Maisonneuve fracture involves fracture of the proximal
fibula associated with an occult and unstable injury of the ankle. The problem
in these patients occur when the ankle injury is presented without a fracture
of the lateral malleolus, or the medial malleolus and the injury is mistakenly
diagnosed as an ankle sprain and the proximal fibular fracture is missed. Examine
the leg for tenderness in the proximal fibula to diagnose a proximal fibula
fracture. The patient could be mistakenly treated for having an isolated
proximal fibular fracture alone and the ankle injury is missed.
High index of
suspicion is necessary to diagnose and treat this injury. Maisonneuve fracture
equals syndesmotic injury. Syndesmotic Injury equals Syndesmotic Reduction and
Fixation. If ankle x-rays show medial or posterior malleolus fracture, or a
medial clear space widening with no fracture of the lateral malleolus, then you
must obtain a long-leg films to assess possible proximal fibular fracture. Clinical
examination of their entire leg for pain and tenderness in addition to long leg
films of the entire leg that includes the ankle, and the knee is mandatory in
case of the patient with approximate fibular fracture to exclude the presence of
an additional ankle injury, or if the patient has an unexplained increase in the
medial clear space of the ankle joint. You should be searching for the presence
of a high fibular fracture. Look for signs of syndesmotic injury such as an
unexplained increase in medial clear space or tibiofibular clear space is
widened and it should be less than 5 millimeters.
So how do you explain this injury? It is explained by the
presence of rotation force to the ankle with transmission of the force through
the interosseous membrane, which exits through a proximal fibular fracture. Maisonneuve
fracture occurs from external rotation of the foot, most often with pronation
mechanism. This force has to go somewhere! If you don't see a fracture of the
fibula then do the squeeze test or the external rotation stress test (both will
show syndesmotic). The injury can involve the deltoid ligament injury or medial
malleolar fracture medially and a fibular fracture proximally. Additionally, the
tibiofibular ligaments are also involved, which can be the anterior
tibiofibular ligament, interosseous ligament, the posterior tibiofibular ligament
or posterior malleolar fracture. This looks like a very unstable ankle injury
that may not be very obvious at presentation and you have to look out for it.
So how do you treat an Maisonneuve Fracture? This treated by
fixation of the tibiofibular syndesmotic injury (key of treatment) or
syndesmotic screws. if you have a medial site injury and there is a tear of the
deltoid ligament, leave it alone. if there's a medial malleolus fracture you
should fix that of the lateral side if there's approximate fibular fracture
leave it alone. If there is a medial malleolar fracture, it should be fixed. If
there is a proximal fibular fracture on the lateral side, leave it alone. As
for the Syndesmotic Injury, the fixation has to be stable and adequate. Because
of the magnitude of the injury, the Maisonneuve fracture may require more
syndesmotic screws than with a routine ankle fracture with syndesmotic injury. After
the fixation you will give a short leg non-weight bearing splint for six to
eight weeks. Here is a patient taste example: the proximal fibular fracture and
you can see increase in the medial clear space and you can see that the
syndesmosis is widened. You can see that in the posterior malleolar fracture
the patient is fixed with syndesmotic screws.
In general, doctors treat patients for pain due to injury or
surgery. Pain intensity varies from person to person and it can be related to
stress, distress, coping strategies, and physiological factors. The physician
should work with the patient for better pain control and for safer prescribing
of medications.The best pain relief is
self-efficacy and resilience. We have found that giving the patient a teddy
bear helps to relieve their pain and anxiety, giving the patient comfort and
confidence in the system.
25% of tibial shaft fractures can be open. Open fractures
can lead to complications including wound problems, osteomyelitis, nonunions,
and infected nonunions. The treatment of open fractures of the tibia can be
challenging. A lot of the concepts are not black and white; they may be in the
grey zone. We don’t know the best time for debridement. We don’t know what the
optimal irrigation solution is and what the optimal pressure for the fluid is.
We don’t know for sure the ideal duration of giving antibiotic prophylaxis, but
we know that it is important to give the appropriate antibiotics early and do
meticulous debridement. We know that the IM rod is better than the plate
fixation or external fixator, and the result of the reamed IM rod or unreamed
IM rod is the same. We need to close or cover the wound before 1 week and the
vac can be used provisionally when we cannot close the wound, primarily at the
optimal time. A grade I fracture is less than 1 cm. a grade II fracture is
1-10cm. A grade III fracture is more than 10 cm, and there is contamination.
Grade III fractures are divided into three types. Grade IIIa fractures require
adequate tissue for closure (or skin graft). Grade IIIb fractures require
extensive periosteal stripping and the patient will need a flap (rotational or
free flap). Grade IIIc fractures have a vascular injury that requires repair or
amputation. The relative indication for amputation is warm ischemia for more
than 6 hours, absent plantar sensation and severe ipsilateral foot trauma.
The
most predictive factor for amputation is the severity of the soft tissue injury
in the ipsilateral extremity. When comparing limb salvage versus amputation,
the patient’s outcome is generally the same at 1-5 years. Lack of plantar
sensation does not predict poor outcome after limb salvage. Segmental fractures
are Grade III fractures, even if the open fracture is 1 cm. The ideal
irrigation solution and the pressure used to controversial. Timing of the
initial debridement is controversial. Irrigation and debridement within 6 hours
was the gold standard in the past. Debridement is performed as a priority
procedure no later than the morning after admission. There is no difference in
infection rate for a patient who has the initial surgery before or after 6
hours, including patients with Type III open fractures. More than 40% of the
patients usually wait longer than 6 hours for their initial surgery after
arrival at the hospital. Delayed surgery for less severe fractures is
acceptable as long as the debridement is done as a priority the following day.
Unless there is a gross contamination, evidence is not clear as to when is the
best time for the debridement. It seems like giving the patient antibiotics
promptly is more important than the time of debridement. The preferred solution
is normal saline and low pressure irrigation. Low pressure lavage may reduce
reoperation rates due to infection, nonunions, and wound healing problems.
Normally the tradition is to use 3, 6, and 9 liters of solution for Type I,
Type II, and Type III open fractures (just recommendations). There is increased
risk of wound healing with antibiotic solution. Meticulous irrigation and
debridement of open fractures is important in decreasing the infection risk.
Prophylaxis should be started as soon as possible. All patients with open
fractures should receive first generation Cephalosporin’s that will cover
gram-positive bacteria. You can give penicillin for farm injuries and
clostridia prone wounds. You will give clindamycin if there is a penicillin
allergy. In Type III open fractures, add aminoglycoside, such as gentamicin. It
was found that local antibiotics delivery at the site of injury decreased the
infection risk, such as cement beaded loaded with antibiotics. Antibiotic
should be given within 3 hours of the time of injury (preferably given as soon
as possible). There is reduction of 59% of acute infection in patients with
open fractures treated with antibiotics. The infection rate is 1.6 times
greater if antibiotics are given after 3 hours. Type I and Type II open
fractures require antibiotic coverage for 24 hours after wound closure. For
Type III open fractures, antibiotic administration should be given for a period
of 72 hours after the injury and no more than 24 hours after wound closure. After
the initial debridement, the patient will need staged debridement within 24-48
hours. There is a reduction infection rate, acute and chronic, for Type III
open fractures with the use of systemic antibiotics and aminoglycoside cement
beads compared with antibiotics alone. This combination of antibiotics lowers
the infection rate for any open tibial fracture that is treated with an IM rod.
