your fixation at the end of the
• Firstly, only expose what you need to subperi- case to confirm the patient can mobilise their
osteally by starting at each end of the fracture hand from the outset to prevent stiffness.
zone, exposing the apices and reducing them
as described previously. Only strip the central
injury zone periosteum if required to reduce
the fracture; otherwise preserve as much blood References
supply along the fracture edges as possible.
• Secondly, lag the fracture only once it has 1. Karl JW, Olson PR, Rosenwasser MP. The epidemiol-
ogy of upper extremity fractures in the United States,
been reduced anatomically. A malreduced 2009. J Orthop Trauma. 2015;29(8):e242–4.
fracture fixed in distraction will almost cer- 2. Wong VW, Higgins JP. Evidence-based medicine:
tainly develop a non-union, and the metalwork management of metacarpal fractures. Plast Reconstr
will eventually fail. Surg. 2017;140(1):140e–51e.
3. Melamed E, Joo L, Lin E, Perretta D, Capo JT. Plate
• Thirdly, do not overbend plates to compress fixation versus percutaneous pinning for unstable
fractures (as one would with a forearm frac- metacarpal fractures: a meta-analysis. J Hand Surg
ture to generate compression on the far cor- Asian Pac Vol. 2017;22(1):29–34.
 Bennett Fracture and Fracture
of Trapeziometacarpal Joint 28
of the Thumb

Laurent Obert, Gauthier Menu, Daniel Lepage,

and Francois Loisel

 natomical Fracture Location

A In the Bennet fracture, the volar ulnar aspect of
and Treatment the metacarpal base remains attached to the volar
oblique ligament which holds this fragment fixed
A Bennett fracture is a fracture-dislocation of the while causing thumb instability. The adductor
thumb CMC joint. However, different types of pollicis (AP) and AP longus are the primary
fracture patterns can be described [1] (Fig. 28.1). deforming forces and combine to supinate,

Fig. 28.1  Bennett fracture (left), extra-articular (middle) or articular and comminuted fracture (Rolando, right)

L. Obert, M.D. (*) • G. Menu, M.D.

D. Lepage, M.D., Ph.D. • F. Loisel, M.D.
Orthopedic, Traumatology, and Hand Surgery Unit,
University Hospital CHRU Besancon, Medical
School, University of Bourgogne-Franche Comte,
Research Unit: Nano Medicine, Besancon, France
e-mail: laurentobert@yahoo.fr;
lobert@chu-­besancon.fr

© Springer International Publishing AG 2018 261

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_28
262 L. Obert et al.

adduct and flex the metacarpal shaft. The articu- Articular fracture can be treated by open
lar portion of the fracture must be fully reduced. reduction and fixation (direct or indirect fixation
Without stabilization, the metacarpal will tend to depending on the volume of bone) by lost key
further displace. wire technique, screws or mini plate.

Preoperative Planning Patient Setup in Theatre

Kapandji views allow to diagnose extra-articular Standard table is used with the patient in the
or articular fractures. CT scan is mandatory to supine position. The surgeon stands on the side of
analyse the volume of bone fragments and to the patient’s head (depending on the dominant
select the best option for fixation (Fig. 28.2). hand of the surgeon) while the image intensifier
Extra-articular fractures can be treated by is coming from the opposite side (Fig. 28.3). An
closed reduction and fixation by Kirschner wire arm tourniquet is recommended for open
or temporary arthrodesis. approaches.

Fig. 28.2  Kapandji view and CT scan can be helpful to analyse the bone fragment and to decide the appropriate
method of fixation

Fig. 28.3  Patient is

placed in supine position
with arm tourniquet. C
arm is positioned from
the surgeon’s opposite
side
28  Bennett Fracture and Fracture of Trapeziometacarpal Joint of the Thumb 263

Closed Reduction Manoeuvres articular fracture patterns usually require open

reduction and fixation. Passive screw home
Axial traction, palmar abduction and slight pro- torque technique method facilitates reduction in
nation done by the assistant allow to reduce artic- acute (fresh) cases (Fig. 28.4).
ular or extra-articular fractures. Comminuted

Closed Reduction and Fixation

Extra-articular fracture, damaged skin in the

zone of incision and choice of the surgeon are
the main reasons to choose this type of treat-
ment. A 1.8 mm Kirschner wire is inserted per-
cutaneously at metacarpal head level (Fig. 28.5)
under X-ray control to reach the trapezium [2].
Temporary arthrodesis of TMC joint is done
for 6 weeks protected by a thumb spica for
6 weeks.

