PERCUTANEOUS FIXATION OF SCAPHOID FRACTURES

Indications

Percutaneous fixation of scaphoid fractures is performed for:

1. (a) Undisplaced scaphoid fractures in active individuals or multiple injuries.

2. (b) Do not use this technique if fractures are displaced >1mm.

Pre-operative assessment

Clinical assessment

• Assess vascularity of the hand, particularly the radial artery.

• Assess for evidence of neural compromise - particularly in the median nerve distribution.

• Assess the condition of the skin in the area of proposed incision.

• Assess for tenderness in other areas around the wrist which may represent a second injury.

Radiological assessment

• Anteroposterior (AP), lateral, 45? oblique and long-axis radiographs of the scaphoid.

• Assess scaphoid length and look for evidence of fracture collapse (hump-back deformity, loss of carpal height).

Operative treatment

Anaesthesia

• General or regional (axillary, supra- or infraclavicular block).

• Intravenous dose of antibiotic as prophylaxis prior to inflation of tourniquet.

Tourniquet

• Well-padded upper armcuff inflated to 250mmHg.

• Plastic exclusion drape to prevent any soaking of padding by skin preparation.

Equipment

• Percutaneousscrewsystemof choice with full selection of implants and screws.

• Radiolucent hand table securely fastened to operating table.

• Image intensifier or mini C-armfluoroscan.

Operating room set up

• The armmust lie centrally on the hand table.

• Surgeon is best seated at the distal end of the affected limb.

• Image intensifier or mini C-armis brought in from the head of the table throughout the procedure.

OPEN REDUCTION AND INTERNAL FIXATION: PLATING

Indications

• Displaced fractures of the middle third of the ulna in adults.

• Monteggia fractures: fracture of the ulna shaft with fracture and/or dislocation of the proximal radius/radial head.

• Fractures of both forearm bones.

Pre-operative planning

Clinical assessment

• Mechanism of injury: Nightstick injury: direct blow; Monteggia fractures: axial compression; forearm fracture: any combination. Ensure adequate examination of the elbow and wrist joint for associated pathology.

• Low- vs. high-energy injury, ensure no open fractures are missed with ulna wound volarly and covered by splint when first examined.

• Arm at risk for compartment syndrome: document neurovascular status early and monitor changes.

• In multiple-injured patients treatment sequence follows the ‘life-before-limb’ protocol.

• Look for occult injuries in the rest of the arm, especially in the carpus/hand.

Radiological assessment

• Rule of 2: 2 views, 2 joints (and 2 visits). Radiographs may be incomplete initially as pain/splints may interfere with the result.

• Traction views in theatre may be necessary for valid pre-operative planning.

Operative treatment

Anaesthesia

• Timing of surgery essential: in low-energy injuries this is notanissue whilst in high-energyoneswith displacement, shortening and/or dislocation, early intervention is preferable to avoid complications.

• General anesthesia preferable. Avoid regional anesthetic/ blocks in acute injuries as they may mask symptoms indicating compartment syndrome in the immediate post-operative period.

• Pre-operative administration of antibiotics and prescrub the limb.

• Apply tourniquet if not contraindicated and inflate following elevation for 3 minutes once limb prepped and draped.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF POSTERIOR WALL FRACTURES – KOCHER–LANGENBECK APPROACH

Indications

Fractures of:

• Posterior wall.

• Posterior column.

• Posterior column and wall.

• Transverse fractures.

• Transverse posterior wall and T-shaped fractures.

Pre-operative planning

Clinical assessment

• Examination of the injured limb is essential, including the soft tissue envelope.

• In cases of high-energy trauma examination for other potential associated injuries should be performed carefully.

• The Advanced Trauma Life Support (ATLS) evaluation protocol should be followed.

Radiological assessment

• Anteroposterior radiograph of the pelvis, as well as Judet views, can provide substantial diagnostic information in terms of fracture type and also indicate the need for emergency treatment (in cases of fracture dislocations of the femoral head) (Fig. 8.1a, b, c,).

• CT scan will supplement the plain radiographs and important additional information can be obtained for the pre-operative planning (Fig. 8.2a,b,c).

Timing of surgery

• Operative treatment is generally delayed for 3–5 days to allow stabilization of the patient's general status.

• Two to four units of blood should be made available, depending on the extent of the fracture pattern.

Indications for emergency acetabular fracture fixation

• Recurrent hip dislocation after reduction despite traction.

• Progressive sciatic nerve deficit after closed reduction

• Irreducible hip dislocation.

• Associated vascular injury requiring repair.

• Open fractures.

Anaesthesia

• General anaesthesia at induction.

