Orthopedic With Answers Review | Dr Hutaif General Orth -...

Vascular anastamoses are exceedingly difficult with amputations distal to the nail fold as the digital vessels bifurcate or trifurcate at this level, and little functional benefit is gained compared to other means of soft-tissue coverage. Single digit amputations, other than
the thumb, are a relative contraindication for replantation. Replantations at the level of the proximal phalanx lead to poor motion of the proximal interphalangeal joint. In a healthy
active adult, an amputation through the wrist is an appropriate situation to proceed with a replantation. A transverse forearm amputation is a good indication with a warm ischemia time
of less than 6 hours.

Scientific References

: Urbaniak JR: Replantation, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1085.
Boulas HJ: Amputations of the fingers and hand: Indications for replantation. J Am Acad Orthop Surg 1998;6:100-105.

Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of
the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common. When arterial injury follows a lateral compression injury, it is usually related to injury of a more anterior vessel like the obturator artery or a branch of the external iliac artery.
REFERENCES: O’Neill PA, Riina J, Sclafani S, et al: Angiographic findings in pelvic fractures. Clin Orthop 1996;329:60-67.
Belley G, Gallix BP, Derossis AM, et al: Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture. J Trauma 1997;43:703-705.

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is
not indicated.
REFERENCES: Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.

Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw
REFERENCES: Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60.
Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292.
Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.
Vocke AK, Vocke AR: Cartilaginous avulsion fracture of the tibial spine. Orthopedics 2002;25:1293-1294.

Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx. Distal interphalangeal joint flexion is permitted to allow movement of the lateral bands distally and dorsally, preventing contracture.
REFERENCES: Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.
Lovet WL, McCalla MA: Management and rehabilitation of extensor tendon injuries. Orthop Clin North Am 1983;14:811-826.

The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing.
REFERENCES: Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101.
McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk?
J Bone Joint Surg Br 2000;82:200-203.
Keating JF, Orfaly R, O’Brien PJ: Knee pain after tibial nailing. J Orthop Trauma
1997;11:10-13.

Distal radial fractures in children are common, and a large amount of displacement is acceptable. In general, 20° of dorsal displacement and complete bayonet apposition in girls to age 12 years and in boys to age 14 years can be expected to remodel with an excellent outcome. The potential for increased fracture displacement and subsequent malunion may exist in up to one third of patients with displaced fractures with less than anatomic reduction. Therefore, early follow-up is recommended and remanipulation is indicated should loss in reduction occur. Consideration for percutaneous pinning of isolated distal radial fracture is reasonable in patients with little growth remaining. In these patients, higher rates of redisplacement exist with little chance for remodeling.
REFERENCES: Gibbons CL, Woods DA, Pailthorpe C, et al: The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-210.
McLauchlan GJ, Cowan B, Annan IH, et al: Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg Br 2002;84:413-417.
Proctor MT, Moore DJ, Patterson JH: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:453-454.
Roy DR: Completely displaced distal radius fractures with intact ulnas in children. Orthopedics 1989;12:1089-1092.

According to a study by the Scoliosis Research Society, the use of anterior decompression is most predictable for improving neurologic status. This is particularly true of bowel and bladder functional loss. Laminectomy is contraindicated because it further destabilizes the spine. Posterior instrumentation and indirect reduction through distraction and ligamentotaxis only incompletely decompress the compromised canal and are successful only if performed within 48 hours of injury. While some improvement may occur with closed management, the amount of recovery is less than that achieved with surgical decompression. A posterior approach and instrumentation may be added to the anterior decompression based on the characteristics of associated injuries to the posterior element.
REFERENCES: Gertzbein SD: Scoliosis Research Society multicenter spine fracture study. Spine 1992;17:528-540.
Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-215.
Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.

The humerus was treated with an intramedullary nail. Findings from two prospective randomized studies of intramedullary nailing or compression plating of acute humeral fractures have shown approximately a 30% incidence of shoulder pain with antegrade humeral nailing. This is the most common complication in both of these series. Nonunions are present in approximately 5% to 10% of humeral fractures treated with an intramedullary nail. Infection has an incidence of approximately 1%. Elbow injury is unlikely unless the nail is excessively long. Rarely, injury to the radial nerve is possible if it is trapped in the intramedullary canal.
REFERENCES: Chapman JR, Henley MB, Agel J, et al: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
McCormack RG, Brien D, Buckley RE, et al: Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective, randomised trial. J Bone Joint Surg Br 2000;82:336-339.

Immediate spica casting is ideal for younger children with uncomplicated femoral fractures that are the result of relatively low-energy injury. Surgical stabilization of pediatric femoral fractures is most commonly performed in children who are older than age 6 years or in children with other factors associated with their femoral fracture, such as concomitant head injury, open fracture, floating knee, severe comminution, or vascular injury.
REFERENCES: Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659.
Sponseller PD: Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-365.
Wright JG: The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg 2000;43:180-189.
Levy J, Ward WT: Pediatric femur fractures: An overview of treatment. Orthopedics 1993;16:183-190.

