Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements. Handbook of fractures / Kenneth A. Egol, Kenneth J. Koval, Joseph D. Zuckerman 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. (PDF) Oxford Handbook of Pediatrics, 2nd caite.info Safety topics Book for daily toolbox talk. Though many of these topics are not new, it will definitely.
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Handbook of Fractures, 3rd Edition. Read more Arthroscopic Management of Distal Radius Fractures Lecture Notes: Orthopaedics and Fractures 4th ed. HANDBOOK OF FRACTURES Third Edition EDITORS John A. Elstrom, M.D. Clinical &sistant Professor University of IUinois Chicago, Illinois Department of. [caite.infoman] Handbook of Fractures (3rd Ed.) - Ebook download as PDF File . pdf), Text File .txt) or read book online.
Revision surgery. Skeletal Traction Fig. Advance the needle until paresthesia is obtained. These require debridement of the intraabdominal and extraabdominal missile paths. The current dose of toxoid is 0. Very high energy above plus gross contamination. Handbook of Thermoplastic Elastomers Pdl Handbook.
A tracheostomy may be necessary. Foreign objects should be removed. Hemodynamic stability is defined as normal vital signs that are maintained w ith only maintenance fluid volumes. In trauma patients, shock is hemorrhagic until proven otherw ise. At a minimum, tw o large-bore intravenous lines should be placed in the antecubital fossae or groin w ith avoidance of injured extremities.
Serial monitoring of blood pressure and urine output is necessary, w ith possible central access for central venous monitoring or Sw an-Ganz catheter placement for hemodynamic instability. Serial hematocrit monitoring should be undertaken until hemodynamic stability is documented. Peripheral blood pressure should be assessed. Blood pressure necessary to palpate a peripheral pulse. Large-bore venous access, Ringer lactate resuscitation, monitoring of urine output, central venous pressure, and pH.
Blood replacement as indicated by serial hematocrit monitoring. Traction w ith Thomas splints or extremity splints to limit hemorrhage from unstable fractures. Consideration of angiography w ith or w ithout embolization or immediate operative intervention for hemorrhage control. Neurogenic Shock This occurs in patients w ith a thoracic level spinal cord injury in w hich sympathetic disruption results in an inability to maintain vascular tone. Consider in a head-injured or spinal cordinjured patient w ho does not respond to fluid resuscitation.
Septic Shock Consider in patients w ith gas gangrene, missed open injuries, and contaminated w ounds closed primarily. This occurs in the early to late phases, but not in the acute presentation. In the absence of open hemorrhage, bleeding into voluminous spaces chest, abdomen, pelvis, thigh must be ruled out. This may require diagnostic peritoneal lavage, angiography, CT, MRI, or other techniques as dictated by the patient presentation.
Saline cross-matched blood may be ready in 10 minutes; it may have minor antibodies. Type O negative blood is used for life-threatening exsanguination. Warming the blood w ill help to prevent hypothermia. Monitor coagulation factors, platelets, and calcium levels. May support systolic blood pressure by increasing peripheral vascular resistance. Are contraindicated in patients w ith severe chest trauma. Liver, splenic, renal parenchymal injury: The Glasgow coma scale Table 2.
These injuries cannot be adequately evaluated by physical examination. Table 2. Revised trauma score: The RTS correlates w ell w ith the probability of survival. Evaluation of multiple trauma patient injury severity score ISS Abbreviated Injury Scale defined body areas external structures. Minor Moderate Severe non-life-threatening Severe life-threatening Critical survival uncertain Fatal dead on arrival. This anatomic scoring system provides an overall score for patients w ith multiple injuries.
It is based on the Abbreviated Injury Scale AIS , a standardized system of classification for the severity individual injuries from 1 mild to 6 fatal. Each injury is assigned an AIS score and is allocated to one of six body regions head, face, chest, abdomen, extremities including pelvis, and external structures. The total ISS score is calculated from the sum of the squares of the three w orst regional values.
It is important to emphasize that only the w orst injury in each body region is used. The ISS ranges from 1 to 75, w ith any region scoring 6 automatically giving a score of The ISS limits the total number of contributing injuries to three only, one each from the three most injured regions, w hich may result in underscoring the degree of trauma sustained if a patient has more than one significant injury in more than three regions or multiple severe injuries in one region.
