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Complications of femoral head fracture

  • Heterotopic ossification   
    • overall incidence is 6-64% 
    • anterior approach has increased heterotopic ossification compared with posterior approach
    • treatment 
      • administer radiation therapy if there is concern for HO 
    • especially if there is associated head injury
  • AVN
    • 23% 
    • risk is greater with delayed reduction of dislocated hip
    • the impact of anterior incision on AVN is unknown
  • Sciatic nerve neuropraxia
    • incidence is 10-23% 
    • usually peroneal division of sciatic nerve
    • spontaneous recovery of function in 60-70%
  • DJD 
    • incidence 8-75%
    • due to joint incongruity or initial cartilage damage
  • Decreased internal rotation 
    • may not be clinically problematic or cause disability


Risk of nonunion






Treatment of a femoral nonunion

Exchange nailing

  • sequential reaming
    • stimulates bone graft
    • allows insertion of a larger, stiffer nail
  • Ream 1-1.5mm larger than implant
  • Larger, stiffer implant
  • No need to bone graft unless atrophic
  • dynamize the construct to try and get compression
  • Reasons for plating
    • metaphyseal fractures 
      • don't get benefit of reaming
    • atrophic 
      • becasue will consider compression and grafting
    • allows better debridement with presence of infection


What is the treatment of an adult galeazzi fracture?

  • Usually operative, requires operative fixation as it requires anatomic fixation of the DRUJ
    • volar approach to the radius
    • dorsal approach to the DRUJ
      • make sure to examine TFCC if does not reduce with the radius
  • Treatment of the ulna
    • immobilization in supination (6 weeks)
      • indicated if DRUJ stable following ORIF of radius
    • percutaneous pin fixation 
      • indicated if DRUJ reducible but unstable following ORIF of radius
      • cross-pin ulna to radius
      • examine the TFCC
      • leave pins in place for 4-6 weeks
    • open surgical reduction
      • indicated if reduction is blocked 
      • suspect interposition of ECU Tendon
      • Examine and repair TFCC if still unstable
    • open reduction internal fixation
      • indicated if a large ulnar styloid fragment exists
      • fix styloid and immobilize in supination


Incidence of DRUJ instability in a galeazzi fracture?  What are signs of this on XR


  • if radial fracture is
  • unstable in 55% 
  • if radial fracture is >7.5 cm from articular surface
    • unstable in 6% 
  • Signs of DRUJ injury
    • ulnar styloid fx
    • widening of joint on AP view
    • dorsal or volar displacement on lateral view
    • radial shortening (≥5mm)
  • 186

    Complications associated with galeazzi fractures

    • Compartment syndrome
      • increased risk with 
        • high energy crush injury
        • open fractures
        • vascular injuries or coagulopathies
    • Neurovascular injury
    • uncommon except type III open fractures 
    • Refracture
      • usually occurs following plate removal
      • increased risk with 
        • removing plate too early
        • large plates (4.5mm)
        • comminuted fractures
        • persistent radiographic lucency
      • prevention 
        • do not remove plates before 18 months after insertion
          • amount of time needed for complete primary bone healing
    • Nonunion
    • Malunion
      • difficult to treat
      • if early enough can treat with osteotomy
      • later will require sauve-kapanji or darrach
    • DRUJ subluxation
      • displaced by gravity, pronator quadratus, or brachioradialis


    Increased risk of galeazzi refracture with...

    removing plate too early
    large plates (4.5mm)
    comminuted fractures
    persistent radiographic lucency


    How to use a RIA

    • Pre-op AP and lateral to measure canal size to determine what size of reamer to use
    • Warn anesthesia of blood loss and 45 min additional OR time
    • Supine on the OR table with adequate flouro access
    • GT start point, careful reaming, severeal passes; change position of guide wire to harvest the entire canal
    • Complications
      • blood loss
        • don't suction when not reaming
      • perforation of canal with guide wire or reamer
      • Iatrogenic fracture


    Approach to proximal humerus malunion

    • decide whether pain is due to soft tissue or boney 
    • assess ROM, NV
    • CT - boney 
    • MRI - soft tissues, RC
    • Arthroscopy
      • release capsule, rotator internal with subscap tenolysis
      • <15mm GT 
        • soft tissue release with acromioplasty
      • >15mm GT
        • release RC, debride then reattach
        • acromioplasty
    • Open Osteotomy
      • varus malunion
    • Hemiarthroplasty
      • no OA present
      • can use an undersized, nonanatomic component so you don't have to do a GT osteotomy
      • mixed results
    • Reverse
      • RC tear with OA present
      • good results but technically very demanding


    Indications for Surgery in Scapula Fracture

    Most (90%) treated non-op with no functional deficits

    Glenohumeral instability:

    >25% glenoid involvement with subluxation of humerus

    >5mm of glenoid articular surface step off or major gap

    Excessive medialization of glenoid


    Displaced scapular neck fracture

    >2.5cm medialization (1cm in the tests)

    30-40o angulation on Y-view

    Glenopolar angle <22o : controversial


    Open fracture

    Coracoid fracture with >1cm displacement

    Loss of rotator cuff function


    Classification Systems for Scapula Fracture


    Type I: proximal to CC ligaments

    Type II: Distal to CC ligaments (Tip)


    Type I: avulsion

    Type II: fracture not compormising subacromial space

    Type III: fracutre compromises subacromial space

    Body fractures: Ideberg classificationType I: Rim fractures (Like a Bankart)

    Ia: anterior rim

    Ib: posterior rim

    Type II: Through the glenoid exiting laterally

    Type III: Through the glenoid exiting superiorly

    Type IV: Through the glenoid exiting medially

    Type V: combination type injuries

    Va: Combination of II & IV

    Vb: Combination of III & IV

    Vc: Combination of II, III & IV

    Type VI: Severe comminution


    Describe Glenopolar angle and the normal value

    Angle between:

    Line connecting top and bottom of glenoid

    Line connecting top of glenoid and most caudal part of scapula

    N = 30-45o


    Internervous Plane Judet Approach to Scapula

    Judet = posterior approach to glenohumeral joint

    Infraspinatus (suprascapular nerve)

    Teres Minor (Lower subscapular nerve)


    Associations of Scapula Fractures

    2-5% mortality rate

    Usually pulmonary or head injury

    Associated with Increased ISS score

    No difference in:

    - Mortality

    - ICU stay

    - Overall hospiital stay

    - Head or abdominal injuries

    Lower rate of extremity fractures

    Orthopaedic injuries (90%)

    - Rib 52%

    - Ipsilateral clavicle fracture 25%

    - Spine fracture 29%

    - Brachial plexus injury 5%

    - 75% of brachial plexus injuries resolve

    Medical Injuries

    - Pumonary injury

    - Pneumothorax

    - Pulmonary contusion

    - Head injury

    - Vascular injury


    X-ray Finding of Scapulothoracic Dissociation.  What MUST you do on exam?

    >1cm lateralization from SP of spine vs. other side

    Must do neurovascular exam & generally a CT angio is warranted as neurovascular compromise common


    Most common vascular injury in scapulothoracic dissociation?

    Subclavian artery injury


    Single most important factor in determining outcome in scapulothoracic injury

    Neurologic compromise (esp Flail extremity) --> poor outcomes


    Treatment for Scapulothoraic dissociation

    Early forequearter amputation for complete brachial plexus injury (flail chest)

    High lateral thoracoctomy or Median sternotomy for vascular injury

    ORIF of any other shoulder girlde injuries (SSSC)


    Outcomes in Scapulothoracic injury

    Flail extremity: 52%

    Early amputation: 21%

    Death: 10%


    Most important risks for nonunion of PHF

    Smoking: increases 5.5x



    What are the risks and protective factors for AVN of the humeral head post PHF


    >8mm calcar fragment on neck

    Maintenance of the medial hinge

    Simple fracture pattern


    4-part fractures

    Angular displaceent >45o

    Displacement of tuberosities >10mm

    GH fracture dislocation

    Head split


    Indications for ORIF of PHF


    GT > 5mm displaced

    2, 3, 4part fractures in young patients

    Head splitting fractures in young


    Common risks post PHF

    Axillary nerve injury: most common


    Screw penetration following ORIF with locked plates


    Acceptable alignment humeral shaft fracture

    <20o anterior angulation

    <30o varus/valgus angulation

    <3cm shortening


    Risk factors for nonunion humeral shaft fracture (treated nonop)




    Transverse fracture


    Opern fracture



    Metabolic abnormalities:

    Vitamin D most common


    Indications for Operative Management humeral shaft fracture


    Open fracture

    Severe soft tissue injury or bone loss

    Vascular injury requiring repair

    Brachial plexus injury

    Ipsilateral forearm fracture (floating elbow)

    Compartment syndrome


    Bilateral humerus fractures

    Polytrauma or associated lower extremity fracture

    Allows early weight bearing through humerus

    Pathologic fractures

    Burns or soft tissue injury that precludes bracing

    Fracture characteristics:

    Distraction at fracture site

    Short oblique or transverse pattern

    Intraarticular extension


    IM Nail vs. ORIF Outcomes in Humeral shaft fracture

    IM Nail has:

    Higher rate of reoperation

    Higher rate of impingement/shoulder pain

    Higher rate of neurologic injury when locking distally

    Higher rate of nonunion