Open Reduction and Fixation

Impossible closed reduction, articular fracture

involvement and associated trapezium fracture
are the main reasons to select this type of
­treatment [3]. A dorsal approach or an
Fig. 28.4  Passive screw home torque technique consists extended J approach to volar side is possible
of doing a thumb traction and a pronation manoeuvre (Fig. 28.6).

Fig. 28.5  Kirschner wire is inserted as distal as possible at metacarpal head level, crossing the joint for stability
264 L. Obert et al.

 urgical Approach and Reduction

S
Instruments

Dorsal approach is easier than volar which needs

to strip the thenar intrinsic muscles (Fig. 28.7).
Dorsal surgical approach is carried out without
dissection of radial nerve but identification of EPB
and APL (Fig. 28.8). A dorsal periosteal proxi-
mally based flap is raised (Figs. 28.9 and 28.10) to
reach the joint, exposing the base of the metacar-
pal and allowing reduction of the articular surface
Fig. 28.6  A dorsal approach can be extended to volar
(Fig.  28.11). Howard rugine (left) or AO rugine
approach
(right) allows to reduce the fragments (Fig. 28.12).
Volar bone fragment is maintained by the rugine
and fixed under X-ray control by K wires or

Fig. 28.7  Representation of the articular zone of the Fig. 28.8  Extensor pollicis brevis (EPB) is the landmark
metacarpal base on a frontal anatomical view of the dorsal approach

Fig. 28.9  The dorsal capsular-periosteal flap is raised as large as possible

28  Bennett Fracture and Fracture of Trapeziometacarpal Joint of the Thumb 265

Fig. 28.10  The dorsal capsular-periosteal flap is raised with a proximal base

Fig. 28.11  The view on the articular surface is sufficient to reach and manipulate the articular fragment
266 L. Obert et al.

Fig. 28.11 (continued)

Fig. 28.12  The most

appropriate rugine is
used to manipulate and
control the articular
fragment
28  Bennett Fracture and Fracture of Trapeziometacarpal Joint of the Thumb 267

Fig. 28.13  Indirect fixation is controlled under X-ray with an appropriate length of threaded Kirschner wire

c­ annulated screws (Fig. 28.13). Periosteal flap is Summary of Tips, Tricks and Pitfalls

reinserted by anchors or transosseous suture on
metacarpal bone. Kapandji view allows final • Reduction and fixation are mandatory for
assessment of fixation (Fig. 28.14). A thumb spica fractures of first metacarpal base.
is mandatory for 4 weeks. Figure 28.15 demon- • Kapandji view allows to analyse the fracture
strates good functional results and a Kapandji preoperatively, intraoperatively and
X-ray view at 1 year of follow-up. postoperatively.
268 L. Obert et al.

Fig. 28.14  The final check radiograph after fixation has to be done in the operating room

Fig. 28.15  At 1-year follow-up, clinical pictures demonstrating a full range of motion; radiograph shows maintenance
of anatomical reduction
28  Bennett Fracture and Fracture of Trapeziometacarpal Joint of the Thumb 269

Fig. 28.15 (continued)

• The passive screw home torque technique 2. Ollie Edmunds J. Traumatic dislocations and instabil-
method facilitates reduction in acute (fresh) ity of the trapeziometacarpal joint of the thumb. Hand
Clin. 2006;22:365–92.
cases. 3. Liverneaux PA, Ichihara S, Hendriks S, Facca S,
• Dorsal approach using a periosteal flap Bodin F. Fractures and dislocation of the base of the
remains a simple way to perform an anatomi- thumb metacarpal. J Hand Surg Eur. 2015;40:42–50.
cal reduction and fixation by pin or screw.