To address some of these limitations, Osler et al. Both systems P. Lateral cervical spine: Clinical clearance cannot occur if the patient has a depressed level of consciousness for any reason e.
Anteroposterior AP chest AP pelvis Possibly a lateral thoracolumbar spine Possibly a CT of the head, cervical spine if not cleared by plain radiographs , thorax, abdomen, or pelvis w ith or w ithout contrast as dictated by the injury pattern P.
It consists of: Restoration of stable hemodynamics. Restoration of adequate oxygenation and organ perfusion. Restoration of adequate kidney function. Treatment of bleeding disorders. Highest-risk injuries include spinal cord injuries, femur fractures, tibia fractures, and pelvic fractures. A high index of suspicion must be follow ed by duplex ultrasonography. Low -molecular-w eight heparin, or low -dose w arfarin has been show n to be more effective than sequential compression devices in preventing thromboses, but it is contraindicated in patients at risk for hemorrhage, especially follow ing head trauma.
Prophylaxis should be continued until adequate mobilization of the patient out of bed is achieved. Vena caval filters may be placed at time of angiography and are effective in patients w ith proximal venous thrombosis. Pulmonary injuries e. Early operative intervention is indicated for: Femur or pelvic fractures, w hich carry high risk of pulmonary complications e. Active or impending compartment syndrome, most commonly associated w ith tibia or forearm fractures.
Open fractures. Vascular disruption. Unstable cervical or thoracolumbar spine injuries. Patients w ith fractures of the femoral neck, talar neck, or other bones in w hich fracture has a high risk of osteonecrosis. Determination of patient medical stability Adequacy of resuscitation Vital signs of resuscitation are deceptive.
Laboratory parameters include base deficit and lactic acidosis. No evidence of coagulopathy As long as homeostasis is maintained, no evidence exists that the duration of the operative procedure results in pulmonary or other organ dysfunction or w orsens the prognosis of the patient. Must be ready to change plan as patient status dictates. Decision making Determined by general surgery, anesthesia, and orthopaedics. Timing and extent of operative intervention based on physiologic criteria.
May require damage control surgery as a temporizing and stabilizing measure. Incomplete resuscitation Based on physiologic assessment. Intensive care includes monitoring, resuscitation, rew arming, and correction of coagulopathy and base deficit. Once the patient is w arm and oxygen delivery is normalized, reconsider further operative procedures.
Mortality rates in trauma patients are associated w ith severe head injury more than any other organ system. Neurologic assessment is accomplished by use of the Glasgow Coma Scale see earlier. Intracranial pressure monitoring may be necessary. Evaluation Emergency computed tomography CT scan w ith or w ithout intravenous contrast is indicated to characterize the injury radiographically after initial neurologic assessment.
Cerebral contusion Diagnosis: Lucid intervals may be accompanied by progressive depressed level of consciousness. Thoracic Injuries These may result from blunt e. Injuries may include disruption of great vessels, aortic dissection, sternal fracture, and cardiac or pulmonary contusions, among others. A high index of suspicion for thoracic injuries must accompany scapular fractures. Emergency thoracotomy may be indicated for severe hemodynamic instability. Chest tube placement may be indicated for hemothorax or pneumothorax.
Evaluation AP chest radiograph may reveal mediastinal w idening, hemothorax, pneumothorax, or musculoskeletal injuries. CT w ith intravenous contrast is indicated w ith suspected thoracic injuries and may demonstrate thoracic vertebral injuries. Evaluation CT scan w ith oral and intravenous contrast may be used to diagnose intraabdominal or intrapelvic injury. Pelvic fractures, lumbosacral fractures, or hip disorders may be observed.
Diagnostic peritoneal lavage remains the gold standard for immediate diagnosis of operable intraabdominal injury. Ultrasound has been increasingly utilized to evaluate fluid present in the abdominal and chest cavities.
Genitourinary Injuries Fifteen percent of abdominal trauma results in genitourinary injury. Evaluation If genitourinary injury is suspected e. Urethral injury may necessitate placement of a suprapubic catheter. If hematuria is present, a voiding urethrogram, cystogram, and intravenous pyelogram are indicated. A compound fracture refers to the same injury, but this term is archaic.