Its affect is more noticed in Type III injuries. Plating of open fractures may
cause chronic infection and infected nonunion. The healing time is doubled with
plated open fractures. The IM rod resulted in a better alignment and lower
reoperation rate than using external fixator. Also, no difference in the
infection rate between the IM rod and the external fixator. You can use a
reamed nail or an unreamed nail. They both have a comparable result and no
difference in the outcome.
When reaming, you can use a bigger rod that provides
better stability. Reamed nailing is superior in closed tibial fractures, but it
is not superior in open tibial fractures. Reaming can cause increased pressure
and disruption of the endosteal blood supply, can cause thermal necrosis and
fat embolism with increased intramedullary risk of infection. The unreamed rod
uses smaller nails and results in less stability but preserves the endosteal
blood supply. Unreamed IM tibial rod appears to have a shorter time to union
and fewer incidence of knee contractures when compared with circular wire
external fixator. Nowadays, more and more orthopedic surgeons are using reamed
nails for open fractures of the tibia. If you have a spiral fracture of the
distal 1/3 of the tibia, you will need to get a CT scan of the ankle to
identify a posterior malleolar fracture, which should be fixed before insertion
of the IM rod. There is a lack of evidence to support the value of external
fixator over the IM rod in open factures of the tibia. Due to patient
discomfort, the high incidence of pin tract infection and loss of alignment,
external fixator should not be used as a definitive fixation. Use external
fixator temporarily (less than 4 weeks) and replace it with a rod in about 14
days. External fixator may be utilized for severely contaminated open
fractures. Tibial fractures treated with a shorter duration of external fixator
has reduction of the infection risk by 80%. When there is a shorter interval
between removal of the external fixator and insertion of the IM rod of the
tibia, there is a reduction of the risk of infection by 85%. In less severe
soft tissue injuries, you do primary closure without tension. In cases of
delayed closure, soft tissue coverage should be done within 7 days. Soft tissue
coverage beyond 7 days will increase the infection. There is no difference in
the incidence of infection in patients who had primary closure and delayed
closure of the wound. It is recommended to do primary closure for Type I, Type
II, and Type IIIa fractures with tension free closure and after timely
antibiotic prophylaxis and adequate debridement. Intraoperative culture after debridement
has no value. It does not predict future infection. In the upper 1/3 of the
tibia, you can treat it by a medial gastrocnemius flap. In the middle 1/3 of
the tibia, you can treat it by a soleus rotational flap. The use of a free flap
for soft tissue coverage was less likely to have wound complications than the
use of a rotational flap. The zone of injury may be larger than expected, and
it may include the rotated muscle flap. The negative pressure wound therapy
(the vac) is used frequently. The vac provides provisional coverage for wounds
where the physician cannot do primary closure. There is decreased infection
rate when using the vac. The vac is used for coverage after the initial
debridement of the open fracture until the definitive coverage is done. It is a
good temporizing dressing and can also be used in fasciotomy wounds. The vac
promotes local wound healing. Bone morphogenetic protein (BMP2) decreases the
need for secondary surgery and is used in acute open tibial fractures treated
with IM rod.
Monteggia fracture is a fracture of the proximal ulna and
radial head subluxation. It is imperative that you restore the length and the
proper alignment of the ulna so that the radial head can be reduced. If we
malalign the ulna, then the radial head will remain subluxed. There are some
cases where the fracture of the ulna is so comminuted that we will be unable to
restore the length of the ulna. We will not even know if we restored the length
of the ulna.
There is a technique that I use in the reconstruction of the ulna
in cases where the ulna is too comminuted. I will open the fracture ulna, and I
will approach the radial head. I will reduce the radial head to the capitellum
and reduce the ulna to the radius and make sure that the proximal radioulnar
joint is anatomic. Once that joint is anatomic, I will pin it with either one
or two K wires. I transfix the ulna to the radial head. We know that the radial
head is reduced, now the ulna will be reduced because the radioulnar joint is
reduced. We are temporarily transfixing the ulna to the radial head, and that
will help to restore the proper length of the ulna. Once the proper length of
the ulna is defined, then reconstruction of the ulna is simplified utilizing a
dorsal ulnar plate. Next, the K wires are removed and the radioulnar joint is
tested for stability. Occasionally, the K wires may be left in place for a few
weeks if needed to provide additional stability, then removed later on.
Monteggia fracture is not a simple fracture. It is a
fracture of the proximal ulna with dislocation of the radial head. Monteggia
fracture can happen in children and in adults. It is one of the most common
injuries that is missed in the emergency room in children. The radial head may
be dislocated or subluxed, and this problem may not be clear on x-rays. If this
injury is missed, then the child will probably need a big surgery to deal with
this big problem. Treatment of this fracture depends on the age of the patient.
In general, in pediatric patients, you will do closed reduction of the ulna and
closed reduction of the radial head. In adult patients, you will do open
reduction with internal fixation of the ulna with dorsal plate and closed
reduction of the radial head. A line drawn from the proximal radius should
bisect the capitellum in all x-ray views. If you are in doubt and not sure, get
x-rays of the other side and compare. Always examine the patient for posterior
interosseous nerve injury.
The most common type is anterior Monteggia. That
means that the apex of the fracture is anteriorly and the radial head goes
anteriorly. Just make it a practice, when you have a fracture of the proximal
ulna, look at the radius and the radial head, and see the position of the
radial head in relationship to the capitellum. Anterior Monteggia is more
common in children. Posterior Monteggia constitutes 70-80% of Monteggia
fractures in adults. There are four types of Monteggia: Type I, Type II, Type
III, and Type IV. Monteggia fracture is classified according to the direction
of displacement of the radial head. The radial head has two relations: relation
with the capitellum and relation with the proximal radioulnar joint. When the
radial head subluxes or dislocates, it subluxes or dislocates from these two
joints. The radial head becomes free. This means that the radius is not
connected to the capitellum or to the superior radioulnar joint. A Type I
fracture is of the middle or the proximal third of the ulna with anterior
dislocation of the radial head, and it has the characteristic that the apex of
the ulnar fracture is anteriorly. Type I fracture is the most common of all
types (especially in children). Type I occurs in about 60% of fractures. In
children, reduce the fractured ulna and reduce the dislocation of the radial
head and immobilize the elbow in flexion and supination. When you flex the
elbow, especially more than 90 degrees, you will relax the biceps (watch the
circulation). A Type II fracture is a posterior type fracture. Posterior
Monteggia is the most common type in adults. It is associated with a higher
complication rate and carries the worst prognosis. 15% of Monteggia fractures
are Type II. It is a fracture of the middle or proximal third of the ulna with
posterior dislocation of the radial head. You should immobilize the elbow in
extension. Type III is a lateral Monteggia. About 20% of Monteggia fractures
are Type III. It is a fracture of the proximal ulna with lateral dislocation of
the radial head. 5% of Monteggia fractures are Type IV; it is very rare. It is
a fracture of the proximal ulna with anterior dislocation of the radial head
and fracture of the proximal third of the radius below the bicipital
tuberosity. The patient will need surgery, even in children. In this case, the
radial head is dislocated, and you also have fractures of the radius and the
ulna. The posterior interosseous nerve is adjacent to the radial neck, placing it
at risk for a traction injury with dislocation of the proximal radius.