References
1. Kapandji A, Moatti E, Raab C. Specific radiography
of the trapezo-metacarpal joint and its technique. Ann
Chir. 1980;34:719–26.
 Hand-Phalanx Fracture-­
Dislocation (PIP Joint) 29
Laurent Obert, Margaux Delord, Gauthier Menu,
Damien Feuvrier, Isabelle Pluvy,
and Francois Loisel

 natomical Fracture Location

A Preoperative Planning
and Treatment
AP and sagittal views are necessary to diagnose
In case of fracture dislocation of proximal inter- the dislocation which can be misdiagnosed.
phalangeal joint (PIP), the indication for surgery Dorsal or volar fragment will guide the surgeon
is a non-concentric PIP joint. If a concentric to choose the right approach. CT scan is helpful
reduction can be achieved (flexing the joint), a to analyse the volume of bone fragments to
dorsal block splint in flexion for several weeks choose the best fixation (Fig. 29.1). Articular
can be advised. External fixation devices are fracture can be treated by open reduction and
available to maintain reduction whilst allowing fixation (direct or indirect fixation depending on
early motion. If over 40–50% of the joint surface the volume of bone) by lost key wire, screw and
is involved, open surgery is mandatory to restore temporary fixation of the joint for 3 weeks.
the joint congruity. Depending on the size of the
fragment and preoperative delay, options include
ORIF, volar plate arthroplasty and hemi-hamate Patient Setup in Theatre
arthroplasty or chondrocostal graft. We will pres-
ent the ORIF technique for recent fracture and Standard table is used with the patient in supine
joint dislocation. position. The surgeon stands on the side of the
patient’s head (depending on the dominant hand
of the surgeon). The image intensifier is posi-
tioned from the opposite side (Fig. 29.2). An arm
tourniquet is applied.

L. Obert, M.D. (*) • M. Delord, M.D.

G. Menu, M.D. • D. Feuvrier, M.D.
I. Pluvy, M.D. • F. Loisel, M.D.
Closed Reduction Manoeuvres
Orthopedic, Traumatology, and Hand Surgery Unit,
University Hospital CHRU Besancon, Medical Axial traction done by the assistant allows to
School, University of Bourgogne - Franche Comte, reduce the joint. A temporary fixation of the joint
Research Unit: Nano Medicine, Besancon, France
e-mail: laurentobert@yahoo.fr;
by Kirschner wire can be done under X-ray
lobert@chu-­besancon.fr control.

© Springer International Publishing AG 2018 271

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_29
272 L. Obert et al.

Fig. 29.1  CT scan demonstrates the number, degree of displacement and volume of fragments

Fig. 29.2  Patient is

placed in supine position
with an arm tourniquet
29  Hand-Phalanx Fracture-Dislocation (PIP Joint) 273

 urgical Approach and Reduction

S Dorsolateral approach is easier than volar and
Instruments allows in all cases to control, reduce and fix the
articular fragment (dorsal or volar). It is some-
The use of a Ioban drape allows to remove the times possible to reduce and to fix the fragment
uninvolved fingers from the surgical field and to percutaneously (Fig. 29.4). If closed reduction is
isolate the injured finger where a dorsolateral or a not followed by anatomical and concentric reduc-
lateral skin incision centred on the PIP joint is tion of the joint, open reduction and fixation is
made [1] (Fig. 29.3). mandatory.

Fig. 29.3  Intraoperative images demonstrating the use of a Ioban drape and the markings for a dorsal incision
274 L. Obert et al.

Fig. 29.4  Radiographs demonstrating

anatomical reduction of the joint
(fixation of the fracture by a Kirschner
wire and of the articular fragment
(palmar one) by a threaded K wire)

After a dorsolateral skin incision, ligaments Temporary fixation of the joint is done by 1.4-­
and palmar plate are reflected to reach the joint mm K wire for 3 weeks (Fig. 29.6). Articular frag-
(Fig.  29.5). The entire articular surface of the ment is maintained and fixed under X-ray control
base of the middle phalanx is then perfectly under by a 1.0- or 1.2-mm K wire or cannulated screw
control. (Fig. 29.7). Ligaments are reattached [2, 3].
29  Hand-Phalanx Fracture-Dislocation (PIP Joint) 275

Fig. 29.5  Intraoperative images: using a dorsolateral approach allows to control the entire articular surface without
tenotomy of extensor tendon

Fig. 29.6  Intraoperative images demonstrating that whilst reduction is not perfect, the joint remains concentric
276 L. Obert et al.