One-third of patients w ith open fractures are multiply injured. Any w ound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherw ise. Soft tissue injuries in an open fracture may have three important consequences: Contamination of the w ound and fracture by exposure to the external environment.
Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection. Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization, compromise the contribution of the overlying soft tissues to fracture healing e.
The applied kinetic energy. Initiate resuscitation and address life-threatening injuries. Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
Identify all injuries to the extremities. Assess the neurovascular status of injured limb s. Assess skin and soft tissue damage: Obvious foreign bodies that are easily accessible may be removed in the emergency room under sterile conditions. Irrigation of w ounds w ith sterile normal saline may be performed in the emergency room if a surgical delay is expected.
Severe pain, decreased sensation, pain to passive stretch of fingers or toes, and a tense extremity are all clues to the diagnosis. A strong suspicion or an unconscious patient in the appropriate clinical setting w arrants monitoring of compartment pressures. Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible.
Indications for angiogram include the follow ing: Extremity radiographs are obtained as indicated by clinical setting, injury pattern, and patient complaints. It is important to include the joint above and below an apparent limb injury.
Classification of open fractures Level of Contamination. Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery. It is useful for communicative purposes despite variability in interobserver reproducibility.
Tscherne Classification of Open Fractures This takes into account w ound size, level of contamination, and fracture mechanism. Small puncture w ound w ithout associated contusion, negligible bacterial contamination, low -energy mechanism of fracture Small laceration, skin and soft tissue contusions, moderate bacterial contamination, variable mechanisms of injury. After initial trauma survey and resuscitation for life-threatening injuries see Chapter 2: Segmental fracture Bone loss Compartment syndrome Crush mechanism Extensive degloving of subcutaneous fat and skin Requires flap coverage any size defect From Bucholz RW.
Grade III: Grade IV: Large laceration w ith heavy bacterial contamination. Factors that modify open fracture classification regardless of initial skin defect Contamination A. Perform a careful clinical and radiographic evaluation as outlined earlier. Court-Brow n C. Exposure to soil Exposure to w ater pools. Heckman JD. Grade 0: Grade I: Grade II: Injury from indirect forces w ith negligible soft tissue damage Closed fracture caused by low to moderate energy mechanisms.
Initiate parenteral antibiosis see later. The current dose of toxoid is 0. Farm injuries: First-generation cephalosporin Add an aminoglycoside Add penicillin and an aminoglycoside Tetanus prophylaxis should also be given in the emergency room see later. Only obvious foreign bodies that are easily accessible should be removed. Grade I. Perform provisional reduction of fracture and place a splint.
In certain centers. Antibiotic Coverage for Open Fractures Table 3. The patient should undergo formal w ound exploration. Both shots are administered intramuscularly. Wound hemorrhage should be addressed w ith direct pressure rather than limb tourniquets or blind clamping. Assess skin and soft tissue damage. From Bucholz RW. If a surgical delay is anticipated. Operative intervention: Important Do not irrigate. Intravenous antibiotic therapy for open fracturesa Type I Cefazolin.
Bone fragments should not be removed in the emergency room. A traumatic skin flap w ith a base-to-length ratio of 1: More recently. Factors of muscle viability Color Normally beefy red. Pulsatile lavage irrigation. Meticulous hemostasis should be maintained. One should close the surgically extended part of the w ound only. The w ound. The w ound should be extended proximally and distally to examine the zone of injury.
The clinical utility of intraoperative cultures has been highly debated and remains controversial. Serial debridement s should be performed every 24 to 48 hours as necessary until there is no evidence of necrotic soft tissue or bone. The fracture surfaces should be exposed.
Fasciotomy should be considered. Meticulous debridement should be performed. Table 3. Extension into adjacent joints mandates exploration. Osseous fragments devoid of soft tissue may be discarded. Soft Tissue Coverage and Bone Grafting Wound coverage is performed once there is no further evidence of necrosis. Severe contamination: Wood may become blood soaked and difficult to differentiate from muscle.
See individual chapters for specific fracture management Table 3. The foreign material itself usually incites an inflammatory response. Periarticular fractures A.