You
should do a neurovascular examination. A nerve injury which involves the
posterior interosseous nerve is not uncommon. Ask the patient to “hitchhike”
and extend their fingers. Make sure the wrist is in dorsiflexion when you ask
the patient to extend the fingers. In posterior interosseous nerve injury, the
finger extensors will not be working. If the posterior interosseous nerve is
injured, observe the patient. In case of posterior interosseous nerve injury in
Monteggia fracture, you will reduce and stabilize the fracture and reduce the
radial head dislocation. Observe the nerve; do not explore the nerve. Typically
the nerve injury is a neuropraxia. It can be expected to resolve itself with
observation in 6-12 weeks. If it does not resolve, you will do EMG and nerve
studies after that period of observation. Any time that you have an ulnar shaft
fracture or any fracture of the proximal ulna, check the radial head position.
Make sure that the radial head is reduced to the capitellum (be aware that the
subluxation may be subtle). Recognition of Monteggia fracture in children is
important. Early appropriate treatment is much easier than treating a missed
radial head dislocation. To treat a Monteggia fracture in adult patients, do
open reduction internal fixation (ORIF) of the ulna. When the ulna is properly
aligned and fixed, the radial head will reduce by itself. After fixation of the
ulnar fracture, if the radial head is still not reduced, then assess the ulnar
reduction. Check for malalignment or malreduction of the ulna. It is imperative
that you restore the length and the proper alignment of the ulna, so that the
radial head can be reduced. If we malalign the ulna, then the radial head will
remain subluxed. Radial head instability may be caused by nonanatomic reduction
of the ulna or by interposition of the annular ligament. Fracture of the ulna
may be too comminuted, and it may not be reduced properly. The fracture may
also need bone graft later on for healing. A Monteggia variant associated with
radial head fracture, in addition to dislocation of the radial head fracture,
in addition to dislocation of the radial head and fracture of the ulna can be a
problem. The radial head fracture is usually fixed or replaced, a prosthesis is
used to replace the radial head in the elderly, especially if the fracture is
comminuted. The subluxation of the radial head is reduced, and the fractured
ulna is fixed as usual. Treatment is different in pediatric patients. The
radial head ossifies around four years of age. In Type I, Type II, and in Type
III Monteggia fractures, you will do closed reduction of the ulna to restore
the length of the ulna, and you will do closed reduction of the radial head.
Closed reduction is much more successful in young children. In anterior
Monteggia, you will immobilize the elbow in flexion and supination. In
posterior Monteggia, you will immobilize the elbow in extension. Ulnar fixation
with a rod or a plate is needed in older patients with unstable fractures. Type
IV fractures require surgery. Surgery is also done in cases where we are unable
to restore the proper length of the ulna, we are unable to reduce the ulna, and
we are unable to reduce the radial head. In this situation, we can use IM rod
or a plate. Dislocation of the radial head with fracture of both the radius and
ulnar shaft. Do closed reduction of the radial head with intramedullary pin
fixation of the radius and the ulnar shaft fractures. The radius and ulnar
shaft fractures are stabilized surgically to give a lever arm for reduction of
the radial head. In this type of fracture, the radial head subluxation may be
missed or unappreciated, because the focus is usually on the forearm fractures.
To treat a missed or neglected Monteggia fracture in children, do osteotomy of the
ulna and lengthening with correction of the angulation, and reduction of the
radial head in addition to plating of the ulna. The patient may need open
reduction of the radial head.
Lisfranc injury is an important topic. If Lisfranc injury is
not diagnosed and treated properly, it can lead to an altered gait, midfoot
arthritis, and long term disability. Lisfranc injury indicated disruption
between the base of the 2nd metatarsal and the medial cuneiform. Lisfranc
injuries are a spectrum of injuries of the tarsometatarsal joints. Diagnosing Lisfranc
injury is important. Diagnosis is missed in about 20%-30% of cases especially
in multiple trauma patients. A high index suspicion is needed to prevent
progression of the foot deformity, chronic pain, and dysfunction. You may need
weight-bearing films for diagnosis of Lisfranc injury. Lisfranc injury may also
be associated with compartment syndrome. Lisfranc injury could be purely
ligamentous or can be associated with fractures. ORIF is better in cases of
fractures. Arthrodesis is better in cases of purely ligamentous injury. In general,
ligamentous injury does worse than fractures. The Lisfranc ligament is a large
oblique ligament that extends from the plantar aspect of the medial cuneiform
to the base of the second metatarsal. The Lisfranc ligament stabilizes the 2nd
metatarsal and maintains the midfoot arch. Osseous stability is provided by the
roman arch of the metatarsals and the recessed keystone of the 2nd
metatarsal base. Tarsometatarsal joint complex is divided into three units:
medial, middle, and lateral. The medial is the 1st metatarsal joint
at 6o mobility. The middle is the 2nd and 3rd
tarsometatarsal joints, and it is rigid. The lateral is the 4th and
5th tarsometatarsal joints; it is mobile which is why you do not
fuse the 4th and 5th tarsometatarsal joints. The dorsalis
pedis artery and the deep peroneal nerve both run between the first and second
metatarsal bases. A direct injury with a plantar displacement is more common. Indirect
injuries are more common than direct injuries. They result from axial loading
or twisting on a plantar flexed midfoot. Dorsal displacement of the 2nd
metatarsal is more common. Check the alignment of the dorsum of the 2nd
metatarsal with the middle cuneiform. Associated fractures are typically tarsal
fractures, especially a cuboid fracture. A “Nutcracker” fracture results from
twisting injury causing forceful abduction of the forefoot. It is a fracture of
the base of the 2nd metatarsal and compression fracture of the
cuboid. nd
metatarsal, at the navicular, and cuboid. Check for widening between the first
and second ray (more than 2 mm is an indication for surgery). In the lateral
view, check the dorsal displacement or subluxation of a metatarsal. It should
be at the level of the corresponding cuneiform. Check for the FLECK sign (bony
fragment). Avulsion fragment of the Lisfranc ligament from the base of the 2nd
metatarsal. The medial side of the fourth metatarsal should line up with the
medial side of the cuboid on the oblique view (30o). CT scan can be
useful and MRI can confirm purely ligamentous injury. These injuries should be
treated with a cast. For a dorsal sprain and no instability, the patient can be
treated with non-weight bearing cast for 6 weeks and return to activity
gradually. Surgery can be done for instability. Open reduction internal
fixation with cortical screws if there is bony fractures. When you do ORIF- you
need anatomic reduction. Hardware removal between 5-6 months (some surgeons
leave the hardware in place indefinitely). Arthrodesis if the injury is purely
ligamentous. Healing of the ligaments is less reliable than bony healing. Purely
ligamentous injury needs primary arthrodesis. Arthrodesis is also done in old injuries
if there is delay in treatment for if there is failure of open reduction and
internal fixation of Lisfranc injury. Midfoot arthrodesis is also used for
chronic Lisfranc injury that leads to severe midfoot arthritis with progressive
arch collapse and midfoot abduction. Fusion of the medial and middle column;
first, second, and third tarsometatarsal joints. Do not fuse the lateral column
(lateral column is mobile). For the lateral column, do reduction and
stabilization by k-wire fixation. Post-traumatic arthritis occurs in up to 50%
of patients. Patient may have altered gait and long term disability. Purely ligamentous
injury has a worse prognosis than injuries with fractures. Malalignment of the
fractures usually lead to arthritis.
Lisfranc classifications are not useful in deciding the treatment or the
prognosis of the injury. Severe injuries are obvious, easily diagnosed, and may
develop compartment syndrome of the foot. Injuries with minimal displacement
could be missed, and they will need surgery regardless of the classification. Arthritis
may develop even with minimal displacement. In general, there are three
patterns of injury: total incongruity, partial incongruity, and divergent. Total
incongruity occurs when all five metatarsals are displaced in the same
direction. Total incongruity occurs lateral or medial, with lateral being more
common. Partial incongruity occurs when one or two metatarsals are displaced
from the others. Divergent occurs when the lateral displacement of the lesser
metatarsals with medial displacement of the first metatarsal. The one thing all
these injuries have in common is disruption of the tarsometatarsal joint
complex. The patient has severe pain in the midfoot and is unable to bear
weight. There may be some swelling in the midfoot dorsally. Plantar bruising
may be present, especially medially. Tenderness over the tarsometatarsal joint.