Summary of Tips, Tricks and Pitfalls

• Reduction and fixation are mandatory in case

of articular fracture and non-concentric joint.
• Dorsal approach remains a simple way to per-
form an anatomical reduction and fixation by
K wire or screw.

References
1. Verma MK, Bradley J, Jebson PJ. The Ioban
drape: a simple method to improve finger surgery
safety and efficiency. Tech Hand Up Extrem Surg.
2012;16(4):202–3.
2. De Haseth KB, Ring D. Management of finger
fractures. In: Bhandari M, editor. Evidence-based
orthopedics. Hoboken, NJ: Wiley-Blackwell; 2012.
p. 987–92.
3. Oak N, Lawton JN. Intra articular fractures of the
Fig. 29.7  Intraoperative images: although reduction of
hand. Hand Clin. 2013;29:535–49.
the fragment is anatomical in this case, the temporary
K-wire fixation of the joint is mandatory
 Index

A Bisphosphonates, 13
Acromioclavicular joint dislocation Blade plates, 28
anatomical fracture location, 89 Bone ball spike, 25
closed reduction manoeuvres, 90 Bone clamps, 104
implant insertion, 91 Bone grafting, 11, 144
open reduction manoeuvres, 91 Bone healing, 3–11
patient setup, 90 bone grafting, 11–12
preoperative planning, 89 cells, application of, 12
reduction instruments, 90 diamond concept, 12
shoulder tray, 90 factors, 6, 7
surgical approach, 90, 91 fracture dependent
type V, 89 fixation method and mechanical
Advanced intraoperative 3D imaging, 45, 46 stability, 10–11
Alcohol, 8 fracture personality and location, 9
Anconeus muscle, detach, 139, 167 soft tissue envelope, 10
Anemia, 7 fracture healing over time, evolution, 5
Angular correction, 36 growth factors, application, 12–13
Antibiotics, 8 patient dependent
Anticoagulants, 8 age and gender, 7
AO-A2 and C1 fractures, 204, 205, 207 comorbidities, 7
AO classification, 201, 202 drug administration, 7–8
ARCADIS Orbic 3D devices, 71 genetic predisposition, 9
Arthroscopic assessment, 70 smoking and alcohol, 8–9
Articular comminution, 3D CT, 135 physical stimulation, 13
Articular depression, identification, 52 primary, 3
Articular osteochondral fragments, 33 secondary
Artis zeego, 45 fracture hematoma, 4
Autologous bone grafting, 11 granulation tissue, 5
hard callus, 6
inflammatory phase, 5
B remodeling, 6
Ball-tipped guide wire, 58 soft callus, 5–6
Bennett fracture, 261 systemic biological factors, 13
anatomical fracture location and treatment, 261–262 upregulation, potential applications for, 11
closed reduction and fixation, 263 Bone-holding forceps, 24, 28
closed reduction manoeuvres, 263 Bone hook and spikes, 25
dorsal capsular-periosteal flap, 264, 265 Bone morphogenetic proteins (BMPs), 12
EPB, 264 Bone spreaders, 26, 27
open reduction and fixation, 263, 264 Bone tamp, 33
patient setup, 262 Bone tracker, 42
preoperative planning, 262 Boyd approach, 184
surgical approach and reduction instruments, Bridge plate, 167–169
264–269 Bumps and bolsters, 21