The patient has a very low T-type acetabular fracture; however, the head is not congruent under the dome so surgical reduction is necessary. The anterior and posterior columns are displaced and will move independent from each other. The extended iliofemoral is the only approach allowing for visualization and reduction of each column. A combined anterior and posterior approach may also be used. The timing of surgery should be within the first 3 weeks of injury to optimize chances of obtaining an accurate reduction because this is an important factor in determining outcome.
REFERENCES: Letournel E, Judet R (eds): Fractures of the Acetabulum, ed 2.
Berlin, Germany, Springer-Verlag, 1991.
Matta JM: Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am
1996;78:1632-1645.

Children have a much greater capacity to heal soft-tissue injuries than adults. Most crush or avulsion fingertip amputations in children, particularly those younger than age 2 years, can be treated with serial dressing changes, even with bone exposed.
REFERENCES: Das SK, Brown HG: Management of lost finger tips in children.
Hand 1978;10:16-27.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg
1996;4:84-92.

The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger
flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have
shown some healing response with callus formation, but these techniques are not successful
in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions
of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Assessment of the acutely injured patient follows the Advanced Trauma Life Support protocol. Cervical cord injury is often associated with a disruption in sympathetic outflow. Absent sympathetic input to the lower extremities leads to vasodilatation, decreased venous return to the heart, and subsequent hypotension. With hypotension, the physiologic response of tachycardia is not possible because of the unopposed vagal tone. This results in bradycardia. Patient positioning, fluid support, pressor agents, and atropine are used to treat neurogenic shock.
REFERENCE: Sutton DC, Siveri CP, Cotler JM: Initial evaluation and management of the spinal injured patient, in Cotler JM, Simpson JM, An HS, et al (eds): Surgery of Spinal Trauma. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 113-126.

With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation.
REFERENCES: Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529.
Moed BR, WillsonCarr SE, Watson JT: Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am 2002;84:752-758.

The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop
2000;20:7-14.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured.
REFERENCES: Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.
Myerson MS: Diabetic neuroarthropathy, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 439-465.

The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of non-weight-bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated.
REFERENCES: Rosenberg GA, Sterra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.
Lawrence SJ, Botte MJ: Jones’ fracture and related fractures of the proximal fifth metatarsal. Foot Ankle 1993;14:358-365.

Closed ruptures of the central slip of the extensor tendon may occur with volar proximal interphalangeal joint dislocation, forced flexion of the proximal interphalangeal joint, or blunt trauma to the dorsum of the proximal interphalangeal joint. The other structures are not typically injured in proximal interphalangeal joint dislocations. Treatment typically requires static splinting of the proximal interphalangeal joint. In the more common dorsal proximal interphalangeal joint dislocation, the volar plate is injured, and early range of motion may be started after reduction.
REFERENCES: Doyle JR: Extensor tendons: Acute injuries, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1925.
Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.

A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men.
REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment.
REFERENCES: Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.
O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 409-420.

Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures.
REFERENCES: Jones BG, Duncan RD: Open tibial fractures in children under 13 years of age-10 years experience. Injury 2003;34:776-780.
Bartlett CS III, Weiner LS, Yang EC: Treatment of type II and type III open tibia fractures in children. J Orthop Trauma 1997;11:357-362.
Robertson P, Karol LA, Rab GT: Open fractures of the tibia and femur in children. J Pediatr Orthop 1996;16:621-626.
Cullen MC, Roy DR, Crawford AH, et al: Open fracture of the tibia in children. J Bone Joint Surg Am 1996;78:1039-1047.

The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better.
REFERENCES: Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144-149.
Blachut PA, O’Brien PJ, Meek RN, et al: Interlocking intramedullary nailing with or without reaming for the treatment of closed fractures of the tibial shaft: A prospective randomized study. J Bone Joint Surg Am 1997;79:640-646.

In this patient, examination reveals an inability to extend the fingers with the wrist extended, but full extension is possible with wrist flexion. These findings demonstrate isolated tenodesis of the flexor digitorum to the ring and little fingers. These findings are not consistent with compartment syndrome or nerve injury. Scarring or entrapment of tendons in forearm fractures can occur.
REFERENCES: Watson PA, Blair W: Entrapment of the index flexor digitorum profundus tendon after fracture of both forearm bones in a child. Iowa Orthop J 1999;19:127-128.
Shaw BA, Murphy KM: Flexor tendon entrapment in ulnar shaft fractures. Clin Orthop 1996;330:181-184.
Kolkman KA, van Niekerk JL, Rieu PN, et al: A complicated forearm greenstick fracture: Case report. J Trauma 1992;32:116-117.
Hendel D, Aner A: Entrapment of the flexor digitorum profundus of the ring finger at the site of an ulnar fracture: A case report. Ital J Orthop Traumatol 1992;18:417-419.

Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint.
REFERENCES: Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.
Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203.

The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.
REFERENCES: Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.
Ballmer FT, Ballmer PM, Baumgaertel F, et al: Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-767.

The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary.
REFERENCES: Althausen PL, Lee MA, Finkemeier CG: Scapulothoracic dissociation: Diagnosis and treatment. Clin Orthop 2003;416:237-244.
Witz M, Korzets Z, Lehmann J: Traumatic scapulothoracic dissociation. J Cardiovasc Surg 2000;41:927-929.