Check the skin condition and rule out compartment syndrome. Check the neurovascular
status of the foot. Plantar ecchymosis is a classic clinical sign of potential
Lisfranc injury. Wight bearing standing x-rays with comparison views if x-rays
are normal and if the physician clinically suspects a Lisfranc injury. Another alternative
is to get physician assisted midfoot stress radiograph. Obtain three views: AP,
oblique, and lateral. Medial border of the second metatarsal should line up
with the medial border of the middle cuneiform on both the AP and the oblique
view. Check for fractures, especially at the base of the 2
Type I
fractures are a stable avulsion fracture of the alar ligament near the tip of
the odontoid. A soft collar can be used to treat Type I fractures. Be aware of
significant ligamentous injuries. Type II fractures are at the base of the
odontoid process. Type II are the most common and are troublesome. The nonunion
rate is about 20-80% due to interruption of the blood supply. The risk factors
of nonunion include if the patient is over the age of 60 years old, if the
patient has more than 6mm of displacement, smoking and diabetes, and you are
unable to achieve reduction. In posterior displacement, extension injury (rare
type) the anterior displacement is more common (flexion injury). Delay in
treatment also increases the rate of nonunion. For treatment of young patients
with no nonunion risks use a halo. The patient is younger than 60 years. The
fracture is minimally displaced. Initial dens displacement is less than 6 mm,
and the reduction is within one week of the injury. Healing will occur in the
majority of cases.
If the patient has a nonunion risk, or when reduction of the
fracture cannot be achieved or maintained, then we need to think about surgery
and the fracture pattern. When the fracture pattern allows, you can put an
anterior screw into the odontoid (to preserve the motion of C1/C2). Odontoid
screw is used in younger patients instead of fusion to avoid loss of 50% of the
neck rotation). Do not use the anterior screw fixation in patients with
osteoporosis, in older patients, or in patients with a short neck. Another
scenario is, if the patient has nonunion risks but the fracture pattern does
not allow you to place an anterior odontoid screw, then you are going to fuse
C1 to C2 (this will lose 50% of neck rotation). In general, C1/C2 fusion is
used in cases of nonunion or it is used in cases of displaced fracture in the
older patient and it can also be used if there is a failure of treatment with a
halo. C1/C2 fusion can also be used if the fracture is comminuted and unstable.
Posterior C1/C2 fusion can be done with different screw or wire constructs. A
vascular watershed area exists between the apex of the odontoid, which is
supplied by branches of the internal carotid artery and the base of the
odontoid, which is supplied by branches of the vertebral artery. Type II
fracture of the odontoid may get nonunion due to cortical bone and poor blood
supply.
Type III fractures extend through the body of C2. This area is rich in
blood supply and the fracture heals in the majority of cases. Treatment for
Type III odontoid fractures includes external cervical orthosis (especially in
the elderly patient) and a halo (if the fracture is displaced) (do not use in
elderly patients). Odontoid fractures in the elderly can occur due to a simple
fall and usually the diagnosis is missed. It is associated with increased
complications and mortality. Do not use a halo in elderly patients. Use an
external cervical orthosis of some sort. Fibrous union might be adequate if the
fracture is not badly displaced, otherwise you will do fusion of C1/C2. For
example, an 80 year old patient with osteoporosis, who is a smoker and has a
displaced odontoid fracture that cannot be reduced, then this fracture will
lead to nonunion and more complications. You need to do posterior C1/C2
arthrodesis. In general, if the elderly patient with an odontoid fracture is
not a good surgical candidate, then you will give the patient a cervical
orthosis. You can do the C1/C2 fusion by using transarticular screws, which you
are not going to do if you have an aberrant vertebral artery. Another technique
can be done for the fusion where fusion between C1/C2 is done with the screw
placed into the C1 lateral mass and the C2 pedicle, plus a bone graft. There is
increased survival for the elderly patient that undergoes surgery for Type II
odontoid fracture. This may be a selection bias, because they have healthier
patients who are physiologically active and young who are fit for surgery. The
synchondrosis between the odontoid and the C2 body fuses by the age of 6 years.
Odontoid fracture in young children usually occurs by the age of 4 years.
Physicians may confuse the synchondrosis with a fracture. The treatment of
odontoid fracture in children is done with a Minerva brace or halo vest, if the
fracture is displaced. You will use more pins and less torque. Finger tighten
the pins. The Os Odontoideum looks like a fracture. It is oval shaped, it has
sclerotic edges, and Os is smaller than the normal dens. The Os Odontoideum is
a congenital process. The mechanism that causes the Os Odontoideum is unknown,
but it is probably developmental or it can result from an old trauma.
The usual story is that the patient visits the emergency
room and comes back to see the doctor because the patient is having constant shoulder
pain and is unable to move the shoulder. When examining the patient, the
patient will have limitation of external rotation of the shoulder. You may be
shown an x-ray, an AP view of the shoulder, and the interpretation of the x-ray
is that the shoulder appears normal. You need to get two x-ray views (orthogonal
views): AP view and axillary view. An AP view x-ray alone will not diagnose
posterior shoulder dislocation. When you have posterior dislocation of the
shoulder, the AP x-ray view will show the classic “lightbulb” humeral head due
to internal rotation of the shoulder.
The humeral head takes on a rounded
appearance. The axillary view x-ray will show dislocation of the shoulder
posteriorly. It is the best view to show the posterior shoulder dislocation. After
reduction, always get an axillary view and check concentric reduction. Locate the
coracoid (anteriorly) and outline it. Locate the acromion (posteriorly). Then locate
the glenoid and determine whether the dislocation is posterior or anterior. In posterior
dislocation of the shoulder, the axillary view will show the humeral head going
posteriorly away from the coracoid and in the direction of the acromion. With posterior
shoulder dislocation, the shoulder is locked in the internal rotation position
with prominence of the posterior shoulder, prominence of the coracoid process,
and flattening of the anterior shoulder. Posterior shoulder dislocation may be
associated with fracture of the lesser tuberosity. 50% of posterior shoulder
dislocations will have a Reverse Hill-sachs lesion or impaction fracture next
to the lesser tuberosity. When you examine the patient and you see limitation
of the range of motion, especially external rotation of the shoulder, you may
think it is adhesive capsulitis (frozen shoulder). Frozen shoulder can start by
limiting the external rotation, however it is usually a global restriction of
the range of motion.