© Springer International Publishing AG 2018 277

P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8
278 Index

C D
Cables, fracture reduction, 28 Deficient cortex, 57
Cannulated screws, 64, 238, 243 Deltoid, 105
Cerclage, 28 Diaphyseal fractures, 32
Clavicle fracture, 97, 98 Direct reduction, 19, 31, 32, 34
anatomical fracture location, 97, 98 Direct vision, 69
implant insertion, 98–99 Distal femoral pin, 21
open reduction maneuver, 98 Distal humerus fractures
patient setup, 98 anatomical fracture location, 133, 134
preoperative planning, 97 closed reduction manoeuvres, 137
surgical approach, 98 lateral view of, 135
Closed reduction, 41, 51 open reduction and fixation, 140–142
acromioclavicular joint dislocation, 90 open reduction manoeuvres, 139, 140
Bennett fracture, 263 patient set-up, 136–137
coronoid fractures, 152, 154 reduction instruments, 137
distal humerus fractures, 137 surgical approach, 137–139
distal ulna fractures, 231 Distal radioulnar joint (DRUJ), 189, 191
forearm fractures, 177, 179, 181 Distal radius fracture
humeral head avulsion, greater tuberosity, 109 A3 and C1–3 fractures, external fixation for, 216–219
humeral shaft fractures, 123 anatomical fracture location, 201
olecranon fractures, 145 AO A2 and C1 fractures, 204, 205, 207
perilunate dislocation, 248 extra-articular AO A3 fractures, 207
proximal humerus fractures, 115 fracture classification and analysis, 201, 204
scaphoid fracture, 239 intra-articular AO B1–3 fractures and C2–3 fractures,
scapula fractures, 103 210–216
Coexisting injuries, 21 operative techniques, 204
Colles fractures, 201 Distal tibial fracture, 23
Collinear reduction clamp, 27 Distal ulna fractures
Computed tomography (CT) scan, 50, 71 anatomical classification, 228
Computer-aided surgery (CAS), 42–44 cadaveric subperiosteal dissection, 231, 232
advanced 3D intraoperative imaging, 45 closed reduction manoeuvres, 231
fracture reduction methods, 44 draping technique, 230
intra-articular fracture fixation, 44–45 fracture patterns, 227
long bone fractures implant insertion, 234–235
closed reduction, 41–42 open reduction manoeuvres, 232–234
control length and rotation, 42–44 patient set-up, 229–230
trauma, 41 styloid fracture and DRUJ dislocation, 229
Condylar blade plate, 28 surgical approach, 231–232
Cone-beam computed tomography (CBCT), 45 toothed reduction clamp, 233
Coronoid fractures treatment and preoperative planning, 228–229
avulsion Double-tipped spear K-wire, 98, 99
closed reduction manoeuvres, 152
open reduction manoeuvres, 152, 153
patient set-up, 151 E
post-operative planning, 153 Elastic stable intramedullary nailing (ESIN), 189
surgery and preoperative planning, indications, 151 Elbow fracture fixation, 144
surgical approach, 152 Electrical stimulators, 13
base of Electrocautery cord, 70
closed reduction manoeuvres, 154 Essex-Lopresti injury, 174, 188
open reduction manoeuvres, 154, 155 Extensor pollicis brevis (EPB), 264
patient set-up, 153 External devices, 19
post-operative planning, 154 External fixator, 20
surgery and preoperative planning, indications, Extra-articular AO A3 fractures, 207–210
153, 154 Extracorporeal shock wave therapy, 13
surgical approach, 154 Extra-vertebral balloon osteoplasty, 49
Coronoid process
C-arm fluoroscopic control, 171
reduction, 170 F
Corticosteroid, 8 Farabeuf forceps, 26
CT scanogram, 72 Femoral distractor, 22
Cytokines, 5 Femoral malrotation, 73, 74
Index 279