Definitive Distal radius Elbow dislocation Selected other sites B. Humerus D. Fracture Stabilization In open fractures w ith extensive soft tissue injury. Femur B. Diaphyseal fractures A. In combination w ith screw fixation for severe soft tissue injury Internal fixation 1. Gunshot injuries are discussed separately. Cloth and leather are usually found betw een tissue planes and may be remote from the site of injury.
Relative indications for type of skeletal fixation in open fractures External fixation 1. Proximal ulnar radius E. Foreign Bodies Foreign bodies. Distraction osteogenesis 4. The expected postsalvage function does not justify limb salvage. The patient presents w ith an injury severity score ISS. High energy close-range shotgun. Some advocate bone grafting at the time of coverage. Even after revascularization the limb remains so severely damaged that function w ill be less satisfactory than that afforded by a prosthesis.
Limb ischemia 1. Low energy stab. The limb is nonviable: Pulse reduced or absent but perfusion normal 1b 2. Immediate or early amputation may be indicated if: The timing of bone grafting after free flap coverage is controversial. Very high energy above plus gross contamination. The severity of the injury w ould demand multiple operative procedures and prolonged reconstruction time that is incompatible w ith the personal.
Bone grafting can be performed w hen the w ound is clean. Hypotensive transiently 1 3. It may be avoided by a high index of suspicion w ith serial neurovascular examinations accompanied by compartment pressure monitoring.
Persistent hypotension 2 D. Gross contamination at the time of injury is causative. Open fractures may result in cellulitis or osteomyelitis. Age Years 1. Compartment syndrome: This devastating complication results in severe loss of function. The permanent cavity is small. The direct passage of the missile through the target tissue becomes the permanent cavity. Chote shot pattern 2. Shotgun w ounding potential is dependent on: The energy of the missile on exiting the tissue exit energy.
This may lead to regions of destruction apparently distant to the immediate path of the missile w ith resultant soft tissue compromise. This includes all handguns. This can draw adjacent material. The temporary cavity cone of cavitation is the result of a stretch-type injury from the dissipation of imparted kinetic energy i. It is large.
Gases are compressible. Load size of the individual pellet 3. The energy delivered by a missile to a target is dependent on: This includes all military rifles and most hunting rifles. The degree of injury created by the missile is generally dependent on the specific gravity of the traversed tissue: A missile projectile achieves a high kinetic energy because of its relatively high velocity.
The behavior of the missile w hile traversing the target: The impact area is relatively small. The energy of the missile on impact striking energy. Administration of antibiotics first-generation cephalosporin. Attention must also be paid to possible injuries sustained after the missile impact.
CourtBrow n C. Temporary cavitization causes a transient lateral displacement of tissue. The two areas of tissue injury: The shock wave. Indications for operative debridement: Missile fragments can often be found distant to the site of missile entry or exit.
Irrigation and debridement of the entrance and exit skin edges. Careful neurovascular examination must be undertaken to rule out the possibility of disruption to vascular or neural elements..
The permanent cavity is caused by localized areas of cell necrosis proportional to the size of the projectile as it travels through.
Specific attention must be paid to retained missile fragments. Figure 4. Steps in treatment include: Follow ing initial trauma survey and management see Chapter 2. In addition. This is secondary to skin flora. Meticulous debridement and copious irrigation w ill minimize the possibility of w ound infection. Compartment syndrome Gastrointestinal contamination 4. Temporary cavitation may produce traction or avulsion injuries to structures remote from the immediate path of the missile.
High-Velocity and Shotgun Wounds These should be treated as high-energy injuries w ith significant soft tissue damage. These may result in injuries ranging from neuropraxia and thrombosis to frank disruption of neural and vascular structures.
These require debridement of the intraabdominal and extraabdominal missile paths. Neurovascular disruption: The incidence of damage to neurovascular structures is much higher in high-velocity injuries military w eapons. Lead poisoning: Synovial or cerebrospinal fluid is caustic to lead components of bullet missiles. Fracture stabilization. Fracture treatment: Generally treat this injury as a closed fracture. These are generally tolerated w ell by the patient and do not w arrant a specific indication for surgery or a hunt for fragments at the time of surgery unless they are causing symptoms pain.