Posterior dislocation of the shoulder is rare (about 5%)
and it is usually stable after reduction if no fracture is present. Posterior dislocation
of the shoulder usually occurs after seizures or electric shock. Why is it that
dislocation of the shoulder most commonly occurs as a posterior shoulder
dislocation with seizures and electric shock? This is a controversial subject. Some
physicians believe that this is due to the fact that the shoulder internal rotator
muscles (pectoralis major, latissimus dorsi, and subscapularis) are stronger
than the external rotator muscles. Up to 50% of posterior dislocations of the
shoulder can go undiagnosed when the patient is examined in the emergency room,
especially if dislocation results from seizures. If posterior dislocation of
the shoulder occurs due to seizures, the patient should be examined carefully
and neurology consult should be done to control the patient’s seizures. Any future
treatment of posterior dislocation of the shoulder may fail due to lack of
controlling seizures. Closed reduction is not difficult in the acute setting and
can be done up to 3 months. Instability is rare with absence of fracture. Immobilize
the arm in neutral rotation with the elbow at the side and posterior to the
plane of the body. Impaction less than 20%, do closed reduction and immobilize
in external rotation. Open reduction is done when posterior dislocation is
chronic or locked. In locked posterior dislocation, the deltopectoral approach
to the shoulder is usually used. If the defect is between 20%-40%, transpose the
lesser tuberosity or the subscapularis tendon into the defect. More than 45%
defect or if the dislocation is more than 6 months, do arthroplasty and place
the prosthesis in less retroversion.
There are many structures present at the anterior aspect of the
ankle. These structures are often susceptible to injury. There are many common
injuries and conditions around the ankle. Anterolateral impingement is a
painful limitation of full range of motion of the ankle due to soft tissue or
osseous (bony) pathology. Soft tissue thickening is commonly seen in athletes
with prior trauma that extends into the ankle joint. Tibial bone spur impinging
on the talus can become a source of chronic ankle pain and limitation of ankle
motion in athletes. Osseous (bony) is a spur on the anterior lip of the tibia
contacting the talus during dorsiflexion. Arthritis of the ankle joint is
commonly the result of a prior injury or inflammation to the ankle joint. It can
usually be diagnosed with an examination and x-ray. Osteochondritis Dissecans
of the Talus is a chip-type fracture that usually occurs with severe ankle
sprains. It causes pain, swelling, and stiffness of the ankle joint. X-rays, CT
scan, or MRI are commonly used for the diagnosis. Tibialis Anterior Tendonitis
is an overuse condition common in runners. It is a common injury that usually
accompanies anterior shin splints. If this tendon is strained, pain and
tenderness will be felt upon active dorsi-flexion or when the tendon is
touched.
There are many structures present at the medial aspect of
the ankle. These structures are often susceptible to injury. There are many
common injuries and conditions around the medial ankle. Posterior tibial
tendonitis or rupture can occur from overuse activities, degeneration, or
trauma. The posterior tibial tendon is one of the major supporting structures
of the foot. The tendon helps to keep the arch of the foot in its normal
position.
When there is insufficiency or rupture of the tendon, the arch begins
to sag, and a flatfoot deformity can occur with associated tight Achilles tendon.
The posterior tibial tendon rupture occurs in a hypovascular zone. This occurs
distal to the medial malleolus. It will present as painful swelling on the
posteromedial aspect of the ankle. The patient will be unable to perform a
single leg toe raise, the too many toes sign will be present, the patient will
be flatfoot, and there will be a fixed deformity of the hind foot. There are
four stages of posterior tibial tendon rupture. Rupture of the posterior tibial
tendon could be missed. Tarsal tunnel syndrome is compression of the tibial
nerve in the tarsal tunnel. The flexor retinaculum covers the nerve. Tarsal tunnel
syndrome is similar to compression of the median nerve in the carpal tunnel. It
can be caused by ganglia, accessory muscles, or soft tissue mass. Tarsal tunnel
syndrome can be differentially diagnosed as a herniated disc, a stress fracture
of the calcaneus, or plantar fasciitis. Tarsal tunnel syndrome will present as
pain on the medial side of the foot. The patient will have pain worse with
dorsiflexion due to tension on the nerve. There will be paresthesia and numbness
of the foot and a positive tinel’s sign behind the medial malleolus. Flexor hallucis
tendonitis is pain, swelling, and weakness posterior to the medial malleolus. Dorsiflexion
of the big toe may be reduced when the ankle is placed in dorsiflexion. Triggering
and pain along the tendon sheath may also occur with toe flexion. Flexor hallucis
tendonitis often occurs in activities such as ballet dancing, in which plantar
flexion is necessary. The deltoid ligament is the primary stabilizer of the ankle
joint. The deltoid ligament provides support to prevent the ankle from
everything. An isolated eversion sprain with a tear of the deltoid ligament is
a rare injury.
There are many structures present at the posterior aspect of
the ankle. These structures are often susceptible to injury. There are many
common injuries and conditions around the posterior ankle. Posterior ankle
impingement (os trigonum) is a posterior talar impingement of the os trigonum
or large process of the talus (stieda syndrome). This is a non-united piece of
accessory bone seen posterior to the talus. It is common in athletes such as
ballet dancers. There will be tenderness in the posterolateral aspect of the ankle
posterior to the peroneal tendon especially with passive plantar flexion. It may
be seen in association with flexor hallucis longus tenosynovitis. Flexor hallucis
longus tenosynovitis is a condition associated with ballet dancing, in which
extreme plantar flexion is necessary. It is characterized by swelling and pain
posterior to the medial malleolus. It is triggered by toe flexion. Dorsiflexion
of the big toe is less when the ankle is dorsiflexed. Achilles tendonitis is
irritation and inflammation that occurs due to overuse. It is characterized by
pain, swelling, and tears within the tendon. It is usually treated with therapy
and injection. Do not inject inside the tendon. It is rarely treated with
surgery. Achilles tendon can become prone to rupture with age, lack of use, or
by aggressive exercises. Rupture is diagnosed by the Thompson test and MRI. It is
treated by conservative treatments without surgery by using a cast or a boot. However,
rupture rate may be high if the patient is treated conservatively. Surgery is
done by approximation of the torn tendons. The risk of surgery is infection or
skin and wound complications.
There are many structures present on the lateral side of the
ankle. These structures are often susceptible to injury. Diagnosis of these
injuries can be confusing and many of these injuries can be missed. Diagnosis of
a sprained ankle may be the wrong diagnosis. A high ankle sprain is a
syndesmotic injury that may require surgery. Other injuries to the lateral side
of the ankle include peroneal tendon subluxation, rupture of the peroneus
longus tendon, peroneal tendonitis, anterior process of the calcaneus fracture,
lateral process of the talus fracture, and Achilles tendonitis.
The anterior tibial artery is a branch of the popliteal
artery (posterior aspect of knee), which divides into the anterior tibial
artery and the posterior tibial artery (posterior). The anterior tibial artery
is a branch of the popliteal artery (posterior aspect of the knee), which
divides into the anterior tibial artery and the posterior tibial artery
(posterior). Sometimes the two divisions are called the anterior tibial artery
and the tibio-fibular trunk. th area of the anterior fibula. Then the extensor hallucis longus
muscle appears, so the anterior tibial artery lies between the tibialis
anterior muscle and the extensor hallucis longus muscle. The extensor hallucis
longus muscle arises from the middle 2/4th area of the anterior
fibula. The extensor hallucis longus then crosses the leg medially to take a
position in the medial side. The big toe is definitely medial, so the extensor
hallucis longus will go towards the big toe and become medial. The other toes
are lateral, so the extensor digitorum longus will be inserted laterally and
the anterior tibial artery will then be between these two muscles in the distal
part of the leg and in front of the ankle. When the extensor hallucis longus
tendon crosses the leg to go medially, it then crosses the anterior tibial
artery. At this point, the anterior tibial artery is between the extensor
hallucis longus and the extensor digitorum longus tendons. At the level of the
ankle joint, this is how we remember the arrangement of the anterior ankle
structures. Tom Has a Very Nice Dog:Tibialis anterior,
extensor Hallucis longus, Vessels, Nerve, extensor Digitorum
longus. This is only good to remember the structures in the distal portion of the
tibia in front of the ankle. This does not work proximally, and this does not
work for the structures in the middle third of the tibia. Extensor hallicus
longus tendon is medial. Anterior tibial artery is lateral. After the anterior
tibial artery passes underneath the extensor retinaculum, the artery is then
called the dorsalis pedis, distally. The deep peroneal nerve pierces the intermuscular
septum to enter the anterior compartment and goes through the substance of the
extensor digitorum longus muscle. of retractors in the posterior part of the
proximal tibia to avoid damage to any of these branches of the popliteal artery
since the bifurcation of the popliteal artery is in this area.