FibeWire, 95, 96 Fracture tables, 19, 20

Fibrin, 5 Frykman classification, 201
Fibula shaft fracture, 34 F-tool, 22, 23
Fixation method, 10, 144
Flexor carpi radialis (FCR) sheath, 192, 194, 204, 207
Flexor pollicis longus tendon, 194 G
Fluoroquinolones, 8 Galeazzi fracture
Fluoroscopic technique, 44, 74 anatomical fracture location, 191
Forearm fractures, 182 AP and lateral radiographs, 192, 193
anatomical fracture location, 173–174 closed reduction manoeuvres, 192
AO fracture classification, 176 fixation of, 199
closed reduction maneuvers, 179–181 open reduction and fixation, 195–198
implant insertion, 186–189 open reduction manoeuvres, 194–195
intramedullary nailing, 180 patient setup, 192
open reduction maneuvers, 185 preoperative planning, 191–192
manual traction, 185 reduction instruments, 192
plate distraction, 186 surgical approach, 192–193
temporal external fixation, 185 Genetic predisposition, 9
patient setup, 179 Glenoid, 106
preoperative planning, 176–179 Global positioning systems (GPSs), 41
reduction instruments, 181 Granulation tissue, 5
surgical approach Greater tuberosity, humeral head avulsion
anterior approach, 182 closed reduction manoeuvres, 109
Boyd approach, 184 implant insertion, 110
intramedullary nailing, approach for, 183 open reduction manoeuvres, 110
Kaplan approach, 185 patient setup, 109
Kocher approach, 184 post-op instructions, 110
medial approach, 185 surgery and preoperative planning, indications, 109
posterolateral approach, 182 surgical approach, 109
ulna, lateral approach, 182–183 X-ray image, 109
temporary reduction, 188
Forearm joint, 174
Fracture hematoma, 4 H
Fracture of necessity, 191 Hand-Phalanx fracture-dislocation
Fracture personality, 9 anatomical fracture location and treatment, 271
Fracture reduction, 41 closed reduction manoeuvres, 271
CAS (see Computer-aided surgery (CAS)) patient setup, 271, 272
collinear reduction clamp, 27 preoperative planning, 271, 272
direct reduction, 31 surgical approach and reduction
external devices, 19–24 instruments, 273–276
Farabeuf and Jungbluth forceps, 26 Hard callus, 6
fracture implants, 36–39 Henry approach, 179, 183
implants Herzberg “Z” approach, 252
nails, 27 Hip screw, 28
plates, 27 Hohmann retractor, 22, 24, 25
wires and cables, 28 Hotchkiss, 185
indications Humeral head avulsion, greater tuberosity
direct reduction, 32 closed reduction manoeuvres, 109
indirect reduction, 32–35 implant insertion, 110
indirect reduction, 31–32 open reduction manoeuvres, 110
instrumentation and techniques, 35 patient setup, 109
angular correction, 35–36 post-op instructions, 110
longitudinal correction, 35 surgery and preoperative planning, indications, 109
rotational and multiplanar correction, 36 surgical approach, 109
translational correction, 36 X-ray image, 109
internal devices, 24–26 Humeral nail, 126
Matta clamps, 26 Humeral shaft fractures
mini-distractor and bone spreaders, 27 anatomical fracture location, 121
periarticular clamp, 27 closed reduction manoeuvres, 123–124
preoperative planning, 82 open reduction and fixation, 127–128
spiked disk, 27 open reduction manoeuvres, 126–127
280 Index

