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Inidcations for non-op treatment of Lisfranc?

nonambulatory patients
presence of serious vascular disease
severe peripheral neuropathy
instability in only the transverse plane

If there is just boney invovlement with no evidence of ligamentous disruption or instaiblity you can treat it in a cast with start WB at 6 weeks (like any #)


What are the indications and surgical option for a lisfranc injury?


  • ​usually wait 2 weeks to allow tissues to settle unless otherwise indicated
  • ex-fix if very unstable
  • open reduction and rigid internal fixation 
    • indications 
      • any evidence of instability (> 2mm shift
      • favored in fracture-dislocations as opposed to purely ligamentous injuries
    • outcomes 
      • anatomic reduction required for a good result
  • primary arthrodesis of the first, second and third tarsometatarsal joints
    • indications 
      • purely ligamentous arch injuries
  • midfoot arthrodesis
    • indications 
      • destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction
      • chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy


What is true about primary fusion in a lisfranc injury?

  • level 1 evidence of arthrodesis over ORIF for purely liagmentous injury
    • equivalent functional outcomes
    • decreased rate of hardware removal
    • decreased rate of revision surger
  • primary arthodesis is an alternative to ORIF in patients with any evidence of instability with possible benefits 
  • medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis 


Complications associated with this injury?

  • Arthritis 
    • most common, treat with arthrodesis
  • Nonuion 
    • uncommon


Post-op care for a lisfranc injury

  • early midfoot ROM, protected weight bearing, and hardware removal (k-wires in 6-8 weeks, screws in 3-6 months)
  • gradually advance to full weight bearing at 8-10 weeks
  • if patient is asymptomatic and screws transfix only first through third TMT joints, they may be left in place
  • preclude return to vigorous athletic activities for 9 to 12 months


Diagnosis and Treatment?

  • Chopart joint dislocation
    • ​get stress views if worried (MVA/brake)
  • ​Treatment
    • ​pins TN 6-8 weeks
    • pins CC 12 weeks
    • NWB 12 weeks


Ways to assess length of fibula

  • Shenton's line - should be equal space around talus on mortis
  • Dime Sign - assess's length of fibula
  • Talocrural Angle - 81 degrees, short lateral malleloi will increase talocrural angle
    • need an XR of the contralateral ankle to do this


Radiological features to assess the syndesmosis

  • Most important in OR is to visualize the syndesmosis
  • Assess 1cm above joint line
    • Should be overlap of tib-fib on mortis
    • Overlap > 10mm on AP
    • has been reported that this has no correlation
  • ER/abduction stress test with dorsiflexion
    • better than other medial mall tenderness or ecchymosisis
    • Should be done in OR
    • Manual=stress



Lauge-Hansen Classficiation

  • SAD (Supination-Adduction)
    • ATFL sprain or distal fibular avulsion
    • Verticle medial malleolus
  • SER (Supination-External Rotation)
    • ATFL Sprain
    • A-P oblique fibula fracture
    • PTFL or posterior malleolus avulsion
    • Medial Mall transverse fracture (or deltoid)
  • PAD (Pronation-Abduction)
    • Medial Mall transverse fracture (or deltoid)
    • ATFL sprain
    • Comminuted fibula fracture (above syndesmosis)
  • PER (Pronation-External Rotation)
    • Medial Mall transverse fracture (or deltoid)
    • ATFL
    • Oblique or spiral fibular fracture (above joint)
    • PTFL or posterior malleolus


Approach to this injury

  • Nonoperative
    • short-leg walking cast/boot
    • indications 
      • isolated nondisplaced medial malleolus fracture or tip avulsions
      • isolated lateral malleolus fracture with < 3mm displacement and no talar shift
      • posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
  • Operative
    • open reduction internal fixation
      • indications
        • any talar displacement 
        • displaced isolated medial malleolar fracture
        • displaced isolated lateral malleolar fracture
        • bimalleolar fracture and bimalleolar-equivalent fracture
        • posterior malleolar fracture with > 25% or > 2mm step-off  [q]
        • Bosworth fracture-dislocations
        • open fractures
    • technique
      • goal of treatment is stable anatomic reduction of talus in the ankle mortise
      • 1 mm shift of talus leads to 42% decrease in tibiotalar contact area
      • overall success rate of 90%
      • prolonged recovery expected (2 years to obtain final functional result)
      • significant functional impairment often noted
  • ORIF superior to closed treatment of bimalleolar fractures