The relationship between the anterior tibial
artery and the deep peroneal nerve changes according to the location. Proximally
the nerve is lateral, then the nerve comes in front of the artery, finally the
nerve stays lateral, distally. CTA around the knee can be done for dislocations
or severe fractures around the knee area. At this level of the distal femur,
you can see the popliteal artery. At the level of the proximal part of the leg,
you can see the three branches of the popliteal artery: anterior tibial artery,
posterior tibial artery, and peroneal artery. Be careful during placement. The anterior tibial artery arises just below the
popliteus muscle. The anterior tibial artery pierces the interosseous membrane
to enter into the extensor compartment or anterior compartment of the leg. The anterior
tibial artery gives the anterior and posterior tibial recurrent arteries. The anterior
tibial recurrent artery is the one that can be injured from tibial tubercle
fracture in children, which can cause compartment syndrome of the leg. The artery
then runs proximally between the tibialis anterior medially and the extensor
digitorum longus laterally. The extensor digitorum longus arises from the upper
3/4
Low back pain is a common condition. 90% of patients with
low back pain will improve without surgery. Usually they get better with
spontaneous resolution of the symptoms within 12 weeks. We usually advise the
patient for early return to activity and function as the symptoms and the pain
permits. The risk factors for development of low back pain are numerous, some
include: vibration exposure, poor physical fitness, smoking and obesity,
anxiety and depression, job dissatisfaction, or repetitive bending or
“stooping” on the job.In summary, if the patient has no
red flags and has a normal neurological exam, there is no reason to get early
radiological studies. Getting early x-rays and early MRIs leads to a better
patient satisfaction but does not give a better patient outcome. If there is no
specific pain pattern, then there is no need for further workup. MRIs are good
studies, but they give false positives. There is degeneration or a bulge of a
disc in 35% of all asymptomatic subjects between 25-39 years of age. In
patients 60 years old or older, the majority of the patients will have changes
in the MRI. MRI abnormalities are common and must be correlated with the age
and the clinical signs and symptoms of the patient. An MRI is good for
diagnosing the lumbar disc herniation, which is sometimes called a ruptured
disc, a slipped disc, or a herniated disc. The most common location of a disc
herniation is a posterolateral herniation involving one nerve root. A
foramninal L4-L5 herniation occurs in about 8%-10% of the cases. It involves
the exiting nerve. A central herniation involves multiple nerve roots. It
predominantly causes low back pain more than leg pain. It may cause bladder and
bowel symptoms. This type of disc herniation causes Cauda Equina Syndrome which
needs urgent diagnosis and surgical treatment. Clinical evaluation for a herniated
disc examines sensory and motor reflexes. The Straight Leg Raising Test is the
most important finding. It can be done in either the sitting or supine
position. The test is positive as indicated by pain in the leg when the
patient’s leg is raised to flex the hip with the knee extended. A positive
straight leg test means a tension sign, something is putting tension or stress
on the sciatic nerve. When the test is positive, it indicates possible disc
herniation.
Treatment is typically non-operative. First, reassure the patient.
Let the patient take some rest (no more than a few days), give the patient
anti-inflammatory medication, and instruct them to attend physical therapy.
Indications for surgery include progressive neurological deficits, Cauda Equina
Syndrome, the patient is not getting better with time and treatment or if the
symptoms are not getting better with conservative treatment, or the patient has
a positive tension sign with persistent sever pain. Patients with sciatica and
positive tension signs or patients with positive neurological findings on
clinical exam with positive MRI findings make ideal surgical candidates.
Surgery results in relief of leg pain in the majority of patients. Back pain
may persist in some patients. Surgery results in neurological improvement, 50 %
motor and sensory and 25% reflexes. In patients with discogenic back pain, they
may need fusion which is a major procedure.The worst pressure on the disc occurs with prolonged
sitting and bending over. This is the position that produces the highest
pressure on the disc. If a patient has back pain but no radiation, by the
patient’s history or physical examination and there are no red flags, then
there is no reason to get x-rays or MRI early in the treatment of the patient.
Red flags include a history of trauma, a tumor, infection, or Cauda Equina
Syndrome symptoms. To rule out a history of trauma you should rule out
fractures with x-rays, MRI, or CT scans. Tumors are a risk if the patient is
older than 50 years old, if the patient had weight loss, or if the patient has
pain at rest or at night. An infection may be present if the patient has fever
and chills, if the patient has a history of diabetes, or if the patient has a
history of IV drug abuse. Cauda Equina Symptoms may be present if the patient
has back pain more than leg pain or if the patient also has bladder and bowel
symptoms. Cauda Equina Syndrome needs to be diagnosed and surgically treated
early. An MRI needs to be ordered urgently in the course of treatment. The MRI
should be ordered STAT. There may need to be a wet read; a wet read is an early
preliminary read of the radiographs. A wet read needs to be communicated with
the physician and can be done while the patient is still on the table of the
MRI.
Femoral neck fracture nonunion has multiple facets and is
important to understand all aspects of this important problem.
Example:
40 year old patient had a displaced femoral neck fracture,
fixed with multiple cancellous screws about 9 months ago. The patient still has
persistent groin pain. The patient cannot bear full weight on the hip. The patient
has a painful limb, antalgic gait, and difficulty in walking. X-rays are not
clear and show a possible nonunion. CT scan shows the nonunion with some Varus
angulation. The treatment for this would be removal of the hardware and valgus
osteotomy. The scenario can be more complicated by adding a healed
femoral shaft fracture to the nonunion of the femoral neck. In this case, you
will do removal of the hardware from the femur and removal of the screws from
the femoral neck nonunion. You will do valgus osteotomy and fixation with a
plate, preferably a blade plate, to treat the nonunion of the femoral neck.
Intracapsular fractures of the proximal part of the femur
are not common in adults younger than 50 years old, but they are associated
with a high incidence of avascular necrosis and nonunion. About 10-30 % of
femoral neck fractures go to nonunion after ORIF. It is usually the vertical
fracture pattern, such as Type III in Pauwels Classification. These fractures
are more prone to nonunion due to shear stress, rather than compression forces
across the fracture site. In Garden Classification fracture Type IV, where the
fracture is completely displaced, the greater the displacement, the higher the
incidence of nonunion and reoperation rate after fixation of the femoral neck. The
inverted triangle pattern of fixation of femoral neck fractures is the one that
is commonly used with the inferior screw posterior to the midline and adjacent
to the calcar. Achieving and maintaining anatomic reduction is important for
femoral neck fracture fixation and healing. The femoral neck fractures are
intracapsular. There will be no abundant callus formation during the healing
(healing is intraosseous only). Sometimes it is difficult to know if the fracture
healed or not. There is no correlation between age, gender, and rate of
nonunion. Varus malreduction correlates with failure of fixation after
reduction and cannulated screw fixation. Posterior comminution of the fracture
does not allow stable fixation and can lead to nonunion. The comminution of the
femoral neck is usually posteriorly and inferiorly. Some recommend adding a
fourth screw in this situation. High energy fractures have a worse prognosis
for healing, especially in patients with metabolic bone disease and nutritional
deficiency. When you see a femoral neck nonunion after fixation, you need to
get blood work and rule out infection (get sedimentation rate and CRP).