Humeral shaft fractures (cont.) Long bone fractures

patient setup, 123 closed reduction, 41
preoperative planning, 121–123 control length and rotation, 42
reduction instruments, 124–125 Longitudinal correction, 35
surgical approach, 125–126 Low-intensity pulsed ultrasonography (LIPUS), 13
Humerus, longitudinal axis of, 133–134
Hybrid plates, 148
Hyperextension, 181 M
Hypothyroidism, 7 Malrotation abnormalities, 72
Matta clamps, 26
Mechanical stability, 10
I Mesenchymal stem cells (MSCs), 3
Ilizarov hybrid technique, 217, 218 Metacarpal fractures
Indirect reduction, 19, 32 anatomical fracture location, 255
Ineffective Poller screws, 64 base, 258, 259
Inflammatory phase, 5 head, 257, 258
Inflatable balloon (IBT), 54 shaft
Inflatable bone tamp, intra-articular fracture reduction anatomical fracture pattern, 255, 256
anatomical fracture location, 49 implant insertion, 257
articular depression, identification, 52–54 pre-op planning, 256
closed reduction manoeuvres, 51 reduction manoeuvres and instruments, 257
instrumentation, 51 surgical approach, 256, 257
patient set-up, 50 theatre setup, 256
preoperative planning, 49–50 Mid-shaft humeral fracture, 122
reduction manoeuvres, 54–55 Miniature robot, 46
Interfragmentary K-wires, 22 Mini C-arm, 239
Internal devices, fracture reduction, 24 Mini-distractor, 27
Interosseous membrane (IOM), 227 Mini-fragment plate, 257
Intra-articular AO B1–3 fractures and C2–3 fractures, 210 Monteggia fractures, 163, 164
Intra-articular fracture fixation, 44 Multifragmentary proximal ulna fractures, 169
Intra-articular fracture reduction, inflatable bone tamp Multilevel fracture, 188
anatomical fracture location, 49 Multiplanar correction, 36
articular depression, identification, 52
closed reduction manoeuvres, 51
instrumentation, 51 N
patient set-up, 50 Nails, 27
preoperative planning, 49 Nonsteroidal anti-inflammatory drugs (NSAIDs), 8
reduction manoeuvres, 54
Intramedullary (IM) nailing, 179, 183, 207
Intraoperative fluoroscopy, 69–70 O
Intraoperative plain radiographs, 70 O-arm imaging system, 71
Olecranon fractures, 146, 147
anatomical fracture location, 143–144
J closed reduction manoeuvres, 145
Joint block, 133 implant insertion
Joystick techniques, 207, 242 type I and IIA, 146–147
Jungbluth forceps, 26 types IIB and III, 147
LCP, 169
open reduction manoeuvres, 145–146
K patient setup, 144–145
Kapandji technique, 22, 205 preoperative planning, 144
Kaplan interval approach, 152, 185 reduction instruments, 145
Kirschner wires, 158, 160 surgical approach, 145
Kocher approach, 184 Olecranon osteotomy, 141
K-wires, 22, 64, 98, 116, 140, 146, 242, 243 osteosynthesis, 142
Kyphon inflatable balloon set, 52 Open reduction, 185, 186
acromioclavicular joint dislocation, 91
clavicle fracture, 98
L coronoid fractures, 152, 154
Laminar spreader, 27 distal humerus fractures, 139
Lesser trochanter profile, 74 distal ulna fractures, 232
Locking Compression Plate (LCP), 178 forearm fractures, 185
Index 281

manual traction, 185 sagittal/frontal planes, 65

plate distraction, 186 second Poller screw, 65
temporal external fixation, 185 Polysling immobilization device, 126
Galeazzi fracture, 194 Posterior dislocation, 94
humeral shaft fractures, 126 Posterior reduction device (PORD™), 21
olecranon fractures, 145 Postoperative roentgenograms, 99, 100
perilunate dislocation, 250 Precision drill, 54
proximal humerus fractures, 117 Preoperative planning
radial head and neck fracture, 159 definition, 77
scapula fractures, 105 digital radiographs and CT scans, 84
ORIF fixation implant, 82
proximal ulna, 167 fracture reduction, 82
radial head, 166, 167 methodology, 78–80
Osborne’s ligament, 139 operative room setup, 80
OSI table, 20, 21 patient setup, 82
Osteoporosis, 79 plate fixation, 82
Osteosynthesis of fractures postoperative considerations, 84
aftercare, 170 process of, 78
bridge plate, 167–169 provisional versus definitive fixation, 80
implant choice, 169 software programs, 84
Monteggia-like lesion, 164–165 surgical approach and pertinent anatomy, 82
ORIF timing of surgery, 80
proximal ulna, 167 Proximal humeral fracture
radial head, 166, 167 closed reduction techniques and manoeuvres, 115–116
patient set-up exposure, 118
posterior approach, 165, 166 implant position, 118–120
prone position, 165 initial assessment, 113
preoperative planning, 163–164 modified axial view, 114
open reduction manoeuvres, 117–118
patient setup, 114–115
P preoperative planning and anaesthesia, 114
Palpation, 69 reduction instruments, 116
Parathyroid hormone (PTH), 13 surgical approach, 116–117
Pelvic external fixator, 20 Proximal interphalangeal joint (PIP), 271
Periarticular clamp, 26, 27 Push-pull reduction device, 25
Perilunate dislocation
anatomical fracture location, 247
closed reduction manoeuvres, 248–250 R
open reduction manoeuvres, 250–252 Radial head and neck fracture
patient set-up, 248 closed reduction manoeuvres, 158
preoperative planning, 247–248 fracture location and pattern, 157, 158
with scaphoid fracture, 249, 252 implant insertion, 159
stage, 249 open reduction manoeuvres, 159
styloid fracture, 248 patient set-up, 158
”sur mesure” reinsertion, 252 preoperative planning, 158
Periosteum, 95 surgical approach, 158–159
Physical stimulation, 13 Radiolucent table, 21
Plate-holding devices, 28 Reamer-irrigator-aspirator (RIA) system, 12
Plate osteosynthesis, 178, 187 Reduction assessment
Platelet-derived growth factor, 12 arthroscopic assessment, 70–71
Platelet-rich plasma (PRP), 12 computed tomography, 71
Plates, 27 direct vision, 69
Pointed reduction forceps, 36 intraoperative fluoroscopy, 69
Point-to-point forceps, 24 intraoperative plain radiographs, 70
Poller screw leg length measurement, 72
application, 64 palpation, 69
cannulated screws, 64 rotational assessment, 72–75
clinical use of, 57–64 3D fluoroscopy, 71–72
distance, 64 Regan-Morrey system, 144
in intramedullary nailing, 58 Regional block, 136
metaphyseal long bone fractures, 65 Remodeling, 6
nail insertion, 64 Reversed Colles fractures, 201
282 Index