Delayed w ound closure w ith possible skin grafts or flaps for extensive soft tissue loss. Extensive and often multiple operative debridements. Intraarticular or subarachnoid retention of missiles or missile fragments is thus an indication for exploration and removal. Gunshot w ounds that pass through the abdomen and exit through the soft tissues w ith bow el contamination deserve special attention.
Local recurrence is higher. Patients w ith fractures and underlying suspicious lesions or history should be referred for biopsy. They may occur later in patients w ith radiation osteonecrosis Ew ing sarcoma. Pathologic fracture complicates but does not mitigate against limb salvage.
Causes include neoplasm. Most are asymptomatic before fracture. Antecedent nocturnal symptoms are rare.
Fractures more common in benign tumors versus malignant tumors.. Most common in children: Humerus Femur Unicameral bone cyst. Alw ays obtain a biopsy of solitary destructive bone lesions even in patients w ith a history of primary carcinoma. Survival is not compromised. Suspect a primary tumor in younger patients w ith aggressive-appearing lesions: Poorly defined margins w ide zone of transition Matrix production Periosteal reaction Patients usually have antecedent pain before fracture..
Ew ing sarcoma. Suspicion of pathologic fracture should be raised in patients presenting w ith fracture involving: Normal activity or minimal trauma. Physical examination: In addition to the standard physical examination performed for the specific fracture encountered. UPEP to rule out possible myeloma hour urine hydroxyproline to rule out Paget disease Specific tests: It is difficult to measure size accurately.
Patients w ith a know n primary malignant disease or metabolic disease.
Table 5. As w ith all fractures. Risk factors such as smoking or environmental exposure to carcinogens. A history of multiple fractures. Paget disease: Search for primary source in patient with suspected metastatic bone lesion 1. Physical examination. Pathologic fracture is the most common orthopaedic complication. Metastatic disease: Bone scan: This is the most sensitive indicator of skeletal disease.
It gives information on the presence of multiple lesions. Osteomalacia and hyperparathyroidism may be present.
Hematopoietic disorders: Review of systems. Chest radiograph: To rule out primary lung tumor or metastases in all cases. Total-body technetiumm bone scan 6. Abdominal ultrasound 7. Systemic Osteoporosis: This is the most common cause of pathologic fractures in the elderly population.
Other useful tests in evaluating a patient w ith suspected pathologic fracture of unknow n origin include the follow ing Table 5. Localized This accounts for the majority of pathologic fractures and includes: Primary malignancy of bone. Contrary to popular belief. Healing and callus formation are normal. Internal fixation w ill eventually fail if the bone does not unite. Healing time is slow er than in normal bone.
Loss of fixation is the most common complication in the treatment of pathologic fractures. Local Disease Nonossifying fibroma. Mechanical support for w eakened or fractured bone to permit the patient to perform daily activities. Operative Treatment Goals of surgical intervention are: Prevention of disuse osteopenia. Decreased length and cost of hospitalization.
Pain relief. Internal fixation. Most common locations include the spine. Correctable disorders include osteomalacia. Paget disease. Noncorrectable disorders include osteogenesis imperfecta. Adjuvant Therapy: Radiation Therapy and Chemotherapy Role in treatment of pathologic fractures: Palliate symptoms. Facilitation of nursing care. Diminish lesion size. Mental obtundation or decreased level of consciousness that precludes the need for local measures to relieve pain.
They delay soft tissue healing and should not be administered until 10 to 21 days postoperatively. Adequate patient management requires multidisciplinary care by oncologists. Cement augmentation. Goals of surgery in treating patients w ith pathologic fractures are: Nails versus plates versus arthroplasty.
Arthroplasty for periarticular fractures. Aggressive rehabilitation. If the acetabulum is not involved. Pathologic fracture treatment includes: Restoration of function. Pathologic femoral shaft fractures may be managed w ith intramedullary nailing. Metastases of Unknown Origin: These treatments are used to decrease the size of the lesion.
Prevent advancement of lesion. Pathologic fracture survival Seventy-five percent of patients w ith a pathologic fracture w ill be alive after 1 year. Pathologic fractures of the femoral neck generally do not unite regardless of the degree of displacement.