• Administration of prophylactic antibiotics as per local hospital protocol.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR DISTAL RADIUS FRACTURES: VOLAR APPROACH

Indications

• Displaced, irreducible extra-articular fractures (A3).

• Unstable, partial intra-articular fractures (B1, B2, B3), or complete (C2, C3).

• Fractures requiring bone grafting.

• Palmarly displaced short oblique fractures.

• Volar Barton's.

• Fractures with primary instability.

Pre-operative planning

Clinical assessment

• Mechanism of injury: grading from low- to highvelocity trauma.

• Typical deformity, swelling, tenderness.

• Evaluate neurovascular status of the hand.

• Assess soft tissue damage.

• Evaluate patient for age, hand dominance, occupation, and level of activity.

• Check for associated ligamentous lesions of fractures of carpal bones.

Radiological assessment

• High-quality anteroposterior and lateral radiographs (Fig. 4.37a,b).

• Oblique films (45? pronated and supinated).

• Assess degree of fragment displacement, quality of bone, whether the fracture is intra-articular or extraarticular, direction of displacement,metaphysealcomminution.

• CT scan if the diagnosis is not clear in plain radiographs.

Timing of surgery

• Immediatelywhenthefractureisopenorprimarycompression of the median nerve is present.

• After 5-6 days if there is important soft tissue swelling (after reduction of the initial displacement and immobilization in a plaster splint).

Operative treatment

Anaesthesia

• At induction, administration of prophylactic antibiotics as per local hospital protocol.

• General anaesthesia is preferable. Avoid a regional anaesthetic/block in acute injuries as it masks symptoms indicating compartment syndrome in the immediate post-operative period.

• Apply a tourniquet to the upper armif not contraindicated (situations in which the soft tissue envelope is extremely traumatized).

Table and equipment

• AOsmall-fragmentset 3.5mmor Jupiter plating system (Fig. 4.38).

• Standard osteosynthesis set as per local hospital protocol.

• Fluoroscopy is necessary for intraoperative imaging.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF A LATERAL TIBIAL PLATEAU FRACTURE

Indications

• Clinical: instability of the knee on valgus testing.

• Radiological: split, central depression or split depression fracture types.

• Joint depression > 3 mm.

Pre-operative planning

Clinical assessment

• Swollen knee.

• Valgus deformity common.

• Common peroneal palsy possible but rare.

• Compartment syndrome – possible but rare.

Radiological assessment

• An anteroposterior (AP) radiograph is most useful to detect fractures and assess degree of joint depression (Fig. 12.1).

• A lateral radiograph is less helpful in determining the degree of depression.

• A CT scan is most useful for additional imaging-mainly indicated in cases where there is doubt about the extent or degree of depressionandincomplexfractures (Fig. 12.2a,b).

Operative treatment

Anaesthesia

• General anaesthesia preferred – avoid local blocks/spinal anaesthesia which mask symptoms and signs of compartment syndrome.

• Prophylactic antibiotics at induction.

Equipment

• Standard AO set with reduction clamps and Kirschner wires.

• Radiolucent table with ability to flex at the level of the knee.

• Equipment to harvest bone graft or calcium phosphate cement.

Set up

• Instrumentation on the side of the injured leg.

• Image intensifier on contralateral side.

• Knee flexed at 90° at the outset of the procedure to facilitate exposure (Figure 12.3a,b).

• Knee brought into extension once the fracture is reduced to complete fixation.

APPLICATION OF A HALO AND HALO-VEST FOR CERVICAL SPINE TRAUMA

Indications

Halo devices are used in a variety of trauma settings, including:

• Reduction of cervical spine facet subluxations and dislocations (usually via axial traction applied through the halo).

• Stabilization of undisplaced cervical spine fractures.

• Post-reduction stabilization of cervical spine fractures,\ subluxations and dislocations.

• Temporary stabilization of a cervical spine injury, prior to definitive surgical treatment, or to facilitate safe transfer of the patient to a specialist spinal centre.

If the patient is physically able to mobilize, the halo can be attached to a “vest”. The vest may be a custom-made plaster or fibre-glass orthosis, or one of the readily available “off-the-shelf” devices. Several orthopaedic implant manufacturers market combinations of haloes and vest orthoses, in a range of sizes. The most useful halo and vest devices contain no ferrous components and are therefore MRI-compatible, permitting scanning of the patient after application.