For the
high angle femoral neck fracture, follow the patient up closely with clinical
exam and x-rays. There might be a Varus collapse on the x-rays. You may see a femoral
neck nonunion or a failed internal fixation. The patient walks with a limp, the
limb is shortened, and the patient may have rotational deformity of the
extremity. In the young patient with a femoral neck nonunion, arthroplasty is
not a desirable option. In a young patient with femoral neck fracture nonunion,
valgus intertrochanteric osteotomy with plate fixation produces a good result
in the majority of cases. Valgus intertrochanteric osteotomy with plate
fixation produces approximately 80% union rate and the procedure makes a
vertical fracture more horizontal, converting the shear forces into compressive
forces. It is done in a healthy, young patient with no joint arthritis and when
the femoral head is intact. This procedure also corrects the Varus
malalignment. Basically, the procedure changes the vertical fracture
orientation to a horizontal fracture to achieve compression. Other procedures
done in the young patient include revision ORIF with or without bone graft, but
this is rarely done. Other procedures done in the young patient also include
free vascularized fibular graft which is done in some patients especially in
the younger patient with a nonviable femoral head. Hemiarthroplasy is done in
patients with low physical demands. The articular cartilage of the patient is
preserved with no evidence of infection. Total hip arthroplasty is done in
patients that are older, in patients that have hip arthritis, if the femoral
head is not viable, or if the hardware is cut out. It can also be done in
younger patients that are active, when the femoral head is not viable and the
patient does not want a free vascularized fibular graft or if the patient had
collapse of the femoral head with nonunion. The problem with total hip
replacement in this situation is more dislocations of the hip postoperatively.
Cervical radiculopathy is caused by cervical nerve root
compression. The patient will have pain and/or progressive neurological deficit
that results from conditions such as disc herniation that irritates a nerve in
the cervical spine. Cervical radiculopathy is an irritation of the cervical
nerve root. Cervical spine and shoulder problems overlap. The condition is of
cervical spine etiology if the patient’s symptoms are relieved by shoulder
abduction, by placing the hand over the head. The relief of the symptoms occurs
due to decreased tension on the nerve roots. In cervical disc problems, be
aware of false positive MRIs especially if the patient is above the age of 40
years old. Nerve conduction studies are not useful; they have a high false
negative rate. EMG and nerve studies may differentiate radiculopathy from
peripheral nerve entrapment. Cervical disc problems usually affect the lower
numbered nerve root.
When you see the middle finger numbness, then this is C7.
When compression of the C7 nerve root, there will be middle finger numbness,
triceps weakness, and the triceps reflex will be affected. The cervical nerve
roots are horizontal in orientation. It does not matter if cervical disc
herniation is central or foraminal, it will compress the same nerve root. C7
nerve root runs above the pedicle of the C7 vertebra. C5-C6 is the most
commonly affected disc and that will compress the C6 nerve root. The patient
will come to the doctor with unilateral arm pain that is relieved by arm
elevation. The numbness and paresthesia will occur in specific dermatomes. The
patient may also have upper trapezius pain or interscapular pain. The patient
may complain of occipital headache. When you examine the patient, do
provocative tests such as the spurling’s test and the shoulder abduction test.
The Spurling’s test is done by extending and rotating the neck towards the
involved side. It reproduces the symptoms by narrowing the neuroforamen. The
Spurling’s test differentiates cervical radiculopathy from peripheral nerve
entrapment. Lifting the arm above the head relieves the symptoms if the
cervical nerve roots are irritated. The Shoulder Abduction test differentiates
cervical pathology from other causes of painful shoulder etiology. Make sure
that you do not have a double crush syndrome, one in the neck and one in the
peripheral nerve. Make sure that you differentiate radiculopathy from
myelopathy. Make sure that you exclude a coexisting myelopathy. Examine the
patient for upper motor neuron signs or cervical
myelopathy. Test the patient
for gait instability. Test the patient for Hoffman’s sign. Test the patient for
Babinski reflex. Test the patient for ankle Clonus. Check to see if the patient
has hyperflexia in the upper and lower extremities (triceps/quadriceps). Even
if there is a bad cervical spine disc problem on the MRI, treat it
conservatively for about 3 months. Give the patient therapy and nonsteroidal
anti-inflammatory medication (NSAIDS). 75% of the patients will improve with
nonoperative treatment. Cervical radiculopathy is generally treated
nonoperatively, in contrast to cervical myelopathy. Do surgery when there is
persistent, severe pain for 6-12 weeks and/or progressive neurological deficit
such as weakness or numbness. The procedure to treat cervical radiculopathy
surgically is usually done anteriorly with direct removal of the lesion that
causes the radiculopathy such as a herniated disc or spurs. When you place the
anterior bone graft or the allograft in the disc space, you open the
nueroforamen, and that will indirectly relieve the nerve. Then you will add the
anterior plate. Some surgeons prefer to do a posterior approach.
With elbow dislocations, recognize the terrible triad: elbow
dislocation, radial head fracture, and coronoid fracture. The terrible triad is
not a simple elbow dislocation; it is a complex elbow dislocation. In addition
to these three injuries of the elbow, there is always a tear of the lateral
ulnar collateral ligament. The treatment usually is reduction and splinting of
the elbow.
This cannot be the definitive treatment; it is the initial
treatment. If no surgery is done, you will have recurrent dislocation of the
elbow. You need to do surgery for reduction and fixation of the fractures and
also to restore the elbow stability. This injury is unstable. Simple reduction
and splinting is not going to work for this injury. You have to recognize the terrible
triad which means surgery. There are multiple types of elbow dislocation based
on the position of the olecranon relative to the humerus. The most common type
of elbow dislocation is the posterolateral type. There are two basic types of
elbow dislocations: simple and complex. Simple elbow dislocations have no
fracture seen, and are usually a ligamentous injury. Complex elbow dislocations
have associated fractures in addition to the ligamentous injury. With any elbow
dislocation, you need to check the shoulder and the wrist for injuries and
fractures because it can occur in up to 15%. When you have a simple dislocation
of the elbow, you need to reduce it and then check the range of stability of
the elbow. If you find that the elbow is stable with range of motion, then you
will do a short period of immobilization with a posterior splint for
approximately one week with the elbow in about 90 degrees of flexion. Then start
active range of motion of the elbow. Recurrence of the dislocation is rare
(less than 1%). If you keep the elbow immobilized more than 3 weeks, there will
be severe stiffness of the elbow. Surgery should be done if the dislocation is
irreducible, if there is associated fracture, or if you are unable to maintain
stability of the elbow. After immobilization and early range of motion of the
elbow, you will see the patient and do follow up x-rays to check joint
congruity and to make sure that the elbow reduction is maintained. To treat the
terrible triad, you should initially do a closed reduction. Open reduction and
internal fixation of the coronoid (if possible), of the radial head or excise
the radial head with radial head arthroplasty if the radial head is
unreconstructable. In addition, you will do lateral ulnar collateral ligament (LUCL)
repair. Never excise the radial head alone in this situation. For an elbow
dislocation with olecranon fracture, do open reduction and plate fixation.
K-wires and tension band is not strong enough to hold the fracture and
stabilize the elbow at the same time. For an elbow dislocation with a radial
head fracture, do fixation or replacement of the radial head (never do excision
of the radial head alone in this situation). The LUCL is the most important
lesion in recurrence or persistence of instability of the elbow following
simple elbow dislocation.