Long-term outcomes following tibial plafond fractures treated with ORIF are satisfactory in most patients despite a high incidence of posttraumatic osteoarthritis. If ORIF is delayed until 10 to 20 days following injury, the major difference in outcomes is fewer complications associated with wound healing. Ankle strength, pain, range of motion, and the development of arthritis are equal regardless of the time until fixation.
REFERENCES: Sirkin M, Sanders R, DePasquale T, et al: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84.
Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Proximal tibial metaphyseal fractures may result in late genu valgum as a result of asymmetric growth of the proximal tibia. These patients are best treated with observation because the deformity is likely to remodel. Osteotomy is not indicated and potentially will lead to recurrence. Stapling of the medial tibial physis is appropriate in patients who have a severe and progressive deformity.
REFERENCES: Cozen L: Knock-knee deformity in children: Congenital and acquired. Clin Orthop 1990;258:191-203.
Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53:1571-1578.
Brammar TJ, Rooker GD: Remodeling of valgus deformity secondary to proximal metaphyseal fracture of the tibia. Injury 1998;29:558-560.
Ogden JA, Ogden DA, Pugh L, et al: Tibia valga after proximal metaphyseal fractures in childhood: A normal biologic response. J Pediatr Orthop 1995;15:489-494.
Salter RB, Best TN: Pathogenesis of progressive valgus deformity following fractures of the proximal metaphyseal region of the tibia in young children. Instr Course Lect 1992;41:409-411.

The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1635-1681.

The incidence of vascular injury in supracondylar humeral fractures is directly related to the degree and direction of displacement. Significant posterior lateral displacement tends to result in brachial artery and median nerve injuries, and posterior medial displacement may lead to radial nerve injury. The brachial artery is always injured at the level of the fracture; therefore, angiography or MRA will not assist in locating the injury. The treatment of choice is surgical reduction and stabilization of the fracture, followed by reassessment of the vascular status. If the hand is pink and warm or pulses can be detected with doppler, it is reasonable to follow the extremity closely after surgery. If the arm becomes pulseless and white, immediate anterior exploration of the arm is indicated. The artery is often entrapped in the fracture and once extricated, will provide adequate blood flow. If the artery is injured, a primary repair or vein graft is needed.
REFERENCES: Shaw BA: The role of angiography in assessing vascular injuries associated with supracondylar humerus fractures remains controversial. J Pediatr Orthop 1998;18:273.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Schoenecker PL, Delgado E, Rotman M, et al: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996;10:410-415.

The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks.
REFERENCES: Prokuski LJ, Eglseder WA Jr: Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma 2001;15:549-554.
Lawlis JF III, Gunther SF: Carpometacarpal dislocations: Long-term follow-up. J Bone Joint Surg Am 1991;73:52-59.

The patient has a perilunate dislocation. A volar dislocation of the lunate is often associated with median nerve dysfunction. This injury to the wrist is often overlooked because of its benign clinical appearance and the presence of other injuries, as it is caused by high-energy mechanisms.
REFERENCES: Ruby LK, Cassidy C: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1297-1300.
Habernek H, Weinstabl R, Kdolsky R, et al: Volar lunate fracture-dislocations of the wrist: Case report for two patients treated with external frame and internal open reduction. J Trauma 1998;45:975-978.

The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability.
REFERENCES: Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.
Ring D, Jupiter JB: Fracture-dislocation of the elbow. J Bone Joint Surg Am 1998;80:566-580.

The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution.
REFERENCES: Brumback RJ, Virkus WW: Intramedullary nailing of the femur: Reamed versus nonreamed. J Am Acad Orthop Surg 2000;8:83-90.
Brumback RJ, Ellison TS, Poka A, et al: Intramedullary nailing of femoral shaft fractures: Part III. Long-term effects of static interlocking fixation. J Bone Joint Surg Am 1992;74:106-112.

Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness.
REFERENCES: Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.
Hodgson SA, Mawson SJ, Stanley D: Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg Br 2003;85:419-422.

The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization.
REFERENCES: Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.
Kabak S, Halici M, Tuncel M, et al: Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): A report of 40 cases. J Orthop Trauma 2003;17:555-562.

The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.
REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.

The A2 and A4 pulleys are considered the most important parts of the pulley system. If these two structures are preserved, 80% of finger flexion can be maintained. If the pulley system is not left intact or is not reconstructed, “bow-stringing” of the flexor tendons occurs with loss of full flexion. The A2 pulley is over the proximal phalanx and the A4 pulley is over the middle phalanx.
REFERENCES: Doyle JR: Anatomy of the finger flexor tendon sheath and pulley system.
J Hand Surg Am 1988;13:473-484.
Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg 1995;3:44-54.

Fractures of the distal radius increase the relative risk of a subsequent hip fracture significantly more in men than in women. A previous spinal fracture has an equally important impact on the risk of a subsequent hip fracture in both genders.
REFERENCE: Haentjens P, Autier P, Collins J, et al: Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: A meta-analysis. J Bone Joint Surg Am 2003;85:1936-1943.

Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.
J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks.
REFERENCES: Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977.
Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.
Shulman AM: Prediction of patients who will develop prolonged occult hypoperfusion following blunt trauma. J Trauma 2004;57:725-800.

The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15° and malrotation of 45° are acceptable. In children older than age 9 years, acceptable alignment is 10° of angulation and 30° of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast.
REFERENCES: Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115.
Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360.
Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.
Noonan KJ, Price CT: Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998;6:146-156.

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level.
REFERENCES: Redfern DJ, Sauve PS, Sakellariou A: Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24:771-774.
Miller SD: Ankle fractures, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1341-1366.

Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with a 86% chance of avoiding a secondary reconstructive procedure.
REFERENCES: Robinson CM, Cairns DA: Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86:778-782.
Deafenbaugh MK, Dugdale TW, Staeheli JW, et al: Nonoperative treatment of Neer type II distal clavicle fractures: A prospective study. Contemp Orthop 1990;20:405-413.

With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.
REFERENCES: Webb LX: New techniques in wound management: Vacuum assisted wound closure. J Am Acad Orthop Surg 2002;10:303-311.
Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int 2002;23:896-901.

The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.
REFERENCES: Pugh DM, McKee MD: Advances in the management of humeral nonunion.
J Am Acad Orthop Surg 2003;11:48-59.
McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly.
REFERENCES: Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.
McKee MD, Wilson TL, Winston L, et al: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.

The AP, obturator oblique, and iliac oblique views of the pelvis reveal a fracture that disrupts the iliopectineal and ilioischial lines, indicating a fracture that involves both anterior and posterior columns. However, it does not have the other features of anterior or posterior column fracture patterns. A displaced posterior wall fracture is also present, best seen on the obturator oblique view. The anterior to posterior directed fracture line on the CT scan indicates a transverse fracture; therefore, the patient has a transverse with posterior wall fracture pattern. A T-type fracture would be similar but would have a break into the obturator ring.
REFERENCES: Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

The patient has a posterior fracture-dislocation of the hip and following reduction, an incarcerated fragment of bone resulted in an incongruent reduction. Whereas expedient removal of the fragment is required to limit articular cartilage damage, this situation is not an emergency and the procedure may be performed when the appropriate surgical team is available and the patient is stabilized. Skeletal traction through either the femur or tibia may relieve some pressure on the joint and prevent articular damage. Nonsurgical care for incarcerated fragments is contraindicated.
REFERENCES: Tile M, Olson SA: Decision making: Non operative and operative indications for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 496-532.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993, pp 337-339, p 507.

The patient is at risk for a pelvic vascular injury and major hemorrhage. This type of complication of pelvic trauma is highest in motorcyclists. Once it is recognized that the pelvic ring has opened, it is important to close that ring to tamponade any venous bleeding with a pelvic binder and to add a skeletal traction pin to the limb on the involved side. This will correct any translational displacement. The noninvasive pelvic binders or sheets are easy to apply and are very effective. They do not compromise future care and allow the surgeons access to the abdomen. External fixation or pelvic resuscitation clamps require a certain amount of skill to apply and are not always available. If the pelvic stabilization does not improve the hemodynamic parameters in 10 to 15 minutes, angiography is necessary.
REFERENCE: Mayo K, Kellam JK: Pelvic ring disruptions, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1052-1108.

This is a very large near circumferential defect with posterior as well as anterior skin and muscle injury. Bone is exposed. The posterior muscles cannot be rotated since they are part of the zone of injury. The bone and other poorly vascularized areas of this wound would not accept a skin graft. The best chance for limb salvage will be to obtain soft-tissue coverage with a free tissue transfer using the latissimus dorsi.
REFERENCES: Mathes SJ, Nahai F: Vascular anatomy of muscle: Classification and applications, in Mathes SJ, Nahai F (eds): Clinical Application for Muscle and Musculocutaneous Flaps. St Louis, MO, CV Mosby, 1982, p 20.
Bos GD, Buehler MJ: Lower-extremity local flaps. J Am Acad Orthop Surg 1994;2:342-351.

Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process.
REFERENCES: McIlveen SJ, Duralde XA, D’Alessandro DF, et al: Isolated nerve injuries about the shoulder. Clin Orthop 1994;306:54-63.
Warner JP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg
1997;5:130-140.

Lateral condylar fractures are challenging to treat because of late displacement and development of a nonunion that may lead to valgus instability, pain, or tardy ulnar nerve palsy. Fractures such as this one with more than 2 mm of displacement on any radiographic view are prone to nonunion and should be stabilized. Fractures with less than 2 mm of displacement usually are stable and may be treated nonsurgically. In these patients, careful follow-up is recommended within several days of casting to check for fracture displacement. Arthrography or MRI may be helpful in these minimally displaced fractures. Fractures with an intact articular cartilage surface, such as noted on these studies, are unlikely to displace further.
REFERENCES: Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425.
Attarian DE: Lateral condyle fractures: Missed diagnoses in pediatric elbow injuries. Mil Med 1990;155:433-434.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.
Badelon O, Bensahel H, Mazda K, et al: Lateral humeral condylar fractures in children: A report of 47 cases. J Pediatr Orthop 1988;8:31-34.

Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 weeks to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications.
REFERENCES: Schemitsch EH, Bhandari M: Fractures of the humeral shaft, in Browner BD: Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1481-1511.
Chapman JR, Henley MB, Agel J: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.

This injury pattern is one of a direct trauma to the mid aspect of the foot. Without additional forces involved, capsular ligamentous injury is not anticipated; therefore, the injury should be a stable pattern. Treatment should consist of protected weight bearing as tolerated in a walking boot or walking cast. Surgical intervention with open reduction and internal fixation, percutaneous pinning, or open reduction and internal fixation with primary tarsometatarsal joint fusion is not indicated with this pattern of injury. The use of external bone stimulation in this acute fracture setting is not indicated. With injuries to the midfoot area where the exact mechanism of injury is uncertain, there should be a high index of suspicion for an associated injury to the tarsometatarsal joint, and standing radiographs or stress radiographs should be obtained.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1265-1296.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,
pp 2181-2245.

During a posterior approach to the shoulder for either a scapular fracture,
glenoid fracture, or posterior shoulder pathology, the interval between the teres minor and infraspinatus is split. Excessive superior retraction on the infraspinatus, or excessive dissection superomedially under the infraspinatus muscle and tendon can cause injury to the suprascapular nerve and/or artery. During dissection in this interval, the axillary artery and axillary nerve are well protected. A branch of the circumflex scapular artery ascends between the teres minor
and infraspinatus muscle, but it is at risk during dissection on the scapula in the mid portion of the interval and not during superior retraction. The profunda brachii artery is not present in
this interval.
REFERENCES: Jerosch JJ, Greig M, Peuker ET, et al: The posterior subdeltoid approach: A modified access to the posterior glenohumeral joint. J Shoulder Elbow Surg 2001;10:265-268.
Judet R: Surgical treatment of scapular fractures. Acta Orthop Belg 1964;30:673-678.
Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484.

Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.
REFERENCES: Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott, Williams and Wilkins, 2001, pp 2091-2132.
Daniels TR, Smith JW, Ross TI: Varus malalignment of the talar neck: Its affects on the position of the foot and on subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.

The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore
function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness.
REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364.
Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.
REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332.
Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372.
Dobbs MB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Beringer DC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

The most common complication of dorsal plating is extensor tenosynovitis, which often causes pain and is a frequent reason for hardware removal. Other less frequent complications include loss of reduction and extensor tendon ruptures, with flexor tendon ruptures occuring to an even lesser degree.
REFERENCES: Rozental TD, Beredjiklian PK, Bozentka DJ: Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956-1960.
Kambouroglou GK, Axelrod TS: Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: A brief report. J Hand Surg Am 1998;23:737-741.

The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting.
REFERENCES: Webb LX, Winquist RA, Hansen ST: Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft: A report of 105 consecutive cases. Clin Orthop 1986;212:133-141.
Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nailing for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.
Hak DG, Lee SS, Goulet JA: Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 2000;14:178-182.

Monteggia fractures in children must be recognized. Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation. In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation. Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion. Posterior Monteggia fractures are less common and may be managed in elbow extension. Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures. Annular ligament repair is rarely needed in the acute fracture.
REFERENCES: Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop 2002;22:548-554.
Kay RM, Skaggs DL: The pediatric Monteggia fracture. Am J Orthop 1998;27:606-609.
Ring D, Jupiter JB, Waters PM: Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998;6:215-224.

All other factors being equal, a patient’s age is the most important factor in determining outcome after peripheral nerve injury. Repair of a nerve laceration within the first 2 weeks is generally considered appropriate. Fascicular repair may be of benefit in larger proximal nerves to reapproximate appropriate nerve bundles; distally perineural or epineural repair is sufficient. Use of a fibrin tissue sealant for nerve repair does not result in improved outcomes over suture repair. Nerve conduits have shown promise in digital nerves but do not have proven benefit in larger caliber nerves.
REFERENCES: Sunderland S: Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY, Churchill Livingstone, 1991.
Wilgis ES, Brushart TM: Nerve repair and grafting, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1325.
Narakas A: The use of fibrin glue in repair of peripheral nerves. Orthop Clin North Am 1988;19:187-199.
Weber RA, Breidenbach WC, Brown RE, et al: A randomized prospective study of
polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 2000;106:1036-1045.

Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris.
REFERENCES: Furry KL, Clinkscales CM: Comminuted fractures of the radial head: Arthroplasty versus internal fixation. Clin Orthop 1998;353:40-52.
Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815.

A higher risk of nonunion and the need for prolonged immobilization is seen after nonsurgical management of proximal pole fractures of the scaphoid. Because of the relatively poor blood supply of the proximal pole, surgical treatment with a compression screw is advocated for fractures of the proximal third of the scaphoid.
REFERENCES: Clay NR, Dias JJ, Costigan PS, et al: Need the thumb be immobilized in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br 1991;73:828-832.
Ring D, Jupiter JB, Herndon JH: Acute fractures of the scaphoid. J Am Acad Orthop Surg 2000;8:225-231.

