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Compare TEA and ORIF for distal humerus fractures

  • No difference in complication rate
  • Negligable data to suggest TEA decreases reoperation
  • Main difference is that TEA has improved functional outcomes (Level 1 evidence)


Classification of distal humerus fractures

AO classification
Jupiter Classficiation

High T
Low T
Lambda - medial and lateral


What imaging can help you assess distal humerus fractures

Medial column - 45deg
Lateral column - 20 deg
Single arch sign - capitellum alone

Double arch sign - both capitellum and trochlea invovled


Complications associated with distal humerus fractures

  • Watch for wound break down
    • Medial flap is more tenuous than the lateral flap, so tend your incision medially
    • If there is wound breakdown the most robust flap is the radial forearm rotational flap
  • Heterotopic ossification
    • Rads vs indomethecin
  • Ulnar neuropathy
    • Usually resolves
    • No evidence for transposition
  • Elbow stiffness
    • Infection 


Options for approaches for distal humerus fractures


  • use posterior approach  - workhorse of the elbow
    • Consider nerve transposition (don't need to do it)
    • Identify proximally and release 6cm proximal and 6cm distal
    • Release osborne's ligament
  • olecranon osteotomy
    • provides the best exposure of the articular surface
    • chevron vs transvers - (pollock says transverse is better because you can come threw the bare area)
    • use a plate to close this back up (the screw tends to have a nonunion)
    • still preferable for posterior trochlea fx and medial epiconyle fx
  • bryan-morray
    • Release the triceps off the olecranon without doing the osteomty
  • triceps split for higher fractures
  • lateral muscles interval
    • is an alternative to visualize the articular
    • elevate ECRB and part of ECRL of supracondylar ridge
    • usually able to work anterior to and sacrifice LCL
    • if fx of lateral column, utilize and mobilize
    • sublux joint to assist in articular visualization



technical pearls of fixing distal humerus fractures

  • Every screw in the distal fragments should pass through a plate
  • Engage a fragment on the opposite side that is also fixed to a plate
  • As many screws as possible should be placed in the distal fragments
  • Each screw should be as long as possible
  • Each screw should engage as many articular fragments as possible
  • The screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure
  • Plates should be applied such that compression is achieved at the supracondylar level for both columns
  • The plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level 


Options for fixation of a distal humerus fracture

  • Bag of bones
  • ORIF
    • olecranon osteotomy best but don't use if considering TEA
    • parallel or orthoganol no awsner
  • TEA
    • elderly, low demand
    • Maximum 10 lbs
    • Better functional outcomes with no increase in complications for revision surgery compared to ORIF
  • Arthrodesis
    • severe post-traumatic OA
    • severe soft tissue/bone loss
    • persistent/chronic infection
    • neurlogical comprimise
    • failed TEA


Rehab following distal humerus fixation

  • depends on nature of fracture ORIF
    • if secure fixation begin early passive motion 7-10 days
    • Don't immobilize for longer than 3 weeks
    • Restrict lifting for 12 weeks
  • TEA
    • Limit ROM for 1 week to allow healing and then AROM
    • Permanent restriction of 5lb limit


Options for coverage around the ankle

  • Dorsalis pedis flap
    • covers medial and lateral ankle
    • campbells says can cover heel as well
  • EDB - cover lateral ankle
  • Heel
    • supramalleolar
    • sural flap
    • FHB or abductor hallucis
  • Peroneal flap is also a good option for distal coverage