Braking time after injury

  • returns to baseline at nine weeks for operatively treated ankle fractures   
  • braking travel time is significantly reduced until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity   


Prognositc factors in ankle fractures

worse outcomes with:

decreased education
alcohol use
increased age
presence of medial malleolar fracture


Injury type? Outcomes?

 supination-adduction fractures

restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery 

Use a lag screw on the fibular and an antiglide plate on the tibia


Indications for surgery and plate choices and reasons for this fracture


  • Indications for surgery
    • ​>3mm displacement
    • talar shift
    • syndesmosis injury
  • lateral 
    • lag screw fixation with neutralization plating
    • bridge plate technique
      • ​comminution
    • posterior antiglide technique
      • peroneal irritation (distal plate)
      • biomechanically superior
    • lag screw fixation with neutralization plating


Approach to posteior malleolus fracture

  • indications for fixation
    • > 25% of articular surface involved
    • > 2 mm articular stepoff
    • syndesmosis injury
  • approach 
    • posterolateral approach   
    • posteromedial approach 
    • decision of approach will depend on fracture lines and need for fibular fixation
  • fixation 
    • anterior to posterior lag screws to capture fragment (if nondisplaced)
    • posterior to anterior lag screw and buttress plate
    • antiglide plate
  • syndesmosis injury
    • stiffness of syndesmosis 70% versus 40% with isolated syndesmosis fixation
    • stress examination of syndesmosis still required after posterior malleolar fixation 


Approach to syndesmosis injury

  • Overview 
    • suspect injury in all ankle fractures 
    • most common in Weber C fracture patterns 
    • fixation usually not required when fibula fracture within 4.5 cm of plafond
    • up to 25% of tibial shaft fractures will have ankle injury
  • Evaluation
    • measure clear space 1 cm above joint 
    • it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements
    • lateral stress radiograph has more interobserver reliability than an AP/mortise stress film - best to do in OR
    • instability of the syndesmosis is greatest in the anterior-posterior direction 
  • Treatment 
    • operative 
      • syndesmotic screw fixation
        • indications 
          • widening of medial clear space 
          • tibiofibular clear space (AP) greater than 5 mm 
          • tibiofibular overlap (mortise) narrowed
          • any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation   
        • technique 
          • length and rotation of fibula must be accurately restored. 
            • "Dime sign"/Shentons line to determine length of fibula    
          • open reduction required if closed reduction unsuccessful or questionable
      • one or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior 20-30 degrees
    • maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis)
  • postoperative 
    • screws should be maintained in place for at least 8-12 weeks
    • must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation
  • controversies 
    • number of screws 
      • 1 or 2 most commonly reported
    • number of cortices 
      • 3 or 4 most commonly reported
    • size of screws 
      • 3.5 mm or 4.5 mm screws
    • implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials)
    • need for hardware removal 
      • no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year


You perform this procedure.  What are the complications?

  • Wound problems (4-5%)
  • Deep infections (1-2%)
    • up to 20% in diabetic patients
    • largest risk factor for diabetic patients is presence of peripheral neuropathy   
  • Post-traumatic arthritis 
    • rare with anatomic reduction and fixation
    • corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes


Measures of adequate resusitation

  • MAP > 60
  • HR < 100
  • urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
  • serum lactate levels
    • most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2 mmol/L) 
  • gastric mucosal ph
  • base deficit
    • normal -2 to +2 
  • pH < 7.24


Classes of shock


Diagnosis? Classification? Indications/Options for surgery?