In a recent analysis of 200 patients with tibial fractures, Bhandari and associates attempted to identify variables that were predictive of reoperation. The variables in the study were type of injury (fracture pattern), degree of open injury, mechanism of injury, cortical bone contact, postoperative complications, polytrauma, anti-inflammatory drug use, nail insertion technique (reamed versus nonreamed), smoking history, alcohol use, diabetes mellitus, peripheral vascular disease, age, disability status pre-injury, gender, surgeon, time to surgery, steroid use, phenytoin use, antibiotic use, anticoagulant use, and type of fixation used. Three variables were statistically significant predictors of reoperation to achieve bone union in the first postinjury year: transverse fracture pattern, open fracture, and cortical contact of 50% or less. Using these three variables, four reoperation risk groups were identified based on the number of these three variables present: 0, 1, 2, or 3. The risk for reoperation was 0%, 18%, 47%, and 94%, respectively. The authors concluded that these statistics can provide prognostic information to patients and help identify those high-risk patients where early intervention to achieve union is indicated. In addition, the data highlights the significance of achieving cortical contact at the time of initial fixation.
REFERENCE: Bhandari M, Tornetta P III, Sprague S, et al: Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma 2003;17:353-361.

Osteonecrosis of the femoral head is a known complication from the use of rigid intramedullary nails for femoral fractures in adolescents. When the nails are placed through the piriformis fossa, the lateral ascending vessels of the femoral neck may be injured, resulting in osteonecrosis of the femoral head in 1% to 2% of patients. Rigid reamed nails placed into the piriformis fossa are contraindicated in children with open growth plates because the physis is a barrier to blood supply and the ligamentum teres does not provide sufficient vascularity. Alternative fixation methods for femoral fractures in adolescents include external fixation and open reduction and internal fixation. Nailing through the tip of the trochanter may decrease the incidence of this serious complication.
REFERENCES: Letts M, Jarvis J, Lawton L, et al: Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-516.
Stans AA, Morrissy RT, Renwick SE: Femoral shaft fracture treatment in patients age 6 to 16 years. J Pediatr Orthop 1999;19:222-228.
Buckley SL: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop 1997;338:60-73.
Beaty JH, Austin SM, Warner WC, et al: Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: Preliminary results and complications. J Pediatr Orthop
1994;14:178-183.

The lateral radiograph shows 8 mm of atlantoaxial translation. In the absence of a bony injury, this represents rupture of the transverse atlantal ligament. The MRI scan reveals soft-tissue swelling posterior to the odontoid and a high intensity zone in the atlanto-dens interval consistent with acute injury. These injuries require arthrodesis because nonsurgical measures will not provide stability. Techniques for C1-2 fusion include Gallie, Brooks, or triple wiring. Transarticular screw fixation across the C1-2 articulation provides the most rigid means of fixation and the highest arthrodesis rates but is technically demanding. Anterior C2-3 arthrodesis will not address the level of instability. The normal atlanto-dens interval is 3 mm in an adult and 4 mm in a child.
REFERENCES: Kurz LT: Transverse atlantal ligament insufficiency, in Clark CR (ed):
The Cervical Spine. Philadelphia, PA, Lippincott-Raven, 1998, pp 401-407.
Fielding JW, Cochran GB, Lansing JF III, et al: Tears of the transverse ligament of the atlas:
A clinical and biomechanical study. J Bone Joint Surg Am 1974;56:1683-1691.

V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of
the thumb.
REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

A volar lunate fragment of a distal radial fracture is considered a critical component to overall joint stability and function. Obtaining a reduction is difficult through a standard volar approach to the radius between the flexor carpi radialis and radial artery. Visualization and reduction of the ulnar volar facet is not possible from this approach. An extended carpal tunnel incision provides access to the entire articular surface, except for the distal radial styloid component.
REFERENCES: Hanel DP, Jones MD, Trumble TE: Wrist fractures. Orthop Clin North Am 2002;33:35-57.
Trumble TE, Culp RW, Hanel DP, et al: Intra-articular fractures of the distal aspect of the radius. Instr Course Lect 1999;48:465-480.

The mechanism and environment in which the injury occurred, the clinical picture, and the radiographic findings of gas in the tissues suggest an anaerobic Gram-positive bacterial infection. This can be a life- and limb-threatening infection. Treatment should consist of wide debridement of all devitalized tissue, and intravenous antibiotics should be started. Wounds should be left open to allow bacterial effluent and increase oxygen tension in the wound. Hyperbaric oxygen may be used as an adjuvant but is no substitute for debridement.
REFERENCES: Pellegrini VD, Reid JS, Evarts CM: Complications, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 1, pp 458-463.
Ayers DC, Murray DC: Complications of the treatment of fractures and dislocations: General considerations, in Epps Jr CH (ed): Complications in Orthopedic Surgery, ed 4. Philadelphia, PA, JB Lippincott, 1994, pp 3-48.