Pre-operative planning

Most halo and halo-vest systems are available as prepacked kits containing all of the necessary implants and tools for halo application and subsequent attachment of the halo to a detachable vest.Acareful check of themanufacturer's kit inventory against the kit components and instruments should be done in every case; do not assume that even a pre-packed kit will be complete! If the halo is to be used for ambulatory cervical spine stabilization, a suitably-sized orthosis (vest) is selected. Standard antiseptic skin preparation solutions should be available. If not supplied in the halo kit, a small pointed scalpel will also be needed.

Over the years the evolution of orthopaedic surgical techniques led to the development of a plethora of orthopaedic textbooks aiming to present the principles of modern orthopaedic surgical practice in order to contribute to the continuing medical education of all the orthopaedic surgeons in training.

The notion of this book arose during the first years of our training. It was difficult to find a book to refer to as a quick yet thorough reference, prior to performing a surgical procedure.

Our aim was therefore to develop a book that would contain a step-wise approach to performing a surgical procedure. Details have been included such as positioning of the patient, the approach and reduction technique, the implant to be inserted, the protocol of post-operative mobilization, complications to look for, when the patient should be seen in the outpatient clinic and whether the implant should be removed. Intraoperative pictures have been incorporated to allow the surgeon to be aware of all the important issues involved.

The most common trauma procedures that a surgeon in training is expected to perform during his residency have been included. Each procedure has been written by an expert or under the supervision of an expert.

This book is expected to be the companion for the resident in training during the long on-call nights in the hospital while preparing for the operations necessary to help our trauma patients.

ACHILLES TENDON REPAIR

Indications

• Controversy regarding this injury as towhethersurgical repair or cast immobilization is the most appropriate method of treatment.

• Healthy, vigorous young adults.

• Athletes.

• According to patient's age, activities, medical history.

Pre-operative planning

Clinical assessment

• Mechanism of injury: mechanical imbalance, degenerative changes, high-energy disruptions, lacerations at the posterior distal tibia aspect.

• Obtain a detailed patient's history.

• Usually sudden onset of pain, audible snap, patient unable to weight bear, unable to toe-raise at the affected site.

• Only leg weakness in chronically ruptured tendon.

• Oedema, bruising, ankle swelling.

• Clinically palpable gap that may be obscured by swelling.

• PerformThompson's test, O'Brien test.

• Compare the affected leg with the contralateral limb.

• Be alert for longstanding ruptures.

Radiological assessment

• Radiographs: only to diagnose associated bony abnormalities.

• High-resolution ultrasonography: produces an acoustic vacuum.

• MRI: to evaluate associated intra-articular injuries and neglected tears.

Operative treatment

Anaesthesia

• At induction administration of prophylactic antibiotics as per local hospital protocol.

• Spinal or general anaesthesia.

Table set up

• The instrumentation set is at the foot end of the table.

Patient positioning

• The patient is placed in prone position.

Draping and surgical approach

• Prepare the skin over lower leg, ankle and entire foot with usual antiseptic solutions (aqueous/alcoholic povidone-iodine). Prepare skin between toes thoroughly.

• Apply standard draping around lower leg in calf region.

• Apply tape aroundtoes tominimizethe risk of infection (Fig. 16.1).

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APPLICATION OF ANTERIOR FRAME

Indications

Fixation of pelvic fractures associated with major bleeding including AP (anteroposterior) II, AP III, LC (lateral compression) II, LC III, vertical shear fractures and fractures with a combined mechanism of injury, according to Young's classification. Depending on the type of pelvic injuryandwhenthe physiological status of the patienthas been normalized, the external fixator could be exchanged with an open reduction and internal fixation procedure of the pelvic ring. This usually takes place after the 4th or 5th day from the time of the injury.

Pre-operative planning

Clinical assessment

• Inspection of the anterior lateral and posterior aspect of the pelvic ring would allow evaluation about the extent of the soft tissue damage.

• Neurological examination of the lower limbs is of paramount importance.

• Careful inspection of the perineal region would allow identification of open fractures. Evaluation of the genitourinary system is of vital importance in order not to missanyinjuries to the urethra, bladderandthe vaginal walls.

Radiological assessment

• Standard anteroposterior radiographs demonstrate the type of fracture.

• Accurate evaluation of the injury to the posterior elements of the pelvic ring (sacrum and sacroiliac joint) require CT scan evaluation.

• Inlet and outlet views would allow accurate evaluation of the displacement of the hemi-pelvis, providing useful information to the surgeon regarding the manoeuvres necessary in theatre for accurate reduction of the fracture.

Timing of surgery

• The application of an external fixator on the pelvis in the presence of hypovolaemia is an emergency procedure. This can be performed either in a trauma room or in the operating theatre.

Operative technique

Anaesthesia

• General anaesthesia.

• Administration of prophylactic antibiotics as per local hospital protocol.