Radial Head Fracture

  • Physical
    • check ROM
      • 30-130 flex-ex
      • 45-45 sup-pro
    • check the pin
  • Imaging
    • ​can get a greenspan view to help assess
      • 45 deg oblique center over the RC joint
    • CT
  • Classification - Mason Allen
    • Type 1 - nondisplaced
    • Type II - partial head fx
    • Type III - complete head
    • Type IV - radial head fx with elbow dislocatoin
  • short period of immobilization followed by early ROM
    • Nondisplaced, stable (30-130)
    • no mechanical block
    • complications
      • nonunion
        • new studies have shown a higher rate of nonunion in nonoperative managmeent than previously expected
  • ORIF
    • Indications
      • Simple fracture
      • < 3 fragments
      • Mechanical block
    • technique
      • plate in safe zone 
      • countersink screws in articular surface
  • Fragment Excision (partial excision)
    • indicated if fragment < 1/3 of head 
    • Cannot be a part of the PRUJ
    • complications
      • even small fragment excision may lead to instability
  • radial head replacement
    • indications
      • for comminuted fracture with 3 or more fragments  
    • complications
      • overstuffing of joint that leads to capitellar wear problems and malalignment instability
  • radial head resection
    • indications
      • older patients with limited demands 
      • in a delayed setting for continued pain of an isolated radial head fracture 
    • contraindications
      • forearm ligament injury (identify with radius pull test)
      • coronoid fracture
      • MCL deficiency
    • complications 
      • muscle weakness
      • wrist pain
      • valgus elbow instability
      • heterotopic ossification
      • arthritis


When would you consider radial head excision?  What are the complications?

  • indications
    • older patients with limited demands 
    • in a delayed setting for continued pain of an isolated radial head fracture 
  • contraindications
    • forearm ligament injury (identify with radius pull test)
    • coronoid fracture
    • MCL deficiency
  • complications 
    • muscle weakness
    • wrist pain
      • proximal migration of radius leads to ulanr positive variance and ulnocarpal abutment
    • valgus elbow instability
    • heterotopic ossification
    • arthritis


Other indications for radial head arthroplasty?  How can you size the head?

  • Indications
    • comminuted radial head fracture
    • nonunion/maluion
    • instabilty (essex-lopraseti)
    • rheumatoid or osteoarthritis
    • tumour
  • ​Modular metallic head
    • ​allows you to size the canal
    • then size the radial head
  • ​Sizing the radial head
    • Size the contralateral joint
    • Size to original radial head - thickness and cup
    • Trial reduction
      • Proximally should line up with less sigmoid notch
      • Lateral UH joint are opposed
    • Flouro
      • Medial and lateral UH joint lines (can't see this until >6mm)
      • Look for congruency of the medial UH joint



Approach to radial head arthroplasty

  • Approach for Surgery
    • ​kocher will allow you to see LUCL
    • EDC split will all you to see more anterior
    • Arm held in pronation to protect the PIN, 2.6cm distal to the RC joint
  • indications
    • for comminuted fracture with 3 or more fragments  
    • technique include two type of metal prosthesis, both are in use
      • loose stemmed prosthesis that acts as a stiff spacer
      • bipolar prosthesis that is cemented into the neck of the radius
      • silicon replacements are no longer used
  • Sizing radial head
    • Size the contralateral head pre-op
    • Size to original radial head - thickness and cup
    • Trial reduction
      • Proximally should line up with less sigmoid notch
      • Lateral UH joint are opposed
    • Flouro
      • Medial and lateral UH joint lines (can't see this until >6mm)
      • Look for congruency of the medial UH joint
  • complications
    • overstuffing of joint that leads to capitellar wear problems and malalignment instability


Describe mechanism of proximal tib-fib dislocation.  Features on exam, reduction mechanism and treatment?

  • Mechanism: Twisting of flexed knee (athletic injury)
  • Physical Exam:
    • Prominent lateral mass
    • Pain worse with ankle DF (proximal fibular migration)
    • Pain worse with knee extension
    • Examine stability at 90 degrees (relaxes LCL)
    • Translation of prox fibula
    • Peroneal nerve
    • Ankle exam
    • LCL and PLC instability to rule out other injuries
  • Closed Reduction:
    • Flex btw 80-110 to relax LCL
    • Reduce opposite direction of dislocation
    • immobilize for 3 weeks (controversial)
  • Open Reduction:
    • Screw with repair of joint capsule
    • immobilize for 6 weeks
    • ​remove in 12 weeks
  • Chronic Dislocation
    • ​usually non-op with activity modificaiton and strap
    • arthrodesis with mid-fibular resection is an option in older patients
    • attempts have been made to use the IT or biceps to create a sling for the head of the fibula
  • Results are improved with LCL/PLC pathology and repair

Note that actue and chronic entities are two seperate issues and should be treated differented.  The IT band can be use 


What are the forces acting on this fracture?  What is the classification? Options for treatment?