Interlocked nails to stabilize the entire bone. Contraindications to surgical management of pathologic fractures are: General condition of the patient inadequate to tolerate anesthesia and the surgical procedure. Radiation and chemotherapy are useful adjunctive therapies in the treatment of pathologic fractures.
Persistent pain follow ing irradiation. Prophylactic fixation of impending pathologic fractures is not recommended on a routine basis. Advantages of prophylactic fixation compared to fixation after fracture occurs are as follow s: Decreased morbidity Shorter hospital stay Easier rehabilitation Pain relief Faster and less complicated surgery Decreased surgical blood loss Table 5.
Pathologic avulsion of the lesser trochanter. Quantitative computed tomography is a sensitive study to assess the degree of bone destruction. Indications for prophylactic fixation Harrington are: Operative stabilization of pathologic fractures of the humerus may be performed to alleviate pain. Consider bone grafting the defect. They occur more frequently w ith noncemented components. Revision surgery. There is a 0. Place cortical w indow s in an anterolateral location on the femur in line w ith the neutral bending axis.
Risk Factors Osteopenia: Osteoporosis or bone loss secondary to osteolysis. Stress risers secondary to cortical defects. Choose the correct starting point for reaming and broaching. Loose components: Inadequate implant site preparation: Large implant w ith inadequate reaming or broaching may be responsible. Type III: Pericapsular pathology: A scarred capsule w ith inadequate release may result in intraoperative fracture.
Type II: Explosion type w ith comminution around the stem. Type IV: Level I: Level II: Level III: Type I: Type V: Type VI: Proximal femur distally to the low er extent of the lesser trochanter 10 cm of the femur distal to level I Covers remainder of femur distal to level II Fracture proximal to the intertrochanteric line that usually occurs during dislocation of the hip Vertical or spiral split that does not extend past the low er extent of the lesser trochanter Vertical or spiral split that extends past the low er extent of the lesser trochanter but not beyond level II.
Classification scheme proposed by Johansson. Modified from Petty W. Revision plus ORIF. American Academy of Orthopaedic Surgeons. Age and medical condition of the patient. Accurate reduction and secure fixation. Treatment Principles Treatment depends on Location of the fracture. Figure 6. Instructional Course Lectures W B Saunders.
Options include: Nonoperative treatment: Modified from Duncan CP. Jackson D. Masri BA. A loose stem should be revised. Stability of the prosthesis. Fractures of the femur after hip replacement.
American Academy of Orthopaedic Surgeons classification of fractures associated with hip arthroplasty. Vancouver classification scheme for periprosthetic fractures about total hip arthroplasties.
Total Joint Replacement. Type B: Type C: Fracture in the trochanteric region Greater trochanter region Lesser trochanteric region Around or just distal to the stem Stable prosthesis Unstable prosthesis Unstable prosthesis plus inadequate bone stock Well below the stem Figure 6.
Bone stock. ORIF is used to maintain abductor function w ith w ide displacement. Composite allograft. Cemented prosthesis. Adequacy of stress riser augmentation. Do not make any new stress riser. Revision of acetabular component is indicated w ith severe polyethylene w ear. The severity of the bone defect.
Fluted long-stem prosthesis. Choice of implant includes: Uncemented prosthesis: Extensive coated long-stem curved prosthesis. Proximal femoral replacement. The functional class of the patient. Long-term results depend on: Implant alignment. Options for fixation include: W ires or cables. Proximal femoral reconstruction. Treatment depends on: The age of the patient. Routine bone graft is used w ith ORIF.
Cortical onlay allograft. Preservation of the periosteal blood supply. Nondisplaced fractures may be treated nonoperatively. Classification NEER. The interface remains intact. In the absence of significant osteopenia. The fracture is nondisplaced. Risk Factors Supracondylar fractures after total knee replacement are multifactorial in origin. Preexisting neurologic disease. Fracture of the patella after total knee arthroplasty may occur. Displaced fractures should be treated by ORIF. The patient has a loose or failing prosthesis in the presence of either a displaced or a nondisplaced fracture.
They generally occur w ithin 10 years after surgery. Notching of the anterior cortex: Biomechanical analysis: There is a high correlation betw een notching and supracondylar fractures in patients w ith rheumatoid arthritis and significant osteopenia. Nondisplaced fractures should be observed and treated w ith crutches and limited w eight bearing. There is a high incidence of late loosening of the acetabular component.