Reverse rule of thumb" technique, 58, 62 Spring plate, 28

Robotic execution, 46 Steinmann pins, 64
Roentgenograms, 100 Sternoclavicular joint dislocations
Rotational assessment, 72 anatomical fracture location, 93, 94
Rotational correction, 36 open reduction manoeuvres, 95–96
Runt-related transcription factor 1 pre-op planning, 94
(RUNX1) expression, 5 surgical approach, 94–95
table setup—instrumentation, 94
Sternotomy, 95
S Subtrochanteric femur fracture, 83
Scaphoid fracture, 240, 241 Superior glenoid fragments, 106
anatomical fracture location, 237–238
closed reduction manoeuvres, 239, 240
implant insertion, 242–243 T
open reduction manoeuvres, 241–242 Tenaculum clamps, 160
patient set-up, 239 Tension band wiring (TBW), 144
perilunate dislocation with, 249 Tensioner, 24, 25
preoperative planning, 238–239 Thomson approach, 183
reduction instruments, 239 Three-dimensional (3D) fluoroscopy, 71
surgical approach Tibial fractures, 10
open dorsal approach, 240 Tibial plateau fractures, Schatzker classification, 50
open volar approach, 240, 241 Tibial torsion, 74
percutaneous/minimally invasive Toothed reduction forceps, 24
arthroscopic-­assisted approach, 241 Translational correction, 36
Scapholunate interosseous ligament (SLD), 224 Trapeziometacarpal joint fracture, 261
Scapula fractures, 106 Type I olecranon fractures, 146
anatomical fracture location, 101 Type IIA olecranon fractures, 146, 147
closed reduction manoeuvres, 103 Type IIB olecranon fractures, 144, 147
implant insertion, 107 Type III olecranon fractures, 147–148
open reduction manoeuvres, 105–107
patient setup, 102–103
preoperative planning, 101–102 U
reduction instruments, 104 Ulnar nerve, 138, 154, 166
surgical approach, 101, 104, 105 Ulnohumeral joint, 143
Schanz screws, 22
Siremobil Iso-C 3D, 45
Skeletal traction, 21 V
Small serrated clamps, 195 Varus angulation, 117
Smoking, 8 Verbrugge style forceps, 24
Soft callus, 5
Soft tissue envelope, 10
Sound surgical technique, 10 W
Spiked disk, 27 Weaver-Dunn’ procedure, 89
Spine injury, 79 Weber forceps, 24
Spiral left humeral fracture, 123 Wires, fracture reduction, 28