What is the best reason for poor prognosis following clubfoot treatment

gastroc weakness from repeated heelcord lengthening


Where is the corona mortis and what are the vessels

4-6 cm lateral to the symphesis along the superior pubic ramus

external iliac/inferior epigastric



What is the emergent management of pelvic ring fractures

  • resuscitation
    • superior gluteal injury most common (APC, vertical shear)
    • internal pudental or obturator (lateral compression)
    • 80% from venous bleeding
    • 10% bone
    • 10% from arterial bleeding
    • transfusion
      • PRBC:FFP:Platelets ideally should be transfused 1:1:1
    • pelvic binder/sheet    
      • flat sheet around GT, don't tie a knot and keep away from the belly
      • IR the lower extremity and can tape the ankles
      • remove as soon as possible
      • contraindications 
        • hypothetical risk of over-rotation of hemipelvis and hollow viscus injury (bladder) in pelvic fractures with internal rotation component (LC)
  • external fixation
    • indications 
      • pelvic ring injuries with an external rotation component (APC, VS, CM)
      • unstable ring injury with ongoing blood loss
    • contraindications 
      • ilium fracture that precludes safe application
      • acetabular fracture
    • technique  
      • theoretically works by decreasing pelvic volume 
      • stability of bleeding bone surfaces and venous plexus in order to form clot
    • should be placed before emergent laparotomy 
  • angiography / embolization
    • controversial and based on multiple variables including:
      •  protocol of institution, stability of patient, proximity of angiography suite , availability and experience of IR staff
    • CT angiography useful for determining presence or absence of ongoing arterial hemorrhage (98-100% negative predictive value)
    • complications
      • gluteal necrosis
      • impotence


Henry Approach

  • Supine, tourniquette, flouro
  • Mark the fracture site
  • Incision centered over fracture in line with biceps tendon and radial styloid
  • Be cautious of lateral antebrachial cutanous nerve
  • Ulnar border of BR is identified and fascia is divided
    • pronator teres proximally
    • FCR distally
  • identify the radial nerve and vessels
    • plane is between the nerve and vessels
    • ligate perforators
  • Subperiosteal disection
    • supnator proximally - supinate to protect the PIN
    • Pronator mid shaft - need to pronate to see the insertion
    • FPL and PQ distally


Thompson approach

  • Planes
    • Proximally between 
      • ECRB (radial nerve)  
      • EDC (pin nerve) 
    • Distally between 
      • ECRB (radial nerve)
      • EPL (pin nerve)  
  • Incision from listers tubercle to lateral epicondyle
    • superficial radial nerve and cephalic vien


Indications for fixation of clavicle fractures

  • absolute
    • unstable Group II fractures (Type IIA, Type IIB, Type V) 
    • open fxs
    • displaced fracture with skin tenting 
    • subclavian artery or vein injury
    • floating shoulder (clavicle and scapula neck fx)
    • symptomatic nonunion
    • posteriorly displaced Group III fxs
    • displaced Group I (middle third) with >2cm shortening 
  • relative and controversial indications
    • brachial plexus injury (questionable b/c 66% have spontaneous return)
    • closed head injury
    • seizure disorder
    • polytrauma patient


Outcomes with operative fixation of clavicle fractures

  • improved functional outcome / less pain with overhead activity 
  • faster time to union
  • decreased symptomatic malunion rate 
  • improved cosmetic satisfaction
  • improved overall shoulder satisfaction
  • increased shoulder strength and endurance
  • increased risk of need for future procedures 
  • implant removal
  • debridement for infection


Options for fixation of a clavicle fracture

  • plate and screw fixation 
    • superior vs anterior plating   
      • superior plating biomechanically higher load to failure and bending
      • superior plating better for inferior bony comminution
      • superior plating has higher risk of neurovascular injury during drilling
    • limited contact dynamic compression plate 
      • 3.5mm reconstruction plate 
      • locking plates 
      • precontoured anatomic plates 
      • lower profile needing less chance for removal surgery
  • intramedullary screw or nail fixation 
    • higher complication rate including hardware migration
  • hook plate 
    • AC joint spanning fixation


Post-operative course of clavicle fracture

sling for 7-10 days followed by active motion
strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
full activity including sports at ~ 3 months


Complications of clavicle ORIF 

  • hardware complications 
    • ~30% of patient request plate removal
    • superior plates associated with increased irritation
  • neurovascular injury (3%) 
    • superior plates associated with increased risk of subclavian artery or vein penetration
    • compression can cause brachial plexus injury
    • examples
      • psuedoanyrsm 
      • hematoma
  • brachial plexus injury
  • adhesive capsulitis 
    • 4% in surgical group develop adhesive capsulitis requiring surgical intervention nonunion (1-5%)
  • infection (~4.8%)
  • mechanical failure (~1.4%)