Subtrochanteric fracture

  • 5cm distal to LT
  • high non-union rate
  • Deforming forces
    • abduction (abductors)
    • flexion (iliopsoas)
    • external rotation (short ERs)
  • Russel-Taylor
    • Type I - no extension into piriformis fossa
    • Type II - extension into greater trochanter with involvement of piriformis fossa
      • look on lateral xray to identify piriformis fossa extension
  • ​​Treatment
    • intramedullary nailing (usually cephalomedullary) 
      • historically Russel-Taylor type I fractures
      • newer design of intramedullary nails has expanded indications
      • most subtrochanteric fractures treated with IM nail 
      • Techniques 
        • 1st generation nail (rarely used)
        • 2nd generation reconstruction nail
        • cephalomedullary nail  
          • trochanteric or piriformis entry portal  
          • piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail   
        • pros 
          • preserves vascularity
          • load-sharing implant
          • stronger construct in unstable fracture patterns
        • cons 
          • reduction technically difficult 
          • nail can not be used to aid reduction 
          • fracture must be reduced prior to and during passage of nail
          • may require percutaneous reduction aids or open clamp placement to achieve and maintain reduction   
          • mismatch of the radius of curvature 
            • nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur 
    • fixed angle plate 
      • surgeon preference
      • associated femoral neck fracture
      • narrow medullary canal
      • pre-existing femoral shaft deformity
      • approach 
        • lateral approach to proximal femur 
        • may split or elevate vastus lateralis off later intermuscular septum
        • dangers include perforating branches of profunda femoris
      • technique 
        • 95 degree blade plate or condylar screw
        • sliding hip screw is contraindicated due to high rate of malunion and failure
        • blade plate may function as a tension band construct 
          • femur eccentrically loaded with tensile force on the lateral cortex converted to compressive force on medial cortex
      • cons 
        • compromise vascularity of fragments
        • inferior strength in unstable fracture patterns



Bisphosphanate fracture 

lateral cortical thickening
transverse fracture orientation
medial beaking
lack of comminution

stenotic canal


What are the options for positioning of this fracture?

  • lateral positioning 
    • advantages  
      • allows for easier reduction of the distal fragment to the flexed proximal fragment 
      • allows for easier access to entry portal, especially for piriformis nail
  • Fracture tablw 
    • advantages 
      • protective to the injured spine
      • address other injuries in polytrauma patients
      • easier to assess rotation


How to get reduction and assess reduction in a subtroch fracture

  • Acceptable reduction
    • ​strive for perfect
    • <10 deg varus
    • 1cm shortening
    • <15 deg of rotation
  • ​Reduction techniques
    • Ensure start point is at the tip of the GT or slightly medial (NOT LATERAL)
      • piriformis start site might be better
    • Closed
      • ​traction, bumps and towels
      • sharp reduction forcep, spikes, pushers, bone clamps
      • ER of the leg
    • ​Open
      • ​clamps, cirlage wires
      • Stimen pins/joystick


Complications associated with subtroch fractures

Varus/ procurvatum malunion 

the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion) malreduction


can be treated with plating


4 long term complications of radial head fracture in adults

  • Elbow stiffness
    • reasons to transpose the nerve when you do your release
      • < 90 deg arc
      • if releasing > 30 deg arc
  • Heterotopic Ossification
    • Concurrent injury
    • Recurrent surgery
    • Delay to surgery
    • Prolonged immobilization
  • PIN Palsy
  • Ulnar nerve injury
  • Infection
  • Instability
  • Elbow OA
  • Fracture displacement