Open reduction and internal fixation of distal humeral fractures in elderly patients often fails. These fractures characteristically have a very small distal segment and poor bone quality, resulting in failure of fixation and nonunion. Nonunion is often painful and functionally debilitating. Total elbow arthroplasty provides good results when used for distal humeral fractures in elderly patients with osteopenic bone and fracture patterns thought to be irreconstructable. Long arm casting may result in union, but the resulting stiffness is unacceptable for an active patient. Elbow arthrodesis has few indications. A sling and range-of-motion exercises will often result in a painful and debilitating nonunion at the fracture site.
REFERENCES: Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intra-articular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Obremskey WT, Bhandari M, Dirschl DR, et al: Internal fixation versus arthroplasty of comminuted fractures of the distal humerus. J Orthop Trauma 2003;17:463-465.

The posterior interosseous nerve is located adjacent to the radial neck, placing it at risk for a traction injury with a dislocation of the proximal radius. The typical neurapraxia that results can be expected to resolve with observation within the first 6 to 12 weeks. If recovery is not clinically evident by 3 months, neurophysiologic studies are indicated.
REFERENCES: Jessing P: Monteggia lesions and their complicating nerve damage. Acta Orthop Scand 1975;46:601-609.
Stein F, Grabias SL, Deffer PA: Nerve injuries complicating Monteggia lesions. J Bone Joint Surg Am 1971;53:1432-1436.

This is a “borderline trauma” patient where serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an ISS > 20 and thoracic trauma (AIS > 2); polytrauma and abdominal/pelvic trauma (Moore > 3) and hemodynamic shock (initial BP 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure > 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing > 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS > 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (eg, Il-6 > 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care.
REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53:452-461.
Bosse M, Kellam JF: Orthopaedic decision making in the multiple trauma patient, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 133-146.

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45.
Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.
Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am 1999;30:119-132.

The patient has a volar displaced two-part intra-articular distal radial fracture-dislocation of the wrist. Although a closed reduction is usually easily obtained, it is very difficult to maintain the reduction without internal fixation. The approach is determined by the direction of the dislocation, in this case volar. Stabilization with a buttress plate neutralizes the axial loading forces on the fractured fragment. A dorsal placed angular stable plate will not provide this buttress effect and will make the reduction difficult.
REFERENCE: Cohen M, McMurtry RY, Jupiter JB: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1328-1335.

The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact.
REFERENCES: Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-539.
Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than
2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-211.
Robinson CM, Court-Brown CM, McQueen MM, et al: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am
2004;86:1359-1365.

The fracture is a both-column fracture in the Judet/Letournel classification and a C3 in the AO classification. There is extension into the sacroiliac joint along the pelvic brim and comminution along the posterior column above the sciatic notch. Both the anterior and posterior columns are separately broken and displaced. However, the defining feature of a both-column pattern, as seen in this patient, is that all articular fragments are on fracture fragments and no joint surface is left intact to the axial skeleton above. The use of three-dimensional images makes it easier to view the location of the fracture fragments and the amount and direction
of displacement.
REFERENCES: Helfet DL, Beck M, Gautier E, et al: Surgical techniques for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 533-603.
Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as “gamekeeper’s thumb.” The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness.
REFERENCES: Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.
J Am Acad Orthop Surg 1997;5:224-229.

Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
REFERENCES: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.
Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.
REFERENCES: Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.
Martinez A, Sarmiento A, Latta LL: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop 2003;417:293-302.

Nonsteroidal anti-inflammatory drugs that are COX-1 primary inhibitors have been shown in animal studies to delay or inhibit fracture healing. COX-2 inhibitors also delay healing but to a lesser extent than COX-1 inhibitors. The other medications listed do not alter fracture callus formation.
REFERENCES: Gerstenfeld LC, Thiede M, Seibert K, et al: Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res 2003;21:670-675.
Harder AT, An YH: The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: A concise review. J Clin Pharmacol 2003;43:807-815.

Pediatric bony Chance fractures occur following severe flexion injuries as seen after motor vehicle accidents with lap belt restraints. There is a high rate of associated intra-abdominal injuries. In the absence of associated injuries, these fractures are best treated with immobilization. Bed rest is not necessary. Surgical fixation usually is not needed. Surgical stabilization and two-level fusion may be indicated in select individuals with progressive kyphosis of more than 25° or other conditions that preclude cast or brace immobilization.
REFERENCES: Greenwald TA, Mann DC: Pediatric seatbelt injuries: Diagnosis and treatment of lumbar flexion-distraction injuries. Paraplegia 1994;32:743-751.
Glassman SD, Johnson JR, Holt RT: Seatbelt injuries in children. J Trauma 1992;33:882-886.
Raney EM, Bennett JT: Pediatric Chance fracture. Spine 1992;17:1522-1524.