The injury progresses from lateral to medial. The lateral
collateral ligament fails first, and it avulses proximally at the lateral
epicondyle. The medial collateral ligament (MCL) fails last. In varus
posteromedial rotary instability, there is an elbow injury plus LUCL tear, plus
coronoid fracture which involves the medial facet of the coronoid. Treatment for
chronic dislocation is open reduction capsular releases with hinge external
fixation and early range of motion. Loss of terminal extension is a
complication of elbow dislocation. Usually for decreased range of motion of the
elbow, you will do static progressive splinting between 6-10 weeks. No manipulation
of the elbow is done, which is different from the knee after total knee
replacement, where you can do manipulation up to three months. With heterotopic
ossification, do excision. Remove the myositis and excise the posterior part of
the MCL to allow more flexion. To be functional, the range of motion of the
elbow should be between 30-130 degrees. Some physicians suggest that if the
flexion is less than 100, you will do release of the posterior bundle of the
MCL in addition to release of the ulnar nerve. If you want more flexion of the elbow,
excise the posterior part of the MCL.
Patellar fractures can involve different topic, and I am
going to try and highlight the important points related to patellar fractures.
The medial patellofemoral ligament is the primary stabilizer of the patella, so
when the patella dislocates, you will have an injury to that ligament and also
an injury to the medial patellar facet articulation cartilage or an
osteochondral fragment. In addition to the medial patellar facet injury, you
will get a lateral femoral condyle injury. Bipartite patella occurs in about 8%
of the population. It could be bilateral in about 50%, and it usually occurs in
the superolateral aspect of the patella. You should observe it and not fix it.
It is not an acute fracture that may need excision or lateral retinacular
release. It can occur in children between 8-10 years old. It is a rare
condition. The patient will be unable to do straight leg raising, so you
suspect that the extensor mechanism is injured. The patient may have a high
riding patella on x-ray with a palpable gap when you examine the patient. The
x-ray may show small flecks of bone as the patellar tendon avulses with a
portion of the distal pole of the patella. Sometimes the bony injury is so
small that the condition can be missed. You should have a high index of suspicion.
You may need to get an MRI to confirm diagnosis. The treatment is usually ORIF
if the fracture is displaced.
The patella is a large sesamoid bone. The quadriceps muscle
is inserted at the proximal pole and the distal pole gives attachment to the
patellar tendon. The patella is triangular in shape. The proximal 3/4 of the
patella is covered with cartilage, however the distal 25% of the patella is not
covered with cartilage. The patella increases the power of the extensor
mechanism by about 50% because it displaces the extensor mechanism anteriorly,
and that will increase the moment arm.
Transverse fractures of the patella can be non-displaced or
displaced. The patella can be pulled apart by the attached quadriceps tendon.
The patient will be unable to do active extension of the knee. Upper or lower
pole fractures of the patella are fractures at the site of attachment of the
patellar tendon. Comminuted fractures of the patella can be non-displaced or
displaced. Comminuted fractures have multiple pieces, are very unstable, and
are difficult to fix. Vertical fractures of the patella are the most common,
and they are stable and nondisplaced. Osteochondral fractures are small fractures of the patella usually associated with acute dislocation of
the patella.
In examination, you may feel a palpable gap. The area of the
knee is usually swollen. The patient will be unable to do straight leg raise.
The lateral view of the knee is the best view to see the fracture. 2-3 mm of
displacement will probably mean that the patient will need surgery.
If you think that the patient’s extensor mechanism is
intact, and the patient is able to do straight leg raise, and the fracture is
nondisplaced or minimally displaced, it is usually a transverse fracture in
this situation, then immobilize the knee straight in a hinged knee brace for
4-6 weeks with weight bearing as tolerated. Sometimes the patient cannot move
the knee because of the pan and injection of lidocaine inside the knee can help
to assess the integrity of the extensor mechanism. If the patient has a total
knee with 2mm displacement of the patella, and the extensor mechanism is
intact, then the patient will be treated conservatively in a brace or in a knee
immobilizer (no surgery).
Indication for surgery is a displaced patellar fracture and
the inability to do straight leg raising.
First, preserve the patella (if
possible). The tension band fixation technique is the gold standard for the
treatment of displaced patellar fractures (the fracture is usually a transverse
fracture), and the tension band technique is the one that gives us the most
complications. The first step in the tension band technique is to reduce the
fracture with reduction clamps. Next, at least two K-wires are placed across
the fracture. An anterior tension band is applied, organized in a Figure-8
pattern. You need to put the Figure-8 tension band wire close to the patella
superiorly and not far away from the patella because that may cause construct
instability and fracture displacement. A second wire may be placed
circumferentially around the patella. Bending the K-wires from both ends may
decrease migration of the wires and decrease the complications. The wire that
is bent at both ends may be difficult to remove. Tension band fixation technique
may be done with K-wires or also with cannulated screws (through the cannulated
screws, you place the wires). It does not matter if you have an open or closed
fracture, you treat it the same way. When you place K-wires, it means
symptomatic hardware and thus a secondary reoperation. It was found that the
longitudinal screws and the tension band wires are a more superior fixation.
The tension band construct when performed correctly will provide absolute
stability and will convert the tension forces from the muscle pull into
compression forces at the articular surface. You want to have anatomic
reduction and stable fixation; don’t judge the reduction by what you see at the
surface of the fracture. Try to see and feel the joint if you can. Check the
x-rays carefully. The surface of the patella may be well reduced, however, the
joint may be distracted or displaced. If you tighten the cerclage wire
aggressively, you may have a good looking surface, but you may have a
distracted join. After you fix the patella, you will do a range of motion of
the knee before closure and give the patient a hinged knee brace, locked into
extension with weight-bearing as tolerated. Weight-bearing is controversial.
Some people start weight-bearing early, and some people start weight-bearing
after 4-6 weeks. A can may be helpful to the patient. You will begin active
flexion at 2-3 weeks (patient will lie prone, flexing and extending the knee).
When the patient is prone, it avoids active knee extension and avoids excessive
stress on the fracture site. At 6 weeks, you can unlock the brace and start
moving the knee, gradually increasing the flexion.
If the patellar fracture is comminuted, you can use the
peripatellar circumferential wire loop fixation, which is commonly used as an
addition to other methods of fixation. You can also use a plate fixation
utilizing a low profile implant and providing stable fixation. This technique
is becoming more popular.
You can also excise the patella partially or completely. In
a partial patellectomy, the distal pole is extra-articular, and if it is
severely comminuted and less than 40% of the patella, then you can excise it
(in general, you would like to preserve the patella). If you can’t preserve the
patella and ORIF is not possible, then do partial patellectomy and preserve the
largest piece. Partial patellectomy may be necessary, but open reduction and
internal fixation (if possible) is associated with a better outcome. You will
do the partial patellectomy in several comminuted inferior pole fractures. You
will do medial and lateral retinacular repair, and a poor outcome may occur
with removal of more than 40% of the patella. Total patellectomy will be done
when the fractured patella cannot be fixed. Total patellectomy can cause
extensor lag and loss of the extensor strength. The quadriceps torque is
reduced by about 50%.
Symptomatic hardware and knee pain is the most common
complication after patellar fracture fixation, especially if you use the
tension band technique. It requires implant removal in about 50% of the time.
This complication will include the hardware migration. Failure after patellar
fracture fixation occurs in about 20% of the time due to increasing age,
fixation with wires, technical errors and noncompliance.