Approach to neurvascular comprimise following clavicle ORIF

  • repeat history and physical
    • inspect wound drainage
    • hematoma in axilla
    • differential BP
  • Post-op XR
    • AP
    • Zanca view
  • CT angio
  • Differential
    • hematoma
    • pseudoanuerysm
    • direct injury to brachial plexus
    • traction injury from positioning
  • Operative treatment
    • call vascular, prep the other leg
    • open incision
    • remove hardware
    • osteotomize for access if need be then secure with larger plate ensureing your screws aren't too long


complications of monteggia fracture

  • PIN neuropathy
    • up to 10% in acute injuries
    • treatment 
      • observation for 2-3 months
      • spontaneously resolves in most cases
      • if no improvement obtain nerve conduction studies
  • Stiffness
  • HO
  • Infection
  • PLRI
  • Malunion with radial head dislocation 
    • usually caused by failure to obtain anatomic alignment of ulna
    • treatment 
      • ulnar osteotomy and open reduction of the radial head


Blocks to reduction of monteggia fracture

poor reduction ulna



osteochondral fragement


Acceptable alignment for tibial shaft fracture

< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
< 10 degrees rotational alignment
if displaced perform closed reduction under general anesthesia


Benefits of IM nail for a tibial shaft fracture

  • IM nailing leads to (versus external fixation)  
    • decreased malalignment
  • IM nailing leads to (versus closed treatment) 
    • decrease time to union
    • decreased time to weight bearing
  • reamed vs. unreamed nails 
    • reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)
    • recent studies show no adverse effects of reaming (infection, nonunion)
    • reaming with use of a tourniquet is not associated with thermal necrosis of the tibial shaft 
    • reamed nails associated with 
      • decreased hardware failure
      • superior union rate
      • decrease time to union


Indications for amputation following lower extremity injury

significant soft tissue trauma (most important - LEAP)
warm ischemia > 6 hrs
severe ipsilateral foot trauma

not stable enough for long reconstructive surgery for dysvascular limb


Complications associated with tibial nailing

  • Knee pain
    • >50% anterior knee pain with IM nailing 
    • occurs with patellar tendon splitting and paratendon approach 
    • pain relief unpredictable with nail removal
    • lateral radiograph is best radiographic views to make sure nail is not too proud proximally 
  • Malunion 
    • high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures   
    • varus malunion leads to ipsilateral ankle pain and stiffness 
    • chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of each segment 
    • center of rotation of angulation is intersection of proximal and distal axes
    • treatment
      • reason to treat
        • arthritis
        • pain 
        • cosmesis
      • treated with osteotomy and nailing
  • Nonunion
    • definition 
      • delayed union if union at 6-9 mos.
      • nonunion if no healing after 9 mos.
    • treatment 
      • nail dynamization if axially stable
      • exchange nailing if not axially stable   
      • reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.    
      • posterolateral bone grafting if significant bone loss
      • non-invasive techniques (electrical stimulation, US)
      • BMP-7 (OP-1) has been shown equivalent to autograft 
      • compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation 
  • Malrotation 
    • most commonly occurs after IM nailing of distal 1/3 fractures 
    • can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
  • Compartment syndrome
    • incidence 1-9% 
    • can occur in both closed and open tibia shaft fxs
    • diagnosis 
      • high incidence of clinical suspicion
      • pain out of proportion
      • pain with passive stretch
      • compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
    • treatment 
      • emergent four compartment fasciotomy
    • outcome 
      • failure to recognize and treat compartment syndrome is most common reason for successful malpractice litigation against orthopaedic surgeons
    • prevention 
      • increased compartment pressure found with 
        • traction (calcaneal) 
        • leg positioning
  • Nerve injury
    • LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity 
    • transient peroneal nerve palsy can be seen after closed nailing 
      • EHL weakness and 1st dorsal webspace decreased sensation
      • treated nonoperatively; variable recovery is expected


Indications for operative correction of tibial malunion

  • valgus > 10-12 deg
  • varus > 6-10 deg;
  • external rotation > 15-20 deg;
  • internal rotation > 10-15 deg;
  • shortening of more than 2 cm;


Risk factors for femoral neck nonunion

Non-anatomic Reduction – especially VARUS
Posterior Comminution
High Shear Angle(pauwel’s angle)

iv.Poor Implant positioning – TAD

v.High Energy Injury with significant fracture displacement




What is the cruciate anastomosis

  • medial circumflex artery
  • lateral circumflex artery
  • inferior gluteal artery
  • first branch of femoris profundis


Poor prognostic factors of amputation according to LEAP

Non- white race
lack of private health insurance
poor social support
involvement in disability litigation