Multiple cytokines (inflammatory mediators) are released following trauma, and their levels can be measured in serum. Persistent elevated levels of IL-6 (> 800 pg/mL) indicate an exaggerated systemic inflammatory response to trauma and have been associated with the development of MODS. Recent work has shown that extensive surgical procedures should be avoided when IL-6 levels remain elevated to prevent the precipitation of MODS. In the future, it is likely that this mediator and possibly others will be used to determine timing and techniques of future treatment.
REFERENCES: Patrick DA, Moore FA, Moore EE, et al: Jack A. Barney Resident Research Award winner: The inflammatory profile of interleukin-6, interleukin-8, and soluble intercellular adhesion molecule-1 in postinjury multiple organ failure. Am J Surg 1996;172:425-429.
Pape HC, van Griesven M, Rice J, et al: Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: Determination of the clinical relevance of biochemical markers. J Trauma 2001;50:989-1000.
Giannoudis PV: When is the safest time to undertake secondary definitive fracture stabilization procedures in multiply injured patients who were initially managed using a strategy of primary temporary skeletal fixation. J Trauma 2002;52:811-812.

Pediatric intracapsular hip fractures are challenging because of the high rates of complications, including osteonecrosis and varus malunion. These patients should be treated as emergencies. Principles of treatment include anatomic reduction with internal fixation. Screw fixation short of the physis is preferred and may need to be supplemented with spica cast immobilization. Fixation may be achieved with smooth pins across the physis when little metaphyseal bone is available. Fixation across the physis with threaded screws is acceptable only when the patient is close to skeletal maturity. Pediatric hip screws are appropriate if immediately available. Emergent open reduction, capsulotomy, or joint aspiration may decrease the rate of osteonecrosis.
REFERENCES: Cheng JC, Tang N: Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999;19:338-343.
Azouz EM, Karamitsos C, Reed MH, et al: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Song KS, Kim YS, Sohn SW, et al: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210.
Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51.

A Weber type B ankle fracture occurs with a supination external rotation mechanism of injury. The fibula generally fails with a spiral fracture pattern. The lag screws provide compression, and the plate acts to neutralize rotational and angular bending forces. A buttress plate resists vertical shear forces. A tension band is used over areas that may fail in tension, such as an olecranon fracture. Compression is provided by the lag screws, and distraction is again resisted by the lag screws.
REFERENCE: Mazzoca AD: Principles of internal fixation, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 308-309.

The majority of mallet fractures can be treated nonsurgically with a distal interphalangeal joint extension splint. Excellent results can be obtained in most patients with splinting alone. The fragment size, amount of displacement, and degree of articular incongruity usually do not affect final outcome, as long as the joint is reduced. Surgical fixation takes on several forms but is fraught with complications including skin/wound problems, loss of fixation, nonunion, and stiffness of the distal interphalangeal joint. Volar subluxation of the distal phalanx remains the primary indication for surgical treatment.
REFERENCES: Green DP, Butler TE Jr: Fractures and dislocations in the hand, in Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 621-623.
Light TR (ed): Hand Surgery Update 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

Lacerated radial nerves are associated with open humeral fractures. All open humeral fractures with radial nerve palsy should be managed with radial nerve exploration and skeletal stabilization. Closed humeral fractures with associated radial nerve palsy usually have an intact nerve with neurapraxia. Most of these patients recover without surgical treatment. If the patient has multiple injuries, skeletal stabilization may be indicated to improve mobilization. For an isolated closed humeral fracture with a radial nerve palsy, the treatment of choice is splinting for 1 to 2 weeks, followed by a humeral fracture brace.
REFERENCES: Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 2004;29:144-147.
Foster RJ, Swiontkowski MF, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

The radiograph shows a comminuted proximal ulnar fracture. The most reliable fixation is a posterior plate, acting as a tension band plate. The fracture involves the proximal shaft of the ulna; therefore, a 3.5-mm compression plate or one of similar size should be used to provide adequate stability. Kirschner wires and tension band wires do not provide axial stability of the comminution of the ulna. Compression screws alone will most likely fail and will not provide axial rotational stability to the construct. A medial plate will not resist the distraction forces across this fracture.
REFERENCES: McKee MD, Seiler JG, Jupiter JB: The application of the limited contact dynamic compression plate in the upper extremity: An analysis of 114 consecutive cases. Injury 1995;26:661-666.
McKee MD, Jupiter JB: Trauma to the adult elbow and fractures of the distal humerus, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, p 1469.

The radiographs reveal a Monteggia injury, with a proximal ulnar shaft fracture and a radial head dislocation. Treatment involves open reduction and internal fixation of the ulnar fracture. With correct reduction of the ulna, the radial head is reducible and remains stable, despite an obvious soft-tissue injury around the elbow. Problems with persistent radial head subluxation are almost always attributed to malreduction of the ulnar fracture. Rare causes of persistent radial head subluxation are interposition of soft tissues in the joint and lateral ligamentous injuries.
REFERENCES: Jupiter JB, Kellam JF: Diaphyseal fractures of the forearm, in Browner B, Jupiter J, Levine A, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1992, pp 1421-1454.
Ring D, Jupiter JB, Simpson NS: Monteggia fractures in adults. J Bone Joint Surg Am 1998;80:1733-1744.

A widened medial clear space indicates instability caused by an associated tear of the deltoid ligament; therefore, nonsurgical management is not warranted. Weber type B distal fibular fractures without a deltoid tear have a medial clear space of

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