Rorabeck CH. Immediate prosthetic revision is indicated in selected cases. Revision Total Knee Arthroplasty. Periprosthetic fractures. A blade plate. Classification scheme for periprosthetic fracture of the knee.
Fractures around the diaphysis or the tip of a femoral component may be treated w ith cortical strut grafts and cerclage w iring. Modified from Lew is PL. Primary revision w ith a stemmed component may be considered if there is involvement of the boneimplant interface.
If bone quality is poor. Long leg casting or cast bracing for 4 to 8 w eeks may be used to treat minimally displaced fractures. Engh GA. ORIF is indicated if the alignment is unacceptable by closed means and if bone stock is adequate for fixational devices.
Bone loss may be addressed w ith autologous grafting. Cases of severe bone loss. Type I fractures involving the tibial plateau typically involve the bone-implant interface. Stuart MJ. Early conversion to a cast brace to preserve knee range of motion is advised. Occur in the tibial plateau Adjacent to the stem Distal to the prosthesis Involve the tubercle The stability of the implant is then used to classify the fractures further: Subtype A is a w ell-fixed implant.
Subtype B is loose. Classification of periprosthetic tibial fractures. Periprosthetic fractures of the tibia associated w ith total knee arthroplasty. Clin Orthop Hansen AD. Subtype C fractures are intraoperative. Modified from Felix NA. Patella Fractures Epidemiology The postoperative incidence is 0. Risk Factors Large. Fragment excision: This may be undertaken for small fragments that do not compromise implant stability or patellar tracking.
This may be necessary in cases of extensive comminution or devascularization w ith osteonecrosis. The patient may be placed in a knee immobilizer for 4 to 6 w eeks. This is indicated for type II. Surgical considerations include adequate medial arthrotomy. Type IIIA: Type IIIB: Treatment options include: ORIF w ith revision of the prosthetic patella. Classification of periprosthetic shoulder fractures. Excessive reaming of the proximal humerus Overimpaction of the humeral component Excessive torque placed on the humerus during implant insertion Classification University of Texas San Antonio Classification of Periprosthetic Shoulder Fractures Fig.
Others advocate aggressive operative stabilization of all periprosthetic fractures of the shoulder. ORIF may be performed w ith cerclage w iring and possible bone grafting.
Nonoperative Treatment Closed treatment involves fracture brace. Fractures occurring proximal to the tip of the humeral prosthesis Fractures occurring in the proximal portion of the humerus w ith distal extension beyond the tip of the humeral prosthesis Fractures occurring entirely distal to the tip of the humeral prosthesis Fractures occurring adjacent to the glenoid prosthesis Treatment Controversial: Some advocate nonoperative treatment w ith surgical intervention indicated for compromise of prosthetic fixation and intraoperative fractures.
Options for postoperative immobilization range from sling immobilization for comfort until range-of-motion exercises can be instituted.
Revision to a long-stem prosthesis may be required for cases w ith gross implant loosening. These occur more commonly in the humerus than in the ulna. The splint may then be changed to a fracture brace for 3 to 6 w eeks. Risk Factors Osteoporosis Paucity of bone betw een the medial and lateral columns of the distal humerus Abnormal humeral bow ing in the sagittal plane Size and angulation of the humeral and ulnar medullary canals Excessive reaming to accommodate the prostheses Revision elbow surgery Classification Fig.
Fractures of the Upper Extremity. Fractures of the Shoulder Girdle. Hippocrates - On Fractures. Children's Orthopaedics and Fractures.
Fractures in Children. Fractures in children. Arthroscopic Management of Distal Radius Fractures. Fractures of the Pelvis and Acetabulum. Fractures of the Hand and Wrist. Pediatric Fractures Dislocations and Sequelae. Musculoskeletal Fatigue and Stress Fractures. Children's Orthopaedics and Fractures, 3rd Edition. Lecture Notes: Orthopaedics and Fractures 4th ed. Rockwood and Wilkins' Fractures in Children. Internal fixation of femoral neck fractures An Atlas.
The initiation, propagation, and arrest of joints and other fractures.